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.

 

Fall Products I Love & Hate

  • posted by Marci Evans
  • Friday, October 02, 2015

In today's vlog I give a roundup up 2 products I love and 1 product I hate. It's my Fall special of showcases and no case that I think you'll love. I'm talking my favorite cures for the common cold, simple and delicious frozen food, and taking yoga challenges to task. Tune in and then let me know some of your favorite (or not so favorite) products for the Fall season!

 

Product Showcase: Fairlife

  • posted by Marci Evans
  • Friday, August 07, 2015
I recently learned about Fairlife milk, a new product from the Coca-Cola company. This milk is different from all other milk for a couple of different reasons. Through a filtering process, lactose, the often tummy bloating and diarrhea causing sugar in milk, is removed. Additionally the milk gets separated into five parts — water, vitamins and minerals, lactose, protein, and fat. Then those parts are recombined and the resulting product has half the sugar and double the protein of normal milk. Fairlife also boasts a significantly longer shelf life than regular milk.

As I was doing a little research on Fairlife, I was surprised by how many negative articles have been written about it. From dietitians criticizing the nutritional tweaks to taste testers complaining about texture and flavor, Fairlife has not received rave reviews.

But I actually read these review after trying Fairlife myself. And given the title of this blog post, it’s no surprise that I’m a fan. I’m a milk drinker, I have been all of my life. My childhood memories include a nightly bowl of cereal before going to bed. I have no affiliations with the dairy council, I just find milk to be a satisfying addition to my diet.

As for Fairlife, I think the nutritional changes make a great option for many people including those who are diabetic, hypoglycemic, and post-bariatric surgery. I think the addition of calcium is great for those who have a hard time getting enough in through food. Also, the elimination of lactose is a significant selling point given the prevalence of lactose intolerance. I bought the 2% version so can’t speak to the skim or chocolate milk, but I found the texture and taste totally delicious.

One very fair criticism of Fairlife is the cost. As milk goes, this is probably one of the priciest options out there. So for big families and people on a tight budget, Fairlife is a tough sell.

I know the grocery store is an overwhelming place filled with sales pitches and gimmicks that make it very hard to know what to buy. So what do you think- is Fairlife a useful new product? Or is another product that’s more hype than help? I’d love to hear your thoughts.

Interview: Omega 3 and Omega 6, What You Need to Know

  • posted by Marci Evans
  • Saturday, October 13, 2012

I was recently asked to give an interview on essential fatty acids. I was actually thrilled to talk about this because getting enough essential fatty acids (omega-3) in your diet is essential to brain health, mental health, and satiety! Through the 90's dietary fat got a very bad rap. But slowly people seem to be coming around to the idea that fats are crucial to eating well. 

In fact, did you know that inadequate dietary fat is association with increased levels of anxiety and depression! Seriously.

If you are interested in learning more, check out my interview. You can read the transcript here or listen to the audio version here.

So what's your biggest obstacle to getting more omega-3s into your diet?

Orthorexia: Can healthy eating be a disease?!

  • posted by Marci Evans
  • Thursday, July 01, 2010

Yesterday, I received several emails with a link to this article on a condition called "Orthorexia."  Most people read the article and wondered if it was serious, wondered if it wasn't some sort of exaggeration or joke.  

And while I admit, reading about it online may seem strange or even ridiculous, it is a true disorder that affects both the physical and emotional health of a lot of people.  Just read my recent client spotlight. What began as "healthy eating" and exercising for her, quickly became orthorexia, which then became a much more severe eating disorder that required residential treatment and intensive outpatient care.  

Now of course I believe in healthy eating and exercise- my life is committed to supporting it in myself and others!  BUT, the distinction between healthy living and orthorexia are two important words: unhealthy obsession.  You can read more on the Orthorexia home page, written by Dr. Steven Bratman who coined the term and wrote the book "Health Food Junkies." 

<Ironically, I just loaned my copy to a client who has suffered mental, emotional, and physical distress FOR YEARS due to an unhealthy obsession with "healthy" eating and exercise.> My clients who suffer from orthorexia share a single characteristic- the obsession diminishes rather than enhances their quality of life.  Relationships suffer, social isolation ensues, they have often feel paralyzed, depression/anxiety is worse, sleep patterns are affected, etc.  

My philosophy is that moderation with food, exercise, and in life- is the key!  And I also believe that we are meant to find enjoyment, satisfaction, and fulfillment from the food we eat.  Anything taken to an extreme is unhealthy.  If you have always been interested in "healthy" living and are curious as to whether or not you are taking a bit too far, the assessment below may be helpful to you.  This is taken from Dr. Bratman's book.

Dr. Bratman suggests that you may be orthorexic, or on your way there, if you:
o Spend more than three hours a day thinking about healthy food.
o Plan your day’s menu more than 24 hour ahead of time.
o Take more pleasure from the “virtuous” aspect of your food than from actually eating it.
o Find your quality of life decreasing as the “quality” of your food increases.
o Are increasingly rigid and self-critical about your eating.
o Base your self-esteem on eating “healthy” foods, and have a lower opinion of people who do not.
o Eat “correct” foods to the avoidance of all those that you’ve always enjoyed.
o So limit what you can eat that you can dine “correctly” only at home, spending less and less time with friends and family.
o Feel guilt or self-loathing when you eat “incorrect” foods.
o Derive a sense of self-control from eating “properly.”

Bratman suggests that if more than four of these descriptions applies to you, it may be time to take a step back and reassess your attitude toward what you eat. If they all apply, you’re in the grip of an obsession.

This seems to be a controversial topic.  I'd love to hear your thoughts.

Striving to live a balanced life in hectic Harvard Square,
Marci