There is a fascinating link between eating disorders (ED’s) and autoimmune (AI) issues. My personal interest in this link stems from a childhood of chronic stomache aches and migraine headaches along with an 18 year experience with anorexia nervosa. Ironically, during my graduate school experience to become an eating disorder specialist, I developed AI symptoms, which lead me to start Autoimmune Paleo (AIP). While exploring all the facets of AIP, I began to link the nutritional deficiencies and stressors of my prior eating disorder to the physical symptoms of my current AI issues. I began to view the nutritional and lifestyle principles of AIP as a logical and holistic approach to repair nutritional deficiencies from my ED, reverse the impact of AI issues, and provide a foundation for a healthy lifestyle. This article will bring together both my personal and professional understanding of the foundations of eating disorders, links with AI disorders, and how AIP may provide a reassuring approach to individuals recovering from eating disorders.
Understanding Eating Disorders
On the surface, ED’s appear to be a disordered relationship with food where a person may severely restrict food intake, binge (consume a large amount of food), potentially seek to rid the body of food by any number of purging or exercising behaviours, and/or be obsessed with calories and weight loss. This disordered type of relationship with food and the body appears to be superficial and a response to societal pressures to be thin. However, our relationship with food and our bodies is far more complicated than what food we take in and what energy we expend, and eating disorders are far more complex than restricting or consuming excess food.
Underneath the surface, ED’s are multi-faceted, complex, deeply personal, and represent an intersection between ourselves and the world around us; how we are “embodied” (Merleau-Ponty, 1962). Thompson (1994) asserted that factors that influence our sense of embodiment, and thus our relationship with food and the body, include race, class, gender, ability, and sexual orientation. Issues of weight bias, stigma, and the thin ideal in our society also impacts our relationship with food and body, making eating disorders a social justice issue (Russell-Mayhew & Grace, 2017). Thompson (1994) further asserted that dieting, self-denial, and eating issues are survival strategies in the face of oppressive and patriarchal societal expectations. Eating disorders are often associated with feelings of deep shame.
On the surface, Anorexia Nervosa (AN) involves severe food restriction, extreme fear of weight gain, and a distorted view of one’s condition (e.g., thinking a person is bigger than they actually are or minimizing the problem) (American Psychiatric Association [APA], 2013), There are different subtypes of AN (restrictive or with binge/purge symptoms) (APA, 2013). Below the surface, AN is a nervous inability to eat and is often fuelled by anxiety, obsessiveness, perfectionism, and a fear of not being good enough. Essentially, the thought of being smaller and refusing food brings a temporary sense of relief from intense anxiety.
Bulimia Nervosa and Binge Eating Disorder
On the surface, Bulimia Nervosa (BN) is a cycle of binge eating and purging while Binge Eating Disorder (BED) is a cycle of binge eating without subsequent purging (APA, 2013). Below the surface, BN is often co-morbid with other addictions and impulsivity (Bulik et al, 1997). The binge/purge cycle brings a temporary sense of relief from major stressors by temporarily changing brain and body chemistry.
A related eating disorder not listed in the DSM-5 is Orthorexia Nervosa, which is an experience where ”healthy” eating and exercise becomes obsessive. The person often develops a self-punishing relationship with food that involves a progressively shrinking universe of foods deemed acceptable (Koven & Abry, 2015). I will admit that when I started AIP to address autoimmune issues, I wondered if I was developing orthorexia because I was obsessing about what I ate. However, I will later describe how this was not the case, and it is the intention behind food choices and health behaviours that is important.
Assessing and Diagnosing Eating Disorders
Eating disorders are often difficult to assess and diagnose, as the line between socially acceptable dieting and concern about health is very blurred. When is being mindful about what we eat and how we care for our body helpful and when is it harmful? By considering eating behaviours and beliefs along a spectrum, we can observe how the severity of behaviours impacts a person’s health and well being. The following red flags (in no particular order) may indicate that a person has developed a disordered relationship with food and the body that requires further assessment and treatment by an eating disorder treatment professional:
- Severely restricting eating or caloric intake
- Excessive counting calories or Fitbit tracking
- Excessive exercise
- Continually talking about a desire for weight loss
- Fear of eating certain foods (typically oils, fats, high calorie foods) or trying new foods
- Enthusiasm for dietary restrictions (e.g., suddenly vegan or keto)
- Chronic stomache aches, health issues related to food intake
- Loss of energy, fatigue, feeling cold
- Amenhorrea (loss of menstruation in biological females)
- Growth of lanugo hair (a thin layer of hair covering the body)
- Anxiety, depression, mood issues
If an individual demonstrates disordered eating and a higher number of red flags for eating disorders, it is critical that they be referred to an eating disorder specialist for diagnosis and treatment. I now turn to a description of the triad of treatment as the first approach to treating eating disorders.
Triad of Treatment
A triad of treatment with an eating disorder treatment team is required to address the physical, nutritional, and psychological aspects associated with the multi-faceted nature of eating disorder recovery. First, a medical doctor who specializes in eating disorders is required to provide medical testing and monitor body functioning throughout recovery. Second, a Registered Dietician who specializes in eating disorders is required to assist with the refeeding process. Finally, a registered mental health professional who specialization in eating disorders (e.g., psychologist or social worker with a minimum of a graduate degree and registration with a professional organization) is required to address the mental, emotional, and relational components of recovery.
If eating disorders are complex and require a triad of medical treatment, how can AIP and a Certified AIP Coach be beneficial? As a Registered Psychologist who has helped many individuals on their recovery journey, some of the primary frustrations people in recovery have expressed is a treatment professional’s belief that “all foods are good”, a person should be able to “eat everything” and “eat intuitively” as a sign of recovery, along with dismissal of troublesome physical symptoms (e.g., constipation, stomache aches, bloating). The fear of weight gain is also often dismissed. From my clinical perspective, it does not make sense to assert that all foods are good foods when food science teaches us that some foods impact the body by causing inflammation and contributing to digestive tract, AI, and mood symptoms.
It wasn’t until I experienced AIP myself that I began to reflect on how AIP may be beneficial to individuals recovering from eating disorders. I believe that once an individual has been weight restored in a medical treatment model, it is critical for them to take responsibility for their future health and well-being by developing a healthy meal plan and lifestyle plan that works for them. This is where AIP may be a nutritional and lifestyle approach that helps restore the body to its’ healthiest functioning. As Angie Alt (2018) from Autoimmune Wellness says, “The goal of AIP is to arrive at the least restrictive diet that produces the absolute best health for the individual.”
Eating Disorders and Autoimmune Issues
It makes logical sense that a disordered relationship with food would lead to nutritional deficiencies that in turn impact a person’s physical and mental health. There is increasing research showing a link between EDs and AI issues. There is complex interplay between digestive and immune system functioning, nutrition, and psychological symptoms. First, there appears to be a bi-directional pattern between ED’s and AI issues (Hedman et al, 2019). Individuals with underlying AI issues may experience physical and mental symptoms that make them want to eat less or crave foods that cause inflammation, while individuals with ED’s do not get enough nutrient-dense foods for sustained immune functioning, thus contributing to AI issues. Individuals with gastro-intestinal related AI diseases (e.g., Celiac, Crohn’s, and inflammatory bowel disease) show an increased risk for ED’s, especially in women and children (Raevuori et al, 2014; Zerwas et al, 2017). Malabsorption and pain can result in a fear of eating, thus restrictive eating behaviours can “look” like an ED (Raevuori et al, 2014; Zerwas et al, 2017), even if they are an attempt to reduce gastrointestinal discomfort. Considering the complex link between ED’s and AI diseases, it makes sense to examine novel approaches that address both nutritional deficiencies and AI issues.
Principles of AIP That Can Inform Eating Disorder Recovery
ED recovery is hard. As a treatment specialist, I can assure you that trying to convince someone who is terrified of food and weight gain to eat real food regularly, weight restore their body, and reduce their obsessiveness with thinness and food is no easy task. We are asking them to do the very things they are most terrified of – eat real food and accept that their body may be a different size and shape than their ED (and society) dictates. They are often dealing with a fear of recovery, fear of weight gain, fear of change, and fear of loss of control.
However, I have come to believe AIP has an important role in restoring deep nourishment and developing a more holistic relationship with food and one’s body. AIP principles of nutrient dense foods, education, and lifestyle are important keys to supporting clients in recovery and can reassure the fears associated with recovery. For individuals recovering from eating disorders, food is medicine. It makes sense to give them the best medicine possible.
In my own recovery from AN, I was seeking to eat “healthy” according to national dietary guidelines and “intuitively” according to my eating disorder recovery therapist. I had expanded my meals to oatmeal and egg whites every morning, multigrain sandwiches and tomato soup for lunch, fruit for snacks, and whole grain pasta with meat for dinner. However, I continued to experience bloating, stomache aches, migraines, brain fog and low mood. It wasn’t until a functional medicine doctor recommended AIP for my AI issues that I no longer experienced stomache aches, rarely had headaches, the bloating disappeared, and I began to feel better and think more clearly. Initially, I was concerned that my obsessiveness over AIP meals was beginning to look like Orthorexia, however, I realized that the intention was completely different. I wasn’t trying to get thin, I was seeking to become healthy. I started to feel better than I had in years. My own recovery experience lead me to study AIP as a reassuring approach to eating disorder recovery.
First, I seek to educate clients on the link between autoimmune issues and eating disorders by simply saying, “Your body does not have enough nutrition at this time to function well. Of course you feel terrible.” I remind them that our bodies are made from the same minerals as the earth and the stars, so it makes sense to nourish our bodies with whole foods from the earth. I remind them that they have been trying to manage their symptoms through restriction or bingeing, substance use, and/or over-exercise, and there is a better way to manage symptoms.
Although AIP typically begins with a restrictive approach to focus on anti-inflammatory foods, people with eating disorders typically have a very restrictive diet to begin with and are “afraid” of many foods. People with ED’s often separate foods into “good” and “bad” food lists, with low fat foods and vegetables given top priority. For example, one client informed me that she would allow herself to drink smoothies. When I inquired what she was putting in her smoothies, her answer was “spinach and water.” She was trying to survive on spinach water! I encourage clients to begin adding more nutrient dense and anti-inflammatory foods to their diet, reminding them that they can’t argue with an avocado! Instead of focusing on restricting calories, AIP focuses on food science that provides a foundation of why our bodies require certain nutrients from certain types of foods. By adding in nutrient dense foods with a focus on organic meats, fresh vegetables, plant-based carbohydrates, and healthy oils to their current meals, their bodies and brains will be getting more nutrients than they currently have, and they will begin to feel better.
I encourage people to focus on nutrient expansion without a focus on calories. Clients have reported that the AIP food lists give them reassurance that they can indeed begin to incorporate more foods into their restrictive diets without the fear of gaining weight too quickly or eating unhealthy foods. They slowly begin to give themselves permission to eat a greater of variety of foods and find the AIP lists reassuring that there is indeed a greater number of “healthy” foods they can consume. I remind them that nourishing their bodies and brains is far more important than a number on the scale.
For most people with eating disorders, “fat” is a four-letter word. I change the word “fat” to “oil” and discuss the science behind and importance of incorporating healthy oils in our diet. For example, oils fuel our brains, create a thickened myelin sheath so nerve conduction is easier, and lubricate our joints for ease of movement. I reassure people that “thin” does not necessarily mean “healthy” and our bodies are meant to have flesh on them. I further reassure clients that their bodies can be healthy at any size and encourage them to incorporate a Health at Every Size philosophy (Bacon, 2020). I encourage clients to plan their recovery meals and snacks for success, engage in mechanical eating to avoid hypoglycemia and reset their body’s natural cues for hunger and satiety, and not to weigh or measure their bodies. I continually reiterate, “Food is medicine” and “Scales are for fish, not for people.”
I explain that AIP focuses on anti-inflammatory, gut healing foods that should feel calming and nourishing to their bodies throughout the recovery process. I encourage people to track their food intake and any physical symptoms so that we can troubleshoot any areas of difficulty. It is not food tracking for self punishment, it is tracking for improved well-being. I now turn to some case studies to illustrate how AIP may be a reassuring approach to individuals recovering from eating disorders.
Zoe (AN with binge/purge symptoms)
Zoe presented with frustration about her binge/purge cycles and said she had BN. However, upon further investigation, she admitted that she was fasting most of the day with lettuce salad for lunch, skipping dinner, then bingeing and purging on crackers and cheese in the evening. We agreed that she did not have bulimia, but rather AN with binge/purge symptoms.
After having Zoe complete a physical exam with her medical doctor to ensure she did not have any serious health issues associated with AN, we began to develop a recovery meal plan beginning with what she was already consuming. She was amenable to making a “healthy” smoothie for breakfast, so we created a smoothie with coconut milk, banana, other berries of her choice, collagen powder, and glutamine powder to heal her gut. As she was already having a salad for lunch, we discussed adding high quality meat (chicken thighs or salmon), a whole avocado, other vegetables, and a healthy dressing made from extra virgin olive oil and balsamic vinegar. I encouraged her to add a baked sweet potato with coconut oil for sustained energy throughout the afternoon. I continually reassured her that these were all foods from the earth, packed with nutrients for her brain and body, and that she would not “get fat” from eating more oils, but would “become healthier” by consuming nutrient dense foods regularly.
Zoe also struggled with obsessively tracking her calories and exercise on her FitBit. I encouraged her to get rid of her FitBit to avoid the harmful tracking, and instead to focus on how she was feeling. It took her a few weeks to stop worrying about calories, and she reported feeling freedom in simply “being” without tracking everything.
We did not do a full AIP restriction diet, as her diet was already severely restricted. The point of eating disorder recovery with AIP is not to be fully AIP compliant, but to increase the range of nutrient dense foods until the individual feels better and is well nourished. As her partner made dinner, we focused on giving herself permission to enjoy being taken care of by having a hot meal prepared for her, rather than focusing on the caloric content of the meal. As she increased her food intake during the day, she reported no longer felt anxious in the evenings, and her desire to binge and purge diminished. After years of suffering, Zoe was able to begin relaxing around food.
Katie (Orthorexia and BN)
Katie reached out for support after being three years sober from drugs and alcohol. She reported being “extremely healthy” with her “clean eating” for approximately a decade, while binge eating and purging on a weekly basis. After further investigation, we determined that her binge/purge cycles occurred more in the evenings, especially on Friday evenings when her children went to their dad’s house and she didn’t know what to do with herself. We determined that she ranged between Orthorexia and BN.
After a physical workup from her doctor, Katie was ready to begin incorporating more nutrient dense foods into her diet. I encouraged her front-load her day with more nutrient dense foods so that she would be less likely to want to binge and purge later in the day. We focused on increasing protein and healthy oils at the beginning of the day, to avoid being over-hungry at the end of the day. Sweet potatoes and chicken thighs became a morning staple for her. We also focused on improving her self-care routines, especially Friday evenings when her children were at their dad’s house.
After a few weeks of increasing protein and nutrient dense foods in the morning, Katie reported the following: “Angela suggested a slow transition to the AIP Paleo diet, which I started focusing on immediately. I was also told to eat more protein, specifically in the AM. I was very surprised as how much food I was eating, compared to my usual diet. Within the first few days I noticed a change in my mood and desire to binge. After several weeks I have binged only twice and purged once; a drastic improvement to my habits over the last 6 months. Although I have not fully transitioned to an all AIP diet (focusing mostly on whole foods), the changes I have made have made have had a lasting impact. I am now two months into these lifestyle changes and my disordered eating feels manageable for the first time in 10 years.”
Disordered eating patterns and symptoms of ED’s are not to be dismissed. It is important to identify when an individual may be severely struggling with disordered eating and “red flags” associated with ED’s and immediately refer them to an eating disorder treatment team (i.e., physician, dietician, and registered mental health professional who specialize in ED’s). However, once a person is weight restored and medically stable, AIP may provide a reassuring approach to nutritional and lifestyle recovery. The food science behind AIP addresses the gastrointestinal and immune system issues associated with ED’s by providing education about nutrient dense foods and lifestyle choices to reduce stress and anxiety, improve immune functioning, and live a healthier, more balanced, vibrant life.
Alt, Angie. (2018). Does AIP cause eating disorders? Retrieved from https://autoimmunewellness.com/does-aip-cause-eating-disorders/
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association.
Bacon, L. (2020). Health at Every Size Community. https://haescommunity.com/
Bulik, C. M., Sullivan, P. F., Carter, F. A., & Joyce, P. R. (1997). Lifetime comorbidity of alcohol dependence in women with bulimia nervosa. Addictive Behaviors, 22(4), 437-446.
Russell-Mayhew, S., & Grace, A. D. (2016). A call for social justice and best practices for the integrated prevention of eating disorders and obesity. Eating Disorders: The Journal of Treatment and Prevention, 21(4), 54-62. doi:10.1080/10640266.2015.1113829
Merleau-Ponty, M. (1962). Phenomenology of perception. London: Routledge and Kegan Paul.
Thompson, B. W. (1994). A hunger so wide and so deep: American women speak out on eating problems. Minneapolis, MN, University of Minnesota Press.
Hedman, A., Breithaupt, L., Hubel, C., Thornton, L. M., Tillander, A., Norring, C., Birgegard, A., Larsson, H., Ludvigsson, J. F., & Savendahl, L. (2019). Bidrectional relationship between eating disorders and autoimmune diseases. The Journal of Child Psychology and Psychiatry, 60(7). https://doi.org/10.1111/jcpp.12958
Koven, N. S., & Abry, A. W. (2015). The clinical basis of orthorexia nervosa: emerging perspectives. Neuropsychiatric Disorders & Treatment, 11, 385–394. doi: 10.2147/NDT.S61665
Raevuori, A., Haukkal, J., Vaarala, O., Suvisaari, J. M., Gissler, M., Grainter, M., Linnal, M. S., & Suokas, J. T. (2014). The increased risk for autoimmune diseases in patients with eating disorders. Plos One, 9(8). e104845
Troop, N. A., Allan, S., Serpell, L, & Treasure, J. (2008). Shame in women with a history of eating disorders. European Eating Disorders Review, 16(6), 480-488. https://doi.org/10.1002/erv.858
Zerwas, S., Larson, J. T., Peterson, L., Thornton, L.M., Quaranta, M, Koch, S. V., Pisetsky, D., Mortenson, P. B., Bulik, C. M. (2017). Eating disorders, autoimmune, and autoinflammatory Disease. Pediatrics, 140(6). E20162089