REviEws

Autophagy in metabolic disease

and ageing
Munehiro Kitada   1,2 and Daisuke Koya   1,2,3 ✉
Abstract | Autophagy is an evolutionarily conserved, lysosome-​dependent catabolic process
whereby cytoplasmic components, including damaged organelles, protein aggregates and
lipid droplets, are degraded and their components recycled. Autophagy has an essential role
in maintaining cellular homeostasis in response to intracellular stress; however, the efficiency
of autophagy declines with age and overnutrition can interfere with the autophagic process.
Therefore, conditions such as sarcopenic obesity, insulin resistance and type 2 diabetes mellitus
(T2DM) that are characterized by metabolic derangement and intracellular stresses (including
oxidative stress, inflammation and endoplasmic reticulum stress) also involve the accumulation
of damaged cellular components. These conditions are prevalent in ageing populations. For
example, sarcopenia is an age-​related loss of skeletal muscle mass and strength that is involved
in the pathogenesis of both insulin resistance and T2DM, particularly in elderly people. Impairment
of autophagy results in further aggravation of diabetes-​related metabolic derangements in insulin
target tissues, including the liver, skeletal muscle and adipose tissue, as well as in pancreatic
β-​cells. This Review summarizes the role of autophagy in the pathogenesis of metabolic diseases
associated with or occurring in the context of ageing, including insulin resistance, T2DM and
sarcopenic obesity, and describes its potential as a therapeutic target.

The increasing incidence of metabolic derangements,
including sarcopenic obesity, insulin resistance and
type 2 diabetes mellitus (T2DM), among elderly people
in the past decade is a subject of serious concern world-
wide1. Ageing causes many physiological changes in body
composition, resulting in an increase in body fat mass,
including increased visceral fat, and a decrease in muscle
mass and strength; these changes are closely related to
metabolic disease2. The accumulation of excessive fat
1
Department of Diabetology
and Endocrinology,
in visceral adipose depots and in non-​adipose tissues,
Kanazawa Medical including the liver and skeletal muscle, is an important
University, Uchinada, factor in the pathogenesis of obesity-​related metabolic
Ishikawa, Japan. disease2. In addition, obesity and sarcopenia often coexist,
2
Division of Anticipatory and it is recognized that sarcopenic obesity worsens
Molecular Food Science meta­bolic disease in older people3. Moreover, impaired
and Technology, Medical
Research Institute,
pancreatic β-​cell function is crucial for the pathogenesis
Kanazawa Medical of T2DM, which is also associated with ageing4.
University, Uchinada, Other hallmarks of ageing include an imbalance in
Ishikawa, Japan. intercellular communication, stem cell exhaustion, dys-
3
Department of General regulated nutrient sensing, genomic instability, telomere
Internal Medicine, Kusatsu attrition, epigenetic alterations, loss of proteostasis,
General Hospital, Kusatsu,
Shiga, Japan.
cellular senescence and mitochondrial dysfunction5.
✉e-​mail: koya0516@ Progressive accumulation of cellular damage owing to
kanazawa-​med.ac.jp intracellular stressors, such as oxidative stress, inflam-
https://doi.org/10.1038/ mation, endoplasmic reticulum (ER) stress and an inad-
s41574-021-00551-9 equate response to hypoxia, ultimately lead to disruption
and dysfunction of cellular metabolic homeostasis, which
are closely associated with ageing5. Under starvation
conditions, autophagy can provide nutrients to maintain
cellular functions through the degradation of large mole­
cules, organelles, proteins and end products. In addition,
autophagy removes damaged organelles, misfolded pro-
teins and lipid droplets, and thus plays a crucial role in
maintaining cellular homeostasis. Autophagic activity
decreases with age in many species, and adequate auto-
phagy is recognized as a central biological pathway that
promotes health and longevity6.
Under conditions of metabolic derangement, prom-
inent accumulation of lipid droplets, protein aggregates
and damaged organelles (all major substrates of auto-
phagy) is observed in β-​cells and insulin target tissues,
including skeletal muscle, liver and adipose tissue.
Impaired autophagy is closely related to the patho-
genesis of several metabolic diseases, including sarco-
penic obesity, insulin resistance and T2DM. Therefore,
induction of adequate autophagy is a potential therapeu-
tic target in the amelioration of age-​related metabolic
derangements.
In this Review, we outline the mechanism of auto-
phagy and its regulation; discuss the relationship bet­
ween impaired autophagy and age-​related metabolic
derangements, including insulin resistance, T2DM and

Nature Reviews | Endocrinology

0123456789();:
Reviews
Key points
• Autophagic activity decreases with age in many species, and adequate autophagy is
recognized as an important biological pathway that promotes health and longevity.
• Basal autophagy and appropriate adaptive autophagy responses induced by
intracellular stress and changes in nutrient status enable elimination of damaged
cellular components and contribute to cellular homeostasis.
• Nutrient-​sensing pathways, including those involving mTORC1, AMPK and SIRT1, ATG12 conjugation system, ATG7 and ATG10 conju-
are involved in the regulation of autophagy at multiple steps during autophagic flux.
• Impairment of autophagy results in further aggravation of diabetes-​related metabolic
derangements in insulin target tissues, including the liver, skeletal muscle and adipose
tissue, as well as in pancreatic β-​cells.
• Calorie restriction, exercise and pharmacological interventions, including several
antidiabetic medicines, induce autophagy and are, therefore, recognized as candidate
therapies for age-​related metabolic disease.
sarcopenic obesity; and discuss candidate therapies for
regulation of autophagy.
Types of autophagy
Three types of autophagy have been distinguished on
the basis of their differing mechanisms of cargo seques-
tration. Microautophagy involves sequestration of cyto-
plasmic components directly into lysosomes, whereas
chaperone-​mediated autophagy involves selective deg-
radation of cargo proteins, which are recognized and
delivered to lysosomes by chaperone complexes. Finally,
macroautophagy is mediated by many proteins encoded
by autophagy-​related genes (ATGs). As macroautophagy
is the most extensively studied of these types in the field
of ageing and metabolic disease, the four sequential
stages of macroautophagy are discussed in detail in the
next sections (Fig. 1)7–11.
Initiation
Intracellular signalling pathways that activate initia-
tion of the autophagic process are triggered by vari-
ous intracellular stresses and alterations in nutrient
status. The target of these pathways is the UNC-​like
autophagy-​activating kinase 1 (ULK1) initiation com-
plex, which consists of ULK1, ATG13, focal adhesion
kinase family interacting protein of 200 kDa (FIP200)
and ATG101. Activation of this complex triggers
membrane nucleation.
Phagophore formation
Nucleation of the membrane requires the lipid kinase
activity of class III phosphatidylinositol-3 kinase com-
plex I (PI3KC3-​CI), which generates phosphatidylino­
sitol 3-​phosphate (PI3P) at the phagophore. PI3KC3-​CI
consists of catalytic subunit vacuolar protein sorting 34
(VPS34), beclin-1, p115, autophagy-​related protein
14-​like protein (ATG14L), activating molecule in
beclin-1-​regulated autophagy protein 1 (AMBRA1) and
nuclear receptor-​binding factor 2 (NRBF2). Once the
ULK1 initiation complex is activated, ULK1 binds
to and phosphorylates ATG14 at Ser19, VPS34 at Ser249
and beclin-1 at Ser15 (as well as at other sites), which
causes activation of PI3KC3-​CI; these proteins then
translocate to the phagophore assembly site, which
is located at a characteristic ER structure called the
omegasome.
0123456789();:
Phagophore elongation
At the omegasome, increased local production of PI3P
results in recruitment of the effector proteins WD
repeat domain phosphoinositide-​interacting protein 2
(WIPI2) and zinc-​f inger FYVE domain-​containing
protein 1 (DFCP1) to the omegasome via the interac-
tion of PI3P with their PI3P-​binding domains. In the
gate ATG12 to ATG5. The ATG12–ATG5 complex then
binds to ATG16L1 and mobilizes to the phagophore as
the ATG12–ATG5–ATG16L1 complex, which binds to
WIPI2 via ATG16L1. ATG2 connects the ER membrane
to the isolation membrane and delivers phospholipids
contained in the ER membrane to the cytoplasmic layer
of the isolation membrane12. Thereafter, phospholipids
delivered by ATG2 are flipped and redistributed by
ATG9, which is a lipid scramblase, thereby driving
phagophore membrane elongation13,14.
In addition to the ER, several membranous orga-
nelles, including the plasma membrane, mitochondria,
recycling endosomes and Golgi complex, contribute
to elongation of the phagophore by donating mem-
brane materials, and parts of these lipid bilayers are
delivered by ATG9-​containing vesicles. Microtubule-
associated proteins 1A/1B light chain 3 (LC3) is cleaved
by ATG4 to form LC3I, and LC3I then conjugates with
phosphatidylethanolamine via ATG7 and ATG3 to
form LC3II. The ATG12 complex promotes LC3II for-
mation and its conjugation to the phagosome. LC3II
interacts with cargo via the LC3-​interacting regions
(LIRs) of autophagy receptors and is also required for
elongation and closure of the phagophore membrane
as autophagosomes mature. In addition, LC3II is
removed by ATG4 from the surface of autophagosomes
and is recycled for the next round of the conjugation
reaction.
Autophagosome–lysosome fusion
PI3KC3-​CII, which is required for autophagosome
maturation, contains ultraviolet radiation resistance-
associated gene protein (UVRAG). Interaction of
UVRAG with the homotypic fusion and vacuole pro-
tein sorting (HOPS) tethering complex stimulates the
fusion of autophagosomes and lysosomes. Rubicon
(encoded by RUBCN) suppresses the formation of
autolysosomes by interacting with UVRAG. Fusion
of the autophagosome membrane with the lysosome
membrane requires both the HOPS complex, which
tethers autophagosomes to lysosomes, and syntaxin-17
(STX17), which facilitates membrane fusion. Pacer
interacts with STX17 and recruits the HOPS com-
plex to autophagosomes. Autophagosome–lysosome
fusion is mediated by trafficking of several proteins,
including small GTPase family proteins such as
Ras-​related protein Rab-7a. Effector proteins, such
as soluble N-​ethylmaleimide-​sensitive fusion attach-
ment protein receptors (SNAREs), within the auto-
phagic cargo are degraded and released into the
cytoplasm.
Lysosomes are regenerated from the autolysosomal
membrane in a process known as autophagic lysosome
re-​formation (ALR), which sets the stage for a new cycle
www.nature.com/nrendo
 Reviews

of autophagosome initiation. The increase in intracellu-
lar amino acid levels resulting from autophagic activity
causes mTORC1 to reactivate, thereby not only shut-
ting down the generation of autophagosomes but also
promoting ALR. During ALR, lysosomal membranes
are recycled to maintain lysosome homeostasis during
autophagy, a process that marks the last stage of auto-
phagy. This step is needed to provide a functional pool
of lysosomes for the generation of autolysosomes during
prolonged starvation.

Plasma membrane Cytoplasm Degradation

• Intracellular stress
• Alteration of Autophagic lysosome Recycling of nutrients
nutrient status reformation
Membrane Mitochondrion
nucleation and
Initiation phagophore
formation Acidic
Protein hydrolases
Membrane sources aggregate
PI3KC3 complex I
• Plasma membrane Lysosome
ULK1 complex VPS34 Beclin-1 • Golgi Autolysosome
ULK1 ATG14L AMBRA1 p115 • Mitochondria
• Recycling endosomes
ATG13 FIP200 • ATG9-containing vesicles
ATG101 SNAREs
Lipid
droplet Rab-7a
Cargo
PI3KC3 sequestration
complex I Phagophore
elongation
ATG12
ULK1 complex
PI3P

2
IPI
G3

ATG10
G1

conjugation Autophagosome–
W I3P
AT

ATG12
1 AT

P lysosome fusion
DFCP1 W 16L G5

Isolation
P1

LC3II
P
PI3P PI3

G AT

membrane
DFC

PE ATG7 PI3KC3-CII
ATG5 HOPS
2

Beclin-1
IPI
AT

ATG16L AT12
ATG2 VPS34
ATG9 ATG5 STX17
Omegasome UVRAG
Nucleus Expansion Pacer VPS15
ATG9
Rough
ER
Sealing Rubicon
Autophagosome ATG4
ATG3

ATG7
LC3I ATG4

LC3 conjugation LC3

system

Fig. 1 | Autophagy. On initiation of autophagy, intracellular stress and
alterations in nutrient status activate UNC-​like autophagy activating
kinase 1 (ULK1). ULK1 then binds to class III phosphatidylinositol-3
kinase (PI3KC3) complex 1 (PI3KC3-​C I), causing generation of
phosphatidylinositol-3-​phosphate (PI3P) at the phagophore assembly site
(located at the omegasome) after membrane isolation from the
endoplasmic reticulum (ER). Local PI3P production drives PI3P-​mediated
recruitment of the effector proteins WD repeat domain phosphoinositide-​
interacting protein 2 (WIPI2) and zinc-​finger FYVE domain-​containing
protein 1 (DFCP1). In the autophagy-​related gene (ATG) 12 conjugation
system, ATG12–ATG5–ATG16L1 complex binds to WIPI2 via ATG16LI. ATG2
delivers phospholipids contained in the ER membrane to the cytoplasmic
layer of the isolation membrane. Then, ATG9 drives membrane expansion.
Membrane materials from other organelles, including the plasma
membrane, mitochondria, recycling endosomes and Golgi complex,
also contribute to phagophore elongation and are delivered by
ATG9-​containing vesicles. The ATG12 complex promotes microtubule-​
associated protein light chain (LC)-3II formation via LC3I from LC3, and its
conjugation to the phagosome via phosphatidylethanolamine (PE). LC3II
interacts with cargo through selective autophagy receptors via
LC3-​interacting regions and is required for elongation and closure of the
phagophore membrane as autophagosomes mature. LC3II is removed by
ATG4 from the surface of autophagosomes. PI3KC3-​CII contains UV
radiation resistance-​associated gene protein (UVRAG), which interacts
with homotypic fusion and vacuole protein sorting (HOPS) and stimulate
autophagosome–lysosome fusion. Rubicon suppresses the formation of
autolysosomes by interacting with UVRAG. Fusion of the autophagosome
membrane with the lysosome membrane requires both the HOPS complex,
which tethers autophagosomes to lysosomes, and syntaxin-17 (STX17).
Pacer interacts with STX17 and recruits HOPS to autophagosomes.
Autophagosome–lysosome fusion is mediated by trafficking proteins,
including small GTPase-​family proteins, such as Rab-7a. Within the
autophagic cargo, effector proteins (such as soluble N-​ethylmaleimide-​
sensitive fusion attachment protein receptors (SNAREs)) are degraded and
released into the cytoplasm for nutrient recycling. Lysosomes are reformed
from the autolysosomal membrane, setting the stage for a new cycle of
autolysosome formation. AMBRA1, activating molecule in beclin-
1-​regulated autophagy protein 1; FIP200, focal adhesion kinase family
interacting protein of 200 kDa; VPS, vacuolar protein sorting. Adapted
from ref.8, Springer Nature Limited.

Nature Reviews | Endocrinology

0123456789();:
Reviews
Ubiquitin-independent
• Mitophagy
• ERphagy
Ubiquitin-dependent
• Mitophagy
• Aggrephagy
Phagosome
Selective autophagy Protein
LIR UBD
receptor aggregate
Protein with Damaged
LIR
integral LIR motif mitochondrion
LC3II Damaged ER
Ubiquitin
Fig. 2 | Selective autophagy. Selective autophagy is
the process by which specific types of cell components
(including protein aggregates, lipid droplets, mitochon-
dria, peroxisomes, lysosomes and endoplasmic reticulum)
are removed and recycled. Efficient recognition and
sequestration of these components within autophago-
somes involves a diverse array of ubiquitin-​dependent and
ubiquitin-​independent cargo signals that physically link
their targets to selective autophagy receptors on the
autophagosome via microtubule-​associated proteins
1A/1B light chain 3 (LC3)-​interacting regions (LIRs, which
bind to lipidated and/or autophagosome membrane-​
associated LC3II), thereby targeting them for degradation.
ER, endoplasmic reticulum; UBD, ubiquitin D.
Selective autophagy
Selective autophagy removes and recycles specific types
of cell components. For example, protein aggregates are
removed by aggrephagy, lipid droplets by lipophagy and
damaged or superfluous mitochondria by mitophagy.
Other forms of selective autophagy remove and recycle
peroxisomes, lysosomes and ER.
Selective autophagy involves efficient recognition and
sequestration of the cargo within autophagosomes15,16.
The cargo signals recognized by selective autophagy
receptors are diverse, but can be broadly grouped
into ubiquitin-​dependent and ubiquitin-​independent
types (Fig. 2; Table 1). These proteins physically link
their targets to the autophagosome via LIR motifs
that bind to lipidated LC3II and/or autophagosome
membrane-​associated LC3II, thereby targeting them
for degradation. In addition to autophagy receptors,
lipids (including phospholipids, such as cardiolipin and
ceramide) have been shown to mediate mitophagy17,18.
Autophagic flux
Autophagy is a dynamic, multistage process. Therefore,
estimating the rate at which autophagy occurs by
static enumeration of autophagic structures at a sin-
gle time point can lead to inaccurate interpretations.
0123456789();:
For  instance, an accumulation of autophagosomes
might indicate either generally increased autophagic
activity or, conversely, decreased activity of one or more
down­stream steps, such as inefficient autophagosome–
lysosome fusion or decreased lysosomal degradation.
Therefore, accurate estimation of autophagic activity
requires a determination of the overall rate of autophagic
degradation, which is termed autophagic flux. This
dynamic parameter represents the amount of autophagic
degradation per unit time.
The most commonly used methods for assessing auto-
phagic flux involve measurement of the turnover rate of
ATG proteins such as LC3 (Supplementary Table 1).
For example, the amount of LC3II roughly correlates
with the number of autophagosomes. However, merely
showing increased levels of LC3II is insufficient to
demon­strate increased autophagic flux, because an
increase in LC3II levels could also occur in the context
of decreased autophagic throughput downstream of
autophagosome–lysosome fusion. Determination
of autophagic flux mandates that the amount of degraded
LC3II in lysosomes is also measured, which can be done
by comparing the amount of LC3II present in cells in
the presence and absence of lysosomal inhibitors such
as bafilomycin A1, chloroquine, pepstatin A or E64d.
Under conditions of increased autophagic flux, the
level of LC3II in autophagosomes will be increased in
the presence of lysosomal inhibitors owing to blockade
of autophagosome–lysosome fusion, which causes
LC3II to accumulate. Autophagic flux can also be eva­
luated by monitoring the levels of selective autophagy
substrates such as sequestosome-1. Similarly to the
LC3 flux assay, the amount of sequestosome-1 degra­
dation can be measured using lysosomal inhibitors
(Supplementary Table 1).
Other methods for measuring autophagic flux involve
transfection with fluorescent reporters that are capable
of indicating the cumulative amount of degradation of
cytoplasm-​derived material within lysosomes. Such
reporters have been used successfully in cultured cells
and model organisms19–21 (Box 1 and Supplementary
Table 1). However, monitoring autophagic flux in vivo
in humans is currently not feasible.
Regulation of autophagy
All organisms respond to intracellular stresses (includ-
ing oxidative stress, inflammation, hypoxia and ER
stress) and to nutrients that are available in the environ­
ment by implementing adaptive changes to cellular
activities including metabolism, growth and autophagy.
Basal autophagy as well as adaptive autophagy responses
induced by intracellular stress and changes in nutrient
status eliminate damaged cellular components and have
an important role in cellular homeostasis (Fig. 3). By con-
trast, impaired or excessive autophagy leads to cell senes-
cence or death owing to the accumulation of damaged
cellular components (Fig. 3).
Nutrient-sensing pathways, including those involving
mechanistic target of rapamycin complex 1 (mTORC1)22–39,
AMP-​a ctivated kinase (AMPK) 23,40–53 and SIRT1
(NAD+-​dependent protein deacetylase sirtuin-1)54–57,
are involved in the regulation of autophagic flux at
www.nature.com/nrendo

multiple steps (Table 2) and show substantial crosstalk58–62
(Fig.  3) . During starvation, autophagy is intensively
induced by activation of AMPK and SIRT1 and sup-
pression of mTORC1 (refs58–62) (Fig. 3). By contrast, auto-
phagy is suppressed under conditions of excess nutrition
through activation of mTORC1 and reductions in
AMPK and SIRT1 activity (Fig. 3). Most of the processes
through which intracellular stress induces autophagy are
mediated by nutrient-​sensing pathways57,63,64. In addition,
lysosome-​mediated degradative pathways are regulated
by genes in the coordinated lysosomal expression and
regulation (CLEAR) network65,66, which includes both
genes related to the lysosomal complement (that is,
encoding hydrolases, transporters and accessory pro-
teins) and genes involved in the regulation of lysosomal
biogenesis and function.
Autophagy, ageing and lifespan
Autophagy is part of a convergent mechanism shared by
various pathways involved in longevity and the regula-
tion of lifespan. The expression of ATG-​related proteins
and other proteins required for the induction of auto-
phagy, such as SIRT1, is decreased in tissues from older
individuals. The capacity of autophagy also declines
with ageing, which contributes to the accumulation of
damaged macromolecules and organelles and results in
adverse effects on lifespan.
Inactivation of autophagy owing to knockdown of
various ATGs leads to reduced lifespan as a result of the
premature onset of age-​related symptoms in several
model organisms, including Saccharomyces cerevisiae,
Caenorhabditis elegans and Drosophila melanogaster 67–69.
However, knockout of Atg3, Atg5 and Atg7 in mice is
embryonically or neonatally lethal, which makes it impos-
sible to examine the role of autophagy in mammalian
longevity70–72. Conversely, mice that overexpress Atg5
exhibit ubiquitously enhanced autophagy and are normal
at birth but develop leanness and loss of weight with
ageing despite the same food intake as their wild-​type
littermates73. However, the lean phenotype of mice
that overexpress Atg5 is accompanied by an extended
lifespan. Mice with a knock-​in gain-​of-​function point
mutation in Becn1 that disrupts the interaction between
beclin-1 and BCL2, thereby constitutively activating
autophagy, also have an extended lifespan74. By contrast,
Table 1 | Selective autophagy
Selective Mammalian cargo proteins
autophagy type
Ubiquitin-​dependent
Mitophagy Optineurin, calcium-​binding and coiled-​coil
domain-​containing protein 2 (also known as
NDP52), TAX1-​binding protein 1 (TAX1BP1),
sequestosome-1
Aggrephagy Neighbour of BRCA1 gene 1 protein (NBR1),
optineurin, Toll-nteracting protein (TOLLIP)
ERphagy NR
Lipophagy NR
ER, endoplasmic reticulum; NR, not reported
Nature Reviews | Endocrinology
0123456789();:
Reviews
expression of rubicon (a negative regulator of autophagy)
is increased in C. elegans, Drosophila and mouse tissues
from aged individuals at the transcript and/or protein
level, whereas expression of this protein is suppressed
in several long-​lived C. elegans models and in mice sub-
jected to calorie restriction75. Knockdown of the gene
encoding rubicon in C. elegans and Drosophila extends
lifespan and (in mice) ameliorates several age-​associated
phenotypes in the heart, kidneys and brain75.
By contrast, several reports published in the past
4 years suggest that autophagy can be detrimental in some
different model systems under certain circumstances. For
instance, elevated autophagy accompanied by increased
mitochondrial permeability shortens lifespan in C. elegans
and in mice76. Moreover, although autophagy is indis­
pensable during development, its attenuation late in
life can extend healthy lifespan in C. elegans77. Finally,
whereas moderate overexpression of Atg1 substantially
extends lifespan in Drosophila, strong induction of its
expression is toxic78.
Pathophysiological roles of autophagy
Overnutrition and lack of exercise cause sarcopenic
obesity, insulin resistance and T2DM, which are asso-
ciated with increased mortality. Ageing can accelerate
these meta­bolic derangements and is also a recognized
risk factor for T2DM. Chronic calorie surplus results in
storage of fat in adipose tissue; moreover, the accumula-
tion of fat — in non-​adipose tissues, including the liver
and skeletal muscle, as well as excess fat in visceral adi-
pose tissue — also provokes insulin resistance. In addi-
tion, excessive ectopic fat accumulation can elevate serum
levels of free fatty acids, resulting in systemic lipotoxicity
and β-​cell dysfunction. T2DM develops as a consequence
of the combination of insulin resistance and relative insu-
lin deficiency. Glucolipotoxicity-​related mitochondrial
dysfunction, oxidative stress, inflammation and ER stress
in pancrea­tic β-​cells, the liver, skeletal muscle and adipose
tissue are closely related to the pathogenesis of T2DM.
Thus, autophagy has an important homeostatic role in
mitigating the adverse cellular effects of chronic calorie
excess through organelle quality control and removal of
protein aggregates and lipid droplets.
The importance of autophagy in the pathogenesis
of metabolic derangements has been shown in mouse
Ubiquitin-​independent
BCL2/adenovirus E1B 19 kDa protein-​interacting
protein 3 (BNIP3), BCL2/adenovirus E1B 19 kDa
protein-​interacting protein 3-​like (BNIP3L, also
known as NIX) and FUN14 domain-​containing
protein 1 (FUNDC1)
Optineurin
FAM134B (also known as reticulophagy regulator
1 (RETREG1))
Patatin-​like phospholipase domain-​containing
enzyme 8 (PNPLA8)
Reviews

Box 1 | Autophagic flux measurement using fluorescent reporters accumulation of damaged organelles or lipid droplets
is crucial for the pathogenesis of metabolic disease. The
Autophagic flux determination using tandem fluorescent reporters (in which red contribution of impaired autophagy to the development
fluorescent protein (RFP) and green fluorescent protein (GFP) are sequentially bound of metabolic disease is illustrated in Fig. 4.
to the cargo protein of interest) does not require lysosome inhibition, and the tandem
fluorescent module can be adapted to determine whether individual autophagic
Pancreatic β-​cell function
structures are degraded after fusion with lysosomes. Examples of such reporters
include RFP–GFP–LC3 and RFP–GFP–sequestosome-1, in which a monomeric RFP The contribution of autophagy to β-​cell physiology and
(such as mCherry) and GFP are bound to the N terminus of LC3. When autophagosomes metabolic adaptation has been demonstrated in mice with
develop, cells transfected with these reporters exhibit yellow fluorescence due to the autophagy-​deficient β-​cells. Mice with β-​cell-​specific
overlap of red and green fluorescence. Within autolysosomes, GFP fluorescence is ablation of Atg7 develop glucose intolerance and
immediately quenched by the acidic environment, leaving only the red fluorescent decreased insulin secretion81,82, which indicates that basal
signal, which is unaffected by acidic conditions. Confocal microscopy can be used autophagy is crucial for insulin secretion. Under physio­
to observe dynamic changes in the fluorescent signal indicative of autophagic flux. logical fasting conditions, insulin secretion decreases
Selective autophagy substrates such as sequestosome-1 can be used instead of LC3. because the early secretory granules of insulin are
In transfected cells, the GFP–LC3–-​RFP–LC3ΔG reporter (in which GFP–LC3 is fused degraded by lysosomes through inactivation of protein
to the N terminus of an RFP–LC3 molecule whose C-​terminal glycine is deleted) is
kinase D. This process, which is called starvation-​induced
co-​translationally processed by ATG4 to produce GFP–LC3 and free RFP–LC3ΔG.
The GFP–LC3 moiety acts as an autophagic substrate and serves to measure autophagic nascent granule degradation83, results in mTORC1
activity. By contrast, free RFP–LC3ΔG lacks the C-​terminal glycine needed for conjuga- activation and increased levels of intracellular amino
tion to the autophagosome membrane and remains in the cytoplasm where it acts as acids despite fasting, which lead to suppression of auto-
an internal control for reporter expression and cellular health. The ratio of GFP–LC3 phagy. Moreover, excess autophagy in β-​cells degrades
to RFP–LC3ΔG is inversely correlated with cumulative autophagic degradation activity insulin-​c ontaining vesicles through vesicophagy,
and can be evaluated using flow cytometry or a fluorescence microplate reader. The resulting in a decrease in insulin content and glucose
consumption of autophagosomes can be assessed by simply measuring the amount intolerance84. Although basal autophagy and appropri-
of reduction in GFP–LC3 via flow cytometry. However, because this system lacks an ate adaptive autophagy responses are both required for
internal control, another reporter must be used to simultaneously evaluate changes the maintenance of β-​cell mass and insulin secretion,
in cellular health.
insulin secretion is inhibited by starvation-induced
An LC3–HiBiT reporter can be used to measure autophagic flux by monitoring LC3
reporter levels in cell lysates. This reporter employs an 11 amino acid HiBiT peptide nascent granule degradation-​mediated suppression
linked to human LC3B. The HiBiT peptide binds with high affinity to the luciferase of autophagy, which prevents hypoglycaemia under
subunit LgBiT, producing active luciferase, which generates luminescence proportional physiological fasting conditions.
to the amount of autophagy in the presence of furimazine. The amount of LC3 reporter Pancreatic β-​cells from patients with T2DM exhibit
within the cell can be measured using a microplate reader. more abundant autophagic vacuoles and autophago-
Keima is a coral-​derived acid-​stable fluorescent protein. Fluorescence microscopy somes and have lower expression of lysosomal genes
detects ionized Keima within lysosomes as a red fluorescent signal at pH <7.0 and than do β-​cells from people without diabetes, which
neutral Keima in the cytoplasm as a green fluorescent signal at pH ≥7.0. Delivery of suggests that T2DM causes alterations at the level of
cytosolic Keima to the lysosome reflects non-​selective macroautophagy, whereas autophagic structure removal85. Indeed, in cultured
delivery of Keima fused to a specific (for example, mitochondrial) protein reflects
β cells, simulation of glucolipotoxicity via treatment
selective autophagy (mitophagy).
Several transgenic mouse models have been engineered to express tandem fluorescent with palmitate and high glucose levels suppresses auto-
reporters, such as GFP–LC3 (systemic and cardiac-​specific models), mCherry–LC3 phagy via decreased lysosome-​related gene expression,
(cardiac-​specific model), mCherry–GFP–LC3 (cardiac-​specific model), monomeric impaired autophagosome–lysosome fusion or decreased
RFP–GFP–LC3 (systemic and cardiac-​specific models), GFP–LC3–RFP–LC3∆G lysosomal acidification86–89. In these β-​cell models,
(systemic model), and mitochondria-​targeted Keima (systemic model). pharmacological lysosome reacidification or autophagy
induction restores autophagic flux even under lipotoxic
models of genetically altered autophagic function. conditions90, whereas blocking autophagy exacerbates
Although Atg7+/− mice show no metabolic abnorma­ lipotoxicity91. Moreover, simultaneous activation of
lities, Atg7+/−ob/ob mice and Atg7+/− mice fed a high-​fat autophagy (by intracellular stresses, such as ER stress)
diet exhibit insulin resistance, increased lipid storage and blockade of autophagic flux causes the accumula-
and elevated inflammation in the liver, skeletal tion of defective lysosomes, which leads to the induction
muscle and adipose tissue79. In addition, Atg4b–/– mice of β-​cell death89. Thus, glucolipotoxicity is involved in
(which have limited autophagic competence) exhibit the β-​c ell dysfunction mediated by dysregulated
a considerable increase in body weight, expanded autophagic flux; however, the detailed mechanism
adipocytes in their visceral fat, increased liver steatosis underlying this process remains unknown.
and insulin intolerance upon metabolic challenge with In addition, ER stress contributes to the production
either a high-fat diet or sugar-​enriched drinking water80. of human islet amyloid polypeptide (hIAPP), which
Moreover, Atg4b–/– mice have increased vulnerability forms amyloid aggregates associated with β-​cell death
to (and increased severity of) streptozotocin-​induced and with the development of T2DM92. Several studies
T1DM owing to their compromised pancreatic β-​cell have demonstrated that autophagy is essential to protect
homeostasis80. Autophagy-​inducing treatment rescues β-​cells from toxic hIAPP oligomer accumulation93,94.
the diabetic pheno­types of these mice79. By contrast,
Atg5-​overexpressing lean mice exhibit increased insulin Liver function
sensitivity, resistance to oxidative stress and enhanced The liver is one of the most metabolically active organs
motor function alongside their extended lifespan73. and controls both glucose and lipid metabolism.
Thus, autophagy at levels insufficient to prevent the Non-​a lcoholic fatty liver disease (NAFLD) caused

www.nature.com/nrendo

0123456789();:
 Reviews

a by hepatic lipid accumulation due to overnutrition is

• Intracellular stress • Hypoxia
• Mitochondrial dysfunction • ER stress responsible for hepatic insulin resistance and contri­
• Oxidative stress • Change in nutrient status butes to T2DM95. Hepatic autophagy is now known to
• Inflammation play a crucial role in the regulation of glucose and/or
lipid metabolism, insulin resistance and energy balance
in the whole body.
In mouse models of obesity or diabetes (such as db/db
Level of autophagy or ob/ob mice, and mice fed a high-​fat diet96) liver cells
exhibit decreased autophagic flux similar to that in
Impaired (insufficient) Basal autophagy or adequate adaptive responses Excessive humans with NAFLD97. Mice with conditional knockout
of Atg7 in hepatocytes exhibit accumulations of swollen
and deformed mitochondria and an increased number
of ubiquitylated protein aggregates and lipid droplets72.
Experiments in mice with hepatocyte-​specific knockout
of Atg7 or cultured mouse hepatocytes with knock­
down of Atg7 or Atg5 expression have revealed that
inhibition of autophagy increases triglyceride storage
↑ Damaged organelles ↓ Clearance of damaged or ↑ Cell death in lipid droplets98. In addition, mice with hepatocyte-
↑ Protein aggregates excess cellular components specific knockout of Vps34 develop hepatomegaly and
↑ Lipid droplets
hepatosteatosis along with impaired protein turnover99.
Moreover, another study demonstrated that small hair-
• Maintenance of pin (sh)RNA-​mediated knockdown of liver Atg7 in mice
• Cellular dysfunction cellular homeostasis
↑ Senescence ↓ Senescence results in insulin resistance, glucose intolerance and ER
stress96. Conversely, restoration of Atg7 expression via
adeno­viral gene delivery in the livers of ob/ob mice or
b mice fed a high-​fat diet improves whole-​body insulin
Overnutrition
↑ Insulin–IGF-I signalling Starvation
sensitivity through the suppression of hepatic glucose
↑ Intracellular amino acids Energy depletion production and enhancement of insulin-​stimulated
glucose disposal in the periphery96.
Transcription factor EB (TFEB) is a member
↑ mTORC1 ↓ mTORC1 of the basic helix–loop–helix leucine-​zipper family of

Fig. 3 | Effects of autophagy on cellular senescence and

regulation of autophagy by nutrient-sensing pathways.
↓ Autophagy ↑ Autophagy
a | Intracellular stresses, including mitochondrial dys­
function, oxidative stress, inflammation, hypoxia, endo-
plasmic reticulum (ER) stress and changes in nutrient
↓ LKB1 ↑ LKB1 status regulate autophagy. Basal autophagy and adequate
↓ AMPK ↓ SIRT1 ↑ AMPK ↑ SIRT1 adaptive autophagy responses promote homeostasis at
↓ NAD+ ↑ NAD+ the cell and organelle levels, resulting in protection from
senescence and prolonged cell survival. Inadequate or
impaired autophagy leads to cellular dysfunction and
c Overnutrition Starvation senescence owing to the accumulation of damaged
TFEB organelles, protein aggregates or lipid droplets, whereas
mTORC1 TFE3 TFEB excessive autophagy leads to reduced cell survival or
TFE3 P mTORC1 P P cell death. b | Excess nutrition decreases autophagy via
mechanistic target of rapamycin complex 1 (mTORC1)
activation and reduces the function of AMP-​activated
Lysosome Cytosol
kinase (AMPK) and sirtuin-1 (SIRT1). By contrast, starvation
or energy depletion induces autophagy via reduced
mTORC1 activity and reduced activation of AMPK and
SIRT1. Crosstalk between nutrient-​sensing pathways that
↑ Lysosomal ↓ Lysosomal converge on mTORC1, AMPK and SIRT1 is mediated by
component genes component genes changes in NAD+ levels or in the activity of liver kinase B1
Nucleus ↑ Autophagy- ↓ Autophagy-
related genes related genes (LKB1). c | The transcription factors TFEB and TFE3 control
TFEB lysosomal numbers and function by positively regulating
TFE3 genes in the coordinated lysosomal expression and regula-
Promoters of Promoters of
tion (CLEAR) network. In overnutrition conditions, TFEB and
CLEAR-related genes CLEAR-related genes TFE3 translocate to the nucleus and drive the expression of
CLEAR-​related genes (which encode autophagy-​related
and lysosomal proteins), resulting in increased lysosomal
biogenesis and increased autophagic flux. By contrast,
under starvation conditions these transcription factors
↑ Autophagic flux ↓ Autophagic flux
remain phosphorylated and inactive in the cytosol.
IGF-​I, insulin-​like growth factor-1.

Nature Reviews | Endocrinology

0123456789();:
Reviews

Table 2 | regulation of autophagy via nutrient-​sensing pathways

Target molecules and phosphorylation site(s) Function Effect on autophagy refs
mTORC1
ATG13 phosphorylation at Ser258 Decreased ULK1 complex activity Decreased initiation 22

ULK1 phosphorylation at Ser637 and Ser757 Decreased ULK1 complex activity Decreased initiation 23,24

ATG14 phosphorylation at Ser3, Ser223, Thr303 Decreased PI3KC3-​CI activity Decreased nucleation 25

and Ser440
AMBRA1 phosphorylation at Ser52 Decreased PI3KC3-​CI activity Decreased nucleation 26

NRBF2 phosphorylation at Ser113 and Ser120 Decreased PI3KC3-​CI activity Decreased nucleation 15

Decreased ULK1-​mediated ATG14 phosphorylation Decreased PI3KC3-​CI activity Decreased nucleation 28

at Ser29
Phosphorylation of p300 at Ser2271, Ser2279, Decreased LC3 acetylation leading to Decreased phagophore elongation; 29

Ser2291 and Ser3375 decreased LC3–ATG7 interaction; decreased decreased nucleation

VPS34 acetylation leading to decreased
PI3KC3-​CI activity
WIPI2 phosphorylation at Ser395 Degraded by HUWE1 Decreased phagophore elongation 30

UVRAG phosphorylation at Ser498 Blocks UVRAG–rubicon interaction leading Decreased autolysosome formation 31

to decreased PI3KC3-​CII activity

UVRAG phosphorylation at Ser550 and Ser571 Increased VPS34 and increased PI3P at the Increased lysosome re-​formation 32

lysosome
Pacer phosphorylation at Ser157 Decreased HOPS–STX17 interaction Decreased autolysosome formation 33

TFEB phosphorylation at Ser211, Ser122 and Decreased translocation into the nucleus Downregulation of genes involved in 34–36

Ser142 lysosomal biogenesis and autophagy

TFE3 phosphorylation at Ser321 Decreased translocation into the nucleus Downregulation of genes involved in 37–39

lysosomal biogenesis and autophagy

AMPK
TSC2 phosphorylation at Thr1227 and Ser1345 Decreased mTORC1 activation Increased flux 40

Raptor phosphorylation at Ser722 and Ser792 Decreased mTORC1 activation Increased flux 41,42

ULK1 phosphorylation at Ser467 , Ser555, Ser574, Increased ULK1 complex activity Increased initiation 43–46

Ser637 and Thr574

ULK1 phosphorylation at Ser317 and Ser777 Increased ULK1 complex activity Increased initiation 23

ULK1 phosphorylation at Ser224 Decreased ULK1 complex activity Decreased initiation 22

ATG9 phosphorylation at Ser761 Increased ATG9-​containing vesicles Increased phagophore elongation 53

VPS34 phosphorylation at Thr163 and Ser165 Non-​autophagic (in the absence of ATG14); Increased nucleation 52

decreased PI3KC3-​CI activity

Beclin-1 phosphorylation at Ser91 and Ser94 Increased PI3KC3-​CI activity Increased nucleation 52

DAPK2 phosphorylation at Ser289 Decreased DAPK2-​mediated Increased nucleation 48

phosphorylation of beclin-1 at Thr119

PAQR3 phosphorylation at Thr32 Increased PI3KC3-​CI activity Increased nucleation 49

RACK1 phosphorylation at Thr50 Increased PI3KC3-​CI activity Increased nucleation 50

SIRT1
ATG5, ATG7 and decreased LC3 acetylation Increased ATG12 conjugation Increased nucleation and phagophore 54,55

elongation
Decreased FOXO1 acetylation Increased Rab-7a levels Increased autolysosome formation 56

Decreased FOXO3 acetylation Increased BNIP3 and NIX levels Increased mitophagy 57

AMBRA1, activating molecule in beclin 1-​regulated autophagy protein 1; AMPK, AMP-​activated kinase; ATG, autophagy related gene; BNIP3, BCL2 and adenovirus
E1B 19kDa-​interacting protein 3; DAPK2, death-​associated protein kinase 2; FOXO, forkhead box O; HOPS, homotypic fusion and protein sorting; HUWE1, E3
ubiquitin ligase; LC3, microtubule-​associated protein 1A/1B-​light chain 3; NRBF2, nuclear receptor binding factor 2; PAQR3, progestin and adipoQ receptor family
member 3; PI3KC3-​C, class III phosphatidylinositol 3-​kinase-​complex; PI3P, phosphatidylinositol-3-​phosphate; Rab-7a, Ras-​related protein; RACK1, receptor of
activated protein C kinase 1; SIRT1, sirtuin-1; STX17 , syntaxin-17; TFE3, transcription factor E3; TFEB, transcription factor EB; TSC2, tuberous sclerosis complex 2;
ULK1, UNC-​like autophagy activating kinase 1; UVRAG, ultraviolet (UV) irradiation resistance-​associated gene; VPS34, vacuolar protein sorting 34; WIPI2, WD-​repeat
domain effector protein 2.

transcription factors. TFEB controls lysosomal bio- starvation conditions, TFEB translocates to the nucleus
genesis and autophagy by regulating the expression where it induces the expression of lysosomal component
of TFEB target genes in the coordinated lysosomal genes and ATGs, resulting in new lysosome generation
expression and regulation (CLEAR) network66. Under and increased autophagic flux. Livers from mice with

www.nature.com/nrendo

0123456789();:

liver-​specific knockout of Tfeb are large and pale, and
their hepatocytes are filled with lipid vacuoles, consis­
tent with impairment of lipid degradation pathways100.
By contrast, livers from mice fed a high-​fat diet that were
injected with an adenoviral expression vector including
human TFEB have a normal dark-​red colour and
markedly less lipid accumulation than do livers from
wild-​t ype controls 100. Liver overexpression of Tfeb
↑ Nutrients Obesity ↓ Exercise
↑ Ectopic and visceral fat accumulation
Lipotoxicity
Oxidative stress, inflammation, ER stress
Normal autophagy
response
Impaired autophagy
response
Glucotoxicity ↑ Damaged organelles, lipid droplets, protein aggregates
Impaired cellular homeostasis
β-cell Liver Adipose tissue Skeletal muscle
↑ Fat Adipocyte ↓ Muscle mass
↓ Insulin
secretion deposition dysfunction ↓ Muscle strength
NAFLD Sarcopenia,
sarcopenic obesity
↑ Insulin resistance,
T2DM
Fig. 4 | relationships between obesity, insulin resistance, T2dM and autophagy.
Excessive nutrition and insufficient exercise lead to obesity with ectopic and visceral
fat accumulation, which result in lipotoxicity, oxidative stress, inflammation and endo-
plasmic reticulum (ER) stress. Under lipotoxic conditions, cellular homeostasis and
autophagy are impaired and lead to organelle damage, lipid droplet accumulation
and protein aggregation in pancreatic β-​cells, liver tissue, adipose tissue and skeletal
muscle. As a result, β-​cells exhibit reduced insulin secretion, and increased lipid
deposition is observed in the liver and is associated with non-​alcoholic fatty liver disease
(NAFLD). An impaired autophagy response also contributes to adipocyte dysfunction,
such as excess or reduced lipid storage or abnormal adipokine secretion. In skeletal
muscle, impaired autophagy contributes to reductions in muscle mass and strength and
impaired muscle quality, leading to the development of sarcopenia (sarcopenic obesity).
Consequently, functional impairment of β-​cells, liver tissue, adipose tissue and skeletal
muscle causes insulin resistance and type 2 diabetes mellitus (T2DM). Glucotoxicity due
to continuous high glucose levels further exacerbates the oxidative stress, inflammation
and ER stress resulting from lipotoxicity. In addition, ageing is involved in both
impairment of autophagy and increased intracellular stress, and impaired autophagy
promotes the development and exacerbation of insulin resistance and T2DM.
Nature Reviews | Endocrinology
0123456789();:
Reviews
attenuates obesity in mice fed a high-​fat diet and the
metabolic syndrome phenotype in ob/ob mice 100.
Similarly to TFEB, TFE3 is another transcription factor
that activates lysosomal biogenesis and autophagy.
The presence of rubicon protein, which inhibits
autophagosome and lysosome fusion, is also thought
to be involved in the pathogenesis of NAFLD. In mice
with hepatocyte-​specific knockout of Rubcn, autophagy
suppression is abolished. Moreover, in Rubcn-​knockout
mice fed a high-​fat diet, hepatotoxicity, lipid droplet
accumulation and hepatic steatosis are all attenuated101.
In addition, expression of Rubcn is increased in cultured
mouse hepatocytes after treatment with palmitate and in
human hepatocytes from patients with NAFLD101. These
results suggest that the pathophysiology of NAFLD
is related to suppression of autophagic flux, which is
mediated by increased expression of RUBCN.
Adipose tissue function
Basal autophagy plays an important part in the regula-
tion of adipocyte development and differentiation. The
role of basal autophagy in adult adipocytes has been elu-
cidated using mice in which autophagy has been geneti­
cally altered. Mice with adipocyte-​specific knockout of
Atg7 exhibit relatively small lipid deposits throughout
the whole body, multilocular lipid droplets in adipocytes
and an increased number of mitochondria102. Ablation
of autophagy in white adipose tissue induces adipocyte
browning, which has several results: increased energy
expenditure; increased insulin sensitivity; reduced levels
of adipokines, such as leptin; and a lean and obesity-
resistant phenotype. However, the loss of normal lipid
deposits leads to increased perinatal and postnatal
mortality, possibly because lipid storage is insufficient
to meet the energy demands associated with acute
stress. When essential autophagy genes (such as Atg7)
are subjected to conditional knockout, the resulting
adipocytes are dysfunctional and tend to lose their lipid
storage and endocrine capabilities. Therefore, basal auto-
phagy is essential for maintaining adipocyte function.
By contrast, Atg4b–/– mice (which show partial auto-
phagic insufficiency) fed a calorie-​rich diet exhibit an
obese phenotype accompanied by large adipocytes80, as
described above. This finding indicates that an adaptive
response of autophagy to metabolic stresses is required
for the suppression of obesity and metabolic diseases.
With ageing, adipose tissue undergoes substantial
changes in abundance, distribution, cellular composi-
tion and endocrine signalling that are associated with
the development of insulin resistance and metabolic
dysfunction103. Autophagy in subcutaneous and visceral
adipose tissue is upregulated in patients with obesity or
T2DM104–107. In addition, the expression of RUBCN in
adipose tissue decreases with age, resulting in increased
autophagic activity. Mice with adipocyte-​specific knock-
out of Rubcn exhibit fat atrophy, glucose intolerance,
dyslipidaemia and hepatic fat accumulation related to
decreased lipid storage capacity and reduced endocrine
activity of adipokines such as adiponectin108. Thus,
rubicon has an essential role in the maintenance of
adipo­cyte function and systemic metabolic homoeostasis
by preventing excessive autophagy.
Reviews
Skeletal muscle function
Skeletal muscle has an important role in glucose meta­
bolism; therefore, the decreased skeletal muscle mass
and strength associated with sarcopenia can increase
the risk of insulin resistance and T2DM, particularly in
older people109,110. Insulin resistance in skeletal muscle is
closely related to reduced muscle mass111 because insulin
and insulin-​like growth factor-1 (IGF-​I) signalling are
both crucial for protein synthesis in muscle112,113. Thus,
an appropriate balance between anabolic and catabolic
states, which is driven by nutrient intake and nutrient-
sensing pathways, is important for maintaining muscle
mass. In addition, obesity and sarcopenia often coexist
and sarcopenic obesity is recognized to worsen several
metabolic diseases, including T2DM3.
The role of basal autophagy in skeletal muscle main-
tenance has been shown in mice with skeletal muscle-
specific knockout of Atg7, which exhibit pheno­types
that include accumulation of abnormal mitochondria
and protein aggregates, abnormalities in motor neuron
synapses, muscle atrophy and age-​dependent decreases
in muscle strength114,115. In addition, autophagy becomes
progressively more dysfunctional in the muscles of age-
ing rodents and in older individuals with sarcopenia or
frailty51,115. Moreover, among elderly people, those who
are overweight exhibit increased dysregulation of seve­
ral autophagic processes, including autophagosome–
lysosome fusion, in skeletal muscle116. The relationship
between insulin resistance and impaired autophagy in
skeletal muscle has been demonstrated in humans and
in vitro studies. For example, expression of ATGs is
decreased in skeletal muscle samples from patients with
T2DM who require more than 100 U of insulin daily, and
this decrease is associated with abnormal mitochondrial
morphology and impaired function in skeletal muscle117.
Moreover, palmitate-​induced cellular senescence and
insulin resistance in cultured muscle cells, including
myoblasts and myotubes, are mediated by impairment
of autophagic flux118.
Insufficient or impaired mitophagy might result in the
accumulation of damaged mitochondria in skeletal mus-
cle during ageing119. In addition, increased lipid deposi-
tion in skeletal muscle cells can causes an age-​associated
decline in mitochondrial function. As lipophagy has
an important role in degradation of lipid droplets in
skeletal muscle cells, impaired lipophagy might lead
to the accumulation of lipid droplets and ultimately to
lipotoxicity in skeletal muscle120. Thus, impairments in
selective autophagy, such as mitophagy and lipophagy,
in skeletal muscle could be involved in the pathogenesis
of age-​associated insulin resistance and T2DM. However,
no direct evidence of reduced mitophagy and lipophagy
in skeletal muscle in older humans is available so far;
further studies are necessary to confirm this hypothesis.
Because of the large energy demand associated
with stellate cell activation, autophagic flux is required
for quie­scent stellate cells (also termed muscle stem
cells) to be activated, proliferate and differentiate into
myoblasts121. Thus, suppression of autophagic flux delays
muscle fibre regeneration. During ageing, the regenera­
tive capacity of muscle stem cells declines, which is
associated with switching of the quiescent state into a
0123456789();:
senescent state. Regarding this point, basal autophagy
is essential for maintenance of the quiescent state in
mouse muscle stem cells122. Dysfunctional autophagy
in aged satellite cells or genetic ablation of autophagy in
young satellite cells induces senescence owing to the loss
of proteostasis as well as increased mitochondrial dys-
function and oxidative stress, which result in declines in
the function and number of satellite cells. Restoration of
autophagy restores the regenerative function of senescent
satellite cells from older individuals122.
Therapeutic interventions
Calorie restriction
Calorie restriction supports longevity and aids in the
treatment of age-​related diseases123. Autophagy mediates
the beneficial effect of calorie restriction on lifespan, and
inhibition of autophagy largely mitigates its longevity‐
enhancing effects124,125. Humans experiencing long-​term
moderate calorie restriction (a ~30% reduction com-
pared with the typical Western diet, for an average of
9.6 years) show increased transcript levels of various auto-
phagy modulators, including AMPK and sirtuin family
members, as well as downregulation of the insulin–IGF-1
signalling pathway in skeletal muscle compared to age‐
matched controls126. Furthermore, the altered skeletal
muscle transcriptional profiles induced by calorie restric-
tion resembled those of younger control individuals126.
A separate study demonstrated that ATGs, including
ULK1 and BECN1, are expressed at higher levels in the
skeletal muscle of people eating a calorie-​restricted diet for
3–15 years than in the skeletal muscle of age-​matched
sedentary individuals eating a typical Western diet127.
In animal models of obesity and T2DM (namely, db/db
mice and mice fed a high-​fat diet), calorie restriction
alleviates hepatosteatosis and improves β-​cell function,
blood glucose levels and lipid profiles; these changes are
associated with improvements in autophagy128–130.
In addition, modified forms of calorie restriction
(such as intermittent fasting, isocaloric twice-​a-​day
(ITAD) feeding or inter-​meal fasting) can activate auto-
phagy, thereby contributing to improvements in blood
glucose levels and lipid metabolic profiles. Intermittent
fasting preserves organelle quality via the autophagy–
lysosome pathway and enhances β-​cell survival in
individuals with obesity-​induced diabetes131. ITAD
feeding also prevents metabolic defects associated
with both obesity and ageing, including glucose intole­
rance and hypertriglyceridaemia, and reduces maxi-
mal oxygen consumption in mice fed a high-​fat diet132.
Finally, Roux-​en-​Y gastric bypass rapidly reduces hepatic
lipid toxicity and attenuates insulin sensitivity in obese
rats with T2DM133,134. In these rats, activation of hepatic
autophagy plays an important part in long-​term control
of hepatic lipid metabolism, which might be related
to inhibition of the mTORC1 signalling pathway and
upregulation of glucagon-​like peptide-1 (GLP-1)133,134.
Exercise
The beneficial effects of exercise include extension of
lifespan, attenuation of metabolic disease and mitiga-
tion of sarcopenia. Acute endurance exercise increases
autophagic activity in the heart, liver, β-​c ells and
www.nature.com/nrendo

adipose tissue in mice135. However, an autophagy‐defi-
cient mouse model that contains knock-​in mutations at
three BCL2 phosphorylation sites (Thr69Ala, Ser70Ala
and Ser84Ala) does not obtain these exercise-​mediated
benefits and is not protected from glucose intolerance
induced by a high-​fat diet135. In addition, mice lacking
collagen VI, another model of compromised autophagy,
are exercise-​intolerant and develop an exacerbated
dystrophic phenotype upon acute and chronic exercise136.
Thus, autophagic regulation plays a crucial role in the
maintenance of skeletal muscle mass and in adaptation
to cellular damage in response to exercise.
Chronic exercise leads to upregulation of auto-
phagy not only in skeletal muscle137,138 but also in the
liver, and this mechanism is involved in amelioration of
hepatosteatosis139–141. Long-​term adaptations to exercise
that are potentiated by exercise-​induced autophagy are
mediated by mild oxidative stress, energetic imbalance,
mitochondrial calcium accumulation and misfolded
proteins. Exercise-​induced autophagy leads to improve-
ments in mitochondrial quality control and protein turn-
over as well as metabolic adaptations and angiogenesis,
which collectively result in enhanced endurance and
improvements in both glucose and lipid homeostasis.
The beneficial effects of calorie restriction and
exercise are mediated by shared pathways involved in
the regu­lation of autophagy, including nutrient-​sensing
pathways. Accordingly, the benefits of exercise might be
related to autophagy-​activating mechanisms that also
underlie the positive effects of calorie restriction on
lifespan and age‐related diseases142,143. However, auto­
phagy induction is differentially affected by exercise
training modes, such as resistance exercise and endurance
exercise, and also by different nutrient intake conditions.
Pharmacological interventions
Antidiabetic medicines, including metformin, GLP-1
receptor agonists and sodium–glucose co-​transporter 2
(SGLT2) inhibitors can show beneficial effects on glucose
and lipid metabolism through modulation of autophagy.
In addition, rapamycin, polyphenols and spermidine
can extend lifespan through induction of autophagy.
Metformin. Metformin has strong positive effects on fun-
damental anti-​ageing mechanisms144, and a previous study
showed lifespan-​extending and health-​extending effects
of metformin in middle-​aged male mice145. Several studies
have demonstrated that metformin is involved in the regu­
lation of glucose and lipid metabolism by autophagy in
the liver, adipose tissue and pancreatic β-​cells. For exam-
ple, metformin attenuates hepatosteatosis via SIRT1 acti-
vation in ob/ob mice146 and via AMPK activation in mice
fed a high-​fat diet147, although metformin also inhibits
autophagy in epididymal adipose tissue147. Furthermore,
metformin attenuates systemic oxidative stress, visceral
adipose tissue inflammasome expression and auto-
phagy in patients with T2DM with obesity107. Thus,
metformin affects the regulation of autophagy in a tissue-​
dependent fashion, and these tissue-​specific responses to
metformin are modulated by obesity. In addition, met-
formin stimulates β-​cell autophagy and prevents β-​cell
apoptosis under conditions of lipotoxicity in vitro148.
Nature Reviews | Endocrinology
0123456789();:
Reviews
GLP-1 receptor agonists and DPP-4 inhibitors. GLP-1
facilitates autophagy by preventing the impairment of
autophagosome–lysosome fusion that would other­
wise occur under conditions of chronic nutrient
excess. Numerous studies conducted in animal models
of diabetes and obesity or in INS-1 cells (an insulin-
secreting pancreatic β-​cell line) have shown that the
protective effects of GLP-1 receptor agonists (including
liraglutide and exendin-4) against glucolipotoxicity in
β-​cells are mediated in part by induction of autophagy via
either AMPK and forkhead box O1 (FOXO1) activation
or restoration of lysosome function89,149–155. Liraglutide
attenuates hepatosteatosis by inducing autophagy via the
AMPK and mTORC1 pathways156,157. In addition, GLP-1,
exendin-4 and liraglutide protect hepatocytes from free
fatty acid-​related death by prohibiting a dysfunctional
ER stress response and by reducing fat accumulation
and apoptosis via activation of both macroautophagy and
chaperone-​mediated autophagy158. Moreover, liraglutide
attenuates hepatosteatosis by restoring autophagic
flux, specifically flux through the GLP-1 receptor and
TFEB-​mediated lysosomal autophagy pathway159.
Dipeptidyl peptidase-4 (DPP-4) inhibitors can induce
endogenous GLP-1 or block its breakdown, thereby
increasing the levels of this incretin hormone. The
DPP-4 inhibitor MK-626 restores insulin secretion by
enhancing autophagy in mice fed a high-​fat diet through
upregulation of GLP-1 (ref.160). Long‐term treatment
with alogliptin, another DPP-4 inhibitor, improves the
survival and health of such mice through autophagy
induction, the mechanism of which is dependent on the
SIRT1–AMPK–mTORC1 cascade161. Moreover, aloglip-
tin has other beneficial effects associated with increased
longevity; for example, this agent increases insulin sensi­
tivity, attenuates the functional decline of pancreatic
β-​cells, decreases organ pathology in the liver, bone and
vasculature, preserves hepatic mitochondrial function
and reduces oxidative stress161. However, whether inhibi-
tion of DPP-4 itself or other factors, including increased
incretin levels, contribute to longevity remains unclear.
Interestingly, IL-6 regulates GLP-1 production by
pancreatic α-​cells162 and is also able to stimulate β-​cell
autophagy, which protects β-​cells against apoptosis
under conditions of metabolic stress163. However, the
regulation of autophagy by IL-6 in β-​cells is specific to
this cell type and differs from that in other tissues.
SGLT2 inhibitors. In addition to its glucose-​lowering
role, SGLT2 inhibitor treatment has multiple beneficial
consequences, including cardioprotective and renopro-
tective effects as well as hepatosteatosis-​ameliorating
effects. As one of the mechanisms by which SGLT2
inhibitors exert organ-​protective effects, SGLT2 inhibi­
tion is expected to induce autophagy through the modu­
lation of nutrient-​s ensing pathways, including the
activation of AMPK or SIRT1 resulting from continuous
energy loss due to increased excretion of glucose into
the urine164,165. Indeed, several studies have shown that
SGLT2 inhibitors exert renoprotective effects by alleviat-
ing autophagic flux impairment in proximal tubular cells
in obese mice fed a high-​fat or high-​sucrose diet and in
mice with streptozotocin-​induced diabetes166. Moreover,
Reviews

the cardioprotective and anti-​inflammatory effects of
SGLT2 inhibitors are partially exerted through auto-
phagy induction167,168. However, whether SGLT2 inhibi-
tion improves longevity through autophagy induction
remains unclear.
Rapamycin. Rapamycin treatment extends lifespan in
mice169,170 and promotes cardioprotection171 and pre-
vents obesity172 in rodents. However, prolonged rapa-
mycin treatment exacerbates insulin resistance and
diabetes173 and actually reduces the lifespan of diabetic
mice174. An intermittent treatment regimen that avoids
these adverse effects of continuous rapamycin has been
found to extend the lifespan of aged female mice175.
In addition, rapamycin attenuates insulin resistance and
hepatosteatosis in rats with T2DM through activation
of autophagy176. However, whether rapamycin treatment
also improves longevity through autophagy induction
remains unclear, and further studies are necessary to
address this point.
Spermidine. Spermidine, a natural polyamine whose
intracellular concentration declines during human
ageing, has been found to increase the life expectancy
of yeast, C. elegans, Drosophila and mice. Enhanced
autophagy contributes to lifespan extension by sper­
midine 177–180. In addition, autophagy induction by
spermidine protects against the detrimental effects of
a high-​fat diet, including weight gain, glucose intole­
rance, increased adipocyte size and hepatosteatosis,
in wild-​type mice80.
Polyphenols. Several polyphenols derived from natural
sources have been shown to act as autophagy inducers.
Resveratrol, which activates SIRT1 (ref.181), has been
shown to increase lifespan in C. elegans via an auto-
phagy‐dependent mechanism182 and to exhibit health‐
promoting effects, especially in obese overfed mice183.
3,4‐Dimethoxychalcone promotes the nuclear translo-
cation of autophagy-​promoting transcription factors,
including TFEB, resulting in autophagy induction and
cardioprotective and anticancer effects in mice184. In addi-
tion, 4,4′-​dimethoxychalcone administration extends
lifespan in yeast, C. elegans and Drosophila; retards the
development of senescence in cultured cells; and pro-
tects mice from prolonged myocardial ischaemia185.
The activation of autophagy by 4,4′-​dimethoxychalcone
depends on inhibition of GATA transcription factors but
is independent of mTORC1 (ref.185).
ACBP blockers. Acyl coenzyme A-​binding protein
(ACBP) has been identified as an appetite stimula-
tor. Physiologically, starvation causes the autophagy-
dependent release of ACBP from many mammalian
cell types, including adipocytes and hepato­cytes, and
an increase in circulating levels of ACBP186. Circulating
ACBP functions as a neuroendocrine factor, such that
its increased levels promote feeding behaviour, conse-
quently mitigating starvation and nutrient deprivation,
which are the cause of autophagy induction187. At the
same time, the autophagy-​driven release of ACBP from
cells results in depletion of intracellular ACBP. The
depletion of intracellular ACBP and increased extracel-
lular concentration of ACBP both cause feedback inhibi­
tion of autophagy in a cell-​autonomous fashion and a
paracrine fashion, respectively186.
Paradoxically, obese mice fed a high-​fat diet and ob/ob
mice exhibit elevated expression of the gene encoding
ACBP in white adipose tissue and the liver as well as
increased levels of ACBP in the circulation186. In these
mice, starvation causes a decrease from baseline in
expression of the gene encoding ACBP in white adipose
tissue and the liver186. In humans, BMI is strongly and
is positively correlated with circulating levels of ACBP;
individuals with anorexia nervosa have abnormally
low circulating levels of this protein186. In addition, in
mice, administration of recombinant ACBP protein or
transgenic overexpression of the gene encoding ACBP
in the liver induces hyperphagia and lipoanabolic reac-
tions along with suppression of autophagy, consequently
leading to obesity186. By contrast, antibody-​mediated
neutralization of ACBP reduces food intake and pro-
moted lipo-​catabolic reactions, thereby reducing fat
mass186. These data indicate that ACBP is a pro-​obesity
factor that promotes hyperphagia. Therefore, ACBP
could be a useful therapeutic target in the prevention
or treatment of obesity and its comorbidities. However,
the relationship between altered autophagic activity
and the role of ACBP in the pathogenesis of obesity
remains unclear.
Conclusions
Impairment of autophagy results in diverse types of
cellular dysfunction that exacerbate the ageing process,
whereas enhancement of autophagy generally promotes
cellular homeostasis and functions to prolong lifespan
and improve metabolic health. As reduced autophagy
is implicated in numerous age-​related diseases, such as
metabolic disease and sarcopenia, therapeutic upregu­
lation of autophagy to adequate levels is a potential
treatment strategy for these diseases. However, the role
of autophagy in cellular physiology differs according
to the cell type and pathological condition. In addi-
tion, no established non-​invasive methods are capa-
ble of detecting autophagic activity in human tissues.
To enable evaluation of the effects of drug treatment on
autophagy in humans, further studies are necessary to
establish non-​invasive methods for autophagy measure-
ment, including methods for analysis of biomarkers in
serum and/or urine samples.
Published online xx xx xxxx

1. Saeedi, P. et al. Global and regional diabetes
prevalence estimates for 2019 and projections
for 2030 and 2045: results from the International
Diabetes Federation Diabetes Atlas, 9th edition.
Diabetes Res. Clin. Pract. 157, 107843
(2019).
2. Kuk, J. L., Saunders, T. J., Davidson, L. E. & Ross, R.
Age-​related changes in total and regional fat
distribution. Ageing Res. Rev. 8, 339–348 (2009).
3. Batsis, J. A. & Villareal, D. T. Sarcopenic obesity in
older adults: aetiology, epidemiology and treatment
strategies. Nat. Rev. Endocrinol. 14, 513–537 (2018).
4. Li, N. et al. Aging and stress induced β cell senescence
and its implication in diabetes development. Aging 11,
9947–9959 (2019).
5. Lopez-​Otin, C., Blasco, M. A., Partridge, L., Serrano, M.
& Kroemer, G. The hallmarks of aging. Cell 153,
1194–1217 (2013).

www.nature.com/nrendo

0123456789();:

6. Choi, A. M., Ryter, S. W. & Levine, B. Autophagy in
human health and disease. N. Engl. J. Med. 368,
651–662 (2013).
7. Hurley, J. H. & Young, L. N. Mechanisms of autophagy
initiation. Annu. Rev. Biochem. 86, 225–244 (2017).
8. Dikic, I. & Elazar, Z. Mechanism and medical
implications of mammalian autophagy. Nat. Rev.
Mol. Cell Biol. 19, 349–364 (2018).
9. Nakatogawa, H., Ishii, J., Asai, E. & Ohsumi, Y. Atg4
recycles inappropriately lipidated Atg8 to promote
autophagosome biogenesis. Autophagy 8, 177–186
(2012).
10. Melia, T. J., Lystad, A. H. & Simonsen, A.
Autophagosome biogenesis: from membrane
growth to closure. J. Cell Biol. 219, e202002085
(2020).
11. Lawrence, R. E. & Zoncu, R. The lysosome as a cellular
centre for signalling, metabolism and quality control.
Nat. Cell Biol. 21, 133–142 (2019).
12. Osawa, T. et al. Atg2 mediates direct lipid transfer
between membranes for autophagosome formation.
Nat. Struct. Mol. Biol. 26, 281–288 (2019).
13. Matoba, K. et al. Atg9 is a lipid scramblase that
mediates autophagosomal membrane expansion.
Nat. Struct. Mol. Biol. 27, 1185–1193 (2020).
14. Maeda, S. et al. Structure, lipid scrambling activity
and role in autophagosome formation of ATG9A.
Nat. Struct. Mol. Biol. 27, 1194–1201 (2020).
15. Mancias, J. D. & Kimmelman, A. C. Mechanisms of
selective autophagy in normal physiology and cancer.
J. Mol. Biol. 428, 1659–1680 (2016).
16. Gatica, D., Lahiri, V. & Klionsky, D. J. Cargo
recognition and degradation by selective autophagy.
Nat. Cell Biol. 20, 233–242 (2018).
17. Chu, C. T. et al. Cardiolipin externalization to the outer
mitochondrial membrane acts as an elimination signal
for mitophagy in neuronal cells. Nat. Cell Biol. 15,
1197–1205 (2013).
18. Dany, M. & Ogretmen, B. Ceramide induced mitophagy
and tumor suppression. Biochim. Biophys. Acta 1853,
2834–2845 (2015).
19. Mizushima, N. & Murphy, L. O. Autophagy assays for
biological discovery and therapeutic development.
Trends Biochem. Sci. 45, 1080–1093 (2020).
20. Klionsky, D. J. et al. Guidelines for the use and
interpretation of assays for monitoring autophagy.
Autophagy 17, 1–382 (2021).
21. Moulis, M. & Vindis, C. Methods for measuring
autophagy in mice. Cells 6, 14 (2017).
22. Puente, C., Hendrickson, R. C. & Jiang, X.
Nutrient-​regulated phosphorylation of ATG13
inhibits starvation-​induced autophagy. J. Biol. Chem.
291, 6026–6035 (2016).
23. Kim, J., Kundu, M., Viollet, B. & Guan, K. L. AMPK
and mTOR regulate autophagy through direct
phosphorylation of Ulk1. Nat. Cell Biol. 13,
132–141 (2011).
24. Shang, L. et al. Nutrient starvation elicits an
acute autophagic response mediated by Ulk1
dephosphorylation and its subsequent dissociation
from AMPK. Proc. Natl Acad. Sci. USA 108,
4788–4793 (2011).
25. Yuan, H. X., Russell, R. C. & Guan, K. L. Regulation
of PIK3C3/VPS34 complexes by MTOR in nutrient
stress-​induced autophagy. Autophagy 9, 1983–1995
(2013).
26. Nazio, F. et al. mTOR inhibits autophagy by controlling
ULK1 ubiquitylation, self-​association and function
through AMBRA1 and TRAF6. Nat. Cell Biol. 15,
406–416 (2013).
27. Ma, X. et al. MTORC1-mediated NRBF2
phosphorylation functions as a switch for the
class III PtdIns3K and autophagy. Autophagy 13,
592–607 (2017).
28. Park, J. M. et al. The ULK1 complex mediates
mTORC1 signaling to the autophagy initiation
machinery via binding and phosphorylating ATG14.
Autophagy 12, 547–564 (2016).
29. Wan, W. et al. mTORC1 phosphorylates
acetyltransferase p300 to regulate autophagy and
lipogenesis. Mol. Cell 68, 323–335.e6 (2017).
30. Wan, W. et al. mTORC1-regulated and HUWE1-
mediated WIPI2 degradation controls autophagy
flux. Mol. Cell 72, 303–315.e6 (2018).
31. Kim, Y. M. et al. mTORC1 phosphorylates UVRAG to
negatively regulate autophagosome and endosome
maturation. Mol. Cell 57, 207–218 (2015).
32. Munson, M. J. et al. mTOR activates the VPS34–UVRAG
complex to regulate autolysosomal tubulation and cell
survival. EMBO J. 34, 2272–2290 (2015).
33. Cheng, X. et al. Pacer is a mediator of mTORC1
and GSK3–TIP60 signaling in regulation of
Nature Reviews | Endocrinology
autophagosome maturation and lipid metabolism.
Mol. Cell 73, 788–802.e7 (2019).
34. Roczniak-​Ferguson, A. et al. The transcription factor
TFEB links mTORC1 signaling to transcriptional
control of lysosome homeostasis. Sci. Signal. 5, ra42
(2012).
35. Martina, J. A., Chen, Y., Gucek, M. & Puertollano, R.
mTORC1 functions as a transcriptional regulator of
autophagy by preventing nuclear transport of TFEB.
Autophagy 8, 903–914 (2012).
36. Martina, J. A. et al. The nutrient-​responsive
transcription factor TFE3 promotes autophagy,
lysosomal biogenesis, and clearance of cellular
debris. Sci. Signal. 7, ra9 (2014).
37. Vega-​Rubin-de-​Celis, S., Peña-​Llopis, S., Konda, M.
& Brugarolas, J. Multistep regulation of TFEB by
mTORC1. Autophagy 13, 464–472 (2017).
38. Napolitano, G. & Ballabio, A. TFEB at a glance.
J. Cell Sci. 129, 2475–2481 (2016).
39. Napolitano, G. et al. mTOR-​dependent phosphorylation
controls TFEB nuclear export. Nat. Commun. 9, 3312
(2018).
40. Inoki, K., Zhu, T. & Guan, K. L. TSC2 mediates cellular
energy response to control cell growth and survival.
Cell 115, 577–590 (2003).
41. Lee, J. W., Park, S., Takahashi, Y. & Wang, H. G. The
association of AMPK with ULK1 regulates autophagy.
PLoS ONE 5, e15394 (2010).
42. Gwinn, D. M. et al. AMPK phosphorylation of raptor
mediates a metabolic checkpoint. Mol. Cell 30,
214–226 (2008).
43. Bach, M., Larance, M., James, D. E. & Ramm, G.
The serine/threonine kinase ULK1 is a target of
multiple phosphorylation events. Biochem. J. 440,
283–291 (2011).
44. Tian, W. et al. Phosphorylation of ULK1 by AMPK
regulates translocation of ULK1 to mitochondria and
mitophagy. FEBS Lett. 589, 1847–1854 (2015).
45. Mack, H. I., Zheng, B., Asara, J. M. & Thomas, S. M.
AMPK-​dependent phosphorylation of ULK1 regulates
ATG9 localization. Autophagy 8, 1197–1214 (2012).
46. Egan, D. F. et al. Phosphorylation of ULK1 (hATG1)
by AMP-​activated protein kinase connects energy
sensing to mitophagy. Science 331, 456–461 (2011).
47. Tamargo-​Gómez, I. & Mariño, G. AMPK: regulation
of metabolic dynamics in the context of autophagy.
Int. J. Mol. Sci. 19, 3812 (2018).
48. Shiloh, R. et al. Non-​canonical activation of DAPK2 by
AMPK constitutes a new pathway linking metabolic
stress to autophagy. Nat. Commun. 9, 1759 (2018).
49. Xu, D. Q. et al. PAQR3 controls autophagy by
integrating AMPK signaling to enhance ATG14L-​
associated PI3K activity. EMBO J. 35, 496–514
(2016).
50. Zhao, Y. et al. RACK1 promotes autophagy by
enhancing the Atg14L-​Beclin 1-Vps34-Vps15 complex
formation upon phosphorylation by AMPK. Cell Rep.
13, 1407–1417 (2015).
51. Aas, S. N. et al. The impact of age and frailty on
skeletal muscle autophagy markers and specific
strength: a cross-​sectional comparison. Exp. Gerontol.
125, 110687 (2019).
52. Kim, J. et al. Differential regulation of distinct Vps34
complexes by AMPK in nutrient stress and autophagy.
Cell 152, 290–303 (2013).
53. Weerasekara, V. K. et al. Metabolic-​stress-induced
rearrangement of the 14-3-3ζ interactome promotes
autophagy via a ULK1- and AMPK-​regulated 14-3-3ζ
interaction with phosphorylated Atg9. Mol. Cell Biol.
34, 4379–4388 (2014).
54. Huang, R. et al. Deacetylation of nuclear LC3 drives
autophagy initiation under starvation. Mol. Cell 57,
456–466 (2015).
55. Lee, I. H. et al. A role for the NAD-​dependent
deacetylase Sirt1 in the regulation of autophagy.
Proc. Natl Acad. Sci. USA 105, 3374–3379
(2008).
56. Gu, X. et al. SIRT1-mediated FoxOs pathways protect
against apoptosis by promoting autophagy in
osteoblast-​like MC3T3-E1 cells exposed to sodium
fluoride. Oncotarget 7, 65218–65230 (2016).
57. Kume, S. et al. Calorie restriction enhances cell
adaptation to hypoxia through Sirt1-dependent
mitochondrial autophagy in mouse aged kidney.
J. Clin. Invest. 120, 1043–1055 (2010).
58. Price, N. L. et al. SIRT1 is required for AMPK
activation and the beneficial effects of resveratrol on
mitochondrial function. Cell Metab. 15, 675–690
(2012).
59. Ghosh, H. S., McBurney, M. & Robbins, P. D.
SIRT1 negatively regulates the mammalian target
of rapamycin. PLoS ONE 5, e9199 (2010).
0123456789();:
Reviews
60. Cantó, C. et al. AMPK regulates energy expenditure
by modulating NAD+ metabolism and SIRT1 activity.
Nature 458, 1056–1060 (2009).
61. Takeda-​Watanabe, A., Kitada, M., Kanasaki, K. &
Koya, D. SIRT1 inactivation induces inflammation
through the dysregulation of autophagy in human
THP-1 cells. Biochem. Biophys. Res. Commun. 427,
191–196 (2012).
62. Kume, S., Thomas, M. C. & Koya, D. Nutrient sensing,
autophagy, and diabetic nephropathy. Diabetes 61,
23–29 (2012).
63. Filomeni, G., De Zio, D. & Cecconi, F. Oxidative
stress and autophagy: the clash between damage
and metabolic needs. Cell Death Differ. 22, 377–388
(2015).
64. Rashid, H. O., Yadav, R. K., Kim, H. R. & Chae, H. J.
ER stress: autophagy induction, inhibition and
selection. Autophagy 11, 1956–1977 (2015).
65. Sardiello, M. et al. A gene network regulating
lysosomal biogenesis and function. Science 325,
473–477 (2009).
66. Settembre, C. et al. TFEB links autophagy to lysosomal
biogenesis. Science 332, 1429–1433 (2011).
67. Hars, E. S. et al. Autophagy regulates ageing in
C. elegans. Autophagy 3, 93–95 (2007).
68. Meléndez, A. et al. Autophagy genes are essential
for dauer development and life-​span extension in
C. elegans. Science 301, 1387–1391 (2003).
69. Dwivedi, M., Song, H. O. & Ahnn, J. Autophagy
genes mediate the effect of calcineurin on life span
in C. elegans. Autophagy 5, 604–607 (2009).
70. Kuma, A. et al. The role of autophagy during the early
neonatal starvation period. Nature 432, 1032–1036
(2004).
71. Sou, Y. S. et al. The Atg8 conjugation system is
indispensable for proper development of autophagic
isolation membranes in mice. Mol. Biol. Cell 19,
4762–4775 (2008).
72. Komatsu, M. et al. Impairment of starvation-​induced
and constitutive autophagy in Atg7-deficient mice.
J. Cell Biol. 169, 425–434 (2005).
73. Pyo, J. O. et al. Overexpression of Atg5 in mice
activates autophagy and extends lifespan. Nat.
Commun. 4, 2300 (2013).
74. Fernández, Á. F. et al. Disruption of the beclin 1–BCL2
autophagy regulatory complex promotes longevity in
mice. Nature 558, 136–140 (2018).
75. Nakamura, S. et al. Suppression of autophagic activity
by Rubicon is a signature of aging. Nat. Commun. 10,
847 (2019).
76. Zhou, B. et al. Mitochondrial permeability uncouples
elevated autophagy and lifespan extension. Cell 177,
299–314.e16 (2019).
77. Wilhelm, T. et al. Neuronal inhibition of the
autophagy nucleation complex extends life span
in post-​reproductive C. elegans. Genes Dev. 31,
1561–1572 (2017).
78. Bjedov, I. et al. Fine-​tuning autophagy maximises
lifespan and is associated with changes in
mitochondrial gene expression in Drosophila.
PLoS Genet. 16, e1009083 (2020).
79. Lim, Y. M. et al. Systemic autophagy insufficiency
compromises adaptation to metabolic stress and
facilitates progression from obesity to diabetes.
Nat. Commun. 5, 4934 (2014).
80. Fernández, Á. F. et al. Autophagy couteracts weight
gain, lipotoxicity and pancreatic β-​cell death upon
hypercaloric pro-​diabetic regimens. Cell Death Dis. 8,
e2970 (2017).
81. Ebato, C. et al. Autophagy is important in islet
homeostasis and compensatory increase of β cell mass
in response to high-​fat diet. Cell Metab. 8, 325–332
(2008).
82. Jung, H. S. et al. Loss of autophagy diminishes
pancreatic β cell mass and function with resultant
hyperglycemia. Cell Metab. 8, 318–324 (2008).
83. Goginashvili, A. et al. Insulin granules. Insulin
secretory granules control autophagy in pancreatic
β cells. Science 347, 878–882 (2015).
84. Yamamoto, S. et al. Autophagy differentially regulates
insulin production and insulin sensitivity. Cell Rep. 23,
3286–3299 (2018).
85. Masini, M. et al. Autophagy in human type 2 diabetes
pancreatic β cells. Diabetologia 52, 1083–1086
(2009).
86. Cnop, M. et al. RNA sequencing identifies dysregulation
of the human pancreatic islet transcriptome by
the saturated fatty acid palmitate. Diabetes 63,
1978–1993 (2014).
87. Las, G., Serada, S. B., Wikstrom, J. D., Twig, G. &
Shirihai, O. S. Fatty acids suppress autophagic turnover
in β-​cells. J. Biol. Chem. 286, 42534–42544 (2011).
Reviews
88. Mir, S. U. et al. Inhibition of autophagic turnover in
β-​cells by fatty acids and glucose leads to apoptotic
cell death. J. Biol. Chem. 290, 6071–6085 (2015).
89. Zummo, F. P. et al. Glucagon-​like peptide 1 protects
pancreatic β-​cells from death by increasing autophagic
flux and restoring lysosomal function. Diabetes 66,
1272–1285 (2017).
90. Trudeau, K. M. et al. Lysosome acidification by
photoactivated nanoparticles restores autophagy
under lipotoxicity. J. Cell Biol. 214, 25–34 (2016).
91. Bugliani, M. et al. Modulation of autophagy influences
the function and survival of human pancreatic β cells
under endoplasmic reticulum stress conditions and in
type 2 diabetes. Front. Endocrinol. 10, 52 (2019).
92. Abedini, A. & Schmidt, A. M. Mechanisms of islet
amyloidosis toxicity in type 2 diabetes. FEBS Lett.
587, 1119–1127 (2013).
93. Kim, J. et al. Amyloidogenic peptide oligomer
accumulation in autophagy-​deficient β cells induces
diabetes. J. Clin. Invest. 124, 3311–3324 (2014).
94. Shigihara, N. et al. Human IAPP-​induced pancreatic
β cell toxicity and its regulation by autophagy. J. Clin.
Invest. 124, 3634–3644 (2014).
95. Perry, R. J., Samuel, V. T., Petersen, K. F. &
Shulman, G. I. The role of hepatic lipids in hepatic
insulin resistance and type 2 diabetes. Nature 510,
84–91 (2014).
96. Yang, L., Li, P., Fu, S., Calay, E. S. & Hotamisligil, G. S.
Defective hepatic autophagy in obesity promotes ER
stress and causes insulin resistance. Cell Metab. 11,
467–478 (2010).
97. González-​Rodríguez, A. et al. Impaired autophagic flux
is associated with increased endoplasmic reticulum
stress during the development of NAFLD. Cell Death
Dis. 5, e1179 (2014).
98. Singh, R. et al. Autophagy regulates lipid metabolism.
Nature 458, 1131–1135 (2009).
99. Jaber, N. et al. Class III PI3K Vps34 plays an essential
role in autophagy and in heart and liver function.
Proc. Natl Acad. Sci. USA 109, 2003–2008 (2012).
100. Settembre, C. et al. TFEB controls cellular lipid
metabolism through a starvation-​induced
autoregulatory loop. Nat. Cell Biol. 15, 647–658
(2013).
101. Tanaka, S. et al. Rubicon inhibits autophagy
and accelerates hepatocyte apoptosis and lipid
accumulation in nonalcoholic fatty liver disease
in mice. Hepatology 64, 1994–2014 (2016).
102. Zhang, Y. et al. Adipose-​specific deletion of autophagy-​
related gene 7 (Atg7) in mice reveals a role in
adipogenesis. Proc. Natl Acad. Sci. USA 106,
19860–19865 (2009).
103. Tchkonia, T. et al. Fat tissue, aging, and cellular
senescence. Aging Cell 9, 667–684 (2010).
104. Kovsan, J. et al. Altered autophagy in human adipose
tissues in obesity. J. Clin. Endocrinol. Metab. 96,
E268–E277 (2011).
105. Jansen, H. J. et al. Autophagy activity is up-​regulated
in adipose tissue of obese individuals and modulates
proinflammatory cytokine expression. Endocrinology
153, 5866–5874 (2012).
106. Kosacka, J. et al. Autophagy in adipose tissue of
patients with obesity and type 2 diabetes. Mol. Cell
Endocrinol. 409, 21–32 (2015).
107. Abad-​Jiménez, Z. et al. Systemic oxidative stress
and visceral adipose tissue mediators of NLRP3
inflammasome and autophagy are reduced in obese
type 2 diabetic patients treated with metformin.
Antioxidants 9, 892 (2020).
108. Yamamuro, T. et al. Age-​dependent loss of adipose
Rubicon promotes metabolic disorders via excess
autophagy. Nat. Commun. 11, 4150 (2020).
109. Anagnostis, P. et al. Type 2 diabetes mellitus is
associated with increased risk of sarcopenia: a
systematic review and meta-​analysis. Calcif. Tissue Int.
107, 453–463 (2020).
110. Wang, T. et al. Type 2 diabetes mellitus is associated
with increased risks of sarcopenia and pre-​sarcopenia
in Chinese elderly. Sci. Rep. 6, 38937 (2016).
111. Srikanthan, P. & Karlamangla, A. S. Relative muscle
mass is inversely associated with insulin resistance
and prediabetes. Findings from the third National
Health and Nutrition Examination Survey. J. Clin.
Endocrinol. Metab. 96, 2898–2903 (2011).
112. O’Neill, B. T. et al. Differential role of insulin/IGF-1
receptor signaling in muscle growth and glucose
homeostasis. Cell Rep. 11, 1220–1235 (2015).
113. O’Neill, B. T. et al. Insulin and IGF-1 receptors regulate
FoxO-​mediated signaling in muscle proteostasis.
J. Clin. Invest. 126, 3433–3446 (2016).
114. Masiero, E. et al. Autophagy is required to maintain
muscle mass. Cell Metab. 10, 507–515 (2009).
115. Carnio, S. et al. Autophagy impairment in muscle
induces neuromuscular junction degeneration and
precocious aging. Cell Rep. 8, 1509–1521 (2014).
116. Potes, Y. et al. Overweight in elderly people induces
impaired autophagy in skeletal muscle. Free Radic.
Biol. Med. 110, 31–41 (2017).
117. Møller, A. B. et al. Altered gene expression and
repressed markers of autophagy in skeletal muscle
of insulin resistant patients with type 2 diabetes.
Sci. Rep. 7, 43775 (2017).
118. Chang, Y. C. et al. Resveratrol protects muscle cells
against palmitate-​induced cellular senescence and
insulin resistance through ameliorating autophagic
flux. J. Food Drug Anal. 26, 1066–1074 (2018).
119. Drake, J. C. & Yan, Z. Mitophagy in maintaining
skeletal muscle mitochondrial proteostasis and
metabolic health with ageing. J. Physiol. 595,
6391–6399 (2017).
120. Lam, T. et al. Reversal of intramyocellular lipid
accumulation by lipophagy and a p62-mediated
pathway. Cell Death Discov. 2, 16061 (2016).
121. Tang, A. H. & Rando, T. A. Induction of autophagy
supports the bioenergetic demands of quiescent
muscle stem cell activation. EMBO J. 33, 2782–2797
(2014).
122. García-​Prat, L. et al. Autophagy maintains stemness
by preventing senescence. Nature 529, 37–42
(2016).
123. Fontana, L. & Partridge, L. Promoting health and
longevity through diet: from model organisms to
humans. Cell 161, 106–118 (2015).
124. Jia, K. & Levine, B. Autophagy is required for dietary
restriction-​mediated life span extension in C. elegans.
Autophagy 3, 597–599 (2007).
125. Hansen, M. et al. A role for autophagy in the extension
of lifespan by dietary restriction in C. elegans. PLoS
Genet. 4, e24 (2008).
126. Mercken, E. M. et al. Calorie restriction in humans
inhibits the PI3K/AKT pathway and induces a younger
transcription profile. Aging Cell 12, 645–651 (2013).
127. Yang, L. et al. Long-​term calorie restriction enhances
cellular quality-​control processes in human skeletal
muscle. Cell Rep. 14, 422–428 (2016).
128. Kim, K. E. et al. Caloric restriction of db/db mice
reverts hepatic steatosis and body weight with
divergent hepatic metabolism. Sci. Rep. 6, 30111
(2016).
129. Gao, X., Yan, D., Zhao, Y., Tao, H. & Zhou, Y.
Moderate calorie restriction to achieve normal
weight reverses β-​cell dysfunction in diet-​induced
obese mice: involvement of autophagy. Nutr. Metab.
12, 34 (2015).
130. Cui, M., Yu, H., Wang, J., Gao, J. & Li, J. Chronic
caloric restriction and exercise improve metabolic
conditions of dietary-​induced obese mice in
autophagy correlated manner without involving
AMPK. J. Diabetes Res. 2013, 852754 (2013).
131. Liu, H. et al. Intermittent fasting preserves β-​cell mass
in obesity-​induced diabetes via the autophagy-​lysosome
pathway. Autophagy 13, 1952–1968 (2017).
132. Martinez-​Lopez, N. et al. System-​wide benefits of
intermeal fasting by autophagy. Cell Metab. 26,
856–871.e5 (2017).
133. He, B., Liu, L., Yu, C., Wang, Y. & Han, P. Roux-​en-Y
gastric bypass reduces lipid overaccumulation in liver
by upregulating hepatic autophagy in obese diabetic
rats. Obes. Surg. 25, 109–118 (2015).
134. Ma, N., Ma, R., Tang, K., Li, X. & He, B. Roux-​en-Y
gastric bypass in obese diabetic rats promotes
autophagy to improve lipid metabolism through
mTOR/p70S6K signaling pathway. J. Diabetes Res.
2020, 4326549 (2020).
135. He, C. et al. Exercise-​induced BCL2-regulated
autophagy is required for muscle glucose homeostasis.
Nature 481, 511–515 (2012).
136. Grumati, P. et al. Physical exercise stimulates
autophagy in normal skeletal muscles but is
detrimental for collagen VI-​deficient muscles.
Autophagy 7, 1415–1423 (2011).
137. Lira, V. A. et al. Autophagy is required for exercise
training-​induced skeletal muscle adaptation and
improvement of physical performance. FASEB J. 27,
4184–4193 (2013).
138. Luo, L. et al. Chronic resistance training activates
autophagy and reduces apoptosis of muscle cells by
modulating IGF-1 and its receptors, Akt/mTOR and
Akt/FOXO3a signaling in aged rats. Exp. Gerontol. 48,
427–436 (2013).
139. Pi, H. et al. Long-​term exercise prevents hepatic
steatosis: a novel role of FABP1 in regulation of
autophagy-​lysosomal machinery. FASEB J. 33,
11870–11883 (2019).
0123456789();:
140. Tang, H. et al. Swimming prevents nonalcoholic fatty
liver disease by reducing migration inhibitory factor
through Akt suppression and autophagy activation.
Am. J. Transl. Res. 11, 4315–4325 (2019).
141. Ghareghani, P. et al. Aerobic endurance training
improves nonalcoholic fatty liver disease (NAFLD)
features via miR-33 dependent autophagy induction
in high fat diet fed mice. Obes. Res. Clin. Pract. 12,
80–89 (2018).
142. Vainshtein, A., Tryon, L. D., Pauly, M. & Hood, D. A.
Role of PGC-1α during acute exercise-​induced
autophagy and mitophagy in skeletal muscle.
Am. J. Physiol. Cell Physiol. 308, C710–C719
(2015).
143. Wohlgemuth, S. E., Seo, A. Y., Marzetti, E., Lees, H. A.
& Leeuwenburgh, C. Skeletal muscle autophagy and
apoptosis during aging: effects of calorie restriction
and life-​long exercise. Exp. Gerontol. 45, 138–148
(2010).
144. Kulkarni, A. S., Gubbi, S. & Barzilai, N. Benefits
of metformin in attenuating the hallmarks of aging.
Cell Metab. 32, 15–30 (2020).
145. Martin-​Montalvo, A. et al. Metformin improves
healthspan and lifespan in mice. Nat. Commun. 4,
2192 (2013).
146. Song, Y. M. et al. Metformin alleviates hepatosteatosis
by restoring SIRT1-mediated autophagy induction
via an AMP-​activated protein kinase-​independent
pathway. Autophagy 11, 46–59 (2015).
147. Li, M., Sharma, A., Yin, C., Tan, X. & Xiao, Y.
Metformin ameliorates hepatic steatosis and improves
the induction of autophagy in HFD‑induced obese
mice. Mol. Med. Rep. 16, 680–686 (2017).
148. Jiang, Y. et al. Metformin plays a dual role in MIN6
pancreatic β cell function through AMPK-​dependent
autophagy. Int. J. Biol. Sci. 10, 268–277 (2014).
149. Jing Yin, J., Bo Li, Y., Ming Cao, M. & Wang, Y.
Liraglutide improves the survival of INS-1 cells by
promoting macroautophagy. Int. J. Endocrinol. Metab.
11, 184–190 (2013).
150. Fan, M. et al. Liraglutide enhances autophagy and
promotes pancreatic β cell proliferation to ameliorate
type 2 diabetes in high-​fat-fed and streptozotocin-​
treated mice. Med. Sci. Monit. 24, 2310–2316
(2018).
151. Miao, X. et al. The glucagon-​like peptide-1
analogue liraglutide promotes autophagy through
the modulation of 5′-AMP-​activated protein kinase in
INS-1 β-​cells under high glucose conditions. Peptides
100, 127–139 (2018).
152. Lim, S. W., Jin, L., Jin, J. & Yang, C. W. Effect of
exendin-4 on autophagy clearance in β cells of rats
with tacrolimus-​induced diabetes mellitus. Sci. Rep. 6,
29921 (2016).
153. Fu, J. et al. Liraglutide protects pancreatic β cells from
endoplasmic reticulum stress by upregulating MANF
to promote autophagy turnover. Life Sci. 252, 117648
(2020).
154. Li, X. D., He, S. S., Wan, T. T. & Li, Y. B. Liraglutide
protects palmitate-​induced INS-1 cell injury by
enhancing autophagy mediated via FoxO1. Mol. Med.
Rep. 23, 147 (2021).
155. Wang, J. et al. Liraglutide protects pancreatic β-​cells
against free fatty acids in vitro and affects glucolipid
metabolism in apolipoprotein E–/– mice by activating
autophagy. Mol. Med. Rep. 12, 4210–4218 (2015).
156. He, Q., Sha, S., Sun, L., Zhang, J. & Dong, M. GLP-1
analogue improves hepatic lipid accumulation by
inducing autophagy via AMPK/mTOR pathway.
Biochem. Biophys. Res. Commun. 476, 196–203
(2016).
157. He, Y. et al. The preventive effect of liraglutide
on the lipotoxic liver injury via increasing autophagy.
Ann. Hepatol. 19, 44–52 (2020).
158. Sharma, S., Mells, J. E., Fu, P. P., Saxena, N. K.
& Anania, F. A. GLP-1 analogs reduce hepatocyte
steatosis and improve survival by enhancing
the unfolded protein response and promoting
macroautophagy. PLoS ONE 6, e25269 (2011).
159. Fang, Y. et al. Liraglutide alleviates hepatic steatosis
by activating the TFEB-​regulated autophagy-​lysosomal
pathway. Front. Cell Dev. Biol. 8, 602574 (2020).
160. Liu, L., Liu, J. & Yu, X. Dipeptidyl peptidase-4 inhibitor
MK-626 restores insulin secretion through enhancing
autophagy in high fat diet-​induced mice. Biochem.
Biophys. Res. Commun. 470, 516–520 (2016).
161. Zhu, B. et al. Alogliptin improves survival and health of
mice on a high-​fat diet. Aging Cell 18, e12883 (2019).
162. Ellingsgaard, H. et al. Interleukin-6 enhances insulin
secretion by increasing glucagon-​like peptide-1
secretion from L cells and alpha cells. Nat. Med. 17,
1481–1489 (2011).
www.nature.com/nrendo

163. Linnemann, A. K. et al. Interleukin 6 protects
pancreatic β cells from apoptosis by stimulation
of autophagy. FASEB J. 31, 4140–4152 (2017).
164. DeFronzo, R. A., Reeves, W. B. & Awad, A. S.
Pathophysiology of diabetic kidney disease: impact
of SGLT2 inhibitors. Nat. Rev. Nephrol. 17, 319–334
(2021).
165. Xu, J., Kitada, M., Ogura, Y., Liu, H. & Koya, D.
Dapagliflozin restores impaired autophagy and
suppresses inflammation in high glucose-​treated
HK-2 cells. Cells 10, 1457 (2021).
166. Fukushima, K., Kitamura, S., Tsuji, K., Sang, Y. &
Wada, J. Sodium glucose co-​transporter 2 inhibitor
ameliorates autophagic flux impairment on renal
proximal tubular cells in obesity mice. Int. J. Mol. Sci.
21, 4054 (2020).
167. Aragón-​Herrera, A. et al. Empagliflozin reduces the
levels of CD36 and cardiotoxic lipids while improving
autophagy in the hearts of Zucker diabetic fatty rats.
Biochem. Pharmacol. 170, 113677 (2019).
168. Xu, C. et al. Canagliflozin exerts anti-​inflammatory
effects by inhibiting intracellular glucose metabolism
and promoting autophagy in immune cells. Biochem.
Pharmacol. 152, 45–59 (2018).
169. Harrison, D. E. et al. Rapamycin fed late in life extends
lifespan in genetically heterogeneous mice. Nature
460, 392–395 (2009).
170. Zhang, Y. et al. Rapamycin extends life and health in
C57BL/6 mice. J. Gerontol. A Biol. Sci. Med. Sci. 69,
119–130 (2014).
171. Chiao, Y. A. et al. Rapamycin transiently induces
mitochondrial remodeling to reprogram energy
metabolism in old hearts. Aging 8, 314–327 (2016).
172. Chang, G. R. et al. Rapamycin protects against high fat
diet-​induced obesity in C57BL/6J mice. J. Pharmacol.
Sci. 109, 496–503 (2009).
173. Lamming, D. W. et al. Rapamycin-​induced insulin
resistance is mediated by mTORC2 loss and
Nature Reviews | Endocrinology
uncoupled from longevity. Science 335, 1638–1643
(2012).
174. Sataranatarajan, K. et al. Rapamycin increases mortality
in db/db mice, a mouse model of type 2 diabetes.
J. Gerontol. A Biol. Sci. Med. Sci. 71, 850–857 (2016).
175. Arriola Apelo, S. I. et al. Alternative rapamycin
treatment regimens mitigate the impact of rapamycin
on glucose homeostasis and the immune system.
Aging Cell 15, 28–38 (2016).
176. Zhou, W. & Ye, S. Rapamycin improves insulin
resistance and hepatic steatosis in type 2 diabetes
rats through activation of autophagy. Cell Biol. Int. 42,
1282–1291 (2018).
177. Eisenberg, T. et al. Induction of autophagy by
spermidine promotes longevity. Nat. Cell Biol. 11,
1305–1314 (2009).
178. Eisenberg, T. et al. Cardioprotection and lifespan
extension by the natural polyamine spermidine.
Nat. Med. 22, 1428–1438 (2016).
179. Morselli, E. et al. Spermidine and resveratrol induce
autophagy by distinct pathways converging on the
acetylproteome. J. Cell Biol. 192, 615–629 (2011).
180. Madeo, F., Eisenberg, T., Pietrocola, F. & Kroemer, G.
Spermidine in health and disease. Science 359,
eaan2788 (2018).
181. Howitz, K. T. et al. Small molecule activators of sirtuins
extend Saccharomyces cerevisiae lifespan. Nature
425, 191–196 (2003).
182. Morselli, E. et al. Caloric restriction and resveratrol
promote longevity through the Sirtuin-1-dependent
induction of autophagy. Cell Death Dis. 1, e10 (2010).
183. Baur, J. A. et al. Resveratrol improves health and
survival of mice on a high-​calorie diet. Nature 444,
337–342 (2006).
184. Chen, G. et al. 3,4-Dimethoxychalcone induces
autophagy through activation of the transcription
factors TFE3 and TFEB. EMBO Mol. Med. 11, e10469
(2019).
0123456789();:
Reviews
185. Carmona-​Gutierrez, D. et al. The flavonoid
4,4′-dimethoxychalcone promotes autophagy-​
dependent longevity across species. Nat. Commun.
10, 651 (2019).
186. Bravo-​San Pedro, J. M. et al. Acyl-​CoA-binding
protein is a lipogenic factor that triggers food intake
and obesity. Cell Metab. 30, 754–767.e9 (2019).
187. Bravo-​San Pedro, J. M. et al. Cell-​autonomous,
paracrine and neuroendocrine feedback regulation of
autophagy by DBI/ACBP (diazepam binding inhibitor,
acyl-​CoA binding protein): the obesity factor. Autophagy
15, 2036–2038 (2019).
Author contributions
M.K. researched data for the article and wrote the manu-
script. M.K. and D.K. contributed to discussion of the article
content and editing of the manuscript. Both authors critically
appraised the manuscript for important intellectual content
and approved the final version to be published. M.K. and D.K.
are responsible for the integrity of the content.
Competing interests
The authors declare no competing interests.
Peer review information
Nature Reviews Endocrinology thanks N. Tavernarakis and
the other, anonymous, reviewer(s) for their contribution to the
peer review of this work.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
Supplementary information
The online version contains supplementary material available
at https://doi.org/10.1038/s41574-021-00551-9.
© Springer Nature Limited 2021