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:
Dr. Deans draws the line 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.
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.)
- 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.