METABOLIC ROLES OF MAJOR BIOCHEMICAL MOLECULES

The first consideration is the major sources of energy that can be used by the body, the
nutrients required for their metabolism, and the biochemical pathways that integrate them.
Carbohydrates perform a fundamental role as the primary energy-production source for the
human body. Source of glucose in the body varies with time. Glycolysis and the subsequent metabolic
pathways form the primary energy molecules ATP, NADH, and FADH2 via the oxidation of glucose
and other carbohydrates. Storage of carbohydrates as glycogen offers a readily available source of
energy when dietary carbohydrate intake is low (Chapter 2). Carbohydrates are also important in the
synthesis of nicotinamide adenine dinucleotide phosphate (NADPH) and nucleic acids.
Amino acids provide several major biochemical functions, including serving as (1) the
building blocks of proteins; (2) the precursors of hormones, neurotransmitters, and other important
signaling molecules (such as nitrous oxide); and (3) contributors to the purine and pyrimidine
components of nucleic acids, co-enzymes [NADH and flavin adenine dinucleotide (FADH2)], and
other fundamental biological molecules. Additionally, excess amino acids can enter the citric acid
cycle and can be used to generate or store biological energy. Furthermore, the metabolism of some
amino acids can be funneled into glucose synthesis (gluconeogenesis) during food deprivation.

Lipids are nonpolar biomolecules. In most tissues, they serve a primary structural role as the
components of biological membranes, creating a lipid bilayer via their hydrophobic and hydrophilic
entities. Their roles in membranes as well as in pathological processes such as atherosclerosis have
raised the awareness of saturated, mono-unsaturated, and poly-unsaturated forms with regard to their
role in diet. However, in adipose tissue, triglycerides are the major storage form of biological energy
and their oxidation yields more energy per carbon than carbohydrates. Lipolysis of triglycerides
mobilizes fatty acids that generate energy through β-oxidation and produces the substrates necessary
for ketone body (acetoacetate and β-hydroxybutyrate) synthesis, an essential fuel source during
prolonged starvation. Oxidation of both fatty acids and ketone bodies spares glucose by preventing its
oxidation. The consumption of dietary cholesterol and fats has a large impact on lipid metabolism
through the generation of plasma lipoproteins [chylomicrons and low-density lipoprotein (LDL) via
very-low density lipoprotein (VLDL)]. The resultant elevation of harmful lipids/lipoproteins
(dyslipidemia) has negative metabolic consequences that directly impact health and disease
throughout all socioeconomic classes of modern society.

INTEGRATION AND REGULATION OF METABOLISM

ATP, associated with
magnesium (Mg2+) for stability,
is the primary form of
biological energy utilized by
the human body.
As such, the catabolic
oxidation of carbohydrates
(glycolysis, citric acid cycle,
and oxidative phosphorylation),
fatty acids/lipids/ketone bodies
(fatty acid degradation), and
amino acids all lead eventually
to the production of ATP. In
contrast, anabolic metabolic
processes (gluconeogenesis, glycogen synthesis, lipid synthesis, triglyceride synthesis, and amino acid
synthesis) consume ATP, NADH, and/or NADPH to store energy (glucose), to store energy, or to
build essential biomolecules. Coupled to all of these processes is the need to eliminate waste products,
including CO2 (exhalation, acid–base balance), reactive and/or free-radical species (antioxidants), and
urea (urea cycle).
 These metabolic pathways are intimately linked at several points in biochemical pathways,
but are also separated into distinct compartments and/or organelles (e.g., cytoplasm versus
mitochondria versus nucleus, etc.) to allow the necessary regulation and control. Additionally, each
organ has unique metabolic needs and functions. These functions and needs must be coordinated in a
variety of organs to maintain a constant supply of energy while preserving some energy for the future.
The body accomplishes this goal by using the nervous system and hormonal signals to differentially
stimulate and inhibit biochemical pathways within various organs in response to supply and demand.
The main signals used to regulate metabolism are insulin, glucagon, catecholamines, glucocorticoids,
and growth hormone (in children).

The liver actively provides the quick fuel (glucose) your body needs, whereas adipose tissue
provides long-term energy storage. Finally, skeletal muscle and the rest of your body constantly
demand this energy. For example, the brain consumes approximately 90 g of glucose in a day, 20% of
the average diet.
The supply and demand of energy must be continuously provided via dietary intake or
breakdown of stores to balance with the energy requirements of respiration, transport, motility, and
synthesis of cells and tissues. Overall, the average adult uses approximately 24 kcal of energy per
kilogram of body mass to insure proper health and to maintain proper weight.
Several key biomolecules (glucose-6-phosphate or G6-P, pyruvate, and acetyl coenzyme A or
acetyl-CoA) link the biochemical pathways for carbohydrates, lipids, and amino acids/proteins and
the pathways they funnel into are tightly regulated and tissue specific. G6-P, pyruvate, and acetyl
CoA link the anabolic and catabolic pathways of carbohydrate metabolism to maintain a constant
supply of energy to maintain homeostasis under constantly changing conditions. The particular
pathways and regulation also depend on the specific functions and needs of each tissue type.

HORMONAL CONTROL OF GLUCOSE METABOLISM

The blood concentration of glucose is regulated within narrow limits.
In the postabsorptive state, the concentration of blood glucose in most mammals is maintained between
4.5 and 5.5 mmol/L. After the ingestion of a carbohydrate meal, it may rise to 6.5 to 7.2 mmol/L, and in
starvation, it may fall to 3.3 to 3.9 mmol/L. A sudden decrease in blood glucose (eg, in response to insulin
overdose) causes convulsions, because of the dependence of the brain on a supply of glucose. However, much
lower concentrations can be tolerated if hypoglycemia develops slowly enough for adaptation to occur. The
coordination of metabolic pathways to achieve this essential balance primarily depends on hormone;
nerve and signaling pathways, including insulin, glucagon, catecholamines, glucocorticoids (slower,
stress-related changes); and cytokines. Errant control leads to disease states if glucose levels are high
(diabetes mellitus or DM) or low (hypoglycemia) and, if too low, even death due to coma.

INSULIN
Insulin is the anabolic hormone of the well-fed state and an important signal to stimulate
storage of excess nutrients as glycogen and triglycerides (fat in adipose tissue). The action of insulin
is experienced by three main targets, the liver, adipose tissue, and striated muscle. The synthesis and
release of insulin is stimulated by glucose and potentiated by amino acids. In the liver, insulin
stimulates glycogenesis (glycogen synthesis), fatty acid synthesis, glycolysis, and the pentose
phosphate pathway. In the adipose tissue, it stimulates glucose and fatty acid uptake and triglyceride
synthesis (energy storage). Similarly, in skeletal muscle, it stimulates glucose uptake, glycogenesis,
and protein synthesis. It is noteworthy that insulin does not influence glucose metabolism in either the
brain or red blood cells.
The release of insulin from the pancreatic β-cells is the result of increased blood glucose
concentrations. Glucose enters the β-cells via the glucose transporter 2 (GLUT2) (passive transport).
The GLUT2 has a weak affinity for glucose so that it favors glucose uptake only after a meal, when
blood glucose levels are high, rather than in the fasted state. Following glucose oxidation, the
increased ATP concentration stimulates K+ channels and depolarizes the cell membrane. This
depolarization opens voltage gated Ca2+ channels. Other signals related to production of inositol
trisphosphate, a second messenger, stimulate Ca2+ release from the endoplasmic reticulum, resulting
in high intercellular Ca2+ concentration and triggering the release of insulin.

Insulin affects the metabolism of cells that have insulin receptors: liver cells (hepatocytes), fat
cells (adipocytes), and muscle cells. The brain and red blood cells are not affected by insulin. Insulin
works via a tyrosine kinase receptor, which phosphorylates target proteins that lead to a number of
metabolic effects. One effect is the rapid translocation of a glucose transporter 4, GLUT4, from
vesicles to the cell surface of skeletal and cardiac muscle and fat cells, increasing glucose transport
into these cells. Insulin also regulates metabolic enzymes such as glycogen synthase and
phosphorylase through activation of type I phosphatase and dephosphorylation.
GLUCAGON
Glucagon is the hormone of fasting produced by pancreatic α-cells, adjacent to the insulin-
producing β-cells. Glucagon signals via G-protein coupled receptors and the secondary messenger
molecule cyclic AMP. In contrast to many mammals, glucagon acts almost exclusively on the liver in
humans. Primarily, it stimulates glycogenolysis, gluconeogenesis, and fatty acid oxidation. Glucagon
levels increase two-to threefold in response to hypoglycemia, and the liver begins production of
glucose from glycogen. During times of high blood glucose, glucagon is reduced to half of its normal
level. Glucagon also stimulates the release of insulin, thereby allowing insulin-sensitive cells to take
up the released glucose. The delicate balance of glucagon and insulin levels is how the body maintains
glucose homeostasis under varying conditions.

CATECHOLAMINES
Catecholamines, including norepinephrine and epinephrine, the latter being primarily the hormone
responsible for the “fight or flight” response to external stresses, can provide almost immediate
(within seconds) regulation of metabolism. Specifically, they stimulate glycogenolysis and glycolysis
for the production of ATP in the muscle. At the same time, they inhibit glycolysis in the liver and
stimulate glycogenolysis to provide glucose for the blood. More recently, synaptically released
catecholamines have emerged as the main physiological pathway for the activation of lipolysis under
conditions of fasting (a condition of chronic stress).
GLUCOCORTICOIDS
Cortisol, a glucocorticoid, is a chronic stress hormone that also regulates metabolism but in the time
frame of hours to days. With prolonged stress, the hypothalamus increases secretion of corticotrophin-
releasing factor, which subsequently leads to production and secretion of adrenocorticotropic
hormone from the anterior pituitary gland and then cortisol from the adrenal glands. Cortisol has
much of the same influence on metabolism as epinephrine but functions via activation of transcription
and translation of genes rather than modulation of enzyme activity. Under conditions where insulin
declines and/or cortisol levels rise, cortisol stimulates transcription of lipases involved in lipogenesis
(glucose sparing), enzymes involved in gluconeogenesis and glycogenesis in the liver, and in the
breakdown of muscle protein. The net effect is restored blood glucose and larger glycogen stores in
the liver. However, this increase is at the expense of muscle and bone and ultimately impairs
immunological function.

DIABETES MELLITUS (DM)

DM is a condition characterized by either the total lack of insulin (Type 1) or resistance of
peripheral tissues to the effects of insulin (Type 2). Both diseases lack the signaling effect of insulin
in the presence of normal or high glucagon and other metabolic signals. The disease of DM is due to
the imbalance in carbohydrate metabolism and its effects on other metabolic pathways.
In type 1 DM, autoimmune destruction of the pancreatic β-cells leads to a complete loss of
insulin production. Although the liver can make glucose, glycogen synthesis is impeded. In the
absence of insulin, gluconeogenesis is unrestrained, elevating blood glucose. However, muscle and fat
cells cannot take up available blood glucose via the GLUT4. Thus, the body is unable to clear the
elevated blood glucose, and the peripheral tissues (muscle and fat) are starved for glucose even when
present at very high levels in the blood. Furthermore, in the absence of insulin, glucagon secretion is
uncoupled from the blood glucose levels (insulin is an important physiological regulator of glucagon
secretion). Unopposed glucagon, together with the other counter regulatory hormones
(catecholamines, cortisol, and growth hormone), inhibits glycogen synthesis and stimulates
gluconeogenesis, glycogenolysis, and lipolysis. Increased lipolysis leads to elevation of free fatty
acids in the blood stream. These fatty acid molecules are partly taken up by liver and incorporated
into lipoproteins to increase VLDL and LDL levels, a risk factor for heart disease. Ketone bodies are
also produced because of the excess of lipolysis, which cannot be inhibited in the absence of insulin.
This can result in the dangerous condition ketoacidosis, if the ketone body level becomes too elevated.
The only available treatment is the injection of exogenous insulin into the body. However, even with
optimal control, the damaging effects of elevated glucose and lipids eventually lead to medical
complications.
 Type 2 DM is characterized by the production of insulin but resistance of its effects on target
tissues. As a result of this resistance, the human body acts as if there is a relative deficiency of insulin,
even when present at high levels. The disease shares many traits with type 1 DM. As in type 1,
gluconeogenesis is unrestrained, and muscle and fat cells do not take up glucose via the GLUT4. As a
result, high levels of blood glucose are present. However, the liver still can make glycogen, and
lipolysis is kept in check because of decreased but present insulin. However, plasma lipoproteins are
typically elevated, often as a consequence of obesity and poor nutrition. Ketoacidosis is not a common
sequela to type 2 DM. However, it can occur in type 2 DM patients under conditions of additional
metabolic stress and after pancreatic failure lead to decreased production and secretion of insulin.
Some older people with type 2 DM may experience a different serious condition called Hyperosmolar
hyperglycemic nonketotic syndrome (HHNS), a condition in which the body tries to get rid of excess
sugar by passing it into the urine. HHNS is usually brought on by an illness, infection, or other factors.
Biochemistry of Ketogenesis
Introduction
Ketogenesis is a metabolic pathway that produces ketone bodies, which provide an alternative
form of energy for the body. The body is constantly producing small amounts of ketone bodies that
can make 22 ATP each in normal circumstances and it is regulated mainly by insulin. In a state of
ketosis, ketone body production is increased when there are decreased carbohydrates or increased
fatty acids. However, ketoacidosis can occur if too many ketone bodies accumulate, such as in cases
uncontrolled diabetes.
Molecular
Ketogenesis produces acetone, acetoacetate, and beta-hydroxybutyrate molecules by breaking
down fatty acids. These ketones are water-soluble lipid molecules made up of two R-groups attached
to a carbonyl group (C = O). Because they are water soluble, they do not require lipoproteins for
transport. Of the three, acetoacetate and beta-hydroxybutyrate are acidic, having pKa values of 3.6
and 4.7 respectively.
Function
In healthy humans, the body is continually making a small amount of ketones to be used by
the body for energy. In times of fasting, even overnight while sleeping, the amount of ketone bodies
in the blood increases. The normal pathways to create energy involve either stored carbohydrate or
non-carbohydrate substances. When ample carbohydrate stores are available, the main pathway used
is glycogenolysis. This involves the breakdown of glycogen stores in muscle and liver.
Gluconeogenesis, the production of glucose from non-carbohydrate sources such as lactate, is often
utilized as well, especially in situations involving exercise.
When carbohydrate stores are significantly decreased, or fatty acid concentration is increased,
there is an upregulation of the ketogenic pathway and an increased production of ketone bodies. This
can be seen in conditions such as type 1 diabetes, alcoholism, and starvation. Most organs and tissues
can use ketone bodies as an alternative source of energy. The brain uses them as a major source of
energy during periods where glucose is not readily available. This is because, unlike other organs in
the body, the brain has an absolute minimum requirement of glucose. The heart typically uses fatty
acids as its source of energy, but also can use ketones. The liver, although the primary site that
produces ketone bodies, does not use ketone bodies because it lacks the necessary enzyme beta
ketoacyl-CoA transferase.
Mechanism
Ketogenesis occurs primarily in the mitochondria of liver cells. Fatty acids are brought into
the mitochondria via carnitine palmitoyltransferase (CPT-1) and then broken down into acetyl CoA
via beta-oxidation. Two acetyl-CoA molecules are converted into acetoacetyl-CoA via the enzyme
thiolase; this is also known as acetyl coenzyme A acetyltransferase (ACAT). Afterward, acetoacetyl-
CoA is converted to HMG-CoA via the enzyme HMG-CoA synthase. HMG-CoA lyase then converts
HMG-CoA to acetoacetate. Acetoacetate can be converted to either acetone through non-enzymatic
decarboxylation, or to beta-hydroxybutyrate via beta-hydroxybutyrate dehydrogenase.
Acetoacetate and beta-hydroxybutyrate are the two ketone bodies used by the body for energy.
Once they reach extrahepatic tissues, beta-hydroxybutyrate is converted to acetoacetate via the
enzyme beta-hydroxybutyrate dehydrogenase, and acetoacetate is converted back to acetyl-CoA via
the enzyme beta-ketoacyl-CoA transferase. Acetyl-CoA goes through the citric acid cycle, and after
oxidative phosphorylation produces 22 ATP per molecule. Acetone does not convert back to acetyl-
CoA, so it is either excreted through urine or exhaled.
Regulation of Ketogenesis
Ketogenesis can be upregulated by hormones such as glucagon, cortisol, thyroid hormones,
and catecholamines by causing greater breakdown of free fatty acids, thus increasing the amount
available to be used in the ketogenic pathway. However, insulin is the main hormonal regulator of this
process.
Insulin regulates many key enzymes in the ketogenic pathway, and a state of low insulin triggers
the process. A low insulin state leads to:
 Increased free fatty acids (FFAs)
o Due to decreased inhibition of hormone-sensitive lipase
 Increased uptake of FFAs into the mitochondria
o Due to decreased activation of acetyl-CoA carboxylase, decreasing malonyl CoA,
which disinhibits Carnitine Palmitoyltransferase 1 (CPT1)
 Increased production of ketone bodies
o Due to increased HMG-CoA activity
Clinical Significance
An overproduction of ketone bodies through increased ketogenesis can pose a problem due to
their acidic nature.
Diabetic ketoacidosis (DKA) is an example involving the overproduction of ketone bodies. It
occurs when there is a lack of, or resistance to, insulin. This usually occurs in people with type I
diabetes, although it can happen to people with advanced type II diabetes as well. In most cases of
type II diabetes, enough insulin production continues to prevent excessive ketogenesis.
Due to the lack of glucose brought in by insulin, cells start to produce glucose via gluconeogenesis.
This process, along with existing glucose that cannot be brought in with insulin, greatly elevates
serum glucose levels. The threshold for DKA is a glucose level of 250. However, it is typically
greater than this amount.
Once carbohydrate stores are depleted and gluconeogenesis cannot occur anymore,
ketogenesis is substantially increased, and there are larger amounts of ketone bodies produced. Due to
the acidic nature of beta-hydroxybutyrate and acetoacetate, this causes an anion gap metabolic
acidosis.
On presentation, patients are usually very dehydrated from being hyperglycemic. The high
glucose levels lead to osmotic diuresis, involving greater osmole concentrations (in this case the
osmole being glucose) that cause an increased osmotic pressure, which leads to reduced water
reabsorption in the kidneys. Along with being dehydrated, patients typically present with confusion,
nausea, vomiting, and abdominal pain. Because of the acidosis, patients often breathe very deeply and
rapidly to eliminate carbon dioxide and cause a respiratory alkalosis. This process is known as
Kussmaul breathing, and, over time, a patient can experience respiratory distress due to the prolonged
exertion of respiratory muscles. Cerebral edema can occur in severe cases of DKA. Because of the
acetone produced by ketogenesis, patients can have breath that smells fruity or like nail polish
remover.
The main goal of treating DKA is to resolve the metabolic acidosis, which involves giving
glucose and insulin to not only lower blood glucose levels but also to downregulate the ketogenic
pathway and decrease the number of ketone bodies produced.
Ketoacidosis also can occur with severe alcoholism and prolonged starvation.