In combination with other factors, hyperglycemia may cause the accelerated progression of atherosclerosis in people with diabetes. Arterial smooth muscle cell (SMC) proliferation and accumulation contribute to formation of advanced atherosclerotic lesions. Therefore, we investigated the effects of hyperglycemia on SMC proliferation and accumulation in vivo and in isolated arteries and SMCs by taking advantage of a new porcine model of diabetes-accelerated atherosclerosis, in which diabetic animals are hyperglycemic without receiving exogenous insulin. We show that diabetic animals fed a cholesterol-rich diet, like humans, develop severe lesions of atherosclerosis characterized by SMC accumulation and proliferation, whereas lesions in nondiabetic animals contain fewer SMCs after 20 weeks. However, high glucose (25 mmol/l) does not directly stimulate the proliferation of SMCs in isolated arterial tissue from diabetic or nondiabetic animals, or of cultured SMCs from these animals or from humans. Furthermore, the mitogenic actions of platelet-derived growth factor, IGF-I, or serum are not enhanced by high glucose. High glucose increases SMC glucose metabolism through the citric acid cycle and the pentose phosphate pathway by 240 and 90%, respectively, but <10% of consumed glucose is metabolized through these pathways. Instead, most of the consumed glucose is converted into lactate and secreted by the SMCs. Thus, diabetes markedly accelerates SMC proliferation and accumulation in atherosclerotic lesions. The stimulatory effect of diabetes on SMCs is likely to be mediated by effects secondary to the hyperglycemic state. Diabetes 50:851-860, 2001 I t is estimated that 75-80% of adults with diabetes die from complications of atherosclerosis. The progression of atherosclerotic lesions is accelerated by diabetes (1). Thus, stroke, coronary heart disease, and peripheral arterial disease are more common and occur at an earlier age in diabetic people than in the general population (1-2).The cellular mechanisms underlying the accelerated progression of atherosclerotic lesions in diabetic arteries are still largely unknown. Hyperinsulinemia, lipid abnormalities, and hyperglycemia have each been suggested to cause this response. Because smooth muscle cell (SMC) proliferation and accumulation are key events in the development of advanced lesions, a number of studies have investigated the regulation of SMC proliferation. Studies on the effects of hyperinsulinemia show that direct mitogenic effects of insulin on SMCs are weak and that the principal mitogenic response elicited by insulin is mediated through a cross-reaction at high unphysiological insulin concentrations with the IGF-I receptor (3-6). Thus, a direct mitogenic action of hyperinsulinemia on SMCs in vivo is unlikely.It is becoming increasingly clear that many of the complications of diabetes arise from hyperglycemia that cannot be completely prevented using the methods of blood glucose control available today. This is particularly apparent for retinopathy, nephropathy,...