The role of eating disorder symptoms in gastroenterology
Eating disorder symptoms motivated by concerns about body shape/weight can be present in or develop in gastroenterology patients, often contributing to maintenance of gastrointestinal symptoms. Importantly, eating disorder symptoms lie along a spectrum—there are many individuals who do not meet full-threshold criteria for a “classic” eating disorder — anorexia nervosa, bulimia nervosa, binge eating disorder — yet have symptoms that could interact with their gastrointestinal presentation. To facilitate evaluation and treatment of patients with eating disorder symptoms, it can be helpful to understand that symptoms generally fall into two categories: thoughts and behaviors.
In the thoughts category, many symptoms may underlie the reason a patient presents with gastrointestinal symptoms. Common examples include: a negative perception of body shape or weight; a desire for thinness or a fear of weight gain; particularly heightened attention to changes in the body shape, or special rules around eating. Some patients may describe significant distress around gastrointestinal symptoms because of these underlying cognitions (e.g., some may perceive early satiety or post-prandial fullness as signals they are gaining weight).
In the behaviors category, common symptoms include attempts to restrict the volume or variety of food, fasting, binge eating, self-induced vomiting, abuse of diuretics or diet pills, use of laxatives, chewing and spitting food, and body shape and weight checking behaviors, such as repeated measurements. These behavioral symptoms can actually create or perpetuate distressing gastrointestinal symptoms and can get in the way of treatment for those conditions.
Clinicians can choose from several screening tools to facilitate a conversation with a patient about possible eating disorder symptoms. The SCOFF is the quickest to use, but may be limited in what symptoms it assesses so other self-report measures like the Eating Attitudes Test-26, the Eating Disorder Diagnostic Scale and the Eating Disorder Examination-Questionnaire may be useful. Of note, patients may be reluctant to recognize or admit to their eating disorder symptoms — in clinics where behavioral health providers are available, having an interdisciplinary visit with the patient can often be helpful.
There are many underlying factors that put an individual at risk for and maintain eating disorder symptoms. Two examples relevant to the gastroenterology setting could be important to consider. First, some patients may present with “sub-threshold” eating disorder symptoms, such as over-concern about the health value of their foods (sometimes called “orthorexia”) or use of stimulant laxatives to “feel empty.” In these cases, screening for these symptoms is paramount (eg, screening for reasons for laxative frequency in patients with chronic constipation) to prevent development of a full-blown eating disorder. Second, once an individual is put on a restrictive diet, they may be at greater risk for developing eating disorder symptoms, particularly binge eating. Prevention can be key here, for example by supporting patients in maintaining weight during treatment for the gastrointestinal condition (eg, while adhering to a gluten-free diet for celiac disease).
We recommend medical providers collaborate with a behavioral health provider (eg, psychologist) to treat any eating disorder symptoms. Medical providers are key to evaluating medical risk management and treating any medical complications. The Academy for Eating Disorders has published a standards of care guide for reference. As many primary care providers are not well-equipped to manage eating disorder symptoms, gastroenterology providers (including RNs, NPs, PAs) could actually fill a huge unmet need in performing the medical evaluation and follow-up for patients with eating disorders. In the case of medical compromise (eg, electrolyte abnormalities, significantly low weight), a higher level of care that integrates medical and behavioral interventions may be needed (eg, day program, residential/inpatient).
Behavioral treatments should be evidence-based and the intensiveness of the level of care should match the severity of eating disorder symptoms. Outpatient cognitive-behavioral therapy for adults with eating disorders is highly effective for patients in as little as 10 weekly, 1-hour outpatient sessions, with longer treatment duration for more severe cases especially when weight gain is needed (eg, up to 40 in anorexia nervosa). Family-based treatment is also an evidence-based treatment for children and adolescents, particularly for anorexia and bulimia. Not all behavioral health providers are trained in cognitive-behavioral therapy for eating disorders, so it is important to identify providers who use evidence-based approaches. A referral outside the gastroenterology setting is not always necessary, though, as many GI psychologists are well-equipped to treat patients with eating disorder symptoms, particularly sub-threshold symptoms. Further, dieticians can add to a multidisciplinary approach in some circumstances to augment treatment, particularly for patients who need to increase their volume of food to support weight gain.
For more information: Helen Burton Murray, MS, is a clinical and research fellow at Massachusetts General Hospital and Harvard Medical School. She recently completed a visiting fellowship via the ROME Foundation and specializes in psychogastroenterology. You can follow her on twitter at @helenbmurray.
Academy of Eating Disorders. AED Report 2016: Eating Disorders: A Guide for Medical Care; 3rd edition. Available at https://higherlogicdownload.s3.amazonaws.com/AEDWEB/27a3b69a-8aae-45b2-a04c-2a078d02145d/UploadedImages/AED_Medical_Care_Guidelines_English_04_03_18_a.pdf.
Disclosures: Murray reports no relevant financial disclosures.