Anorexia: Ketosis for Recovery

a excerpt expanded from Uncommon Testosterone (2025)

This post is expanded from my book Uncommon Testosterone (2025). It explores the intersection of metabolic dysfunction, eating disorders, and how the ketogenic diet accidentally became a pathway to healing for one woman I knew.

Uncommon Testosterone
CHAPTER 3
Sexual & Reproductive Health

Photo by Emiliano Vittoriosi on Unsplash

Anorexia Kills

Anorexia nervosa holds the dark distinction of being the deadliest of all mental health disorders. The state of willful, chronic starvation that is anorexia wreaks havoc on the gut microbiome (Bulik et al. 2019), the brain, and the central nervous system. It undermines the very physiological scaffolding on which psychological recovery relies, making anorexia notoriously difficult to treat.

Historically, rates of recovery from anorexia have been poor (Steinhausen 2002). Anorexics face a five-fold increase in mortality risk compared to the general population (Krug et al. 2025, Søeby et al. 2024) and it is particularly dangerous to adolescent girls. One study found an astronomical standardized mortality ratio of 21.7 among anorexic girls between 8–14 years old (Quadflieg et al. 2024), while a meta analysis revealed that 20% of individuals with anorexia nervosa diagnosis died by suicide (Arcelus et al. 2011).

One of the barriers to recovery from anorexia is the insidious nature of social incentive structures. Anorexia hides in plain sight—disguised as discipline, self-control, and perfection. Sometimes, even while the body is breaking down, the world applauds the resulting appearance. Among fashion models, ballerinas, and endurance athletes, anorexia is sometimes rewarded by praise and career opportunities from those who would exploit patient suffering for profit.

Cold plunging can sometimes be part of the problem. In one survey, over half of respondents with eating disorders reported intentionally using cold (like ice baths or cold showers) to promote temporary fat loss (Reas et al. 2019). While I’m a huge advocate for use of cold plunge therapy for treating mood disorders (e.g., van Tulleken et al. 2018), in the case of anorexia the results could be counter-productive.

The Metabolism of Cold Thermogenesis

Deliberate cold expsoure is nutrionally demanding. It initially activates the sympathetic division of the central nervous system, causing a fight-for-flight response, characterized by the gasp reflex, that causes the liver to release glycogen stores to increase blood glucose. That glucose provides energy to muscles in case of an emergency, like running from a predator. However, during whole body cold exposure, when no predator appears, the sympathetic response can yield to the parasympathetic. Known as the rest and digest response, parasympathetic activation is characterized by the dive reflex in which the heart rate and brain waves slow.

Cold thermogenesis, either by muscle shivering or by activating brown fat, requires energy to produce the heat necessary to defend core body temperature. Initially, that energy can come from the glycogen released by the liver. However, continuous glucose monitoring data from subjects in the ice bath shows those glycogen reserves can be depleted in less than two minutes. That’s why the body will also release into the bloodstream fat stored in white fat cells, so that fat metabolism can take over to fuel cold thermogenesis when the glucose metabolism is exhausted.

Continuous ketone monitoring data from a reader in the ice bath showed an almost instant spike in blood ketones when cold plunging. Because ketones are an intermediary product of fat metabolism, their presence during the ice bath indicates that cold thermogenesis is being fueled by fats. In fact, an ice bath is fastest way to stimulate production of endogenous ketones.

Ketosis heals

Medical professionals have long understood that the brain works better on ketones. For example, a ketogenic diet has been recognized as an effective treatment for epilepsy since at least the 1920s (Dietch et al. 2023). More recently, Dr. Chris Palmer has successfully employed a ketogenic diet to treat his psychiatric patients suffering from schizophrenia and anxiety (Palmer 2022).

New research has revealed that a ketogenic diet can help treat anorexia. In one remarkable case published in 2020, a 29-year-old woman who battled anorexia nervosa for over 15 years and had already failed multiple rounds of inpatient treatment began a strict ketogenic diet. She later received low-dose ketamine infusions under medical supervision. Within just three months, her symptoms went into full remission. She stabilized her eating habits, gained weight, and—most notably—her obsessive fears about food and body image disappeared. She maintained this recovery without relapse for more than a year (Scolnick et al. 2020).

A recent case series tracked three adult women with BMIs as low as 11–13—levels typically associated with extreme physiological risk. Each had long histories of anorexia nervosa that failed to respond to standard therapies. They were placed on a highly structured, animal-based ketogenic diet, rich in fat and protein but nearly devoid of carbohydrate. Over one to five years, all three achieved what researchers called multi-year remission. They gained 20 to 30 kilograms, restored their menstrual cycles, and reported profound improvements in mood, anxiety, and relationship with food. None relapsed during the follow-up period (Norwitz, Hurn, et al. 2023).

In five patients who had already restored their weight but still suffered from body image anxiety and anorexic thinking, a combination of a ketogenic diet and six ketamine infusions resulted in marked improvements in shape and weight concern, emotional regulation, and overall well-being (Calabrese et al. 2022). In two other case studies, women reported that a ketogenic diet followed by ketamine therapy silenced the “anorexic voice” that had tormented them for decades (Scolnick & Beckwith 2023, Scolnick 2017). Both experienced complete and lasting remission, leading to the hypothesis that ketogenic interventions plus ketamine modify glutamate metabolism in the brain that may be at the root of anxiety.

Because glutamate is the dominant exicatory neurotransmitter in the brain, excess levels of glutamate have been associated with anxiety disorders (Włodarczyk et al. 2020). Moreover, pancreatic abnormalities associated with Type 2 diabetes can be associated with glutamine abnormalities. Emerging evidence shows that patients with chronic pancreatitis (CP) and abdominal pain have structural and functional alterations in the central nervous system associated with excess glutamate in the cingulate cortex, a brain region involved in emotion, cognition, and pain processing (Hermens et al. 2020). Thus, therapies that modify glutamate metabolism in the brain, such as ketosis and ketamine, may support treatment of anorexia and reduce general levels of anxiety.

And it is in ketosis for recovery from anorexia that I have some personal experience.