During starvation, less than half of the energy used by the brain comes from metabolized glucose. Because the human brain can use ketone bodies as major fuel sources, the body is not forced to break down skeletal muscles at a high rate, thereby maintaining both cognitive function and mobility for up to several weeks. This response is extremely important in human evolution and allowed for humans to continue to find food effectively even in the face of prolonged starvation.
Initially, the level of insulin in circulation drops and the levels of glucagon, epinephrine and norepinephrine rise. At this time, there is an up-regulation of glycogenolysis, gluconeogenesis, lipolysis, and ketogenesis. The body's glycogen stores are consumed in about 24 hours. In a normal 70 kg adult, only about 8,000 kilojoules of glycogen are stored in the body (mostly in the striated muscles). The body also engages in gluconeogenesis to convert glycerol and glucogenic amino acids into glucose for metabolism. Another adaptation is the Cori cycle, which involves shuttling lipid-derived energy in glucose to peripheral glycolytic tissues, which in turn send the lactate back to the liver for resynthesis to glucose. Because of these processes, blood glucose levels remain relatively stable during prolonged starvation.
However, the main source of energy during prolonged starvation is derived from triglycerides. Compared to the 8,000 kilojoules of stored glycogen, lipid fuels are much richer in energy content, and a 70 kg adult stores over 400,000 kilojoules of triglycerides (mostly in adipose tissue). Triglycerides are broken down to fatty acids via lipolysis. Epinephrine precipitates lipolysis by activating protein kinase A, which phosphorylates hormone sensitive lipase (HSL) and perilipin. These enzymes, along with CGI-58 and adipose triglyceride lipase (ATGL), complex at the surface of lipid droplets. The concerted action of ATGL and HSL liberates the first two fatty acids. Cellular monoacylglycerol lipase (MGL), liberates the final fatty acid. The remaining glycerol enters gluconeogenesis.
Fatty acids cannot be used as a direct fuel source. They must first undergo beta oxidation in the mitochondria (mostly of skeletal muscle, cardiac muscle, and liver cells). Fatty acids are transported into the mitochondria as an acyl-carnitine via the action of the enzyme CAT-1. This step controls the metabolic flux of beta oxidation. The resulting acetyl-CoA enters the TCA cycle and undergoes oxidative phosphorylation to produce ATP. The body invests some of this ATP in gluconeogenesis to produce more glucose.
Triglycerides and long-chain fatty acids are too hydrophobic to cross into brain cells, so the liver must convert them into short-chain fatty acids and ketone bodies through ketogenesis.  The resulting ketone bodies, acetoacetate and β-hydroxybutyrate, are amphipathic and can be transported into the brain (and muscles) and broken down into acetyl-CoA for use in the TCA cycle. Acetoacetate breaks down spontaneously into acetone, and the acetone is released through the urine and lungs to produce the “acetone breath” that accompanies prolonged fasting. The brain also uses glucose during starvation, but most of the body's glucose is allocated to the skeletal muscles and red blood cells. The cost of the brain using too much glucose is muscle loss. If the brain and muscles relied entirely on glucose, the body would lose 50% of its nitrogen content in 8–10 days.
After prolonged fasting, the body begins to degrade its own skeletal muscle. To keep the brain functioning, gluconeogenesis continues to generate glucose, but glucogenic amino acids—primarily alanine—are required. These come from the skeletal muscle. Late in starvation, when blood ketone levels reach 5-7 mM, ketone use in the brain rises, while ketone use in muscles drops.
Autophagy then occurs at an accelerated rate. In autophagy, cells cannibalize critical molecules to produce amino acids for gluconeogenesis. This process distorts the structure of the cells, and a common cause of death in starvation is due to diaphragm failure from prolonged autophagy.