Building a therapeutic alliance: Eating disorders in GI
The connection between disordered eating and GI seems like an easy one to make.
Kyle Staller, MD, MPH, director of the gastrointestinal motility laboratory at Massachusetts General Hospital, said people with a history of eating disorders, including those now in recovery, may have longstanding changes in how they perceive their gut function that can lead them to present to a gastroenterologist with GI-type symptoms.
“People with active eating disorders who are restricting, tend to have acute dysfunction of the GI tract, which can mimic many of the GI conditions we take care of,” Staller told Healio Gastroenterology. “It’s important for gastroenterologists to recognize the relationships that can happen there, but also not to stigmatize patients who may have an eating disorder history, because their behavior may not be driving the symptoms.”
While it may be easy to see a link between GI issues and eating disorders, identifying cause and effect is not so simple. Studies have shown that eating disorders have a greater presence among patients with GI disorder compared with healthy control individuals.
“Conceptually, what we see in practice and what patients describe is that eating disorder symptoms lie on a spectrum,” Helen Burton Murray, PhD, a psychologist in the Massachusetts General Hospital division of gastroenterology, said. “They can either be present in someone who might already be presenting to gastroenterology, or patients might develop eating disorder behaviors as a result of gastrointestinal symptoms.”
If gastroenterologists are likely to treat patients with eating disorders, what are some of the signs they should look out for and what can they do to help?
Disorders to Look For
According to Monia E. Werlang, MD, from the department of gastroenterology and hepatology at the University of South Carolina School of Medicine Greenville, about 20% of patients who present to general GI practice have some kind of eating disorder. That includes the “traditional” or body weight/shape eating disorders like anorexia, bulimia and binge eating disorder, as well as a newer diagnosis, avoidant restrictive food intake disorder, or ARFID.
Along with other chronic conditions, there are also several GI-specific conditions in which eating disorders are more common.
“In patients who have diseases that are managed by diet, for example diabetes, celiac disease or even hypertension, there is a higher prevalence of eating disorders than in individuals who do not have those conditions,” Werlang said. “In the GI world, we have some studies that indicate higher prevalence among patients with chronic constipation, irritable bowel syndrome, gastroparesis and inflammatory bowel disease.”
Patients with some kind of eating disorder/GI interaction may present in one of a few categories, according to Burton Murray. They can have a history of disordered eating but are no longer eating disorder symptomatic, they may have a current eating disorder or they might be at risk for developing disordered eating.
“The risk for disordered eating is often where patients in the ARFID realm fall into, where they might be at risk for developing avoidant eating to try to manage or prevent their GI symptoms,” she said. “ARFID is not primarily motivated by body image disturbance like other ‘classic’ eating disorders. Some patients may have some concerns about their body shape and weight, but it’s not what is driving avoidance of certain foods or restriction of the volume of their food intake.”
Although it is natural for people to avoid foods that might cause GI disturbance, Burton Murray said it moves into an eating disorder category when an individual starts avoiding so many foods or limits their intake to such an extent that it leads to medical or psychosocial problems.
The diagnosis and treatment of patients with eating disorders can often be limited due to some common misconceptions. The most common, according to Werlang, is that eating disorders are exclusive to young women and girls. However, the GI conditions that may predispose someone to developing an eating disorder do not fall neatly into that preconceived idea.
“Diabetes, hypertension and GI conditions, they’re not typical conditions of the young female,” Werlang said. “They’re common in older patients, male and female. One of the things we want to demystify and take away from people’s thoughts is that you should only have your ‘eating-disorder radar’ on for young females.”
Because of the stigma behind eating disorders, it might also be difficult to approach the subject with patients in a GI setting. Staller said it is important to be cognizant if the conversation starts to become overly focused on food choice. Rigidity and inflexibility on diet might be an indication of some kind of disorder.
“A very restrictive diet should be difficult to follow for most of us,” Staller said. “When patients are very enthusiastic about cutting things out and very rigid about bringing them back in, that should raise an alarm bell.”
That can be particularly difficult in GI where restrictive diets, like the low FODMAP diet, have become an important part of treatment for some conditions. In patients with potential risk for eating disorders, however, they can be exactly the wrong thing to introduce.
“Sometimes, our first instinct is to reach for restricted diets because, number one, patients really demand them,” Staller said. “They like to avoid pharmacotherapy when they can. Number two, they certainly can be helpful in terms of preventing symptoms.
“In general, we have to take our patient’s preferences into account, but a one-size-fits-all approach is definitely not the right answer for some of their eating behaviors.”
Burton Murray said there are several screening tools that GIs can use to help them get a sense of when a patient might have some problems around eating.
“There are scales that align with some of the common prototypic motivations for ARFID in patients with GI conditions, like fear of aversive consequences, fear of GI symptoms and lack of interest in eating or low appetite. Another prototypic motivation for ARFID is sensory sensitivity to the characteristics of food, like taste, texture or smell, but we see that less in adult GI cases.”
Once a GI identifies that a patient may be struggling with their eating, they can refer a patient to a behavioral psychologist like Burton Murray. From there, she said the end goal is to change cognitions around what patients do through changing their behavior. While many treatments exist for eating disorders, Burton Murray focuses on the behavioral aspects of cognitive behavioral therapy.
“First, we’re establishing regular patterns, making sure that patients are eating on a regular schedule and, if needed, ensuring that they increase their volume of intake to support weight gain, if that’s a target,” she said. “In the case of ARFID symptoms, it’s about exposure to foods that maybe the patient hadn’t been eating or an amount of food. We continue that work by specifically helping patients approach rather than avoid foods, and we have several skills that can help them do so, depending on the prototypic motivation. Some patients may also benefit from a consultation or multidisciplinary work with a nutritionist.”
Knowledge Gaps and Future Research
Despite the prevalence of eating disorders among patients with GI conditions, GIs still lack reliable tools to help diagnose them. An overlap in symptoms makes discerning eating-related problems even more difficult for GIs.
“Patients with anorexia often have nausea and can develop significant constipation due to poor oral intake,” Werlang said. “Once the patient comes into your office and they have several complaints, it can be very difficult for the GI physician to diagnose that without proper tools. The focus of research moving forward should include the development of diagnostic and screening tools that are appropriate for the GI physician to use in the office.”
Staller believes that future research needs to be dedicated to the mechanisms of how GI conditions contribute to eating disorders and vice versa. In his practice, he sees patients who may have previously had an eating disorder and continue to experience GI symptoms despite recovering from their eating problems and effectively addressing those cognitions.
“They’re no longer participating in eating disorder behaviors, that includes any restriction, purging or other behaviors,” he said. “Yet, they are probably still predisposed to experiencing GI symptoms. Things like bloating, constipation and dyspepsia.”
Staller suggested that research could focus on how changes to the nervous system or the microbiome that come from past eating disorders contribute to future GI conditions.
Burton Murray said there is also the question of which patients are at highest risk for develop avoidant-restrictive eating around their GI symptoms. Despite some clinical intuitions, there are no solid data to show how to tailor treatment for each patient.
“It’s a really important area from a precision medicine perspective,” Burton Murray said. “Many patients can be put on restrictive or elimination diet and be completely fine. However, we don’t have data to suggest which patients that might be okay for or to identify which individuals might be at risk for developing problems around eating.”
Burton Murray is hopeful that eventually they will have enough data from their clinical population to identify risk factors and better care for patients.
“My research is focused on understanding what is the best way for us to apply an ARFID-focused behavioral intervention for patients with functional GI conditions,” she said. “Right now for ARFID, the typical behavioral treatment is between 16 and 30 sessions, which often may be infeasible in the GI setting. I’m currently evaluating an eight-session treatment and effectively help patients with their functional GI symptoms and avoidant restrictive eating to improve medical and nutritional status.”
Werlang said the most important thing for a GI to do is to be upfront with their patients. Even if they are experiencing a GI condition and have a history of an eating disorder, they might not volunteer that information or they might not even be aware they are related.
“They may not think it’s relevant,” Werlang said. “And sometimes, they’re not, but matters can develop over time that the GI physician, if they know the history of the eating disorder, may be able to help.
“It’s important for the GI to keep an eye out for patients who have limited their diet significantly to improve their GI symptoms.”
Staller has a similar approach. For him, the important thing GIs should keep in mind is that honest conversation is often the best approach. It can be easy for classifications and technicalities to muddy the waters, but Staller said community GIs should not feel like they need to tackle situations like these alone.
“It’s about asking questions about feeding, eating and history of disordered eating respectfully and with an open mind,” he said. “By doing that, you can create a therapeutic alliance that will then allow your patient to feel much more comfortable sharing some of these behaviors that they may be concerned about.
“You don’t need to feel like you don’t have the expertise to deal with it. Just by asking about it can show an open space and that the patient is safe share those things. Then, you can get the expertise if you need it down the road.”
Expertise from multidisciplinary team that includes a psychologist like Burton Murray can be key to treatment, but even she thinks the best way to start is just by asking the right questions.
“Asking patients about how their eating is impacting their quality of life is often the best way to build that alliance,” she said. “It’s important that we’re trying to improve their quality of life, and if we can have a conversation about how eating is impacting it, that could lead to having them get further treatment around their eating.”
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- Werlang ME, et al. Am J Gastroenterol. 2021;doi:10.14309/ajg.0000000000001029.