Eating disorders and veganism

by Laura Janse Van Rensburg and Michael Metoudi, RDs

​With the rise in veganism currently taking shape in modern society along with updated clinical guidance in this area, there is an ongoing 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, which include Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder and Avoidant Restrictive Food Intake Disorder (ARFID), are a group of life-threatening mental health conditions affecting people of all ages, genders, ethnicities and backgrounds that impact both physical and psychological functioning. They should therefore be taken seriously as they give rise to the highest mortality and morbidity rate of any mental health illness. Eating disorders have often been seen as female disorders when in fact they 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 25% 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 prevalence 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 it is commonly thought that ‘they are overweight so how can they have an eating disorder?’.  Furthermore, those within the LGBTQIA+ community, including both adults and adolescents were found to have higher rates of disordered eating behaviours compared to the society as a whole. This may be due to them experiencing higher levels of discrimination, harassment and denial of services by health and mental health care providers and therefore more reluctant to reach out for help as a result. 

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 and is recognised as a non-religious ethical belief protected under Article 9 of the European Convention on Human Rights. For some, the choice to adopt a whole foods plant-based diet, focusing on consuming more whole foods such as fruit and vegetables, whole grains, legumes, nuts and seeds, herbs, and spices and excludes all animal products, including red meat, poultry, fish, eggs, and dairy products rather than processed foods, will most likely be related to health and well-being. Whereas a vegan diet, whilst also excluding the use of animal products, may be less restrictive in nature, generally incorporating some additional processed foods such as desserts, meat analogues and other confectioneries that may be challenging for an individual with a restrictive type of eating disorder.

An individual with an eating disorder may have many reasons to choose to follow a vegan or plant-based diet, such as for health, ethics and the environment. 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 overlapping behaviours. Some of these disordered eating behaviours include specific food selection, complete exclusion of food groups, making eating-related issues important in one’s own life, obsessively focusing on the 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. 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. 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.

A number of studies have now examined the relationship between vegetarianism, veganism and eating disorders. Although there may be some correlation between certain eating disorder behaviors and adopting plant-based or vegan diets, research from a recent systematic review conducted by McClean and colleagues showed there to be no causal link between an individual choosing to follow a vegan diet and the risk in developing an eating disorder. The same colleagues recently published a qualitative study this year on the treatment experiences of individuals living with an eating disorder who chose to follow a vegan diet. They found there to be better treatment outcomes when health care professionals were seen willing to be flexible in working with and acknowledging an individual’s vegan and vegetarian values within treatment. Similarly, a 2020 systematic review did not find a causal link between eating disorders and vegetarianism in adolescents. In many of the studies there appears to be a higher prevalence of vegetarian women with an eating disorder diagnosis, yet in other studies, no correlation between the two was found. The majority of individuals in studies reported that the adoption of a vegetarian diet came one year after the first symptoms of their eating disorder appeared, suggesting that in most cases, the eating disorder preceded adopting a vegetarian or vegan dietary pattern. Those that follow a vegetarian or vegan diet appear to have lower overall dietary restraint scores (i.e. the conscious limitation of food intake and perception of eating less than desired in order to prevent weight gain) and tend to score lower on the Eating Disorder Examination Questionnaire  (EDE-Q), a universal tool to diagnose eating disorders. These findings have prompted a position statement from the Academy of Nutrition and Dietetics to conclude that there is no increased risk of developing an eating disorder if choosing to follow a vegetarian or vegan diet. However, the phenomenon of pseudovegetarianism is something that should continue to be considered 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 evidence-based treatment surrounding  this. It is however important to screen individuals with an eating disorder who may use a vegan diet as a means to mask or control their eating disorder. A new eating disorder examination questionnaire has recently been developed in order to assess the reasons and motivations for individuals to adopt a vegan diet in order to mitigate potential health risks, and potentially address the occurrence of pseudovegetarianism. 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. A recent qualitative study by Hunter et al has highlighted the potential benefits of plant-based diets in helping those recover from restrictive eating disorders, highlighting that plant-based diets may facilitate a new meaning in their relationship with food. However this research is preliminary and further study in this area is needed.  

According to MEED clinical guidelines (2022) for eating disorders, a patient may have a lack of trust in the system as well as in staff and this alone can lead to a lack of adherence to treatment. Staff working within eating disorders facilities will 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 should be 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.  

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 may not not be 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 restoration diet 
• The use of plant-based meat alternatives is essential for calories
• Desserts and more processed foods play a role in weight restoration and should not be avoided

The BDA’s Mental Health Special Interest Group has recently developed a practice guidance around Anorexia Nervosa and veganism, including guidance on how to re-feed safely on a vegan diet including the use of vegan-based oral nutritional supplements and enteral feeds. 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:

MEAL	PORTION	EXAMPLE
Breakfast	1 Cereal 1 ‘Dairy’ 2 Fruit   1 Carb + 2 x fat	2 x Weetabix/ 1 cup cereal 250ml Alpro protein milk 250ml Fruit juice (100%)   2 slices of toast + 2 tsp vegan spread
Snack	1 Fruit 1 ‘Dairy’	1 Fruit 125g Alpro Greek Style yoghurt
Lunch	1 Carb 1 Prot 1 veg 2 Fat 1 Fruit   1 Dessert/ snack	2 slices bread/ 1 bagel/ 1 pita/ 1 standard wrap 60g ‘chicken pieces’/vegan ham/tofu/tempeh/vegan burger Raw vegetable on side 2 tsp vegan spread or 2 tsp vegan mayonnaise 1 Fruit   170g vegan custard pot/ Vegan slice/ 2 scoops vegan ice cream/ Trek Cereal bar/ 25g crisps
Snack	1 ‘Dairy’ ½ Carb + 2 fat	250ml Alpro protein milk 1 slice toast with 2 tsp vegan spread/ 2 tsp peanut butter
Dinner	1 Carb 1 Prot 1 Veg 2 Fats   1 Dessert/ Snack	1 cup cooked pasta/ ⅔ cup cooked rice/ 1 jacket potato 60g chicken pieces’/vegan ham/tofu/tempeh/vegan burger 1 cup cooked vegetables Oil in cooking   170g vegan custard pot/ Vegan slice/ 2 scoops vegan ice cream/ Trek Cereal bar/ 25g crisps
Snack	1 ‘Dairy’ 1 x Digestive	250ml Alpro protein milk 1 x Digestive biscuit

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. 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. 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.