nutrients
Review
Sarcopenia as a Little-Recognized Comorbidity of Type II
Diabetes Mellitus: A Review of the Diagnosis and Treatment
Christian Salom Vendrell 1 , Elisa García Tercero 2 , Juan Bautista Moro Hernández 3
and Bernardo Abel Cedeno-Veloz 4, *
Citation: Salom Vendrell, C.; García
Tercero, E.; Moro Hernández, J.B.;
Cedeno-Veloz, B.A. Sarcopenia as a
Little-Recognized Comorbidity of
Type II Diabetes Mellitus: A Review
of the Diagnosis and Treatment.
Nutrients 2023, 15, 4149. https://
doi.org/10.3390/nu15194149
Received: 16 August 2023
Revised: 12 September 2023
Accepted: 14 September 2023
Published: 26 September 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Nutrients 2023, 15, 4149. https://doi.org/10.3390/nu15194149
1 Hospital Universitario Doctor Peset, 46017 Valencia, Spain
2 Hospital Universitario de la Ribera, 46600 Alzira, Spain
3 Medical Science Liaison, Abbott Nutrición, 28050 Madrid, Spain; juan.moro@abbott.com
4 Hospital Universitario de Navarra, 31008 Pamplona, Spain
* Correspondence: ba.cedeno.veloz@navarra.es
Abstract: Background: Type II diabetes mellitus (T2DM) is one of the most widespread metabolic
diseases worldwide, with a significant impact on morbi-mortality. Sarcopenia has a high risk in this
population (two times more risk) and a high impact at the functional level, especially in older adults.
In addition, it poses enormous challenges in the diagnosis, prevention, and treatment of this disease
concomitantly. The objective is to review the current knowledge on the state of muscle mass and the
pathogenesis, diagnosis, and treatment of sarcopenia in people with T2DM. Methods: A bibliographic
search was conducted in the PubMed-Medline databases for articles from 2015 with previously
defined terms. Results: A loss of muscle mass in older diabetic patients who are malnourished or at
risk of malnutrition has a proven negative impact on their autonomy and is closely related to the
risk of sarcopenia as a high-impact disease, and also with frailty, as an associated multidimensional
syndrome. Notably, we found that malnutrition and protein deficiency are often underdiagnosed in
obese and overweight T2DM patients. Biochemical markers could help in the future with approaches
to managing T2DM and sarcopenia concomitantly. The four essential elements which form the
basis of care for patients with diabetes and sarcopenia are pharmacological treatment, nutrition
management, regular physical exercise, and correct daily regime. Conclusions: The increasing
prevalence of sarcopenia among older patients with T2DM has significant negative impacts on quality
of life and is a public health concern. Effective diagnosis and management require a multidisciplinary
approach involving pharmacological treatment, nutrition, exercise, and correct daily regime, with
future research needed to understand the underlying mechanisms and improve diagnostic and
treatment strategies.
Keywords: diabetes; frailty; sarcopenia; malnutrition; functional impairment; oral supplementation
-HMB and exercise
1. Introduction
Diabetes mellitus is a disorder in which an alteration in the carbohydrate metabolism
predominates, resulting from a decrease in pancreatic insulin secretion, a decreased pe-
ripheral sensitivity to insulin, or a variable combination of both. It is also characterized by
abnormalities in the lipid and protein metabolism.
Long-term persistent hyperglycemia is not just a hallmark of T2DM, but also a major
contributing factor to a wide array of organ damage. Furthermore, hyperglycemia is
intricately linked with macrovascular complications, affecting larger blood vessels and
leading to conditions such as coronary artery disease and stroke, as well as microvascular
complications that impact smaller blood vessels, resulting in issues such as retinopathy,
nephropathy, and neuropathy. The cumulative effect of these complications significantly
elevates the risk of morbidity and mortality, making the management of blood sugar levels
crucial for long-term health outcomes [1].
https://www.mdpi.com/journal/nutrients
Nutrients 2023, 15, 4149 2 of 15

T2DM represents a major health burden for older adults, affecting approximately
25% of people over the age of 65 years worldwide, with this percentage being expected to
increase further in the coming decades [1].
The VIDA study was the first to assess nutritional status in a cohort of hospitalized
older patients and found a prevalence of 21.2% malnutrition and 39.1% nutritional risk [2,3].
Malnutrition worsens with age and is more pronounced in women, and is a factor that
increases population-wide mortality rates. Later, the PREDyCES [4] and SeDREno [5]
studies showed that diabetes is significantly associated with an increased risk of developing
malnutrition.
Malnutrition may be underdiagnosed in overweight or obese patients, and dietary
restrictions may even hinder nutrient intake. These restrictions often result in a negative
energy/protein imbalance, increasing the risk of developing malnutrition, particularly
when there is a lack of protein. Several factors contribute to the degree of malnutrition in
these patients: gastroparesis due to poor intake; diabetic foot, which increases energy and
protein requirements; and diabetic renal disease because of restrictions in protein intake
in pre-dialysis patients [2,3]. However, the coexistence of obesity, T2DM, and sarcopenia
presents a challenging health scenario, often referred to as “sarcopenic obesity”, which
has severe implications for morbidity, functional decline, and quality of life [6]. The
combination of obesity and a low handgrip strength suggest an increased risk of type
2 diabetes mellitus (OR 3.57, 95% CI 2.04–6.24) [7]. Understanding this triad is essential for
developing comprehensive diagnostic and treatment strategies.
Older people with T2DM have higher rates of functional disability, concomitant
illnesses, and common geriatric conditions, irrespective of the presence of microvascular
and macrovascular complications. One of these illnesses is sarcopenia, a degenerative
condition in which there is a lack of muscle or a low muscle mass, which can be a secondary
to a disease state, medical condition, or to aging itself [5,8].
The prevalence of sarcopenia among individuals with T2DM is notably elevated,
exhibiting a considerable range of variability. According to the existing literature, these
prevalence rates fluctuate significantly, spanning from as low as 7% to as high as 29.3% [8].
Different mechanisms may explain the higher prevalence of sarcopenia in people with
T2DM. Insulin’s anabolic effect on skeletal muscle is well known; it may be gradually lost
in T2DM due to the reduced insulin sensitivity associated with this disease. In addition, the
decrease in insulin’s effect may lead to decreased protein synthesis and increased protein
degradation, resulting in reductions in muscle mass and strength (Figure 1) [9].
In both type 1 and type 2 diabetes mellitus, muscle strength and architecture are also
adversely affected, this being a pathophysiological situation that is linked to muscle mass.
For all these reasons, DM is considered to be a risk factor for developing sarcopenia [10].
Chronic hyperglycemia promotes the accumulation of advanced glycation end-products
(AGE) in the skeletal muscle, with a correlation between AGEs and a weakened grip
strength, lower leg extension ability, and slower gait speed [9,10].
Similarly, diabetes is intricately linked with a rise in inflammatory cytokines, such
as interleukin-6 and tumor necrosis factor-alpha. These elevated levels of inflammatory
markers are thought to play a pivotal role in promoting the loss of muscle mass, as well
as contributing to reduced muscle strength and function. The cascade of inflammation
can trigger catabolic pathways in the muscle tissue, leading to protein degradation and
subsequent muscle atrophy. This, in turn, can result in a diminished physical performance
and functional capacity, exacerbating the already complex health challenges faced by
individuals with T2DM [9,10].
T2DM is characterized by a metabolic imbalance in which ATP levels are adversely
affected and mitochondria play a key role. Mitochondria are the main source of reactive
oxygen species (ROS) and are essential for redox homeostasis, metabolism, and many
cellular functions, including apoptosis and maintaining Ca2+ levels [9,10].
ts 2023, 15,Nutrients
x FOR PEER 15, 4149
2023,REVIEW 3 of 15 3 of 15

Figure 1. Interaction between sarcopenia and diabetes. Adapted from Landi F. et al., 2013 [9]. First,
Figure 1. Interaction between sarcopenia and diabetes. Adapted from Landi F. et al., 2013 [9].
the insulin resistance of skeletal muscle is the most important link between sarcopenia and diabetes.
First, the
Normal b-cell response to insulin
insulin resistance ofto
resistance is skeletal
enhance muscle is the most
the secretion important
of insulin link
and the between sarcopenia and
prolonged
diabetes.
physiologic increase Normal
in the plasmabeta-cell
insulin response to insulin
concentration couldresistance is to enhance
lead to further the secretion
reduction of insulin and the
in skeletal
muscle insulin prolonged
sensitivity. physiologic
Second, increase in the plasma
hyperglycemia insulin concentration
is associated with multiplecouldmetabolic
lead to further reduction
abnormalities, potentially correlated
in skeletal muscle with
insulin muscleSecond,
sensitivity. cell damage, and muscle
hyperglycemia mitochondrial
is associated with multiple metabolic
dysfunction leads to elevated accumulation of intramyocellular lipid metabolites. Third,
abnormalities, potentially correlated with muscle cell damage, and muscle mitochondrial insulin dysfunction
deficiency leads leads
to a protein catabolic state with loss of muscle mass.
to elevated accumulation of intramyocellular lipid metabolites. Third, insulin deficiency leads
to a protein catabolic state with loss of muscle mass.
In both type 1 and type 2 diabetes mellitus, muscle strength and architecture are also
adversely affected, this
The being a pathophysiological
relationship situation metabolism,
between mitochondria, that is linkedinflammation,
to muscle mass. and the different
For all these reasons,
signalingDMpathways
is considered to beina this
involved risk complex
factor forinteraction
developingis sarcopenia
very important[10]. [9,10].
Chronic hyperglycemia
Alterationspromotes the accumulation
in the mitochondrial metabolic ofpathways
advanced(such glycation end- phosphoryla-
as oxidative
products (AGE) in the
tion andskeletal muscle, with
the tricarboxylic acidacycle)
correlation between
can induce AGEsinand
changes genea weakened
expression that can lead
to different
grip strength, lower outcomes
leg extension in immune
ability, cells.gait
and slower Forspeed
example,[9,10].M1 macrophages are adversely af-
Similarly,fected in the
diabetes tricarboxylic
is intricately cycle
linked andaenter
with rise ina inflammatory
pro-inflammatory state, while
cytokines, such M2
as macrophages
undergo β-oxidation and produce anti-inflammatory
interleukin-6 and tumor necrosis factor-alpha. These elevated levels of inflammatory responses [11].
markers are thought Mitochondria
to play a pivotalplay role
an essential role inthe
in promoting theloss
regulation
of muscle of immune responses by mod-
mass, as well
as contributingulating autophagy,
to reduced muscle endoplasmic reticulumThe
strength and function. stress, and of
cascade inflammasome
inflammationactivation
can through
various
trigger catabolic mechanisms,
pathways in the including ROS production
muscle tissue, leading toand changes
protein in mitochondrial
degradation and DNA, which
regulate
subsequent muscle and control
atrophy. This, inthe
turn,transcription
can result inof immune system
a diminished physical cells. All these features under-
performance
and functional capacity, exacerbating the already complex health challenges faced by response in
score the importance of mitochondria in the modulation of the inflammatory
individuals withT2DM [11] (Figure
Diabetes Mellitus 2).Type II [9,10].
Finally, the higher
T2DM is characterized by a metabolic prevalence of sarcopenia
imbalance in which ATP in T2DM levelsis are
alsoadversely
related to the presence
of macrovascular and microvascular complications,
affected and mitochondria play a key role. Mitochondria are the main source of reactive i.e., retinopathy, nephropathy, and
oxygen speciesneuropathy.
(ROS) and Chronic kidney
are essential disease
for redoxsecondary
homeostasis, to diabetic nephropathy
metabolism, and many may affect muscle
mass, and diabetic peripheral neuropathy
cellular functions, including apoptosis and maintaining Ca levels [9,10].may2+ lead to a reduction in physical activity and
performance due to postural instability or vision loss.
The relationship between mitochondria, metabolism, inflammation, and the different Macrovascular complications such
as peripheral vascular disease can also contribute
signaling pathways involved in this complex interaction is very important [9,10]. to induce muscle ischemia, as well as a
poorer muscle strength, mass, and physical
Alterations in the mitochondrial metabolic pathways (such as oxidativeperformance [12].
phosphorylation and the tricarboxylic acid cycle) can induce changes in gene expression
that can lead to different outcomes in immune cells. For example, M1 macrophages are
adversely affected in the tricarboxylic cycle and enter a pro-inflammatory state, while M2
macrophages undergo β-oxidation and produce anti-inflammatory responses [11].
 Mitochondria play an essential role in the regulation of immune responses by
modulating autophagy, endoplasmic reticulum stress, and inflammasome activation
through various mechanisms, including ROS production and changes in mitochondrial
DNA, which regulate and control the transcription of immune system cells. All these
Nutrients 2023, 15, 4149 features underscore the importance of mitochondria in the modulation of4 ofthe 15
inflammatory response in T2DM [11] (Figure 2).

Figure 2.
Figure 2. Biological
Biological mechanism
mechanism potentially
potentially explaining
explaining diabetes-related
diabetes-related muscle
muscle dysfunction
dysfunction [11].
[11].
Adapted from Rocha M et al., 2020 [11]. Diminished β-cell function leads to decreased
Adapted from Rocha M et al., 2020 [11]. Diminished β-cell function leads to decreased insulin insulin
secretion and increased insulin resistance, affecting multiple organs and tissues. The underlying
secretion and increased insulin resistance, affecting multiple organs and tissues. The underlying
molecular mechanisms include inflammation, lipotoxicity, mitochondrial dysfunction, and
molecular mechanisms include inflammation, lipotoxicity, mitochondrial dysfunction, and endoplas-
endoplasmic reticulum stress.
mic reticulum stress.
Finally, the higher prevalence of sarcopenia in T2DM is also related to the presence
Reduced bone mass is another significant concern commonly observed in patients who
of macrovascular and microvascular
fit the profile of having complications,
T2DM and sarcopenia. i.e., retinopathy,
This decrease nephropathy,
in bone density and
contributes
neuropathy. Chronic kidney disease secondary to diabetic nephropathy may
to an elevated risk of fragility fractures. The incidence of these fractures is particularly affect muscle
mass,among
high and diabetic
women, peripheral
who areneuropathy
already moremaysusceptible
lead to a reduction in physical
to bone-related activity
issues suchand
as
performance due to postural instability or vision loss. Macrovascular
osteoporosis. These fractures not only pose immediate health risks, but also often leadcomplications such
to
as peripheral
long-term vascular disease
complications, can also
including contribute
a reduced to induce
mobility muscleofischemia,
and quality as well as a
life [13,14].
poorerThemuscle strength,
objective mass, the
is to review andcurrent
physical performance
knowledge on the[12].
state of muscle mass and the
Reduced bone mass is another significant concern commonly
pathogenesis, diagnosis, and treatment of sarcopenia in people with T2DM. observed in patients
who fit the profile of having Diabetes Mellitus Type II and sarcopenia. This decrease in
bone
2. density contributes to an elevated risk of fragility fractures. The incidence of these
Methodology
fractures is particularly
This narrative review high among
aims women,
to provide anwho are already
in-depth analysismore susceptible
of the to bone-
existing literature
related issues such as osteoporosis. These fractures not only pose immediate
concerning the relationship between T2DM, frailty, and sarcopenia. The primary objec- health risks,
but also often lead to long-term complications, including a reduced mobility
tive is to review and synthesize the information on the pathophysiology, diagnosis, and and quality
of life [13,14].of sarcopenia as a comorbidity in T2DM patients.
management
The objective is to review the current knowledge on the state of muscle mass and the
2.1. Literature Search
pathogenesis, diagnosis, and treatment of sarcopenia in people with type II diabetes
mellitus.
A comprehensive bibliographic search was conducted using multiple databases, in-
cluding PubMed, Scopus, and Google Scholar, focusing on articles published from 2015 to
present. The search terms used were “Diabetes Mellitus Type II”, “frailty”, “sarcopenia”,
“pathophysiology”, “diagnosis”, and “treatment.”

2.2. Inclusion and Exclusion Criteria

The inclusion criteria were articles that provided insights into the relationship between
T2DM and sarcopenia, its prevalence in diabetic patients, its underlying pathophysiology,
and its inflammatory component. Studies that offered management recommendations or
Nutrients 2023, 15, 4149 5 of 15

discussed the history of diabetes and diabetic control were also included. The exclusion
criteria were articles that did not focus on T2DM or sarcopenia, were not peer-reviewed, or
were published before 2015.

2.3. Review Process

After the initial search, a pool of authors reviewed the articles to assess their relevance
and quality. A total of 2506 articles met the defined search criteria, and 56 were selected for
the narrative review based on the selection criteria. These articles were then thoroughly
reviewed to extract their key findings, which were categorized into various sub-topics such
as diagnostic methods, treatment options, and future directions.

2.4. Data Synthesis

The data extracted from the selected articles were synthesized to provide a cohesive
understanding of the relationship between T2DM, frailty, and sarcopenia. This included
aspects such as the relationship between diabetes and sarcopenia, its prevalence in diabetic
patients, and its pathophysiology and inflammatory components, as well as management
recommendations and the history of diabetes and diabetic control.

3. Results
In our comprehensive literature search, we identified a total of 2506 articles that met
the defined search criteria. After a rigorous review process conducted by the pool of
authors, 56 articles were selected for inclusion in this narrative review. These articles were
chosen based on their relevance to the key questions that we aimed to answer:
(A) What is the pathophysiology and prevalence of a loss of muscle mass and function
associated with T2DM?
(B) What is the best treatment for a loss of muscle mass and function in T2DM patients?
(C) How feasible is the measurement of muscle mass and function in T2DM?
The main results are presented below:

3.1. Diagnostic Methods

As we have mentioned, diabetic patients are at a higher risk for sarcopenia and
malnutrition. The prevalence of sarcopenia in these patients varies due to the lack of
unified diagnostic criteria across the different series that have been reported (muscle
strength, muscle quantity/quality, and physical performance), as well as techniques for
quantitative assessments of muscle mass (dual-energy X-ray absorptiometry or bioelectrical
impedance analyses) [8]; so, until a common assessment method is developed and unified,
it is advisable for diagnoses to be made based on the existing available methods in each unit.
With respect to malnutrition in diabetic patients, an early nutritional assessment
using any validated screening tool is essential. There are no specific tools for diabetics,
although they do exist for the different settings in which they may be performed (inpatient,
outpatient, or older patient), which can be seen in Table 1 [15].
The Geriatric Nutritional Risk Index (GNRI) is an indicator of nutritional status. It is a
simple and accurate screening tool that includes objective factors, such as weight, height,
and serum albumin. The GNRI is associated with the presence of sarcopenia in people with
T2DM [16].
This index is calculated using the formula: (1.489 × albumin, g/L) + (41.7 × current
weight/ideal weight).
Patients are graded as serious risk (GNRI < 82), moderate risk (GNRI 82 to <92), mild
risk (GNRI 92 to 98), or no risk (GNRI > 98) [16].
It should be noted that, although many patients with T2DM are obese based on their
BMI, they may also have sarcopenia, so it is important to consider more specific measures
of body composition other than weight in these patients [8].
Nutrients 2023, 15, 4149 6 of 15

Table 1. Parameters required for the diagnosis of undernutrition/malnutrition.

Diagnostic Method Objective

Assess history for malabsorption: previous GI procedures, taste disorders, anorexia, nausea,
vomiting, gastrointestinal motility disorders, dysphagia, oral health issues, history of pulmonary
Medical history
aspiration, diabetic gastroparesis, allergies, drug use,
nutritional supplements, and medications, etc.
Assess loss of fat and muscle in specific body regions: orbital, temporal, and intercostal spaces, etc
Physical
Muehrcke’s lines in the fingernails suggest hypoalbuminemia, alopecia is associated with protein
examination
deficiency, and scaling of the scalp results from essential fatty acid deficiency.
Anthropometric data Calculate body mass index (BMI) and percentage of unintentional weight loss.
Use questionnaires to assess nutritional risk: Nutritional Risk Screening 2002 (NRS 2002), Subjective
Nutrition
Global Assessment (SGA), Mini Nutritional Assessment (MNA), Malnutrition Universal Screening
assessment
Tool (MUST), and Short Nutritional Assessment Questionnaire (SNAQ).
Bioelectrical Bioelectrical impedance analysis (BIA) provides a detailed description of body composition (fat mass,
methods fat-free mass, body water, lean body mass, and vector analysis).
The use of muscle ultrasonography to assess the quadriceps provides a simple, quick, and
Imaging tests cost-effective way of estimating total body muscle quantity and quality, but the cut-off points for this
tool have not yet been validated in the population.
Changes in biochemical parameters such as ghrelin, leptin, adiponectin, myostatin, cancer-associated
Biochemical
fibroblast (CAF), tumor necrosis factor-alpha (TNF-a), Interleukin-1 (IL-1), Interleukin-6 (IL-6),
laboratory markers
growth hormone (GH)/Insulin-like growth factor I (IGF-1), and testosterone.

Assessments of patients’ overall functional capacity can be performed with the Senior
Fitness Test battery of tests or the Short Physical Performance Battery (SPPB), which have
the advantage of not requiring sophisticated equipment, being easy to use, comparison
values in terms of sex and age being available and, moreover, can be applied in both the
hospital and extra-hospital settings [17].
These tests provide us with a general idea of physical fitness and some of its compo-
nents, but they are not very helpful for prescribing exercise loads according to results.
On the other hand, there are more reproducible and specific techniques for assessing
functional performance or the physical quality that we want to work on, and these can serve
as a reference for planning the workload. Among these are, for example, an estimation
or measurement of the maximal oxygen uptake (peak oxygen consumption), ventilatory
thresholds, actual maximum heart rate, or maximal force (one-repetition maximum, 1RM)
of the muscle groups that we want to train. These techniques require more sophisticated,
expensive equipment and require more physical space as well as a greater degree of
specialization by the professionals who perform the assessments [17].
Key biochemical markers such as myostatin, Irisin, Brain-Derived Neurotrophic Fac-
tor (BDNF), pro-inflammatory cytokines, Growth Hormone/Insulin-like Growth Factor
1 (GH/IGF1), and testosterone play significant roles in the pathogeneses of these inter-
connected conditions and their pathways could, in the future, help with diagnoses [18].
For instance, Myostatin and Irisin are directly involved in muscle metabolism and can be
indicative of muscle atrophy, while BDNF and pro-inflammatory cytokines are linked to
inflammation, a common underlying factor in both T2DM and sarcopenia. GH/IGF1 and
testosterone levels can also provide insights into the metabolic and hormonal imbalances
that exacerbate these conditions. Accurate diagnoses and effective treatment strategies
must, therefore, consider these biochemical markers to provide a comprehensive approach
to managing T2DM and sarcopenia concomitantly.

3.2. Treatment
3.2.1. Choosing a Glucose-Lowering Drug
Glucose-lowering medications appear to have a significant role in the development or
mitigation of sarcopenia among patients with diabetes. These drugs vary in their impacts
 treatment strategies must, therefore, consider these biochemical markers to provide a
comprehensive approach to managing T2DM and sarcopenia concomitantly.

3.2. Treatment
Nutrients 2023, 15, 4149 3.2.1. Choosing a Glucose-Lowering Drug 7 of 15
Glucose-lowering medications appear to have a significant role in the development
or mitigation of sarcopenia among patients with diabetes. These drugs vary in their
impacts
on muscleonmass
muscle
andmass and function,
function, largely
largely due due to differences
to differences in their mechanisms
in their mechanisms of
of action [19]
action [19]
(Figure 3): (Figure 3):

Figure
Figure 3. Plausible
Plausible mechanisms
mechanisms by by which
which glucose-lowering
glucose-lowering drugs
drugs might
might impact
impact on
on sarcopenia
sarcopenia
acting
acting on sarcopenia. DPP-4i, dipeptidyl peptidase-4
peptidase-4 inhibitors;
inhibitors; GLP-1
GLP-1 Ras,
Ras,glucagon-like
glucagon-likepeptide-1
peptide-
1receptor
receptoragonists;
agonists;GLUT4,
GLUT4,glucose
glucosetransporter
transporter type
type 4;
4; SGLT2i,
SGLT2i, sodium-glucose
sodium-glucose transport
transport protein
protein
22 inhibitors; ↑, increase; ↓,
inhibitors; and TZDs, thiazolidinediones. ↑, increase; ↓, decrease. Blue color and continue lines
and TZDs, thiazolidinediones. decrease. Blue color and continue lines
indicate a beneficial effect on sarcopenia; yellow color and dotted lines indicate a detrimental effect
indicate a beneficial effect on sarcopenia; yellow color and dotted lines indicate a detrimental effect
on sarcopenia [19]. Adapted from Massimino E et al., 2021 [19].
on sarcopenia [19]. Adapted from Massimino E et al., 2021 [19].

While
While numerous
numerous studies
studies have
have attempted
attempted to to evaluate
evaluate the
the effects
effects of
of glucose-lowering
glucose-lowering
medications on sarcopenia [20–41], these investigations are
medications on sarcopenia [20–41], these investigations are often marredoften marred by several
by several limita-
limitations. These include small sample sizes, inconsistent or varying techniques
tions. These include small sample sizes, inconsistent or varying techniques for assessing for
assessing sarcopenia, and a focus on sarcopenia as a secondary objective rather
sarcopenia, and a focus on sarcopenia as a secondary objective rather than as the primary than as
the primary focus of the study. Additionally, these studies often involve populations
focus of the study. Additionally, these studies often involve populations of varying age of
varying
ranges andagelack
ranges and lack comprehensive
comprehensive data onorcomorbidities
data on comorbidities usual physicaloractivity
usual levels.
physical
activity levels. findings have suggested that insulin does not appear to have a significant
Preliminary
effect on the development or progression of sarcopenia. Dipeptidyl peptidase-4 (DPP-4)
inhibitors, on the other hand, seem to have neutral effects on muscle mass and function.
Interestingly, the use of Sodium-Glucose Co-Transporter-2 (SGLT2) inhibitors has been
associated with an increased likelihood of developing sarcopenia, particularly in patients
already at risk [19].
Identifying patients at a higher risk for sarcopenia and choosing the most appropriate
glucose-lowering drug may help reduce the risk of it developing.

3.2.2. Nutritional Intervention

A mainstay of the treatment for these patients is medical nutrition therapy, both for
adequate control of their diabetes and to prevent disease-related malnutrition [42].
Malnutrition is present in more than 20% of hospitalized older diabetic patients.
Malnutrition in patients with diabetes worsens if not corrected and leads to a poorer
prognosis and longer hospitalizations [3].
Nutrients should preferably be provided orally and, where this is not possible, via the
enteral route; parenteral feeding should be reserved for those cases when the digestive route
is contraindicated. As a more specialized route, post-pyloric feeding may be considered in
cases where there is severe gastroparesis [43,44].
Whenever patients require artificial feeding, the enteral route, if not contraindicated,
should be used, since parenteral nutrition is associated with a higher frequency of hyper-
glycemia and greater insulin requirements. For example, enteral nutrition should be started
early for critical care patients, preferably within the first 24 h of admission, after they have
achieved hemodynamic stability [43,44].
Nutrients 2023, 15, 4149 8 of 15

Diets specifically designed to manage hyperglycemia, which incorporate carbohy-

drates with a low glycemic index, high fiber content, and enrichment with monounsaturated
fatty acids, have been shown to be effective in achieving optimal glycemic control. Notably,
these specialized diets also have the added benefit of reducing the need for insulin, thereby
offering a more holistic approach to diabetes management [45].
For patients who are grappling with both malnutrition and diabetes, it is strongly
advised that their protein energy requirements be carefully calculated. This calculation
should take into account various factors such as the level of physical activity engaged in by
the patient and any additional disease conditions or stress factors they may be experiencing,
among others. Furthermore, in scenarios where the patient is also dealing with obesity,
these protein energy requirements should be adjusted to align with the patient’s weight to
ensure the optimal nutritional balance and disease management [45].
With respect to the formulas used in enteral and oral nutrition, diabetes-specific
formulas must have the following characteristics [46,47]: a low carbohydrate content, low
glycemic index, moderate to high monounsaturated fat content in relation to the total
caloric value, and high fiber content, although the effects of the latter on postprandial
glycemic control do not appear to be very significant.
It should be remembered that, while there are no specific recommendations on mi-
cronutrients for patients with diabetes, supplementation with β-hydroxy-β-methylbutyrate
(HMB), a metabolite of leucine catabolism, seems to be helpful in preventing muscle atrophy
in diabetic patients [48].
Research has demonstrated that the implementation of outpatient nutrition counseling
programs, specifically designed to prevent sarcopenia in patients with T2DM who are at a
high risk, can be highly effective. These programs are not only associated with a marked
decrease in the incidence of sarcopenia, but also offer a proactive approach to managing
this common comorbidity in diabetic patients [46,47].

3.2.3. Physical Activity

Muscle strength and architecture are affected in diabetic patients who are also at a high
risk for developing myopathy. It is therefore important and necessary to begin an exercise
training program based on therapeutic exercises from the earliest stages of their diabetes in
order to achieve better glycemic control, prevent the progression of other complications,
and increase the active life expectancy of these patients [49].
The American Diabetes Association guidelines [50] recommend physical exercise as
part of diabetes treatment, as it helps to improve glycemic control, as well as improve the
control of cardiovascular risk factors, weight, and a better quality of life.
Traditionally, different types of exercise are classified in binary terms as endurance or
strength exercises. However, this classification is oversimplified. Further classifications of
exercise are metabolically related (aerobic vs. anaerobic) or related to the type of muscle
contraction: isotonic, when the contraction against a force causes the length of the muscle
to shorten (concentric) or lengthen (eccentric), and isometric (static or without change in
muscle length).
Aerobic exercise is a form of physical activity that involves sustained and repetitive
movements engaging the large muscle groups, primarily aimed at improving cardiovascu-
lar and respiratory function. This category includes a variety of activities, such as walking,
cycling, jogging, and swimming, each offering different levels of intensity and specific
health benefits. Resistance or strength training, on the other hand, focuses on building
muscle mass and enhancing muscle strength. This type of training incorporates a range of
exercises that utilize free weights, weight machines, body weight, or resistance bands to
target specific muscle groups. Flexibility exercises are designed to improve the range of
motion in the joints, thereby enhancing overall mobility. These exercises are particularly
beneficial for maintaining joint health and preventing stiffness. Balance exercises aim to
improve stability and coordination, which are crucial for gait and fall prevention. These
exercises are especially important for older adults or individuals with conditions that affect
Nutrients 2023, 15, 4149 9 of 15

balance. Activities such as tai chi and yoga offer a holistic approach by combining elements
of flexibility, balance, and resistance training. These activities not only improve physical
health, but also have the added benefit of enhancing mental well-being [50] (Table 2).

Table 2. Quality classification of physical activities.

• Walking
• Swimming
• Dancing

Aerobic activities • Cycling

• Ellipticals
• Low-impact aerobics
• Water aerobics
• Resistance band exercises
• Self-loading or with a load
• Climbing stairs
Strength exercises • Sit-to-stand
• Carrying things
• Some tai chi exercises
• Yoga
• Balance

To improve • Agility
balance or • Coordination
neuromotor
• Gait
fitness
• Proprioceptive training
• Multifaceted activities: tai chi and yoga

Flexibility • Take joints through a set of range of motion exercises at the start of each session and perform
different sets of stretches at various times throughout the session

In hospitalized older adults with DM, multicomponent exercise interventions, together

with the Vivifrail exercise program [50], have been found to be effective in improving
performance status, as measured with the SPPB, in addition to improving handgrip strength
and functionality.
Regular cardiorespiratory exercise increases insulin sensitivity, reduces time of hyper-
glycemia, and results in a reduction in glycosylated hemoglobin (HbA1c) by between 0.3%
and 0.6% [51]. Performed at a high intensity, these cardiorespiratory exercises have greater
benefits for glycemic control than if they are performed at a low intensity [52].
On the other hand, resistance training increases lean muscle mass, which, in turn,
is known to be related to insulin sensitivity. Hence, this form of exercise is of greater
importance to diabetic patients with pre-sarcopenia [53].
For individuals with T2DM to lose visceral fat, a moderately high volume of exercise
(approximately 500 kcals) performed 4–5 times per week is necessary [54].

3.2.4. Correct Daily Regime

The endogenous circadian system modulates the timing of behavioral rhythms and
physiological processes. There are interindividual differences in the timing of circadian
rhythms defined as chronotypes and these are related to health and behavioral problems,
especially when evening types are compared to morning types [55] Evening types, when
compared to morning types, are significantly associated with diabetes (OR 1.73; 95% CI,
Nutrients 2023, 15, 4149 10 of 15

1.01–2.95), metabolic syndrome (OR 1.74; 95% CI, 1.05–2.87), and sarcopenia (OR 3.16; 95%
CI, 1.36–7.33), especially in men.
Among the interventions for correcting daily regime, nutrition, physical activity, and
behavioral therapy stand out as the key components of lifestyle interventions for resetting
chronotypes [56], improving glycemic control, and preventing or treating T2DM and
sarcopenia.
Within the dietary recommendations, which are known as chrononutrition, are a
Mediterranean-style dietary pattern, macronutrient composition with a low glycemic index
and load carbohydrates, high in fiber and protein and accompanied by fat and/or protein
to reduce glucose and insulin spikes, and a food sequence of first consuming low-energy
dense foods that contain water, such as soups, vegetables, or fruits, followed by protein-rich
foods and then starch-rich foods to improve glycemic and insulin responses [56].
In relation to exercise, because the time of day when exercise is performed can influ-
ence its effect on circadian rhythm, mitochondrial function, and muscle performance, a
personalized exercise prescription is recommended according to the chronotype of each
individual [57].
Behavioral therapy uses cognitive and behavioral techniques to help people change
their eating habits, physical activity, and stress management. It provides regular feedback
and support from a trained professional, either in person or through technology, to improve
the adherence to and maintenance of a healthy life plan. Improving the adherence to
interventions for diabetes and sarcopenia is key to their effectiveness [56].

4. Discussion
Diabetes is a major health issue due to its high incidence and prevalence, as well as
the impact of increased morbidity and mortality on patients afflicted with it.
A loss of muscle mass in older diabetic patients who are malnourished or at risk for
malnutrition has a demonstrably negative impact on their autonomy. It is closely related
to the risk of sarcopenia, a high-impact disease, and also to frailty, a multidimensional
syndrome associated with adverse health events and, ultimately, disability [58,59].
The prevalence of malnutrition is high in both institutionalized and hospitalized older
adults. However, preventive measures can be instituted when older patients live in their
own homes, so it is worth choosing tools that allow for assessments to be made of the risk
for malnutrition presented by each patient. This should be conducted not only at the time
of screening, but also on a continuous basis once the nutrition intervention begins. The first
difficulty that arises is the validation of the questionnaire, considering the heterogeneity of
the population and the lack of a single model or standard test [58,59].
From a clinical point of view, it is extremely important to implement improvements
in the methods used to identify sarcopenia and its associated risk factors in patients with
T2DM, and hence to institute therapeutic strategies focused on adequate intake and regular
physical activity and correct daily regimes in a timely manner [60].
In light of the current review, it is crucial to adopt a multidimensional approach to
the screening, prevention, and management of T2DM and sarcopenia. Screening methods
should ideally involve medical history, physical exams, and nutritional assessments. The
Short Physical Performance Battery (SPPB) stands out as a practical approach to sarcopenia
for assessing functional capacity due to its simplicity and easy reproducibility. Regarding
pharmacological interventions, the potential modification of hypoglycemic drugs should
be evaluated on a case-by-case basis, with SGLT2 inhibitors being the only ones directly
related to sarcopenia. Dietary interventions can play a significant role, with high-protein
diets and HMB showing promise in improving muscle mass. Exercise regimens should
be tailored to individuals, focusing on multicomponent exercise interventions. Vivifrail
offers an exercise program based on SPPB that improves the functional capacity in this
population. Special attention should be given to the timing of insulin administration to
avoid hypoglycemia during physical activity. Behavioral therapy employs cognitive and
behavioral techniques to help people to change their eating habits, physical activity levels,
Nutrients 2023, 15, 4149 11 of 15

and stress management strategies. These considerations form the basis of a comprehensive
approach to managing these complex conditions.
Due to the scant evidence available, trials aimed at developing specific physical
activity programs and interventions using supplementation for patients with this profile
are needed.

5. Future Directions
The current review sheds light on the under-recognized issue of sarcopenia as a
comorbidity in patients with T2DM. While we explored the existing literature to understand
the pathophysiology, prevalence, diagnostic methods, and treatment options, there are
several avenues for future research that could provide more comprehensive insights into
this complex relationship.

5.1. Pathophysiology
Understanding the molecular mechanisms that link T2DM and sarcopenia could be a
fertile ground for future research. Identifying specific biomarkers and pathways could lead
to targeted therapies that can mitigate the effects of sarcopenia in T2DM patients.

5.2. Diagnostic Methods

The review highlighted various diagnostic methods such as dual-energy X-ray ab-
sorptiometry and bioelectrical impedance analyses. However, there is a need for more
cost-effective and accessible diagnostic tools that can be used in primary care settings.

5.3. Treatment Options

While we discussed the roles of glucose-lowering medications and nutritional inter-
ventions, future studies should focus on the efficacy of combining these treatments with
physical exercise and other lifestyle modifications such as correct daily regimes. Clinical
trials comparing different treatment modalities could provide valuable data.

5.4. Prevalence
The wide range of prevalence rates (7% to 29.3%) indicates a need for large-scale
epidemiological studies to obtain a more accurate picture. Understanding the factors
contributing to this variability can help with targeted interventions.

5.5. Technology Integration

The use of wearable technology for the continuous monitoring of muscle mass and
function could offer real-time data, aiding in early diagnoses and treatment adjustments.

5.6. Patient-Centered Approaches

Future research should also focus on the quality of life and functional outcomes
from the patient’s perspective. This could involve developing patient-reported outcome
measures specific to T2DM and sarcopenia.
By addressing these areas, we can hope to build a more comprehensive understanding
of sarcopenia in the context of T2DM, ultimately leading to better diagnostic and treatment
strategies that can improve patient outcomes.

6. Conclusions
The prevalence of sarcopenia is increasing among older patients with T2DM. Differ-
ent mechanisms may explain the association between the two, such as impaired insulin
sensitivity, chronic hyperglycemia, the accumulation of advanced glycation end-products
(AGEs), subclinical inflammation, and microvascular and macrovascular complications.
The high negative impact of this situation on quality of life, affecting physical and
psychosocial health, makes it a public health concern.
Nutrients 2023, 15, 4149 12 of 15

The four essential elements that form the basis of care for patients with diabetes are
pharmacological treatment, nutrition management, regular physical exercise, and correct
daily regime.
Health professionals should be vigilant about sarcopenia, paying special attention to
older and/or diabetic patients, in order to implement the appropriate nutritional, phar-
macological, and physical activity measures. With this, we will be able to reduce the
prevalence, severity, and disability of this geriatric syndrome in the older population. Fu-
ture research should focus on elucidating the molecular mechanisms linking T2DM and
sarcopenia, developing cost-effective diagnostic tools, and evaluating the efficacy of com-
bined treatment modalities. These efforts aim to provide a comprehensive understanding
that can improve diagnostic accuracy and patient outcomes.

Author Contributions: C.S.V.: conceptualization, writing original draft, reviewing and editing.
E.G.T.: conceptualization, writing original draft, reviewing and editing. J.B.M.H.: conceptualization,
reviewing and editing. B.A.C.-V.: conceptualization, writing original draft, reviewing and editing,
supervision. All authors have read and agreed to the published version of the manuscript.
Funding: This research was sponsored by Abbott Nutrition. The sponsor had no role in the design,
execution, interpretation, or writing of the study.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: C.S.V: reports receiving speaker honorarium from Abbott Laboratories, Fresenius-
Kabi, Vegenat, Persan, Nestlé, Nutricia and Ordesa. E.G.T: receiving consulting fees from Abbott
Laboratories, Persan and Nestlé Health Science and financial support for attending symposia from
Fresenius Kabi. J.B.M.H: Medical Department employee at Abbott Laboratories. B.A.C-V: reports
receiving speaker honorarium from Nutricia, and Abbott Laboratories, and grant support from
Abbott. The authors declare that the research was conducted in the absence of any commercial or
financial relationships that could be construed as a potential conflict of interest. C.S.V, E.G.T and
B.A.C-V did not receive funding from Abbott Nutrition for this work.

References
1. Glovaci, D.; Fan, W.; Wong, N.D. Epidemiology of Diabetes Mellitus and Cardiovascular Disease. Curr. Cardiol. Rep. 2019, 21, 21.
[CrossRef] [PubMed]
2. Sanz Paris, A.; García, J.M.; Gómez-Candela, C.; Burgos, R.; Martín, A.; Matía, P.; Martín Palmero, Á. Malnutrition prevalence in
hospitalized elderly patients. Nutr. Hosp. 2013, 28, 592–599. [PubMed]
3. Gómez-Candela, C.; Pérez, L.; Sanz París, A.; Burgos, R.; Matía, P.; García, J.M.; Martín Palmero, Á. Análisis del perfil de los
pacientes ancianos diabéticos hospitalizados que participaron en el estudio VIDA. Nutr. Hosp. 2016, 33, 31–36. [CrossRef]
4. Álvarez Hernández, J.; León Sanz, M.; Planas Vilá, M.; Araujo, K.; García de Lorenzo, A.; Celaya Pérez, S. Prevalence and costs of
malnutrition in hospitalized dysphagic patients: A subanalysis of the predyces study. Nutr. Hosp. 2015, 32, 1830–1836. [CrossRef]
[PubMed]
5. Murillo, A.Z.; Petrina-Jáuregui, M.E.; Ripa-Ciáurriz, C.; Sánchez, R.S.; Villazón-González, F.; Faes, G.-D.; Fernández-López,
C.; Calles-Romero, L.; Martín-Palmero, Á.; Riestra-Fernández, M.; et al. SeDREno study-prevalence of hospital malnutrition
according to GLIM criteria, ten years after the PREDyCES study. Nutr. Hosp. 2021, 38, 1016–1025. [CrossRef]
6. Donini, L.M.; Busetto, L.; Bischoff, S.C.; Cederholm, T.; Ballesteros-Pomar, M.D.; Batsis, J.A.; Bauer, J.M.; Boirie, Y.; Cruz-Jentoft,
A.J.; Dicker, D.; et al. Definition and Diagnostic Criteria for Sarcopenic Obesity: ESPEN and EASO Consensus Statement. Obes.
Facts 2022, 15, 321–335. [CrossRef] [PubMed]
7. Cuthbertson, D.J.; Bell, J.A.; Ng, S.Y.; Kemp, G.J.; Kivimaki, M.; Hamer, M. Dynapenic obesity and the risk of incident Type 2
diabetes: The English Longitudinal Study of Ageing. Diabet. Med. 2016, 33, 1052–1059. [CrossRef] [PubMed]
8. Izzo, A.; Massimino, E.; Riccardi, G.; Della Pepa, G. A Narrative Review on Sarcopenia in Type 2 Diabetes Mellitus: Prevalence
and Associated Factors. Nutrients 2021, 13, 183. [CrossRef]
9. Landi, F.; Onder, G.; Bernabei, R. Sarcopenia and diabetes: Two sides of the same coin. J. Am. Med. Dir. Assoc. 2013, 14, 540–541.
[CrossRef] [PubMed]
10. Tan, S.; Gunendi, Z.; Meray, J.; Yetkin, İ. The evaluation of muscle strength and architecture in type 1 diabetes mellitus: A
cross-sectional study. BMC Endocr. Disord. 2022, 22, 153. [CrossRef]
Nutrients 2023, 15, 4149 13 of 15

11. Rocha, M.; Apostolova, N.; Diaz-Rua, R.; Muntane, J.; Victor, V.M. Mitochondria and T2D: Role of Autophagy, ER Stress, and
Inflammasome. Trends Endocrinol. Metab. 2020, 31, 725–741. [PubMed]
12. Çakmak, G.; Ganidağlı, S.; Efendioğlu, E.M.; Öztürk, E.; Öztürk, Z.A. Do Long-Term Complications of Type 2 Diabetes Increase
Susceptibility to Geriatric Syndromes in Older Adults? Medicina 2021, 57, 968. [CrossRef] [PubMed]
13. Ni, Y.; Fan, D. Diabetes mellitus is a risk factor for low bone mass-related fractures: A meta-analysis of cohort studies. Medicine
2017, 96, e8811. [CrossRef] [PubMed]
14. Pechmann, L.M.; Petterle, R.R.; Moreira, C.A.; Borba, V.Z.C. Osteosarcopenia and trabecular bone score in patients with type 2
diabetes mellitus. Arch. Endocrinol. Metab. 2021, 65, 801–810. [CrossRef] [PubMed]
15. Fernández-Pombo, A.; Rodríguez-Carnero, G.; Castro, A.I.; Cantón-Blanco, A.; Seoane, L.M.; Casanueva, F.F.; Crujeiras, A.B.;
Martínez-Olmos, M.A. Relevance of nutritional assessment and treatment to counteract cardiac cachexia and sarcopenia in
chronic heart failure. Clin. Nutr. 2021, 40, 5141–5155. [CrossRef]
16. Takahashi, F.; Hashimoto, Y.; Kaji, A.; Sakai, R.; Kawate, Y.; Okamura, T.; Kitagawa, N.; Okada, H.; Nakanishi, N.; Majima, S.; et al.
Association between Geriatric Nutrition Risk Index and The Presence of Sarcopenia in People with Type 2 Diabetes Mellitus: A
Cross-Sectional Study. Nutrients 2021, 13, 3729. [CrossRef]
17. Rikli, R.E.; Jones, C.J. Development and validation of criterion-referenced clinically relevant fitness standards for maintaining
physical independence in later years. Gerontologist 2013, 53, 255–267. [CrossRef] [PubMed]
18. Ladang, A.; Beaudart, C.; Reginster, J.Y.; Al-Daghri, N.; Bruyère, O.; Burlet, N.; Cesari, M.; Cherubini, A.; da Silva, M.C.; Cooper,
C.; et al. Biochemical Markers of Musculoskeletal Health and Aging to be Assessed in Clinical Trials of Drugs Aiming at the
Treatment of Sarcopenia: Consensus Paper from an Expert Group Meeting Organized by the European Society for Clinical
and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the Centre Académique de
Recherche et d’Expérimentation en Santé (CARES SPRL), Under the Auspices of the World Health Organization Collaborating
Center for the Epidemiology of Musculoskeletal Conditions and Aging. Calcif. Tissue Int. 2023, 112, 197–217.
19. Massimino, E.; Izzo, A.; Riccardi, G.; Della Pepa, G. The Impact of Glucose-Lowering Drugs on Sarcopenia in Type 2 Diabetes:
Current Evidence and Underlying Mechanisms. Cells 2021, 10, 1958. [CrossRef] [PubMed]
20. Koshizaka, M.; Ishikawa, K.; Ishibashi, R.; Takahashi, S.; Sakamoto, K.; Yokoh, H.; Baba, Y.; Ide, S.; Ide, K.; Ishi kawa, T.; et al.
Comparison of Visceral Fat Reduction by Ipragliflozin and Metforminin Elderly Type 2 Diabetes Patients: Sub-Analysisofa
Randomized-Controlled Study. Diabetes Ther. 2021, 12, 183–196. [CrossRef] [PubMed]
21. Ishii, S.; Nagai, Y.; Kato, H.; Fukuda, H.; Tanaka, Y. Effect of the Dipeptidyl Peptidase- 4 Inhibitor Sitagliptin on Muscle Mass and
the Muscle/Fat Ratio in Patients with Type 2 Diabetes. J. Clin. Med. Res. 2020, 12, 122–126. [CrossRef] [PubMed]
22. Yajima, T.; Yajima, K.; Takahashi, H.; Yasuda, K. The effect of dulaglutide on body composition in type 2 diabetes mellitus patients
on hemodialysis. J. Diabetes Complicat. 2018, 32, 759–763. [CrossRef] [PubMed]
23. Perna, S.; Guido, D.; Bologna, C.; Solerte, S.B.; Guerriero, F.; Isu, A.; Rondanelli, M. Liraglutide and obesity in elderly: Efficacy
in fat loss and safety in order to prevent sarcopenia. A perspective case series study. Aging Clin. Exp. Res. 2016, 28, 1251–1257.
[CrossRef] [PubMed]
24. Rondanelli, M.; Perna, S.; Astrone, P.; Grugnetti, A.; Solerte, S.B.; Guido, D. Twenty-four-Week effects of liraglutide on body
composition, adherence to appetite, and lipid profile in overweight and obese patients with type 2 diabetes mellitus. Patient
Prefer. Adherence 2016, 10, 407–413. [PubMed]
25. Hong, J.Y.; Park, K.Y.; Kim, B.J.; Hwang, W.M.; Kim, D.H.; Lim, D.M. Effects of Short Term Exenatide Treatment on Regional Fat
Distribution, Glycated Hemoglobin Levels, and Aortic Pulse Wave Velocity of Obese Type 2 Diabetes Mellitus Patients. Endocrinol.
Metab. 2016, 31, 80–85. [CrossRef] [PubMed]
26. Tsurutani, Y.; Nakai, K.; Inoue, K.; Azuma, K.; Mukai, S.; Maruyama, S.; Lizuka, T.; Matsuzawa, Y.; Saito, J.; Omura, M.; et al.
Comparative study of the effects of ipragliflozin and sitagliptin on multiple metabolic variables in Japanese patients with type 2
diabetes: A multicentre, randomized, prospective, open-label, active-controlled study. Diabetes Obes. Metab. 2018, 20, 2675–2679.
[CrossRef] [PubMed]
27. Sano, M.; Meguro, S.; Kawai, T.; Suzuki, Y. Increased grip strength with sodium-glucose cotransporter 2. J. Diabetes 2016, 8,
736–737. [CrossRef] [PubMed]
28. Shimizu, M.; Suzuki, K.; Kato, K.; Jojima, T.; Iijima, T.; Murohisa, T.; Iijima, M.; Takekawa, H.; Usui, I.; Hiraishi, H.; et al.
Evaluation of the effects of dapagliflozin, a sodium-glucose co-transporter 2 inhibitor, on hepatic steatosis and fibrosis using
transient elastography in patients with type 2 diabetes and non-alcoholic fatty liver disease. Diabetes Obes. Metab. 2019, 21,
285–292. [CrossRef]
29. Sugiyama, S.; Jinnouchi, H.; Kurinami, N.; Hieshima, K.; Yoshida, A.; Jinnouchi, K.; Nishimura, H.; Suzuki, T.; Miyamoto, F.;
Kajiwara, K.; et al. Dapagliflozin Reduces Fat Mass without Affecting Muscle Mass in Type 2 Diabetes. J. Atheroscler. Thromb.
2018, 25, 467–476. [CrossRef]
30. Yamakage, H.; Tanaka, M.; Inoue, T.; Odori, S.; Kusakabe, T.; Satoh Asahara, N. Effects of dapagliflozin on the serum levels of
fibroblast growth factor 21 and myokines and muscle mass in Japanese patients with type 2 diabetes: A randomized, controlled
trial. J. Diabetes Investig. 2020, 11, 653–661. [CrossRef] [PubMed]
31. Tobita, H.; Sato, S.; Miyake, T.; Ishihara, S.; Kinoshita, Y. Effects of Dapagliflozin on Body Composition and Liver Tests in Patients
with Nonalcoholic Steatohepatitis Associated with Type 2 Diabetes Mellitus: A Prospective, Open-label, Uncontrolled Study.
Curr. Ther. Res. Clin. Exp. 2017, 87, 13–19. [CrossRef]
Nutrients 2023, 15, 4149 14 of 15

32. Sasaki, T.; Sugawara, M.; Fukuda, M. Sodium-glucose cotransporter 2 inhibitor-induced changes in body composition and
simultaneous changes in metabolic profile: 52-week prospective LIGHT (Luseogliflozin: The Components of Weight Loss in
Japanese Patients with Type 2 Diabetes Mellitus) Study. J. Diabetes Investig. 2019, 10, 108–117. [CrossRef]
33. Bouchi, R.; Terashima, M.; Sasahara, Y.; Asakawa, M.; Fukuda, T.; Takeuchi, T.; Nakano, Y.; Murakami, M.; Minami, I.; Izumiyama,
H.; et al. Luseogliflozin reduces epicardial fat accumulation in patients with type 2 diabetes: A pilot study. Cardiovasc. Diabetol.
2017, 16, 32. [CrossRef]
34. Inoue, M.; Hayashi, A.; Taguchi, T.; Arai, R.; Sasaki, S.; Takano, K.; Inoue, Y.; Shichiri, M. Effects of canagliflozin on body
composition and hepatic fat content in type 2 diabetes patients with non- alcoholic fatty liver disease. J. Diabetes Investig. 2019, 10,
1004–1011. [CrossRef] [PubMed]
35. Inoue, H.; Morino, K.; Ugi, S.; Tanaka Mizuno, S.; Fuse, K.; Miyazawa, I.; Kondo, K.; Sato, D.; Ohashi, N.; Ida, S.; et al. SUMS-
ADDIT-1 Research group. Ipragliflozin, a sodium-glucose cotransporter 2 inhibitor, reduces body weight and fat mass, but not
muscle mass, in Japanese type 2 diabetes patients treated with insulin: A randomized clinical trial. J. Diabetes Investig. 2019, 10,
1012–1021. [CrossRef] [PubMed]
36. Yamamoto, C.; Miyoshi, H.; Ono, K.; Sugawara, H.; Kameda, R.; Ichiyama, M.; Yamamoto, K.; Nomoto, H.; Nakamura, A.;
Atsumi, T. Ipragliflozin effectively reduced visceral fat in Japanese patients with type 2 diabetes under adequate diet therapy.
Endocr. J. 2016, 63, 589–596. [CrossRef]
37. Iemitsu, K.; Kawata, T.; Iizuka, T.; Takihata, M.; Takai, M.; Nakajima, S.; Minami, N.; Umezawa, S.; Kanamori, A.; Takeda, H.;
et al. Efficacy and Safety of Ipragliflozin in Patients with Type 2 Diabetes ASSIGN-K Study. J. Endocrinol. Metab. 2019, 9, 51–62.
[CrossRef]
38. Kato, M.; Sakai, K.; Saito, K.; Tsutsui, K.; Yamashita, S.; Kato, N. Efficacy and safety of ipragliflozin in Japanese patients with
type 2 diabetes receiving conventional therapy: Clinical implication of the importance of exercise habits during treatment with
ipragliflozin. Diabetol. Int. 2017, 8, 275–285. [CrossRef]
39. Miyake, T.; Yoshida, S.; Furukawa, S.; Sakai, T.; Tada, F.; Senba, H.; Yamamoto, S.; Koizumi, Y.; Yoshida, O.; H irooka, M.; et al.
Ipragliflozin Ameliorates Liver Damage in Non-alcoholic Fatty Liver Disease. Open Med. 2018, 13, 402–409. [CrossRef] [PubMed]
40. Matsuba, R.; Matsuba, I.; Shimokawa, M.; Nagai, Y.; Tanaka, Y. Tofogliflozin decreases body fat mass and improves peripheral
insulin resistance. Diabetes Obes. Metab. 2018, 20, 1311–1315. [CrossRef] [PubMed]
41. Ferrari, U.; Then, C.; Rottenkolber, M.; Selte, C.; Seissler, J.; Conzade, R.; Linkohr, B.; Peters, A.; Drey, M.; Thorand, B. Longitudinal
association of type 2 diabetes and insulin therapy with muscle parameters in the KORA-Age study. Acta Diabetol. 2020, 57,
1057–1063. [CrossRef]
42. Burgos Peláez, R.; García Almeida, J.M.; Matía Martín, P.; Palma Milla, S.; Sanz Paris, A.; Zugasti Murillo, A.; Alfaro Martínez, J.J.;
Artero-Fullana, A.; Calañas Continente, A.; Chinchetru, M.J.; et al. Abordaje de la desnutrición en pacientes hospitalizados con
diabetes/hiperglucemia y otras patologías [Malnutrition management of hospitalized patients with diabetes/hyperglycemia and
concurrent pathologies]. Nutr. Hosp. 2022, 39, 1–8. (In Spanish) [CrossRef] [PubMed]
43. Sanz Paris, A.; Álvarez Hernandez, J.; Ballesteros-Pomar, M.A.; Botella-Romero, F.; León-Sanz, M.; Martín-Palmero, A.; Olmos,
M.M.; Olveira, G. Evidence-based recommendations and expert consensus on enteral nutrition in the adult patient with diabetes
mellitus or hyperglycemia. Nutrition 2017, 41, 58–67. [CrossRef] [PubMed]
44. Barazzoni, R.; Deutz, N.E.P.; Biolo, G.; Bischoff, S.; Boirie, Y.; Cederholm, T.; Cuerda, C.; Delzenne, N.; Leon Sanz, M.; Ljungqvist,
O.; et al. Carbohydrates and insulin resistance in clinical nutrition: Recommendations from the ESPEN expert group. Clin. Nutr.
2017, 36, 355–363. [CrossRef] [PubMed]
45. Vaquerizo Alonso, C.; Grau Carmona, T.; Juan Díaz, M.; Spanish Society of Intensive Care Medicine and Coronary Units-Spanish
Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE). Recomendaciones para el soporte nutricional y metabólico
especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Hiperglucemia y diabetes mellitus [Guidelines
for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive
Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): Hyperglycemia
and diabetes mellitus]. Med. Intensiva 2011, 35 (Suppl. S1), 48–52. (In Spanish) [CrossRef]
46. Chan, L.C.; Yang, Y.C.; Lin, H.C.; Wahlqvist, M.L.; Hung, Y.J.; Lee, M.S. Nutrition counseling is associated with less sarcopenia in
diabetes: A cross-sectional and retrospective cohort study. Nutrition 2021, 91–92, 111269. [CrossRef]
47. Velázquez-Alva, M.C.; Irigoyen-Camacho, M.E.; Zepeda-Zepeda, M.A.; Lazarevich, I.; Arrieta-Cruz, I.; D’Hyver, C. Sarcopenia,
nutritional status and type 2 diabetes mellitus: A cross-sectional study in a group of Mexican women residing in a nursing home.
Nutr. Diet. 2020, 77, 515–522. [CrossRef]
48. Holeček, M.; Vodeničarovová, M.; Fingrová, R. Dual Effects of Beta-Hydroxy-Beta-Methylbutyrate (HMB) on Amino Acid, Energy,
and Protein Metabolism in the Liver and Muscles of Rats with Streptozotocin-Induced Type 1 Diabetes. Biomolecules 2020, 10,
1475. [CrossRef]
49. de Luis Román, D.; Garrachón Vallo, F.; Carretero Gómez, J.; López Gómez, J.J.; Tarazona Santabalbina, F.J.; Guzmán Rolo, G.;
García Almeida, J.M.; Sanz Paris, A. La masa muscular disminuida en la diabetes de tipo 2. Una comorbididad oculta que
debemos tener en cuenta [Decreased muscle mass in type-2 diabetes. A hidden comorbidity to consider]. Nutr. Hosp. 2023, 11,
59–66. (In Spanish) [CrossRef]
Nutrients 2023, 15, 4149 15 of 15

50. Colberg, S.R.; Sigal, R.J.; Yardley, J.E.; Riddell, M.C.; Dunstan, D.W.; Dempsey, P.C.; Horton, E.S.; Castorino, K.; Tate, D.F. Physical
Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care 2016, 39, 2065–2079.
[CrossRef]
51. Umpierre, D.; Ribeiro, P.A.B.; Kramer, C.K.; Leitão, C.B.; Zucatti, A.T.N.; Azevedo, M.J.; Gross, J.L.; Ribeiro, J.P.; Schaan, B.D.
Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: A systematic
review and meta-analysis. JAMA 2011, 305, 1790–1799. [CrossRef] [PubMed]
52. Grace, A.; Chan, E.; Giallauria, F.; Graham, P.L.; Smart, N.A. Clinical outcomes and glycaemic responses to different aerobic
exercise training intensities in type II diabetes: A systematic review and meta- analysis. Cardiovasc. Diabetol. 2017, 16, 37.
[CrossRef] [PubMed]
53. Viecelli, C.; Aguayo, D. May the Force and Mass Be with You-Evidence-Based Contribution of MechanoBiological Descriptors of
Resistance Exercise. Front. Physiol. 2022, 12, 686119. [CrossRef]
54. Ida, S.; Kaneko, R.; Imataka, K.; Murata, K. Relationship between frailty and mortality, hospitalization, and cardiovascular
diseases in diabetes: A systematic review and meta-analysis. Cardiovasc. Diabetol. 2018, 18, 81. [CrossRef]
55. Yu, J.H.; Yun, C.H.; Ahn, J.H.; Suh, S.; Cho, H.J.; Lee, S.K.; Yoo, H.J.; Seo, J.A.; Kim, S.G.; Choi, K.M.; et al. Evening chronotype is
associated with metabolic disorders and body composition in middle-aged adults. J. Clin. Endocrinol. Metab. 2015, 100, 1494–1502.
[CrossRef]
56. Papakonstantinou, E.; Oikonomou, C.; Nychas, G.; Dimitriadis, G.D. Effects of Diet, Lifestyle, Chrononutrition and Alternative
Dietary Interventions on Postprandial Glycemia and Insulin Resistance. Nutrients 2022, 14, 823. [CrossRef]
57. Choi, Y.; Cho, J.; No, M.H.; Heo, J.W.; Cho, E.J.; Chang, E.; Park, D.H.; Kang, J.H.; Kwak, H.B. Re-Setting the Circadian Clock
Using Exercise against Sarcopenia. Int. J. Mol. Sci. 2020, 21, 3106. [CrossRef] [PubMed]
58. Sanz, A. Special Issue Diabetes and Muscle: From the Assessment to Treatment. Nutrients. Available online: https://www.mdpi.
com/journal/nutrients/special_issues/3A1M1755Y5 (accessed on 15 September 2023).
59. Gamgaram, V.K.D.; Olivares, M.G.; Fuster, G.O. Olveira Fuster, Diabetes y sarcopenia. Nutr. Clin. Med. 2023, XVII, 75–88.
60. Hashimoto, Y.; Takahashi, F.; Okamura, T.; Hamaguchi, M.; Fukui, M. Diet, exercise, and pharmacotherapy for sarcopenia in
people with diabetes. Metabolism 2023, 144, 155585. [CrossRef]

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.
 HHS Public Access
Author manuscript
Cell Metab. Author manuscript; available in PMC 2021 April 05.
Author Manuscript

Published in final edited form as:

Cell Metab. 2017 August 01; 26(2): 310–323. doi:10.1016/j.cmet.2017.06.010.

Insulin Regulation of Proteostasis and Clinical Implications

Haleigh A. James1, Brian T. O’Neill2, K. Sreekumaran Nair1,*
1Division
of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 First Street SW,
Rochester, MN 55905, USA
2Division of Endocrinology and Metabolism, Fraternal Order of Eagles Diabetes Research Center,
University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
Author Manuscript

Abstract
Maintenance and modification of the cellular proteome are at the core of normal cellular
physiology. Although insulin is well known for its control of glucose homeostasis, its critical role
in maintaining proteome homeostasis (proteostasis) is less appreciated. Insulin signaling regulates
protein synthesis and degradation as well as posttranslational modifications at the tissue level and
coordinates proteostasis at the organism level. Here, we review regulation of proteostasis by
insulin in postabsorptive, postprandial, and diabetic states. We present the effects of insulin on
amino acid flux in skeletal muscle and splanchnic tissues, the regulation of protein quality control,
and turnover of mitochondrial protein pools in humans. We also review the current evidence for
the mechanistic control of proteostasis by insulin and insulin-like growth factor 1 receptors based
on preclinical studies. Finally, we discuss irreversible posttranslational modifications of the
Author Manuscript

proteome in diabetes and how future investigations will provide new insights into mechanisms of
diabetic complications.

Introduction
Virtually all cellular functions are determined by cellular proteome abundance and quality.
The proteome, made up of all proteins expressed by a cell, tissue, or organism at a single
time point, is determined by protein turnover, which is the balance between protein synthesis
and degradation. Free amino acids derived from diet, degradation of endogenous proteins
(via autophagy and proteasome pathways), and in vivo synthesis (only nonessential amino
acids) play critical roles in regulating protein synthesis and degradation. Through highly
regulated processes, amino acids may be either incorporated into proteins to become part of
Author Manuscript

the proteome or released back into the free amino acid pool where they may be oxidized,
producing carbon dioxide and nitrogen in the process (Figure 1). Since the amino moiety of
amino acids is the obligatory component of all proteins, net urinary loss of nitrogen is
traditionally used as a measure of net protein degradation. The determinants of which amino
acids undergo degradation versus incorporation into the proteome are not fully understood.
Irreversibly damaged amino acids derived from degradation of endogenous proteins are
likely degraded, while intact amino acids are preferentially acylated to tRNA for peptide

*
Correspondence: nair@mayo.edu.
 James et al. Page 2

synthesis (Goldberg, 2003; Ljungqvist et al., 1997). Meal-derived amino acids are
Author Manuscript

incorporated into proteins, depending on the need and capacity to produce proteins, while
the rest are degraded and used as energy sources like other fuels, such as glucose and fatty
acids (Walrand et al., 2008). Insulin plays a key regulatory role in amino acid metabolism,
and amino acids in turn affect insulin action in a bidirectional way by regulating glucose and
protein metabolism (Patti et al., 1998). It is therefore imperative that any discussion of
insulin’s impact on proteostasis should include the role of amino acids.

Protein turnover in health is a precisely regulated process that fluctuates in response to many
physiologic alterations and becomes altered in different pathological states. This review
focuses mainly on human studies in view of the high relevance of proteostasis in human
health. We also provide substantial data from both in vitro and in vivo human and animal
studies that support insulin’s pivotal role in the regulation of proteostasis via key biological
pathways, including protein biogenesis (transcription and translation), folding, trafficking,
Author Manuscript

posttranslational modifications (PTMs), and degradation. Here we show that insulin

deficiency, as occurs in type 1diabetes mellitus (T1DM), and reduced insulin sensitivity in
type 2 diabetes mellitus (T2DM) and other conditions have significant, detrimental effects
on proteostasis. We propose that these alterations in proteostasis may explain many
complications that reduce both healthspan and lifespan in diabetes and other conditions with
reduced insulin action.

Protein Catabolic State in the Insulin-Deficient State

Insulin is the predominant hormone involved in the regulation of many vital biological
functions, including fuel metabolism, mitochondrial biogenesis and physiology, and
remodeling of tissues. Increased plasma glucose concentration is the most sensitive and
Author Manuscript

standard biomarker of insulin deficiency, but insulin deficiency in T1DM also causes a
catabolic state with profound muscle wasting (Reed, 1954), increased urinary nitrogen
excretion (Lukens, 1953), and increased plasma amino acid levels (Felig, 1975). These
manifestations indicate depletion of body protein content and are corrected by insulin
replacement, demonstrating the key anticatabolic role that insulin plays in the maintenance
of the human proteome. The catabolic state of insulin deficiency also causes abnormalities in
energy metabolism (Karakelides et al., 2007), with altered mitochondrial physiology and
increased reactive oxygen species production, which can lead to oxidative damage of
proteins and alterations in the regulation of proteostasis (Zabielski et al., 2016).
Understanding insulin’s regulation of proteostasis is essential, not only to define the role of
insulin in normal physiological functions, but also to understand the underpinning
mechanisms of altered physiology and both acute and chronic complications of diabetes.
Author Manuscript

Insulin’s Effects on Whole-Body Protein Turnover

Our understanding of insulin’s effects on whole-body proteostasis has evolved over time
with the emergence of stable isotope tracer approaches and highly sensitive mass
spectrometry techniques. Early nitrogen balance studies showed increased urine nitrogen
excretion resulting from amino acid degradation in animals with experimentally induced
diabetes and diabetic humans deprived of insulin (Chaikoff and Forker, 1950; Lukens, 1953;

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 3

Sokhey and Allan, 1924). The increase in urinary nitrogen in individuals with T1DM was
Author Manuscript

specifically due to lack of insulin, since insulin replacement reversed this process (Atchley et
al., 1933). In vitro studies also demonstrated increased protein synthesis and decreased
degradation in muscles exposed to insulin (Fulks et al., 1975). Together, these findings led to
a conclusion that insulin independently prevented protein degradation and stimulated
synthesis, but later studies revealed that this conclusion does not completely hold true in
human physiology. The use of isotopically labeled amino acid tracers allowed measurement
of whole-body protein synthesis and degradation in humans (Bier, 1989; Waterlow, 1984).
Studies utilizing stable isotope-labeled amino acid tracer approaches elucidated that, while
insulin deficiency does lead to increased protein degradation, it surprisingly also increases
protein synthesis, although the increment in protein degradation exceeds that of synthesis
(Luzi et al., 1990; Nair et al., 1983). By definition, in a high-protein-turnover state, flux
through protein synthesis and degradation cycles is increased. This is a highly energy-
Author Manuscript

consuming process since both synthesis and degradation require ATP as fuel, which
therefore contributes to the catabolic state of T1DM. Insulin replacement reversed the
changes observed during insulin deficiency (Nair et al., 1987a; Umpleby et al., 1986), and
protein degradation measured in nondiabetic fasting men has been shown to decrease in a
dose-dependent manner with insulin infusion (Fukagawa et al., 1985). Together, these
studies show that insulin’s protein-conserving property in humans is largely a result of its
ability to suppress protein degradation, and that protein accretion induced by insulin is in
part due to balancing protein turnover by decreasing flux through synthetic and degradation
pathways, with greater reduction of degradation at the whole-body level.

It is important to note that the above-mentioned human studies were performed in the
postabsorptive condition when the sole source of essential amino acids was degradation of
endogenous proteins. Under these experimental conditions, insulin decreases circulating
Author Manuscript

essential amino acid concentrations by its inhibition of protein degradation (Barazzoni et al.,
2012; Pozefsky et al., 1969), so results were likely affected by the deficiency of amino acids,
which serve as stimulants for signaling cascades that increase protein synthesis. Most
notably, the mammalian target of rapamycin (mTOR) pathway is activated by amino acids
and serves as a master regulator of protein synthesis as well as cellular, organ, and
organismal growth (Bar-Peled and Sabatini, 2014; Laplante and Sabatini, 2012). In normal
human physiology, insulin secretion in response to a mixed meal is usually accompanied by
an amino acid load. To elucidate the effects of amino acids in addition to insulin on protein
homeostasis, subsequent studies revealed that, in both diabetic and nondiabetic persons,
whole-body protein synthesis increased and protein degradation decreased significantly
when amino acids and insulin were co-infused compared with insulin infusion alone (Luzi et
al., 1990). Therefore, amino acids administered with insulin, as occurs in the postprandial
Author Manuscript

state, enhance insulin’s inhibition of protein degradation and induce whole-body protein
synthesis, thereby matching nutritional supply with hormonal changes, leading to organismal
growth under nutrient-replete conditions.

Insulin Elicits Opposing Effects on Protein Turnover in Different Tissues

The whole-body studies do not indicate whether the regulation of protein turnover (average
of all proteins in different tissues) by insulin occurs equally in all tissues. Like its differential

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 4

effects on glucose metabolism by suppressing hepatic glucose production in liver, while

Author Manuscript

enhancing glucose uptake in skeletal muscle (Rizza et al., 1981), insulin exerts differential
effects on protein turnover in different tissues. Isotopically labeled amino acids in
combination with blood flow measurements across tissue beds have been utilized to measure
incorporation of amino acids into proteins, and appearance of amino acids from degradation
of proteins, thereby providing evidence of tissue-specific protein flux in the context of
whole-body homeostasis. When regional protein flux was studied in skeletal muscle in the
leg and compared with splanchnic tissues (which include liver, gastrointestinal tract, and the
other visceral organs) in nondiabetic individuals by using stable isotope tracers of
phenylalanine, leucine, and tyrosine, protein degradation in the skeletal muscle exceeded
protein synthesis after an overnight fast, leading to net amino acid release from muscle
(Figure 2A) (Meek et al., 1998). At the same time, protein synthesis in the splanchnic tissues
exceeded degradation, leading to net uptake of amino acids (Meek et al., 1998; Nygren and
Author Manuscript

Nair, 2003). These results indicate that liver, among other splanchnic tissues, increases
protein synthesis in response to decreased insulin action (Figure 2A). Insulin infusion alone
did not significantly change protein synthesis in skeletal muscle, but it did inhibit protein
synthesis across the splanchnic bed. Conversely, insulin strongly inhibited skeletal muscle
protein degradation in a dose-dependent manner, but it did not affect protein degradation in
the splanchnic region. Insulin infusion caused progressive equalization of protein synthesis
and degradation in the skeletal muscle and splanchnic tissues, leading to net amino acid
balance in both regions (Meek et al., 1998). These findings and later studies (Nygren and
Nair, 2003) indicate that amino acids are preferentially stored within skeletal muscle during
times when insulin is present (postprandial), but they are available for release during times
of insulin deficiency (fasting) when synthesis of essential plasma proteins by the liver is still
required. In this way, skeletal muscle can be viewed as a valuable protein and amino acid
reservoir, which allows our bodies to carry out necessary functions via circulating proteins
Author Manuscript

even when we are not actively ingesting amino acids.

Studies in T1DM further confirmed the profound impact of insulin on body protein turnover.
Unlike the relatively low insulin levels in nondiabetic persons in the postabsorptive state
compared with the postprandial state, complete insulin deficiency occurs in individuals with
T1DM who are not treated with insulin. When regional protein flux was studied in T1DM in
the postabsorptive state, splanchnic protein synthesis was substantially higher during insulin
deprivation than during insulin treatment (Nair et al., 1995). In contrast, protein synthesis in
the skeletal muscle of the leg was not affected by insulin deprivation, while protein
degradation was markedly increased, indicating net protein depletion in the skeletal muscle
bed results from accelerated protein degradation and not due to reduced protein synthesis
(Figure 2C). Protein degradation in both leg and splanchnic tissues was suppressed by
Author Manuscript

insulin treatment. Therefore, insulin’s whole-body protein-conserving property resulted

mostly from inhibition of protein degradation in skeletal muscle (Nair et al., 1995).
Together, these studies in T1DM demonstrated the pivotal role of insulin, maintaining
protein balance at the whole-body level.

Amino acids are integral protein components, which must be present for insulin to act as an
anabolic hormone in both the splanchnic tissues and skeletal muscle. Insulin, by its
inhibition of protein degradation, reduces the essential amino acid concentrations in the

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 5

postabsorptive state. Therefore, insulin infusion, with its associated hypoaminoacidemia,

Author Manuscript

does not stimulate protein synthesis in skeletal muscle or splanchnic tissues during the
postabsorptive state, but the addition of amino acids leads to dose-dependent increases in
protein synthesis and protein accretion in both skeletal muscle and splanchnic tissues
(Figures 2B and 3) (Nygren and Nair, 2003). Irrespective of whether insulin is infused intra-
arterially (Chow et al., 2006; Gelfand and Barrett, 1987) or intravenously (Barazzoni et al.,
2012; Nygren and Nair, 2003), it decreases muscle protein degradation, but does not enhance
protein synthesis when administered without amino acids. When a multiple regression
analysis was performed to determine the relative impact of insulin and amino acid
concentrations on regional protein flux, leg protein synthesis was found to be regulated by
both insulin and amino acid concentrations, while leg protein degradation was suppressed
primarily by insulin. In contrast, splanchnic protein synthesis was stimulated and
degradation was inhibited by amino acids (Nygren and Nair, 2003).
Author Manuscript

Measurement of individual amino acids has provided insight, but also elicited further
questions about proteostasis during different metabolic conditions. For example, in a
pioneering report, plasma branched-chain amino acids (BCAAs) were shown to be higher in
insulin-resistant obese people, and were most responsive to insulin’s ability to lower amino
acid concentrations (Felig et al., 1969). Plasma BCAAs have also been found to be increased
in type 2 diabetic humans (Wahren et al., 1972), and they rise to a greater degree after
protein ingestion in diabetics than in nondiabetic controls (Wahren et al., 1976). Insulin
deficiency (Nair et al., 1995) and resistance (Halvatsiotis et al., 2002) increase leucine
transamination, which affects BCAA concentrations. BCAA infusion in humans has also
been reported to reduce insulin-induced glucose disposal (Nair et al., 1992; Tessari et al.,
1985). Recent evidence indicates that plasma BCAA levels can predict the development of
T2DM by many years (Wang et al., 2011). Whether these amino acids play a causal role in
Author Manuscript

diabetes in humans or are a result of insulin resistance remains a question, but rodent models
show that dietary BCAAs may contribute to obesity-related insulin resistance (Newgard et
al., 2009; White et al., 2016). Overall, these studies imply that reduced insulin action
increases BCAA concentrations and, in return, BCAAs further inhibit insulin action.

Effects of insulin deficiency in vivo cannot be fully delineated from those of glucagon and
cortisol, both of which, but especially glucagon, increase rapidly and consistently during
insulin deficiency. Glucagon has been shown to enhance not only protein degradation but
also leucine oxidation during insulin deficiency (Nair et al., 1987b), and inhibition of
hyperglucagonemia during insulin deficiency normalizes increased leucine oxidation in
T1DM (Charlton and Nair, 1998). Hyperglucagonemia also has been shown to inhibit amino
acid-induced stimulation of protein synthesis (Charlton et al., 1996). Increased plasma
Author Manuscript

cortisol increases protein degradation (Simmons et al., 1984). It is possible that the effects of
insulin deficiency in vivo on protein turnover may be enhanced by the effects of both
glucagon and cortisol excess. The cortisol increase following transient insulin deprivation is
at best marginal in humans, but glucagon levels consistently increase upon insulin
deprivation in T1DM. Glucagon’s effect has been clearly delineated from that of insulin or
its deficiency in studies where somatostatin was used to suppress glucagon. These studies
clearly demonstrated that glucagon accelerates degradation of proteins and leucine oxidation

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 6

during insulin deficiency and high glucagon reduces amino acid-induced protein synthesis in
Author Manuscript

humans (Charlton et al., 1996).

In general, amino acids and insulin levels rise together in the postprandial state, but they can
diverge in certain clinical situations, such as T1DM with insulin deficiency or in conditions
of severe insulin resistance (Henderson et al., 2010) where insulin’s action is reduced but
amino acid levels continue to be high. Skeletal muscle protein degradation that exceeds
protein synthesis seems to result in net transfer of amino acids to the splanchnic bed (Figure
2C), explaining the muscle wasting observed in persons with chronic uncontrolled diabetes,
or what was described as “melting down of flesh into urine” by Aretaeus in AD 50 (Reed,
1954).

While both protein degradation and synthesis in the splanchnic bed are upregulated during
insulin deficiency, synthesis exceeds degradation, leading to net positive protein balance
Author Manuscript

(Figure 2C), presumably to allow continued synthesis of plasma proteins, including clotting
factors that are essential for survival of species. Among splanchnic tissues, intestinal
mucosal protein synthesis is lower during insulin deprivation in T1DM than during insulin
treatment or in nondiabetic individuals, indicating that insulin is required for maintenance of
intestinal mucosal protein synthesis (Charlton et al., 2000). While liver tissue protein
synthesis seems to be unaffected by increasing insulin or amino acids in nondiabetic swine
(Ahlman et al., 2001), insulin administered directly to the liver via the portal vein increased
liver tissue protein synthesis to a greater degree than when insulin was administered
systemically (Freyse et al., 2006). The impact of insulin deficiency on liver tissue protein
synthesis in humans remains to be determined. In diabetic rodents, liver protein synthesis is
reduced and seems to be related to lower abundance of specific mRNA levels (Jefferson et
al., 1983). Because the liver is a major site where proteins are synthesized before being
Author Manuscript

released into systemic circulation, it is important to know whether synthesis rates of these
liver-derived plasma proteins are increased during insulin deficiency.

Regulation of Plasma Protein Turnover by Insulin

Plasma proteins, which are largely synthesized and secreted by the liver, are affected by
insulin deficiency and replacement in different ways. Early studies reported a differential
effect of insulin deficiency in T1DM on albumin and fibrinogen synthesis rates (De Feo et
al., 1991), with synthesis rates being decreased for albumin but increased for fibrinogen.
Increased fibrinogen synthesis during insulin deficiency may also be contributed to by
increased glucagon levels in human (Tessari et al., 1997). In the swine model, it has also
been shown that insulin with amino acids maintains synthesis of albumin but inhibits that of
fibrinogen (Ahlman et al., 2001). Mouse models of impaired insulin signaling in liver show
Author Manuscript

that expression of albumin is suppressed by the transcription factor, forkhead box O (FoxO)
isoform 1, which is inhibited by insulin signaling (Chen et al., 2016). A more comprehensive
study evaluating 41 plasma proteins showed that fractional synthesis rates of 24 were altered
in patients with T1DM who were deprived of insulin compared with nondiabetic controls
(Jaleel et al., 2009). Insulin treatment normalized synthesis of only 13, and actually altered
synthesis of 14 additional proteins. Many of the proteins which demonstrated different
synthesis rates during insulin deprivation or treatment included apoplipoproteins, mediators

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 7

of complement pathways, antioxidants, transport proteins, and those involved in coagulation

Author Manuscript

and platelet aggregation, which strongly suggests that cardiovascular complications of DM

may also involve pro-coagulant changes in the plasma proteome in addition to
atherosclerotic changes in the vessel walls. The mechanisms behind these alterations in
turnover of specific plasma proteins are still not known. Since most of these proteins are
synthesized and released by the liver, there is evidence that FoxO transcription factors
mediate at least some of these effects. Namely, FoxOs control albumin expression in the
liver (Chen et al., 2016), modulate hepatic mitochondrial function in response to insulin
signaling (Cheng et al., 2009), and are critical mediators of gluconeogenesis (Haeusler et al.,
2014; O-Sullivan et al., 2015; Xiong et al., 2013). But determinations of protein synthetic
rates or proteomic analyses in cellular or mouse models in which hepatic FoxO signaling is
disrupted remain to be carried out.

These observations clearly indicate the variable effects of insulin deficiency on synthesis of
Author Manuscript

individual plasma proteins. Moreover, despite improving glycemic control, normal synthesis
is not restored for all proteins, suggesting that the peripheral insulin administration is not
equal to portal delivery, consistent with results from the diabetic dog model (Freyse et al.,
2006). Many of the proteins that exhibit altered synthesis in T1DM are involved in
lipoprotein metabolism, inflammation, and coagulation, all of which play important roles in
cardiovascular disease. It remains to be determined whether the above abnormalities will
explain the persistently increased rates of cardiovascular disease in patients with T1DM
(Almdal et al., 2004; Kannel and McGee, 1979), even when glycemic control is achieved
(ACCORD Study Group, 2016), decreasing the risk of microvascular complications (The
Diabetes Control and Complications Trial Research Group et al., 1993). Although much
more work needs to be done to advance our understanding of plasma protein alterations in
diabetes, these findings provide some insight and possible mechanisms underlying the
Author Manuscript

increased cardiovascular disease risk associated with diabetes.

Insulin’s Effects on the Mitochondrial Proteome and Other Protein Pools

As described above, the presence and absence of insulin and amino acids induce changes in
protein flux in skeletal muscle and splanchnic tissues. These changes represent the average
of each individual protein’s turnover within that tissue, and not all proteins respond the same
way to physiologic alterations. For example, the fractional synthesis rate of myosin heavy
chain, a major structural protein that acts as part of the contractile apparatus within skeletal
muscle, is not affected by acute insulin deficiency or replacement in persons with T1DM
(Charlton et al., 1997). In contrast, insulin deprivation in diabetic mice increases skeletal
muscle mitochondrial protein degradation and decreases synthesis, resulting in reduced
amounts of protein available for mitochondrial respiration and β-oxidation (Robinson et al.,
Author Manuscript

2016; Zabielski et al., 2016). As expected, mitochondrial respiration and ATP production is
reduced in diabetic mice (Franko et al., 2012; Zabielski et al., 2016) deprived of insulin,
along with coupling and phosphorylation efficiency, while oxidant emission is higher.
Disruption of mitochondrial function or fission/fusion can itself induce muscle atrophy via
FoxO3 (Romanello et al., 2010), and these changes often accompany insulin deprivation.
Proteins involved in cellular uptake of fatty acids are paradoxically upregulated, leading to

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 8

an accumulation of incomplete fatty acid oxidation products within skeletal muscle

Author Manuscript

(Zabielski et al., 2016).

Mitochondrial protein regulation by insulin has been demonstrated in human muscle as well.
Persons with T1DM have reduced muscle mitochondrial ATP production and expression of
oxidative phosphorylation (OXPHOS) genes when deprived of insulin compared with when
treated with insulin (Karakelides et al., 2007). In nondiabetic persons, skeletal muscle
mitochondrial mRNA and protein synthesis increase in response to high-dose insulin
provided with amino acids (Robinson et al., 2014; Stump et al., 2003). This is associated
with increased activity of mitochondrial oxidative enzymes and ATP production in
nondiabetic individuals, but type 2 diabetic persons exposed to the same conditions do not
exhibit the same increased ATP production (Stump et al., 2003). Further studies have shown
that amino acids are essential components which must be present for skeletal muscle
mitochondrial protein synthesis to increase in response to insulin, although insulin alone
Author Manuscript

enhances transcript levels of many genes encoding mitochondrial proteins (Barazzoni et al.,
2012; Karakelides et al., 2007). Synthesis of myofibrillar and sarcoplasmic proteins, on the
other hand, is not significantly affected by insulin, even when amino acids are co-infused
(Robinson et al., 2014).

In addition to the studies in skeletal muscle, several recent studies in adipose tissue reveal
the importance of insulin resistance and diabetes in the regulation of both the mitochondrial
and cellular proteome in fat. A proteomic analysis of visceral adipose tissue from diet-
controlled type 2 diabetic people and lean normal glucose-tolerant controls revealed
upregulation of inflammatory pathways and downregulation of metabolic pathways,
including mitochondrial proteins involved in β-oxidation, tricarboxylic acid (TCA) cycle,
and OXPHOS, although these study participants were not matched for age (Kim et al.,
Author Manuscript

2014). When comparing proteomic analysis of mitochondrial isolates from visceral adipose
biopsies of obese with those of non-obese individuals, again TCA cycle and β-oxidation
proteins were reduced in this tissue (Lindinger et al., 2015). Another study using age-,
gender-, and BMI-matched individuals also revealed downregulation of an OXPHOS subunit
in visceral adipose tissue from diabetic patients compared with controls, suggesting that both
obesity and diabetes affect the mitochondrial proteome (Fang et al., 2015). Along similar
lines as mentioned in muscle, fatty acid transport proteins were increased in adipose tissue
of diabetic people relative to controls (Kim et al., 2014).

T2DM and obesity are often accompanied by hyperinsulinemia, and one study aimed to
determine the role of hyperinsulinemia on adipocyte proteostasis (Minard et al., 2016).
Differentiated 3T3-L1 adipocytes were treated with 10 nM insulin for up to 5 days and
Author Manuscript

proteomic analyses, which included measures of synthesis and degradation rates, were
performed. In agreement with insulin’s ability to enhance protein synthesis and decrease
degradation, hyperinsulinemia increased the synthesis and stability of 662 proteins, while it
decreased only one, and had minimal effect on the long-lived mitochondrial proteins.
Several proteins involved in folding and quality control, including chaperones, were
increased indicating that the hyperinsulinemia maintained proteostasis. It is important to
note that the control cells were treated with 10% serum, which contains growth factors that
may already partially or fully activate the phosphoinositide-3 kinase (PI3K)-Akt-FoxO

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 9

pathway and suppress degradation pathways, although hyperinsulinemia did significantly

Author Manuscript

suppress autophagy flux. Clearly, adipose tissue depends on insulin signaling to maintain its
capacity for lipid storage, since loss of insulin signaling by deletion of the insulin receptor,
specifically in adipocytes, results in lipodystrophic diabetes and adipocyte apoptosis
(Boucher et al., 2016; Sakaguchi et al., 2017).

In conjunction with new discoveries about the effects of diabetes and insulin on
mitochondrial protein expression and degradation, high-resolution mass spectrometry has
also revealed novel targets for PTMs of mitochondrial proteins in response to insulin. In
healthy persons, a phosphoproteomic analysis of mitochondrial isolates from muscle
biopsies before and after a 4-hr hyperinsulinemic-euglycemic clamp demonstrated a 2-fold
increase in the number of mitochondrial phosphoproteins (Zhao et al., 2014). Nearly half of
the phosphorylation sites (94 sites) were exclusively detected after insulin stimulation. The
identified phosphoproteins included 22 subunits of the electron transport chain, as well as
Author Manuscript

several proteins in the TCA cycle, β-oxidation, and mitochondrial transports, among others.
The functional significance of these phosphorylation events remains to be investigated, but
these data along with others showing the significant impact of diabetes on degradation rates
of mitochondrial proteins (Zabielski et al., 2016) reveal a global regulation of the
mitochondrial proteome by insulin signaling.

More recently, advances in high-resolution mass spectrometry have led to the identification
of specific low-molecularweight peptides, which are released after protein degradation
(Robinson et al., 2016). Through this method, persons with T1DM have been found to have
higher degradation of muscle proteins involved in mitochondrial OXPHOS (e.g., ATP
synthase, cytochrome c oxidase), proteome homeostasis (ribosomal proteins), regulation of
DNA structure and transcription (histones), muscle contraction (myosin isoforms), glucose
Author Manuscript

metabolism (phosphoglucomutase-1 isoform), oxygen transport (myoglobin), and calcium

cycling (sarcoendoplasmic reticulum calcium ATPase isoforms) during insulin deprivation
compared with when insulin is replaced to maintain euglycemia. Conversely, some proteins,
such as calpain-3 isoform b (proteolytic enzyme) and fibrinogen β chain isoform 1
preproprotein (involved in cell adhesion), were degraded at a faster rate during insulin
replacement compared with deprivation (Robinson et al., 2016). These data indicate that
although mitochondrial proteins are specific targets of insulin’s regulation of muscle
proteostasis, many other protein pools are also altered by insulin signaling.

Taken together, these data illustrate the complex and variable effects of insulin on the
mitochondrial proteome and other protein pools within muscle and adipose tissue. The
increased degradation of many proteins during insulin deficiency is consistent with the
Author Manuscript

clinical muscle wasting observed in patients with uncontrolled diabetes, but newer
techniques and higher-resolution proteomics are beginning to reveal the complexity of
protein pools and cellular compartments that are controlled by insulin. The specific proteins
degraded during insulin deficiency are integral to numerous biological processes that
coordinate energy production and consumption, including protein synthesis, ATP
production, and muscle contraction, allowing for coordinated modulation of muscle function
in response to nutrient and growth factor availability.

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 10

Mechanisms of Insulin’s Effects on Skeletal Muscle Protein Flux

Author Manuscript

Insulin’s impact on skeletal muscle protein synthesis in vitro has been observed as far back
as the 1950s (Manchester and Young, 1958; Sinex et al., 1952), and since the discovery of
insulin in 1921, researchers had hypothesized a cellular receptor that transmits insulin
signaling. The discovery of the insulin receptor (IR) as a tyrosine kinase receptor began a
large body of research to identify the signaling cascade by which insulin influences a
multitude of actions on the cell (Kasuga et al., 1982). We now know that IR is ubiquitously
expressed and highly homologous to the insulin-like growth factor 1 receptor (IGF-1R), with
both receptors transmitting similar intracellular signals to regulate glucose and protein
metabolism in skeletal muscle and across tissues. While circulating insulin levels rise and
fall dynamically in response to glucose load, IGF-1 levels remain more consistent and are
bound to IGF binding proteins which limit their bioavailability. Another stark contrast is that
insulin is solely produced by b cells in the pancreas, while IGF-1 can be produced by many
Author Manuscript

tissues, although 75% of circulating IGF-1 is produced by the liver in response to growth
hormone. IGF-1 is classically described as a critical hormone for muscle growth, since its
expression increases in response to exercise, and infusion of IGF-1 or growth hormone
locally in muscle causes hypertrophy (Adams and Haddad, 1996; Adams and McCue, 1998).
Indeed, in primary human myoblasts and myotubes, expression of IGF-1R is reported to be
6-fold higher than expression of IR (Palsgaard et al., 2009). However, classic studies show
that IR increases in abundance during myoblast differentiation into myotubes (Beguinot et
al., 1986), and recent work demonstrates that expression of IR predominates overexpression
of IGF-1R in differentiated muscle by nearly 4-fold (O’Neill et al., 2016). Indeed, insulin is
functionally more important than IGF-1 in maintaining muscle mass, since knockout of IR,
specifically in skeletal muscle, leads to a 20% decrease in muscle size, whereas muscle-
specific deletion of IGF-1R displays no change in muscle mass (O’Neill et al., 2015).
Author Manuscript

Nonetheless, IR and IGF-1R play overlapping roles in the maintenance of muscle mass,
since muscle-specific knockout of both receptors in MIGIRKO mice leads to a marked 60%
muscle atrophy and reduced survival.

In the fed state and under normal growth conditions, insulin and IGF-1 are abundant and
engage their respective receptors (Figure 4A). Upon ligand binding to the extracellular
surface, IR and IGF-1R autophosphorylate and bind to insulin receptor substrates (IRS)
(Taniguchi et al., 2006). The signals are further propagated through PI3K to Akt, which then
phosphorylates FoxO transcription factor isoforms 1, 3, and 4, inhibiting FoxO activity and
preventing translocation into the nucleus. Akt can also activate the mammalian target of
rapamycin complex 1 (mTORC1) by phosphorylating and inhibiting tuberous sclerosis 1 and
2. In the presence of insulin and amino acids, mTORC1 is potently activated (Nobukuni et
Author Manuscript

al., 2005), thereby promoting protein synthesis and muscle hypertrophy. By regulating
mTORC1 and FoxO pathways, insulin modulates the two critical regulators of protein
synthesis and degradation in muscle (Figure 4).

Insulin’s Molecular Regulation of Muscle Protein Synthesis

Insulin, via Akt, can activate the mTORC1 complex, which is a nutrient sensor and master
regulator of protein synthesis and cellular/organ growth (Bar-Peled and Sabatini, 2014;

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 11

Laplante and Sabatini, 2012). These pathways are critical for normal muscle development
Author Manuscript

and function, since muscle-specific deletion of mTOR or the mTORC1 regulator RAPTOR
in mice results in myopathies leading to muscle atrophy and early death (Bentzinger et al.,
2008; Risson et al., 2009). In addition to activation by insulin and other growth factors,
amino acids, particularly leucine and arginine, are known to be potent regulators of
mTORC1– S6 kinase activity (Hara et al., 1998; Sancak et al., 2008). Recent reports show
that these sensing mechanisms are initiated at the lysosomal membrane by modulators of
mTORC1 complex activity. Sestrin2 senses leucine and CASTOR proteins sense arginine to
influence Rag GTPases, which modulate mTORC1 activity and increase protein synthesis
(Chantranupong et al., 2016; Kim et al., 2008; Sancak et al., 2008; Wolfson et al., 2016).
Once mTORC1 is activated, protein synthesis is increased by activation of the S6Kinase
cascade and inhibition of eukaryotic initiation factor 4E-binding protein 1 (4E-BP1), which
together allow for maximal translation of proteins by ribosomes (Ma and Blenis, 2009; Shah
Author Manuscript

et al., 2000). Maximal activation of mTORC1 occurs with both insulin/growth factor
stimulation and amino acid supplementation, indicating a duality of regulation of this critical
node of growth (Avruch et al., 2006).

Human studies have shown that administration of insulin alone reduces amino acid
concentrations, which does not allow for stimulation of protein synthesis, despite increases
in transcript levels of many genes (Barazzoni et al., 2012). This lack of enhancement of
protein synthesis by insulin alone was attributed to lack of activation of mTOR, p70
ribosomal S6 kinase (p70S6K), and 4E-BP1, although there was enhanced phosphorylation
of Akt. As mentioned above, amino acids are potent regulators of mTOR, and thus adding
amino acids with insulin increases muscle protein synthesis (Robinson et al., 2014),
supporting the important regulation of mTOR signaling by pathways distinct from insulin.
Human studies have suggested that in vivo amino acids derived from degradation of proteins
Author Manuscript

are preferentially acylated to tRNA (Ljungqvist et al., 1997), thus ensuring that, even in the
fasting state, proteome content is preserved. Of interest, the studies on MIGIRKO mice, in
which IR and IGF-1R are deleted, specifically in muscle, demonstrated increased muscle
protein synthesis and mTORC1 activation in association with substantially higher muscle
protein degradation (O’Neill et al., 2016), which explains why some muscle mass is
preserved despite deletion of both IR and IGF-1R. There also was evidence of increased
muscle amino acid concentrations consistent with the hypothesis derived from the human
studies discussed above showing that amino acids per se can stimulate protein synthesis, but
the higher degradation of proteins due to reduced insulin effect results in muscle wasting.

Insulin’s Molecular Regulation of Protein Degradation

Protein degradation in skeletal muscle occurs by two cellular pathways: the ubiquitin-
Author Manuscript

proteasome and autophagy-lysosome pathways, which are controlled by several intracellular

signaling mechanisms (Cohen et al., 2015). Classic in vitro studies demonstrate that insulin
suppresses muscle protein degradation (Fulks et al., 1975), but the investigation of ubiquitin
ligases and use of specific inhibitors of proteasomes and lysosomes have shed light on how
insulin and IGF-1 control these pathways of degradation. In insulin-deficient rats, muscle
protein degradation was increased within 7 days, primarily via ubiquitination and
proteasomal degradation (Lecker et al., 1999), and the proteasome inhibitor MG132 was

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 12

sufficient to block this increase (Price et al., 1996). Proteasomal degradation was also
Author Manuscript

increased in the insulin-resistant db/db mouse model, and it was partially reversed by
treatment of mice with the insulin sensitizer rosiglitazone (Wang et al., 2006). These results
are consistent with human studies in T1DM demonstrating increased protein degradation in
insulin-deficient states (Nair et al., 1983) corrected by insulin.

Insulin and IGF-1 can suppress the transcriptional increase in E3 ubiquitin ligases, atrogin-1,
and MuRF-1, which accompany increased proteolysis in muscle, indicating direct regulation
of the ubiquitin-proteasome system by these growth factors (Sacheck et al., 2004). Insulin
also suppresses autophagy in muscle more than in liver (Naito et al., 2013). As mentioned
earlier, insulin activates mTORC1 to increase protein synthesis, and mTORC1 also
suppresses autophagy at least in part by phosphorylation of autophagy-activating kinases
ULK1/2 (Jung et al., 2009). There is some debate as to whether mTORC1 activation or
inhibition leads to increased proteasomal degradation. Two studies show that genetic or
Author Manuscript

pharmacologic inhibition of mTORC1 enhances proteolysis by proteasomal degradation

(Zhao et al., 2015), possibly via activation of Mpk1/ERK5 signaling, leading to upregulation
of proteasomal components (Rousseau and Bertolotti, 2016). However, other cellular models
of chronic mTORC1 activation also showed increases in protein degradation (Zhang et al.,
2014). The latter study indicated that proteasomal subunits were increased by Nrf1 signaling
to replenish amino acid recycling. Regardless, animal models show us that both proteasomal
and autophagy-lysosomal degradation are increased in muscle from mice with muscle-
specific deletion of IR or deletion of both IR and IGF-1R (O’Neill et al., 2016). Insulin
deprivation in STZ-induced diabetic mice also increases protein degradation through the
autophagy-lysosome pathway (Robinson et al., 2016). Taken together, these studies indicate
that insulin regulates muscle proteostasis via suppression of both ubiquitin-proteasome and
autophagy-lysosomal degradation.
Author Manuscript

The downstream targets of insulin and IGF-1 that control muscle protein turnover are FoxO
isoforms (O’Neill et al., 2016). Skeletal muscle expresses three isoforms of FoxO: FoxO1,
FoxO3, and FoxO4. The suppression of all three isoforms of FoxO by IR and IGF-1R via
Akt is critical to the maintenance of muscle mass in the fed state (Figure 4A). With
prolonged fasting or in the context of insulin-deficient diabetes, FoxO transcription factors
translocate to the nucleus and activate transcription of a number of genes, including E3
ubiquitin ligases and proteasomal subunits as well as autophagy-lysosome mediators (Figure
4B). The upregulation of the proteasome and autophagy-lysosome pathways by FoxOs
enhances protein degradation, leading to muscle atrophy and a high-protein-turnover state.

The discovery that FoxO transcription factors are downstream targets of IR/IGF-1R
Author Manuscript

signaling originally occurred in Caenorhabditis elegans. In 1997, daf-16 was cloned and
identified as the C. elegans homolog of mammalian FoxOs (Ogg et al., 1997). Daf-16 was
known to be downstream of daf-2, the IR/IGF-1R homolog, and to mediate the longevity-
promoting effects when daf-2 activity was reduced. FoxOs were soon identified as direct,
suppressible targets of insulin-PI3K-Akt signaling in mammalian cells (Guo et al., 1999;
Nakae et al., 1999; Rena et al., 1999; Tang et al., 1999). In skeletal muscle, FoxOs were next
identified as critical regulators of a transcriptional program for muscle atrophy (Sandri et al.,
2004), upregulating both the ubiquitin-proteasomal and autophagy-lysosomal protein

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 13

degradation pathways in response to starvation or growth factor deprivation (Mammucari et

Author Manuscript

al., 2007; Zhao et al., 2007). While these studies initially implicated FoxO3 as the more
important isoform, recent work has shown that deletion of all three FoxO isoforms expressed
in muscle (FoxO1, FoxO3, and FoxO4) is required to prevent muscle atrophy from genetic
loss of IR and IGF-1R or starvation (Milan et al., 2015; O’Neill et al., 2016). Impressively,
the 60% decrease in muscle mass with muscle-specific deletion of IR and IGF-1R is
completely rescued with deletion of FoxOs 1, 3, and 4, demonstrating that FoxOs, not
mTORC1, are the specific targets of insulin and IGF-1 signaling that control muscle size.
Thus, insulin and IGF-1 signaling pathways are critical to the regulation of muscle protein
turnover, and this regulation is dependent on suppression of FoxO-regulated protein
degradation (Figure 4).

The Importance of Insulin and Diabetes in Protein Quality

Author Manuscript

Insulin affects not only protein quantity, but also quality, which can have important clinical
implications. Genes are expressed through a multi-step process of transcription into mRNA,
followed by translation into polypeptides (Figure 5). Polypeptides subsequently undergo
highly regulated folding processes in order to become functional proteins, although
misfolding may also occur, yielding dysfunctional proteins. The proteome is much larger
than the genome it stems from, since various proteins can be made from one gene via the
complex processes of mRNA splicing, protein folding, and PTMs, which are covalent
additions of functional groups. Some PTMs, such as phosphorylation, glycosylation,
methylation, and ubiquitination, occur via reversible targeted enzymatic reactions and have
many beneficial functions, including promoting proper protein folding and stability, aiding
in cell signaling, and targeting proteins for degradation. Insulin is well known to act by
phosphorylation of specific amino acids in signaling proteins, such as IRS-PI3K-Akt and
Author Manuscript

MAPK signaling intermediates, to perform its biological functions (Taniguchi et al., 2006).
Other PTMs, such as oxidation, carbonylation, glycation, and deamidation, occur
spontaneously and irreversibly as a result of oxidative or other environmental stress. Ideally,
these irreversibly damaged proteins are targeted for degradation by cellular defense
mechanisms, but high levels of oxidant or other metabolic stress can overwhelm the system,
leading to build up of dysfunctional proteins. Accumulation and/or aggregation of these, as
well as misfolded proteins, can interfere with normal physiological processes and lead to
disease (Figure 5) (McCoy and Nair, 2013).

Certainly, the widespread glycation that occurs in uncontrolled diabetes represents a classic
example of how irreversible and detrimental PTMs occur in response to environmental stress
(hyperglycemia due to insulin deficiency) and lead to disease (Brownlee, 2000). Glycated
Author Manuscript

hemoglobin (hemoglobin A1c) acts as a biomarker of overall diabetes control, and higher
levels are associated with end-organ damage, including nephropathy, neuropathy,
retinopathy, and cardiovascular disease (Nathan et al., 2005; The Diabetes Control and
Complications Trial Research Group et al., 1993). Glycation is only one PTM affecting
protein quality during insulin deficiency, however, and is unlikely to fully explain the myriad
complications associated with diabetes.

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 14

Diabetic patients have been found to have significantly greater oxidative protein damage
Author Manuscript

compared with nondiabetic individuals (Figure 5) (Martin-Gallan et al., 2003). Importantly,

ApoA-1, a major component of high-density lipoprotein (HDL) integral to the transfer of
cholesterol from peripheral macrophages to the liver for subsequent excretion or recycling,
has been shown to undergo accelerated oxidative PTM in individuals with T1DM who are
deprived of insulin (Jaleel et al., 2010). Furthermore, HDL in type 1 diabetic patients with
either good or poor glycemic control has significantly decreased cholesterol efflux capacity
and antioxidative function compared with HDL in nondiabetic controls (Manjunatha et al.,
2016). This occurred in association with more irreversible PTMs affecting functionally
important HDL proteins, including ApoA-4, ApoD, and ApoE, in diabetic patients. Given
HDL’s important role in maintaining vascular health, this study implicates altered HDL
protein quality as a potential mechanism for the higher rates of cardiovascular disease in
patients with T1DM, even when their quantity of HDL is normal (Manjunatha et al., 2016).
Author Manuscript

The study of protein quality during normal and altered physiological states has only begun in
recent years, and we have much more to learn. On the basis of the recent findings of
damaging PTMs associated with impaired function of HDL-associated proteins in T1DM,
we suspect that investigation in this field will continue to grow and hope that it will elucidate
more mechanisms responsible for the widespread complications associated with diabetes.

Conclusion
The past several years have generated remarkable advances in our knowledge of the dynamic
regulation of cellular physiology by insulin through regulation of protein function, synthesis,
and degradation. From classic studies in isolated skeletal muscle showing that insulin can
change protein turnover to recent advances in identifying specific protein pools that are
Author Manuscript

degraded in the diabetic state, our understanding of insulin’s effect on proteostasis has
clearly progressed. In muscle, we have identified the specific signaling pathways
downstream of insulin that control muscle protein degradation and help maintain muscle
mass. The coordination of amino acid flux between tissues by insulin helps orchestrate
proteostasis at the organismal level to maintain normal growth. Lastly, new discoveries in
the effect of diabetes on PTMs of the proteome have enhanced our understanding of this
complex disease.

Despite this progress, many questions remain unanswered. Whether FoxO isoforms also
mediate insulin’s regulation of proteostasis in tissues other than muscle is not fully known.
The specific downstream targets of the insulin-FoxO axis that regulate degradation of
specific protein pools, such as mitochondrial or other cellular proteins, are not completely
understood. Furthermore, insulin’s effect on proteostasis has been best studied in insulin-
Author Manuscript

sensitive tissues, including skeletal muscle and, to a lesser extent, liver and adipose tissue,
but whether these mechanisms hold true in other tissues, especially brain and heart, requires
more investigation. Diabetic cardiomyopathy is an entity prompting more studies directly on
heart tissue than on vasculature, but human tissue samples are not easy to obtain. Moreover,
the link between diabetes and vascular disease is a prime reason for the development of
complications and mortality. How insulin affects the proteome in the vasculature is less well
explored. In addition, the link between diabetes and cognitive decline, including

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 15

Alzheimer’s disease, is of great interest, and future studies will need to expand on the
Author Manuscript

knowledge of insulin resistance/diabetes in the regulation of protein aggregates and other

aspects of proteostasis in the CNS. As we near the 100-year anniversary of the discovery of
insulin, we realize that understanding the biology of this pivotal hormone is more important
than ever, with diabetes rates reaching pandemic levels. Fortunately, we live in an exciting
time when the discovery of insulin’s regulation of proteostasis is more achievable than ever
and will likely lead to novel areas of intervention to slow the development of complications
and morbidity from diabetes.

ACKNOWLEDGMENTS
Supported by grants from the NIH (RO1 DK 41973, AG 09531, and U24DK100469) and the Mayo Clinic.
B.T.O’N. was funded by a K08 training award from the National Institute of Diabetes and Digestive and Kidney
Diseases of the NIH (K08DK100543).
Author Manuscript

REFERENCES
ACCORD Study Group. (2016). Nine-year effects of 3.7 years of intensive glycemic control on
cardiovascular outcomes. Diabetes Care 39, 701–708. [PubMed: 26822326]
Adams GR, and Haddad F (1996). The relationships among IGF-1, DNA content, and protein
accumulation during skeletal muscle hypertrophy. J. Appl. Physiol (1985) 81, 2509–2516.
[PubMed: 9018499]
Adams GR, and McCue SA (1998). Localized infusion of IGF-I results in skeletal muscle hypertrophy
in rats. J. Appl. Physiol (1985) 84, 1716–1722. [PubMed: 9572822]
Ahlman B, Charlton M, Fu A, Berg C, O’Brien P, and Nair KS (2001). Insulin’s effect on synthesis
rates of liver proteins. A swine model comparing various precursors of protein synthesis. Diabetes
50, 947–954. [PubMed: 11334437]
Almdal T, Scharling H, Jensen JS, and Vestergaard H (2004). The independent effect of type 2 diabetes
mellitus on ischemic heart disease, stroke, and death: a population-based study of 13,000 men and
Author Manuscript

women with 20 years of follow-up. Arch. Intern. Med 164, 1422–1426. [PubMed: 15249351]
Atchley DW, Loeb RF, Richards DW, Benedict EM, and Driscoll ME (1933). On diabetic acidosis: a
detailed study of electrolyte balances following the withdrawal and reestablishment of insulin
therapy. J. Clin. Invest 12, 297–326. [PubMed: 16694129]
Avruch J, Hara K, Lin Y, Liu M, Long X, Ortiz-Vega S, and Yonezawa K (2006). Insulin and amino-
acid regulation of mTOR signaling and kinase activity through the Rheb GTPase. Oncogene 25,
6361–6372. [PubMed: 17041622]
Bar-Peled L, and Sabatini DM (2014). Regulation of mTORC1 by amino acids. Trends Cell Biol. 24,
400–406. [PubMed: 24698685]
Barazzoni R, Short KR, Asmann Y, Coenen-Schimke JM, Robinson MM, and Nair KS (2012). Insulin
fails to enhance mTOR phosphorylation, mitochondrial protein synthesis, and ATP production in
human skeletal muscle without amino acid replacement. Am. J. Physiol. Endocrinol. Metab 303,
E1117–E1125. [PubMed: 22967500]
Beguinot F, Kahn CR, Moses AC, and Smith RJ (1986). The development of insulin receptors and
responsiveness is an early marker of differentiation in the muscle cell line L6. Endocrinology 118,
Author Manuscript

446–455. [PubMed: 3510122]

Bentzinger CF, Romanino K, Cloetta D, Lin S, Mascarenhas JB, Oliveri F, Xia J, Casanova E, Costa
CF, Brink M, et al. (2008). Skeletal muscle-specific ablation of raptor, but not of rictor, causes
metabolic changes and results in muscle dystrophy. Cell Metab. 8, 411–424. [PubMed: 19046572]
Bier DM (1989). Intrinsically difficult problems: the kinetics of body proteins and amino acids in man.
Diabetes Metab. Rev 5, 111–132. [PubMed: 2647431]
Boucher J, Softic S, El Ouaamari A, Krumpoch MT, Kleinridders A, Kulkarni RN, O’Neill BT, and
Kahn CR (2016). Differential roles of insulin and IGF-1 receptors in adipose tissue development
and function. Diabetes 65, 2201–2213. [PubMed: 27207537]

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 16

Brownlee M (2000). Negative consequences of glycation. Metabolism 49, 9–13. [PubMed: 10693913]
Chaikoff IL, and Forker LL (1950). The antidiabetic action of insulin on nitrogen metabolism.
Author Manuscript

Endocrinology 46, 319–326. [PubMed: 15411907]

Chantranupong L, Scaria SM, Saxton RA, Gygi MP, Shen K, Wyant GA, Wang T, Harper JW, Gygi
SP, and Sabatini DM (2016). The CASTOR proteins are arginine sensors for the mTORC1
pathway. Cell 165, 153–164. [PubMed: 26972053]
Charlton MR, and Nair KS (1998). Role of hyperglucagonemia in catabolism associated with type 1
diabetes: effects on leucine metabolism and the resting metabolic rate. Diabetes 47, 1748–1756.
[PubMed: 9792544]
Charlton MR, Adey DB, and Nair KS (1996). Evidence for a catabolic role of glucagon during an
amino acid load. J. Clin. Invest 98, 90–99. [PubMed: 8690809]
Charlton MR, Balagopal P, and Nair KS (1997). Skeletal muscle myosin heavy chain synthesis in type
1 diabetes. Diabetes 46, 1336–1340. [PubMed: 9231659]
Charlton M, Ahlman B, and Nair KS (2000). The effect of insulin on human small intestinal mucosal
protein synthesis. Gastroenterology 118, 299–306. [PubMed: 10648458]
Chen Q, Lu M, Monks BR, and Birnbaum MJ (2016). Insulin is required to maintain albumin
Author Manuscript

expression by inhibiting forkhead box O1 protein. J. Biol. Chem 291, 2371–2378. [PubMed:
26668316]
Cheng Z, Guo S, Copps K, Dong X, Kollipara R, Rodgers JT, Depinho RA, Puigserver P, and White
MF (2009). Foxo1 integrates insulin signaling with mitochondrial function in the liver. Nat. Med
15, 1307–1311. [PubMed: 19838201]
Chow LS, Albright RC, Bigelow ML, Toffolo G, Cobelli C, and Nair KS (2006). Mechanism of
insulin’s anabolic effect on muscle: measurements of muscle protein synthesis and breakdown
using aminoacyl-tRNA and other surrogate measures. Am. J. Physiol. Endocrinol. Metab 291,
E729–E736. [PubMed: 16705065]
Cohen S, Nathan JA, and Goldberg AL (2015). Muscle wasting in disease: molecular mechanisms and
promising therapies. Nat. Rev. Drug Discov 14, 58–74. [PubMed: 25549588]
De Feo P, Gaisano MG, and Haymond MW (1991). Differential effects of insulin deficiency on
albumin and fibrinogen synthesis in humans. J. Clin. Invest 88, 833–840. [PubMed: 1909352]
Fang L, Kojima K, Zhou L, Crossman DK, Mobley JA, and Grams J (2015). Analysis of the human
Author Manuscript

proteome in subcutaneous and visceral fat depots in diabetic and non-diabetic patients with morbid
obesity. J. Proteomics Bioinformatics 8, 133–141.
Felig P (1975). Amino acid metabolism in man. Annu. Rev. Biochem 44, 933–955. [PubMed:
1094924]
Felig P, Marliss E, and Cahill GF Jr. (1969). Plasma amino acid levels and insulin secretion in obesity.
N. Engl. J. Med 281, 811–816. [PubMed: 5809519]
Franko A, von Kleist-Retzow JC, Bose M, Sanchez-Lasheras C, Brodesser S, Krut O, Kunz WS,
Wiedermann D, Hoehn M, Stohr O, et al. (2012). Complete failure of insulin-transmitted
signaling, but not obesity-induced insulin resistance, impairs respiratory chain function in muscle.
J. Mol. Med. (Berl) 90, 1145–1160. [PubMed: 22411022]
Freyse EJ, Fischer U, Knospe S, Ford GC, and Nair KS (2006). Differences in protein and energy
metabolism following portal versus systemic administration of insulin in diabetic dogs.
Diabetologia 49, 543–551. [PubMed: 16447053]
Fukagawa NK, Minaker KL, Rowe JW, Goodman MN, Matthews DE, Bier DM, and Young VR
(1985). Insulin-mediated reduction of whole body protein breakdown. Dose-response effects on
Author Manuscript

leucine metabolism in postabsorptive men. J. Clin. Invest 76, 2306–2311. [PubMed: 3908486]
Fulks RM, Li JB, and Goldberg AL (1975). Effects of insulin, glucose, and amino acids on protein
turnover in rat diaphragm. J. Biol. Chem 250, 290–298. [PubMed: 1141208]
Gelfand RA, and Barrett EJ (1987). Effect of physiologic hyperinsulinemia on skeletal muscle protein
synthesis and breakdown in man. J. Clin. Invest 80, 1–6. [PubMed: 3298320]
Goldberg AL (2003). Protein degradation and protection against misfolded or damaged proteins.
Nature 426, 895–899. [PubMed: 14685250]
Guo S, Rena G, Cichy S, He X, Cohen P, and Unterman T (1999). Phosphorylation of serine 256 by
protein kinase B disrupts transactivation by FKHR and mediates effects of insulin on insulin-like

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 17

growth factor-binding protein-1 promoter activity through a conserved insulin response sequence.
J. Biol. Chem 274, 17184–17192. [PubMed: 10358076]
Author Manuscript

Haeusler RA, Hartil K, Vaitheesvaran B, Arrieta-Cruz I, Knight CM, Cook JR, Kammoun HL,
Febbraio MA, Gutierrez-Juarez R, Kurland IJ, et al. (2014). Integrated control of hepatic
lipogenesis versus glucose production requires FoxO transcription factors. Nat. Commun 5, 5190.
[PubMed: 25307742]
Halvatsiotis P, Short KR, Bigelow M, and Nair KS (2002). Synthesis rate of muscle proteins, muscle
functions, and amino acid kinetics in type 2 diabetes. Diabetes 51, 2395–2404. [PubMed:
12145150]
Hara K, Yonezawa K, Weng QP, Kozlowski MT, Belham C, and Avruch J (1998). Amino acid
sufficiency and mTOR regulate p70 S6 kinase and eIF-4E BP1 through a common effector
mechanism. J. Biol. Chem 273, 14484–14494. [PubMed: 9603962]
Henderson GC, Nadeau D, Horton ES, and Nair KS (2010). Effects of adiposity and 30 days of caloric
restriction upon protein metabolism in moderately vs. severely obese women. Obesity (Silver
Spring) 18, 1135–1142. [PubMed: 20134416]
Jaleel A, Klaus KA, Morse DM, Karakelides H, Ward LE, Irving BA, and Nair KS (2009). Differential
Author Manuscript

effects of insulin deprivation and systemic insulin treatment on plasma protein synthesis in type 1
diabetic people. Am. J. Physiol. Endocrinol. Metab 297, E889–E897. [PubMed: 19654285]
Jaleel A, Henderson GC, Madden BJ, Klaus KA, Morse DM, Gopala S, and Nair KS (2010).
Identification of de novo synthesized and relatively older proteins: accelerated oxidative damage to
de novo synthesized apolipoprotein A-1 in type 1 diabetes. Diabetes 59, 2366–2374. [PubMed:
20622162]
Jefferson LS, Liao WS, Peavy DE, Miller TB, Appel MC, and Taylor JM (1983). Diabetes-induced
alterations in liver protein synthesis. Changes in the relative abundance of mRNAs for albumin and
other plasma proteins. J. Biol. Chem 258, 1369–1375. [PubMed: 6822503]
Jung CH, Jun CB, Ro SH, Kim YM, Otto NM, Cao J, Kundu M, and Kim DH (2009). ULK-Atg13-
FIP200 complexes mediate mTOR signaling to the autophagy machinery. Mol. Biol. Cell 20,
1992–2003. [PubMed: 19225151]
Kannel WB, and McGee DL (1979). Diabetes and cardiovascular risk factors: the Framingham study.
Circulation 59, 8–13. [PubMed: 758126]
Karakelides H, Asmann YW, Bigelow ML, Short KR, Dhatariya K, Coenen-Schimke J, Kahl J,
Author Manuscript

Mukhopadhyay D, and Nair KS (2007). Effect of insulin deprivation on muscle mitochondrial ATP
production and gene transcript levels in type 1 diabetic subjects. Diabetes 56, 2683–2689.
[PubMed: 17660267]
Kasuga M, Zick Y, Blithe DL, Crettaz M, and Kahn CR (1982). Insulin stimulates tyrosine
phosphorylation of the insulin receptor in a cell-free system. Nature 298, 667–669. [PubMed:
6178977]
Kim E, Goraksha-Hicks P, Li L, Neufeld TP, and Guan KL (2008). Regulation of TORC1 by Rag
GTPases in nutrient response. Nat. Cell Biol 10, 935–945. [PubMed: 18604198]
Kim SJ, Chae S, Kim H, Mun DG, Back S, Choi HY, Park KS, Hwang D, Choi SH, and Lee SW
(2014). A protein profile of visceral adipose tissues linked to early pathogenesis of type 2 diabetes
mellitus. Mol. Cell Proteomics 13, 811–822. [PubMed: 24403596]
Laplante M, and Sabatini DM (2012). mTOR signaling in growth control and disease. Cell 149, 274–
293. [PubMed: 22500797]
Lecker SH, Solomon V, Price SR, Kwon YT, Mitch WE, and Goldberg AL (1999). Ubiquitin
Author Manuscript

conjugation by the N-end rule pathway and mRNAs for its components increase in muscles of
diabetic rats. J. Clin. Invest 104, 1411–1420. [PubMed: 10562303]
Lindinger PW, Christe M, Eberle AN, Kern B, Peterli R, Peters T, Jayawardene KJ, Fearnley IM, and
Walker JE (2015). Important mitochondrial proteins in human omental adipose tissue show
reduced expression in obesity. J. Proteomics 124, 79–87. [PubMed: 25865306]
Ljungqvist OH, Persson M, Ford GC, and Nair KS (1997). Functional heterogeneity of leucine pools
in human skeletal muscle. Am. J. Physiol 273, E564–E570. [PubMed: 9316447]
Lukens F (1953). The influence of insulin on protein metabolism. Diabetes 2, 491–497. [PubMed:
13116847]

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 18

Luzi L, Castellino P, Simonson DC, Petrides AS, and DeFronzo RA (1990). Leucine metabolism in
IDDM. Role of insulin and substrate availability. Diabetes 39, 38–48. [PubMed: 2210059]
Author Manuscript

Ma XM, and Blenis J (2009). Molecular mechanisms of mTOR-mediated translational control. Nat.
Rev. Mol. Cell Biol 10, 307–318. [PubMed: 19339977]
Mammucari C, Milan G, Romanello V, Masiero E, Rudolf R, Del Piccolo P, Burden SJ, Di Lisi R,
Sandri C, Zhao J, et al. (2007). FoxO3 controls autophagy in skeletal muscle in vivo. Cell Metab.
6, 458–471. [PubMed: 18054315]
Manchester KL, and Young FG (1958). The effect of insulin on incorporation of amino acids into
protein of normal rat diaphragm in vitro. Biochem. J 70, 353–358. [PubMed: 13596350]
Manjunatha S, Distelmaier K, Dasari S, Carter RE, Kudva YC, and Nair KS (2016). Functional and
proteomic alterations of plasma high density lipoproteins in type 1 diabetes mellitus. Metabolism
65, 1421–1431. [PubMed: 27506748]
Martin-Gallan P, Carrascosa A, Gussinye M, and Dominguez C (2003). Biomarkers of diabetes-
associated oxidative stress and antioxidant status in young diabetic patients with or without
subclinical complications. Free Radic. Biol. Med 34, 1563–1574. [PubMed: 12788476]
McCoy RG, and Nair KS (2013). The 2010 ESPEN Sir David Cuthbertson Lecture: new and old
Author Manuscript

proteins: clinical implications. Clin. Nutr 32, 728–736. [PubMed: 23481224]

Meek SE, Persson M, Ford GC, and Nair KS (1998). Differential regulation of amino acid exchange
and protein dynamics across splanchnic and skeletal muscle beds by insulin in healthy human
subjects. Diabetes 47, 1824–1835. [PubMed: 9836512]
Milan G, Romanello V, Pescatore F, Armani A, Paik JH, Frasson L, Seydel A, Zhao J, Abraham R,
Goldberg AL, et al. (2015). Regulation of autophagy and the ubiquitin-proteasome system by the
FoxO transcriptional network during muscle atrophy. Nat. Commun 6, 6670. [PubMed: 25858807]
Minard AY, Wong MK, Chaudhuri R, Tan SX, Humphrey SJ, Parker BL, Yang JY, Laybutt DR,
Cooney GJ, Coster AC, et al. (2016). Hyperactivation of the insulin signaling pathway improves
intracellular proteostasis by coordinately up-regulating the proteostatic machinery in adipocytes. J.
Biol. Chem 291, 25629–25640. [PubMed: 27738101]
Nair KS, Garrow JS, Ford C, Mahler RF, and Halliday D (1983). Effect of poor diabetic control and
obesity on whole body protein metabolism in man. Diabetologia 25, 400–403. [PubMed: 6317503]
Nair KS, Ford GC, and Halliday D (1987a). Effect of intravenous insulin treatment on in vivo whole
Author Manuscript

body leucine kinetics and oxygen consumption in insulin-deprived type I diabetic patients.
Metabolism 36, 491–495. [PubMed: 3553851]
Nair KS, Halliday D, Matthews DE, and Welle SL (1987b). Hyperglucagonemia during insulin
deficiency accelerates protein catabolism. Am. J. Physiol 253, E208–E213. [PubMed: 3303968]
Nair KS, Matthews DE, Welle SL, and Braiman T (1992). Effect of leucine on amino acid and glucose
metabolism in humans. Metabolism 41, 643–648. [PubMed: 1640850]
Nair KS, Ford GC, Ekberg K, Fernqvist-Forbes E, and Wahren J (1995). Protein dynamics in whole
body and in splanchnic and leg tissues in type I diabetic patients. J. Clin. Invest 95, 2926–2937.
[PubMed: 7769135]
Naito T, Kuma A, and Mizushima N (2013). Differential contribution of insulin and amino acids to the
mTORC1-autophagy pathway in the liver and muscle. J. Biol. Chem 288, 21074–21081. [PubMed:
23744068]
Nakae J, Park BC, and Accili D (1999). Insulin stimulates phosphorylation of the forkhead
transcription factor FKHR on serine 253 through a Wortmannin-sensitive pathway. J. Biol. Chem
274, 15982–15985. [PubMed: 10347145]
Author Manuscript

Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, Orchard TJ, Raskin P, and Zinman B
(2005). Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N.
Engl. J. Med 353, 2643–2653. [PubMed: 16371630]
Newgard CB, An J, Bain JR, Muehlbauer MJ, Stevens RD, Lien LF, Haqq AM, Shah SH, Arlotto M,
Slentz CA, et al. (2009). A branched-chain amino acid-related metabolic signature that
differentiates obese and lean humans and contributes to insulin resistance. Cell Metab. 9, 311–326.
[PubMed: 19356713]
Nobukuni T, Joaquin M, Roccio M, Dann SG, Kim SY, Gulati P, Byfield MP, Backer JM, Natt F, Bos
JL, et al. (2005). Amino acids mediate mTOR/raptor signaling through activation of class 3

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 19

phosphatidylinositol 3OH-kinase. Proc. Natl. Acad. Sci. USA 102, 14238–14243. [PubMed:
16176982]
Author Manuscript

Nygren J, and Nair KS (2003). Differential regulation of protein dynamics in splanchnic and skeletal
muscle beds by insulin and amino acids in healthy human subjects. Diabetes 52, 1377–1385.
[PubMed: 12765947]
O’Neill BT, Lauritzen HP, Hirshman MF, Smyth G, Goodyear LJ, and Kahn CR (2015). Differential
role of insulin/IGF-1 receptor signaling in muscle growth and glucose homeostasis. Cell Rep. 11,
1220–1235. [PubMed: 25981038]
O’Neill BT, Lee KY, Klaus K, Softic S, Krumpoch MT, Fentz J, Stanford KI, Robinson MM, Cai W,
Kleinridders A, et al. (2016). Insulin and IGF-1 receptors regulate FoxO-mediated signaling in
muscle proteostasis. J. Clin. Invest 126, 3433–3446. [PubMed: 27525440]
O-Sullivan I, Zhang W, Wasserman DH, Liew CW, Liu J, Paik J, DePinho RA, Stolz DB, Kahn CR,
Schwartz MW, et al. (2015). FoxO1 integrates direct and indirect effects of insulin on hepatic
glucose production and glucose utilization. Nat. Commun 6, 7079. [PubMed: 25963540]
Ogg S, Paradis S, Gottlieb S, Patterson GI, Lee L, Tissenbaum HA, and Ruvkun G (1997). The Fork
head transcription factor DAF-16 transduces insulin-like metabolic and longevity signals in C.
Author Manuscript

elegans. Nature 389, 994–999. [PubMed: 9353126]

Palsgaard J, Brown AE, Jensen M, Borup R, Walker M, and De Meyts P (2009). Insulin-like growth
factor I (IGF-I) is a more potent regulator of gene expression than insulin in primary human
myoblasts and myotubes. Growth Horm. IGF Res 19, 168–178. [PubMed: 19010705]
Patti ME, Brambilla E, Luzi L, Landaker EJ, and Kahn CR (1998). Bidirectional modulation of insulin
action by amino acids. J. Clin. Invest 101, 1519–1529. [PubMed: 9525995]
Pozefsky T, Felig P, Tobin JD, Soeldner JS, and Cahill GF Jr. (1969). Amino acid balance across
tissues of the forearm in postabsorptive man. Effects of insulin at two dose levels. J. Clin. Invest
48, 2273–2282. [PubMed: 5355340]
Price SR, Bailey JL, Wang X, Jurkovitz C, England BK, Ding X, Phillips LS, and Mitch WE (1996).
Muscle wasting in insulinopenic rats results from activation of the ATP-dependent, ubiquitin-
proteasome proteolytic pathway by a mechanism including gene transcription. J. Clin. Invest 98,
1703–1708. [PubMed: 8878419]
Reed JA (1954). Aretaeus, the Cappadocian: history enlightens the present. Diabetes 3, 419–421.
[PubMed: 13220446]
Author Manuscript

Rena G, Guo S, Cichy SC, Unterman TG, and Cohen P (1999). Phosphorylation of the transcription
factor forkhead family member FKHR by protein kinase B. J. Biol. Chem 274, 17179–17183.
[PubMed: 10358075]
Risson V, Mazelin L, Roceri M, Sanchez H, Moncollin V, Corneloup C, Richard-Bulteau H, Vignaud
A, Baas D, Defour A, et al. (2009). Muscle inactivation of mTOR causes metabolic and dystrophin
defects leading to severe myopathy. J. Cell Biol 187, 859–874. [PubMed: 20008564]
Rizza RA, Mandarino LJ, and Gerich JE (1981). Dose-response characteristics for effects of insulin on
production and utilization of glucose in man. Am. J. Physiol 240, E630–E639. [PubMed: 7018254]
Robinson MM, Soop M, Sohn TS, Morse DM, Schimke JM, Klaus KA, and Nair KS (2014). High
insulin combined with essential amino acids stimulates skeletal muscle mitochondrial protein
synthesis while decreasing insulin sensitivity in healthy humans. J. Clin. Endocrinol. Metab 99,
E2574–E2583. [PubMed: 25222757]
Robinson MM, Dasari S, Karakelides H, Bergen HR 3rd, and Nair KS (2016). Release of skeletal
muscle peptide fragments identifies individual proteins degraded during insulin deprivation in type
Author Manuscript

1 diabetic humans and mice. Am. J. Physiol. Endocrinol. Metab 311, E628–E637. [PubMed:
27436610]
Romanello V, Guadagnin E, Gomes L, Roder I, Sandri C, Petersen Y, Milan G, Masiero E, Del Piccolo
P, Foretz M, et al. (2010). Mitochondrial fission and remodelling contributes to muscle atrophy.
EMBO J. 29, 1774–1785. [PubMed: 20400940]
Rousseau A, and Bertolotti A (2016). An evolutionarily conserved pathway controls proteasome
homeostasis. Nature 536, 184–189. [PubMed: 27462806]

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 20

Sacheck JM, Ohtsuka A, McLary SC, and Goldberg AL (2004). IGF-I stimulates muscle growth by
suppressing protein breakdown and expression of atrophy-related ubiquitin ligases, atrogin-1 and
Author Manuscript

MuRF1. Am. J. Physiol. Endocrinol. Metab 287, E591–E601. [PubMed: 15100091]

Sakaguchi M, Fujisaka S, Cai W, Winnay JN, Konishi M, O’Neill BT, Li M, Garcia-Martin R,
Takahashi H, Hu J, et al. (2017). Adipocyte dynamics and reversible metabolic syndrome in mice
with an inducible adipocyte-specific deletion of the insulin receptor. Cell Metab. 25, 448–462.
[PubMed: 28065828]
Sancak Y, Peterson TR, Shaul YD, Lindquist RA, Thoreen CC, Bar-Peled L, and Sabatini DM (2008).
The Rag GTPases bind raptor and mediate amino acid signaling to mTORC1. Science 320, 1496–
1501. [PubMed: 18497260]
Sandri M, Sandri C, Gilbert A, Skurk C, Calabria E, Picard A, Walsh K, Schiaffino S, Lecker SH, and
Goldberg AL (2004). Foxo transcription factors induce the atrophy-related ubiquitin ligase
atrogin-1 and cause skeletal muscle atrophy. Cell 117, 399–412. [PubMed: 15109499]
Shah OJ, Anthony JC, Kimball SR, and Jefferson LS (2000). 4E-BP1 and S6K1: translational
integration sites for nutritional and hormonal information in muscle. Am. J. Physiol. Endocrinol.
Metab 279, E715–E729. [PubMed: 11001751]
Author Manuscript

Simmons PS, Miles JM, Gerich JE, and Haymond MW (1984). Increased proteolysis. An effect of
increases in plasma cortisol within the physiologic range. J. Clin. Invest 73, 412–420. [PubMed:
6365973]
Sinex FM, Macmullen J, and Hastings AB (1952). The effect of insulin on the incorporation of C14
into the protein of rat diaphragm. J. Biol. Chem 198, 615–619. [PubMed: 12999777]
Sokhey SS, and Allan FN (1924). The relationship of phosphates to carbohydrate metabolism: time
relationship of the changes in phosphate excretion caused by insulin and sugar. Biochem. J 18,
1170–1184. [PubMed: 16743349]
Stump CS, Short KR, Bigelow ML, Schimke JM, and Nair KS (2003). Effect of insulin on human
skeletal muscle mitochondrial ATP production, protein synthesis, and mRNA transcripts. Proc.
Natl. Acad. Sci. USA 100, 7996–8001. [PubMed: 12808136]
Tang ED, Nunez G, Barr FG, and Guan KL (1999). Negative regulation of the forkhead transcription
factor FKHR by Akt. J. Biol. Chem 274, 16741–16746. [PubMed: 10358014]
Taniguchi CM, Emanuelli B, and Kahn CR (2006). Critical nodes in signalling pathways: insights into
insulin action. Nat. Rev. Mol. Cell Biol 7, 85–96. [PubMed: 16493415]
Author Manuscript

Tessari P, Inchiostro S, Biolo G, Duner E, Nosadini R, Tiengo A, and Crepaldi G (1985).

Hyperaminoacidaemia reduces insulin-mediated glucose disposal in healthy man. Diabetologia
28, 870–872. [PubMed: 3910497]
Tessari P, Iori E, Vettore M, Zanetti M, Kiwanuka E, Davanzo G, and Barazzoni R (1997). Evidence
for acute stimulation of fibrinogen production by glucagon in humans. Diabetes 46, 1368–1371.
[PubMed: 9231665]
The Diabetes Control and Complications Trial Research Group, Nathan DM, Genuth S, Lachin J,
Cleary P, Crofford O, Davis M, Rand L, and Siebert C (1993). The effect of intensive treatment
of diabetes on the development and progression of long-term complications in insulin-dependent
diabetes mellitus. N. Engl. J. Med 329, 977–986. [PubMed: 8366922]
Umpleby AM, Boroujerdi MA, Brown PM, Carson ER, and Sonksen PH (1986). The effect of
metabolic control on leucine metabolism in type 1 (insulin-dependent) diabetic patients.
Diabetologia 29, 131–141. [PubMed: 3699304]
Wahren J, Felig P, Cerasi E, and Luft R (1972). Splanchnic and peripheral glucose and amino acid
Author Manuscript

metabolism in diabetes mellitus. J. Clin. Invest 51, 1870–1878. [PubMed: 5032528]

Wahren J, Felig P, and Hagenfeldt L (1976). Effect of protein ingestion on splanchnic and leg
metabolism in normal man and in patients with diabetes mellitus. J. Clin. Invest 57, 987–999.
[PubMed: 947963]
Walrand S, Short KR, Bigelow ML, Sweatt AJ, Hutson SM, and Nair KS (2008). Functional impact of
high protein intake on healthy elderly people. Am. J. Physiol. Endocrinol. Metab 295, E921–
E928. [PubMed: 18697911]

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 21

Wang X, Hu Z, Hu J, Du J, and Mitch WE (2006). Insulin resistance accelerates muscle protein

degradation: activation of the ubiquitin-proteasome pathway by defects in muscle cell signaling.
Author Manuscript

Endocrinology 147, 4160–4168. [PubMed: 16777975]

Wang TJ, Larson MG, Vasan RS, Cheng S, Rhee EP, McCabe E, Lewis GD, Fox CS, Jacques PF,
Fernandez C, et al. (2011). Metabolite profiles and the risk of developing diabetes. Nat. Med 17,
448–453. [PubMed: 21423183]
Waterlow JC (1984). Protein turnover with special reference to man. Q. J. Exp. Physiol 69, 409–438.
[PubMed: 6382379]
White PJ, Lapworth AL, An J, Wang L, McGarrah RW, Stevens RD, Ilkayeva O, George T,
Muehlbauer MJ, Bain JR, et al. (2016). Branched-chain amino acid restriction in Zucker-fatty
rats improves muscle insulin sensitivity by enhancing efficiency of fatty acid oxidation and acyl-
glycine export. Mol. Metab 5, 538–551. [PubMed: 27408778]
Wolfson RL, Chantranupong L, Saxton RA, Shen K, Scaria SM, Cantor JR, and Sabatini DM (2016).
Sestrin2 is a leucine sensor for the mTORC1 pathway. Science 351, 43–48. [PubMed: 26449471]
Xiong X, Tao R, DePinho RA, and Dong XC (2013). Deletion of hepatic FoxO1/3/4 genes in mice
significantly impacts on glucose metabolism through downregulation of gluconeogenesis and
Author Manuscript

upregulation of glycolysis. PLoS One 8, e74340. [PubMed: 24015318]

Zabielski P, Lanza IR, Gopala S, Heppelmann CJ, Bergen HR 3rd, Dasari S, and Nair KS (2016).
Altered skeletal muscle mitochondrial proteome as the basis of disruption of mitochondrial
function in diabetic mice. Diabetes 65, 561–573. [PubMed: 26718503]
Zhang Y, Nicholatos J, Dreier JR, Ricoult SJ, Widenmaier SB, Hotamisligil GS, Kwiatkowski DJ, and
Manning BD (2014). Coordinated regulation of protein synthesis and degradation by mTORC1.
Nature 513, 440–443. [PubMed: 25043031]
Zhao J, Brault JJ, Schild A, Cao P, Sandri M, Schiaffino S, Lecker SH, and Goldberg AL (2007).
FoxO3 coordinately activates protein degradation by the autophagic/lysosomal and proteasomal
pathways in atrophying muscle cells. Cell Metab. 6, 472–483. [PubMed: 18054316]
Zhao X, Bak S, Pedersen AJ, Jensen ON, and Hojlund K (2014). Insulin increases phosphorylation of
mitochondrial proteins in human skeletal muscle in vivo. J. Proteome Res 13, 2359–2369.
[PubMed: 24641631]
Zhao J, Zhai B, Gygi SP, and Goldberg AL (2015). mTOR inhibition activates overall protein
degradation by the ubiquitin proteasome system as well as by autophagy. Proc. Natl. Acad. Sci.
Author Manuscript

USA 112, 15790–15797. [PubMed: 26669439]

Author Manuscript

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 22
Author Manuscript
Author Manuscript

Figure 1. Simplified Whole-Body Model of Proteostasis

Amino acids, derived from diet, degradation of endogenous proteins, and in vivo synthesis
Author Manuscript

(nonessential amino acids only), are distributed through cellular compartments and the
bloodstream. They travel via blood vessels to different tissues, where they may be
incorporated into proteins via protein synthesis (PS) and become part of the whole-body
proteome. Within the tissues, protein degradation (PD) releases amino acids back into the
amino acid pool, where they may be recycled via acylation to tRNA for further PS. The
amino acids that are not directed for PS are oxidized, releasing carbon dioxide (CO2) and
nitrogen in the process. The rate of protein turnover, which includes the processes of PS and
PD, is tissue-dependent and variably influenced by insulin.
Author Manuscript

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 23
Author Manuscript
Author Manuscript

Figure 2. Protein Flux between Gut, Splanchnic Tissue, and Skeletal Muscle during
Author Manuscript

Postabsorptive, Postprandial, and Insulin-Deficient States

(A) In the nondiabetic postabsorptive (fasting) state, protein degradation (PD) exceeds
protein synthesis (PS) in the muscle, leading to efflux of amino acids into the systemic pool
and uptake by the splanchnic tissue where PS exceeds PD. This allows continued synthesis
of necessary proteins, such as clotting factors, in the liver even when amino acids are not
actively being ingested.
(B) In the nondiabetic postprandial (mixed-meal fed) state, a high-dose amino acid load
from the gut triggers increased PS and decreased PD in the splanchnic bed. Insulin is also
secreted and inhibits PD in the muscle. PS increases in muscle owing to the additive effects
of insulin and amino acids.
(c)In the insulin-deficient state, muscle PD is greatly increased and PS is not affected. This
leads to transfer of a large amount of amino acids from muscle to the splanchnic bed, where
Author Manuscript

both PS and PD are increased, but PS exceeds PD, resulting in net positive protein balance,
presumably as a mechanism to allow continued synthesis of necessary proteins and perhaps
to deal with the stress incurred by the absence of insulin.

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 24
Author Manuscript
Author Manuscript

Figure 3. The Effects of Insulin and Amino Acids on Phenylalanine Balance and Protein
Dynamics in Skeletal Muscle and Splanchnic Bed
The top panels show net phenylalanine balance, and the bottom panels show changes in
protein synthesis (PS) and protein degradation (PD), with use of labeled phenylalanine and
tyrosine as tracers across the leg and splanchnic beds in fasting healthy individuals during
infusion of normal saline (NS), insulin alone (Ins), insulin + baseline replacement of amino
acids (LoAA/Ins), insulin + high-dose physiologic amino acids (HiAA/Ins), and
Author Manuscript

somatostatin + baseline replacement of insulin, glucagon, and growth hormone + high-dose

physiologic amino acids (SRIH/AA) or saline (SRIH/NS). The SRIH/AA treatment shows
the effects of high-dose amino acids alone, since insulin, glucagon, and growth hormone are
maintained at baseline levels. Phenylalanine is an essential amino acid that cannot be
synthesized by humans, and it is disposed of in muscle exclusively by incorporation into
proteins (protein synthesis). Therefore, phenylalanine balance represents the difference
between PS and PD in muscle. In liver, it is converted to tyrosine, so an independent tyrosine
tracer was used along with the phenylalanine tracer to measure splanchnic PS and PD.
(A and B) NS infusion led to a statistically significant negative phenylalanine balance in the
leg, while insulin infusion balanced phenylalanine in the leg. Adding amino acids to insulin
increased phenylalanine balance in a dose-dependent manner in both the muscle and
splanchnic bed.
Author Manuscript

(C)PD exceeds PS in the leg during NS infusion, but PS increases and exceeds PD when
both insulin and high-dose physiologic amino acids (HiAA/Ins) and when high-dose amino
acids alone (SRIH/AA) are infused.
(D)In the splanchnic bed, PD and PS are nearly equal during NS and insulin infusion, but PS
increases in a dose-dependent manner and exceeds PD when amino acids are added to
insulin or when high-dose amino acids alone are infused.

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 25

Data are represented as mean ± SEM. *Indicates that phenylalanine balance is different
between baseline and intervention (p < 0.05). #Indicates that the rate of PD is different than
Author Manuscript

the rate of PS (p < 0.05). Adapted from Nygren and Nair (2003).
Author Manuscript
Author Manuscript
Author Manuscript

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 26
Author Manuscript
Author Manuscript

Figure 4. Mechanisms for the Regulation of Protein Turnover in Muscle by Insulin and Insulin-
Author Manuscript

like Growth Factor 1

(A) In the fed state, muscle growth and maintenance of muscle mass are stimulated by
insulin, amino acids, and, to a lesser extent, insulin-like growth factor 1 (IGF-1). Insulin
engages the insulin receptor and signals via the IRS-PI3K-Akt pathway to suppress
translocation of forkhead box O (FoxO) isoforms 1, 3, and 4, and inhibit their transcriptional
activity. Inhibition of FoxOs suppresses proteasomal and autophagy-lysosomal protein
degradation. In addition, mammalian target of rapamycin complex 1 (mTORC1) is activated
by amino acids and Akt to enhance protein synthesis, which ultimately leads to net protein
gain and muscle growth.
(B) Decreased insulin signaling, as occurs with fasting or in diabetes, increases FoxO
isoform translocation and transcription of critical mediators of ubiquitin-proteasome and
autophagy-lysosome systems, leading to a marked increase in protein degradation that
outweighs protein synthesis, leading to muscle atrophy and a high-protein- turnover state.
Author Manuscript

IGF-1R, insulin-like growth factor-1 receptor; IRS, insulin receptor substrates; PI3K,
phosphoinositidase-3 kinase.

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 James et al. Page 27
Author Manuscript
Author Manuscript
Author Manuscript

Figure 5. Protein Biogenesis and Homeostasis

Protein synthesis begins with transcription of genes into mRNA, which is followed by
translation into polypeptides. Insulin facilitates both of these processes, and amino acids are
necessary for translation. Polypeptides are folded into specific configurations in order to
become functional proteins, but they may become dysfunctional if misfolded. Properly
folded proteins may undergo reversible posttranslational modifications (PTMs), which aid in
various protein functions, or they may undergo irreversible PTMs (oxidation, glycation, etc.)
from oxidative or other environmental stress. The proteins damaged by irreversible PTMs, as
well as misfolded ones, are usually targeted for proteasome-mediated degradation or
autophagy, and amino acids may be recycled. If excess misfolding occurs or environmental
stress overwhelms the system, damaged proteins may accumulate and/or aggregate, leading
to disease. LMW, low molecular weight; ROS, reactive oxygen species.
Author Manuscript

Cell Metab. Author manuscript; available in PMC 2021 April 05.

 JAMDA 14 (2013) 540e541
JAMDA
journal homepage: www.jamda.com
Editorial
Sarcopenia and Diabetes: Two Sides of the Same Coin
Francesco Landi MD, PhD *, Graziano Onder MD, PhD, Roberto Bernabei MD
Department of Gerontology-Geriatrics, Catholic University of Sacred Heart, Rome, Italy
Recognizing that loss in lean body mass is a frequent problem
found among older adults with diabetes, this issue of the Journal of
the American Medical Directors Association includes a report from
Leenders and colleagues1 documenting the impact of type 2 diabetes
on muscle mass, strength, and functional capacity in an older popu-
lation. The authors demonstrated that skeletal muscle mass, leg
muscle strength, and functional capacity are reduced in older patients
with type 2 diabetes, when compared with age-matched normogly-
cemic controls.
This study contributes significantly to improving our knowledge
about the relationship between diabetes and sarcopenia, an area that
remains substantially poorly studied. So far, few observational studies
have reported lower muscle strength among older men with type 2
diabetes compared with healthy controls. Interestingly, Park and
colleagues2 showed that older subjects with type 2 diabetes have
a 30% greater decline over 3 years in leg muscle strength compared
with healthy age-matched controls. Furthermore, the impairment in
muscle strength observed among older subjects with diabetes has
been correlated with intramuscular fat storage, which is almost 3
times higher than in controls.3
Diabetes and loss of muscle mass may share some common
etiological pathways, including reduced physical activity, and their
association might be explained by common features of diabetes,
including lower activity of some anabolic hormones, such as in-
sulinlike growth factor-1, testosterone, and ghrelin and the negative
effects of diabetes on blood flow to muscle cells.4,5 However, some
issues explaining the association between diabetes and loss in muscle
mass and strength and possible interventions for older subjects with
diabetes and sarcopenia need to be addressed.6e8
First, the insulin resistance of skeletal muscle is probably the
most important link between sarcopenia and diabetes (Figure 1).
Insulin resistance is defined as a reduced response of target tissues,
such as skeletal muscle, to insulin. Muscle insulin resistance is
considered to be the starting or key defect that is evident decades
before b-cell failure.9 Normal b-cell response to insulin resistance is
to enhance the secretion of insulin and the prolonged physiologic
increase in the plasma insulin concentration could lead to further
DOI of original article: 10.1016/j.jamda.2013.02.006.
* Address correspondence to Francesco Landi, MD, PhD, Centro Medicina
dell’Invecchiamento (CEMI), Istituto di Medicina Interna e Geriatria, Università
Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, 00168 Roma, Italy.
E-mail address: francesco.landi@rm.unicatt.it (F. Landi).
1525-8610/$ - see front matter Copyright Ó 2013 - American Medical Directors Association, Inc.
http://dx.doi.org/10.1016/j.jamda.2013.05.004
Downloaded for Anonymous User (n/a) at Abbott Laboratories from ClinicalKey.com by Elsevier on July 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
reduction of skeletal muscle insulin sensitivity.8 Therefore, the
increase of insulin concentration aggravates the underlying skeletal
muscle insulin resistance. This vicious circle indicates that insulin
resistance begins the sequence of events leading to the onset of type
2 diabetes.
Second, hyperglycemia is associated with multiple metabolic
abnormalities, potentially correlated with muscle cell damage:
elevation of the plasma free fatty acid concentration and increment in
circulating level of inflammatory cytokines can be commonly
observed in patients with diabetes. Interestingly, some authors have
hypothesized that an intramuscular inflammation-related pathway
can induce a proteolytic process in skeletal muscle with myofilament
degradation through caspase-3 activation.10 Particularly, tumor
necrosis factor-a can also trigger the extrinsic pathway of apoptosis
and induce mitochondrial dysfunction in skeletal myocytes.11 Finally,
the muscle mitochondrial oxidative capacity is often impaired,
causing a reduction in fat oxidation activity. As a consequence, the
muscle mitochondrial dysfunction leads to elevated accumulation of
intramyocellular lipid metabolites.9
Third, insulin plays a relevant role in protein anabolism.12 Amino
acids and insulin have a synergistic effect on stimulating muscle
protein anabolism.3 Indeed, in physiological conditions, the
maximum protein anabolism occurs during the fed state, when the
concentrations of insulin and amino acids are elevated. Insulin
stimulates protein synthesis in skeletal muscle cells only when
intramuscular amino acid availability is maintained or increased,
while, independently of dose, insulin is not able to enhance muscle
protein synthesis when amino acid availability is low.3 In addition,
it has been shown that insulin deficiency leads to a protein cata-
bolic state with loss of muscle mass that could be reversed by
insulin therapy. Therefore, a clear relationship exists among
insulin, muscle anabolism, and protein intake, as shown by the fact
that even though insulin has a stimulatory effect on muscle
protein synthesis, an adequate availability of amino acids is
necessary to increase the synthetic rate.13,14 The anabolic effect of
insulin on muscle mass might have relevant therapeutic implica-
tions, and insulin, in association with amino acid supplementation,
might be proposed as a potential treatment for muscle loss, not
only in the diabetic population, but also in a general older
population.15e17
In conclusion, diabetes can cause loss of skeletal muscle mass
and strength, but more studies are needed to improve our knowl-
edge on the interaction between diabetes, with the associated
insulin resistance, and sarcopenia.18,19 In particular, the effect of
 Editorial / JAMDA 14 (2013) 540e541 541

Fig 1. The interaction between sarcopenia and diabetes.

insulin on proteolysis and protein synthesis deserves more studies
in vivo and the effect of exogenous insulin and/or agents that
enhance insulin on muscle protein synthesis and breakdown should
be evaluated.20
References
1. Leenders M, Verdijk LB, van der Hoeven L, et al. Type 2 diabetes patients
show a greater decline in muscle mass, muscle strength, and functional
capacity with aging. J Am Med Dir Assoc 2013;14:585e592.
2. Park SW, Goodpaster BH, Strotmeyer ES, et al. Accelerated loss of skeletal
muscle strength in older adults with type 2 diabetes: The health, aging, and
body composition study. Diabetes Care 2007;30:1507e1512.
3. Bassil MS, Gougeon R. Muscle protein anabolism in type 2 diabetes. Curr Opin
Clin Nutr Metab Care 2013;16:83e88.
4. Morley JE. Diabetes, sarcopenia, and frailty. Clin Geriatr Med 2008;24:
455e469.
5. Fielding RA, Vellas B, Evans WJ, et al. Sarcopenia: An undiagnosed condition in
older adults. Current consensus definition: Prevalence, etiology, and conse-
quences. International Working Group on Sarcopenia. J Am Med Dir Assoc
2011;12:249e256.
6. Boirie Y. Fighting sarcopenia in older frail subjects: Protein fuel for strength,
exercise for mass. J Am Med Dir Assoc 2013;14:140e143.
7. Roman D, Mahoney K, Mohamadi A. Sarcopenia: What’s in a name? J Am Med
Dir Assoc 2013;14:80e82.
8. Cesari M, Vellas B. Sarcopenia: A novel clinical condition or still a matter for
research? J Am Med Dir Assoc 2012;13:766e767.
9. DeFronzo RA, Tripathy D. Skeletal muscle insulin resistance is the primary
defect in type 2 diabetes. Diabetes Care 2009;32:S157eS163.
10. Lee SW, Dai G, Hu Z, et al. Regulation of muscle protein degradation:
Coordinated control of apoptotic and ubiquitin-proteasome systems by
phosphatidylinositol 3 kinase. J Am Soc Nephrol 2004;15:1537e1545.
11. Marzetti E, Lees HA, Manini TM, et al. Skeletal muscle apoptotic signaling
predicts thigh muscle volume and gait speed in community-dwelling older
persons: An exploratory study. PLoS One 2012;7:e32829.
12. Wolfe RR. Effects of insulin on muscle tissue. Curr Opin Clin Nutr Metab Care
2000;3:67e71.
13. Landi F, Marzetti E, Bernabei R. Perspective: Protein: what kind, how much,
when? J Am Med Dir Assoc 2013;14:66e67.
14. Morley JE, Argiles JM, Evans WJ, et al. Society for Sarcopenia, Cachexia, and
Wasting Disease. Nutritional recommendations for the management of sarco-
penia. J Am Med Dir Assoc 2010;11:391e396.
15. Sinclair A, Morley JE, Rodriguez-Mañas L, et al. Diabetes mellitus in older
people: Position statement on behalf of the International Association of
Gerontology and Geriatrics (IAGG), the European Diabetes Working Party
for Older People (EDWPOP), and the International Task Force of Experts in
Diabetes. J Am Med Dir Assoc 2012;13:497e502.
16. Pandya N, Nathanson E. Managing diabetes in long term care facilities: Benefits
of switching from human insulin to insulin analogs. J Am Med Dir Assoc 2010;
11:171e178.
17. Meyers RM, Reger L. Diabetes management in long term care facilities:
A practical guide. J Am Med Dir Assoc 2009;10:589.
18. Landi F, Liperoti R, Fusco D, et al. Sarcopenia and mortality among older
nursing home residents. J Am Med Dir Assoc 2012;13:121e126.
19. Landi F, Russo A, Liperoti R, et al. Anorexia, physical function, and incident
disability among the frail elderly population: Results from the ilSIRENTE study.
J Am Med Dir Assoc 2010;11:268e274.
20. Colberg SR, Zarrabi L, Bennington L, et al. Postprandial walking is better for
lowering the glycemic effect of dinner than pre-dinner exercise in type 2
diabetic individuals. J Am Med Dir Assoc 2009;10:394e397.

Downloaded for Anonymous User (n/a) at Abbott Laboratories from ClinicalKey.com by Elsevier on July 28, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.