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THE ENDOCRINE SYSTEM [ANSWER]

Starvation 1. A typical, healthy adult man in the resting


basal state expends approximately 20 kcal/kg,
which equals 1400 kcal/day in this person.
A 26-year-old male prisoner begins a hunger strike Ordinary spontaneous movements would
to protest what he considers unfair prison policies. account for another 300 to 400 kcal/day. His 1
He drinks only tap water, and his only exercise is hour of exercise would require approximately
two daily half-hour walks at approximately 2.5 250 kcal. Thus his total daily energy
miles/hr. The temperature in his cell is maintained expenditure might be approximately 2000
at 72 oF. His starting weight is 70 kg (154 lbs), of kcal initially. As fasting continued, his basal
which 14% is body fat. At the end of 4 weeks, he is metabolic rate would diminish about 15% to
urged by the prison physician, family, friends, and approximately 1200 kcal/day and lethargy
his attorney to stop his fast because of his might also reduce both spontaneous and
deteriorating condition. voluntary physical movement. Thus, for the 4
weeks, his overall energy expenditure could
1. What would you estimate his daily energy
average 1800 kcal/day.
expenditure to be?

2. Approximately how much weight would he have 2. His total caloric needs for 28 days would be

lost in 4 weeks? What would be the 56,000 endogenous kcal (1800 per day x 28

approximate distribution of this lost weight in days). Ninety percent of this would be

carbohydrate, protein, and fat? In lean body supplied by fat at 9 kcal/g. Thus, 0.9 x 56,000

mass and adipose tissue? What would his ¡Â 9 equals 5600 g or 5.6 kg of fat. Adipose

respiratory quotient be at that time? tissue is composed of 15% water. Hence, 5.6
¡Â 0.85 or 6.6 kg of adipose tissue would be
3. What changes in plasma levels of energy lost. Ten percent of the caloric needs would be
substrates would occur in the first 3 days of supplied by protein at 4 kcal/g. Thus, 0.1 x
his fast? What changes in urinary constituents 56,000 ¡Â 4 equals 1400 g or 1.4 kg of protein
would be expected? that would be lost. The source of this protein

4. On what immediate and on what ultimate is lean body mass, which is composed of 72%

sources of energy would brain metabolism water. Thus, 1.4 ¡Â 0.28, or 5 kg, of lean body

depend? mass would be lost. Carbohydrate stores of


energy are very low and contribute no more
5. What early changes in plasma levels of than 0.3 to 0.4 kg, all in the first 2 days. Thus
hormones would occur? How would this the estimated total weight loss would be 6.6
regulate his energy metabolism? plus 5, plus 0.4, or 12 kg. His respiratory
quotient would be slightly greater than 0.7
6. What other hormonal compensatory
because of the predominance of fat as a
mechanisms would be called into play to
substrate for oxidation.
conserve energy and prolong life?

7. What physiologic events would occur when he 3. Plasma glucose would decrease to a lower,
stopped his fast by drinking a large quantity of but stable level after glycogen stores were
orange juice? depleted. Plasma free fatty acids and glycerol
would increase because of accelerated
lipolysis, and keto acids (beta-

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hydroxybutyrate and acetoacetate) would The loss of somatomedin's stimulation of
increase as a result of increased free fatty protein synthesis shunts amino acids away
acid delivery to the liver. Plasma branch chain from anabolic storage toward conversion to
amino acids would increase because of needed glucose. Maintenance of cortisol and
increased proteolysis in muscle. Urinary elevated growth hormone levels diminishes
nitrogen would increase, indicating the sensitivity of muscle to insulin and further
degradation of endogenous protein. Excretion preserves the glucose supply to the brain.
of sodium in the urine would promptly cease
in the absence of sodium intake after a small 7. Ingestion of any source of carbohydrate would
fall in extracellular fluid volume. Excretion of raise plasma glucose and thereby rapidly
the predominantly intracellular electrolytes stimulate insulin release and inhibit glucagon
(potassium and phosphate) would continue, and growth hormone release. Glucose
indicating the loss of protoplasm. oxidation would increase and thus raise the
respiratory quotient. Storage of glucose as
4. Initially, the brain would be almost entirely glycogen in liver and muscle would be
dependent on glucose generated by stimulated by insulin. At the same time,
gluconeogenesis, mostly from amino acid uptake of potassium and phosphate by these
substrates liberated by muscle proteolysis. tissues would be stimulated, causing a
Gradually, however, keto acids generated by decrease in their plasma levels. A sharp
oxidation of free fatty acids would become decrease in plasma free fatty acids, keto
brain substrates and would eventually supply acids, and branch chain amino acids would be
two thirds of the brain's energy needs. This expected as the high insulin levels reduced
would help to conserve lean body mass lipolysis, ketogenesis, and proteolysis.
during fasting.

5. Plasma insulin would decrease and plasma


glucagon would increase. The lower ratio of
insulin to glucagon facilitates mobilization of
liver glycogen, adipose tissue triglycerides,
and muscle protein.

6. Serum thyroid-stimulating hormone (TSH) and


its response to thyrotropin-releasing hormone
(TRH) would decrease. In addition, serum
triiodothyronine (T3) would decrease because
of reduced 5' monodeiodination of thyroxine
(T4). The net result is a lower level of the
active T3 molecule, which contributes to the
decrease in resting energy expenditure.
Cortisol secretion would increase modestly,
facilitating muscle proteolysis and
gluconeogenesis. Growth hormone levels
increase, facilitating lipolysis. However,
conversion of growth hormone to
somatomedin would be greatly diminished.

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