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Vol. 20, No. 2, Eebruary, 1967, pp. 139-148

Printed in (‘..S..4.

Some Metabolic Changes Induced by Low

Carbohydrate Diets1’2



O BESITY CONTINUES tO be the most corn- burden of protein to be metabolized when

mon mamfestation of malnutrition in carbohydrate is limited to not more than
Out’ affluent societies (1). “To reduce and 50-60 g/day.
stay ieduced’ ‘ (2) is the goal which many While such an unbalanced caloric mix-
ttlre provides an interesting base from

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people puistie endlessly like an elusive
is-ill-o-the-wisp. The generally high rate of which to study the metabolic aspects of
failure iii this effort emphasizes both the the obese patient, the misguided and in-
complexity of the obesity problem and discriminate use of the widely advocated
the general inability of doctors or their low-carbohydrate diet may be a distinct
patients to
handle it well. Obesity for the hazard to health. Some of these dangers
young child or adolescent is of even are: dehydration with an increased de-
greater concern because of the added erno- mand upon the kidneys to excrete end
tional trauma involved and because of the products of nitrogen catabolism; ketosis,
increased chance of continuing to be obese with potential disturbance of acid-base
as an aduilt (3). balance ; aggravation of hyperuricemia;
Almost everything is blamed as the significant and occasionally alarming ele-
cause of obesity except for two of man- vations of blood lipids; and finally, such
kind’s ITlost common faults-greed and diets unless carefully chosen may not sup-
laziness. In searching for the easy way to ply adequate levels of important nutrients
weight loss, almost every conceivable diet suich as calcium, riboflavin, thiamine, and
may 1)C attemj)ted from time to time, sulch ascorbic acid.
as the currently popular low-carbohydrate In view of the widespread use of low-
(bet. carbohydrate diets and the existing con-
Pennington (4) has very interestingly fusion and claims for their virtues, a
reviewed the long historical background study was conducted under the controlled
and use of carbohydrate-restricted diets. conditions of the Clinical Research Cen-
In their practical application, such diets ter to evaluate some of the varied meta-
emphasize protein and fat and result in- bolic effects of such diets. Two categories
evitably in significant increased intakes of of subjects were chosen for study and the
saturated fat and cholesterol and a heavy results are presented herein.

‘From the Clinical Research Center and Depart- MATERIALS AND METHODS
ment of Medicine, College of Medicine, University
The first group studied was comprised of
of Iowa. Iowa City, Iowa 32240.
2 This study was supported by Public Health
four healthy male prison volunteers of about
Service, National Institutes of Health, General normal weight and distribution of adipose tis-

Clinical Research Centers Branch Grant no. MO!- sue. Their ages ranged from 29-40 years.
FR-3!) and from a grant-in-aid, The Cereal In- Group 2 consisted of five young girls, ages
stitute, (;hicago, Illinois. 15, 16, 17, 20, and 21, and two older women,

140 Krehl et al.

aged 36 and 53. All of this group were signifi- fatty acids were determined by the use of the
cantly obese but otherwise healthy; all had Technicon AutoAnalyzer using a technique
tried one or snore diets for reducing purposes developed in this laboratory (5). Glucose 6-phos-
without lasting success. plate dehydrogenase was determined by the
Prior to admission, all patients were carefully method of Kornberg (6). All other biochemical
Screened for their interest and motivation for determinations were made utilizing the standard
continued participation in the study and they niethodologies employed in the laboratories of
were fully informed concerning the demanding the Clinical Research Center and University
schedules of diet, exercise, and the limitations Hospitals. Ketone bodies in the urine were de-
of freedom imposed by a strict metabolic ward termined qualitatively twice daily and recorded
schedule. Ill addition, each of the obese mdi- as small, medium, or large; if found to be large,
viduals completed the Minnesota Multiphasic the urine sample was further diluted so as to
Personality Inventory and submitted a 1,000 le read in the range of small or medium. In
word essay entitled “Why I Am Fat and What this way a reasonable estimation of the com-
I Can Do About It.” (The results of these tests ptratme degree of ketonuria was afforded. A
constitute another report.) On admission, a his- range of values from 1 to 40 was established
examination were and the ketone body excretion recorded accord-

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tory and complete physical
obtained and the following base-line studies ingly.
conducted: photoroentgenogram, electrocardio- Blood pressures were recorded twice daily;
gram, PBI, BMR, “I uptake (4-24 hr), and a the patients in group 1 were weighed once each
front and side view photograph was made. On day and those in group 2 twice each day, on
admission and weekly thereafter, the following arising and at bedtime. All patients were given
Ia boratory studies were conducted: hematocrit, supervised physical therapy; those in group 1
hemoglobin, whitecell count and differ-
blood approximately 1 hr daily while the obese pa-
ential distribution, BUN, uric acid, cholesterol, tients in group 2 had three approximately 1-hr
fasting blood glucose, triglycerides, free fatty periods of physical exercise under supervision
acids, creatinine, RBC, glucose 6-phosphate daily. During the day, all patients were out of
dehydrogenase, electrolytes (potassium, chloride, bed and “up and about” unless ill. No patient
sodium, C0), total serum protein, serum albu- was permitted to leave the Clinical Research
min, and serum globulin. Daily fluid intake was Center area without an escort, and all were Un-
recorded and daily urine excretions were col- der the continued surveillance of our staff. A
lected and the volumes recorded. Once each schedule of occupational therapy was provided
week aliquots of urine were evaluated for so- in the form of “hobby activities.” The patients
dium, potassium, chloride, uric acid, and creat- tolerated this restrictive and tightly controlled
mine. The cholesterol, triglycerides, and free regimen with no more than a healthy amount
of grumbling, and patient cooperation on the
TABLE I whole was splendid.
The basic diets employed were composed of
Composition of Various Low Carbohydrate’
mixed natural foods but uniquely characterized
Diets Used
by a rigid restriction of carbohydrate content to
less than 12 g daily. On these diets the main var-
iant was the percent of calories derived from
I 11 III IV V either fat or protein. The composition of the
diets is listed in Table m and shows, in addition,
Fat, #{182};, 70 60 50 44J 30 the content of monounsaturated fatty acids,
Protein, % 30 40 50 60 70 polyunsaturated fatty acids, saturated fatty acids,
Monounsat. fat, g 80 67 55 37 32 cholesterol, and PUS/S ratio. A daily supple-
Polyunsat. fat, g 35 26 23 21 13
ment of the essential vitamins was provided.
Sat. fat, g 67 74 60 42 26
The men, of normal weight, in group 1 were
Cholesterol, mg 1 ,878 1 ,423l ,l83 1,126 892
first given a general hospital diet of about 2,700
PUS/S ratio 0.5l 0.35 0.39 0.50 0.51
cal (based on 15 cal/pound) during a 1-week
2,500-2,900 cal level. control period of adjustment on the Clinical
a Provides < 12 g carbohydrate daily. Research Center. There was a slight redulction
Metabolic Changes and Low Carbohydrate Diets 141

and then stabilization of weight during this in- the course of the experiment is to be
troductory period. The men were then placed
noted. This emphasizes the difficulties in
on the diets varying in protein and fat content
interpreting triglyceride values particu-
for periods of 1 month on each of the five die-
larly when obtained on a casual basis. It
tary periods. During each dietary period, two of
is worthy of comment that those patients
the four men received a small supplement of 50
g of carbohydrate, primarily using bread plus
receiving the 50-g supplement of carbohy-
a small amount of orange juice as sources of drate did not exhibit an exaggerated ele-
carbohydrate. The final period VI was again a vation of triglyceride levels.
period of adjustment for 2 weeks in which they When the serum free fatty acids are
were given a more normal type of diet, in which considered (Fig. 3), it can be observed that
10% of the calories were derived from protein, after initial period of lability, the values
40% from fat, and 50% from mixed carbohy-
T’lie obese patients in group 2 followed a sim-

ilar dietary program except that the caloric in-


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take was restricted to 1,200 cal daily. In addi-
(ion, sodium was restricted to approximately
1,250 mg daily. 400



Experimental Group 1
200 0.4 P<O p<0.05 010
The serum cholesterol data for the men -iiTI- iTTP<__p<O.lO8,020

of normal weight in group 1 are plotted

in Fig. 1. In all subjects serum choles- 00 I It III if Y TI
0% 2014 60% 40% 50% 40% 60% j30%F 0%

terol increased significantly during those

dietary periods in which the percent of I L..J._LJ
27 5 II 825 I 8 522296 320273 0172431 7 142128
calories derived from fat was over 50%. Sept. Oct. Nov. Dec. Jan. Feb.
The cholesterol content of these diets, at
Fic. 1. Serum cholesterol; weight maintained
the caloric level consumed, ranged from
approximately 1,400 to 1,800 mg/day. The
two subjects, ND and TR, who received TRIGLYCERIDES
the supplement of 50 g of carbohydrate
daily (mainly in the form of starch) ex-
hibited a smaller increase in serumm choles-
terol. In dietary period VI, which provided 90

a more normal distribution of calories, a

dramatic drop in cholesterol values was 50
noted, after which there was a readjustment
back to the cholesterol level at the start of :‘ 110
the experiment. It should be emphasized
that the diets were fed at a level so as to
maintain a stable weight throughout the
study. In this way, the influence of weight - r U UI W Y VI
30 -ii
loss on cholesterol could be counteracted
(7). In Fig. 2 it can be shown that there
27 5 II 18 25 I 8 5 2229 6 132027 3 10 7 2431 7 14 6 8 21 28
was a tendency toward increased serum Sept. Oct. Nov. Dec. Jan. Feb.
triglyceride values which was progressive.
Ftc. 2. Serum triglycerides; weight maintained
The great fluctuation in values during constant.
142 KreIil et al.

FREE FATTY ACIDS vlo ich progressi ely increased from period
U) 1)eliod as the I)rotein content of the
I000 diet increased. While elevations of blood
urea nitrogen did not reach alarming

levels, these are significant increases, cer-
tainly for individuals with normal ienal
function. One might well consider how
sticli values could be greatly increased
under circumstances of moderate dehydra-
400’- tion om- in the presence of reduced renal
function. Of great significance was the
abrupt return of the BUN to a normal
200’- I U UI if V VI
- %F4fr%r50%PF0%F 60%
lange of values when the more normal

L/7 LJL 25 1815 22 29 613 26 27 3 10 7 25 31

diet was resumed duiing period VI (Fig.
Oct. Nov.

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Sept. Dec. Jan. Feb.
The over-all average data for the men
Fic. 3. Serum free fauv acids; weight maintained in grout are Presente(l in Fig. 6 and in-
dicate that a low-carbohydrate diet, even
at a relatively high caloric intake, may be

tolerated for reasonable periods of time
6-’i . #{149}1 #{149} #{149}!., jU #{149}.#{149}, even though very high protein diets were
\ I #{149}
imposed in the later stages of the experi-
ment. At a caloric level sufficiently high to
maintain weight, there is a significant
elevation of serum cholesterol and a mod-
crate elevation of serum triglycerides on
I I j_____j_______j_j__I
27 5 II 1825 I
5 2229
I I t1I
6 32027
3 0
7 2431
7 4 8 21 28
such diets. Uric acid remained remark-
Sept. Oct. Nov. Dec. Jon. Feb.
ably constant and in the normal range,
Fic. 4. Serum uric acid values. and ketosis was not evident despite the
absence of carbohydrate in the diet; again,
became more stable and no significant it should be emphasized that there was no
changes were obsemved. Again, the wide deficiency of calories in this experiment.
fluctuation of individual values for free NORMAL ADULT MEN

fatty acids in the serum emphasizes the

361 IAvG OF 41
difficulty of interpreting free fatty acid
values since they are influenced by so
many factors.
Despite the very high protein content 24

of the diets used, no significant elevations

in serum uric acid were noted throughout
the course of the experiment (see Fig. 4).
In view of the differences observed here as
compared to the results found in the obese
patients, it is worth noting that ketosis did
not develop in these patients despite the 70/.
00% FAT

very high fat content of the diet. 0i - 3 5 - 9 3 IT - 17 19 - 21 23

Of significance, however, was the in- WEEKS

crease in blood urea nitrogen values Fit;.5. Serial blood urea nitrogen levels.
Metabolic Changes and Low Carbohydrate Diets 143

180 duced a number of gratifying results. All

- 76 WEIGHT p;ttients lost weight at a rate commen-

, a___.__.._..___,._____._____. #{149}‘‘ 1
surate with caloric restriction and exer-
72 -15vR
cisc pattern imposed (Figs. 7 and 12) al-
800 - URIC ACID -‘I though temporary periods of plateauls in
\ A #{149}-#{149}“. weight loss were encountered which inter-

\I\i S%,_
estingly created considerable anxiety and

- \/ ‘‘FF.A.
occasional depression. In patient MP
this was particularly noted at the time of
400 the menstrual period. Significant too was
._._.#{149}...,,#{149}_ #{149}#{149}__#{149}i ,..‘CHOL. the high level of appetite satiation from
V these diets, particularly during period I
200 - -“TO
#{149}%.“-.-.i”-”%d at a level of 70% of calories from fat and
I II III if T: Vt
70%F 30%F[60%F lsI50sPlTi1io1475%P I 1 30% from protein. Incidentally, this is the
-1____I_____I____j I I I I I_______I_____(_.____1
27 5 II 18 25 I 8 15 2229 6 3 2027 3 JO 7 24 31 7 4 21 28 ratio of fat to protein calories which is

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Sept. Oct. Nov. Dec. Jon. Feb.
easiest to meet on a carbohydrate-re-
Ftc. 6. Average values for weight, uric acid, free
fatty acids, cholesterol, and triglycerides of four
adult men.
Initial Thyroid Function Data

Experimental Group 2

The patients in group 2 (female), all of

Patients, Female Age BMR
ae 4’
whom were distinctly obese, had com- AW 53 +7 12% 6.1
plete thyroid function tests to rule out the MP 36 -18 16% 5.8
possibility of hypothyroidism as a con-
CC 16 +27 14% 7.6
tributing factor to their obesity. The data
CE 17 -10 12% 6.2
on these studies are presented in Table
JJ 21 -3 11% 7.4
II. There was a considerable fluctuation DVR 20 +4 9% 7.9
in the basal metabolic rates but only one DiR 15 0 14% 7.9
patient (MP) had a significantly low
a At 24 hr.
BMR. The PBI values for all patients were
in the normal range, while the 131J uptake
data at 24 hr were interpreted as “low
in any patient,
that these
was no evidence of myx-
and it was not con-
patients were signifi-
hypothyroid range.”

I 250

cantly “hypometabolic.”
300 URiC ACiD10 ,
Because of the limits of time that group
2 patients had available to be studied on
the Clinical Research Center, only the first
three dietary periods could be used for the TRIGLYCERIDES
obese adult women and two dietary periods 00

(70% fat and 30% protein, 50% fat and

V 70% FAT 60% FAT .JL. 50% FAT
50% protein) of 1 month each for the five - r 30% PROTEIN T 40% PROTEIN T 50% PROTEIN

8 25 2 9 6 23 SI 6 3 20 27
obese young girls. APRIL MAY JUNE

The results of caloric restriction to Fic. 7. Serial changes in weight, and serum uric
1,200 cal/day in the obese patients pro- acid, cholesterol, triglycerides, and glucose.
144 Krehl et al.

stricted diet which leans heavily on meat, versa! in the direction of serum choles-
fish, and dairy products as a source of terol and triglyceride is noted with the
calories. As the 1,200-cal diet becomes tendency to regain the initial levels (Fig.
established as a way of life, a significant 7). Evidently time is a significant factor
educational impact is made that hunger and unless experiments are conducted for
can be abated and the desire for food more a long enough period, these phases of tn-
than amply satisfied under these circum- glyceride and cholesterol metabolism do
stances even though more than the accuis- not become apparent. A similar observa-
tomed amount of exercise was undertaken. iion has been made in an out-patient
On the other hand, the monotony and study currently proceeding in our facility.
dietary limitations imposed by the im- Serum glucose levels remained in the nor-
balanced diets created many moments of mal range throtighouit this expenitnental pe-
anxiety and difficulties for both the pa- nod (Figs. 7 and 12). It was noted that
tients and the research dietitians who pro- at the end of diet period III, patient MP
vided the diets. had a significantly abnormal glucose toler-

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Evidence of a metabolic change factor ance curve up to 3 hr, and the 2-hr glu-
soon became evident with the develop- cose tolerance of patient A W was also ab-
ment of hyperuricemia, significantly above normal.
the norm;tl range. Also a significant dif- An interesting relationship may be
ference is noted with regard to cholesterol noted between serum uric acid levels and
and triglyceride levels in the serum of the urinary ketone bodies as shown in Fig. 8.
obese women on a calorie-restricted diet as Both Patients MP and A W exhibited sig-
compared to the men in the group 1 nificont increases in serum uric acid levels
study. In diet period I (70% fat and 30% along with marked elevations of ketone

protein calories) there is a fall in serum bodies in the urine. \Vhen Benemid was
cholesterol and triglyceride levels despite administered, a prompt drop in serum
the high fat and greater than normal cho- uric aci(l was noted with a concomitant
lesterol intake. This is similar to the find- increase in the uric acid excreted in the
ings of Galbraith et al. (7) regarding the urine. It is postulated that uric acid dc-
impact of weight reduction on serum rations in the serum may be exaggerated
cholesterol levels. On the other hand, as with in increase of ketone body excretion
time progressed in diet period II, a re- in the urine, )Os5ib1y related to a competi-
tive renal excretion site for uric acid and


ketone bodies, with preferential excretion
6 NP-URIC ACID- BLOOD A 40 - URIC ACED- BLOOD of ketone bodies and retention of uric
acid (9-11).
,,t\DIIJROB/DI \Vhile all of the obese patients were
mildly ketotic on the caloric-restricted,

low-carbohydrate (liets, no significant ab-



normalities were noted in the seruim dcc-
trolytes of these patients and no unusually
I000 abnormal losses of chloride, sodium, or

potassium were evident in the urine in
400 0 association with this degree of ketosis (see
DES1 j Figs. #{182})
and 10).
8 25 2 9 6 23 31 6 0 20 27 1825 2 9 6 23 31 6 13 20 27
APRIL MAT JUNE APRIL MAY JUNE Again, as in the case of the group 1
Fic. 8. Interrelationships of uric acid and ketonc study on the men of normal weight, there
body excretion. were noted marked elevations in the blood
Metabolic Changes and Low Carbohydrate Diets 145

SERUM ELECTROLYTES interesting, however, that this was less of a
problem in the younger girls as compared
to the older women. Serum cholesterol
levels in this group were, of course, at a
20 lower base-line level yet did fall progres-
-U oo Cl sively as weight was lost. Here the time
i 80
factor is much shorter and perhaps the
previously noted “rebound” in cholesterol
levels has not yet become manifest. Tri-
glyceride levels were slightly elevated
20 .-‘‘---.-‘“--.--‘-----....-.--.--.--------- CO2

8 25 2 9 6 23 31 6 3 2027 BLOOD UREA NITROGEN

Fic. 9. Serial serum electrolyte levels.

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I 60%

I 2 3 4 5 6 7 8 9 0 II

Fic. 11. Blood urea nitrogen changes with in-

creasing (lietary protein.

2O5 - L (AVG AVG
a. 195

Fm. 10. Electrolytes in serum and urine. 180

urea nitrogen increasing thiough the die-
tary periods as the protein content of the
I 40
diet was progressively increased. \\Thile
these elevations are not in the patholog- (20

ical range, they suggest a trend which

could become seriously exaggerated with
the development of dehydration, acute 80 :R1DE25

illness with nausea and vomiting, or in-

creased renal failure (see Fig. 11).
60 -
The results obtained in the five obese 40
girls for weight loss, serum cholesterol, tri-
glycerides and glucose, and uinic acid lev- 20

- 3.___.__ URIC ACID

els are shown in Fig. 12. Again, weight loss
01 I

commensurate with the degree of caloric (4 21 28 6

restriction and activity was noted and
Fm. 12. Serial changes of weight and serum
continued with the usual fluctuations of cholesterol, triglycerides, glucose, and uric acid in
weight relating to water retention. It is obese teenagers.
146 Krehl et al.

OBESE TEENAGERS of calories, regardless of whether these are

(AVG. OF 5) derived from fat, carbohydrate, or protein.
BLOOD Bloom (12) has pointed ouit the similani-
ties of a carbohydrate-deficient diet and
fasting, since the metabolic mixture of
fasting is comprised primarily of fat and
1 protein derived from endogenous sources
while the carbohydrate-restricted diet pro-
vides these calories in the form of food.
There is good documentation from a
number of sources which demonstrates
that the amount of salt excreted in the
fasting or carbohydrate-restricted individ-
URIC ACID - URINE ual is a function of the metabolic mixture
available to the cells (14). Carbohydrate

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in the metabolic mixture in excess of that
derived from protein inhibits the sodium
30 excretion of fasting. Sodium excretion is
decreased when carbohydrate utilization is
KETONE increased. Gamble et al. (15) suggested that
early in fasting there was a loss of extra-
cellular fluid, loss of water from reduction
Fic. 13. Interrelationships between uric acid in
of cell volume, and water loss from metab-
serum and urine and ketone body excretion.
olism of cell substance and that these muil-
while blood glucose remained in the low tiple factors accounted for the early weight
normal range. loss in excess of caloric expenditure. Such
Again, as with the other members of findings have been observed by many
group 2, there was noted marked and others.
worrisome elevations of uric acid levels in In the experiment in group 1, the adult
these young girls, and again this seemed to men of normal weight receiving a carbo-
be associated with increased losses of ke- hydrate-restricted diet at a level sufficient
tone bodies in the urine. As ketonuria de- to maintain weight did not increase their
creased, serum uric acid levels decreased serum free fatty acids or urinary ketone
(Fig. 13). bodies as has been observed by Azar and

Bloom (13).
The observation of significant keto-
The wide appeal of carbohydrate-re-
nunia in the obese Patients studied in
stricted diets may relate to the fact that
this experiment is not completely in ac-
they offer something different, are gener-
cord with the observation of Bloom (16)
ally more permissive than the usual die-
tary programs for weight reduction, and that obesity not only increased the resist-

the initial loss of weight is quite signifi- ance of both sexes to fasting ketosis but
cant as a result of diuresis of salt and also abolished the susceptibility of women
water; this is not related to an increased to ketosis. It is possible that the greater
catabolism of fat and is hence artifactual. amount of exercise taken by our patients
After this initial loss of weight as meas- could explain this difference.
tired by the scales, continued and sus- While Kekwick and Pawan (17) reported
tained loss of adipose tissue depends in that weight loss was most rapid with high-
the final analysis on prolonged restriction fat diets at a caloric intake of 1,000/day,
Metabolic Changes and Low Carbohydrate Diets 147

their experimental periods were of cx- under the controlled circumstances of the
tremely short duration and the nesulits re- Clinical Research Center on diets rigidly
ported were undoubtedly influenced by restricted in carbohydrate content and con-
significant losses of salt and water. taming varying levels of protein and fat.
Pilkington et al. (18) observed that the The men of normal weight, when re-
rate of weight loss in a diet consisting ceiving a low-carbohydrate diet at a ca-
mainly of fat does not differ significantly loric level sufficient to maintain weight, cx-
from the weight loss rate on an isocaloric hibited significant elevations of blood
diet containing mainly carbohydrate if the lipid levels, particularly of cholesterol,
experimental periods are of sufficiently and also developed moderate elevations
long duration. Similar observations were of the blood urea nitrogen. Under cm-
made by Anderson (19). Yudkin and ctlmstances of an adequate caloric intake,
Carey (20) report an interesting study on no significant elevations of uric acid or
the inevitability of calories and note that ketone bodies were noted.
“the obese patient loses weight on this Obese females, on the other hand, when

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diet, not because of some peculiar metab- given a 1 ,200-cal carbohydrate-restricted
olism effect but because of a reduction in diet, exhibited a weight loss commensu-
calories.” rate with their caloric intake and activ-
The observation of elevations of blood ity. Significant hyperunicemia developed
ui-ca nitrogen and of uric acid in obese which may have been exaggerated by a

patients on low-carbohydrate, calorie-re- concomitant excretion of ketone bodies in

stnicted diets emphasizes the need for the urine, and this may reflect a competi-
caution in the indiscriminate use of such tion at a common site in the renal tubule.
diets without proper supervision. \Vliile cholesterol levels fell in the initial
In the final analysis, the success of a phase of weight reduction, they tended to
weight reduction program will relate not return to the initial level with the passage
as much to the kind of diet that is used of time.
but rather to the understanding of food The basis of a sound weight reduction
and its caloric value and the impoitance program should be based on nutritional
of a regular exercise and activity program. education with respect to food and its use
This obviously involves a considerable de- in achieving caloric balance and on the
gree of education and relearning about need for regular exercise and physical ac-
the whole process of food and its use in tivity. Emphasis should focus on the
everyday living. In our study, daily in- need for a long persistent effort in this
struction was given by the dietitians in an most difficult problem. Calories still count
educational effort to teach the patients -afl(1 it would seem that the most de-
fundamentals of nutrition and calorie sirable metabolic mixture at a reduiced
balance. The imposition of a regular pro- calorie level would be the one that would
gram of exercise and physical activity also represent all the basic categories of nit-
became quite meaningful to these patients. tritional elements and provide a balanced
While we do not anticipate that all in- contribution of all essential nutiients. The
dividuals will follow what they learn, we advocates of severely restricted carbohy-
definitely believe that this must be the drate diets must consider and share the
base from which any weight reduction pro- responsibility related to the increased
gram is built. hazards of such diets.

Both patients of normal weight and 1. MACBRIDE, C. M. The diagnosis of obesity. The
those with significant obesity were studied Medical Clinics of North America. Philadelphia
148 Krehl et al.

and London: Saunders, 1964, vol. 48, no. 5, p. 11. BENOIT, F. L., R. L. MARTIN AND R. H. WATTEN.
1307. Changes in body composition during weight
2. JOLLIFFE, N. How to Reduce and Stay Reduced. reduction in obesity. Ann. Internal Med. 63:
New York: Simon and Schuster, 1957. 604, 1965.
3. MAYER, J. Obesity in childhood and adolescence. 12. BLOOM, IV. L., AND G. J. AZAR. Similarities of
The Medical Clinics of North America. Phila- carbohydrate deficiency and fasting-I. Weight
deiphia and London: Saunders, 1964, vol. 48, loss, electrolyte excretion, and fatigue. Arch.
no. 5, p. 1347. Internal Med. 112: 87, 1963.
4. PENNINGTON, A. W. Treatment of obesity: de- 13. AZAR, G. J., AND W. L. BLOOM. Similarities of
velopments of the past 150 years. Am. J. Digest. carbohydrate deficiency and fasting-Il. Ke-
Diseases 21: 65, 1954. tones, nonesterified fatty acids, and nitrogen
5. GooD, E., A. LOPEZ-S AND W. A. KREHL. An excretion. Arch. Internal Med. 112: 92, 1963.
improved rapid system of lipid analysis. Federa- 14. BLoosi, W. L. Inhibition of salt excretion by
tion Proc. 24: 438, 1965. carbohydrate. Arch. Internal Med. 109: 80,
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