Metabolic Derangement- Extreme calorie restriction edition

This is my final post in this first series on metabolic derangement.

Subtitle is “One of the Mechanisms Through Which I Think Eat the Food May Work” but that was too long and untitley.

I’m going back to the touchier subject again. The subject of the people who report very low calorie intake and either lose no weight or even report weight gain. I will again be discussing some of the data out of the final study discussed in the first post and again in the second post.  I will be presenting more raw data from that study, but also getting into the realm of speculation and opinion.  Some of that speculation and opinion will revolve around why I personally think the concept of ETF may work.  If talking about calorie restriction triggers you to want to restrict, please do not read this.  My wish is for everyone to eat an adequate number of calories to support a healthy metabolism and enough activity to make substantive change in health.

Again the abstract for this study can be read here:

In the first post of the series I examined the data to suggest that slowing of metabolism is a real phenomenon. Likewise there is likely a cap on how slow it can get and touched on this study showing that people greatly underestimated calorie intake.  In the second post I examined the demographics of people reporting very low calorie intake and found that some really weren’t as overweight as you’d assume someone would be for trying to eat 1000 calories a day.

In this post I’d specifically like to discuss two things.  I’ll get into details on the dramatic underestimation of calorie intake of almost everyone in that study and then talk about the infamous subject 10 who really did have a pretty slow metabolism and was accurately recording calories.

Before I launch into the full discussion, let me again reiterate that no where in here should you construe me as saying “no one can eat 1000 calories per day”.  I know that is a fact-people can and do. I wrestled at a weight class my senior year that required a very low body fat % and frequently restricted my calorie intake severely to cut weight. It got harder as the season went on (I’m sure as my metabolism slowed and possibly after I cannibalized some lean body mass).  Also wrestlers, boxers, MMA fighters, fitness competitors, and body builders frequently use severe calorie restriction for specific purposes.  I don’t think it’s healthy and it’s common in those groups to end up with metabolic derangement (frequently discussed in the female fitness competitor circle) as a result. Also, as discussed in my first post, anorexics often maintain severely low calorie intakes, resulting in low body weight and potentially ending in death.  They also slow metabolisms.

But then there’s another group that reports very low calorie intakes and no weight loss or even report gaining weight!  I made the case in my first post that those people are likely under reporting their calorie intake.  So let’s dive back into the study I mentioned above.  10 women reporting restrictive intakes and no weight loss. They are recording strict food diaries over a two week period. Their TDEE and calorie intake is measured using the doubly labeled water method.  Now let’s look at what I consider to be the most fascinating piece of information from that study.

calorie intake

So much to see here.  Let me briefly explain what you are looking at in the event that the figure doesn’t make sense. The subjects are numbered at the bottom.  The black bars are the total number of calories these women are burning per day.  The striped bar is the calorie intake they report through a food diary.  Before study entrance the subjects had completed a one week food diary (without training) that showed low calorie intake. All of the subjects from 1-8 had essentially normal metabolisms based on measured RMR.  At study entry each of the ten underwent training by a nutritionist and watched a video on preparing a food diary.

So these people all had more training than most of us on taking a food diary. How did they do?  Let’s zoom in on subject 1 because I think her history is so similar to a lot of women in our modern world. In the study they report that Subject 1 had first noted being overweight at age 8.  Had been on “hundreds” (her words) of diets.  History of depression, though currently stable and off treatment.  Normal thyroid function. Highest adult weight was 112 kg (246 pounds) and currently at 88.5 kg (195 pounds).  After training to take a food diary and knowing that they were going to measure her real intake she recorded taking in around 1100 kcal per day.  Her measured TDEE is 3000.  This is an active woman actually! Her RMR is actually higher than predicted.  Active, normal metabolism woman, thinks she is eating 1100 calories per day.  Really ate ~3300 calories per day.  Above her TDEE.  During a study when she knows that she is going to have her real calorie intake measured chemically and there will be no way to “lie”.

Let that sink in for a minute.  She’s not the only one, in-fact 9/10 totally underestimated calories.  It’s not like Subject 1 was even an outlier. Subjects 2, 6, and 7, also all recorded/reported intakes below 1000 calories and ate at or above their TDEE with intakes of roughly 2700, 2600, and 3100 respectively.

Four out of ten of these women (who knew their real calorie intake would be measured) underestimated their calorie intake by 1/3.  So far I’ve essentially just reported fact from the study. I’m now going to move into what I think this says.  I think this says that they aren’t lying.  How would 40% of these women choose to lie, even knowing their lie would be found out?  The demographics of these women can be seen in my second post, they are all somewhat different with different backgrounds so you can’t just speculate “They found a bunch of crazy people”.   I honestly think, that even when recording what they think they are eating, they eat more then they realize. I can’t speculate on if that is eating substantially larger portions, legitimately forgetting to record food, unconscious binging, binging at night or even in their sleep, or some combination of the above.  I really think that these people’s view of and relationship with food is so broken that through whatever combination of events they are eating 3 times what they think they are.  Even subject 8 with her normal BMI I discussed previously, she underestimated by 50% and ate over TDEE. I think people’s eating shame, food guilt, orthorexia, body image, mental state, etc becomes so injured, they are essentially blind to what they are really eating.  Even more philosophically- the ID takes over for the ego when you try to do stupid things to it, like feed it 1000 calories per day.

So back to a fact: the reason these women were not losing or even gaining while reporting 1000 calorie intake (or less) is they were eating more then they burned.  It’s the hard truth of how sucky we are at estimating our calorie intake (see section 2 of my first post).  In fact the hard truth is that only 20% -while under the watchful eye of a food diary and study conditions- were able to make a net negative in calories for the two weeks.  I know subject 10 did lose weight (more on her in a minute), they don’t report on subject 4, but I assume she also lost weight having created a ~800 calorie deficit per day.  Which, as my previous posts have suggested, is too much and you can see in her TDEE which is lower then many of the other patients that had similar body weights. While 20% in the study created a deficit, 50% actually ate above TDEE during the study.

So here’s where I suspect the concept of ETF comes in.  I suspect it maybe is less about “healing metabolism” as it is about “healing relationship with food”. Because frankly something isn’t working if you underestimate by 3-fold under strict study conditions when you know you are being observed.  I think if a person embraces the concept of ETF and begins to gives themselves permission to eat enough calories they heal their relationship with food to the point that instead of saying they eat 1000 and eat 3000, they can then sustain intakes of 2500-2700 and make slow loss over time.  Oh there’s certainly some metabolic healing in people with slow metabolisms which were only 40% of the people in this study in people who reported chronically low calorie intake. I have no idea how long it takes in those people. As I previously presented in severe anorexics their metabolisms are above predicted by 4 weeks of re-feeding- how that applies here, I don’t know for sure.

So back to subject 10. Not only was her metabolism super slow (23% below predicted) she accurately measured and recorded her intake.  During the study period she created a deficit of roughly 300 below her very low TDEE of 1600.  She lost weight, which again suggests that when not under the strict observation period of the study, she was probably eating at her TDEE.  Many people who report no weight loss or weight gain on very low calorie intakes will then look at this case and suspect that this patient is the one that applies to them. There are many confounders with her however.  She had hyperthyroidism treated with thyroid ablation 17 years before which is what led to her weight gain. She was also on three psychiatric medications which could be either slowing metabolism or affecting appetite.  At study entrance she had normal thyroid studies, but 18 months after the study ended was found to have hypothyroidism.  Ugh.  Complicated.

But beyond the possibly complicating factors for her having a low metabolism, let’s remember her demographics: age 52, weight 153, height roughly 5’3″. Knowing that her metabolism is almost 25% slow, when I look at the health calc and play around with the numbers- even for her to have a TDEE of 1600 requires her to be very sedentary. When put her in and put the sleep nob to 7 hours it would give her a predicted TDEE of 1950, which is 18% higher then her real TDEE.  There’s not much room for movement based on the information we have.  I’d suggest that I’ve presented information previously to suggest that her low calorie intake is in-part related to her low TDEE.  Also her weight may not be as much the issue given her weight and height (her body fat is reported at 44%).  I’d say she really does need to eat more and move more and work on some recomposition of her body fat, focus less on her body weight.  For her ETF really probably is about healing metabolism and having energy to move!

The rest of us, know matter where we are, need to give ourselves a break.  Chances are, depending on your age and weight, you need closer to 2500-3000 calories per day and thinking that you are going to be able to sustain on levels far below that is wrong headed.  Chances are, as suggested above, even if you try to get way, way below a healthy intake your body will find a way to protect itself. Eat the food, play more, just move.

22 thoughts on “Metabolic Derangement- Extreme calorie restriction edition

  1. A great post, doc. But I also think it’s a bit short sighted to tell someone with diagnosed hypothyroidism to just ETF. Get the thyroid hormone levels right. THEN try to ETF. Eating the food will not fix your surgically ablated thyroid! You should know that!

    • I’m pretty sure I stated that she had normal thyroid levels at the start of the study. It’s hard to know at the time of the study with normal thyroid levels what role her thyroid was playing in the slow metabolism. Everyone needs to be working with a doctor and everyone needs to have thyroid studies done regularly, especially if you aren’t making progress in improving health.

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    • That depends on the person. I really think a lot of them, if they really figure out how much they are allowed to eat and give themselves permission may very well be able to get a handle on their eating. It’s like a defense mechanism, a primordial one, the body protecting itself from itself. The “issue” with sending them to a psychologist is that I don’t think they are aware of doing it, so there’s not much to talk about when it comes to that regard. That said, I would guess that the vast majority will have underlying issues related to body image, marriage, childhood, etc that needs working on and the psychologist will help with that and potentially allow for breakthroughs with their eating.

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  5. Fascinating! As a loser of over 100 lbs not to mention kicking drugs I have always suspected those that claim plateau etc are just eating too much. It never occurred to me that they were deluding themselves. The mind games we play on ourselves particularly in regards to our relationship with food is nearly unbelievable. Great article. Thanks.

  6. I hope this isn’t stirring the pot too much. 🙂 In the whole reported-vs-actual calorie intake conflict, might some of the discrepancy come from mislabled food? If I recall correctly, manufacturers are allowed 25% wiggle room in nutrition labeling, and if these women are eating foods targeted at dieters, it seems that the manufacturers have a stake in under-reporting how many calories are in each serving of their food.

    This could go a little way to explaining the not-uncommon occurence of people losing weight when they eat unpackaged foods – they are able to actually track their calorie intake based on USDA numbers instead of manufacturers’ claims.


    • I don’t think that’s stirring the pot. It’s very possible- though again a lot of the reported differences are far greater then 25% depending on the study. I think it’s a testament to how difficult to measure calories is. I think if you aren’t used a kitchen scale it’s very hard to be accurate enough, though again in the grand scheme of things I think people should work on improving relationship with food enough that 100% accuracy isn’t needed.

  7. What about the other side of the coin, not eating enough calories. Case and point, I have been restricting calories for YEARS. At first I felt great and weight was falling off of me like melting butter. Then the fatigue, depression, mood swings etc hit and I never fully recovered. During this time I started to gain weight even though I was eating the exact same calories (1500 to 1800) per day and maintaining my rigorous exercise routine. I did end up giving myself HYPOTHROIDISM as well as an eating disorder. But my question is this, I have been put on 1400 calorie diets and have not budged in weight in fact gone the other direction. Can’t putting on weight even though watching every little thing that one is eating, be contributed to undereating and stressing the body?? I found GOKALEO.COM and was blown away by the fact that I can eat up to 2800 per day! I have been told by doctors, personal trainers, NATURAL PATHS and numerous websites and exercise programs – DO NOT EAT ANYMORE THAN 1800 calories a day! I am still confused as to why I can eat more and lose weight, but I do feel better physically. Interested in your feedback

    • The reason is that this “obesity epidemic” has made people lose their minds. People have no freaking clue how many calories people really eat. They did an experiment called the Minnesota Starvation Experiment where they fed men like 1600 calories and they actually went crazy. Like eating garbage. Unless you are locked in a metabolic ward the hard truth is that most people’s bodies are smarter then them and will eat the calories they need. Hypothyroidism is one of the few things that can really slow down the metabolism and make you gain on pretty low calorie diets, but beyond that, it’s basically always eating more then you think, even if it’s through unconscious eating.

    • In well done doubly labeled water studies the average women in the US that is normal weight is eating 2450 calories (or there abouts) average. That’s a lot more then 1800 and….normal weight women.


  9. OK, this is 6 years old, so my apologies for “lazarusing” this topic. One of your fundamental assumptions here is based on a dubious side-result of the study, which is based on the underlying assumptions negated by the study. In other words, we have a contradiction, where the underlying assumption is a constant metabolic rate. Read the abstract again carefully: “…by comparing patients’ self-reported energy intake with energy intake estimated by doubly labeled water and body composition analyses”. Doubly-labeled water is used to measure energy *expenditure*, not intake. So they *estimate* intake based on the person’s measured expenditure and difference in body composition, which themselves are based on measured metabolic rates in (usually, *healthy*) people. Thus, the assumption, which leads to a contradiction, is therefore false. The assumption is that these formulae can be used to infer metabolic rates to individuals.

    In case my point isn’t clear, let me try to elucidate: You measure TDEE very precisely. You ask participants to measure TEI as precisely as possible. You then use body composition and formulae to *estimate* what the *actual* TEI *might have been*, if the formulae are correct. You find a disparity. One conclusion is that the participants are lying or underestimating TEI, but a simpler explanation is that these estimates are simply inapplicable to individuals. And we know that is the case, because they are in fact, rough correlations with rather large SDs and at best, they can predict *populations*, not individuals. Since that’s the case, you have no idea how far off a person’s self-reported TEI is off, and any conclusions you make from that, will be dubious at best.

    • If you look at the full study, they measured the patients RMR using standard methods (in this case it was the Beckman metabolic cart) and also used a very accurate method to measure their Thermic effect from food (using a standardized method- see below) and their body composition at beginning and end of study using “Fat body mass and fat-free body mass were estimated by underwater weighing using four-point hydrodensitometry and residual lung volume measuring systems “.

      So they weren’t just estimating stuff they were measuring. So they aren’t just estimating TEI- they are accurately measuring their expenditure, they are accurately measuring their resting metabolic rates and accurately measuring how much loss of energy from ineffeciencies (digestion, etc) and then measuring changes in body (fat) mass at the end of the study period- which means you can accurately then calculate how much they are taking in. That is unless you think you could burn energy from a source that isn’t from your body stores or food you are eating (photosynthesis? absorption of solar rays? not sure) which if that is what you are proposing, I think our conversation here is done.

      “Thermic effect of food TEF was evaluated as the 3-hour thermic response to a 710-kcal liquid meal (Ensure Plus, Ross Nutritional Division, Columbus, Ohio) (8), (12). On completion of the RMR measurement, a 20-minute rest period ensued; then the patient ingested the liquid meal. Thereafter, gas exchange was measured by indirect calorimetry for 10 of every 30 minutes over the 3 hours, and the TEF was calculated as the integrated energy expenditure 3 hours after the meal minus the RMR. Results are expressed as a percentage of the ingested meal.”

  10. There is one big inaccuracy in the article. The doubly labeled water method was used to measure the TEE, not the food intake. But then based on subject weight at the end, scientists determined the amount of underreported calories

  11. No it doesn’t change the conclusion. I used to think the same thing that they measure the energy intake with the doubly labeled water until Jame Craiger explained in his article “Do dietitans accurately report their food intake”

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