Brain metabolism during fasting

Cachexia of malignancy: potential role of insulin in nutritional management

Patients manifesting the syndrome of cachexia of malignancy exhibit an abnormal diabetic glucose tolerance. In our patients this has been correlated with a marked resistance to administered insulin, while insulin receptors on monocytes are normal. Lipolysis remains responsive to the effects of insulin. The oxidation of FFA, as a substrate for metabolism, has been reported to be increased, and the utilization of glucose as a metabolic fuel is reduced. Increased Cori cycle activity has been demonstrated, which produces an enhanced gluconeogenesis from lactate and amino acids; there is an expenditure of 6 ATP for the synthesis of each mole of glucose. An attempt to interrupt the Cori cycle in man, using hydrazine sulfate to inhibit the enzyme phosphoenolpyruvate carboxykinase, has not resulted in reproducible clinical benefit. However, successful treatment of the underlying tumor may produce a total reversal of the cachexia syndrome, suggesting that neoplasms have the potential to elaborate an, as yet, unidentified metabolic toxin. The use of insulin to counteract the reported abnormalities should be examined as a possible supportive measure in the total nutritional management of the cancer patient.

Optic neuropathy in ketogenic diet

A symmetrical, bilateral optic neuropathy is reported in 2 patients being treated with ketogenic diets for seizure control. Laboratory tests suggested a thiamine deficiency, and both patients recovered normal visual function after several weeks of treatment with thiamine. The risk of optic nerve dysfunction occurring during the treatment with a ketogenic diet can be minimised if routine vitamin B supplements are given and periodic evaluation of optic nerve function undertaken.

Hypoglycemia in children

The factors that sustain postabsorptive glucose concentrations have been analyzed and the adverse effects of various hypoglycemic disorders on these factors examined. The role of alanine has been reviewed and the importance of glycerol as a precursor of glucose and of ketones as a fuel substitute for glucose emphasized. Finally, we have suggested that fasting functional hypoglycemia replace ketotic hypoglycemia as a descriptive term and that we relinquish the concept of leucine-sensitive hypoglycemia as a specific entity.

Kinetics of ketone body metabolism in fasting humans

The rates of production of total ketone bodies (acetoacetate + beta-hydroxybutyrate) were determined using an isotope tracer technique in 23 obese subjects submitted to a fast of variable duration (15 hr--23 days). Constant infusions of 14C-acetoacetate were used in most studies, but similar results were obtained with pulse injections of this tracer or with constant infusions of 14C-D(-)-beta-hydroxybutyrate. Blood concentration, production rate, and urinary elimination of total ketones rose during approximately the first 3 days of fast and plateaued thereafter at values amounting, respectively, to 7.09 +/- 0.32 mumole/ml, 1908 +/- 80 mumole/min and 167 +/- 14 mumole/min. The rates of ketogenesis are significantly higher than those usually reported in the literature. Ketonemia was an exponential function of production rate suggesting that tissue uptake becomes progressively saturated as inflow rate rises. The same type of relationship between concentration and inflow rate was observed in nine control overnight fasted obese subjects rendered hyperketonemic with infusions of variable amounts of unlabeled acetoacetate. The comparison between the fasted and the control subjects at ketone concentrations of 3--10 mumole/ml showed that on an average, starvation is associated with a 35% decrease in the metabolic clearance rate of ketones. These data suggest that fasting is associated with an impairment of mechanisms for utilizing ketones, this defect contributing to the hyperketonemia of food deprivation.

Lipogenesis in the developing brain: utilization of radioactive leucine, isoleucine, octanoic acid and beta-hydroxybutyric acid

Incorporation of radioactivity from intracranially injected radioactive leucine, isoleucine (ketogenic amino acids), octanoic acid and beta-hydroxybutyric acid into the brain lipids of 15 to 16 day-old rats was examined. The results showed that radioactivity from all the above precursors was incorporated into brain lipids. Radioactivity from injected isoleucine was incorporated into odd numbered fatty acids indicating an alternate pathway to alpha-oxidation for the biosynthesis of these fatty acids in the brain. For some as yet unclear reasons, a substantial portion of the radioactivity from injected octanoic acid was incorporated into free fatty acids. Utilization of these compounds for providing carbon for lipogenesis during development under unstressed normal conditions is discussed.

Energy metabolism in feasting and fasting

During feasting on a balanced carbohydrate, fat, and protein meal resting metabolic rate, body temperature and respiratory quotient all increase. The dietary components are utilized to replenish and augment glycogen and fat stores in the body. Excessive carbohydrate is also converted to lipid in the liver and stored along with the excessive lipids of dietary origin as triglycerides in adipose tissue, the major fuel storage depot. Amino acids in excess of those needed for protein synthesis are preferentially catabolized over glucose and fat for energy production. This occurs because there are no significant storage sites for amino acids or proteins, and the accumulation of nitrogenous compounds is ill tolerated. During fasting, adipose tissue, muscle, liver, and kidneys work in concert to supply, to convert, and to conserve fuels for the body. During the brief postabsorptive period, blood fuel homeostasis is maintained primarily by hepatic glycogenolysis and adipose tissue lipolysis. As fasting progresses, muscle proteolysis supplies glycogenic amino acids for heightened hepatic gluconeogenesis for a short period of time. After about three days of starvation, the metabolic profile is set to conserve protein and to supply greater quantities of alternate fuels. In particular, free fatty acids and ketone bodies are utilized to maintain energy needs. The ability of the kidney to conserve ketone bodies prevents the loss of large quantities of these valuable fuels in the urine. This delicate interplay among liver, muscle, kidney, and adipose tissue maintains blood fuel homeostasis and allows humans to survive caloric deprivation for extended periods.

Fasting metabolism in infants. I. Effect of severe undernutrition on energy and protein utilization

Fasting energy metabolism was studied in infants to determine the rates of utilization of endogenous carbohydrate, fat, and protein in relation to length of fasting, glucose homeostasis, other circulating energy substrates and hormones, and severe depletion of energy reserves due to prior malnutrition. Five subjects about 1 yr of age were each studied before and after restoration of their energy reserves. Following 3 days of a standard maintenance intake of energy and protein, the subjects were fasted until glycogen oxidation became negligible. Total energy utilization, determined by hourly oxygen consumption, did not diminish as a result of fasting but was significantly less when malnourished than when recovered, 66 versus 79 kcal/kg/day. In all cases the major energy source shifted from oxidation of dietary carbohydrate and glycogen to oxidation of fat, determined from the respiratory quotient, until the oxidation of glycogen became negligible and fat provided 94% of energy in the malnourished subjects after 21 hr and 92% in the recovered subjects after 27 hr. Utilization of protein, determined from urinary nitrogen excretion, remained very low in the malnourished infants accounting for a maximum of 4% of energy, 103 mg N/kg/day, whereas after recovery, protein utilization doubled as a result of fasting, finally accounting for 7% of energy, 226 mg N/kg/day (p less than 0.005). Urea accounted for 60% of total urinary N in both groups and plasma urea increased correspondingly in the recovered but not in the malnourished subjects. Plasma glucose decreased to about 40 mg/100 ml in both groups as glycogen oxidation diminished. The maximum amount of glucose that could have been derived from dietary carbohydrate, glycogen, glycerol, and amino acids decreased over this time from about 6 to 1 mg/kg/min. Alanine declined in relation to glucose concentration and was not different in the two groups in spite of the difference in urea production. Glycerol free fatty acids, beta-hydroxybutyrate, and acetoacetate increased in both groups, but the latter three of these remained significantly less in the malnourished group. Insulin decreased rapidly and remained equally low in both groups. Urinary epinephrine increased in both groups and cortisol was elevated after fasting, while growth hormone did not increase significantly. It is concluded that fasting infants complete the transition from dietary carbohydrate to endogenous fat as the major energy source much faster than do adults, proportionate to relatively greater energy utilization. Severe wasting did not prevent energy homeostasis in spite of greatly depleted body fat. Oxidation of fat continued to provide virtually all of the fasting energy requirements, although ketosis was relatively less. Utilization of endogenous protein also increased as a result of fasting but, by contrast, provided only a very small fraction of total energy, and this was substantially diminished as a result of wasting, similar to what has been found in starved adults...

Substrate interaction in intravenous feeding: comparative effects of carbohydrate and fat on amino acid utilization in fasting man

Data are presented on the metabolic and endocrine effects of intravenous infusions in normal fasting man observed under highly controlled conditions over a period of six to eight days duration. There are comparative data on a variety of intravenous feeding programs. The data on total starvation are based on studies from the literature, some of which were carried out in this laboratory. The data on low dose glucose, high dose glucose, glycerol, fat emulsion, and amino acids, each given separately, demonstrate changes seen with simple infusion of a single substrate in fasting. These data are now compared with the utilization of amino acid infusions when accompanied by low dose glucose, high dose glucose, glycerol, and fat emulsion. In all, nine experimental intravenous feeding programs are presented, based on data from 35 subjects observed over a total of 370 subject-days. The findings show a strong interaction between glucose or lipid and protein metabolism. In fasting, glucose had protein sparing effect, most evident when given at high dose. Glycerol, in an amount equal to that contained in 2000 ml of ten per cent fat emulsion, had a mild protein sparing effect. Fat emulsion was no more effective. When amino acids were given alone, normal fasting human subjects were always in negative nitrogen balance with the daily nitrogen loss half that seen in starvation alone. Although amino acids given alone have a protein sparing effect, this is accomplished only at the expense of a high nitrogen excretion including an amount equivalent to the entire infusion plus an additional loss from the body's native proteins. The provision of energy yielding non-protein substrates with the amino acids markedly improved nitrogen economy in the following order: glycerol, low dose glucose, fat emulsion and high dose glucose. When caloric provision with glucose approached the isocaloric level for normal diet, the utilization of amino acids was maximized. When given with amino acids, fat emulsion was more effective than the available glycerol alone. THE ACCOMPANYING ENDOCRINE AND BIOCHEMICAL CHANGES SUGGEST THAT THE MILIEU FOR IDEAL UTILIZATION OF INFUSED AMINO ACIDS IS VARIABLE: ketones at low range (carbohydrate) or moderately elevated (fat emulsion); insulin elevated (carbohydrate) or unchanged (fat emulsion). The utilization of the infused amino acids was markedly improved in both endocrine settings, suggesting that it is the provision of energy as substrate as well as the endocrine setting that determines amino acid utilization. There were other changes in plasma intermediates, particularly fatty acids, glucose and urea, all consistent with the concept that when amino acids are given without other substrates, the amino acids must be maximally utilized for gluconeogenesis. When other substrates are provided (particularly glucose at high dose) then this mandate no longer exists and protein synthesis from the amino acids is favored. Several of the plasma amino acid concentrations responded to glucose when added to amino acid infusion. Amino acids alone produced increases in concentration of all the amino acids found in the infusion with the exception of alanine, arginine, and threonine. Many of these increases were abated by the addition of glucose to the amino acid infusion, suggesting an increased utilization rate. Glycerol and fat emulsion, while modulating increases in the plasma amino acid concentration, did so to a lesser extent than did glucose. This lowering of amino acid concentration was unaccompanied by an increase in urinary excretion. The assumption is therefore made that the provision of the added glucose favors the incorporation of amino acid into protein. There is no evidence from these data to suggest that a rising concentration of ketones in the blood favors amino acid utilization or protein synthesis.

Fetal utilization of maternally derived ketone bodies for lipogenesis in the rat

When D-beta-[3-14C]hydroxybutyrate was injected via the femoral vein into pregnant Sprague-Dawley rats at 21 days of gestation, D-beta-[3-14C]hydroxybutyrate was enzymatically detected in fetal plasma within 5 min. The time course of the incorporation of DL-beta-[3-14C]hydroxybutyrate into fetal lipids was studied. Lipid extracts of brown adipose tissue exhibited the greatest relative incorporation followed by pancreas, liver and lung. Less radioactivity was incorporated into brain and placenta. The incorporation into fetal lipids was several-fold greater than into maternal lipids. The labelling of the individual phospholipids was similar in the different tissues with phosphatidylcholine accounting for more than 50%. 75% of the radioactivity in brown adipose tissue was in the triacylglycerol fraction. In brain, liver and placenta, approximately half of the neutral lipid radioactivity was in cholesterol. Experiments in which D-beta-[3-14C]hydroxybutyrate was directly injected into fetuses in utero confirmed that this substrate was directly used by the fetuses without maternal intervention. These studies demonstrate that the rat placenta is permeable to beta-hydroxybutyrate and suggest that this ketone body is rapidly used by the fetus for the synthesis of fatty acids and cholesterol.

Effect of citrate on the activities of 6-phosphofructokinase from nervous and muscle tissues from different animals and its relationships to the regulation of glycolysis

1. Citrate inhibits the activities of phosphofructokinase from muscles and nervous tissues from different animals across the Animal Kingdom except for the insects. The enzymes from the flight muscle of nine different insects and the cerebral ganglion of the locust were investigated: no inhibition by citrate was observed. Inhibition was observed with the enzymes from both aerobic (e.g. pectoral muscle of pigeon) and anaerobic (e.g. fish muscle, pectoral muscle of the game birds) muscles. It is suggested that this inhibition is of physiological importance in decreasing the rate of glucose utilization in skeletal muscle of animals during starvation and/or prolonged exercise. 2. The rates of glucose utilization by the sartorius and gastrocnemius muscles of the frog were markedly decreased by ketone bodies. The latter elevated the glucose 6-phosphate and citrate contents of the gastrocnemius muscle, indicating that citrate inhibition of phosphofructokinase could be, in part, responsible for the decreased rate of glycolysis. 3. These findings provide evidence that the concept of the glucose-fatty acid-ketone-body cycle involves both aerobic and anaerobic skeletal muscle and nervous tissue from a wide range of animals except the insects. In the latter the concept of the cycle may not be applicable.

Intravenous glucose, aminoacids, and fat in the postoperative period. A controlled evaluation of each substrate

The metabolic effects of hypocaloric (2-51 MJ), equicalorific quantities of intravenous glucose, crystalline aminoacids, and soyabean emulsion were comapred with those of fasting in 4 groups of male patients (closely matched for age, weight, and fat-free mass) on the day of vagotomy and pylorplasty and on the fast 3 postoperative day. Patients given glucose alone excreted less nitrogen than the fasting patients but nitrogen sparing was greatest in the group given aminoacids alone. There was no evidence of any nitrogen sparing when intravenous fat was the source of energy. There was no difference in blood glucose, free fatty acids, and insulin concentrations among the groups. Ketone-body concentrations rose in the fasting and fat-fed groups but remained low in the groups who received glucose or aminoacids. This study indicates that, in the short term, the increased preservation of protein achieved by the infusion of aminoacids compared with that produced by the traditional infusion of glucose does not warrant the extra cost involved.

Intravenous amino acids as the sole nutritional substrate. Utilization and metabolism in fasting normal human subjects

The fasting normal human volunteer subject provides an ideal experimental setting for the initial investigation of foodstuffs whose use is proposed for the acutely ill surgical patient. In the normal human subject many variables can be controlled; the achievement of an ideal body fuel economy is quite simple; if a favorable utilization of injected foodstuffs cannot be achieved in this setting, it is unlikely, and remains to be proven, that utilization will be satisfactory under the challenges of acute surgical trauma. In this experimental model, employing four normal human volunteer subjects, nutrition has been provided by the intravenous infusion of isotonic amino acids (FreAmine(R) II) at a 3.4% concentration. No other source of calories or nutrients was provided. In this setting, utilization was very poor; the subjects were in negative nitrogen balance throughout. The nitrogen excretion was significantly greater than the total of infused nitrogen. The changes in protein, fat and carbohydrate intermediates, as well as the alteration in hormone concentrations, suggest the following endocrine governance of fuel economy in this setting: a sharp rise in glucagon with maintenance of insulin concentration; rapid gluconeogenesis at the expense of both injected and endogenous amino acids; a progressive ketosis without any associated improvement in protein economy; fat oxidation to meet caloric need. The changes in plasma amino acid concentrations are of outstanding interest. They demonstrate changes appropriate to the infusion gradient with the exception of three amino acids whose concentrations did not respond to high infusate levels (serine, lysine, and alanine); likewise, by the fact that methionine rose remarkably though present in only low concentrations in the infusion. These data, taken with other information reported in the literature, as well as continuing studies in these laboratories, strongly suggest that the utilization of infused amino acids for protein synthesis is favored by the provision of an additional caloric source such as glucose.

Development of mitochondrial energy metabolism in rat brain

1. The development of pyruvate dehydrogenase and citrate synthase activity in rat brain mitochondria was studied. Whereas the citrate synthase activity starts to increase at about 8 days after birth, that of pyruvate dehydrogenase starts to increase at about 15 days. Measurements of the active proportion of pyruvate dehydrogenase during development were also made. 2. The ability of rat brain mitochondria to oxidize pyruvate follows a similar developmental pattern to that of the pyruvate dehydrogenase. However, the ability to oxidize 3-hydroxybutyrate shows a different developmental pattern (maximal at 20 days and declining by half in the adult), which is compatible with the developmental pattern of the ketone-body-utilizing enzymes. 3. The developmental pattern of both the soluble and the mitochondrially bound hexokinase of rat brain was studied. The total brain hexokinase activity increases markedly at about 15 days, which is mainly due to an increase in activity of the mitochondrially bound form, and reaches the adult situation (approx. 70% being mitochondrial) at about 30 days after birth. 4. The release of the mitochondrially bound hexokinase under different conditions by glucose 6-phosphate was studied. There was insignificant release of the bound hexokinase in media containing high KCl concentrations by glucose 6-phosphate, but in sucrose media half-maximal release of hexokinase was achieved by 70mum-glucose 6-phosphate 5. The production of glucose 6-phosphate by brain mitochondria in the presence of Mg(2+)+glucose was demonstrated, together with the inhibition of this by atractyloside. 6. The results are discussed with respect to the possible biological significance of the similar developmental patterns of pyruvate dehydrogenase and the mitochondrially bound kinases, particularly hexokinase, in the brain. It is suggested that this association may be a mechanism for maintaining an efficient and active aerobic glycolysis which is necessary for full neural expression.

Homeostasis during hypoglycemia: central control of adrenal secretion and peripheral control of feeding

Intravenous infusions of manose or B-hydroxybutyrate, metabolic fuels which can be oxidized by brain, abolished adrenal discharge of epinephrine in rats during insulin-induced hypoglycemia, whereas infusion of fructose, a sugar which does not cross the blood-brain barrier, did not. In contrast, increased feeding behavior during hypoglycemia was prevented both by the sugars and by B-hydroxybutyrate. Thus, while the sympathetic response during marked hypoglycemia may have been initiated by alterations in cerebal metabolism, the feeding response evidently was not, and a decrease in the utilization of glucose per se does not appear to be the critical stimulus in either case.

The mechanism by which glucagon induces the release of amino acids from muscle and its relevance to fasting

A raised level of glucagon was attained rapidly, and maintained steadily, for an hour or more in the circulation of fed, or of fasted, rabbits. During this time the concentrations of 18 amino acids, of glucose and of insulin, were measured in samples of arterial blood and of blood leaving the skeletal muscles, taken simultaneously. The glucagon raised the level of glucose in the arterial blood, while, at the same time, decreasing the levels of most of the amino acids. The rate of release of amino acids from the skeletal muscles increased during this time. When the store of hepatic glycogen had been depleted by a previous injection of glucagon, or by fasting, glucagon still caused a rise in blood glucose, but the rise was less, and was less well sustained, than that seen when the glycogen stores of the liver were normal. The second injection of glucagon, or fasting, caused the glycogen depleted liver to convert certain amino acids, obtained from the blood, into glucose, lowering the blood levels of these amino acids. The muscles now released amino acids. There was no detectable difference in the release of amino acids from muscle whether glucagon was given systemically or into the artery supplying the muscles. However, a systemic injection of L-alanine, together with glucagon, abolished the fall in the level of amino acids in the blood, and suppressed their release from muscle. During fasting a steady fall in the blood levels of five amino acids occurred, probably due to their use by the liver for glucose synthesis; the temporary rise in the levels of other amino acids, which are not readily used for glucose synthesis, seems to be due to their concomitant release, from the breakdown of muscle protein. We conclude that the elevated level of glucagon, which is found in fasting, ensures that an acceptable level of the blood glucose is maintained by means of two mechanisms; first by releasing glucose from liver glycogen, and then, when fasting is prolonged, by causing the liver to synthesize glucose from certain of the amino acids in the blood, thus decreasing their concentration in the blood. This fall in the levels of these amino acids in the blood is, we believe, the stimulus which leads first to the release of amino acids from the muscles, and then to the breakdown of muscle protein to replace these released amino acids, and thus to maintain a continuous supply of these amino acids for glucose synthesis.

Correlation of blood and brain amino acids in hypoglycemic and normoglycemic rats

Utilization of gluconeogenic amino acids as a source of energy by brain can occur in starved newborn rats. This capacity is lost later in life as evidenced by changing ratios in blood and brain concentrations between fed and fasted animals.

Changes during development in transport processes of the blood-brain barrier

The permeability of the blood-brain barrier to several classes of compounds was studied in rats between the ages of 15 days and 9 weeks. 14C-labelled test substances were injected simultaneously with two reference isotopes, 3H2O and 113mIn-labelled EDTA, into the common carotid artery followed by decapitation 10 s later. There was evidence that a monocarboxylic acid transport system in 15 to 23 day-old rats had a capacity at least six times greater than that present in adult animals. L-Lactate and acetate showed the highest permeability. At all ages there was a constant ratio between L-lactate and (-)D-3-hyroxybutyrate values. D-Glucose permeability increased with age, while that of several amino acids tested was the same in young and adult rats.

The oxidation of glucose, ketone bodies and acetate by the brain of normal and ketonaemic sheep

1. The utilization and oxidation of glucose, acetate and ketone bodies by the brain of sheep has been determined from measurements of arteriovenous (A-V) differences and cerebral blood flow, as well as by infusing 14C-labelled metabolites. 2. The A-V difference for glucose was generally more than one sixth, on a molar basis, that of oxygen. 3. The mean rate of glucose utilization by the brain of conscious sheep (0-508 +/- 0-063 mumole/g per minute) was maintained even when the capillary glucose concentration was below 1-4 mM. 4. The amount of 14CO2 produced from [U-14C]glucose by the brain was consistent with glucose being the only energy source for the brain, even during hypoglycaemia and hyperketonaemia. 5. There was no appreciable production of lactate or pyruvate by the brain. 6. There was no significant A-V difference for acetate across the brain in normal or undernourished pregnant sheep. The small A-V differences that were measured show that less than 5% of the CO2 produced could be derived from acetate, a conclusion that is supported by experiments using [U-14C]acetate. 7. No significant A-V difference was detectable across the brain for 3-hydroxybutyrate or acetoacetate in normal fed, pregnant ketonaemic or even anaesthetized sheep infused with acetoacetate. Experiments in which [U-14C]-D(-)-3-hydroxybutyrate was infused also showed that less than 5% of CO2 was derived from ketone bodies. 8. In anaesthetized sheep infused with acetoacetate, measurements were made simultaneously across brain, heart and skeletal muscle. In contrast to the non-significant uptake of ketone bodies by the brain, uptake by heart and skeletal muscle was sufficient to account for nearly 60% of their oxygen consumption. 9. Experiments using [14C]hydroxybutyrate confirmed that during infusion of acetoacetate most of the CO2 produced by the heart, but not by the brain, was derived from ketone bodies. 10. In anaesthetized sheep ketone bodies penetrate only slowly into cerebrospinal fluid. 11. It is proposed that mechanisms for the utilization of ketones by the sheep brain have not evolved because glucose utilization by the brain is a smaller fraction of whole body glucose utilization than in man and rats.

Starvation in man

Starvation entails a progressive selection of fat as body fuel. Soon after a meal glucose utilisation by muscle ceases and fatty acids are used instead. Ketoacid levels in blood become elevated over the first week, and the brain preferentially uses these instead of glucose. The net effect is to spare protein even further, as glucose utilisation by brain is diminished. Nevertheless, there is still net negative nitrogen balance, but this can be nullified by amino acid or protein supplementation. Insulin appears to be the principal regulatory hormone. Recent data suggest that decreased levels of active T3 may play a role by sparing otherwise obligated calories by decreasing metabolic needs.

[Metabolic differences between males and females and between normal and obese subjects during total fast]

In 24 normal and 24 obese subjects of both sexes circulating substrates (blood sugar, free fatty acids, ketone bodies) and hormones (insulin, growth hormone, pancreatic glucagon) were determined during 6 days of total fast. In normals the blood sugar fell to lower levels than in the obese. Plasma free fatty acids and ketone concentrations rose faster in normal than in obese subjects, and faster in females than in males. Plasma insulin concentrations declined to a greater extent in obese than in normal subjects. In all groups studied a significant increase of the pancreatic glucagon level within 1-3 days of fasting was observed, however, its rise occurred faster in normal females than in males. Growth hormone (GH) rose significantly in normal males but not in obese males. Following high overnight fasting values in some normal females showed no significant increase in GH levels but significantly higher GH values than obese females after 1-6 days of fasting. After summarizing starvation-induced metabolic changes common to all study groups the respective differences found between males and females and between normal and obese subjects are discussed.

Effect of ketosis on respiratory sensitivity to carbon dioxide in obesity

We investigated whether the respiratory defect in the obesity-hypoventilation syndrome might respond to dietary manipulation. The effects of hypocaloric ketogenic regimens on the ventilatory response to carbon dioxide were studied in a manner excluding changes in weight or thoracic mechanics as factors. Six obese subjects with hyporesponse (less than 1.1 1/min/mm Hg) and 12 with normal response were fasted or given a diet containing 400 kcal per day of protein. During ketosis carbon dioxide response more than doubled in those with hyporesponse (0.8 +/- 0.1 to 1.8 +/- 1/min/mm Hg, P less than 0.05) but was unchanged in those with normal response. This improvement could not be accounted for by changes in weight, pulmonary function, pH or degree of ketosis between the two groups. However, a significant positive (r = 0.70; P less than 0.001) correlation between ketone-body concentrations and carbon dioxide response was observed in subjects with hyporesponse. These results indicate that depressed sensitivity to carbon dioxide in obese patients can be increased by dietary manipulation.

Pathogenesis, diagnosis and treatment of diabetic ketoacidosis

The diagnosis of diabetic ketoacidosis must be suspected and the initiation of treatment should be prompt to provide a satisfactory outcome in the treatment of diabetic ketoacidosis. Corrections of fluid and electrolyte deficiencies should be made slowly; rapid "push"injections or large infusions of sodium bicarbonate should avoided and ample amounts of potassium should be given early. Precautions should be taken so that blood glucose concentrations do not fall rapidly, and so that blood glucose levels of 250-300 mg/100 ml are maintained by the administration of 5-10% glucose solutions. Bicarbonate therapy is indicated only in severe acidosis (pH less than or equal to 7.1). Physicians who are trained in the care of diabetes mellitus should supervise the treatment. In our hospital the same staff physicians and fellows attend all patients with diabetes. In addition the efforts of our house staff and nurses have contributed significantly to the care of these patients.

Effects of brief starvation on muscle amino acid metabolism in nonobese man

A reduction in the release of substrate amino acids from skeletal muscle largely explains the decrease in gluconeogenesis characterizing prolonged starvation. Brief starvation is associated with an increase in gluconeogenesis, suggesting increased release of amino acids from muscle. In the present studies, accelerated amino acid release from skeletal muscle induced by brief starvation was sought to account for the accompanying augmentation of gluconeogenesis. To do this amino acid balance across forearm muscles was quantified in 15 postabsorptive (overnight fasted) subjects and in 7 subjects fasted for 60 h. Fasting significantly reduced basal insulin (11.3-7.5 muU/ml) and increased glucagon (116-134 pg/ml). Muscle release of the principal glycogenic amino acids increased. Alanine release increased 59.4%. The increase in release for all amino acids averaged 69.4% and was statistically significant for threonine, serine, glycine, alanine, alpha-aminobutyrate, methionine, tyrosine, and lysine. Thus, with brief starvation, muscle release of glycogenic amino acids increases strikingly. This contrasts with the reduction of amino acid release characterizing prolonged starvation. The adaptation of peripheral tissue metabolism to brief starvation is best explained by the decrease in insulin.

Glycolytic metabolism in cultured cells of the nervous system. II. Regulation of pyruvate and lactate metabolism in the C-6 glioma cell line

Pyruvate and lactate efflux from C-6 glioma cells has been found to be regulated by both the medium glucose concentration and the medium concentration of the two acids. Each moves down a concentration gradient until the extracellular level is in equilibrium with the intracellular. Long-term growth studies demonstrated that the cells preferentially utilize glucose but that once it is depleted, they will take up first pyruvate, followed by lactate, for further metabolism. Changes in the intracellular levels of the two metabolites correspond to those seen in the medium. The rate of glycogen breakdown parallels that of medium glucose ultilization. Preliminary results with the C-1300 neuroblastoma cells showed pyruvate and lactate efflux rates comparable to those of the glioma cells.

Glycerol: major contributor to the short term protein sparing effect of fat emulsions in normal man

Intravenous fat emulsions have been advocated as acceptable alternatives to hyperosmolar glucose solutions in parenteral nutrition. The ability of a fat emulsion (soy bean oil suspended in glycerol) to produce nitrogen sparing in the absence of nitrogen intake was examined in normal man. The protein conservation obtained by the fat emulsion can be duplicated by the infusion of glycerol alone in the same amount as that available from the fat emulsion.

[Breath acetone and ketonemia in normal- and overweight subjects during total fasting (author's transl)]

In subjects of ideal weight (7 males and 7 females) total whole blood ketones and breath acetone were determined during a 6 day fast, and in obese subjects (8 males, 18 females) during 6-28 days of fasting. Development of starvation ketosis was significantly slower in overweight than in normal weight subjects. Breath acetone concentration was up to blood ketone levels of 4 mMol/1 a linear function of the blood ketone concentration, beyond that level, however, an additional exponential component became apparent. The highest acetone elimination found was 4.46 mg/min, corresponding to 6.4 g acetone and 11.2 g acetoacetic acid in 24 hours. Hence the decarboxylation of acetoacetic acid to acetone may be an additional mechanism for the lowering of ketoacidosis in starvation.

Energy metabolism and hormonal profile in children with edematous protein-calorie malnutrition

Modifications in energy metabolism and endocrine homeostasis (plasma insulin and growth hormone values, glucose and free fatty acid levels, serum thyroxine and TSH, free thyroxine index, and urinary catecholamines) were investigated in eight children with edematous protein-calorie malnutrition. Caloric expenditure was low at admission and correlated linearly with increased caloric intake throughout the study. The hormonal changes at admission were characterized by a negligible insulin response to intravenous arginine or glucose and by markedly elevated growth hormone levels which were neither increased by arginine nor suppressed by intravenous glucose. Serum thyroxine values were low, but free thyroxine index and serum TSH levels were within normal limits. At admission to the study, 24-hour urinary excretion of dopamine and norepinephrine was relatively reduced in relation to the excretion of epinephrine. All these modifications were corrected at time of the recovery study. It is suggested that in edematous protein-calorie malnutrition, insulin acts as the primary regulator of peripheral fuel release and that the high, nonsuppressible growth hormone levels may form part of an important homeostatic mechanism to provide substrates for brain metabolism via lipolysis.

Activities of citrate synthase, NAD+-linked and NADP+-linked isocitrate dehydrogenases, glutamate dehydrogenase, aspartate aminotransferase and alanine aminotransferase in nervous tissues from vertebrates and invertebrates

1. The activities of citrate synthase and NAD+-linked and NADP+-linked isocitrate dehydrogenases were measured in nervous tissue from different animals in an attempt to provide more information about the citric acid cycle in this tissue. In higher animals the activities of citrate synthase are greater than the sum of activities of the isocitrate dehydrogenases, whereas they are similar in nervous tissues from the lower animals. This suggests that in higher animals the isocitrate dehydrogenase reaction is far-removed from equilibrium. If it is assumed that isocitrate dehydrogenase activities provide an indication of the maximum flux through the citric acid cycle, the maximum glycolytic capacity in nervous tissue is considerably greater than that of the cycle. This suggest that glycolysis can provide energy in excess of the aerobic capacity of the tissue. 2. The activities of glutamate dehydrogenase are high in most nervous tissues and the activities of aspartate aminotransferase are high in all nervous tissue investigated. However, the activities of alanine aminotransferase are low in all tissues except the ganglia of the waterbug and cockroach. In these insect tissues, anaerobic glycolysis may result in the formation of alanine rather than lactate.