Insulin action is decreased by high muscle glycogen concentrations in skeletal muscle. Patients with McArdle's disease have chronic high muscle glycogen levels and might therefore be at risk of developing insulin resistance. In this study, six patients with McArdle's disease and six matched control subjects were subjected to an oral glucose tolerance test and a euglycemic-hyperinsulinemic clamp. The muscle glycogen concentration was 103 Ϯ 45% higher in McArdle patients than in controls. Four of six McArdle patients, but none of the controls, had impaired glucose tolerance. The insulin-stimulated glucose utilization and the insulin-stimulated increase in glycogen synthase activity during the clamp were significantly lower in the patients than in controls (51.3 Ϯ 6.0 vs. 72.6 Ϯ 13.1 mol ⅐ min Ϫ1 ⅐ kg lean body mass Ϫ1 , P Ͻ 0.05, and 53 Ϯ 15 vs. 79 Ϯ 9%, P Ͻ 0.05, n ϭ 6, respectively). The difference in insulin-stimulated glycogen synthase activity between the pairs was significantly correlated (r ϭ 0.96, P Ͻ 0.002) with the difference in muscle glycogen level. The insulinstimulated increase in Akt phosphorylation was smaller in the McArdle patients than in controls (45 Ϯ 13 vs. 76 Ϯ 13%, P Ͻ 0.05, respectively), whereas basal and insulinstimulated glycogen synthase kinase 3␣ and protein phosphatase-1 activities were similar in the two groups. Furthermore, the ability of insulin to decrease and increase fat and carbohydrate oxidation, respectively, was blunted in the patients. In conclusion, these data show that patients with McArdle's glycogen storage disease are insulin resistant in terms of glucose uptake, glycogen synthase activation, and alterations in fuel oxidation. The data further suggest that skeletal muscle glycogen levels play an important role in the regulation of insulin-stimulated glycogen synthase activity. glycogen synthase; protein phosphatase; glycogen synthase kinase 3; glucose clamp technique; glycogen storage disease type V SKELETAL MUSCLE serves as the major site of whole body insulin-mediated glucose disposal (10). The two main metabolic end points for insulin action are glucose uptake across the plasma membrane and glycogen synthesis, both of which can be dysfunctional in different pathophysiological conditions of insulin resistance (9). However, the cellular and molecular mechanisms responsible for impaired muscular insulin are not fully elucidated. Studies investigating the function of different insulin-signaling molecules as possible sites of dysfunction have so far been inconclusive (34,43). It has, however, been shown that, in humans, glycogen exerts a negative effect on the ability of insulin to increase muscle glycogen synthase activity (7,21,28), but the effect of glycogen levels on insulin-stimulated muscle glucose uptake has not been studied. In rodent skeletal muscle studied in vitro, glycogen synthase activity and glucose transport are decreased by glycogen loading and increased by glycogen depletion. There is evidence that protein kinase B/Akt plays a role in this regulation (...