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2型糖尿病以十二指肠为中心的神经激素假说:机制综述与治疗前景

The Duodenum-Centered Neurohormonal Hypothesis of Type 2 Diabetes: A Mechanistic Review and Therapeutic Perspective.

作者信息

Kapralou Athena N, Yapijakis Christos, Chrousos George P

机构信息

General Surgery Department, Euroclinic Hospital, 115 21 Athens, Greece.

Unit of Orofacial Genetics, 1st Department of Pediatrics, School of Medicine, National Kapodistrian University of Athens, 115 27 Athens, Greece.

出版信息

Curr Issues Mol Biol. 2025 Aug 14;47(8):657. doi: 10.3390/cimb47080657.

Abstract

Type 2 diabetes mellitus (T2DM) is a multifactorial disorder defined by insulin resistance, β-cell dysfunction, and chronic hyperglycemia. Although peripheral mechanisms have been extensively studied, increasing evidence implicates the gastrointestinal tract in disease onset. Insights from bariatric surgery, gut hormone signaling, and incretin-based therapies suggest that the gut contributes actively beyond nutrient absorption. Yet, a cohesive framework integrating these observations remains absent, leaving a critical gap in our understanding of T2DM's upstream pathophysiology. This work builds upon the anti-incretin theory, which posits that nutrient-stimulated neurohormonal signals-termed "anti-incretins"-arise from the proximal intestine to counteract incretin effects and regulate glycemic homeostasis. The excess of anti-incretin signals, perhaps stimulated by macronutrient composition or chemical additives of modern diets, disrupts this balance and may cause insulin resistance and β-cell depletion, leading to T2D. We hypothesize that the neuroendocrine signals produced by cholecystokinin (CCK)-I and secretin-S cells, both located in the proximal intestine, function as endogenous anti-incretins. In this context, we hypothesize a novel model centered on the chronic overstimulation of I and S cells by high-fat, high glycemic index modern diets. This drives what we term "amplified digestion"-a state marked by heightened vagal and hormonal stimulation of biliary and pancreatic secretions, increased enzymatic and bile acid activity, and alterations in bile acid composition. This condition leads to an extended breakdown of carbohydrates, lipids, and proteins into absorbable units, thereby promoting excessive nutrient absorption and ultimately contributing to insulin resistance and progressive β-cell failure. Multiple lines of clinical, surgical, and experimental evidence converge to support our model, rooted in the physiology of digestion and absorption. Western dietary patterns appear to induce an over-digestive adaptation-marked by excessive vagal and hormonal stimulation of biliary and pancreatic secretion-which amplifies digestive signaling. This heightened state correlates with increased nutrient absorption, insulin resistance, and β-cell dysfunction. Interventions that disrupt this maladaptive signaling-such as truncal vagotomy combined with duodenal bypass-may offer novel, physiology-based strategies for T2DM treatment. This hypothesis outlines a potential upstream contributor to insulin resistance and T2DM, grounded in digestive tract-derived neurohormonal dysregulation. This gut-centered model may provide insight into early, potentially reversible stages of the disease and identify a conceptual therapeutic target. Nonetheless, both the hypothesis and the accompanying surgical strategy-truncal vagotomy combined with proximal intestinal bypass-remain highly exploratory and require systematic validation through mechanistic and clinical studies. Further investigation is warranted to clarify the molecular regulation of I and S enteroendocrine cells, including the genetic and epigenetic factors that may drive hypersecretion. While speculative, interventions-surgical or pharmacologic-designed to modulate these digestive signals could represent a future avenue for research into T2DM prevention or remission, pending rigorous evidence.

摘要

2型糖尿病(T2DM)是一种多因素疾病,其特征为胰岛素抵抗、β细胞功能障碍和慢性高血糖。尽管外周机制已得到广泛研究,但越来越多的证据表明胃肠道与疾病的发生有关。减肥手术、肠道激素信号传导和基于肠促胰岛素的疗法的研究结果表明,肠道的作用不仅限于营养物质的吸收。然而,目前仍缺乏一个整合这些观察结果的连贯框架,这使得我们对T2DM上游病理生理学的理解存在关键空白。这项工作基于抗肠促胰岛素理论,该理论认为营养物质刺激产生的神经激素信号——称为“抗肠促胰岛素”——来自近端肠道,以抵消肠促胰岛素的作用并调节血糖稳态。抗肠促胰岛素信号的过量,可能是由现代饮食中的宏量营养素组成或化学添加剂刺激引起的,会破坏这种平衡,并可能导致胰岛素抵抗和β细胞耗竭,从而引发2型糖尿病。我们假设位于近端肠道的胆囊收缩素(CCK)-I细胞和促胰液素-S细胞产生的神经内分泌信号充当内源性抗肠促胰岛素。在此背景下,我们提出了一个新模型,该模型以高脂肪、高血糖指数的现代饮食对I细胞和S细胞的慢性过度刺激为中心。这会导致我们所说的“消化增强”——一种以迷走神经和激素对胆汁和胰腺分泌的刺激增强、酶和胆汁酸活性增加以及胆汁酸组成改变为特征的状态。这种情况会导致碳水化合物、脂质和蛋白质进一步分解为可吸收单元,从而促进营养物质的过度吸收,并最终导致胰岛素抵抗和进行性β细胞功能衰竭。多条临床、手术和实验证据都支持我们基于消化和吸收生理学的模型。西方饮食模式似乎会诱导一种过度消化适应——其特征是迷走神经和激素对胆汁和胰腺分泌的过度刺激——从而增强消化信号。这种增强的状态与营养物质吸收增加、胰岛素抵抗和β细胞功能障碍相关。破坏这种适应不良信号的干预措施——如迷走神经切断术联合十二指肠旁路术——可能为T2DM治疗提供新的、基于生理学的策略。这一假设概述了胰岛素抵抗和T2DM的一个潜在上游因素,其基础是消化道衍生的神经激素失调。这个以肠道为中心的模型可能有助于深入了解该疾病的早期、可能可逆的阶段,并确定一个概念性的治疗靶点。尽管如此,这一假设以及与之相关的手术策略——迷走神经切断术联合近端肠道旁路术——仍具有高度的探索性,需要通过机制和临床研究进行系统验证。有必要进一步研究以阐明I细胞和S肠内分泌细胞的分子调控,包括可能导致分泌过多的遗传和表观遗传因素。虽然具有推测性,但旨在调节这些消化信号的干预措施——手术或药物——在获得严格证据之前,可能代表了未来T2DM预防或缓解研究的一个方向。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/21ec/12384155/e0671c1603b7/cimb-47-00657-g001.jpg

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