Deaths caused by starvation are relatively rare in America. For the most part, they occur either as a result of child abuse or fasting (Figure 20.1). The average 70-kg man, lying in bed, not exerting himself, requires approximately 1650 cal of energy per day. Asleep, he utilizes 65 cal per h and, while awake, uses 77 cal per h.7 If he walks slowly, he utilizes 200 cal per h, running 570 cal per h, and walking up stairs 1100 cal per h. A manual laborer can require up to 6000-7000 cal per day.

Food can be grouped into three general categories: carbohydrates, fat, and protein. Tissues prefer to use carbohydrates for energy. The amount of carbohydrate stored in the body (glycogen in liver and muscle; glucose in blood) has a combined caloric value of approximately 1200 cal, insufficient to supply a 70-kg man with 1 d worth of calories. Therefore, if one stops eating, the body has to utilize fat and protein after the first 24 h of starvation. As fasting continues, there will be a progressive depletion of fat and protein, with fat depletion progressing at a faster rate than protein because fat provides more calories per weight of tissue. As fat is utilized for calories, ketones are produced and appear in the blood. Thus, after 12 h of fasting, blood acetone concentrations of approximately 1.0 mg/100 mL develop, with concentrations of 10-50 mg% in 36 h (J.C. Garriott, personal communication).

As starvation continues, protein is gradually depleted in three different phases. First is a rapid mobilization of protein stores that are converted by the liver to glucose, with the glucose used principally to supply energy to the brain. This is followed by a reduction in the utilization of protein. As total depletion of the fat stores approaches, protein is again rapidly utilized as a source of calories. Death usually occurs shortly after. If one assumes that fat

Figure 20.1 Starvation.

constitutes 20-25% of the body weight in males and 25-30% in females and then assumes 2000 cal are needed per day, for the average individual there would be sufficient energy supply for 60-70 days. This correlates very well with actual fasting conditions.

Frommel et al. describe four individuals who went on a voluntary fast for political reasons.8 With sedentary activities, no problem was encountered up to 18% of original body loss (28-35 days of fasting). When weight loss exceeded 18%, they developed muscle weakness, syncopal episodes, and decreased mental alertness. Fasting was stopped at 40 days following development of Wernicke's syndrome by one of the four.

There appears to be no definite level of weight loss that can be considered lethal.9 When loss of original body weight for adults reaches 40%, deaths begin to occur. With semi-starvation over a long period of time, the level is somewhat higher. For children, the level at which death begins is significantly lower.

Leiter and Marlis reported on the fasting to death of 10 young healthy males in Northern Ireland.10 Information on these cases was obtained from the media, which gave reports of their ages, weights, and duration of fasts. Individuals consumed no calories or vitamins, only water. Their average age was 25.6 ± 0.7 years. One died after 45 d of fasting. The other nine survived from 57 to 73 d. The mean survival time for all 10 was 61.6 ± 2.5 d. These authors concluded that the maximum limit of total fasting in healthy, non-

obese individuals in their mid to late 20s is approximately 60 d. Death in these individuals occurred when approximately 70-94% of the body fat and approximately 19-21% of body protein were lost.

Individuals who have undergone starvation report an initial feeling of hunger and hunger pains, with craving for food wearing off very rapidly. This is followed by both mental and physical lethargy, fatigue, and progressive loss of weight.9,11,12 As the starvation continues, the lethargy becomes extreme, with mental impairment and loss of interest in everything.

At autopsy, there is essentially complete lack of fat in the subcutaneous and deep fat depots. The skin is pale and cadaverous in 82.5% of the cases and dark brown in 17.5% of the cases.12 Edema is present in one third of the cases and may mask the amount of weight loss. Peritoneal effusions may occur. Edema is rare in individuals with brown-colored skin. There is severe atrophy of skeletal muscles, the heart, liver, spleen, and kidneys, but not the brain.9,12 The small intestinal wall appears swollen, with reddish discolored mucosa in 27.2% of the cases. Almost half the cases in one study had ulcerations of the mucosa of the colon, described as "pseudo-dysentery.12

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