This is a companion piece to the UCSD EDC2014 Review Part I so that those interested can review how the MinnieMaud Method lines up against these new evidence-based treatment approaches for restrictive eating disorders, specifically temperament-based treatment. Some of the material found within this post is an updated version with several new clinical data points of what is outlined in the blog post: I Need How Many Calories?!!
The MinnieMaud Method (the term I use for the science-based framework for recovery outlined here on Your Eatopia) is a temperament-based treatment approach. There are three facets to applying the MinnieMaud Method: 1) re-feeding, 2) resting and 3) brain re-training.
The re-feeding guidelines outlined in the MinnieMaud Method are a bit on the low side when compared to those found in evidence-based inpatient treatment settings. They reflect what energy balanced non eating-disordered age/height and sex equivalents eat on average to support daily energy requirements and those data are provided by doubly labeled water method clinical trial results, as no other measurement provides such unequivocal accuracy in reporting.
As my current database of searchable References on Your Eatopia is out-of-date (needing some 300 additional entries as well as a cleanup of some data entry errors in the existing 800 entries), I will actually provide the references below for this post until such time as I have updated the references section because this topic is such a difficult concept for many with restrictive eating disorders to accept, given a dominant culture that reveres undereating.
Calorie Needs for Everyone Else
We lie about what we eat. Yes, in health survey after health survey, adult women report eating on average just under 2000 kcal/day and men around 2500 kcal/day. i, ii, iii
And yet, when we actually measure the intake in laboratory settings rather than relying on self-generated food journals or survey responses, then we eat about one quarter to one third more than the surveys would suggest we are eating. And just in case the following quote is obscure— we are eating more than we say we do because our energy expenditures are actually higher. In other words, we are not overshooting our energy needs when we are eating a third more than we say we are eating.
“The measurement of dietary intake by self-report has played a central role in nutritional science for decades... Recently, the doubly-labeled water method has been validated for the measurement of total energy expenditure in free-living subjects, and this method can serve as a reference for validating the accuracy of self-reported energy intake. Such comparisons have been made in nine recent studies, and considerable inaccuracy in self-reports of energy intake has been documented. Reported intakes tend to be lower than expenditure and thus are often underestimates of true habitual energy intake. Because the degree of underreporting increases with intake, it is speculated that individuals tend to report intakes that are closer to perceived norms than to actual intake.” iv [emphasis mine]
“Social desirability and social approval distort energy intake estimates from structured questionnaires, in a manner that appears to vary by educational status.” v
Both 7-day or 14-day self-report trials are all over the map in the actual underreporting that occurs and many researchers will classify trial subjects as failed-dieters, obese, average-weighted etc. etc., which likely removes validity from the trial data as an inherent bias stands that obese individuals are more prone to underreport food intake— a bias that does not stand up under clinical trial scrutiny.vi And that bias fails to address other valid influences such as social desirability and approval as being strong motivators for the underreporting of food intake, as highlighted by Dr. Hebert and colleagues (quoted above).
The underreporting for both men and women can range from 2% to 58%. However, in the one and only doubly labeled water trial where two groups of women were identified as either non-restrictors or restrictors of food intake and all were weight-stable, the non-restricting group ate on average 2400 kcal/day and the restricting group ate just shy of 2000 kcal/day.vii Admittedly this is a small study, but I use it because it identifies a clear non-dieting control group.
If we average the studies reviewed by Dr. Hebert and his colleagues, then people eat on average 25% more than they think they do (or report that they do). As most adult women say they eat just shy of 2000 kcal/day, then on average they actually eat 2500 kcal/day to maintain their health and weight.
But the fact that we eat much more than we say we do does not have any causative effect on obesity onset or persistence. It only reflects the fact that our actual intakes match our energy expenditures. Doubly labeled water method trials are measuring actual energy expenditure and intake. A non-dieting subject, regardless of BMI, will naturally match her energy intake to her energy expenditure.
As a common research bias, we end up knowing more about male energy requirements under all manner of situations when compared to female energy requirements. We know that an 11-man sailing crew traveling around the world averaged 4700 kcal/day; six mountain climbers ascending above 19 000 ft. (6000 m) also required 4700 kcal/day; a short-term space flight equaled similar average intake as found on earth (2800 kcal/day); soldiers in Zimbabwe required 5600/kcal/day; and yet more soldiers on field operations in extreme cold and heat required 4300 and 3900 kcal/day.viii As a complete mind-bender, consider the fact that the astronauts were eating 2800 kcal/day and they all weighed 0 lbs. (0 kg) while doing so— in space you are weightless.
There is one trial that did include female cross-country skiers along with their male counterparts. The energy requirements for the female skiers were 3585 to 4827 kcal/day.ix
Urban Chinese adult women (age ranges 35-49) had energy intake levels confirmed at 2300 kcal/day. That their intake was somewhat lower than averages found in North America is not due to racial differences but rather a discrepancy in average height (lower in China compared to North America for that age range).x
Pregnant adult women require on average 2854 kcal/day in the first trimester, 3070 kcal/day in the second trimester and 3092 kcal/day in the final trimester.xi
The compilation of 22 studies indicates that adult women have an average confirmed intake of 2500 kcal/day, using the doubly labeled water method. The average confirmed intake for the adult men was 3400 kcal/day. However, the age range in this compilation for the females was 25 and older, whereas for the males it was 22 and older. Because males younger than around 25 will consume more (for developmental reasons), the average intake listed for males is a bit higher than for fully matured male adults (approximately 3000 kcal/day).xii
And all these data are for those over the age of 25. What does that mean for those between the ages of 12-24? The doubly labeled water trial method is the only way to be sure of what individuals actually consume to maintain health and weight and even then we struggle to tease out true non-restricting results from within those trials.
One lone doubly labeled water trial confirms that 12 to 18 year-old males and females who maintained weight during the trial had total energy expenditure requirements that averaged 3072 kcal/day.xiii
In the absence of actual data, we have to use studies of under reporting on this age group to extract likely energy requirements from there. It is worth noting that in an additional analysis of a representative cross-section of those who completed the French Étude Individuelle National des Consommations Alimentaires survey, 40% of the children ages 11 to 17 had attempted to lose weight in the past year and 41% wanted to weigh less, out of a total of 881 males and females assessed.
In the same study, children ages 3 to 10 underreported food intake by 4.8%, and those between ages 11 to 17 underreported by 26%. No significant differences were found between males and females in underreporting values, and no incidences of over reporting occurred for those aged 11 to 17.xiv
In one U.K. study where the survey results of 16-17 year old female dieters and non-dieters were compared, self-reported intake for dieters was 1604 kcal/day and 2460 kcal/day for non-dieters.xv Given that underreporting appears to occur to the same rate for 11 to 17 year olds as it does for their adult counterparts (see previous paragraph), we can extrapolate that non-dieting teenage girls actually eat an average 3047 kcal/day to support all their metabolic and developmental needs to arrive at biological adulthood at age 25.
Rather conveniently, 16 to 17 year old dieting and non-dieting males were also assessed for their self-reported intakes and male dieters stated they consumed 2190 kcal/day whereas non-dieters stated they consumed 3066 kcal/day.xvi As there are no distinctions between rates of underreporting for males and females in this age range, 16 to 17 year old non-dieting males actually eat an average 3833 kcal/day to support development to age 25.
And there you have it. Of course beyond those average intake amounts, there will be standard deviation from the mean on either side of approximately ±200-400 kilocalories, but the majority of energy-balanced individuals will eat the amounts listed.
However, none of the above data on actual required energy for various age- and sex-matched subgroups will apply to you if you have a restrictive eating disorder. These data apply only to energy-balanced individuals and those with restrictive eating disorders are energy deficient.
How Energy Requirements Play Out In Recovery
It is actually quite difficult to find good studies on successful energy intake for realizing remission, because the marker for success has predominantly been a target weight that is 90% of so-called IBW (ideal body weight). And IBW is always assigned as the body mass index (BMI) range of 18.5-24.9 where almost all subjects barely make it to BMI 20 during their weight restoration efforts.
Given that BMI only reflects the incidence of height over weight squared across human populations, there is no index range that is universally ideal. Only 4% of the adult female population will have naturally inherited a weight set point between BMI 18.5-20.9. Therefore we could be looking at a disproportionate number of subjects who are actively restricting and yet are clinically defined, for the purpose of the studies under scrutiny, as in remission.
In Dr. Evelyn Attia’s review of the current status of treatment for anorexia nervosa, she highlights that adequate re-feeding generally sits between 3000-4000 kcal/day.xvii Dr. Philip Mehler indicates that, depending on the treatment program, daily intake will peak between 3500-5000 kcal/day.xviii
In one study comprising 47 women between the ages of 18 to 25, the researchers wanted to determine whether food energy density and variety had any impact on the rate and/or robustness of remission from a restrictive eating disorder. That’s not a bad number of subjects in a field where we usually have very small numbers of participants. The researchers were able to determine that patients who ate higher density foods and a greater variety of foods had a longer duration of illness and yet realized higher rates of success (i.e. remission).
But wait, the devil is in the details. Their BMI levels at admittance into inpatient care were, let’s just say bordering on non-viable. Both groups (those who ate high density/variety and those who did not) dutifully restored weight to BMI 20 with almost no variation on either side of that marker. At 8-month follow-up for the high density/variety group and approximately 5.5-month follow-up for the lower density/variety group, the former group had a drop in BMI of 1.0 from their peak weight restoration, and the latter group had relapsed to halfway between peak and pre-admittance BMI points. The high density/variety group had a higher caloric intake but it was statistically not significant (as per the calculations performed within the study). The discrepancy was approximately 400 kcal/day on average more for the high density/variety group.
In real terms, high density caloric foods coupled with a greater variety of food choice slowed the rate of decline post treatment for the very short duration where subjects were still involved in the trial. In fact, only 9 of the original 47 completed the one-year follow-up. During the inpatient portion, the patients in both groups had their caloric intake slowly increased to a maximum of 3000 kcal/day. Once they had reached 90% IBW, in outpatient setting, then we see the slower rate of recidivism for those eating higher density foods and a greater variety of foods than those eating lower density foods and less variety as well.xix
To be fair, the lack of clinical evidence outlining actual energy requirements that reverse both weight loss and repair physical damage is likely due to an understandable emphasis on medical stabilization. Stabilization necessarily focuses on supporting weight restoration that does not result in straining the brittle body such that it leads to death. But IBW 90% is as meaningless a marker for identifying remission from a restrictive eating disorder, as is BMI for identifying health status in the population at large.
I think we could safely say that a good part of why remission rates remain lack luster is not only because treatment is “brainless”1, but also because treatment is still often foodless as well.
When young adult males were semi-starved (consuming 1570 kcal/day) for a mere three months, their re-feeding process involved ad libitum eating up to 10,000 kcal/day. In fact the initial post-starvation period return to their pre-study eating habits resulted in absolutely no weight restoration, and for many it caused further health (both mental and physical) deterioration.xx
The cumulative energy deficits that are average for those with active restrictive eating disorders are very rarely as low as 165 000 kilocalories and that was the estimated average cumulative deficit for the subjects in the Minnesota Starvation Experiment. A net energy deficit (combined energy expenditures and insufficient energy intake) of 1000 kcal/day for a mere six months generates a cumulative energy deficit of 180 000 kilocalories.
And we know that the restrictive eating disorder prodrome (the period during which active restriction is underway but the symptoms are subclinical from a severity point of view) is often active for 2 to 6 years before clinical symptoms might trigger external pressure on the patient to seek treatment. Like sleep deprivation, energy deficits are cumulative.
Even if we were to assume that the metabolic suppression that occurs to survive over the short term (during ongoing restriction of energy intake) does lower the absolute net energy depletion during a period of active restriction, the catabolic cellular destruction throughout the body is severe. Both weight restoration and physical repair require energy in excess of what is required by an equivalent non eating-disordered energy-balanced individual who maintains health and weight.
All this is by way of saying that the three pillars of the MinnieMaud Method are equal in importance. The temperament-based treatment, referred to as brain re-training within the MinnieMaud Method context, is as important as ad libitum (free or unrestricted) re-feeding, as is also resting to remove the risk of activity being used as a maladaptive behavior that still reinforces the misidentification of food as a threat.
In fact, in the absence of ad libitum feeding, a patient will have insufficient scaffolding from which she could practice and reinforce temperament-based treatment. I am not merely talking about the necessity for adequate energy to enable the brain to function. The behavior activation system (BAS: triggering approach behaviors) will never get a workout if re-feeding consists of frameworks that continue to reinforce the behavior inhibition system (BIS: triggering avoidance behaviors).
“Recover, but not too much,” applied during re-feeding, is not an approach that can be overcome through temperament-based treatment as a way to realize full remission. That is not to say that such an approach may not be very suitable when choosing to pursue harm reductive outcomes as a way to improve quality of life. And in fact many presentations at UCSD EDC2014 cover off excellent evidence-based approaches for harm reduction for those with severe restrictive eating disorders (please see subsequent posts in the UCSD EDC 2014 series on the Your Eatopia blog for more details).
To understand more about the distinguishing elements of remission vs. harm reduction, please see Remission accomplished: what does it signify?
1 Please see UCSD EDC 2014: Review Part I I am referencing Dr. Walter Kaye’s point that restrictive eating disorder treatment cannot remain brainless— meaning that focus on rest and refeeding alone does not realize robust remission rates.
i Health Canada, Statistic Canada, Canadian community health survey cycle 2.2, nutrition intakes from food (provincial, regional and national summary data tables), Vol.1, Revised March 31, 2008 and February 2009.
ii Public Health England, Food Standards Agency, National diet and nutrition survey: results from years 1-4 (combined) of the rolling programme (2008/2009 – 2011/12) Executive Sumary, p.11
iii National Health and Nutrition Examination Survey, Intake of calories and selected nutrients for the United States population, 1999-2000, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.
iv DA Schoeller, How accurate is self‐reported dietary energy intake? Nutrition reviews, Vol48 (10), pp.373-379, 1990.
v JR Hebert, CB Ebbeling, CE Matthews, TG Hurley, Y Ma, S Druker, L Clemow Systematic errors in middle-aged women's estimates of energy intake: comparing three self-report measures to total energy expenditure from doubly labeled water, Annals of epidemiology, Vol.12 (8), pp.577-586, 2002.
vi I Asbeck, M Mast, A Bierwag, J Westenhöfer, KJ Acheson, MJ Müller, Severe underreporting of energy intake in normal weight subjects: use of an appropriate standard and relation to restrained eating, Public health nutrition, Vol.5 (5), pp. 683-690, 2002.
vii RJ Tuschl, P Platte, RG Laessle, W Stichler, K-M Pirke, Energy expenditure and everyday eating behavior in healthy young women, The American journal of clinical nutrition, Vol.52 (1), pp. 81-86, 1990.
viii DA Schoeller, Recent advances from application of doubly labeled water to measurement of human energy expenditure, The Journal of nutrition, Vol.129 (10), pp.1765-1768, 1999.
ix AM Sjöjin, AB Andersson, JM Högberg, KR Westerterp, Energy balance in cross-country skiers: a study using doubly labeled water, Medicine and science in sports and exercise, Vol.26 (6), pp.720-724, 1994.
x M Yao, MA McCrory, G. Ma, Y Li, GG Dolnikowski, SB Roberts, Energy requirements of urban Chinese adults with manual or sedentary occupations, determined using the doubly labeled water method, European journal of clinical nutrition, Vol.56 (7), pp.575-584, 2002.
xi NF Butte, WW Wong, MS Treuth, KJ Ellis, E O’Brian Smith, Energy requirements during pregnancy based on total energy expenditure and energy deposition, The American journal of clinical nutrition, Vol.79 (6), pp.1078-1087, 2004.
xii LO Schulz, DA Schoeller, A compilation of total daily energy expenditures and body weights in healthy adults,The American journal of clinical nutrition, Vol.60 (5), pp.676-681, 1994.
xiii G Bandini, DA Schoeller, HN Cyr, WH Dietz, Validity of reported energy intake in obese and nonobese adolescents, The American journal of clinical nutrition, Vol.52 (3), pp.421-425, 1990.
xiv L Sandrine, M Touvier, M Balin, I Huybrechts, C Dubuisson, A Dufour, M Bertin, B Mair, L Lafay, Characteristics of energy under-reporting in children and adolescents, British journal of nutrition, Vol.105 (11), pp.1671-1680, 2011.
xv H Crawley, R Shergill-Bonnert, The nutrient and food intakes of 16–17 year old female dieters in the UK, Journal of Human Nutrition and Dietetics, Vol.8 (1), pp.25-34, 1995.
xvi H Crawley, C Summerbell, The nutrient and food intakes of British male dieters aged 16–17 years, Journal of Human Nutrition and Dietetics, Vol.11 (1), pp.33-40, 1998.
xvii E Attia, Anorexia nervosa: current status and future directions, Annual review of medicine 61, pp.425-435, 2010.
xviii PS Mehler, AB Winkelman, DM Andersen, JL Gaudiani, Nutritional rehabilitation: practical guidelines for refeeding the anorectic patient, Journal of nutrition and metabolism (2010), 2010.
xix JE Schebendach, LES Mayer, MJ Devlin, E Attia, IR Contento, RL. Wolf, BT Walsh, Dietary energy density and diet variety as predictors of outcome in anorexia nervosa, The American journal of clinical nutrition 87(no. 4), pp.810-816, 2008.
xx A Keys, J Brožek, AHenschel, O Mickelsen, H Longstreet Taylor, The biology of human starvation (2 vols), 1950.