GUARANA POTENTIAL TO PREVENT OBESITY

Guarana’s anti-obesity potential was the subject of a study that included researchers from UFRGS,  from the Universidad de la Costa, Colombia, and from the Federal University of Sergipe (UFS). From experiments with rats, scientists have proved that, in addition to preventing weight gain and fat accumulation, the plant can alleviate other conditions associated with obesity, such as insulin resistance. The results were published in the scientific journal Phytotherapy Research.

Rich in caffeine and with known antioxidant and anti-inflammatory properties, the extract from roasted guarana seeds has long been used as stimulant, aphrodisiac, tonic and also for weight loss. However, as the researchers claim that there was a lack of studies proving the supplement efficacy and security. “This extract is used in formulations (along with other compounds) for weight loss, but no one had proved the effect of this extract in its pure form,” says the study co-author Rafael Bortolin, professor at the Universidad de la Costa and collaborator at UFRGS Center for Oxidative Stress Studies.

During 18 weeks, 24 rats were fed with an ordinary western diet – developed by the group to induce obesity in the animals –, while another 24 consumed a low-fat control diet. Also, half of each group received guarana powder supplementation in a quantity that, if transposed to humans, would be equivalent to 300 milligrams per person per day.

According to Bortolin, the manufacturer of the guarana extract used in the research recommends a daily use of 1 to 3 grams, “however, we didn’t find scientific basis for this prescription. Also it is not easy to find out on the label what guarana is indicated for, but people in general use it because of its caffeine to feel alert and avoid sleepiness.” The use of guarana in these high doses, he explains, is to achieve a higher caffeine intake that keeps the user awake, similar to what happens whe we drink coffee. “The difference is that in order to lose weight, the use must be chronic, so it cannot be a high dose. Unlike a day when you have to study for a test and stay up all night, which is a momentary (acute) use when you can use a higher dosage.”

The scientists observed that guarana supplementation decreased weight gain and prevented excessive fat accumulation among animals fed with the Western diet. It also prevented other conditions related to obesity, as insulin resistance and dysregulation of adipokines – substances secreted by the adipose tissue, directly related to body fat distribution, and whose imbalance is associated with obesity and metabolic syndromes among other diseases.

After demonstrating guarana’s efficacy for the prevention and treatment of obesity, researchers began investigating its safety and possible adverse effects. “Many studies evaluating therapeutic potentials forget to evaluate the toxic potential of compounds (or extracts). We evaluated the toxic potential and identified no toxicity of guarana (in the concentration we used) in either the control group or the obese diet group,” explains Bortolin. It is important to emphasize, however, that effects of the excessive use of guarana were not studied. “It is quite possible that at higher doses it might exert some toxicity, because it has caffeine. Just as coffee can be toxic in high doses, so can guarana,” warns the researcher.

Finally, the mechanisms by which the substance acts to prevent weight gain were investigated. After verifying no quantity reduction of food intake, neither significant changes in the gut microbiota of the animals that consumed guarana, scientists analyzed changes in the brown adipose tissue – one of the two types of adipose tissue that we have in our body (the other is white).

While white adipose tissue has as its primary function the storage of energy, brown adipose tissue maintains body temperature and is the major site of thermogenesis in the mammals. Thermogenesis is a metabolic process that involves energy expenditure for heat production. A larger quantity of brown adipose tissue can, therefore, lead to a higher energy expenditure and, consequently, to weight loss.

“Thermogenesis is characterized by fat burning for heat production, instead of ATP [adenosine triphosphate, the molecule responsible for storing energy for the basic activities of cells]. It occurs because the mitochondria present in the brown adipose tissue have a lot of UCP, which is a protein that breaks down an electron gradient necessary for the production of ATP.  Thus, if we have a larger volume of this tissue, or if we have more mitochondria in this tissue, or if we have more UCPs in these mitochondria we can say that we promote thermogenesis, that is, we ‘activate’ the tissue,” explains Bortolin.

And that is what happened in the experiments. Guarana not only induced the expansion of brown adipose tissue but it also increased the number of mitochondria contained in it and the activation of proteins involved in the thermogenesis process. “It is known that the protein called by the acronym AMPK is related to energy expenditure and could contribute to the activation of brown adipose tissue. So, we investigated this protein and noticed that it was more phosphorylated (active) in the animals that consumed guarana. In addition, we also observed an increase in mitochondria number and UCP content. In summary, we saw that guarana was able to activate brown adipose tissue and we suggest that one of the mechanisms is via AMPK,” complements the researcher. It is worth reiterating, however, that this was an initial step. Tests on obese humans are still needed to confirm the study results.

Scientific Article

BORTOLIN, Rafael Calixto et al. Guarana supplementation attenuated obesity, insulin resistance, and adipokines dysregulation induced by a standardized human Western diet via brown adipose tissue activation. Phytotherapy Research, 13 mar. 2019.

CAFFEINE ICREASES FAT BURNING

The studies by David Costill in the late 1970s (2) showed that caffeine can increase the mobilisation of fatty acids from their stores. Fat is stored in several tissues but mostly in adipose tissues. The fatty acids are released from adipose tissue, can be transported to the muscle and be used as fuel. Some, but not all, studies show also an increase in fat oxidation with this elevation in fatty acids. However, it is not always true that an elevation in fatty acids levels in the blood also results in increased fat oxidation. This increase in fat oxidation was originally used to explain the performance benefits but it is now generally accepted that the increase in fat oxidation, does not spare muscle glycogen and improve performance. The performance enhancing effects of caffeine are predominantly through effects on the central nervous system.

New study finds increased fat oxidation with caffeine

The authors conducted a placebo controlled double blind study. Participants conducted two experimental trials. Before one of these they ingested 3 mg/kg of caffeine and before the other trial they ingested the same amount of a placebo. The capsules were ingested 1 hour before exercise. The participants (12 in total) exercised at fatmax intensity. This means that in an earlier test, the researchers had established the exercise intensity where these participants oxidised most fat. This is highly individual but on average was around 50% VO2max, a low-to-moderate exercise intensity.

During the hour of cycling, the subjects oxygen uptake and carbon dioxide production were measured and fat and carbohydrate oxidation were calculated from this. What the researchers found was an average total fat oxidation of 19.4 grams for the hour with placebo and 24.7 grams with caffeine. That is a whopping 27% more fat oxidation. They also found that there was no difference in energy expenditure and thus the increased fat oxidation meant that carbohydrate use was used (or carbohydrate was spared).

The researchers found an average total fat oxidation of 19.4 grams for the hour with placebo and 24.7 grams with caffeine. That is a whopping 27% more fat oxidation with caffeine.

Questions raised

The findings raise two questions. How does this relate to the rest of the literature, because we don’t want to make the mistake of drawing a conclusion on the basis of a single published study. The second question is what are the practical implications, if any?

The finding that caffeine can increase fat oxidation is not new. Several studies have shown this before, but it is important to realise that there are also many studies that did not see any effect of caffeine on fat oxidation. The different findings can at least party be explained by the exercise intensity used in the studies. A previous study by Juan del Coso’s research team (2) showed that effects of caffeine on fat oxidation could be observed at lower intensities but not at higher intensities (>80%VO2max).

There are other factors that could affect the outcomes as well, such as how trained the tested individuals were, the duration of the activity, the control of the diet before the trials and so on. But overall the findings of the study are in line with several previous studies and I would conclude that caffeine CAN in some situations increase fat oxidation. I was maybe a little surprised by the magnitude of change in this study, which seems a little greater than other studies. Of course, the effects may have been exaggerated by the fact that these studies were conducted in the fasted state (no breakfast), when fat oxidation is naturally high. As soon as we ingest a breakfast or eat carbohydrate, fat oxidation may be reduced by 30%. But the study is solid and well done and the authors need to be complimented. The issue is not the study, but may be the interpretation of the results by others.

Does it matter?

The million dollar question: does it matter? What are the practical implications of these findings? The authors are very careful not to speculate too much here. They just say that if people use caffeine for weight loss or for reducing body fat, they need to consider the negative effects of caffeine as well. I have seen social media reports who also linked the use of caffeine and the 27% increase in fat oxidation to weight loss. But let’s be clear: Weight loss will only occur when the energy expended exceeds energy intake. Caffeine did not increase energy expenditure, so you would still have to reduce intake to lose weight regardless of whether you burn more fat or not. The second observation is of course that even in this study where the effects on fat oxidation seem to be rather large, we are talking about a difference of only 5 grams of fat per hour of exercise. This means that in order to lose 1kg of body fat, one would have to exercise 200 hours!!

…..we are talking about a difference of only 5 grams of fat per hour of exercise. This means that in order to lose 1kg of body fat, one would have to exercise 200 hours!!

If an 80 kg person would like to lose 2% fat, it would take them a year, IF they exercised for an hour every day! So in terms of weight loss these findings are probably not important. Where the findings may potentially be important is that we stimulate fat oxidation more with caffeine, we therefore stress fat oxidation pathways more and we may adapt more. But how often would we need to do this in order to get significant adaptations that also translate to a performance or health effect? Without longer term studies such questions are difficult to answer.

References

  1. Ruiz-Moreno, C., Gutiérrez-Hellín, J., Amaro-Gahete, F.J. et al. Caffeine increases whole-body fat oxidation during 1 h of cycling at Fatmax. Eur J Nutr (2020). https://doi.org/10.1007/s00394-020-02393-z
  2. Costill DL, Dalsky GP, Fink WJ. Effects of caffeine ingestion on metabolism and exercise performance. Med Sci Sports. 1978 Fall;10(3):155-8. PMID: 723503.
  3. Gutiérrez-Hellín, J; Del Coso, J. Effects of p-Synephrine and Caffeine Ingestion on Substrate Oxidation during Exercise, Medicine & Science in Sports & Exercise: September 50(9): 1899-1906, 2018. doi: 10.1249/MSS.0000000000001653

TRIGLY-X STARVATION EXPERIMENT FORMULA

This formula was developed for a starvation study by a group of scientists researching body fat loss. Everything indicates that it was used for the “Starvation Experiment in Minnesota, United States” (1944).

The formula was kept secret during the experiment and was also not disclosed in subsequent reports. However, some time later, in an unknown way, the formula was leaked from the saved files of the experiment and later it was replicated for new studies related to the loss of body fat. In this way, TRIGLY-X is created.

In the first experiment, human studies were conducted where some volunteers ended up with anorexia, starvation and extreme thinness changing their eating behavior forever. The details of this experiment were not published until years later. The extreme starvation and fat loss of the participants is believed to have resulted from administering the TRIGLY-X formula. Until today the information about its creation is unknown and it is only known that the formula is really effective in eliminating body fat. It should be taken with extreme caution and responsibility, strictly following the directions on the package. CAUTION: DO NOT LEAVE IN REACH OF CHILDREN.

THE EFFECT OF (L-) CARNITINE ON WEIGHT LOSS IN ADULTS

Clinical evidence which investigated the effects of l-carnitine, a vitamin-like substance, on weight loss had led to inconsistent results. This study therefore aimed to examine the effect of l-carnitine supplementation on body weight and composition by including the maximum number of randomized controlled trials (RCTs) and to conduct a dose-response analysis, for the first time.

Methods and results: Online databases were searched up to January 2019. In total, 37 RCTs (with 2292 participants) were eligible. Meta-analysis showed that l-carnitine supplementation significantly decreased body weight [Weighted mean difference (WMD) = -1.21 kg, 95% confidence interval (CI): -1.73, -0.68; P < 0.001], body mass index (BMI) (WMD = -0.24 kg/m2, 95% CI: -0.37, -0.10; P = 0.001), and fat mass (WMD = -2.08 kg, 95% CI: -3.44, -0.72; P = 0.003). No significant effect was seen for waist circumference (WC) and body fat percent. The meta-analysis of high-quality RCTs only confirmed the effect on body weight. A non-linear dose-response association was seen between l-carnitine supplementation and body weight reduction (P < 0.001) suggesting that ingestion of 2000 mg l-carnitine per day provides the maximum effect in adults. This association was not seen for BMI, WC and body fat percent.

L-carnitine is an amino acid, it’s actually more of a vitamin-like substance that plays a number of roles in your body.  It’s formed in your liver and kidneys and made from two essential amino acids (lysine and methionine). Some medical professionals prescribe L-carnitine in supplement form to help support those with heart conditions, diabetes, erectile dysfunction, and other health conditions. But because of its role in fat metabolism, it’s best known for its ability to aid in weight loss, particularly when combined with a healthy diet and exercise routine.

L-carnitine plays an essential role in the transportation of fats to the mitochondria, where they’re converted to energy. There’s a whole lot of science to it, of course, but to keep it simple, we’ll put it this way: L-carnitine could very well be the answer to your weight loss dreams. Take a look below at 5 benefits of L-carnitine weight loss supplement and how it can help you shed pounds both directly and indirectly.

1. L-carnitine burns fat

With higher levels of L-carnitine, your body becomes more efficient at burning fat. Not only does this decrease the amount of fat that your body stores, but it also helps reduce visceral belly fat, the kind that surrounds your vital organs and potentially leads to fatty liver disease and other serious health conditions.

2. More energy during and after a workout

As your body’s capacity for fat-burning rises, so does your energy level. L-carnitine not only helps you increase the amount of fat burned with every workout, but you also get more energy for better workouts and an active lifestyle.

3. L-carnitine boosts your metabolism to help you lose weight

Taking that energy increase into your exercise routine will allow you to perform with more intensity, providing a boost to your metabolism. A more efficient metabolism significantly aids your weight loss program because you’ll increase the amount of calories you’re able to burn—even at rest.

4. Enhanced recovery from an L-carnitine injection

L-carnitine helps reduce the buildup of lactic acid in your muscles.  Muscle lactate buildup is responsible for pain and muscle fatigue after an intense workout. L-carnitine helps clear out the lactate so you recover more quickly and can get back to that fat-melting exercise that’s so central to your weight loss program.

5. L-carnitine aids the body’s immune system

In addition to the fat-burning and weight loss benefits of L-carnitine, it also aids the body’s immune system and functions as an effective antioxidant as well.  How does this connect to your weight loss program? Easy: The better you feel, the more likely you are to put on your gym clothes on and get your body moving.

It’s important to note that L-carnitine will not help you burn fat or lose weight if you don’t combine it with a healthy diet and exercise routine. If you’ve already established a healthy routine, but it doesn’t seem to be helping you shed pounds, L-carnitine lipotropic injections might be just what you need to help increase the impact of the work you’re already doing.

Conclusions: l-carnitine supplementation provides a reducing effect on body weight, BMI and fat mass, especially among adults with overweight/obesity.

Reference: Effects of l-carnitine supplementation on weight loss and body composition: A systematic review and meta-analysis of 37 randomized controlled clinical trials with dose-response analysis. Nasir Talenezhad, Mohammad Mohammadi, Nahid Ramezani-Jolfaie, Hassan Mozaffari-Khosravi, Amin Salehi-Abargouei. 10.1016/j.clnesp.2020.03.008.

THE STARVATION EXPERIMENT

To inform treatment, mental health providers often like to discuss research findings with their patients. It offers an opportunity for individuals to understand a providers reasoning for using a particular modality while eliciting change. For the treatment of eating disorders in particular, Garner (1997) recommends providing information from research or psychoeducation to individuals with eating disorders. It is suggested to be a core component of eating disorder treatment because it can act as a source of motivation and reduce defensiveness in patients (Garner, Rockert, Olmsted, Johnson, & Coscina, 1985). One of the most prominent studies used as a source of psychoeducation in eating disorder treatment is the Minnesota Starvation Study by Keys et al. (1950). Not only did it provide a wealth of knowledge about the psychological and physiological effects of starvation, a key component in anorexia nervosa, but it also offered insight into the rehabilitation/refeeding process. Discussing these findings helps our patients and providers understand the process of restrictive eating and how to implement adaptive refeeding. 

Origin 

During this time in history, starvation and other forced atrocities were occurring throughout Europe in World War II. It was clear there would be a critical need for a large-scale relief feeding (Keys et. al, 1950). As a consultant to the War Department and a professor of physiology at the University of Minnesota, Ancel Keys sought to explore how individuals would be affected physiologically and psychologically by a limited diet. Additionally and most importantly, he wanted to identify how he could best help these individuals in the refeeding process to provide postwar rehabilitation.  

What is the Minnesota Starvation Study? 

In November 1944, physiologist, Ancel Keys, and psychologist, Josef Brozek, conducted a study at the University of Minnesota to identify the best type of rehabilitation diet for individuals who had experienced starvation. In order to test types of refeeding, the researchers first had to conduct a study on semi-starvation. This additional exploration provided information about the effects of semi-starvation on the mind and body and offered significant insight into symptoms related to anorexia nervosa and bulimia nervosa.  

Recruitment Process 

To conduct this research, Keys et al. (1950) recruited thirty-six young, healthy men to participate in this almost year-long study. This was a difficult task due to many young men serving in the military at the time. Fortunately, there was a group of young men assigned to the Civilian Public Service in the United States and Keys received approval from the War Department to recruit from this sample. In order to participant in the study, individuals had to meet the following criteria: Must be in good physical and mental health; must be able to get along reasonably well with others; and must have a true interest in relief and rehabilitation. In order to have optimal motivation and cooperation in the study, the researchers believed that the participants needed to have a personal sense of responsibility in improving the nutritional status of famine victims. 

Study Activities 

Throughout the entire study, participants worked on tasks in the laboratory and were allowed to take university classes and participate in university activities.  Each participant was required to keep a personal journal of their daily lives within the study. The participants’ basic functions, body weight, size, and strength were recorded regularly. They were given psychomotor and endurance tests as they walked or ran on treadmills in their laboratory as well as intelligence and personality measures from psychologists (Keys et al., 1950). 

Phases 

The experiment was conducted in the following way: The first 12-weeks was a control period, the next 24 weeks involved semi-starvation, and the last 12-weeks involved controlled rehabilitation. An additional 8 weeks of unrestricted rehabilitation was held for twelve of the subjects. For 8 to 12 months following the starvation recovery, the study conducted follow-up examinations.  

During the first three months, the researchers observed and collected data about their participants’ normal eating behaviors. The participants ate food provided by a full-time cook and two assistants under the supervision of a trained dietitian. Each individual’s meals were adjusted to their body size in order to maintain caloric balance. They consumed around 3500 calories of food per day and were determined to have had an appropriate amount of nutrients and vitamins. 

For the following six months, the men’s diets were restricted to half of their normal intake to reflect the conditions of war in Europe. They were served two meals a day and ate approximately 1570 calories a day. As a result, they lost approximately 25% of their weight.  

For the final three months of the study, participants were refed and rehabilitated. They were divided into 4 groups and refed with different caloric amounts starting at a low quantity. A small group of subjects stayed for an additional 8 weeks and were fed an unrestricted diet. During those first two weeks of the unrestricted diet, each participant was allowed to choose their own meals and consequently ate between 7,000-10,000 calories per day.  

Results and Observations 

After reviewing and analyzing the data collected throughout the baseline, starvation period, and refeeding/rehabilitation period, notable changes were observed in physical, psychological, behavioral, and social aspects of the volunteers’ lives. Not only had the participants’ bodies’ gone through physical changes, but their psychological well-being had been impacted. 

Cognitive Differences. First, Keys et al. (1950) noticed a significant difference in the themes of the participants’ cognitions. Compared to the start of the study, the participants were far more preoccupied with food. Food and eating became focal points in conversations, reading, dreams, and even daydreams. For example, when they watched movies, the study’s participants were recorded commenting on the frequency of food and eating mentioned. Some volunteers developed concentration issues due to their preoccupation with food. Additionally, their interest in food expanded into new habits of reading cookbooks and collecting recipes (Garner & Garfinkel, 1985). Three participants even changed their occupations to reflect their extreme interest in eating and food: Three became chefs and one went into the agriculture field (Keys et al., 1950). 

Eating Changes. Second, Keys et al. (1950) observed changes in the participant’s baseline behavior. During mealtimes, participants were recorded becoming possessive over their food. Worried that others may try to eat their meals, they would guard their food defensively with their elbows. At meal times, participants were recorded eating all the food on their plates to the “last crumb” and “licking” their plates clean. Some even became upset when non-participants in the cafeteria “wasted” food.  

Moreover, those that enjoyed gum started chewing to excess. Gum-chewing became a health concern due to participants “rapidly” chewing 2-3 sticks at a time until their mouths became sore. The researchers had to place a cap on gum packages chewed per day to two. Others developed tobacco-smoking habits because it provided some relief from the hunger they experienced during the semi-starvation phase. 

During the rehabilitative phase, more eating behaviors developed. Men started eating “several” meals in one sitting and developed gastrointestinal upset and headaches as a result. They experienced difficulties in reading their own hunger cues. Participants described feeling hungrier and using binge-eating and purging behaviors during the refeeding period. Even after five-months of refeeding, they continued to use these behaviors and developed body image concerns. 

Behavioral and Personality Changes. Many were observed collecting food-themed items and even rummaging through garbage to find food. The participants developed an extreme distaste for wasting food. Such behaviors have been observed in individuals with anorexia nervosa (Crisp, Hsu, Harding, & Hartshorn, 1980). Similarly, participants used methods to create the illusion that they had more food on their plates than in reality. They started “toying” with their food, cutting it into small pieces, and making their meal consumption last for hours, which previously would have lasted minutes. There was also a remarkable increase in the use of spices and salt to add flavor to meals. Moreover, participants who had been mostly extraverted in their social life, became isolated and described themselves as feeling socially inadequate. Keys et al. (1950) also reported a decrease in the sex drive and interest of their volunteers. 

Emotional Changes. During the semi-starvation and the rehabilitative phases, participants were recorded developing new anxiety and depressive symptoms not present at the beginning of the study. Using the Minnesota Multiphasic Personality Inventory (MMPI), Keys et al. (1950) recorded significant increases on the Hysteria, Hypochondriasis, and Depression scales indicating increased anxiety related to somatic concerns and depressive symptoms. Especially during the semi-starvation period, some participants endorsed becoming more sensitive and argumentative with others. Over the first 6 weeks of the rehabilitation period, many men reported feeling even more depressed than the semi-starvation phase; especially those individuals in the rehabilitation group that were fed less calories in the beginning of the phase to test refeeding strategies. Keys et al. (1950) remarked that the only times these participants showed positive emotional reactions were in response to discussing their weight, food, or hunger. 

Physical Observations. Lastly, the participants’ physical changes throughout the experiment were significant. Not only had the participants’ weight changed during the different stages of the study, they started to experience new issues with gastrointestinal discomfort, dizziness, headaches, decreased need for sleep, edema, hair loss, and cold intolerance. Even their basal metabolic rate (BMR), or amount of energy in calories the body requires at rest, changed depending on the stage of the study. By the end of the semi-starvation period, the volunteers’ BMRs had decreased by 40% from their baselines. Keys et al. (1950) suggested that this was due to the low caloric intake which reduced the body’s need for energy. Additionally, in the semi-starvation period, the volunteers’ weight dropped by 25% and their muscle mass decreased by 40%.  

What does this all mean? 

Keys et al. (1950) originally explored optimal methods for the refeeding of individuals following starvation. In order to do so, the researchers had to conduct a study in which healthy participants were voluntarily semi-starved. As a result, Keys et al. (1950) discovered a wealth of knowledge pertaining to the detrimental effects of starvation and restriction to physical and psychological functioning. The men in this study were healthy physically and psychologically at the beginning of the experiment. Following semi-starvation, the participants developed symptoms similar to those of anorexia nervosa, bulimia nervosa, and binge-eating disorder.  

Understanding the findings from this study is important for several reasons. First, it may provide insights into why starvation may be reinforcing for some individuals. The description of the experience of extreme caloric restriction sounds aversive. Yet, it is possible that the food preoccupation that accompanies extreme caloric depletion is reinforcing in the sense that the individual struggling thinks less about other things that may be stressful – but seemingly less in the individuals’ “control.” In this way, the starvation of anorexia nervosa is functioning as a distraction or avoidance behavior. At the same time, this preoccupation may give individuals with anorexia nervosa the mistaken impression that there is not much that constitutes who they are other than restricting food – thereby making the prospect of recovery quite scary. Thus, understanding that this is an artifact of starvation can be very hope producing. Second, it may help parents have a greater understanding of some of the perplexing and sometimes frustrating behaviors that arise during the course of meal management (e.g., slow eating, shredding food). By appreciating that these are adaptations of starvation rather than overt acts of defiance, parents may be in a better position to understand the behaviors of their children.  

In summary, this study suggests that the act of restriction and extreme dieting impacts an individual’s physical, social, behavioral, and psychological well-being. To this day, the Minnesota Starvation Study is considered one of the most critical pieces of psychoeducation to share in the treatment of eating disorders.

By Chantal Gil, PsyD

References 

Crisp, A. H., Hsu, L. K. G., Harding, B., & Hartshorn, J. (1980). Clinical features of anorexia nervosa: A study of a consecutive series of 102 female patients. Journal of Psychosomatic Research, 24(3), 179-191. 

Garner, D. M. (1997). Psychoeducational principles in treatment. In D. M. Garner & P. E. Garfinkel (Eds.), Handbook of treatment for eating disorders (pp. 147-177). New York, NY, US: The Guilford Press. 

Garner, D. M., & Garfinkel, P. E. (1985). Handbook of psychotherapy for anorexia nervosa and bulimia. Guilford Press. 

Kalm, L. M., & Semba, R. D. (2005). They starved so that others be better fed: remembering Ancel Keys and the Minnesota experiment. The Journal of nutrition, 135(6), 1347-1352. 

Keys, A., Brozek, J., Henshel, A., Mickelson, O., & Taylor, H.L. (1950). The biology of human starvation, (Vols. 1–2). Minneapolis, MN: University of Minnesota Press.

Tucker, T. (2007). The great starvation experiment: Ancel Keys and the men who starved for science.Minneapolis, MN: University of Minnesota Press. 

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