Allergies, Intolerances, and Sensitivities in Eating Disorder Recovery
By Sam Wierzbicki MS RD
Recently, I sat down to a belated birthday dinner with a friend at a newly opened Manhattan restaurant. As we were perusing the menu, our waiter came to the side of our table and asked “Any questions about the menu?” When we shook our heads no, she followed up with the question, “Any food allergies or intolerances?” It struck me at that moment how common this question has become at many food establishments. And maybe more importantly, how common it is for diners to be responding in the affirmative.
As a whole, we seem to be seeing, suspecting, or experiencing food allergies, intolerances, or sensitivities in greater numbers than we have in decades past (and research tells us food allergy prevalence has in fact been increasing). Maybe you've noticed friends or family members all of sudden avoiding gluten or dairy due to perceived sensitivities. Or maybe you've felt not-so-hot after certain meals and wondered about your own body's reaction to the food.
Food intolerances and sensitivities seem to be buzzwords as of late in health and nutrition spaces. And as with any new wave of widespread interest when it comes to how food can impact health, there can be a lot of misinformation and confusion that arises. I've noticed that my clients are often left scratching their heads when it comes to really understanding the differences in allergies, intolerances, and sensitivities in connection to what they are experiencing, so let's start there.
Food allergy, intolerance, sensitivity…tomayto, tomahto, right?
Mmm, not exactly. The terms food allergy, food intolerance, and food sensitivity are often used interchangeably in society at large, but there are distinct differences in what triggers them, their mechanism of action in the body, and the severity of symptoms you might be experiencing.
FOOD ALLERGY 101
Food allergies occur when your immune system reacts to a protein found in certain foods, mistakes it as a threat, and produces antibodies to fight it off.
There are nine major food allergens that account for the vast majority of allergic reactions to food: milk, eggs, peanuts, tree nuts, soy, wheat, fish, shellfish and sesame seed.
Symptoms of food allergies can appear immediately after eating any amount of the allergen and can range from milder reactions such as rashes to life-threatening reactions such as anaphylaxis.
FOOD INTOLERANCE 101
Unlike allergies, food intolerances do not involve the immune system. Symptoms of food intolerances occur when the body has trouble digesting certain foods. This happens due to the body lacking enzymes needed to break food down in our GI tract or due to reactions to additives or natural compounds in foods.
Symptoms are generally mild and can change in presentation or severity based on the amount of food eaten. Though uncomfortable, symptoms are not physically harming the body or potentially dangerous.
FOOD SENSITIVITY 101
Currently, food sensitivity is not an official medical diagnosis, but it is understood to be a non-life threatening and often delayed immune response to specific foods. Unlike allergies, symptoms do not always appear immediately after food is consumed.
Like intolerances, the symptoms, while unpleasant, are generally mild and can change in presentation or severity based on the amount of food eaten.
Why is knowing the difference between these important?
Food allergies can be potentially life-threatening, and it's medically necessary to avoid consuming the food that our immune system reacts to. While food intolerances and sensitivities can result in unpleasant symptoms that may impair our functioning and quality of life, they aren't inherently dangerous. This matters because it means that we can respond to intolerances and sensitivities differently (i.e. we don't need to immediately jump to saying goodbye to suspected food culprits forever) and there's a bit more wiggle room for exploration and nuance.
Confirming a suspected food intolerance or sensitivity is unfortunately not so easy. At current, there is not one validated test or assessment that can tell us all the foods we might be intolerant and/or sensitive to. And those at-home food sensitivity tests that you may have seen on your Instagram feed are actually not so accurate. They test for a specific antibody that might be present when we are commonly exposed to foods versus sensitive to foods. What that means is that you might be pinged for a sensitivity to a food that is simply in your normal rotation and that in actuality your body does fine with. It can feel really frustrating that there aren't simple, easy, affordable ways to determine if we're experiencing food sensitivities or intolerances. Because of that, it might feel alluring to jump right to eliminating that suspected food from what you eat and never look back.
But let's take a pause for a moment and talk about that choice.
Why might it be a bad idea to remove foods from our intake without further exploration?
Taking foods out of our diet can really challenge our relationship with food and our overall health. When we start eliminating foods or food groups, we run the following risks:
Undernourishment and/or gaps in our nutrient intake which can lead to health complications
Increased fixation, anxiety, or fears around food to ensure suspected food is not accidentally eaten
Avoidance of eating in public spaces that are not fully controllable, leading to increased isolation
And for those of us actively working to heal from disordered eating or eating disorders, navigating how to deal with suspected intolerances or sensitivities while not detracting from that work can become really complex. Negative physiological reactions to food (a la potential intolerances and sensitivities) and our emotional relationship to food do not exist in separate bubbles. In fact, they may overlap a lot more than you've considered.
Where I start this journey of exploration with my clients, and where I'd encourage you to begin, is to try cultivating curiosity around the potential overlap. Ask yourself the below questions and see what you may uncover.
How has my relationship with food informed my suspicions of food intolerances of sensitivities? We live in a society where diet culture is pervasive, and weight loss is sold to us as a cure-all for feeling crappy both physically and emotionally. If you've ever been on a diet or attempted to lose weight by manipulating your food intake, it's possible your relationship to food has suffered. Sometimes, suspecting that we have food sensitivities or intolerances (and eliminating foods for this reason) can provide an alternate method to control or restrict the foods we eat in a way that might be aligned with diet culture, weight loss desires, or even eating disorder behaviors.
How might my beliefs or anticipation around the symptoms I experience in connection to food actually shape my physical symptoms? We already talked about how eliminating foods for the purpose of food intolerance or sensitivity management can potentially increase distress and fixation around food. Being distressed can show up in our bodies as stomach churning, GI upset, changes to bowel movements, etc. Physiologically, stress inhibits our digestion and increases our sensitivity to physical sensations. If you're feeling stressed about accidentally eating food for fear of uncomfortable symptoms appearing, you might be experiencing the somatization of stress rather than of your body's physiological reaction to food.
What's the timeline around when I first saw my relationship with food decline and when I first started noticing uncomfortable symptoms after eating? Are they distinct time periods? Do they overlap? This question is for everyone out there currently struggling with their relationship with food. We know that physiological complications of disordered eating or eating disorders can present in a variety of ways - migraines, bloating, GI pain after eating, stomach distention, and constipation to name a few. These complications can appear identically to some symptoms of food intolerances and sensitivities. It may be helpful to explore these potentially related timelines to note if they seem entirely distinct, totally overlap, or somewhere in between.
If this exploration brings up more questions than answers, you are not alone. Navigating how to address our body’s physical reaction to food while considering our emotional connection to food is not simple, but it is possible! If you're looking for more support on this journey, working with a dietitian can be an invaluable tool.