Why might someone cut out a food group?
There are many reasons why a person might stop eating foods from a certain food group. A very common one is that they may be following a special diet such as Paleo that often eliminates grains and dairy. (Note: Vegans technically do not eliminate the MyPlate dairy group if they include the fortified milk alternatives that contain a similar nutrient profile to dairy products.) Another reason is that they may choose to follow a diet for weight loss where they have eliminated a food group (often grains). They may have an illness or medical condition that decreased their appetite or requires the restriction of certain foods. This group should have close medical supervision so I am not going to cover this topic here.
Children who are picky eaters may very temporarily refrain from eating foods from certain food groups and this is generally not a cause for concern. However, there is an eating disorder called avoidant/restrictive food intake disorder (ARFID) that may resemble picky eating on the surface but is much more severe and leaves the sufferer at risk of nutrient deficiencies. Often those with ARFID will not eat fruits and vegetables (aside from possibly fried potatoes). There was a really great article recently published in Today's Parent if you are interested in learning more about ARFID. Those with other types of eating disorders may be missing intake from certain food groups as well.
So if a person eliminates a food group from their diet, are they going to become deficient?
No, not necessarily. With a well-planned diet, it can be possible to eliminate a food group (or possibly multiple food groups) without deficiencies. There is a greater risk of developing deficiencies of the micronutrients in the chart above with the elimination of the food groups mentioned (or with the elimination of fats/oils). However, increasing the intake from certain food groups can lessen the risk of deficiency from eliminating others. For instance, if a person is eating a large variety of vegetables, they may adequately cover the vitamin A, vitamin C, folate, and potassium that they might have otherwise missed by restricting fruit intake. Grains contain many B vitamins but these can also be obtained from other foods if these foods are consumed on a regular basis:
- Thiamin (vitamin B1): pork, trout, black beans
- Riboflavin (vitamin B2): dairy products, beef, almonds
- Niacin (vitamin B3): peanut butter, beef, chicken breast
- Pyridoxine (vitamin B6): chickpeas, salmon, chicken breast, potatoes, bananas
- Folate (vitamin B9): spinach, asparagus, Brussels sprouts
- Vitamin B12: animal-derived foods (meat, dairy, eggs) and fortified products (such as some plant-based milk alternatives)
The above list is far from exhaustive but does contain some of the most common food items that are good or excellent sources of these vitamins. Generally, dietitians will recommend a "foods first" approach, i.e. getting all of your nutrients from foods rather than supplements, if possible. However, if there are concerns that micronutrient needs are not being met and dietary variety cannot be expanded, a multivitamin and mineral supplement is warranted. Water-soluble vitamins are of particular concern since it can only take a few weeks for a severe deficiency to develop without intake (e.g. as little as one month for scurvy). Many nutrients (such as the B vitamins) are not required to be listed on the label. If you have any questions about whether your current intake is adequate, I highly recommend checking in with a dietitian who will be supportive of your health goals.
Are these diets that are restricting food groups for weight loss all a form of orthorexia?
Orthorexia actually isn't an official diagnosis in the DSM but it generally refers to someone who has developed disordered eating habits in an effort to eat in a way that is more "pure," "cleaner," or "healthier." I recently read a really great article on this topic over on the Eating Disorder Hope website and I highly recommend checking it out. In the article, eating disorder dietitian rockstar Jessica Setnick says the following:
"My mission in life is to no longer focus on any diagnostic criteria but educate people that we all have eating behaviors. Everyone who eats has an eating behavior, and most of us have some kind of dysfunctional eating behavior that may or may not meet any diagnostic criteria. The question is really, “are your eating behaviors positively or negatively impacting your life?” So checking those “boxes” becomes much less important and what is more significant is how your eating behaviors are affecting your daily life."
She says in the article that her bottom line regarding orthorexia is, "can someone stay nourished?" If they are flexible enough with their diet that they are able to stay nourished, that they can be relaxed about "mistakes," that their way of eating is not diminishing their quality of life (or that of others) and their self-esteem... these may all be the most important questions. (I'd add that improvement of lab values is another consideration.) It is true that dietary interventions for weight loss may lead to a decreased quality of life and/or disordered eating in some individuals so it is critical that individuals continue to evaluate whether a certain dietary approach is benefiting them. The research on whether weight cycling due to yo-yo dieting leads to greater health risks compared to not trying weight loss strategies at all remains inconclusive.
What I think is not OK is when we try to tell someone else what their goals should or should not be for their bodies (e.g. whether they should or should not have a weight loss goal). I believe that it can be wrong, to the point where it can become a bullying behavior, to try and define someone else's healthy normal is (not only for eating but for general lifestyle choices). As was expressed at the AUCD conference last month, normal is overrated! It is perfectly fine in many cases to be atypical. Some food behaviors that are deleterious to one person may provide life-changing benefits to someone else, so maybe let's not be so quick to make judgements, eh? Pushing foods on people, harsh criticism, and automatically slapping a layperson diagnosis of orthorexia on people who are choosing not to follow the Dietary Guidelines or who choose to "eat clean" gets us nowhere.
Which is better, a nutrition supplement shake or a multivitamin?
Every time I present my research on severe nutrient deficiencies in ARFID, I get asked which is the best multivitamin or supplement shake to recommend to patients. In a patient who is only accepting only a handful of types of foods, the answer is going to be the one that they will accept. This can end up being a large added expense for parents/caregivers who may have to purchase quite a few brands to find one that is accepted. The goal is to increase vitamin intake to prevent deficiencies while the person works on increasing dietary variety. The gummies or other vitamins that resemble candy are absolutely fine if that is what the person accepts. If the person cut a food group for weight loss and cannot get the needed micronutrients from the foods in their diet, a multivitamin will probably be the better choice (if the person is unwilling to increase dietary variety).
When the person is underweight or failure-to-thrive along with being a selective eater, nutrition supplement shakes can offer several advantages over a multivitamin. The primary advantage is that supplement shakes provide calories and often protein that a simple multivitamin does not. This also makes the shakes an appropriate choice for patients who have poor appetite due to chemotherapy or illness and are malnourished or losing weight. The disadvantages of the supplement shakes are that they are typically far more expensive than the multivitamin and they often contain more added sugar and oils that may not be desired. In addition, it may end up being more difficult to get someone who restricts types of food to consume a whole shake instead of a small multivitamin.
How much is too much when it comes to micronutrients?
Many micronutrients (even the water-soluble ones) have a Tolerable Upper Intake Level (UL). The UL is the highest level of daily intake from both food and supplements that is unlikely to result in adverse effects in the general population. The UL does not apply to individuals with certain medical conditions who are undergoing specific nutritional therapies under medical supervision. It is difficult to exceed the UL with foods alone (although not impossible); the biggest risk comes with consuming high-dose supplements. For this reason, it is generally unnecessary to use supplements that exceed 100% of the DV for micronutrients.