Digestive Disorders and Eating Disorders: A Complicated Mix

  • posted by Marci Evans
  • Monday, March 06, 2017

Several years into my work as a nutrition therapist I found myself really grappling with a clinical dilemma. Many of my clients were not only suffering from an eating disorder but they were also suffering from pretty severe digestive issues. And these digestive issues were not only complicating their recovery but they were seriously impacting my clients’ quality of life. In fact, many clients who had made tremendous strides in their eating disorder recovery were suffering with digestive symptoms that other clinicians had promised would go away once they got better from their ED.

So I delved into the research, participated in a year long integrative nutrition therapy training, exchanged supervision with colleagues who specialize in digestive health, attended workshops, and I thought A LOT. In fact, I want to make a big shout out to my friend and colleague Lauren Dear who is an amazing digestive health dietitian and has taught me so much. (Sidebar: I have the honor to speak with Lauren at three upcoming conferences. See below!)

All of this study (and continued study!) led to a series of talks on the intersection of EDs and digestive disorders that I have and will be giving in 2017. And with enthusiasm, I’m writing to let you know that I am also in the process of developing an online self-study course on the topic. I will have it ready this spring and can’t wait to share it with you. I believe in my heart it will help you feel more capable in helping your clients heal. Below I’ll provide links with upcoming places I’ll be speaking on this important topic. But for now, I’d like to share some juicy tidbits!

Critical Research Nuggets:
  • Up to 98% of clients with eating disorders have a functional gut disorder (FGD) (Note: FGDs are things like Irritable Bowel Syndrome, gatric reflux, bloating, constipation, and diarrhea (to name a few).
  • People who suffer from FGDs and EDs share the same underlying mental health challenges- namely anxiety and depressive disorders
  • These mental health challenges can lead to digestive symptoms that can perpetuate long after the ED symptoms have resolved
  • EDs can actually cause FGDs and FGDs can make a person vulnerable to the development of an ED. This means it is BOTH the chicken and the egg.
  • Childhood GI issues are a key risk factor for the later development of an ED
  • Both EDs and FGDs negatively impact body image. A person who suffers from both has a double whammy to contend with!
  • Anorexia Nervosa changes the gut microbiome by deceasing bacterial diversity. Lower numbers of bacterial diversity are associated with greater levels of eating disorder psychopathology.
Specific Concerns for the ED Population
Traditionally, medical providers and dietitians have encouraged an elimination diet of some kind to treat these enduring and often puzzling symptoms. However, eliminating foods is really the opposite of the goal of nutrition therapy for EDs. Restriction, even if medically indicated, complicates ED recovery. In my personal experience, I have seen well-intended clients/practitioners advocate for an elimination protocol that has led to full blown relapse. So what are we to do as clinicians who feel desperate to help our clients fully recover and treat any concomitant digestive health concerns? I have a few take home points for you to consider.

Key Take Home Messaging

 There are many non-harmful interventions to try with clients.

  1. Most if not all behavioral interventions that support ED recovery will also support digestive health. Root out remaining ED behaviors as most will reinforce negative GI symptoms.
  2. Sensitive systems require CONSISTENCY & BALANCE.
  3. A stressed out person will likely have a stressed out gut. Help clients embrace hypnotherapy, meditation, deep breathing, guided relaxation. The relationship between head brain and gut brain is REAL!
  4. Food variety improves the gut microbiome and is a key ingredient to ED recovery.
  5. The goal is to include as many foods as possible for mental, emotional, and psychological well-being.
  6. Integrate the use of digestive enzymes, probiotics, and well-researched supplements to help manage symptoms.
  7. Fuel healthy bacteria by integrating fermented foods and drinks.
  8. Incorporate a stool or squatty potty for more anatomically supported elimination (ie the squat position makes it way easier to poop!).
  9. Eliminate “diet foods” as they contain a lot of additives that worsen digestive symptoms and are often a culprit in the ED
  10. Play with changing the texture of foods rather than eliminating them all together
One Last Request
Clinicians, please stop telling your clients that all of their GI problems will resolve by eliminating ED behaviors and enduring the refeeding process. While this may be true for some clients and for some symptoms, the research is quite clear that this is often not the case! But the good news is that with a varied and creative toolbox, it’s possible to support ED recovery and improve your client’s digestive well-being.

Upcoming Talks

MEDA’s National Conference- March 11th, co-presenting with Lauren Dear
ANCE- The Massachusetts Dietetic Association’s Annual Conference- March 31st, co-presenting with Lauren Dear
EDPRO Online Symposium- April 28th-May 2nd (early bird registration opens March 20th!)
iaedp Online Live Webinar- August 10th, co-presenting with Lauren Dear

 

Selected Citations
Abraham, S., & Kellow, J. (2011). Exploring eating disorder quality of life and functional gastrointestinal disorders among eating disorder patients. Journal of Psychosomatic Research, 70(4), 372–377.
Boyd, C., Abraham, S., & Kellow, J. (2010). Appearance and disappearance of functional gastrointestinal disorders in patients with eating disorders. Neurogastroenterology and Motility, 22(12), 1279–1283.
Janssen, P. (2010). Can eating disorders cause functional gastrointestinal disorders? P. Janssen Eating and functional gastrointestinal disorders. Neurogastroenterology & Motility, 22(12), 1267–1269.
Kleiman, S. C., Watson, H. J., Bulik-Sullivan, E. C., Huh, E. Y., Tarantino, L. M., Bulik, C. M., & Carroll, I. M. (2015). The Intestinal Microbiota in Acute Anorexia Nervosa and During Renourishment: Relationship to Depression, Anxiety, and Eating Disorder Psychopathology. Psychosomatic Medicine, 77(9), 969–981.
Peters, SL. (2016). Randomised clinical trial: the efficacy of gut-directed hypnotherapy is similar to that of the low FODMAP diet for the treatment of irritable bowel syndrome. Aliment Pharmacol Ther. Sep;44(5):447-59.
Sato, Y., & Fukuco S. (2015). Gastrointestinal symptoms and disorders in patients with eating disorders. Clin J Gastroenterol, Oct;8(5):255-63.
Surdea-Blaga, T., Baban, A., Nedelcu, L., Dumitrascu, D. (2016). Psychological interventions for irritable bowel syndrome. Journal of Gastrointestinal and Liver Diseases, 25(3).
Voci, S. C., & Cramer, K. M. (2009). Gender-related traits, quality of life, and psychological adjustment among women with irritable bowel syndrome. Quality of Life Research, 18(9), 1169–1176.

 



If you liked this post, you might also like one of these recent posts:

  1. Dietitians: Are you Ready for the EDRDpro Symposium? Marci Evans 22-Mar-2017
  2. Digestive Disorders and Eating Disorders: A Complicated Mix Marci Evans 06-Mar-2017
  3. Defining Self-Acceptance... Or At Least My Definition Marci Evans 18-Feb-2017
  4. Practice Taking a Pause Marci Evans 15-Feb-2017
  5. BED and The Well-Trained Clinician: Are You Helping Without Harming? Marci Evans 06-Feb-2017
  6. 5 Week Mindful Eating Meal Support Series Marci Evans 12-Jan-2017
  7. Healing the Hate: A Better Body Image in the New Year Marci Evans 10-Jan-2017
  8. Resolutions: Making change a reality Marci Evans 28-Dec-2016
  9. Healthy Selfishness Marci Evans 23-Dec-2016
  10. Holiday Bill of Rights Marci Evans 07-Dec-2016
Comments
Michelle commented on 06-Mar-2017 06:58 PM
Such a fascinating topic, Marci! My personal experience with an ED and most recently autoimmune illness (that I've been healing with functional medicine interventions, including removing triggering foods, like corn, from my food choices) has made this intersection very real and concerning to me. I've become hyper aware of how easily a relapse can happen when going down this road but, fortunately, have not had a relapse of my ED. Is your online course open to professions other than RDs? I'm a personal trainer and yoga instructor...

Given your mention of using a multi-pronged approach to gut healing, including techniques around stress reduction/resilience, you might be interested in an approach I use as one intervention for that with belly massage, using a soft/squishy massage ball. It's one of my favourite practices for myself and daughter (who sometimes struggles with anxiety). I'd be happy to share the link with you here or email it to you, with your permission.

In any event, please keep doing what you're doing. I appreciate your dialogue around these intersections. So helpful.

Thanks
Michelle
Marci commented on 07-Mar-2017 08:37 PM
Hi Michelle,
Thank you so much for your thoughtful response. My course will be open to anyone and everyone who is interested but geared towards helping professionals. That definitely includes you. :) You should feel really proud of the fact that you have kept your recovery steady while working really hard to find a pattern of eating that allows you to feel well. This is SUCH a hard thing to do. I would really really love to learn about the belly massage. Please post a link here in the comments!

Warmly,
Marci
Megan Anderson commented on 15-Mar-2017 11:39 AM
Hi Marci,

Thanks for such an interesting and informative post! As a future RD who is recovering from orthorexia, your blog and information is always so helpful!

Just a quick question. You mentioned using "digestive enzymes, probiotics, and well-researched supplements to help manage symptoms." Do you have any specific supplements or probiotics that you would recommend? Or any resources to help determine what supplements/probiotics would be useful?

Thanks,
Megan
Kait Fortunato commented on 21-Mar-2017 03:57 PM
Please put me on your list for this online training !! Would love more
Tools for helping clients. Thank you for sharing and all your work!
Marci commented on 21-Mar-2017 03:57 PM
Hey Megan! I'm so sorry for my delay in getting back to you. I somehow missed your comment in my inbox. You question is excellent. One of my absolute favorite resources is the app "Clinical Guide to Probiotic Products US Edition." It's an incredible research based tool to guide choosing a probiotic. I also highly recommend Iberogast as a safe herbal supplement to try for IBS-like symptoms and Natural Calm is another favorite for constipation. Those are a handful of my favorites!!
Marci commented on 21-Mar-2017 05:03 PM
You got it Katie!! Thanks so much for your sweet note. :)
Michelle commented on 23-Mar-2017 10:11 AM
Thanks for your reply Marci and encouragement! I'm so happy you're interested in the belly massage. Here's the video I mentioned, with my daughter demo-ing the practice:

https://www.youtube.com/watch?v=vPniHZu5X5Y&t=24s

Would love to hear your thoughts!

Cheers,
Michelle
Marci commented on 23-Mar-2017 12:56 PM
Can't wait to check it out and practice myself Michelle!!
Megan commented on 04-Apr-2017 08:24 PM
This post just makes me want to sing! Not only do some healthcare providers try to convince you it's "all in your head", YOU then end up trying to convince yourself that it is all in your head.
Marci commented on 05-Apr-2017 08:04 AM
Sing away Megan! I couldn't agree more. Often, GI issues get written off as someone being dramatic or crazy. My hope is to empower clinicians and patients with real info so they can advocate for their needs!

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