Vegetarianism, Veganism, and Eating Disorders

Vegetarianism and Veganism

Vegetarianism and veganism have become popular diets, but for those struggling with an eating disorder or at risk for developing one, being vegetarian or vegan may raise a red flag.

According to The Vegetarian Resource Group, a 2016 national poll found that approximately 8 million or 3.3% of adults in the United States are vegetarian or vegan. Of these 8 million, approximately 4.3 million U.S. adults are vegetarian and approximately 3.7 million U.S. adults are vegan.

Vegetarianism has a higher prevalence among those who have an eating disorder or with a history of one. In one study it was found that individuals with an eating disorder history were more likely to have ever been vegetarian (52% of individuals with an eating disorder history compared to 12% of those with no eating disorder history) or currently be vegetarian (24% of individuals with an eating disorder history compared to 6% of those with no eating disorder history). Similar results were found in another study where approximately 45% of those with anorexia reported being vegetarian.

Vegetarianism Defined

A vegetarian is someone who consumes a primarily plant-based diet that excludes meat, poultry, and seafood. The term vegetarian is broad. Under the general term vegetarian, there are different subtypes that vary by which foods they consume and exclude. The different types of vegetarianism include:

  • Lacto-ovo-vegetarian: Consume both dairy and egg products, but do not consume meat, poultry, and seafood.
  • Lacto-vegetarian: Consume dairy products (such as milk, cheese, and yogurt), but do not consume egg products, or meat, poultry, and seafood.
  • Ovo-vegetarian: Consume eggs and egg products, but do not consume dairy products, or meat, poultry, and seafood.
  • Vegan: Excludes all products derived from an animal (including those coming from meat, poultry, seafood, dairy, and eggs).

Reasons Behind Choosing To Be Vegetarian Or Vegan

People choose to be vegetarian or vegan for many different reasons including for health concerns, weight control, ethical concerns, environmental concerns, religious beliefs, or for numerous other reasons. Among U.S. adults who were either vegetarian or vegan in the 2016 national poll, top reasons cited for choosing to be vegetarian or vegan included concern about animals (29%), health reasons including weight loss (18%), and ethics/political beliefs (10%). Health reasons including weight loss was the second highest reason for choosing to be either vegetarian or vegan, which may cause a need for concern in some. The problem arises when vegetarianism or veganism is taken to an extreme or used as a mask to hide or maintain an eating disorder.

When people use vegetarianism or veganism in an “unhealthy” way to purposely restrict food intake in an effort to lose weight then a red flag should be raised. Those who have an eating disorder or have a history of an eating disorder often choose to become vegetarian or vegan due to weight-related reasons. One study found that 42% of individuals with an eating disorder history were primarily motivated by weight-related reasons compared to 0% of the individuals with no eating disorder history.

The Correlation Between Vegetarianism and Eating Disorders

Vegetarianism is believed to have some kind of correlation with eating disorders. In fact, in one study 68% of individuals with an eating disorder and vegetarian history believed that there was a correlation between vegetarianism and their eating disorder. Further, these same individuals reported that being vegetarian helped them to lose weight as well as to maintain their eating disorder by providing another way to eliminate calories and feel in control. Vegetarianism may serve as a mask to cover up an eating disorder in an attempt to restrict food and lose weight. It provides an easier and more socially acceptable way to justify avoiding certain foods, while not raising a cause for concern when eating with others. Saying you are vegetarian makes it easier to restrict food and say “no, I can’t eat that because I’m vegetarian”; rather than admit to restricting foods on purpose. Individuals with an eating disorder may also use vegetarianism as an aid to maintain and enable the eating disorder by helping to control food intake and encouraging obsessive food rules that go along with eating disorder black and white thinking. It is also possible that a vegetarian or vegan diet may start with the best of intentions but slowly become disordered, obsessing over food judgments and rigid rules.

Recommendations During Treatment

A vegan diet is not advised for those in treatment or struggling with an eating disorder due to its very restrictive nature. Following a vegan diet can also make it difficult to meet the caloric requirements necessary in treatment. A vegetarian diet may be ok for some depending on the motivation for choosing to be vegetarian, but it is still not encouraged. The intention behind choosing to be vegetarian can distinguish a “true” vegetarian from one just using it in an “unhealthy” way to fuel their eating disorder or in an effort to lose weight. When chosen for the right reasons a “true” vegetarian diet includes a variety of plant foods. Instead of cutting certain foods out, a “true” vegetarian swaps foods for alternatives of equal nourishment, listening to their body to make sure they are getting the nutrients it needs. It is important for individuals with an eating disorder to explore and challenge their motives for choosing to be vegetarian with their treatment team. This gives insight about the function their vegetarianism serves and if it is being used by the eating disorder or negatively affecting their relationship with food. If choosing to be vegetarian for actual ethical reasons such as to protect the environment or animals, it may be acceptable for some. Whether a vegetarian diet is appropriate for you is a decision that should be made together with your treatment team after further exploring the topic. If the motivation for choosing to be vegetarian is instead for weight loss or to control food intake, the greatest gift a person can do for their recovery is to gradually let go of the vegetarianism and its restrictions, which can hinder recovery. While in treatment it may be necessary to take a break or “vacation” from vegetarianism to further explore these intentions fully. This allows the necessary work to be done to heal your relationship with food and to make sure caloric and nutrient requirements are being met.

If you really desire to be vegetarian or vegan for the right reasons a suggestion may be to let go of the vegetarianism or veganism for now while in treatment and to consider it later down the road if you still decide to do so once you have been fully recovered and remained stable for a while. Give yourself time to prioritize your recovery and to ensure you are giving your whole self to the process without vegetarianism or veganism holding you back. This will increase your chances of achieving full recovery!

Nutrition Recommendations

Vegetarian and vegan diets can make it more difficult to obtain certain nutrients. A well-planned vegetarian diet can meet nutrient needs when done correctly and with the right intentions, but some extra planning may be needed. The key is to eat a balanced diet that includes a variety of different foods. If together with your treatment team, you decide that a vegetarian or vegan diet may be acceptable for you there are some nutrients to keep in mind that may be harder to obtain. For additional nutrition guidance and to ensure adequate intake of these nutrients work with a Registered Dietitian to learn how to incorporate these nutrients into your diet, as well as discuss if any supplements may be needed.

Nutrients of Concern for Vegetarians and Vegans

The nutrients of concern for vegetarians (including vegans) include protein, iron, omega-3 fatty acids, and zinc.

  • Protein: According to the Academy of Nutrition and Dietetics, vegetarian and vegan diets can usually meet the recommended amount of protein when caloric intakes are adequate. This may be a concern though for vegetarians and vegans with an eating disorder such as anorexia who are restricting their caloric intake. Eating protein from a variety of plant-based foods while meeting caloric requirements can ensure protein requirements are met. Lacto-ovo-vegetarians, lacto-vegetarians, and ovo-vegetarians can get protein by consuming egg and/or dairy products. In addition, plant sources of protein include legumes (beans, lentils, and peas), tofu and other soy products, meat analogs, nuts, nut butters, and seeds, as well as grains (such as quinoa and wild rice).
  • Iron: Vegetarians and vegans can generally get enough iron from a variety of plant-based foods. Although, iron coming from plants (non-heme iron) is not as well absorbed as the form found in animal products (heme iron) due to compounds called phytates. This may make iron a concern for some vegetarians and vegans, especially women of childbearing age. Iron absorption can be enhanced by eating vitamin C rich foods (such as citrus fruits, tomatoes, and broccoli) along with iron-rich foods. Plant-based sources of iron include fortified breads and cereals, whole grains, leafy green vegetables (such as spinach), legumes (beans, lentils, and peas), soy products (such as tofu, tempeh, and soymilk), nuts, nut butters, and seeds, as well as dried fruit (such as dried apricots, dried figs, and raisins).
  • Omega-3 Fatty Acids: Intakes of the omega-3 fatty acids EPA and DHA are typically lower in vegetarians and absent in vegans since the main food source is fish. Lacto-ovo-vegetarians and ovo-vegetarians may have a higher intake if they consume eggs rich in omega-3s. The best plant-based sources of omega-3 fatty acids are flaxseed and flaxseed oil, chia seeds, walnuts, canola oil, and soy products (such as soybean oil and tofu).
  • Zinc: Vegetarians and vegans can usually obtain adequate zinc, but like iron, plant food sources are not as well absorbed due to phytates. This can be a concern for some vegetarians and vegans who consume high phytate foods such as whole grains, legumes, nuts, and seeds. Food preparation techniques such as soaking, sprouting, and fermentation can reduce the binding of zinc by phytic acid and counter its effects, thus increasing the absorption of zinc. Good food sources of zinc for vegetarians and vegans include legumes (beans, lentils, and peas), soy products (such as tofu), whole grains, fortified bread and cereals, nuts, nut butters, and seeds. For lacto-ovo-vegetarians and lacto-vegetarians another good source of zinc are dairy products such as milk, yogurt, and cheese.

Additional Nutrients of Concern for Vegans

While a vegan diet is not advised while in treatment, if you do choose to be vegan there are some additional nutrients of concern, in addition to the ones listed above. Since a vegan diet is more restrictive, excluding all products coming from animals (including meat, poultry, seafood, dairy, and eggs) it is important to make sure you get enough of the nutrients listed below. These additional nutrients of concerns for vegans include calcium, vitamin D, and vitamin B12.

  • Calcium: Calcium is an especially important nutrient for those with an eating disorder due to its role in bone health. Milk and dairy products are the best sources of calcium. Since vegans do not consume milk or dairy products their calcium intake is often lower. It is important that vegans make sure they get enough calcium from alternative sources. Plant-based sources of calcium include leafy green vegetables (such as bok choy, cabbage, collard greens, and kale), broccoli, calcium-set tofu, almonds and almond butter, and calcium-fortified foods including fortified breads and cereals, fortified plant-based milk (such as soy milk, almond milk, and rice milk), as well as fortified orange juice.
  • Vitamin D: Like calcium, Vitamin D is also of special importance for those with an eating disorder due to the role it plays with calcium in bone health. The best source of vitamin D is actually not from food, but from the sun (especially during the spring and summer). Our bodies naturally produce vitamin D when our skin is exposed to sunlight. Vitamin D is found in very few foods naturally (such as eggs), so several foods are fortified with vitamin D. Foods fortified with vitamin D include fortified bread and cereals, fortified dairy products (such as milk and yogurt), plant-based milks (such as fortified soy milk and almond milk), and fortified orange juice. Since vegans do not consume dairy products or eggs it is important that they receive vitamin D naturally from the sun or plant-based foods fortified with vitamin D. If sun exposure and intake of foods fortified with vitamin D are insufficient to meet needs, a vitamin D supplement may be recommended for vegans, especially during winter and fall. Talk with your physician and Registered Dietitian to assess whether a Vitamin D supplement may be needed.
  • Vitamin B12: Vitamin B12 is not found in plant foods unless they have been fortified with it. It is mostly only available in animal foods (including dairy products and eggs) making vitamin B12 an especially important nutrient of concern for vegans. Fortified vitamin B12 sources for vegans include fortified bread and breakfast cereals, and fortified soy products (such as soy milk, tofu, and other meat alternative products). Vegans must consume vitamin B12 fortified foods or take a vitamin B12 supplement to meet vitamin B12 requirements or they are at risk for deficiency. It has been suggested that all vegans should supplement with vitamin B12 since it is the most reliable way to make sure they are receiving enough. To find out if you are meeting your needs for vitamin B12 or if a supplement may be appropriate for you consult with your physician and Registered Dietitian.

 

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Additional Reading:

Learning to Eat Normally When Recovering From an Eating Disorder
Intuitive Eating
Mindful Eating
Treating Eating Disorders
Myths About Eating Disorders
Using Challenge and Fear Foods in Eating Disorder Recovery
Eating at Restaurants While in Recovery from an Eating Disorder

About the Author:

Elyse Metelka, MS, RD, CDN is a Registered Dietitian (RD) and Certified Dietitian Nutritionist (CDN). She is the owner and founder of Elyse Metelka Nutrition, a private practice located in New York City providing nutrition counseling and education. Elyse specializes in eating disorders, sports nutrition, nutrition for figure skaters, vegetarian nutrition, and intuitive eating. She is an “anti-diet” Dietitian who believes that all foods fit. Elyse has worked on the helpline at the National Eating Disorders Association (NEDA) to help those affected by eating disorders. Elyse is also currently a member of the Project HEAL HEALers Circle, helping to increase access to eating disorder treatment by providing free treatment to a Project HEAL grant recipient.

References

How Many Adults in the U.S. are Vegetarian and Vegan. https://www.vrg.org/nutshell/Polls/2016_adults_veg.htm

Bardone-Cone AM, Fitzsimmons-Craft EE, Harney MB, et al. The Inter-Relationships between Vegetarianism and Eating Disorders among Females. J Acad Nutr Diet. 2012;112(8):1247-1252.

Kadambari R, Cowers S, Crisp A. Some correlates of vegetarianism in anorexia nervosa. Int J Eat Disord. 1986;5(3):539-544.

Melina V, Craig W, Levin S. Position of the Academy of Nutrition and Dietetics: Vegetarian Diets. J Acad Nutr Diet. 2016;116(12):1970-1980.

Written – 2019