Wednesday, October 12, 2016

‘L’Italiana in Algeri,’

Review: ‘L’Italiana in Algeri,’ a Comedy With Coloratura and Pasta

By CORINNA da FONSECA-WOLLHEIM



From left, Ildar Abdrazakov, René Barbera and Marianna Pizzolato in the opera “L’Italiana In Algeri,” at the Metropolitan Opera. Sara Krulwich/The New York Times

There came a point during Tuesday’s performance of Rossini’s “L’Italiana in Algeri” at the Metropolitan Opera when I vowed I would stop laughing at the sophomoric spectacle in front of me.
I think it was when the chorus of masked, rubber-bellied eunuchs started whipping a row of twerking harem girls, in sync with the music. I had already cringed at the extravagant black-tufted wigs that covered the chest and back of the bass Ildar Abdrazakov in a scene showing his character, the Algerian bey Mustafà, in his bath. And I had stared, with alarmed bemusement, at Mr. Abdrazakov’s soft-shoeing, air-guitar-playing, floor-pounding performance, which seemed to grow more unhinged as the evening wore on.
But my resolution came to naught. Jean-Pierre Ponnelle’s 1973 staging of this battle of the sexes, framed by Rossini and his librettist as an abduction drama, may be the silliest and most stereotype-laden production in the Met’s repertory. But it’s still very funny — irresistibly so, as I found out.
This revival is conducted by James Levine, making his first appearance in his new role as music director emeritus. He conducted this effervescent music with a steady hand, sure pacing and an eye for instances of opulent instrumental color, which are tucked in among the otherwise briskly efficient score.

By METROPOLITAN OPERA 1:34
Excerpt: 'L'Italiana in Algeri'

Excerpt: 'L'Italiana in Algeri'

James Levine conducts the Metropolitan Opera Orchestra in the Overture of Rossini’s opera.
 By METROPOLITAN OPERA on October 5, 2016. .

The opera’s female lead is Isabella, a feisty Italian captive who uses charm, wit and mountains of pasta to spring free her lover, Lindoro, who was taken into slavery some months earlier. The vocally challenging Isabella — requiring nimble coloratura and a certain earthiness in the form of a grounded low register — had been planned for the American mezzo-soprano Elizabeth DeShong. But illness forced her to withdraw, leaving the Italian mezzo Marianna Pizzolato to take over, in her Met debut.
The froufrou production, with its over-the-top performances, proved a fine foil for Ms. Pizzolato’s matronly, no-nonsense presence and her dark-toned, coolly assured singing and crystal-clear diction. Marshaling all the matter-of-fact bossiness of an Italian mama, she disarmed the vainglorious Mustafà.
René Barbera, also in his first Met appearance, brought a light, urbane tenor to the role of Lindoro, the somewhat colorless object of Isabella’s affections and intrigue. The suave baritone Nicola Alaimo was almost miscast as the hapless Taddeo, singing with elegance and richness of tone.
The sunny-voiced soprano Ying Fang perfectly inhabited the part of Elvira, Mustafà’s jilted, ditsy wife. The vibrant Canadian-Tunisian mezzo Rihab Chaieb, as Elvira’s slave, Zulma, and the solid baritone Dwayne Croft, as the put-upon pirate captain Haly, offered strong support.
But the evening belonged, for better or worse, to Mr. Abdrazakov. His eye-rolling, pantomiming performance sometimes grew exhausting, but vocally, he remained focused and resonant in every angle and turn of the sometimes preposterous coloratura passages Rossini assigned to him.
At the end of the opera, his character collapses into gluttonous silence. When Mustafà realizes that in the meantime, the Italians have made their escape, there is little left for him to do except throw fistfuls of spaghetti after them.
“L’Italiana in Algeri” runs through Oct. 29 at the Metropolitan Opera, Lincoln Center; metopera.org.
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Opera Review: Rossini’s ‘L’Italiana in Algeri’ at the Metropolitan Opera

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Ildar Abdrazakov as Mustafà in Rossini's L'Italiana in Algeri. Photo by Ken Howard/Metropolitan Opera.
Ildar Abdrazakov as Mustafà in Rossini’s “L’Italiana in Algeri.” Photo by Ken Howard/Metropolitan Opera.
This second week of the Metropolitan Opera’s 2016-2017 season brings the welcome returns of Rossini’s “L’Italiana in Algeri” (“The Italian Girl in Algiers”) and James Levine.  A presence for most of the 50 years that the Met has been at Lincoln Center, Music Director Emeritus Levine was rapturously cheered by the near-capacity audience.  In addition to conducting the silly romantic comedy, he oversaw the impressive debuts of mezzo-soprano Marianna Pizzolato as Isabella, the titular Italian Girl, and American tenor René Barbera as her true love Lindoro.
Rossini depicts the ensuing chaos in innovative ways. 
Returning to the repertory after a 12-year absence, the 1973 Jean-Pierre Ponnelle production doesn’t look dated.  Ponnelle (1932-1988), an innovative director/designer, never shied from questioning content.  Perhaps if the opera was “The French Girl in Algiers,” he would have.  As Rossini wrote the opera in 1813, “L’Italiana” takes place two decades before the French Occupation of Algeria.  Therefore, the dreamy, pastel painted sets and costumes copied from illustrations by nineteenth-century adventurers and fairy tale illustrators are appropriate.  Still, Rossini did make a political statement about Italian unification, which Isabella expresses in “Pensa alla patria” (“Think of your homeland”), front and center.
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Isabella’s declaration comes after a wild ordeal.  She, along with the love-struck Taddeo (baritone Nicola Alaimo), are captured after their ship is wrecked on the orders of the Bey Mustafà (bass-baritone Ildar Abdrazakov).  Mustafà isn’t technically interested in treasure, but wants an Italian wife to add to his harem, which includes the loyal Elvira (soprano Ying Fang).  His plan to marry off Elvira to Lindoro (Barbera), another Italian in captivity, so he can marry Isabella is easier to decree than implement…Lindoro is Isabella’s long-lost fiancé!
Rossini depicts the ensuing chaos in innovative ways.  Unlike other Romantic-era composers, his score is never pseudo-Oriental.  The Act 1 finale has each of the main characters expressing their confusion by mimicking clocks ticking.  Lindoro and Taddeo finally dupe Mustafà by initiating him into the Order of Pappatachi, requiring him to “See and not see” – foreshadowing Italian Futurism by a century.
The cast made both excellent singing and stage partners.  Marianna Pizzolato’s Isabella is the smartest, most mature character.  Many of the musical motifs in the “Overture” are sung by Isabella, which Pizzolato did splendidly.  Being her actual “slave,” René Barbera instinctively deferred to her by combining a strong balance of physical comedy, choreography, and the singing of two long arias.  (Unfortunately, a cellphone went off during the first one.)  Even baritone Dwayne Croft, a normally serious artist, let loose as Haly the pirate captain, reveling in chasing Taddeo back and across the stage and being tricked by servants into washing the floor.
The Italian Girl is in the title, but Mustafà is the catalyst.  Ildar Abdrazakov made sure everyone had a good time at his expense.  The only things the Bey is good at is selecting his wardrobe (Doctor Who would envy his fez), dancing, and, of course, singing.  Abdrazakov never stood still and didn’t sacrifice his resonant voice doing so.  A neat acoustics test for aspiring bass-baritones would be if they can yell “Pappatachi,” and then measure it against Abdrazakov’s booming delivery.
Running Time: 3 hours and 15 minutes, including one intermission.
Rossini’s “L’Italiana in Algeri” runs through October 29, 2016 at the Metropolitan Opera.  For more information and tickets, click here.

Rossini’s Comic ‘L’Italiana in Algeri’ at the Met
By   |  
October 8, 2016 AT 7:31 PM

Last Updated: 
October 8, 2016 7:33 pm

Dwayne Croft as Haly and Ildar Abdrazakov as Mustafà in Rossini's L'Italiana in Algeri. Photo by Ken Howard/Metropolitan Opera.
Dwayne Croft as Haly and Ildar Abdrazakov as Mustafà in Rossini's L'Italiana in Algeri. (Howard/Metropolitan Opera)

NEW YORK—The Jean-Pierre Ponnelle production of Rossini’s “L’Italiana in Algeri” (The Italian Girl in Algiers) has been a crowd pleaser at the Metropolitan Opera since 1973. With witty additions by stage director David Kneuss and with music director emeritus James Levine conducting and a fine cast, the opera still delights.
Rossini’s 1813 opera deals with captivity and a rescue, but the resourceful title character is the one who wins freedom for herself and her lover. 
The setting is the seaside palace of the Bey (chieftain) Mustafà in Algiers in the early 19th century. His wife Elvira suspects that her husband’s affection for her has waned and she turns out to be right.
Like many rich and powerful men, he feels he is entitled to trade in his spouse for a newer model, even though he has a harem on the premises to keep him amused. Mustafà decides to marry his wife off to Lindoro, a young Italian man who had been captured by pirates. The ruler orders his henchman Haly to find an attractive Italian woman for him. 
Meanwhile, Lindoro’s lover Isabella is shipwrecked and falls into the clutches of Haly’s band of pirates. The Turks want to sell Isabella’s traveling companion Taddeo into slavery, but he talks them out of it by claiming he is her uncle.
Actually, Taddeo wants Isabella for himself but has not had any success. The pirates decide that Isabella is the right woman for their leader.
Mustafà promises to grant Lindoro his freedom and to allow him to return to Italy if he will take Elvira off Mustafà’s hands. Elvira, in turn, is still in love with her faithless spouse.
The Ponnelle production is old-fashioned in the best sense.
Mustafà is overjoyed when he learns of the captive Italian woman. When the ruler, dubbed “the scourge of women” by his eunuchs, meets Isabella, he is immediately smitten. On her part, she is confident she can outsmart him.
When Isabella is reunited with Lindoro, they have a couple of rocky moments because naturally she thinks he is running off with Elvira.
But the lovers are soon reconciled, and Isabella tells Mustafà that she wants Lindoro to remain as her servant. She also toys with the ruler, making him wait for her and then frustrates him by insisting that Elvira join them for coffee.
Lindoro convinces Mustafà that Isabella desires him but to win her over, he must take part in a ritual in which he eats, drinks, and sleeps while not paying attention to what is going on around him.
The Bey revels in his plate of pasta while the lovers make their getaway.  At the end, Mustafà learns what happened and good naturedly makes peace with Elvira.
The opera begins with a buoyant overture, one of Rossini’s special talents. The cast is up to the musical challenges of Rossini’s music while maintaining a steady stream of laughs.
Portraying Mustafà, Ildar Abdrazakov seems to be having the time of his life as the egotistical womanizer. While the bass has distinguished himself in a wide range of roles at the Met, this one reveals a flair for zany comedy. Some of his funniest moments occur when he isn’t even singing, such as his attempts to fling a bouquet into Isabella’s window. He also excels more demanding singing, as evidenced by his challenging Act I aria, “Gia d’insolito ardore” (An unusual ardor).
Elizabeth DeShong was originally scheduled to play the title character but had to withdraw for health reasons. The Met came up with an excellent replacement, mezzo-soprano Marianna Pizzolato.
The cast is up to the musical challenges of Rossini’s music.
Pizzolato has made a specialty of the part in European opera houses and is at home with the comedy as well the deep feelings that Isabella expresses in her aria “Cruda sorte!” (cruel fate). This is her debut at the Met and she will return in Rossini’s “Guillaume Tell” in November.
Another notable debut was by the romantic lead, American tenor René Barbera, who contributed some of the most impressive singing, with striking high notes.
The effective supporting cast included baritone Nicola Alaimo as Taddeo, soprano Ying Fang as Elvira, mezzo-soprano Rihab Chaieb, as Elvira’s slave, Zulma, and baritone Dwayne Croft, as the pirate captain Haly.
The Ponnelle production is old-fashioned in the best sense. It conveys the composer’s intentions without imposing a visual style that is inconsistent with the content. 
The packed house responded enthusiastically to the performance. Because of the colorful set, visual comedy and bouncy score, “L’Italiana in Algeri” is also a good choice for children, assuming they are old enough to sit through an opera. The Met should consider an abridged version for its Christmas holiday performances.
‘L’Italiana in Algeri’
Metropolitan Opera House 
30 Lincoln Center Plaza
Tickets: 212-362-6000 or MetOpera.org
Running Time: 3 hours, 5 minutes
Closes: Oct. 29
Barry Bassis has been a music, theater, and travel writer for over a decade for various publications.
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[Met Performance] CID:356494
L'Italiana in Algeri {74} Metropolitan Opera House: 10/12/2016., Broadcastlive on Metropolitan Opera Radio Sirius XM channel 74

(Broadcast)

Metropolitan Opera House
October 12, 2016 Broadcast


L'ITALIANA IN ALGERI [74]
Giaochino Rossini-Angello Anelli/Luigi Mosca

Isabella...................Marianna Pizzolato
Lindoro....................René Barbera
Taddeo.....................Nicola Alaimo
Mustafà....................Ildar Abdrazakov
Elvira.....................Angela Mannino
Zulma......................Rihab Chaieb
Haly.......................Dwayne Croft

Harpsichord................Bryan Wagorn

Conductor..................James Levine

Production.................Jean-Pierre Ponnelle
Designer...................Jean-Pierre Ponnelle
Associate Designer.........David Reppa
Stage Director.............David Kneuss

Broadcast live on Metropolitan Opera Radio Sirius XM channel 74


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Tuesday, September 27, 2016

Alzheimer's Disease Is Type 3 Diabetes

. 2008 Nov; 2(6): 1101–1113.
Published online 2008 Nov.
PMCID: PMC2769828

–Evidence Reviewed

Suzanne M. de la Monte, M.D., M.P.H.1,2,3 and Jack R. Wands, M.D.3
Author information ► Copyright and License information ►

Introduction

Alzheimer's disease (AD) can only be diagnosed with certainty by postmortem demonstration of abundant neurofibrillary tangles and neuritic plaques with accompanying accumulation of amyloid precursor protein, amyloid-β (APP-Aβ) deposits in plaques and vessel walls in selected regions of the brain. Dementia-associated structural lesions are caused by neuronal cytoskeletal collapse and accumulation of hyperphosphorylated and polyubiquitinated microtubule-associated proteins, such as tau, resulting in the formation of neurofibrillary tangles, dystrophic neuritis, and neuropil threads.– Progressive loss of fibers and cells and disconnection of synaptic circuitry mediate the cerebral atrophy that worsens over time. The biochemical, molecular, and cellular abnormalities that precede or accompany AD neurodegeneration, including increased activation of prodeath genes and signaling pathways, impaired energy metabolism, mitochondrial dysfunction, chronic oxidative stress, and DNA damage, are virtually stereotypical,– yet they lack a clear etiology. For nearly three decades of relatively intense research on AD, the inability to interlink this constellation of abnormalities under a single primary pathogenic mechanism resulted in the emergence and propagation of various heavily debated theories, each of which focused on how one particular component of AD could trigger a cascade that contributes to the development of all other known abnormalities. However, reevaluation of the older literature revealed that impairments in cerebral glucose utilization and energy metabolism represent very early abnormalities that precede or accompany the initial stages of cognitive impairment– and led us to the concept that impaired insulin signaling has an important role in the pathogenesis of AD and the proposal that AD represents “type 3 diabetes.”
Characteristic features of diabetes mellitus syndromes include impairments in insulin actions and signaling that result in chronic hyperglycemia, irrespective of subtype, etiology, pathogenesis, or insulin availability. Type 1 diabetes mellitus (T1DM) is caused by destruction (usually autoimmune) of pancreatic islet beta cells and attendant insulin deficiency. Type 2 diabetes mellitus (T2DM), the most common form, is caused by insulin resistance in peripheral tissues and is most frequently associated with aging, a family history of diabetes, obesity, and failure to exercise. Individuals with T2DM have hyperglycemia and hyperinsulinemia. Insulin resistance in T2DM is partly mediated by reduced insulin receptor expression, insulin receptor tyrosine kinase activity, insulin receptor substrate (IRS) type 1 expression, and/or phosphatidyl-inositol-3 (PI3) kinase activation in skeletal muscle and adipocytes. Gestational diabetes is pregnancy associated and caused by insulin deficiency and hyperglycemia. Nonalcoholic steatohepatitis (NASH), or metabolic syndrome, is associated with hepatic insulin resistance but overlaps with T2DM.– Type 3 diabetes mellitus (T3DM, discussed later) corresponds to a chronic insulin resistance plus insulin deficiency state that is largely confined to the brain but, like NASH, can overlap with T2DM. We have proposed that T3DM represents a major pathogenic mechanism of AD neurodegeneration.,
Interest in clarifying the roles of T2DM, insulin resistance, and hyperinsulinemia in relation to cognitive impairment, AD-associated neuronal cytoskeletal lesions, or APP-Aβ deposits in the brain began around 2000,,,,– but since around 2005, this field literally exploded with new information and a new concept, i.e., that primary brain insulin resistance and insulin deficiency mediate cognitive impairment and AD.,,– This idea was fueled by evidence that tau gene expression and phosphorylation are regulated through insulin and insulin-like growth factor (IGF) signaling cascades., In addition, research performed in our laboratory demonstrated that many key aspects of the central nervous system (CNS) degeneration that occur in AD can be effectuated by impaired insulin signaling.–
By way of review, insulin and IGF-1 mediate their effects by activating complex intracellular signaling pathways starting with ligand binding to cell surface receptors, followed by autophosphorylation and activation of the intrinsic receptor tyrosine kinases.– Insulin/IGF-1 receptor tyrosine kinases phosphorylate IRS molecules,,– which transmit signals downstream by activating the extracellular signal-related kinase/mitogen-activated protein kinase (ERK/MAPK) and PI3 kinase/Akt pathways, and inhibit glycogen synthase kinase 3β (GSK-3β). Major biological responses to signaling through IRS molecules include increased cell growth; survival, energy metabolism, and cholinergic gene expression; and inhibition of oxidative stress and apoptosis.– These very same signaling pathways are activated in various cell types, tissues, and target organs that express insulin and IGF receptors and therefore are practically universal. Moreover, these pathways are phylogenetically conserved and have critical roles in regulating development, growth, survival, senescence, carcinogenesis, and neurodegeneration.

Potential Roles of Obesity and Type 2 Diabetes Mellitus in Alzheimer's Disease Pathogenesis

There is an ongoing debate about the degree to which T2DM and, more recently, T1DM contribute to AD pathogenesis. This concept has been fueled by the rising prevalence rates of obesity, T2DM, and AD over the past several decades. Moreover, an interrelationship among these entities is suggested by (1) increased risk of developing mild cognitive impairment (MCI), dementia, or AD in individuals with T2DM, or obesity/dyslipidemic disorders; (2) progressive brain insulin resistance and insulin deficiency in AD;,,, (3) cognitive impairment in experimental animal models of T2DM and/or obesity;, (4) AD-type neurodegeneration and cognitive impairment in experimentally induced brain insulin resistance and insulin deficiency;,– (5) improved cognitive performance in experimental models and humans with AD or MCI after treatment with insulin sensitizer agents or intranasal insulin;,– and (6) shared molecular, biochemical, and mechanistic abnormalities in T2DM and AD.,– The urgency of this problem is spotlighted by the estimated 24 million people in the world with dementia and the expectation that, if current trends continue, prevalence rates of AD are likely to double every 20 years in the future. While aging is clearly the strongest risk factor for AD, emerging data suggest that T2DM and dyslipidemic states can contribute substantially to the pathogenesis of AD either directly or as cofactors.
Epidemiologic studies provide convincing evidence for a significant association between T2DM and MCI or dementia and furthermore suggest that T2DM is a significant risk factor for developing AD.,–However, those findings are not without controversy, and in a longitudinal survey, investigators found that although borderline diabetics had a significantly increased risk for future development of diabetes, dementia, or AD, the risk effects were independent rather than linked. What this means is that insulin resistance, i.e., impaired ability to respond to insulin stimulation, can vary among target organs and be present in just one or two organs and not in others, a phenomenon that could explain the lack of complete overlap between T2DM and AD. Correspondingly, the finding that obesity (body mass index [BMI] > 30) without T2DM produces a three-fold increase in risk for subsequently developing AD whereas overweight, but nonobese, subjects (BMI 25–30) experience a two-fold increase in risk for AD calls into question the specific effects of obesity and T2DM versus a yet unknown associated factor in relation to AD pathogenesis.
Mechanistically, the increased risk of dementia in T2DM and obesity could be linked to chronic hyperglycemia, peripheral insulin resistance, oxidative stress, accumulation of advanced glycation end products, increased production of pro-inflammatory cytokines, and/orcerebral microvascular disease. The potential role of cerebral microvascular disease as a complicating, initiating, or accelerating component of AD has been recognized for years. However, a magnetic resonance imaging study demonstrated that older adults with T2DM have a moderately increased risk for developing lacunes and hippocampal atrophy and that the severity of those lesions increases with the duration and progression of T2DM. Another study showed that T2DM and impaired fasting glucose occur significantly more frequently in AD than in non-AD controls. However, since diffuse and neuritic plaques were similarly abundant in T2DM and control brains, and since neurofibrillary tangles, one of the hallmarks and correlates of dementia in AD, were not increased in T2DM, the results suggest that T2DM can enhance progression but may not be sufficient to cause AD. Therefore, what remains unclear is the net contribution of T2DM or obesity to the pathogenesis of AD-type neurodegeneration. To address this question, we utilized an established experimental model of chronic high-fat diet (HFD) feeding of C57BL/6 mice to examine the degree to which obesity/T2DM was sufficient to produce histopathological, molecular, and/or biochemical brain abnormalities of AD-type neurodegeneration, i.e., T3DM.
High-fat diet feeding for 16 weeks doubled mean body weight, caused T2DM, and marginally reduced mean brain weight. Those effects were associated with significantly increased levels of tau, IGF-1 receptor, IRS-1, IRS-4, ubiquitin, glial fibrillary acidic protein (GFAP), and 4-hydroxynonenal and decreased expression of β actin. Importantly, HFD feeding also caused brain insulin resistance manifested by reduced top-level (Bmax) insulin receptor binding and modestly increased brain insulin gene expression. However, HFD fed mouse brains did not exhibit AD histopathology or increases in APP-Aβ or phospho-tau, nor were there impairments in IGF signaling, which typically occurs in AD. In essence, although the chronic obesity with T2DM model exhibited mild brain atrophy with insulin resistance, oxidative stress, and cytoskeleton degradation, the effects were modest compared with AD, and other more robust experimental models of T3DM,, and most of the molecular, biochemical, and histopathological features that typify AD were not present. Therefore, T2DM and obesity may contribute to, i.e., serve as cofactors of AD but by themselves are probably not sufficient to cause AD. Moreover, the findings in the T2DM/obesity model indicate the unlikelihood that brain insulin resistance is sufficient to cause AD and that additional significant abnormalities, such as ongoing DNA damage and mitochondrial dysfunction, are required.

Alzheimer's Disease is Type 3 Diabetes: Evidence from Human Studies

This hypothesis was directly investigated by first examining postmortem cases of advanced AD and determining if the neurodegeneration was associated with significant abnormalities in the expression of genes encoding insulin, IGF-1, and IGF-2 peptides, their receptors, and downstream signaling mechanisms. In that study, we demonstrated advanced AD to be associated with strikingly reduced levels of insulin and IGF-1 polypeptide and receptor genes in the brain (Figure 1). In addition, all the signaling pathways that mediate insulin and IGF-1-stimulated neuronal survival, tau expression, energy metabolism, and mitochondrial function were perturbed in AD. This study carries additional significance because it established that, like all other pancreatic and intestinal polypeptide genes, the insulin gene was also expressed in the adult human brain. Moreover, the results taught us that endogenous brain deficiencies in insulin, IGF-1, IGF-2, and their corresponding receptors, in the absence of T2DM or obesity, could be linked to the most common form of dementia-associated neurodegeneration in the Western hemisphere. Since the abnormalities identified in the brain were quite similar to the effects of T1DM or T2DM (though none of the patients had either of these diseases), including abnormalities in IGFs,– which are important for islet cell function,, we proposed the concept that AD may represent a brain-specific form of diabetes mellitus and coined the term “type 3 diabetes.”
Figure 1.
Impaired insulin and IGF (A, C) receptor and (B, D) polypeptide gene expression in late/end-stage AD (A, B) temporal cortex and (C, D)hippocampus. Gene expression was measured by qRT-PCR using RNA isolated from the temporal cortex or hippocampus from ...
Even before the initial study had been published, it was realized that if brain insulin/IGF resistance and insulin/IGF deficiency were causal in the pathogenesis of AD, the related abnormalities should be detectable in the early stages of disease and possibly worsen as disease progresses. The investigations were extended to examine the brains of patients with different degrees, i.e., Braak stages,, of AD. In that study, we measured the expression of genes encoding insulin, IGF-1, IGF-2 polypeptides, and their corresponding receptors as well as tau and amyloid precursor protein (APP). In addition, we used competitive equilibrium and saturation binding assays to further characterize the degree to which growth factor-transmitted signaling was impaired in the brains with different severities of AD. Finally, the study included the measurement of steady-state levels of adenosine triphosphate and genes regulating acetylcholine homeostasis and energy metabolism.
Using the previously mentioned approaches, we demonstrated progressive AD Braak stage-dependent reductions in insulin, IGF-1, and IGF-2 receptor expression, with more pronounced deterioration in insulin and IGF-1 compared with IGF-2 receptors, and the lowest levels of gene expression in brains with AD Braak Stage 6 (Figure 2). Therefore, loss of insulin and IGF-1 receptor-bearing neurons begins early and progresses with disease such that, in the advanced stages, the deficits are severe and global. These results provided further evidence that the abnormalities in AD are not restricted to insulin signaling pathways, as they also involve IGF-1 and IGF-2 stimulated mechanisms. Analysis of growth-factor polypeptide genes also revealed AD Braak stage-dependent impairments in insulin, IGF-1, and IGF-2 polypeptide expression, corresponding with progressive trophic factor withdrawal (Figure 2). Again, the results support the hypothesis that abnormalities in insulin and IGF signaling mechanisms begin early in the course of AD and are therefore likely have an important role in its pathogenesis.
Figure 2.
Brain insulin and IGF deficiency and resistance increase with progression of AD. Postmortem histopathological studies categorized the brains as having normal aging (Braak 0–1), or mild (Braak 2–3), moderate to severe (Braak 4–5), ...
The eventual paucity of local growth-factor gene expression could substantially impair growth-factor signaling and produce a state of growth-factor withdrawal, which is a well-established mechanism of neuronal death. Therefore, to complement the molecular data, we performed competitive equilibrium and saturation binding assays to determine if reduced levels of growth factor receptor expression were associated with and perhaps mediated by impaired ligand-receptor binding as occurs with insulin/IGF resistance. Those investigations demonstrated progressive declines in equilibrium (Figure 2) and top-level binding (Bmax) to the insulin, IGF-1, and IGF-2 receptors but either unchanged or increased binding affinity, suggesting that impaired insulin/IGF actions in AD brains were mediated by decreased polypeptide and receptor gene expression due to cell loss.
Through a series of in vitro and in vivo experiments performed by several groups, including our own, we have been able to draw the conclusion that neuronal and oligodendroglial cell survival and function are integrally related to the integrity of insulin and IGF signaling mechanisms in the brain.,,,,,,Similarly, impairments in insulin/IGF signaling lead to deficits in energy metabolism with attendant increased oxidative stress, mitochondrial dysfunction, proinflammatory cytokine activation, and APP expression.,,, Correspondingly, the reduced expression of neuronal and oligodendroglial specific genes and the increased expression of astrocytic and microglial inflammatory genes in AD were attributed to progressive brain insulin/IGF deficiency and resistance. Although this point requires the generation of experimental models to demonstrate proof of principle, the finding that microglial, astrocytic, and APP mRNA levels are all increased in the early stages of neurodegeneration supports the inflammatory hypothesis of AD. Previous studies demonstrated that microglial activation promotes APP-Aβ accumulation– and that APP gene expression and cleavage increase with oxidative stress. Therefore, the mechanism we propose is that impaired insulin/ IGF signaling leads to increased oxidative stress and mitochondrial dysfunction,,, which induces APP gene expression and cleavage. The attendant APP-Aβ accumulations cause local neurotoxicity– and further increase in oxidative stress-induced APP expression and APP-Aβ deposition.
A critical goal in these investigations was to draw connections between brain insulin/IGF deficiency and resistance and the major dementia-associated structural and biochemical abnormalities in AD. In this regard, the postmortem studies demonstrated that the Braak stage-associated declines in tau mRNA paralleled the progressive reductions in insulin and IGF-1 receptor expression in AD. In addition, the studies demonstrated AD Braak stage-associated declines in choline acetyltransferase (ChAT) expression with reduced colocalization of ChAT with insulin or IGF-1 receptor immunoreactivity in cortical neurons. These results correspond with experimental data demonstrating that neuronal tau and ChAT gene expression are regulated by IGF-1 and insulin stimulation. Therefore, brain insulin and IGF deficiency and resistance could account for the cytoskeletal collapse, neurite retraction, synaptic disconnection, loss of neuronal plasticity, and deficiencies in acetylcholine production, all of which correlate with cognitive decline and dementia in AD. Altogether, the studies utilizing postmortem human brain tissue provide solid evidence that AD is associated with fundamental abnormalities in insulin/IGF signaling mechanisms that are highly correlated with development and progression of structural, molecular, and biochemical lesions that correlate with dementia. Although the abnormalities noted in AD share features in common with T1MD and T2MD, they are nonetheless distinguished by the dual presence of trophic factor deficiencies and trophic factor receptor resistance, ergo the term “type 3 diabetes.”

Alzheimer's Disease Is Type 3 Diabetes: Experimental Animal Model Results

The human postmortem brain studies linked many of the characteristic molecular and pathological features of AD to the reduced expression of the insulin and IGF genes and their corresponding receptors. However, without direct experimentation that generates cause–effect data, conclusions drawn from human studies would remain correlative rather than mechanistic. Consequently, we utilized experimental models to demonstrate that diabetes mellitus-type molecular and biochemical abnormalities could be produced in CNS neurons and brain by exposure to streptozotocin (STZ). Streptozotocin is 2-Deoxy-2{[methyl-nitrosoamino)carbonyl]amino}D-glucopyranose, i.e., a nitrosamide methylnitrosourea linked to the C2 position of D glucose. Once metabolized, the N nitrosoureido is liberated and causes DNA damage through generation of reactive oxygen species such as superoxide, hydrogen peroxide, and nitric oxide.,Streptozotocin causes diabetes because it is taken up by insulin-producing cells, such as beta cells, in pancreatic islets.
We treated rats with a single intracerebral injection of STZ (ic-STZ) and allowed the rats to grow older for 2 to 8 weeks. The rats were subjected to Morris water maze tests of spatial learning and memory, and their brains were examined for histopathological, biochemical, and molecular indices of AD-type neurodegeneration.
Although a similar model had been generated much earlier by other investigators,– and it was noted that the ic-STZ treatments reduced cerebral glucose utilization and oxidative metabolism, it inhibited insulin receptor function, and it caused progressive deficits in learning, memory, cognitive behavior, and cerebral energy balance,, efforts were not made to connect these effects of ic-STZ to AD by characterizing the neuropathology, molecular pathology, abnormalities in genes expression pertinent to insulin and IGF-1 signaling in brain or by evaluating the integrity of the pancreas. Our goal in generating the model was to demonstrate that AD-type neurodegeneration with features of T3DM could be produced in the absence of either T1DM or T2DM.
The ic-STZ-injected rats did not have elevated blood glucose or insulin levels, and pancreatic architecture and insulin immunoreactivity were similar to control, yet their brains were atrophied and had striking evidence of neurodegeneration with cell loss, gliosis, and increased immunoreactivity for p53, activated GSK-3β, phospho-tau, ubiquitin, and APP-Aβ., Moreover, quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) studies demonstrated that the ic-STZ-treated brains had significantly reduced expression of genes corresponding to neurons (Hu), oligodendroglia [myelin-associated glycoprotein-1 (MAG-1)], and ChAT and to increased expression of genes encoding GFAP, microglia-specific proteins [allograft inflammatory factor-1 (AiF-1)]), acetylcholinesterase (AChE), tau, and APP., Increased p53 and decreased Hu and MAG-1 expression in ic-STZ-treated brains suggest that neuronal and oligodendroglial cell loss and cerebral atrophy were mediated by apoptosis. These findings correspond well with previous studies demonstrating increased expression of various proapoptosis molecules, including p53,, colocalization of increased p53 immunoreactivity in neurons and white matter glia, and reduced levels of Hu and MAG-1 mRNA in human brains with AD. Loss of oligodendroglia could contribute to the early white matter degeneration and synaptic disconnection–in AD.
The previously mentioned adverse effects of ic-STZ were associated with reduced expression of genes encoding insulin, IGF-2, insulin receptor, IGF-1 receptor, and IRS-1 and reduced ligand binding to the insulin and IGF-2 receptors (Figure 3). Note that most of these effects were also detected in brains with sporadic AD and were found to increase with disease progression. The reduced levels of IRS-1 mRNA observed in both AD and rats treated with ic-STZ were reminiscent of the murine IRS-1 and insulin receptor knock-out models, which exhibit reduced brain and body weights due to impaired insulin stimulated growth and survival signaling.,, The combined effects of reduced insulin/IGF polypeptide gene expression, receptor expression, receptor binding, and IRS expression all point toward failure of insulin/IGF signaling mechanisms in the brain as a major consequence of ic-STZ treatment. Importantly, many molecular abnormalities that characteristically occur in AD and were produced by ic-STZ, including increased GSK-3β activation, increased tau phosphorylation, and decreased neuronal survival, could be mediated by downstream effects of impaired insulin and IGF signaling in the CNS. Again, similar results have been reported by other investigators using this experimental model of neurodegeneration.– Therefore, the ic-STZ experimental animal model recapitulates many of the characteristic features of AD-type neurodegeneration/T3DM.
Figure 3.
Effects of intracerebral ic-STZ treatment on CNS expression of insulin and IGF (A) genes and (B) receptors and (C) ligand binding to the insulin, IGF-1, or IGF-2 receptors in temporal lobe tissue. Rat pups were given 50 mg/kg ic-STZ or vehicle and sacrificed ...
Corresponding with the findings in AD, the ic-STZ-treated brains had increased levels of activated GSK-3β, phospho-tau, ubiquitin, APP and APP-Aβ and decreased levels of tau protein. These results are consistent with previous studies demonstrating that tau is regulated by insulin/IGF-1 stimulation, and that tau phosphorylation and ubiquitination increase with oxidative stress and activation of GSK-3β.Similarly, APP mRNA increases with oxidative stress and is a feature of sporadic AD., Increased APP gene expression could account for APP-Aβ accumulation in AD and ic-STZ-treated brains. Potential sources of oxidative stress in AD and the ic-STZ model include (1) mitochondrial dysfunction;,, (2) microglial cell activation with increased cytokine release; and (3) impaired insulin/IGF signaling through PI3 kinaseAkt, leading to increased levels of GSK-3β activity.
A crucial step was to determine whether ic-STZ could cause disturbances in acetylcholine homeostasis and cognitive impairment as they occur in AD. QRT-PCR and immunohistochemistry detected reduced levels of ChAT and increased levels of AChE mRNA and protein in icSTZ-treated brains relative to control brains. Note that energy metabolism leads to production of Acetyl-CoA, which is needed to make acetylcholine. Since the ChAT gene is responsive to insulin and IGF-1 stimulation, deficits in insulin/IGF signaling and energy metabolism push in the direction of cholinergic deficiency mediated by impaired energy metabolism and decreased expression of ChAT, which are key features in AD. In addition, increased levels of AChE expression in the ic-STZ brains could result in increased degradation of acetylcholine, thereby exacerbating the acetylcholine deficits caused by reduced ChAT expression. The significance of these results is highlighted by the prominent learning and memory deficits detected in ic-STZ-treated rats.,

Type 3 Diabetes May Be Treatable, Preventable, or Curable with Antidiabetes Drugs

The findings that (1) pronounced insulin/IGF deficiency and resistance develop early in the course of AD; (2) insulin/IGF signaling abnormalities progress with severity of neurodegeneration;, and (3) an experimental animal model with features closely mimicking the molecular, biochemical, and neuroanatomical pathologies of AD could be generated by intracerebral delivery of a drug that causes T1DM or T2DM led us to test the hypothesis that AD-type neurodegeneration and cognitive could be reduced or prevented by early treatment with insulin-sensitizer antidiabetes agents such as peroxisome proliferator-activated receptor (PPAR) agonists. Peroxisome proliferator-activated receptor agonists function at the level of the nucleus to activate insulin-responsive genes and signaling mechanisms. PPAR-α, PPAR-δ, and PPAR-γ are all expressed in adult human brains, including AD, but PPAR-δ is the most abundant of the three isoforms. The experimental design involved treating rats with ic-STZ, followed by a single intraperitoneal injection of saline, a PPAR-α (GW7647; 25 µg/kg), PPAR-δ (L-160,043; 2 µg/kg), or PPAR-γ (F-L-Leu; 20 µg/kg) activator (CalBiochem, Carlsbad, CA). The doses used were considerably lower than those routinely given to treat T2DM. The major effects of the PPAR agonist treatments were to prevent brain atrophy, preserve insulin and IGF-2 receptor bearing CNS neurons, and particularly with regard to the PPAR-δ agonist, prevent ic-STZ-induced deficits in learning and memory. Since the ic-STZ-mediated losses of insulin and IGF-expressing cells were not prevented by the PPAR agonist treatments, the PPAR agonists probably functioned by preserving insulin and IGF responsive (receptor-bearing) cells, including neurons and oligodendroglia. In support of this concept was finding that insulin receptor expression and binding were increased by the PPAR agonist treatments (Figure 4). Peroxisome proliferator-activated receptor agonist mediated preservation of insulin/IGF responsive neurons was associated with increased expression of ChAT, which has an important role in cognition, as cholinergic neuron deficits are a fundamental feature of AD.– Importantly, the PPAR-δ agonist mediated increases in insulin binding, and ChAT were associated with significant improvements in learning and spatial memory tasks as demonstrated using Morris water maze tests (Figure 5). These effects of the PPAR agonist treatments are consistent with the facts that ChAT expression is regulated by insulin/IGF, and insulin/IGF resistance mediates cognitive impairment in AD. The PPAR-mediated increases in MAG-1 expression, corresponding to oligodendroglia, were of particular interest because previous research demonstrated that one of the earliest AD lesions was white matter atrophy and degeneration with loss of oligodendroglial cells. Within the context of the present discussion, white matter atrophy in AD can now be interpreted as a manifestation of CNS insulin/IGF resistance since oligodendroglia require intact insulin/IGF signaling mechanisms for survival and function, including myelin synthesis., Besides preserving insulin and IGF receptor-bearing CNS cells and signaling mechanisms germane to survival, energy metabolism, and neurotransmitter functions, the PPAR agonists rescued the ic-STZ model by lowering critical AD-associated indices of oxidative stress, including microglial and astrocyte activation, p53, nitric oxide synthase and nicotinamide adenine dinucleotide phosphate (NADPH) oxidase gene expression, lipid peroxidation, DNA damage, APP expression, and tau phosphorylation.6,28,29,91,92,125,126
Figure 4.
Treatment with PPAR agonists restores brain insulin receptor binding in ic-STZ-treated rats. Long Evans rat pups were treated with 50 mg/kg ic-STZ or vehicle and sacrificed 30 days later to examine brains for insulin and IGF polypeptide and receptor ...
Figure 5.
Peroxisome proliferator-activated receptor-δ agonist treatment preserves visual-spatial learning and memory in ic-STZ-treated rats. Long Evans rat pups were treated with 50 mg/kg ic-STZ or vehicle, followed by a single intraperitoneal injection ...

Conclusions

Altogether, the results from these studies provide strong evidence in support of the hypothesis that AD represents a form of diabetes mellitus that selectively afflicts the brain. Positive data stemmed from (1) direct analysis of postmortem human brains with documented AD; (2) an experimental animal model in which brain diabetes with cognitive impairment and molecular and pathological features that mimic AD was produced by intracerebral administration of a drug that is commonly used to produce T1DM or T2DM; and (3) a study showing that PPAR agonists, which are used to treat T2DM, prevent many of the AD-associated neurodegenerative effects of ic-STZ. The data are supported by abundant in vitro experiments that demonstrated essentially the same or similar effects of STZ or oxidative stress treatments of neuronal cells. The human and experimental animal model studies also showed that CNS impairments in insulin/IGF signaling mechanisms can occur in the absence of T1DM or T2DM. Finally, we demonstrated that although obesity with T2DM causes brain insulin resistance with some features of AD-type neurodegeneration, the effects are relatively modest, not associated with significant histopathological lesions, and lack most of the critical abnormalities that typify AD. Therefore, T2DM was deemed not sufficient to cause AD, although it could possibly serve as a cofactor in its pathogenesis or progression. Altogether, the data provide strong evidence that AD is intrinsically a neuroendocrine disease caused by selective impairments in insulin and IGF signaling mechanisms, including deficiencies in local insulin and IGF production. At the same time, it is essential to recognize that T2DM and T3DM are not solely the end results of insulin/IGF resistance and/or deficiency, because these syndromes are unequivocally accompanied by significant activation of inflammatory mediators, oxidative stress, DNA damage, and mitochondrial dysfunction, which contribute to the degenerative cascade by exacerbating insulin/ IGF resistance. Referring to AD as T3DM is justified, because the fundamental molecular and biochemical abnormalities overlap with T1DM and T2DM rather than mimic the effects of either one. Some of the most relevant data supporting this concept have emerged from clinical studies demonstrating cognitive improvement and/or stabilization of cognitive impairment in subjects with early AD following treatment with intranasal insulin or a PPAR agonist.,,–

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