This first post was actually the impetus to start this blog. I have been reviewing various pieces of information related to the concept of slowing the metabolism from chronic dietary restriction or anorexia. I have no doubts that this is a real phenomenon. Medical science has no doubts that this is a real phenomenon. Whenever however a phenomenon exists people will double down on that phenomenon and use it as an explanation for all that ails them.
I see these claims in my clinical practice. I call them the “I only eat salad” set. My favorite example of this was the guy that told me he “Only ate salad” and couldn’t lose weight, but as he was saying it he had a 32 oz regular coke from the gas station under his chair- at 10 AM. He wasn’t trying to lie to me. He just really had no idea how many calories he was consuming (and of course eating a salad at some point during his day). I sent that particular guy to a nutritionist and he lost weight. On the internet the “I only eat salad” set often make even bigger claims. Saying things like “I gained a ton of weight eating 1000 calories a day while exercising”. That’s what I’m going to discuss here. I’ve had many people ask me in private messages to explain what I think is going on when people are claiming that. I’m going to present the data that I’ve found while trying to decide about this.
Ok so let’s get a few things out of the way before I get into the meat of what I have to discuss here: I think the cure for solving weight problems is activity and a right relationship with food and body. The first part is relatively easy: start walking/lifting/running/moving more then you are now. Anyone can do that. The second part is harder- having a right relationship with your body and your food. A lot of people actually should get professional help for this part. Eating disorder teams, counselors, fessing up to your family, etc. I see near universal penetrance between mental health issues (even severe medical psych issues) and the 1000 calorie claims. There’s no coincidence there. People with mental health problems often have issues surrounding body image and food. Certainly exercise can help, but someone with any major degree of issue related to their body and food needs to have professional help.
I also would never advocate for a restrictive diet. This has been covered well over at gokaleo.com. If what I’m saying below triggers you to think “I need to restrict harder” then you are missing the point in-fact you should go get professional help on this (as noted above). I advocate for the concept of “Eat the Food”- when you stop vilifying food, it loses it’s power over you. However when we have “dirty foods” many people end up binging on them. I advocate for getting a healthy metabolism, then making a small change to your calorie intake 300-500 deficit per day (when you have a healthy metabolism) and slow weight loss is almost certainly the only way that works permanently.
Fast weight loss through drastic changes to diet usually result in rebound because the changes are unsustainable and because the body works to get back to it’s set point. The rest of what I’m going to say is nothing personal, it’s just data. It’s what I’ve found related to the concept of metabolic derangement, not me personally making things up. I have no particular person in mind when I write this. I’m not singling you (yes at this minute I am talking to *you* thinking that I am) out. I’m going to number my discussion into topics and then discuss what medical science suggests about it.
This is not meant to be an exhaustive review of the literature, or in the form of a medical/research paper. The amount of life energy I have to put into this is limiited, so at times the detail is not fleshed out as much as some people would hope- I’d welcome your work on it and comments are welcome if I’ve missed something here.
First, a few definitions: BMR- basal metabolic rate, the basic calorie requirement to run your body if you were in a coma. RMR- is resting metabolic rate, it’s very similar to BMR. TDEE- total daily energy expenditure, ie. the real number of calories you burned by not being in a coma.
1) Metabolic derangement- aka the slow metabolism
This exists. We know that. How slow can it get? There’s no complete answer to that, but I’d suspect that it’s around 10-20%. Doesn’t sound like very much does it? What am I basing that number off of? The best group to examine this in would probably be anorexia- people who’s psychological drive to restrict calories can lead to their own death.
This study shows that anorexics (avg BMI 13.7) refed at 3500 calories for 3 weeks increased BMR by 20% http://www.ncbi.nlm.nih.gov/pubmed/16754418 But also worth noting that predicted BMR for those patients at baseline were 10% lower than a standard method of estimating BMR. At follow-up their BMR was only 3% lower than predictive calculators.
But doctor- BMR isn’t everything! TDEE is what matters!
This study showed that TDEE of anorexics was the same as matched constitutionally thin controls and regular weight controls. These anorexics had an average BMI under 16.5 (would be something like 5’2″ and 88 pounds) and their average TDEE (measured through double labeled water) was 1911 kcal (I converted from kjoules used in the study): http://www.ncbi.nlm.nih.gov/pubmed/16912058
These numbers are similar to another study that showed RMR and TDEE of 1171 and 1946 in “acutely ill” anorexics with average BMI 15.1 (would be 5’2″ and 82 pounds): http://www.ncbi.nlm.nih.gov/pubmed/?term=measured+RMR+anorexia+nervosa Which is roughly 10% lower for BMR than the calculator here (http://www.health-calc.com/diet/energy-expenditure-advanced)would suggest from someone with the same statistics.
A much larger cohort study looked at BMR in adolescent and adult anorexics and again (when using the WHO estimates for BMR- which is what I think the health calc above uses) showed roughly a 17% reduction in BMR in anorexics with an average BMI of 15.6: http://www.ncbi.nlm.nih.gov/pubmed/11933912
Ok well, maybe this only applies to people with the condition anorexia and wouldn’t apply to large swaths of people who don’t have that condition and mental state. Perhaps if there were a group that had a controlled intake and were “exercising” we would have some data to what happens to larger groups of people. Unfortunately for the history of mankind, we do have that data. The German physicians and scientists recorded meticulously and there is large sets of data to what happened to people in concentration camps.
I won’t go into detail on this because the horrors of concentration camps is not needed for the big picture of this discussion. Matt Stone talks about it here: http://180degreehealth.com/2010/01/the-concentration-camp-diet
There’s also a detailed article here which says (caution, the description of the autrocities is horrific, even in this wikipedia article): http://en.wikipedia.org/wiki/Mauthausen-Gusen_concentration_camp ” The work in the quarries — often in unbearable heat or in temperatures as low as −30 °C (−22 °F) — led to exceptionally high mortality rates.[c] The food rations were limited, and during the 1940–1942 period, an average inmate weighed 40 kilograms, roughly 88 pounds. It is estimated that the average energy content of food rations dropped from about 1,750 calories a day during the 1940–1942 period, “
This group was all men during the times noted there. They ate 1750 calories per day and weighed an average of 88 pounds- meaning roughly half weighed less than 88 pounds! Conditions actually got worse because of food shortages and the death rates were staggering, both from starvation, but also the horrific abuses.
As Matt Stone discusses in his blog linked above, it’s pretty amazing that anyone would be recommending that people eat 1500 calories a day to lose weight. Even more astounding, depressing and bordering on the insane is Bob Harper’s (the biggest loser “fame”) book apparently recommends for women to eat 800 calories a day to lose weight. *I haven’t read it and won’t be
In summary when people are starved, either in concentration camps or through anorexia they get very thin (BMI’s down to an average of 15- much lower results in death for most people) and BMR and TDEE lowers by somewhere in the neighborhood of 10-20%.
2) People are not good at estimating caloric intake or activity levels.
Oh and it’s worse in people that are struggling with their weight.
The data to support this is almost overwhelming. I’ll include a few studies that show this.
This article in the Atlantic discusses it so well, I’ll just link it: http://www.theatlantic.com/health/archive/2012/03/why-calories-count-the-problem-with-dietary-intake-studies/254886/ and quote this here: “We have no nice way of saying this. Whether consciously or unconsciously, most people cannot or do not give accurate information about what they eat. “
This study looked at monozygotic (i.e. “identical”) twins one of which was obese and one wasn’t. This is a relatively unique circumstance- normally identical twins are very concordant for presence of obesity. In this study showed that the obese twin under reported physical activity and calorie intake- they moved less then they thought and eat more then they reported. http://www.ncbi.nlm.nih.gov/pubmed/20010905
The type of meal matters also, fast food meals are greatly underestimated in calorie content: http://www.ncbi.nlm.nih.gov/pubmed/23704170 including: ” underestimation of calorie content increased substantially as the actual meal calorie content increased”
Meaning the larger the meal the worse we are at estimating calories, which means that heavier people (who usually eat larger meals because ultimately that’s how you get to a heavier weight) are worse at estimating food intake: http://www.ncbi.nlm.nih.gov/pubmed/16954358
3. They have studied diet non-responders
So the final section here is reviewing some of the literature on people reporting low dietary intake and unsuccessful weight loss. It’s not to late to turn back if this information might bother you or trigger you to try to restrict your calorie intake.
This older study showed that people reporting dietary intakes of 1200 kcal per day under reported calorie intake by an average of 47% and overestimated activity level by 51% (of note their measured TDEE and RMR were within 5% of that which would be predicted by body composition): http://www.ncbi.nlm.nih.gov/pubmed/1454084
This newer study used doubly labeled water to compare the true expenditure and intake of women again reporting very low intakes. 8/10 women had TDEE and RMR within 15% of predicted and were simply greatly underestimating their intake. Those 8 people were estimating intakes between 600-1000, while their average intake was roughly 2200, underestimating by an average of roughly 50% (my estimate by looking at the figure). Consistent with the previous study. Three of those 8 were actually underestimating their calorie intake by almost 3 fold (two estimated 1000 calories intake and was consuming over 3000). Of note one of those 8 women who was the closest to estimating their real calorie intake did eat below TDEE during the two weeks of the study period, the rest all ate at their TDEE despite reporting intakes much, much lower than their TDEE. http://www.ncbi.nlm.nih.gov/pubmed/7594141
Of the two women not discussed in the above section one had a normal RMR but a very low TDEE (19% below predicted), suggesting a very sedentary lifestyle, though the possibility exists for the “efficient metabolism” idea. She also underestimated calories consumed by 38%.
The final one is the most interesting- she really did have both a low RMR and TDEE 23% and 25% lower than predicted, respectively. Her situation was complicated by severe mental health issues requiring three psychotropic medications, which was thought to be possibly related to the low metabolism. She was the only one that accurately recorded her intake- but what she recorded was below her TDEE and she lost weight during the two week study, suggesting that her observed behavior during the two weeks was different from her chronic behavior. Their conclusion about this last study participant:
“An interesting aspect of this one documented case of a hypometabolic patient is that the patient reported her energy intake accurately during the relatively short-term 2-week doubly labeled water period. On the other hand, her long-term energy intake as estimated from TEE (1,545 kcal/day) was 645 kcal/day greater than intake (900 kcal/day, Figure 8) estimated during the 2-week food record period. The result is that she lost weight over the 2 weeks of study. This finding raises the issue of long-term energy requirements vs that estimated over the relatively short 2-week period of doubly labeled water evaluation. A patient can report accurately for 2 weeks when participating in the study but not give a reliable picture of intake over months or years. “
I also think it’s important to point out that this 10th person was 52 years old, BMI was 27.7 at 153 pounds with a body fat % of 44% and down from her high weight of 183.
Up until now I’ve essentially just presented data. Now is the time to turn back and not read the rest if you won’t want to hear my opinions. Of course anytime you present information in a certain way and in a certain order you have imbued it with your opinion. So you probably already know what my conclusions are on all this.
The two questions: 1) does metabolic injury exist and 2) can someone eat 1000 calories a day and gain weight or even maintain a stable weight.?
1) yes- on the order of 10-20% but it can be recovered in as short as three weeks in anorexics 2) no
But doctor, what about the lady that had a metabolism 25% slower than expected. Yes, there are going to be outliers, but as far as I can find this is the slowest metabolism I’ve found/seen/heard of and 25% lowered calories is no where near the low levels people report. If I had that metabolism it would lower my estimated TDEE from about 3k to about 2250, certainly slow, but not “1000 calories and gaining weight” slow.
So if someone can’t gain weight on 1000 calories per day, what is going on when someone says that? No one can know without entering someone into an expensive metabolic study. I will never be able to guess what the real answer is for an individual person because I can never know what is in their hearts or minds. I will never know for sure, but we do differentials in medicine. A differential is when you speculate on the possible diagnosis for something before you do confirmational testing. I’m going to present a differential of this problem, in the order that I think is mostly likely (then include some explanation for each one).
1) People simply just don’t know how much they are eating. I’m not just saying, per se, they are intentionally lying, I really think some people may even have such a disordered relationship with food that they could report eating 1000 per day and actually be eating over 3000 as was seen in several people in that last study. Some may honestly be having dissociative events and eating without even being consciously aware of it.
2) They really are eating 1000 calories many days and eating huge binges the other days. They actually may be binging to the point of greatly exceeding weekly calorie expenditures. I don’t feel like looking for the data, but there are studies that show that the larger the binge the more calories consumed. If that makes sense. I would envision the real possibility that someone is eating 1000 calories 4 days per week and eating 5000 calories on the other 3. That would be a weekly calorie intake of 19000, which could easy exceed a sedentary persons weekly calorie need. They may at that point have such psychiatric distress from those binges that they couldn’t/wouldn’t be able to admit it.
3) The issue revolves around a person’s understanding of their weight. I think there may be a subset of people who really just think they have been “gaining weight”. Like they’ve been at a relatively steady weight (when thinking only of lean mass and body fat) and gained some serious swelling/water weight related to over-restriction. Or they have this memory of what their “weight is” like how I’ve been 5’7″ on my drivers license since high school, but never was 5’7″. Perhaps they don’t weight themselves or don’t have a scale and have a memory from high school of what “they are supposed to weigh” and then suddenly when they step on a scale after a long period of restriction they are stunned to see they have gained weight…even though they maybe even lost weight from their real high weight (which they perhaps never ever saw on the scale). I would propose that this “patient number 10″ from the last study could be someone like that. BMI 27.7 and 157 pounds? She’s 5’3″! Not skinny maybe at a 44% body fat, but certainly not a “morbidly obese” person that we need to enter into a study. A TDEE of 1500? I don’t care how efficient her metabolism is- that sounds like someone who’s at a decent weight and needs to lift weights/exercise/increase TDEE and do some recomp, not someone who needs to “restrict to lose some weight”. Keep in mind that I also think “overweight” BMI 25-30 may be provide long term health benefit! In the early 1990’s a BMI of 27 was considered in the normal range, we changed the scale because we were worried about capturing more people “at risk” for obesity.
4) Something “crazy” is going on. That’s the only other option really. It’s either a restrict/binge/restrict cycle, chronically underestimating intake, or not really knowing what their actual weight/body fat is doing- because I can’t envision any other possibility for “getting fat” on a steady diet of 1000 calorie per day. I don’t think there’s any room in science for this. You’ve read some of the data (or at least my review of it) you can decide for yourself if there’s some other explanation.
Let’s circle back around to the initial (and most important) point: restriction hasn’t worked. It basically never works long term. The answer to most people’s weight problems is by getting a right relationship with food and moving the body more. Improving health, not striving for thinness. Healthy comes from fitness. Plenty of studies to show that fit diabetics have nearly the same risk of heart disease as non-diabetics. Fitness is the answer coupled with fixing the emotional/psychologic/psychiatric issue that underpine this for almost all of us. EAT THE FOOD and get your relationship right so there’s no guilt and you can really start to get a handle on your intake.
I personally fell within somewhere in between the “chronically understimated” and “binged” when I tried to get out of shape again after the birth of my first daughter. I started trying to get in shape again, hadn’t been making much gains. Had been toying with some orthorexia and trying to “eat clean”. Then about 1.5 years ago I suddenly realized that I had eaten 7 big cookies after a normal sized lunch and 1/4 of a sheet cake that night after dinner…. I’m still not sure what “woke me out of it” that next morning when I realized how many calories I had consumed that previous day. I never really counted them, but I’ve just never dealt with that kind of overeating again. I eat a cookie or even three when I’m hungry, but I certainly don’t eat 7 when I’m not hungry anymore. I don’t need to, I’m not using food for what I was using it for anymore.
I wish that insight for you also.