Eating disorders and veganism

by Laura Janse Van Rensburg, Registered Dietitian

https://www.lauramaydietitian.co.uk

​

With the rise in veganism currently taking shape in modern society, there is no doubt that we need to amend past practices and perceptions in relation to eating disorders and veganism in order to combat the stigma associated with this choice of lifestyle. 

Eating disorders are often seen as female disorders when in fact that are complex mental illnesses that have no stereotypes. According to BEAT, the UK’s Eating Disorder Charity, 1.25 million people in the UK suffer from eating disorders and ¼ of the population diagnosed with an eating disorder are male. When thinking about eating disorders, Anorexia Nervosa or Bulimia Nervosa may be the first ones that spring to mind, however Binge Eating Disorder has the highest incidence of all the eating disorders yet often goes untreated or unrecognised. Those in larger bodies are often not noted to suffer from an eating disorder as ‘they are overweight so how can they have an eating disorder?’.  Furthermore, lesbian, gay and bisexual youth were found to have higher incidences of disordered eating behaviours but may be more reluctant to reach out for help. Eating disorders are life-threatening conditions that impact both physical and psychological functioning and should be taken seriously.  ¹

As we think about Eating Disorders Awareness week, let us draw some attention to the importance of patient choice in regard to their lifestyle decisions. Veganism is a way of living based on the principle of avoiding animal use as much as possible, encompassing both dietary and non-dietary choices (Vegan Society, 2016).  For some, the choice to adopt a plant-based diet, a focus on more whole foods rather than processed foods, will be centred around the focus on health and well-being whereas a vegan diet is less restrictive. A plant-based diet consists of all minimally processed fruits, vegetables, whole grains, legumes, nuts and seeds, herbs, and spices and excludes all animal products, including red meat, poultry, fish, eggs, and dairy products.² A vegan diet, whilst also excluding the use of animal products may include some processed foods such as desserts, meat analogues and other confectioneries.

A patient who chooses to follow a vegan or plant-based diet may have many reasons for their choice and although there may be some correlation between certain eating disorders and plant-based diets, we cannot say that veganism causes someone to develop an eating disorder. We know that eating disorder behaviours (in particular anorexia nervosa) are centred around strict and rigid food rules. When we draw this comparison to someone who may adopt a vegan diet, we may see some similar behaviours. Some of these would include specific food selection, making eating-related issues important in one’s own life, focusing on quality of food, reduction in variety of food due to specific nutrition rules, rigid food rules and an inability to be flexible in food choices.¹ Furthermore, there is no doubt that in modern times, it is more socially acceptable to follow a vegan diet and therefore the diet can often be used as a mode of restriction. ^3,4,5 The term pseudovegetarianism was coined in a 1987 study to define the population of people who use vegetarian diets as a mode of calorie restriction rather than a lifestyle choice due to the ethical nature of the diet.⁶

A number of studies have examined the relationship between vegetarianism and eating disorders. A 2012 study looked at individuals with and without an eating disorder, as well as individuals in different stages of recovery, to determine past and current motivations to become vegetarian. When looking at age of experiencing the first onset of eating disorder symptoms, 59.6% reported that vegetarianism came at least one year after the onset of the first eating disorder symptom. A high percentage of participants (68.1%) felt that there was a direct relationship between their eating disorder and their vegetarianism. The factors included in this was the ability to lose weight, maintain control of their diet and maintain their eating disorder through the use of vegetarianism. ⁷ A 2020 systematic review addressing eating disorders and vegetarianism in adolescents noted that a causal link between the two could not be found. In many of the studies there was a higher prevalence of vegetarian women with an eating disorder diagnosis, yet in other studies, no correlation between the two was found. Numerous individuals in the studies addressed reported that the adoption of a vegetarian diet followed their eating disorder.⁴ The phenomenon of pseudovegetarianism is therefore perhaps something that needs to be thought about in clinical practice.

Regardless of the reasons a patient decides to follow a vegan diet, it is our duty as clinicians to respect patient choice and offer treatment based on this. In both inpatient and outpatient settings, understanding how to nourish the patient and work collaboratively with them is an important step in working toward recovery (MEED 2022). In a consensus statement between The Royal College of Psychiatrists, The British Dietetic Association and BEAT, it is stated that treating someone with anorexia nervosa (AN) requires respecting that person’s religion or beliefs, including veganism. 

According to MEED guidelines (2022), a patient may have lack of trust in the system as well as in staff and this alone can lead to a lack of adherence to treatment. Staff need to recognise this, avoid confrontation and work collaboratively with the patient and their wider network for treatment to succeed. There is no doubt therefore, that a patient who decides to follow a vegan diet should be offered their preferred meals and their lifestyle choice respected by all members of staff that are active in their care. Failure to do so could be detrimental as the patient may choose to disengage from care. Whilst a patient’s choice can be respected during an admission, it is also true that in life-saving circumstances there has to be some flexibility and the use of non-vegan enteral feeds may be required for naso-gastric tube feeding. If a patient is not willing to be flexible in this instance, then health care providers should seek legal advice for support and clarification.⁸

For some clinicians there may be some concern over the re-feeding of a patient who chooses to follow a vegan diet. Whilst it is possible for safe re-feeding to occur on a vegan diet, it is likely not possible on a whole food plant-based diet. This is due to the following reasons:

• The high fibre content of plant-based foods could result in gastric discomfort
• Most whole plant-based foods are naturally lower in calories
• Reduction of oils is not possible on a weight gain diet 
• The use of plant-based meat alternatives is essential for calories
• Desserts and processed foods play a role in weight gain and cannot be avoided

Through the development of trust and rapport with the patient, the conversation around the re-feeding diet plan can be done in a therapeutic manner by a qualified dietitian. Patients need to understand that their personal choice is being respected but that they need to adhere to the meal plan as prescribed which may often contain food items that make them feel uncomfortable. Re-feeding using a vegan meal plan is entirely possible due to the number of available meat, dairy and dessert alternatives available in the market today. In fact, these products often have the same, if not more calories than their animal counterparts. A refeeding meal plan of 2500kcal (protein 100g) can be provided by a plan as follows:

Focus is often placed on the nutritional quality of vegan diets. It is important to understand that a patient suffering with AN will likely have nutritional deficiencies due to the nature of the restricted diet, whether they follow a vegan diet or not. A patient who follows a vegan diet will need to be supplemented with Vitamin B12 throughout an admission and other vitamins may be required especially if a blood test shows deficiencies. 

Concerns about animal welfare, climate change and the health impact of the foods we eat, are all reasons behind the increased adoption of vegan diets. ⁸ Whilst there is a correlation between vegan diets and eating disorders, it is clear from literature that veganism does not cause a person to develop an eating disorder. Eating disorders are complex mental illnesses that are often associated with depression, OCD or other anxiety disorders and therefore cannot be blamed on one lifestyle choice. ¹ Regardless of a patient’s cultural, religious or dietary belief, these should always be respected in treatment. It is our responsibility as clinicians to put our patients first and to ensure that we are treating them in the same way that we would want to be treated should we ever be in their shoes. 

References

1. Hornberger L, Lane M. Identification and management of Eating Disorders in Children and Adolescents. Pediatrics 2021 Jan; 147 (1):e2020040279. doi: 10.1542/peds.2020-040279. Epub 2020 Dec21. PMID: 33386343.
2. Ostfield R. Definition of a plant-based diet and overview of this special issue. J Geriatr Cardiol 2017 May; 14(5):315. doi: 10.11909/j.issn.1671-5411.2017.05.008. PMID:  28630607.
3. Brytek-Matera A, Czepczor-Bernat K, Jurzak H, Kornacka M, Kolodziejczyk N. Strich health-oriented eating patterns (orthorexic eating behaviours) and their connection with a vegetarian and vegan diet. Eat Weight Disord. 2019; 24(3): 441-452. doi: 10.1007/s40519-018-0563-5. Epub 2018 Aug 29. PMID: 30155858.
4. Sergentanis T, Chelmi M, Liampas A, Yfanti C, Panagouli E, Vlachopapadopoulou E, MichalacosS, Bacopoulou F, Psaltoppulou T, Tsitsika A. Vegetarian diets and eating disorders in adolescents and young adults: A Systemic Review. Children (Basel). 2020 Dec 28;8(1):12. doi: 10.3390/children8010012. PMID: 33379220.
5. Craig W, Mangels A, Fresan U, Marsh K, Miles F, Saunders A, Haddad E, Heskey C, Johnston P,Larson-Meyer E, Orlich M. The Safe and Effective Use of Plant-Based Diets with Guidelines for Health Professionals. Nutrients. 2021 Nov 19;13(11):4144. doi: 10.3390/nu13114144. Epub 2021 Nov 19. PMID: 34836399
6. O’Connor M, Touyz S, Dunn S, Beumont P. Vegetarianism in Anorexia Nervosa. A review of 116 consecutive cases. MJA 1987 Dec 147(11-12): 540-542. doi.org/10.5694/j.1326-5377.1987.tb133677.x
7. Bardon-Cone A, Fitzsimmons-Craft E, Harney M, Maldonado C, Lawson M, Smith R, Robinson P. The Inter-relationships between  Vegetariansim and Eating Disorders among Females. J Acad Nutr Diet 2012; 112 (8): 1247-1252.
8. Fuller S, Brown A, Rowley J, Elliott-Archer J. Veganism and eating disorders: assessment and management considerations. BJPsych Bull. 2022 Apr;46 (2): 116-120. doi: 10.1192/bjb.2021.37. Epub 2021 Mar 27. PMID: 33928893.