In vivo inter-organ protein metabolism of the splanchnic region and muscle during trauma, cancer and enteral nutrition

Presence of early stage cancer does not impair the early protein metabolic response to major surgery

BACKGROUND

Combined bilateral mastectomy and reconstruction is a common major surgical procedure in women with breast cancer and in those with a family history of breast cancer. As this large surgical procedure induces muscle protein loss, a preserved anabolic response to nutrition is warranted for optimal recovery. It is unclear whether the presence of early stage cancer negatively affects the protein metabolic response to major surgery as this would mandate perioperative nutritional support.

METHODS

In nine women with early stage (Stage II) breast malignancy and nine healthy women with a genetic predisposition to breast cancer undergoing the same large surgical procedure, we examined whether surgery influences the catabolic response to overnight fasting and the anabolic response to nutrition differently. Prior to and within 24 h after combined bilateral mastectomy and reconstruction surgery, whole body protein synthesis and breakdown rates were assessed after overnight fasting and after meal intake by stable isotope methodology to enable the calculation of net protein catabolism in the post-absorptive state and net protein anabolic response to a meal.

RESULTS

Major surgery resulted in an up-regulation of post-absorptive protein synthesis and breakdown rates (P < 0.001) and lower net protein catabolism (P < 0.05) and was associated with insulin resistance and increased systemic inflammation (P < 0.01). Net anabolic response to the meal was reduced after surgery (P < 0.05) but higher in cancer (P < 0.05) indicative of a more preserved meal efficiency. The significant relationship between net protein anabolism and the amount of amino acids available in the circulation (R²  = 0.85, P < 0.001) was independent of the presence of non-cachectic early stage breast cancer or surgery.

CONCLUSIONS

The presence of early stage breast cancer does not enhance the normal catabolic response to major surgery or further attenuates the anabolic response to meal intake within 24 h after major surgery in patients with non-cachectic breast cancer. This indicates that the acute anabolic potential to conventional feeding is maintained in non-cachectic early stage breast cancer after major surgery.

Serum Metabolomics of Burkitt Lymphoma Mouse Models

Burkitt lymphoma (BL) is a rare and highly aggressive type of non-Hodgkin lymphoma. The mortality rate of BL patients is very high due to the rapid growth rate and frequent systemic spread of the disease. A better understanding of the pathogenesis, more sensitive diagnostic tools and effective treatment methods for BL are essential. Metabolomics, an important aspect of systems biology, allows the comprehensive analysis of global, dynamic and endogenous biological metabolites based on their nuclear magnetic resonance (NMR) and mass spectrometry (MS). It has already been used to investigate the pathogenesis and discover new biomarkers for disease diagnosis and prognosis. In this study, we analyzed differences of serum metabolites in BL mice and normal mice by NMR-based metabolomics. We found that metabolites associated with energy metabolism, amino acid metabolism, fatty acid metabolism and choline phospholipid metabolism were altered in BL mice. The diagnostic potential of the metabolite differences was investigated in this study. Glutamate, glycerol and choline had a high diagnostic accuracy; in contrast, isoleucine, leucine, pyruvate, lysine, α-ketoglutarate, betaine, glycine, creatine, serine, lactate, tyrosine, phenylalanine, histidine and formate enabled the accurate differentiation of BL mice from normal mice. The discovery of abnormal metabolism and relevant differential metabolites may provide useful clues for developing novel, noninvasive approaches for the diagnosis and prognosis of BL based on these potential biomarkers.

Rapid diagnosis and prognosis of de novo acute myeloid leukemia by serum metabonomic analysis

Acute myeloid leukemia (AML) is a life-threatening hematological disease. Novel diagnostic and prognostic markers will be essential for new therapeutics and for significantly improving the disease prognosis. To characterize the metabolic features associated with AML and search for potential diagnostic and prognostic methods, here we analyzed the phenotypic characteristics of serum metabolite composition (metabonome) in a cohort of 183 patients with de novo acute myeloid leukemia together with 232 age- and gender-matched healthy controls using (1)H NMR spectroscopy in conjunction with multivariate data analysis. We observed significant serum metabonomic differences between AML patients and healthy controls and between AML patients with favorable and intermediate cytogenetic risks. Such differences were highlighted by systems differentiations in multiple metabolic pathways including glycolysis/gluconeogenesis, TCA cycle, biosynthesis of proteins and lipoproteins, and metabolism of fatty acids and cell membrane components, especially choline and its phosphorylated derivatives. This demonstrated the NMR-based metabonomics as a rapid and less invasive method for potential AML diagnosis and prognosis. The serum metabolic phenotypes observed here indicated that integration of metabonomics with other techniques will be useful for better understanding the biochemistry of pathogenesis and progression of leukemia.

Increased protein-energy intake promotes anabolism in critically ill infants with viral bronchiolitis: a double-blind randomised controlled trial

OBJECTIVE

The preservation of nutritional status and growth is an important aim in critically ill infants, but difficult to achieve due to the metabolic stress response and inadequate nutritional intake, leading to negative protein balance. This study investigated whether increasing protein and energy intakes can promote anabolism. The primary outcome was whole body protein balance, and the secondary outcome was first pass splanchnic phenylalanine extraction (SPE(Phe)).

DESIGN

This was a double-blind randomised controlled trial. Infants (n=18) admitted to the paediatric intensive care unit with respiratory failure due to viral bronchiolitis were randomised to continuous enteral feeding with protein and energy enriched formula (PE-formula) (n=8; 3.1 ± 0.3 g protein/kg/24 h, 119 ± 25 kcal/kg/24 h) or standard formula (S-formula) (n=10; 1.7 ± 0.2 g protein/kg/24 h, 84 ± 15 kcal/kg/24 h; equivalent to recommended intakes for healthy infants <6 months). A combined intravenous-enteral phenylalanine stable isotope protocol was used on day 5 after admission to determine whole body protein metabolism and SPE(Phe).

RESULTS

Protein balance was significantly higher with PE-formula than with S-formula (PE-formula: 0.73 ± 0.5 vs S-formula: 0.02 ± 0.6 g/kg/24 h) resulting from significantly increased protein synthesis (PE-formula: 9.6 ± 4.4, S-formula: 5.2 ± 2.3 g/kg/24 h), despite significantly increased protein breakdown (PE-formula: 8.9 ± 4.3, S-formula: 5.2 ± 2.6 g/kg/24 h). SPE(Phe) was not statistically different between the two groups (PE-formula: 39.8 ± 18.3%, S-formula: 52.4 ± 13.6%).

CONCLUSIONS

Increasing protein and energy intakes promotes protein anabolism in critically ill infants in the first days after admission. Since this is an important target of nutritional support, increased protein and energy intakes should be preferred above standard intakes in these infants. Dutch Trial Register number: NTR 515.

Absorption kinetics are a key factor regulating postprandial protein metabolism in response to qualitative and quantitative variations in protein intake

We have previously demonstrated that increasing the habitual protein intake widened the gap in nutritional quality between proteins through mechanisms that are not yet fully understood. We hypothesized that the differences in gastrointestinal kinetics between dietary proteins were an important factor affecting their differential response to an increased protein intake. To test this hypothesis, we built a 13-compartment model providing integrative insight into the sequential dynamics of meal nitrogen (Nm) absorption, splanchnic uptake, and metabolism, and subsequent peripheral transfer and deposition. The model was developed from data on postprandial Nm kinetics in certain accessible pools, obtained from subjects having ingested a (15)N-labeled milk or soy protein meal, after adaptation to normal (NP) or high (HP) protein diets. The faster absorption of Nm after soy vs. milk caused its earlier and stronger splanchnic delivery, which favored its local catabolic utilization (up to +30%) and limited its peripheral accretion (down to -20%). Nm absorption was also accelerated after HP vs. NP adaptation, and this kinetic effect accounted for most of the HP-induced increase (up to +20%) in splanchnic Nm catabolic use, and the decrease (down to -25%) in peripheral Nm anabolic utilization. The HP-induced acceleration in Nm absorption was more pronounced with soy than with milk, as were the HP effects on Nm regional metabolism. Our integrative approach identified Nm absorption kinetics, which exert a direct and lasting impact on Nm splanchnic catabolic use and peripheral delivery, as being critical in adaptation to both qualitative and quantitative changes in protein intake.

Increasing habitual protein intake results in reduced postprandial efficiency of peripheral, anabolic wheat protein nitrogen use in humans

BACKGROUND

The postprandial retention of dietary protein decreases when the prevailing protein intake increases.

OBJECTIVE

We investigated the influence of the prevailing protein intake on the regional utilization and anabolic use of wheat protein during the postprandial non-steady state in humans.

DESIGN

Healthy adults (n = 8) were adapted for 7 d, first to a normal-protein diet (NP: 1 g x kg(-1) x d(-1)) and then to a high-protein diet (HP: 2 g x kg(-1) x d(-1)). After each adaptation period, the subjects received the same single, solid mixed meal containing [15N]-labeled wheat protein. The postprandial kinetics of dietary nitrogen were then measured for 8 h in blood and urine. These data were further analyzed by using a multicompartmental model to predict the postprandial kinetics of dietary nitrogen in unsampled pools.

RESULTS

The postprandial whole-body retention of wheat protein nitrogen, measured 8 h after meal ingestion, decreased by 10% when the subjects switched from the NP diet to the HP diet. According to modeling results, this resulted from an increased splanchnic utilization of dietary nitrogen for urea production, whereas its incorporation into splanchnic proteins was unchanged, leading to a 20-30% decrease in peripheral availability and anabolic use in HP-adapted compared with NP-adapted subjects having ingested the same protein load.

CONCLUSIONS

By combining clinical experimentation with compartmental modeling, we provide a global overview of postprandial dietary protein metabolism. Increasing prior protein intake was shown to reduce the postprandial retention of wheat protein nitrogen, mainly by diminishing the efficiency of its peripheral availability and anabolic use.

Amino Acid Adequacy in Pathophysiological States

Amino acid utilization and, therefore, demand differ between the healthy state and various disease states. In the healthy state most circulating amino acids are derived from dietary proteins that are stored and broken down in the gut and released gradually into the portal circulation, and from continuous turnover of body protein. In disease states, the amino acid composition of amino acids derived from periferal protein breakdown and released in the circulation, is different, for example because a substantial part of the branched-chain amino acids is broken down to yield glutamine and alanine, which are released in the circulation. It appears to be advantageous to mimic this continuous autoinfusion in patients, dependent of parenteral of enteral tube feeding. In disease, different endpoints should be used to assess the adequacy of the administered amino acid mix. Maintenance of a positive nitrogen balance and growth is less important than support of wound healing and immune function. Several amino acids such as glutamine, cysteine, and taurine are shown or suggested to be conditionally essential in disease, and to form substrate in the stressed patient for anabolic processes in liver, immune system, and injured sites. Amino acid toxicity is rare, and protein restriction for patients with renal or liver failure is obsolete because this only aggravated malnutrition. A true example of protein toxicity consists of gastrointestinal hemorrhage that precipitates hepatic encephalopathy in liver insufficiency, most likely because hemoglobin is an unbalanced protein because it lacks the essential amino acid isoleucine.

Intestinal lysine metabolism is driven by the enteral availability of dietary lysine in piglets fed a bolus meal

Previous steady-state continuous-feeding studies have shown that the gut mucosa removes substantial amounts of both dietary and systemic amino acids. However, enteral nutrition is often given under non-steady-state conditions as a bolus meal, and this has been shown to influence systemic metabolism. Therefore, our aim was to quantify the relative metabolism of dietary and systemic lysine by the portal-drained viscera (PDV) under non-steady-state conditions after a single bolus meal. Five 28-day-old piglets implanted with arterial, venous, and portal catheters and with an ultrasonic portal flow probe were given an oral bolus feeding of a milk formula containing a trace quantity of intrinsically 15N-labeled soy protein and a continuous intravenous infusion of [U-13C]lysine for 8 h. Total lysine use by the PDV was maximal 1 h after the meal (891 micromol x kg(-1) x h(-1)) and was predominantly of dietary origin (89%), paralleling the enteral delivery of dietary lysine. Intestinal lysine use returned to a low level after 4 h postprandially and was derived exclusively from the arterial supply until 8 h. Cumulative systemic appearance of dietary lysine reached 44 and 80% of the ingested amount 4 and 8 h after the meal, respectively, whereas the PDV first-pass use of dietary lysine was 55 and 32% of the intake for these two periods, respectively. We conclude that the first-pass utilization rate of dietary lysine by the PDV is directly increased by the enteral lysine availability and that it is higher with a bolus than with continuous oral feeding.

Contribution of plasma proteins to splanchnic and total anabolic utilization of dietary nitrogen in humans

Splanchnic tissues are largely involved in the postprandial utilization of dietary amino acids, but little is yet known, particularly in humans, about the relative contributions of different splanchnic protein pools to splanchnic and total postprandial anabolism. Our aim was to develop a compartmental model that could distinguish dietary nitrogen (N) incorporation among splanchnic constitutive, plasma (splanchnic exported), and peripheral proteins after a mixed-protein meal in humans. Eight healthy subjects were fed a single mixed meal containing 15N-labeled soy protein, and dietary N postprandial kinetics were measured in plasma free amino acids, proteins, and urea and urinary urea and ammonia. These experimental data and others previously obtained for dietary N kinetics in ileal effluents under similar experimental conditions were used to develop the compartmental model. Six hours after the mixed-meal ingestion, 31.5, 7.5, and 21% of ingested N were predicted to be incorporated into splanchnic constitutive, splanchnic exported, and peripheral proteins, respectively. The contribution of splanchnic exported proteins to total splanchnic anabolism from dietary N was predicted to be approximately 19% and to remain steady throughout the simulation period. Model behavior and its predictions were strongly in line with current knowledge of the system and the scarce, specific data available in the literature. This model provides the first data concerning the anabolism of splanchnic constitutive proteins in the nonsteady postprandial state in humans. By use of only slightly invasive techniques, this model could help to assess how the splanchnic anabolism is modulated under different nutritional or pathophysiological conditions in humans.

Approaches to quantifying protein metabolism in response to nutrient ingestion

The investigation of protein metabolism under various nutritional and physiological conditions has been made possible by the use of indirect, principally tracer-based methods. Most studies were conducted at the whole-body level, mainly using steady-state isotopic techniques and equations based on simple two-pool models, in which amino acids are either free or protein bound. Because whole-body methods disregard regional contributions to protein metabolism, some regional approaches have tried to distinguish the distribution of protein kinetics in the different tissues. The organ-balance tracer technique, involving the arteriovenous catheterization of regions or organs with concomitant isotopic tracer infusion, distinguishes between amino acid uptake and release in the net amino acid balance and measures protein synthesis and degradation under steady-state conditions. Last, the importance has become clear of the difference in dietary and endogenous amino acids recycled from proteolysis for anabolic and catabolic pathways. In humans, the dual tracer technique, which consists of the simultaneous oral/enteral administration and intravenous infusion of different tracers of the same amino acid, allows an estimate of the splanchnic uptake of amino acids administered. Furthermore, the whole-body retention of labeled dietary nitrogen after the ingestion of a single protein meal has enabled a clearer understanding of the metabolic fate of dietary amino acids. Based on such data, a newly developed compartmental model provides a simulation of the regional distribution and metabolism of ingested nitrogen in the fed state by determining its dynamic fate through free and protein-bound amino acids in both the splanchnic and peripheral areas in humans.

Isotopic studies of protein and amino acid requirements

The quantification of protein and amino acid requirements in health and disease is still an incompletely resolved issue, despite its importance to our knowledge of nutrition, to the clinical management of most health disorders and to food policy. However, the dynamic and adaptive features of protein metabolism render this determination difficult. The first nitrogen balance studies performed have demonstrated their limitations in providing accurate protein and amino acid requirements. Isotopic methods developed over the past 15 years have considerably enhanced the quantification of amino acid and protein requirements and our knowledge of the physiological phenomena underlying these needs. These methods are consistently being improved and producing new estimates for protein and amino acid requirements, together with a clearer understanding of this complex issue.

Peripheral and splanchnic metabolism of dietary nitrogen are differently affected by the protein source in humans as assessed by compartmental modeling

We used a previously developed compartmental model to assess the postprandial distribution and metabolism of dietary nitrogen (N) in the splanchnic and peripheral areas after the ingestion of a single mixed meal containing either (15)N-labeled milk or soy purified protein. Although the lower whole-body retention of dietary N from soy protein was measured experimentally, the splanchnic retention of dietary N was predicted by the model not to be affected by the protein source, and its incorporation into splanchnic proteins was predicted to reach approximately 35% of ingested N at 8 h after both meals. However, dietary N intestinal absorption and its appearance in splanchnic free amino acids were predicted to be more rapid from soy protein and were associated with a higher deamination, concomitant with a higher efficiency of incorporation of dietary N into proteins in the splanchnic bed. In contrast, soy protein was predicted to cause a reduction in peripheral dietary N uptake, as a consequence of both similar splanchnic retention and increased oxidation compared with milk protein. In addition, protein synthesis efficiency was reduced in the peripheral area after soy protein intake, leading to dietary N incorporation in peripheral proteins that fell from 26 to 19% of ingested N 8 h after milk and soy protein ingestion, respectively. Such a model thus enables a description of the processes involved in the differential metabolic utilization of dietary proteins and constitutes a valuable tool for further definition of the notion of protein quality during the period of protein gain.

Influence of L-methionine-deprived total parenteral nutrition with 5-fluorouracil on gastric cancer and host metabolism

AIM: To investigate the influence of L-methionine-deprived total parenteral nutrition with 5-FU on gastric cancer and host metabolism.

METHODS: N-methyl-N’-nitro-nitrosoguanidine (MNNG) induced gastric cancer rats were randomly divided into four groups: Met-containing TPN group (n = 11), Met-deprived TPN group (n = 12), Met-containing TPN+5-FU group (n = 11) and Met-deprived TPN+5-FU group (n = 12). Five rats in each group were sacrificed after 7 d of treatment and the samples were taken for examination. The remaining rats in each group were then fed separately with normal diet after the treatment until death, the life span was noted.

RESULTS: The tumors were enlarged in Met-containing group and shrank in Met-deprived group markedly after the treatment. The DNA index (DI) of tumor cells and the body weight (BW) of rats had no significant change in the two groups, however, the ratio of tumor cells’ S phase was increased. The ratio of G2M phase went up in Met-containing group, but down in Met-deprived group. In the other two groups that 5-FU was added, the BW of rats, and the diameter of tumors, the DI of tumor cells, the S and G2M phase ratio of tumor cells were all decreased, particularly in Met-deprived plus 5-FU group. Pathological examination revealed that the necrotic foci of the tumor tissue increased after Met-deprived TPN treatment, and the nucleoli of tumor cells enlarged. In -MetTPN+5-FU group, severe nuclear damage was also found by karyopyknosis and karyorrhexis, meanwhile there was slight degeneration in some liver and kidney cells. The serum free Met and Cysteine decreased markedly (P ＜ 0.001), while other amino acids, such as serum free serine and glutamine increased significantly (P ＜ 0.005). All the rats died of multiple organ failure caused by cancer metastasis. The average survival time was 18.6 d in Met-containing TPN group, 31 d in Met-deprived TPN group, 27.5 d in Met-containing TPN+5-FU group, and 43 d in Met-deprived TPN+5-FU group (P ＜ 0.05).

CONCLUSION: Met-deprived TPN causes methionine starvation of tumor cells, and can enhance the anti-tumor effect of 5-FU and prolong the life span of gastric cancer-bearing rats.

Energy nutrients modulate the splanchnic sequestration of dietary nitrogen in humans: a compartmental analysis

We used a previously developed compartmental model to assess the postprandial distribution and metabolism of dietary nitrogen (N) in the splanchnic and peripheral areas after the ingestion of a single meal containing milk protein either alone (MP) or with additional sucrose (SMP) or fat (FMP). The addition of fat was predicted to enhance splanchnic dietary N anabolism only transiently, without significantly affecting the global kinetics of splanchnic retention and peripheral uptake. In contrast, the addition of sucrose, which induced hyperinsulinemia, was predicted to enhance dietary N retention and anabolism in the splanchnic bed, thus leading to reduced peripheral dietary amino acid availability and anabolism. The incorporation of dietary N into splanchnic proteins was thus predicted to reach 18, 24, and 35% of ingested N 8 h after MP, FMP, and SMP, respectively. Such a model provides insight into the dynamics of the system in the nonsteady postprandial state and constitutes a useful, explanatory tool to determine the region-specific utilization of dietary N under different nutritional conditions.

Postprandial modulation of dietary and whole-body nitrogen utilization by carbohydrates in humans

BACKGROUND

Sucrose exerts a sparing effect on whole-body protein metabolism, mainly during the absorptive phase.

OBJECTIVE

We aimed to characterize the acute postprandial effect of addition of sucrose on deamination of dietary and endogenous nitrogen, with particular consideration being given to the effects of bioavailability.

DESIGN

Twenty-one subjects equipped with ileal tubes ingested (15)N-labeled soy protein combined with [(13)C]glycine, with (n = 10) or without (n = 11) sucrose. Dietary and endogenous ileal flow of nitrogen were determined from the ileal effluents. The kinetics of dietary amino acid transfer to the blood were characterized by (13)CO(2) enrichment in breath and (15)N enrichment in plasma amino acids. Deamination of dietary and endogenous amino acid was determined from body urea, urinary nitrogen, and (15)N enrichment.

RESULTS

(13)CO(2) recovery in breath and (15)N plasma amino acid enrichments were highly correlated (R:(2) >/= 0.95, P: < 0.001, for both meals) and markedly delayed by sucrose (half-(13)CO(2) recovery: 274 min compared with 167 min), whereas exogenous and endogenous ileal nitrogen kinetics and balances remained unchanged. Addition of sucrose halved the early (0-2 h) deamination peak of dietary nitrogen and reduced endogenous nitrogen oxidation over the first 4 h. Both were reduced by 18-24% over the 8-h period after the meal.

CONCLUSIONS

Without changing the nitrogen absorptive balance, sucrose markedly affected the bioavailability profile, which is governed by gastric emptying. Endogenous and dietary nitrogen were not spared in the same way and over the same periods, showing that the metabolism of endogenous and dietary nitrogen may be affected differently by nutritional modulation, even if the effects are of a similar magnitude over the entire postprandial period.

Nutritional support of the cancer patient: issues and dilemmas

Malnutrition in cancer patients results from multifactorial events and is associated with an alteration of quality of life and a reduced survival. A simple nutritional assessment program and early counselling by a dietitian are essential to guide nutritional support and to alert the physician to the need for enteral (EN) or parenteral nutrition (PN). A daily intake of 20-35 kcal/kg, with a balanced contribution of glucose and lipids, and of 0.2-0.35 g nitrogen/kg is recommended both for EN and PN, with an adequate provision of electrolytes, trace elements and vitamins. EN, always preferable for patients with an intact digestive tract, and PN are both safe and effective methods of administering nutrients. The general results in clinical practice suggest no tumor growth during nutritional support. The indiscriminate use of conventional EN and PN is not indicated in well-nourished cancer patients or in patients with mild malnutrition. EN or PN is not clinically efficacious for patients treated with chemotherapy or radiotherapy, unless there are prolonged periods of GI toxicity, as in the case of bone marrow transplant patients. Severely malnourished cancer patients undergoing major visceral surgery may benefit from perioperative nutritional support, preferably via enteral access. Nutritional support in palliative care should be based on the potential risks and benefits of EN and PN, and on the patient's and family's wishes. Research is currently directed toward the impact of nutritional pharmacology on the clinical outcome of cancer patients. Glutamine-supplemented PN is probably beneficial in bone marrow transplant patients. Immune diets are likely to reduce the rate of infectious complications and the length of hospital stay after GI surgery. Further studies are needed to determine the efficacy of such novel approaches in specific populations of cancer patients, and should also address the question of the overall cost-benefit ratio of nutritional pharmacology, and the effect of nutritional support on length and quality of life.

Protein metabolism and the gut

This paper reviews the recent literature concerning the importance of the gut in extraintestinal protein metabolism. A growing body of evidence suggests that the gut modulates amino acid flux and inter-organ relationships in various metabolic states. This may be particularly true during the absorptive period, when the gut: (1) controls amino acid absorption; (2) may modulate catabolism and uptake for synthesis of absorbed amino acid; and (3) consequently influences the availability of liver and extrasplanchnic amino acids, as well as their pattern and kinetics through portal flow delivery.

Changes in protein, carbohydrate, and fat metabolism with aging: possible role of insulin

Age is associated with modifications of body composition, i.e., an increase in body fat mass and a decrease in protein mass. Because insulin controls substrate disposal and production, these changes could theoretically be related to changes in either insulin action or secretion on the various substrates. On the basis of available evidence, insulin action on whole-body amino acid and protein metabolism seems not to be impaired in the aged. Decreased synthesis of contractile and mitochondrial proteins in muscle, associated with decreased gene expression, was described in humans. Decreased physical activity apparently represents an important factor responsible for decreased muscle protein synthesis and mass in the elderly. Exercise in the elderly may acutely revert these changes, although its chronic effects are still uncertain. In addition, the possible interaction between insulin and exercise in the maintenance of muscle mass needs to be specifically investigated in aged people. Higher free fatty acid (FFA) absolute flux and oxidation rates were observed in healthy elderly subjects in both the fasting state and following hyperinsulinemia, but not when normalized over fat mass. This suggests that FFA kinetics reflect the established changes in fat mass. Insulin sensitivity on glucose metabolism is usually normal in the aged, despite subtle impairments in insulin secretion, hepatic uptake, and onset of action. Finally, data support the operation of the Randle cycle (i.e., inverse relationships between fat and glucose oxidation) in the elderly.