Teenagers, Vegan Diets, and Anorexia Nervosa
Restrictive plant-based diets are socially acceptable ways to reduce food intake. They also set the stage for malnutrition and disordered eating.
I remember one of the first teenagers with anorexia nervosa I saw in my clinical practice. She had completed in-patient care and was being treated by a variety of medical and mental health professionals.
The most memorable aspect of that first visit was the anguish on the part of both mother and daughter. It felt like there were storm clouds hanging above our heads in the office that day. Anorexia had consumed their lives over the past few years and the future looked uncertain and scary.
Anorexia nervosa (AN) is the most deadly of all psychiatric disorders. After diagnosis, up to 1 in 10 will be dead within 10 years. After two decades, 1 in 5 will have died. At least 20% of these deaths will be from suicide. In the end, less than half of AN patients recover fully from their illness.
Medical complications from AN are extensive. The brain may permanently atrophy. Bone density is often reduced to the point of osteoporosis. The heart can be damaged; arrhythmias and sudden cardiac death are not infrequent.
While psychiatric medications and therapy are commonly used as treatment tools, they have limited success in AN.
Certain people have a greater risk of developing an eating disorder. There appears to be a genetic link along with certain temperament and personality factors like perfectionism and anxiousness. Low self-esteem and difficulty communicating negative emotions are also risk factors.
Puberty and adolescence represent peak times for the development of an eating disorder. Girls are more affected than boys and tend to exhibit more severe symptomology. Family and social dynamics play a role.
The COVID-19 era drove increased rates of anorexia nervosa (AN) among teenage girls. A study in Canada showed a greater than 60% increase in AN cases during the initial implementation of draconian social policies like school and business closures, and cancellation of extracurricular activities. Those diagnosed with AN were in a worse state than those diagnosed prior to this time period. Physical confinement, social isolation, lack of routine, and more social media usage may contribute to this dramatic increase and worsening of symptoms.
What are the red flags that someone is in the grip of disordered eating? There are dozens of possible signs and symptoms. Dieting and dysfunctional food-related behaviors are ever present. One staggering piece of data I first learned from psychiatrist Dr James Greenblatt is that half of all people with eating disorders transition to a vegan or vegetarian diet prior to the onset of their eating disorder.
Nutritious foods like meat and dairy are avoided when practicing a vegan or vegetarian diet. And while some people claim ethical reasons for avoiding these foods, “plant-based” diets are also a socially acceptable way to restrict overall food and calorie intake.
Orthorexia is a term for the pathological obsession with “healthy” or “clean” eating. In practice, it often looks like restricting certain foods or ingredients with the ultimate goal of attaining thinness.
Veganism in particular is having a cultural moment. Perhaps you’ve heard the joke “How can you tell if someone is a vegan? Don’t worry, they’ll tell you.” Celebrities and social media influencers are notorious in their embrace of whatever keeps them relevant, including restrictive fad diets. Veganism also gives them a chance to claim some kind of moral high ground though I imagine that many of them are probably incapable of articulating an authentic and deeply considered rationale for their choices.
“Meatless Mondays” and a relentless focus on “plant-based” eating as a saintly ideal creates a situation where people can claim a variety of justifications (health, animal rights, climate change) for eliminating whole categories of nutritious foods from their diet.
So what happens when a teenager chooses a restrictive diet like veganism? Like most people who start a vegan diet, they may feel good if they clean up their diet in general, consuming less sugar, less processed food, less fried foods. But in short order, nutrient deficiencies will develop. They may experience hunger, cravings, reduced energy, poor sleep and mood issues. Their hair may start falling out. They may lose muscle mass and gain more fat tissue. These symptoms, in my experience, drive many people to quit a vegan diet. But a person with anorexia may not stop, and eventually become severely malnourished.
Zinc deficiency—which is common in both vegan diets and anorexia— may actually perpetuate the disease. A deficiency in this key mineral can affect appetite by reducing the ability to taste and smell food. It worsens all gut symptoms because digestive enzymes and stomach acid depend on zinc for their production. Zinc deficiency can lead to depression and attention deficit. Because melatonin production relies on zinc, sleep may be affected.
Many other nutrient deficiencies can develop on a vegan diet and in anorexia. B12 deficiency can lead to permanent neurological damage. Lack of vitamins D & A can affect immune function, skin health and vision. Iron deficiency can lead to easy bruising, shortness of breath and fatigue. Lack of essential fatty acids means that the brain— which is made up of 60% fat—is left starving.
Many of the symptoms of nutrient deficiencies are identical to those of anorexia nervosa: Lack of appetite and profound digestive issues. Neurological issues. Fatigue. Mental-emotional conditions like depression and anxiety.
Dairy, meat, eggs and fish are ideal for the developing bodies and brains of children. Regardless of how one might feel about these foods, they are necessary for humans to reach their physical and mental potential.
One of the arguments I often hear is that a vegan can simply take supplements to correct for any deficiencies. This reflects a profound misunderstanding of nutrition and human physiology. Whole foods like meat are complex and cannot simply be reduced to a collection of supplement capsules. Fake meats and fortified foods can make their nutrition labels appear to replicate truly nutritious foods, but they are decidedly not the same thing.
My clinical experience also gives me firsthand knowledge of how difficult it is to correct deficiencies in vegans using pills, powders and injections. Working with these patients can feel like running in place; we attempt to correct an array of deficiencies while also trying to keep up with the ongoing lack of nutritional input that should be coming from real food.
The bodily changes that arrive with puberty can be dramatic and scary for many kids. It’s telling that 80% of 13 year olds have attempted to lose weight. Driven by strong societal influences, children and teenagers may decide to adopt a restrictive “plant-based” diet in their attempt to manage the shape of their body. But veganism is not appropriate for children and adolescents. It leads to malnutrition and can facilitate the development and perpetuation of disordered eating.
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