Starvation strikes! (trigger warning: graphic images)

By therapist Sarah McMahon

Ancel Keys’ “Great Starvation Study” provides invaluable feedback when understanding the impact of starvation on our body. This study took place towards the end of World War II, well before ethics approval was required for scientific investigations. The purpose was to investigate the effects of dietary restriction on the human body and understand what is required for successful rehabilitation from starvation. The results were remarkable and particularly relevant for people suffering from eating issues. Interestingly, this experiment revealed that all participants developed eating disorder thoughts & behaviours simply as a consequence of starvation and losing weight. Further, it indicated the search for food trumps everything, with participants becoming preoccupied with food when they were starving. All other human characteristics such as sociability, sex drive and other interests become subordinate to interest in food.

The Great Starvation Study

 Using 36 physically and psychologically healthy men as participants, the study was organised into three distinct phases:

• 12 week control phase, to collect “baseline data” on each participants;
• 24 week starvation phase, with dramatic reduction of calories causing the participants to lose 25% of their body weight (some of the participants even dropped down to a BMI of 14!);
• A 20 week refeeding/ recovery phase, to provide a rehabilitative diet to renourish the participants.

The results of the study are detailed in Dr Ancel Keys 1950s book, “The Biology of Human Starvation”, which describes the following behaviour which was observed during starvation:

Ritualistic eating:

 The participants changed the way they eat, including developing weird eating rituals, hoarding food, consuming vast amounts of tea and coffee, and chewing gum incessantly- up to 40 packs per day.

 “As starvation progressed, the number of men who toyed with their food increased. They made what under normal conditions would be weird and distasteful concotions… those who ate in the common dining room smuggled out bits of food and consumed them on their bunks in a long drawn out ritual… Towards the end of the starvation some of the men would dawdle for almost two hours after a meal which previously they would have consumed in a matter of minutes… cookbooks, menus and information bulletins on food production became intensely interesting to many of the men who previously had little or no interested in dietetics or agriculture… [they] often reported that they got a vivid vicarious pleasure from watching other persons eat or from just smelling food…They became obsessed with food, eating with elaborate rituals and adding water to their plates to make their food last longer. Many collected cook books and recipes…”

Binge eating:

 During the refeeding stage of the experiment, many of the men who lost their appetites ate “more or less continuously”. They reported feelings of self deprecation, disgust & self criticism for doing so. Most of their eating normalised after about 8 months of refeeding, however binge eating did continue to remain a problem for some. For example the study reported that one of the subjects, whilst working in a grocery store:

“…suffered a complete loss of willpower and ate several cookies, a sack of popcorn, and two overripe bananas before he could “regain control” of himself. He immediately suffered a severe emotional upset, with nausea, and upon returning to the laboratory he vomited. He was self deprecatory, expressing disgust and self criticism.”

Emotional changes:

 Despite their robust psychological health prior to the study, most participants experienced significant emotional changes as a result of starvation. These included depression, irritability, anger, increased anger, apathy and neglecting personal hygiene.

“Two of the men suffered severe psychological stress- one became suicidal, another cut off three of his fingers in an act of self mutilation”

Remember these men had no prior history of psychological illness or emotional difficulties.

Social and sexual changes:

Many of the men changed from being more gregarious to progressively withdrawn and isolated. Humour, a sense of friendship and connectedness diminished. Increased feelings of social inadequacy took place. Social initiative & sociability reduced. Men became reluctant to plan activities, make decisions or participate in groups. More alone time took place because contact with people was “too much trouble” or “too tiring”. Withdrawal from contact with the opposite sex also took place. One man described his difficulties as follows:

“I am one of about 3 or 4 who still go out with girls. I fell in love with a girl during the control period but I see her only occasionally now. It is almost too much trouble to see her even when she visits me in the lab. It requires effort to hold her hand. If we go to watch a show the most interesting part of it for me is the scenes where people are eating.”

Physical changes:

Physical changes that took place as a result of starvation included: gastro intestinal discomfort; decreased need for sleep, dizziness, headaches, hypersensitivity to noise and light, reduced strength, fluid retention, hair loss, decreased tolerance of the cold. The metabolism decreased, as did body temperature, heart rate and respiration.

 “They described lethargy, irritability, anxiety that approached each time they were to learn how much they were allowed to eat the following week… they had dizziness, cold intolerance (requiring heavy blankets even if the middle of summer), muscle soreness, hair loss, reduced coordination, edema, and ringing in the ears. Some had to withdraw from their university classes because they did not have the capability to concentrate. Their sex drive disappeared.”

Whilst most of he subjects reported feelings of tiredness, weakness, listlessness, apathy and lack of energy, a number still also engaged in deliberate exercise.

The Recovery Process

Excessive weight gain occurred initially during recovery for most participants- in general participants regained their original weight plus about 10%. This gradually (over about 9 months) declined towards pre-experiment levels during the follow up period (without the participants actively trying to lose weight).

 The men had to eat about double of their normal food requirements to rehabilitate their body… DOUBLE!

“The character of the rehabilitation diet is important also, but unless calories are abundant, then extra proteins, vitimins and minerals are of little value…”

Their metabolism sped up again, particularly in people who had larger increases in food intake. Weight gain tended to take place around the stomach and buttocks initially and then dispersed.
Personality improvements took time and related to weight gain rather than increased calorie consumption.

Emotional difficulties didn’t improve immediately following increased short term calorie intake. They were also correlated with weight gain.

A normalised relationship with food began to develop and after about five months of refeeding with the majority of men reporting some normalisation of eating patterns by this time. By eight months, most men had returned to normal eating patterns, however some continued to report abnormal eating. For example, one man reported consuming about 25% more food than he did prior to the weight loss.

Conclusion

From this study, I firstly encourage you to take a moment to reflect on the role that starvation and weight loss play in eating disorder symptoms. Do you think there is a connection? I do! I also encourage you to consider the extent to which these changes negatively impact on the whole life of someone who restricts food. It extends far beyond food and weight to every aspect of a person’s social and psychological functioning.

My conclusions? This study:

• Highlights the importance of weight restoration and refeeding in recovery.
• Normalises the fact that people feel “out of control” when refeeding commences, having difficulty in identifying hunger & fullness.
• Reminds us that these feelings are normalised after prolonged “mechanical” eating…so for anyone recovering from an eating disorder, keeping up mechanical eating continuously is one of the most important things in recovery.
• The interesting thing is that any evidenced based treatment program for eating disorder- in particular CBT E & Maudsley Family Therapy begin with, and focus on initially, with establishing regular eating patterns comprising of every day, sometimes & occasional food, and also integrate rather than abstain from the “forbidden food” that typically triggers binge eating.

Please share your conclusions & observations too!