The Elephant in the Room: Navigating Conversations About Eating Disorders with GI Patients

Jayne DuBois, ND

Eating disorders are complex psychiatric conditions that frequently present in medical settings under the guise of benign gastrointestinal symptoms such as constipation, bloating, or abdominal pain. Because of the way that these disorders manifest in the mind and in a patient’s interpretation of their symptoms, they are reported in such a way that the true nature of the issue often goes unrecognized. 

The challenge for clinicians lies in identifying when GI symptoms are related to a primary eating disorder.  Failure to do so can delay appropriate treatment and exacerbate both the eating disorder and gastrointestinal distress. This article explores two patient cases that illustrate the intersection between eating disorders and GI complaints, highlighting the need for a nuanced approach to diagnosis and care.

Case 1: Unmasking Binge Eating Disorder

A 54-year-old female patient was referred to the clinic by her acupuncturist with the primary goal of reducing or discontinuing her medications. During the initial visit, her chief complaints included anxiety, depression, insomnia, chronic constipation, and a recent labral tear. The patient followed a gluten-free and mostly vegetarian diet, avoiding meat and gluten due to perceived impact on her constipation. A 24-hour dietary recall suggested that her caloric intake was adequate, but the patient expressed concern about recent weight gain associated with her injury. This concern became a focal point of the clinical encounter, suggesting the presence of disordered eating behaviors and creating the need for an entirely different clinical discussion than the one the patient intended.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) outlines key criteria for diagnosing binge eating disorder², including:

• Daily restriction of caloric intake relative to body requirements
• Intense fear of gaining weight
• Poor body image
• Purging behaviors (vomiting, excessive exercise, laxative use)
• Recurrent episodes of binge eating
  • Eating more rapidly than normal
  • Eating until uncomfortably full
  • Eating large quantities of food when not physically hungry
  • Eating alone due to embarrassment about how much one is eating
  • Feeling disgusted, depressed or guilty after binging

During the remainer of the clinical interview, the patient disclosed a history of body dysmorphia and issues with food that extended back many years. She described herself as having always been active, with a background in gymnastics, but noted that her motivation for exercise was primarily weight loss rather than enjoyment. In high school, she shifted from sports to theater and experienced weight gain, which became a source of shame. Her family frequently teased her about her preoccupation with food, and she revealed that she had been dieting since the fifth grade. Weighing herself regularly had become a routine part of her life.  Her body image was notably poor, and she endorsed a deep-seated fear of gaining weight.

At the time of the interview, the patient admitted to restricting her caloric intake on a near-daily basis, though she did not actively count calories. She reported eating a predominantly plant-based diet but frequently felt hungry. Despite her best efforts to control her diet, she found herself binging regularly in a way that matched the DSM criteria.  What initially appeared to be a case of GI distress with some psychological overlay evolved into a clear case of binge eating disorder (BED). Based on the DSM criteria, the patient met the diagnostic threshold for BED, which is characterized by episodes of binge eating, accompanied by significant distress, in the absence of compensatory behaviors like purging or excessive exercise. Her episodes of caloric restriction, coupled with a pervasive fear of weight gain and poor body image, further solidified the diagnosis.

Case 2: “Atypical” Anorexia Nervosa

A 32-year-old female patient presented as a warm handoff from a local partial hospitalization program (PHP) after completing treatment for bipolar II disorder and binge eating disorder. Her past medical history was significant for irritable bowel syndrome with diarrhea (IBS-D), gastroesophageal reflux disease (GERD), concussions, migraines, hay fever, recurrent urinary tract infections (UTIs), vaginitis, and premenstrual dysphoric disorder (PMDD). She had undergone a cholecystectomy and an appendectomy in recent years and was taking several psychiatric medications, including bupropion, sertraline, lamotrigine, and trazodone.

At intake, the patient reported daily caloric restriction and a persistent fear of gaining weight. She described her body image as, “I wish I was thinner”.  Despite her diagnosis of binge eating disorder, she restricted her food intake throughout the day and only ate at night. Weighing herself approximately once per month, she had no history of purging behaviors. Her BMI at intake was 33.2.

The patient’s GI symptoms included frequent bowel movements (up to five per day), abdominal pain relieved by bowel movements, and mucus in her stool. She reported daily nausea, particularly in the mornings, and a history of ulcers treated a year prior. Despite these symptoms, the patient had never undergone an endoscopy.

A 24-hour dietary recall revealed that the patient typically skipped breakfast and lunch, consuming only a small meal in the evening. Her snacks were minimal, often limited to a few chips or a single serving of food. Her restricted dietary intake and poor body image, combined with her ongoing fear of weight gain, suggested a diagnosis of anorexia nervosa, restricting type, rather than binge eating disorder. After intake, this patient was referred to a multidisciplinary care team, including nutrition counseling, dialectical behavior therapy (DBT), and psychiatric follow-up.  Supportive therapies were introduced to manage her GI symptoms, including craniosacral therapy, demulcent herbs⁸, probiotics, and digestive enzymes. After six months, she matriculated into another intensive outpatient program (IOP) with a new diagnosis of anorexia nervosa, restricting type.  She was treated for hypophosphatemia during nutritional rehabilitation.  Most psychological and GI symptoms improved as a result of (and not before) comprehensive nutritional rehabilitation.

Relevant Questions to Ask in a Clinical Interview When Suspecting an ED:

• Do you have any history of disordered eating?  What did that look like?
• Do you ever change how much you’re eating or drinking to lose weight?  When was the last time you remember doing this? Have you ever dieted in the past?
• Would you say that you are afraid to gain weight?  How afraid?
• How would you describe your body image?
• Have you ever tried to lose weight by engaging in a purging behaviors such as vomiting, taking a laxative, or exercising to burn calories?
• Do you ever find yourself binge eating?  What I mean by that is eating more rapidly than normal, eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone because of feeling embarrassed by how much one is eating, feeling disgusted with oneself, depressed or guilty after binging.  Do you relate to any of those?
• Are there any foods that you think are bad or that you’re afraid to eat?
• Do you weigh yourself?  How often?
• Do you ever find yourself body checking?  How often?
• Do you count calories?
• Would you say that the thoughts you have about food and your body are intrusive?  Do you ever feel bombarded or tortured by them when a part of you knows they might not be true?
• What percentage of your thought life do these thoughts take up?
• Can you tell when you’re hungry and when you’re full?
• Do you have a family member who makes critical comments about their own body, or about your body?

Broader Considerations in Eating Disorder Care

Eating Disorders and the GI System

GI symptoms are common in patients with eating disorders, often manifesting as dyspepsia, GERD, constipation, bloating, and diarrhea⁴. However, these symptoms are frequently a consequence of the eating disorder itself rather than an organic GI pathology. For example, patients with anorexia nervosa often experience early satiety, bloating, and abdominal discomfort due to reduced gastric motility and visceral hypersensitivity associated with prolonged caloric restriction⁵. These symptoms can drive patients toward further restriction, creating a vicious cycle of malnutrition and gastrointestinal distress.

The Risk of  Overdiagnosing Binge Eating Disorder 

It is important to note that binge eating disorder is frequently overdiagnosed, often due to misunderstandings about what constitutes a binge. Many patients may report binge eating when, in reality, their eating behaviors do not meet the clinical definition of a binge. A key aspect of diagnosing BED is recognizing that binge eating episodes are often preceded or followed by restrictive eating patterns. In Case 1, the patient’s restriction during the day led to compensatory binge eating at night, a hallmark feature of BED.  When behaviors don’t meet the criteria of a true binge, a more accurate diagnosis to be consider would be anorexia nervosa, restricting type.

BMI is frequently cited in discussions of eating disorders, but it is not always a clinically necessary measure, particularly in weight-inclusive care settings¹. In cases like this, blind weights (where the patient is not informed of their weight) can be used to prevent reinforcing disordered behaviors or exacerbating body image concerns. It is essential for clinicians to understand that not all patients with BED are in larger bodies, and not all patients in larger bodies have BED³. Weight stigma⁶, particularly in medical settings, can damage the therapeutic relationship and prevent patients from seeking appropriate care. To avoid contributing to this stigma, clinicians should use weight-neutral language and focus on behavior change as the primary outcome of treatment, rather than weight loss.

Delivering an Eating Disorder Diagnosis 

Delivering an eating disorder diagnosis requires sensitivity and skill, particularly when patients may be defensive or unaware of the seriousness of their condition. Arguing with a patient who is in a state of starvation, whether physical or emotional, can be counterproductive. Instead, clinicians should approach these conversations with a focus on collaborative care and minimal expectations. Once diagnosed, regular monitoring of weight, vitals, and lab values should be implemented, with referrals to a multidisciplinary care team as needed. Red flags such as hypophosphatemia⁵, orthostatic hypotension, or significant weight loss may necessitate higher levels of care.

Take-Home Points: Intersection of GI and Eating Disorders 

These two cases highlight the importance of accurate diagnosis and comprehensive care in patients with eating disorders, particularly when GI symptoms are present. Eating disorders often present with normal or high BMI, and clinicians’ internal biases can create barriers to appropriate care. In many cases, GI symptoms such as nausea, bloating, and diarrhea are a direct consequence of disordered eating behaviors rather than primary gastrointestinal disorders⁵.

The main takeaway for diagnosis and management of primary eating disorders with secondary gastrointestinal complaints is that nutritional rehabilitation should always be considered the primary treatment goal.  Without nutritional rehabilitation, GI symptoms will persist at best and escalate at worst.  The sooner this aspect of care is addressed, the more likely it will be that naturopathic therapeutics will shine during support of the nutritional rehabilitation process.  Many GI symptoms and abnormal lab values will improve with appropriate nutritional interventions. 

The central liability in the naturopathic approach is that restrictive diets, which are often prescribed for GI complaints, can exacerbate or even trigger eating disorders³.  Naturopathic clinicians should prioritize the maxim that eating disorders can present with GI symptoms and co-occur with GI disorders – in either case, the eating disorder must be treated first.  The clinical value of restrictive diets warrants recalibration through the models of harm reduction and weight-neutral care by focusing on treating the cause through behavior change and caloric restoration.

Conclusion

Eating disorders are complex conditions that often intersect with GI symptoms, making diagnosis and treatment challenging.  In many cases, gastrointestinal symptoms in patients with eating disorders are secondary to the disordered eating behaviors, and addressing those behaviors first is critical for effective treatment. A weight-neutral, harm-reduction approach can foster healthier relationships with food and body image, leading to better outcomes. Accurate diagnosis and compassionate care are essential in supporting patients on their path to recovery.

References

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