Hyperglycemia explains the development of late diabetic complications in patients with diabetes type 1 and type 2 only partially. Most therapeutic efforts relying on intensive glucose control failed to decrease the absolute risk for complications by more than 10%, especially in patients with diabetes type 2. Therefore, alternative pathophysiological pathways have to be examined, in order to develop more individualized treatment options for patients with diabetes in the future. One such pathway might be the metabolism of dicarbonyls, among them methylglyoxal and the accumulation of advanced glycation end products. Here we review currently available epidemiological data on dicarbonyls and AGEs in association with human diabetes type 1 and type 2.

Energy production is inevitably linked to the generation of toxic metabolites, such as reactive oxygen and carbonyl species, known as major contributors to ageing and degenerative diseases. It remains unclear how cells can adapt to elevated energy flux accompanied by accumulating harmful by-products without taking any damage. Therefore, effects of a sudden rise in glucose concentrations were studied in yeast cells. This revealed a feedback mechanism initiated by the reactive dicarbonyl methylglyoxal, which is formed non-enzymatically during glycolysis. Low levels of methylglyoxal activate a multi-layered defence response against toxic metabolites composed of prevention, detoxification and damage remission. The latter is mediated by the protein quality control system and requires inducible Hsp70 and Btn2, the aggregase that sequesters misfolded proteins. This glycohormetic mechanism enables cells to pre-adapt to rising energy flux and directly links metabolic to proteotoxic stress. Further data suggest the existence of a similar response in endothelial cells.

Patients with type 2 diabetes (T2DM) have a two- to three-fold increased risk for Alzheimer's disease (AD), the most common form of dementia. Vascular complications might explain partially the increased incidence of neurodegeneration in patients with T2DM. Alternatively, neuronal resistance for insulin/insulin-like growth factor-1 (IGF- 1) might represent a molecular link between T2DM and AD, characterizing AD as "brain-type diabetes". According to this hypothesis, brains from AD patients showed substantially downregulated expression of the Insulin receptor (IR), the IGF-1 receptor (IGF-1R), and the insulin receptor substrate (IRS) proteins. Similar changes in insulin/IGF-1 signaling (IIS) have been described in animals fed a high fat diet and human T2DM, suggesting that decreased IIS might be involved in the pathogenesis of both T2DM and AD. In contrast, type 2 diabetic patients suffering from AD accumulate less β-amyloid (Aβ) compared to non-diabetic AD patients raising the question, whether the changes in IIS are cause, consequence, or compensatory counterregulation to neurodegeneration. Recent data in C. elegans showed that reducing IIS decreases Aβ toxicity. This effect is accomplished via two transcription factors downstream of IIS, DAF-16 and HSF- 1: The first detoxification path leads to degradation of the toxic misassemblies and is mediated via HSF-1. The second mechanism mediates the formation of low toxic, high molecular weight aggregates from highly toxic small molecular weight aggregates regulated by DAF-16 suggesting that Insulin/IGF-1 transmitted signals influence Aβ proteotoxicity. The current review discusses possible implications of recent findings in humans and model organisms for the understanding and possible therapeutic approaches of diabetes associated dementia.

In brains from patients with Alzheimer's disease (AD), expression of insulin receptor (IR), insulin-like growth factor-1 receptor (IGF-1R), and insulin receptor substrate proteins is downregulated. A key step in the pathogenesis of AD is the accumulation of amyloid precursor protein (APP) cleavage products, β-amyloid (Aβ)

Recent data suggest that brains of patients with Alzheimer's disease (AD) are insulin and insulin-like growth factor-1 (IGF-1) resistant. So far, there have been two different approaches to investigate possible therapeutic implications of modulating cerebral insulin/IGF-1 signaling (IIS) in AD. One approach is peripheral or intranasal administration of insulin or IGF-1. Intranasal and peripheral insulin administration has been shown to improve memory in patients with AD. Additionally, peripheral IGF-1 administration resulted in decreased amyloid-beta (Aβ) levels in brains of AD mouse models accompanied by elevated Aβ levels in the cerebrospinal fluid (CSF). Insulin and IGF-1 regulate multicargotransporters influencing trafficking of several molecules including Aβ from the brain to the blood as well as to the CSF and possibly vice versa. Furthermore, insulin and related peptides regulate neurovascular coupling changing regional blood flow. Thus, positive effects of peripheral insulin/IGF-1 administration on AD pathology might be due to changes in the blood-brain-barrier (BBB) and/or in the transport between the CSF/blood and the brain. Clinical and experimental data suggest that increased serum insulin and IGF-1 levels do not necessarily correlate with an upregulation of neuronal insulin/IGF-1 receptor signaling. Therefore, the second approach in investigating the role of neuronal IIS for the pathogenesis of AD analyzes knockout mice lacking components of the IIS in AD models. Haploinsufficiency of the IGF- 1 receptor (IGF-1R) (IGF-1R(+/-) mice) as well as neuronal deficiency of the insulin receptor (IR) (nIR(-/-) mice) or IGF-1R (nIGF-1R(-/-) mice) leads to delayed Aβ accumulation when crossed with mouse models for AD. Furthermore, insulin receptor substrate (IRS)-2 knockout mice (IRS-2(-/-) mice) show reduced Aβ levels in an Alzheimer background. These data suggest beneficial effects of decreased neuronal IIS on Alzheimer-pathology and question the therapeutic outcome of long-term administration of insulin or IGF-1 in patients with AD. Whether the observed phenomenon of cerebral insulin and IGF-1 resistance even at an early stage of Alzheimer's disease is cause, consequence or possibly counter-regulation to AD-pathology needs further investigation and should lead to critical discussions. The current review discusses the pros and cons of targeting insulin/IGF-1 signaling as therapeutic approach for AD.