The Calorie Conundrum
I think it is fair to say that we live in a world that is obsessed with calories. The concept of calories alongside the “energy in, energy out” principle – as a means to control body size and supposedly our health – has ruled the wellness world since the dawn of diet culture.
When it comes to recovering from hypothalamic amenorrhoea (HA), relative energy deficiency in sport (RED-S) or a malnourishment disorder in the context of an energy deficit – it’s logical and potentially appropriate to consider using calorie counting as a method to restore a healthy energy balance.
But is counting calories ever truly appropriate or helpful and should you count calories when you’re looking to get your period back?
My aim in this article is to provide a review of the notion of calorie counting, including potential pitfalls and possible benefits in the context of HA recovery. It is not my intention to provide a definitive answer to the “calorie conundrum” for those looking to recover missing periods, but rather to provide you with knowledge and insights to enable you to decide what may work best for you.
What is a calorie?
A calorie is a unit of energy equating to approximately 4.1868 joules of energy and loosely defined as the amount of heat needed to raise the temperature of a quantity of water by one degree.
All nutritive foods contain calories and our ability to convert that energy into another usable form of energy within the body, is the reason (quite simply) that we are alive and the reason our bodies are able to perform all physical and physiological tasks, including breathing, digesting food, thinking and moving (1, 2, 3).
The amount of energy foods provide is normally recorded in thousands of calories (kilocalories or kcal). However, people often use the term “calories” instead, since “kilocalories” is an awkward word to use!
What are the pitfalls of counting calories?
There are many reasons why you may wish to take a long hard look at calorie counting as a strategy for achieving your goals or improving your health circumstances (including HA recovery). I’ve summarised some of the key considerations below.
Human bodies are not laboratories
The idea that a calorie “is a calorie, is a calorie” is so pervasive that we often forget about the sources of these calories, the context in which they are found and how they are used in the body.
You’ve probably heard the phrase “all calories are equal”. Yet whilst calories may be “equal” outside the body, this is not the case inside the body (4). The actual energy (or “calorie”) content of certain foods may differ from the energy that is theoretically calculated and this is due to key differences in food digestibility and food structure (5, 6, 7). It follows that when comparing different foods that contain the same number of calories, this does not mean that those foods will affect the body in the same way.
Whilst historically the calorie “system” takes into some consideration the processes involved in the digestion and absorption of calories from different foods and macronutrients, the same cannot be said for the metabolism of those foods. That is, different nutrients contain different biochemical structures that require different biochemical pathways and processes for extracting their energy.
Protein provides a brilliant example of this. Technically, carbohydrates and proteins (gram for gram) share the same caloric “value”. Both proteins and carbohydrates contain approximately (note, this value is not definite) 4kcal per gram.
However, the calories in protein are only 70% available for use as energy, once they have been metabolised (the energy “releasing” process that occurs after digestion and absorption). The energy derived from carbohydrates is conversely ~92% available, whilst fats provide ~98% energy (or caloric) availability.
But let’s look at another example. Take tree nuts, for example. Nuts are well known for their energy density and high fat content (ranging between 40–75 g per 100 g) (8). However, eating nuts as part of a healthy diet does not affect body weight (and thus energy balance), according to experimental and observational studies (9).
The reasons for this are proposed to include mechanisms involving appetite control, dietary induced thermogenesis (how much heat foods release in the process of extracting their energy), and discrepancies in the amount of the “food available energy” to the human body (10).
So, you see that the composition of one’s diet plays a huge role in how accurately and how effectively we can actually “calorie count”.
How we prepare and consume food makes a difference
The nuances of food composition and the energy (or caloric) availability of foods is further confounded by how we select, prepare and consume different foods.
As alluded to above in the case of nuts, the presence of fibre (a group of complex, undigestible carbohydrates found in plants) makes food harder to breakdown, reducing the accessibility of some of the energy stored in the food (11). Even natural differences in food state (whether we prefer to eat green or yellow bananas, for example) change the energy availability of the food, to a degree.
Different preparation methods, like cooking, blending and juicing, also make a difference with industrial processing methods in particular making food more energy “available” to us (12).
How we “combine” foods also matters. Whether we eat carbohydrates on their own or with proteins, fats and fibre will affect the glycemic load (a measurement of how much food will raise a person's blood glucose after eating it). This, in turn, will have an impact on how we use and store that energy (13).
Counting calories blindly removes the context from which that calorie originated in the food, what effect different foods and their combinations can have on our hormones and even the brain chemistry that controls hunger and eating behaviours.
Our energy requirements are not uniform or static
As wonderful as it is to feel in control of our health with a daily calorie “quota”, generic calorie prescriptions, such as 2000kcal per day for women and 2500kcal per day for men, are based on population averages that may not be relevant or hugely helpful in the context of individual health. We are all quite simply wonderfully (and energetically) unique.
One of the ways this is expressed is in our individual gut microbiota (the microbial populations that live within our guts). In recent years emerging evidence has shown us that these microbial species have a marked impact on our ability to harvest energy from digested food (14, 15). Whilst the extent to which we can (and should) influence this internal ecosystem to promote health is not yet fully known, it is clear that the impact of the microbiota on the calorie “currency” of food will differ from person to person.
Another important consideration is that a daily calorie prescription will not take into account the daily changes in energy requirement that each individual body will experience. These changes are derived from multiple factors, including non-exercise-induced activity thermogenesis (NEAT) (16), emotional stress (17), temperature adaptions, physiological changes (for example, having a menstrual cycle) and recovery from injury or illness.
Finally, someone who has been subsisting on a very low daily calorie intake before commencing recovery from a malnourished state may need a lot more energy than will be conventionally accounted for. This “extra” energy will be needed to help restore healthy function of numerous physiological processes, as well as make up for the hypermetabolism (a state in which metabolism will speed up to capture the increase in energy supplied), which may occur as part of this process.
Calories do not = pleasure
It’s also important to mention the role of pleasure and food satisfaction when considering the validity of calorie counting.
In my experience working with clients, we are often looking to put pleasure back on the menu and restore a natural, playful and curious relationship with food. One the best ways to kill the fun (in my humble opinion) is to reduce the process of eating to arithmetic.
Quite simply, calories do not = pleasure.
Furthermore, if individuals have placed high emphasis on calorie “control” (self-imposed or otherwise) in the process of reaching a state of malnourishment, relative energy deficiency or HA, then we must seriously question together whether calorie counting is the answer to recovery.
I know for many women, having a “ballpark” number to reach or a calorie goal can be helpful initially. However, we must also remember that calorie counting removes an innate and intuitive ability to build and balance a meal that is both satisfying and nourishing.
Are there any benefits to counting calories in HA recovery?
Whilst, I hope I may have answered this question above – ultimately, the question is for you to answer.
In some cases, aiming for a minimum number* may be helpful if you’re feeling very lost, but once you’ve reached that minimum, I recommend you stop counting the rest.
Once you gain confidence in building meals and supporting daily intake in accordance with that quotient, I recommend stopping counting calories (and as soon as possible) to enable a swifter return to a place of intuition with food. Be patient.
Continued focus on the ‘numbers’ – from calories consumed or burned, to weight or steps taken – risks serving the underlying beliefs and behaviours that have led to HA or relative energy deficiency, rather than the true values or goals of recovery.
*Note, there is no single quotient and I recommend working with a registered nutrition professional specialising in this area to help determine a safe and achievable starting point. If you are working solo then a minimum of 2000kcal should be reached (please then stop counting). A common recommendation in the literature is to aim (initially) for a 5% increase in body weight, which can result in period recovery and improve bone mineral density in patients with HA (18).
Closing Thoughts
There is a place for calories within the nutrition world and public health arena. Policy makers must take an oversimplified view around food and public health so that messaging is clear, appreciating that this can contribute to confusion, misguided dietary choices and an over-reliance on calories.
However, our bodies are highly complex biochemical ecosystems with intricate processes and elaborate mechanisms that regulate energy balance. What, when and how we eat also makes a difference; and remember – we eat food, not calories.
Rediscovering and relearning how to eat and nourish ourselves as women is often where we need to focus for true, long-lasting recovery. If you’re asking me personally if I think counting calories is the answer to this… what at do you think?
DISCLAIMER: It’s important to note that counting calories may be appropriate or necessary when recovering from an eating disorder (ED) under the supervision of a dietician or registered nutritionist, in conjunction with medical and psychological support.
All content found on this website has been created for informational and educational purposes only. It is not a substitute for individual medical or mental health advice, diagnosis or treatment. Always seek the advice of your doctor or other qualified health provider with any questions you may have regarding a medical condition or eating disorder recovery. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.
Remember that we are all beautifully unique and what works for one person may not work for another.