Protons (51) From peripheral cells to the brain

Hunger and satiety. Can these be modelled from a very simple energy availability concept?

This post is a minimally referenced ramble through how I see satiety working.

At the peripheral cellular level energy influx is controlled, to a large extent, via reactive oxygen species. These regulate insulin signalling which controls the translocation of GLUT4 and CD36 proteins to the cell surface and so facilitates the diffusion in to the cell of glucose and fatty acids respectively.

When a single cell has adequate calories it generates ROS, largely from the electron transport chain, which disable insulin signalling. This insulin "resistance" is there to limit excessive ingress of calories. ROS are the signal that no further calories are needed. At the most basic level cellular energy ingress is regulated by the core energy utilising apparatus of the cell. Excess substrate means excess ROS means shut down caloric ingress.

This is a self-contained cellular satiety signal of the most basic type. When the cell has fully adequate supplies of ATP, a high mitochondrial membrane voltage and a deeply reduced CoQ couple then ROS generation becomes almost inevitable.

It is a core, deep level, simple system. How it works is the subject of the Protons thread of posts, as is how it malfunctions.

I find it very, very difficult to envisage that the control of ingress of calories on a whole body basis (hunger/satiety) is not similarly integrated around an ROS generating system within dedicated neurons of the brain, with the hypothalamus being the most likely location.

I've had this as a persistent suspicion for a very long time but you can't get around to reading about everything at the same time. And I have to admit that neurological thinking about hunger and satiety has always struck me as a highly disreputable field. Insulin and satiety smell like cholesterol and the lipid hypothesis.

So yesterday I finally went and had a look for a reasonably recent review of ROS within the hypothalamus and this one came up pretty high in the PubMed listing

Impact of hypothalamic reactive oxygen species in the regulation of energy metabolism and food intake

This gives a flavour:

"Thus, it appears that NPY/AgRP neurons activation is mediated by a decrease in ROS levels while POMC neurons activation is driven by ROS (Andrews et al., 2008). Indeed, icv administration of ROS scavengers induces significantly lower c-Fos expression in POMC neurons and increases food intake during light cycle, observed via an increase of c-Fos expression in AgRP/NPY neurons (Diano et al., 2011). Similarly, addition of H2O2 depolarizes POMC neurons, increases the firing rate, and an icv injection of H2O2 causes significantly less feeding of mice after an overnight fast".

A lot of the work cited is not terribly well performed and no one has the Protons framework to slot their findings in to, but it's a start. What I am looking for is that these cell types do express GLUT proteins and CD36 proteins. I would expect them to be sampling arterial blood or CSF and integrating NADH and FADH2 inputs to their mitochondrial electron transport chain to "decide" whether there are adequate calories to consider that satiety or hunger might be the preferred descriptor of the body's current state.

Whether these cells express insulin receptors to facilitate ingress of substrate is something to be picked at. As I am completely biased against the concept that insulin is a satiety hormone, I would prefer this not to be the case but may be wrong. Time will tell. It looks logical to me that the brain would look at the nutrient levels present in excess of those being disposed of by peripheral insulin in to peripheral cells. As large numbers of peripheral cells become "full" under the influence of insulin, the brain should pick up the rising level of excess nutrients as the signal to call a halt on hunger. Doing this within the brain shouldn't need insulin, merely a set of relatively low affinity transporters to allow glucose and lipid uptake as insulin completes its peripheral function. Satiety should be picked up when enough cells have enough calories, whole body, that they no longer behave as a calorie "sump". The job of the brain is to pick up evidence from the nutrient levels that the sump is full and satiety can be declared.

For hunger, high affinity transporters would allow ROS to be generated easily and falling ROS would signal that energy availability was low.

These signals will come from the neural mitochondrial ETC generating ROS. The best ROS generating nutrients will be the most satiating. Saturated fats spring to mind if you follow the Protons thread.

Obviously there are whole load more hormones which can influence the generation of ROS within neurons. Physiology has applied layers and layers of signalling to maximise reproductive fitness. I have minimal interest in these "higher level" signals. They are there, they will modulate the core process I've been talking about but I see no way that they will do anything fundamentally different from or in opposition to the ROS system.

I'll give the rest of the review a bit of a read and see if it's worth posting about.

Peter

Insulin makes you hungry (11) But not in Denmark?

Preamble. The best papers are those which challenge your ideas. When they conflict with what appears to be very hard evidence which support your mindset they become really exciting. Sometimes you just have to shrug, label the new finding as important and put it on the back burner to be ruminated about over the coming months. Sometimes a potential explanation is possible. This post is essentially a fairytale set in Denmark. It may be completely wrong. Or not. Here we go.

This paper came up in the comments to the last post from Gabor Erdosi via raphi. It is from Astrup's group in Denmark and I have to say I have a lot of time for Prof Astrup as he was one of the more influential people who objected to the gross stupidity of Denmark's transient fat tax a few years ago. The fat tax was abandoned quite rapidly as sensible EU dwelling Danes merely popped across their open border and stocked up with un-fat-taxed butter in Germany. Anyway:

The role of postprandial releases of insulin and incretin hormones in meal-induced satiety-effect of obesity and weight reduction

This is the crucial graph

Take 12 lean people, feed them a 600kcal sandwich for breakfast, wait just over three hours then offer them an ad-lib, well mixed pasta salad and see how much of this they eat.

The higher their insulin went after breakfast, the less they ate at lunchtime.

Insulin exposure is clearly associated with reduced subsequent food intake. You might be tempted to assume causality here, but you can't. It's an observational study of a very specific set of people. It can be used to generate an hypothesis, such as insulin suppresses subsequent food intake. But then you would have to test that hypothesis.

You could also simply go back through the literature to interventional studies which actually imposed changes in insulin levels and come to the opposite conclusion. Rodin et al did this here

Effect of insulin and glucose on feeding behavior

which makes that particular hypothesis untenable. Insulin makes you hungry.

Here are the core findings, clamp values first

Here are the hunger ratings

and the amount of liquid food consumed, via a straw, through a screen:

To me personally, his study is very convincing. The principle is simple, logical and comprehensible. I would have been happier if he had also tracked FFAs in the study but we all know what insulin does to FFA levels (in the absence of fat ingestion). My personal view is that the brain looks at the availability of calories. Normoglycaemia with rapidly falling FFAs (the effect of insulin on adipocytes) is going to generate hunger. No one would expect any different. The action of insulin is the inhibition of lipolysis. Much higher levels are needed to facilitate the uptake of glucose.

We have a paradox, excellent. Direct insulin infusion makes you hungry. Insulin response to food makes you less hungry.

That is so cool.

Sooooo. Is it even remotely possible to explain the observation picked up by Prof Astrup in his 12 lean Danes? Starting from the basis that insulin drives calorie loss in to adipocytes with subsequent hunger? Speculation warning.

This group of Danes is very unusual. They have lived, on average, for 34 years in modern Denmark and they are not over weight. They have never counted a calorie, never been to Weight W@tchers, never had an eating disorder. They eat as much as they are comfortable with and eat again when they are hungry. If they pig out at Christmas they don't need to go on a diet in the New Year. They put zero effort in to being lean. That is a very special sort of person. They have normal appetite control.

When we give them a fixed calorie breakfast the insulin response varies. With these normal people I think it is a reasonable assumption that if the 600kcal is high compared to their preferred size of breakfast, the insulin level will go higher. There is more food than needed so more to store, that needs more insulin.

Members of the group who fancied many more than 600kcal for breakfast will have produced a low insulin response to the 600kcal specified by the study.

Now, it gets interesting because you cannot remotely account for a 1200kcal (3000kJ) difference in lunchtime eating by speculating about preferred breakfast size. The effect is too big.

The storage of calories is the simplest of actions of insulin. It does other things too. For these we have to go to the very, very artificial model of Veech's isolated working rat hearts. However some of the findings do have some bearing on real life.

In this paper

Substrate signaling by insulin: a ketone bodies ratio mimics insulin action in heart

we have this snippet:

"Unexpectedly, insulin increased cardiac hydraulic work but decreased net glycolytic flux and O2 consumption, improving net cardiac efficiency by 28%".

Insulin facilitates glucose diffusion in to the myocytes but partitions it in to stored glycogen. Glycolysis actually decreases but there is an increase in efficiency which gives the 28% increase in cardiac work.

Let that sink in. Insulin makes energy production more efficient while diverting calories in to storage. If you wanted to fatten someone up that seems like a good plan.

From a related paper by Veech's group

Insulin, ketone bodies, and mitochondrial energy transduction

we have a slight elaboration:

"The increase in efficiency associated with insulin administration is not readily explained by such a straightforward mechanism [as for ketones]; other factors, such as reduction of the mitochondrial NAD couple or specific effects like covalent modification of mitochondrial membrane protein, will have to be considered as possible factors altering efficiency of ATP synthesis".

Veech's model runs on glucose alone but there will undoubtedly be residual FFAs in the cardiac myocytes. You just have to wonder whether the effect of insulin is to extract these from the mitochondrial uncoupling proteins and covalently bind them in to intracellular triglycerides. An interesting idea and it would certainly tighten the coupling of the ETC.

Bottom line: Insulin, when working as it should, diverts calories to storage but increases efficiency of energy production to allow normal metabolism. I hold that this happens in the elevated insulin individuals of the lean subject group. Recall that all of these people are naturally lean. When the insulin wears off they realise, metabolically, that they have gained a (very) little weight while running a very efficient metabolism. If they have extra stored calories which, being naturally lean, they don't need, why should they eat much at lunch time?

The hypoinsulinaemic lean people get their 600kcal, decide it is way too little to bother storing and partition it towards utilisation. There is no drive towards storage, very little insulin, no insulin mediated increased efficiency. Substrate is available, it gets oxidised. Very little gets stored. This is the low insulin state. When lunch is presented to this naturally weight stable person their metabolism realises that it has not maintained fat stores after the 600kcal breakfast so they eat more at lunch time.

We have a period of high efficiency calorie conservation in the high insulin group and a period of low efficiency calorie wastage in the low insulin individuals. Because these people have that rare gem, a functional metabolism, they simply adjust subsequent food intake to reflect their previous fuel partitioning during the three hours from breakfast to lunch.

It is perfectly reasonable to mistake this scenario as an indicator that insulin is a satiety signal. Easily done. It's incorrect.

Peter

The invariable after-thought: Does insulin correlate inversely with reduced food intake in either the obese group at the start of the study or after marked weight loss?

No. Of course not.

Insulin makes you hungry (10) Processing

I picked up a link to this paper from an image of a table, somewhere on Tinternet. I didn't realise which paper it was. It was really interesting from the metabolic point of view and I kept looking through the results section to find the post-prandial metabolic effect of ultra-processed foods vs unprocessed foods. You know, the effect which might determine where the calories from a given food might end up, either available for metabolism versus lost in to adipocytes.

Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake

This is from the introduction

"Ultra-processed foods may facilitate overeating and the development of obesity (Poti et al., 2017) because they are typically high in calories, salt, sugar, and fat (Poti et al., 2015) and have been suggested to be engineered to have supernormal appetitive properties (Kessler, 2009; Moss, 2013; Moubarac, 2015; Schatzker, 2015). Furthermore, ultra-processed foods are theorized to disrupt gut-brain signaling and may influence food reinforcement and overall intake via mechanisms distinct from the palatability or energy density of the food (Small and DiFeliceantonio, 2019)"

What this is saying is that making foods high in calories + "supernormal appetitive properties" makes you eat more, so you become fat. And that they alter gut brain signalling to increase "reinforcement" and so increase intake. You have to put the excess calories somewhere so you get fat.

Supernormal appetitive properties. Energy density. Reinforcement.

Psychobabble.

But the bottom line is that highly processed foods do produce steady weight gain over two weeks and low processed foods do the opposite.

What we need to know is how a given food affects both the acute and chronic metabolic response, especially insulin levels and signalling. That's not going to come from the psychobabblers.

Luckily there are groups with an interest in the metabolic effects of food, rather than being lost in un-Rewarding theories of reinforcement. Like this group:

Does food insulin index in the context of mixed meals affect postprandial metabolic responses and appetite in obese adolescents with insulin resistance? A randomised cross-over trial

They compared two meals with the same low glycaemic index (GI) but differing insulin secretion indices (Insulin index, II). Both meals had very similar macros and they look suspiciously like processed vs unprocessed. Insulin (and glucose) were higher after the high II meals:

The low II meals generated less hunger in the post prandial period. I'm not sure what hunger has to do with weight gain, I get the impression from people like Hall et al that calorie intake controls weight gain. Hunger is something else, will-power dependent maybe.

The second study has some problems too. The low II food did not taste as good as the high II food. So Rewarders have a lifeline here. And if you are making a marketable commodity to be labelled as "food", anything you can do to increase its palatability is going to improve sales. If palatability should turn out to be intrinsically linked to a food's II then you are set to drive hunger combined with those increased sales. Win-win for the shareholders but not so much for the consumers. No one wants to be fat. Equally, no one can tolerate being hungry...

The second problem is that there was no increase in food intake for the high II group during the end-of-study buffet. An increase in food intake here would have been nice, to corroborate the increased hunger. But that meal was a free choice buffet being offered to people who were already obese, so poor food choices may well have over-ridden the differences in experimental meal induced hunger. Back in the days of better designed studies the post-insulin test meal was a uniform soup-like liquid, consumed via a straw through a screen so there were no visual or food choice cues to influence food intake. A pity, but there you go.

Insulin makes you hungry. Not directly, but by diverting calories in to storage. You lose those calories so your brain gets hungry. Making you fat is how insulin makes you hungry. Pure CICO but the calories-out go in to your adipocytes...

Peter

Ketogenic diets are unhelpful and dangerous for managing mitochondrial diseases. Maybe (2)

I'm hoping we all remember Sauer. If not there's a post here:

Sauer vs Lisanti

And a brief summary at the start of this one:

Sauer and 13-HODE

Sauer demonstrated that food withdrawal from rats carrying tumour xenografts makes those tumours grow like wildfire. He went on to show that it was 13-HODE which made the tumours grow and that either linoleic acid or arachidonic acid (both 13-HODE precursors) were essential for tumour growth in his model. Fasting released these carcinogenic PUFA from adipocytes when the rats were starved.

You cannot make 13-HODE without linoleic acid. Or arachidonic acid if you prefer.

Do you want to make a tumour grow? Feed your model linoleic acid. It's easy. Or you could try using a Ketocal based ketogenic diet for glioblastoma multiforme management in real live humans. There was a trial doing this recently:

Ketogenic diet treatment as adjuvant to standard treatment of glioblastoma multiforme: a feasibility and safety study

which didn't really pick up any benefit, it was only a pilot study. Serious concern about the composition of the ketogenic diet was expressed in this letter to the editor:

Problems associated with a highly artificial ketogenic diet: Letter to the Editor Re: van der Louw EJTM, Olieman JF, van den Bemt PMLA, et al. ‘Ketogenic diet treatment as adjuvant to standard treatment of glioblastoma multiforme: a feasibility and safety study’

link tweeted by Miki Ben-Dor.

Much of the diet was Ketocal based "consisting of refined vegetable oils from sunflower, soy, and palm fruit..."

This looks like an excellent source of the 13-HODE precursor linoleic acid, which Sauer might have recognised as the growth promoter in his rat models.

I would suspect that the ketogenic diet supplied benefit from ketosis, but this was largely offset by tumour promotion from the linoleic acid content.

Is there any end to the damage done by the lipid hypothesis?

Probably not.

Peter

Total Cholesterol and major cardiovascular events

This is a pure observational study:

Low total cholesterol is associated with increased major adverse cardiovascular events in men aged ≥70 years not taking statins

As such, let's generate an hypothesis.

Let's assume total cholesterol (TC) is utterly, totally and completely meaningless. About anything.

Let's assume that TC is a surrogate for "something" (Something Good) which is really important.

Let's assume that people with high TC are doing something right. Something which the study never even thought about, let alone measured.

Let's assume that statins do absolutely nothing (being generous).

Let's assume people only get put on a statin if their TC is high, ie, they are doing Something Good.

The Something Good behaviour pattern persists despite the statin.

The statination makes the TC number decrease, which makes the statin victims look as if they are doing the Something Bad which, obviously, lowers your TC. But they're not. They do well despite the statin and despite the artificially lowered TC.

EPIC Norfolk suggests looking at HbA1c if you want to look at cardiovascular and all cause mortality. Hints about Something Good here in Norfolk?

Peter

Edit: No one (least of all me) would suggest HbA1c elevation is causative of all cause mortality. But at least it starts you looking at the correct metabolic pathways! End edit.

Metformin (11) a SHORT paradox

I'll just throw this one out there as I found it while looking for something else:

Metformin paradoxically worsens insulin resistance in SHORT syndrome

SHORT syndrome is a (very, very rare) genetic failure of insulin signalling at the PIK3 regulatory subunit 1 level. Insulin binds to its receptor but signalling fails due to a single downstream gene defect giving severe insulin resistance. People with this syndrome are, needless to say, very thin. They maintain normoglycaemia using a very high level of insulin which does, given a high enough concentration, produce normoglycaemia. There doesn't appear to be any problem with secreting insulin from the pancreas. In fact, to overcome the failure of insulin signalling during her OGTT the patient's pancreas produced a plasma insulin of 688mIU/l*. In new money that is just under 5000pmol. As in roughly ten times what you might expect. Severe, but not quite insuperable, insulin resistance.

*The paper specifies insulin in mIU/ml. I'm assuming this is a typo or a font failure because clinical insulin concentrations are usually expressed as microIU/ml or mIU/l. Obviously if it really is 688mIU/ml the concentrations will be 1000 times those quoted. Gulp. People really should use the SI system.

Back to the patient. The obvious thing to do is to give an insulin sensitising agent, number one in popularity nowadays being metformin.

This turned out to be a bit of a boo boo.

During an OGTT under metformin the patient's insulin resistance worsened and mild hyperglycaemia ensured but this was despite a plasma insulin concentration which was simply too high to measure. The lab could measure up to around 7000pmol (pax typos) and it looks like the curve went MUCH higher than that.

That is despite metformin's predictable and recently found ability to suppress insulin release from mouse islets.

From the Protons perspective metformin blunts insulin signalling via blockade of mitochondrial glycerol-3-phosphate dehydrogenase. Its beneficial effects to increase insulin sensitivity come from reduced exposure to insulin signalling in peripheral cells. The peripheral cells of a person with SHORT syndrome barely see insulin signalling at all even without the metformin. You would hardly expect further blocking any residual insulin signalling to help matters. It doesn't.

It's the sort of paradox which only happens when you are in the wrong paradigm of metformin's mechanism of action. Might have been a chance to make progress...

Peter

Addendum: The lady in question did not seem to enjoy her experience with the medics too much:

"As we intended to check the effects of this approach, an extended 75 g OGTT was performed on metformin 4 days later. This showed dramatic and paradoxical worsening of insulin tolerance with insulin concentrations above the upper assay detection limit (Fig. 1b). Metformin treatment was discontinued. She was discharged home on Dydrogesterone and vitamin D supplementation. We planned to perform investigations on other family members, and particularly on her younger brother, but despite several reminders they failed to attend clinic appointments as well as declined admission to the hospital".

Ketogenic diets are unhelpful and dangerous for managing mitochondrial diseases. Maybe.

I think this is probably an abstract from a short communication at a conference. I picked it up from Miki Ben-Dor on twitter



I think we can say that ketogenic diets are pretty rubbish for managing mitochondrial illnesses.

By chance there is also a twitter discussion on-going relating to omega 6 based ketogenic diets.

First, nutritionists LOVE omega 6 PUFA and HATE saturated fats. In case anyone hadn't noticed. This tweet came from laura cooper, this time picked up via Raphi and Tucker.

Supported by this

It seems very likely that we can combine these two concepts and come up with some sort of an explanation.

I think we can accept that the ketone induced metabolic changes noted by Veech in isolated working rat hearts, resulting in increased energy yield per ATP molecule, still apply even with poorly functional mitochondria, because there is comparable improvement in the control of abnormal mitochondria induced intractable epilepsy vs ordinary intractable epilepsy. The ketogenic diet is clearly doing something...

That's good.

Everything else is bad.

If there is a significant problem with the structure/function of complex I ketones will not be directly helpful. They deliver acetyl-CoA to the TCA and essentially nothing else. There will be a small FADH2 input from succinate dehydrogenase but all other electrons will be presented as NADH, which needs a functional complex I to do anything much.

To bypass a poorly functional complex I we really need input as FADH2 directly to the CoQ couple without having to turn the TCA. That means beta oxidation of fatty acids, in particular it needs those fatty acids to be fully saturated because electron transporting flavoprotein only receives electrons to form FADH2 from the first desaturation step at the start of beta oxidation. Any double bonds skip this step.

Using PUFA immediately reduces energy sourced via this route.

The next thing we need to realise that modern nutritionist derived ketogenic diets cause, amongst other things, pancreatitis. I posted about pancreatitis, Intralipid and propofol here. It should come as no surprise that the side effects (from here) of PUFA based ketogenic diets in children can be severe, they're probably a lot higher in PUFA than even F3666 rodent chow...

"Other early-onset complications, in order of frequency, were hypertriglyceridemia, transient hyperuricemia, hypercholesterolemia, various infectious diseases, symptomatic hypoglycemia, hypoproteinemia, hypomagnesemia, repetitive hyponatremia, low concentrations of high-density lipoprotein, lipoid pneumonia due to aspiration, hepatitis, acute pancreatitis, and persistent metabolic acidosis. Late-onset complications also included osteopenia, renal stones, cardiomyopathy, secondary hypocarnitinemia, and iron-deficiency anemia".

Then there are cardiolipins. Each cytochrome C molecule is anchored to the outer surface of the inner mitochondrial membrane by four lipid anchors. Their nature is largely controlled by the dietary lipid supply. Modern PUFA based ketogenic diets will result in highly unsaturated cardiolipin anchors. Damaged mitochondria produce an excess of ROS. ROS break PUFA based cardiolipins giving apoptosis or, if ATP levels are too low for this, necrosis. Not going to do your ragged red muscle fibres any good. Or you cardiomyopathic cardiomyocytes.

I could go on, but you get the flavour.

Is there any end to the damage done by the lipid hypothesis?

Probably not.

Peter

Confirmation bias is so nice

Excellent work:

Scientific discourse in the era of open science: a response to Hall et al. regarding the Carbohydrate-Insulin Model

Via raphi on twitter

Peter

Personal update 2019

Okay, personal update time.

Back in the middle of May this year Paul emailed me to let me know that Dr Kwasniewski had died at the age of 82. The possibility of his having had bowel cancer several years ago is apparently nearly impossible to follow up on but it doesn't appear to have been directly related to his passing away. I'd been meaning to post on this but never quite got round to it until Marco also emailed me with the same news last week. The Optimal Diet (OD) has served me well for about 17 years or so.

May was an interesting time for me. For a set of reasons not at all related to my own health I had been tempted to try the scenario of a paleolithic ketogenic diet, much along the lines of the Paleomedicina PKD protocol. I was basically interested in the level of practicality involved before suggesting it to a friend with a "modern-ketosis" resistant neurological problem. The practicalities eventually proved too problematic so the PKD option was never taken up.

I personally never expected that the PKD would change much for me.

I was wrong.

First, I stopped snoring. As far as I am aware, completely. Within a few days. I have a severely deformed nasal septum, probably traumatic in origin (if playing "toss the caber" as a kid with a larch pole, don't throw it straight up in the air in case it comes vertically back downwards directly on to your nose. Ouch). Both nostrils are severely narrowed. I never expected to ever stop snoring.

Second, the low back pain from which I got enormous relief with the OD, went. I've had three minor positional back injuries in five months but each resolution has been incredibly rapid with minimal analgesic needs.

My minor dry skin problems went within a few days, though this coincided with onset of decent access to sunlight in May, the Spring had been cool here in the UK.

Oh, and I dropped from 66kg to 62kg in a month, 11-12% body fat to 9%, estimated by lower body impedance on a set of Tanita home scales.

I carried on with the PKD.

So now I am stuck.

I really enjoy not being awakened by my wife to get me to roll back to sleeping on my side again, sometimes several times a night. I like having no back pain. I like the continued muscle strength development at the bouldering wall.

On the downside it is very socially uncomfortable. It has really brought home to me how utterly easy standard modern ketogenic eating really is. A bit of cooking and a few sweeteners and there is almost nothing you can't have within the diet.

Over the months on PKD I've added in very occasional cheese and a very, very occasional glass of Proseco on a Friday night, without apparent problems. Adding cauliflower or broccoli triggered low back soreness (I have to wonder if this is a nocebo effect, not exactly double blind!).

So nowadays I'm thinking about protein, GH, IGF-1 and insulin. I've always been cautious about protein levels but there are features about higher protein within a solidly ketogenic background that limits IGF-1 generation per unit GH secretion.

There are a number of posts there.

Currently I am, somewhat reluctantly, almost completely plant free. I'm no guru on this way of eating any more than on anything else, plus I'm very late to the party!

Peter

The paradoxical fat mice (2)

This is the intra-peritoneal insulin tolerance test (ITT) result from the mice in

Caloric Restriction Paradoxically Increases Adiposity in Mice With Genetically Reduced Insulin

as mentioned a post or two ago and which needs some sort of an explanation:

The two asterisks denote that for both of the calorie restricted groups of mice there is an elevated glucose compared to the ad-lib groups in the late part of the ITT, irrespective of whether the insulin gene dose had been reduced by 50% or 75%. Obviously the effect is biologically trivial but the p value of less than 0.05 makes me think the effect is real.

I think to understand this we have to go back some time and look at the concept that metformin has no effect on blood glucose in the absence of insulin. This is the graph from here, discussed here:



My interpretation was/is that, on a background of no metformin (upper line) that insulin (given at 90 mins) generated insulin induced insulin resistance from about sixty minutes later (time 150 mins) and this become p less than 0.05 by 90 minutes after the insulin (time 180 mins), illustrated by the failure to generate insulin-induced insulin resistance in the metformin treated mice (the lower trace).

This is insulin-induced insulin resistance in type 1 diabetic mice revealed by metformin treatment.

Next we can look at type 1 diabetic mice chronically treated with long acting exogenous insulin for a few weeks before an ITT. These have pre existing insulin-induced insulin resistance before any intra-peritoneal short acting insulin is given, taken from here, previously discussed here:

In this case the mice with established insulin resistance simply developed hyperglycaemia when injected with intra-peritoneal short acting insulin. There are no p values but by eyeball the 120 minute value on the upper curve looks like it might be stastically significantly elevated compared to time zero. The message here is that insulin given to an insulin resistance patient can produce hyperglycaemia.

This is the Somogyi Effect. It is real.

In the real world insulin secretion and insulin sensitivity are carefully balanced. Anything which increases insulin secretion increases tissue exposure to insulin and down regulates insulin action. Insulin is the messenger between insulin secretion at the pancreas and insulin response/resistance at the tissues. This is in addition to the shared use of reactive oxygen species to generate both insulin secretion and insulin responsiveness.

We know that the mice with full Ins2 knockout and with or without Ins1 partial knockout are phenotypically normal and have fairly normal insulin levels in their blood.

Aside: To actually get reduced insulin levels Johnson's lab have more recently used a full Ins1 knockout with or without partial Ins2 knockout. The partial Ins2 knockouts do have lowered insulin, are slim, don't get fatty liver and live much longer than they should do. It's all in here. Nice. End aside.

So reduced insulin genotype mice should be more insulin sensitive than full insulin complement mice, though we didn't have a fully normal group in either of the papers from the Johnson lab.

Without calorie restriction (CR) Ins1 partial knockout have their insulin system in balance. With caloric restriction they are so insulin sensitive that when they have an insulogenic calorie restricted small meal they lose calories in to their adipocytes and enter torpor, ie insulin signalling is verging on pathological. So they get fat too. They are not insulin resistant.

But during an ITT they do not merely have the modest insulin levels they might produce in response to their normal small meals. They get 0.75iu/kg of insulin IP, probably more than they have ever seen before. It works. Insulin signalling drops plasma glucose for about 30 minutes. At this point the tissues realise that they are seeing more insulin than they have ever seen in their lives. Insulin-induced insulin resistance kicks in and with it the Somogyi Effect to give elevated glucose.

I think the graph at the top of this page shows an acute onset insulin-induced insulin resistance.

This insulin resistance effect appears to be releasing glucose from the liver, or failing to oppose glucagon action here. It might also have allowed a release of free fatty acids from those greedy adipocytes which precipitated daily torpor. It is just possible that the transient insulin resistant state during the brief ITT might be the only few hours of the entire life of the CR mice that they were not hungry...

Peter

Ketones in Tehran

Just a one-liner

This is a quite fascinating paper from Iran. Bear in mind that none of the authors appears to be a native english speaker and that they could really have done with some editorial assistance, but the results seem quite significant to me. Seyfried gets a thank you for input to the study design but clearly was not an author.

Feasibility, Safety, and Beneficial Effects of MCT Based Ketogenic Diet for Breast Cancer Treatment: A Randomized Controlled Trial Study

They recruited patients who were deemed to need chemotherapy before breast cancer surgery. Half got chemo alone and the other half got chemo plus 12 weeks on a calorie restricted, MCT based ketogenic diet. They all went to surgery and were followed up post-op for about 30 months.

As far as I can make out 30 people in each group completed the intervention. Each of the cross ticks ("censored") are patients lost to follow up in some way, around 10 in each group.

It looks very much like none of the available for follow up patients in the intervention group died. Forty percent (about ten people?) died in the control group, p=0.04.

This is from a 12 week ketogenic pre-surgery intervention. If a drug had produced this effect it would be a blockbuster. There was no instruction to stay ketogenic after the 12 week trial period finished, though there are hints that at least some of the women did.

Interesting, to say the least.

Peter

The paradoxical fat mice (1)

This paper is very interesting. I think I picked it up via Raphi on twitter. It comes from Jim Johnson's lab.

Caloric Restriction Paradoxically Increases Adiposity in Mice With Genetically Reduced Insulin

The background is in these two papers:

Phenotypic alterations in insulin-deficient mutant mice

Compensatory Responses in Mice Carrying a Null Mutation for Ins1 or Ins2

The paradoxical mice all had the Ins2 gene fully knocked out and in addition to this some mice also had one allele for the Ins1 gene knocked out (Ins1+/-). So the mice in the study had either a half or a quarter of the normal mouse insulin gene complement. Some mice were fed ad-lib, some were 40% calorie restricted (CR).

The CR, lowest insulin gene group (Ins1+/-) had significantly elevated total fat mass and a significantly elevated percentage of bodyweight as fat. That's a paradox to the insulin hypothesis of obesity and so really interesting. The Ins1+/+ group also had a (ns) increase in percentage body fat but not in absolute fat mass, so the trend is there too, but only a trend.

Metabolically, the split is between ad-lib vs CR groups.

All mice had the same maximal insulin response to a 2g/kg intraperitoneal glucose tolerance test but the CR groups had a very significantly reduced peak and AUC for glucose, ie they were much more insulin sensitive. The intra-peritoneal insulin tolerance test result might be worth a post in its own right, it's paradoxical too but there won't be space to cover it today.

So let's have a look at energy expenditure (EE) from Fig3 C.

To make things a bit clearer I've copy pasted the light period from the left half of the graph on to the end of the dark period to give more of an idea of the EE curves are really like during dark to light transition:

The red line starts horizontally with no significant difference in EE between ad-lib fed mice or CR mice. There is a modest increase during the dark (active) period when the CR mice get their three very small meals, as indicated. After the last meal a precipitous and highly significant fall in EE occurs. The mice enter torpor, a state of extreme lassitude and hypothermia. At around two hours in to the next light period the mice wake up and EE returns to just below that of the ad-lib mice and the cycle repeats. The ad-lib mice behave like normal mice.

The CR mice have a profound hypometabolic period every day. You could argue, if you are a cico-tard, that this is why they store excess fat. They eat all the food they can get but expend relatively little energy so they become fat: CICO. But I would disagree.

Here's my guess as to what is happening. Speculation warning.

We know that the CR mice are exquisitely insulin sensitive. They are that way because they have a low number of insulin genes and they never get enough food to trigger a major insulin spike anyway. The CR is the dominant factor but it needs the genetic background to get the paradox to occur. Insulin-induced insulin resistance, acute or chronic, does not occur due to lifetime low insulin exposure. The fact that all mice are capable of producing the same maximal insulin response to an IPGTT does not mean that the CR group experience an equivalent insulin exposure to the ad-lib group during their routine lives. They never get enough food to trigger a maximal insulin response.

The CR mice spent the bulk of the light period with a slightly low EE. Dark period arrives and with it food. As the food is eaten there is an upward trend in EE followed by a drop. The second small meal arrives, again an upswing followed by a drop. The third and final meal gives the same upswing but the drop in EE which follows just goes on downward. The mice enter torpor, a state of profound lassitude and hypothermia.

I think torpor happens because the mice simply have no accessible calories.

This is despite the fact that it occurs immediately after the third of their calorie restricted meals. Their problem is that the meals generate an insulin response. The mice are so insulin sensitive that calories are lost in to adipocytes (and probably hepatocytes) under the over-effective action of insulin.

They lose calories in to adipocytes. These are calories out. The adipocytes get bigger with the lost fat.

Torpor occurs BECAUSE the mice have become fatter.

This is the equivalent of the hunger which follows for a human under a euglycaemic (or even hyperglycaemic) hyperinsulinaemic clamp. There is no hypoglycaemia but fatty acids become locked in to adipocytes by the hyperisulinaemia and hunger follows due a lack of available calories. I posted about it here.

At two hours in to the light period insulin drops low enough to allow lipolysis. The mice wake up.

That's all.

Except: Why do the CR mice have paradoxically (although ns) elevated fasting insulin cf the ad lib mice? There are two reasons. Here are the blood sample times added to the EE graph. The arrows are not quite in the correct clock times, as detailed in the methods, but the times related to feeding/metabolism are approximately correct.

The green arrow is the sampling time for the ad-lib fed mice. It is about six hours in to the light period and the mice would normally have been asleep during the hours leading up to it. Light-period snacking, from the respiratory exchange ratio (RER) graph in Fig3 D, would not normally have started by this time so it's a very simple physiological fasting sample.

The blue arrow for the fasting CR mice just hits the end of torpor. I'm not sure these mice ever have a time when they wouldn't eat, given the chance, but here they are in their hypometabolic phase and have minimal access to calories. At this time insulin is actually a little (ns) higher than for the ad-lib groups (Fig1 D). Higher insulin means fat stays in adipocytes. Why is insulin high?

Calorie restriction does many things in addition to dropping metabolic rate. If you fast a hard working group of humans for 5 days they develop a post prandial increase in GIP (glucose-dependent insulinotropic hormone). This was found in the CR mice in both the fasting and fed state (Fig4 C). GIP facilitates insulin release, hence insulin is a little higher the CR mice and loss of calories in to adipocytes more severe, necessitating torpor.

It's interesting as to why GIP might be elevated under hunger conditions. Possibly generating and saving fat becomes a priority when calories are low. The Ins1+/- CR mice certainly have the highest RER (>1.05) after their third meal, suggesting that they prioritise the conversion of glucose to fat. This DNL, should it occur in the liver, might go some way to explaining the elevated triglycerides in both of the CR groups. Maybe. Accentuated DNL in people who have undergone massive weight loss via gastric bypass surgery is routine during an OGTT. Like these people.

Anyway, I'll stop now. This post is about 1/4 the length it started out as, so if corners seem a bit cut then mea culpa.

Peter

Hyperlipid Protons ambassadors

Many people may have noticed that the blog Hyperlipid is not exactly the most user friendly of blogs. The prose clearly appears to make sense but some of the concepts are not always particularly simple unless you have the Protons idea well understood.

Last year (2018) Mike Eades made a sterling presentation which summarised the concept in a talk at Low Carb Down Under in terms that were much more accessible



and Brad Marshall now has a blog on which, throughout 2019, he has been writing around ideas which derive partly from the Protons thread on Hyperlipid. But in significantly more user friendly language, while still being on the spot.

Fire in a Bottle

is his website, a very neat name. It's good. He farms low PUFA pigs too.

Peter

*Very few things in life are quite so disappointing as finding that insulin interacts directly with the NOX4 (NADH oxidase 4) complex to generate the bulk of the initiating low levels of superoxide/H2O2 which trigger insulin signalling. Some ROS do come from the electron transport chain but NOX4 seems rather important. Sigh. Bulk ROS to terminate/blunt insulin signalling do appear to be ETC derived...

The sweet taste of DMEM

I mentioned in the last post that few papers ever specify the glucose concentration used for cell culture. This came up in comments from Alex and I think it deserves a mention in a post of its own.

The standard methods description for almost all cell culture usually specifies that DMEM was used, along with assorted ancillary chemicals and a source of growth factors, usually foetal bovine serum, but rarely the glucose concentration.

A brief trip to any commercial supplier's website gives you approximately 50 DMEM formulations. Three or four have zero glucose and are intended to allow you to specify your own glucose concentration. Another five or six use the original 1g/l of glucose giving 5mmol/l, ie a physiological glucose concentration. This is described as "low glucose".

The other forty-odd specify 4.5g/l, ie 25mmol/l.

I've never done cell culture but I gather the normal technique is to use 25mmol/l medium, let the cells use the glucose to grow and when the glucose drops toward 10mmol/l then they are re-fed with new medium at 25mmol/l of glucose. This works. For decades.

It also provides you with enormous information about the behaviour of cells under hyperglycaemic conditions.

Obviously, 25mmol/l of glucose in an intact human is pure pathology but it is well tolerated by the cells in culture because there is no other caloric source which inputs as FADH2. No free fatty acids.

At the most basic level a glucose concentration of 25mmol/l should a) never occur at all and b) if it does occur it should promptly trigger, via insulin acting on adipocytes, a fall in FFAs to 100 micromol/l or less.

This graph is from a paper on pancreatic beta cell death. From the open circles it is clear that, with glucose held at physiological concentration of 5mmol/l (G5), palmitate is harmless at up to at least 400micromol/l.



This should surprise no one because a 60 hour fast in a healthy human will provide 2000micromol/l of mixed free fatty acids with a glucose of just under 5mmol/l. And no multiple organ failure.

Compare that with the closed circles where glucose is pathologically high at 20mmol/l. Physiological fasting levels of FFAs then unmask the gross pathology of glucose at 20mmol/l. Typical of ordinary cell culture concentration.

Given the idiotic stand of the cardiologist community against saturated fat and given the apparent safety of pathologically elevated glucose in fat-free or PUFA supplemented cell culture medium it should come as no surprise that very few labs worry about the consequences of their grossly non-physiological DMEM.

Demonstrating the pathology of hyperglycaemia using (and blaming) saturated fatty acids or the converse lack of acute toxicity from PUFA (low FADH2 input) is a route to funding which would surely discourage any questioning of the techniques of cell culture which have been successfully used for decades. As folks say:

"We've always done it that way".




That's all I really wanted to say but here are a couple of odds and ends:

There are groups for whom glucose matters. Even if stuck in the incorrect complex I inhibition paradigm for metformin's action, the concentration of glucose is recognised as important by some.

This group:

Metabolic determinants of cancer cell sensitivity to glucose limitation and biguanides

have developed a system for glucose homeostasis in cell culture

Their approach is pretty well unique. It is NOT how cell culture is normally done.


The other brief aside while I'm on cell culture from an outsider viewpoint is FBS, foetal bovine serum. This contains essential growth factors. You can pretty well translate it as "insulin" or "IGF-1".

When cell culture shows that metformin works to reduce cancer cell growth, it is working in the presence of insulin signalling (usually combined with hyperglycaemia). Which metformin blocks at the glycerophosphate shuttle level, without the need for a lethal blockade of complex I.

Peter

Who gave you pancreatitis?

Background: Propofol is a mainstay anaesthetic induction agent. Its use is associated with occasional pancreatitis episodes. I won't wander aside about the poor dog which was referred for cataract surgery and which did eventually recovered from its perioperative fulminating pancreatitis.

Propofol is dissolved in what is essentially Intralipid, a soybean emulsion used for parenteral nutrition. The lipid emulsion gives a transient hypertriglyceridaemia. Hypertriglyceridaemia from any cause is associated with pancreatitis.

Me, being me, would automatically blame the PUFA in the Intralipid. But then I would.

I came across this paper by accident this morning:

Distinctive roles of unsaturated and saturated fatty acids in hyperlipidemic pancreatitis

It's good. The group even give you the glucose concentration used in their cell culture, 0.2%, ie 200mg/dl or around 10mmol/l. Not normal but hardly seriously pathological.

Aside: Less innocent groups keep quiet about glucose concentration and can reliably show endoplasmic reticulum stress and any other nasty attributable to palmitic acid. With how much glucose??? End aside.

This is what they found:

"Unsaturated fatty acids at high concentrations but not saturated fatty acids induced intra-acinar cell trypsin activation and cell damage and increased PKC expression"

So. If you have a genetic hypertriglyceridaemia, say lipoprotein lipase deficiency, and you get acute necrotising pancreatitis (not fun) there is every possibility that it was induced by the high content of polyunsaturated fatty acids in those triglycerides and the FFAs derived from them.

Which means that your cardiologist put you in the ITU. Avoid saturated fats, replace them with polyunsaturated oils. Thank you Public Health England and your equivalents world wide.

The converse might well be that loss of the gene for lipoprotein lipase, or similar loss, might not have been a big deal when humans lived by eating elephants. Or even until corn oil took off as a cholesterol lowering scam.

Peter

Protons (50) The video

Dave Speijer has a great video up on YouTube based largely around his recent paper in BioEssays.

Can All Major ROS Forming Sites of the Respiratory Chain Be Activated By High FADH2/NADH Ratios?

It's nice to hear the man himself on a subject about which he has spent a great deal of time thinking. Here it is:



Many thanks to Andrew Moore, editor-in-chief at BioEssays and publisher of many of Dr Speijer's papers, for the heads up that this video had been produced.

Peter

Protons (49) Complex III

Dave Speijer, an extremely insightful person if ever there was one, has a new paper out:

Can All Major ROS Forming Sites of the Respiratory Chain Be Activated By High FADH2/NADH Ratios?

the link to which I am extremely grateful to Bob for forwarding to me. This concept is purely from Dr Speijer. But I like it. A lot.

I'll start with an old doodle I produced about a decade ago depicting the front end of the electron transport chain. Matrix is at the top, cytoplasm at the bottom:

Electrons travel from NADH to Coenzyme Q, reducing it to QH2 which donates them to complex III being oxidised back to Q in the process.

The unlabelled blobs in the diagram are complex II (succinate dehydrogenase), electron transporting flavoprotein dehydrogenase and mitochondrial glycerophosphate dehydrogenase, all of which compete with complex I for CoQ as an electron acceptor. Given a high membrane voltage, a deeply reduced CoQ couple with most of the CoQ as QH2, then reverse electron transport back through complex I gives superoxide/H2O2 generation (provided the mitochondrial NAD pool is also highly reduced so unable to accept electrons (ie little NAD+, lots of NADH).

This is pretty straight forward and is the gist of the Protons thread. The extension of this is that, under high substrate availability, H2O2 from this process stops insulin facilitated caloric ingress to the cell.

Another major site of ROS generation in the ETC is complex III. Dave Speijer would hold that this is also triggered, like RET, by a deeply reduced CoQ couple. This is why.

So here is a stripped out version of the above doodle:

The problem here is that it's not that simple. Complex III does rather odd things with its two electrons. Electron bifurcation is a standard enzymic technique perfected very early on by proto-biology and it is exactly what happens here. One electron travels to cytochrome C (which only ever carries one electron at a time) and then on to complex IV and O2. The other does not:

The second electron is transferred backwards to another  CoQ molecule and so partially reduces it to QH*, the radical semiquinone.

So (oxidised) Q is a necessary electron acceptor for complex III. Under high substrate availability and with most of the CoQ couple present as QH2 there will be very little Q available.

With one electron securely on cytochrome C, with any delay in the availability of Q, the second electron can be left sitting on one of the two haem groups along its route, easily available for donation to O2 to give superoxide, so adding its ROS signal to that of complex I. Both indicate that enough substrate is present and it is time to limit insulin signalling, to limit caloric ingress.

Nothing, absolutely nothing, about the construction of the ETC is random.

The general principle that a highly reduced CoQ couple is a signal to halt caloric ingress in to the cell applies to complex III just as much as to complex I.

When you want to resist insulin, you really want to resist insulin. Superoxide is then your friend.

If you fail to limit caloric ingress then eventually ROS from complex III are ideally placed to break the cardiolipins which anchor the water soluble cytochrome C to the inner mitochondrial membrane. Destroy these anchors and the ROS signal changes from"resist insulin" (good) to "perform apoptosis" (possibly not quite so good)...

And of course ROS in excess of physiological signalling are going to activate all sorts of inflammatory pathways.

Peter

Aside: The process of ROS generation is probably limited by pairing of complex IIIs (complex III is always a dimer in-vivo) for cooperation to use one Q to accept an electron from each of the pair. This should limit ROS generation as one Q will be available to two complex IIIs, twice that avaiable if they were each working alone. Nothing is random. End aside.

On belief structures in lipidology (2) KODA-CP

Altavista put up an excellent link to an article describing an AI algorithm capable of mining pubmed abstracts and coming up with gold. The exact opposite of modern meta-analysis (repeat after me: the meta-analysis of dross is dross). And the AI algorithm could use old data to predict recent discoveries! Sadly, the university I graduated from is currently teaching final year vet students that any publication over five years old is unimportant/can be ignored. The end of science. Alt was prompted to share his gem following this link put up by Hap:

C‐reactive protein promotes atherosclerosis by increasing LDL transcytosis across endothelial cells

Which is worth thinking about (and ignoring). Unless anyone thinks that LDL transcytosis across human umbilical vein derived endothelial cells (HUVECs) in culture resembles the process of arteriosclerosis, I think we can safely ignore this aspect of the modelling in the paper. Just ask yourself how severe is venous arteriosclerosis, with or without C-reactive protein. And the cells in the model die if you expose them to anything greater than 35mg/ld LDLc! But it brings up the apoE-/- mouse, a truly fascinating subject.

The apoE-/- mouse is also a model. They develop hyperlipidaemia and rapidly progressive "arteriosclerosis". Obviously, the apoE-/- lipid particles, which lack their apoE attachment protein, work their way (using active transcytosis of course) through the endothelium of blood vessels and cause cholesterol to accumulate in the subendothelial space and... Well. It's a pretty neat evolutionary dead end, if you believe it.

The apoE-/- model tells us more than anyone could ever want to know about apoE-/- mice. I've just spent some considerable time on Pubmed and SciHub trying to find out if there is any sort of full blown apoE-/- syndrome in humans. Not apoE2/E2 etc, more like no apoE at all. Zero. Zilch. Like the mice.

No luck finding it so far.

EDIT Yay, Adam found it

Effects of the absence of apolipoprotein e on lipoproteins, neurocognitive function, and retinal function

No suggestion of CVD. Just shows how important adding over 1% by weight of dried (oxidised) egg yolk to the diet to generate the "model" might be!

END EDIT



But apoE-/- mice are interesting in their own right. They really do accumulate lipids on their arterial linings in a manner exuberant enough to make a lipidologist wet their knickers. None of this messing about with the non-lipid intimal thickening so characteristic of real human arteriosclerosis. Lipids, lots of them, just "invade" the arterial walls and stick. Right there, pretty well on the surface.

But.

Every now and then you trip over an interesting paper, in this case about why apoE-/- mice really have vascular problems. Here's one:

TLR2 Plays a Key Role in Platelet Hyperreactivity and Accelerated Thrombosis Associated with Hyperlipidemia

The paper is long and complex and very, very clever. As per usual. And less than five years old.

Here is the scene-setter from the discussion

"Patients with enhanced platelet reactivity are at increased risk for cardiovascular events.4, 37–39 Enhanced platelet reactivity is associated with chronic and acute inflammation, infections, diabetes, and a number of pathophysiological states related to dyslipidemia, including atherosclerosis, diabetes, and metabolic syndrome". My italics.

The mechanism appears to be through CD36, a multifunctional scavenger-type receptor present on most cells but here they are looking at platelets:

"Previously we have linked platelet hyperreactivity in dyslipidemia to accumulation in circulation of specific oxidized phospholipids, oxPC-CD36, which activate platelets via the scavenger receptor CD36"

The "previously" citation is to:

Phosphoproteomic Analysis of Platelets Activated by Pro-Thrombotic Oxidized Phospholipids and Thrombin

which introduces us to KODA-CP, or to put it more elegantly 9-keto-12-oxo-10-dodecenoic-phosphatidyl choline. This was just one of the more effective CD36 activators of the many lipid products present in oxidised lipoproteins.


So. Hyperlipidaemia facilitates the generation of KODA-CP which activates CD36, which activates TLR2, which makes platelets super sticky.

KODA-CP must have linoleic acid or arachidonic acid as part of its parent molecule.

The platelets stick. In apoE-/- mice enough of them stick to form massive aggregates on the arterial surface that look a bit like late stage lipid infiltrated arteriosclerosis plaques. It's a model.

BTW, platelets carry apoB labeled lipoproteins, among the many physiologically appropriate contents of their cytoplasmic granules (link below). Under the more normal generation of arterial intimal hyperplasia which precedes pathology I consider this lipid will simply be used for normal repair/hyperplasia processes. But there is nothing physiological about apoE-/- mice. They look like they should stick a ton of platelets to any damaged vascular wall, with more apoB labels than any-(mouse)-body knows what to do with. Given enough omega 6 PUFA to generate the KODA-CP.

Apart from the cardiologist derived omega 6 PUFA (another link below), did you notice the core involvement of the CD36 receptor? CD36 also facilitates free fatty acid uptake in to many cells. It is stored within cells and translocates to the cell surface, a bit like GLUT4 proteins, when needed. Stored in the cell, translocated when needed.

What controls CD36 translocation to the cell surface?

Insulin, of course (another post there).

Just thought you might like to know.

Peter

Let's just summarise. Lacking the apoE protein limits the utilisation of lipoproteins, much as having a fully non functional LDL receptor does in familial hypercholesterolaemia. This increases the concentration of lipoprotein particles in the circulation.

Applying the Dunning-Kruger effect to lipidology: Lots of LDLc particles = lots of invasion. QED. That's been it for the last 50 years. I don't thing many lipidologists every get past this obvious, unarguable, simple fallacy. Oh, also core to lipid "therapy" has been, and still is, giving corn oil to lower the LDLc count.

In reality the elevated lipoproteins are a marker of reduced utilisation and are associated with an increased residency time in the circulation. Given lipids based on palmitic, stearic or oleic acids I don't think that would matter.

Given lipids filled with linoleic acid, the essential precursor of KODA-CP, you will get a progressive rise in KODA-CP associated with increasing persistence of the lipoproteins. The more KODA-CP the more activation of platelets via CD36/TLR2 (and undoubtedly other pathways) and the stickier the platelets become.

Given the pathological intake of linoleic acid promoted by cardiologists and lipidologists working under their cholesterophobic hypothesis it seems perfectly possible that seed oils (and insulin) may well be drivers of the platelet adhesion which is core to the vascular damage in apoE-/- mice. Platelets even carry apoB100 labeled lipoproteins in their cytoplasmic granules which allows us to immuno-stain lipid accumulations with this LDLc implicating flag.

Given lipoproteins which lack apoE on their surface, accumulation of KODA-CP, hyperreactive platelets and a surfeit of insulin we are in a position to understand how the apoE-/- mouse works. Which is cool for those of us who like to understand things.

How much of this applies to actual human arteriosclerosis? Increasing platelet stickiness will amplify the normal response to arterial injury. I think this may be real. The rest is just a very extreme, rather bad model.

Most models, like this one, are usually useless.

Is it conceivable that cardiological dietary advice represents the exact opposite of the correct approach? That it would actively worsen the problem it is aiming to ameliorate?

Yep. But we knew that anyway.

Increasing linoleic acid in the diet is undoubtedly a facilitator of the generation of KODA-CP and the activation of the subsequent cascade goes a long way to explain the Sydney Diet Heart Study and the Minnesota Coronary Experiment. People died. From corn oil.

I'll stop now.



Some helpful links that didn't integrate neatly in to the text.

Effects of saturated and polyunsaturated fat diets on the chemical composition and metabolism of low density lipoproteins in man (1980, written on papyrus)

Apolipoprotein B release from activated human platelets (1986, probably on parchment, safe to ignore).

On belief structures in lipidology

Dr Thomas "Just-take-the-statin" Dayspring writes on twitter:

"Any apoB-lipoprotein less than 70 nm in diameter can pass be pass thru endothelium - The LDLs are 20.5-25 nm. Remnants and IDLs are less than 70 nm and greater than 30 nm. The term small, dense LDL is way too simplistic - Big LDLs, like small LDs (less than 20.5 nm) if present in excess can invade artery"

This statement makes a prediction. It predicts that the accumulation of lipid in arteriosclerosis will be, initially, sub-endothelial.

As in this review of transcytosis (because passive "leakage" of LDLc down a concentration gradient across an endothelial cell layer is laughably impossible for particles over 6 nm across. No, that 6 nm is not a typo, according to the review). Not that "impossible" means anything to a lipidologist.

"During the initial stages of atherosclerosis, LDL particles are transported [transcytosed] across the EC [endothelial cell] barrier and accumulate in the subendothelial space".

So. All we need to do is a few post mortem examinations, find some poor people who had early arteriosclerosis at the time they died, and look for that lipid which will be sitting neatly under that single layer of endothelial cells lining their arteries. That is the prediction embedded in Dayspring's tweet.

If we go to this paper:

Early Human Atherosclerosis. Accumulation of Lipid and Proteoglycans in Intimal Thickenings Followed by Macrophage Infiltration

EDIT: from a link in Subbotin's excellent "Excessive intimal hyperplasia in human coronary arteries before intimal lipid depositions is the initiation of coronary atherosclerosis and constitutes a therapeutic target" END EDIT

we can find real images of real arteries from real people who died of non related causes while carrying different levels of arteriosclerosis:

Left side images are van Giesen stained for histology, central images are with Sudan IV for lipid and right hand are immunostained with anti-CD68 antibodies to show macrophages. The pairs of small black arrowheads indicate the level where the intima stops and the outer media layer begins. The vascular endothelium is a single cell layer at the top of each image.

Let's look at the circled image in detail. This is an example of early atherosclerosis from a real human with real early changes who died of non related causes. It's just the sort of place you might hope to catch an LDLc particle creeping between the cells of a single endothelial layer or freshly spat out after transcytosis by an endothelial cell. Lipid stains bright red:

Well, there's the lipid, deep, deep down at the junction of the intima and the media, right between the arrow heads...

There is none anywhere near the endothelial cell layer. If you believe that LDLc, as a result of a concentration gradient between artery and sub endothelial layers, "moves" or "invades" across that endothelial cell layer you have to explain how there is none at all in the sub-endothelial area and there is a progressive accumulation at the intima-muscularis junction. How does the lipid get from the top of the image to the deep spaces without any of it showing up in the lipid-free zone between the two?

"Beam me down, Scotty" is undoubtedly the most plausible explanation.

It is very, very hard to explain how utterly disreputable the lipid hypothesis is. All of this angst about increased LDLc and/or apoB counts on LC diets is based on the assumption that somewhere, somehow, cholesterol is the cause of heart disease. How LDLc "invades" (by active and controlled transcytosis!) the sub-endothelial space, disappears from there and then suddenly appears at over 200micrometres deeper, with none showing in the intervening zone requires a belief tenet which bears no resemblance to reality...

This was bollocks in the 1950s. My question is, as always, at what time did it stop being bollocks?

No one would reasonably doubt that the lipid deep down at the intima/media junction level comes from lipoproteins (though there are other plausible explanations). No one would doubt that loading the lipoproteins with with linoleic acid is likely to be a Bad Thing. No one would doubt that generating oxidative derivatives of the lipids in those lipoproteins might be a Bad Thing.

But trans-endothelial "invasion" is beyond belief.

This would suggest that all lipidologists are talking crap.

Nothing new there then.

Peter

Metform (11) metformin vs mtG3Pdh knockout

This paper is interesting (and badly written):

A high carbohydrate diet does not induce hyperglycaemia in a mitochondrial glycerol-3-phosphate dehydrogenase-deficient mouse

It uses a mtG3Pdh knockout mouse, which is essentially a mouse which behaves as if it was on an enormous dose of metformin without all of that toxic blockade of complex I which gives a potentially lethal lactic acidosis at high dose rates. If you feed these mice standard crapinabag they are phenotypically normal. If you feed them a diet consisting some casein, a little PUFA to avoid EFA deficiency and the rest of the calories from pure sucrose they become rather interesting.

Eating pure sucrose does not make normal mice fat. It does make them insulin resistant and hyperinsulinaemic and, of course, insulin resistant adipocytes refuse to retain fat unless insulin action is facilitated by the oxidation of PUFA. Hence the normal body weight.

But the knockout mice actually become slim on sucrose. Here are the data, we can ignore the heterozygous (HET) groups:

They are slim because insulin levels are low. From the Protons perspective the function of the glycerophosphate shuttle in the pancreas is to drive enough reverse electron transport through complex I to trigger insulin release. Less RET, less insulin release, less fat storage, less hunger. Here is the isolated response of the perfused pancreas model to hyperglycaemia:

First phase insulin release is about a third of that in the normal mice. The mice are not diabetic because, in the absence of the glycerophosphate shuttle, RET to allow insulin signalling is generated by beta oxidation supplying electron transfering flavoprotein the CoQ couple via mtETFdh. Insulin signalling still happens but at the "cost" of increased lipid oxidation in the peripheral tissues.

What doesn't happen is sucrose induced insulin resistance. Again I consider this is triggered via the glycerophosphate shuttle causing RET at a level to shut down insulin signalling, which simply doesn't happen in the knockout mice. Lack of glycerophosphate shuttle also stops the generation of insulin-induced insulin resistance under conditions of high insulin concentrations coupled with energy replete cells.

Does anyone recall this figure from Metformin (01) post back in 2017?



Insulin was given at 90 minutes. At 150 minutes in the upper (non metformin-ed) rats insulin action starts to fail, at about the correct time for insulin-induced insulin resistance. By 180 minutes that upper trace, the non-metformin group, shows an upward trend in glucose as exogenous insulin levels are no longer high enough to overcome insulin-induced insulin resistance (the rats are DM T1 under insulin withdrawal).

At 180 minutes in the lower line showing metformin treated rats we can see the continued action of insulin being facilitated by the metformin because it blocks insulin-induced insulin resistance. It was mention in the comments to the post that, clinically, this effect of metformin might worsen the possibility of hypos in humans if combined with exogenous insulin usage. Potentially fatal hypos.

So what happens if you inject a sucrose treated mtG3Pdh knockout mouse with exogenous insulin to check their insulin sensitivity? Insulin sensitivity is preserved, to fatal effect:

All of the mice with the mtG3Pdh knockout died under exogenous insulin. This is exactly how I would expect metformin to behave in humans using insulin. A functional glycerophosphate shuttle allowed a sucrose diet to block this fatal sensitivity to exogenous insulin.

Obviously the mtG3Pdh mice have a normal complex I. Might they still develop lactic acidosis? Sadly the group didn't look at this (they had no idea back in 2003 that they had developed a meformin mimic model mouse). I do think there might be some elevation of systemic lactate despite a normal complex I.

In the absence of the glycerophosphate shuttle glycolysis is going to run directly to lactate to maintain redox balance. If glycolysis proceeds at a rate in excess of oxidation of the lactate within mitochondria (recall oxphos is slow compared to glycolysis) then some glycolytic lactate will spill outwards, though this is never likely to reach ICU-needing levels. No need to have a complex I blockade to generate mild lactic acidosis.

Does this metformin-ed like mouse have the exercise gains seen in human cyclists after popping 500mg of metformin pre-race?

That requires that we look at a different model.

Peter