Medical management of obesity

Obesity is a heterogeneous condition. Some individuals suffer severe, life-threatening medical complications as a result of their obesity, whereas others appear to remain healthy for their entire lives despite substantially greater-than-normal amounts of body fat. A personal or family history of adverse health consequences of obesity and an upper-body fat distribution suggests that the patient will have greater health risks from obesity, and these patients stand to benefit more from successful treatment. Therefore, one can justify more aggressive approaches in helping them to make permanent changes in eating and exercise behavior, which are the cornerstones of obesity management. Supplementing these interventions with behavior therapy is necessary for patients unable to make lifestyle changes by themselves. Pharmacotherapy is appropriate for patients with medically complicated obesity in whom other approaches have not succeeded.

Adenoviral-mediated gene transfer to human adipocytes in vitro, and human adipose tissue ex vivo and rabbit femoral adipose tissue in vivo

Adenoviral-mediated gene transfer has proven useful in several organ systems to understand gene action and to provide a potential therapeutic modality for localized, organ-specific gene overexpression. However, the application of adenoviral-mediated gene transfer to adipocytes and adipose tissue has not been evaluated. We evaluated the feasibility of in vitro and ex vivo transfer of the beta-galactosidase gene to human adipocytes and adipose tissue by means of adenoviral vectors. The efficiency (percentage of cells transduced) of adenoviral-mediated gene transfer of the beta-galactosidase gene to human adipocytes in vitro and to human adipose tissue ex vivo was 21 +/- 3% and 14 +/- 3%, respectively. Adenoviral-mediated gene transfer in a rabbit femoral adipose tissue was also demonstrated in vivo. Adenoviral-mediated gene transfer may facilitate studies on understanding the biology of adipocytes and provide a potential tool for the modulation of adipocyte function in vivo and thereby for the treatment of obesity.

Pituitary desensitization to gonadotropin-releasing hormone increases abdominal adiposity in hyperandrogenic anovulatory women

OBJECTIVE

To determine whether hyperandrogenism in anovulatory women affects body fat distribution.

DESIGN

Prospective nonrandomized study.

SETTING

An academic research environment.

PATIENT(S)

Ten hyperandrogenic anovulatory patients and 10 healthy women matched by body mass index.

INTERVENTION(S)

Regional body fat analysis was performed before and after 3 months of GnRH analogue (GnRH-a) therapy.

MAIN OUTCOME MEASURE(S)

Body fat distribution was measured by waist-to-hip circumference ratio, single-slice computed tomography imaging (L2-3 interspace), and total body dual-energy x-ray absorptiometry.

RESULT(S)

Weight, body mass index, waist-to-hip circumference ratio, total body and leg fat mass, and subcutaneous adipose area were unaffected by the presence of hyperandrogenism or the use of GnRH-a therapy. Basal abdominal fat mass, abdomen-to-leg fat mass ratio, visceral adipose area, and total visceral adipose volume were comparable in both study groups. The abdominal fat mass increased in both groups during GnRH-a therapy, whereas the abdomen-to-leg fat mass ratio rose significantly only in the hyperandrogenic patients. During GnRH-a therapy, the hyperandrogenic patients demonstrated a significant increase in visceral adipose area compared with the healthy women so that total visceral adipose volume increased significantly in the former but not the latter.

CONCLUSION(S)

Three months of GnRH-a administration preferentially increased abdominal fat, as measured by single-slice computed tomography imaging and total body dual-energy x-ray absorptiometry, in hyperandrogenic anovulatory women.

Intramuscular fatty acid metabolism evaluated with stable isotopic tracers

We evaluated the applicability of stable isotopic tracers to the study of intramuscular fatty acid metabolism by infusing both [U-13C]palmitate and [1-13C]oleate intravenously for 4 h into fasted conscious rats. Skeletal muscles were sequentially biopsied, and the concentration and 13C enrichment of fatty acids were measured by gas chromatography/combustion/isotope ratio mass spectrometry. Throughout the study, the 13C enrichment of plasma palmitate and oleate remained substantially greater than intramuscular nonesterified palmitate and oleate enrichment, which in turn was greater than intramuscular triglyceride palmitate and oleate enrichment. Fractional synthesis rates of intramuscular triglycerides in gastrocnemius and soleus were 0.267 +/- 0.075 and 0. 100 +/- 0.030/h (P = 0.04), respectively, as determined by using [U-13C]palmitate, and were 0.278 +/- 0.049 and 0.075 +/- 0.013/h (P = 0.02), respectively, by using [1-13C]oleate. We conclude that plasma free fatty acids are a source for intramuscular triglycerides and nonesterified fatty acids; the latter are likely the synthetic precursors of the former. Uniformly and singly labeled [13C]fatty acid tracers will provide an important tool to study intramuscular fatty acid and triglyceride metabolism.

Measurement of plasma glycerol specific activity by high performance liquid chromatography to determine glycerol flux

Previous methods for measuring plasma glycerol specific activity (SA) are suboptimal, making the determination of glycerol kinetics in vivo with radiotracers difficult. A new high performance liquid chromatography (HPLC) method is described that permits the accurate and specific measurement of glycerol SA. The method involves isolation of glycerol from plasma and the formation of a tribenzoyl derivative. Glycerol rate of appearance was measured in five human volunteers using both [2-3H]glycerol and [2H5] glycerol. There was close agreement between the glycerol appearance rates measured using the two approaches (1.66 +/- 0.14 vs. 1.70 +/- 0.10 micromol x kg(-1) x min(-1), respectively, P = NS). This HPLC method offers improved specificity over existing methods of measuring glycerol turnover using radiotracers.

Adipocyte macrophage colony-stimulating factor is a mediator of adipose tissue growth

Adipose tissue growth results from de novo adipocyte recruitment (hyperplasia) and increased size of preexisting adipocytes. Adipocyte hyperplasia accounts for the severalfold increase in adipose tissue mass that occurs throughout life, yet the mechanism of adipocyte hyperplasia is unknown. We studied the potential of macrophage colony-stimulating factor (MCSF) to mediate adipocyte hyperplasia because of the profound effects MCSF exerts on pluripotent cell recruitment and differentiation in other tissues. We found that MCSF mRNA and protein were expressed by human adipocytes and that adipocyte MCSF expression was upregulated in rapidly growing adipose tissue that encircled acutely inflamed bowel and in adipose tissue from humans gaining weight (4-7 kg) with overfeeding. Localized overexpression of adipocyte MCSF was then induced in rabbit subcutaneous adipose tissue in vivo using adenoviral-mediated gene transfer. Successful overexpression of MCSF was associated with 16-fold increases in adipose tissue growth compared with a control adenovirus expressing beta-galactosidase. This occurred in the absence of increased cell size and in the presence of increased nuclear staining for MIB-1, a marker of proliferation. We conclude that MCSF participates in adipocyte hyperplasia and the physiological regulation of adipose tissue growth.

Diet effects on fatty acid metabolism in lean and obese humans

The primary role of adipose tissue is to serve as a temporary storage site for energy in the form of nonesterified fatty acids. The regulation of adipose tissue lipolysis, which allows the appropriate delivery of fatty acids to meet the lipid fuel needs of lean tissue, is affected by the amount and the location of fat, as well as by the diet. Excessive accumulation of triacylglycerol fatty acids (obesity) is associated with an increased risk of insulin resistance, diabetes, hyperlipidemia, and hypertension. Some of these abnormalities may be related to dysregulation of fatty acid metabolism. Body fat distribution exerts a major influence on endogenous nonesterified fatty acid metabolism, which may in turn mediate some of the metabolic abnormalities associated with upper-body obesity. The effects of diet on fatty acid metabolism can be dramatic and are not the same in upper-body and lower-body obesity. Different obesity phenotypes may respond differently to low-fat, high-complex-carbohydrate diets, and the response is further modified depending on whether the diet is isoenergetic or restricted in energy.

Effects of oral contraceptives on free fatty acid metabolism in women

These studies examined whether women using oral contraceptives have abnormalities in free fatty acid (FFA) metabolism compared with women not using oral contraceptives. Plasma palmitate kinetics ([3H]palmitate) were measured at rest, following glucose ingestion, and during epinephrine infusion in 13 oral contraceptive users and 13 matched women not using oral contraceptives. Oral contraceptive users had significantly greater plasma triglyceride concentrations and glucose responses to oral glucose tolerance testing. No differences in basal (2.1 +/- 0.1 v 1.8 +/- 0.2 micromol x kg fat-free mass x FFM(-1) x min[-1]), glucose-suppressed (0.6 +/- 0.1 v 0.5 +/- 0.1 micromol x kg FFM(-1) x min[-1]), or epinephrine-stimulated (3.3 +/- 0.1 v 3.6 +/- 0.2 micromol x kg FFM(-1) x min[-1]) palmitate flux were detected between women using and not using oral contraceptives. The respiratory quotient (RQ) also was not different between groups. We conclude that the increase in plasma triglycerides and the mild glucose intolerance seen with oral contraceptive use is not associated with significant abnormalities of FFA metabolism.

Health consequences of fat distribution

Body fat distribution is now recognized as an important predictor of the adverse health consequences of obesity. Upper body obesity, especially with increasing visceral fat, is associated with hypertension, insulin resistance, dyslipidemia, type II diabetes mellitus and premature coronary death. Several lines of evidence suggest that abnormal adipose tissue lipolysis, resulting in elevated free fatty acid (FFA) availability, may contribute to some of the metabolic consequences of upper body obesity. The vast majority of the elevated systemic FFA release appears to come from upper body, non-splanchnic adipose tissue. Thus, dysregulation of upper body, non-splanchnic adipose tissue lipolysis may play an important role in contributing to health consequences of fat distribution.

Effects of gender on resting leg blood flow: implications for measurement of regional substrate oxidation

These studies were designed to examine whether the respiratory quotient (RQ) of leg tissue (primarily skeletal muscle) would increase to a greater degree in women than in men during meal ingestion. We found that mean leg and systemic RQ values were similar in men under both basal and fed conditions, whereas the agreement was poor in women. In women, leg RQ values tended to be greater than the systemic RQ, whereas splanchnic RQ values tended to be lower than the systemic RQ. The possibility that measurement imprecision accounted for the different findings in women could not be excluded because the arteriovenous blood O2 differences were almost twice as great in men as in women (53.7 +/- 5.4 vs. 28.6 +/- 2.9 ml of O2/l, respectively; P < 0.01), as were venoarterial blood CO2 differences. The smaller arteriovenous differences in women appeared to limit our ability to accurately measure their leg RQ values. O2 uptake relative to leg fat-free mass (FFM) was not different between men and women, whereas leg blood flow relative to leg FFM was greater in women than in men (55 +/- 3 vs. 39 +/- 2 ml.kg FFM-1.min-1, respectively; P < 0.001). These findings were confirmed by examining data from other studies conducted in our laboratory to create a larger data set. We conclude that resting leg blood flow in women is greater (relative to FFM) than in men, making it more difficult to accurately measure leg RQ in women.

Free fatty acid turnover measured using ultralow doses of [U-13C]palmitate

Low intravenous infusion rates of [U-13C]palmitate were used to measure systemic palmitate flux at rest (0.5 nmol . kg-1 . min-1) and during exercise (2 nmol . kg-1 . min-1) in healthy adults. The 13C enrichment of plasma palmitate was determined by gas chromatography/combustion/isotope ratio mass spectrometry (GC/C/IRMS). Palmitate flux was also measured using palmitate radiotracers, which were infused simultaneously to serve as a reference method. Flux values obtained using the two different methods were virtually identical. Overnight postabsorptive palmitate flux was measured on four occasions in three individuals; the flux values were highly reproducible with a coefficient of variation of 11% and 12% for intra-day measurement, and 13% and 8% for inter-day measurement, for [1-(14)C]palmitate and [U-(13)C]palmitate, respectively. During exercise, palmitate turnover measured with [U-(13)C]palmitate and [3H]palmitate were well correlated (r = 0.91). Compared to conventional stable isotope approaches, (e.g., [1-(13)C]palmitate analyzed by GC/MS), [U-(13)C]palmitate reduces the tracer dose by two orders of magnitude when the samples are analyzed with GC/C/IRMS. Uniformly labeled [13C]palmitate is suitable for the measurement of free fatty acid flux in humans.

Localization of leptin receptor in the human brain

Leptin (OB protein), the product of the adipose-specific ob gene, exerts important effects in the regulation of food intake and energy expenditure. Based upon results from animal studies, several groups have suggested that this action may be exerted in the brain, specifically in the hypothalamic region. However, to date, the localization of the OB-R in the human brain has not been described. One aim of this study was to contribute to a better understanding of the role that the central nervous system plays in the pathogenesis of obesity in humans. A first stage was to determine the OB-R expression in the human brain by means of immunohistochemistry and Western blotting. Several brain regions from 17 lean, 14 obese, and 4 diabetic (NIDDM) subjects, obtained from archival autopsy material, were sampled. Brain samples from neocortex, hypothalamus, medualla, limbic system, pineal and cerebellum were routinely processed in paraffin and analyzed with the avidin-biotin immunoperoxidase and diaminobenzidine detection method. Western blotting (WB) analysis was done on fresh brain tissue from an obese patient. Specific OB-R immunoreactivity was localized in the choroid plexus epithelium, ependymal lining, and neurons of the hypothalamic nuclei (arcuate, suprachiasmatic, mamillary, paraventricular, dorsomedial, supraoptic and posterior), nucleus basalis of Meynert, inferior olivary nuclei and cerebellar Purkinje cells. No differences in OB-R immunoreactivity were found among the three groups examined. WB analysis yielded 97- and 125-kD bands in the hypothalamus and cerebellum. In summary, this paper presents the first evidence to indicate the specific localization of the OB-R in the brain of lean, obese and NIDDM subjects.

Obesity and cardiovascular disease: is body structure a factor?

Obesity is associated with increased cardiovascular morbidity and mortality. Individuals who predominantly store fat abdominally (particularly in the visceral area), more often present with an atherogenic lipid profile and are more frequently characterized by hemostatic, metabolic and anatomical abnormalities compatible with insulin resistance and increased atherothrombotic risk. Weight loss improves many of the cardiovascular risk factors associated with abdominal obesity.

Regional lipolytic responses to isoproterenol in women

We previously found that epinephrine, a mixed beta- and alpha-adrenoreceptor agonist, stimulates systemic and nonsplanchnic upper body free fatty acid (FFA) release but not lower body FFA release in healthy nonobese women. To evaluate the role of beta-adrenergic-mediated effects on this regional difference in lipolysis, we measured systemic, leg, and splanchnic FFA kinetics ([3H]palmitate) in seven healthy nonobese women before and during an intravenous isoproterenol infusion. Isoproterenol increased systemic palmitate flux (87 +/- 12 vs. 100 +/- 10 mumol/min, P < 0.05) but failed to affect leg [10.8 +/- 1.2 vs. 11.4 +/- 2.3 mumol/min, P = not significant (NS)] or splanchnic (10.8 +/- 3.2 vs. 10.0 +/- 1.8 mumol/min, P = NS) palmitate release. Upper body nonsplanchnic palmitate release increased from 56 +/- 14 to 71 +/- 10 mumol/min. Systemic O2 consumption increased (227 +/- 11 to 241 +/- 10 ml/min, P = 0.006) during isoproterenol infusion, as did leg (318 +/- 42 vs. 404 +/- 53 ml/min, P < 0.01) and splanchnic (827 +/- 104 vs. 970 +/- 108 ml/min, P < 0.05) plasma flow. These results suggest that lower body adipose tissue lipolysis in women is less sensitive or responsive than nonsplanchnic upper body adipose tissue to beta-adrenergic stimulation and that regional differences in alpha 2-adrenergic-receptor responses were not responsible for the similar regional differences we observed previously with epinephrine.

Lipolytic responsiveness to epinephrine in nondiabetic and diabetic humans

To determine whether the sensitivity of adipose tissue lipolysis to catecholamines is increased in poorly controlled insulin-dependent diabetes, the lipolytic response to epinephrine was measured in seven nondiabetic volunteers and seven poorly controlled diabetic subjects with use of [1-(14)C]palmitate as a tracer. Subjects received sequential 1-h infusions of epinephrine, which produced epinephrine concentrations of approximately 1,000, approximately 1,750, approximately 3,500, and approximately 6,000 pmol/l. A pancreatic clamp was used to maintain constant plasma hormone levels. Concentration-response curves were constructed for each subject from the integrated lipolytic response during each epinephrine infusion. There was no difference in maximal lipolytic response (117 +/- 19 vs. 152 +/- 11 mumol.kg-1.h-1) or in maximally effective (3,171 +/- 267 vs. 3,357 +/- 349 pmol/l) or half-maximally effective (1,081 +/- 109 vs. 1,015 +/- 120 pmol/l) epinephrine concentrations between nondiabetic and diabetic subjects, respectively (all P = NS). In control subjects, maximum beta-hydroxybutyrate concentrations were achieved at lower epinephrine concentrations than those required for a maximum lipolytic effect. Thus, under pancreatic clamp conditions, the lipolytic response to epinephrine in nondiabetic and diabetic subjects was similar.

Lipolysis: contribution from regional fat

In vitro studies of adipocytes taken from different body fat regions suggest substantial differences in lipolysis between intra-abdominal, lower-body subcutaneous, and abdominal subcutaneous regions. Gender and obesity appear to influence these regional differences. In situ measurements of glycerol release from adipose tissue provided further evidence that regional heterogeneity of lipolysis occurs in humans. In vivo studies of regional free fatty acid (FFA) release have confirmed that adipose tissue lipolysis varies between upper- and lower-body fat. Release of FFA from lower-body adipose tissue is less than that from upper-body adipose tissue in both obese and non-obese men and women. In non-obese men and women, meal ingestion suppresses FFA release from all adipose tissue regions, and adrenergic stimulation activated FFA release from different sites in a gender-specific fashion. Significant regional and gender differences in adipose tissue lipolysis occur in humans, and this could contribute to differences in the health effects of adipose tissue and could theoretically influence body fat distribution.

Postprandial leg and splanchnic fatty acid metabolism in nonobese men and women

These studies were conducted to determine whether there are gender-specific regional differences in meal triglyceride fatty acid uptake. Systemic and regional oleate ([3H]oleate) kinetics were measured in nine nonobese men and eight nonobese women before and at the end of a 6-h meal, administered as small frequent feedings to achieve steady-state chylomicronemia. Chylomicron uptake in the splanchnic bed accounted for 71 +/- 15% of meal triglyceride disappearance in men and 20 +/- 7% in women (P < 0.01), whereas leg chylomicron uptake could only account for 12 +/- 2 and 8 +/- 4% (P not significant in men vs. women) of meal triglyceride disappearance. Meal ingestion suppressed (P < 0.05) systemic and regional free fatty acid release in both men and women. Splanchnic nonchylomicron triglyceride release and leg nonchylomicron triglyceride uptake were not significantly different in men and women. In summary, the largest quantitative difference between men and women in fatty acid kinetics during meal ingestion is a substantially greater splanchnic uptake of meal triglyceride fatty acids in men. This could represent greater meal fatty acid storage in visceral adipose tissue.

Contribution of leg and splanchnic free fatty acid (FFA) kinetics to postabsorptive FFA flux in men and women

We have previously shown that upper-body adipose tissue is more lipolytically active than lower-body adipose tissue in lean and obese women. The present studies were conducted to determine whether these regional differences are also present in men. Twenty-five lean, healthy men and 24 lean, healthy women underwent measures of body composition, postabsorptive systemic free fatty acid (FFA) flux, and leg and splanchnic FFA uptake and release. Upper-body adipose tissue was more lipolytically active than lower-body adipose tissue in both men (53.4 +/- 32.2 v 26.6 +/- 12.9 micromol x kg fat(-1) x min(-1), P < .001, respectively) and women (41.2 +/- 22.3 v 18.4 +/- 8.2 micromol x kg fat(-1) x min(-1), P < .001, respectively). The correlations between leg FFA release and systemic FFA flux were modest in women and men (r = .38, P = .07 and r = .56, P = .003, respectively) as were the correlations between splanchnic FFA release and systemic FFA flux (r = .41, P = .06 and r = .40, P = .07, respectively). No effect of gender on the relationship between leg or splanchnic FFA release and systemic FFA flux was detected. In summary, upper-body FFA release is greater than lower-body FFA release in both men and women, and the relationship between leg or splanchnic FFA release and systemic FFA release is weak and similar in men and women. These findings suggest that regional differences in postabsorptive FFA kinetics are unlikely to be responsible for differences in regional fat distribution.

Effects of epinephrine on regional free fatty acid and energy metabolism in men and women

Upper-body and lower-body adipocytes respond differently to physiological catecholamines in vitro. It is not known whether this is true in vivo or whether gender differences exist in the regional adipose tissue responses to epinephrine. These studies were therefore conducted to examine free fatty acid (FFA) release ([3H]palmitate) from lower-body (leg), splanchnic, and upper-body adipose tissue in normal-weight adult men (n = 8) and women (n = 7). In response to intravenous epinephrine (10 ng.kg-1.min-1), palmitate release increased (P < 0.01) in both men (168 +/- 10 to 221 +/- 15 mumol/min) and women (177 +/- 12 to 234 +/- 18 mumol/min). Basal leg palmitate release was similar in women and men (16.8 +/- 2.9 and 12.4 +/- 1.3 mumol/min, P = not significant) but doubled (P < 0.01) in response to epinephrine in men and was virtually unchanged in women. Splanchnic palmitate release increased (P < 0.05) in men (n = 6) but not in women (n = 6), whereas nonsplanchnic upper-body palmitate release increased more in women than in men. Upper-body (splanchnic and nonsplanchnic) palmitate release increased (P < 0.05) in both men and women in response to epinephrine. In summary, lower-body adipose tissue FFA release increased in response to epinephrine in men but not women, whereas upper-body palmitate release increased in both groups. These findings are consistent with some in vitro findings and suggest that catecholamine action may play a role in determining gender-based differences in body fat distribution.

Gender differences in regional fatty acid metabolism before and after meal ingestion

These studies were conducted to determine whether men and women differ with regards to their overnight postabsorptive (basal) and postprandial fatty acid kinetics. Systemic oleate turnover ([9,10(3)H]oleate) was measured before and after the consumption of a mixed meal. Leg and splanchnic free fatty acid (FFA) uptake and release were measured, allowing the calculation of upper-body subcutaneous FFA release.

RESULTS

basal oleate flux was virtually identical in men and women (3.0 +/- 3 versus 2.9 +/- 0.4 mumol.kg FFM-1.min-1), however, oleate Ra suppressed more in women than in men following meal ingestion (0.5 +/- 0.1 versus 0.8 +/- 0.1 mumol.kg FFM-1.min-1, P < 0.05). The fractional contribution of basal, regional FFA release to total FFA flux was not significantly different between men and women. In contrast, oleate release by upper-body subcutaneous adipose tissue was significantly greater (30 +/- 5 vs 8 +/- 3 mumol/min, respectively, P < 0.01) in men than in women during the meal nadir of FFA flux, whereas splanchnic oleate release was a greater percentage (39 +/- 7% vs 20 +/- 3%, respectively, P < 0.05) of nadir oleate Ra in women than in men. Thus, normal weight men and women differ significantly in the postprandial regulation of adipose tissue lipolysis in that men's upper-body subcutaneous adipose tissue is more resistant to the antilipolytic effects of meal ingestion. Differential regulation of regional adipose tissue lipolysis could contribute to the gender based differences in body fat distribution.

Contribution of blood flow to leg glucose uptake during a mixed meal

Insulin has important effects to increase skeletal muscle (leg) blood flow under euglycemic hyperinsulinemic clamp conditions and after oral glucose tolerance testing. The present studies examined the effects of mixed meal consumption on the components of leg glucose uptake (LGU) in lean, healthy adults. Seventeen men and women underwent measures of leg plasma flow and arteriovenous (AV) glucose difference before and for 6 h after a mixed meal providing one-third of daily energy expenditure. Another eight men and women underwent the same studies before and during the consumption of the same-size meal administered in small frequent feedings over 6 h. After the bolus meal, peak leg AV glucose gradient increased approximately fivefold (P < 0.001), whereas the peak increase in leg plasma flow was 20% (NS). No significant contribution of increased leg blood flow to the increase in postprandial LGU was apparent. Over the last 100 min of the frequent-feedings meal, the leg AV difference increased approximately fourfold (P < 0.001 vs. basal), whereas leg blood flow increased only by 16% (NS vs. basal). We conclude that after a mixed meal, leg (primarily skeletal muscle) blood flow does not increase enough for blood flow to be a major contributor to glucose uptake. These findings raise questions regarding the relative importance of insulin's hemodynamic effects in modulating glucose tolerance under more usual conditions.

Fatty acid kinetic responses to running above or below lactate threshold

During running exercise above the lactate threshold (LT), it is unknown whether free fatty acid (FFA) mobilization can meet the energy demands for fatty acid oxidation. This study was performed to determine whether FFA availability is reduced during running exercise above compared with below the LT and to assess whether the level of endurance training influences FFA mobilization. Twelve marathon runners and 12 moderately trained runners ran at a workload that was either above or below their individual LT. Fatty acid oxidation (indirect calorimetry) and FFA release ([1-14C]palmitate) were measured at baseline, throughout exercise, and at recovery. The plasma FFA rate of appearance increased during exercise in both groups; running above or below the LT, but the total FFA availability for 30 min of exercise was greater (P < 0.01) in the below LT group (marathon, 23 +/- 2 mmol; moderate, 21 +/- 2 mmol) than in the above LT group (18 +/- 3 and 13 +/- 3 mmol, respectively). Total fatty acid oxidation (indirect calorimetry) greatly exceeded circulating FFA availability, regardless of training or exercise group (P < 0.01). No statistically significant exercise intensity or training differences in fatty acid oxidation were found (above LT: marathon, 71 +/- 12, moderate, 64 +/- 17 mmol/30 min; below LT: marathon 91 +/- 12, moderate, 60 +/- 5 mmol/30 min). In conclusion, during exercise above or below LT, circulating FFA cannot meet the oxidative needs and intramuscular triglyceride stores must be utilized. Further marathon training does not enhance effective adipose tissue lipolysis during exercise compared with moderate endurance training.