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ENDOCRINE
SYSTEM
By
Meroka A,
Med BiochemDept,
KEMU
Overview: The Body’s Long-Distance Regulators
Hormones are chemical signals that are secreted into the circulatory
system and communicate regulatory messages within the body.
Hormones reach all parts of the body, but only target cells are
equipped to respond to the same.
Hormones convey information via the bloodstream to target cells
throughout the body.
Classification of Hormones
1. Proteins and Polypeptides, including hormones secreted by the anterior
and posterior pituitary gland, the pancreas (insulin and glucagon), the
parathyroid gland (parathyroid hormone), and many others.
2. Steroids secreted by the adrenal cortex (cortisol and aldosterone), the
ovaries (estrogen and progesterone), the testes (testosterone), and the
placenta (estrogen and progesterone)
3. Derivatives of the aminoacid tyrosine, secreted by the thyroid (thyroxine
and tri-iodothyronine) and the adrenal medullae (epinephrine and
norepinephrine)
Control Pathways and Feedback Loops
• The endocrine systemsecretes hormones that coordinate slower but
longer-acting responses including reproduction, development, energy
metabolism, growth, and behavior
• A common feature is a feedback loop connecting the response to the
initial stimulus
• Negative feedbackregulates many hormonal pathways involvedin
homeostasis
• Signaling by any of these hormones involves three key events:
– Reception
– Signal transduction
– Response
Transportationof Hormones
1, Endocrine: glands or specialized cells release hormones into the circulating
blood that influence the function of cells at another location in the body
2, Neuroendocrine: neurons secrete substances (neurohormones) that reach
the circulating blood and influence the function of cells at another
location of the body.
3. Paracrine, in which cells secret substances that diffuse into the extracellular
fluid and affect neighboring cells.
1. Mechanisms of Hormonal Action
The first step of a hormone’s action is to bind to specific receptors at
the target cell.
Locations for the different types of hormones:
1) On the surface of the cell membrane.
protein, peptide, and catecholamine hormones
2) In the cell cytoplasm.
steroidhormones
3) In the cell nucleus.
thyroid hormones (T3 and T4)
2.Second MessengerMechanisms for Mediating Intracellular
Hormonal Functions
Hydrophilic hormones (proteins, peptides and catecholamine)
--bind the receptors on the membrane,
--activate some enzyme on the membrane,
-- regulate the concentration of some messengers (second messengers) in the cytoplasm.
There are at least three kinds of second messengers: cAMP, Calciumionsand productsof
membrane phospholipidmetabolism.
3.Hormones That Act Mainlyon the Genetic Machineryof the Cell
a) Steroid hormones increase protein synthesis
b) Thyroid hormonesincrease genetranscription in the cellnucleus
SECRETORY
CELL
Hormone
molecule
Signal receptor
VIA
BLOOD
VIA
BLOOD
TARGET
CELL
TARGET
CELL
Signal
transduction
pathway
OR
Cytoplasmic
response
DNA
NUCLEUS
Nuclear
response
Receptor in plasma membrane Receptor in cell nucleus
DNA
NUCLEUS
mRNA
Synthesis of
specific proteins
Signal
transduction
and response
Signal
receptor
Hormone
molecule
SECRETORY
CELL
• Binding of a hormone to its receptor initiates a signal transduction
pathway leading to responses in the cytoplasm or a change in gene
expression
• The same hormonemay have different effects on target cells that have
– Different receptors for the hormone
– Different signal transductionpathways
– Different proteins for carrying out the response
Paracrine Signaling by Local Regulators
• In paracrine signaling, non-hormonal chemical signals called local
regulators elicit responses in nearby target cells
• Types of local regulators:
– Neurotransmitters
– Cytokines and growthfactors
– Prostaglandins help regulate aggregation of platelets, an early step
in formation of blood clots
• The hypothalamus and the pituitary gland control much of the endocrine
system
• Tropic hormones, hormones that regulate endocrine organs
• Tropic hormones are secreted into the blood and transported to the
anterior pituitary
The hypothalamus and pituitary integrate many functions
of the vertebrate endocrine system
Hormones Secreted by the Hypothalamus and Their Effects on
Anterior Pituitary
Corticotropin-releasing hormone (CRH)– Stimulates secretion of ACTH
(adrenocorticotropic hormone)
Gonadotropin-releasing hormone (GnRH) Stimulates secretion of FSH
(follicle-stimulatinghormone) and LH (luteinizing hormone)
Thyrotropin-releasing hormone(TRH)-stimulates secretion of TSH (thyroid-
stimulation hormone)
Melanocyte-stimulating hormone release inhibiting factor (MIF)-inhibits
secretion of MSH(Melanocyte-stimulating hormone)
Melanocyte-stimulatinghormone releasing factor (MRF)-stimulate
secretion of MSH
Growth hormone release inhibitinghormone (GHRIH)or Somatostatin
(SS) – inhibits secretion of growth hormone
Growth hormone-releasing hormone (GHRH)– stimulates growth
hormone secretion
Prolactin-inhibitingfactor (PIF)- inhibits prolactin secretion
Prolactin-releasingfactor (PRF)-stimulates prolactin section
Mammary glands,
uterine muscles
Hypothalamus
Kidney tubules
Oxytocin
HORMONE
TARGET
ADH
Posterior
pituitary
Neurosecretory
cells of the
hypothalamus
Axon
Anterior
pituitary
Neurosecretory cells
of the hypothalamus
Endocrine cells of the
anterior pituitary
Portal vessels
Pituitary hormones
(blue dots)
Pain receptors
in the brain
Endorphin Growth hormone
Bones
Liver
MSH
Melanocytes
Prolactin
Mammary
glands
ACTH
Adrenal
cortex
TSH
Thyroid
Testes or
ovaries
FSH and LH
TARGET
HORMONE
Hypothalamic
releasing
hormones
(red dots)
Tropic Effects Only
FSH, follicle-stimulating hormone
LH, luteinizing hormone
TSH, thyroid-stimulating hormone
ACTH, adrenocorticotropic hormone
Nontropic Effects Only
Prolactin
MSH, melanocyte-stimulating hormone
Endorphin
Nontropic and Tropic Effects
Growth hormone
Posterior Pituitary Hormones
• The two hormones released from the posterior pituitary act directly on
non-endocrine tissues
• Oxytocin induces uterine contractions and milk ejection
• Antidiuretic hormone (ADH) enhances water reabsorption in the kidneys
Estrogen Oxytocin
from
ovaries
fromfetus
and mother’s
posterior pituitary
Induces oxytocin
receptorson uterus
Stimulatesuterus
to contract
Stimulates
placentato make
Prostaglandins
Stimulate more
contractions
of uterus
Positive
feedback
INNER
MEDULLA
OUTER
MEDULLA
CORTEX
Osmolarity of
interstitial
fluid
(mosm/L)
NaCl
Urea
H2O
Active
transport
Passive
transport
300
300
300 100
100
400 200
H2O
H2O
H2O
H2O
H2O
H2O
600 400
900 700
1200
300
400
H2O
600
1200
1200
600
900
300
400
NaCl
NaCl
NaCl
NaCl
NaCl
NaCl
Urea
H2O
Urea
H2O
H2O
H2O
H2O
H2O
Anterior Pituitary Hormones
• The anterior pituitary produces both tropic and non-
tropic hormones
Tropic Hormones
• The four strictly tropic hormones are
– Follicle-stimulating hormone(FSH)
– Luteinizing hormone (LH)
– Thyroid-stimulating hormone (TSH)
– Adrenocorticotropichormone (ACTH)
• Each tropic hormone acts on its target endocrine tissue to stimulate
release of hormone(s) with direct metabolic or developmental effects -
(Release hormones)
Hypothalamus
Anterior pituitary
Control by hypothalamus
Pituitary gonadotropins
in blood
FSH LH
FSH
LH
GnRH
Inhibited by combination of
estrogen and progesterone
Inhibited by low levels of
estrogen
Stimulated by high levels
of estrogen
LH surge triggers
ovulation
FSH and LH stimulate
follicle to grow
Mature
follicle
Growing follicle
Ovarian cycle
Corpus
luteum
Degenerating
corpus luteum
Follicular phase Ovulation Luteal phase
Progesterone and
estrogen secreted
by corpus luteum
Estrogen secreted
by growing follicle in
increasing amounts
Progesterone and estro-
gen promote thickening
of endometrium
Peak causes
LH surge
Ovarian hormones
in blood
Estrogen level
very low
Progesterone
Estrogen
Endometrium
Uterine (menstrual) cycle
Menstrual flow phase Proliferative phase Secretory phase
Days
28
25
20
15
14
10
5
0
Non-tropic Hormones
• Non-tropic hormones produced by the anterior pituitary:
• Prolactin stimulates lactationin mammals but has diverse effects in
different vertebrates
• MSH influences skin pigmentationin some vertebrates and fat
metabolismin mammals
• Endorphins inhibit pain
Parathyroid Hormone and Calcitonin: Control of Blood Calcium
• Two antagonistic hormones, parathyroidhormone (PTH)
and calcitonin, play the major role in calcium (Ca2+)
homeostasis in mammals. Calcitonin stimulates Ca2+
deposition in bones and secretion by kidneys, lowering
blood Ca2+ levels
STIMULUS:
Rising blood
Ca2+ level
Thyroid gland
releases
calcitonin.
Calcitonin
Stimulates
Ca2+ deposition
in bones
Reduces
Ca2+ uptake
in kidneys
Blood Ca2+
level declines
to set point
Homoeostasis:
Blood Ca2+ level
(about 10 mg/100 mL)
STIMULUS:
Falling blood
Ca2+ level
Blood Ca2+
level rises
to set point
Stimulates
Ca2+ release
from bones
PTH
Parathyroid
gland
Stimulates Ca2+
uptake in kidneys
Active
vitamin D
Increases
Ca2+ uptake
in intestines
Insulin and Glucagon: Control of Blood Glucose
(Pancreatic hormones)
• The pancreas secretes insulin and glucagon, antagonistic hormones that
help maintainglucose homeostasis
• Glucagon is produced by alpha cells
• Insulin is produced by beta cells
Beta cells of
pancreas
release insulin
into the blood.
Insulin
Liver takes
up glucose
and stores it
as glycogen.
STIMULUS:
Rising blood glucose
level (for instance, after
eating a carbohydrate-
rich meal)
Blood glucose level
declines to set point;
stimulus for insulin
release diminishes.
Homeostasis:
Blood glucose level
(about 90 mg/100 mL)
STIMULUS:
Dropping blood glucose
level (for instance, after
skipping a meal)
Blood glucose level
rises to set point;
stimulus for glucagon
release diminishes.
Liver breaks
down glycogen
and releases
glucose into the
blood.
Body cells
take up more
glucose.
Alpha cells of pancreas
release glucagon into
the blood.
Glucagon
Target Tissues for Insulin and Glucagon
• Insulinreduces blood glucoselevels by
– Promoting the cellular uptake of glucose
– Slowing glycogen breakdown in the liver
– Promoting fat storage
• Glucagon increases blood glucose levels by
– Stimulating conversion of glycogen to glucose in the liver
– Stimulating breakdown of fat and protein into glucose
STOP THERE!
• The adrenal glands are adjacent to the kidneys
• The adrenal medulla secretes epinephrine (adrenaline) and
norepinephrine (noradrenaline)
• They are secreted in response to stress-activated impulses from
the nervous system
• They mediate various fight-or-flight responses
Adrenal Hormones: Response to Stress
Different receptors different cell responses
Epinephrine
a receptor
Epinephrine
 receptor
Epinephrine
 receptor
Vessel
constricts
Vessel
dilates
Intestinal blood
vessel
Skeletal muscle
blood vessel
Liver cell
Different intracellular proteins different cell responses
Glycogen
deposits
Glycogen
breaks down
and glucose
is released
from cell
Melatonin and Biorhythms
• The pineal gland, located in the brain, secretes melatonin
• Light/dark cycles control release of melatonin
• Primary functions of melatonin appear to relate to biological
rhythms associated with reproduction
Invertebrateregulatory systems also involve endocrine and nervous
systeminteractions
• Diverse hormones regulate homeostasis in invertebrates
• In insects, molting and development are controlled by three main
hormones:
– Brain hormone stimulates release of ecdysone from the prothoracic
glands
– Ecdysone promotes molting and developmentof adult characteristics
– Juvenilehormone promotes retentionof larval characteristics
Brain
hormone (BH)
Brain
Neurosecretory
cells
Corpus
cardiacum
Corpus
allatum
Prothoracic
gland
Ecdysone
EARLY
LARVA
LATER
LARVA PUPA ADULT
Juvenile
hormone
(JH)
Low
JH
Growth Hormone
• Growth hormone (GH) has tropic and non-tropic actions
• It promotes growth directly and has diverse metabolic
effects
• It stimulates production of growth factors
Diabetes Mellitus
• Diabetes mellitus is perhaps the best-known endocrine
disorder
• It is caused by a deficiency of insulin or a decreased
response to insulin in target tissues
• It is marked by elevated blood glucose levels

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Best Hormones and the Endocrine System-1.ppt

  • 2. Overview: The Body’s Long-Distance Regulators Hormones are chemical signals that are secreted into the circulatory system and communicate regulatory messages within the body. Hormones reach all parts of the body, but only target cells are equipped to respond to the same. Hormones convey information via the bloodstream to target cells throughout the body.
  • 3. Classification of Hormones 1. Proteins and Polypeptides, including hormones secreted by the anterior and posterior pituitary gland, the pancreas (insulin and glucagon), the parathyroid gland (parathyroid hormone), and many others. 2. Steroids secreted by the adrenal cortex (cortisol and aldosterone), the ovaries (estrogen and progesterone), the testes (testosterone), and the placenta (estrogen and progesterone) 3. Derivatives of the aminoacid tyrosine, secreted by the thyroid (thyroxine and tri-iodothyronine) and the adrenal medullae (epinephrine and norepinephrine)
  • 4. Control Pathways and Feedback Loops • The endocrine systemsecretes hormones that coordinate slower but longer-acting responses including reproduction, development, energy metabolism, growth, and behavior • A common feature is a feedback loop connecting the response to the initial stimulus • Negative feedbackregulates many hormonal pathways involvedin homeostasis
  • 5. • Signaling by any of these hormones involves three key events: – Reception – Signal transduction – Response
  • 6. Transportationof Hormones 1, Endocrine: glands or specialized cells release hormones into the circulating blood that influence the function of cells at another location in the body 2, Neuroendocrine: neurons secrete substances (neurohormones) that reach the circulating blood and influence the function of cells at another location of the body. 3. Paracrine, in which cells secret substances that diffuse into the extracellular fluid and affect neighboring cells.
  • 7. 1. Mechanisms of Hormonal Action The first step of a hormone’s action is to bind to specific receptors at the target cell. Locations for the different types of hormones: 1) On the surface of the cell membrane. protein, peptide, and catecholamine hormones 2) In the cell cytoplasm. steroidhormones 3) In the cell nucleus. thyroid hormones (T3 and T4)
  • 8. 2.Second MessengerMechanisms for Mediating Intracellular Hormonal Functions Hydrophilic hormones (proteins, peptides and catecholamine) --bind the receptors on the membrane, --activate some enzyme on the membrane, -- regulate the concentration of some messengers (second messengers) in the cytoplasm. There are at least three kinds of second messengers: cAMP, Calciumionsand productsof membrane phospholipidmetabolism. 3.Hormones That Act Mainlyon the Genetic Machineryof the Cell a) Steroid hormones increase protein synthesis b) Thyroid hormonesincrease genetranscription in the cellnucleus
  • 9. SECRETORY CELL Hormone molecule Signal receptor VIA BLOOD VIA BLOOD TARGET CELL TARGET CELL Signal transduction pathway OR Cytoplasmic response DNA NUCLEUS Nuclear response Receptor in plasma membrane Receptor in cell nucleus DNA NUCLEUS mRNA Synthesis of specific proteins Signal transduction and response Signal receptor Hormone molecule SECRETORY CELL
  • 10. • Binding of a hormone to its receptor initiates a signal transduction pathway leading to responses in the cytoplasm or a change in gene expression • The same hormonemay have different effects on target cells that have – Different receptors for the hormone – Different signal transductionpathways – Different proteins for carrying out the response
  • 11. Paracrine Signaling by Local Regulators • In paracrine signaling, non-hormonal chemical signals called local regulators elicit responses in nearby target cells • Types of local regulators: – Neurotransmitters – Cytokines and growthfactors – Prostaglandins help regulate aggregation of platelets, an early step in formation of blood clots
  • 12. • The hypothalamus and the pituitary gland control much of the endocrine system • Tropic hormones, hormones that regulate endocrine organs • Tropic hormones are secreted into the blood and transported to the anterior pituitary The hypothalamus and pituitary integrate many functions of the vertebrate endocrine system
  • 13. Hormones Secreted by the Hypothalamus and Their Effects on Anterior Pituitary Corticotropin-releasing hormone (CRH)– Stimulates secretion of ACTH (adrenocorticotropic hormone) Gonadotropin-releasing hormone (GnRH) Stimulates secretion of FSH (follicle-stimulatinghormone) and LH (luteinizing hormone) Thyrotropin-releasing hormone(TRH)-stimulates secretion of TSH (thyroid- stimulation hormone) Melanocyte-stimulating hormone release inhibiting factor (MIF)-inhibits secretion of MSH(Melanocyte-stimulating hormone)
  • 14. Melanocyte-stimulatinghormone releasing factor (MRF)-stimulate secretion of MSH Growth hormone release inhibitinghormone (GHRIH)or Somatostatin (SS) – inhibits secretion of growth hormone Growth hormone-releasing hormone (GHRH)– stimulates growth hormone secretion Prolactin-inhibitingfactor (PIF)- inhibits prolactin secretion Prolactin-releasingfactor (PRF)-stimulates prolactin section
  • 15. Mammary glands, uterine muscles Hypothalamus Kidney tubules Oxytocin HORMONE TARGET ADH Posterior pituitary Neurosecretory cells of the hypothalamus Axon Anterior pituitary
  • 16. Neurosecretory cells of the hypothalamus Endocrine cells of the anterior pituitary Portal vessels Pituitary hormones (blue dots) Pain receptors in the brain Endorphin Growth hormone Bones Liver MSH Melanocytes Prolactin Mammary glands ACTH Adrenal cortex TSH Thyroid Testes or ovaries FSH and LH TARGET HORMONE Hypothalamic releasing hormones (red dots) Tropic Effects Only FSH, follicle-stimulating hormone LH, luteinizing hormone TSH, thyroid-stimulating hormone ACTH, adrenocorticotropic hormone Nontropic Effects Only Prolactin MSH, melanocyte-stimulating hormone Endorphin Nontropic and Tropic Effects Growth hormone
  • 17. Posterior Pituitary Hormones • The two hormones released from the posterior pituitary act directly on non-endocrine tissues • Oxytocin induces uterine contractions and milk ejection • Antidiuretic hormone (ADH) enhances water reabsorption in the kidneys
  • 18. Estrogen Oxytocin from ovaries fromfetus and mother’s posterior pituitary Induces oxytocin receptorson uterus Stimulatesuterus to contract Stimulates placentato make Prostaglandins Stimulate more contractions of uterus Positive feedback
  • 19. INNER MEDULLA OUTER MEDULLA CORTEX Osmolarity of interstitial fluid (mosm/L) NaCl Urea H2O Active transport Passive transport 300 300 300 100 100 400 200 H2O H2O H2O H2O H2O H2O 600 400 900 700 1200 300 400 H2O 600 1200 1200 600 900 300 400 NaCl NaCl NaCl NaCl NaCl NaCl Urea H2O Urea H2O H2O H2O H2O H2O
  • 20. Anterior Pituitary Hormones • The anterior pituitary produces both tropic and non- tropic hormones
  • 21. Tropic Hormones • The four strictly tropic hormones are – Follicle-stimulating hormone(FSH) – Luteinizing hormone (LH) – Thyroid-stimulating hormone (TSH) – Adrenocorticotropichormone (ACTH) • Each tropic hormone acts on its target endocrine tissue to stimulate release of hormone(s) with direct metabolic or developmental effects - (Release hormones)
  • 22. Hypothalamus Anterior pituitary Control by hypothalamus Pituitary gonadotropins in blood FSH LH FSH LH GnRH Inhibited by combination of estrogen and progesterone Inhibited by low levels of estrogen Stimulated by high levels of estrogen LH surge triggers ovulation FSH and LH stimulate follicle to grow Mature follicle Growing follicle Ovarian cycle Corpus luteum Degenerating corpus luteum Follicular phase Ovulation Luteal phase Progesterone and estrogen secreted by corpus luteum Estrogen secreted by growing follicle in increasing amounts Progesterone and estro- gen promote thickening of endometrium Peak causes LH surge Ovarian hormones in blood Estrogen level very low Progesterone Estrogen Endometrium Uterine (menstrual) cycle Menstrual flow phase Proliferative phase Secretory phase Days 28 25 20 15 14 10 5 0
  • 23. Non-tropic Hormones • Non-tropic hormones produced by the anterior pituitary: • Prolactin stimulates lactationin mammals but has diverse effects in different vertebrates • MSH influences skin pigmentationin some vertebrates and fat metabolismin mammals • Endorphins inhibit pain
  • 24. Parathyroid Hormone and Calcitonin: Control of Blood Calcium • Two antagonistic hormones, parathyroidhormone (PTH) and calcitonin, play the major role in calcium (Ca2+) homeostasis in mammals. Calcitonin stimulates Ca2+ deposition in bones and secretion by kidneys, lowering blood Ca2+ levels
  • 25.
  • 26. STIMULUS: Rising blood Ca2+ level Thyroid gland releases calcitonin. Calcitonin Stimulates Ca2+ deposition in bones Reduces Ca2+ uptake in kidneys Blood Ca2+ level declines to set point Homoeostasis: Blood Ca2+ level (about 10 mg/100 mL) STIMULUS: Falling blood Ca2+ level Blood Ca2+ level rises to set point Stimulates Ca2+ release from bones PTH Parathyroid gland Stimulates Ca2+ uptake in kidneys Active vitamin D Increases Ca2+ uptake in intestines
  • 27. Insulin and Glucagon: Control of Blood Glucose (Pancreatic hormones) • The pancreas secretes insulin and glucagon, antagonistic hormones that help maintainglucose homeostasis • Glucagon is produced by alpha cells • Insulin is produced by beta cells
  • 28.
  • 29. Beta cells of pancreas release insulin into the blood. Insulin Liver takes up glucose and stores it as glycogen. STIMULUS: Rising blood glucose level (for instance, after eating a carbohydrate- rich meal) Blood glucose level declines to set point; stimulus for insulin release diminishes. Homeostasis: Blood glucose level (about 90 mg/100 mL) STIMULUS: Dropping blood glucose level (for instance, after skipping a meal) Blood glucose level rises to set point; stimulus for glucagon release diminishes. Liver breaks down glycogen and releases glucose into the blood. Body cells take up more glucose. Alpha cells of pancreas release glucagon into the blood. Glucagon
  • 30. Target Tissues for Insulin and Glucagon • Insulinreduces blood glucoselevels by – Promoting the cellular uptake of glucose – Slowing glycogen breakdown in the liver – Promoting fat storage
  • 31. • Glucagon increases blood glucose levels by – Stimulating conversion of glycogen to glucose in the liver – Stimulating breakdown of fat and protein into glucose STOP THERE!
  • 32.
  • 33. • The adrenal glands are adjacent to the kidneys • The adrenal medulla secretes epinephrine (adrenaline) and norepinephrine (noradrenaline) • They are secreted in response to stress-activated impulses from the nervous system • They mediate various fight-or-flight responses Adrenal Hormones: Response to Stress
  • 34. Different receptors different cell responses Epinephrine a receptor Epinephrine  receptor Epinephrine  receptor Vessel constricts Vessel dilates Intestinal blood vessel Skeletal muscle blood vessel Liver cell Different intracellular proteins different cell responses Glycogen deposits Glycogen breaks down and glucose is released from cell
  • 35.
  • 36. Melatonin and Biorhythms • The pineal gland, located in the brain, secretes melatonin • Light/dark cycles control release of melatonin • Primary functions of melatonin appear to relate to biological rhythms associated with reproduction
  • 37. Invertebrateregulatory systems also involve endocrine and nervous systeminteractions • Diverse hormones regulate homeostasis in invertebrates • In insects, molting and development are controlled by three main hormones: – Brain hormone stimulates release of ecdysone from the prothoracic glands – Ecdysone promotes molting and developmentof adult characteristics – Juvenilehormone promotes retentionof larval characteristics
  • 39. Growth Hormone • Growth hormone (GH) has tropic and non-tropic actions • It promotes growth directly and has diverse metabolic effects • It stimulates production of growth factors
  • 40. Diabetes Mellitus • Diabetes mellitus is perhaps the best-known endocrine disorder • It is caused by a deficiency of insulin or a decreased response to insulin in target tissues • It is marked by elevated blood glucose levels