Weird question but I'm curious: since he is the Horseman of Famine do his clerics/oracles/etc not believe in eating? If so how do they survive? Maybe they eat just enough to not take damage but are still starving.
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They eat stuff. This is Trelmarixian's obedience.
Abstain from eating or drinking until you experience the bitter pangs of hunger. Meditate in this state for just under an hour, and then gorge yourself upon any available substance regardless of its suitability as food, such as sand, ashes, or flesh. Gain a +4 profane bonus on saving throws against effects that cause exhaustion, fatigue, nausea, or sickness.
Note that "regardless of its suitability as food" means that they can, in fact, gorge on food if that is what is available--so long as they first starve themselves and meditate.
As Trelmarixian's creator, here are my thoughts:
Feeling hunger pangs is a religious devotion to Trelmarixian's faithful, however it tends to serve the Four better if their mortal cultists don't kill themselves off by virtue of their devotions. Starve yourself ritualistically, but don't die from it, because you're needed to cause famine and starve other mortals in the grand scheme of things.
Also consider that since Trelmarixian embraces "Famine" as more than starvation, but inclusive of every form of wasting, that his cults might have a myriad of aspects. Consider addictions, cancer, spiritual decay, etc.