Treat Anorexia With Ketosis
- Thomas P Seager, PhD
- 4 days ago
- 15 min read
Updated: 1 day ago
Fix nutrition before undertaking ice baths
Summary
Anorexia is the deadliest of all mental disorders. 20% die by suicide.
The anxiolytic effects of the ketogenic diet may allow people with anorexia to meet their minimum nutritional needs without activating the negative emotions associated with feeding.
The diet discipline that people with anorexia display may help them comply with ketogenic requirements where others fail. In this way, restrictive eating may be the superpower that saves the anorexic, despite advice from Eating Disorders Anonymous groups that discourage such discipline.
While an ice bath is the fastest way to stimulate production of endogenous ketones, I recommend a ketogenic diet prior to cold plunge therapy for recovery from anorexia.
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). People with anorexia 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 an 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 exposure is nutritionally 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. It also fuels cold thermogenesis, either through muscles shivering or activation of non-shivering thermogenesis in brown fat.
Thermogenesis 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, as i wrote in Ice Bath for Type 2 Diabetes, continuous glucose monitoring (CGM) 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 (CKM) 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, as I wrote in Ice Bath for Fast Ketosis, 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—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.
It is in ketosis for recovery from anorexia that I have some personal experience.
Metabolic Collapse Behind a Runway Smile
In 2018, I was dating a tall, beautiful, former runway model. She was the kind of woman I used to think was out of my league. She was someone I admired for her wit and intelligence, but at 6'1" and 125 pounds, she was shockingly thin. Beneath her charm and beguiling collarbones was an eating disorder so entrenched it had persisted through the birth of five children and twenty years.
As a teenager she had been hospitalized for anorexia. She admitted that some days her diet consisted of nothing more than a caffeinated soda and aspirin. She adopted a vegetarian diet, on false moral pretenses, to excuse herself from eating anything at all. After hospitalization, she recovered just enough body fat to achieve a gaunt appearance and the approval of society. At 17 years old, she became a runway model. Tall, thin girls were popular at the time and as long as she maintained a body composition that kept her out of the hospital, she could make tens of thousands of dollars as a walking coat hanger for dress designers.
By the time we met, her all-carbohydrate diet had wrecked her mitochondria. The phosphoric acid in the soda she still craved robbed her of magnesium. The concentrated soda sugar drove her insulin resistance so high that her HbA1c reached 7.2%, despite her emaciated figure.
She had full-blown Type 2 diabetes, and I had no idea.
Ketosis: An Accidental Lifeline
It wasn’t until we’d returned from a week-long trip to a foreign country that the truth was revealed to me. While we were there, she was relaxed and curious and we ate well together. Soon after we got back home, I made an off-hand comment that I meant as a compliment.
“Babe, you look like you’ve gained five pounds!” I told her.
To my surprise, that sent her into an emotional tailspin that resulted in upheaval of relationship, near-starvation, and shame. In my defense, I had no idea she was anorexic. I was naive to anorexia. I had no prior experience with it, and besides that, she always ate well when she was in my company.
When we out to eat, I always ordered for her, just like I had on our first date. I’d tell her, “If you don’t like it, we’ll send it back. We’ll go through the whole menu if we have to, until we find something that works for you,” and that took the anxiety away for her.
When she stayed over with me at my place, I cooked duck, lamb, omelets—the fatty, protein-rich meals I preferred on the ketogenic regimen i adopted to recover from my own compulsive eating disorder. By the time I had ballooned to 250lb, I realized that I’d better get a handle on my diet. To lose weight, I adopted the Atkins diet I’d learned about when caring for my diabetic son. I’d lost more then 50lbs by the time I’d met her.
When she was with me, she was accidentally eating my low-carb diet, too. That’s when she realized that ketosis shifted something in her.
Her anxiety eased. Her mood stabilized. She began to gain weight—not just physically, but mentally and emotionally too. Her HbA1c dropped below 6%. She regained strength, clarity, and a sense of self.
She discovered something very few people with anorexia ever do: a way out.
The ketogenic diet didn’t just nourish her—it calmed her. Ketones offered her brain a new fuel source, helping her think clearly and reduce the mental obsession with food and weight.
For her, keto was a way of relieving the anxiety associated with anorexia without starvation. When she was eating a high-carb diet, the only way to get the benefit of ketones would be for her to undergo severe caloric restriction. That is, without eating fat and protein, it was only by starving herself entirely that she could exhaust the glucose reserves in her muscles and glycogen reserves in her liver so that her body could switch over to burning fat. Only then, as a intermediary product of fat metabolism, could she stimulate her body to produce endogenous ketones to better fuel her brain.
It wasn’t until after her recovery that she came to understand that ketones have an anxiolytic effect (Scolnick 2017). “Anxiolytic” means that ketones reduce anxiety, and it is anxiety that is the origin of anorexia. That is, anorexia is not the problem, per se. Anorexia is the brain's search for a solution to the deeper problem of anxiety.
It seems reasonable to suggest that when people with anorexia are able to go several days without food, they put themselves into ketosis in a way that provides psychological comfort far more rewarding than the physiological discomfort. Thus, by regimenting, controlling, disciplining their diet, they can achieve both a sense of self-control and a reduction in overall anxiety.
That’s why the typical advice in Eating Disorders Anonymous (EDA) to avoid any sort of eating restrictions during recovery is likely counter-productive for people with anorexia. After all, their dietary discipline is their superpower. With a ketogenic diet, they can harness that discipline to choose foods that support ketosis, reduce anxiety, and maintain minimum nutritional requirements.
So if ketones are so good for anorexia, and cold plunges stimulate production of endogenous ketones, why don’t I recommend cold plunge as a therapy for anorexia?
I Don’t Recommend Cold Plunge for Anorexia—Yet
Cold plunge therapy boosts mitochondrial function, reduces inflammation, balances sex hormones, and lifts mood… but for people suffering from anorexia? I don’t recommend it. Not yet.
I did find one case of a woman who claimed that cold plunge therapy aided her recovery from anorexia. Her name is Megan Hamill, although she goes by “soulfullyginger” on Instagram, and she was the subject of a BBC interview in February 2023 in which she described how cold water swimming helped lift her out of depression and “shifted her mindset.”
It’s possible that the mood-lifting effects of cold plunge therapy will help those people with anorexia find the motivation to make changes. However, the BBC article doesn’t describe Megan's diet. It only says that she is obsessive about exercise, training six days a week (and sometimes twice a day) in preparation for her Ironman competitions. It’s possible that her extensive aerobic exercise regimen, in combination with her cold plunge practice, is helping her burn excess carbs and keeping some level of ketone bodies present in her bloodstream.
We don’t know for sure.
The nutritional demands of a regular ice bath can be acute. For example, mitochondria require magnesium for proper function, and if dietary magnesium is insufficient, then the body will rob magnesium from the bones, increasing the risk of osteoporosis. Furthermore, zinc is essential for mitochondrial function, and it is implicated in healthy glutamate metabolism. Where zinc is deficient, the body is more susceptible to insulin resistance, and glutamate excess can increase anxiety—which is the opposite of the desired effect. Therefore, stabilizing body weight and restoring minimum nutritional requirements via a ketogenic diet should precede a practice of cold plunge therapy. In the context of anorexia—where the body is already depleted—cold could become a dangerous stressor, rather than a therapy.
I should mention that my former girlfriend who recovered from anorexia also began an ice bath practice, but only after stabilizing her diet. What I witnessed in her was that the ketogenic diet gave her brain a chance to reset. Ketones created a bridge from anxiety to nourishment.
When you’re ready to recover from anorexia, consider first a magnesium supplement, a zinc supplement, or warm baths in Epsom salt (magnesium sulfate) and zinc sulfate. Then, add animal fats. For those who tolerate dairy, cream and butter (or ghee) are excellent choices. Duck fat is delicious and great for frying potatoes. Beef tallow and lard (pork fat) are also good choices—especially when they’re pasture-raised. If you resist those, then fruit oils like coconut, avocado, and olive oil might be easier to add to your diet. A tablespoon of coconut oil with raw honey on it makes for a delicious, well-tolerated snack that nourishes and promotes ketosis.
After you’ve introduced these foods into the diet and adopted regular feeding habit, that’s when cold plunge therapy might help support mental health without further impoverishing your body of essential nutrients.
UPDATE 7 JULY 2025
Shortly after posting this article, I got an email from a woman who had recovered from anorexia and works with other recovering from anorexia. Her views are more consistent with traditional advice and she agreed to allow me to publish our correspondence.
Dear Thomas, Many clinicians, dietitians, and people with lived experience of eating disorders have found that any type of diet-especially one as restrictive as ketogenic-can be profoundly harmful for those in recovery. Creating food rules or categorising certain foods as “good” or “bad” tends to reinforce anxiety and fear around eating. In fact, a core part of healing from anorexia is learning to make peace with all foods, including carbohydrates, and moving away from restriction in any form. The idea that ketosis is therapeutic for anorexia can unintentionally perpetuate further fear of essential nutrients (e.g., carbohydrates) which are critical both physiologically and psychologically during recovery. -- Recovered Reader
Dear Reader, Thanks for writing. The experience of the woman with anorexia who contributed to this article diverges with the advice of the many clinicians, dietitians and people with eating disorders that you're citing. Her experience agrees with those cases recently documented in the scientific literature, in which the ketogenic diet reduced anxiety, provided nutritional support, and fueled the brain for other therapies (e.g., ketamine, cognitive behavioral therapy, CBT) that helped resolve underlying trauma. Because carbohydrates are not an essential nutrient, any unintended fear of them is inconsequential compared to the benefit gained by feeding on healthy fats and some protein. She found that the advice she got from Eating Disorders Anonymous (EDA), which is consistent with what you describe as "moving away from restriction in any form" was counter productive for her. To be sure, there is a danger in some restrictive diets. For example, she admits that her vegetarian phase was a mask that reinforced her anorexia. I think that's what the normal advice to on diet restrictions is hoping to avoid. She also noticed that it was hard to give up soda and sweetened beverages. She craved them like an alcoholic craves wine. And she learned to forgo them like her life depended on it. My view is that, given the poor rates of recovery from anorexia and the pervasive abuse of ice baths within pro-ana communities, those people who have failed to respond to conventional advice would do well to experiment with a ketogenic diet. Having said that, your email represents an important counter-point to my view from a position of expertise. I'm admittedly in the minority. -- Thomas
Dear Thomas, Thank you so much for your thoughtful reply and for taking the time to share your perspective. I really appreciate your openness to including a range of views in this conversation. I also appreciate that you’re exploring ideas beyond the usual mainstream narratives (I’m very much someone who questions conventional thinking myself). At the same time, I wanted to share why I feel so strongly that a ketogenic diet and carbohydrate restriction can be deeply problematic in recovery from anorexia, not because it goes against official guidelines, but because of what I’ve experienced firsthand and witnessed in others. While it’s true that carbohydrates aren’t technically essential for survival in a healthy body (as the body can make glucose from other sources) the situation is completely different when someone has been in a prolonged state of severe restriction and starvation. At my most unwell, having suffered from the age of 12, I was 23 years old, 156 cm tall, and weighed 32 kilograms. At that point, my body was breaking down anything it could find to stay alive. My hormonal function had collapsed, my digestion was shutting down, and my nervous system was in a constant state of stress. In that context, continuing to avoid or limit any major food group didn’t promote resilience or balance. It instead kept me in survival mode. Reintroducing carbohydrates wasn’t about chasing a dietary dogma. It was about giving my body and brain a clear signal that the famine was over. That shift calmed my physiology, helped stabilise my moods, and slowly allowed me to trust food again. The experience of fear towards food when suffering from this illness is so extreme that it is difficult to put into words that would do it justice. I’ve seen this over and over in others who have recovered: eating all foods, without moral labels or rules, can look “unhealthy” or “uncontrolled” to someone on the outside. But for a person whose life has revolved around rigid avoidance and constant hunger, it’s often the most healing, life-saving thing they can do. Restriction (even if it’s framed as clean eating or metabolic therapy) can so easily become another mask for the same patterns of control and fear. It can also create a huge risk of relapse. I completely respect that you’re coming from a place of wanting to help people find what works. For me and for many I’ve seen heal, learning to see no food as inherently dangerous was the thing that made recovery possible, not the thing that held it back. Thanks again for holding space for different perspectives - it really does mean a lot to someone who feels so passionate about this topic. I just felt it was important to share this side of it, because for those of us who have been on the brink of losing our lives to restriction, the freedom to eat everything is often the healthiest choice by far. I am more than happy for you to include my text as an addendum. Thanks, -- Recovered Reader
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About the Author
Thomas P Seager, PhD is an Associate Professor in the School of Sustainable Engineering at Arizona State University. Seager co-founded the Morozko Forge ice bath company and is an expert in the use of ice baths for building metabolic and psychological resilience.
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