October 14, 2025 • 64 mins
Deprived of food, our bodies do the best they can to keep us alive and functioning as long as possible. As the days pass, the rhythms of our lives change: our metabolism, our heartbeats, our hormones, even our thoughts shift to adjust to this period of scarcity. This response is evolutionarily engrained, following a variable but fairly prescribed path. In this episode, we trace that path, exploring what happens when our bodies are not given the energy stores they need, how patterns of metabolism alter, leading our bodies to consume themselves, and the profound consequences this has on every part of our physiology and psychology. We also tell the story of how we came to learn about these outcomes, chiefly through a WWII-era study called the Minnesota Starvation Experiment. This is the first of two episodes centered around malnutrition, starvation, and famine. Next week, we’ll explore the broad topic of famine, of which starvation is merely one component.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hello. My name is Jim Graham. I'd like to tell
you about an experience that I had during World War
Two as a guinea pig and an experiment in semi starvation.
On February twelfth, nineteen forty five, we began our twenty
four weeks of semi starvation. We were expected to lose
about one fourth of our body weight during the next
(00:22):
six months. The days began to drag out, each day
getting longer and longer, and there seemed to be no
end of starvation in sight. Six months seemed like forever.
I'd look in the mirror and see that my eyes
looked hollow, my cheeks were only a thin covering for
the bones in my face, and my hair was getting thinner.
(00:46):
If I tried to smile, it was just a grimace.
I didn't feel like smiling in the first place, and
I never laughed. My muscles were almost gone, my bones protruded,
and sitting on a hard chair was uncomfortable even for
a few minutes. Most of us carried around pillows to
sit on. I couldn't walk up a flight of stairs
(01:09):
without stopping to rest once or twice on the way up.
I felt like an old man. And probably looked like one,
since I made no effort to stand up straight. I
thought about food all the time. I started collecting cookbooks,
you know the kind with beautiful color pictures of delicious
looking dishes. I felt cold all the time, even though
(01:34):
it was the middle of summer. Nothing felt better than
to find a nice warm spot in the sunshine and
do nothing but lie there and soak up the heat
of the sun. We became very irritable and intolerant. Little
things seemed to annoy us. We were no longer polite
with each other or with visitors. It seemed as if
(01:56):
the veneer of civilization had been removed. Leave bear the
animal underneath. We didn't enjoy having guessed because it was
an effort to entertain them, and we were not usually
very diplomatic about showing our feelings about it. Food occupied
our thoughts all the time. At meal time, each one
(02:18):
had his special way of dealing with the food. A
couple of the fellows would eat their food quickly and
then leave the cafeteria and try to forget about it.
Most of the rest of us dawdled over our food.
Some would mix their food altogether, others would savor each
bite of each item on the plate. We'd been told
(02:39):
before the experiment that the food might become monotonous since
there were only three menus, but it was far from monotonous.
It was food, and any food tasted good. To this day,
I find one of the tastiest foods is a simple
boiled potato. It's delicious. Any food looked good. Even the
(03:01):
dirty crusts of bread in the street looked appetizing, and
we envied the fat pigeons picking at them. Wasting food
is a crime. We felt the waste of food and
restaurants was intolerable. On July twenty ninth, nineteen forty five,
was the day semi starvation was to end and we
were to begin eating again. It was also my twenty
(03:25):
third birthday. After the experiment was over, I was still
hungry for a long time. Even when I could eat
all I wanted, I would finish a meal and still
feel hungry. My stomach just would not hold anymore. For months,
I carried candy bars or cookies in my pocket and
munched continually. In six months, I went from a low
(03:47):
of one hundred and twenty two pounds to a high
of two hundred and twenty five pounds. It took me
three years to get back to normal weight and normal
eating habits. In conclusion, I would like to say that
I have experienced hunger and the apathy and depression that
goes with it, but we lived in sanitary quarters under
(04:10):
the constant care of doctors. Most people in areas of
famine die of other diseases because of the body's inability
to resist disease. Furthermore, we knew that it would all
be over on a certain date. I often think how
horrible it would be to be starving and never know
(04:31):
when it would end.
Speaker 2 (04:33):
If ever, it's that is such a fascinating perspective, and
(05:26):
like the fact that that video exists is kind of incredible. Yeah, yeah, yeah.
Speaker 3 (05:33):
It's yeah. It's especially that what he says at the end,
they're like knowing that it's going to end, and how
much that can change the way that you are experienced.
Speaker 2 (05:44):
I don't know, it's I mean, it's like and we'll
get into it more later, but yeah, this is like
artificial settings important nonetheless, but like, yes, this is not
the type of thing that people experience under real world
conditions of starvation. Yeah, so but yeah, so again that
was Jim Graham who participated in the Minnesota Semi Starvation experiment.
(06:06):
That's from a video that was recorded in nineteen ninety
and it's part of Colorado State University's Digital library collections,
specifically university publications, and we will post a link to
the full video and the transcript as well on our
website so you can watch, or listen to or read
the entire thing. So, yeah, hi, I'm.
Speaker 3 (06:26):
Aaron Welsh and I'm Erin Almanepneke.
Speaker 2 (06:29):
And this is this podcast will kill You.
Speaker 3 (06:32):
So this week and next we're going to be talking
about starvation and famine and those words, along with hunger
and malnutrition, have been used a lot lately in discussions
surrounding the ongoing genocide and famine happening in Gaza and
the conflict raging Insudan.
Speaker 2 (06:51):
All of these words, you know, starvation, famine, hunger, malnutrition
are associated with a lack of food and the subsequent
effects of that lack of food. But each one of
these words has a distinct meaning, and so what we
want to do with these two episodes is to provide
a bit of context for understanding, you know, what it
is that we're talking about. When we talk about starvation
(07:14):
and what it means to declare a famine.
Speaker 3 (07:17):
Yeah, so we're starting out this week discussing starvation, the
physiological and psychological impacts, and a little bit about its history.
And you'll hear more about that Minnesota semi starvation experiment.
Speaker 2 (07:29):
Yes you will. And then next week we'll turn to famine.
We'll go through the definition or definitions of famine, what
causes famine, and how famines have changed throughout history, before
we outline some of what's happening with the famine in
Gaza and other food in security crises in other areas
of the world.
Speaker 3 (07:48):
Yeah, we have a lot to cover these two episodes,
so we decided to do things a little differently and
just start right into it. Yes, Yeah, we're going to
take a quick break and then get started. My goal
(08:20):
for this first part of today's episode is to walk
us through what is happening in our bodies, what happens
inside of our bodies when we are deprived of food.
So I'm going to start with what's happening on like
a fairly minute scale, like how does the inner machinery
of our body keep ticking if we don't provide it
(08:41):
with any source of energy, and that process can happen
for any reason. Right. It could be because you lack
access to food. It could also be because of prolonged illness.
It could be a restrictive food intake disorder, It could
be any number of things. But I'm going to go
through the mechanism of what's going on. But then we're
going to take a step back a little bit outside
(09:02):
of our bodies and talk about some of the bigger
picture consequences of prolonged starvation, especially in the context in
which we most commonly see starvation today around the globe,
which is lack of access to food.
Speaker 2 (09:17):
Right, right, right, so population level.
Speaker 3 (09:19):
Effects exactly exactly, Yeah, well, individual and population level, but
like right, so it's a lot, it's all depressing. As animals,
we use the food that we eat to create energy,
and that is the process that we call metabolism. And
(09:41):
we don't have to get deep into biochemistry. Don't worry,
because I simply cannot. But there are three main macronutrients
that are most important, at least for my discussion today,
and that is carbohydrates or glucose, fats, and protein, and
these are the majority of what makes up our foods.
Of course, there's a lot lo of micronutrients. We've covered
(10:01):
several of them on this podcast. They are essential to
keep us functioning, but the big three are what we're
going to focus on today. We have to break down
and use carbohydrates, fats, and proteins in different ways via
a whole bunch of complicated cycles in order to create
energy and keep our cells alive. And all animals do this,
(10:27):
and because food is almost never, like constantly available, we
all have All animals have mechanisms physiologic adaptations in order
to survive in times of food scarcity or food deprivation,
and the exact adaptations are going to vary a lot
by species, which is why bears can hibernate for months
(10:48):
on end, salmon can traverse thousands of kilometers without eating,
snakes can only eat a couple of times a year.
But humans, we have relatively high metabolic rates, especially relative
to our body stores of energy, so we actually need
food on a pretty regular basis in order to survive.
Speaker 2 (11:08):
There are also behavioral adaptations like caching food, which I mean,
of course humans, but like like we talked about in hypothermia,
I know as.
Speaker 3 (11:15):
I was writing this I was like, we just went
over this in hypothermia. So when animals, including humans, are
deprived of food, we experience hunger, and the feeling of
hunger is driven by a pretty complex interplay between hormonal
and neurologic signals. But hunger is also a biological drive,
(11:40):
So in animals, including in humans, it's a driving force
of behavior. And in a lot of animal studies, animals
across the spectrum, like mammals, birds, everything, will engage in
riskier and riskier behavior in an attempt to access food
if they are hungry or starve, and in many animal models,
(12:03):
the hunger drive actually out competes or overrides nearly all
other biologic incentives.
Speaker 2 (12:10):
How does it compare it to like thirst drive?
Speaker 3 (12:13):
That's actually a good question. I didn't see any things
directly comparing that, but they're also very closely related because
a lot of times, you know, if you are deprived
of food, you may also be deprived of water. There's
also some animals who get their water primarily from their food. So, yeah,
it's a good question, but I don't have like an
exact answer to it. Yeah, so I'm going to go
(12:34):
into a little bit mechanistically about what's happening during that
time during starvation, and there are a lot of hormonal
drivers and things at play that are controlling our hunger
cues and our satiety cues. But I think what's important
to keep in mind as we go through this is that,
in my opinion, maybe this is an opinion, none of
(12:56):
this explanation is really adequate to explain what happens to
people and animals but also humans when they feel hungry
all the time, for days or weeks on end. I
think that our first hand account helped to explain some
of that bigger picture about how it feels to be hungry,
(13:19):
but the biology doesn't quite I think, do that justice?
Speaker 2 (13:23):
Yeah, I mean it can't.
Speaker 3 (13:26):
It can't.
Speaker 2 (13:27):
It can't because it's so clinical.
Speaker 3 (13:29):
Yes exactly, yeah so, but metabolically absolute food deprivation proceeds
in relatively predictable stages. It starts with what's often called
fasting and then proceeds through starvation, and without intervention this
will end in death. So the first phase of food
(13:50):
deprivation is it's often called fasting, and there's arguments about
like when do you hit the threshold between fasting and
starvation and et cetera. But the point is that this
is just the first few hours after you've eaten food.
Once we've absorbed all that we can from our meal,
the first thing that our body is going to do
is start using glycogen, which is the long branchy chains
(14:14):
of glucose that we store in our liver, right, and
we start breaking this down in order to keep our
blood sugar levels up.
Speaker 2 (14:22):
Okay, so this is what happens after you eat a meal.
Speaker 3 (14:25):
After you eat and you've digested and used up all
the glucose in your meal.
Speaker 2 (14:29):
Right, got it?
Speaker 3 (14:30):
Yep. Yeah, we'll also start to use some of our
adipose tissue storage, especially to like fuel our muscles and
things like that. This phase, though, the glycogen storage that
we have in our liver only lasts for about a
few hours, which is why we usually start to feel
hungry a few hours after eating. After a few hours
(14:51):
without food, our livers glycogen stores are depleted, and our
brain requires glucose in order to function in the rest
of the tissues in our body can use other energy sources.
They can go through these biochemical pathways to like directly
use proteins or fats in order to make energy. In
(15:12):
order to make ATP. But our brain really needs glucose.
That's what it is dependent on. So our liver abides
and starts making glucose. And this is a process called gluconeogenesis,
literally making new glucose.
Speaker 2 (15:27):
This is it's like I remember all of this in
such vague terms from like bio one oh one, right,
and it's I don't know if it's coming back to me,
but by the end of this it would be back.
Speaker 3 (15:40):
You have certainly come across this, I'm sure in like
most biology, gluconeogenesis. Yeah, yeah, it's actually one of my
favorite words.
Speaker 2 (15:49):
It's a good word.
Speaker 3 (15:50):
It's a good word.
Speaker 2 (15:51):
Yeah.
Speaker 3 (15:52):
We go through glycogenolysis, and now we make gluga eugenesis. Anyways,
at first, like the very first, our body starts to
do this with some protein because protein is very easy
for our bodies to make glucose from. Okay, so we'll
start breaking down a little bit of protein in order
to feed our brain. But proteins in our body are
(16:13):
not really there for energy storage. We use proteins in
our body for building stuff. We use it to make
our muscles, we use it as enzymes. Right, So our
body tries to preserve protein aside from what we eat
and then have to use. Right, So pretty quickly our
(16:35):
body switches and we start relying more on our adipose tissue,
our fat in order to fuel our body. We cannot, though,
make glucose directly from the fatty acids part of fat. Okay,
but we store fat and sorry this is getting a
little technical, but we store fat in the form of
(16:56):
something called triglycerides, which is three fats and a glycrool,
and that one glycerol we can make glucose from.
Speaker 2 (17:05):
Okay, could we just pause and start so now can
you put me in like a timeline of what is happening,
and when like step one you eat, step two you digest,
step three you start to pull the glycogen from your liver,
and then step four where does proteins that what happens
(17:25):
with the proteins and fats at that point.
Speaker 3 (17:27):
It's not like an exact like this day you switch,
because it's going to depend on your body composition and
like what your last meal was and all of those
sorts of shits. Right, But in general, after a meal,
the first few hours you're going to be mostly using
glycogen stores. After those glycogen stores are depleted. Your body
is going to start breaking down your own body in
(17:49):
order to get the glucose that you need. It might
use a little bit of protein at first, but primarily
it's going to rely on using your fat stores. Where
are fat stores, I mean, all over your whole body.
Speaker 2 (18:03):
It's just everywhere. It's just sort of a shop.
Speaker 3 (18:07):
Yep, exactly. Yeah, Okay, So we start seeing a lot
of this process called fatty acid oxidation, and that is
the majority of what we're going to see for potentially
weeks on end, depending on how much fat storage you have.
The process of fatty acid oxidation will also result in
the formation of keytone bodies.
Speaker 2 (18:27):
People who have heard.
Speaker 3 (18:28):
Of the whole keto diet thing will have heard of this.
Speaker 2 (18:31):
We should do an episode on the Keto diet, though
we probably should.
Speaker 3 (18:35):
Our brains can actually use keytone bodies. They can use
ketones as fuel. Our brain prefers glucose, but it will
use this as it is required to. But this whole
process is basically our body adapting to this starvation. We
will use up all of our fat stores, and how
(18:55):
long we can survive in this particular phase is going
to depend pretty much on our body composition, our age,
our comorbidity, is all of these things. But it's usually
a period of a few weeks or so. After that
we enter what's kind of called phase three, and that
I think of it as when our body is really
(19:18):
not able to compensate anymore, because this is the point
at which we've run through these fat stores and now
we have to rely on skeletal muscle. Yeah, and our
body has to start breaking down our muscle proteins in
order to use them for energy. And you can imagine
that that's not good for our body. We need our muscles,
(19:40):
but that is what our body will do in order
to keep it alive in the short term. Right.
Speaker 2 (19:47):
Can I ask a question about like how food consumption
changes this process?
Speaker 3 (19:53):
Yeah, it's a really good question. So it's not common
that people are completely deprived of food and how absolutely
no access to food.
Speaker 1 (20:02):
Right.
Speaker 3 (20:02):
More often people are going to get very small amounts
of food a little bit at a time, or maybe erratically,
and that is what is sometimes called this like semi starvation.
The way to think about that is it's going to
kind of fluctuate where you are in this continuum. As
soon as you eat, your body is going to use
up all of that food that it can. Is it
(20:24):
going to be able to store any extra? It totally
depends on how deprived you have been, right, But you
can think of it as kind of keeping people cycling
between these first few phases for a potentially more prolonged
period of time. But it could be that you're kind
of going your body is doing all things at once, right,
You've if you've used up all of your fat stores,
(20:46):
and then you get access to food, then your body's
going to use that food. But then as soon as
you've used that up, you don't have any fat stores,
so you're going to go right back to using your.
Speaker 2 (20:54):
Protein something straight back to protein.
Speaker 3 (20:56):
Okay, okay, yeah, so that's I mean, Actually, what happens
this process, especially once you get to the point of
breaking down your own skeletal muscle for fuel, can progress
fairly rapidly, and if food does not become available, this
will end in death kind of directly from starvation. There
(21:17):
are in the literature kind of two different syndromes that
we most often see in people who are affected by starvation,
and collectively this is called severe acute malnutrition. This is
like the end stage of this This is like phase three,
end stage of lack of access to food. This used
(21:38):
to be called it was when I learned it actually
called protein energy malnutrition. But separately, within this there's two
different syndromes. One is known as quashiocore and the other
is Marasmus. Yes, and a lot of the literature around
severe acute malnutrition or SAM, focuses on children under the
age of five because they are by far the most
(22:01):
vulnerable too severe acute malnutrition and the complications that can arise.
But it's not the only they are not the only people.
It's really important to remember that other groups are very
vulnerable to food deprivation, including pregnant or breastfeeding people, including
the elderly, and including children and adults with certain disabilities
(22:24):
or comorbid conditions, things like cystic fibrosis or cerebral palsy.
I mean, there are so many conditions that might make
you more susceptible to malnutrition.
Speaker 2 (22:33):
Yeah, but I.
Speaker 3 (22:34):
Want to go through these two syndromes in a little
bit of detail, and then we'll talk bigger picture about
all of the complications that happen as your body has
gone through this starvation process. So Marasmus is also known
as acute wasting, and this is when you lose a
very substantial amount of weight, and usually in a relatively
(22:57):
brief period, although some people, if they have been experiencing
prolonged semi starvation, it might be over kind of a
longer time period. But it's diagnosed based on specific like
body weight and height measurements, or by measuring the upper
arm circumference and having that be below a certain circumference.
It's like a good indicator of how much weight someone
(23:19):
has lost. And this is really the kind of most
classic process that happens as what I described of starvation.
So as you have no food, you use up all
of your fat stores, and then you start to eat
away at your muscles and then you are experiencing Marasmus.
Does that make sense? Yes?
Speaker 2 (23:40):
Yes.
Speaker 3 (23:42):
The other condition is quashiocore, which historically was thought of
as primarily a protein malnutrition.
Speaker 2 (23:51):
What does that mean?
Speaker 3 (23:52):
Yeah, it used to be.
Speaker 1 (23:54):
So.
Speaker 3 (23:54):
It was first seen in certain populations in association with
a very low protein diet or in infant after they
switched from breast milk to very low protein like say
all corn diets or something like that. Okay, And so
based on those kind of like epidemiological studies, and in
contrasting that to Marasmus, which was thought of as purely
like a calorie deficit uh huh, without necessarily only a
(24:18):
protein deficit. This was classified initially as like, oh, this
is a protein deficit rather than like a total energy deficit.
But it turns out that that's not really quite as
clear cut, and the exact path of physiology is not
entirely understood. We really don't understand quashio court right now,
but it does look different physiologically than Marasmus or wasting.
(24:44):
It's characterized by this edema, this fluid collection and swelling
underneath the skin especially, and it starts in the lower
legs but can also be in the face, in the arms.
And there's also fatty liver infiltration that we see, and
you can get from that like distension of the abdomen,
and then we'll have like flaky skin and other changes
(25:06):
that we don't necessarily see with Marasmus or wasting. We
think from what I could tell from the literature that
quashi or core more specifically, might be like a maladaptive
response to the way that our body is processing protein
in the face of a very low protein diet, if
(25:28):
that makes sense.
Speaker 2 (25:30):
Yeah, okay, So I'm curious, Like the food that we
eat is not just food, right, Like there are different
qualities of food, different like types of food, different energy sources,
and so how does that play a role? I mean,
maybe this is jumping ahead a bit and asking sort
of about like refeeding, but like, how does that play
a role in you know, the development of these sort
(25:52):
of symptoms or conditions?
Speaker 3 (25:54):
Yeah, I mean in all, honestly, we don't like really
fully know because we don't know, Like there can be
a lot of First of all, marasmus and quashiocore are
not necessarily mutually exclusive. They can happen simultaneously, but they
also can happen in let's say, like the same communities
(26:15):
and sometimes when people are exposed to or have access
to the same foods. And so that's why it's not
entirely clear, like, you know, if we let's say, if
we're focusing on humanitarian aid and like what types of
foods do we need to get into an area to
prevent quashiocore more specifically, It's not quite as clear as that,
except that protein is definitely an important part of that.
(26:38):
But it's not as clear cut as like, Yeah, it's
just not as clear cut as like protein malnutrition equals quashiocore.
Speaker 2 (26:46):
Right, okay, okay, Yeah.
Speaker 3 (26:48):
It's also more difficult to estimate in terms of the
distribution of it. We don't have as good of a
handle on it. It does tend to be even more
severe than Marathis alone. And is that because there's this
like maladaptive component to it. We see like increases in
oxidative stress in quaeshiocre compared to Marasmus, we see even
(27:13):
more microbiome changes. Is there a microbiome component? There's like
a lot of questions, but what.
Speaker 2 (27:18):
Do you mean by maladaptive response? Though, Like I.
Speaker 3 (27:22):
Mean, like you aren't they they aren't breaking down and
using the protein that they do have in a way
that would like sustain them for longer. Is the best
way that I can Okay. Yeah. There was a paper
that came out in the Lancet not too long ago
that was more specifically looking at like one type of
metabolism called one carbon metabolism, which is one of these
(27:44):
many biochemical pathways, and it's thought that maybe that is
affected more severely in queshuocore compared to Marasmus. So maybe
it's that that we're not using this one pathway as well. Why,
we don't know. But overall, severe acute malnutrition, like both
(28:15):
of these combine effect up to seventeen million children or
more worldwide and untreated. Once a kid meets criteria for
severe acute malnutrition, it has a mortality rate of ten
to fifteen percent per month. So the overall effects of
this are really profound. Physically, it's manifest like you see
(28:39):
it as this loss of the subcutaneous fat that's going
to be like the last fat that your body tries
to hold on to, and that's what gives you a
very gaunt appearance. And then you're going to have this
muscle wasting, which is also going to come with weakness
because your muscles are literally like being eaten away by
your own by Your skin becomes dry and wrinkly, your
(29:04):
hair becomes sparse and thin. The cheeks look very sunken
because you've lost the cheek pads, this fat that's in
your cheek. Physiologically, your heart rate slows down, your blood
pressure is very low, your body temperature is low, oftentimes,
especially towards the most severe stages. Appetite is gone, which
(29:26):
can make it really hard for people to start eating again,
and sometimes when they do, they are faced with nausea, vomiting, diarrhea.
And that's because during this process, your digestive system is
essentially shutting down. Starvation affects every single organ system in
(29:48):
our body. Glucose homeostasis is disrupted, and so we often
see hypoglycemia. And that's especially true in quashio core compared
to marasmus or wasting. Again, something maladaptive happening there. We also,
and this one's really important, see huge alterations in our
immune system function.
Speaker 2 (30:08):
It's one of the biggest.
Speaker 3 (30:09):
Yeah, it's one of the biggest because many people, especially
kids with severe acute malnutrition, will end up very sick
with life threatening infections, and cause of death is often
from infection and not directly from starvation itself, right, right,
But this is directly because of a secondary immune deficiency, right.
(30:33):
It's so it is the starvation that is putting you
at risk for.
Speaker 2 (30:36):
Infection ultimate versus proximate cause type exactly. Yeah.
Speaker 3 (30:39):
Yeah, but this immune deficiency comes from a combination of
different things. There's disruption in all of our major barriers, right,
There's disruptions of your skin integrity, of your respiratory barrier,
of your gut barrier. But then we also see an
increase in the activation of inflammatory pathways. We see T
cell dysfunction, We see a reduction in anti micro activity
(31:00):
of most of our immune cells. And then, like I mentioned,
we see this like offlining of our entire digestive system
because it's not doing anything and so our body is
trying to preserve energy. We see our liver, our pancreas,
our biliary system are intestinal tract essentially not functioning at
their typical capacity. We also see huge changes in the
(31:22):
gut microbiome, which can sometimes include bacterial overgrowth in the
small bowel huh. Especially in kids, we can get impairment
of thyroid function and cortisol and growth hormones, which can
have profound effects for the rest of their life.
Speaker 2 (31:37):
I mean, so many of the aspects of starvation. Whatever,
at what point in your life it happens, it can,
it will stay with you.
Speaker 3 (31:44):
Forever, forever, forever, forever. Absolutely, And then there's changes in
our brain functioning as well, and not just an increase
in lethargy and irritability, but also the psychological effects which
are really profound and honestly not quite as well characterized.
But I know erin you'll talk a lot more about
(32:06):
some of the initial data that we have on this
from that semi starvation experiment. There was also a more
recent review paper that highlighted several hundred studies, not all
of which were a lot of which were in that
kind of artificial type of environment that's where a lot
of our data comes from. But there was also at
least some papers that were looking at the effects of
starvation psychologically in more unfortunately realistic situations, like in areas
(32:33):
of famine or chronic starvation and things like that, and
we consistently see increases in depression, anxiety, higher psychological distress.
We also see increases in competitive behavior and social withdrawal. Yeah,
And of course in most situations of chronic malnutrition or
(32:57):
acute starvation that we see in our way world today
happen after natural disasters, armed conflict, and these are situations
when lack of access to food is not the only stressor.
Speaker 2 (33:10):
Right compounding trauma exactly.
Speaker 3 (33:13):
And there is not a lot of studies that have
directly looked at all of those compounded effects, but we
can often unfortunately see them play out on our cell
phones from videos. Yeah, many of these changes also have
lifelong effects, and unfortunately we don't even have all that
much data on it. We have really clear data on
(33:35):
the profound effects of starvation during pregnancy on the fetus
and on growth of those babies thereafter. We don't have
as much long term data on the effects of malnutrition,
but there are at least some that like exposure to
severe malnutrition, especially in childhood, is associated with increased risk
of cardiovascular disease, hypertension, dysfunction of your glucose metabolism, and
(33:59):
cognitive and developmental delays right forever, forever. And you had
mentioned Aaron about treatment. Yeah, and it might sound like
treatment should be straightforward, right if the problem is lack
of access to food, get people access to food. Yeah,
it's nope, not that it's not straightforward, not straightforward for
(34:19):
a lot of reasons. Right, in the context of starvation,
both like acute food insecurity and more chronic food instability,
we do rely on food like that is the number
one thing, and a lot of times humanitarian programs and
things like that are going to rely on what's called
ready to use therapeutic food or RUTF, and this is
(34:43):
something that has been specially formulated based on studies to
try and hit at those most important nutrients. Right. We
have a good amount of proteins, we have all of
the essential amino acids. We've got micronutrients which are really important,
even though I didn't focus on them. In severe acute
malnutrition specifically, it's usually treatment with this like ready to
(35:05):
use therapeutic food and often a short course of antibiotics
if you've gotten to the point of meeting criteria for
severe acute malnutrition.
Speaker 2 (35:13):
Right. Yeah.
Speaker 3 (35:15):
And it used to be that the treatment of this,
especially like the most severe forms and in times of
crisis or famine, it used to rely almost entirely on
these like centralized treatment centers, which were almost always set
up by external you know, NGOs and nonprofits. But it
has really shifted for the better to more community based
(35:35):
care because A, that's going to get access to a
lot more people. B it's going to mean that caregivers
can stay, especially with their children and their other children
who might not be as sick as the ones who
need the most help. But there is always in areas
of like mass food insecurity and starvation, there will always
(35:56):
be people who are sick enough, whether from starvation alone
or the combination of starvation and infection or other underlying illness,
that they do need hospitalization. And that's specifically because of
a risk called refeeding syndrome. Yes, yeah, And basically this
is that as you rapidly increase nutrient intake when you've
(36:19):
been deprived for so long, your body switches from this
prolonged state of breakdown to all of a sudden being like,
we've got food we need to build up, so we
switch from what's called catabolism to ennabolism, so instead of
breaking down our body, we're building up storage. This leads
to a pretty huge surge in insulin secretion, because that's
(36:42):
one of our main hormones involved in storing energy during starvation.
It's not that we have absolutely no insulin, but our
insulin levels are incredibly low, and this is going to
stimulate the uptake and storage of glucose, which can result
in really severe high boglycemia in the case of prolonged
(37:03):
starvation because you don't have that much doors to begin with.
But it also because of the effects of insulin, stimulates
the uptake of a bunch of different electrolytes into ourselves.
It shifts electrolytes into our cells, including potassium, magnesium, is phosphorus,
and this can result in really dangerous electrolyte abnormalities that
(37:24):
can cause things like heart a rhythmias, seizures, respiratory failure,
and even death.
Speaker 2 (37:31):
How do we prevent that from happening?
Speaker 3 (37:33):
I mean, first it's monitoring, and then it's repleating those
electrolytes and the sugar if needed. How do we do
that by giving people that whether it's through iv or
through eating, so making sure that they're getting enough potassium,
making sure that they're getting enough magnesium and phosphorus, yeah,
and fixing.
Speaker 2 (37:52):
Those monitoring those levels essentially. I mean, I imagine that
would be very difficult to do in situations where you know,
there's already a lot, there's already eight is being blockaded
right e for instance.
Speaker 3 (38:07):
Well, and so many of the areas where we see,
especially like acute disasters, the healthcare infrastructure is not there either.
Yeah right, So yeah, So refeeding syndrome is a very
real risk if you are not able to identify it
and manage it.
Speaker 2 (38:25):
And those who are most vulnerable to refeeding syndrome. Are
those who are also at the most extreme of end
of malnutrition or can it really happen to anyone who's
been in a semi starved or like experiencing chronic hunger
for a while.
Speaker 3 (38:38):
Yeah, that's a really good question. You don't necessarily have
to meet criteria for severe acute malnutrition to be at
risk for refeeding syndrome. Okay? Is it is really this
prolonged risk? So often people might have meat criteria for
severe acute malnutrition, but not necessarily in order to potentially
have refeeding syndrome.
Speaker 2 (38:58):
Okay.
Speaker 3 (39:00):
Yeah, it's something we unfortunately see a lot actually in
the hospitals in the context of like restrictive food intake
disorders like inarexiaan and things like that. It's not uncommon
to see refeeding syndrome in those contexts as well. I
see and globally, millions millions of children face food insecurity,
especially in low and middle income countries. It is estimated
(39:23):
that at least ten percent of deaths in children under
age five globally are due to severe acute malnutrition, and
there are estimates as high as forty five percent of
deaths in kids under age five being at least in
part due to undernutrition, meaning it's a combination of their
(39:45):
susceptibility to infections and all of these other things as
a result of undernutrition.
Speaker 2 (39:50):
I mean, starvation is not just a simple lack of food.
Speaker 3 (39:54):
Correct correct right, right, especially, and we'll talk a lot
more about this next week. But so many of the
situations that we see kind of acute disruptions in food supply,
we also see displacement. We also see armed conflict. We
(40:15):
also see crowding. We also see lack of or dismantling of,
or disruption of clean water facilities, sanitation facilities. All of
those things are going to put people at higher risk
of the spread of infectious disease, and we know that
they are more susceptible to infectious disease. We see things
like outbreaks of diarrheal diseases, which can be very devastating
(40:38):
cause dehydration and electrolyte imbalance when you are already facing malnutrition.
And even when we talk about the global estimates on
kids who are affected by malnutrition or wasting, those estimates
tend not to capture the groups of kids and adults
(40:59):
who efface acute malnutrition because of things more acutely, like
natural disasters or conflicts, and these kind of more emergency situations,
those are often actually not reflected in the larger statistics
when we talk about the burdens of severe acute malnutrition,
which is grim. And we'll talk more about those acute
(41:20):
famine situations next week, but Aaron, can you tell me
a little bit more about how we learned what we
know about these effects of starvation on our bodies?
Speaker 2 (41:31):
I can tell you about one way we learned, Yes,
thank you. The brochure read will you starve that they
(42:04):
be better fed? More than four hundred people said that
they would. Of those, one hundred were interviewed and thirty
six were selected to participate in what would be known
as the Minnesota Starvation Experiment. So in nineteen forty four,
as World War II entered its fifth year, researchers in
Europe and the US grew increasingly aware of the dire
(42:26):
situation that was facing much of war torn Europe and
of the horrific and brutal conditions in Nazi concentration camps.
Millions of people who had gone months, even years without
access to enough food and clean water, adequate shelter, and
clothing and healthcare, leading disease to spread unchecked. People realized
(42:49):
that when this massive global conflict came to an end,
which seemed more and more likely as the months went by,
massive numbers of relief workers would be needed to deliver
food and resources in liberated cities and camps. But there
was no agreed upon plan for how best to distribute
these resources, like what and how much food to give
(43:12):
a starving city? What kind of food? In November of
nineteen forty four, after years of lobbying for funds to
study the effects of starvation, physiologist ansel Keys was finally
granted the opportunity to begin his study. He distributed those
pamphlets that say, you know, will you starve that they
be better fed. He distributed them to thousands of conscientious
(43:36):
objectors who, after being drafted into the war, had exercised
their right to refuse service for moral or religious reasons.
Side note, before I forget, I wanted to mention that
this is not this experiment is not ansel Keys's only
claim to fame, or even his biggest claim to fame.
He also developed k rations for American troops. So these
(43:58):
were these ready to eat non parish meals breakfast, dinner,
and supper, and that soldiers could carry around with them.
And there are YouTube videos of people trying these out
like today, like unboxing, and like reviews of the different
types of k rations like those are eighty years old.
I mean, I think they were also made up through
(44:22):
the nineteen fifties. I'm not sure. Don't quote me on that,
keeping it in the podcast anyway, Yeah, old. And he
also in addition to k rations, he along with his wife,
popularized the Mediterranean diet.
Speaker 3 (44:37):
I saw that too, I was like, wow, Keys.
Speaker 2 (44:41):
Keys Keys, Yep, he was kind of an influential guy
about that, I know. Yeah, But anyway, so Keys was
interested in starvation not only in terms of its effects
on the body and the mind, like what is actually
happening during starvation, but especially how best to feed someone,
to treat someone, to treat the starvation without causing further harm,
(45:03):
and also what while making efficient use of limited resources,
Like the resources were limited most of Europe was under
rationing anyway, And so he designed this experiment where he
took thirty six young healthy men and put them on
a semi starvation diet. And on this podcast, we are
(45:24):
I think fairly accustomed to thinking of the word volunteer
in quotes like, especially when it comes to early twentieth
century medical experiments, but in this case volunteer seems to
truly mean volunteer and al yeah, I.
Speaker 3 (45:41):
Feel like that sets this apart almost more than anything, absolutely,
that he did not experiment on people unwillingly.
Speaker 2 (45:50):
Right, Yeah, he didn't. Like he was really, I think,
very deliberate about what he was doing, as were the
men who participate. Like ansel Keys, was seemed truly motivated
by the desire, the passion to reduce suffering in people
around the world, and many of the men who participated
(46:10):
were later interviewed in like the early two thousands about
their experiences, and they all said that if given the chance,
they would do it again, which is I think that's like,
that's they were very proud of their contribution because I
think to be a conscientious objector during World War Two
it came with many complex emotions that some of the
(46:31):
men talked about. One man said, quote, you know, the
sense of not sharing the fate of one's generation, but
of sort of coasting alongside all of that. You couldn't
feel you were part of anything terribly significant in what
you were doing, end quote. And so this was kind
of their way of like contributing to the effort to
defeat fascism without compromising their morals.
Speaker 3 (46:54):
Which.
Speaker 2 (46:55):
Yeah. So the experiment started in November nineteen forty four
with a three month control period during which the men
all received a standard diet of thirty two hundred calories
of food a day or kill a calories. I'm just
going to say calories from this point forward, because that's
how we tend to think of calories today. Yeah, So
thirty started with three months thirty two hundred calories of
(47:16):
food a day. Some of the men, like I think
are the first hand account. Jim Graham, he actually needed more.
He was losing weight on that because he was quite
an active person anyway. Yeah. So then there began, after
those three months, a six month period of semi starvation.
So it started on February twelfth, nineteen forty five, And
(47:37):
this with the semi starvation, was a daily caloric intake
of roughly eighteen hundred calories a day. So there were
two meals a day, one at eight am and one
at six pm, except on Sundays, where they got I
think just one larger meal and the food tended to
reflect what the most impacted areas of Europe might be consuming,
(47:58):
so things like potatoes, turnips, brown bread, stuff like that. Breakfast,
for example, might consist of a small bowl of farina,
two slices of toast, a dish of fried potatoes, some jello,
a bit of jam, and a small glass of milk.
And initially the men were allowed to eat gum, but
that stopped after some of the guys were going through
(48:19):
like forty packs a day a day just for something
to like put in your mouth. Yeah, And the men
were also expected to walk twenty two miles each week,
and so this was and they had to like record
this I think, I actually don't know how they how
they tracked this, but the idea was that they would
be consuming fewer calories than they expended. So it was
(48:43):
supposed to be like a three thousand calorie expenditure daily
and they were only in taking eighteen hundred calories of food.
Speaker 3 (48:51):
So they had to remain active enough that that wasn't.
Speaker 2 (48:54):
Yes, yeah, yeah, but other than that, you know, their
movements weren't too restricted. There was a buddy system that
was instituted at one point, but they were given you know,
various administrative or housekeeping duties. They attended political science and
language classes as prep to become international relief workers when
this was over, and the goal was to have participants
(49:17):
lose two and a half pounds a week, which is
a lot, so that at the end of six months
they lost twenty five percent of their total body mass.
Everyone was routinely weighed, their strength and their endurance was tested,
blood was screened, other body measurements were taken, and they
were also routinely given intelligence and personality tests just to
(49:40):
kind of assess like psychological status. Interesting and results from
their weekly weigh in were posted at the end of
each week could cause tensions to run high. Some people
would just avoid it until they absolutely had to see
how much they were getting. It would determine how much
food you got to eat the following week. One of
the men, Yeah, one of the men, Daniel Peacock, recalls
(50:04):
that quote. We were given our food along a cafeteria line,
and if the guy ahead of you is given five
slices of bread, that's pretty hard to conceal, and if
you're only getting three, that's pretty touchy. End quote. They
were also all required to keep a journal to keep
track of their mental and physical progress, like you know what.
(50:25):
Some of the guys described how when they had to
cross the street, when they were like out on their walks,
they would wait until they encountered a driveway so that
they wouldn't have to step down or step up on
the curb because they were just had no energy. They
noted how they lost any sex drive whatsoever pretty quickly. Quote.
(50:47):
I have no more sexual feeling than a sick oyster,
wrote one man. Sick oysters. Yeah, and they became obsessed
with food. Quote. Eating became a ritual. Some people diluted
their food with water to make it seem like more.
Others would put each little bite and hold it in
their mouth a long time to savor it. So eating
(51:08):
took a long time end quote. There's a lot of
fascinating diary snippets that I encountered. So I'm going to
read you a few just from like a few of
the different months, because you can see sort of a
little bit of like the month by month. Yeah, month too. Quote.
I just don't have any desire to do the things
I should do or the things I want to do.
(51:28):
Instead of writing a letter, I read a newspaper. Instead
of studying, I read a pamphlet instead of cleaning. I
putter around, making excuses such as, well, I really won't
have enough time to do the complete job. I'll do
it later end quote. And then month two, I purchased
a tube of toothpaste yesterday, finally got around to using
it for the first time last night. Had a desire
(51:49):
to eat the paste, but controlled it. Month five, I
also found myself becoming senselessly irritable, particularly when I watched
some of the bizarre eating habits of others. One mixture
that came near flooring me was potatoes, jam, sugar, gingerbread,
all thrown into a bowl of oatmeal and used as
a sandwich spread. I hate to see guys picking around
(52:11):
with this or that to make a superb sandwich, all
the time letting their soup get cold. And Month six
stayed up until five am last night studying cookbooks so
absorbing I can't stay away from them, which might be
our first hand he did mention becoming like obsessed with cookbooks.
After the six months of semi starvation ended on July
(52:34):
twenty ninth, nineteen forty five, there was a three month
period of refeeding, the men had lost on average the goal,
which was a quarter of their body weight. Their hearts
had shrunk by almost seventeen percent, they beat a lot
more slowly, like, their pulse was a lot slower, blood
pressure dropped tremendously, they became anemic, their lung capacity had
(52:57):
decreased by thirty percent, and a few experienced pretty severe
neurological symptoms that had to be treated like separately. For
the refeeding portion, the men were placed into different treatment
groups based on caloric intake, protein levels, and supplemental vitamins,
and the men began to receive daily calories ranging from
(53:18):
two thousand to three thousand. But immediately, like in the
weeks that followed the refeeding, their weight continued to drop
kind of like, almost alarmingly, because the edema that they
had developed during the semi starvation portion had been disguising
just how much weight they had truly lost, And so
six weeks into refeeding, the group receiving two thousand calories
(53:43):
had only regained zero point three percent of the weight
that they had lost. Wow, And even the group that
was receiving the most calories, which was three thousand, had
regained after six weeks nineteen point two percent, and they
still complained of all the same things during the semi
starvation period edema, depression, exhaustion, aches and pains, a bottomless
(54:05):
pit of hunger. Apathy was a big one. Irritability and
mood swings. Calories were upped again. I think antel Keys
was like, why isn't anyone regaining any weight? And finally
that's when improvement seemed to be, like actual actually made
protein and supplemental vitamins at least in this experiment didn't
(54:26):
seem to make a difference. And the real lesson that
kind of emerged was that two thousand calories a day
was simply not enough for rehabilitation or at least like
rehabilitation on any sort of you know, timescale for people
of this body size and activity levels. They needed at
(54:46):
least four thousand calories. I feel like.
Speaker 3 (54:51):
That's so important because it just shows that, like when
you have been subjected to under nutrition for so long,
you can't just go back to like we think today
if two thousand calories as like a standard diet or whatever, right,
you can't just go back to You can't just have
the bare minimum your body has nothing, and it's going
(55:12):
to try and build that up and it's not going
to be able to.
Speaker 2 (55:15):
It's not going to be able to. Yeah, there's such
a recovery process. Yeah. And so when the experiment ended,
which was in November nineteen forty five, normalcy still hadn't
returned for any of the men. They were allowed to
at that point when they and then the twelve months
was all over, the men were allowed to eat whatever
(55:37):
and how much they wanted. Some began to eat ten
thousand calories a day because they just felt like they
will never they could eat a huge meal and still
feel hungry, just empty. Yeah. Others ate so much that
they had to go to the hospital because they would
be vomiting and it was Yeah, some had to be
treated for that. Food. Anxiety remained for with these men
(55:58):
for a very long time, and their bodies, you know,
their heart and their lungs took They took a lot
longer to return to baseline than anticipated. Within a few
months of the experiments, and Keys and his colleagues wrote
up a pamphlet to distribute to aid workers, and it
proved to be crucial after the war ended in delivering
(56:20):
appropriate aid and it's on the Internet archive. If you're curious,
I'll link to it. It went over physical changes, behavioral changes,
refeeding how to help people cope with what they had
gone through. There was a really interesting thing. This is
when like communal feeding areas were still like very much
a thing, and it would be like do not allow
people to stand in line, like it is incredibly demoralizing,
(56:42):
you know. There was like a lot of really interesting
and who knows how much of this was like from
the experiment or just like this is what we think,
but it was a really considerate sort of like what
is the mentality? Not just about food, but it was
like what these considering what these people have gone through,
a more empathetic approach to how can we relieve the suffering? Yeah. Yeah,
(57:07):
Also in nineteen fifty Keys published a two volume whopper
of a book titled The Biology of Human Starvation. It
was almost fourteen hundred pages. And yeah, I didn't read
any of that, but I'm sure it's out there. But
the Minnesota Starvation experiment was really groundbreaking for being among
(57:32):
the first to systematically study what happens to both the
body and the mind during long periods of semi starvation
and how to rehabilitate a starving person. It wasn't the first,
so there were a few actually that also happened during
World War Two. There was the Warsaw Ghetto hunger study
in nineteen forty two, which was kind of done surreptitiously,
(57:52):
and then there were studies in the Netherlands in nineteen
forty four to nineteen forty five. There was actually a
fair amount of starvation research. One author described world War
two as quote a cornucopia of starvation research, a wealth
of hunger end quote. Yeah. The Minnesota starvation experiment marked
(58:14):
a necessary and crucial step forward in our understanding of
how to deliver aid to victims of mass starvation. But
for many it came too late. World War Two in
Europe ended on May eighth, nineteen forty five, and in
Japan a few months later on August fourteenth, months before
(58:34):
the study ended, thousands of concentration camp survivors died of
refeeding syndrome in the weeks after the camps were liberated.
Could they have been saved if the study had started earlier,
I don't know. To me, the real question is why
wasn't there any interest in the effects or treatment of
(58:56):
starvation until this time, until World War Two. One English
officer remembered meeting with public health advisors in January nineteen
forty five, which was the month that Auschwitz was liberated. Quote,
it was frightening to realize how little any of us
knew about severe starvation in our lifetime. Millions of our
(59:16):
fellow men had died in terrible famines in China, in India,
in the USSR, without these tragedies having yielded more than
a few grains of knowledge of how best to deal
with such situations on a scientific basis. End Quote. The
opportunity was there, It had been there to come up
(59:37):
time and time again. Modern science existed. Western medicine simply
lacked interest or a sense of urgency in understanding this problem.
Maybe it was a little bit of hubrius mixed up
with a sense of superiority, like we've got our stuff
figured out, it won't happen to us.
Speaker 3 (59:53):
We don't have to worry here. Yeah, it's happening over there.
Speaker 2 (59:56):
Yeah. And so when starvation came to Europe, no one
really knew what to do, and it didn't come alone.
It rarely does. Starvation is just one component of a famine.
It rides alongside disease, fear, violence, despair, and a perpetual
sense of uncertainty, of not knowing when anything will end.
(01:00:21):
Things that can't and shouldn't be captured in a medical
experiment like the Minnesota starvation experiment. And I want to
end with a quote from a paper by Sharman apt Russell. Quote,
the Minnesota experiment itself did not reproduce the cold that
Europeans experienced in World War Two, the lack of fuel
(01:00:42):
for cooking food and heating the house, the lack of
warm clothes, the lack of shoes. It did not reproduce
the fear, the knowledge that you might die at any time,
that you might be humiliated or injured, or tortured or killed.
It did not reproduce the murder of a neighbor, the
corpses in the street, the inexplicable loss of human decency.
(01:01:04):
It did not reproduce the death of your son. End quote.
Famine is so much more than starvation, and starvation is
so much more than a lack of food. And so
that is kind of where I want to end things today,
so that next week that's sort of what we'll talk
about is like the bigger picture that encompasses all of this.
(01:01:27):
So yeah, yep.
Speaker 3 (01:01:30):
So make sure you tune in next week.
Speaker 2 (01:01:32):
Tune in next week. In the meantime, there's some sources
that we could share, so so many, so many. I
want to shout out just two in particular. There are
several more that will be on our website. But one
is by Sharman apt Russell, The Hunger Experiment, and that
another is by Calm and Semba titled They Starved so
(01:01:56):
that Others be Better fed, remembering Ansel keys and the Minnesota.
Speaker 3 (01:02:01):
I have quite a lot of papers. I also had
a book. I read a book, a few chapters of
a book called Hunger, The Biology and Politics of Starvation,
published in twenty ten. It was fine. It's like more
detailed than you need in all honesty, but it does
have some good just like overview parts of the biochemistry
(01:02:22):
and things. I really enjoyed a Nature Reviews Disease primer's
paper from twenty seventeen called Severe Childhood Malnutrition, and then
a couple of different there was an Annual Reviews in
Physiology the Comparative Physiology of Food Deprivation from Feast to Famine.
That one was really good for some of the biochemistry.
If you want details on biochemistry too, there's also a
(01:02:43):
Stanford has like a PDF of literally every biochemical like
metabolic pathway that's just kind of fun to go through
and see how they all interconnect in which ones you're
doing versus not doing at any given time. But we'll
post the sources from this week's episode in every single
one of our episodes on our website guest will Kill
You dot com under the episodes tab.
Speaker 2 (01:03:03):
We will thank you to Bloodmobile for providing the music
for this episode and all of our episodes.
Speaker 3 (01:03:10):
Thank you to Leanna and Tom and Pete and Brent
and Jessica and Mike and I'm sure I'm forgetting people
everyone at exactly great network.
Speaker 2 (01:03:20):
Thanks to you listeners for you know, listening, for tuning
in wherever you're tuning in however you are let us
know what you think. And a big thank you, of
course to our generous patrons. Your support really really means
the world to us.
Speaker 3 (01:03:35):
It does.
Speaker 2 (01:03:36):
Thank you well.
Speaker 4 (01:03:37):
Until next time, wash your hands, feelthy animals.
Speaker 2 (01:04:01):
O
Hello. My name is Jim Graham. I'd like to tell
you about an experience that I had during World War
Two as a guinea pig and an experiment in semi starvation.
On February twelfth, nineteen forty five, we began our twenty
four weeks of semi starvation. We were expected to lose
about one fourth of our body weight during the next
(00:22):
six months. The days began to drag out, each day
getting longer and longer, and there seemed to be no
end of starvation in sight. Six months seemed like forever.
I'd look in the mirror and see that my eyes
looked hollow, my cheeks were only a thin covering for
the bones in my face, and my hair was getting thinner.
(00:46):
If I tried to smile, it was just a grimace.
I didn't feel like smiling in the first place, and
I never laughed. My muscles were almost gone, my bones protruded,
and sitting on a hard chair was uncomfortable even for
a few minutes. Most of us carried around pillows to
sit on. I couldn't walk up a flight of stairs
(01:09):
without stopping to rest once or twice on the way up.
I felt like an old man. And probably looked like one,
since I made no effort to stand up straight. I
thought about food all the time. I started collecting cookbooks,
you know the kind with beautiful color pictures of delicious
looking dishes. I felt cold all the time, even though
(01:34):
it was the middle of summer. Nothing felt better than
to find a nice warm spot in the sunshine and
do nothing but lie there and soak up the heat
of the sun. We became very irritable and intolerant. Little
things seemed to annoy us. We were no longer polite
with each other or with visitors. It seemed as if
(01:56):
the veneer of civilization had been removed. Leave bear the
animal underneath. We didn't enjoy having guessed because it was
an effort to entertain them, and we were not usually
very diplomatic about showing our feelings about it. Food occupied
our thoughts all the time. At meal time, each one
(02:18):
had his special way of dealing with the food. A
couple of the fellows would eat their food quickly and
then leave the cafeteria and try to forget about it.
Most of the rest of us dawdled over our food.
Some would mix their food altogether, others would savor each
bite of each item on the plate. We'd been told
(02:39):
before the experiment that the food might become monotonous since
there were only three menus, but it was far from monotonous.
It was food, and any food tasted good. To this day,
I find one of the tastiest foods is a simple
boiled potato. It's delicious. Any food looked good. Even the
(03:01):
dirty crusts of bread in the street looked appetizing, and
we envied the fat pigeons picking at them. Wasting food
is a crime. We felt the waste of food and
restaurants was intolerable. On July twenty ninth, nineteen forty five,
was the day semi starvation was to end and we
were to begin eating again. It was also my twenty
(03:25):
third birthday. After the experiment was over, I was still
hungry for a long time. Even when I could eat
all I wanted, I would finish a meal and still
feel hungry. My stomach just would not hold anymore. For months,
I carried candy bars or cookies in my pocket and
munched continually. In six months, I went from a low
(03:47):
of one hundred and twenty two pounds to a high
of two hundred and twenty five pounds. It took me
three years to get back to normal weight and normal
eating habits. In conclusion, I would like to say that
I have experienced hunger and the apathy and depression that
goes with it, but we lived in sanitary quarters under
(04:10):
the constant care of doctors. Most people in areas of
famine die of other diseases because of the body's inability
to resist disease. Furthermore, we knew that it would all
be over on a certain date. I often think how
horrible it would be to be starving and never know
(04:31):
when it would end.
Speaker 2 (04:33):
If ever, it's that is such a fascinating perspective, and
(05:26):
like the fact that that video exists is kind of incredible. Yeah, yeah, yeah.
Speaker 3 (05:33):
It's yeah. It's especially that what he says at the end,
they're like knowing that it's going to end, and how
much that can change the way that you are experienced.
Speaker 2 (05:44):
I don't know, it's I mean, it's like and we'll
get into it more later, but yeah, this is like
artificial settings important nonetheless, but like, yes, this is not
the type of thing that people experience under real world
conditions of starvation. Yeah, so but yeah, so again that
was Jim Graham who participated in the Minnesota Semi Starvation experiment.
(06:06):
That's from a video that was recorded in nineteen ninety
and it's part of Colorado State University's Digital library collections,
specifically university publications, and we will post a link to
the full video and the transcript as well on our
website so you can watch, or listen to or read
the entire thing. So, yeah, hi, I'm.
Speaker 3 (06:26):
Aaron Welsh and I'm Erin Almanepneke.
Speaker 2 (06:29):
And this is this podcast will kill You.
Speaker 3 (06:32):
So this week and next we're going to be talking
about starvation and famine and those words, along with hunger
and malnutrition, have been used a lot lately in discussions
surrounding the ongoing genocide and famine happening in Gaza and
the conflict raging Insudan.
Speaker 2 (06:51):
All of these words, you know, starvation, famine, hunger, malnutrition
are associated with a lack of food and the subsequent
effects of that lack of food. But each one of
these words has a distinct meaning, and so what we
want to do with these two episodes is to provide
a bit of context for understanding, you know, what it
is that we're talking about. When we talk about starvation
(07:14):
and what it means to declare a famine.
Speaker 3 (07:17):
Yeah, so we're starting out this week discussing starvation, the
physiological and psychological impacts, and a little bit about its history.
And you'll hear more about that Minnesota semi starvation experiment.
Speaker 2 (07:29):
Yes you will. And then next week we'll turn to famine.
We'll go through the definition or definitions of famine, what
causes famine, and how famines have changed throughout history, before
we outline some of what's happening with the famine in
Gaza and other food in security crises in other areas
of the world.
Speaker 3 (07:48):
Yeah, we have a lot to cover these two episodes,
so we decided to do things a little differently and
just start right into it. Yes, Yeah, we're going to
take a quick break and then get started. My goal
(08:20):
for this first part of today's episode is to walk
us through what is happening in our bodies, what happens
inside of our bodies when we are deprived of food.
So I'm going to start with what's happening on like
a fairly minute scale, like how does the inner machinery
of our body keep ticking if we don't provide it
(08:41):
with any source of energy, and that process can happen
for any reason. Right. It could be because you lack
access to food. It could also be because of prolonged illness.
It could be a restrictive food intake disorder, It could
be any number of things. But I'm going to go
through the mechanism of what's going on. But then we're
going to take a step back a little bit outside
(09:02):
of our bodies and talk about some of the bigger
picture consequences of prolonged starvation, especially in the context in
which we most commonly see starvation today around the globe,
which is lack of access to food.
Speaker 2 (09:17):
Right, right, right, so population level.
Speaker 3 (09:19):
Effects exactly exactly, Yeah, well, individual and population level, but
like right, so it's a lot, it's all depressing. As animals,
we use the food that we eat to create energy,
and that is the process that we call metabolism. And
(09:41):
we don't have to get deep into biochemistry. Don't worry,
because I simply cannot. But there are three main macronutrients
that are most important, at least for my discussion today,
and that is carbohydrates or glucose, fats, and protein, and
these are the majority of what makes up our foods.
Of course, there's a lot lo of micronutrients. We've covered
(10:01):
several of them on this podcast. They are essential to
keep us functioning, but the big three are what we're
going to focus on today. We have to break down
and use carbohydrates, fats, and proteins in different ways via
a whole bunch of complicated cycles in order to create
energy and keep our cells alive. And all animals do this,
(10:27):
and because food is almost never, like constantly available, we
all have All animals have mechanisms physiologic adaptations in order
to survive in times of food scarcity or food deprivation,
and the exact adaptations are going to vary a lot
by species, which is why bears can hibernate for months
(10:48):
on end, salmon can traverse thousands of kilometers without eating,
snakes can only eat a couple of times a year.
But humans, we have relatively high metabolic rates, especially relative
to our body stores of energy, so we actually need
food on a pretty regular basis in order to survive.
Speaker 2 (11:08):
There are also behavioral adaptations like caching food, which I mean,
of course humans, but like like we talked about in hypothermia,
I know as.
Speaker 3 (11:15):
I was writing this I was like, we just went
over this in hypothermia. So when animals, including humans, are
deprived of food, we experience hunger, and the feeling of
hunger is driven by a pretty complex interplay between hormonal
and neurologic signals. But hunger is also a biological drive,
(11:40):
So in animals, including in humans, it's a driving force
of behavior. And in a lot of animal studies, animals
across the spectrum, like mammals, birds, everything, will engage in
riskier and riskier behavior in an attempt to access food
if they are hungry or starve, and in many animal models,
(12:03):
the hunger drive actually out competes or overrides nearly all
other biologic incentives.
Speaker 2 (12:10):
How does it compare it to like thirst drive?
Speaker 3 (12:13):
That's actually a good question. I didn't see any things
directly comparing that, but they're also very closely related because
a lot of times, you know, if you are deprived
of food, you may also be deprived of water. There's
also some animals who get their water primarily from their food. So, yeah,
it's a good question, but I don't have like an
exact answer to it. Yeah, so I'm going to go
(12:34):
into a little bit mechanistically about what's happening during that
time during starvation, and there are a lot of hormonal
drivers and things at play that are controlling our hunger
cues and our satiety cues. But I think what's important
to keep in mind as we go through this is that,
in my opinion, maybe this is an opinion, none of
(12:56):
this explanation is really adequate to explain what happens to
people and animals but also humans when they feel hungry
all the time, for days or weeks on end. I
think that our first hand account helped to explain some
of that bigger picture about how it feels to be hungry,
(13:19):
but the biology doesn't quite I think, do that justice?
Speaker 2 (13:23):
Yeah, I mean it can't.
Speaker 3 (13:26):
It can't.
Speaker 2 (13:27):
It can't because it's so clinical.
Speaker 3 (13:29):
Yes exactly, yeah so, but metabolically absolute food deprivation proceeds
in relatively predictable stages. It starts with what's often called
fasting and then proceeds through starvation, and without intervention this
will end in death. So the first phase of food
(13:50):
deprivation is it's often called fasting, and there's arguments about
like when do you hit the threshold between fasting and
starvation and et cetera. But the point is that this
is just the first few hours after you've eaten food.
Once we've absorbed all that we can from our meal,
the first thing that our body is going to do
is start using glycogen, which is the long branchy chains
(14:14):
of glucose that we store in our liver, right, and
we start breaking this down in order to keep our
blood sugar levels up.
Speaker 2 (14:22):
Okay, so this is what happens after you eat a meal.
Speaker 3 (14:25):
After you eat and you've digested and used up all
the glucose in your meal.
Speaker 2 (14:29):
Right, got it?
Speaker 3 (14:30):
Yep. Yeah, we'll also start to use some of our
adipose tissue storage, especially to like fuel our muscles and
things like that. This phase, though, the glycogen storage that
we have in our liver only lasts for about a
few hours, which is why we usually start to feel
hungry a few hours after eating. After a few hours
(14:51):
without food, our livers glycogen stores are depleted, and our
brain requires glucose in order to function in the rest
of the tissues in our body can use other energy sources.
They can go through these biochemical pathways to like directly
use proteins or fats in order to make energy. In
(15:12):
order to make ATP. But our brain really needs glucose.
That's what it is dependent on. So our liver abides
and starts making glucose. And this is a process called gluconeogenesis,
literally making new glucose.
Speaker 2 (15:27):
This is it's like I remember all of this in
such vague terms from like bio one oh one, right,
and it's I don't know if it's coming back to me,
but by the end of this it would be back.
Speaker 3 (15:40):
You have certainly come across this, I'm sure in like
most biology, gluconeogenesis. Yeah, yeah, it's actually one of my
favorite words.
Speaker 2 (15:49):
It's a good word.
Speaker 3 (15:50):
It's a good word.
Speaker 2 (15:51):
Yeah.
Speaker 3 (15:52):
We go through glycogenolysis, and now we make gluga eugenesis. Anyways,
at first, like the very first, our body starts to
do this with some protein because protein is very easy
for our bodies to make glucose from. Okay, so we'll
start breaking down a little bit of protein in order
to feed our brain. But proteins in our body are
(16:13):
not really there for energy storage. We use proteins in
our body for building stuff. We use it to make
our muscles, we use it as enzymes. Right, So our
body tries to preserve protein aside from what we eat
and then have to use. Right, So pretty quickly our
(16:35):
body switches and we start relying more on our adipose tissue,
our fat in order to fuel our body. We cannot, though,
make glucose directly from the fatty acids part of fat. Okay,
but we store fat and sorry this is getting a
little technical, but we store fat in the form of
(16:56):
something called triglycerides, which is three fats and a glycrool,
and that one glycerol we can make glucose from.
Speaker 2 (17:05):
Okay, could we just pause and start so now can
you put me in like a timeline of what is happening,
and when like step one you eat, step two you digest,
step three you start to pull the glycogen from your liver,
and then step four where does proteins that what happens
(17:25):
with the proteins and fats at that point.
Speaker 3 (17:27):
It's not like an exact like this day you switch,
because it's going to depend on your body composition and
like what your last meal was and all of those
sorts of shits. Right, But in general, after a meal,
the first few hours you're going to be mostly using
glycogen stores. After those glycogen stores are depleted. Your body
is going to start breaking down your own body in
(17:49):
order to get the glucose that you need. It might
use a little bit of protein at first, but primarily
it's going to rely on using your fat stores. Where
are fat stores, I mean, all over your whole body.
Speaker 2 (18:03):
It's just everywhere. It's just sort of a shop.
Speaker 3 (18:07):
Yep, exactly. Yeah, Okay, So we start seeing a lot
of this process called fatty acid oxidation, and that is
the majority of what we're going to see for potentially
weeks on end, depending on how much fat storage you have.
The process of fatty acid oxidation will also result in
the formation of keytone bodies.
Speaker 2 (18:27):
People who have heard.
Speaker 3 (18:28):
Of the whole keto diet thing will have heard of this.
Speaker 2 (18:31):
We should do an episode on the Keto diet, though
we probably should.
Speaker 3 (18:35):
Our brains can actually use keytone bodies. They can use
ketones as fuel. Our brain prefers glucose, but it will
use this as it is required to. But this whole
process is basically our body adapting to this starvation. We
will use up all of our fat stores, and how
(18:55):
long we can survive in this particular phase is going
to depend pretty much on our body composition, our age,
our comorbidity, is all of these things. But it's usually
a period of a few weeks or so. After that
we enter what's kind of called phase three, and that
I think of it as when our body is really
(19:18):
not able to compensate anymore, because this is the point
at which we've run through these fat stores and now
we have to rely on skeletal muscle. Yeah, and our
body has to start breaking down our muscle proteins in
order to use them for energy. And you can imagine
that that's not good for our body. We need our muscles,
(19:40):
but that is what our body will do in order
to keep it alive in the short term. Right.
Speaker 2 (19:47):
Can I ask a question about like how food consumption
changes this process?
Speaker 3 (19:53):
Yeah, it's a really good question. So it's not common
that people are completely deprived of food and how absolutely
no access to food.
Speaker 1 (20:02):
Right.
Speaker 3 (20:02):
More often people are going to get very small amounts
of food a little bit at a time, or maybe erratically,
and that is what is sometimes called this like semi starvation.
The way to think about that is it's going to
kind of fluctuate where you are in this continuum. As
soon as you eat, your body is going to use
up all of that food that it can. Is it
(20:24):
going to be able to store any extra? It totally
depends on how deprived you have been, right, But you
can think of it as kind of keeping people cycling
between these first few phases for a potentially more prolonged
period of time. But it could be that you're kind
of going your body is doing all things at once, right,
You've if you've used up all of your fat stores,
(20:46):
and then you get access to food, then your body's
going to use that food. But then as soon as
you've used that up, you don't have any fat stores,
so you're going to go right back to using your.
Speaker 2 (20:54):
Protein something straight back to protein.
Speaker 3 (20:56):
Okay, okay, yeah, so that's I mean, Actually, what happens
this process, especially once you get to the point of
breaking down your own skeletal muscle for fuel, can progress
fairly rapidly, and if food does not become available, this
will end in death kind of directly from starvation. There
(21:17):
are in the literature kind of two different syndromes that
we most often see in people who are affected by starvation,
and collectively this is called severe acute malnutrition. This is
like the end stage of this This is like phase three,
end stage of lack of access to food. This used
(21:38):
to be called it was when I learned it actually
called protein energy malnutrition. But separately, within this there's two
different syndromes. One is known as quashiocore and the other
is Marasmus. Yes, and a lot of the literature around
severe acute malnutrition or SAM, focuses on children under the
age of five because they are by far the most
(22:01):
vulnerable too severe acute malnutrition and the complications that can arise.
But it's not the only they are not the only people.
It's really important to remember that other groups are very
vulnerable to food deprivation, including pregnant or breastfeeding people, including
the elderly, and including children and adults with certain disabilities
(22:24):
or comorbid conditions, things like cystic fibrosis or cerebral palsy.
I mean, there are so many conditions that might make
you more susceptible to malnutrition.
Speaker 2 (22:33):
Yeah, but I.
Speaker 3 (22:34):
Want to go through these two syndromes in a little
bit of detail, and then we'll talk bigger picture about
all of the complications that happen as your body has
gone through this starvation process. So Marasmus is also known
as acute wasting, and this is when you lose a
very substantial amount of weight, and usually in a relatively
(22:57):
brief period, although some people, if they have been experiencing
prolonged semi starvation, it might be over kind of a
longer time period. But it's diagnosed based on specific like
body weight and height measurements, or by measuring the upper
arm circumference and having that be below a certain circumference.
It's like a good indicator of how much weight someone
(23:19):
has lost. And this is really the kind of most
classic process that happens as what I described of starvation.
So as you have no food, you use up all
of your fat stores, and then you start to eat
away at your muscles and then you are experiencing Marasmus.
Does that make sense? Yes?
Speaker 2 (23:40):
Yes.
Speaker 3 (23:42):
The other condition is quashiocore, which historically was thought of
as primarily a protein malnutrition.
Speaker 2 (23:51):
What does that mean?
Speaker 3 (23:52):
Yeah, it used to be.
Speaker 1 (23:54):
So.
Speaker 3 (23:54):
It was first seen in certain populations in association with
a very low protein diet or in infant after they
switched from breast milk to very low protein like say
all corn diets or something like that. Okay, And so
based on those kind of like epidemiological studies, and in
contrasting that to Marasmus, which was thought of as purely
like a calorie deficit uh huh, without necessarily only a
(24:18):
protein deficit. This was classified initially as like, oh, this
is a protein deficit rather than like a total energy deficit.
But it turns out that that's not really quite as
clear cut, and the exact path of physiology is not
entirely understood. We really don't understand quashio court right now,
but it does look different physiologically than Marasmus or wasting.
(24:44):
It's characterized by this edema, this fluid collection and swelling
underneath the skin especially, and it starts in the lower
legs but can also be in the face, in the arms.
And there's also fatty liver infiltration that we see, and
you can get from that like distension of the abdomen,
and then we'll have like flaky skin and other changes
(25:06):
that we don't necessarily see with Marasmus or wasting. We
think from what I could tell from the literature that
quashi or core more specifically, might be like a maladaptive
response to the way that our body is processing protein
in the face of a very low protein diet, if
(25:28):
that makes sense.
Speaker 2 (25:30):
Yeah, okay, So I'm curious, Like the food that we
eat is not just food, right, Like there are different
qualities of food, different like types of food, different energy sources,
and so how does that play a role? I mean,
maybe this is jumping ahead a bit and asking sort
of about like refeeding, but like, how does that play
a role in you know, the development of these sort
(25:52):
of symptoms or conditions?
Speaker 3 (25:54):
Yeah, I mean in all, honestly, we don't like really
fully know because we don't know, Like there can be
a lot of First of all, marasmus and quashiocore are
not necessarily mutually exclusive. They can happen simultaneously, but they
also can happen in let's say, like the same communities
(26:15):
and sometimes when people are exposed to or have access
to the same foods. And so that's why it's not
entirely clear, like, you know, if we let's say, if
we're focusing on humanitarian aid and like what types of
foods do we need to get into an area to
prevent quashiocore more specifically, It's not quite as clear as that,
except that protein is definitely an important part of that.
(26:38):
But it's not as clear cut as like, Yeah, it's
just not as clear cut as like protein malnutrition equals quashiocore.
Speaker 2 (26:46):
Right, okay, okay, Yeah.
Speaker 3 (26:48):
It's also more difficult to estimate in terms of the
distribution of it. We don't have as good of a
handle on it. It does tend to be even more
severe than Marathis alone. And is that because there's this
like maladaptive component to it. We see like increases in
oxidative stress in quaeshiocre compared to Marasmus, we see even
(27:13):
more microbiome changes. Is there a microbiome component? There's like
a lot of questions, but what.
Speaker 2 (27:18):
Do you mean by maladaptive response? Though, Like I.
Speaker 3 (27:22):
Mean, like you aren't they they aren't breaking down and
using the protein that they do have in a way
that would like sustain them for longer. Is the best
way that I can Okay. Yeah. There was a paper
that came out in the Lancet not too long ago
that was more specifically looking at like one type of
metabolism called one carbon metabolism, which is one of these
(27:44):
many biochemical pathways, and it's thought that maybe that is
affected more severely in queshuocore compared to Marasmus. So maybe
it's that that we're not using this one pathway as well. Why,
we don't know. But overall, severe acute malnutrition, like both
(28:15):
of these combine effect up to seventeen million children or
more worldwide and untreated. Once a kid meets criteria for
severe acute malnutrition, it has a mortality rate of ten
to fifteen percent per month. So the overall effects of
this are really profound. Physically, it's manifest like you see
(28:39):
it as this loss of the subcutaneous fat that's going
to be like the last fat that your body tries
to hold on to, and that's what gives you a
very gaunt appearance. And then you're going to have this
muscle wasting, which is also going to come with weakness
because your muscles are literally like being eaten away by
your own by Your skin becomes dry and wrinkly, your
(29:04):
hair becomes sparse and thin. The cheeks look very sunken
because you've lost the cheek pads, this fat that's in
your cheek. Physiologically, your heart rate slows down, your blood
pressure is very low, your body temperature is low, oftentimes,
especially towards the most severe stages. Appetite is gone, which
(29:26):
can make it really hard for people to start eating again,
and sometimes when they do, they are faced with nausea, vomiting, diarrhea.
And that's because during this process, your digestive system is
essentially shutting down. Starvation affects every single organ system in
(29:48):
our body. Glucose homeostasis is disrupted, and so we often
see hypoglycemia. And that's especially true in quashio core compared
to marasmus or wasting. Again, something maladaptive happening there. We also,
and this one's really important, see huge alterations in our
immune system function.
Speaker 2 (30:08):
It's one of the biggest.
Speaker 3 (30:09):
Yeah, it's one of the biggest because many people, especially
kids with severe acute malnutrition, will end up very sick
with life threatening infections, and cause of death is often
from infection and not directly from starvation itself, right, right,
But this is directly because of a secondary immune deficiency, right.
(30:33):
It's so it is the starvation that is putting you
at risk for.
Speaker 2 (30:36):
Infection ultimate versus proximate cause type exactly. Yeah.
Speaker 3 (30:39):
Yeah, but this immune deficiency comes from a combination of
different things. There's disruption in all of our major barriers, right,
There's disruptions of your skin integrity, of your respiratory barrier,
of your gut barrier. But then we also see an
increase in the activation of inflammatory pathways. We see T
cell dysfunction, We see a reduction in anti micro activity
(31:00):
of most of our immune cells. And then, like I mentioned,
we see this like offlining of our entire digestive system
because it's not doing anything and so our body is
trying to preserve energy. We see our liver, our pancreas,
our biliary system are intestinal tract essentially not functioning at
their typical capacity. We also see huge changes in the
(31:22):
gut microbiome, which can sometimes include bacterial overgrowth in the
small bowel huh. Especially in kids, we can get impairment
of thyroid function and cortisol and growth hormones, which can
have profound effects for the rest of their life.
Speaker 2 (31:37):
I mean, so many of the aspects of starvation. Whatever,
at what point in your life it happens, it can,
it will stay with you.
Speaker 3 (31:44):
Forever, forever, forever, forever. Absolutely, And then there's changes in
our brain functioning as well, and not just an increase
in lethargy and irritability, but also the psychological effects which
are really profound and honestly not quite as well characterized.
But I know erin you'll talk a lot more about
(32:06):
some of the initial data that we have on this
from that semi starvation experiment. There was also a more
recent review paper that highlighted several hundred studies, not all
of which were a lot of which were in that
kind of artificial type of environment that's where a lot
of our data comes from. But there was also at
least some papers that were looking at the effects of
starvation psychologically in more unfortunately realistic situations, like in areas
(32:33):
of famine or chronic starvation and things like that, and
we consistently see increases in depression, anxiety, higher psychological distress.
We also see increases in competitive behavior and social withdrawal. Yeah,
And of course in most situations of chronic malnutrition or
(32:57):
acute starvation that we see in our way world today
happen after natural disasters, armed conflict, and these are situations
when lack of access to food is not the only stressor.
Speaker 2 (33:10):
Right compounding trauma exactly.
Speaker 3 (33:13):
And there is not a lot of studies that have
directly looked at all of those compounded effects, but we
can often unfortunately see them play out on our cell
phones from videos. Yeah, many of these changes also have
lifelong effects, and unfortunately we don't even have all that
much data on it. We have really clear data on
(33:35):
the profound effects of starvation during pregnancy on the fetus
and on growth of those babies thereafter. We don't have
as much long term data on the effects of malnutrition,
but there are at least some that like exposure to
severe malnutrition, especially in childhood, is associated with increased risk
of cardiovascular disease, hypertension, dysfunction of your glucose metabolism, and
(33:59):
cognitive and developmental delays right forever, forever. And you had
mentioned Aaron about treatment. Yeah, and it might sound like
treatment should be straightforward, right if the problem is lack
of access to food, get people access to food. Yeah,
it's nope, not that it's not straightforward, not straightforward for
(34:19):
a lot of reasons. Right, in the context of starvation,
both like acute food insecurity and more chronic food instability,
we do rely on food like that is the number
one thing, and a lot of times humanitarian programs and
things like that are going to rely on what's called
ready to use therapeutic food or RUTF, and this is
(34:43):
something that has been specially formulated based on studies to
try and hit at those most important nutrients. Right. We
have a good amount of proteins, we have all of
the essential amino acids. We've got micronutrients which are really important,
even though I didn't focus on them. In severe acute
malnutrition specifically, it's usually treatment with this like ready to
(35:05):
use therapeutic food and often a short course of antibiotics
if you've gotten to the point of meeting criteria for
severe acute malnutrition.
Speaker 2 (35:13):
Right. Yeah.
Speaker 3 (35:15):
And it used to be that the treatment of this,
especially like the most severe forms and in times of
crisis or famine, it used to rely almost entirely on
these like centralized treatment centers, which were almost always set
up by external you know, NGOs and nonprofits. But it
has really shifted for the better to more community based
(35:35):
care because A, that's going to get access to a
lot more people. B it's going to mean that caregivers
can stay, especially with their children and their other children
who might not be as sick as the ones who
need the most help. But there is always in areas
of like mass food insecurity and starvation, there will always
(35:56):
be people who are sick enough, whether from starvation alone
or the combination of starvation and infection or other underlying illness,
that they do need hospitalization. And that's specifically because of
a risk called refeeding syndrome. Yes, yeah, And basically this
is that as you rapidly increase nutrient intake when you've
(36:19):
been deprived for so long, your body switches from this
prolonged state of breakdown to all of a sudden being like,
we've got food we need to build up, so we
switch from what's called catabolism to ennabolism, so instead of
breaking down our body, we're building up storage. This leads
to a pretty huge surge in insulin secretion, because that's
(36:42):
one of our main hormones involved in storing energy during starvation.
It's not that we have absolutely no insulin, but our
insulin levels are incredibly low, and this is going to
stimulate the uptake and storage of glucose, which can result
in really severe high boglycemia in the case of prolonged
(37:03):
starvation because you don't have that much doors to begin with.
But it also because of the effects of insulin, stimulates
the uptake of a bunch of different electrolytes into ourselves.
It shifts electrolytes into our cells, including potassium, magnesium, is phosphorus,
and this can result in really dangerous electrolyte abnormalities that
(37:24):
can cause things like heart a rhythmias, seizures, respiratory failure,
and even death.
Speaker 2 (37:31):
How do we prevent that from happening?
Speaker 3 (37:33):
I mean, first it's monitoring, and then it's repleating those
electrolytes and the sugar if needed. How do we do
that by giving people that whether it's through iv or
through eating, so making sure that they're getting enough potassium,
making sure that they're getting enough magnesium and phosphorus, yeah,
and fixing.
Speaker 2 (37:52):
Those monitoring those levels essentially. I mean, I imagine that
would be very difficult to do in situations where you know,
there's already a lot, there's already eight is being blockaded
right e for instance.
Speaker 3 (38:07):
Well, and so many of the areas where we see,
especially like acute disasters, the healthcare infrastructure is not there either.
Yeah right, So yeah, So refeeding syndrome is a very
real risk if you are not able to identify it
and manage it.
Speaker 2 (38:25):
And those who are most vulnerable to refeeding syndrome. Are
those who are also at the most extreme of end
of malnutrition or can it really happen to anyone who's
been in a semi starved or like experiencing chronic hunger
for a while.
Speaker 3 (38:38):
Yeah, that's a really good question. You don't necessarily have
to meet criteria for severe acute malnutrition to be at
risk for refeeding syndrome. Okay? Is it is really this
prolonged risk? So often people might have meat criteria for
severe acute malnutrition, but not necessarily in order to potentially
have refeeding syndrome.
Speaker 2 (38:58):
Okay.
Speaker 3 (39:00):
Yeah, it's something we unfortunately see a lot actually in
the hospitals in the context of like restrictive food intake
disorders like inarexiaan and things like that. It's not uncommon
to see refeeding syndrome in those contexts as well. I
see and globally, millions millions of children face food insecurity,
especially in low and middle income countries. It is estimated
(39:23):
that at least ten percent of deaths in children under
age five globally are due to severe acute malnutrition, and
there are estimates as high as forty five percent of
deaths in kids under age five being at least in
part due to undernutrition, meaning it's a combination of their
(39:45):
susceptibility to infections and all of these other things as
a result of undernutrition.
Speaker 2 (39:50):
I mean, starvation is not just a simple lack of food.
Speaker 3 (39:54):
Correct correct right, right, especially, and we'll talk a lot
more about this next week. But so many of the
situations that we see kind of acute disruptions in food supply,
we also see displacement. We also see armed conflict. We
(40:15):
also see crowding. We also see lack of or dismantling of,
or disruption of clean water facilities, sanitation facilities. All of
those things are going to put people at higher risk
of the spread of infectious disease, and we know that
they are more susceptible to infectious disease. We see things
like outbreaks of diarrheal diseases, which can be very devastating
(40:38):
cause dehydration and electrolyte imbalance when you are already facing malnutrition.
And even when we talk about the global estimates on
kids who are affected by malnutrition or wasting, those estimates
tend not to capture the groups of kids and adults
(40:59):
who efface acute malnutrition because of things more acutely, like
natural disasters or conflicts, and these kind of more emergency situations,
those are often actually not reflected in the larger statistics
when we talk about the burdens of severe acute malnutrition,
which is grim. And we'll talk more about those acute
(41:20):
famine situations next week, but Aaron, can you tell me
a little bit more about how we learned what we
know about these effects of starvation on our bodies?
Speaker 2 (41:31):
I can tell you about one way we learned, Yes,
thank you. The brochure read will you starve that they
(42:04):
be better fed? More than four hundred people said that
they would. Of those, one hundred were interviewed and thirty
six were selected to participate in what would be known
as the Minnesota Starvation Experiment. So in nineteen forty four,
as World War II entered its fifth year, researchers in
Europe and the US grew increasingly aware of the dire
(42:26):
situation that was facing much of war torn Europe and
of the horrific and brutal conditions in Nazi concentration camps.
Millions of people who had gone months, even years without
access to enough food and clean water, adequate shelter, and
clothing and healthcare, leading disease to spread unchecked. People realized
(42:49):
that when this massive global conflict came to an end,
which seemed more and more likely as the months went by,
massive numbers of relief workers would be needed to deliver
food and resources in liberated cities and camps. But there
was no agreed upon plan for how best to distribute
these resources, like what and how much food to give
(43:12):
a starving city? What kind of food? In November of
nineteen forty four, after years of lobbying for funds to
study the effects of starvation, physiologist ansel Keys was finally
granted the opportunity to begin his study. He distributed those
pamphlets that say, you know, will you starve that they
be better fed. He distributed them to thousands of conscientious
(43:36):
objectors who, after being drafted into the war, had exercised
their right to refuse service for moral or religious reasons.
Side note, before I forget, I wanted to mention that
this is not this experiment is not ansel Keys's only
claim to fame, or even his biggest claim to fame.
He also developed k rations for American troops. So these
(43:58):
were these ready to eat non parish meals breakfast, dinner,
and supper, and that soldiers could carry around with them.
And there are YouTube videos of people trying these out
like today, like unboxing, and like reviews of the different
types of k rations like those are eighty years old.
I mean, I think they were also made up through
(44:22):
the nineteen fifties. I'm not sure. Don't quote me on that,
keeping it in the podcast anyway, Yeah, old. And he
also in addition to k rations, he along with his wife,
popularized the Mediterranean diet.
Speaker 3 (44:37):
I saw that too, I was like, wow, Keys.
Speaker 2 (44:41):
Keys Keys, Yep, he was kind of an influential guy
about that, I know. Yeah, But anyway, so Keys was
interested in starvation not only in terms of its effects
on the body and the mind, like what is actually
happening during starvation, but especially how best to feed someone,
to treat someone, to treat the starvation without causing further harm,
(45:03):
and also what while making efficient use of limited resources,
Like the resources were limited most of Europe was under
rationing anyway, And so he designed this experiment where he
took thirty six young healthy men and put them on
a semi starvation diet. And on this podcast, we are
(45:24):
I think fairly accustomed to thinking of the word volunteer
in quotes like, especially when it comes to early twentieth
century medical experiments, but in this case volunteer seems to
truly mean volunteer and al yeah, I.
Speaker 3 (45:41):
Feel like that sets this apart almost more than anything, absolutely,
that he did not experiment on people unwillingly.
Speaker 2 (45:50):
Right, Yeah, he didn't. Like he was really, I think,
very deliberate about what he was doing, as were the
men who participate. Like ansel Keys, was seemed truly motivated
by the desire, the passion to reduce suffering in people
around the world, and many of the men who participated
(46:10):
were later interviewed in like the early two thousands about
their experiences, and they all said that if given the chance,
they would do it again, which is I think that's like,
that's they were very proud of their contribution because I
think to be a conscientious objector during World War Two
it came with many complex emotions that some of the
(46:31):
men talked about. One man said, quote, you know, the
sense of not sharing the fate of one's generation, but
of sort of coasting alongside all of that. You couldn't
feel you were part of anything terribly significant in what
you were doing, end quote. And so this was kind
of their way of like contributing to the effort to
defeat fascism without compromising their morals.
Speaker 3 (46:54):
Which.
Speaker 2 (46:55):
Yeah. So the experiment started in November nineteen forty four
with a three month control period during which the men
all received a standard diet of thirty two hundred calories
of food a day or kill a calories. I'm just
going to say calories from this point forward, because that's
how we tend to think of calories today. Yeah, So
thirty started with three months thirty two hundred calories of
(47:16):
food a day. Some of the men, like I think
are the first hand account. Jim Graham, he actually needed more.
He was losing weight on that because he was quite
an active person anyway. Yeah. So then there began, after
those three months, a six month period of semi starvation.
So it started on February twelfth, nineteen forty five, And
(47:37):
this with the semi starvation, was a daily caloric intake
of roughly eighteen hundred calories a day. So there were
two meals a day, one at eight am and one
at six pm, except on Sundays, where they got I
think just one larger meal and the food tended to
reflect what the most impacted areas of Europe might be consuming,
(47:58):
so things like potatoes, turnips, brown bread, stuff like that. Breakfast,
for example, might consist of a small bowl of farina,
two slices of toast, a dish of fried potatoes, some jello,
a bit of jam, and a small glass of milk.
And initially the men were allowed to eat gum, but
that stopped after some of the guys were going through
(48:19):
like forty packs a day a day just for something
to like put in your mouth. Yeah, And the men
were also expected to walk twenty two miles each week,
and so this was and they had to like record
this I think, I actually don't know how they how
they tracked this, but the idea was that they would
be consuming fewer calories than they expended. So it was
(48:43):
supposed to be like a three thousand calorie expenditure daily
and they were only in taking eighteen hundred calories of food.
Speaker 3 (48:51):
So they had to remain active enough that that wasn't.
Speaker 2 (48:54):
Yes, yeah, yeah, but other than that, you know, their
movements weren't too restricted. There was a buddy system that
was instituted at one point, but they were given you know,
various administrative or housekeeping duties. They attended political science and
language classes as prep to become international relief workers when
this was over, and the goal was to have participants
(49:17):
lose two and a half pounds a week, which is
a lot, so that at the end of six months
they lost twenty five percent of their total body mass.
Everyone was routinely weighed, their strength and their endurance was tested,
blood was screened, other body measurements were taken, and they
were also routinely given intelligence and personality tests just to
(49:40):
kind of assess like psychological status. Interesting and results from
their weekly weigh in were posted at the end of
each week could cause tensions to run high. Some people
would just avoid it until they absolutely had to see
how much they were getting. It would determine how much
food you got to eat the following week. One of
the men, Yeah, one of the men, Daniel Peacock, recalls
(50:04):
that quote. We were given our food along a cafeteria line,
and if the guy ahead of you is given five
slices of bread, that's pretty hard to conceal, and if
you're only getting three, that's pretty touchy. End quote. They
were also all required to keep a journal to keep
track of their mental and physical progress, like you know what.
(50:25):
Some of the guys described how when they had to
cross the street, when they were like out on their walks,
they would wait until they encountered a driveway so that
they wouldn't have to step down or step up on
the curb because they were just had no energy. They
noted how they lost any sex drive whatsoever pretty quickly. Quote.
(50:47):
I have no more sexual feeling than a sick oyster,
wrote one man. Sick oysters. Yeah, and they became obsessed
with food. Quote. Eating became a ritual. Some people diluted
their food with water to make it seem like more.
Others would put each little bite and hold it in
their mouth a long time to savor it. So eating
(51:08):
took a long time end quote. There's a lot of
fascinating diary snippets that I encountered. So I'm going to
read you a few just from like a few of
the different months, because you can see sort of a
little bit of like the month by month. Yeah, month too. Quote.
I just don't have any desire to do the things
I should do or the things I want to do.
(51:28):
Instead of writing a letter, I read a newspaper. Instead
of studying, I read a pamphlet instead of cleaning. I
putter around, making excuses such as, well, I really won't
have enough time to do the complete job. I'll do
it later end quote. And then month two, I purchased
a tube of toothpaste yesterday, finally got around to using
it for the first time last night. Had a desire
(51:49):
to eat the paste, but controlled it. Month five, I
also found myself becoming senselessly irritable, particularly when I watched
some of the bizarre eating habits of others. One mixture
that came near flooring me was potatoes, jam, sugar, gingerbread,
all thrown into a bowl of oatmeal and used as
a sandwich spread. I hate to see guys picking around
(52:11):
with this or that to make a superb sandwich, all
the time letting their soup get cold. And Month six
stayed up until five am last night studying cookbooks so
absorbing I can't stay away from them, which might be
our first hand he did mention becoming like obsessed with cookbooks.
After the six months of semi starvation ended on July
(52:34):
twenty ninth, nineteen forty five, there was a three month
period of refeeding, the men had lost on average the goal,
which was a quarter of their body weight. Their hearts
had shrunk by almost seventeen percent, they beat a lot
more slowly, like, their pulse was a lot slower, blood
pressure dropped tremendously, they became anemic, their lung capacity had
(52:57):
decreased by thirty percent, and a few experienced pretty severe
neurological symptoms that had to be treated like separately. For
the refeeding portion, the men were placed into different treatment
groups based on caloric intake, protein levels, and supplemental vitamins,
and the men began to receive daily calories ranging from
(53:18):
two thousand to three thousand. But immediately, like in the
weeks that followed the refeeding, their weight continued to drop
kind of like, almost alarmingly, because the edema that they
had developed during the semi starvation portion had been disguising
just how much weight they had truly lost, And so
six weeks into refeeding, the group receiving two thousand calories
(53:43):
had only regained zero point three percent of the weight
that they had lost. Wow, And even the group that
was receiving the most calories, which was three thousand, had
regained after six weeks nineteen point two percent, and they
still complained of all the same things during the semi
starvation period edema, depression, exhaustion, aches and pains, a bottomless
(54:05):
pit of hunger. Apathy was a big one. Irritability and
mood swings. Calories were upped again. I think antel Keys
was like, why isn't anyone regaining any weight? And finally
that's when improvement seemed to be, like actual actually made
protein and supplemental vitamins at least in this experiment didn't
(54:26):
seem to make a difference. And the real lesson that
kind of emerged was that two thousand calories a day
was simply not enough for rehabilitation or at least like
rehabilitation on any sort of you know, timescale for people
of this body size and activity levels. They needed at
(54:46):
least four thousand calories. I feel like.
Speaker 3 (54:51):
That's so important because it just shows that, like when
you have been subjected to under nutrition for so long,
you can't just go back to like we think today
if two thousand calories as like a standard diet or whatever, right,
you can't just go back to You can't just have
the bare minimum your body has nothing, and it's going
(55:12):
to try and build that up and it's not going
to be able to.
Speaker 2 (55:15):
It's not going to be able to. Yeah, there's such
a recovery process. Yeah. And so when the experiment ended,
which was in November nineteen forty five, normalcy still hadn't
returned for any of the men. They were allowed to
at that point when they and then the twelve months
was all over, the men were allowed to eat whatever
(55:37):
and how much they wanted. Some began to eat ten
thousand calories a day because they just felt like they
will never they could eat a huge meal and still
feel hungry, just empty. Yeah. Others ate so much that
they had to go to the hospital because they would
be vomiting and it was Yeah, some had to be
treated for that. Food. Anxiety remained for with these men
(55:58):
for a very long time, and their bodies, you know,
their heart and their lungs took They took a lot
longer to return to baseline than anticipated. Within a few
months of the experiments, and Keys and his colleagues wrote
up a pamphlet to distribute to aid workers, and it
proved to be crucial after the war ended in delivering
(56:20):
appropriate aid and it's on the Internet archive. If you're curious,
I'll link to it. It went over physical changes, behavioral changes,
refeeding how to help people cope with what they had
gone through. There was a really interesting thing. This is
when like communal feeding areas were still like very much
a thing, and it would be like do not allow
people to stand in line, like it is incredibly demoralizing,
(56:42):
you know. There was like a lot of really interesting
and who knows how much of this was like from
the experiment or just like this is what we think,
but it was a really considerate sort of like what
is the mentality? Not just about food, but it was
like what these considering what these people have gone through,
a more empathetic approach to how can we relieve the suffering? Yeah. Yeah,
(57:07):
Also in nineteen fifty Keys published a two volume whopper
of a book titled The Biology of Human Starvation. It
was almost fourteen hundred pages. And yeah, I didn't read
any of that, but I'm sure it's out there. But
the Minnesota Starvation experiment was really groundbreaking for being among
(57:32):
the first to systematically study what happens to both the
body and the mind during long periods of semi starvation
and how to rehabilitate a starving person. It wasn't the first,
so there were a few actually that also happened during
World War Two. There was the Warsaw Ghetto hunger study
in nineteen forty two, which was kind of done surreptitiously,
(57:52):
and then there were studies in the Netherlands in nineteen
forty four to nineteen forty five. There was actually a
fair amount of starvation research. One author described world War
two as quote a cornucopia of starvation research, a wealth
of hunger end quote. Yeah. The Minnesota starvation experiment marked
(58:14):
a necessary and crucial step forward in our understanding of
how to deliver aid to victims of mass starvation. But
for many it came too late. World War Two in
Europe ended on May eighth, nineteen forty five, and in
Japan a few months later on August fourteenth, months before
(58:34):
the study ended, thousands of concentration camp survivors died of
refeeding syndrome in the weeks after the camps were liberated.
Could they have been saved if the study had started earlier,
I don't know. To me, the real question is why
wasn't there any interest in the effects or treatment of
(58:56):
starvation until this time, until World War Two. One English
officer remembered meeting with public health advisors in January nineteen
forty five, which was the month that Auschwitz was liberated. Quote,
it was frightening to realize how little any of us
knew about severe starvation in our lifetime. Millions of our
(59:16):
fellow men had died in terrible famines in China, in India,
in the USSR, without these tragedies having yielded more than
a few grains of knowledge of how best to deal
with such situations on a scientific basis. End Quote. The
opportunity was there, It had been there to come up
(59:37):
time and time again. Modern science existed. Western medicine simply
lacked interest or a sense of urgency in understanding this problem.
Maybe it was a little bit of hubrius mixed up
with a sense of superiority, like we've got our stuff
figured out, it won't happen to us.
Speaker 3 (59:53):
We don't have to worry here. Yeah, it's happening over there.
Speaker 2 (59:56):
Yeah. And so when starvation came to Europe, no one
really knew what to do, and it didn't come alone.
It rarely does. Starvation is just one component of a famine.
It rides alongside disease, fear, violence, despair, and a perpetual
sense of uncertainty, of not knowing when anything will end.
(01:00:21):
Things that can't and shouldn't be captured in a medical
experiment like the Minnesota starvation experiment. And I want to
end with a quote from a paper by Sharman apt Russell. Quote,
the Minnesota experiment itself did not reproduce the cold that
Europeans experienced in World War Two, the lack of fuel
(01:00:42):
for cooking food and heating the house, the lack of
warm clothes, the lack of shoes. It did not reproduce
the fear, the knowledge that you might die at any time,
that you might be humiliated or injured, or tortured or killed.
It did not reproduce the murder of a neighbor, the
corpses in the street, the inexplicable loss of human decency.
(01:01:04):
It did not reproduce the death of your son. End quote.
Famine is so much more than starvation, and starvation is
so much more than a lack of food. And so
that is kind of where I want to end things today,
so that next week that's sort of what we'll talk
about is like the bigger picture that encompasses all of this.
(01:01:27):
So yeah, yep.
Speaker 3 (01:01:30):
So make sure you tune in next week.
Speaker 2 (01:01:32):
Tune in next week. In the meantime, there's some sources
that we could share, so so many, so many. I
want to shout out just two in particular. There are
several more that will be on our website. But one
is by Sharman apt Russell, The Hunger Experiment, and that
another is by Calm and Semba titled They Starved so
(01:01:56):
that Others be Better fed, remembering Ansel keys and the Minnesota.
Speaker 3 (01:02:01):
I have quite a lot of papers. I also had
a book. I read a book, a few chapters of
a book called Hunger, The Biology and Politics of Starvation,
published in twenty ten. It was fine. It's like more
detailed than you need in all honesty, but it does
have some good just like overview parts of the biochemistry
(01:02:22):
and things. I really enjoyed a Nature Reviews Disease primer's
paper from twenty seventeen called Severe Childhood Malnutrition, and then
a couple of different there was an Annual Reviews in
Physiology the Comparative Physiology of Food Deprivation from Feast to Famine.
That one was really good for some of the biochemistry.
If you want details on biochemistry too, there's also a
(01:02:43):
Stanford has like a PDF of literally every biochemical like
metabolic pathway that's just kind of fun to go through
and see how they all interconnect in which ones you're
doing versus not doing at any given time. But we'll
post the sources from this week's episode in every single
one of our episodes on our website guest will Kill
You dot com under the episodes tab.
Speaker 2 (01:03:03):
We will thank you to Bloodmobile for providing the music
for this episode and all of our episodes.
Speaker 3 (01:03:10):
Thank you to Leanna and Tom and Pete and Brent
and Jessica and Mike and I'm sure I'm forgetting people
everyone at exactly great network.
Speaker 2 (01:03:20):
Thanks to you listeners for you know, listening, for tuning
in wherever you're tuning in however you are let us
know what you think. And a big thank you, of
course to our generous patrons. Your support really really means
the world to us.
Speaker 3 (01:03:35):
It does.
Speaker 2 (01:03:36):
Thank you well.
Speaker 4 (01:03:37):
Until next time, wash your hands, feelthy animals.
Speaker 2 (01:04:01):
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