I have broken out Drs. Jessie Menzel and Rebecca Bernard’s talk: Is it an Eating Disorder or what? Children with Gastrointestinal Symptoms or Avoidant-Restrictive Food Intake Disorder. For Dr. Menzel’s material please review the post: UCSD EDC2014: Review Part IV-A.
Dr. Rebecca Bernard addressed the topic of gastrointestinal symptoms and eating disorders. Gastrointestinal symptoms are common in eating disorders. I have gone into some significant detail on this topic in the blog post: Tummy Troubles.
Worrisomely several gastrointestinal disorders can present with symptoms similar to eating disorders, and this will be particularly the case with children (eg. weight loss, food refusal, vomiting and amenorrhea). Dr. Bernard indicates that an eating disorder may be primary, secondary or comorbid to the gastrointestinal symptoms that are present.
The overlap of eating disorders and gastrointestinal symptoms involves mostly small or case studies for inflammatory bowel disease (IBD) and eating disorders.
To confirm the above statement from Dr. Bernard, in a review of psychosocial functioning for those with pediatric inflammatory bowel disease, the researchers had the following to say:
“Mackner and Crandall reported that children with IBD had significantly more problematic eating behaviors than healthy children, and gender differences were found in the relationships among body image, weight, and eating problems. For girls, body image was a significant predictor of problematic eating behaviors, but weight was not. For boys, the opposite was found: weight was significantly associated with eating problems but body image was not. The limited research in this area suggests that further investigation of eating disorders among children with IBD is warranted.” 1
Dr. Andreas Karwautz and colleagues found a disproportionately high number of patients with celiac disease had co-morbid eating disorders (29.3%) and in 86% of the cases, the celiac disease preceded the eating disorder. 2
Given that the median time to diagnosis for those with celiac disease appears to be 13.2 years 3, it does not surprise me that a disproportionately high number of patients develop co-morbid eating disorders. The anxiety associated with what is causing the symptoms would likely center on food types as possible threats to overall wellbeing and quality of life.
Functional gastrointestinal symptoms are common in eating disorders. Functional means that there is not any physical damage but a change in function of the organ in the absence of any physical reason. As per the research cited, 52% presented with irritable bowel syndrome, 51% with heartburn, 31% abdominal bloating, 24% constipation, 23% dysphagia (difficulty/discomfort swallowing) and 22% anorectal pain disorder. 4
Dr. Bernard then provided some information on inflammatory bowel disease. The most common forms of IBD are ulcerative colitis and Crohn’s disease. IBD is a chronic inflammation of all or part of the digestive tract. The course of IBD varies from acute illness to full remission.
The types of ulcerative colits are as follows:
Ulcerative colitis: rectal bleeding, urgency or having frequent, small bowel movements.
Protosigmoidtis: bloody diarrhea, abdominal cramps/pain, and an inability to move the bowels despite an urge to go.
Left-sided colitis: bloody diarrhea, abdominal cramping/pain on the left side, weight loss.
Pancolitis: bloody diarrhea, abdominal cramping/pain on the left side, weight loss.
Fulminant colitis: rare and life-threatnening.
Crohn’s diseae commonly affects the last part of the small intestine (the ileum) and the colon. Symtpoms can be mild or severe and can develop gradually or suddenly. Symptoms include: diarrhea, abdominal pain/cramping (that can include nausea and vomiting), blood in stool, ulcers, reduced appetite and weight loss (due to changes in appetite as well as an inability to digest and absorb food).
Types of disordered eating behaviors that can appear with IBD are: food preoccupation, restricted eating, and food avoidance. Risk factors that have been identified for determining the presence of eating disorders co-morbid to IBD are as follows:
Delayed growth and/or puberty
Fear of abdominal discomfort/preoccupation with avoiding foods related to discomfort
Weight/body concerns (eg. from prescription steroid use needed to treat IBDs)/negative body image
Symptoms of depression/low self-esteem
Disease severity (eg. need for surgery)
Poor social functioning/interpersonal relationships. 5
Celiac disease is an autoimmune disorder. Actually, most specifically it is a non-IgE mediated immune response to gluten. The response subsequently causes inflammation and damage to the lining (mores specifically the villi) of the small intestine. The prevalence is 0.5 to 1%.
However that average prevalence statistic is deceptive, because the prevalence is certainly higher for identified at-risk groups. The prevalence for patients with Type I diabetes mellitus is 3-6%; it’s up to 20% in first-degree relatives of an already diagnosed celiac disease patient; 10-15% for those with symptomatic iron-deficiency anemia; 3-6% for those with asymptomatic iron-deficiency anemia; 1-3% for patients with osteoporosis. The prevalence was up to 50% in symptomatic patients evaluated in a tertiary referral center. 6
Gastrointestinal symptoms for celiac disease include bloating, abdominal pain, diarrhea, vomiting, weight loss. I will add however that those symptoms are just the standard presentation— common but by no means definitive. Symptoms also include: anemia, weight gain, constipation, steatorrhea (fatty stools), gas, vitamin deficiencies, chronic fatigue, bone pain, pareshesias (burning, prickling, itching or tingling of skin), edema, headaches, peripheral neuropathy, fuzzy-mindedness.
In children symptoms of celiac disease may include: failure to thrive, paleness, irritability, inability to concentrate, wasted buttocks, pot belly with or without painful bloating, pale malodorous bulky stools, frequent foamy diarrhea. 7
The types of disordered eating behaviors that may present with celiac disease include:
Preoccupation with food
Dieting
Binge eating, purging, laxative abuse
Excessive exercise
Potential risk factors for the onset of disordered eating co-morbid with celiac disease include:
Preoccupation with diet (gluten-free)
Body image concerns or disturbances
Fear of food causing abdominal discomfort
Symptoms of depression and low self-esteem 8
Irritable bowel syndrome has no known organic cause and the intestines are functioning normally. It affects 10-15% of the US population and makes up 33-55% of the visits to gastroenterologists. Symptoms will vary but include abdominal pain or cramping, feeling bloated, gas, diarrhea or constipation and mucus in the stool.
Types of disordered eating behaviors that may present with IBS include: preoccupation with food and dietary restrictions. Potential risk factors for the onset of disordered eating co-morbid with IBS include:
Preoccupation with diet and avoiding foods that cause discomfort
Fear of pain/discomfort form eating
Symptoms of depression, low self-esteem
Body shame
Interpersonal difficulties
Physical limitations (eg. low energy) 9
Treatment consideration for children and adolescents presenting with ARFID and a co-morbid gastrointestinal condition include:
If the patient is of low weight, weight restoration takes precedence. Communication between the gastroenterology team and the eating disorder treatment team is essential. Awareness of dietary restrictions and disease management will be important for the eating disorder treatment team to know.
For patients with functional gastrointestinal symptoms, consider the value of adjunct treatment options such as biofeedback, anxiety management strategies (CBT) to help address the gastrointestinal symptoms.
For patients with mild gastrointestinal symptoms and eating disorders the focus is to normalize symptoms. The symptoms will be alleviated with improved nutrition and weight restoration.
Dr. Bernard then wrapped up the talk by providing two case studies.
An 8-year-old boy presented to an outpatient eating disorder clinic after “falling off” his growth curve.
Long-standing history of picky-eating
Progressively cutting out old foods and refusing to try new foods
Intake consisted primarily of peanut butter, chicken nuggets, Ritz Crackers and Wendy’s hamburgers.
No comorbid anxiety disorder. Denied fear of weight gain or becoming fat
Treatment applied in this case was family-based treatment and behavioral parent training.
A 16-year-old female had a long-standing history of intermittent abdominal pain:
Hospitalized twice due to chronic abdominal pain, nausea, early satiety (feeling full fast) and weight loss/malnutrition.
Trauma history; no current PTSD but is anxious. Has panic attacks and has developed emetophobia(fear of vomiting).
She denies have any fear of weight gain/becoming fat and is upset about being too thin.
Extensive gastrointestinal workup was negative.
The treatment applied in this case was family-based treatment, cognitive behavioral therapy for anxiety management and biofeedback.
In Context
As you can see, Dr. Bernard’s presentation was geared to practitioners who may have had little prior knowledge of gastrointestinal conditions and symptoms and it provided a good first pass of terminology and symptoms.
As we discuss gastrointestinal symptoms, anxiety and orthorexia in depth here on the blog and on theforums, this review may seem a bit rudimentary. But coming up next is Dr. James Lock’s presentation on family based treatment for adults as well as those with ARFID and so clearly the intent of both Dr. Menzel’s and Dr. Bernard’s presentations were to create common understanding prior to looking at FBT application in more depth.
For more details on gastrointestinal symptoms, anxiety, orthorexia:
1. Lerner HG. “The dance of anger: A woman's guide to changing the patterns of intimate relationships.” (New York: Harper & Row; 1985).
1. LM MacKner, WV Crandall, EM Szigethy, Psychosocial functioning in pediatric inflammatory bowel disease, Inflammatory bowel diseases. Vol.12(3), pp.239-244, 2006.
2. A Karwautz, G Wagner, G Berger, U Sinnreich, V Grylli, W-D Huber, Eating pathology in adolescents with celiac disease, Psychosomatics, Vol.49(5), pp.399-406, 2008.
3. AM Gray, IN Papanicolas, Impact of symptoms on quality of life before and after diagnosis of coeliac disease: results from a UK population survey, BMC health services research, Vol.10(1), p.105, 2010.
4. C Boyd, S Abraham, J Kellow, Psychological features are important predictors of functional gastrointestinal disorders in patients with eating disorders, Scandinavian journal of gastroenterology, Vol.40(8), pp.929-935, 2005.
5. VM Quick, C Byrd-Bredbenner, D Neumark-Sztainer, Chronic illness and disordered eating: a discussion of the literature, Advances in Nutrition: An International Review Journal, Vol.4(3), pp. 277-286, 2013.
6. C Dubé, A Rostom, R Sy, A Cranney, N Saloojee, C Garritty, M Sampson et al., The prevalence of celiac disease in average-risk and at-risk Western European populations: a systematic review, Gastroenterology, Vol.128(4), pp. S57-S67, 2005.
7. http://www.celiac.com/articles/6/1/What-are-the-symptoms-of-celiac-disease/Page1.html, retrieved January 26, 2015.
8. VM Quick, C Byrd-Bredbenner, D Neumark-Sztainer, Chronic illness and disordered eating: a discussion of the literature, Advances in Nutrition: An International Review Journal, Vol.4(3), pp. 277-286, 2013.
9. ibid.