Speaker 1: Hello. My name is Jim Graham. I'd like to tell
Speaker 1: you about an experience that I had during World War
Speaker 1: Two as a guinea pig and an experiment in semi starvation.
Speaker 1: On February twelfth, nineteen forty five, we began our twenty
Speaker 1: four weeks of semi starvation. We were expected to lose
Speaker 1: about one fourth of our body weight during the next
Speaker 1: six months. The days began to drag out, each day
Speaker 1: getting longer and longer, and there seemed to be no
Speaker 1: end of starvation in sight. Six months seemed like forever.
Speaker 1: I'd look in the mirror and see that my eyes
Speaker 1: looked hollow, my cheeks were only a thin covering for
Speaker 1: the bones in my face, and my hair was getting thinner.
Speaker 1: If I tried to smile, it was just a grimace.
Speaker 1: I didn't feel like smiling in the first place, and
Speaker 1: I never laughed. My muscles were almost gone, my bones protruded,
Speaker 1: and sitting on a hard chair was uncomfortable even for
Speaker 1: a few minutes. Most of us carried around pillows to
Speaker 1: sit on. I couldn't walk up a flight of stairs
Speaker 1: without stopping to rest once or twice on the way up.
Speaker 1: I felt like an old man. And probably looked like one,
Speaker 1: since I made no effort to stand up straight. I
Speaker 1: thought about food all the time. I started collecting cookbooks,
Speaker 1: you know the kind with beautiful color pictures of delicious
Speaker 1: looking dishes. I felt cold all the time, even though
Speaker 1: it was the middle of summer. Nothing felt better than
Speaker 1: to find a nice warm spot in the sunshine and
Speaker 1: do nothing but lie there and soak up the heat
Speaker 1: of the sun. We became very irritable and intolerant. Little
Speaker 1: things seemed to annoy us. We were no longer polite
Speaker 1: with each other or with visitors. It seemed as if
Speaker 1: the veneer of civilization had been removed. Leave bear the
Speaker 1: animal underneath. We didn't enjoy having guessed because it was
Speaker 1: an effort to entertain them, and we were not usually
Speaker 1: very diplomatic about showing our feelings about it. Food occupied
Speaker 1: our thoughts all the time. At meal time, each one
Speaker 1: had his special way of dealing with the food. A
Speaker 1: couple of the fellows would eat their food quickly and
Speaker 1: then leave the cafeteria and try to forget about it.
Speaker 1: Most of the rest of us dawdled over our food.
Speaker 1: Some would mix their food altogether, others would savor each
Speaker 1: bite of each item on the plate. We'd been told
Speaker 1: before the experiment that the food might become monotonous since
Speaker 1: there were only three menus, but it was far from monotonous.
Speaker 1: It was food, and any food tasted good. To this day,
Speaker 1: I find one of the tastiest foods is a simple
Speaker 1: boiled potato. It's delicious. Any food looked good. Even the
Speaker 1: dirty crusts of bread in the street looked appetizing, and
Speaker 1: we envied the fat pigeons picking at them. Wasting food
Speaker 1: is a crime. We felt the waste of food and
Speaker 1: restaurants was intolerable. On July twenty ninth, nineteen forty five,
Speaker 1: was the day semi starvation was to end and we
Speaker 1: were to begin eating again. It was also my twenty
Speaker 1: third birthday. After the experiment was over, I was still
Speaker 1: hungry for a long time. Even when I could eat
Speaker 1: all I wanted, I would finish a meal and still
Speaker 1: feel hungry. My stomach just would not hold anymore. For months,
Speaker 1: I carried candy bars or cookies in my pocket and
Speaker 1: munched continually. In six months, I went from a low
Speaker 1: of one hundred and twenty two pounds to a high
Speaker 1: of two hundred and twenty five pounds. It took me
Speaker 1: three years to get back to normal weight and normal
Speaker 1: eating habits. In conclusion, I would like to say that
Speaker 1: I have experienced hunger and the apathy and depression that
Speaker 1: goes with it, but we lived in sanitary quarters under
Speaker 1: the constant care of doctors. Most people in areas of
Speaker 1: famine die of other diseases because of the body's inability
Speaker 1: to resist disease. Furthermore, we knew that it would all
Speaker 1: be over on a certain date. I often think how
Speaker 1: horrible it would be to be starving and never know
Speaker 1: when it would end.
Speaker 2: If ever, it's that is such a fascinating perspective, and
Speaker 2: like the fact that that video exists is kind of incredible. Yeah, yeah, yeah.
Speaker 3: It's yeah. It's especially that what he says at the end,
Speaker 3: they're like knowing that it's going to end, and how
Speaker 3: much that can change the way that you are experienced.
Speaker 2: I don't know, it's I mean, it's like and we'll
Speaker 2: get into it more later, but yeah, this is like
Speaker 2: artificial settings important nonetheless, but like, yes, this is not
Speaker 2: the type of thing that people experience under real world
Speaker 2: conditions of starvation. Yeah, so but yeah, so again that
Speaker 2: was Jim Graham who participated in the Minnesota Semi Starvation experiment.
Speaker 2: That's from a video that was recorded in nineteen ninety
Speaker 2: and it's part of Colorado State University's Digital library collections,
Speaker 2: specifically university publications, and we will post a link to
Speaker 2: the full video and the transcript as well on our
Speaker 2: website so you can watch, or listen to or read
Speaker 2: the entire thing. So, yeah, hi, I'm.
Speaker 3: Aaron Welsh and I'm Erin Almanepneke.
Speaker 2: And this is this podcast will kill You.
Speaker 3: So this week and next we're going to be talking
Speaker 3: about starvation and famine and those words, along with hunger
Speaker 3: and malnutrition, have been used a lot lately in discussions
Speaker 3: surrounding the ongoing genocide and famine happening in Gaza and
Speaker 3: the conflict raging Insudan.
Speaker 2: All of these words, you know, starvation, famine, hunger, malnutrition
Speaker 2: are associated with a lack of food and the subsequent
Speaker 2: effects of that lack of food. But each one of
Speaker 2: these words has a distinct meaning, and so what we
Speaker 2: want to do with these two episodes is to provide
Speaker 2: a bit of context for understanding, you know, what it
Speaker 2: is that we're talking about. When we talk about starvation
Speaker 2: and what it means to declare a famine.
Speaker 3: Yeah, so we're starting out this week discussing starvation, the
Speaker 3: physiological and psychological impacts, and a little bit about its history.
Speaker 3: And you'll hear more about that Minnesota semi starvation experiment.
Speaker 2: Yes you will. And then next week we'll turn to famine.
Speaker 2: We'll go through the definition or definitions of famine, what
Speaker 2: causes famine, and how famines have changed throughout history, before
Speaker 2: we outline some of what's happening with the famine in
Speaker 2: Gaza and other food in security crises in other areas
Speaker 2: of the world.
Speaker 3: Yeah, we have a lot to cover these two episodes,
Speaker 3: so we decided to do things a little differently and
Speaker 3: just start right into it. Yes, Yeah, we're going to
Speaker 3: take a quick break and then get started. My goal
Speaker 3: for this first part of today's episode is to walk
Speaker 3: us through what is happening in our bodies, what happens
Speaker 3: inside of our bodies when we are deprived of food.
Speaker 3: So I'm going to start with what's happening on like
Speaker 3: a fairly minute scale, like how does the inner machinery
Speaker 3: of our body keep ticking if we don't provide it
Speaker 3: with any source of energy, and that process can happen
Speaker 3: for any reason. Right. It could be because you lack
Speaker 3: access to food. It could also be because of prolonged illness.
Speaker 3: It could be a restrictive food intake disorder, It could
Speaker 3: be any number of things. But I'm going to go
Speaker 3: through the mechanism of what's going on. But then we're
Speaker 3: going to take a step back a little bit outside
Speaker 3: of our bodies and talk about some of the bigger
Speaker 3: picture consequences of prolonged starvation, especially in the context in
Speaker 3: which we most commonly see starvation today around the globe,
Speaker 3: which is lack of access to food.
Speaker 2: Right, right, right, so population level.
Speaker 3: Effects exactly exactly, Yeah, well, individual and population level, but
Speaker 3: like right, so it's a lot, it's all depressing. As animals,
Speaker 3: we use the food that we eat to create energy,
Speaker 3: and that is the process that we call metabolism. And
Speaker 3: we don't have to get deep into biochemistry. Don't worry,
Speaker 3: because I simply cannot. But there are three main macronutrients
Speaker 3: that are most important, at least for my discussion today,
Speaker 3: and that is carbohydrates or glucose, fats, and protein, and
Speaker 3: these are the majority of what makes up our foods.
Speaker 3: Of course, there's a lot lo of micronutrients. We've covered
Speaker 3: several of them on this podcast. They are essential to
Speaker 3: keep us functioning, but the big three are what we're
Speaker 3: going to focus on today. We have to break down
Speaker 3: and use carbohydrates, fats, and proteins in different ways via
Speaker 3: a whole bunch of complicated cycles in order to create
Speaker 3: energy and keep our cells alive. And all animals do this,
Speaker 3: and because food is almost never, like constantly available, we
Speaker 3: all have All animals have mechanisms physiologic adaptations in order
Speaker 3: to survive in times of food scarcity or food deprivation,
Speaker 3: and the exact adaptations are going to vary a lot
Speaker 3: by species, which is why bears can hibernate for months
Speaker 3: on end, salmon can traverse thousands of kilometers without eating,
Speaker 3: snakes can only eat a couple of times a year.
Speaker 3: But humans, we have relatively high metabolic rates, especially relative
Speaker 3: to our body stores of energy, so we actually need
Speaker 3: food on a pretty regular basis in order to survive.
Speaker 2: There are also behavioral adaptations like caching food, which I mean,
Speaker 2: of course humans, but like like we talked about in hypothermia,
Speaker 2: I know as.
Speaker 3: I was writing this I was like, we just went
Speaker 3: over this in hypothermia. So when animals, including humans, are
Speaker 3: deprived of food, we experience hunger, and the feeling of
Speaker 3: hunger is driven by a pretty complex interplay between hormonal
Speaker 3: and neurologic signals. But hunger is also a biological drive,
Speaker 3: So in animals, including in humans, it's a driving force
Speaker 3: of behavior. And in a lot of animal studies, animals
Speaker 3: across the spectrum, like mammals, birds, everything, will engage in
Speaker 3: riskier and riskier behavior in an attempt to access food
Speaker 3: if they are hungry or starve, and in many animal models,
Speaker 3: the hunger drive actually out competes or overrides nearly all
Speaker 3: other biologic incentives.
Speaker 2: How does it compare it to like thirst drive?
Speaker 3: That's actually a good question. I didn't see any things
Speaker 3: directly comparing that, but they're also very closely related because
Speaker 3: a lot of times, you know, if you are deprived
Speaker 3: of food, you may also be deprived of water. There's
Speaker 3: also some animals who get their water primarily from their food. So, yeah,
Speaker 3: it's a good question, but I don't have like an
Speaker 3: exact answer to it. Yeah, so I'm going to go
Speaker 3: into a little bit mechanistically about what's happening during that
Speaker 3: time during starvation, and there are a lot of hormonal
Speaker 3: drivers and things at play that are controlling our hunger
Speaker 3: cues and our satiety cues. But I think what's important
Speaker 3: to keep in mind as we go through this is that,
Speaker 3: in my opinion, maybe this is an opinion, none of
Speaker 3: this explanation is really adequate to explain what happens to
Speaker 3: people and animals but also humans when they feel hungry
Speaker 3: all the time, for days or weeks on end. I
Speaker 3: think that our first hand account helped to explain some
Speaker 3: of that bigger picture about how it feels to be hungry,
Speaker 3: but the biology doesn't quite I think, do that justice?
Speaker 2: Yeah, I mean it can't.
Speaker 3: It can't.
Speaker 2: It can't because it's so clinical.
Speaker 3: Yes exactly, yeah so, but metabolically absolute food deprivation proceeds
Speaker 3: in relatively predictable stages. It starts with what's often called
Speaker 3: fasting and then proceeds through starvation, and without intervention this
Speaker 3: will end in death. So the first phase of food
Speaker 3: deprivation is it's often called fasting, and there's arguments about
Speaker 3: like when do you hit the threshold between fasting and
Speaker 3: starvation and et cetera. But the point is that this
Speaker 3: is just the first few hours after you've eaten food.
Speaker 3: Once we've absorbed all that we can from our meal,
Speaker 3: the first thing that our body is going to do
Speaker 3: is start using glycogen, which is the long branchy chains
Speaker 3: of glucose that we store in our liver, right, and
Speaker 3: we start breaking this down in order to keep our
Speaker 3: blood sugar levels up.
Speaker 2: Okay, so this is what happens after you eat a meal.
Speaker 3: After you eat and you've digested and used up all
Speaker 3: the glucose in your meal.
Speaker 2: Right, got it?
Speaker 3: Yep. Yeah, we'll also start to use some of our
Speaker 3: adipose tissue storage, especially to like fuel our muscles and
Speaker 3: things like that. This phase, though, the glycogen storage that
Speaker 3: we have in our liver only lasts for about a
Speaker 3: few hours, which is why we usually start to feel
Speaker 3: hungry a few hours after eating. After a few hours
Speaker 3: without food, our livers glycogen stores are depleted, and our
Speaker 3: brain requires glucose in order to function in the rest
Speaker 3: of the tissues in our body can use other energy sources.
Speaker 3: They can go through these biochemical pathways to like directly
Speaker 3: use proteins or fats in order to make energy. In
Speaker 3: order to make ATP. But our brain really needs glucose.
Speaker 3: That's what it is dependent on. So our liver abides
Speaker 3: and starts making glucose. And this is a process called gluconeogenesis,
Speaker 3: literally making new glucose.
Speaker 2: This is it's like I remember all of this in
Speaker 2: such vague terms from like bio one oh one, right,
Speaker 2: and it's I don't know if it's coming back to me,
Speaker 2: but by the end of this it would be back.
Speaker 3: You have certainly come across this, I'm sure in like
Speaker 3: most biology, gluconeogenesis. Yeah, yeah, it's actually one of my
Speaker 3: favorite words.
Speaker 2: It's a good word.
Speaker 3: It's a good word.
Speaker 2: Yeah.
Speaker 3: We go through glycogenolysis, and now we make gluga eugenesis. Anyways,
Speaker 3: at first, like the very first, our body starts to
Speaker 3: do this with some protein because protein is very easy
Speaker 3: for our bodies to make glucose from. Okay, so we'll
Speaker 3: start breaking down a little bit of protein in order
Speaker 3: to feed our brain. But proteins in our body are
Speaker 3: not really there for energy storage. We use proteins in
Speaker 3: our body for building stuff. We use it to make
Speaker 3: our muscles, we use it as enzymes. Right, So our
Speaker 3: body tries to preserve protein aside from what we eat
Speaker 3: and then have to use. Right, So pretty quickly our
Speaker 3: body switches and we start relying more on our adipose tissue,
Speaker 3: our fat in order to fuel our body. We cannot, though,
Speaker 3: make glucose directly from the fatty acids part of fat. Okay,
Speaker 3: but we store fat and sorry this is getting a
Speaker 3: little technical, but we store fat in the form of
Speaker 3: something called triglycerides, which is three fats and a glycrool,
Speaker 3: and that one glycerol we can make glucose from.
Speaker 2: Okay, could we just pause and start so now can
Speaker 2: you put me in like a timeline of what is happening,
Speaker 2: and when like step one you eat, step two you digest,
Speaker 2: step three you start to pull the glycogen from your liver,
Speaker 2: and then step four where does proteins that what happens
Speaker 2: with the proteins and fats at that point.
Speaker 3: It's not like an exact like this day you switch,
Speaker 3: because it's going to depend on your body composition and
Speaker 3: like what your last meal was and all of those
Speaker 3: sorts of shits. Right, But in general, after a meal,
Speaker 3: the first few hours you're going to be mostly using
Speaker 3: glycogen stores. After those glycogen stores are depleted. Your body
Speaker 3: is going to start breaking down your own body in
Speaker 3: order to get the glucose that you need. It might
Speaker 3: use a little bit of protein at first, but primarily
Speaker 3: it's going to rely on using your fat stores. Where
Speaker 3: are fat stores, I mean, all over your whole body.
Speaker 2: It's just everywhere. It's just sort of a shop.
Speaker 3: Yep, exactly. Yeah, Okay, So we start seeing a lot
Speaker 3: of this process called fatty acid oxidation, and that is
Speaker 3: the majority of what we're going to see for potentially
Speaker 3: weeks on end, depending on how much fat storage you have.
Speaker 3: The process of fatty acid oxidation will also result in
Speaker 3: the formation of keytone bodies.
Speaker 2: People who have heard.
Speaker 3: Of the whole keto diet thing will have heard of this.
Speaker 2: We should do an episode on the Keto diet, though
Speaker 2: we probably should.
Speaker 3: Our brains can actually use keytone bodies. They can use
Speaker 3: ketones as fuel. Our brain prefers glucose, but it will
Speaker 3: use this as it is required to. But this whole
Speaker 3: process is basically our body adapting to this starvation. We
Speaker 3: will use up all of our fat stores, and how
Speaker 3: long we can survive in this particular phase is going
Speaker 3: to depend pretty much on our body composition, our age,
Speaker 3: our comorbidity, is all of these things. But it's usually
Speaker 3: a period of a few weeks or so. After that
Speaker 3: we enter what's kind of called phase three, and that
Speaker 3: I think of it as when our body is really
Speaker 3: not able to compensate anymore, because this is the point
Speaker 3: at which we've run through these fat stores and now
Speaker 3: we have to rely on skeletal muscle. Yeah, and our
Speaker 3: body has to start breaking down our muscle proteins in
Speaker 3: order to use them for energy. And you can imagine
Speaker 3: that that's not good for our body. We need our muscles,
Speaker 3: but that is what our body will do in order
Speaker 3: to keep it alive in the short term. Right.
Speaker 2: Can I ask a question about like how food consumption
Speaker 2: changes this process?
Speaker 3: Yeah, it's a really good question. So it's not common
Speaker 3: that people are completely deprived of food and how absolutely
Speaker 3: no access to food.
Speaker 1: Right.
Speaker 3: More often people are going to get very small amounts
Speaker 3: of food a little bit at a time, or maybe erratically,
Speaker 3: and that is what is sometimes called this like semi starvation.
Speaker 3: The way to think about that is it's going to
Speaker 3: kind of fluctuate where you are in this continuum. As
Speaker 3: soon as you eat, your body is going to use
Speaker 3: up all of that food that it can. Is it
Speaker 3: going to be able to store any extra? It totally
Speaker 3: depends on how deprived you have been, right, But you
Speaker 3: can think of it as kind of keeping people cycling
Speaker 3: between these first few phases for a potentially more prolonged
Speaker 3: period of time. But it could be that you're kind
Speaker 3: of going your body is doing all things at once, right,
Speaker 3: You've if you've used up all of your fat stores,
Speaker 3: and then you get access to food, then your body's
Speaker 3: going to use that food. But then as soon as
Speaker 3: you've used that up, you don't have any fat stores,
Speaker 3: so you're going to go right back to using your.
Speaker 2: Protein something straight back to protein.
Speaker 3: Okay, okay, yeah, so that's I mean, Actually, what happens
Speaker 3: this process, especially once you get to the point of
Speaker 3: breaking down your own skeletal muscle for fuel, can progress
Speaker 3: fairly rapidly, and if food does not become available, this
Speaker 3: will end in death kind of directly from starvation. There
Speaker 3: are in the literature kind of two different syndromes that
Speaker 3: we most often see in people who are affected by starvation,
Speaker 3: and collectively this is called severe acute malnutrition. This is
Speaker 3: like the end stage of this This is like phase three,
Speaker 3: end stage of lack of access to food. This used
Speaker 3: to be called it was when I learned it actually
Speaker 3: called protein energy malnutrition. But separately, within this there's two
Speaker 3: different syndromes. One is known as quashiocore and the other
Speaker 3: is Marasmus. Yes, and a lot of the literature around
Speaker 3: severe acute malnutrition or SAM, focuses on children under the
Speaker 3: age of five because they are by far the most
Speaker 3: vulnerable too severe acute malnutrition and the complications that can arise.
Speaker 3: But it's not the only they are not the only people.
Speaker 3: It's really important to remember that other groups are very
Speaker 3: vulnerable to food deprivation, including pregnant or breastfeeding people, including
Speaker 3: the elderly, and including children and adults with certain disabilities
Speaker 3: or comorbid conditions, things like cystic fibrosis or cerebral palsy.
Speaker 3: I mean, there are so many conditions that might make
Speaker 3: you more susceptible to malnutrition.
Speaker 2: Yeah, but I.
Speaker 3: Want to go through these two syndromes in a little
Speaker 3: bit of detail, and then we'll talk bigger picture about
Speaker 3: all of the complications that happen as your body has
Speaker 3: gone through this starvation process. So Marasmus is also known
Speaker 3: as acute wasting, and this is when you lose a
Speaker 3: very substantial amount of weight, and usually in a relatively
Speaker 3: brief period, although some people, if they have been experiencing
Speaker 3: prolonged semi starvation, it might be over kind of a
Speaker 3: longer time period. But it's diagnosed based on specific like
Speaker 3: body weight and height measurements, or by measuring the upper
Speaker 3: arm circumference and having that be below a certain circumference.
Speaker 3: It's like a good indicator of how much weight someone
Speaker 3: has lost. And this is really the kind of most
Speaker 3: classic process that happens as what I described of starvation.
Speaker 3: So as you have no food, you use up all
Speaker 3: of your fat stores, and then you start to eat
Speaker 3: away at your muscles and then you are experiencing Marasmus.
Speaker 3: Does that make sense? Yes?
Speaker 2: Yes.
Speaker 3: The other condition is quashiocore, which historically was thought of
Speaker 3: as primarily a protein malnutrition.
Speaker 2: What does that mean?
Speaker 3: Yeah, it used to be.
Speaker 1: So.
Speaker 3: It was first seen in certain populations in association with
Speaker 3: a very low protein diet or in infant after they
Speaker 3: switched from breast milk to very low protein like say
Speaker 3: all corn diets or something like that. Okay, And so
Speaker 3: based on those kind of like epidemiological studies, and in
Speaker 3: contrasting that to Marasmus, which was thought of as purely
Speaker 3: like a calorie deficit uh huh, without necessarily only a
Speaker 3: protein deficit. This was classified initially as like, oh, this
Speaker 3: is a protein deficit rather than like a total energy deficit.
Speaker 3: But it turns out that that's not really quite as
Speaker 3: clear cut, and the exact path of physiology is not
Speaker 3: entirely understood. We really don't understand quashio court right now,
Speaker 3: but it does look different physiologically than Marasmus or wasting.
Speaker 3: It's characterized by this edema, this fluid collection and swelling
Speaker 3: underneath the skin especially, and it starts in the lower
Speaker 3: legs but can also be in the face, in the arms.
Speaker 3: And there's also fatty liver infiltration that we see, and
Speaker 3: you can get from that like distension of the abdomen,
Speaker 3: and then we'll have like flaky skin and other changes
Speaker 3: that we don't necessarily see with Marasmus or wasting. We
Speaker 3: think from what I could tell from the literature that
Speaker 3: quashi or core more specifically, might be like a maladaptive
Speaker 3: response to the way that our body is processing protein
Speaker 3: in the face of a very low protein diet, if
Speaker 3: that makes sense.
Speaker 2: Yeah, okay, So I'm curious, Like the food that we
Speaker 2: eat is not just food, right, Like there are different
Speaker 2: qualities of food, different like types of food, different energy sources,
Speaker 2: and so how does that play a role? I mean,
Speaker 2: maybe this is jumping ahead a bit and asking sort
Speaker 2: of about like refeeding, but like, how does that play
Speaker 2: a role in you know, the development of these sort
Speaker 2: of symptoms or conditions?
Speaker 3: Yeah, I mean in all, honestly, we don't like really
Speaker 3: fully know because we don't know, Like there can be
Speaker 3: a lot of First of all, marasmus and quashiocore are
Speaker 3: not necessarily mutually exclusive. They can happen simultaneously, but they
Speaker 3: also can happen in let's say, like the same communities
Speaker 3: and sometimes when people are exposed to or have access
Speaker 3: to the same foods. And so that's why it's not
Speaker 3: entirely clear, like, you know, if we let's say, if
Speaker 3: we're focusing on humanitarian aid and like what types of
Speaker 3: foods do we need to get into an area to
Speaker 3: prevent quashiocore more specifically, It's not quite as clear as that,
Speaker 3: except that protein is definitely an important part of that.
Speaker 3: But it's not as clear cut as like, Yeah, it's
Speaker 3: just not as clear cut as like protein malnutrition equals quashiocore.
Speaker 2: Right, okay, okay, Yeah.
Speaker 3: It's also more difficult to estimate in terms of the
Speaker 3: distribution of it. We don't have as good of a
Speaker 3: handle on it. It does tend to be even more
Speaker 3: severe than Marathis alone. And is that because there's this
Speaker 3: like maladaptive component to it. We see like increases in
Speaker 3: oxidative stress in quaeshiocre compared to Marasmus, we see even
Speaker 3: more microbiome changes. Is there a microbiome component? There's like
Speaker 3: a lot of questions, but what.
Speaker 2: Do you mean by maladaptive response? Though, Like I.
Speaker 3: Mean, like you aren't they they aren't breaking down and
Speaker 3: using the protein that they do have in a way
Speaker 3: that would like sustain them for longer. Is the best
Speaker 3: way that I can Okay. Yeah. There was a paper
Speaker 3: that came out in the Lancet not too long ago
Speaker 3: that was more specifically looking at like one type of
Speaker 3: metabolism called one carbon metabolism, which is one of these
Speaker 3: many biochemical pathways, and it's thought that maybe that is
Speaker 3: affected more severely in queshuocore compared to Marasmus. So maybe
Speaker 3: it's that that we're not using this one pathway as well. Why,
Speaker 3: we don't know. But overall, severe acute malnutrition, like both
Speaker 3: of these combine effect up to seventeen million children or
Speaker 3: more worldwide and untreated. Once a kid meets criteria for
Speaker 3: severe acute malnutrition, it has a mortality rate of ten
Speaker 3: to fifteen percent per month. So the overall effects of
Speaker 3: this are really profound. Physically, it's manifest like you see
Speaker 3: it as this loss of the subcutaneous fat that's going
Speaker 3: to be like the last fat that your body tries
Speaker 3: to hold on to, and that's what gives you a
Speaker 3: very gaunt appearance. And then you're going to have this
Speaker 3: muscle wasting, which is also going to come with weakness
Speaker 3: because your muscles are literally like being eaten away by
Speaker 3: your own by Your skin becomes dry and wrinkly, your
Speaker 3: hair becomes sparse and thin. The cheeks look very sunken
Speaker 3: because you've lost the cheek pads, this fat that's in
Speaker 3: your cheek. Physiologically, your heart rate slows down, your blood
Speaker 3: pressure is very low, your body temperature is low, oftentimes,
Speaker 3: especially towards the most severe stages. Appetite is gone, which
Speaker 3: can make it really hard for people to start eating again,
Speaker 3: and sometimes when they do, they are faced with nausea, vomiting, diarrhea.
Speaker 3: And that's because during this process, your digestive system is
Speaker 3: essentially shutting down. Starvation affects every single organ system in
Speaker 3: our body. Glucose homeostasis is disrupted, and so we often
Speaker 3: see hypoglycemia. And that's especially true in quashio core compared
Speaker 3: to marasmus or wasting. Again, something maladaptive happening there. We also,
Speaker 3: and this one's really important, see huge alterations in our
Speaker 3: immune system function.
Speaker 2: It's one of the biggest.
Speaker 3: Yeah, it's one of the biggest because many people, especially
Speaker 3: kids with severe acute malnutrition, will end up very sick
Speaker 3: with life threatening infections, and cause of death is often
Speaker 3: from infection and not directly from starvation itself, right, right,
Speaker 3: But this is directly because of a secondary immune deficiency, right.
Speaker 3: It's so it is the starvation that is putting you
Speaker 3: at risk for.
Speaker 2: Infection ultimate versus proximate cause type exactly. Yeah.
Speaker 3: Yeah, but this immune deficiency comes from a combination of
Speaker 3: different things. There's disruption in all of our major barriers, right,
Speaker 3: There's disruptions of your skin integrity, of your respiratory barrier,
Speaker 3: of your gut barrier. But then we also see an
Speaker 3: increase in the activation of inflammatory pathways. We see T
Speaker 3: cell dysfunction, We see a reduction in anti micro activity
Speaker 3: of most of our immune cells. And then, like I mentioned,
Speaker 3: we see this like offlining of our entire digestive system
Speaker 3: because it's not doing anything and so our body is
Speaker 3: trying to preserve energy. We see our liver, our pancreas,
Speaker 3: our biliary system are intestinal tract essentially not functioning at
Speaker 3: their typical capacity. We also see huge changes in the
Speaker 3: gut microbiome, which can sometimes include bacterial overgrowth in the
Speaker 3: small bowel huh. Especially in kids, we can get impairment
Speaker 3: of thyroid function and cortisol and growth hormones, which can
Speaker 3: have profound effects for the rest of their life.
Speaker 2: I mean, so many of the aspects of starvation. Whatever,
Speaker 2: at what point in your life it happens, it can,
Speaker 2: it will stay with you.
Speaker 3: Forever, forever, forever, forever. Absolutely, And then there's changes in
Speaker 3: our brain functioning as well, and not just an increase
Speaker 3: in lethargy and irritability, but also the psychological effects which
Speaker 3: are really profound and honestly not quite as well characterized.
Speaker 3: But I know erin you'll talk a lot more about
Speaker 3: some of the initial data that we have on this
Speaker 3: from that semi starvation experiment. There was also a more
Speaker 3: recent review paper that highlighted several hundred studies, not all
Speaker 3: of which were a lot of which were in that
Speaker 3: kind of artificial type of environment that's where a lot
Speaker 3: of our data comes from. But there was also at
Speaker 3: least some papers that were looking at the effects of
Speaker 3: starvation psychologically in more unfortunately realistic situations, like in areas
Speaker 3: of famine or chronic starvation and things like that, and
Speaker 3: we consistently see increases in depression, anxiety, higher psychological distress.
Speaker 3: We also see increases in competitive behavior and social withdrawal. Yeah,
Speaker 3: And of course in most situations of chronic malnutrition or
Speaker 3: acute starvation that we see in our way world today
Speaker 3: happen after natural disasters, armed conflict, and these are situations
Speaker 3: when lack of access to food is not the only stressor.
Speaker 2: Right compounding trauma exactly.
Speaker 3: And there is not a lot of studies that have
Speaker 3: directly looked at all of those compounded effects, but we
Speaker 3: can often unfortunately see them play out on our cell
Speaker 3: phones from videos. Yeah, many of these changes also have
Speaker 3: lifelong effects, and unfortunately we don't even have all that
Speaker 3: much data on it. We have really clear data on
Speaker 3: the profound effects of starvation during pregnancy on the fetus
Speaker 3: and on growth of those babies thereafter. We don't have
Speaker 3: as much long term data on the effects of malnutrition,
Speaker 3: but there are at least some that like exposure to
Speaker 3: severe malnutrition, especially in childhood, is associated with increased risk
Speaker 3: of cardiovascular disease, hypertension, dysfunction of your glucose metabolism, and
Speaker 3: cognitive and developmental delays right forever, forever. And you had
Speaker 3: mentioned Aaron about treatment. Yeah, and it might sound like
Speaker 3: treatment should be straightforward, right if the problem is lack
Speaker 3: of access to food, get people access to food. Yeah,
Speaker 3: it's nope, not that it's not straightforward, not straightforward for
Speaker 3: a lot of reasons. Right, in the context of starvation,
Speaker 3: both like acute food insecurity and more chronic food instability,
Speaker 3: we do rely on food like that is the number
Speaker 3: one thing, and a lot of times humanitarian programs and
Speaker 3: things like that are going to rely on what's called
Speaker 3: ready to use therapeutic food or RUTF, and this is
Speaker 3: something that has been specially formulated based on studies to
Speaker 3: try and hit at those most important nutrients. Right. We
Speaker 3: have a good amount of proteins, we have all of
Speaker 3: the essential amino acids. We've got micronutrients which are really important,
Speaker 3: even though I didn't focus on them. In severe acute
Speaker 3: malnutrition specifically, it's usually treatment with this like ready to
Speaker 3: use therapeutic food and often a short course of antibiotics
Speaker 3: if you've gotten to the point of meeting criteria for
Speaker 3: severe acute malnutrition.
Speaker 2: Right. Yeah.
Speaker 3: And it used to be that the treatment of this,
Speaker 3: especially like the most severe forms and in times of
Speaker 3: crisis or famine, it used to rely almost entirely on
Speaker 3: these like centralized treatment centers, which were almost always set
Speaker 3: up by external you know, NGOs and nonprofits. But it
Speaker 3: has really shifted for the better to more community based
Speaker 3: care because A, that's going to get access to a
Speaker 3: lot more people. B it's going to mean that caregivers
Speaker 3: can stay, especially with their children and their other children
Speaker 3: who might not be as sick as the ones who
Speaker 3: need the most help. But there is always in areas
Speaker 3: of like mass food insecurity and starvation, there will always
Speaker 3: be people who are sick enough, whether from starvation alone
Speaker 3: or the combination of starvation and infection or other underlying illness,
Speaker 3: that they do need hospitalization. And that's specifically because of
Speaker 3: a risk called refeeding syndrome. Yes, yeah, And basically this
Speaker 3: is that as you rapidly increase nutrient intake when you've
Speaker 3: been deprived for so long, your body switches from this
Speaker 3: prolonged state of breakdown to all of a sudden being like,
Speaker 3: we've got food we need to build up, so we
Speaker 3: switch from what's called catabolism to ennabolism, so instead of
Speaker 3: breaking down our body, we're building up storage. This leads
Speaker 3: to a pretty huge surge in insulin secretion, because that's
Speaker 3: one of our main hormones involved in storing energy during starvation.
Speaker 3: It's not that we have absolutely no insulin, but our
Speaker 3: insulin levels are incredibly low, and this is going to
Speaker 3: stimulate the uptake and storage of glucose, which can result
Speaker 3: in really severe high boglycemia in the case of prolonged
Speaker 3: starvation because you don't have that much doors to begin with.
Speaker 3: But it also because of the effects of insulin, stimulates
Speaker 3: the uptake of a bunch of different electrolytes into ourselves.
Speaker 3: It shifts electrolytes into our cells, including potassium, magnesium, is phosphorus,
Speaker 3: and this can result in really dangerous electrolyte abnormalities that
Speaker 3: can cause things like heart a rhythmias, seizures, respiratory failure,
Speaker 3: and even death.
Speaker 2: How do we prevent that from happening?
Speaker 3: I mean, first it's monitoring, and then it's repleating those
Speaker 3: electrolytes and the sugar if needed. How do we do
Speaker 3: that by giving people that whether it's through iv or
Speaker 3: through eating, so making sure that they're getting enough potassium,
Speaker 3: making sure that they're getting enough magnesium and phosphorus, yeah,
Speaker 3: and fixing.
Speaker 2: Those monitoring those levels essentially. I mean, I imagine that
Speaker 2: would be very difficult to do in situations where you know,
Speaker 2: there's already a lot, there's already eight is being blockaded
Speaker 2: right e for instance.
Speaker 3: Well, and so many of the areas where we see,
Speaker 3: especially like acute disasters, the healthcare infrastructure is not there either.
Speaker 3: Yeah right, So yeah, So refeeding syndrome is a very
Speaker 3: real risk if you are not able to identify it
Speaker 3: and manage it.
Speaker 2: And those who are most vulnerable to refeeding syndrome. Are
Speaker 2: those who are also at the most extreme of end
Speaker 2: of malnutrition or can it really happen to anyone who's
Speaker 2: been in a semi starved or like experiencing chronic hunger
Speaker 2: for a while.
Speaker 3: Yeah, that's a really good question. You don't necessarily have
Speaker 3: to meet criteria for severe acute malnutrition to be at
Speaker 3: risk for refeeding syndrome. Okay? Is it is really this
Speaker 3: prolonged risk? So often people might have meat criteria for
Speaker 3: severe acute malnutrition, but not necessarily in order to potentially
Speaker 3: have refeeding syndrome.
Speaker 2: Okay.
Speaker 3: Yeah, it's something we unfortunately see a lot actually in
Speaker 3: the hospitals in the context of like restrictive food intake
Speaker 3: disorders like inarexiaan and things like that. It's not uncommon
Speaker 3: to see refeeding syndrome in those contexts as well. I
Speaker 3: see and globally, millions millions of children face food insecurity,
Speaker 3: especially in low and middle income countries. It is estimated
Speaker 3: that at least ten percent of deaths in children under
Speaker 3: age five globally are due to severe acute malnutrition, and
Speaker 3: there are estimates as high as forty five percent of
Speaker 3: deaths in kids under age five being at least in
Speaker 3: part due to undernutrition, meaning it's a combination of their
Speaker 3: susceptibility to infections and all of these other things as
Speaker 3: a result of undernutrition.
Speaker 2: I mean, starvation is not just a simple lack of food.
Speaker 3: Correct correct right, right, especially, and we'll talk a lot
Speaker 3: more about this next week. But so many of the
Speaker 3: situations that we see kind of acute disruptions in food supply,
Speaker 3: we also see displacement. We also see armed conflict. We
Speaker 3: also see crowding. We also see lack of or dismantling of,
Speaker 3: or disruption of clean water facilities, sanitation facilities. All of
Speaker 3: those things are going to put people at higher risk
Speaker 3: of the spread of infectious disease, and we know that
Speaker 3: they are more susceptible to infectious disease. We see things
Speaker 3: like outbreaks of diarrheal diseases, which can be very devastating
Speaker 3: cause dehydration and electrolyte imbalance when you are already facing malnutrition.
Speaker 3: And even when we talk about the global estimates on
Speaker 3: kids who are affected by malnutrition or wasting, those estimates
Speaker 3: tend not to capture the groups of kids and adults
Speaker 3: who efface acute malnutrition because of things more acutely, like
Speaker 3: natural disasters or conflicts, and these kind of more emergency situations,
Speaker 3: those are often actually not reflected in the larger statistics
Speaker 3: when we talk about the burdens of severe acute malnutrition,
Speaker 3: which is grim. And we'll talk more about those acute
Speaker 3: famine situations next week, but Aaron, can you tell me
Speaker 3: a little bit more about how we learned what we
Speaker 3: know about these effects of starvation on our bodies?
Speaker 2: I can tell you about one way we learned, Yes,
Speaker 2: thank you. The brochure read will you starve that they
Speaker 2: be better fed? More than four hundred people said that
Speaker 2: they would. Of those, one hundred were interviewed and thirty
Speaker 2: six were selected to participate in what would be known
Speaker 2: as the Minnesota Starvation Experiment. So in nineteen forty four,
Speaker 2: as World War II entered its fifth year, researchers in
Speaker 2: Europe and the US grew increasingly aware of the dire
Speaker 2: situation that was facing much of war torn Europe and
Speaker 2: of the horrific and brutal conditions in Nazi concentration camps.
Speaker 2: Millions of people who had gone months, even years without
Speaker 2: access to enough food and clean water, adequate shelter, and
Speaker 2: clothing and healthcare, leading disease to spread unchecked. People realized
Speaker 2: that when this massive global conflict came to an end,
Speaker 2: which seemed more and more likely as the months went by,
Speaker 2: massive numbers of relief workers would be needed to deliver
Speaker 2: food and resources in liberated cities and camps. But there
Speaker 2: was no agreed upon plan for how best to distribute
Speaker 2: these resources, like what and how much food to give
Speaker 2: a starving city? What kind of food? In November of
Speaker 2: nineteen forty four, after years of lobbying for funds to
Speaker 2: study the effects of starvation, physiologist ansel Keys was finally
Speaker 2: granted the opportunity to begin his study. He distributed those
Speaker 2: pamphlets that say, you know, will you starve that they
Speaker 2: be better fed. He distributed them to thousands of conscientious
Speaker 2: objectors who, after being drafted into the war, had exercised
Speaker 2: their right to refuse service for moral or religious reasons.
Speaker 2: Side note, before I forget, I wanted to mention that
Speaker 2: this is not this experiment is not ansel Keys's only
Speaker 2: claim to fame, or even his biggest claim to fame.
Speaker 2: He also developed k rations for American troops. So these
Speaker 2: were these ready to eat non parish meals breakfast, dinner,
Speaker 2: and supper, and that soldiers could carry around with them.
Speaker 2: And there are YouTube videos of people trying these out
Speaker 2: like today, like unboxing, and like reviews of the different
Speaker 2: types of k rations like those are eighty years old.
Speaker 2: I mean, I think they were also made up through
Speaker 2: the nineteen fifties. I'm not sure. Don't quote me on that,
Speaker 2: keeping it in the podcast anyway, Yeah, old. And he
Speaker 2: also in addition to k rations, he along with his wife,
Speaker 2: popularized the Mediterranean diet.
Speaker 3: I saw that too, I was like, wow, Keys.
Speaker 2: Keys Keys, Yep, he was kind of an influential guy
Speaker 2: about that, I know. Yeah, But anyway, so Keys was
Speaker 2: interested in starvation not only in terms of its effects
Speaker 2: on the body and the mind, like what is actually
Speaker 2: happening during starvation, but especially how best to feed someone,
Speaker 2: to treat someone, to treat the starvation without causing further harm,
Speaker 2: and also what while making efficient use of limited resources,
Speaker 2: Like the resources were limited most of Europe was under
Speaker 2: rationing anyway, And so he designed this experiment where he
Speaker 2: took thirty six young healthy men and put them on
Speaker 2: a semi starvation diet. And on this podcast, we are
Speaker 2: I think fairly accustomed to thinking of the word volunteer
Speaker 2: in quotes like, especially when it comes to early twentieth
Speaker 2: century medical experiments, but in this case volunteer seems to
Speaker 2: truly mean volunteer and al yeah, I.
Speaker 3: Feel like that sets this apart almost more than anything, absolutely,
Speaker 3: that he did not experiment on people unwillingly.
Speaker 2: Right, Yeah, he didn't. Like he was really, I think,
Speaker 2: very deliberate about what he was doing, as were the
Speaker 2: men who participate. Like ansel Keys, was seemed truly motivated
Speaker 2: by the desire, the passion to reduce suffering in people
Speaker 2: around the world, and many of the men who participated
Speaker 2: were later interviewed in like the early two thousands about
Speaker 2: their experiences, and they all said that if given the chance,
Speaker 2: they would do it again, which is I think that's like,
Speaker 2: that's they were very proud of their contribution because I
Speaker 2: think to be a conscientious objector during World War Two
Speaker 2: it came with many complex emotions that some of the
Speaker 2: men talked about. One man said, quote, you know, the
Speaker 2: sense of not sharing the fate of one's generation, but
Speaker 2: of sort of coasting alongside all of that. You couldn't
Speaker 2: feel you were part of anything terribly significant in what
Speaker 2: you were doing, end quote. And so this was kind
Speaker 2: of their way of like contributing to the effort to
Speaker 2: defeat fascism without compromising their morals.
Speaker 3: Which.
Speaker 2: Yeah. So the experiment started in November nineteen forty four
Speaker 2: with a three month control period during which the men
Speaker 2: all received a standard diet of thirty two hundred calories
Speaker 2: of food a day or kill a calories. I'm just
Speaker 2: going to say calories from this point forward, because that's
Speaker 2: how we tend to think of calories today. Yeah, So
Speaker 2: thirty started with three months thirty two hundred calories of
Speaker 2: food a day. Some of the men, like I think
Speaker 2: are the first hand account. Jim Graham, he actually needed more.
Speaker 2: He was losing weight on that because he was quite
Speaker 2: an active person anyway. Yeah. So then there began, after
Speaker 2: those three months, a six month period of semi starvation.
Speaker 2: So it started on February twelfth, nineteen forty five, And
Speaker 2: this with the semi starvation, was a daily caloric intake
Speaker 2: of roughly eighteen hundred calories a day. So there were
Speaker 2: two meals a day, one at eight am and one
Speaker 2: at six pm, except on Sundays, where they got I
Speaker 2: think just one larger meal and the food tended to
Speaker 2: reflect what the most impacted areas of Europe might be consuming,
Speaker 2: so things like potatoes, turnips, brown bread, stuff like that. Breakfast,
Speaker 2: for example, might consist of a small bowl of farina,
Speaker 2: two slices of toast, a dish of fried potatoes, some jello,
Speaker 2: a bit of jam, and a small glass of milk.
Speaker 2: And initially the men were allowed to eat gum, but
Speaker 2: that stopped after some of the guys were going through
Speaker 2: like forty packs a day a day just for something
Speaker 2: to like put in your mouth. Yeah, And the men
Speaker 2: were also expected to walk twenty two miles each week,
Speaker 2: and so this was and they had to like record
Speaker 2: this I think, I actually don't know how they how
Speaker 2: they tracked this, but the idea was that they would
Speaker 2: be consuming fewer calories than they expended. So it was
Speaker 2: supposed to be like a three thousand calorie expenditure daily
Speaker 2: and they were only in taking eighteen hundred calories of food.
Speaker 3: So they had to remain active enough that that wasn't.
Speaker 2: Yes, yeah, yeah, but other than that, you know, their
Speaker 2: movements weren't too restricted. There was a buddy system that
Speaker 2: was instituted at one point, but they were given you know,
Speaker 2: various administrative or housekeeping duties. They attended political science and
Speaker 2: language classes as prep to become international relief workers when
Speaker 2: this was over, and the goal was to have participants
Speaker 2: lose two and a half pounds a week, which is
Speaker 2: a lot, so that at the end of six months
Speaker 2: they lost twenty five percent of their total body mass.
Speaker 2: Everyone was routinely weighed, their strength and their endurance was tested,
Speaker 2: blood was screened, other body measurements were taken, and they
Speaker 2: were also routinely given intelligence and personality tests just to
Speaker 2: kind of assess like psychological status. Interesting and results from
Speaker 2: their weekly weigh in were posted at the end of
Speaker 2: each week could cause tensions to run high. Some people
Speaker 2: would just avoid it until they absolutely had to see
Speaker 2: how much they were getting. It would determine how much
Speaker 2: food you got to eat the following week. One of
Speaker 2: the men, Yeah, one of the men, Daniel Peacock, recalls
Speaker 2: that quote. We were given our food along a cafeteria line,
Speaker 2: and if the guy ahead of you is given five
Speaker 2: slices of bread, that's pretty hard to conceal, and if
Speaker 2: you're only getting three, that's pretty touchy. End quote. They
Speaker 2: were also all required to keep a journal to keep
Speaker 2: track of their mental and physical progress, like you know what.
Speaker 2: Some of the guys described how when they had to
Speaker 2: cross the street, when they were like out on their walks,
Speaker 2: they would wait until they encountered a driveway so that
Speaker 2: they wouldn't have to step down or step up on
Speaker 2: the curb because they were just had no energy. They
Speaker 2: noted how they lost any sex drive whatsoever pretty quickly. Quote.
Speaker 2: I have no more sexual feeling than a sick oyster,
Speaker 2: wrote one man. Sick oysters. Yeah, and they became obsessed
Speaker 2: with food. Quote. Eating became a ritual. Some people diluted
Speaker 2: their food with water to make it seem like more.
Speaker 2: Others would put each little bite and hold it in
Speaker 2: their mouth a long time to savor it. So eating
Speaker 2: took a long time end quote. There's a lot of
Speaker 2: fascinating diary snippets that I encountered. So I'm going to
Speaker 2: read you a few just from like a few of
Speaker 2: the different months, because you can see sort of a
Speaker 2: little bit of like the month by month. Yeah, month too. Quote.
Speaker 2: I just don't have any desire to do the things
Speaker 2: I should do or the things I want to do.
Speaker 2: Instead of writing a letter, I read a newspaper. Instead
Speaker 2: of studying, I read a pamphlet instead of cleaning. I
Speaker 2: putter around, making excuses such as, well, I really won't
Speaker 2: have enough time to do the complete job. I'll do
Speaker 2: it later end quote. And then month two, I purchased
Speaker 2: a tube of toothpaste yesterday, finally got around to using
Speaker 2: it for the first time last night. Had a desire
Speaker 2: to eat the paste, but controlled it. Month five, I
Speaker 2: also found myself becoming senselessly irritable, particularly when I watched
Speaker 2: some of the bizarre eating habits of others. One mixture
Speaker 2: that came near flooring me was potatoes, jam, sugar, gingerbread,
Speaker 2: all thrown into a bowl of oatmeal and used as
Speaker 2: a sandwich spread. I hate to see guys picking around
Speaker 2: with this or that to make a superb sandwich, all
Speaker 2: the time letting their soup get cold. And Month six
Speaker 2: stayed up until five am last night studying cookbooks so
Speaker 2: absorbing I can't stay away from them, which might be
Speaker 2: our first hand he did mention becoming like obsessed with cookbooks.
Speaker 2: After the six months of semi starvation ended on July
Speaker 2: twenty ninth, nineteen forty five, there was a three month
Speaker 2: period of refeeding, the men had lost on average the goal,
Speaker 2: which was a quarter of their body weight. Their hearts
Speaker 2: had shrunk by almost seventeen percent, they beat a lot
Speaker 2: more slowly, like, their pulse was a lot slower, blood
Speaker 2: pressure dropped tremendously, they became anemic, their lung capacity had
Speaker 2: decreased by thirty percent, and a few experienced pretty severe
Speaker 2: neurological symptoms that had to be treated like separately. For
Speaker 2: the refeeding portion, the men were placed into different treatment
Speaker 2: groups based on caloric intake, protein levels, and supplemental vitamins,
Speaker 2: and the men began to receive daily calories ranging from
Speaker 2: two thousand to three thousand. But immediately, like in the
Speaker 2: weeks that followed the refeeding, their weight continued to drop
Speaker 2: kind of like, almost alarmingly, because the edema that they
Speaker 2: had developed during the semi starvation portion had been disguising
Speaker 2: just how much weight they had truly lost, And so
Speaker 2: six weeks into refeeding, the group receiving two thousand calories
Speaker 2: had only regained zero point three percent of the weight
Speaker 2: that they had lost. Wow, And even the group that
Speaker 2: was receiving the most calories, which was three thousand, had
Speaker 2: regained after six weeks nineteen point two percent, and they
Speaker 2: still complained of all the same things during the semi
Speaker 2: starvation period edema, depression, exhaustion, aches and pains, a bottomless
Speaker 2: pit of hunger. Apathy was a big one. Irritability and
Speaker 2: mood swings. Calories were upped again. I think antel Keys
Speaker 2: was like, why isn't anyone regaining any weight? And finally
Speaker 2: that's when improvement seemed to be, like actual actually made
Speaker 2: protein and supplemental vitamins at least in this experiment didn't
Speaker 2: seem to make a difference. And the real lesson that
Speaker 2: kind of emerged was that two thousand calories a day
Speaker 2: was simply not enough for rehabilitation or at least like
Speaker 2: rehabilitation on any sort of you know, timescale for people
Speaker 2: of this body size and activity levels. They needed at
Speaker 2: least four thousand calories. I feel like.
Speaker 3: That's so important because it just shows that, like when
Speaker 3: you have been subjected to under nutrition for so long,
Speaker 3: you can't just go back to like we think today
Speaker 3: if two thousand calories as like a standard diet or whatever, right,
Speaker 3: you can't just go back to You can't just have
Speaker 3: the bare minimum your body has nothing, and it's going
Speaker 3: to try and build that up and it's not going
Speaker 3: to be able to.
Speaker 2: It's not going to be able to. Yeah, there's such
Speaker 2: a recovery process. Yeah. And so when the experiment ended,
Speaker 2: which was in November nineteen forty five, normalcy still hadn't
Speaker 2: returned for any of the men. They were allowed to
Speaker 2: at that point when they and then the twelve months
Speaker 2: was all over, the men were allowed to eat whatever
Speaker 2: and how much they wanted. Some began to eat ten
Speaker 2: thousand calories a day because they just felt like they
Speaker 2: will never they could eat a huge meal and still
Speaker 2: feel hungry, just empty. Yeah. Others ate so much that
Speaker 2: they had to go to the hospital because they would
Speaker 2: be vomiting and it was Yeah, some had to be
Speaker 2: treated for that. Food. Anxiety remained for with these men
Speaker 2: for a very long time, and their bodies, you know,
Speaker 2: their heart and their lungs took They took a lot
Speaker 2: longer to return to baseline than anticipated. Within a few
Speaker 2: months of the experiments, and Keys and his colleagues wrote
Speaker 2: up a pamphlet to distribute to aid workers, and it
Speaker 2: proved to be crucial after the war ended in delivering
Speaker 2: appropriate aid and it's on the Internet archive. If you're curious,
Speaker 2: I'll link to it. It went over physical changes, behavioral changes,
Speaker 2: refeeding how to help people cope with what they had
Speaker 2: gone through. There was a really interesting thing. This is
Speaker 2: when like communal feeding areas were still like very much
Speaker 2: a thing, and it would be like do not allow
Speaker 2: people to stand in line, like it is incredibly demoralizing,
Speaker 2: you know. There was like a lot of really interesting
Speaker 2: and who knows how much of this was like from
Speaker 2: the experiment or just like this is what we think,
Speaker 2: but it was a really considerate sort of like what
Speaker 2: is the mentality? Not just about food, but it was
Speaker 2: like what these considering what these people have gone through,
Speaker 2: a more empathetic approach to how can we relieve the suffering? Yeah. Yeah,
Speaker 2: Also in nineteen fifty Keys published a two volume whopper
Speaker 2: of a book titled The Biology of Human Starvation. It
Speaker 2: was almost fourteen hundred pages. And yeah, I didn't read
Speaker 2: any of that, but I'm sure it's out there. But
Speaker 2: the Minnesota Starvation experiment was really groundbreaking for being among
Speaker 2: the first to systematically study what happens to both the
Speaker 2: body and the mind during long periods of semi starvation
Speaker 2: and how to rehabilitate a starving person. It wasn't the first,
Speaker 2: so there were a few actually that also happened during
Speaker 2: World War Two. There was the Warsaw Ghetto hunger study
Speaker 2: in nineteen forty two, which was kind of done surreptitiously,
Speaker 2: and then there were studies in the Netherlands in nineteen
Speaker 2: forty four to nineteen forty five. There was actually a
Speaker 2: fair amount of starvation research. One author described world War
Speaker 2: two as quote a cornucopia of starvation research, a wealth
Speaker 2: of hunger end quote. Yeah. The Minnesota starvation experiment marked
Speaker 2: a necessary and crucial step forward in our understanding of
Speaker 2: how to deliver aid to victims of mass starvation. But
Speaker 2: for many it came too late. World War Two in
Speaker 2: Europe ended on May eighth, nineteen forty five, and in
Speaker 2: Japan a few months later on August fourteenth, months before
Speaker 2: the study ended, thousands of concentration camp survivors died of
Speaker 2: refeeding syndrome in the weeks after the camps were liberated.
Speaker 2: Could they have been saved if the study had started earlier,
Speaker 2: I don't know. To me, the real question is why
Speaker 2: wasn't there any interest in the effects or treatment of
Speaker 2: starvation until this time, until World War Two. One English
Speaker 2: officer remembered meeting with public health advisors in January nineteen
Speaker 2: forty five, which was the month that Auschwitz was liberated. Quote,
Speaker 2: it was frightening to realize how little any of us
Speaker 2: knew about severe starvation in our lifetime. Millions of our
Speaker 2: fellow men had died in terrible famines in China, in India,
Speaker 2: in the USSR, without these tragedies having yielded more than
Speaker 2: a few grains of knowledge of how best to deal
Speaker 2: with such situations on a scientific basis. End Quote. The
Speaker 2: opportunity was there, It had been there to come up
Speaker 2: time and time again. Modern science existed. Western medicine simply
Speaker 2: lacked interest or a sense of urgency in understanding this problem.
Speaker 2: Maybe it was a little bit of hubrius mixed up
Speaker 2: with a sense of superiority, like we've got our stuff
Speaker 2: figured out, it won't happen to us.
Speaker 3: We don't have to worry here. Yeah, it's happening over there.
Speaker 2: Yeah. And so when starvation came to Europe, no one
Speaker 2: really knew what to do, and it didn't come alone.
Speaker 2: It rarely does. Starvation is just one component of a famine.
Speaker 2: It rides alongside disease, fear, violence, despair, and a perpetual
Speaker 2: sense of uncertainty, of not knowing when anything will end.
Speaker 2: Things that can't and shouldn't be captured in a medical
Speaker 2: experiment like the Minnesota starvation experiment. And I want to
Speaker 2: end with a quote from a paper by Sharman apt Russell. Quote,
Speaker 2: the Minnesota experiment itself did not reproduce the cold that
Speaker 2: Europeans experienced in World War Two, the lack of fuel
Speaker 2: for cooking food and heating the house, the lack of
Speaker 2: warm clothes, the lack of shoes. It did not reproduce
Speaker 2: the fear, the knowledge that you might die at any time,
Speaker 2: that you might be humiliated or injured, or tortured or killed.
Speaker 2: It did not reproduce the murder of a neighbor, the
Speaker 2: corpses in the street, the inexplicable loss of human decency.
Speaker 2: It did not reproduce the death of your son. End quote.
Speaker 2: Famine is so much more than starvation, and starvation is
Speaker 2: so much more than a lack of food. And so
Speaker 2: that is kind of where I want to end things today,
Speaker 2: so that next week that's sort of what we'll talk
Speaker 2: about is like the bigger picture that encompasses all of this.
Speaker 2: So yeah, yep.
Speaker 3: So make sure you tune in next week.
Speaker 2: Tune in next week. In the meantime, there's some sources
Speaker 2: that we could share, so so many, so many. I
Speaker 2: want to shout out just two in particular. There are
Speaker 2: several more that will be on our website. But one
Speaker 2: is by Sharman apt Russell, The Hunger Experiment, and that
Speaker 2: another is by Calm and Semba titled They Starved so
Speaker 2: that Others be Better fed, remembering Ansel keys and the Minnesota.
Speaker 3: I have quite a lot of papers. I also had
Speaker 3: a book. I read a book, a few chapters of
Speaker 3: a book called Hunger, The Biology and Politics of Starvation,
Speaker 3: published in twenty ten. It was fine. It's like more
Speaker 3: detailed than you need in all honesty, but it does
Speaker 3: have some good just like overview parts of the biochemistry
Speaker 3: and things. I really enjoyed a Nature Reviews Disease primer's
Speaker 3: paper from twenty seventeen called Severe Childhood Malnutrition, and then
Speaker 3: a couple of different there was an Annual Reviews in
Speaker 3: Physiology the Comparative Physiology of Food Deprivation from Feast to Famine.
Speaker 3: That one was really good for some of the biochemistry.
Speaker 3: If you want details on biochemistry too, there's also a
Speaker 3: Stanford has like a PDF of literally every biochemical like
Speaker 3: metabolic pathway that's just kind of fun to go through
Speaker 3: and see how they all interconnect in which ones you're
Speaker 3: doing versus not doing at any given time. But we'll
Speaker 3: post the sources from this week's episode in every single
Speaker 3: one of our episodes on our website guest will Kill
Speaker 3: You dot com under the episodes tab.
Speaker 2: We will thank you to Bloodmobile for providing the music
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Speaker 3: Thank you to Leanna and Tom and Pete and Brent
Speaker 3: and Jessica and Mike and I'm sure I'm forgetting people
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Speaker 4: Until next time, wash your hands, feelthy animals.
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