Gut issues and eating disorders are a painful but treatable pair

Gut issues and eating disorders are like a chicken and egg scenario. It is common to have both illnesses at the same time. More than 90 per cent  of people with an eating disorder will meet diagnostic criteria for gut issues, and symptoms can present a significant barrier in recovery. Responding to readers’ questions on IBS (Irritable Bowel Syndrome), Australian dietician Kate Lane says it will be helpful to first talk about how IBS is diagnosed. 

By Kate Lane

IBS involves recurrent abdominal pain, at least once a week on average, over the past three months plus two of the following:

1) the pain is related to passing bowel motions,

2) there is a change in how often you pass a bowel movement, or

3) there is a change in the appearance of your bowel movements (harder or softer for example).

IBS is only one of many disorders under a broader umbrella of functional gastrointestinal disorders which also include diarrhoea and constipation that do not meet IBS criteria, problems with swallowing, heartburn, reflux, excessive belching or flatulence and dysfunction of the diaphragm, abdominal muscles or pelvic floor.

Functional gut issues are those that have no clear structural or biochemical cause, which is why scopes, blood markers and other diagnostic tests may come back “fine”. They arise from a mix of biological, socio-cultural, environmental and psychological factors that change the way the body is working despite everything “looking normal”.

Eating disorders and gut issues have much in common

About 40 per cent of patients seen by gastroenterologists will have a functional gut issue and women are affected more than men; in IBS two-thirds of sufferers are female. Known risk factors for functional gut issues include mental illness, infection or inflammation of the gut, disruption to the balance of bacteria in your large intestine, food intolerance, genetic predisposition and adverse life events in both childhood and adulthood. Do you notice that many of these are frequently reported in people who develop an eating disorder too? It is hard to determine cause and effect when it comes to eating disorders and functional gut issues, given there is so much common ground.

The role of nutrition, or lack of it

What is known about eating disorders, is that they enhance the physiological and psychological vulnerability for functional gut issues via disruption to gut-brain communication, gut hormone signalling, gut motility and gut sensitivity. Malnutrition changes everything from the integrity and function of the gut lining, to the availability of digestive enzymes, the balance of bacteria in the gut, and the nerve and hormone signals to and from the digestive system. This can result in compromised digestion or food-tolerance (even if the food was well tolerated in the past) and the emergence of uncomfortable symptoms. Nutritional rehabilitation resolves most of the gut issues reported, though some may persist even after a person considers themselves recovered from their eating disorder.

Time, and a regular, adequate and varied diet are the key

When considering the role of food in managing functional gut issues it is essential for the focus to be on restoring the gut to full function before turning to other treatments such as an elimination diet. Unfortunately, elimination diets will likely cut out foods that will be much better tolerated given time and healing. Additionally, often the first foods to go are contributors to good gut health and function (e.g. certain grains, dairy, nuts and oils). So, to answer the reader’s question, besides allowing time, a dietary intake that is regular, adequate and as varied as possible, is the most helpful thing you can do to achieve a better long-term outcome.

Anxiety can make matters worse

It is also important to understand that the gut, brain and our emotions are inextricably linked. Accordingly, it is often deeper issues, or anxiety around the symptoms themselves, that contribute to discomfort far more than specific foods. Separating the two causes is difficult though, which is why it may help to work on reducing preoccupation with gut sensations and bowel movements in addition to improvements in dietary variety and balance. Psychological work in this area may draw on elements from CBT (cognitive behavioural therapy) to challenge unhelpful beliefs or fears regarding gut function, as well as mindfulness strategies to calm the autonomic nervous system and reduce symptom-related anxiety.

Team of experts is essential to achieve ongoing healing

Finally, I  encourage anyone experiencing ongoing gut issues, even after ceasing treatment for an eating disorder, to remain connected with a medical professional, dietitian and psychologist knowledgeable in this area. Each treatment team member has a role to play in ruling out other possible causes of your symptoms. They also each have a role to play in helping you filter through which treatments or management strategies have merit, and which are more likely to do more harm than good.  Some of the helpful strategies used by the clients I see include:

  • appropriate and temporary medications prescribed by a medical professional
  • adequate fluids with small meal plan adjustments (not food group eliminations)
  • gentle abdominal self-massage
  • a warm fragrant wheat bag on the belly
  • abdominal breathing

However, what’s needed most of all is a great deal of body-respect and self-compassion in order to move forward with life while accommodating the time and extra care your body needs to heal.

Summary

  • Functional gut issues (including IBS) are extremely common in eating disorders and the two share common biological, socio-cultural, environmental and psychological risk-factors.
  • Eating disorders increase vulnerability to functional gut issues via disruption to gut-brain communication, gut hormone signalling, gut motility and gut sensitivity.
  • Common symptoms include:
    • abdominal pain or cramping
    • bloating and distention
    • flatulence
    • belching
    • heartburn
    • reflux
    • regurgitation or involuntary vomiting
    • diarrhoea
    • constipation
  • Nutritional rehabilitation and time will resolve gut issues in many cases but they can remain an ongoing issue even after recovery from an eating disorder.
  • Symptom management should involve an experienced multi-disciplinary team who takes a holistic approach beyond that of elimination diets alone.

Further reading

For more information on Functional Gastrointestinal Disorders, the International Foundation for Gastrointestinal Disorders website is a useful resource: https://iffgd.org

If you’d like to hear more about gut issues in eating disorders, I’ve learned a great deal from the work of Registered Dietitian (RD) Marci Evans, and her colleague Lauren Dear (RD) in the U.S.

Marci has an excellent podcast episode on this topic on Food Psych by Christy Harrison (RD) that I highly recommend: https://christyharrison.com/foodpsych/6/the-truth-about-digestion-and-gut-health-with-marci-evans

Headspace is a well-known app for mindfulness training: https://www.headspace.com

Inside Out and the Australia and New Zealand Academy for Eating Disorders have directories of professionals who specialise in the treatment of eating disorders and associated health concerns.

https://insideoutinstitute.org.au/treatment-services

https://www.xcdsystem.com/ANZAED/member_directory/

Do you identify with these readers’ experiences?

Here are the questions, from two readers, in Australia and Ireland, which have inspired Kate’s helpful and informative article on gut issues:

Sarah:

Honestly, like ED, IBS is a soul crushing chronic illness. Some days, when I’m frustrated, I just ask why would I get over an ED to be left with this? It definitely flares up with more stress/anxiety – but just having it causes anxiety. Like ED, it can feel very lonely and quite hopeless.

I have seen all kinds of medical people over the past few years. When they can’t find anything physically wrong, they call it IBS and turn to elimination diets, which isn’t ideal for someone with an ED. There are some natural remedies but if it’s a bad day, it’s completely out of control. I’ve read a lot about mind/gut connection. Many people struggle with it but most are not talking about it. 

 • Have I caused my IBS because I had an eating disorder? Ever since I had food poisoning in Greece on a holiday years ago, my digestion has never been the same. Did my ED contribute to a weaker digestive system?

• Even if I eat the same exact things two days in a row, I might get a reaction one day and not the other. Why?

• I meditate, I exercise, I do breathing exercises…. From a mindfulness perspective, what more can I do? It’s virtually impossible to completely eliminate stress from my life.

• What can I do to ease stomach gurgling/noises? These aren’t hunger noises – they come both before and after eating.

Nicola:

I was in strong recovery but under enormous stress and developed IBS…dietitians placed me on restrictive diets to try eliminate symptoms but a lot of my diet and food I enjoyed were eliminated. As well, a lot of the suggested food I didn’t enjoy and also this food was difficult to source so slowly I began developing chronic fear of food…I felt sad, angry, and disgusted with my body. 

The constipation led me to feel sore, sluggish, physically dirty, and contaminated.

I was tired, depressed, suicidal, in constant fear, panic, couldn’t sleep or concentrate, can’t eat out socially anymore, and often feel suicidal idealisation.

  • How does someone trying to recover manage the pain, bloating and constipation after food?
  • Should a person in recovery follow the food-map diet plan for IBS?
  • What is the most advisable way to manage IBS in a person trying to recover from an eating disorder?
  • How do you manage food fear if the food is hurting my digestive system?
  • Why are foods I once tolerated now causing problems?
  • How do I know if it is my high stress and low confidence or the food that is causing my problem?
  • How do I overcome my obsession with my bowel movements?

Do you have a question? A note from The Diary Healer editor, June Alexander

Are you experiencing symptoms other than IBS that you find difficult and confusing in dealing with during your recovery from an eating disorder? Or perhaps you are encountering ongoing challenges in other ways, beyond your recovery from an eating disorder? Healing from an eating disorder is ongoing.

Write to me at june@junealexander.com and I will do my best to find an expert in the field to respond to you. You can be sure, that if you are suffering silently, others are, too. So reach out, and in helping yourself, you also will be helping others.

Hugs, June