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.

 

Defining Self-Acceptance... Or At Least My Definition

  • posted by Marci Evans
  • Saturday, February 18, 2017

My client, whom we'll call Sally, was telling me how she's been reading up on all sorts of positive body image blogs. You know, blogs that encourage you to love yourself and accept yourself as you are right now. And that was just all too far from reality for her to be able to swallow. She told me "I can't love my body. I can't stand living in it. I don't feel good physically in my body. Why would I accept something that makes me so miserable?" 

And I understood what Sally was saying. Often, people confuse self-acceptance with stagnation. Staying miserable, learning to put up with something you hate. Many people wrongly assume that they'll never change if they accept themselves (not to mention love themselves!) as they are right now. But it turns out that isn't true.

ACCEPTING SOMETHING DOESN'T MEAN YOU HAVE TO LIKE IT. The reality is that self-acceptance FACILITATES CHANGE. Acceptance can be defined as "the act of assenting or believing." Once we come to truly accept where we are at in life, what works for us, and what doesn't, we are then able to make decisions based on that reality. Here are a couple of diagrams to show what I mean.

Cycle of Non-Acceptance

Cycle of Acceptance

I share this message with you as a new year is about to begin because it's a time that you might be thinking about setting goals and contemplating how you'd like to improve upon this past year. So  you just might want to consider adding self-love and self-acceptance to the top of your list. Ironically, it just might help you accomplish everything else you had in mind.

I'm going to leave you with a quote from a fabulous book that I stumbled upon while researching this blog post. The quote relates to accepting your body as it is right now.

How can you begin to learn the lesson of acceptance? By recognizing that what is, just is, and that the key to unlocking the prison of self-judgment lies in your own mind. You can either continue to fight against your body's reality by complaining bitterly and immersing yourself in self-deprecation, or you can make the very subtle but powerful  mental shift into acceptance. Either way, the reality remains the same. Acceptance or rejection of your body only carries weight in your mind; your perception has no bearing on how your body actually looks, so why not choose the ease of acceptance rather than the pain of rejection? The choice is yours. "

Found in "If Life is a Game, These are the Rules" by Cherie Carter-Scott PhD

Have you had an experience with self-acceptance? Please share it!

Practice Taking a Pause

  • posted by Marci Evans
  • Wednesday, February 15, 2017

By Sarah Patten, RD LDN


One of my favorite routines after getting out of bed in the morning involves making a steaming hot cup of coffee and taking a moment before taking my first sip to pause, gaze out my kitchen window, and set an intention for my day ahead. This ritual started a couple of years ago as I began to realize how busy the days can be and how easy it is to fill the waking hours to the brim without taking the time to slow down and check in. I found myself talking with clients and friends about the importance of mindfulness, self inquiry, and pausing, but realized that I too needed to hear that message and bring focused attention to sloooowwwwwwwwwingggg down.

Sometimes setting an intention to set an intention is the hardest part

At first, I had to remind myself to take that moment or would chide myself with self-criticism if I'd rushed around after waking up too late/hitting snooze and had forgotten about the intention to set an intention altogether. Just like any type of habit change, however, with enough practice and repetition, the new ritual stuck and now it's the part of my morning I look forward to most. This “mindfulness moment” allows me the opportunity to assess how I'm feeling, what I'm grateful for, what I'm worried about, and what I'd like to practice for the day ahead. Solidifying this habit in the morning has also helped to make it much more natural to return to this practice throughout the day.

Even the fullest days can hold mindful moments

Maybe it's taking a moment to check in while waiting in line at the grocery store, sitting down to eat lunch, or washing dishes at the end of a long day – wherever it may be, the realization that there IS time to take time throughout a busy day has been a huge change for me. We all have the ability to slow down and check in with ourselves, no matter how full our time may seem.

This past Christmas, I received the perfect gift to accompany this morning ritual - “Journey to the Heart” by Melody Beattie. This book has a daily reading for each day of the year and always seems to deliver just the message I need to hear. There was a reading a few weeks ago that gave me pause for thought and it felt important to share. It's entitled “Look at What's Right” - a reflection about how we can spend so much time looking for flaws in ourselves, even in the name of self improvement,”that we often forget to stop and take stock of what is going well or what we value within ourselves. Here's the reading:

“Take time to notice what's right in ourselves, in others, and in the world around us. We may become so concerned with correcting ourselves we become habituated to seeing what's wrong. Not just seeing it – constantly looking for it. The question itself – What's wrong? – is enough to keep us on edge.

"There are times to take stock, do an inventory. Times to learn and grow. But spirituality and joy do not stem from trudging around in the muck of what's wrong with others, ourselves, and life. We do not have to seek out mistakes and errors, poking and picking at ourselves to continue our growth. Poking and picking hurts. Our lessons will be revealed to us, and they will present themselves naturally. Growth will occur.

"Give yourself a break. Ask yourself what's right, what's good, what's true, what's beautiful. Sometimes the lesson isn't in discovering what's wrong. Sometimes the lesson is discovering that the world is all right – and so are you.”

So, with that, I'd challenge all of you to practice taking a pause today (and maybe eventually every day) to acknowledge what's right. Give yourself the gift of self compassion, give yourself some space from that internal critic, and call out a strength you possess – even if it seems tiny or insignificant. With practice and persistence, everything gets easier.

 

Healing the Hate: A Better Body Image in the New Year

  • posted by Marci Evans
  • Tuesday, January 10, 2017

 

I originally wrote this video blog for Recovery Warriors which is a phenomenal community and resource for anyone looking for additional support in their eating disorder recovery. But you don't have to have an eating disorder to have crappy body image. So if you'd like to feel better about your body, this one's for you.

Key Point: You cannot talk your way to better body image. If you treat yourself with hate you will continue to feel hate towards your body. In this video blog I share with you the why and the how to improve your body image through actionable steps.

After you view this video blog, I hope you will share what you plan to start doing that feels good to your body. What action step or steps will you start making today?


Healthy Selfishness

  • posted by Marci Evans
  • Friday, December 23, 2016

 

 

 

 

 

Photo Credit: I discovered this photo from my friend and colleague Leslie Schilling's facebook post. Check out her blog- you'll love her sensible and sassy nutrition expertise.

 
This time of year is all about giving. So I thought I’d be a little subversive and talk about taking. This post is all about healthy selfishness. What is healthy selfishness you ask? Well, it’s a term I made up. And I think the term is both awesome and useful. Yes, we have all heard the whole airline analogy- in case of an emergency you have to put your oxygen mask on before your child’s. But it’s so much more than that!

Health selfishness is about becoming clear on what you need, owning what you need whenever possible, and not apologizing for it. In essence, it’s about becoming attuned to your own sense of what is right for you . And the really amazing thing is that when you are attuned and responsive to your own needs, your capacity to give to others grows.

It may be helpful for us to break this down into categories. And when you are a tad OCD like me, breaking things down into categories always feels like the right thing to do! Let’s think about your wellness in three areas: physical, mental, emotional. You can imagine them like a Venn diagram because they are separate but have areas of overlap.

In order for you to become more clear about ways you need a little more healthy selfishness in your life, consider answering the following questions:
1. When it comes to my physical, mental, or emotional health what do I need more/less of?
2. What would it require for me to get more/less of that thing?
3. Am I willing to take what it requires?
4. If I have trouble justifying it for myself, would I think it seemed reasonable for someone else?

I’ll share with you one example but this type of “taking stock” can work in any area of your life. I’ll stick with food and eating since that’s what I know best!

1. I need to take 20 min and eat a balanced lunch during the day.
2. When I’m swamped at work, it may require keeping a co-worker waiting. At home, it may require me taking a break from paying attention to my kids.
3. Hmm, I’m not sure if it’s worth it. If I stop and eat I may feel like I’m losing time but there is a chance that having brain fuel will actually allow me to be more productive at work and may also prevent the frenetic snacking that happens in the late afternoon. I’ll try it out once this week so I can better assess the pros and cons of taking more time for myself.
4. Yes, I think it would be reasonable for pretty much anyone to stop for 20 min during the day and eat.

Happy Holidays and cheers to more healthy selfishness in each of your lives.
 
**Note if you are reading this and currently suffering with an eating disorder, your capacity to sense your own needs may be a very difficult task. In fact, the very act of recovering from an eating disorder is learning of how to listen and effectively respond to your inner needs and requires the support and expertise of a treatment team. If you are a research nerd like me, you may be interested in checking out this article entitled “Body self: development, psychopathologies, and psychoanalytic significance.”