Lipolysis and Gluconeogenesis From Glycerol During Weight Reduction With Very-Low-Calorie Diets Jorge A. Vazquez and Uzma Kazi ‘The aim of this study was to determine if the rates of lipolysis and the conversion of glycerol into glucose are higher during weight reduction with a ketogenic than a nonketogenic very-tow-calorie diet (VLCD}. Sixteen obese women were randomly “ssigned to consume either a ketogenic or nonketogenic 615-kcal/d diet for 28 days while confined to a metabolic ward. Glycerol and glucose rates of appearance (R,s) and the conversion of glycerol into glucose were measured before and after 14 and 28 days of treatment with a simultaneous, primed, constant infusion of U-["C}-glycerol and 6-(*H}-glucose. Resting energy expenditure (REE) and rates of substrate oxidation were measured by indirect calorimetry. Data were onalyzed by repeated-measures ANOVA, There were no diet or time effects on the plasma glycerol concentration or glycerol Rs. There wi modest but significant time effect on the glucose R, and on the conversion of glycerol into glucose when expressed as a percentage of the glycerol or glucose R,. However, even after 28 days of treatment, the conversion of glycerol into glucose Recounted for only 16% and 58% of glucose and glycerol R,s, respectively. At day 28, plasma glucose and alanine ‘concentrations were lower and the rate of protein oxidation was higher in the ketogenic than in the nonketogenic VLCD group. ‘We conclude that in severe obesity, (1} the rates of lipolysis and gluconeogenesis from glycerol are not increased by altering the composition of the VLCD; (2) glycerol is a minor gluconeogenic precursor during weight reduction; and (3) nonketogenic VLCDs are more advantageous than ketogenic VLCDs sparing. Copyright © 1994 by W.B. Saunders Company LURING STARVATION, stored triglycerides (TG) are hydrolyzed and free fatty acids (FFA) and glye- cerol are released from adipocytes to meet energy demands.’ Under these conditions, FFA and ketone bodies become the preferred fuels in the body.! However, not all FFA released from TG lipolysis are used as an energy source. Some FFA are re-esterified into partially hydrolyzed TG without leaving the adipocyte (internal recycling), and others are re-esterified into TG elsewhere in the body and later returned to the adipose tissue for storage (ie, external recycling) In contrast to FFA, glycerol is not considered a ‘major oxidative substrate.’ Most of the glycerol produced from TG hydrolysis is converted into either glucose or TG. Previous studies in animals‘ and humans” have shown that 30% to 60% of the glycerol released from adipose tissue is converted into glucose. After exercise ot a pro- longed fast, the relative importance of glycerol to gluconeo- genesis increases." ‘Because of the risks and poor long-term results associ- ated with starvation, very-low-calorie diets (VLCDs) have come to be the preferred treatment for reducing body fat mass in severely obese patients.* The aim of these diets isto produce maximal fat mobilization while preserving lean body mass. VLCDs vary widely in their macronutrient composition. It is well accepted that the VLCD composi- tion is important for protein sparing,” but the importance of the VLCD composition in enhancing lipolysis and fat oxidation is not known. Based on observations made during a total fast, it has been hypothesized that low-carbohydrate (Ketogenic) VLCDs will result in greater rates of lipolysis and fat mobilization than high-carbohydrate (nonketo- genic) VLCDs."” If this isthe case, it may also be expected that the relative contribution of glycerol to gluconeogenesis ‘would be greater in ketogenic than in nonketogenic VL- CDs. Since an increase in gluconeogenesis from glycerol may reduce gluconeogenesis from other precursors," this. adaptation may be an important mechanism of protein sparing during treatment with a VCD. ‘Metaboliem, Vol 43, No 10 (October), 1984: pp 1282-1299 ‘maintaining normal plasma glucose concentration and promoting protein ‘To assess the validity of these hypotheses, in the present study we have measured the whole-body rate of lipolysis and the contribution of glycerol to gluconeogenesis in patients consuming a ketogenic VLCD or an isocaloric and isonitrogenous nonketogenic VLCD for 28 consecutive days. To ensure compliance with treatment, patients were confined to a matabolic ward for the duration of the study. SUBJECTS AND METHODS Subjects Sixteen severely obese (body mass index > 35 kg/m’) women were studied. A complete medical evaluation showed that all patients were in good health except for being obese. None of the patients were receiving medication at the time of the study. The Study was approved by the Institutional Review Board of the University of Pittsburgh. All patients gave written informed con- sent forthe study. Experimental Design All patients were admitted to the Clinical Research Center of the University of Pitisburgh Medical Center for a period of 31 ‘consecutive days. During the first 3 days (days ~3 to ~1), patients ‘consumed a meat-free, weight-maintaining diet that provided 75 protein and 2,500 keal/d. On the fourth day (day 0), they were randomly assigned to receive either a 615-keal/d ketogenic diet or ‘an isocaloric and isonitrogenous nonketogenic VLCD. The diets From the Clinical Nutrition Research Unit, Department of Medi- cine, University of Piasburgh School of Medicine, Pinsburgh, PA. ‘Submited August 9, 1993; accepted January 11, 1994 Supported by Grants No. DK 39157 and SMOIRR-00056 from the ‘National Insites of Health. Presented in abstract form atthe Annual ‘Meeting of the American Federation of Clinical Research, April 1993, (Clin Res 41:124A, 1993). “Address reprint requests o Jonge A. Vazquez, MD, Clinical Nutrition Research Unit, Montefiore University Hospital, University of Pasburgh Medical Centr, 200 Lothrop St, Pisburgh, PA 15213-2582. ‘Copyright © 1994 by W.B. Saunders Company 0026-0495 /94/4310-0015$03.00/0 12931298 ‘were provided as five equal feedings and were consumed at approximately 8 aw, 12 noon, and 3,7, and 8PM daily. The duration of treatment with each diet was 28 days (days 0 to 28). Both diets were provided in liquid form. Patients were encouraged to con- sume noncaloric fluids liberally. Patients were weighed day in the ‘morning after voiding, Temperature, pulse rate, and supine and standing blood pressures were measured twice daily. Electrocardio- grams were obtained weekly, Activity was limited to walking in the hospital ward ad libitum. Giycerol and ghicose whole-body kinetics and indirect calorimetry were performed after an overnight fast on ‘days 0, 14, and 28 of dietary treatment. Diets Patients in the Ketogenic VLCD group consumed a diet that provided 615 kcal, 70 g protein, 33 g fat, and 9 g carbohydrate per day. Patients in the nonketogenic VLCD group consumed a dict that provided 615 keal, 70 g protein, 3g fat, and 86 g carbohydrate per day. The diets also contained electrolytes, vitamins, and ‘minerals to meet or exceed the recommended dietary allowances." ‘The ketogenic VLCD was prepared by Food Tek (Morris NJ). The nonketogenic VLCD (HMR 70 Plus) was a gift from Health Management Resources (Boston, MA). The diets were ‘made isocaloric by adding Polycose (Ross Laboratories, Columbus, OH) in the amount of 5 g per package to HMR 70 Plus In addition, the electrolyte content of HMR 70 Plus was modified by adding 194 ‘mg sodium and 229 mg potassium per package. ‘The diets were prepared fresh daily by adding water. Compliance was monitored by observing patients at mealtime and by daily measurement of urinary acetoacetic acid concentration (Labstix, Miles Laborato- ries, Elkhart, IN), Indirect Calorimetry Indirect calorimetry was performed between 8 and 9 aw after an ‘overnight fast using a ventilated-hood technique and the Metabolic Measurement Cart (Deltatrac, Sensormedic, Anaheim, CA). Glycerol and Glucose Kinetics ‘The glucose and glycerol rates of appearance (R,s) and the rate of conversion of glycerol into glucose (gluconeogenesis) were ‘measured during a simultancous, primed, continuous infusion of [U=!C}-glycerol (25 wCi, 0.22 wCi/min) and D-[6-'H-glucose (20 ‘Ci, 0.20 Ci/min) for 240 minutes. (U-C} glycerol and 0-{6-H] glucose were obtained from Amersham (Arlington Heights, IL) Both tracers were free of contaminants as evidenced by a single peak on high-performance liquid chromatography (HPLC). After ‘an overnight fast and while the patient rested comfortably in bed, ‘an 18-gauge catheter was placed in an antecubital vein and a 19-gauge buttery catheter was placed retrogradely in contralat eral hand vein. To obtain arterialized venous blood, the hand with the butterfly catheter was placed ina Plexiglas heated box that was calibrated to maintain a constant temperature (55°C) for the uration of the study. Before and at 120, 150, 180, 210, and 240 ‘minutes ofthe infusion, arterialized blood was obtained, Analysis Giucose and glycerol specific activities were determined by ion exchange and HPLC using a carbohydrate ion-exchange column (BioRad HPX-87C, Hercules, CA; 80°C) and a refractive index detector as described in detail by Nurjhan et al The ghicose and alyeerol peaks were collected manually, and the radioactivity associated with each peak was measured using double-labeled liquid scintillation-counting methodology. Under these conditions, there is ailing ofthe glucose fraction into the glycerol fraction. If ‘uncorrected, this will hve the effect of overestimating the glycerol VAZQUEZ AND KAZI specifi activity and underestimating the contribution of glycerol to sluconeogenesis. To reduce this error to a minimum, the initial aslycerol peak was dried under a stream of nitrogen, resuspended in 100 wl. water, and reinjected into the HPLC system. The glucose concentration was measured by the glucose oxidase method using 4 glucose analyzer. The glycerol level was measured enzymatically as previously described" except that fuorometry was used for detec. tion. The plasma B-hydroxybutyrate (B-OHB) level was measured enzymatically." Nonesterified free fatty acid (NEFFA) levels were ‘measured enzymatically using a commercial kit (Wako Chemical USA, Richmond, VA). The urine nitrogen level was determined by micro-Kjeldahl technique. Insulin, glucagon, triiodothyronine (75), and thyroxine (T.) levels were measured by radioimmunoas. say using commercial kits (ICN Biomedical, Costa Mesa, CA), Plasma amino acid levels were measured by HPLC (PicoTag, ‘Waters, Milford, MA). Calculations Glucose and glycerol specific activities were calculated by dividing the ’H-glicose, “C:glucose, or *C-glycerol radioactivity (simtegrations per minute per milliliter) by the glucose and lycerol concentration, respectively. The specific activities of slyc- cerol and ghicose reached near-constant values during the 180 t0 240 minutes of infusion. The coefficients of variation of the 180-10 240-minute values were less than 10% of the means. The glucose and glycerol R,s were calculated by dividing the *H-glucose and 'C.alycero! infusion rates by the respective mean (180 10 240 ‘minutes) specific activites. The percentage of glucose derived from slyeerol was determined from the ratio of plasma “C-ghucose Specific activity and plasma 'C-glycerol specific activity.$7 The rate of conversion of plasma glycerol to glucose was calculated as the product ofthe percentage of glucose derived from glycerol and the shucose R, calculated from the 6-(H)-glucose infusion and °H- glucose specific activity.” Since the hepatic glycerol and glucose specific activities were not measured, these calculations underest ‘mate the true values. Net carbohydrate and fat oxidation rates were calculated from the gas-exchange data corrected by ketone storage and excretion.!¥ Net protein oxidation was calculated from the 24-hour urinary nitrogen excretion. Statistics Calculations and statistical analyses were performed using pro- grams 4V and SV of the BMDP Statistical Software package (Berkeley, CA), The data were analyzed using repeated-measures ANOVA with diet and time as independent variables. When Significant interaction (P < 05) effects were found, a Scheffe's Maltiple-Comparison Test was used to determine specific group iflerences.'* The results are presented as the mean + SEM. RESULTS General The Ketogenic and nonketogenie VLCD groups were comparable with respect to age (48 + 3 44 5 years) and body mass index (41 5 v 37 = 6 kg/m’). Both diets were well tolerated by all patients. In particular, diarrhea, orthostatic hypotension, arrhythmias, clectrolyte imbal- ances, hyperuricemia, and elevated liver function tests did not occur with either diet. Body weight loss after 28 days of treatment averaged 85 + 1.0 kg on the ketogenic diet and 7.6 + 2.0kg on the nonketogenic diet (P = NS)LUPOLYSIS DURING WEIGHT REDUCTION uubstrates and Hormones On day 0, there were no significant differences between the diet groups for any of the substrates and hormones ‘neasured (Table 1). As expected, there were significant differences in plasma B-OHB concentrations between the ketogenic and nonketogenic VLCD groups. In both groups, there were gradual increases in plasma B-OHB concentra- tions with time, However, in the nonketogenic VLCD group the plateau plasma B-OHB concentration was just above the physiological plasma concentration,!” whereas it was clearly in the ketotic range in the ketogenic VLCD group. By day 14, B-OHB was 3.7-fold higher in the ketogenic than in the nonketogenic diet group (P < 01) and remained that way until day 28 (P <.05). The plasma NEFFA concentration showed an increase with time in both diets. ‘The increases in NEFFA were somewhat larger and oc- 1295, curred sooner in the ketogenic group than in the nonketo- genic group, although the diet and interaction effects did not reach statistical significance. In contrast, there were neither time, diet, nor interaction effects on the plasma glycerol concentration. During treatment with the VLCDs, we observed a small but significant reduction in the plasma glucose concentra- tion with time. At both day 14 and day 28 of treatment, the plasma glucose concentration was lower in the ketogenic than in the nonketogenic VLCD group (Table 1). However, differences between the groups were small and approached but did not reach (P = .059) statistical significance. We also observed significant reductions in the plasma insulin concen- tration with time. As with glucose, the reductions in insulin concentrations were smaller in the nonketogenic than in the ketogenic VLCD group, but differences between the 1nd Hormone Concentrations “Diet Tine wo Owe ey 28 Diet Time B-OHB (mmol/) Ketogenic oszo1 20205" aa 205° 2 <.001 <.001 Nonketogenic oa=01 07 2018 oso. All o5+01 10a 2020.8" NEFFA (umol/L) Ketogenic 108 = 84 aggre 112 +305 <.001 076 Nonketogenic gate 71 998-2 111 at 970 = 78* ode e111" Giycerot mol/L) Ketogenic 90210 er=7 wet 63 832 03 Nonketogenic B28 mat 64210 al m6 ns nT Glucose (nmol/L) Kerogonic 4g+03 40202 38203 959 on 130 Nonketogenic 49204 4802 45403 all 48202 43202" 4102" Alanine urmol/L) Ketogenic 201 = 18" 165.9" 035 <.001 on Nonketogenic 371 +43 22 = 22" 280 = 20*t All 4400 + 27 239 = 16" 220 = 19" Insulin (pmol/L) Ketogenie 4ae7 sa27 m <.001 or Nonketogenic o221 26.29 All wast 65 = 14" nse Glucagon pg/L) Ketogenic 229 + 58 221 = 64 mse 693 sv 8 Nonketogenie 238-= 61 278 + 88 205 = 94 a 233.2 41 2ar = 52 250 + 60 Talomoll) Ketogenie arsoa tasot ogo 066 <.001 874 Nonketogenic 1902 13202 12201 all 1801 n2sor 10201" Taloemol/L) Ketogenic ar=5 of e645 ana 08 ” Nonketogenic 100+ 4 26 925 All otee 24 asa 'NOTE, Data are presented as the mean = SEM *P <5 compared with day 0. 1P < 05 compared with day 14 1 < 05 compared withthe katogenic VLCD.1296 groups were small and neither the diet nor interaction effects were significant (Table 1). Treatment with both VLCDs produced a gradual and significant reduction in plasma alanine concentrations with time. The reductions were of greater magnitude in the ketogenic than in the nonketogenic VLCD group, and on both day 14 and day 28 the differences between the diets were significant (Table 1). Treatment with the VLCDs also produced significant time effects on plasma T; and T, concentrations. However, there were no diet or interaction effects on T; concentra tions, and the diet effect for T; concentrations approached but did not reach (P = .066) statistical significance. There were no diet, time, or interaction effects on the plasma slucagon concentration, Glycerol and Glucose Res The glycerol and glucose R,s are shown in Fig 1. The glucose R, showed a modest but significant statistical (P < .05) effect over time. However, there were some small differences in the response of the two diet groups. In the ketogenic VLCD group, the glucose R, was lower at day 14 than at day 0 and remained low at day 28. Inthe nonketo- genic VLCD group, the glucose R, was alo lower at day 14 than at day 0, but at day 28 it increased and approached the day-0 value, Nonetheless, neither the diet nor the diet X time interaction effects were significant, and the impor- tance and physiological significance of these changes are unclear, VAZQUEZ AND KAZI In contrast to glucose, there were neither diet, time, nor diet X time interaction effects on the glycerol R,. Glycerol Conversion Into Glucose On average, 0.6 umol/kg/min glycerol was converted into glucose at day 0 in both groups. This amount repre- sented 46% and 49% of the glycerol R, and 10% and 11% of the glucose R, for the ketogenic and nonketogenic VLCD groups, respectively. When expressed as micromoles per kilogram per minute, the conversion of glycerol into glucose did not change with time in either diet (Fig 2) However, there were modest (10%) but significant in- creases with time (P <.05) when the conversion was expressed as a percentage of the glycerol R, or as a percentage of the glucose R, (Fig 2). However, regardless of how the data are expressed, the increases were similar in both diets, and even after 28 days of treatment, the contribution of glycerol to gluconeogenesis was small, accounting for only 58% of the glycerol R, and 16% of the glucose R,, Energy Metabolism and Substrate Oxidation ‘The resting energy expenditure (REE) and the net rates, of substrate oxidation at days 0, 14, and 28 of treatment are shown in Table 2. At day 0, there were no differences between the diet groups in REE or in the rates of protein, fat, and carbohydrate oxidation. There were significant reductions in both REE and the rate of carbohydrate Glucose katogenie Bi HEE Nonketogenic semol/kg/min as Glycerol £ 2 Time (days) Fig Time (days) {A) Glycerol, and (B) glucose Rat 0, 4, and 28 days of treatment with a ketogenic or nonketopenic VLCD. There was a significant ime ‘effec P <_05) in the glucose R,, but not inthe glycerol R Diet and interaction effects were not significant for either subeerate1297 LUPOLYSIS DURING WEIGHT REDUCTION mol/kg/min % GLY Ra % GLU Ra 1 EE Ketogenic Al EE Nonkstogenic Time (days) Teme (daye) Time (days) Fig2. Rate of glycerol (GLY) conversion into glucose (GLU) at 0,14, and 28 days of treatment with» ketogenic or nonketogenic VLCD.(A) The absolute rate of conversion (wmnol/kg/min} slucose R, but not when expressed as smol/kg/min. Diet and inte oxidation and increases in the rate of lipid oxidation with time. By day 28, fat oxidation accounted for 84% and 77% of the nonprotein energy production in the ketogenic and rnonketogenic VLCD groups, respectively. The changes in REE and carbohydrate and fat oxidation with time were similar in both groups, and neither the diet nor interaction effects were significant. ‘There was no significant diet effect for the rate of protein oxidation, but the time and interaction effects were signifi- cant (Table 2). From day 0 to day 14, there was a 22% increase in the rate of protein oxidation on the ketogenic diet (P < .05), whereas the increase was only 3% on the nonketogenic diet (P < .0S). By day 28, the rate of protein oxidation had decreased in both VLCD groups as com- pared with day 14 (P < .05 for both groups). However, the rate of protein oxidation was still 11% higher than at day 0 in the ketogenic VLCD group, whereas it was 12% lower than at day 0 in the nonketogenic VLCD group (P < .05). ‘As a result, the rate of protein oxidation at day 28 was, significantly higher in the ketogenic group than in the rnonketogenic group (Table 2). DISCUSSION Glycerol is primarily produced in adipose tissue as a result of complete hydrolysis of stored TG. Since adipose | the rate of conversion expressed as % ofthe glycerol R,:(C) the rate of conversion expressed as Shot the glucose R, There was a significant time effec? <.05} when the rate of conversion ction effects were nat significant regardless ofthe method of expression. pressed a8 % of the glycerol Rand as % of the tissue lacks glycerol kinase, glycerol produced from lipoly- sis is not reused for TG synthesis in the adipocyte and is {quantitatively released into plasma. Therefore, both the plasma glycerol and the glycerol R, in plasma are consid- ered reliable indexes of lipolysis*”* Based on these indexes, we have demonstrated that in severely obese patients, treatment with VLCDs does not increase the whole-body rate of lipolysis even after 28 days of treatment. Since during caloric deprivation fat becomes the pre- ferred fuel in the body, we expected to find a higher rate of lipolysis at days 14 and 28 of treatment with the VLCDs than at day 0. The reasons that the rate of lipolysis did not increase with time in the present study are not clear. Regardless of the mechanisms involved in this process, it has been suggested that in the obese this may be a protective mechanism, reflecting a decreased need for lipolysis per unit of fat mass to meet the energy requir ment of the lean body mass.'®"* Moreover, it has been argued that an exaggerated release of FFA in response (0 caloric deprivation in obese individuals may be hazardous, since it might overwhelm the albumin-binding sites.” Itshould be pointed out that the patients in the ketogenic VLCD group consumed higher amounts of fat than the patients in the nonketogenic VLCD group (32 v 3 g/d). Assuming that glycerol accounts for approximately 11% of1298 VAZQUEZ AND KAZI Table2. indiect Colorimetry Data Dayo Daya Bey 28 Diet iTime «Ox Tine Vos aL leinn Ketogenic 249.29 nee 237 =9 265 01 190 Nonketogenic 275 = 16 2211 2a 7 all Bi=9 245 2 8 240 = 6* \Yo0, (mL/min) Ketogenic mss ww 425 315 <.001 263 Nonketogenie 2a=8 176 1524 a 20725 rea 4° 523" PRO. Ketogenic 0.80 = 001 0.73 0.01 0.74 0.01 60 <0 388 Nonketogenie 0s 002 0750.01 0720.01 all oat = 0.01 0.74 = 001" 0.73001 REE heals) : Ketogenic 1,709 = 58 1610 «73 1.592 = 56 259 <.001 29 Nonketogenie 1878 + 95 1,709 «72 1640 = 47 Al 1.787 » 57 11856 2 51" eta = 37" Notfat oxidation (g/d) Ketogenie oe=t1 wen 125210 299 006 386 Nonkatogenie wen 126 = 10 tais9 all 107 = 10 12527" 1332 7" Net carbohydrate oxidation (g/d) Ketogeniec 149.217 mee 31218 97 <.001 295 Nonketogenic vaear aren 10=15 all 133217 gent ae "Net protein oxidation (g/d) Ketogenic sos e522" sonar 332 02 ov Nonketogenie 23 5923 S023 all S623 62=2" 56220 NOTE, Data ae presented as the mean = SEM, ‘Abbreviations: Vo, rate of oxygen consumption; Veo, rate of CO, production; NPRO, C nonprotein espiratory quotient *P <.05 compared with day 0, 4 < .05 compared with day 14, 3 < 05 compared withthe ketogenic VECO, @ typical TG molecular weight, we estimated that our typical patient in the ketogenic VLCD group consumed about 3.5 g (0.035 g/kg/d or 0.38 umol/kg/d or 0.0003, umol/kg/min) of glycerol per day. Because this is a small amount in relation to the glycerol R, and since all the studies were performed in the fasting state, we believe that the difference in glycerol intake is unlikely to have affected our results, Ina previous study, Bortz ct al? showed that after a short fast 55.9% (range, 30.4% to 81.3%) of the glycerol R, is converted into glucose and that it accounted for 8.3% (range, 2.0% to 15.6%) of the glucose hepatic output in obese patients. Therefore, our results are within the range previously reported in obese patients and confirm that the contribution of glycerol to gluconeogenesis in obese pa- tients is small" However, it should be taken into consider- ation that in contrast to other gluconeogenic precursors such as lactate and alanine whose carbons are originally derived from glucose, gluconeogenesis from glycerol repre- sents the most important source of influx of new carbon into the glucose pool.’ Furthermore, it has been demonstrated. that glycerol may reduce gluconeogenesis from other precur- sors.!/ Bortz et al? have shown that during a prolonged fast, nearly 90% of the glycerol R, is converted into glucose and that it may account for as much as 60% of the total glucose hepatic output. In the present study, we found more modest increases in the percentage of the glycerol R, converted into glucose (58%) and in the percentage of elycerol contributing to the glucose hepatic output (16%) during caloric restriction. However, the subjects in the present study consumed 70 g protein and 615 kcal/d for 28 days, and the obese subjects in their study fasted for as long as 35 days." Its reasonable to expect that the amount of calories and protein consumed by the patients and the shorter duration of treatment in the present study are factors that might attenuate the contribution of glycerol to sluconeogenesis. ‘The results of this study have important implications for the treatment of obesity with VLCDs, First, it suggests that the composition of VLCDs is not an important factor in the mobilization and oxidation of body fat. Therefore, this outcome variable is not useful in determining the optimal composition of VLCDs. Second, this study showed that the rate of gluconeogenesis from glycerol during treatment with, LCDS is small. This finding implies that, as in starvation, amino acids are the major gluconeogenic precursors duringLUPOLYSIS DURING WEIGHT REDUCTION treatment with VLCDs. Indeed, the plasma alanine concen- tration (Table 1) and protein oxidation (Table 2) data suggest that gluconeogenesis from amino acids was still prominent in both VLCD groups even after 28 days of treatment. Finally, since there were no differences in hepatic glucose output while the plasma glucose and alanine concentrations were lower in the ketogenic than in nonketogenic VLCD groups, it appears that the rate of ‘gluconeogenesis from amino acids was higher in the keto- genic group, but barely enough to maintain a normal plasma glucose concentration. Therefore, taken together, 1299 ‘our results indicate that the nonketogenic VLCD used in this study was superior to the ketogenic VLCD in maintain- ing normal plasma glucose concentration and promoting protein sparing, ACKNOWLEDGMENT We are indebted to Judy Arch, RD, and the nurses of the Clinical Research Center of the University of Pittsburgh School of Medicine for assistance during the performance of these studies, ‘and to Janine Janosky, PRD, for statistical advice. REFERENCES 1. Cahill GF; Starvation in man, N Engl J Med 282:668-675, 1970 2. Vaughan M: The metabolism of adipose tissue in vitro. J Lipid Res 2:293-316, 1961 3, Bortz WM, Pavle P, Haff AC, et al: Glycerol tumover and ‘oxidation in man, J Clin Invest 51:1537-1546, 1972 4, Winkler B, Rathgeb I, Steele R, et al: Conversion of glycerol to.glucose in normal dog. Am J Physiol 219:497-502, 1970 '5. 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