As if recovery wasn’t already difficult enough from a mental standpoint, there are often physical discomforts too!
This blog post is about stomach in Anorexia recovery. Reading this blog post will not make your tummy feel better, but it may provide you with some knowledge that will make you feel in the know about what you are experiencing.
First off, through, remember that you are unique. You may experience some or none of the things I will describe in this post. That says nothing about your recovery progress. Second, you have to understand that stomach problems are very normal. In fact, in a study looking into the number of people in eating disorder recovery who get some sort of tummy complaint it was found that around 98% do.
Most of the time our tummy woes are to do with the process of re-establishing the optimal functioning of the stomach after it has had a long stint of sub-par operations. First of all, lets take a look at some of the things that take place when we go into a state of malnutrition, as these may help you understand why coming out of a state of malnutrition is a big deal.
When you go into prolonged energy deficit:
Metabolic rate decreases
As body weight falls and intake falls, the body reduces metabolic rate in order to run more efficiently. This includes slowing of the movement of food through the stomach or delaying gastric emptying.
Peristalsis is the movement of food along the intestinal tract and it is done by the muscles that surround the whole gastrointestinal tract. The rate of peristalsis is controlled by the stretch of the stomach when food is eaten (so pressure) and hormonal secretions that happen in response to eating food. When you are starving, this movement slows down in order to preserve energy. Makes sense really. If the production line of food going through your body is low, you don’t need a conveyor belt that is running at the rate of knots.
Delayed gastric emptying (gastroparesis) is when the stomach empties slower than normal. This means that you can feel full for ages after eating. It is an annoyance when you are trying to eat a lot of food and you feel physically full all the time. But it won’t stay like that forever. You have to train the system back up by continually putting pressure on it to function faster by increasing your demand for its services — yes, by eating more!
Endocrine responses to energy deficit can occur (such as decreased thyroid hormones, insulin, testosterone and leptin; and increased levels of cortisol and ghrelin) resulting in decreased thermogenesis and overall metabolic rate. Low energy intake and minimal body fat are perceived as indicators of energy unavailability — your body assumes that there is no food in the environment — resulting in a homeostatic endocrine response aimed at conserving energy and promoting energy intake. This, as you can imagine, has a number of implications for the optimum functioning of the body.
The body starts to allocate energy only to areas that are vital. Energy is allocated to muscles and organs depending on how important they are to survival rather than optimal functioning. This is like if you get a wage cut, you are going to stop spending as much money on luxury items and allocate everything that you have to necessities. If the decrease in wages continues to be less than you need to spend each month, you will gradually cut back more and more. Things will get pretty desperate.
Mental energy gets allocated away from more interesting things such as work, people, sex, hobbies, reading etc and instead is put towards thinking about food, as your brain assumes that your decrease in intake is due to you forgetting to forage well enough, or not enough food so you need to look for more. You will notice that you are thinking of food all the time and unable to hold much interest in other things. This is your body trying to motivate you to search for and consume food — this makes not being able to eat even more painful. The constant, looping, thoughts around food as also exhausting and repetitive enough to make you think you are going mad.
In some of us, when we go into energy deficit, we actually feel like we have more disposable energy. We don’t. That is what I think of as the “migratory effect” of starvation. In animals that migrate, they do so when the resources in the environment become scarce. This tells them to move on to pastures new, and they do. I have always thought that my proclivity to movement was generated by the energy deficit. It is not that I really had more energy, it was that my brain thought it important enough that I move and find more food. Of course I didn’t do that. I moved to the freaking gym instead.
Sadly, even if you feel like you have energy in your legs, and you feel like you should use it, doing so comes at a cost. Just because you feel like you want to move doesn’t mean you have excess energy at all. Spending that energy in the gym or out running means that you are effectively wasting it, as it could have been used elsewhere. If you are in energy deficit, all energy is precious, and burning it off in the gym comes at the cost of some other part of your body that is lacking in resources. Don’t be fooled into thinking that you can go running, even if you want to.
What happens when you start eating more?
One thing to look out for if you are very malnourished is refeeding syndrome — shifts in fluid and electrolytes due to moving from a catabolic state to an anabolic state when you start eating food again. This can happen if your intake or weight was very low before you started to eat again. This is what (rarely, but we still have to pay attention to it) happens when a person goes from a very malnourished state to eating more. If the body immediately starts to make more energy as you eat more food and doesn’t have the nutrients required to meet the demand of processing more energy, you can get in trouble. If you are eating a very low amount of food, or at a very low weight, work with a professional for blood and intake monitoring in the first couple of days to make sure this is not a factor.
Aside from refeeding syndrome the negative consequences of eating more are generally superficial. In that, they feel crappy, but are not damaging as such. Quite the opposite really.
In this initial stage it is very important that you rest as much as possible.
In this initial period, many of us notice this very uncomfortable gaining of water. This is your body trying to achieve rehydration. It can happen really suddenly too! If you gain a lot of weight initially, it is usually just water. The body can hold onto water in a way that it cannot hold onto food. Of course your disordered thoughts will tell you that you are broken and that you have suddenly overnight got fat. You haven’t. It would be impossible for you to gain several pounds of bodyweight in a day.
Bottom line: if you “blow up” initially in refeeding don’t get too excited. It is likely just water.
Stomach problems in Anorexia recovery
Why does your stomach hurt? Lots of reasons why it has every right to!
- Your stomach and intestines have not been given any maintenance or repair work due to lack of funding (food). Before this system is going to work well again, repairs will have to be undertaken. I experienced a lot of “growing pains” in recovery, and general discomfort. Delayed gastric emptying means that you have the sense of food sitting in the stomach a long time after eating. This can make you feel overly full, bloated, and yuk.
- Inadequate intake leads to the slowing down of the emptying of the stomach etc, so initially increases on intake can lead to nausea, cramps, constipation etc. You need to keep pushing food along that conveyer belt so that it knows to speed up again. This can be uncomfortable for sure, but keep eating.
- Low volume of food over time leads to shrinking of the stomach. When you start to eat again, you will be uncomfortably full until this rights itself and your stomach expands. Again, we need to train the system back up. Keep eating!
- Common physical effects include: gas, bloating, diarrhea, constipation, acid reflux, frequent bowl movements, ingestion. None of these things are particularly sexy, and all of them are somewhat embarrassing. They are all also very normal, and to be expected in Anorexia recovery. Constipation is very common until your rate of stomach processing gets up to speed, and can be uncomfortable.
- Restriction leads to a reduction in gut bacteria and a culling of all apart from the die-hard terminator-like bacteria who can survive on practically nothing. Podcast on this here. So when you start eating again, the lack of diversity in your gut may be responsible for the bloating, gas, etc. The important thing to note here, is that you have to keep eating in order for the diversity in your gut to re-establish.
- When you have been eating limited types of foods, your stomach will be out of practice for processing them. Practice makes perfect — eat!
- If you have Anorexia, eating more food creates anxiety initially. Anxiety places you in your sympathetic nervous system which is the fight or flight one. We were not designed to digest food well while in the sympathetic nervous system. Over time you will start to feel less anxiety about eating, and your digestion can improve because you start eating from you parasympathetic nervous system (the rest and digest one) instead. Some digestion problems can also be put down to sub-optimal digestion due to being in fight or flight rather than rest and digest mode.
IBS/Temporary food intolerances
You may get IBS symptoms if you start eating more food. You can even gave temporary food intolerances but this is only due to the fact that you have not been eating enough of these foods for your body to build up a resistance to them. I think that this may also have something to do with the lack of diversity of bugs in your gut that is a result of restriction. Whatever you do — and I don’t care how many “health gurus” tell you that you should abstain from eating certain types of food — don’t stop eating these foods! Think of it as a case of needing to keep practicing in order to get your digestive system up to scratch. Oh course if you have celiac disease, or something like that, then that is different. Most of us don’t.
I know a number of people who have become concerned in the refeeding stage and been tested for food intolerances. One of the worst things that you can do for yourself mentally is be given a list of foods that you should avoid eating. I had some very bad cramping and some very concerning loud gurgling when I was in recovery..I showed all the signs of gluten intolerance when I started eating bread in higher quantities. I kind of knew deep down this was due to me starting to eat more, and that my system wasn’t used to it, but I still had a wealth of gluten-free advocating friends telling me that I needed to cut out gluten. It was suggested to me by many people that I should look into cutting gluten out of my diet (That was when gluten-free was at the peak of fashion and the cure-all for everything).
I had a stint with being gluten free, and my eating disorder was all over that! When I came to my senses 6 months or so later, and started eating gluten again, yes, the IBS symptoms kicked off. However, after a month or so it got better. I am so very happy about this, because gluten is delicious in all forms. I eat a lot of bread, bagels, bakery items. These foods make me happy. They were well worth the temporary gas and bloating.
I think that patience is key here. In my case, my body had suffered 12 years of intense restriction and over exercise. It was going to take more than a month or so of eating well for it to get over that.
As you start to eat more, you can full full to the point of bursting one minute, and empty and hungry the other. This happens as the system tries to reccaliberate itself to your new increased intake. It is mostly to do with your endocrine system and the hormones that regulate feelings of hunger tuning up.
While this system tunes up, you will spend a lot of time having to eat when you are not hungry, or when you feel feel. This all feels just … wrong. It will feel “wrong” for a while. In a way, it has to feel wrong in order for your system to change. Regardless of how wrong it feels, eating is always right.
There is no normal here. Some of us go into periods of extreme hunger. Some of us continue to feel full throughout the entire refeeding process. In my experience if you are not feeling any hunger at all, you need to up your intake. Most of us start to feel hunger around 3000 calories, but some need in excess of 5000 or more (myself included). Some people start to feel fullness again on higher intakes, and feel full even before they are due to eat. There is no norm here, it can all happen. The body is an organism. The only blanket statement is that you have to eat regardless of your hunger. And that there is no harm in eating more and seeing what happens.
Don’t count on hunger cues to suddenly start making sense when weight restoration is reached. Especially if you have been restricting food while weight restoring, you will have mental hunger due to that deprivation present.
Weight gain will complicate your mental processes and cause you to want to go back to restriction — fear of weight gain is an inappropriate response that is generated by Anorexia. Be ready for it, and commit to eating regardless of how you feel about it.
Weight initially gathers around the vital organs. I have a whole blog post dedicated to this process of accumulation and redistribution here.
After weight restoration is achieved, the physical restoration still may not be complete. Hence, many of us continue to need a high intake after weight restoration. Metabolic rate can stay really high in this time. This is another reason why it is foolhardy to compared a weight restored person in recovery from Anorexia to a member of the general public when setting caloric intake requirements.
What do you do?
- Continue to eat at regular intervals regardless of how awkward it feels. We have to train this system up!
- Give it foods that are easy for it to process = high in fat!
- Drink adequate amounts of water and fluids, just enough but not too much.
- Rest. There is so much going on here. Take recovery seriously. This is a huge restoration project for your body!
- Increase intake of fats as these can help with bowl movement regularity.
- Breathing practices before and after eating to help you reduce anxiety and stay in the parasympathetic nervous system.
- Buy loose comfortable clothing and throw out any “small” clothes. Not food related directly, but it is cathartic!
- Did I mention that you have to continue to eat? You do.
THE ENDOCRINOPATHIES OF ANOREXIA NERVOSA https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278909/
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