TREIMM-1081; No.
of Pages 8
Review
The immunomodulating role of
exercise in metabolic disease
Graeme I. Lancaster and Mark A. Febbraio
Cellular and Molecular Metabolism Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
A lack of physical activity is linked to the development of
many chronic diseases. It is now well established that
the immune system and inflammation play a central role
in the development of numerous chronic metabolic dis-
eases including insulin resistance, type 2 diabetes, ath-
erosclerosis, nonalcoholic fatty liver disease, and
specific types of cancer. Physical exercise elicits potent
anti-inflammatory effects that are likely to account for
many of the salutary actions of regular exercise on
chronic metabolic diseases. Here we review the anti-
inflammatory and immunomodulatory mechanisms by
which the beneficial effects of exercise on chronic meta-
bolic diseases may be mediated.
Inflammation at the nexus of metabolic disease
The World Health Organization has estimated that in
excess of 1 billion people worldwide are overweight, with
300 million defined as clinically obese. Obesity is associat-
ed with the development of a cluster of chronic metabolic
diseases such as insulin resistance, type 2 diabetes, ath-
erosclerosis, nonalcoholic liver disease, hypertension, and
some forms of cancer [1]. Physical inactivity is major
contributor to the development of chronic metabolic dis-
eases [2]. Furthermore, regular exercise prevents, or at
least delays, the progression of a host of metabolic diseases
including cardiovascular disease, insulin resistance, type 2
diabetes, and hypertension [2]. Indeed, it has been ob-
served that exercise as a therapeutic intervention can be
as effective as the medications that are prescribed for
chronic metabolic diseases [3,4]. Although some of the
beneficial effects of exercise in chronic metabolic diseases
are likely to be attributable to an increase in energy
expenditure and consequently a reduction in the accumu-
lation of fat mass in individuals who consume calories in
excess of their daily requirements, numerous studies have
demonstrated that the salutary actions of exercise are
independent of its effect on weight loss [5]. Exercise pro-
motes numerous molecular and cellular changes in several
tissues and these adaptations are likely to underpin many
of the salutary actions of exercise.
Corresponding authors: Lancaster, G.I. (graeme.lancaster@bakeridi.edu.au);
Febbraio, M.A. (mark.febbraio@bakeridi.edu.au).
Keywords: exercise; muscle; immune cells; inflammation; metabolic disease;
anti-inflammatory.
1471-4906/$ – see front matter
ß 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.it.2014.02.008
The past two decades have identified inflammation as a
key nexus between obesity and the development of chronic
metabolic diseases [1]. A plethora of studies have described
how inappropriate activation of components of the immune
system and induction of local inflammation in key cells and
tissues underpins the development of chronic metabolic
diseases. For example, in obesity the immune cell profile of
the adipose tissue is substantially altered such that proin-
flammatory macrophages, neutrophils, and CD8+ T lym-
phocytes accumulate, while regulatory T cells and
eosinophils decrease, and initiate a state of local inflam-
mation that contributes to the development of systemic
insulin resistance. In cardiovascular disease, immune cells
accumulate within the arterial vasculature and contribute
to the formation of atherosclerotic plaques [6–8].
Exercise elicits potent and wide-ranging effects on the
immune system [9,10], principle amongst these being its
anti-inflammatory effects. Although exercise can be proin-
flammatory and has, in some instances, been associated
with increased production of proinflammatory mediators
such as tumor necrosis factor-a (TNF-a), interleukin-1b
(IL-1b), and C-reactive protein, this is typically only the
case after extreme forms of exercise such as marathon
running or Ironman triathlon, which are associated with
muscle damage and even systemic endotoxemia [11,12].
However, in most instances exercise is anti-inflammatory
in nature. The cytokine profile induced by exercise is
classically anti-inflammatory, comprising marked
increases in the levels of several potent anti-inflammatory
cytokines such as IL-10, IL-1 receptor antagonist (IL-1ra),
and IL-6 [12]. An elegant and powerful demonstration of
the anti-inflammatory effects of exercise is the observation
that prolonged cycling exercise reduced endotoxin-induced
TNF-a production in vivo in humans [13]. Preventing or
attenuating inflammation is likely to be an important
mechanism by which physical activity and exercise protect
against the development of chronic metabolic diseases
[3,14].
Here we discuss some of the latest research on the anti-
inflammatory effects of exercise in the context of chronic
metabolic diseases (Figure 1), outline several novel hypoth-
eses, and highlight areas for further research. Specifically,
we discuss how exercise can impact on several tissues that
are deleteriously affected in metabolic disease, such as
adipose tissue – a key site in the control of systemic
metabolism – and liver and skeletal muscle. We also
discuss the role of exercise as a modulator of Toll-like
receptor (TLR) function and how this may counteract some
of the negative effects of obesity. Finally, we discuss the
Trends in Immunology xx (2014) 1–8 1
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Review Trends in Immunology xxx xxxx, Vol. xxx, No. x

Adipose ssue size

Recruitment of M1 macrophages
and CD8+ T lymphocytes
TLR4 expression and acvaon

TLR4

MyD88
MyD88

IL-10

Monocyte/ IL-1ra
IL-6 macrophage

TLR4 Lipid accumulaon

MyD88
TLR4 expression and acvaon

TLR4
MyD88
MyD88
Lipid accumulaon
TLR4 expression and acvaon
TRENDS in Immunology

Figure 1. The anti-inflammatory effects of exercise in the context of obesity. As discussed in the text, exercise may mediate potent salutary actions in the context of
metabolic disease via its anti-inflammatory effects. Given the proinflammatory effects of several lipids, limiting lipid accumulation, either by limiting the expansion of
adipose tissue or by decreasing the accumulation of lipid in the skeletal muscle and liver, is likely to be a key anti-inflammatory effect of exercise. Furthermore, by inhibiting
the expansion of adipose tissue, exercise limits the recruitment of proinflammatory M1 macrophages and CD8+ T lymphocytes, cells known to promote insulin resistance. It
is well established that exercising muscle releases myokines. The release of interleukin-6 (IL-6) from skeletal muscle and subsequent production of IL-1 receptor antagonist
(IL-1ra) by monocytes and macrophages may represent an important anti-inflammatory action of exercise. Finally, exercise can decrease the expression and activation of
Toll-like receptor 4 (TLR4) in several tissue and cell types and this may contribute to exercise’s ability to protect against the deleterious effects of obesity.

role of IL-1b and the inflammasome in metabolic diseases
and suggest that a primary anti-inflammatory effect of
exercise may be via the inhibition of IL-1 signaling
(Figure 1).
Obesity and adipose tissue-resident immune cells
A hallmark of obesity is a shift in the immune cell profile of
the adipose tissue [8]. Thus, the proportion of resident M2
anti-inflammatory, alternatively activated macrophages
[15], eosinophils [16], and CD4+ T lymphocytes [17]
decreases and the proportions of M1 proinflammatory, clas-
sically activated macrophages [15], neutrophils [18], B lym-
phocytes [19] and CD8+ T lymphocytes [17] are increased.
Mechanistically, this change in the adipose tissue immune
cell profile initiates a state of local inflammation within the
adipose tissue that induces both local and systemic insulin
resistance. Remarkably, the targeted deletion of even a
single immune cell type through genetic or antibody-medi-
ated approaches can protect against the development of
insulin resistance in mice fed a high-fat diet [17–20]. It is
likely that the obesity-associated transition of the adipose
tissue immune cell profile from principally anti-inflamma-
tory cell types toward proinflammatory cell types is a key
event initiating the development of local and systemic
insulin resistance [8]. Several hypotheses have been pro-
posed to explain the key events that lead to the shift in the
adipose tissue immune cell profile in obesity [8]. The death
of adipocytes within the adipose tissue, adipose tissue
hypoxia, production of chemotactic factors, and increased
free fatty acid (FFA) fluxes have all been proposed to
regulate the obesity-associated shift in the immune cell
2
profile [21]; however, in each instance adipose tissue
expansion due to adipocyte hypertrophy is central. An
increase in adipose tissue mass is a hallmark of human
obesity. A key beneficial effect of exercise is via its effects
on weight loss and/or the prevention of weight gain. Ac-
cordingly, by limiting the expansion of adipose tissue,
exercise would be predicted to ameliorate obesity-induced
changes in the adipose tissue immune cell profile and,
importantly, contribute to the maintenance of whole-body
insulin sensitivity.
Several studies have shown that chronic exercise train-
ing in mice fed a high-fat diet, which is associated with
reductions in adipose tissue mass, results in a marked
reduction in the levels of proinflammatory cytokines in
adipose tissue compared with non-exercising controls [22–
25]. Importantly, this reduction in adipose tissue inflam-
mation following exercise training is associated with a
substantial reduction in macrophage adipose tissue con-
tent [22–25], an effect that is probably attributable to a
decrease in the recruitment of M1 proinflammatory macro-
phages [23,24]. Chronic exercise training was also associ-
ated with an increase in the expression of CD163, a marker
of M2 macrophages [24]. Studies examining adipose tissue
inflammation in humans following exercise are limited, but
there is experimental support that a combination of diet
and exercise reduces adipose tissue inflammation and
macrophage recruitment [26], although others report little
effect of endurance training alone on adipose tissue inflam-
mation [27]. Of note, however, in this latter study, endur-
ance exercise training increased the number of CD163+
cells within the adipose tissue, indicative of increased
TREIMM-1081; No. of Pages 8
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numbers of M2 macrophages. CD8+ T lymphocytes accu-
mulate in the adipose tissue of high-fat diet-fed mice
progressively over the course of the dietary period and
CD8+ T lymphocytes contribute to obesity-induced inflam-
mation and insulin resistance [17]. In mice fed a high-fat
diet for 16 weeks, exercise training (60 min/day, 5 days/
week) reduced high feeding-induced increases in adipose
tissue CD8+ T lymphocyte recruitment compared with non-
exercise trained control mice [23]. Collectively, these data
argue that exercise training prevents the deleterious
changes in the adipose tissue immune cell profile that
occur in obesity, attenuating the recruitment of M1 pro-
inflammatory macrophages and CD8+ T lymphocytes and
increasing numbers of M2 macrophages. These effects are
most parsimoniously explained by the effects of exercise in
preventing the expansion of adipose tissue.
Exercise and lipid accumulation and inflammation in
liver and skeletal muscle
Hepatic lipid accumulation is a central feature of several
metabolic diseases. For example, excess hepatic lipid ac-
cumulation induces hepatic insulin resistance leading to
elevated hepatic glucose production and hyperglycemia
and plays a key role in the development of nonalcoholic
fatty liver disease. Although excess hepatic lipid accumu-
lation is likely to exert deleterious actions via multiple
mechanisms, increased liver inflammation is a hallmark of
hepatosteatosis and has been mechanistically linked to the
development of obesity-induced hepatocellular carcinoma
[28], alcoholic liver disease [29], and obesity-induced insu-
lin resistance [30]. Specifically, obesity-induced hepatocel-
lular carcinoma is associated with marked macrophage
and neutrophil recruitment into the liver and increased
production of proinflammatory cytokines, such as TNF-a
and IL-6, which are critical in promoting obesity-induced
tumorigenesis [28]. Inflammation in alcoholic liver disease
has been shown to be dependent on inflammasome activa-
tion and IL-1b production in Kupffer cells (liver-resident
macrophages) [29]. Finally, in obesity-associated liver in-
flammation, numerous proinflammatory cytokines are el-
evated in the liver of mice fed a high-fat diet [31].
Activation of Kupffer cells is likely to be important in
the pathogenesis of obesity-associated insulin resistance
because their depletion improves insulin sensitivity [32].
However, the activation of inflammatory pathways in liver
parenchymal cells is also likely to contribute to obesity-
induced liver inflammation because hepatocyte-specific
deletion of IkB kinase beta (IKKb), a critical regulator of
the nuclear factor kB (NF-kB) family of transcription
factors, reduces liver inflammation and improves insulin
sensitivity [30]. Several human studies have demonstrated
that aerobic exercise training such as brisk walking (5
days/week for 30–60 min) or cycling (3 days/week for
30–45 min) for 4–16 weeks reduces hepatosteatosis
[33,34] and, furthermore, can improve hepatic lipid com-
position by altering the profile of liver lipids toward an
increase in polyunsaturated lipids [35]. Given the crucial
role of hepatosteatosis in promoting liver inflammation
and of liver inflammation in the development of numerous
diseases, reductions in hepatic lipid content are likely to
represent an important anti-inflammatory effect of exer-
Trends in Immunology xxx xxxx, Vol. xxx, No. x
cise. Exercise training in mice fed a high-fat–high-fructose
diet, which induces hepatosteatosis and nonalcoholic fatty
liver disease, reduced hepatic inflammation as evidenced
by reduced macrophage infiltration and TNF-a expression
[36].
Skeletal muscle lipid accumulation is a central feature
of obesity, insulin resistance, and type 2 diabetes. Al-
though immune cells, most notably macrophages, have a
well established role in obesity-induced inflammation in
adipose tissue and liver [8], the contribution of macro-
phages to skeletal muscle insulin resistance, or indeed
whether obesity promotes macrophage accumulation in
skeletal muscle, is unclear. However, two recent studies
have examined the effect of obesity and type 2 diabetes on
the recruitment of macrophages into skeletal muscles.
First, it was shown that overweight, type 2 diabetic
humans had significantly greater expression of CD11b
and CD11c (macrophage markers) in skeletal muscle biop-
sies compared with overweight, non-type 2 diabetics [37].
Interestingly, obesity per se did not appear to promote
macrophage recruitment because no differences were ob-
served between overweight non-type 2 diabetics and lean
non-type 2 diabetics [37]. However, in a second study the
same group showed that mice fed a high-fat diet for 1 week
had elevated F4/80 and CD11c expression in quadriceps
muscle, indicative of increased macrophage recruitment
[38].
Although the role of immune cells in skeletal muscle
insulin resistance is poorly defined, obesity induces the
activation of c-Jun N-terminal kinase (JNK) in skeletal
muscle [39,40], which contributes to the development of
skeletal muscle insulin resistance [40]. Given the impor-
tant role of adipose tissue hypertrophy and hepatostea-
tosis in promoting adipose tissue and liver inflammation,
respectively, we hypothesize that the accumulation of
lipids is critical in mediating obesity-induced inflamma-
tion, and potentially macrophage recruitment, in skeletal
muscle. Importantly, exercise training in obese patients
with type 2 diabetes increases mitochondrial content and
the capacity of skeletal muscle to oxidize fatty acids [41].
Furthermore, 8 weeks of aerobic exercise training (cycling
and running 5 days/week) was recently shown to increase
the expression of lipolytic proteins concomitant with a
decrease in intramuscular lipid content in obese humans
[42]. Based on these findings, we hypothesize that a likely
anti-inflammatory effect of exercise training is via an
increased capacity of the skeletal muscle to utilize fatty
acids, resulting in decreased lipid content. This would be
predicted to decrease recruitment of macrophages, and
potentially other immune cells, into skeletal muscle and
limit the activation of known proinflammatory signaling
pathways (e.g., JNK). Although there is some evidence
that obesity and a high-fat diet can promote macrophage
recruitment into skeletal muscle, further work is required
to substantiate these findings. Of particular interest
would be a time-course analysis to determine when macro-
phages initially start to accumulate in the skeletal muscle
and to what degree they increase on prolonged high-fat
feeding. Furthermore, given the important roles of numer-
ous other immune cells in addition to macrophages in
adipose tissue, determining whether other immune cell
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Review
types are also recruited to skeletal muscle in obesity is
of interest. Finally, determining whether the macro-
phages, and potentially other immune cells, that are
recruited to the skeletal muscle are causally involved
in skeletal muscle insulin resistance would be important.
In vivo this may be a difficult question to address, but in
vitro findings support the idea that activated macro-
phages can promote insulin resistance in skeletal muscle
[43].
Exercise ameliorates TLR-dependent inflammation
The TLRs are a family of transmembrane receptors that
are central to innate immunity [44]. However, in addition
to their central role in regulating responses to pathogens,
the activation of specific TLRs, most notably TLR4, has
been suggested to play a role in the development of obesity-
induced insulin resistance, type 2 diabetes, and atheroscle-
rosis [45,46]. Lipopolysaccharide (LPS), a component of the
outer cell wall of Gram-negative bacteria, is the canonical
ligand for TLR4. However, in addition to recognizing clas-
sical pathogen-associated molecular patterns such as LPS,
it is now well established that TLR4 is a receptor for
numerous host molecules [47]. These damage-associated
molecular patterns are typically molecules that, under
homeostatic conditions, are not exposed to TLR4, but on
cell damage are released and can subsequently induce
inflammatory responses [47]. In the context of metabolic
disease, it has been proposed that specific TLRs can be
activated by numerous ligands (e.g., saturated FFAs [48–
50], oxidized low-density lipoproteins [LDLs] [51]) that are
elevated in metabolic diseases. Deletion of TLR4 has been
shown to ameliorate obesity-induced inflammation and
insulin resistance [52,53] and atherosclerosis in mouse
models of disease [53].
There are several features of acute exercise and chron-
ic exercise training that suggest that a principal anti-
inflammatory effect of exercise may be mediated via
effects on TLR pathway activation. First, chronic exercise
training can decrease the circulating levels of TLR
ligands that are known to be elevated in metabolic dis-
ease. Specifically, given the proposed roles for saturated
FFAs and oxidized LDLs as mediators of TLR activation
in metabolic disease, the ability of chronic exercise train-
ing to reduce the levels of these ligands may reduce TLR-
dependent inflammation in numerous metabolic diseases
[33,54]. Furthermore, it was recently shown that the
liver-secretory protein fetuin-A may serve as an adaptor
protein, facilitating the presentation of FFAs to TLR4 and
thereby contributing to the development of obesity-in-
duced inflammation and insulin resistance [50]. Elevated
fetuin-A levels have been linked to numerous metabolic
diseases [55,56]. Interestingly, exercise training has been
shown to reduce circulating fetuin-A levels [57,58] and
fetuin-A levels are inversely correlated with maximal
oxygen uptake during an exercise test, a measure of
cardiorespiratory fitness [58]. These data suggest that
reductions in circulating fetuin-A levels and, therefore, a
decrease in the capacity of FFAs to be presented to TLR4,
in addition to a reduction in the levels of specific TLR
ligands, may constitute an important anti-inflammatory
effect of exercise training.
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Trends in Immunology xxx xxxx, Vol. xxx, No. x
Observations that both acute exercise (90 min of cycling
in humans) [59] and exercise training (resistance training
in elderly women) [60,61] decrease the expression of TLR4
on the surface of monocytes have led to the proposal that a
major anti-inflammatory effect of exercise may be via
downregulation of TLR4 expression [3,14]. Many [62–
65], although not all [66], subsequent studies have con-
firmed these initial findings. Circulating monocytes are the
precursors to tissue macrophages and given the important
role for proinflammatory macrophages in the development
of several metabolic diseases, including insulin resistance,
type 2 diabetes, and atherosclerosis [8], exercise-induced
decreases in monocyte TLR4 expression may be an impor-
tant mechanism by which the anti-inflammatory effects of
exercise are mediated. In support of this, it was recently
shown that exercise-trained apolipoprotein E (ApoE)-defi-
cient mice fed a high-fat diet – a model of atherosclerosis –
had significantly reduced vascular TLR4 expression [67].
Importantly, however, the effects of exercise on TLR4
expression are not limited to monocytes. Feeding rats a
high-fat diet caused a dramatic increase in not only the
expression of TLR4 but also the activation of TLR4 signal-
ing in skeletal muscle, liver, and adipose tissue [68], effects
that were significantly attenuated by either chronic exer-
cise training (5 days/week for 8 weeks) or acute exercise
(two 3-h acute exercise bouts separated by a 45-min rest
period) [68]. This exercise-induced decrease in the expres-
sion and activation of the TLR4 signaling pathway in high-
fat diet-fed rats was closely associated with reduced acti-
vation of JNK, a serine kinase that is strongly implicated
in the development of obesity-induced insulin resistance,
and decreased serine phosphorylation of insulin receptor
substrate-1 (IRS1), a marker of inactivation of the insulin
signaling pathway [68].
A hallmark of acute exercise is an increase in lipolysis
and consequently an increase in the circulating levels of
FFAs [69]. The primary function of the exercise-induced
increase in lipolysis of stored lipid is to provide the con-
tracting skeletal muscles with a fuel source to maintain
continued contraction [69]. However, the finding that cer-
tain FFAs, primarily saturated FFAs, are ligands for TLR4
[48,49] raises the intriguing idea that saturated FFAs
released from adipose tissue stores during exercise may
initiate proinflammatory signaling. It was recently dem-
onstrated that mice deficient in either TLR2 or TLR4 had
greatly reduced activation of the mitogen-activated protein
kinases p38 and JNK in skeletal muscles following acute
exercise [70]. Furthermore, administration of heparin to
elevate plasma FFA level to that seen during exercise
mimicked the effects of exercise, arguing that exercise-
induced increases in plasma FFA levels activate mitogen-
activated protein kinase (MAPK) signaling in skeletal
muscles via the activation of TLR2 or TLR4 [70]. We
hypothesize that it is unlikely that the exercise-induced
increase in circulating FFA levels constitutes a major
proinflammatory action of exercise. Indeed, following pro-
longed exercise, where circulating FFA levels are greatly
increased, it has been repeatedly demonstrated that proin-
flammatory cytokine production by circulating monocytes
is unaltered, arguing that exercise-induced increased
plasma FFA levels are not proinflammatory [59,71]. The
TREIMM-1081; No. of Pages 8
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functional consequences of FFA-induced activation of TLR
signaling in skeletal muscle is at present unknown and
awaits further research.
These data provide evidence that some of the anti-
inflammatory and beneficial health effects of exercise
may be mediated through multiple effects on TLR4. Spe-
cifically, exercise may reduce the availability of endoge-
nous TLR4 ligands, decrease the expression of TLR4, and
decrease the activation of TLR4 signaling.
Exercise tempers inflammatory signals upstream and
downstream of IL-1
Proinflammatory cytokines are elevated in numerous met-
abolic diseases [1]. Although mechanistic roles have been
described for some of these, the cytokine that is perhaps
best characterized in terms of its involvement in disease
pathogenesis is IL-1b [72]. IL-1b is a master cytokine,
controlling local and systemic inflammation [72]. IL-1b
levels are increased in and have been shown to contribute
to numerous metabolic diseases, including atherosclerosis,
obesity-induced insulin resistance [73], type 2 diabetes
[74], and alcoholic liver disease [29]. The production of
IL-1b is regulated by the NLRP3 inflammasome [47].
Recent evidence also proposes an important role for IL-
1a in vascular inflammation in atherosclerosis, although
IL-1a release is inflammasome independent [75]. To date,
three agents that target the IL-1 pathway have been
approved for therapeutic use in various inflammatory dis-
eases [72]. Preliminary studies support the therapeutic
potential of targeting IL-1 in type 2 diabetes and clinical
trials evaluating the targeting of IL-1b in myocardial
infarction, stroke, and cardiovascular deaths are ongoing
[72,76]. Collectively, basic and clinical research supports
an important role for IL-1 in the development and progres-
sion of several metabolic diseases.
The release of specific cytokines from contracting skele-
tal muscle was first demonstrated over a decade ago [77].
These discoveries led to the concept that muscle is a
secretory organ, releasing myokines during exercise, and
potentially in disease states, that influence metabolism
within other tissues [78]. Although numerous cytokines
have been identified as being released from exercising
skeletal muscle [e.g., leukemia inhibitory factor (LIF),
IL-7, myostatin, insulin-like growth factor 1 (IGF-1), fibro-
blast growth factor 2 (FGF-2)], the prototypical cytokine
released from contracting muscle is IL-6 [78]. However, in
addition to the release of myokines, exercise also results in
an increase in the circulating concentrations of numerous
other cytokines not released from the contracting skeletal
muscle. Most prominent among these is IL-1ra [12,79].
Both IL-1b and IL-1a induce signaling through the IL-1
receptor (IL-1R). IL-1ra binds to the IL-1R but exerts no
biological activity and therefore functions as a competitive
inhibitor of IL-1 signaling. In contrast to IL-6, which tends
to peak at the cessation of exercise, circulating IL-1ra
levels are modestly elevated at the end of exercise, but
increase considerably in the hours following exercise. This
observation can be most parsimoniously explained by the
fact that IL-6 is a potent inducer of IL-1ra, and, indeed,
infusion of recombinant IL-6 into humans at levels seen
during exercise increases circulating IL-1ra levels [80]. Of
Trends in Immunology xxx xxxx, Vol. xxx, No. x
note, the levels of IL-1ra observed following exercise are
considerably higher than that seen for other cytokines.
Although the precise source of the exercise-induced
increase in IL-1ra has not been definitely established,
peripheral blood mononuclear cells are a likely source.
Given the critical role of the proinflammatory cytokines
IL-1a and IL-1b in a range of metabolic disorders and the
potential therapeutic utility of targeting IL-1b and IL-1a,
it is an intriguing idea that during exercise the contracting
skeletal muscle releases IL-6 that subsequently induces
the release of IL-1ra from circulating immune cells and
potentially tissue macrophages. We hypothesize that exer-
cise-induced increases in IL-1ra may contribute to the anti-
inflammatory effects of exercise by inhibiting the deleteri-
ous actions of IL-1a and IL-1b. This could be tested in
several ways. First, given our suggestion that skeletal
muscle IL-6 production during exercise stimulates IL-
1ra production, deletion of IL-6 specifically from skeletal
muscle using IL-6 ‘floxed’ mice would provide an interest-
ing model to test this hypothesis. A complementary ap-
proach would be to study mice in which IL-1ra was
specifically deleted from immune cells. To date, IL-1ra
‘floxed’ mice have not been reported in the literature,
but the deletion of IL-1ra from the immune system specifi-
cally could be achieved by transplanting bone marrow from
donor global IL-1ra knockout mice into recipient wild type
mice. In both models, mice would be high-fat diet fed with
or without the addition of regular exercise training and
metabolic analysis conducted after a set period of high-fat
diet.
As discussed in the preceding section, TLRs belong to a
large collection of receptors known as pattern-recognition
receptors [47]. Another class of pattern-recognition recep-
tor that has been implicated in the development of numer-
ous metabolic diseases is the NLRP3 inflammasome [81],
which controls the release of IL-1b. Similar to the case with
TLRs, ligands for the NLRP3 inflammasome (e.g., FFAs,
oxidized LDL) are elevated in chronic metabolic diseases.
Therefore, as described above for TLRs, exercise-induced
decreases in the levels of these ligands may also reduce
activation of the NLRP3 inflammasome and, therefore,
reduce the levels of IL-1b.
Concluding remarks and outlook
As discussed above, the adipose tissue immune cell profile
changes dramatically in the transition from the lean to the
obese state. Numerous immune cell types have been shown
to contribute to adipose tissue inflammation and systemic
insulin resistance in the obese state or, by contrast, con-
tribute to the maintenance of insulin sensitivity in the
lean, healthy state [8]. This raises several important ques-
tions for further research. First, does exercise prevent the
accumulation of other immune cell types that contribute to
adipose tissue inflammation and insulin resistance, such
as neutrophils [18]? Second, does exercise prevent the
high-fat diet-mediated loss of adipose tissue immune cells
that are important in preventing inflammation in adipose
tissue and regulate insulin sensitivity, such as eosinophils
[16] and CD4+CD25+ T-regulatory lymphocytes [82]? Given
that the effects of exercise on the adipose tissue immune
cell profile are likely to be mediated in the main by
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preventing adipose tissue expansion, we hypothesize that
exercise training may prevent the accumulation of delete-
rious immune cells that promote inflammation and insulin
resistance and prevent the loss of adipose tissue immune
cells that are important in the maintenance of insulin
sensitivity. Third, what is the effect of both acute exercise
and exercise training on the adipose tissue immune cell
profile in the non-obese state? Because exercise training
markedly increases systemic insulin sensitivity, and the
immune cell profile of the adipose tissue has a major
impact on systemic insulin sensitivity, it is an intriguing
hypothesis that effects on the adipose tissue immune cell
profile may contribute to the beneficial effects of exercise
training on whole-body insulin sensitivity. For example,
does exercise training affect the numbers of eosinophils,
M2 alternatively activated macrophages, or CD4+CD25+ T-
regulatory lymphocytes – cells that are critical to the
regulation of systemic insulin sensitivity in the lean and
healthy state – within the adipose tissue? Finally, does
acute exercise (i.e., a single bout of exercise) influence the
adipose tissue immune cell profile and might this contrib-
ute to post-exercise insulin sensitivity? In this regard, it is
intriguing to note that fasting-induced lipolysis and the
subsequent release of FFAs from adipose tissue is a potent
stimulus that promotes the recruitment of M2 alternative-
ly activated macrophages into adipose tissue [83]. Exercise
is also a potent inducer of adipose tissue lipolysis and,
accordingly, we hypothesize that acute exercise may dy-
namically regulate the adipose tissue immune cell profile,
promoting the accumulation of M2 alternatively activated
macrophages. This may represent an important, weight
loss-independent mechanism by which exercise promotes a
favorable adipose tissue immune cell profile.
Given the multitude of mechanisms by which exercise
promotes an anti-inflammatory state, it seems likely that
the anti-inflammatory effects of exercise are central to its
salutary actions in chronic metabolic diseases. Given these
diverse beneficial effects of exercise in chronic metabolic
disease, it is little wonder that the concept that ‘exercise is
medicine’ is gaining considerable support [14]. Future
studies will be required to delineate the molecular mecha-
nisms by which the anti-inflammatory actions of exercise
prevent the development of chronic metabolic diseases.
However, perhaps the greatest challenge will be to get
more people exercising and being more physically active.
Given the myriad benefits of exercise, encouraging more
people to do more exercise and be more physically active
will be a key goal for the future.
Acknowledgments
The authors thank all of their current and past staff and collaborators
who have contributed to this body of work. They gratefully acknowledge
the Australian Research Council and the National Health and Medical
Research Council (NHMRC) for continued funding support. M.A.F. is a
Senior Principal Research Fellow of the NHMRC.
References
1 Hotamisligil, G.S. (2006) Inflammation and metabolic disorders.
Nature 444, 860–867
2 Booth, F.W. et al. (2012) Lack of exercise is a major cause of chronic
diseases. Comp. Physiol. 2, 1143–1211
6
Trends in Immunology xxx xxxx, Vol. xxx, No. x
3 Handschin, C. and Spiegelman, B.M. (2008) The role of exercise and
PGC1alpha in inflammation and chronic disease. Nature 454, 463–469
4 Knowler, W.C. et al. (2002) Reduction in the incidence of type 2 diabetes
with lifestyle intervention or metformin. N. Engl. J. Med. 346, 393–403
5 Krogh-Madsen, R. et al. (2013) Normal physical activity obliterates the
deleterious effects of a high-caloric intake. J. Appl. Physiol. (1985) 116,
231–239
6 Mathis, D. (2013) Immunological goings-on in visceral adipose tissue.
Cell Metab. 17, 851–859
7 Libby, P. et al. (2013) Immune effector mechanisms implicated in
atherosclerosis: from mice to humans. Immunity 38, 1092–1104
8 Osborn, O. and Olefsky, J.M. (2012) The cellular and signaling
networks linking the immune system and metabolism in disease.
Nat. Med. 18, 363–374
9 Gleeson, M. (2007) Immune function in sport and exercise. J. Appl.
Physiol. (1985) 103, 693–699
10 Walsh, N.P. et al. (2011) Position statement. Part one: immune
function and exercise. Exerc. Immunol. Rev. 17, 6–63
11 Jeukendrup, A.E. et al. (2000) Relationship between gastro-intestinal
complaints and endotoxaemia, cytokine release and the acute-phase
reaction during and after a long-distance triathlon in highly trained
men. Clin. Sci. (Lond.) 98, 47–55
12 Ostrowski, K. et al. (1999) Pro- and anti-inflammatory cytokine balance
in strenuous exercise in humans. J. Physiol. 515, 287–291
13 Starkie, R. et al. (2003) Exercise and IL-6 infusion inhibit endotoxin-
induced TNF-alpha production in humans. FASEB J. 17, 884–886
14 Gleeson, M. et al. (2011) The anti-inflammatory effects of exercise:
mechanisms and implications for the prevention and treatment of
disease. Nat. Rev. Immunol. 11, 607–615
15 Lumeng, C.N. et al. (2007) Obesity induces a phenotypic switch in
adipose tissue macrophage polarization. J. Clin. Invest. 117, 175–184
16 Wu, D. et al. (2011) Eosinophils sustain adipose alternatively activated
macrophages associated with glucose homeostasis. Science 332, 243–
247
17 Nishimura, S. et al. (2009) CD8+ effector T cells contribute to
macrophage recruitment and adipose tissue inflammation in obesity.
Nat. Med. 15, 914–920
18 Talukdar, S. et al. (2012) Neutrophils mediate insulin resistance in
mice fed a high-fat diet through secreted elastase. Nat. Med. 18, 1407–
1412
19 Winer, D.A. et al. (2011) B cells promote insulin resistance through
modulation of T cells and production of pathogenic IgG antibodies. Nat.
Med. 17, 610–617
20 Patsouris, D. et al. (2008) Ablation of CD11c-positive cells normalizes
insulin sensitivity in obese insulin resistant animals. Cell Metab. 8,
301–309
21 Sun, K. et al. (2011) Adipose tissue remodeling and obesity. J. Clin.
Invest. 121, 2094–2101
22 Jung, D.Y. et al. (2013) Short-term weight loss attenuates local tissue
inflammation and improves insulin sensitivity without affecting
adipose inflammation in obese mice. Am. J. Physiol. Endocrinol.
Metab. 304, E964–E976
23 Kawanishi, N. et al. (2013) Exercise attenuates M1 macrophages and
CD8+ T cells in the adipose tissue of obese mice. Med. Sci. Sports Exerc.
45, 1684–1693
24 Kawanishi, N. et al. (2010) Exercise training inhibits inflammation in
adipose tissue via both suppression of macrophage infiltration and
acceleration of phenotypic switching from M1 to M2 macrophages in
high-fat-diet-induced obese mice. Exerc. Immunol. Rev. 16, 105–118
25 Vieira, V.J. et al. (2009) Effects of exercise and low-fat diet on adipose
tissue inflammation and metabolic complications in obese mice. Am. J.
Physiol. Endocrinol. Metab. 296, E1164–E1171
26 Bruun, J.M. et al. (2006) Diet and exercise reduce low-grade
inflammation and macrophage infiltration in adipose tissue but not
in skeletal muscle in severely obese subjects. Am. J. Physiol.
Endocrinol. Metab. 290, E961–E967
27 Auerbach, P. et al. (2013) Differential effects of endurance training and
weight loss on plasma adiponectin multimers and adipose tissue
macrophages in younger, moderately overweight men. Am. J.
Physiol. Regul. Integr. Comp. Physiol. 305, R490–R498
28 Park, E.J. et al. (2010) Dietary and genetic obesity promote liver
inflammation and tumorigenesis by enhancing IL-6 and TNF
expression. Cell 140, 197–208
TREIMM-1081; No. of Pages 8
Review
29 Petrasek, J. et al. (2012) IL-1 receptor antagonist ameliorates
inflammasome-dependent alcoholic steatohepatitis in mice. J. Clin.
Invest. 122, 3476–3489
30 Arkan, M.C. et al. (2005) IKK-beta links inflammation to obesity-
induced insulin resistance. Nat. Med. 11, 191–198
31 Cai, D. et al. (2005) Local and systemic insulin resistance resulting
from hepatic activation of IKK-beta and NF-kappaB. Nat. Med. 11,
183–190
32 Huang, W. et al. (2010) Depletion of liver Kupffer cells prevents the
development of diet-induced hepatic steatosis and insulin resistance.
Diabetes 59, 347–357
33 Johnson, N.A. et al. (2009) Aerobic exercise training reduces hepatic
and visceral lipids in obese individuals without weight loss. Hepatology
50, 1105–1112
34 Sullivan, S. et al. (2012) Randomized trial of exercise effect on
intrahepatic triglyceride content and lipid kinetics in nonalcoholic
fatty liver disease. Hepatology 55, 1738–1745
35 Haus, J.M. et al. (2013) Improved hepatic lipid composition following
short-term exercise in nonalcoholic fatty liver disease. J. Clin.
Endocrinol. Metab. 98, E1181–E1188
36 Kawanishi, N. et al. (2012) Exercise training attenuates hepatic
inflammation, fibrosis and macrophage infiltration during diet
induced-obesity in mice. Brain Behav. Immun. 26, 931–941
37 Fink, L.N. et al. (2013) Expression of anti-inflammatory
macrophage genes within skeletal muscle correlates with insulin
sensitivity in human obesity and type 2 diabetes. Diabetologia 56,
1623–1628
38 Fink, L.N. et al. (2014) Pro-inflammatory macrophages increase in
skeletal muscle of high fat-fed mice and correlate with metabolic risk
markers in humans. Obesity (Silver Spring) 22, 747–757
39 Hirosumi, J. et al. (2002) A central role for JNK in obesity and insulin
resistance. Nature 420, 333–336
40 Sabio, G. et al. (2010) Role of muscle c-Jun NH2-terminal kinase 1 in
obesity-induced insulin resistance. Mol. Cell Biol. 30, 106–115
41 Sparks, L.M. et al. (2013) Nine months of combined training improves
ex vivo skeletal muscle metabolism in individuals with type 2 diabetes.
J. Clin. Endocrinol. Metab. 98, 1694–1702
42 Louche, K. et al. (2013) Endurance exercise training up-regulates
lipolytic proteins and reduces triglyceride content in skeletal muscle
of obese subjects. J. Clin. Endocrinol. Metab. 98, 4863–4871
43 Samokhvalov, V. et al. (2009) Palmitate- and lipopolysaccharide-
activated macrophages evoke contrasting insulin responses in
muscle cells. Am. J. Physiol. Endocrinol. Metab. 296, E37–E46
44 Kawai, T. and Akira, S. (2010) The role of pattern-recognition receptors
in innate immunity: update on Toll-like receptors. Nat. Immunol. 11,
373–384
45 Konner, A.C. and Bruning, J.C. (2011) Toll-like receptors: linking
inflammation to metabolism. Trends Endocrinol. Metab. 22, 16–23
46 Seneviratne, A.N. et al. (2012) Toll-like receptors and macrophage
activation in atherosclerosis. Clin. Chim. Acta 413, 3–14
47 Chen, G.Y. and Nunez, G. (2010) Sterile inflammation: sensing and
reacting to damage. Nat. Rev. Immunol. 10, 826–837
48 Nguyen, M.T. et al. (2007) A subpopulation of macrophages infiltrates
hypertrophic adipose tissue and is activated by free fatty acids via Toll-
like receptors 2 and 4 and JNK-dependent pathways. J. Biol. Chem.
282, 35279–35292
49 Shi, H. et al. (2006) TLR4 links innate immunity and fatty acid-induced
insulin resistance. J. Clin. Invest. 116, 3015–3025
50 Pal, D. et al. (2012) Fetuin-A acts as an endogenous ligand of TLR4
to promote lipid-induced insulin resistance. Nat. Med. 18, 1279–
1285
51 Stewart, C.R. et al. (2010) CD36 ligands promote sterile inflammation
through assembly of a Toll-like receptor 4 and 6 heterodimer. Nat.
Immunol. 11, 155–161
52 Higashimori, M. et al. (2011) Role of Toll-like receptor 4 in intimal foam
cell accumulation in apolipoprotein E-deficient mice. Arterioscler.
Thromb. Vasc. Biol. 31, 50–57
53 Michelsen, K.S. et al. (2004) Lack of Toll-like receptor 4 or myeloid
differentiation factor 88 reduces atherosclerosis and alters plaque
phenotype in mice deficient in apolipoprotein E. Proc. Natl. Acad.
Sci. U.S.A. 101, 10679–10684
54 Kraus, W.E. et al. (2002) Effects of the amount and intensity of exercise
on plasma lipoproteins. N. Engl. J. Med. 347, 1483–1492
Trends in Immunology xxx xxxx, Vol. xxx, No. x
55 Mori, K. et al. (2012) Fetuin-A and the cardiovascular system. Adv.
Clin. Chem. 56, 175–195
56 Stefan, N. and Haring, H.U. (2013) The role of hepatokines in
metabolism. Nat. Rev. Endocrinol. 9, 144–152
57 Jenkins, N.T. et al. (2011) Plasma fetuin-A concentrations in young and
older high- and low-active men. Metabolism 60, 265–271
58 Malin, S.K. et al. (2013) Fetuin-A is linked to improved glucose
tolerance after short-term exercise training in nonalcoholic fatty
liver disease. J. Appl. Physiol. (1985) 115, 988–994
59 Lancaster, G.I. et al. (2005) The physiological regulation of Toll-
like receptor expression and function in humans. J. Physiol. 563,
945–955
60 Flynn, M.G. et al. (2003) Toll-like receptor 4 and CD14 mRNA
expression are lower in resistive exercise-trained elderly women. J.
Appl. Physiol. (1985) 95, 1833–1842
61 McFarlin, B.K. et al. (2004) TLR4 is lower in resistance-trained older
women and related to inflammatory cytokines. Med. Sci. Sports Exerc.
36, 1876–1883
62 Oliveira, M. and Gleeson, M. (2010) The influence of prolonged cycling
on monocyte Toll-like receptor 2 and 4 expression in healthy men. Eur.
J. Appl. Physiol. 109, 251–257
63 Simpson, R.J. et al. (2009) Toll-like receptor expression on classic and
pro-inflammatory blood monocytes after acute exercise in humans.
Brain Behav. Immun. 23, 232–239
64 Stewart, L.K. et al. (2005) Influence of exercise training and age on
CD14+ cell-surface expression of Toll-like receptor 2 and 4. Brain
Behav. Immun. 19, 389–397
65 Timmerman, K.L. et al. (2008) Exercise training-induced lowering of
inflammatory (CD14+CD16+) monocytes: a role in the anti-
inflammatory influence of exercise? J. Leukoc. Biol. 84, 1271–1278
66 Reyna, S.M. et al. (2013) Short-term exercise training improves insulin
sensitivity but does not inhibit inflammatory pathways in immune
cells from insulin-resistant subjects. J. Diabetes Res. http://dx.doi.org/
10.1155/2013/107805
67 Wu, X.D. et al. (2013) Effect of aerobic exercise on miRNA–TLR4
signaling in atherosclerosis. Int. J. Sports Med. http://dx.doi.org/
10.1055/s-0033-1349075
68 Oliveira, A.G. et al. (2011) Physical exercise reduces circulating
lipopolysaccharide and TLR4 activation and improves insulin
signaling in tissues of DIO rats. Diabetes 60, 784–796
69 Jeppesen, J. and Kiens, B. (2012) Regulation and limitations to fatty
acid oxidation during exercise. J. Physiol. 590, 1059–1068
70 Zbinden-Foncea, H. et al. (2012) TLR2 and TLR4 activate p38 MAPK
and JNK during endurance exercise in skeletal muscle. Med. Sci.
Sports Exerc. 44, 1463–1472
71 Starkie, R.L. et al. (2001) Circulating monocytes are not the source of
elevations in plasma IL-6 and TNF-alpha levels after prolonged
running. Am. J. Physiol. Cell Physiol. 280, C769–C774
72 Dinarello, C.A. et al. (2012) Treating inflammation by blocking
interleukin-1 in a broad spectrum of diseases. Nat. Rev. Drug
Discov. 11, 633–652
73 Wen, H. et al. (2011) Fatty acid-induced NLRP3–ASC inflammasome
activation interferes with insulin signaling. Nat. Immunol. 12, 408–
415
74 Masters, S.L. et al. (2010) Activation of the NLRP3 inflammasome by
islet amyloid polypeptide provides a mechanism for enhanced IL-1beta
in type 2 diabetes. Nat. Immunol. 11, 897–904
75 Freigang, S. et al. (2013) Fatty acid-induced mitochondrial uncoupling
elicits inflammasome-independent IL-1alpha and sterile vascular
inflammation in atherosclerosis. Nat. Immunol. 14, 1045–1053
76 Ridker, P.M. et al. (2012) Effects of interleukin-1beta inhibition with
canakinumab on hemoglobin A1c, lipids, C-reactive protein,
interleukin-6, and fibrinogen: a phase IIb randomized, placebo-
controlled trial. Circulation 126, 2739–2748
77 Steensberg, A. et al. (2000) Production of interleukin-6 in contracting
human skeletal muscles can account for the exercise-induced increase
in plasma interleukin-6. J. Physiol. 529, 237–242
78 Pedersen, B.K. and Febbraio, M.A. (2012) Muscles, exercise and
obesity: skeletal muscle as a secretory organ. Nat. Rev. Endocrinol.
8, 457–465
79 Ostrowski, K. et al. (1998) A trauma-like elevation of plasma
cytokines in humans in response to treadmill running. J. Physiol.
513, 889–894
7
TREIMM-1081; No. of Pages 8
Review
80 Steensberg, A. et al. (2003) IL-6 enhances plasma IL-1ra, IL-10, and
cortisol in humans. Am. J. Physiol. Endocrinol. Metab. 285, E433–
E437
81 Grant, R.W. and Dixit, V.D. (2013) Mechanisms of disease:
inflammasome activation and the development of type 2 diabetes.
Front. Immunol. 4, 50
Trends in Immunology xxx xxxx, Vol. xxx, No. x
82 Feuerer, M. et al. (2009) Lean, but not obese, fat is enriched for a unique
population of regulatory T cells that affect metabolic parameters. Nat.
Med. 15, 930–939
83 Kosteli, A. et al. (2010) Weight loss and lipolysis promote a dynamic
immune response in murine adipose tissue. J. Clin. Invest. 120, 3466–
3479