Many individuals in recovery from an eating disorder may experience ongoing chronic complaints of emotional imbalance, gastrointestinal symptoms (abdominal pain and constipation being common), chronic fatigue, and disrupted or abnormal sleep. There are medical reasons why these problems may be experienced, and holistic support for recovery is imperative. Some aspects which I consider medically when working with clients in recovery from eating disorders are detailed here. This list is by far from inclusive, but I hope will give some insight into what holistic recovery by working with a naturopathic doctor will often include. I work with clients in recovery from eating disorders in office as well as remotely, and if you find this information useful or know of an individual who may benefit from it, please do send them my way.
Digestive dysfunction is very common in individuals with eating disorders. The normal parasympathetic state necessary for digestion often is quite the opposite as food is one of the primary things which provoke stress. With centrally mediated digestive dysfunction such as this not enough can be said about working to reduce stress associated with food consumption. Support for stress reduction related to meals and food consumption, possibly including deep breathing techniques, gentle yoga or grounding poses, and flower essences may be helpful.
Individuals who are trapped in patterns of restricted eating or dysfunctional eating patterns are definitely more challenging as any dietary restrictions can lead to further unnecessary focus on diet and may promote an orthorexic state. As a naturopath who often recommends dietary changes, this is not the primary approach which I utilize when dealing with eating disorders. I have also seen improvement in digestive symptoms with digestive enzyme usage at and between meals, and often utilize this possibly in combination with digestive bitters or Betaine HCl to support digestion.
There are multiple things which may contribute to constipation when in individuals who have a history of an eating disorder including historic laxative abuse, medications, thyroid abnormalities, chronic stress, and small intestinal bacterial overgrowth (SIBO). Psychiatric medications often have gastrointestinal side effects including constipation, and a modification of medications or dosage may help. Thyroid abnormalities, often due to dysfunction at the level of the hypothalamus are very common in eating disorders. This also may present with symptoms of constipation and is important to rule out with a thyroid panel - http://tinyurl.com/95stu79. Individuals with eating disorders, particularly anorexia nervosa, often have higher levels of cortisol, which both decreases appetite and is associated with the chronic stress state. Similar findings are also true for individuals with obsessive-compulsive disorders. I often recommend testing for this with an adrenal stress profile - http://tinyurl.com/bt9nnvs - and if abnormalities are found supporting the reduction in overall stress levels may be helpful. Phosphatidylserine, a phospholipid cellular membrane component, has evidence for reducing the cortisol and HPA axis activation in response to stress.
· Lawson EA, Holsen LM, Desanti R, Santin M, Meenaghan E, Herzog DB, Goldstein JM, Klibanski A. Increased hypothalamic-pituitary-adrenal drive is associated with decreased appetite and hypoactivation of food-motivation neurocircuitry in anorexia nervosa. Eur J Endocrinol. 2013 Oct 1;169(5):639-47. http://tinyurl.com/odxwl5j
· Oskis A, Loveday C, Hucklebridge F, Thorn L, Clow A. Diurnal patterns of salivary cortisol and DHEA in adolescent anorexia nervosa. Stress. 2012 Nov;15(6):601-7. http://tinyurl.com/n9hgm9z
· Kluge M, Schüssler P, Künzel HE, Dresler M, Yassouridis A, Steiger A. Increased nocturnal secretion of ACTH and cortisol in obsessive compulsive disorder. J Psychiatr Res. 2007 Dec;41(11):928-33. http://tinyurl.com/pnbekot
- Monteleone P, Maj M, Beinat L, Natale M, Kemali D. Blunting by chronic phosphatidylserine administration of the stress-induced activation of the hypothalamo-pituitary-adrenal axis in healthy men. Eur J Clin Pharmacol. 1992;42(4):385-8. http://tinyurl.com/oqw2kxa
Certain strains of probiotics support the reduction of anxiety and the stress response in the body, especially when taken on a longer term basis.
- Messaoudi M, Lalonde R, Violle N, Javelot H, Desor D, Nejdi A, Bisson JF, Rougeot C, Pichelin M, Cazaubiel M, Cazaubiel JM. Assessment of psychotropic-like properties of a probiotic formulation (Lactobacillus helveticus R0052 and Bifidobacterium longum R0175) in rats and human subjects. Br J Nutr. 2011 Mar;105(5):755-64. http://tinyurl.com/35cawey
- Ait-Belgnaoui A, Colom A, Braniste V, Ramalho L, Marrot A, Cartier C, Houdeau E, Theodorou V, Tompkins T. Probiotic gut effect prevents the chronic psychological stress-induced brain activity abnormality in mice. Neurogastroenterol Motil. 2014 Apr;26(4):510-20. http://tinyurl.com/pz3z7ya
- Dinan TG, Cryan JF. Regulation of the stress response by the gut microbiota: implications for psychoneuroendocrinology. Psychoneuroendocrinology. 2012 Sep;37(9):1369-78. http://tinyurl.com/pl387g2
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. A lactulose breath test for small intestinal bacterial overgrowth (SIBO) may be appropriate. More information about SIBO and the naturopathic treatment of this condition can be found here - http://tinyurl.com/pos5u28. Intestinal dysbiosis (small or large intestine) may contribute to skin symptoms, emotional balance, thyroid dysfunction, and a multitude of other problems which if present may further motivate testing. Large intestinal health, flora balance, and digestive function are best assessed with a comprehensive digestive stool analysis with parasitology – consider testing options from Genova Diagnostics – http://tinyurl.com/p7dbwx2 - and Doctor’s Data Inc - http://tinyurl.com/q4256rk - which are available from Regenerus Labs. Diagnosis and appropriate treatment of may improve a multitude symptoms.
· Million M, Angelakis E, Maraninchi M, Henry M, Giorgi R, Valero R, Vialettes B, Raoult D. Correlation between body mass index and gut concentrations of Lactobacillus reuteri, Bifidobacterium animalis, Methanobrevibacter smithii and Escherichia coli. Int J Obes (Lond). 2013 Nov;37(11):1460-6. http://tinyurl.com/pjrsczh
· Armougom F, Henry M, Vialettes B, Raccah D, Raoult D. Monitoring bacterial community of human gut microbiota reveals an increase in Lactobacillus in obese patients and Methanogens in anorexic patients. PLoS One. 2009 Sep 23;4(9):e7125. http://tinyurl.com/ov7p62j
· Kim G, Deepinder F, Morales W, Hwang L, Weitsman S, Chang C, Gunsalus R, Pimentel M. Methanobrevibacter smithii is the predominant methanogen in patients with constipation-predominant IBS and methane on breath. Dig Dis Sci. 2012 Dec;57(12):3213-8. http://tinyurl.com/pnh3eez
Altered bowel habits commonly coexist in individuals with anxiety and depression. Looking at a recent study, state (ie current) anxiety coexisted in 84.1% of individuals with gastrointestinal disorders, most commonly related to food allergies (p < 0.001), small intestinal bacterial overgrowth (SIBO) (p = 0.001), Helicobacter pylori (Hp) infection (p = 0.01) and ulcerative colitis in active phase (p = 0.03). Trait (ie overall tendency toward) anxiety was found to be related to similar issues as well, with the addition of irritable bowel syndrome. These relationships do not directly imply causation, but indicate that there is a mental/emotional relationship with bowel issues which also should be addressed as previously mentioned.
- Addolorato G, et al. State and trait anxiety and depression in patients affected by gastrointestinal diseases: psychometric evaluation of 1641 patients referred to an internal medicine outpatient setting. Int J Clin Pract. 2008 Jul;62(7):1063-9. http://tinyurl.com/lp8thou
Supporting the almost inevitable factors of anxiety and depression which often surround a preoccupation with food is also very important for long term recovery. Individuals with chronic anxiety and depression are often poor methylators and require more available methylated forms of Vitamin B12 (methylcobalamin) and/or methylated folate. A B complex will also support the improvement of energy and adrenal function. Antioxidants and nutritive support also have some evidence for reducing symptoms of depression. Vitamin C is one antioxidant with such evidence which also may improve symptoms of constipation.
- Atmaca M, Tezcan E, Kuloglu M, Kirtas O, Ustundag B. Serum folate and homocysteine levels in patients with obsessive-compulsive disorder. Psychiatry Clin Neurosci. 2005 Oct;59(5):616-20. http://tinyurl.com/pkf8spp
- Sanmukhani J, Satodia V, Trivedi J, Patel T, Tiwari D, Panchal B, Goel A, Tripathi CB. Efficacy and Safety of Curcumin in Major Depressive Disorder: A Randomized Controlled Trial. Phytother Res. 2014 Apr;28(4):579-85. http://tinyurl.com/q2mqxws
- Moretti M, Colla A, de Oliveira Balen G, dos Santos DB, Budni J, de Freitas AE, Farina M, Severo Rodrigues AL. Ascorbic acid treatment, similarly to fluoxetine, reverses depressive-like behavior and brain oxidative damage induced by chronic unpredictable stress. J Psychiatr Res. 2012 Mar;46(3):331-40. http://tinyurl.com/njzh8ch
Obsessive compulsive behaviors are also common with eating disorders. Imbalances with glutamate are associated with obsessive compulsive disorder, and working to address this possible imbalance may improve obsessive behaviors around food as well. N-acetyl cysteine has some evidence for reducing obsessive compulsive behavior via modulation of glutamate. Supporting the excitatory – inhibitory neurotransmitter balance with GABA also may be beneficial.
· Pittenger C, Bloch MH, Williams K. Glutamate abnormalities in obsessive compulsive disorder: neurobiology, pathophysiology, and treatment. Pharmacol Ther. 2011 Dec;132(3):314-32. http://tinyurl.com/nsb2lef
· Russo AJ, Pietsch SC. Decreased Hepatocyte Growth Factor (HGF) and Gamma Aminobutyric Acid (GABA) in Individuals with Obsessive-Compulsive Disorder (OCD). Biomark Insights. 2013 Aug 18;8:107-14. http://tinyurl.com/ngspy9c
· Grant JE, Odlaug BL, Kim SW. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study. Arch Gen Psychiatry. 2009 Jul;66(7):756-63. http://tinyurl.com/oepm2xr
· Egashira N, Shirakawa A, Abe M, Niki T, Mishima K, Iwasaki K, Oishi R, Fujiwara M. N-Acetyl-L-Cysteine Inhibits Marble-Burying Behavior in Mice. J Pharmacol Sci. 2012;119(1):97-101. http://tinyurl.com/ofbd9y9
The avoidance of fat due to the fear of becoming fat is a central theme in anorexia nervosa, however the inclusion of fats with each meal will do much to improve the process of digestion. When I work with clients who have difficulty including these foods in the diet I do much to specifically address the benefits of healthy fats such as fish oils, avocados and the benefits they may have on skin, gastrointestinal function, hormonal balance, and cravings. Focusing on the importance of foods for other parts of function (rather than just caloric value) is often part of the transition from anorexic to healthy eating behavior.