Eating Disorders and Gut Health – Which comes first?

**If you or someone you know, is struggling with an ED please reach out for help. This article is meant to provide information and is not a substitute for any professional help**

Almost all people struggling with an eating disorder (ED) also experience digestive issues problems which may impact the development of an ED and definitely interfere with recovery. In Canada, gastrointestinal (GI) issues are quite common, according to a 2012 study, Canada has the highest rate of IBS worldwide (prevalence of 18% compared to 11% worldwide).

As a health professional working with clients struggling with ED, I see the link quite clearly. The question often asked is: can GI issues lead to the development of an ED? And can restrictions, binge eating, purging lead to short or long term GI issues?

Let’s dive deep and understand the impact of gut health on ED and vice versa.

Keep reading to learn more about this fascinating subject!

Before We Start…

EDs are one of the most dangerous mental health issues in our society. To get an overview on eating disorders, check out my latest post on EDs. We are also going to talk about the microbiome so check out this article for an in depth explanation.

Now that you’re all caught up on eating disorders and on the gut microbiome, we can get into this article! Most of the research done in the field of gut health and eating disorders has been done specifically in anorexia nervosa but these same issues can also be present in other types of eating disorders. Again, almost all people suffering from an eating disorder also experience gastrointestinal (GI) issues, the most common ones are: irritable bowel syndrome (IBS), heartburn, bloating, constipation, dysphagia (trouble with chewing or swallowing food), nausea, stomach pain and fullness (1, 2, 3). These issues can have profound impacts on eating disorder development as well as be very difficult for those living them, especially while recovering from an ED.

Can GI issues lead to the development of eating disorders?

EDs are multifactorial diseases, I like to describe is as an onion with multiple layers. It is hard, not to say impossible, to determine the root cause of them, however GI issues have been identified as a possible risk factor (4). People living with IBS may search for solutions to their GI issues by turning to the low FODMAP diet for example. This diet is used to identify foods that are linked to the person’s IBS symptoms, this restrictive diet, as well as all other restrictive diets are linked to the development of EDs (5). **Not to say that the low FODMAP diet doesn’t have it’s place however the restrictive component of it can be a trigger** Celiac disease has also been seen as a risk factor for EDs as the treatment for celiac disease is to cut out all gluten from one’s diet and this restriction can lead to further restriction of food and turn into an ED (4). GI issues can cause fear of certain foods that can lead to the development of restrictive eating patterns, if you live with GI issues such as IBS or celiac disease, please seek professional help from a registered dietitian and avoid following any restrictive diets without proper guidance.

Can EDs cause GI issues?

Yes, EDs are linked with a higher risk of developing GI issues such as IBS (6). This section will break down the impacts of common ED symptoms on gut health.

What is the link between food restriction and gut health?

Restriction or eating too little energy (calories) for one’s needs is present in many different types of eating disorders, it is most characteristic of anorexia nervosa but can also be found in bulimia nervosa, atypical eating disorders and disordered eating or even in simply dieting. Many people with EDs who restrict their food intake also suffer from delayed gastric emptying (3) which is when food stays in your stomach longer than it should. This can lead to gastrointestinal (GI) symptoms such as bloating, stomach pain, feelings of fullness and constipation (3). These types of symptoms are seen after the body is unused to being fed adequate amounts of food and can cause a lot of pain especially to those trying to recover from EDs.

There is more and more evidence that restriction linked with eating disorders can modify the gut microbiome (8). The microbiome (the bacteria in our guts) is a growing area of research and the bacteria in our gut has been linked to many different aspects of our mental and physical health. The gut microbiome is responsible for helping our bodies metabolize nutrients such fibre (prebiotics) that they can turn into short chain fatty acids that have beneficial effects on our body (8). People with an altered microbiome cannot digest fibre in the same way which leads to digestion issues.

Restriction of energy is linked with a decreased microbiome diversity which can cause many issues (9). This dysbiosis (imbalance of the gut microbiome) has actually been found to perpetuate malnutrition and make it harder to recover from an ED (9). The gut microbiome also affects what is called the “gut-brain axis” and affect our hormones, immune system and hunger and fullness cues (7). Dysbiosis of the gut microbiome caused by malnutrition could be linked with higher rates of anxiety and depressive symptoms which could exacerbate the mental health state of people with eating disorders (8). Hormonal issues are often associated with low levels of body fat found in many eating disorders and dysbiosis of the microbiome is also linked to hormonal issues in women (8).

Dysbiosis in EDs is associated with higher levels of inflammation and stress. EDs cause significant stress on the body and high cortisol levels (a chronic stress hormone) have been linked to gut permeability problems or “leaky gut” which could also cause GI issues, as people suffering from a “leaky gut” experience higher levels of inflammation in the GI tract and throughout the body (8).

For more information, check out the last article on the effect of calorie restriction on the body.

What are the effects of binge eating on gut health?

Binge eating involves eating large amounts of food in a short period of time and is a symptom of certain types of anorexia, bulimia, binge eating disorder and other atypical eating disorders. The gut microbiome is affected by modified eating patterns, our gut microbes are sensitive to our circadian rhythms (our internal clock) and disruptions in eating patterns can lead to microbiome dysbiosis (9). This dysbiosis can be linked to the similar side effects as seen above such as hormonal imbalances, inflammation and digestion issues (9). Furthermore, a binge also interferes with the body’s ability to digest and will cause delayed gastric emptying. Furthermore, the increase volume in stomach leads to an over expansion which, in some cases, cause stomach rupture.

What are the effects of compensatory behaviours on gut health?

Compensatory behaviours such as laxative use, self-induced vomiting, diuretic use, enemas, etc. are also linked to gut issues. Compensatory behaviours are most associated with bulimia but are also found in certain types of anorexia and other eating disorders. The most common purging behaviour is self-induced vomiting, this can have very serious consequences on health especially with regards to electrolyte imbalances (10). Electrolyte imbalance is a risk factor for cardiac arrest. Self-induced vomiting is also linked to many GI issues such as heartburn, acid reflux (damage to the lower esophageal sphincter), damage to the stomach lining, GI motility problems, diarrhea and constipation (10). Self-induced vomiting is also linked to acute sialadenosis – when parotid glands become very swollen and painful (some have referred to this as ”chipmunk” appearance). Laxative use can cause constipation, bloating, cramping, GI motility problems, electrolyte imbalances, diarrhea, stomach issues and decreases in microbiome diversity, leading to similar issues as the ones seen above (3, 10). IBS is linked with self-induced vomiting as well as laxative use (10). Over exercising can be associated with “leaky gut” seen above which causes increased inflammation in the gut and the body in general (8). Enemas can cause changes to the microbiome as well.

Practical Tips to Reduce GI Symptoms in Recovery

Having any types of GI issues is not fun. Especially during recovery as you are healing your relationship with your body and food, reducing the intensity of symptoms can help you in the recovery process. Here are my top 3 tips:

1- Have 3 balanced meals and snacks at regular times: Regulating eating is an essential part of recovery and can help reduce GI symptoms. With the help of a Registered Dietitian- divide your energy intake in 3 meals and 3 snacks.

2- Slow down and eat mindfully: Slowing down and chewing your foods will help with digestion and may reduce bloating. Mindful eating is also an important part of recovery to reduce stress around meals which tend to increase GI issues.

3- Keep hydrated (after your meals!): Making sure you are getting the adequate amount of fluid is essential! However, try to drink in between or after meals to avoid spoiling your appetite.

Conclusion

GI issues and EDs are intertwined and dealing with either or is very difficult on your own and can be dangerous, please seek professional from a registered dietitian help if you suffer from any GI issues or think you may be suffering from an ED. I am excited to see what new research on the microbiome and EDs will reveal in time. For now, the connection between these two is evident and is important to address in recovery.

I hope this article was helpful. Please to do not hesitate to reach out!

The Balanced Practice is a team of professionals specialized in eating disorder outpatient treatment. We strive to provide evidence based nutrition counselling to support you, or your loved one, in achieving full recovery. Schedule a connection call now.

Marie-Pier Pitre-D’Iorio, RD, B.Sc.Psychology
Lead Registered Dietitian at The Balanced Practice

Thank you Céleste Bouchaud for informative article!

References:

1. Boyd C, Abraham S, Kellow J. Psychological features are important predictors of functional gastrointestinal disorders in patients with eating disorders. Scand J Gastroenterol. 2005 Aug;40(8):929–35.
2. Salvioli B, Pellicciari A, Iero L, Di Pietro E, Moscano F, Gualandi S, et al. Audit of digestive complaints and psychopathological traits in patients with eating disorders: a prospective study. Dig Liver Dis Off J Ital Soc Gastroenterol Ital Assoc Study Liver. 2013 Aug;45(8):639–44.
3. Zipfel S, Sammet I, Rapps N, Herzog W, Herpertz S, Martens U. Gastrointestinal disturbances in eating disorders: Clinical and neurobiological aspects. Auton Neurosci. 2006 Oct;129(1–2):99–106.
4. Santonicola A, Gagliardi M, Guarino MPL, Siniscalchi M, Ciacci C, Iovino P. Eating Disorders and Gastrointestinal Diseases. Nutrients. 2019 Dec 12;11(12).
5. Mari A, Hosadurg D, Martin L, Zarate-Lopez N, Passananti V, Emmanuel A. Adherence with a low-FODMAP diet in irritable bowel syndrome: are eating disorders the missing link? Eur J Gastroenterol Hepatol. 2019;31(2):178–82.
6. Perkins SJ, Keville S, Schmidt U, Chalder T. Eating disorders and irritable bowel syndrome: is there a link? J Psychosom Res. 2005 Aug;59(2):57–64.
7. Waldholtz BD, Andersen AE. Gastrointestinal symptoms in anorexia nervosa. A prospective study. Gastroenterology. 1990 Jun;98(6):1415–9.
8. Seitz J, Belheouane M, Schulz N, Dempfle A, Baines JF, Herpertz-Dahlmann B. The Impact of Starvation on the Microbiome and Gut-Brain Interaction in Anorexia Nervosa | Endocrinology [Internet]. [cited 2020 Feb 2]. Available from: https://www.frontiersin.org/articles/10.3389/fendo.2019.00041/full
9. Are the Gut Bacteria Telling Us to Eat or Not to Eat? Reviewing the Role of Gut Microbiota in the Etiology, Disease Progression and Treatment of Eating Disorders [Internet]. [cited 2020 Feb 2]. Available from: https://www-ncbi-nlm-nih-gov.proxy3.library.mcgill.ca/pmc/articles/PMC5490581/
10. Forney KJ, Buchman-Schmitt JM, Keel PK, Frank GKW. The medical complications associated with purging. Int J Eat Disord. 2016 Mar;49(3):249–59.
11. Lovell RM and Ford AC. Global prevalence of and risk factors for irritable bowel syndrome: A meta-analysis. Clin Gastroenterol Hepatol. 2012 Jul;10(7):712-21.e4.
12. Norris, et al. Gastrointestinal Complications Associated with Anorexia Nervosa: A Systematic Review. Int J Eat Disord 2016; 49:3 216-237.