The Battle in Your Belly
Most of Mirasol's clients experience gastrointestinal disturbances at one time or another during their recovery. Some come into treatment with a long list of food allergies and sensitivities. Others may find that eating regularly again can result in a range of uncomfortable symptoms including gas, bloating, constipation and diarrhea. For both the client and their treatment team, it's not easy to tell if a sudden intolerance for wheat, dairy or animal products is a clinical issue, or a way to avoid eating broad categories of food. How can they work together to disentangle eating disorder cause and effect, and reduce the discomfort of weight restoration?
A food allergy is an immune system reaction that occurs soon after eating a certain food. Even a tiny amount of the allergy-causing food can trigger signs and symptoms such as digestive problems, hives or swollen airways. In some people, a food allergy can cause severe symptoms or even a life-threatening reaction known as anaphylaxis.1
Unlike food allergies, food intolerances do not involve an immune response. Lactose intolerance is the inability to produce lactase to break down lactose, a component of milk and some other dairy products. Lactose intolerance causes gastrointestinal symptoms within 30-60 minutes of consuming lactose-based foods.2 Most children are born with the ability to make lactase, an enzyme that helps the small intestine digest lactose, the sugar found in milk. But with age, lactase levels decline, which means there's nothing to prevent lactose from entering the colon undigested, where bacteria break the sugars down and create excess gas and fluid. Chronic illness — including eating disorders — can inhibit the body's ability to produce lactase.3
Celiac disease is an intolerance for gluten (the proteins found in wheat, rye and barley). It's a genetic predisposition that can be activated by infection, stress, or hormonal changes. For people with celiac disease, consuming gluten creates an immune response that destroys the villi, or hair-like protrusions in the gut that move food forward and allow for proper absorption of nutrients. There is no cure, but a gluten-free diet will help prevent further medical complications.
Individuals with a history of Irritable Bowel Syndrome (IBS) may be tested for SIBO (small intestinal bacterial overgrowth). The theory behind SIBO is that stress or an infection can cause bacteria that normally reside in the colon to make their way into the small intestine, where they can produce digestive symptoms such as bloating, malabsorption and chronic diarrhea. Some tests have shown a high correlation between SIBO and IBS, as well as diabetes and celiac disease. Since both conditions can result in disordered small bowel function, it's difficult to clinically distinguish SIBO from other diseases.5
Testing ... Testing ...
Unfortunately, testing for food allergies and sensitivities is an inexact science.
Lactose intolerance can be identified using either a blood test for glucose levels or a breath test for hydrogen after consuming a liquid containing high levels of lactose. In the past, it was standard practice for people with the condition to avoid all dairy products. But experts now recommend that you keep some cheese, yogurt, and even milk in your lactose-intolerance diet.
The Celiac Disease Foundation recommends a tTG-IgA (Tissue Transglutaminase IgA) blood test, which will be positive in 98% of patients with celiac disease and negative for 95% of healthy people without celiac disease. But antibody testing is not definitive. Because of potential for false positives, a biopsy of the small intestine is considered the only way to diagnose celiac disease.4 Currently, the only treatment for celiac disease is adherence to a strict gluten-free diet. That means avoiding foods with wheat, rye and or barley, including bread and beer.
Food allergies are identified using skin prick or blood tests that measure the presence of IgE (immunoglobulin E) antibodies for specific foods. However, 50-60% of both blood and skin tests will result in a false positive, since the test may be:
- measuring your response to the undigested food proteins.
- detecting proteins that are similar among foods but do not trigger allergic reactions.5
SIBO is typically diagnosed using a hydrogen, lactulose or glucose breath test to measure levels of hydrogen and methane. The tests may be performed at home or at a clinic and require a 12-hour fast a special diet the preceding day. At-home kits may be obtained from numerous breath testing laboratories. But while breath testing is easy to perform, the results are difficult to interpret.7 Hydrogen and methane releases occur in both healthy and unhealthy individuals, and there is no consensus on the ranges that would establish the presence of SIBO.2
The primary treatment for SIBO is antibiotic therapy, which reduces the bacterial overload and reverses the mucosal inflammation associated with overgrowth and malabsorption. However this approach is problematic because of the potential for drug resistance and interactions, and the need for recurrent courses of antibiotics. One clinical trail demonstrated an average duration of symptom improvement of only 22 days.1
The second line of defense involves dietary changes. The Low FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols) diet has shown some positive results for reduction of IBS and SIBO symptoms.
FODMAP foods include fermentable:
- Oligosaccharides: Jerusalem artichoke, cabbage, onion, and garlic.
- Disaccharides: Cow or goat milk.
- Monosaccharides: Apples, peaches, mangos, and pears.
- Polyols: Avocados, apricots, prunes, snow peas, and xylitol.8
However, the FODMAP diet does not eradicate symptoms and could be damaging to overall health. For individuals struggling to recover from an eating disorder, any treatment that involves restricting or eliminating consumption of large categories of food leads down a slippery slope that could actually make recovery more difficult.
So Where Do We Go from Here?
Unfortunately, recovery from an eating disorder will likely involve considerable gastrointestinal distress. One consequence of an eating disorder is decimation of healthy bacteria in the gut during bouts of restriction and compulsive exercise. As the body begins to recover, gastrointestinal disturbances (bloating, distention, flatulence, gas, diarrhea, loose stools, poorly digested foods, constipation, burping) may be worsen until the large intestine's natural population of essential helpful bacteria is fully restored.
While you wait for your body to recover, there are a number steps you can take to rule out other more serious problems, reduce your symptoms and increase your odds for sustained recovery.
- Don't drastically increase your food intake when you have an active eating disorder without medical supervision. If you are sensitive to certain foods, work with your dietitian to slowly reintroduce them to your meal plan.
- Most eating disorders co-occur with anxiety, which can aggravate gastrointestinal disorders. Use tools to reduce mealtime stress, including deep breathing techniques, gentle yoga, tapping or flower essences. 9
- If your pain is sustained or severe (6 or more on a scale of 1 to 10), consult with your doctor to rule out:
· inflammatory conditions such as Crohn's or ulcerative colitis
· neuropathic or myopathic disease
· biopsy-confirmed celiac disease
· any food allergy whose severity could lead to anaphylactic shock
· obstruction in the GI tract
· thyroid abnormalities
- Eat at regular intervals, timing meals and snacks 2-3 hours apart to decrease stomach discomfort.
- Digestive enzyme supplements can help in the early phases of recovery. Yogurts with active cultures of Lactobacillus bulgaricus and Streptococcus thermophiles can support normalization of gut function and ease the desire to restrict. Saccharomyces boulardii (over-the-counter product Florastor) also aids in supporting the re-colonization of good bacteria and easing some of the gastrointestinal distress common in recovery.2 Digestive enzymes may be combined Betaine HCl to support digestion.9 However, bacterial strains vary widely, and since everyone has different gut microbiota (collection of beneficial bacteria), there is no such thing as a probiotic that will work for everyone.10
- Psychiatric medications often have gastrointestinal side effects including constipation, and a modification of medications or dosage may help.
- Your doctor may recommend simethicone (Gas-X) to relieve gas pain or medication such as Reglan to help food move through your system.
- Heating pads, hot water bottles, warm compresses or — best of all — a purring cat can help relieve abdominal pain.
- Frequent bowel movements and diarrhea are common when you start eating more regularly. Try adding soluble fibers such as oats, oatmeal, applesauce and brown rice.
- Enteric-coated peppermint capsules and mint tea can help relieve intestinal spasms and cramping.
- SIBO testing is still controversial, but there is a well-established correlation between eating disorders and imbalances in gastrointestinal flora imbalances are also more common in individuals with eating disorders. Research comparing the microbiota of individuals with anorexia nervosa to both a normal and obese population has shown that higher levels of Methanobrevibacter smithii are more common in those with anorexia nervosa. This strain of bacteria is also most commonly associated with constipation-type IBS. If you've ruled out other issues and still have all the symptoms, a test for SIBO may be appropriate.
- Most of all, be patient. Remember that intestinal distress is normal for people in early recovery from eating disorders. Give your body the nourishment and the time it needs to learn how function efficiently again. And meanwhile, keep moving forward!
- 1 Mayo Clinic Food Allergy Overview
- 2 Tummy Troubles
- 3 Can You Develop Lactose Intolerance Later in Life?
- 4 Screening for Celiac Disease
- 5 Food Allergy Blood Tests
- 6 Small Intestinal Bacterial Overgrowth
- 7 SIBO-Small Intestine Bacterial Overgrowth
- 8 The Low FODMAP Diet Warning for IBS and SIBO Sufferers
- 9 Medical Perspective on Holistic Eating Disorder Recovery
- 10 Do Probiotics Really Work?