Restrictive diets are nothing new. The term “diet” transitioned from noun to verb in the late 1650s, and unusual (and sometimes dangerous) diet notions have punctuated Western history ever since. Against this backdrop of ever-changing yet always-present diet ideas, is the reality that food allergies are on the rise. And this – in some cases – provides the perfect environment in which an eating disorder can develop… or lurk.
We recognize that the relationship between diet-related medical conditions and eating disorders is nuanced and complex. Below we provide a broad overview of food allergies and intolerances, and what we know (and don’t know) about their relationship to eating disorders.
According to the American Academy of Allergy, Asthma and Immunology, more than 50 million Americans have an allergy of some kind. Food allergies are estimated to affect 4 to 6 percent of children and 4 percent of adults, according to the Centers for Disease Control and Prevention.
Food allergy symptoms, while most common in babies and children, can appear at any age; one can develop an allergy to foods that have been eaten for years with no problems.
True food allergies are characterized by an overactive immune response to a particular protein in food(s). Reactions can range from discomfort such as hives to an extreme response called anaphylaxis, whereby breathing becomes impaired, which can result in death. Highly sensitive individuals can react to airborne particles of the offending foods, whereby breathing or touching the food in and of itself can lead to a serious, even fatal reaction. Those who know they are allergic at this level most often carry an epi-pen, a life-saving injection of epinephrine that can buy them time before getting to an emergency room.
While any food can cause an adverse reaction, 90% are caused by “the big 8”: eggs, milk, tree nuts, peanuts, fish, shellfish, wheat and soy. A suspected food allergy can be formally diagnosed and treated by a physician who specializes in food allergies. To find an allergist/immunologist near you, search here.
Celiac disease, diagnosed in approximately 1% of the US population, is an autoimmune inflammatory reaction caused by the ingestion of wheat gluten and similar proteins in rye, barley, and to a lesser degree, oat. Endoscopic biopsy, used to diagnose this condition, will show villous atrophy of the small intestine. Most individuals with celiac disease experience symptoms when exposed to gluten, but some do not. Associated symptoms include abdominal pain, bloating, diarrhea, poor appetite, weight loss, muscle wasting, and failure to thrive, short stature, and pubertal delay in children and adolescents. Non-symptomatic individuals may present with abnormal lab work, such as low iron (anemia), that leads to further diagnostic testing. The only treatment is life-long adherence to a gluten-free diet.
For more information on Celiac disease check out resources including:
- The Celiac Disease Foundation
- Beyond Celiac
- Celiac Disease Center at the Columbia University Medical Center
Food Intolerances and Sensitivities
Food intolerances are another reason why some individuals restrict their food intake. While not as severe as an allergy, intolerances interfere with quality of life, so finding out exactly what one is sensitive to is important. Intolerances may cause various types of reactions including headaches, fatigue, bloating and gastrointestinal discomfort. Lactose (milk sugar) intolerance is a relatively common disorder that’s easily confirmed by a gastroenterologist. Treatment consists of a low-lactose diet, use of lactose-free foods, and pre-meal intake of a lactase enzyme supplement. An intolerance to other food-related substances, like food preservatives, dyes, and sulfites is harder to diagnose. This is often accomplished by the elimination of suspected “trigger” foods for a specific period of time, followed by a systematic food reintroduction. While an elimination diet is helpful in establishing a diagnosis, it should not be maintained for a prolonged period of time unless necessary.
Related but different from celiac disease as described above is non-celiac gluten sensitivity, which affects up to 6% of the US population. The physiology of non-celiac gluten sensitivity is poorly understood; it is unclear as to whether this disorder is an immune-mediated process or not. Gluten sensitivity does not manifest in villous atrophy of the small intestine.
Although a wide range of gastrointestinal symptoms (diarrhea, constipation, bloating) and generalized symptoms (“brain fog”, fatigue, headache, joint pain, skin rash) are attributed to this disorder, diagnosis is complicated by a lack of reliable biomarkers. Individuals with non-celiac gluten sensitivity may benefit from a gluten-free diet to ease symptoms, but gluten ingestion will not cause intestinal damage.
Complications with Eating Disorders
The relationship between food allergies (including Celiac disease), food intolerances and sensitivities, and other medical problems that interface with an individual’s diet (such as Type 1 diabetes, irritable bowel syndrome, etc.) and eating disorders is a research topic of growing interest. What we know so far is that:
- The presence of a diet-related medical condition can sometimes delay identification and treatment of an eating disorder.
- Eating disorder symptoms can, in some cases, masquerade as food intolerance or sensitivity. In these cases, normalization of eating (and weight, if indicated) will help improve tolerance and decrease sensitivity to certain foods or food groups.
It is advisable to establish care with medical professionals rather than to self-diagnose any of the conditions described above. Discuss the risks and benefits of implementing a restricted diet, including the diet’s impact on nutrient intake, weight, and psychological well-being, and clarify the intended duration of the restricted diet, as well as the plan for reintroducing a wider range of foods.
Choosing to eliminate any category or type of food should not be done because of a fad or on a whim. A balanced diet that includes varied food groups, to the extent possible given the presence of a diagnosed medical condition, provides the most support for overall physical and psychological health.