When we think about eating disorders, we most commonly think about individuals who avoid eating to the extreme for their body image or people who have an unhealthy pattern of binging & purging, as can be found in anorexia or bulimia.

But what about when we end up with disordered eating in the name of health?

In 2015, one of the leading gastroenterologists in the US, Dr. Eamonn M.M. Quigley rightly stated that, “most recently, and belatedly, the important role of the ubiquitous interloper into the gastrointestinal environment, food, has begun to be recognized and serious research efforts devoted to understanding its role in IBS and to the development of dietary approaches to the management of IBS”. In other words, we’re finally (FINALLY) starting to understand that food plays a part in the symptoms of IBS & we’re now seriously researching the area.

This sentence has always made me laugh, because patients have commonly and clearly told their healthcare providers that food is related to their symptoms. A study from the American Journal of Gastroenterology, that came out a year before Dr. Quigley’s statement, found that for almost 200 patients, 84% of them believed that certain food items were important triggers in their gut symptoms (2). We’ve seen this in numerous conditions and the perception is only increasing – food can be related to symptoms. We have also seen the increased use of therapeutic diets like the low FODMAP diet or IC (interstitial cystitis) diets that are routinely recommended by healthcare providers, and programs with less evidence that people will follow like elimination diets and non-celiac gluten sensitivity with or without guidance. These topics are discussed with ease on social media leading people down ever more restrictive eating pattern pathways with the belief that if they could just find that one magic food trigger, the problem will go away.  

And the thing is, changing diet can help with some symptoms – at least in the short term. And for diets, like the low FODMAP program, we’ve seen evidence that it works…to a point. But what if the removal of food can be a double-edged sword?

In gastrointestinal health, we’ve had a name change that has huge implications on how we think about gut disorders. We’ve previously known conditions like IBS, constipation, and dyspepsia as “functional” gastrointestinal disorders. This contrasts with organic GI disorders like Crohn’s, colitis, and celiac disease where we have testing that can ‘prove’ you have a condition. In our functional GI disorders, we don’t have a specific test to say, yes you have IBS. We use diagnostic criteria without a scope, scan, or blood test to prove it (although we may rule out other conditions first using those testing methods). Recently, we’ve seen the terminology go from ‘functional GI disorders’ to ‘disorders of gut-brain interactions’ or DGBI. This highlights the extreme importance of these conditions being complex interactions of gut physiology & the brain through the nervous system.  

So, how does this relate to disordered eating?

We have seen an increase in our understanding of the link between spiraling gut symptoms (this can also be found in other non-GI conditions) and food avoidance or restriction. To the point that many individuals diagnosed with DGBIs could meet the criteria for the eating disorder “Avoidant-Restrictive Food Intake Disorder” or ARFID. In this disordered eating pattern, we see that instead of people being motivated by their body shape or weight, they still have an eating disturbance present, but it is caused by different motivators – with one of those motivators being fear. The fear of a negative consequence that will result from eating a food such as nausea, bloating, abdominal pain, or other such symptoms.

A study from 2020 (3), found in over 400 patients presenting to a neurogastroenterology clinic for their initial appointment, that 24% of the individuals met the criteria for ARFID – almost one in four – with 93% of those patients reporting fear of GI symptoms.

At face value, this might not seem like a problem. Should avoiding foods because they are causing GI distress be considered an eating disorder?

The problem is, within disorders of gut-brain interactions, we can see that food avoidance and restriction can, in the long term ,perpetuate gut symptoms. The continual search for the food that is causing the problem, micromanaging each meal, and viewing all foods as potentially dangerous can be part of the problem within the gut-brain axis, leading to more symptoms. It was suggested in the 2016 study that “It is possible that these [DGBI] patients were more susceptible to developing ARFID symptoms because underlying processes that could be maintenance factors across DGBI and ARFID (eg, visceral hypersensitivity)”.  

We are starting to see more evidence that extreme food restriction can lead to lower amounts of healthy foods being eaten as well as contributing to problems like delayed gastric emptying, leading to even more heightened sensations like bloating & fullness (4). Which can then lead to the desire to restrict and avoid more food leading to a spiral of food & symptoms that can be difficult to tease out.  

So, what do you need to keep in mind?

• Gut-brain interactions are complex and food restriction and avoidance may exacerbate gut symptoms rather than eliminate them as hoped (even if it seems initially helpful)
• Cognitive, behavioural and emotional responses to our symptoms in disorders of gut-brain interactions (like IBS, bloating & dyspepsia) can be part of the problem
• Part of the solution of DGBIs will not only focus on treatments like food elimination and random probiotics but gut-hypnotherapy, cognitive behavioural therapy and re-introducing foods in a controlled manner – that can be scary, but is part of the process
• Self-treatment in these conditions can be dangerous – eliminating food is not necessarily just affecting your gut; it can exacerbate your condition. Getting help from a trained professional can be vitally important

References

• Thomas A, Quigley EM. Diet and irritable bowel syndrome. Curr Opin Gastroenterol. 2015 Mar;31(2):166-71. doi: 10.1097/MOG.0000000000000158. PMID: 25612261.
• Böhn L, Störsrud S, Törnblom H, Bengtsson U, Simrén M. Self-reported food-related gastrointestinal symptoms in IBS are common and associated with more severe symptoms and reduced quality of life. Am J Gastroenterol. 2013 May;108(5):634-41. doi: 10.1038/ajg.2013.105. PMID: 23644955.
• Murray HB, Bailey AP, Keshishian AC, Silvernale CJ, Staller K, Eddy KT, Thomas JJ, Kuo B. Prevalence and Characteristics of Avoidant/Restrictive Food Intake Disorder in Adult Neurogastroenterology Patients. Clin Gastroenterol Hepatol. 2020 Aug;18(9):1995-2002.e1. doi: 10.1016/j.cgh.2019.10.030. Epub 2019 Oct 24. PMID: 31669056.
• Nicholas JK, van Tilburg MAL, Pilato I, Erwin S, Rivera-Cancel AM, Ives L, Marcus MD, Zucker NL. The diagnosis of avoidant restrictive food intake disorder in the presence of gastrointestinal disorders: Opportunities to define shared mechanisms of symptom expression. Int J Eat Disord. 2021 Jun;54(6):995-1008. doi: 10.1002/eat.23536. Epub 2021 May 24. PMID: 34028851; PMCID: PMC8352498.

Dr. Kim Bretz believes that health doesn’t have to be so hard and that science can make it easier – she supports using the best research available, along with clinical experience and combining it with patient preference.