Differential effects of oral, peripheral intravenous, and intraportal glucose on hepatic glucose uptake and insulin and glucagon extraction in conscious dogs.

The effect of equal (1.1 +/- 0.1 g/kg body wt) amounts of glucose administered orally, or by peripheral intravenous or intraportal infusion on hepatic glucose uptake and fractional hepatic extraction of insulin and glucagon was studied in conscious dogs with chronically implanted Doppler flow probes on the portal vein and hepatic artery and catheters in the portal vein, hepatic vein, carotid artery, and superior mesenteric vein. Portal vein and hepatic vein plasma flow increased only after oral glucose administration. Arterial plasma glucose increased equally to 150-160 mg/100 ml after all three routes of glucose administration. Portal vein glucose was similar after oral (195 +/- 15 mg/100 ml) and intraportal glucose infusion (215 +/- 11 mg/100 ml) and significantly higher than after peripheral intravenous glucose. Hepatic glucose uptake after oral (68 +/- 4%) and intraportal glucose administration (65 +/- 7%) significantly exceeded that after peripheral intravenous glucose infusion (23 +/- 5%). The amount of insulin above basal presented to the liver during the 180 min after oral glucose was 7.6 +/- 1.3 U, 4.3 +/- 0.6 U after intraportal glucose, and 4.1 +/- 0.6 U after peripheral intravenous glucose. Hepatic extraction of insulin increased significantly after oral glucose (42 +/- 3 to 61 +/- 4%), but was unchanged after intraportal and peripheral intravenous glucose administration. When the portal vein glucose levels achieved during peripheral intravenous glucose infusion for 90 min were maintained by a subsequent 90-min intraportal glucose infusion, hepatic glucose uptake was significantly greater during the intraportal glucose infusion. Glucagon secretion was suppressed equally after oral glucose, intraportal glucose, and peripheral intravenous glucose administration; fractional hepatic extraction of that hormone, which was significantly less than that of insulin, was unchanged. These results indicate that hepatic glucose uptake is significantly greater after oral and intraportal glucose administration than after peripheral intravenous glucose infusion. This difference is not simply related to the amount of glucose or insulin presented to the liver and the increased hepatic glucose uptake did not depend solely upon the augmented fractional hepatic extraction of insulin. Hepatic extraction of insulin and hepatic glucose uptake appear to be regulated independently.     

Effect of dexamethasone on hepatic glucose and insulin metabolism after oral glucose in conscious dogs.

To examine whether hyperinsulinemia associated with glucocorticoid treatment results solely from hypersecretion of insulin or also involves altered fractional hepatic extraction, oral glucose (1 g/kg body wt) was administered to dogs with or without dexamethasone treatment (2 mg/d for 2 d). Dexamethasone significantly increased basal glucose and insulin concentrations in the portal vein, hepatic vein, and femoral artery, reduced basal fractional hepatic extraction of insulin from 43 +/- 4% to 22 +/- 4%, and, after oral glucose, increased retention by the liver of net glucose released into the portal system from 27 +/- 4% to 53 +/- 13%. Intraportal insulin infusion (1 and 2 mU/kg per min) after 7 d of dexamethasone treatment (2 mg/d) caused less suppression of endogenous glucose production, and less exogenous glucose was required to maintain an euglycemic clamp than in control animals. Dexamethasone treatment is associated with: decreased basal fractional hepatic insulin extraction contributing to hyperinsulinemia; and less suppression of endogenous glucose production and increase in peripheral uptake in response to insulin, but no reduction in net hepatic glucose uptake after oral glucose.     

Effect of gastric inhibitory polypeptide on plasma levels of chylomicron triglycerides in dogs.

To determine whether gastric inhibitory polypeptide (GIP) promotes the clearance of chylomicron triglycerides (TG) from the circulation in dogs, chyle collected from donor dogs via a thoracic duct fistula was infused at a rate of 2 ml/min i.v. into normal recipient dogs during an infusion of either porcine GIP (1 microgram/kg per h) or saline as a control. In the GIP-infused dogs the rise in plasma TG was significantly below that of the control animals [mean peak of 36 +/- 4 mg/dl vs. 82 +/- 18 mg/dl (P less than 0.05)]. It is concluded that GIP exerts an effect upon the removal of chylomicron TG from the blood. The results suggest that GIP may play a physiologic role in the disposition of ingested fat.     

Glucose-induced responses of insulin and gastric inhibitory polypeptide in various animal models

In order to clarify the role of gastric inhibitory polypeptide (GIP) in an enteroinsular axis, 19 healthy mongrel dogs were divided into following groups: 5 normal dogs (N), 4 dogs with gastrojejunostomy (GJ), 5 dogs with duodenal fistula (D) and 5 vagotomized dogs (V). Four weeks after the operation glucose was administered orally or intraduodenally in a conscious state. In group D, glucose administration was repeated under atropine injection (A). Glucose-induced response of plasma GIP was exaggerated in all the groups compared with group N. The regression equation reported by Lauritsen and Moody was obtained in each dog from the ratio of plasma insulin to blood glucose and from plasma GIP. The slope of the regression line was elevated in group GJ and reduced in group V. However, groups D and A did not reveal any difference in the slope of the regression line compared with group N. From the present study, it might be concluded that the B-values in Lauritsen and Moody's equation indicates the sensitivity of the B cell in the pancreatic islet and that GIP secretion plays an important role in the glucose-induced insulin response even in the conditions with various surgical modifications.     

Role of vagus nerve in secretion of gastric inhibitory polypeptide in dogs

In order to clarify the role of the vagus nerve in the secretion of gastric inhibitory polypeptide (GIP), experiments were performed on dogs. Response of plasma GIP to intraduodenal instillation of glucose was slightly lower in a group which received atropine, than in a group of normal dogs. The response of plasma GIP to intraduodenal glucose load was not different between vagotomized dogs and normal dogs. Electric stimulation of the vagus nerve did not produce any significant changes in plasma GIP in anesthetized dogs. In conclusion, the present study indicates that the role of the vagus nerve on GIP secretion is tiny, if any, and that the nervous influence does not overcome the effect of intraluminal administration of glucose.     

Interrelationships among insulin, glucagon, and gastric inhibitory polypeptide in insulinoma

The interrelationships of serum insulin, glucagon, and gastric inhibitory polypeptide were examined in 13 patients with insulinoma during fed and fasted states. Compared with normal subjects, patients with insulinoma had significantly lower glucose and higher insulin levels during both the fed and the fasted states. Although glucagon concentration was higher at the completion of the fast in patients with insulinoma compared with normals, no significant differences were apparent during the fed state. No difference was noted in gastric inhibitory polypeptide either during the fed state or at the termination of the fast. Under the conditions of the study, no direct suppressive effect of insulin on glucagon or gastric inhibitory polypeptide secretion was apparent. In addition, as opposed to that in normals, the insulinotropic effect of glucagon did not appear to be blunted by hypoglycemia in most of the patients. After glucagon injection, all symptomatically hypoglycemic patients experienced an amelioration of symptoms and restoration of the plasma glucose into the normal range.     

Impaired feedback control of fat induced gastric inhibitory polypeptide (GIP) secretion by insulin in obesity and glucose intolerance

Abstract. To investigate the role of endogenous insulin on the secretion of immunoreactive gastric inhibitory polypeptide (IR-GIP) the response of IR-GIP and immunoreactive insulin (IRI) to an oral fat load (100 g triglyceride) alone and during an intravenous glucose infusion (0.7 g/kg/h) was examined in normal weight and obese subjects. In normal weight subjects the fat induced integrated rise of IR-GIP was 112.7 ± 9.4 ng/ml/120 min. When glucose and fat were given together this IR-GIP response was lowered to 46.2 ± 2.9 ng/ml/120 min while the serum IRI response to i.v. glucose and the glucose tolerance were enhanced by fat ingestion. In obese subjects with normal glucose tolerance the GIP suppressing effect of i.v. glucose infusion was less marked than in controls. The integrated IR-GIP response to fat ingestion was 225.6 ± 20.3 ng/ml/120 min and to fat plus glucose 152.6 ± 14.8 ng/ml/120 min. In obese subjects with glucose intolerance i.v. glucose completely failed to lower the exaggerated secretion of IR-GIP following oral fat. Thus, a graded abnormality of the GIP response to glucose induced insulin release occurs in obesity with normal and pathological glucose tolerance. After reducing the ideal body weight of six obese subjects with glucose intolerance by hypocaloric diet for 3 weeks the exaggerated rise of IR-GIP after oral fat was reversed and the lowering effect of i.v. glucose on the IR-GIP response re-established.     

Glucagon-like polypeptide and insulin contents in the brain from acute hepatic failure dogs

Insulin contents in the thalamus-hypothalamus were significantly increased in acute hepatic failure dogs treated with dimethylnitrosamine. Glucagon immunoreactivity (GI) contents also tended to increase in the same portion of the brain. However, insulin and GI contents in the cerebral cortex and midbrain did not rise. Glucagon-like immunoreactivity (GLI) contents were much higher than GI in all the brain regions tested, but the levels were not significantly altered in hepatic failure dogs. A simultaneous infusion of insulin and glucagon to hepatic failure dogs failed to produce an elevation of insulin, GI and GLI contents even in the thalamus-hypothalamus.     

Intraportal glucose delivery alters the relationship between net hepatic glucose uptake and the insulin concentration.

To examine the relationship between net hepatic glucose uptake (NHGU) and the insulin level and to determine the effects of portal glucose delivery on that relationship, NHGU was evaluated at three different insulin levels in seven 42-h-fasted, conscious dogs during peripheral glucose delivery and during a combination of peripheral and portal glucose delivery. During peripheral glucose delivery, at arterial blood glucose levels of approximately 175 mg/dl and insulin levels reaching the liver of 51 +/- 2, 92 +/- 6, and 191 +/- 6 microU/ml, respectively, NHGUs were 0.55 +/- 0.30, 1.52 +/- 0.44, and 3.04 +/- 0.79 mg/kg per min, respectively. At hepatic glucose loads comparable to those achieved during peripheral glucose delivery and inflowing insulin levels of 50 +/- 4, 96 +/- 5, and 170 +/- 8 microU per ml, respectively, NHGUs were 1.96 +/- 0.48, 3.67 +/- 0.68, and 5.52 +/- 0.92 mg/kg per min when a portion of the glucose load was delivered directly into the portal vein. The results of these studies thus indicate that net hepatic glucose uptake is dependent on both the plasma insulin level and the route of glucose delivery and that under physiological conditions the "portal" signal is at least as important as insulin in the determination of net hepatic glucose uptake.     

Insulin regulation of renal glucose metabolism in conscious dogs.

Previous studies indicating that postabsorptive renal glucose production is negligible used the net balance technique, which cannot partition simultaneous renal glucose production and glucose uptake. 10 d after surgical placement of sampling catheters in the left renal vein and femoral artery and a nonobstructive infusion catheter in the left renal artery of dogs, systemic and renal glucose and glycerol kinetics were measured with peripheral infusions of [3-3H]glucose and [2-14C]glycerol. After baseline measurements, animals received a 2-h intrarenal infusion of either insulin (n = 6) or saline (n = 6). Left renal vein insulin concentration increased from 41 +/- 8 to 92 +/- 23 pmol/l (P < 0.05) in the insulin group, but there was no change in either arterial insulin, (approximately 50 pmol/l), glucose concentrations (approximately 5.4 mmol/l), or glucose appearance (approximately 18 mumol.kg-1.min-1). Left renal glucose uptake increased from 3.1 +/- 0.4 to 5.4 +/- 1.4 mumol.kg-1.min-1 (P < 0.01) while left renal glucose production decreased from 2.6 +/- 0.9 to 0.7 +/- 0.5 mumol.kg-1.min-1 (P < 0.01) during insulin infusion. Renal gluconeogenesis from glycerol decreased from 0.23 +/- 0.06 to 0.17 +/- 0.04 mumol.kg-1.min-1 (P < 0.05) during insulin infusion. These results indicate that renal glucose production and utilization account for approximately 30% of glucose turnover in postabsorptive dogs. Physiological hyperinsulinemia suppresses renal glucose production and stimulates renal glucose uptake by approximately 75%. We conclude that the kidney makes a major contribution to systemic glucose metabolism in the postabsorptive state.     

Glucose ingestion in dogs alters the hepatic extraction of insulin. In vivo evidence for a relationship between biologic action and extraction of insulin.

Oral glucose (25 g) fed to seven healthy, conscious dogs resulted in an increase in peripheral plasma glucose from 109 +/- 3 to 178 +/- 10 mg/dl. Concurrently serum insulin increased in the portal vein to levels approximately threefold greater than those in the periphery. Hepatic insulin delivery rose from 10.8 +/- 0.7 to 59.0 +/- 19.9 m U/min at 60 min. coincident with an increased hepatic insulin extraction from 3.3 to 41.4 mU/min (corresponding to an increase in hepatic extraction from 31 +/- 4 to 59 +/- 7%), both returning to basal at 3 h. In each animal there was a positive correlation between hepatic insulin delivery and extraction (r = 0.80, P less than 0.001 for the seven experiments combined). These changes in heptic insulin delivery and extraction after glucose metabolism associated with insulin action. As hepatic insulin extraction increased, hepatic glucose output declined, both parameters returning to basal levels by 3 h, indicating a negative correlation between hepatic insulin extraction and hepatic glucose output (r = 0.63, P less than 0.001; n = 7). The factors that mediate this marked and rapidly occurring increase in hepatic insulin extraction after oral glucose are unknown, and may include hepatic insulin delivery, glucose levels in the blood flow, and gut factors released by oral glucose intake. The association of changes in hepatic insulin extraction in vivo with an insulin effect on the liver as measured hepatic glucose output is consistent with in vitro observations relating insulin degradation to receptor binding.     

Impact of a glycogen phosphorylase inhibitor and metformin on basal and glucagon-stimulated hepatic glucose flux in conscious dogs

The effects of a glycogen phosphorylase inhibitor (GPI) and metformin (MT) on hepatic glucose fluxes (μmol · kg(-1) · min(-1)) in the presence of basal and 4-fold basal levels of plasma glucagon were investigated in 18-h fasted conscious dogs. Compared with the vehicle treatment, GPI infusion suppressed net hepatic glucose output (NHGO) completely (-3.8 ± 1.3 versus 9.9 ± 2.8) despite increased glucose 6-phosphate (G-6-P) neogenesis from gluconeogenic precursors (8.1 ± 1.1 versus 5.5 ± 1.1). MT infusion did not alter those parameters. In response to a 4-fold rise in plasma glucagon levels, in the vehicle group, plasma glucose levels were increased 2-fold, and NHGO was increased (43.9 ± 5.7 at 10 min and 22.7 ± 3.4 at steady state) without altering G-6-P neogenesis (3.7 ± 1.5 and 5.5 ± 0.5, respectively). In the GPI group, there was no increase in NHGO due to decreased glucose-6-phosphatase flux associated with reduced G-6-P concentration. A lower G-6-P concentration was the result of increased net glycogenesis without altering G-6-P neogenesis. In the MT group, the increment in NHGO (22.2 ± 4.4 at 10 min and 12.1 ± 3.6 at steady state) was approximately half of that of the vehicle group. The lesser NHGO was associated with reduced glucose-6-phosphatase flux but a rise in G-6-P concentration and only a small incorporation of plasma glucose into glycogen. In conclusion, the inhibition of glycogen phosphorylase a activity decreases basal and glucagon-induced NHGO via redirecting glucose 6-phosphate flux from glucose toward glycogen, and MT decreases glucagon-induced NHGO by inhibiting glucose-6-phosphatase flux and thereby reducing glycogen breakdown.     

Intraportal glucose delivery enhances the effects of hepatic glucose load on net hepatic glucose uptake in vivo.

Although the importance of the hepatic glucose load in the regulation of liver glucose uptake has been clearly demonstrated in in vitro systems, the relationship between the hepatic glucose load and hepatic glucose uptake has yet to be defined in vivo. Likewise, the effects of the route of glucose delivery (peripheral or portal) on this relationship have not been explored. The aims of the present study were to determine the relationship between net hepatic glucose uptake (NHGU) and the hepatic glucose load in vivo and to examine the effects of the route of glucose delivery on this relationship. NHGU was evaluated at three different hepatic glucose loads in 42-h fasted, conscious dogs in both the absence (n = 7) and the presence (n = 6) of intraportal glucose delivery. In the absence of intraportal glucose delivery and in the presence of hepatic glucose loads of 50.5 +/- 5.9, 76.5 +/- 10.0, and 93.6 +/- 10.0 mg/kg/min and arterial insulin levels of approximately 33 microU/ml, NHGU was 1.16 +/- 0.37, 2.78 +/- 0.82, and 5.07 +/- 1.20 mg/kg/min, respectively. When a portion of the glucose load was infused into the portal vein and similar arterial insulin levels (approximately 36 microU/ml) and hepatic glucose loads (52.5 +/- 4.5, 70.4 +/- 5.6, and 103.6 +/- 18.4 mg/kg/min) were maintained, NHGU was twice that seen in the absence of portal loading (3.77 +/- 0.40, 4.80 +/- 0.59, and 9.62 +/- 1.43 mg/kg/min, respectively). Thus, net hepatic glucose uptake demonstrated a direct dependence on the hepatic glucose load that did not reach saturation even at elevations in the hepatic glucose load of greater than three times basal. In addition, the presence of intraportal glucose delivery increased net hepatic glucose uptake apparently by lowering the threshold at which the liver switched from net glucose output to net glucose uptake.     

Effects of atropine upon various components mediating postprandial gastric acid secretion in dogs

Dose-response curves in chronic gastric fistula dogs were first obtained to chemical stimulants of the three accepted physiological excitatory components regulating postprandial gastric acid secretion. These were: 2-deoxy-D-glucose, a central vagal stimulant; gastrin, a hormone; and histamine, a paracrine factor. Using equiactive doses of each, a dose of atropine just maximal for suppressing all of the anatomical phases of food-induced acid secretion in vagally innervated pouch dogs was found to inhibit substantially the responses to all three of the above stimulants. The above results argue in favor of an interdependent model among the above factors for regulating postprandial gastric acid secretion in the dog.     

Contribution of insulin-stimulated glucose uptake and basal hepatic insulin sensitivity to surrogate measures of insulin sensitivity

OBJECTIVE: The goal of this study was to evaluate the performance of surrogate measures of insulin sensitivity and insulin secretion. RESEARCH DESIGN AND METHODS: The homeostasis model assessment (HOMA) of insulin resistance (IR) and the insulin sensitivity index (S(i)) from oral glucose tolerance test (OGTT) were compared with the M value from a hyperinsulinemic-euglycemic clamp in 467 subjects with various degrees of glucose tolerance. Endogenous glucose production (EGP) and hepatic insulin sensitivity were determined in a subset (n = 143). Insulin secretion was estimated as the HOMA beta-cell index and as the insulinogenic index from the first 30 min of the OGTT (I/G30) and compared with the first-phase insulin response (FPIR) to an intravenous glucose tolerance test (n = 218). RESULTS: The M value correlated with the HOMA-IR (r = -0.591, P < 0.0001) and the S(i) (r = 0.533, P < 0.0001) indexes in the total study group. HOMA-IR correlated with basal EGP in the total study group (r = 0.378, P < 0.0005) and in subjects with diabetes (r = 0.330, P = 0.01). However, neither HOMA-IR nor S(i) correlated significantly with the M value in subjects with impaired fasting glucose (IFG) (r = -0.108, P = 0.5; r = 0.01, P = 0.9) or IFG/impaired glucose tolerance (IGT) (r = -0.167, P = 0.4; r = 0.09, P = 0.6). The HOMA-IR correlated with hepatic insulin sensitivity in the whole study group (r = -0.395, P < 0.005) as well as in the IFG/IGT subgroup (r = -0.634, P = 0.002) and in the diabetic subgroup (r = -0.348, P = 0.008). In subjects with IFG/IGT, hepatic insulin sensitivity was the most important determinant of HOMA-IR, explaining 40% of its variation. The HOMA beta-cell index showed a weak correlation with FPIR in the whole study group (r = 0.294, P = 0.001) but not in the subgroups. In contrast, the I/G30 correlated with FPIR in the whole study group (r = 0.472, P < 0.0005) and in the IFG/IGT subgroup (r = 0.493, P < 0.005). CONCLUSIONS: HOMA-IR is dependent upon both peripheral and hepatic insulin sensitivity, the contribution of which differs between subjects with normal and elevated fasting glucose concentrations. These discrepancies develop as a consequence of a nonparallel deterioration of the variables included in the equations with worsening of glucose tolerance.     

Comparison of the time courses of insulin and the portal signal on hepatic glucose and glycogen metabolism in the conscious dog.

To investigate the temporal response of the liver to insulin and portal glucose delivery, somatostatin was infused into four groups of 42-h-fasted, conscious dogs (n = 6/group), basal insulin and glucagon were replaced intraportally, and hyperglycemia was created via a peripheral glucose infusion for 90 min (period 1). This was followed by a 240-min experimental period (period 2) in which hyperglycemia was matched to period 1 and either no changes were made (CON), a fourfold rise in insulin was created (INS), a portion of the glucose (22.4 mumol.kg-1.min-1) was infused via the portal vein (Po), or a fourfold rise in insulin was created in combination with portal glucose infusion (INSPo). Arterial insulin levels were similar in all groups during period 1 (approximately 45 pM) and were 45 +/- 9, 154 +/- 20, 43 +/- 7, and 128 +/- 14 pM during period 2 in CON, INS, Po, and INSPo, respectively. The hepatic glucose load was similar between periods and among groups (approximately 278 mumol.kg-1.min-1). Net hepatic glucose output was similar among groups during period 1 (approximately 0.1 mumol.kg-1.min-1) and did not change significantly in CON during period 2. In INS net hepatic glucose uptake (NHGU; mumol.kg-1.min-1) was -3.8 +/- 3.3 at 15 min of period 2 and did not reach a maximum (-15.9 +/- 6.6) until 90 min. In contrast, NHGU reached a maximum of -13.0 +/- 3.7 in Po after only 15 min of period 2. In INSPo, NHGU reached a maximum (-23.6 +/- 3.5) at 60 min. Liver glycogen accumulation during period 2 was 21 +/- 10, 84 +/- 17, 65 +/- 16, and 134 +/- 17 mumol/gram in CON, INS, Po, and INSPo, respectively. The increment (period 1 to period 2) in the active form of liver glycogen synthase was 0.7 +/- 0.4, 6.5 +/- 1.2, 2.8 +/- 1.0, and 8.5 +/- 1.3% in CON, INS, Po, and INSPo, respectively. Thus, in contrast to insulin, the portal signal rapidly activates NHGU. In addition, the portal signal independent of a rise in insulin, can cause glycogen accumulation in the liver.     

Effects of L-arginine on systemic and renal haemodynamics in conscious dogs.

1. The effects of L-arginine on systemic and renal haemodynamics were investigated in conscious dogs. L-Arginine was administered intravenously at doses of 15 and 75 mumol min-1 kg-1 for 20 min. 2. Mean arterial blood pressure, heart rate and cardiac output were not changed significantly by L-arginine infusion. However, L-arginine infusion induced a significant elevation of renal blood flow from 50 +/- 3 to 94 +/- 12 ml/min (means +/- SEM, P less than 0.01). 3. Simultaneous infusion of NG-monomethyl-L-arginine (0.5 mumol min-1 kg-1) significantly inhibited the increase in renal blood flow produced by L-arginine (15 mumol min-1 kg-1) without significant changes in mean arterial blood pressure or heart rate. 4. Pretreatment with atropine completely inhibited the L-arginine-induced increase in renal blood flow, whereas pretreatment with indomethacin attenuated it (63 +/- 4 versus 82 +/- 10 ml/min, P less than 0.05). 5. A continuous infusion of L-arginine increased renal blood flow in the intact kidney (55 +/- 3 versus 85 +/- 9 ml/min, P less than 0.05), but not in the contralateral denervated kidney (58 +/- 3 versus 56 +/- 4 ml/min, P greater than 0.05). 6. These results suggest that intravenously administered L-arginine produces an elevation of renal blood flow, which may be mediated by facilitation of endogenous acetylcholine-induced release of endothelium-derived relaxing factor and vasodilatory prostaglandins.     

Synergistic interaction between exercise and insulin on peripheral glucose uptake.

The interaction of exercise and insulin on glucose metabolism was examined in 10 healthy volunteers. Four study protocols were used: study 1: plasma insulin was raised by approximately 100 microunits/ml while plasma glucose was maintained at basal levels for 2 h (insulin clamp). Study 2: subjects performed 30 min of bicycle exercise at 40% of VO2 max. Study 3: an insulin clamp was performed as per study 1. Following 60 min of sustained hyperinsulinemia, however, subjects exercised for 30 min as per study 2. Study 4: subjects were studied as per study 3 except that catheters were inserted into the femoral artery and vein to quantitate leg glucose uptake. During the 60-90 min period of hyperinsulinemia (study 1), glucose uptake averaged 8.73 +/- 0.10 mg/kg per min. With exercise alone (study 2), the increment in peripheral glucose uptake was 1.43 +/- 0.30 mg/kg per min. When hyperinsulinemia and exercise were combined (study 3), glucose uptake averaged 15.06 +/- 0.98 mg/kg per min (P less than 0.01) and this was significantly (P less than 0.001) greater than the sum of glucose uptake when exercise and the insulin clamp were performed separately. The magnitude of rise in glucose uptake correlated closely with the increase in leg blood flow (r = 0.935, P less than 0.001), suggesting that the synergism is the result of increased blood flow and increased capillary surface area to exercising muscle. More than 85% of total body glucose metabolism during studies 1 and 3 was accounted for by skeletal muscle uptake. These results demonstrate that (a) insulin and exercise act synergistically to enhance glucose disposal in man, and (b) muscle is the primary tissue responsible for the increase in glucose metabolism following hyperinsulinemia and exercise.