Keys, Ancel et al. The Biology of Human Starvation. The University of Minnesota Press: Minneapolis, MN, 1950.

p. xviii

“It is interesting that the obese man or woman can be placed on a diet as low as 600, or even 400, calories without loss of body nitrogen or other ill effects and without depression of the basal metabolic rate. In these respects obese persons and persons of normal weight differ strikingly in their response to a low intake of calories.”

p. xix

“The basal metabolic rate in semi-starvation may fall as much as 50 per cent below normal standards based on energy exchange per square meter of surface area.”

p. xxiii

“And, whether the origin is primary or secondary the presence of undernutrition makes a special kind of person, different morphologically, chemically, physiologically, and psychologically from his well-fed counterpart.”

p. 15

“In the individual the severity of clinical edema is not by itself a reliable guide to his nutritional state. Where the complications of malaria, dysentery, anemia, and vitamin deficiencies exist, the edema appears more readily and in more extreme form.”

p. 23

“The substantial improvement of the diet in 1943 was paralleled by an epidemic incidence of hypertension.”

p. 40 – Table showing before and after recovery weights. Differences ranged from .7 kg above starting to 7.2 kg above starting.

p. 45

“The increased sensitivity to cold was evidenced in several ways in addition to the subjective reports: nearly all the men wore heavier underclothing and overclothing.”

p. 55

“…the red blood cell count dropped from a pre-starvation level of 5.52 to 4.45 million per cu. Mm. during semi-starvation, and the hemoglobin value from 87 to 81 per cent.”

p. 62

“The men were commonly found to be somewhat irritable during the semi-starvation period. All the subjects reported a distinctly decreased sex interest and a reduced frequency of erections while on the restricted diet.”

p. 78

“Extremely high food intakes – as high as 7000-10,000 Cal. per day – were achieved by most of the subjects during the first 2 weeks of ad lib eating, but the intakes tended to level off at more reasonable values of about 3200 to 4500 Cal. per day.”

p. 87

“According to this report the average actual caloric intake in 44 factories in the Tokyo area steadily declined from a level of 3012 Cal. daily in 1938 to an average of 2301 cal daily in 1943. But over these same years the average body weights of the men in these factories declined only .80kg and the women workers gained an average of .45 kg.”

p. 119

“During the first week of uncontrolled rehabilitation (R13) the individual intakes varied from 4400 cal to 5800 cal, with the week’s average of 5219 cal per man per day. Some of the men commented that they were still hungry at the end of the very large meals, even though they were unable to ingest any more food. All of the men ate snacks between meals and in the evenings.”

p. 127

“At R58 the body weight had returned close to the control value while the body fat, on the percentage basis, remained slightly elevated.”

In the undernutrition experiment carried out by Benedict et al. the weight increased very rapidly on the termination of the reduced diet. Six weeks later the men not only regained all the weight lost but exceeded their pre-experimental weight by 3.1 kg.”

p. 128

“…they had very low resistance to eating snacks between meals. Some men had eaten a large meal; subject No. 27 commented at the end of R13 on having ‘an odd sensation of being full yet still hungry.’”

p. 129

“In refeeding, especially when the caloric intake is high, fat deposits tend to increase at a faster rate than the ‘active’ tissues.”

p. 177

“During the subsequent 8 weeks there was further increase in the body fat which brought the fat content of the body in all subjects well above the pre-starvation level. Thirty-three weeks after the end of the semi-starvation period the values for body fat showed a decrease and returned to a near normal level at 58 weeks.”

p. 179

“Anthropometric data support this conclusion and indicate that during rehabilitation the adipose tissue increased in size more rapidly than the muscles. In the highest caloric group the circumferences of the upper arm, calf, and thigh showed an average recovery of 45, 46, and 54 per cent of the starvation decrement, whereas the abdominal circumference exhibited a recovery of 101 per cent [at week 12 of refeeding].”

p. 212

“The evidence is quite consistent that the human thyroid atrophies during starvation.”

p. 217

“Chakrabarty, in a study of famine victims in India, found the islet cells fewer in number than normal and foamy in structure.”

p. 240

“Two reports from Japanese prison camps have indicated that during the periods of serious food restrictions most cases of acne disappeared. After liberation, when the food intake was restored to normal, the acne returned to its pre-starvation form.”

“Ivanovsky reported that the hair grew slowly, fell out prematurely, and rapidly became gray. The growth of the nails was retarded.”

p. 242

“The dry and scaly skin was probably an expression of an altered skin metabolism as a result of a decreased blood flow through the skin. There was indirect evidence that the blood flow through the skin had been decreased during semi-starvation.”

p. 243

“About a third of the subjects remarked that their hair was falling out at an abnormally rapid rate.”

p. 256

“The evidence is overwhelming that anemia develops during prolonged periods of caloric restriction, and the degree of anemia appears to be related to the extent of starvation…The anemia… is not of the iron deficiency type.”

p. 258

“…evidence indicates that a mild leucopenia with a relative lymphocytosis develops.”

p. 267

“A definite leucopenia developed during semi-starvation; the leucocyte count, which was 6346 per cu. Mm. of blood in the control period, dropped to 4129 at S24, a decrease of 34.9 per cent.”

p. 291

“If our calculations are approximately correct, there remains the question as to how much of the reduction in metabolism can be accounted for by the lowered body temperature of the starving organism.”

p. 333

“After 12 weeks of controlled rehabilitation on restricted food intakes, the men in the Minnesota Experiment were allowed to eat what they would. The result was a large increase in food intake, a sudden gain in weight, and an abrupt rise in B.M.R. In some cases the B.M.R. change was startling. For example, subject 126 used 153 cc. of oxygen per minute in basal rest on October 17 and 265 cc. on October 24. October 20 was the last day of restricted feeding, so the rise from 153 to 265 cc. of oxygen per minute occurred in 3 days. In this period of 3 days the subject gained 6 pounds and the basal pulse rate rose from 36 to 60.”

p. 338

“In the Minnesota experiment the total rate of basal metabolism at the end of semi-starvation was almost 40 per cent less than in the control period.”

p. 346

“Schenk claimed that daily intakes of 320 gm. of protein and 7300 cal, as observed among the Olympic athletes, are essential for hard manual work or strenuous exercise.”

p. 359

“In general, at diets of 3000 cal or more, nitrogen equilibrium can be maintained at an intake of 40 gm. of protein or less. At diets below 3000 cal, nitrogen balance is harder to obtain, even at higher nitrogen intakes.”

p. 365

“…spontaneous reduction of physical activity is one of the most prominent features of semi-starvation.”

p. 380

“A more detailed study (Evans and Strang, 1931) was performed on 5 patients with an average initial weight of 157.5 kg. They received first a maintenance diet of 2413 cal containing 69 gm. of protein, which was sufficient for nitrogen equilibrium. On the reducing diet, which contained 59 gm. of protein, 10 gm. of carbohydrate, and 7 gm. of fat, totaling 335 cal., a nitrogen loss occurred, but this was amazingly small (2 gm. of nitrogen in 5.5 weeks). The addition of only 20 gm. of carbohydrate (increasing the total caloric intake to 445 cal. per day) brought these patients into nitrogen equilibrium at an excretion level of 0.15 gm. of nitrogen per kg. of ‘ideal’ weight. Nitrogen equilibrium was maintained in one patient for 260 days, during which time there was a total weight loss of 67.1 kg.”

p. 381

“The loss of fat produces no untoward symptoms such as accompany the weight loss of normal subjects during semi-starvation. Furthermore, no decrease of the B.M.R. below normal standards has been reported in obese patients during the period of weight reduction.”

p. 518

“The behavior of calcium is more difficult to interpret since it tends to be excreted throughout a starvation period at a rate which may be of the order of 10 times that calculated on the basis of the body tissue lost.”

p. 545

“To test this, he reduced his own food intake by one half for 5 days and then for an additional 3 days went completely without food. The increase in his blood sugar level following glucose was much greater after the starvation period than before. Sevringhaus observed the same thing after 2 days of starvation.”

p. 546

“Because of the high fat diet of the Eskimos, Heinbecker studied their glucose tolerance curves both before and after 82 hours of fasting. The basal blood sugar during the starvation decreased from 110-120 mg. per 100 cc. to about 80 mg. The glucose tolerances after the ingestion of about 2 gm. of glucose per kg. of body weight were normal in the control period. After 3.5 days of starvation the glucose tolerance showed blood sugar levels close to 300 mg. per 100cc. These returned only very slowly to normal.”

p. 578

“Along with the increased water consumption, starving persons tend to have a marked salt hunger and will consume several times the normal quota of salt if it is available.”

p. 579

“In some animal forms, at least, chronic undernutrition prolongs the natural life span. It has been suggested that the natural life span is fixed, not in time, but in terms of total metabolism or some function of the rate of living. But in man severe undernutrition makes him look, feel, and act prematurely old. There are also changes in basal

metabolism and in sexual function which resemble those produced by age. What is the long-range effect on physiological age and on longevity of the individual?”

p. 581

“…the starving man is weak and cold, both physiologically and subjectively, and his behavior bears this out. On the other hand, his behavior is often misleading. He acts dull and insensitive; he looks and behaves as though he were unaware of or incapable of feeling many of the ordinary stimuli of sound, sight, or touch.”

p. 585

“…in a number of cases among the women the decline in metabolic rate was disproportionately great; only small losses in body weight sufficed to produce large declines in metabolism among these women.”

p. 607

“In any list of the cardinal signs and symptoms of severe undernutrition there will be several items which pertain directly or indirectly to the heart and circulation. These include bradycardia, hypotension, a lowering of the skin temperature, and frequently vertigo and slight cyanosis.”

“Rates as low as 30 to 40 beats per minute were often observed in bed rest…”

p. 612

“The complaint of coldness is very common among undernourished people, and the skin has often been reported as cold to the touch. This might, of course, be attributed to the general reduction in body temperature which is usually observed. Leyton found the average 4 p.m. temperature in 100 men to be 35.7 C (96.3F). But the suggestion that the peripheral circulation is diminished is also supported by the pallor of the skin which is out of proportion to the slight to moderate anemia usually present.”

p. 613

“In 40 persons who received subcutaneous injections of 1 mg. of adrenalin there was extraordinarily little response to the drug.”

p. 620

“Before the war patients with hypertension accounted for about 10 per cent of all admissions to the Therapeutic Clinic of the Pavlov First Medical Institute. This proportion dropped during the period of semi-starvation and increased progressively thereafter through 1943. In January 1943 patients with hypertension constituted 20 per cent of the admissions, and by June of that year the figure had risen to 60 per cent.”

p. 621

“Obviously, many factors may have been involved in this epidemic of hypertension in Leningrad, but the outstanding peculiarity of the period was severe semi-starvation for 6 months, followed by refeeding, with the necessity for hard work at all times.”

p. 638

“An almost universal complaint among the subjects in the Minnesota Experiment was some degree of faintness immediately after standing up from a chair or bed.”

p. 659

“The decrease of the QRS and T wave amplitudes is probably the most remarkable change in the electrocardiogram in starvation. It may be due to the following factors:

1) Decrease of heart size. The decrease of the amplitudes was accompanied by a very marked decrease of the heart size as determined by teleroentgenograms…

2) Myocardial degeneration…

3) Rotation of the heart around a transversal axis…

4) Decreased metabolic rate…

5) Fluid accumulation in chest or pericardium…”

p. 664

“Polyuria and nocturia have been reported by practically every observer of starvation conditions.”

p. 740

“The important question of what part of the respiratory-cardiovascular system was principally responsible for the poor delivery of oxygen to the working muscles cannot be answered directly. The low concentration of hemoglobin at the end of the semi-starvation period undoubtedly contributed to the poor muscular oxygen supply.”

p. 753

“Jaworski found no changes in the vagina in starved Polish women but concluded there was considerable reduction in the size of the ovaries.”

“The majority of investigators have agreed that the testes are reduced in size in semi-starvation, the average percentage change being rather similar to that of the body as a whole.”

p. 755

“The excretion of total, neutral 17-ketosteroids for the 5 men studied after 8 weeks of semi-starvation averaged 7.9 mg. per 24 hours. This is considerably below the mean excretion level of 11.3 mg. observed for normal young men…”

p. 762 – Sperm were motile for an average of 4.8 hours at S24 vs.25.5 at R20

p. 777

“The official daily ration in the Auschwitz concentration camp was one liter of watery soup, 250 gm. of bread, and about 25 gm. of margarine or sausage or imitation honey, providing an estimated maximum intake of 1000 cal. per day.”

p. 797

“Constipation was mentioned as one of the semi-starvation symptoms, bowel movements being reduced from once a day to one or two times a week.”

p. 833

“Food in all its ramifications became the principal topic of conversation, reading, and daydreams for almost all Minnesota subjects. When they read books or attended movies, they were much impressed by the frequency with which food and eating were mentioned. Cookbooks, menus, and information bulletins on food production became intensely interesting to many of the men who previously had had little or no interest in dietetics or agriculture.”

p. 834

“A few planned to become cooks. Halfway through starvation 13 out of 34 men mentioned cooking among their plans following completion of the experiment. The men who took part in Greely’s expedition of 1881 and suffered from prolonged semi-starvation in the Arctic had similar ideas. In the diary entry for November 24, 1883, Brainard wrote: ‘Fredericks is going to run a saloon in Minneapolis. Long wants to open a restaurant at Ann Arbor. Jewell thinks he would like to run the grocery in Ralston’s colony.’”

p. 827-828

“The subjects reported that their nails grew more slowly and that their hair was falling out in large amounts. Shaving was necessary less frequently. The men noted, particularly in shaving, that cuts and wounds bled less than normally and were slower to heal. Physical ability to laugh heartily, sneeze, or blush was reduced or absent during the later stages of semi-starvation. Muscle cramps and particularly muscle soreness were frequently reported. The jarring of knee joints, especially when walking on hard pavements, was an annoyance to some. Pigmentation, thinning, and roughening of the skin occurred. Changes in the sensitivity of the skin, paresthetic and hypesthetic in character, were observed in only three cases, but there were many complaints that the extremities ‘went to sleep.’

Tolerance to heat was increased; for example, subjects could hold hot plates without discomfort. They asked that their food, coffee, and tea be served unusually hot. Conversely, cold temperatures were poorly tolerated. Complains of being cold or of having cold hands and feet were frequent and persistent. In hot summer weather many of the subjects slept under heavy blankets and wore extra clothing during the day. Vertigo, giddiness, and momentary blackouts were experienced on rising from lying or sitting positions by almost all the subjects during the first months and by some subjects throughout the semi-starvation period…

Objective tests revealed no impairment of visual acuity but many subjects complained of transient visual disturbance such as inability to focus, eye-aches, and ‘spots’ before their eyes. Standard measurements of hearing showed a slight but consistent increase in auditory acuity during the period of semi-starvation. It is difficult to determine whether the frequent complaints that ordinary sounds and noises were disturbing and annoying had a direct physiological basis in the ‘improved’ auditory sensitivity or were primarily signs of an increased irritability. Sensations of ringing in the head were primarily signs of an increased irritability. Sensations of ringing in the head were reported. Except for hunger pains and some decrease in the frequency of bowel movements, gastrointestinal symptoms were rare.

The marked decreases in pulse rate and basal metabolism may be regarded as critical indicators of a lowering of speed in the automatic functions of the body…

The marked reduction in strength and endurance was paralleled by a general curtailment of self-initiated, spontaneous activities… They described their increasing weakness, loss of ambition, narrowing of interest, depression, irritability, and loss of libido as a pattern characteristic of ‘growing old…’

During rehabilitation the recovery from dizziness, apathy, and lethargy was most rapid. Tiredness, loss of sex drive, and weakness were slow to improve. Although visible edema tended to disappear, in some men there was little change or even an increase in edema. Cramps, vague aches and pains, and paresthesias were unrelieved from some time. Some of the men had new complaints such as flatus, distention, belching, and stomach-ache. Those subjects who gained the most weight became concerned about their increasing sluggishness, general flabbiness, and the tendency of fat to accumulate in the abdomen and buttocks. At the end of 3 months of rehabilitation, even in those subjects who were maintained on the highest caloric intake the over-all physical condition was considerably inferior to the pre-starvation status. Later reports from the subjects indicated that it was not until after an additional 3 months of ‘normal’ living and supernormal eating that their physical capacity approached pre-experimental levels.”

p. 835

“Satisfaction was also obtained from consumption of coffee and tea, both of which were used in large quantities, presumably for their pharmacological as well as their filling and warming effects. It was generally reported that coffee and tea provide a ‘lift.’ Because some of the men increased their consumption to 15 or more cups daily, it became necessary to limit all subjects to a maximum of 9 cups per day… Heavy gum chewers would take 2 or 3 sticks at a time, chew them until the sweet taste was gone, discard them, and then replace them with fresh sticks in chain fashion. One of the men chewed up to 40 packages of gum per day and developed a sore mouth from such continuous exercise. Thereafter, the use of gum was restricted to 2 packages a day.”

p. 836-837

“Social initiative especially, and sociability in general, underwent a remarkable change. The men became reluctant to plan activities, to make decisions, and to participate in group activities. Their earlier active interest in having a voice in the making of policies and rules for the conduct of the non-scientific aspects of the experiment dwindled. They spent more and more time alone.”

p. 839

“Sexual feeling and expression declined in the Minnesota Experiment until by the end of the semi-starvation period they were virtually extinguished in all but a few subjects. The diminution of the strength of the sex drive was so dramatic that the subjects were struck by the change and used colorful language to describe it.”

p. 846

“During… (R13), of 17 men who made a reference to food cravings, 7 had no specific cravings. The remaining 10 men had a predilection, in about equal proportion, for sweets (ice cream and pastries) and dairy products.”

pp. 852-853

“I’m cold… I’m weak…And now I have edema…Social graces, interests, spontaneous activity and responsibility take second place to concerns of food… I don’t like to sit near guests, for then it is necessary to entertain and talk with them… I am one of about three or four who still go out with girls. I fell in love with a girl during the control period but I see her only occasionally now. It’s almost too much trouble to see her even if she visits me at the Lab. It requires effort to hold her hand. Entertainment must be tame. If we see a show, the most interesting part of it is contained in scenes where people are eating. I couldn’t laugh at the funniest picture in the world, and love scenes are completely dull… Now, eight months after the end of starvation, I am fat and healthy although my muscles have not yet returned to their former tone.”

p. 859

“As semi-starvation progressed in the Minnesota Experiment, complaints of inability to concentrate for any period of time and of difficulty in developing thoughts became numerous.”

pp. 864-865

“There was a statistically highly significant increase in scores on the scales of social introversion, depression, and cycloid tendencies (emotional instability) and a decrease in those on the scales of ascendancy (social leadership), self-confidence, and freedom from nervous tenseness.”

p. 880

“In four subjects the reaction to the semi-starvation regimen took the form of a ‘character neurosis,’ the men being unable to stay on the semi-starvation diet; in two of these subjects the response to the stress was particularly violent and bordered on a psychosis. One man developed a hysteroid reaction that led to self-mutilation.”

p. 968

“At equal degrees of weight loss, anorexia nervosa patients are similar to famine victims in numerous respects: the pulse is slow, averaging about 50; the blood pressure is low, rarely above 120 mm. Hg. Systolic; amenorrhea is almost universal. The basal metabolic rate is reduced to an average of -30 per cent, but values down to o-73 per cent have been obtained…The body temperature is low…”

p. 978

“It has been repeatedly demonstrated in many species of laboratory and domestic animals that certain types of congenital malformations frequently appear in the offspring as a result of maternal nutrition deficiencies.”

p. 979

“Burke et al. observed a correlation between the adequacy of the maternal diet and the pediatric rating of the offspring. Almost all the cases of congenital defects were found among the infants born to mothers whose diet during pregnancy had been severely inadequate.”

p. 1003

“There is reason to believe that the epithelial lining of the gastrointestinal tract becomes more permeable to microorganisms in severe undernutrition. The morphological changes in the intestinal tract would strongly suggest this.”

p. 1041

“There is a fundamental connection between obesity and diabetes. Kisch found that 50 per cent of all the obese persons he examined exhibited some degree of glycosuria.”

p. 1042

“It is proper to suggest that obesity, which first may only resemble diabetes superficially in a tendency to produce glycosuria and abnormal sugar tolerance tests, may slowly produce irreversible changes, even though weight reduction may correct the glycosuria temporarily. Allen supports the general clinical impression that in obese persons in whom glycosuria disappears during dietary reduction, true diabetes is very apt to appear later.”

“Mahaux and others have concluded that there was a real increase in diabetes morbidity in Germany immediately following World War I, and that this was associated with an increased food intake following a period of undernutrition.”

p. 1048

“For many years it has been generally believed that yeast may be beneficial to diabetics. The insulin requirement of depancreatized dogs is increased on a diet definitely deficient in B vitamins, and this extra defect may be corrected either with yeast or with a mixture of B vitamins.”