What are Gastrointestinal Disturbances in Eating Disorders?

Many individuals with an eating disorder experience a range of gastrointestinal (GI) symptoms, such as bloating, cramping, decreased appetite, early satiety (feeling full soon after eating only a small amount of food), reflux, constipation, nausea, and diarrhoea (Beumont et al, 1993; Chami et al, 1995). This is due to the changes in GI sensitivity and function, caused by not getting the nutrition that the body needs, and eating disorder behaviours such as self-induced vomiting or laxative abuse (Norris et al, 2016). These symptoms can also be experienced at the beginning of treatment as changes to eating are made, however often this is in the short term as the GI tract adapts to being renourished.

The difficulty is the cycle that develops between disordered eating behaviours and GI symptoms, as shown below:

Gastrointestinal Disturbance in Eating Disorders

Gastrointestinal disturbances occur in individuals with eating disorders of all presentations.

Constipation

Constipation can occur due to:

• Food restriction leading to decreased stool volume.

• Food restriction leading to longer transit time of the entire GI system (Wiklund et al, 2021).

• Electrolyte disturbances (especially low potassium levels) and dehydration, due to selfinduced vomiting or laxative misuse (Hetterich et al., 2019; Zipfel et al., 2006).

• Discontinuing the use of laxatives after prolonged use and the large intestine having become functionally dependent on them (Mehler, 2011).

• An increased delivery and stool volume due to bingeing, leading to colon discomfort and constipation (Cremonini et al., 2009).

• Use of eating disorder behaviours such as vomiting, laxative misuse, and excessive exercise causing an increase in abnormal intra-abdominal pressure and leading to structural damage of pelvic floor muscles. This can result in constipation, diarrhoea, and faecal incontinence. (Santonicola et al, 2019; Silvernale et al, 2020)

Bloating / abdominal distension

Bloating can occur due to:

• Chronic food restriction causing the muscles of the small and large intestine to waste away, due to break down of muscle and underuse. This results in food taking longer to travel through the digestive tract (known as delayed stomach emptying) and causing stomach aches, bloating and wind.

• Bingeing, where large volumes of food are consumed in a short amount of time, causing abdominal pain and bloating.

Reflux

Reflux can occur due to:

• Binge eating episodes put pressure on the sphincter between the oesophagus and stomach, allowing gastric acid to return back through to the oesophagus.

• Continuous acid exposure due to vomiting, impairing function of the sphincter between the oesophagus and stomach.

• Slowed gastric emptying caused by restricting food intake and weight loss.

Poor appetite / Early satiety

Poor appetite or early satiety can occur due to:

• Slowed gastric emptying caused by restricting food intake and weight loss.

• Increased anxiety exacerbating feelings of fullness.

Treatment Plan

Some tips to help manage gastrointestinal symptoms include:

• Eat regularly – 3 meals and 3 snacks per day

• Make sure you are drinking enough

• Eat a broad variety of foods, across all food groups – be mindful that too little, or too much fruit & vegetables can cause GI upset

• Work on reducing and stopping disordered eating behaviours (restricting, bingeing, vomiting, laxative abuse)

• Try stress reduction strategies such as meditation, deep breathing, slow yoga, guided relaxation

“Gastrointestinal problems will improve when food intake and disordered eating behaviours interfering with digestion are normalised. If you are working towards increasing the frequency, quantity, and/or variety of food you are eating, it is normal to expect some GI discomfort in the shortterm. This does not mean you have eaten too much and is a normal part of the recovery journey for many people. Some people find it helpful to alleviate this discomfort by using a hot water bottle or engaging in a distracting activity after eating. It may take some time for the system to recover normal functioning.” (CCI, 2018)

Abraham, S., & Kellow, J. E. (2013). Do the Digestive Tract Symptoms in Eating Disorder Patients Represent Functional Gastrointestinal Disorders? BMC Gastroenterology, 13(38). doi: 10.1186/1471-230X-13-38

Beumont, P. J., Russell, J. D., Touyz, S. W.(1993) Treatment of anorexia nervosa. Lancet. 341(8861):1635-1640. doi: 10.1016/0140-6736(93)90769-d

Centre for Clinical Interventions (CCI). (2018). Gastrointestinal Problems in Eating Disorders. Western Australia. [PDF file]. Retrieved from https://www.cci.health.wa.gov.au/-/media/CCI/Mental-HealthProfessionals/Eating-Disorders/Eating-Disorders---Information-Sheets/Eating-Disorders-Information-Sheet---17---Gastrointestinal-Problems.pdf

Chami, T. N., Andersen, A. E., Crowell, M. D., Schuster, M. M. & Whitehead, W. E. (1995). Gastrointestinal Symptoms in Bulimia Nervosa: Effects of Treatment. The American Journal of Gastroenterology, 90(1):88–92.

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Hetterich, L., Mack, I.,Giel, K. E.,Zipfel, S., &Stengel, A.(2019). An Update on Gastrointestinal Disturbances in Eating Disorders. Molecular and Cellular Endocrinology, 497, 110318.doi: 10.1016/j.mce.2018.10.016

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Norris, M. L., Harrison, M. E., Isserlin, L., Robinson, A., Feder, S., & Sampson, M. (2016). Gastrointestinal Complications Associated with Anorexia Nervosa: A Systematic Review. The International Journal of Eating Disorders, 49(3), 216-237. doi: 10.1002/eat.22462

Rigaud, D., Bedig, G., Merrouche, M., Vulpillat, M., Bonfils, S., & Apfelbaum, M. (1988). Delayed Gastric Emptying in Anorexia Nervosa is Improved by Completion of a Renutrition Program. Digestive Diseases and Sciences, 33, 919–925. doi: 10.1007/BF01535985

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Santonicola, A., Gagliardi, M., Guarino, M. P. L., Siniscalchi, M., Ciacci, C., & Iovino, P. (2019). Eating Disorders and Gastrointestinal Diseases. Nutrients, 11(12), 3038. doi:10.3390/nu11123038

Silvernale, C. J.,Kuo, B., &Staller, K.(2020).Sa1678 pelvic floor prolapse associated with GI-specific healthcare utilization and anorexia nervosa in an eating disorder patient cohort.Gastroenterology, 158(6),S379.doi: 10.1016/S0016-5085(20)31642-5

Wiklund, C. A., Rania, M., Kuja-Halkola, R., Thornton, L. M., & Bulik, C. M. (2021). Evaluating Disorders of Gut-Brain Interaction in Eating Disorders. International Journal of Eating Disorders, 54(6), 925-935. doi: 10.1002/eat.23527

Zipfel, S., Sammet, I., Rapps, N., Herzog, W., Herpertz, S., & Martens, U. (2006). Gastrointestinal Disturbances in Eating Disorders: Clinical and Neurobiological Aspects. Autonomic Neuroscience, 129(1-2), 99-106. doi:10.1016/j.autneu.2006.07.023