This blog post highlights the potential importance of tryptophan supplementation in improving therapeutics in anorexia (and other eating disorders) and some of my insights about the 2017 anorexia-tryptophan study. I also share the high incidence of eating disorders, overlaps with anxiety and the case for tryptophan supplementation given the many low serotonin symptoms (anxiety, obsessive thoughts/behaviors, perfectionism, negative-self-talk, low self-esteem and depression) we see with anorexia and other eating disorders. And the importance of a comprehensive nutritional approach.
I’ve updated the original blog with newer research on low zinc and iron with males with eating disorders – and how this ties in with serotonin production and also pyroluria (read on below).
According to The National Eating Disorders Association (NEDA), eating disorders are
serious but treatable mental and physical illnesses that can affect people of all genders, ages, races, religions, ethnicities, sexual orientations, body shapes, and weights. National surveys estimate that 20 million women and 10 million men in America will have an eating disorder at some point in their lives.
While no one knows for sure what causes eating disorders, a growing consensus suggests that it is a range of biological, psychological, and sociocultural factors.
While NEDA does acknowledge that some of the causative factors may be biological, unfortunately there is no mention of nutritional psychiatry or tryptophan on the site. You’ll see this to be the case in the majority of conventional treatment centers.
The 2017 paper on tryptophan potential for anorexia
The paper, Improving therapeutics in anorexia nervosa with tryptophan, does acknowledge that the “growing body of evidence suggests that our diet is an important contributing factor in the development, management and prevention of a number of psychiatric illnesses.”
It discusses what we know about tryptophan being “the sole precursor” of serotonin, a neurotransmitter and that when used as a supplement it has therapeutic benefits when serotonin is low.
The author proposes that excessive dieting and food restriction decrease brain tryptophan and serotonin and propose the “potential importance of tryptophan supplementation in improving therapeutics in anorexia patients” (together with psychotherapy).
Given that anorexia has the “highest lethality of all psychiatric illnesses” and that there are currently “no FDA approved pharmacological treatments available” for anorexia, the urgency for implementing nutritional psychiatry approaches is high. The authors also share that the antidepressants and antipsychotics which are commonly used to treat the co-occurring anxiety, depression, OCD and psychosis are not very effective.
The author mentions a paper that used 250 mg tryptophan twice a day but based on my work with individuals with anxiety, we know an individualized approach is best. A typical starting dose of tryptophan is 500mg used once or twice a day and I use the trial approach to determine the ideal dose for each person.
Incidence of anorexia and eating disorders in general
Here are a few select anorexia and eating disorder statistics from NEDA. I find much of this alarming and in some cases surprising (like the high incidence of males who are affected):
- 40% to 60% of elementary school girls (ages 6-12) are concerned about their weight
- 2% to 13% of adolescent girls meet the criteria for eating disorders
- Males represent 25% of individuals with anorexia (they are at a higher risk of dying because they are often diagnosed later since many people assume males don’t have eating disorders)
- Male athletes, especially those competing in sports that emphasize diet, appearance, size and weight, are at risk. In weight-class sports (wrestling, rowing, horse racing) and aesthetic sports (bodybuilding, gymnastics, swimming, diving) about 33% of male athletes are affected. In female athletes in weight class and aesthetic sports, disordered eating occurs at estimates of up to 62%.
- In one study of ultra-Orthodox and Syrian Jewish communities in Brooklyn, 1 out of 19 girls was diagnosed with an eating disorder, which is a rate about 50 percent higher than the general U.S. population.
- Despite similar rates of eating disorders among non-Hispanic Whites, Hispanics, African-Americans, and Asians in the United States, people of color are significantly less likely to receive help for their eating issues.
- Elevated rates of binge-eating and purging by vomiting or laxative abuse was found for both males and females who identified as gay, lesbian, bisexual, or “mostly heterosexual” in comparison to their heterosexual peers.
Prevalence of anxiety and making the case for low serotonin
The prevalence of anxiety is high in those with eating disorders (which is one of the reasons for this particular blog):
- Anxiety is also diagnosed in 48-51% of people with anorexia nervosa, 54-81% of people with bulimia nervosa, and 55-65% of people with binge eating disorder
- Two-thirds of people with anorexia also showed signs of an anxiety disorder several years before the start of their eating disorder.
In one study, after dietary treatment (called refeeding), plasma tryptophan levels normalized in patients with anorexia:
Disturbance in serotonin function has been described as central to the psychobiology of this disorder
Plasma TRP normalizes during the course of refeeding, supporting the hypothesis that serotonin function is disturbed in patients with anorexia nervosa.
We also see a large number of low serotonin symptoms in those with eating disorders:
- Childhood obsessive-compulsive traits, such as perfectionism, having to follow the rules, and concern about mistakes, were much more common in women who developed eating disorders than women who didn’t.
- Binge eating disorder patients … also had significantly higher levels of negative affect, and lower self-esteem
- In a study of women with eating disorders, 94% of the participants had a co-occurring mood disorder
There are all classic low serotonin symptoms: obsessive thoughts/behaviors, perfectionism, negative-self-talk, low self-esteem and depression.
This further supports the rationale for tryptophan supplementation and is another reason for this blog. I have extensive experience in the use of tryptophan and 5-HTP and believe they should be part of all eating disorder programs.
There is one big difference in that typically we see afternoon and evening sugar and carb cravings with low serotonin-type anxiety. Whereas with anorexia, the low self-esteem, obsessive thinking and body dysmorphia (feeling shame or disgust with parts of their body or appearance) may prevent someone acting on these cravings. However, if there are sugar and carb cravings (and bingeing), this is the time they will typically occur.
Here are two recent blog posts that share case studies where tryptophan was used with success:
- Tryptophan calms comfort eating, eases self-doubt, reduces uncontrollable late night snacking and results in a lot more peace around food
- Tryptophan for my teenager: she laughs and smiles, her OCD and anxiety has lessened, and she is more goal oriented and focused on school
Anorexia and other eating disorders require a multidisciplinary team and a targeted nutritional approach
I don’t currently work with clients with anorexia as it requires a multidisciplinary team. I did, however, work with a few clients with anorexia when I worked at Recovery Systems over 10 years ago. They had a therapist, nutritionist and doctor on their team and a nutritional approach led to more improvements than they had experienced at prior in-house eating disorder clinics where they had received psychological support only or psychological support and medication. Our approach included addressing low serotonin with tryptophan or 5-HTP, addressing low zinc and low iron, low vitamin D, addressing the gut/microbiome, low B vitamins, low omega-3 fatty acids and more (based on the unique needs of the client).
I now refer eating disorder clients to Dr. James Greenbatt, MD, an eating disorder specialist and integrative psychiatrist. He has a wonderful book on the topic: Answers to Anorexia – a Breakthrough Nutritional Treatment That is Saving Lives, with the second edition coming out soon. In the first edition he does address neurotransmitter deficiencies but we differ in our approach. He doesn’t use individual amino acids like tryptophan or 5-HTP and prefers to use a blend of amino acids based on a blood or urinary amino acid test.
In this article, New Approaches to Treating Anorexia, Dr. Greenblatt covers the multidisciplinary aspect, current treatment options, the limited medical options and the need for targeted nutrition therapy. Although this article doesn’t address tryptophan and low serotonin, he does discuss the key role of zinc, B vitamins and omega-3 fatty acids.
UPDATE: October 10, 2024
Given that most of the eating disorder research is conducted primarily in females, it’s encouraging to share the results of this 2022 paper, Sex differences and associations between zinc deficiency and anemia among hospitalized adolescents and young adults with eating disorders, which reports that “zinc deficiency is equally severe and anemia is more common in hospitalized males with eating disorders compared to females.”
Liquid zinc sulfate tastes like water when zinc levels are low. I saw those with anorexia being willing to drink it when I worked in Julia Ross’ Clinic, so it’s a relatively easy way to start to increase zinc levels and improve appetite. Zinc and iron both help increase serotonin production, and zinc is key for pyroluria/social anxiety which is common in this population.
Also, with pyroluria, morning nausea negatively affects appetite so it’s often helpful to address this in conjunction with using amino acids. Vitamin B6 is part of the pyroluria protocol and is another serotonin co-factor. Evening primrose oil, also part of the pyroluria protocol, improves zinc absorption. This is all covered in the pyroluria chapter in my book.
Resources if you are new to using the amino acids as supplements
If you are new to using the amino acids tryptophan/5-HTP, GABA or tyrosine as supplements, here is the Amino Acids Mood Questionnaire from The Antianxiety Food Solution (you can see the low serotonin symptoms here) and a brief overview here, Anxiety and targeted individual amino acid supplements: a summary.
If you suspect low serotonin or low levels of any of the neurotransmitters and do not yet have my book, The Antianxiety Food Solution – How the Foods You Eat Can Help You Calm Your Anxious Mind, Improve Your Mood, and End Cravings, I highly recommend getting it and reading it before jumping in and using amino acids so you are knowledgeable. And be sure to share it with the team you or your loved one is working with.
The book doesn’t include product names (per the publisher’s request) so this blog, The Antianxiety Food Solution Amino Acid and Pyroluria Supplements, lists the amino acid products that I use with my individual clients and those in my group programs.
Have you (or a loved one) been diagnosed with anorexia or another eating disorder?
Did you see the most success with an approach that included nutritional psychiatry and serotonin support with tryptophan or 5-HTP?
What else has helped?
Feel free to post any questions here too.
I really enjoyed this blog post – thank you. I have a child with AN and recently also diagnosed with co-occurring OCD (although we are not 100% convinced of that and wonder if more anxiety).
In any event, they recently started low dose of fluoxetine. Nutritional psychiatry is new to me. Is tryptophan supplementation compatible with SSRIs generally? What type of health provider would have the knowledge to answer this?
AJ
I’m glad you enjoyed this blog post. I would immerse yourself in all things related to nutritional psychiatry – everything on my blog is about this topic and so is my book The Antianxiety Food Solution. My book does not contain anything about eating disorders but the information on eating a whole foods diet, blood sugar control, amino acids (like tryptophan and GABA and DPA), zinc (and possibly pyroluria), and gut health is foundational. For more specifics on anorexia, Dr. Greenblatt’s book is excellent.
I would discuss this with your prescribing doctor if you have not already done so: Revisiting fluoxetine (Prozac) and suicidal preoccupations https://www.sciencedirect.com/science/article/abs/pii/0736467994904227
I have clients take tryptophan or 5-HTP 6 hours away from the SSRI (all with the prescribing doctor’s approval and monitoring). It’s advised to use these amino acids when someone is on only 1 prescription psych medication.
A functional medicine doctor, integrative doctor, naturopathic doctor or nutritionist may be familiar with all this depending on what training they have received.
Trudy, how long does it usually take to see the benefits of lower anxiey/lower OCD when taking Tryptophan?
Thank you!
Pam
Pam
Provided the symptoms are caused by low serotonin, the person has the ideal dose for their symptoms and they are using a quality product, we see results in a few minutes when doing the initial one-off trial. We adjust up or down over the next few weeks to find a good baseline dose.
It sounds like you are new to the amino acids (and possibly other anxiety nutrition solutions like gluten/sugar/caffeine removal, blood sugar control, gut health, pyroluria etc), I recommend my book “The Antianxiety Food Solution” as a great place to start. It has an entire chapter on the amino acids with dosing and timing information and other questions you may have. More here https://www.everywomanover29.com/blog/the-antianxiety-food-solution-by-trudy-scott/
Hello Trudy,
Can I have your email to get in touch with you directly?
I take 50 mg of trazadone to sleep. Can I introduce tryptophan into my daily regime even though I take trazadone?
I know I desperately need this to increase my serotonin based off of my symptoms that line up with low serotonin. I had anorexia 18 years ago, but still struggle with perfectionism and unhappiness. I’ve learned quite a lot from your summit talks! Thank you. I’m healing my gut from SIFO and SIBO and gut permeability. I’m negative for hpylori and negative in parasites. I’m taking good supplements but nothing for mood health. Please get in touch with me.
Does Trudy have a Nutritional Psychiatrist she recommends?
I live in California should that matter with telehealth.
Thank you,
Linda Seidman
Linda
If you are seeking help for anorexia or another eating disorder I would reach out to Dr. James Greenblatt. He does offer practitioner training and may have a referral for you in California.
Hi Trudy, love your information just have a question I’d prefer u contact me via email?
Karly
Please ask your question on the blog so everyone benefits from your question and my answer
I’m looking for they articles citated. But i can’t download. Can You sendme they articles please. I’m doctor and i’m.interested un learning more
Carolina
If you’re referring to the stats and related studies, you can find those here https://www.nationaleatingdisorders.org/statistics-research-eating-disorders. This site has excellent information about eating orders but does not include anything on nutritional psychiatry, functional medicine and amino acids like tryptophan, 5-HTP, DPA, GABA etc.
Hi. I’m looking for the book on Amazon and other sites, but is unavailable. Where can i Buy , please, i needed. I suffer from.anorexia . I’m mexico
Carolina
My apologies, but it may be out of print as I see he has a 2nd edition coming. https://www.psychiatryredefined.org/anorexia-book/ I’ve reach out to find out when it will be available and updated the blog
You may find this article by Dr. Greenblatt helpful https://www.waldeneatingdisorders.com/popular-searches/new-approaches-to-treating-anorexia/
Good day Trudy:
Absolutely loved the blog. The more I read on your topics the more I can spot amino acid deficiencies. I do have a question: in order to improve low serotonin levels, does 5-HTP and Tryptophan have to be taken simultaneously, or one vs the other..or are they the same amino acid?
Thanks for your time.
Sheila
Glad to hear. They are 2 different amino acids and some do better on one vs the other. I sometimes have folks use them both but at different times of the day (usually tryptophan later and 5-HTP earlier if needed).
It sounds like you are new to the amino acids (and possibly other anxiety nutrition solutions like gluten/sugar/caffeine removal, blood sugar control, gut health, pyroluria etc), I recommend my book “The Antianxiety Food Solution” as a great place to start. It has an entire chapter on the amino acids with dosing and timing information. More here https://www.everywomanover29.com/blog/the-antianxiety-food-solution-by-trudy-scott/
Are there any restrictions to consider when BMI is extremely low? Is there any research on nutritional support for ARFID (Avoidant Restrictive Food Intake Disorder)?
Jane
Anxiety is common with Avoidant Restrictive Food Intake Disorder (ARFID) but “unlike anorexia, ARFID does not involve any distress about body shape or size, or fears of fatness.” (Here is the link on NEDA about ARFID for other blog readers https://www.nationaleatingdisorders.org/learn/by-eating-disorder/arfid)
However, with ARFID there is also often fears of choking or vomiting, and phobias and worries about certain foods – so I would also want to look into low serotonin and address this with tryptophan or 5-HTP if there are other low serotonin symptoms. It’s something I do with all conditions regardless of diagnosis. Low GABA is also always considered when there is anxiety.
ARFID is also common in autism spectrum disorder and there are some overlaps with “picky eating”. Nutritional and functional medicine autism practitioners are an excellent resource for the addressing the food/texture/sensory aspect, as are occupational therapists who work with ASD.
This 2021 paper, Macro- and Micronutrient Intake in Children with Avoidant/Restrictive Food Intake Disorder, lists low B1, B2, C, K, zinc, iron, and potassium in kids with ARFID (https://pubmed.ncbi.nlm.nih.gov/33513954/) but it’s possible they had low levels of some of these nutrients beforehand and that this contributed to the restrictive eating. Low zinc and low iron come to mind. They are also needed to make serotonin, and low zinc can affect appetite.
I’ve also seen fears of choking or vomiting in clients with pyroluria so would assess for this too. And low GABA can be a factor in episodes of choking https://www.everywomanover29.com/blog/gaba-helps-a-stressed-young-boy-with-episodes-of-choking-or-tightening-in-his-throat/
I’d suspect possible gut, gluten and dairy issues (a case here https://www.psychiatrist.com/pcc/eating/gluten-disorder-and-lactose-intolerance-concomitant-with-avoidantrestrictive-food-intake-disorder/).
In summary I like to see a full functional medicine and nutritional workup – as with any condition. And the psychological support too, including addressing past or current trauma if needed.
I’m not clear on what this question refers to – Are there any restrictions to consider when BMI is extremely low?
Are you a practitioner working with individuals with ARFID and what is your approach?
Can you take myo-inositol if you are considered bi-polar
Nancy
I’m not aware of issues with inositol but if someone is on medications it’s always recommended to discuss with prescribing doctor. That said, one interesting study found this: “inositol has been a very effective treatment, replacing lithium, for mood stabilization and psoriasis.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2834624/
Hi Trudy, my 26 year old daughter has OCD. She is pyrrole and undermethylator, which she takes supplements for. She has also been on 20mg of Lexapro for several years. I’d very much like her to try adding Tryptophan but am concerned about dosage and seratonin syndrome. What do you suggest. Her current doctor is wary about adding Tryptophan. Is there a physician you would recommend in Sydney, Australia.
Many many thanks
J L
You may find this blog post helpful https://www.everywomanover29.com/blog/taper-from-antidepressant-tryptophan-amino-acids/
Hi Trudy,
My 16 year old daughter has Anorexia. We have tried supplementing with 5HTP without any benefit. I just received her Great Plains OATS test and it indicated that she had a Mitochondrial Enzyme deficiency (3-Hydroxyglutaric Acid). This enzyme is needed to breakdown lysine, hydroxylysine and tryptophan. Could the enzyme issue be the problem rather than the need for the amino acid? Do you know anything about this?
Thanks, BP
Brette
I’m not aware of slightly elevated levels of 3-Hydroxyglutaric acid impacting the effectiveness of 5-HTP or tryptophan. I’m curious to hear what feedback you have received from the practitioner who ordered this OAT. I’m guessing it’s slightly elevated and “may indicate mitochondrial dysfunction.” If that’s the case I’d focus on mito support.
I can share that we increase 5-HTP from the original baseline trial to see if benefits are observed with a higher and higher dose. I assume you did that after the initial trial. Can you share her low serotonin symptoms (and scores out of 10 with 10 being worst) and what dose you used? Did any symptoms improve and if yes how many notches?
I can also share that some people do better on tryptophan and if 5-HTP doesn’t help we then do a trial of tryptophan, increasing to find the ideal dose.
I just saw your response – thanks so much. She scored a 30 on Julia Ross’s Type 1 online questionnaire; 12 on Type 2; 15 on Type 3; 13 on Type 4- Needing help in all areas. I was just re-visiting amino acids for my daughter and tried using the Lidtke Tryptophan chewable. Just 100mg made a bit of a difference (5HTP didn’t help earlier). Do I keep giving her up to 5 of these tablets? When do I know to stop? Or how many times per day and to dose? How do I combine all of the amino acids? Do I give them all at the same time after the trial? She is using the Pure Encapsulations Amino-NR but I guess this isn’t a strong enough dose of them to help. Thanks in advance.
Brette
I have clients use one amino acid at a time to find the baseline before adding another one. I can’t consult via the blog but the initial trial is promising. I recommend using Julia’s book or mine to figure out the dosing and timing.