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Review
Self-Eating for Muscle Fitness:
Autophagy in the Control of Energy Metabolism
David Sebastián1,2,3,* and Antonio Zorzano1,2,3,*
1Institutefor Research in Biomedicine (IRB Barcelona), The Barcelona Institute of Science and Technology, Barcelona, Spain
2Departament de Bioquı́mica i Biomedicina Molecular, Facultat de Biologia, Universitat de Barcelona, Barcelona, Spain
3Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III,

Madrid, Spain
*Correspondence: david.sebastian@irbbarcelona.org (D.S.), antonio.zorzano@irbbarcelona.org (A.Z.)
https://doi.org/10.1016/j.devcel.2020.06.030

Cellular processes that sense and transmit metabolic changes are crucial for adaptation to external signals.
In this regard, autophagy provides energy upon nutrient deprivation and represents a quality control mech-
anism that eliminates damaged organelles or proteins. Here, we review recent findings on the metabolic path-
ways controlling autophagy in skeletal muscle, a plastic tissue that undergoes major changes in energy de-
mands. We also analyze the implications of autophagy in the regulation of energy metabolism in muscle and
how alterations in this process affect energy homeostasis at the whole-body level and the development of
metabolic diseases and aging.

Introduction in muscle adaptation to exercise. Interestingly, alterations in

The maintenance of cellular homeostasis is essential for tissue
function and cell survival. Comprising about 40% of whole-
body lean mass, skeletal muscle plays a key role in the regulation
of energy metabolism. Muscle is a highly plastic tissue, respond-
ing and adapting to changes in energy demands, such as those
occurring during nutrient deprivation or physical activity and ex-
ercise. Therefore, cellular processes aimed to sense and trans-
mit metabolic changes within skeletal muscle are crucial for
cellular homeostasis in this tissue and at the whole-body level.
In this context, autophagy has emerged as a crucial process.
Autophagy operates under basal conditions and can be induced
under appropriate stress conditions. Basal autophagy is respon-
sible for the removal of damaged organelles and maintenance of
basal energy homeostasis, which is especially important in long-
lived post-mitotic cells, such as skeletal muscle fibers. In
contrast, induced autophagy is characterized by the degradation
of intracellular macromolecules and organelles to meet energy
requirements in situations of nutrient deficiency or high-energy
demands, such as fasting and exercise or physical activity. Three
main forms of autophagy have been described, namely macro,
micro, and chaperone mediated, which differ in the mechanism
of substrate selection and delivery into the lysosome for degra-
dation. In this regard, macroautophagy (hereafter referred to as
autophagy) involves the formation of a double-membrane
vesicle named autophagosome, which engulfs the cargo to be
degraded and transports it to the lysosome for its clearance. Mi-
croautophagy and chaperone-mediated autophagy participate
in the degradation of small portions of cytosol and selected pro-
teins by directly delivering them to lysosomes in a chaperone-in-
dependent or -dependent manner.
The importance of autophagy in skeletal muscle function and
metabolic homeostasis has been revealed by studies on various
mouse models deficient in this process. These studies have
demonstrated a tight interconnection between muscle meta-
bolism and autophagy, as well as an essential role of autophagy
muscle autophagy have also been shown to be associated
with changes in whole-body energy metabolism. Therefore, the
aim of this review is to summarize research findings on the role
of autophagy in the regulation of energy metabolism in skeletal
muscle and how this process impacts on muscle plasticity and
systemic energy balance.
Autophagy: Molecular Regulation
Autophagy is an evolutionarily conserved process of recycling
and degradation of cellular components, such as cytoplasmic
components, protein aggregates, and damaged organelles.
These components, also named the cargo, are engulfed within
a double-membrane vesicle, the so-called autophagosome.
These vesicles are then fused with the lysosome, forming the au-
tolysosome, where the cargo is finally degraded by the action of
lysosomal hydrolases. Autophagy can be either non-selective
(also named bulk) or selective. In the former, an entire region of
the cytoplasm is engulfed by the autophagosome and then
degraded in the lysosome. In contrast, in selective autophagy,
a specific substrate or organelle is preferentially targeted for
degradation based on its interaction with autophagy receptors.
Autophagy is a tightly regulated process that involves more
than 40 autophagy-related (ATG) proteins in yeast, of which 19
proteins are required for autophagosome formation (Kim and
Lee, 2014). Most of them have mammalian homologs, suggest-
ing that they are evolutionary conserved in mammals (Kim and
Lee, 2014). Key steps in autophagy include the following: initia-
tion, vesicle nucleation or formation of the isolation membrane,
vesicle elongation, fusion with the lysosome, and degradation
(Figure 1). Details of the autophagic machinery and its regulation
have been reviewed elsewhere (Galluzzi et al., 2017; Yin et al.,
2016), and therefore, only the most relevant aspects are high-
lighted here. Autophagy is triggered by activation of the ULK1
complex, formed by ULK1, ATG13, FIP200, and ATG101.
Upon induction of autophagy, the serine threonine kinase

268 Developmental Cell 54, July 20, 2020 ª 2020 Elsevier Inc.

Review
1. AUTOPHAGY INITIATION 2. MEMBRANE NUCLEATION AND
PHAGOPHORE FORMATIOM
BECLIN1
VPS34
ATG14
VPS34
VPS15
Class III PI3K complex
AMPK
ULK1 ATG13
FIP2OO ATG101
WIPI 2
ULK1 complex Isolation
mTORC1 membrane
ATG9
Delivery of
lipids in ATG2
ATG9-
containing ATG18
vesicles
Figure 1. Molecular Regulation of Autophagy
Upon activation of the ULK1 complex, different complexes are recruited to the isolation membrane. Class III PI3K complex catalyzes the formation of PI3P, which
recruits WIPI2 and ATG2/ATG18 complex. ATG9-containing vesicles are thought to be a source of lipids for isolation membrane formation. Once formed, the
isolation membraneor phagophore maturates by action of ATG12-ATG5-ATG16L and LC3-PE. Autophagosome closure is mediated by ESCRT members. Finally,
autophagosome could either fuse directly with the lysosome to form the autolysosome or fuse first with late endosomes forming the amphisome. Once the
autolysosome is formed, degradation of the cargo occurs.
ULK1 is activated, thereby phosphorylating ATG13 and FIP200
(Hosokawa et al., 2009; Jung et al., 2009). Once activated, the
ULK1 complex recruits the Beclin 1-Vps34 complex (class III
PI3K complex) to the site of autophagosome formation. In addi-
tion, ULK1 directly phosphorylates Beclin 1, which can interact
with Ambra 1 or ATG14L (Nazio et al., 2013; Russell et al.,
2013). Vps34 is a lipid kinase responsible for the formation of
phosphatidylinositol-3 phosphate (PI3P), which recruits proteins
such as DFCP1 and WIPI to promote the initiation of double-
membrane vesicle nucleation (Axe et al., 2008; Lu et al., 2011).
The WIPI family of proteins is comprised of four members, with
WIPI1 and WIPI2 being the most studied. WIPI2 appears to be
involved in the recruitment of the autophagosome maturation
complex ATG12-ATG5-ATG16L to the isolation membrane by
direct binding to ATG16L, whereas WIPI1 may operate as a
negative regulator of autophagosomes (Polson et al., 2010; Proi-
kas-Cezanne et al., 2015). Other steps that are important in the
formation of isolation membrane involve the Atg2/Atg18 com-
plex (Suzuki et al., 2007), which binds to PIP3, and Atg9-contain-
ing membranes, which are suggested to provide the starting ma-
terial for the isolation membrane formation (Orsi et al., 2012).
Vesicle elongation and completion of the autophagosome is
mediated by two ubiquitin-like conjugation systems, namely
ATG12-ATG5-ATG16L and ATG8 (LC3)-phosphatidylethanol-
amine (Mizushima et al., 1998), leading to the formation of the
lipid-conjugated form of LC3 (LC3-phosphatidylethanolamine,
or LC3-II). LC3-II then localizes to the autophagosomal mem-
branes and participates in the formation and elongation of the
autophagosome. LC3 also plays a role in selective autophagy
by interacting with various autophagy receptors, such as p62,
NBR1, optineurin, NDP52, BNIP3, and FUNDC1. Finally, closure
of the autophagosome has been recently shown to be regulated
by members of the endosomal sorting complex required for
transport (ESCRT) (Takahashi et al., 2018). Once formed, the
ll
3. PHAGOPHORE EXPANSION 4. FUSION WITH THE LYSOSOME 5. DEGRADATION
Late endosome Lysosome
ESCRT
complex
Amphisome
Phagophore Autophagosome Autolysosome
ATG12 LC3
ATG5 conjugation
ATG16L system Lysosome
conjugation
system
mature autophagosome fuses with the lysosome to form the au-
tolysosome, where the cargo is degraded by the action of
several lysosomal acid hydrolases. In addition, autophago-
somes can merge with late endosomes prior to fusion with
lysosomes to form amphisomes, which deliver cargo in the
autophagic vesicle (Nakamura and Yoshimori, 2017). Finally,
cargo-degradation components are recycled for biosynthetic
purposes or permanently removed (Figure 1).
Metabolic Control of Autophagy in Muscle
Skeletal muscle is a key tissue in the integration of energy meta-
bolism. It shows remarkable plasticity, which allows for rapid
adaptation to changes in energetic demands, in which auto-
phagy has been described to play a major role. In this regard,
skeletal muscle is one of the tissues with either the highest basal
or the highest stimulated autophagic flux, as determined using
GFP-LC3 transgenic mice (Mizushima et al., 2004). Muscle is
composed by different muscle fibers subtypes, which show
distinct metabolic properties and differences in autophagy. Skel-
etal muscle fibers are characterized as one type of slow-twitch
fibers (type I) and three types of fast-twitch fibers (type IIa, IIx/
d, and IIb), of which types I and IIa are oxidative, whereas types
IIx and IIb are primary glycolytic. Importantly, autophagy has
been shown to be higher in fast-twitch fibers than in slow-twitch
fibers (Mizushima et al., 2004). The main conditions associated
with metabolic adaptations in muscle that are shown to regulate
autophagy are detailed below.
Regulation of Autophagy by Nutrient Availability
At a cellular level, autophagy is a key process in energy produc-
tion and is tightly regulated by nutrient availability via the modu-
lation of a number of signaling pathways. Skeletal muscle is a
high-energy-demanding tissue that primarily relies on glucose
and fatty acids for ATP generation. Glucose and fatty acid oxida-
tion in skeletal muscle are subjected to negative regulation by
Developmental Cell 54, July 20, 2020 269
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Review
AA
Glucose (Amino acids)

Leucine Arginine Methionine

GCN2
Sestrins
CASTOR 1 SAMTOR
Glucose Sestrins eIF2α
CASTOR 1
GATOR 2
AMP/ATP ATF4
GATOR 1
SAMTOR
AMPK
ATF4 Autophagy genes
FOXO3
mTORC1

MUSCLE CELL TFEB FOXO3 Autophagy genes

ULK1 ATG13 Lysosomal and

TFEB
autophagy genes
FIP2OO ATG101

ULK1 complex
Nucleus
BECLIN1 AMBRA1
VPS34
ATG14
VPS15

Class III PI3K complex

Activation of
Autophagy

Figure 2. Metabolic Regulation of Autophagy by Amino Acids and Glucose

Amino acids are sensed by mTORC1 through a mechanism depending on sestrins, CASTOR, and SAMTOR, although this has not been validated specifically in
skeletal muscle. In conditions of amino acid availability, activation of mTORC1 inhibits autophagy via phosphorylation and inactivation of ULK1 complex and then
inhibition of ATG14-Beclin 1-Vps34. mTORC1 also inhibits the ULK1 activator Ambra1 and TFEB. In conditions of amino acid deficiency, mTORC1 is inactivated
and then autophagy induced. Amino acid deficiency also activates GCN2, which phosphorylates and activates eIF2a-inducing ATF4 and the transcription of
autophagy genes. Glucose starvation induces autophagic flux through activation of AMPK, which phosphorylates and inactivates mTORC1, activating the ULK1
complex. In addition, AMPK can activate ULK1 and Beclin 1 independently of mTORC1 and phosphorylate and activate FoxO3, leading to the induction of
autophagy gene expression.

each other, and glucose utilization inhibits lipid oxidation and
vice versa by the so-called Randle or glucose-fatty acid cycle
(Hue and Taegtmeyer, 2009; Randle et al., 1963). In contrast to
glucose and fatty acids, amino acids are not a significant energy
source for skeletal muscle, where their oxidation accounts for
3%–6% of ATP generation during prolonged exercise in humans
and is negligible during resting conditions (Gibala, 2001). How-
ever, variations in the relative amount of these substrates have
an impact on the regulation of autophagy within the muscle by
acting on several energy-sensing pathways (Figures 2 and 3).
Amino Acids. The amino acid pool in skeletal muscle is main-
tained by the coordination of protein synthesis and protein
degradation. Only six amino acids are metabolized in resting
skeletal muscle: aspartate, asparagine, glutamate, and the
branched-chain amino acids (BCAAs) valine, leucine, and isoleu-
cine. Of these, leucine and part of the isoleucine molecule can be
oxidized in muscle, via their conversion to acetyl-CoA. The car-
bon skeleton of BCAAs and aspartate are used for the novo syn-
thesis of tricarboxylic acid (TCA) cycle intermediates and gluta-
mine (Wagenmakers, 1998). However, in addition to their role
as energy substrates, amino acids obtained from the circulation
or from protein degradation in muscle play a crucial role in the
regulation of signaling pathways that modulate muscle growth,
metabolism, and function (Torre-Villalvazo et al., 2019). In this re-
gard, during a meal, increased levels of amino acids activate pro-
tein synthesis and the inhibition of autophagy, ultimately leading
to an increase in muscle mass (Zhang et al., 2014). The mecha-
nism by which amino acids modulate autophagy involve the acti-
vation of mTORC1 (Figure 2). Essential amino acids, such as
leucine, are sensed by mTORC1 by a mechanism that is not fully
understood. For a deep understanding of the biology of mTOR
and how it senses amino acid availability, we refer the readers
to excellent reviews (Kim and Guan, 2019; Wolfson and Sabatini,
2017). Briefly, leucine is sensed by sestrins and arginine by
CASTOR1, which, upon amino acid binding, dissociate from
and release their suppressive effects on GATOR2 (a positive
regulator of mTORC1), thereby activating mTORC1. Methionine
is sensed in the form of SAM (S-adenosylmethionine) by SAM-
TOR, which, upon SAM binding, dissociates from and inhibits
GATOR1 (a negative regulator of mTORC1), thus leading to
mTORC1 activation. Whether those mechanisms of amino acid
sensing operate in muscle cells remains to be determined.
Canonically, mTORC1 inhibits autophagy through interaction
with the ULK1/FIP200/Atg13 complex by phosphorylating and
inhibiting ULK1 (Kim et al., 2011). In addition, it has been shown
that mTORC1 also inhibits AMBRA1 and ATG14 (Nazio et al.,
2013; Yuan et al., 2013), two autophagy-stimulatory interactors
of BECN1, and the transcription factor EB (TFEB), a crucial

270 Developmental Cell 54, July 20, 2020


Review
FFA
(Free fatty acids)
PKR
FFA
JNK
DAG
mTORC1
ULK1 complex
MUSCLE CELL
Class III PI3K complex
Activation of
Autophagy
Figure 3. Metabolic Regulation of Autophagy by Lipids
Contradictory results have been found for the effect of lipids on autophagy depending on the duration of fatty acid exposure or cell context. High levels of fatty
acids could activate autophagy by inhibiting mTORC1 or by activating different pathways depending on PKR-eIF2a, JNK, and PKC, leading to an increase in
autophagosome formation, although the molecular mechanisms and whether they are preserved in skeletal muscle are not known. In addition, high levels of lipids
have been shown to impair autophagosome-lysosome fusion.
transcription factor involved in the expression of genes involved
in the autophagy-lysosome pathway (Settembre et al., 2013).
However, studies using either pharmacological or genetic ap-
proaches have shown that mTORC1 is responsible only for the
regulation of 10% of autophagic flux in muscle (Sandri, 2010b).
In this respect, accurate biochemical analyses have determined
that rapamycin-mediated mTOR inhibition increases protein
breakdown by only 10% in myotubes—a much smaller response
than the 50% increase in protein breakdown after Akt inhibition
(Zhao et al., 2007). In addition, in vivo inhibition of mTOR by ra-
pamycin or by RNAi approaches is not sufficient to induce mus-
cle atrophy or autophagosome formation (Mammucari et al.,
2007; Zhao et al., 2007). Moreover, knockout (KO) mice for
mTOR or Raptor (an mTORC1 component) show muscular dys-
trophy rather than muscle atrophy (Risson et al., 2009). There-
fore, these data suggest that mTORC1 is not the major energy
sensor involved in the regulation of autophagy in skeletal muscle.
Importantly, amino acids can regulate autophagy indepen-
dently of mTORC1 signaling (Figure 2). In this context, the
eIF2a kinase GCN2, a sensor of amino acid availability, induces
the expression of a set of genes involved in the formation, elon-
gation, and function of the autophagosome by activating the eI-
F2a-ATF4 pathway (B’chir et al., 2013). In addition, the lack of
some amino acids, such as leucine, glutamate, and glutamine,
leads to a reduction of acetyl-CoA pools, which has been shown
to induce autophagy (Mariño et al., 2014). However, whether
these mechanisms are preserved in skeletal muscle is still
not known.
ll
eIF2α
PKC
Autophagosome
Lysosome
Autolysosome
Glucose. Glucose availability regulates autophagy by control-
ling the energetic charge of the cell. Thus, in conditions of
glucose deprivation, cellular levels of ATP decrease, leading to
an increase in the AMP/ATP ratio and activation of AMPK (Hardie
et al., 2012), which in turn promotes autophagy by various mech-
anisms (Figure 2). AMPK inhibits mTORC1 by directly phosphor-
ylating Raptor (a component of mTORC1 complex) (Gwinn et al.,
2008) or by phosphorylating and activating TSC2 (an upstream
inhibitor of mTORC1) (Inoki et al., 2003), finally leading to the acti-
vation of autophagy. Independently of mTORC1 inhibition,
AMPK also triggers autophagy by phosphorylation and activa-
tion of ULK1 and BECN1 (Egan et al., 2011a; Kim et al., 2013a;
Kim et al., 2011). Although the exact serine residues in ULK1
phosphorylated by AMPK remain unclear, Ser317, -467, -555,
-574, -637, and -777 may have a role (Bach et al., 2011). Howev-
er, it has been reported that phosphorylation of Ser555 is not suf-
ficient to increase autophagosome content in rodent muscle or in
human myotubes (Fritzen et al., 2016). Activation of AMPK by
glucose deprivation is also responsible for the phosphorylation
and activation of the transcription factor FoxO3 (Greer et al.,
2007; Sanchez et al., 2012), which is responsible for inducing
key autophagic genes such as LC3, Bnip3, Vps34, Atg12, and
GABARAP (Mammucari et al., 2007) (Figure 2). Contrary to
glucose starvation, high glucose availability inhibits autophagy.
In this regard, glucose has been described to inhibit autophagy
via activation of mTORC1 independently of AMPK, via the forma-
tion of a lysosomal v-ATPase-Ragulator-Rag GTPase complex
(Efeyan et al., 2013). In all, glucose regulates autophagy by
Developmental Cell 54, July 20, 2020 271
 ll
distinct signaling pathways, which might depend on the cellular
context or the type or duration of changes in glucose concen-
tration.
During fasting, the combined effect of low amino acid and
glucose availability leads to the activation of autophagy. In this
regard, the effects of fasting-mimetic dietary interventions
known to expand health span, such as caloric restriction, inter-
mittent fasting, and time-restricted feeding, have been
described to mediate their benefits, in part, through regulation
of autophagy. Long-term caloric restriction (3–15 years) in hu-
mans is associated with an increase in autophagy mediators
such as Beclin 1 and LC3 in skeletal muscle (Yang et al.,
2016). In addition, a time-restricted feeding model (isocaloric
twice a day feeding) increases autophagic flux in skeletal muscle
and other tissues, leading to an increase in muscle mass, energy
expenditure, and protection from obesity and diabetes (Marti-
nez-Lopez et al., 2017). Low-carbohydrate diets, such ketogenic
diets, are known to mimic calorie restriction and extend longevity
and health span (Roberts et al., 2017) and have been shown to
reverse high-fat-diet-induced alterations in muscle by activating
autophagy through inhibition of Akt and mTOR signaling (Li
et al., 2018).
Lipids. The role of lipids in the regulation of autophagy is less
characterized than that of amino acids or glucose. Several
studies have shown that an increase in lipids is associated with
a reduction in autophagy (Figure 3). In this regard, an in vitro
fusion assay of autophagosomes and lysosomes obtained
from mouse liver has shown that changes in membrane lipid
composition reduces autophagosome-lysosome fusion by up
to 70% (Koga et al., 2010). Moreover, the long-term incubation
of b cells with a high concentration of palmitate impairs auto-
phagy and lysosomal acidification and activity (Las et al.,
2011). In contrast, other studies in b cells have shown that 12 h
of treatment with palmitic acid triggers autophagy by blocking
mTORC1 or activating the PKR-JNK pathway (Choi et al.,
2009; Komiya et al., 2010). Moreover, palmitate has also been
shown to induce autophagy in human osteosarcoma U2OS cells
by disrupting the interaction of STAT3 and PKR and leading to
PKR-dependent phosphorylation of eIF-2a (Shen et al., 2012).
In skeletal muscle cells, long exposure to palmitate may inhibit
autophagy, as indicated by decreased levels of LC3II and
increased levels of p62 (Choi et al., 2018). However, other
studies have shown that increased levels of fatty acids activate
autophagy (Niso-Santano et al., 2015; Tan et al., 2012). In this
respect, in human cancer cells, short-term incubation with
palmitate induces canonical autophagy, whereas oleate triggers
non-canonical autophagy dependent on an intact Golgi appa-
ratus (Niso-Santano et al., 2015). In contrast, in MEF (mouse em-
bryonic fibroblasts) and HepG2 cells, palmitate, but not oleate,
increases autophagic flux by a mechanism involving PKC activa-
tion (Shen et al., 2012). A possible explanation for this discrep-
ancy could be the duration of fatty acid exposure (acute versus
chronic) and/or the cellular context. However, these mecha-
nisms have not been described yet in muscle. In skeletal muscle
in vivo, contradictory results have been obtained. For instance,
upon high-fat feeding, autophagy has been found to be unal-
tered in rats (Campbell et al., 2015) and either decreased (Choi
et al., 2018) or increased in mice (Liu et al., 2015b; Moresi
et al., 2012). In humans, autophagic flux is repressed in primary
272 Developmental Cell 54, July 20, 2020
Review
myotubes of severely obese subjects, which is a model of
chronic lipid overload (Bollinger et al., 2015). Therefore, lipid
oversupply might have a biphasic role on autophagy in muscle,
first increasing in order to protect from insulin resistance. How-
ever, if lipid excess persists, this adaptive role is lost and auto-
phagy decreases, thereby exacerbating insulin resistance.
Regulation of Autophagy by Insulin
Under conditions of high nutrient availability, increased insulin
levels are a major regulator of autophagy in muscle (Figure 4).
A recent multi-dimensional transcriptomic analysis has shown
that, under euglycemic clamp conditions, physiological levels
of insulin are associated with the downregulation of an auto-
phagy transcriptional network in muscle (Batista et al., 2019).
In addition, several KO mouse models have shed light on the
involvement of insulin in the regulation of autophagy and the
possible molecular players involved. Hence, muscle-specific
ablation of insulin receptor (IR) in mice leads to a moderate
reduction in muscle mass, and this is further impaired in double
KO mice for IR and IGF-1 receptor (IGF1R), thereby reflecting the
importance of insulin signaling in muscle mass maintenance
(O’Neill et al., 2016). Importantly, these effects are associated
with an increase in autophagy, which is dependent on FoxO1,
FoxO3, and FoxO4, as illustrated by a reversal in increased auto-
phagy upon combined deletion of these transcription factors in
double KO mice (O’Neill et al., 2016). In addition to IR and
IGF1R, a main actor of the insulin signaling pathway is the protein
kinase Akt, which controls approximately 50% of autophagy in
skeletal muscle (Zhao et al., 2007). Akt phosphorylates FoxO3,
preventing its nuclear translocation and thus the transcription
of FoxO3-dependent autophagic genes (Mammucari et al.,
2007). In addition, Akt phosphorylates and inhibits TSC2, a nega-
tive regulator of mTORC1 (Manning and Toker, 2017), thus acti-
vating mTORC1 and inhibiting autophagy. Therefore, upon acti-
vation of the insulin signaling pathway, insulin represses
autophagic gene expression, which is mediated mainly by inhibi-
tion of FoxO transcription factors.
Regulation of Autophagy by Exercise and Physical
Activity
Exercise training induces multiple adaptations in skeletal mus-
cle, and these depend on the type of exercise. Resistance exer-
cise is associated with increased muscle mass, while endurance
exercise is characterized by metabolic adaptations oriented to
increase muscle oxidative capacity. Importantly, in both types
of adaptation, autophagy seems to play an important role by
maintaining cellular energy homeostasis and regulating organ-
elle and protein turnover after exercise (Halling and Pile-
gaard, 2017).
The first observation of a role of autophagy in exercise was
observed in mouse muscle fibers 2 to 7 days after a single stren-
uous treadmill running bout (Salminen and Vihko, 1984). This was
followed by a number of studies showing that acute endurance
exercise activates autophagy in mouse skeletal muscle (Grumati
et al., 2011; He et al., 2012; Jamart et al., 2012b; Pagano et al.,
2014). In contrast, the role of resistance exercise on autophagy
in rodents is less well defined to date. Resistance exercise has
been associated either with an activation of autophagy with a
reduced number of autophagosomes or with no changes in
LC3II protein levels during the recovery period after exercise
(Luo et al., 2013; Ogasawara et al., 2016). Studies in humans

Review
Insulin
IGF1
Akt
TSC2
mTORC1
MUSCLE CELL ULK1 complex
Class III PI3K complex
Activation of
Autophagy
Figure 4. Regulation of Muscle Autophagy by Insulin
Under high-nutrient conditions, insulin activates Akt, which, by activating mTORC1 and inhibiting FoxO3, inhibits autophagy and autophagic gene expression,
respectively.
have also given contradictory results, suggesting either activa-
tion or inhibition of autophagy during endurance or resistance
exercise. This discrepancy could be due to the lack of robust
measurements of autophagic flux, differences in exercise proto-
cols, and variations in times of muscle sampling (Fritzen et al.,
2016; Fry et al., 2013; Jamart et al., 2012b; Møller et al., 2015;
Ogborn et al., 2015; Schwalm et al., 2015; Smiles et al., 2015).
Nonetheless, it is becoming apparent that endurance exercise
induces autophagy, probably in an exercise duration-dependent
manner, whereas autophagy does not seem to be essential for
muscle adaptations to resistance exercise.
The mechanisms by which exercise regulates autophagy in
muscle involve mTOR, AMPK, Akt, and FoxO3 signaling path-
ways (Figure 5). Hence, inactivation of mTORC1 leads to a
decrease in ULK1 Ser757 phosphorylation and activation of
autophagy in mouse skeletal muscle during exercise (Pagano
et al., 2014) and 10 h post exercise (Halling et al., 2016). In addi-
tion, AMPK has been shown to be necessary for exercise-
induced autophagy (Egan et al., 2011b) by phosphorylation of
ULK1 in Ser317 and Ser555, which are increased in response
to a single exercise bout. This association of exercise-induced
AMPK and autophagy is also supported by results from some
human studies (Møller et al., 2015; Schwalm et al., 2015),
although this correlation has not been detected in other work
(Fritzen et al., 2016). AMPK can also activate autophagy by
phosphorylation and activation of FoxO3, which is induced in ul-
tra-endurance exercise (Jamart et al., 2012b; Zhao et al., 2007)
and which activates the expression of autophagic genes in mus-
cle (Mammucari et al., 2007). The role of Akt in muscle autophagy
ll
Insulin
Receptor (IR)
FOXO3
FOXO3 Autophagy genes
Nucleus
is less clear because distinct forms of exercise have different ef-
fects on Akt activation. Thus, following a single bout of exercise,
Akt is dephosphorylated and then inactivated (He et al., 2012).
However, during a sprint, endurance and resistance exercise,
Akt is activated, preferentially when exercise is performed in a
fed state (Camera et al., 2010; Guerra et al., 2010), which would
negatively regulate FoxO3 and inhibit autophagic gene expres-
sion. Interestingly, increased expression and activity of FoxO3
has been observed in human and mouse skeletal muscle
following acute endurance exercise (Jamart et al., 2012a; Louis
et al., 2007). These data suggest that Akt and AMPK-mediated
FoxO3 regulation contributes to the transcriptional regulation
of autophagy in skeletal muscle in response to exercise. In addi-
tion to FoxO3, other transcription factors participate in the regu-
lation of autophagy during exercise. In this regard, lysosomal
Ca2+ release through mucolipin 1 (MCOLN1) activates the phos-
phatase calcineurin, which dephosphorylates TFEB, leading to
its nuclear translocation and activation of lysosomal genes in
response to exercise (Medina et al., 2015). It has also been pro-
posed that PGC1a plays a role in basal and exercise-induced
autophagy. In this regard, muscle PGC1a overexpression is
associated with an increase in BNIP3 protein expression and
an increased basal autophagic flux (Lira et al., 2013), whereas
both total and muscle-specific PGC1a KO mice show a reduc-
tion in exercise-induced autophagy (Halling et al., 2016; Vain-
shtein et al., 2015). The precise mechanism by which PGC1a
regulates autophagy is unknown, but a direct regulation of auto-
phagy gene expression or an indirect effect by controlling mus-
cle oxidative capacity has been proposed.
Developmental Cell 54, July 20, 2020 273
 ll
Review

Exercise/Muscle contraction

Endurance/
Acute Resistance
exercise exercise
AMPK

mTORC1 Ca2+ Akt PGC1α

FOXO3

ULK1 complex
Calcineurin PGC1α
Autophagy genes
MUSCLE CELL

FOXO3 Autophagy genes

Class III PI3K complex

TFEB TFEB Lysosomal and

autophagy genes

Activation of
Autophagy Nucleus

Figure 5. Metabolic Regulation of Autophagy by Exercise

Muscle contraction and exercise lead to activation of autophagy by inhibiting mTORC1 and activating AMPK, which can also inhibit mTORC1 and activate UKL1.
Moreover, AMPK activates FoxO3, inducing the expression of autophagy genes. Different forms of exercise have been found to modulate Akt. Hence, acute
exercise blocks Akt, relieving the inactivation of FoxO3 and therefore increasing FoxO3-dependent gene transcription. In contrast, endurance and resistance
exercise activate Akt, inhibiting FoxO3. Increases in calcium following exercise activate the phosphatase calcineurin, which activates TFEB and the expression of
lysosomal and autophagy genes. Finally, PGC1a is activated during exercise and induces the expression of autophagy genes.

Together, these data reflect the complexity of exercise-
induced autophagy in muscle, which appears to involve the inter-
connection of various signaling pathways. In addition, the
different types and duration of exercise, as well as the distinct
molecular markers and techniques used for monitoring auto-
phagy, increase the difficulty of data interpretation.
Autophagy and Regulation of Skeletal Muscle Energy
Metabolism
As described in previous sections, autophagy is regulated in
different physiological and pathological conditions, such as fast-
ing, atrophy, and exercise (Figure 6). Importantly, many of the
pathways leading to autophagy regulation are performed via
the control of skeletal muscle metabolism.
In addition to its role in quality control, autophagy serves to
mobilize cellular energy stores to provide nutrients in times of
need. In this regard, autophagy is involved in glycogen degrada-
tion via a process called glycophagy, which is crucial for the
maintenance of glucose homeostasis in skeletal muscle (Kotou-
las et al., 2006). In this process, it has been suggested that the
interaction of STBD1 (starch-binding domain-containing protein
1) with GABARAPL1 plays an important role by tethering
glycogen to autophagic membrane structures for lysosomal
degradation (Jiang et al., 2010). The importance of autophagy
in glycogen breakdown has been demonstrated by a number
of studies showing that alterations in this process underlie the
basis of several muscular disorders, previously described as
lysosomal storage diseases (Margeta, 2020). In this context,
Pompe disease, caused by loss-of-function mutations in the
lysosomal hydrolase acid a-glucosidase (GAA) responsible for
glycogen catabolism in the lysosome, and Danon disease,
caused by mutations in LAMP2 gene, are associated with the
accumulation of glycogen granules and with a deficient delivery
of glycogen accumulated inside autophagosomes to lysosomes
for its degradation (Nishino et al., 2000). Interestingly, muscle-
specific ablation of Vps15 in mouse leads to a severe myopathy
associated with defects in autophagosome and lysosome fusion
and the accumulation of glycogen. In contrast, the overexpres-
sion of the Vps37-Vps15 complex in muscle cells derived from
Danon disease patients results in a partial amelioration of
glycogen overload (Nemazanyy et al., 2013).
Loss of muscle homeostasis due to alterations in autophagy
has been suggested to underlie the development of several my-
opathies and muscular dystrophies. Decreased autophagy in
skeletal muscle-specific ATG7 KO mice was associated with
an accumulation of protein aggregates, abnormal mitochon-
dria, and oxidative stress, leading to muscle atrophy, weak-
ness, and several features of myopathy (Masiero et al., 2009).
In addition, autophagy has been shown to be decreased in
several muscular dystrophies, such as collagen VI muscular
dystrophy (Grumati et al., 2010) and Duchenne muscular dys-
trophy (De Palma et al., 2012), as well as in a variety of lyso-
somal storage disorders such as the aforementioned Pompe
and Danon diseases (Margeta, 2020). Patients affected by

274 Developmental Cell 54, July 20, 2020


Review
LOCAL EFFECTS
Impaired lysosomal
degradation of glycogen
Decreased insulin and
Activation of
exercise-stimulated
Autophagy
glucose uptake
Mitochondrial dysfunction and
reduced energy metabolism
Figure 6. Muscle Autophagy and Regulation of Energy Metabolism
Alterations in muscle autophagy are associated with abnormalities in muscle metabolism (local effects) and to changes in whole-body energy metabolism
(systemic effects). Deficient autophagy in muscle has been shown to be associated with the development of myopathies such as Pompe and Danon diseases.
Furthermore, impaired autophagy could lead to mitochondrial dysfunction, decreased insulin-stimulated and exercise-induced glucose uptake, and reduced
energy metabolism in muscle, leading to muscle atrophy, exercise intolerance, and insulin resistance. Importantly, mitochondrial dysfunction induced by reduced
autophagy in muscle leads to increased expression and secretion of FGF21, which has been shown to have beneficial effects at the whole-body level, such as
protection from diet-induced obesity and glucose intolerance.
multisystem disorder Vici syndrome show a pattern of vacuolar
myopathy with glycogen storage and immature, hypoplastic,
and atrophic muscle fibers (Hedberg-Oldfors et al., 2017). Simi-
larly, Epg5-deficient mice show muscle denervation and myo-
fiber degeneration (Zhao et al., 2013). Interestingly, EPG5 is
the human homolog of the metazoan-specific autophagy
gene epg-5, encoding a key autophagy regulator implicated
in the formation of autolysosomes (Tian et al., 2010) by interact-
ing with Rab7 and VAMP7/8 proteins (Wang et al., 2016). How-
ever, increased autophagy is also associated with some
muscular dystrophies, such as MDC1A, a severe form of
congenital muscular dystrophy characterized by mutations in
the gene encoding laminin a2 (Gawlik and Durbeej, 2011). In
this regard, an increase in autophagy has been found in the
dy3k/dy3k mutant mouse model for laminin a2 and muscle bi-
opsies from two MDC1A patients (Carmignac et al., 2011).
Therefore, both reduced and increased autophagy can induce
myopathies, indicating that a fine balance of autophagic flux
is necessary to preserve muscle homeostasis (Sandri, 2010a).
Muscle atrophy also occurs in response to denervation or
inactivity and in response to fasting and various diseases,
including sepsis, AIDS, renal and cardiac failure, cancer (cancer
cachexia), and diabetes. Several studies indicate that activation
of autophagy is one of the molecular mechanisms underlying
muscle atrophy in these conditions (Mammucari et al., 2007;
Zhao et al., 2007). The decrease in PI3K-Akt signaling associated
to these catabolic conditions induces the nuclear translocation
and activity of FoxO transcription factors, such as FoxO3, which
activate autophagic gene expression. In this regard, specific
ablation of FoxO transcription factors in skeletal muscle protects
from fasting- and denervation-induced muscle atrophy (Milan
et al., 2015). Therefore, an excessive autophagy aggravates
muscle loss in muscle-wasting conditions. Muscle-specific over-
expression of DOR/TP53inp2, a positive autophagy regulator
(Mauvezin et al., 2010), exacerbates muscle wasting in strepto-
zotocin-induced diabetes and cancer cachexia in mice (Penna
et al., 2019; Sala et al., 2014). Interestingly, TP53inp2 is naturally
repressed in human insulin resistance and in murine models of
diabetes, suggesting that TP53INP2 repression would reduce
ll
SYSTEMIC EFFECTS
Myopathies Protection against
(Pompe and Danon disease) diet-induced obesity
and glucose intolerance
FGF21
Exercise intolerance
levels
Muscle atrophy
Browning of white
Insulin resistance adipose tissue
muscle atrophy under conditions that favor protein loss in skel-
etal muscle (Sala et al., 2014). Ablation of the transcription factor
Runx1 also leads to excessive autophagy and potentiates mus-
cle atrophy in denervated muscles (Wang et al., 2005), suggest-
ing that Runx1 is required to preserve muscle mass upon dener-
vation. Interestingly, the response to these different stimuli that
induce muscle atrophy and weakness differs between fiber
types. For example, oxidative type I fibers are more resistant
to fasting but more sensitive to inactivity and denervation-
induced atrophy, whereas type II fibers are more vulnerable to
cancer cachexia, diabetes, and aging (Wang and Pessin,
2013). However, the molecular basis for this selectivity and
whether differences in autophagy flux could contribute to that
remain unresolved. Regarding autophagy, a skeletal muscle-
specific transgenic mouse model of the tyrosine kinase Fyn,
whose activity is higher in fast-twitch muscles, shows a marked
atrophy of glycolytic fibers due to STAT3-dependent reduction in
the Vps34/p150/Beclin 1/ATG14 complex and consequently in
autophagy (Yamada et al., 2012). These data could potentially
explain the fiber-type-specific muscle wasting observed in
this model.
Autophagy has been shown to regulate glucose utilization in
muscle. Pharmacological inhibition of autophagy in C2C12 mus-
cle cells reduces insulin-stimulated glucose uptake (Liu et al.,
2015a). In vivo, the role of skeletal muscle autophagy in glucose
metabolism has been studied in several mouse models deficient
for proteins involved in the regulation of autophagy. For instance,
BCL2 AAA knockin mutant mice, which have reduced autophagy
due to an inhibition of BCL2-BECN1 dissociation, and ATG6+/
mice show reduced GLUT4 translocation to plasma membrane
and glucose uptake in response to exercise (He et al., 2012;
Lira et al., 2013). In addition, prolonged iron overload, which re-
sults in an autophagy defect in skeletal muscle by altering
mTORC1, has been shown to contribute to impaired insulin-
stimulated glucose uptake and insulin signaling (Jahng et al.,
2019). In contrast, another study has demonstrated that deficient
autophagy in skeletal muscle by knocking out ATG7 does not
have an impact on AMPK activation or glucose homeostasis
(Lo Verso et al., 2014). However, this study revealed that
Developmental Cell 54, July 20, 2020 275
 ll
autophagy is critical for the preservation of mitochondrial func-
tion during damaging muscle contraction.
The role of autophagy in lipid metabolism has gained consid-
erable interest due to its potential implication in obesity and
metabolic syndrome. In liver, it has been shown that lipid drop-
lets (LDs) can be degraded by autophagy by a process called lip-
ophagy, which is activated in response to fasting or sustained
lipid overload (Singh et al., 2009). Several mechanisms have
been described to regulate lipophagy, such as Rab7-mediated
translocation of autophagosomes and lysosomes to the LDs
(Schroeder et al., 2015), TFEB-mediated activation of PGC1a
target genes involved in fatty acid catabolism, including lipoph-
agy (Settembre et al., 2013), and FOXO1 activation (Lettieri Bar-
bato et al., 2013). However, in skeletal muscle, lipophagy has
been much less studied (Lam et al., 2016).
Defects in autophagy are also associated with alterations in
mitochondrial function, which could contribute to impaired en-
ergy homeostasis in muscle. In this regard, specific ablation of
Atg7 in muscle exacerbates mitochondrial dysfunction and
oxidative stress during aging (Carnio et al., 2014). Interestingly,
TFEB, which is involved in autophagy and lysosomal biogenesis,
has also been shown to regulate mitochondrial mass and func-
tion in muscle by inducing the expression of genes involved in
mitochondrial biogenesis, fatty acid oxidation, and oxidative
phosphorylation (Mansueto et al., 2017). Moreover, modulation
of autophagy by other proteins that are not constituents of the
canonical autophagy machinery has also been linked to alter-
ations in mitochondria and energy metabolism in muscle. In
this regard, mice lacking collagen-type VI a (COLA6 KO mice)
show impaired autophagy, which leads to the accumulation of
dysfunctional mitochondria and an altered mitochondrial
network (Grumati et al., 2010, 2011). In addition, ablation of the
mitochondrial fusion protein Mfn2 inhibits autophagic degrada-
tion of mitochondria (mitophagy), thereby leading to the accumu-
lation of damaged mitochondria and to an impairment of mito-
chondrial function and glucose metabolism in C2C12
myotubes and skeletal muscle in vivo (Sebastián et al., 2012,
2016). These results suggest that the regulation of mitochondrial
turnover by autophagy is crucial for the maintenance of energy
metabolism in muscle. In this regard, ablation of the mitophagy
protein Parkin in muscle leads to an impairment in mitochondrial
function (Peker et al., 2018). Moreover, skeletal muscle-specific
ablation of the mitophagy protein FUNDC1 in mice results in an
LC3-mediated mitophagy defect, leading to impaired mitochon-
drial energetics and decreased muscle fat utilization (Fu et al.,
2018). Interestingly, Urolithin A, a natural compound found in
pomegranate fruit, has been found to activate mitophagy in mus-
cle and to increase complex-II-dependent mitochondrial respira-
tion (Ryu et al., 2016).
Importantly, the role of autophagy in regulating metabolism
described above has important physiological implications in
skeletal muscle, such as muscle adaptation to exercise, as
well as some of the metabolic benefits associated with it. Hence,
deficient autophagy and glucose uptake in BCL2 AAA knockin
mutant mice or ATG6+/ mice is associated with a decrease in
exercise capacity (He et al., 2012; Lira et al., 2013). Specific abla-
tion of ATG7 in muscle has also been shown to induce muscle
atrophy and reduce muscle power (Kim et al., 2013b; Masiero
et al., 2009). Increased mitochondrial mass and function driven
276 Developmental Cell 54, July 20, 2020
Review
by TFEB enhances physical performance and coordinates meta-
bolic flexibility during exercise (Mansueto et al., 2017). In addi-
tion, decreased autophagy and mitophagy in muscle of Mfn2-
deficient mice is associated with muscle atrophy and a reduction
in muscle force and exercise capacity during aging (Sebastián
et al., 2016). Reduced mitophagy in either Parkin or FUNDC1
KO mice is also linked to reduced exercise performance (Fu
et al., 2018; Peker et al., 2018). Together, these data reveal a
tight connection between autophagy, the control of muscle
metabolism, exercise-induced muscle adaptations, and condi-
tions associated to muscle wasting.
Skeletal Muscle Autophagy and the Regulation of
Whole-Body Energy Metabolism
The role of autophagy on muscle metabolism also has marked
implications for energy metabolism at the whole-body level, as
demonstrated by several studies performed in KO mouse
models for various autophagic regulators. In this regard, BCL2
AAA knockin mutant mice are more susceptible to high-fat-
diet-induced glucose intolerance, mainly due to an impaired
response to the beneficial metabolic effects of exercise (He
et al., 2012). Mice lacking AMPK specifically in muscle show
an impairment in fasting-induced autophagy, which leads to a
downregulation of muscle proteolysis and reduced circulating
levels of alanine, resulting in an impairment in liver gluconeogen-
esis (Bujak et al., 2015). These findings establish an essential
requirement for skeletal muscle AMPK-mediated autophagy in
preserving blood glucose levels during prolonged fasting. How-
ever, muscle-specific Atg7 KO mice, which show impaired auto-
phagy and mitochondrial dysfunction, have a reduced fat mass,
together with enhanced glucose clearance and energy expendi-
ture. In addition, these animals are protected from diet-induced
obesity and insulin resistance (Kim et al., 2013b). Interestingly,
these effects are caused by an ATF4-mediated increase in
FGF21, a cytokine released from Atg7-deficient muscles, which
increases fatty acid oxidation and the browning of white adipose
tissue. Although basal levels of FGF21 expression in muscle are
low compared with other tissues, this stress-induced FGF21
secretion constitutes an adaptive endocrine crosstalk between
alterations in muscle autophagy and changes in metabolism in
other tissues (Tezze et al., 2019). This adaptive mechanism has
also been described upon muscle-specific ablation of FUNDC1,
which impairs mitophagy and mitochondrial function but confers
protection from diet-induced obesity, glucose intolerance, and
insulin resistance (Fu et al., 2018). Similar to the ablation of
ATG7, FUNDC1 deficiency induces a retrograde response in
muscle involving increased expression of FGF21, thereby pro-
moting thermogenic remodeling of adipose tissue (Fu et al.,
2018). These studies reveal a tight connection between the pres-
ence of mitochondrial dysfunction in muscle, probably as a
consequence of impaired autophagy and/or mitophagy, and
the triggering of an integrated stress response to promote meta-
bolism in other tissues. In this regard, skeletal muscle-specific
ablation of the mitochondrial fusion protein OPA1 leads to severe
mitochondrial dysfunction in skeletal muscle but also to
improved glucose tolerance and protection from diet-induced
obesity, mediated by increased levels of FGF21 (Pereira et al.,
2017; Rodrı́guez-Nuevo et al., 2018; Tezze et al., 2017). Some
of the alterations detected in Opa1-deficient muscles are also

Review
driven by activation of a TLR9-driven inflammatory pathway,
which may be linked to impaired mitophagy (Rodrı́guez-Nuevo
et al., 2018). Nonetheless, not all muscle alterations in autophagy
or mitochondrial function lead to this inflammatory stress
response, and it is still not known whether this stress response
depends on the type of alteration or the intensity of mitochondrial
dysfunction. In addition, activation of autophagy has been
shown to improve muscle metabolism and function (Ryu et al.,
2016). However, whether this activation leads to amelioration
of whole-body energy metabolism and whether it is useful for
the treatment of metabolic diseases are unresolved questions.
Autophagy participates in a stress response by controlling the
production of hormones, cytokines, metabolites, and other fac-
tors that cause the crosstalk between tissues or organs in meta-
bolic homeostasis and in adaptive responses. Muscle auto-
phagy participates in such a coordination through the
operation of non-cell-autonomous and systemic responses. In
this connection, in Caenorhabditis elegans, excessive auto-
phagy in pharyngeal muscle in gbp-2 mutants leads to death
when subjected to starvation, by a mechanism that could be re-
verted by the presence of certain amino acids and their action on
specific neurons, suggesting a crosstalk between muscle auto-
phagy and neuronal responses (Kang and Avery, 2009). It has
also been reported that muscle overexpression of the transcrip-
tion factor FOXO and its target 4E-BP activates autophagy, de-
lays muscle functional decay, and extends lifespan in Drosophila
by decreasing feeding behavior and the release of insulin from
producing cells (Demontis and Perrimon, 2010).
Muscle autophagy can be also regulated through non-cell-
autonomous mechanisms that are initiated in other tissues or or-
gans. In this connection, intestine-specific AMPK activation in-
duces autophagy not only in the intestine but also in brain and
muscle, leading to reduced insulin-like peptide signaling and
slower systemic aging in Drosophila (Ulgherait et al., 2014). In
addition, during Caenorhabditis elegans development, loss of
cuticle annular furrow collagens elicits autophagy in the hypo-
dermis, intestine, and muscle by secretion of DAF-7 by specific
ciliated neurons (Zhang et al., 2019). Together, these data sug-
gest a bidirectional close multisystemic relationship between
muscle autophagy and metabolism crucial for the maintenance
of organismal homeostasis.
Concluding Remarks and Future Perspectives
Numerous studies have provided evidence of a close relation-
ship between autophagy and energy metabolism. Autophagy,
as a catabolic process, is tightly regulated by a variety of meta-
bolic signals and, on the other hand, has a crucial role in meta-
bolic adaptation and energy metabolism. Autophagy is very
active in skeletal muscle, which, as a central tissue in energy
homeostasis, is a strategic target tissue to combat metabolic
diseases. Therefore, the study of the molecular components
of the close interrelationship between muscle autophagy and
metabolism has gained attention in recent years. In this regard,
metabolic cues originated from different nutrient conditions and
physiological conditions such as muscle contraction and exer-
cise are known to modulate autophagy in muscle. Importantly,
functional autophagy is also necessary for correct metabolic
adaptation, muscle function, and exercise performance. Alter-
ations in muscle autophagy are associated with several dis-
ll
eases, such as myopathies and muscular dystrophies, cancer
cachexia, and diabetes. However, whether those alterations
are directly attributable to changes in autophagy (i.e., those
observed in Atg KO mouse models) or may be a consequence
of more general alterations that also involve autophagy needs
further investigation. Moreover, the precise role of autophagy
in physiology and in pathology in humans remains inconclusive,
as most studies have been conducted in mouse models defec-
tive for autophagy proteins. Furthermore, research into auto-
phagy in human tissue samples is technically challenging,
owing to the difficulty in measuring autophagic flux. In addition,
the study of autophagy in exercise is particularly complex
because different duration and types of exercise may be asso-
ciated with distinct upstream or downstream autophagic mech-
anisms. Of particular interest is the connection between de-
fects in autophagy in muscle and the activation of adaptive
responses targeting other tissues. Defective muscle meta-
bolism due to impaired autophagy could lead to amelioration
of energy metabolism and protection from metabolic disease
at the whole-body level, although more studies are needed to
understand this connection and the molecular players involved.
In this regard, studies oriented to (1) decipher how autophagy is
regulated specifically in different types of muscles and in
response to different factors; (2) discover key molecular players
involved in muscle autophagy and their regulation; and (3) un-
derstand the factors involved in the multisystemic role of mus-
cle autophagy would be of great importance in coming years. In
all, based on recent advances in the study of autophagy in
muscle physiology and metabolic regulation, autophagy
emerges as a promising therapeutic target to combat meta-
bolic diseases in the near future.
ACKNOWLEDGMENTS
Due to space constraints, we have not included all relevant references in this
growing field, so we kindly ask readers and authors for their understanding.
This study was supported by research grants from the MINECO (SAF2016-
75246R), the Generalitat de Catalunya (Grant 2017SGR1015), INFLAMES
(PIE-14/00045) from the Instituto de Salud Carlos III, CIBERDEM (‘‘Instituto
de Salud Carlos III’’), the Fundación Ramon Areces (CIVP18A3942), the Funda-
ción BBVA, the Fundació Marató de TV3 (20132330), and EFSD. A.Z. is a recip-
ient of an ICREA ‘‘Academia’’ Award (Generalitat de Catalunya). We gratefully
acknowledge institutional funding from the MINECO through the Centres of
Excellence Severo Ochoa Award and from the CERCA Programme of the Gen-
eralitat de Catalunya.
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