Study of the Relationship Between Glucose and

Insulin Responses to an Oral Glucose Load in Man

Gerald Reaven, M.D., and Rupert Miller, Ph.D.,
with the technical assistance of Nancy Ballot and Judith Grindle,
Palo Alto
MATERIAL AND METHODS
SUMMARY
Glucose tolerance tests were performed on 125 pa-
Oral glucose tolerance tests have been performed on 125 tients selected from the Medical Outpatient Clinic
patients, and the ensuing changes in plasma glucose and
insulin concentrations have been measured. The possible Patients with a previous history of insulin administra-
effects of factors which could modify the nature of these tion or diabetic ketoacidosis were not tested. Also ex-
responses (obesity, age, sex, family history of diabetes, cluded were patients receiving therapy for diabetes, those
and indications for performing the tolerance test) have greater than 50 per cent overweight, and any individual
been extensively evaluated. None of these variables were
suspected of having a disease which might affect carbo-
found to have a statistically significant effect on the plasma
glucose and insulin responses. Two general relationships hydrate metabolism. Age and sex characteristics of the
between glucose and insulin responses have been defined patient population are given in table 1, and indica-
within the population studied. One, based on the quantita- tions for performing the tolerance test are listed in
tive aspects of the glucose and insulin responses, indicated table 2. All subjects received 7 oz. of a synthetic carbo-
that there was at first an increase, and then, a decrease
in the insulin response to progressive degrees of hyper- hydrate beverage (Glucola), which has been shown to
glycemia. The second relationship was independent of the produce a blood glucose response very similar to that
absolute concentrations of either glucose and insulin, and following a 100 gm. oral glucose load. Although Wilker-
states that the pattern of glucose response during the three son and associates3 have indicated that there is no need
hours of the tolerance test determines the pattern of the in- for a high carbohydrate diet before a glucose tolerance
sulin response during this same time interval. DIABETES
17:560-69, September, 1968.
TABLE 1
Age and sex distribution of patient population
The introduction of a specific immunoassay for
Age Number of patients
measurement of insulin1 has resulted in considerable (yrs.) Male Female
knowledge concerning plasma insulin concentrations of 10-19 2 2
patients with various disorders of carbohydrate metabol- 20-29 5 4
30-39 11 18
ism. However, since these studies were primarily aimed 40-49 17 15
at elucidating mechanisms of disease, a glucose-insulin 50-59 15 18
60-69 7 7
relationship with general physiological applicability has 70-79 2 2
not emerged. The primary objective of the current study Total 59 66
was to determine whether or not such a relationship
TABLE 2
existed. In order to examine this question it was neces-
Indications for which tolerance test performed*
sary to establish the plasma glucose and insulin responses
to a glucose load in a heterologous population and to Number
evaluate the possible factors that affected these responses. Indications of patients
Subsequent analysis of these data resulted in the defini- History of hyperglycemia and/or
glycosuria 55
tion of two general relationships between glucose and Family history of diabetes mellitus 24
insulin responses within the population studied. History of "hyperlipemia" and/or
coronary artery disease 23
History of possible reactive hypoglycemia 17
From the Departments of Medicine, Preventive Medicine Obesity 15
and Statistics, Stanford University School of Medicine and History of big babies 5
Stanford University, Palo Alto, California. *In some cases more than one indication was present.

560 DIABETES, VOL. 17, NO. 9-

 GERALD REAVEN, M.D., AND RUPERT MILLER, PH.D.

test in patients without a history of restricted food in-
take, detailed dietary histories were used to exclude all
patients whose average daily carbohydrate intake was
less than 200 grams.
Blood was drawn free-flowing into tubes containing
EDTA before the administration of glucose, and one,
two, and three hours later. Plasma was obtained after
separation in a refrigerated centrifuge, and two aliquots
were immediately quick frozen in acetone-dry ice. One
aliquot was used for measurement of glucose concentra-
tion4; the other used to determine immunoreactive in-
sulin by a modification of the method of Hales and
Randle,5 using insulin I-125 and insulin binding reagent
obtained from the Radiochemical Center at Amersham,
England.
In order to compare our data with those recently re-
ported by Berson and Yalow,6 the patient population
was divided into four groups based on their degree of
hyperglycemia (table 3). Since we measured plasma
glucose, which is approximately 15 per cent higher than
blood glucose,7 the upper limits of our divisions have
been proportionately increased. The four groups are
designated as (1) normoglycemic; (2) patients with
impaired glucose tolerance; (3) patients with mild
diabetes; and (4) patients with severe diabetes. These
four major groups were each further divided into three
sub-groups on the basis of degree of obesity, i.e., patients
who were less than 10 per cent overweight; those who
were between .10 and 30 per cent overweight; and
finally patients who were between 30 and 50 per cent
overweight. This classification was based upon the use
of standard life insurance tables for height and weight.
RESULTS
A. Determination of glucose and insulin responses
1. Plasma glucose and insulin concentrations and
"total" insulin response. Mean glucose and insulin con-
centrations at all time intervals appear in table 4 and
are illustrated in figure 1. There were only minor
differences between insulin concentrations of the four
groups of patients fasting or three hours after the glu-
cose load. Patients with impaired tolerance had the
highest mean insulin concentrations one and two hours
after receiving glucose, while those with severe diabetes

TABLE 3
Criteria for classification
Plasma glucose
) concentration
Number of (mg./lOOml.)
Group patients Fasting 1-hr. 2-hr.
Normoglycemic 44 <100 <185 <130
Impaired tolerance 40 One or more points
between normo-
glycemic and mild
diabetes
Mild diabetes 21 . >100 >210 >130 FIG. I. Plasma glucose and insulin concentrations of the four
Severe diabetes 20 >150 patient groups (mean SE).

TABLE 4
Plasma glucose and insulin concentrations (mean SE) before and after an oral glucose load

Glucose concentration (mg./lOOml.) Insulin concentration

Group No. Fasting 1-hr. 2-hr. 3-hr.
Normo- Fasting 1-hr. 2-hr. 3-hr.
glycemic 44 87 1 129 4 98 3 83 3
Impaired 263 9611 63 6 42 6
tolerance 40 99 2 186 5 140 6 95 5
Mild 334 133 + 15 11317 5812
diabetes 21 115 4 258 8 22115 14014
Severe 234 9413 10123 35 6
diabetes 20 21713 39025 41122 33021
243 44 6 49 7 36 5
SEPTEMBER, 1 9 6 8
56i
 PLASMA GLUCOSE AND INSULIN RESPONSES IN MAN

had the lowest levels at these times. In general there TABLE 5

was great variability in the magnitude of the in- Comparisons* of insulin concentrations for the four patient
dividual insulin responses, and this is exemplified by groups at each hour
the relatively large standard errors. This wide spectrum
of individual insulin response has been previously com- Impaired Mild Severe
tolerance diabetes diabetes
mented upon by Berson and Yalow,6 who demonstrated Normo- 0 hr. NS 0 hr. NS Ohr. NS
that this was due to biological variation rather than glycemic lhr. I, .05 1 hr. NS lhr. | , . 01
to imprecision in the measurement of immunoreactive 2hr. j,.01 2 hr. NS 2 hr. NS
insulin. However, the variability of the insulin responses 3 hr. NS 3 hr. NS 3 hr. NS
makes it difficult to assess the significance of differences Impaired 0 hr. f, .05 0 hr. NS
between groups. tolerance lhr. j , . 10 1 hr. | , .01
Examination of the insulin and glucose concentrations 2 hr. NS 2 hr. f, .01
3 hr. f, .05 3 hr. NS
revealed that their distributions (at any time, within
any group, etc.) were skewed to the right; that is, there Mild 0 hr. NS
diabetes 1 hr. f, .01
was scattering of a few very high values relative to
2hr. f, .10
the bulk of the measurements. (This observation was 3hr. NS
unrelated to age, sex, obesity, or family history of
*Arrows indicate whether insulin concentrations of pa-
diabetes.) Converting to the logarithms of the con-
tient groups on the left of the table are increased (j-) or
centrations compensated for these very large values and decreased ( | ) when compared to concentrations of groups
created a more "normal" looking distribution. Also, the on the top. Numbers, .10, .05, .01, represent significance
log transformation stabilized the variances. Groups of levels (P-value) by a (two-tailed) /-test for the difference
patients with higher concentrations had higher standard between the two groups. NS is used when differences were
considered nonsignificant (P > .10).
deviations; after taking logarithms all groups had ap-
proximately similar standard deviations. Since both these
properties (normality and stable variances) are desirable thereby enhanced.
for statistical analysis, all statistical comparisons and Another way to evaluate insulin response to glucose
analyses were performed using the logarithms of the is to estimate the area under the insulin concentration
observed concentrations. curve for the three hours of the glucose tolerance test.
Results of applying twenty-four individual (two- The insulin and glucose areas are estimated from the
tailed) /-tests to the six possible comparisons between formulas
the four patient groups at each of the time intervals (!) ^rea = VS Io + ^0 + hzo + -^ liS0
G
are summarized in table 5. Insulin concentrations of area = X/2 Go + G60 + G120 -j- V2 G180,
normal patients and those with mild diabetes were not where Io, I6o, I120, Iiso and Go, G60, G120, G18o are the
significantly different at any time interval. The highest insulin and glucose levels at times o, 60, 120, 180 min.
concentrations were observed in patients with impaired This estimate of "total" insulin response for the four
tolerance, the lowest in patients with severe diabetes. groups of patients is illustrated in figure 2, and the
However, it is of interest that insulin concentrations of significance of the results appears in table 6. In gen-
normal patients were significantly higher than patients eral the results were similar to those described when
with severe diabetes only at the one-hour interval. insulin concentrations were compared at each time
With so many /-tests in table 5, namely twenty-four, interval. Patients with impaired tolerance had the great-
there is a slight danger that one or two had significant est insulin response, patients with mild diabetes had
P-values ( < .05) by chance. The P-values were re- an insulin response which was not statistically different
ported as measures of the disparity between patient from normal individuals, and patients with severe dia-
groups and not as absolute criteria of significance for betes had a depressed insulin response.
each comparison. A number of the differences were sig- 2. Plasma glucose and insulin concentration and
nificant beyond question (P < .01). Since the dif- "total" responses of the patient groups subdivided by
ferences which were significant at the 5 per cent and weight. Mean glucose and insulin concentrations are
10 per cent levels were consistent with the 1 per cent seen in table 7, and "total" insulin responses are illus-
level significant differences, the validity of the 5 per trated in figure 3. The degree of obesity did not appear
cent and 10 per cent level significant differences is to have a consistent effect on the magnitude of either

562 DIABETES, VOL. 17, NO. 9

 GERALD REAVEN, M.D., AND RUPERT MILLER, PH.D.

TABLE 6 SERUM INSULIN RESPONSE (TOTAL AREA-yuU/mL )

Comparisons* of insulin areas for the four patient groups

Impaired Mild Severe

tolerance diabetes diabetes
Normo-
glycemic |,.oi NS t.-io 300
Impaired
tolerance f, .01
Mild
diabetes f,.10
*Arrows indicate whether insulin areas of patient groups 200
on the left of the table are increased (^ ) or decreased (J^)
when compared to areas of groups on the top. Numbers
.10, .05, .01 represent significance levels (P-value) by a
two-tailed Mest for the difference between the two groups.
NS is used when differences were considered nonsignificant
(P > .10). 100

the insulin or the glucose response. Within each patient

group, the insulin concentrations of the three obesity
groups were compared at each time interval by (two-
tailed) /-tests. Only two of the forty-eight comparisons N0RM0- IMRWRED MLD SEVERE
GLYCEMtC TOLERANCE DIABETES DIABETES
were statistically significant. Since so many comparisons
were made, these two were attributed to random varia- FIG. 2. " T o t a l " plasma insulin response (area under the i n -
sulin concentration curve) of the four patient groups
tions. Not only were all the other comparisons statis- (mean SE). Numbers of patients in each group are
tically nonsignificant, but there was no consistent direc- in parentheses.
tion to the differences between the obesity groups. The
effect of obesity on the "total" insulin response was cose load. Similar analyses were made of the glucose
analyzed by carrying out twelve individual (two-tailed) responses, and no significant correlation between obesity
/-tests. Only one of the comparisons was barely signi- and hyperglycemia emerged.
ficant at the io per cent level, and this was also 3. Effect of other factors on plasma glucose and in-
attributed to random variation. Consequently, we can sulin responses. Extensive statistical analyses were car-
establish no statistically significant effect of obesity on ried out to determine whether other variables (age, sex,
the magnitude of the insulin response to an oral glu- family history of diabetes, or indications for performing

TABLE 7
Plasma glucose and insulin concentrations (mean SE) before and after an oral glucose load

Patients Glucose concentration Insulin concentration

S..T1 /ivil %
UHg./ iuu 1111.7
Group Degree of obesity No. Fasting 1-hr. 2-hr. 3-hr. Fasting 1-hr. " 2-hr. 3-hr.
Normo- <10 per cent 25 86+ 2 129+ 5 96 5 84 5 26+ 4 8214 58+ 9 44+10
glycemic >10 per cent <30 per cent 7 89+ 4 139+16 99+ 7 71 8 30+ 5 118+29 80+17 39+11
>30 per cent <50 per cent 12 87 2 123 8 100 6 87 6 24 4 114+24 62+ 8 38+ 6
Impaired < 10 per cent 13 94+ 4 178 4 14311 90 9 30+ 4 113+26 100+30 50+ 9
tolerance > 10 per cent <30 per cent 17 99 3 190+10 131 7 89+ 5 30+ 6 135+17 102+23 48+ 8
>30 per cent <50 per cent 10 104 4 19212 15213 10913 4312 154+45 147+44 88+46
Mild <10 per cent 6 97 8 25610 21036 134+36 2510 94+14 106+21 52+15
diabetes > 10 per cent <30 per cent 10 120+ 5 25715 21922 13817 23 7 85+22 102+46 28+ 6
>30 per cent <50 per cent 5 127 9 26212 228+23 149+32 20r 5 112+33 95+34 27+12
Severe <10 per cent 11 21419 38533 421+33 358+29 23 4 41 + 10 44+10 38+ 8
diabetes > 10 per cent <30 per cent 4 19212 334+12 336+26 272+33 28 7 58+ 7 65+16 39+ 8
>30 per cent <50 per cent 5 24430 44667 450+34 31641 24 8 41+ 8 47+12 30+ 8

SEPTEMBER, 1968 563

 PLASMA GLUCOSE AND INSULIN RESPONSES IN MAN
PLASMA INSULIN RESPONSE (TOTAL AREA->uU/ml. )
< 10% OVERWEIGHT
> I O < 3 O % OVERWEIGHT
> 3 0 % OVERWEIGHT
[IMPAIRED MILD
TOLERANCE DIABETES
( 2 0 (7) (12) (13) (17) (10) (6) (10) (5)
FIG. 3. "Total" plasma insulin response (area under the in-
sulin concentration curve) of the four patient groups
subdivided by weight (mean SE). Number of pa-
tients in each group are in parentheses.
the tolerance test) had any effect on the nature of the
glucose and/or insulin responses described to this point.
In no case were these factors of any significance, and
the details have been omitted for the sake of brevity.
Consequently, there did not appear to be any variables
known to modify carbohydrate metabolism which
uniquely influenced the glucose and insulin responses of
any portion of this heterologous population.
B. Relationship between glucose and insulin responses.
In the previous section patients have been discussed
in terms of conventional clinical classifications. How-
ever, these distinctions are somewhat arbitrary. Figure
4 depicts the frequency distribution of glucose responses.
It is apparent that no clear separation between two
populations, normal and diabetic, emerges. Instead, a
relatively continuous spectrum of glucose responses is
seen. Therefore, on the basis of these results, and in
view of the previously demonstrated lack of effect of
other variables on the glucose response, the 125 pa-
tients were considered as one group in our further
attempts to establish meaningful glucose-insulin rela-
tionships.
Inspection and analysis of the glucose and insulin
responses of the patient groups suggested two possible
relationships between these variables. In the first place,
the magnitude of the insulin responses seemed to rise
maximally above normal with moderate hyperglycemia
("impaired tolerance") but thereafter to fall with in-
creasing degrees of hyperglycemia. This suggested that
564
the quantitative relationship between "total" glucose
and insulin responses in our patient population had a
"horseshoe" shape. In addition to this quantitative rela-
tionship, there emerged an independent qualitative rela-
tionship between patterns of insulin and glucose re-
sponse. When glucose concentration fell rapidly between
one and two hours, insulin concentration also fell at a
similar rate. Conversely, when hyperglycemia persisted,
insulin concentrations remained elevated, and in pa-
tients with mild and severe diabetes there was actually
a rise in insulin between one and two hours. In this
section we will attempt to quantify and validate these
relationships.
1. Quantitative relationship between glucose and in-
sulin responses. The areas of the glucose and insulin
(II) (4) (5) concentration curves (derived from the logs of the
concentrations) were used as measures for glucose and
insulin responses, and these are plotted for the 125
patients in figure 5. The "horseshoe" effect is exhibited
in the higher insulin areas for patients with glucose
areas (in logs) in the range 6.25 to 6.75 as compared
with lower insulin areas outside this range.
Better graphically to depict the rise and fall in in-
sulin areas with increasing glucose areas, a smoothed
nonparametric regression analysis is plotted in figure 6.
Figure 6 was constructed as follows: For each patient
in the sample of 125. the five other patients with the
closest higher glucose areas and the five other patients
with the nearest lower glucose areas were grouped to-
gether to form a group of eleven patients. The eleven
insulin areas for this group were averaged, and this
average value was plotted over the middle glucose area
for the group. This yields 115 points in figure 6. The
five patients with the absolute lowest glucose areas
could not be included as they would not have five neigh-
bors with lower glucose areas; similarly, for the five
absolute highest. This smoothing reduces the excessive
randomness in the data so that the shape of the re-
gression curve becomes more apparent. The average of
eleven values was selected because with 125 patients
this provides an adequate amount of smoothing without
too much distortion of the data and regression curve.
The "horseshoe" effect is exhibited in the higher in-
sulin areas for patients with glucose areas (in logs) in
the range 6.25-6.75 as compared with lower insulin
areas outside this range. Whether the "horseshoe" is a
quadratic function or some general nonlinear curve is
impossible to answer with only 125 patients. It is clear,
however, that for glucose areas in the midrange the
insulin areas are higher than those at either end.
DIABETES, VOL. 17, NO. 9
 GERALD REAVEN, M.D., AND RUPERT MILLER, PH.D.

FIG. 4. Histogram (frequency plot) of "total" glucose re-

sponse (area under glucose concentration curve) for
all 125 patients.

o 8 o .m .o ,
* A* Am Am A> A> 82 .g ig 18 '2 '8 '8 mmm m
2 g 8= Si 8? ge 8e
Glucose Response ( A r e a )

8.0 7.0

6.0 7.0 8.0

2
Glucose Response (Area for Glucose logs)

FIG. 6. Smoothed regression plot of "total" glucose response

(area under glucose concentration curve in logs) and
"total" insulin response (area under insulin concentra-
tion curve in logs). For each glucose value on the
abscissa the ordinate value is the average of eleven
insulin values.

3.0 2. Qualitative relationship betiveen patterns of glu-

6.0 7.0 8.0
Glucose Response (Area for Glucose logs)
FIG. 5. "Total" glucose response (area under glucose con-
centration curve in logs) and "total" insulin response
(area under insulin concentration curve in logs) for
each of the 125 patients.
cose and insulin response. In order to investigate the
possibility that there was an association between glucose
and insulin responses independent of the "horseshoe"
relationship, we have used a statistical technic called
"canonical correlations."8 The idea behind canonical cor-
relations is the following. We have four measurements

SEPTEMBER, 1968 565

 PLASMA GLUCOSE AND INSULIN RESPONSES IN MAN

of glucose concentration Go, G60, G120, Giso, and four
measurements of insulin concentration Io, Ieo, I120J Iiso,
for each patient. Suppose the four glucose measurements
are combined (linearly) to obtain one value for glucose
(2) G = a0G0 + axG60 + a2G120 + a3G180.
The numbers a0, ai, a2, a3 are arbitrary. The same thing
can be done for insulin with possibly different coeffi-
cients b0, b l5 b2, b.3:
(3) I = bolo + bJeo + b2l12o + b8I180.
The question posed and answered by canonical cor-
relations is what choice of a0, ai5 a2, a3 and b 0 , b l5 b 2 , b 3
will yield the maximum correlation between G and I?
In other words, what two combinations give the maxi-
mum (linear) relationship between glucose (G) and
insulin (I)?
This question can be answered with the aid of a
computer, and for the data of the 125 patients the
optimal combinations (for the logarithms) are:
a 0 = 0.08 bn = 0.28
&1= +1.28
(4) a2 = 2.79 b>2=1.48
a , = +1.28 b 3 = 0.47
responses observed in our patient population. Addition
or subtraction of a constant at each glucose (or insulin)
level in equation 5 does not change the value of G
(or I ) . Thus the relation of G to I is one of patterns
of response over time, and knowledge of the pattern of
either response enables prediction of the response of the
other variable. Three idealized patterns are illustrated
in figure 7, in which the relationship of the insulin re-
sponse to three different glucose responses is indicated.
High positive values for G, i.e., situations in which
glucose concentration at one hour is much higher than
at two hours, must be accompanied by high positive
values for I (pattern A in figure 7 ) . Pattern A is very
similar to the observed relationship between insulin
and glucose responses in normoglycemic patients, and
is characterized by a rapid fall in both glucose and
insulin concentrations between one and two hours. Sec-
Glucose and Insulin Patterns
from Canonical Correlations

The maximal canonical correlation (i.e., the correla-

tion coefficient between the two combinations with these Glucose Insulin

coefficients) is -\- .62, which is highly significant (P

< 0.01).
Although these coefficients provide a statistically sig- I 2 3

nificant mathematical correlation between glucose and Tune (hrs.)

Pattern A
insulin responses, the biological meaning of this rela-
tionship is not immediately apparent. Our approach to
this question is as follows: the absolute size of the
coefficients a0, ai, etc. and b0, bi, etc. are not important, Glucose Insulin
only their relative sizes, since a scale factor doesn't
change the correlation coefficient. Consequently we can
say that the relative magnitude of coefficients a0, b 0 and I 2 3 I 2 3
b.3 are small when compared to the other coefficients, Time (hrs.) Time (hrs.)
and their effects can be ignored for purposes of sim- Pattern B
plicity. Considering the relative sizes of the remaining
coefficients, we can further simplify our combinations to
the following: Glucose Insulin

G G 2G
= 60 ll!O
(5)

I 2 3 I 2 3
In replacing the coefficients in (4) with the coeffi-
cients in ( 5 ) , very little is lost in the correlation be- Time (hrs.) Time (hrs.)

tween G and I; the correlation drops from .62 to .58. Pattern C

In view of the positive linear correlation between FIG. 7. Three idealized examples demonstrating the character-
glucose (G) and insulin ( I ) , equation 5 defines the istics of the relationship between patterns of glucose
and insulin responses defined by the use of canonical
physiological relationship between glucose and insulin correlations.

566 DIABETES, VOL. 17, NO. 9

 GERALD REAVEN, M.D., AND RUPERT MILLER, PH.D.
ondly, small positive or negative values of G (situations
in which blood glucose at two hours is relatively high)
will be related to small positive or negative values of
I (figure 7, pattern B). This states that a slower rate of
fall in glucose concentration between one and two hours
is associated with a constant insulin level, and pattern
B resembles the relationship observed between these two
variables in patients with either impaired tolerance or
with mild diabetes. Finally, when glucose concentration
falls at an even slower rate, large negative values for G
exist, and these will be associated with large negative
values for I (figure 7, pattern C). This relationship is
a good representation of the situation in patients with
severe diabetes. In this instance, a sluggishly falling
glucose concentration curve is associated with a con-
tinuing rise in insulin concentration.
It must be emphasized that this linear relationship
is dependent upon the pattern of change, and not on
the absolute magnitude of plasma levels of glucose and
insulin. Furthermore, the linear relationship that emerges
does not identify which of the two variables is the
determinant of the other. However, it seems unlikely
that the pattern of insulin response determines the glu-
cose response, i.e., there is no reason why (pattern C)
a continuous rise in insulin concentration should result
in a slow fall in glucose concentration. On the other
hand, it does seem reasonable that prolonged hyper-
glycemia might elicit a continuous insulin response.
Consequently, it is suggested that the pattern of glucose
response determines the pattern of insulin response, and
that the patterns of change result in a strong relation-
ship between glucose and insulin responses. However,
it is clear that these two variables are continuously
interacting with each other, and what appears to be
the simplest relationship needn't be the only one, nor
even the most correct one.
In order to evaluate further the effect of obesity, the
ponderal index ( = height in inches /^weight in
pounds) was included as a variable in the canonical
correlation analysis. This provides a further check on
whether obesity is related to glucose or insulin levels.
The result was no change in the maximal correlation
coefficient whether the ponderal index was included
with the glucose values or the insulin values. The cor-
relation coefficient remained at .62 (there was a slight
increase in the third decimal) and the coefficients in
(4) remained essentially undisturbed. In other words,
obesity (as measured by the ponderal index) has no
relation to either glucose or insulin levels.
A canonical correlation analysis on two sets of four
SEPTEMBER, 1 9 6 8
variables produces three other correlations besides the
maximal correlation .62. These correspond to linear
combinations other than (4) which are independent
of (4). The three other correlations in this case were
.46, .33, and .015, the first of which has P < .01. How-
ever, the coefficients in the linear combinations re-
lated to these correlations had no conceivable physio-
logical interpretation.
DISCUSSION
Two general relationships between plasma glucose
and insulin responses to an oral glucose load have been
defined, quantified, and statistically validated. However,
the biological validation of these relationships requires
that certain criteria be satisfied. In the first place, it is
essential that the patient population from which these
relationships were derived be a representative one. The
relatively large size of the study group offers some
assurance in this regard. Furthermore, the general re-
sults of the glucose tolerance tests, which represent the
basis for all subsequent analyses, were very similar to
those recently reported by Berson and Yalow6 from an
even larger patient population. Consequently, there ap-
pears to be some support for the notion that the basic
data were derived from a representative population.
Secondly, since we are trying to establish a relation-
ship between only two variables, glucose and insulin
responses, the possible effects of other factors on these
two variables must be excluded. In this regard, our
inability to demonstrate a significant effect of obesity
on the magnitude of insulin response is in marked
contrast to the recent suggestion of Karam and associ-
ates9 that only obese diabetics have exaggerated insulin
responses. However, these investigators did not take into
account the effect of severity of diabetes on insulin
response, and their nonobese patients with diabetes were
considerably more hyperglycemic than their obese dia-
betic group. Our results are similar to those of Berson
and Yalow6 and of Perley and Kipnis10 in that they
indicate that nonobese patients with diabetes may have
an insulin response to an oral glucose load which is
greater than that seen in normoglycemic subjects. How-
ever, Perley and Kipnis found that obese patients, when
matched for glucose levels, had significantly greater in-
sulin responses than did nonobese individuals. Although
obesity did seem to result in somewhat increased in-
sulin response in our patient population, the differences
were not statistically significant. It is possible that this
discrepancy results from our exclusion of the extremely
obese patient. In any case, within our patient popula-
567
 PLASMA GLUCOSE AND INSULIN RESPONSES IN MAN
tion, neither obesity, nor any other factor, had a signifi-
cant effect on either the glucose or insulin response to
an oral glucose load. The lack of any apparent influences
on these responses led us to feel that we could justi-
fiably isolate the two variables of plasma glucose and
insulin response and consider their relationship within
the entire patient population.
When this was done, a strong linear relationship be-
tween patterns of glucose and insulin response emerged
which indicated that these two variables were associ-
ated, and suggested that the pattern of glucose response
determined the pattern of insulin response. This rela-
tionship was independent of the degree of glucose in-
tolerance and of the quantitative nature of the glucose
and insulin responses. If absolute concentrations of
plasma glucose and insulin are considered to be impor-
tant physiological characteristics, the relationship be-
tween the magnitude of the glucose and insulin re-
sponses must also be examined. When this was done,
the relationship observed had a "horseshoe" shape. A
similar relationship has recently been observed in an
entirely different patient population.11 Patients with the
best glucose tolerance had the lowest insulin levels.
As glucose tolerance deteriorated, higher insulin con-
centrations were associated with higher glucose con-
centrations, suggesting that glucose removal was im-
paired in these patients; and that greater amounts of
insulin were called forth in an effort to maintain glu-
cose homeostasis. With further impairment of glucose
removal, hyperglycemia did not appear capable of elicit-
ing a significant increase in absolute insulin response.
Finally, in patients with the most severe hyperglycemia,
insulin concentrations were absolutely low, suggesting
a primary impairment of insulin secretion. The simplest,
but not exclusive, interpretation of this complex rela-
tionship is that hyperglycemia might be related to at
least two causes, e.g., decreased insulin secretion and
impaired biologic activity of immunoreactive insulin.
Similar conclusions have recently been reached by Ber-
son and Yalow.6 Meaningful attempts to assess the rela-
tive importance of these two factors in regulation of
blood glucose homeostasis are more likely to result from
study of glucose and insulin responses under steady
state conditions. Such investigations are currently un-
derway in our laboratory.
Another way to quantitate the insulin response to a
glucose load is to relate the insulin concentration at any
given time to the concomitantly existing glucose con-
centration. This relationship can be thought of as an
"insulinogenic index," and in two recent publica-
568
tions10-12 this approach has been used to compare the
insulin response of diabetic patients with that of nor-
mal subjects. Seltzer et al.12 have determined their "in-
sulinogenic index" by dividing the increment of insulin
concentration over fasting by the increment in glucose
concentration ( A I / A G ) . Perley and Kipnis10 simply
divide the insulin concentration by the glucose concen-
tration ( I / G ) . In both studies patients with diabetes
had a lower mean "insulinogenic index," and the authors
conclude that these patients did not put out "appropri-
ate" amounts of insulin in response to the glycemic
stimulus. Using the criteria of Seltzer and associates,
the "insulinogenic index" of our patients fell directly
in proportion to their degree of hyperglycemia. On the
other hand, if we used the method of Perley and
Kipnis, patients with impaired tolerance had a mean
"insulinogenic index" equal to or greater than that of
normal subjects. However, in spite of the "appropriate-
ness" of their insulin response, they had significantly
higher glucose concentrations. Therefore, depending upon
which "index" we used, different conclusions as to
the relationships between glucose and insulin responses
emerged. Furthermore, although attempts to relate in-
sulin response to glucose concentration may seem rea-
sonable, implicit in these particular transformations of
the basic data are many assumptions concerning the
physiological relationship between these two variables
for which no evidence is presented. Finally, the use of
these transformations tends to result in a circular argu-
ment. Diabetic patients are hyperglycemic by definition.
The degree to which they are hyperglycemic appears in
the denominator of the equations, and a priori makes
very likely the thesis that patients with diabetes (hyper-
glycemia) will have a lower "insulinogenic index." For
example, the patients we studied with mild diabetes
would have to achieve absolute mean insulin concen-
trations greater than 265 fiU./pet ml. and 379 ju,U./per
ml. at the one and two-hour intervals in order not to
be considered insulin deficient by the method of Seltzer
et al.
Our concern about the use of "insulinogenic indices"
does not imply that the two relationships between glu-
cose and insulin responses we described are any more
useful. We can make no claim as to the biological
significance of these relationships, nor are they neces-
sarily relevant to the question of whether or not all
hyperglycemia is related to insulin deficiency. Further-
more, it is unlikely that they are the only possible re-
lationships that exist between glucose and insulin re-
sponses to glucose loads, and they are certainly limited
DIABETES, VOL. 17, NO. 9
 GERALD REAVEN, M.D., AND RUPERT MILLER, PH.D.
by the lack of early measurements. However, although
they may appear to be self evident, we have presented
evidence in an effort to document the fact that they are
statistically valid interpretations of the experimental
results. It is our opinion that further attempts to define
and validate other possible relationships might prove
more useful in the long run than comparisons of vari-
ous groups of patients on the basis of arbitrary trans-
formations of experimental results.
ACKNOWLEDGMENT
This study was supported in part by U.S. Public
Health Service Research Grant HE 08506 from the
National Institutes of Health, FR-70 from the General
Clinical Research Centers Branch, Division of Research
Facilities and Resources, and a research grant from
Charles Pfizer and Co., Inc.
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