Written by Talia Cecchele
Digestive issues are one of the most common side effects of an eating disorder, irrespective of the type of eating disorder, body weight or size. Gut health is influenced by many factors and people can experience digestive issues by engaging in any disordered eating and compensatory behaviours.
It's really common. Studies suggest that specifically for anorexia nervosa, greater than 95% of people will experience gastrointestinal (GI) complaints [1].
Why do digestive issues occur?
Pre-existing Gut Disorders
Digestive issues in eating disorders and disordered eating can be related to a pre-existing gastrointestinal condition such as irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD), engaging in eating disorder behaviours (e.g. self-induced vomiting or laxative abuse), malnutrition and weight loss or a combination of these. However, most commonly gut health issues are functional in nature meaning that the process of digestion is negatively impacted due to starvation.
Compensatory Behaviours
Vomiting and laxative misuse which are common in bulimia nervosa and other eating disorders can interfere with normal GI functioning by slowing down digestion, causing loss of muscle tone, bloating, gas and abdominal pain. Laxative abuse can have severe side effects including blood or mucus in the stool, incontinence and in worst cases, paralysis of the intestine (which can lead to surgical removal of part or all of the colon) and increased risk of colon cancer.
Starvation and Malnourishment
In starvation mode, the cave man brain doesn't want to spare a single bit of energy on digestion because normal digestion isn't necessary for human survival. When the body isn't receiving adequate energy from food, it needs to source fuel from somewhere else and the body does this by slowing down metabolism and breaking down muscles to convert the muscle protein into energy. As a result from this and the gastrointestinal tract being underused due to restriction, the muscles of the stomach and intestines lose tone and become weak.
Also, in starvation fewer enzymes and hormones required for digestion are produced, further impacting digestion. Learn more about energy requirements in eating disorder recovery to explore this further.
What are the common digestive issues experienced?
Gut health issues experienced by people with disordered eating and eating disorders include:
Gastroparesis (slow stomach emptying) as a result of starvation and calorie restriction. This can make someone feel "Christmas lunch" full even after eating half a sandwich
Bloating & abdominal distention as a result of gastroparesis and/or weak abdominal muscles and reduced abdominal fat. When abdominal muscles are weak and there is an insufficient layer of fat the abdominal wall can't hold in the food and you can "see" your meal
Constipation due to gastroparesis, dehydration and simply not having enough volume of food in the gut
Diarrhoea due to food travelling too quickly through the gut without enough time for proper absorption of nutrients
Flatulence (farting) which can often cause discomfort
Abdominal pain
Nausea
Early satiety (feeling full quickly) and feeling full all the time
IBS-type symptoms including food intolerances such as transient (temporary) lactose intolerance (note: it is not recommended to follow an elimination diet during nutritional rehabilitation - we need to give the gut nutrition, not restrict it further).
During the early stages of nutritional rehabilitation, it can be easy to think that feeling full on a small amount of food means that you don't have to eat as much or not follow the meal plan recommended by your Dietitian. The ED self likes this logic, however not eating and prolonging nutritional rehabilitation will only make your digestive symptoms worse as the gut remains undernourished. In the initial stages (first few months at least), meals will be eaten according to time and be prescriptive rather than relying on hunger and fullness cues.
How to manage digestive issues in recovery
Eating disorder recovery, specifically nutritional rehabilitation, is often complicated by digestive discomfort and the misinterpretation of fullness being experienced as weight gain or feeling "fat." GI issues will improve with time with nutritional rehabilitation, weight restoration and cessation of any behaviours interfering with digestion.
There are some practical tips to help ease the discomfort following a meal:
Wear loose fitting clothes during and after meals. Clothes that fit tightly around your stomach or even tight leggings can increase bloating and abdominal pain
Remember, some level of bloating is normal after eating
Use a hot water bottle or sip on herbal tea after a meal (peppermint is a good flavour)
Hug a pillow or blanket
Distract yourself with a puzzle, calling a friend, knitting, watching a movie or any other activity
Talk to someone! This could be a friend, family member or recovery community. Being open with how you feel and the discomfort you are experiencing is important as sometimes you might need to hear a rational voice when the eating disorder voice is loud.
Avoid lying flat for at least 30-60 minutes after a meal. Let gravity help move things along
Avoid filling up on too many fluids with your meals, sip them in between
Practice breathing techniques or meditation
Be patient, it will get better!
What to consider when healing gut issues
Medication
Alongside proper nourishment, your doctor or dietitian might recommend medication to ease the discomfort from gastroparesis or constipation. Medications like metoclopramide, fibre supplements or stool softeners (not stimulants) can be helpful temporarily.
Healing takes time
It can take time for your gut health to return to normal, and unfortunately some people will experience lasting side effects as a result of chronic restriction and starvation. If you are concerned about your digestion please don't restrict your diet or engage in unhealthy behaviours or self-medicate. It is important you seek professional medical advice.
If you need support with gut issues in eating disorder recovery, schedule a discovery call with one of our specialist eating disorder dietitians at the TC Nutrition clinic. Find out more about our team here.
Talia Cecchele
TCN Founder
References:
[1] Kessler U, Rekkedal GÅ, Rø Ø, et al. Association between gastrointestinal complaints and
psychopathology in patients with anorexia nervosa. Int J Eat Disord. 2020;53:802–806. https://doi.org/10.1002/eat.23243
Talia Cecchele Nutrition is a team of registered dietitians that specialise in eating disorder recovery, disordered eating, digestive issues and sports nutrition. We aim to bring balance back to nutrition, help you to break free from food rules and find food freedom. We offer virtual consultations and group programs so whether you are based in London, the United Kingdom or around the world we would love to support you. To enquire about a private consultation please fill out a contact form.