THE

.MEssIcAs

Vol.

JOURNAL

20,

No.

OF

CLINICAL

2, Eebruary,
Printed

Some

NurRITloN

1967,
in

pp.

139-148

(..S..4.

Metabolic

Changes

Induced

Carbohydrate
W.

A.

KREHL,

ELEANOR

BESITY

mamfestation

Out

affluent

stay

ieduced

societies
(2)

puistie

The

complexity
the

of

general

patients

the

young
greater

concern

tional

aduilt

of

ITlost
In

weight

except
common

almost

the

products

of

to

time

popular

time,

vations
diets

to
diet

ply

reviewed

the

and

long

of

use

In their
emphasize

lipids;

significant
and

fat

From
of Iowa.

the

This

City,

study

of

results

a heavy
and

Medicine,

Centers

FR-3!)

and

stitute,

(;hicago,

by
of

Branch

grant-in-aid,

are

the

such
not

sup-

nutrients

thiamine,

and

use

the

of

low-

existing

for
their
under
the
Clinical

con-

virtues,
controlled

Research

Cen-

Depart-

presented

herein.

MATERIALS

AND

METHODS

University
The

supported
Institutes

Clinical Research
from

Center
of

may

important

and

ele-

finally,

ter to evaluate
some
of the varied
metabolic
effects
of such
diets.
Two
categories
of subjects
were
chosen
for study
and
the

32240.

Iowa
was

intakes
and

Research
College

National

and

of

acid-base

alarming

chosen

diets

conditions

such
diets
result
in-

increased
cholesterol

Clinical

Medicine,
Iowa

diets.

application,
and
fat

ketosis,

and

of

and
claims
was conducted

study

background

deend

hyperuricemia;

calcium,
riboflavin,
acid.
view
of the widespread

fusion

interestingly

carbohydrate-restricted

in

saturated

very

historical

practical
protein

evitably

of

has

increased
excrete
of

as

In

distinct
dangers

catabolism;
of

levels

these

to

blood

carbohydrate
(4)

an

occasionally

carefully

ascorbic

low-carbohydrate

with
kidneys

and
unless

suich

sulch

be

of

from

aspects
of
and
inadvocated

disturbance

adequate

mix-

base

may

aggravation
of

than

caloric

Some

nitrogen

potential

significant

manand
way

health.

when
more

metabolic
the misguided
of the widely

dehydration
upon
the

with

the

of

the easy
conceivable

every

currently

as

for two
faults-greed

from

Pennington

of

not

the

diet

to

are:
mand

to be obese
blamed

for

attemj)ted

as the
(bet.

hazard

erno-

because

is

searching

loss,
1)C

the
even

to

interesting

use

low-carbohydrate

be metabolized

unbalanced

an

discriminate

balance

obesity

laziness.

Service,

and

of

added

of continuing

everything

kinds

the

for

an

study
patient,

their

(3).

Almost
cause

Obesity
is

of

involved

chance

as an

ment

it well.
adolescent

or

limited

to
obese

the

and

doctors

to

is

provides

which

of

the

PH.D.,
M.D.

of protein

50-60
g/day.
While
such
ttlre

rate

both
problem

of

because

trauma

increased

elusive

high

obesity

to

many

an

emphasizes

inability

handle
child
or

may

generally

effort

this

iii

burden

and

which

like

ROBERT

carbohydrate

in

reduce

goal

endlessly

is-ill-o-the-wisp.
failure

To

the

corn-

malnutrition

(1).
is

most

LoPEz-S,
M.D.,
E. HODGES,

ALFREDO
AND

MS.,

Public

four

Health

Health,

normal

General

Grant

no.

The

Cereal

first

sue.

MO!-

15,
139

male

weight
Their

16,

and

ages
2

Group

In-

Illinois.

group

healthy

17,

studied

and

from
of
21,

comprised

volunteers

distribution

ranged

consisted
20,

was

prison

five
and

of
29-40

about

adipose

tis-

years.

young
two

of

of

girls,
older

ages

women,

Downloaded from www.ajcn.org by on December 9, 2007

people

the

of

Low

Diets12

PH.D.,

GOOD,

be

tO

CONTINUES

mon

M.D.,

I.

by

Krehl

140
aged

36

and

cantly

53.

obese

tried

one

All

lasting

Prior

for

their

informed

of

schedule.

Ill

each

the

I Can Do
constitute

About
another

tory

complete

and

and

Ia boratory

studies

was
the

conducted:

and

made.

white

lected and
week
aliquots

the

a
On

following

of

dium,

potassium,

mine.

The

urine

uric

cholesterol,

acid,

for
and

triglycerides,

and
and

sofree

in

at

TABLE

Low

Diets

the

recorded

tients

com-

accord-

of

daily.

bed

During

and

was

der

the

patients

the
escort,

an

continued

with

no

was

basic

by a rigid
than

iant

was

of

of

our

staff.

was

provided

than

patient

healthy

amount

cooperation

on

the

splendid.

diets

natural

less

out

patient

activities.
The patients
and tightly
controlled

more

and

pa-

Clinical
Research
and all were Un-

therapy

in the form of hobby

tolerated
this restrictive

on

given

were

ill. No

surveillance

of occupational

regimen

were

unless

leave

without

each

day,

approximately
1-hr
under
supervision

all

about

to

area

mixed

Used

three
exercise

permitted

Center

The

Carbohydrate

2 had

day,

each

those
in group
while
the obese

daily

and

daily;

once

patients

therapy;

the

up

twice

All

physical

twice

weighed

1 hr

in group

periods

recorded
were

group

physical

approximately

whole

Various

of

of

was
afforded.
40 was established

excretion

bedtime.

of grumbling,

Composition

de-

recorded

to be large,

estimation

body

those

schedule

creat-

and

day
arising

each

evaluated

were

chloride,

if found

of ketonuria
from
1 to

Blood
pressures
were
the patients
in group
1

supervised

Once

range

the ketone

were

and

further

reasonable

degree
of values

urine

ingly.

hematocrit,

recorded.

the

of

University

diluted
so as to
of small or medium.
In

was

the

in

way

and
daily

or large;

standard

laboratories

Center
in

the

biochemical
the

the

twice

sample

6-phosby

utilizing
in

bodies

medium,

urine

and

blood

volumes

qualitatively

ptratme
range

cell count
and differential
distribution,
BUN,
uric acid, cholesterol,
fasting
blood
glucose,
triglycerides,
free fatty
acids,
creatinine,
RBC,
glucose
6-phosphate
dehydrogenase,
electrolytes
(potassium,
chloride,
sodium,
C0),
total
serum
protein,
serum
albumin, and serum globulin.
Daily fluid intake was
recorded
and daily urine
excretions
were colhemoglobin,

Ketone

termined

read

made

Research

Hospitals.

this

were
studies

hr),

were

of the

technique

determined

(6). All other

employed

le

What

was

niethodologies

Clinical

use
a

(5). Glucose

laboratory

determinations

the

1,000

and

this

of Kornberg

as small,

electrocardio-

(4-24

thereafter,

were

Fat

examination
base-line

following

weekly

ward
mdi-

Multiphasic

conducted:
photoroentgenogram,
gram,
PBI, BMR,
I uptake
front
and side view photograph
admission

limitations

results
of these
tests
On admission,
a his-

physical

the

the

I Am

It. (The
report.)

and

in

dehydrogenase

the

by the
using

employed

foods

but

restriction

were

uniquely

composed

of carbohydrate

12 g daily.

On

these

of

characterized

content

diets

the

to

main

var-

Period

Fat,
Protein,

#{182};,
%

Monounsat.

fat,

Polyunsat.
Sat.

Cholesterol,
PUS/S

mg
ratio

2,500-2,900
a
Provides

cal

44J

30

the

60

70

polyunsaturated

80

67

55

37

32

cholesterol,

35

26

23

21

13

67
74
1 ,878 1 ,423l

60

42

26

1,126
0.50

level.

12 g carbohydrate

daily.

892
0.51

The

in

m and

is listed

50

,l83

of

protein.

diets

50

0.39

percent

or

fat

40

0.35

the

either

60

0.5l

<

IV

70

III

30
g

fat,

fat,

11

ment

content

of

of

Table

the

derived

PUS/S

essential

from

composition
shows,

monounsaturated
fatty

and

calories

acids,

in

ratio.

A
was

the

addition,

fatty
saturated

vitamins

of

acids,

fatty

daily

acids,

supple-

provided.

The men, of normal

weight,
in group
1 were
first given a general
hospital
diet of about 2,700
cal
(based
on 15 cal/pound)
during
a 1-week
control
period
of adjustment
on the Clinical
Research
Center.
There
was
a slight
redulction

Downloaded from www.ajcn.org by on December 9, 2007

obtained

demanding

submitted

Why

they

metabolic
the obese

of

and

entitled

the

Minnesota

Inventory

essay

and

by a strict

and

determined

AutoAnalyzer

method
for

study

were

acids

developed

carefully

motivation

the

exercise,

addition,

Personality

and
in

completed

word

fatty

Technicon

had

purposes

were

concerning

diet,

al.

plate

imposed

viduals

signifiall

reducing

interest

were

freedom

for

all patients

participation

schedules

were

healthy;

diets

continued
fully

group

success.

to admission,

Screened

this

otherwise

or snore

without

of

of

but

et

Metabolic
and

then

stabilization

troductory
the

for

periods

tary

diets

varying

of 1

periods.

the
g

four
of

of

in

received

a small

adjustment

given

10%

of the

40%

from

for

a more
and

of

were

derived

50%

from

50

sources

in

type

of
plus

VI was

2 weeks

normal

calories
fat,

as

period

die-

two

bread

diet,

of

again
in

from

protein,

mixed

carbohy-

2 followed

the

course

Diets
of

larly

when

vation

the

experiment

the
on

is

to

be

difficulties
in
values
particu-

a casual

basis.

It

of comment
that
those
patients
the 50-g supplement
of carbohynot exhibit
an exaggerated
ele-

of triglyceride

after

141

emphasizes
triglyceride
obtained

is worthy
receiving
drate
did
When
considered

they
which

which

Carbohydrate

noted.
This
interpreting

of

using
juice

final

five

supplement

orange

of

in-

content

the

period,

a small

The

were

dietary

Low

placed

fat

of

primarily

amount

this

then

and
each

each

carbohydrate,

carbohydrate.
period
of

were

protein

on

and

during

men

month

During

men

weight

The

period.

on

Changes

levels.

the
serum
free
(Fig. 3), it can

initial

period

of

drates.

fatty
acids
be observed

lability,

the

are
that
values

CHOLESTEROL

Tlie

obese

ilar

dietary

take

was

patients

in

program

except

restricted

sodium

1,250

mg

to
was

1,200

restricted

that

the

cal

daily.

to

sim-

caloric
In

in-

500

addi-

approximately
400

daily.

RESULTS

300

I,

Experimental

Group

1
200

The
serum
cholesterol
data
for the men
of normal
weight
in group
1 are
plotted
in

Fig.

terol

1.

In

all

increased

dietary

serum

significantly

periods

calories

subjects

in

derived

from

the

fat

00

supplement

daily

of

(mainly

hibited

in

the

a smaller

terol.
In dietary
a more
normal
dramatic
noted,

after

loss
(7).

was

In

in

if

50%

40%

TI

60%

j30%F

0%

l70
I

27

50%.

starch)

5 II

Sept.

Fic.

825

Oct.

L..J._LJ

522296

320273

Nov.

1. Serum

0172431

Dec.

Jan.

Feb.

weight

cholesterol;

7 142128

maintained

constant.

TRIGLYCERIDES

serumm

which

of

choles90

provided

calories,

values
a readjustment

a
was

be counteracted
shown
that
there
increased

23Or-

ex-

weight
throughout
the
the influence
of weight

toward

III
40%

j180t

level at the start

of
should
be emphasized
fed at a level
so as to

could
can be

60%

carbohydrate
of

increase

a stable
this way,

tendency

triglyceride
The
great

form

It
2014

010

iTTP<__p<O.lO8,020

of

over

of

drop
in cholesterol
which
there
was

on cholesterol
In Fig. 2 it
a

period
VI,
distribution

back
to the cholesterol
the experiment.
It
that
the diets
were
maintain
study.

50

I
0%

The
cholesterol
content
of these
diets,
at
the
caloric
level
consumed,
ranged
from
approximately
1,400 to 1,800 mg/day.
The
two
subjects,
ND
and
TR,
who
received
the

p<0.05

those

percent

was

P<O
-iiTI-

choles-

during

which

0.4

serum

values
which
was progressive.
fluctuation
in values
during

50

110

70

UI

VI

-ii

30

27 5 II 18 25 I 8

Sept.

Ftc.
constant.

Oct.

2. Serum

5 2229

Nov.

6 132027

Dec.

triglycerides;

3 10 7 2431

7 14 6 8 21 28

Jan.

Feb.

weight

maintained

Downloaded from www.ajcn.org by on December 9, 2007

(ion,

group

KreIil

142

et

al.

vlo ich

FREE FATTY ACIDS

I000

800

progressi

1)eliod

U)

diet

increased.

urea

nitrogen

levels,

these

tainly

for

UI

if

%F4fr%r50%PF0%F

25 1815

LJL

L/7

Oct.

Sept.

VI

22 29

613

Nov.

26

27

diet

10 7 25 31

Dec.

Jan.

of

free

fauv

acids;

maintained

in

constant.
URIC

at

ACID

#{149}1

#{149}

jU

#{149}!.,

that

even

#{149}.#{149},

Sept.

Oct.

5 2229

t1I
6

became

more
were

fluctuation

acids

uric

stable

I
I
I
7 2431

Dec.

4. Serum

changes

LI
3

32027

Nov.

Fic.

fatty

LIIII
7 4

Jon.

acid

Feb.

no

At

of

individual

values

in

the

emphasizes

wide

for

values

of

interpreting

since

they

are

free

normal
normal

of

elevation

such

diets.

VI

(Fig.

free

Fig.

the

men

6 and

intake,

is

acid

and

high
a mod-

triglycerides

on

remark-

the

normal

evident
in the

range,

despite
the
diet;
again,

be emphasized
that
there
was
of calories
in this experiment.
NORMAL

ADULT

to

significant

remained

in

be
time

diets
were
the experi-

and

serum

Uric

may

cholesterol

even

of

sufficiently

there

of

in-

diet,
periods

level

serum

constant

it should
deficiency

for

in

caloric

weight,

no

MEN

the
361

difficulty

period

reasonable

a caloric

crate
ably

significant

the

to

data

and
ketosis
was
not
absence
of carbohydrate

Again,

serum

8 21 28

values.

and

obsemved.

how

more

very
high
protein
the later
stages
of

in

elevation
j_____j_______j_j__I

the

high

though

maintain

cerienal

increased
dehydra-

low-carbohydrate

for

ment.

27 5 II 1825

BUN

Presente(l

a relatively

imposed

the

average

are

#{149}

consider

greatly
moderate

duiing

over-all

tolerated

6-i

well

when

resumed

grout

dicate

7.-

normal

5).

Feb.

weight

with

fatty

IAvG

OF

41

acid

influenced

by

32

so

many
factors.
Despite
the
very
high
protein
content
of the diets
used,
no significant
elevations
in serum
uric acid were
noted
throughout

24

BLOOD

UREA

NITROGEN

the course
In view
of

of the experiment
(see
the differences
observed

compared

to the

patients,

it is worth

not
very
Of
crease

results

found

noting

in
that

Fig.
here
the

obese

ketosis

did

develop
in these
patients
despite
high fat content
of the diet.
significance,
in

blood

however,
urea

was
nitrogen

4).
as

the

70/.

30!.
0i

the

FAT
PROT.
3

00%
FAT
40%PROT.

50T.
50%
9

40%

FAT

30%
FAT
70%PROT

60%PROT
3

IT

17

19 -

WEEKS

in-

values

FAT
PROF

Fit;.5. Serial blood

urea

nitrogen

levels.

REG.
DET
21

23

Downloaded from www.ajcn.org by on December 9, 2007

3. Serum

of

values

was
The

Fic.

alarming

increases,

of

return

lange

60%

of the
blood

of

the presence
of reduced
renal
Of
great
significance
was
the

om- in

abrupt
I
-

period

reach

be

could

function.
200-

not

circumstances

tion

from

significant
might

values

under
400-

did

are
One

sticli

increased

I)rotein
content
While
elevations

individuals

function.
600H-

ely

the

as

Metabolic

Changes

and

duced

180
76

Carbohydrate

Low

WEIGHT

a___.__.._..___,._____._____.

#{149}

72

-15vR

URIC ACID

\
\/

FF.A.

#{149}%.-.-.i-%d
I

II

,..CHOL.

the
the

menstrual
high
level

-TO

these

III

-1____I_____I____j

Oct.

Ftc.

Nov.

6. Average

fatty

acids,

adult

men.

T:

Vt

Dec.

values

cholesterol,

for

Jon.

Feb.

weight,

and

4 21 28

uric

from
of

easiest

acid,

free

of

four

triglycerides

30%
ratio

Group

possibility
tributing

hypothyroidism
to their
obesity.

on

these

studies

II.

There

was

in

the

basal

patient
BMR.

are
a

The

had

PBI

in the normal
data
at 24

hr

as a
The

presented

in

considerable

metabolic

(MP)

protein

meet

on

range,
were

but

Table

only

one

significantly
for

all

low

patients

while
the
interpreted

the

Research

is the

which

II

Function

Age

low

range.

of time
to be
Center,

that
studied

only

Data

BMR

ae

53
36

+7
-18

12%

6.1

16%

5.8

CC

16

7.6

17

+27
-10

14%

CE

12%

6.2

JJ

21

-3

11%

7.4

DVR

20

+4

9%

7.9

DiR

15

14%

a At 24 hr.

I
250

the

and

50%

protein)

the

five

obese young
girls.
The
results
of
caloric
1,200
cal/day
in the
obese

CHOLESTEROL

for

the

TRIGLYCERIDES

periods

00

V
r

25

APRIL

restriction
patients

ACiD10

first

fat

for

URiC

on

dietary
periods
could
be used
adult
women
and two dietary
fat and
30%
protein,
50%
each

7.9

group

three
obese
(70%

1 month

is

carbohydrate-re-

300

of the limits
had
available

of

this

and

uptake

as

hypometabolic.

Clinical

fat

were

131J

hypothyroid

Female

of
was
from

period

calories
a

Thyroid

AW

condata

Clinically
there
was no evidence
of myxedema
in any patient,
and it was not considered
that
these
patients
were
signifiBecause
patients

too

from

Incidentally,

to

MP

fluctuation

rates

values

euthyroid-borderline

cantly

time

in group
2 (female),
all of
distinctly
obese,
had
comfunction
tests to rule out
the

of
factor

MP

the

during

TABLE

Patients,

The
patients
whom
were
plete
thyroid

at

of calories

protein.
fat

and

patient

noted

70%

Initial

Experimental

anxiety

particularly

to

inter-

period.
Significant
of appetite
satiation

of

in

which

In

al-

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Sept.

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diets,

exer-

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considerable

particularly

at a level

lsI50sPlTi1io1475%P

30%F[60%F

of

depression.

was

commen-

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encountered

created

All

and

periods

were

this

70%F

loss

rate

(Figs.

temporary

#{149}#{149}__#{149}i

._._.#{149}...,,#{149}_

imposed

occasional

400

200

though

results.

at
a
restriction

caloric

pattern

143

gratifying

weight

with

estingly

S%,_

of

lost

surate

weight

#{149}-#{149}.

\I\i

600

-I

number

p;ttients

cisc
800

Diets

to
pro-

Fic.
acid,

7. Serial
cholesterol,

70%
30%

FAT
PROTEIN

6
MAY

changes

T
23

60%
40%

.JL. 50%
T 50%

FAT
PROTEIN

SI

20

FAT
PROTEIN

27

JUNE

in

triglycerides,

weight,
and

and

serum

glucose.

uric

Krehl

144

stricted
diet
which
leans
fish,
and
dairy
products
calories.

As

the

heavily
as a

1,200-cal

et

on meat,
source
of

diet

becomes

al.

versa!

in

terol

and

the

to

tendency

7).

Evidently

and

unless

a long

enough

than

glyceride

and

stances
tomed

satisfied

even
amount

under

these

though
more
of exercise

circum-

than
the accuiswas undertaken.

On
the
dietary
balanced

other
hand,
the
monotony
limitations
imposed
by
the
diets
created
many
moments

anxiety

and

difficulties

for

and the
the diets.

research

dietitians

tients
vided

of

became

metabolic

evident

ment
of hyperuricemia,
the norm;tl
range.
ference
and

is noted
triglyceride

obese

women

compared
study.
In

on

to
diet

calories)
and
fat and

lesterol
ings
of

intake.
Galbraith

impact

of

cholesterol

time

Also

regard

levels

in

to
the

of

the

diet
the
fat

weight

reduction

levels.

On

progressed

in

on

the

diet

period

with

bodies

in

OBESE
NP-URIC

ACID-

BENEMID

ADULT

(0-25

A 40 -

qBD

ACED-

re-

in

BID

the

It

norpe-

was

noted

III,

patient

that
MP
toler-

the

A W

2-hr

was

glu-

also

ab-

the

renal
ketone

acid

in

uric

be

site

dc-

exaggerated
excretion

to

for

the

acid

body

related

a competi-

uric

acid

preferential
and

serum

concomitant

ketone

bodies

was

in

excreted

that
may

with

levels
ketone

Benemid

acid

excretion

8.

sig-

acid

drop
with

uric

Fig.

of

\Vhen

)Os5ib1y

bodies,

uric

prompt

of

urine,

in

be
and

exhibited

elevations

noted

increase

may
levels

shown
A W

serum

postulated
the
serum

in

and

excretion

retention

of

uric

(9-11).

all

mildly

facility.
the

glucose

as

urine.

the

is

\Vhile

,,t\DIIJROB/DI

out-patient

relationship
uric
acid

in

was

in

of

BLOOD

do

our

and

and

ketone
URIC

tn-

observa-

in

It

bodies
MP

in

with

WOMEN

BLOOD

serum

marked

aci(l

tive

for

of

expenitnental

to 3 hr,
of patient

increases

along

urine.
rations

as

up

ketone

increase

the

II,

an

abnormal

Patients

uric

find-

hand,

period

administered,

serum

other

12).

diet

interesting
between

nificont

30%

is similar
to the
et al. (7) regarding

in

this

and

curve
tolerance

Both

there
is a fall
in serum
triglyceride
levels
despite
greater
than
normal
choThis

similar

remained

ance

urinary

as

group

and

in

of

a significantly

An
noted

dif-

serum

phases

normal.

cholesterol

a calorie-restricted

these

made

throtighouit

had

factor

conducted
metabolism

levels

end

(Fig.

significant

proceeding

(Figs.

cose

above

significant

the
men
in
period
I (70%

protein
cholesterol
the high

develop-

been

the

levels

are

cholesterol

glucose

the

apparent.

range

at

factor

the

significantly

with

nod

is

choles-

with

initial

period,

currently

Serum

pro-

change
with

has

pa-

the
who

iion

mal

time

serum

noted

of

ketotic

the

obese

on

patients

the

were

caloric-restricted,

low-carbohydrate

no

(liets,

significant

ab-

C.
NP-URIC

(600

ACID-URINE

A.W.-URIC

normalities

ACID-URINE

were

trolytes

(400

of

noted

these

patients

abnormal

losses

of

potassium

were

evident

association

with

this

in

the

and

seruim
no

dcc-

unusually

(200
I000
800
6OO

400

DES1
8 25
APRIL

6 23
MAT

31

0
JUNE

20

27

Fic. 8. Interrelationships
body

excretion.

1825
APRIL

Figs.
2

of uric

6 23
MAY

31

13

20

acid

and

#{182})
and

Again,
ketonc

study

on

were

noted

sodium,
in

degree

the
of

or

urine

in

ketosis

(see

10).

27

JUNE

chloride,

as

in

the

men

the

of normal

case

marked

elevations

of

the

group

weight,
in

the

there
blood

Downloaded from www.ajcn.org by on December 9, 2007

Evidence
soon

both

become

study

the

experiments

not

and
imof

of

is

regain

established
as a way
of life, a significant
educational
impact
is made
that
hunger
can be abated
and the desire
for food more
amply

direction

triglyceride

Metabolic
SERUM

leo

Changes

and

Low

interesting,

ELECTROLYTES

OBESE

Carbohydrate

WOMEN

Diets

however,

problem

in

the

145

that

younger

this

was

girls

less

of a

as compared

60

to
40
20
-U

oo

80

the

older

women.

levels

in

this

group

lower

base-line

level

sively
as weight
factor
is much
previously
noted

Cl

Serum
were,

cholesterol

of

yet

course,

did

fall

at

progres-

was lost.
Here
the
time
shorter
and
perhaps
the
rebound
in cholesterol

60

levels
has
glyceride

40

20

CO2

.----.---.-------....-.--.--.---------

25

not
yet become
manifest.
Trilevels
were
slightly
elevated

23

31

BLOOD

2027

UREA

NITROGEN

28

APRIL

MAY

TEENAGE

GIRLS

JUNE
24

Fic.

9. Serial

serum

electrolyte

levels.
20

(AVG.

SERUM

URINE

;0

(6

5 GIRLS

SERUM
URINE

70%
30%

FAT
PROTEIN

60%
40%

FAT
PROTEIN

50%
50%

FAT
PROTEIN

II

WEEKS

Fic.

11.

creasing

Blood

(lietary

urea

nitrogen

OBESE

2(0
Co

2O5

changes

with

in-

protein.

TEENAGERS

(AVG AVG
5)

WEIGHT

200

a.
10.

Fm.

urea

Electrolytes

nitrogen

in

serum

increasing

tary

periods

as

diet

was

these

elevations

the

protein

they

could
the

become
development

not

content
in

suggest
seriously
of

die-

of

the

are

shown

in Fig.

CHOLESTEROL
I 40

(20

patholog-

trend

exaggerated
dehydration,

which
(00-

with
acute

12. Again,

weight

:R1DE25

80

illness
with
nausea
and
vomiting,
or increased
renal
failure
(see Fig. 11).
The
results
obtained
in the five obese
girls
for weight
loss, serum
cholesterol,
triglycerides
and
glucose,
and
uinic acid
levels

(60

\\Thile

the

180

the

increased.

are

range,

urine.

thiough

progressively

ical

and

195

60

40

20
-

loss

3.___.__

URIC

01

commensurate
restriction
continued
weight

and
with

relating

with
the
activity
the
to

usual
water

degree
was

of caloric
noted
and

fluctuations
retention.

Fm.

of
It

is

21
JUNE

12. Serial

cholesterol,
obese

ACID

(4

changes

triglycerides,
teenagers.

6
JULY

28

of
glucose,

weight
and

and
uric

serum
acid

in

Downloaded from www.ajcn.org by on December 9, 2007

ELECTROLYTES,

Krehl

146
OBESE

al.

of calories,
regardless
of whether
derived
from
fat, carbohydrate,

TEENAGERS
(AVG.

et

OF 5)

Bloom

BLOOD

(12)

ties

of

since

fasting

is

protein
the

vides

these

URINE

calories

urine

the

between

and

ketone

body

uric

worrisome

acid

elevations

in

the

low

of uric

of
and
in

girls,
and again
this seemed
with
increased
losses
of
in the urine.
As ketonuria

to
kede-

uric

acid

levels

decreased

13).
DISCUSSION

The

wide

appeal

stricted
diets
may
they
offer
something
ally
more
permissive
tary

the

programs

initial

loss

cant
as a
water;
this
catabolism
After
tired
the

loss
final

of

analysis

of

metabolic

form

pro-

from

demonstrates

salt

excreted

mixture

from
of

protein
fasting.

when

increased.

Gamble
in

in

in

excess

inhibits
Sodium

the

of

that

the sodium
excretion
is

carbohydrate

utilization

et al.

fasting

cellular

(15)

there

was

of

water

is

suggested
a

loss

that

tiple

weight

reduction,

of

weight

is quite

and

adipose

tissue

on

prolonged

as measand
susdepends
restriction

in

accounted

excess

findings

of

from

extra-

reduction

of

for

caloric

have

the

early

weight

expenditure.

been

Such

observed

by

many

the

adult

others.

In

the

men

experiment

of

in group

normal

weight

hydrate-restricted
to

weight

serum

free

bodies

as has

Bloom

(13).
in

this

the

with

that

obesity

of

also
to

the
both

ketosis.

could
that

explain

this

Kekwick
loss
at

Azar

and
keto-

studied

completely

of

to

ac-

Bloom
the

fasting

(16)
resist-

ketosis

susceptibility

but

of women

that

taken

in
in

increased

is possible

exercise

diets

not

the

their
ketone

significant

Patients

sexes
It

weight

by

only

of

While

observed

observation

not

abolished

amount

urinary

of
is

sufficient

increase

or

obese

experiment

cord

fat

been

a carbo-

a level
not

acids

observation

nunia

at
did

fatty

1,

receiving

diet

maintain

ance

signifi-

loss

factors
in

The

relate
to the fact
that
different,
are generthan
the usual
die-

for

fluid,

of cell volume,
and water
loss from
metabolism
of cell substance
and that
these
muil-

carbohydrate-re-

initial
loss of weight
the
scales,
continued

by

tained

of

result
of diuresis
of salt
and
is not related
to an increased
of fat and is hence
artifactual.

this

sources

which

amount

and

diet
of food.

documentation

sources

decreased

loss

levels

serum

(Fig.

in

acid

excretion.

members
marked

creased,

the

early

while
blood
glucose
remained
normal
range.
Again,
as with
the
other
group
2,
there
was
noted
these
young
be associated
tone
bodies

good

of

fat

JULY

13. Interrelationships
and

of

endogenous

in the

and

mixture

by

the
our

greater
patients

difference.
and
was

a caloric

Pawan
most
intake

(17)

rapid

reported
with

of

high-

1,000/day,

Downloaded from www.ajcn.org by on December 9, 2007

0
KETONE

Fic.

metabolic
from

is

derived
excretion

30

serum

similanidiet

fasting
or carbohydrate-restricted
individual is a function
of the metabolic
mixture
available
to the
cells
(14).
Carbohydrate
in

JUNE

the

carbohydrate-restricted

of

that

ouit

primarily

derived

while

There

ACID

the

comprised

number

URIC

pointed

carbohydrate-deficient

fasting,
1

has

these
are
protein.

or

Metabolic
their

experimental

tremely

short

ported

were

rate

losses
et

of

of

fat

the

diet

rate

mainly

the

calories
loses

and
weight

some

peculiar

because

of

note
on

observation

ui-ca

of

nitrogen

and

of

patients

on

low-carbohydrate,

stnicted

diets

emphasizes

caution

in

diets

without

In

the

weight
as

the

proper

final

much

to

rather

and

its

in

obese

need

the

success
will

of

value

diet

and

of

relate
that

understanding

the

their

a
not

is

used

of

food

and

of

basis

of

should

of a regular
exercise
and activity
program.
This
obviously
involves
a considerable
de-

education

with

gree

of

need

the

whole

everyday

and

process
living.

struction

was

educational

of

about

and

our

effort
The

food

In
given

fundamentals
balance.

of

relearning

its

study,

by

the

to

teach

in

the

dividuals

will

definitely

base

follow

believe

from

gram

which

what
that

any

this

weight

they

learn,

must

reduction

be

for

tivity.
for

-afl(1

it

sirable

long

those

with

significant

of

the

tritional

the

drate

food

to

passage

such

the
ac-

the

this

count
de-

most

provide

the

in

still
at

essential

reduiced
would

of

nit-

a balanced

nutiients.

restricted

consider

use

on

effort
that

related

of

focus

be the one
that
basic
categories

all

must

its
on

physical

Calories

severely

responsibility

and

and

and

of
of

reduction
nutritional

and

mixture

elements

diets

to

seem

would
the

contribution
advocates

on

persistent

would

all

weight

based

problem.

level

hazards

patients

initial

tended

with

should

and
to

The
carbohy-

share

the

the

increased

diets.
REFERENCES

SUMMARY

Both

tubule.

the

they

exercise

metabolic

calorie
represent

we

is built.

in

balance

Emphasis

difficult

pro-

renal

fell

respect

regular

most

pro-

in

a competi-

the

a sound

caloric

need

gram
of exercise
and physical
activity
also
became
quite
meaningful
to these
patients.
While
we do not
anticipate
that
all in-

by

bodies

reflect

in

level

be

achieving

an

calorie

a regular

in

in-

patients

and
of

in

daily

dietitians

nutrition

imposition

use

may

site

initial

activ-

developed

reduction,

program

education

and

time.

The

impoitance

when

exaggerated

levels

the

or

commensu-

of ketone

this

weight

to

loss

been

cholesterol

return

acid

hand,

intake

excretion

of

other

weight

at a common

phase

the

caloric

have

urine,

tion

uric

hyperunicemia

may

\Vliile

the

kind
the

Significant

of

intake,

carbohydrate-restricted
a

ity.

the

such

on

exhibited
with

cm-

caloric

noted.

1,200-cal

rate
which

for

of

diet,

elevations
Under

adequate

females,
a

blood

cholesterol,

nitrogen.

were

ca-

cx-

of
of

elevations

bodies

weight,

moderate

an

significant

concomitant

supervision.
program

caloric

blood

use

analysis,

to

of

calorie-re-

the

indiscriminate

reduction

but

acid

of

Obese

in

to maintain

urea

re-

at

elevations

blood

ctlmstances

no

fat.

when
diet

developed

the

given

a reduction

uric

of

con-

and

particularly

also

ketone

that
this

metab-

elevations

sufficient

levels,

and

and

weight,

significant

lipid

calories.
The

level

rigidly

protein

low-carbohydrate

hibited

if the

diets

content
of

normal

the

of

on

levels

of
a

loric

sufficiently

circumstances

carbohydrate

men

ceiving

isocaloric

of

in

147

Center

varying

The

significantly

controlled
Research

taming

observations
were
(19).
Yudkin
and
interesting
study
on

of

but

restricted

an

the

Diets

normal
obesity

weight
were

and
studied

1.

MACBRIDE,

Medical

C. M. The
Clinics

of

North

diagnosis
America.

of

obesity.
Philadelphia

The

Downloaded from www.ajcn.org by on December 9, 2007

because

effect

by

consisting

on

are

inevitability
of
obese
patient

olism

Clinical

carbohydrate

periods

not

under

re-

diet

differ

not

duration.
Similar
by
Anderson
(20) report
an

diet,

cx-

loss

Carbohydrate

of

influenced

in

Low

nesulits

loss
does

containing

the
the

the

and
water.
observed
that

weight

experimental

long
made
Carey

were

and

of salt
al. (18)

weight

mainly
from

periods
duration
undoubtedly

significant
Pilkington

and

Changes

148

Krehl
London:

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Saunders,

1964,

vol.

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no.

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p.

et
11.

New

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adolescence.

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velopments
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improved

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fects

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