Does AIP Cause Eating Disorders?

A few weeks back, a comment on our Instagram account drew our attention. Now it isn’t like we don’t notice what this big, awesome community is saying on our social media channels. After all, we have them so we can be in conversation with all of you, but it’s also true that with such a large and engaged audience it’s not humanly possible to stay on top of every comment and personally respond. We wouldn’t be able to do any of the other work you have come to know and appreciate! So, why did this particular comment garner our attention? Because the commenter insinuated that AIP causes disordered eating and that the leaders in the community are ignoring it… whew. That’s heavy.

To be absolutely crystal clear, let me share what our stance has been since the beginning and will always be: The goal of AIP is to arrive at the least restrictive diet that produces the absolute best health for the individual. We don’t think anyone should be any more food restricted than is necessary.

We don’t typically respond to individual social media conversations with entire blog posts, but this time we are going to cut right to the heart of the matter, because we take disordered eating very, very seriously. If the topic is being raised, we feel it is time to once again take the bull by the horns and address it.

Before I share the history of the community-wide response to this issue, I think we need to define a few words, review what the experts have to say, and take a look at warnings signs and ways to address disordered eating, ‘cause being on the same page is important when a topic carries so much emotional weight for so many.

Defined Eating Disorders and Orthorexia

Let’s start with defined eating disorders. As of 2013, the Diagnostic & Statistical Manual of Mental Disorders: Fifth Edition (DSM-V), defined four eating disorders. The DSM-V is like the “bible” for mental health professionals and helps them diagnose their patients.

The disorders they recognize are: binge-eating disorder, anorexia nervosa, bulimia nervosa, and other specified or unspecified feeding or eating disorder (they are grouped as “eating disorder – not otherwise specified”). “Specified” is when someone fits almost all the criteria for a diagnosis of one of the first three disorders, but maybe hasn’t had any physical ramifications yet. “Unspecified” is when someone doesn’t fit the current categories.

The biggie missing from this list and the one that most often gets brought up in the AIP community? Orthorexia nervosa or just “orthorexia.” Orthorexia was coined by Steve Bratman, M.D. in a 1997 Yoga Journal article as a “problematic fixation on eating healthy food.”

Since that time a more nuanced definition, proposed diagnostic criteria, and an assessment has been developed by Dr. Bratman and his colleagues, but it has not yet been accepted into the DSM. If you’d like to read his full definition and proposal you can find it here.

I think it’s important to note that Dr. Bratman came to the medical world through the alternative medicine practitioner door. In other words, he’s seen the full spectrum of eating behaviors and describes himself a “healthy eating” proponent.

Do AIPers have a “problematic fixation?”

AIP, in and of itself, is not orthorexia, but it is possible that some in the community might be at-risk for or have developed this issue. I’ve written about this in the past (more on the history below), but the experts from Dr. Bratman to evolutionary psychiatrists in the larger Paleo community, like Dr. Emily Deans, have carefully visited this topic in detail. What they have to say is very helpful in recognizing the difference between a disordered approach and not, so let’s look at it:

Dr. Bratman makes the distinction this way:

Adopting a theory of healthy eating is NOT orthorexia. A theory may be conventional or unconventional, extreme or lax, sensible or totally wacky, but, regardless of the details, followers of the theory do not necessarily have orthorexia. Here is the central point: Enthusiasm for healthy eating doesn’t become ‘orthorexia’ until a tipping point is reached, and enthusiasm transforms into obsession. Orthorexia is an emotionally disturbed, self-punishing relationship with food that involves a progressively shrinking universe of foods deemed acceptable. A gradual constriction of many other dimensions of life occurs so that thinking about healthy food can become the central theme of almost every moment of the day… This may result in social isolation, psychological disturbance and even, possibly, physical harm.

Dr. Deans draws the line this way:

But like all psychiatric conditions the cardinal issue is that the obsession interferes with normal functioning or relationships or causes pathology, such as anxiety. Orthorexia can have a number of different forms… for some it involves what they eat (e.g. only certain foods), sometimes it involves the preparation or creation (no eating food cooked in aluminum pans or any food ever exposed to pesticides). Is just eating paleo/primal ‘orthorexia’ on its own? Absolutely not… If… eating takes up a disruptive amount of time, makes you unduly anxious or is causing major problems in your life, you might want to consider some professional help.

I think in the AIP community it is possible that for those at-risk, this starts out innocently. We are all here, because we want to heal. We really, really, really want to feel better. And when AIP helps, it’s easy to think, “Okay, I’ll do it even better. If restricting these foods worked, then I should restrict even more foods and I should add other kinds of healing diets, ‘cause more is better.”

But the truth is that more is not always better, especially if “more” refers to restriction. That level of restriction can head in the direction of disordered eating in a hurry.

So, what are the risk factors for disordered eating?

Diet is definitely a risk factor for developing an eating disorder. Both Dr. Bratman and Dr. Deans agree on that. The risk rises with the level of restriction. Dr. Bratman defines raw food veganism and the very extreme, fruitarianism (which he notes is not nutritionally sound), as the riskiest, however he also says, “But with a nutritionally sound diet, what matters is not whether the theory is wrong or right, scientific or unscientific. It’s how it impacts you as a person.”

So, could AIP lead to disordered eating? Yes. But basically, there is a big “know thyself” caveat here.

Part of that “know thyself” bit might be understanding other risk factors. The National Eating Disorders Association (NEDA) defines the following as risk factors to be aware of:

  • Having a close relative with an eating disorder
  • Having a close relative with a mental health condition
  • History of dieting
  • Negative energy balance (burning off more calories than you take in)
  • Type 1 (insulin-dependent) diabetes (Research has found that approximately one-quarter of women diagnosed with type one diabetes will develop an eating disorder.)
  • Perfectionism
  • Body image dissatisfaction
  • Personal history of an anxiety disorder
  • Behavioral inflexibility (“There is only one right way.”)
  • Weight stigma
  • Teasing or bullying
  • Appearance ideal internalization (buying into socially-defined “ideal body”)
  • Acculturation (Racial and ethnic minority groups, especially those who are undergoing rapid Westernization, may be at increased risk for developing an eating disorder.)
  • Limited social networks
  • Historical trauma

If you see yourself in any of these factors, it’s probably smart to consider how great that risk is before undertaking any kind of diet, AIP or otherwise. If you have several of them, I would assume that risk goes up and the more likely you are to need therapeutic and possibly healthcare team support before undertaking a healing protocol.

It’s not weak to seek extra support, it’s brave and downright smart. Maybe a protocol like AIP can still work for you, but perhaps you’ll need to take the process slower, determining if less restrictive levels achieve the health objectives you were hoping for without the need to go further. (This is, in part, why we advocate in our book for a slow-and-steady transition for most folks and why I’ve been coaching this style for years in SAD to AIP in SIX.)

Or maybe you and your support team will decide that other approaches to helping manage your autoimmune disease are more appropriate given your personal risk for developing an eating disorder.

What if I think I’m already struggling with disordered eating?

At Autoimmune Wellness we have never denied that there may be members of the AIP community struggling with disordered eating or those who are at-risk for developing these patterns (as there are in any dietary theory group). We are not mental health professionals or eating disorder specialists, but our understanding based on conversation with professionals who are and the literature available, is that evaluating warning signs and getting help early is the best way forward. According to the NEDA, the following are common emotional/behavioral warning signs to be aware of:

  • In general, behaviors and attitudes that indicate that weight loss, dieting, and control of food are becoming primary concerns
  • Preoccupation with weight, food, calories, carbohydrates, fat grams, and dieting
  • Refusal to eat certain foods, progressing to restrictions against whole categories of food
  • Appears uncomfortable eating around others
  • Food rituals
  • Skipping meals or taking small portions of food at regular meals
  • Any new practices with food or fad diets, including cutting out entire food groups
  • Withdrawal from usual friends and activities
  • Frequent dieting
  • Extreme concern with body size and shape
  • Frequent checking in the mirror for perceived flaws in appearance
  • Extreme mood swings

Again, keep Dr. Bratman and Dean’s distinctions in mind when considering this list. Also, be aware that there are physical warning signs. I did not include them here, because many are overlapping with autoimmune disease symptoms and in an effort not to confuse readers I thought it best to leave them out. Ultimately, if you think you may have or be developing an eating disorder, that is sufficient reason on its own to involve a professional and be evaluated. Don’t rely on self-diagnosis, Internet research, or friendly advice, seek appropriate help.

Have the leaders in the AIP community ignored eating disorders?

Let me be frank… it is completely untrue to characterize AIP leaders, ourselves included, as having ignored the possibility or existence of disordered eating patterns in our community. It is not enough to just say that, though – it’s important to show the history and demonstrate our efforts on this controversial topic. We have not been shy.

In April, May, and June of 2014 I published blog posts on orthorexia and body image on my then solo blog. They migrated with me to Autoimmune Wellness and can be found here, here, and here. When I was writing my first book, The Alternative Autoimmune Cookbook, I decided to dedicate a whole section to the topic, entitled “A Short Word on Balance.”

I then took it further with another section on body image, entitled “My Butt Manifesto.” The book was published in December of 2014. While my understanding may have evolved some since that time and hopefully my writing style itself has improved, the same core effort to address the topic was there.

In 2014 I also launched my online group health coaching program for AIP with a very deliberate and slow transition style. I learned almost immediately that I would sometimes encounter members who were struggling with this disordered tendency or had in the past. I adopted a very forward approach to it and use it to this day.

First, I reach out to these members and thank them publicly for sharing with the group and then privately to ask if they have therapeutic support, if I can help them find a professional to join them, or even offering full refunds if they find the process too triggering so that those funds can be applied to therapy.

Mickey and I do the same in our private practices with individuals. Without fail, when a group member or client has needed to identify this support and I have reached out to mental health professionals for referrals, those professionals have been impressed with and grateful for my awareness.

Also in 2014, Eileen Laird of Phoenix Helix addressed the topic here. She was especially keen to point out how food fear could slide into a disordered approach. In 2015, Sarah Ballantyne of The Paleo Mom addressed the topic by featuring a guest post about a woman who actually found some relief not only from health issues, but her serious eating disorder struggle through a Paleo template.

(While I am not suggesting that Paleo, AIP, or any other dietary protocol can “cure” eating disorders, it should be noted that even Dr. Dean’s recognizes how sometimes a particular protocol can actually give certain individuals a sense of freedom about food. She discusses it in this post.)

Our book, The Autoimmune Wellness Handbook, has a section on this issue. We have mentioned it multiple times on our podcast over the years. And we include touching on it and discussing how to appropriately address it in our AIP Certified Coach training program. That is just the start. If I were to research every social media post, I’d have many, many more examples of how we and other leaders in our community have attempted to address disordered eating.

We absolutely believe in the healing power of food and do not think that AIP automatically produces an eating disorder. We know AIP and many similar protocols do, in fact, work wonders for many forms of illness without causing a disordered struggle. We also want to be leaders who are advocates for balance and an approach that discourages disordered eating of all kinds. After all, this journey is about being our best selves, not developing burdened hearts and minds.

About Angie Alt

Angie Alt is part of the blogging duo behind Autoimmune Wellness. She helps others take charge of their health the same way she took charge of her own after suffering with Celiac and other autoimmune diseases; one creative, nutritious meal at a time. Her special focus is on mixing “data with soul” by looking at the honest heart of the autoimmune journey (which sometimes includes curse words). She’s also a world traveler who has been medically evacuated from two foreign countries. Strategizing worst-case scenarios is now something of a hobby. She is a Certified Health Coach through the Institute for Integrative Nutrition and author of The Alternative Autoimmune Cookbook: Eating for All Phases of the Paleo Autoimmune Protocol. You can also find her on Instagram.

34 comments

  • Kelsey says

    Love this Ang, what a great way to combat the negativity with sensitivity and accuracy. 💕

    • Angie Alt says

      Thanks for commenting Kelsey! We are sure doing our best to answer the tough spaces of this journey w/ compassion & helpful info.

  • Melanie says

    As someone who has worked with Angie and has a history with eating disorders, I can 100% back up what is posted here. I felt very supported, and Angie was quick to reach out to me when she learned of my past tendencies. Thank you, Angie, for your support then and now!

    • Angie Alt says

      Aaaaw. Thanks for commenting Melanie. It is my privilege to get to be a part of any journey.

  • Calley says

    This is an amazingly thorough analysis and explanation and an excellent piece of writing!! Wow.

  • Thank you for this thorough discussion. As an LMHC and Eating Disorders therapist (past and present), I have never considered a medically-necessary diet to be an Eating Disorder, though I have seen how it can develop into one depending on the person’s preoccupation and obsessional behaviors around food, such as a Type I diabetic using food and the restriction of insulin to gain control of body weight. As a person with Celiac Disease that didn’t respond well enough with the standard gluten free diet, the AIP really helped move my health in the direction of recovery post diagnosis, and a modified AIP with essential reintroduction has kept me healthy. But like your discussion, I have had family members and friends insinuate and express concern that the AIP looks like eating disordered behavior from the outside; one demanded that I prove that I did not have an ED requiring outside professional help, which I happily provided. This post could be helpful in explaining to concerned family members and friends how their concerns, though valid, may be identifying behavior that does not pair 1:1 with weight loss behaviors and preoccupation of orthorexia or restricting anorexia nervosa. To put it bluntly, there are far more direct means that people with ED’s will engage if they wanted to control their weight and eating relationship issues.

    • Angie Alt says

      Yes! Thanks so much for sharing your views here Imei. Your background & personal experience make them particularly valuable to this conversation & helping folks see the differences.

  • Maureen Pesch says

    I started AIP on January 1st after learning that I have Hashimoto’s. Since then I have lost 12 lbs. I am 5’9″ and now weigh 130 lbs. I didn’t need to lose any weight and I’m not doing this to lose weight – I did it to bring down the thyroid antibodies, which were close to 1000. I retested after 4.5 months on AIP and my numbers dropped to 465, so I know that it’s working. Just two weeks ago a friend told me that I have an eating disorder. I was surprised and defensive, but have taken this well-meant observation to heart and am working hard to eat more while staying away from gluten and foods that I am sensitive to. I know though testing that I’m highly sensitive to dairy and eggs – both of which I love. So, the timing of your article couldn’t have been better! I am focused on what I can and cannot eat, and therefore, I spend more time planning, shopping, and preparing meals. Eating at someone else’s house and eating out are hard, because I don’t want to be a burden and it’s embarrassing having to explain to a server (in front of my boss and co-workers) what my restrictions are. Thanks for writing this article, as I needed to understand how this could be perceived as an eating disorder, what I need to be aware of, and what to watch for. Thank you!

    • Angie Alt says

      You are so welcome Maureen! I’m glad it is helping you evaluate how to make a few tweaks & see your friend’s comment as well-meaning.

  • Excellent article. I’ve always been impressed that the community is cautious with regards to the potential to contribute to or exacerbate disordered eating. It can be a slippery slope, and I feel like everyone walks it with care.

    • Angie Alt says

      Thanks for commenting Jan! We are definitely trying hard to be aware leaders who talk about “the good, the bad, & the ugly,” so that everyone has all the tools they need.

  • Susan says

    Appreciate this. Before paleo I was a nervous eater because I never knew what foods would make me feel awful. So, much like the Whole30 is for some people, AIP is food freedom for me. As for “orthorexia”, the concern-trolling one can get for following a restricted diet, especially one that looks trendy, can border on gaslighting. I find it helpful to say, “I eat as much as I want, I just don’t eat foods that hate me.” 😉

    • Angie Alt says

      Susan, that’s a great reply if it helps you deal w/ negative interactions around the steps you are taking to manage your disease. “Concern-trolling” is an interesting way to think about some of that behavior leading to the negative interactions (I’ve written about it in relation to commenting on people’s weight).

  • Felicity says

    Hi Angie,
    Great article, as always. I do find myself still rather conflicted, however. Dr Deans says (above) that the line into orthorexia is crossed when one’s diet interferes with normal relationships. But how could AIP possibly not? Every time I’m invited to a work lunch I have to spend hours on the phone and sending emails to the organisers, the restaurant/cafe etc. just to make sure there will be something aip-friendly for me to eat, or else decline the invitation. It impacts daily life because I must constantly be aware of what I can eat – I can’t just pop down to the nearest KFC if I get hungry during the day so I need to be always prepared. I don’t like to eat around other people anymore because I’m tired of comments about how “healthy” I am while watching them eat foods I wish I could safely taste. Does this constitute a disorder or is it just part & parcel of managing my condition? More importantly, if it does indicate a disorder, what can I do about it? Surely going off AIP and permanently chaining myself to a toilet is not a viable option.

    • Angie Alt says

      Felicity, if needing to make arrangements so you can enjoy a great meal or prepping ahead feels like it is negatively impacting your relationships that might mean you need to speak w/ a professional & evaluate together whether or not things are disordered for you. You & that professional can make decisions about how to take action if it is determined it’s a problem. If it just feels like part of the steps you are taking right now to help manage your disease, then I wouldn’t be as concerned. For instance, we don’t think of Type 1 Diabetics, carefully managing their diseases, including watching numbers all the time in relation to food consumption as disordered. We just think of them as managing their disease. I think the line is something you know internally and seeking help if it feels like you’ve crossed it is definitely the right step.

  • Casey says

    What an interesting conversation! I’ve been very aware of how my own health issues have pushed me towards disordered eating patterns. When I discovered AIP I was teetering on the edge of anorexia, not because of body image issues, but because I was in so much pain every time that I ate. I had become afraid of food and would put off eating until I absolutely had to. Until the hunger was causing more pain than the food would. At one point my husband made me promise to eat at least 700 calories a day. And it was hard to do. AIP saved me from that. Within a week of following the AIP rules I was eating without pain. The food fears lingered for a long time (there was one Thanksgiving where I wouldn’t allow bread at the table I was sitting at…I was a bit intense for a while), but eventually they subsided. I don’t eat a strict AIP diet anymore, having reintroduced many foods, but if my health starts to head in the wrong direction I can always rely on the AIP diet to help me feel better. I think that fear of food and how much pain it can cause is incredibly powerful, and I imagine a lot of people who turn to AIP have felt it.

    • Angie Alt says

      Thanks for commenting here Casey! I’m so glad that AIP eventually helped you heal & find balance.

  • Kat says

    Thank you for posting about this. I have been struggling with disordered eating the last few months which was triggered while on the AIP elimination phase. This was not the fault of the diet itself but of my mental health (anxiety, need for control and ocd tendencies) combined with my experience of illness. I learned to no longer trust my body and it’s reactions while I was ill, which grew into fear. I felt better on AIP so much that fear began to take over when it was time to reintroduce foods. I became irrationally terrified that the foods would harm me or kill me. I just didn’t want to be sick again.

    Fear and constant worry/thought about food is a warning sign that is often not mentioned in writings about disorders and was the tipping point for me. When the fear became overwhelming, it is time to seek professional help.

    Your wellness handbook was the first place I had actually seen this risk mentioned. This blog and your books has been a place I’ve gone to in my recovery for a place to read positive things about food as nourishment and variety as nutrition.

    Since my disorder does not fall into one of the defined ED boxes as I’m sure is true for many of your readers who are also struggling or at risk, I hope that you’ll continue to address this issue and it’s warning signs as we all learn more about this.

    • Angie Alt says

      Thank you for being so vulnerable in sharing your struggle, Kat. I’m so glad you found information that helped in our book & here on the blog. I hope you’ll find lots of support w/ a professional moving forward.

  • Shelley says

    As a person who has an eating disorder (30+ years), AIP has been the final refuge in helping calm my internal storm. Starting with LC, I have followed a meandering path trying and discarding various eating patterns in an effort to help manage my autoimmune disease and balance my body’s hormones. Collectively, this journey has been successful in doing this as well as going far in restoring my mental calm. When I stick to AIP, my body responds to it dramatically. No urge to binge, no need to purge. No obsessing about what, where, when I’m going to eat. I can just be. My mind and body are still. I am so thankful that my years of searching led me to AIP.

    • Angie Alt says

      What an awesome outcome for you Shelley! Thanks for sharing your journey!

  • Elizabeth says

    Thanks SO much for this article. Funny enough, a few weeks after starting on the AIP protocol, a friend of mine, out of love and care, mentioned that I need to be careful about developing an eating disorder, and I was totally caught off guard. For me, the protocol has given me so much relief from pain, and a feeling of control and empowerment that the idea of it being negative or could lead to a disorder seemed ridiculous. I do agree that once one gains control over their body, pain, etc. that developing anxiety around eating things that aren’t part of the protocol could have a negative affect. I’m about 4 months in and reaping the benefits!!!

    • Angie Alt says

      Thanks for sharing Elizabeth! It sounds like your friend reached out w/ care, but that for you it has been a positive, self-aware journey.

  • Lori Johnson says

    I went on AIP for a year to try to help myself. I have Secondary Sjogrens which includes Chronic Pancreatitis, Vasculitits, Hypythyroidism, RA and diabetes….so far. I didn’t think it had helped much so I went back to just Paleo. It had DEFINITELY helped. My autoimmune disease didn’t go away (which was my hope) but it was much easier to deal with. I intend to go back to AIP. What I can say for sure is that AIP opened my eyes to healthy, whole foods and I am grateful EVERY SINGLE DAY for this website!! I think maybe sometimes people say things because they can’t do it themselves so instead of an attaboy they denigrate. I give you a load of attaboys for what you have taught us so far and what you will share with us all in the future. Thank you and nice blog post.

    • Angie Alt says

      Thanks for sharing & the encouragement Lori. We certainly hope our work is positive.

  • As a licensed therapist who has a lot of personal and professional experience in eating disorders and specializes clinically in this area, as well as autoimmune, holistic wellness, I’m grateful for such a comprehensive post on this topic. I cannot wait to direct folks to this page.

    • Angie Alt says

      Thank you so much Lori! We appreciate you sharing from such a knowledgeable position & seeing us a great resource.

  • Lisa says

    Not to insult anyone in particular, but most women have many of the risk factors to some degree, most of the time, if not all of the time. It’s not really AIP that’s the problem, it’s keeping a handle on all the things we might not like about ourselves or our bodies. People also have a great tendency to blame a thing, or a protocol etc, instead of looking at themselves as responsible adults making wise or unwise choices. Yes, occasionally we find ourselves unintentionally doing something obsessive, but again, as adults making our own choices, it’s up to each one of us to assess things and make adjustments. It’s called personal responsibility and self awareness, quit blaming others for all of your problems.

    • Angie Alt says

      Lisa, we certainly believe in a strong value of personal responsibility & I appreciate what you are saying here. It is certainly really important to know yourself & be honest about your risk factors, but I also think some may not be in that self-awareness space when they encounter these issues or they just may need additional help to identify & overcome them.

  • Caroline says

    It’s great to see this article. As a clinical psychologist, and someone who is using AIP principles to alleviate symptoms of RA, I have found from my own experience that the restrictive aspects of AIP can trigger the common emotional and cognitive cycles which can lead to disordered eating of the binge-eating type. This is because restricting and avoiding certain food types is a risk factor for developing binge-eating disorder – there is a risk for any of us that when we ‘slip’, we can be at risk of eating more of a previously avoided food than we would normally eat (perhaps telling ourselves that we ‘might as well’ make the most of being able to eat that avoided food while we are ‘off the wagon’ and that we will get back onto it again soon). It is going to be useful for others trying to apply AIP to help relieve themselves of symptoms of disease, to be aware of this and to be able to find resources to help learn to avoid the all or nothing thinking styles than can underpin these sorts of binge/avoid cycles.

    • Angie Alt says

      Thanks very much for sharing your insight & expertise here Caroline. We really hope the open conversation will help anyone struggling w/ these issues.

  • Mary Anne Lloyd says

    I am glad you are talking about this. I have been on the AIP for 6 months and I can see how one could slip into an eating disorder. It’s difficult to let go of the diet especially if you are hoping that the next day might be the day that it actually kicks in and changes your life. I have had great results in shedding some unneeded pounds, but it has had no affect at all on my autoimmune issue. It is hard to give in and start re-introducing Foods because it also means you are giving up. Recently, I started adding a few things back in – mostly out of necessity to have a “life”. It is not a very social diet, one can begin to feel like a social outcast and a pain if you are a guest to dinner, on vacation, or most anything social – all that can weigh on you and keep you from socializing- a begining trait for an eating disorder. One should really be careful on this journey.

    • Angie Alt says

      Thanks for sharing Mary Anne! I don’t think you are giving up if you feel it’s time to reintroduce more foods. That might be the right next step for you.

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