• Catherine Lott


Updated: Oct 18

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.