A recurring issue for most of us in recovery will be problems with the stomach- digestion, sensitivities, apparent intolerances, wind (trapped and not-so trapped!), fluid retention, diarrhoea, constipation, nausea, acid reflux .. the list of possible symptoms feels endless.
So what is going on with stomach in anorexia recovery? It can help make the process possibly a little more tolerable if you know what's going on, and it can also make you more prepared if you're just starting on the recovery process. Try not to panic. Remember, everyone of us is unique and I can't say this enough: there is no 'right' way to recover. You're not necessarily going to experience every one (or even any) of these stomach symptoms; It is likely that you're going to have some kind of stomach issues - these problems during treatment and recovery are very typical issues. One study found that up to 97% of people experienced some sort of gastro- intestinal problems before treatment even began.
So to help understand why coming out of a state of malnourishment can be so difficult and uncomfortable, we need to start by looking at some of the things that take place when we go into a starvation response in the first place.
When we go into prolonged energy deficit:
The Metabolic rate decreases
As intake and body weight falls, the body reduces metabolic rate in order to run more efficiently. This includes the slowing of the movement of food through the stomach or delayed gastric emptying.
Peristalsis is the wave- like muscle contraction that moves food through the digestive tract . Peristalsis occurs by a complex cooperation of muscles and nerves, which are governed by hormones. The rate of peristalsis or motility is controlled by the stretch of the stomach when food is eaten (so pressure) along with these hormonal secretions that happen in response to eating food. When you are starving, this movement slows down in order to preserve energy.
Gastroparesis, or delayed gastric emptying is simply that -when the stomach empties more slowly than normal. It brings with it something that is really challenging in recovery-the sensation of feeling full for a long time after eating. It can make it really hard when we are trying to increase our intake when we feel physically full all the time. But it really won’t stay like that forever. It's vital to keep putting pressure on the system by eating more which will make it function faster.
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 (which is why we always feel cold) and overall decreased metabolic rate.
Low energy intake and minimal body fat are perceived as indicators of energy unavailability ( the body assumes there is no, or very little, food available in the environment) and sparks an endocrine response aimed at conserving energy and promoting energy intake.
This has several implications for the functioning of the body.
Energy is reallocated
The body starts to allocate energy only to areas that are vital. Energy is allocated to muscles and organs depending on how essential they are to survival rather than optimal functioning. Think of cutting back on non-essentials if they cut back your hours at work- you will naturally start to focus your spending on the essentials. And if you lose even more work hours, you would start to allocate everything that you have to just necessities. If the decrease in work hours continues, things start to get pretty desperate.
Mental energy gets allocated away from more 'unnecessary' things such as sex, other people, work, hobbies, and instead is put towards obsessively thinking about food. You will notice that you are thinking of food continually and unable to focus or concentrate on very little else. Your brain is trying to motivate you to search for food, and this constant message is no respecter of whether you're trying to sleep or if you're trying to work when you're enervated already - there is an overriding primal drive is to find and consume food— which only makes not being able to eat even more cruel and painful. The constant, looping, thoughts around food can be exhausting and repetitive enough to make you think you are going mad.
In some of us when we go into energy deficit, we can actually temporarily feel like we have more disposable energy. This is actually a side effect of the body switching energy production while your metabolism is making a major shift.
So in reality, our insulin and glucose levels can get thrown out of balance.
Insulin is a hormone that shuttles glucose (blood sugar) from the bloodstream into the body's cells, where's it's stored as glycogen for later use as energy. When insulin is low, that keeps the glucose in your blood. This happens in the case of starvation so that we have more blood glucose available for quick energy,
Our bodies will also start to increase a process known as lipolysis, or breaking down fat to release fatty acids for energy. and we'll break down protein reserves, usually muscle, for another energy source, and undergo large mineral losses that affect our body’s electrical systems, like your heart. Symptoms of all of this can in turn lead to weakness, apathy, memory lapses, and muscle cramps.
So, 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. If you are in energy deficit, all energy is precious, and burning it off walking or running or at the gym comes at the cost of some other part of your body that is lacking in resources.
What happens when you start eating more?
One thing to look out for if you are very malnourished is refeeding syndrome ( see my dedicated post on Refeeding Syndrome here)— this can be result in a potentially fatal shift in fluid and electrolytes due to moving from a catabolic state to an anabolic state when you start eating food again. This can happen, (rarely but we still have to pay attention to the risk) if your intake or weight was very low before you started to eat again, or if you had little or no food for five days or more.
So If the body immediately starts to make more energy as we eat more food and doesn’t have the nutrients required to meet the demand of processing more energy, we can get in trouble. If you have been eating a very low amount of food, or are at a very low weight, make sure you work with a GP in the first week of refeeding for blood and intake monitoring to make sure this isn't a factor.
Aside from the very real risks of refeeding syndrome, the negative consequences of eating more feel horrible, but are all about reversing and repairing the damage cause by starvation
In this initial stage it is very important that you rest as much as possible.
Water weight
In this initial period, many of us notice this very uncomfortable gaining of water. This is your body trying to achieve rehydration. and it can happen really suddenly.
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 ,try not to freak out. It's most likely just water.
Stomach problems in Anorexia recovery
It's almost inevitable that you are going to have stomach issues while you're working to reverse the effects of starvation
Your stomach and intestines have not been given any maintenance or repair work due to lack of food. Before this system is going to work well again, repairs will have to be undertaken. We do experience 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 really uncomfortable
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 is going to 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 consistently increasing your portions.
Common physical effects include: gas, bloating, diarrhoea, constipation, acid reflux, frequent bowl movements, ingestion. None of these things are particularly sexy, and all of them can be debilitating and embarrassing. They are all also very normal, in Anorexia recovery.
Restriction leads to a reduction in gut bacteria and a culling of all apart from the most resilient bacteria. So when you start eating again, the lack of diversity in your gut can account for a lot of 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 itself.
When you have been eating limited types of foods, your stomach will be out of practice for processing them. Yes, you've got it-the only way your body can relearn how to process these other foods is practice.
If you have Anorexia, eating more food creates (often devastating) anxiety initially. Anxiety pushes you into 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 (eventually) 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 when you start eating more food. It's also common to exhibit signs of 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.
No matter how tempting it is, and no matter how many 'insta experts' tell you to that you should abstain from these foods, don't stop eating them! Think of it as a case of needing to keep practicing in order to retrain your gut. Occasionally we may diagnosed with coeliac disease or gluten intolerance or something like that, but it's more likely the result of the long period of intense restriction.
It is super common to show signs of gluten or dairy intolerance, and you will probably be inundated with online messages or concerned friend- experts telling you what you need to cut out(it seems that almost everyone has some food intolerance or other); but after years of restriction, with patience and consistency, it's more likely than not that your body can learn to process things like gluten again.
Hunger
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 recalibrate itself to your new increased intake. It is mostly to do with your endocrine system and the re-establishing of the hormones that regulate feelings of hunger.
While this system tunes up, you will spend a lot of time having to mechanically eat when you are not hungry, or when you already feel full. This will feel completely wrong, and It will feel “wrong” for a while. In a way, its a sign that you're doing it right if it does feel wrong, because this is the only way your system will 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. What I learned is that if you are not feeling any hunger at all, you need to up your intake. 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; any restriction prolongs the recovery process and can lead to mental hunger.
Weight gain
Weight gain will complicate your mental processes and will drive you back to your restrictive behaviours. 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.
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 can be harmful to compare a weight restored person in recovery from Anorexia to a member of the general public when considering caloric needs
So what can you do?
Continue to eat at regular intervals regardless of how wrong or impossible it feels.
Give your system 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 bowel movement regularity.
Try different techniques, such as breathing practices before and after eating, to help you reduce anxiety and get you into your the parasympathetic nervous system.
SOURCES
THE ENDOCRINOPATHIES OF ANOREXIA NERVOSA https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278909/
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