The Intersection Between Gut Health And Eating Disorders

Last week I set myself the rather challenging task of summarising in a blog article the reason why dismissing food intolerances as eating disorders is a drastic oversimplification of the very complicated interrelated relationship between gut health and psychological wellbeing.

This whole article was instigated when I found myself aghast at an Instagram post from a public, relatively well-known Nutritionist (yes, a proper, qualified, science-based one). This woman has a lot of really solid, very down-to-earth opinions. She is incredibly vocal (and intelligent, her arguments well formed - though expressed in really colloquial terms, which actually serves to make her very approachable for some) in the arena of Body Positivity, Inclusivity, Non-Diet Mentality and Intuitive Eating. Her post was written from her perspective of the fact that a non-diet mentality is the most appropriate way to be. In fact, I think she's just launched a Non-Diet Facebook group for nutritionists and dieticians who practice from a Non-Diet stance.

So far, so strange - a Nutritionist promoting 'Non-Diet', when the word "diet" literally refers to the food you eat, and I'm assuming she endorses actually eating food... but then, to argue like this I would be playing word semantics. Which I'm not going to do (more of this a little later). Instead, the Non-Diet approach is  anti-restrictive eating which is intended to alter body shape or size for any reason whatsoever. It's a response against any societal or self-motivated pressures for anyone to feel the need to change their physique.

The whole idea of 'non-diet' from a Vegan Nutritionist may seem a touch hypocritical - but I get where she's coming from. And her Veganism is an ethical, meat stance (I think, though happy to be corrected). What it is NOT is anything to do with her controlling her body through food. Instead, she's controlling the food she eats through making a choice which, for her is rooted in ethics.

A Non-Diet approach, in contrast, is an attempt to alleviate the pressure from those who have spent a lifetime using nutritional control as a tool for weight management. This is about saying that no person should feel the need to control their food intake to control their body. The discussion goes further - arguing that people can be healthy at every size (relatively accurate, though not universally true) and that society has eternally repressed people (both men and women) by promoting body types which are unrealistic for many to aspire to (this time incredibly accurate and pretty universally true). The whole ethos is based on the fact that our bodies do not determine our worth as people and that society can get over itself if it needs us to be a certain shape, weight, size, colour etc. etc.

This background is important because I want to show you how absolutely grounded in common sense and sanity this Nutritionist is with her stance when it comes to her recommendations to her clients. Her patient population resonates strongly to her message - and the string of hand claps after each of her lengthy Instagram posts where she 'busts some myths' or 'shouts down nutribollocks' are testament to the fact that she has a lot of encouragement, both from fellow professionals dealing in this arena and also from beleaguered patients who seek someone in authority who permits them to shed their miserable diets of restriction and self-control.

From this place of authority and with the support of many (professionals and patients alike) this Nutritionist took to Instagram - this time to argue that ‘food intolerances' and certain ways of eating which eliminated or excluded certain foods were both a) completely unnecessary and b) based on no scientific basis whatsoever - and hence (natural conclusion here) c) diets of elimination for gut health were simply thinly veiled eating disorders.

She is accurate, in that sometimes, some people do use so-called 'food intolerances' to justify food avoidance because they are scared of weight, fat, shape, size, eating etc. etc.

Heck, I even wrote a whole page for Paleo In The UK on "Purpose, Macronutrients & Weight Loss" - stating quite clearly that "We have witnessed many individuals claim to be ‘free’ of disordered eating when they have found Paleo, when realistically they have simply used this eating style to legitimise their disorder or diet mentality."

And yes, it is absolutely this Nutritionist's privilege to state that this is the reality that she sees in her practice every day. She is absolutely correct in that sometimes a way of eating that promotes eliminating certain foods is grasped by someone in the grip of a food restriction mentality in order to control their body (shape, weight, size) and then the diet or food intolerance message is abused.

But what this Nutritionist fails to mention or acknowledge is that anyone using a way of eating founded on health to legitimise disordered eating is actually abusing that way of eating. It is the same whether the diet being abused is Veganism (a diet based on restrictions) or whether it's Paleo (a diet based on restrictions) or whether it's Zone (a diet based on carefully calculated restrictions) or whether it's 'just eating healthily' (which this Nutritionist promotes and is, ironically, a diet which still contains restrictions).

It is not the way of eating that is flawed in any of these cases - these are just choices (as Veganism can just be an ethical choice). And yes, sometimes the notion of food intolerances or sensitivities is abused by individuals to justify their desire to avoid foods that they deem 'fattening' or 'calorific'.

However, the Nutritionist in question went on to rubbish certain physiological issues as if they were utter nonsense, claiming that they were not scientifically validated, suggesting that issues of sensitivity or intolerance to certain ingredients (namely, gluten) was all in people's heads, though, to give her credit, she did use the posh terminology and said it was all 'nocebo' effect... (explained later))

So this is what got to me. Yes, it is perfectly fair to warn of the dangers of taking restrictive diets as a legitimisation of eating disorders. But to post something on Instagram that was supposed to be about the intersection between gut health and eating disorders (literally in her title), this Nutritionist put a rolling eye emoji after the phrase 'leaky gut' and dismissed food intolerances as "Nocebo". This represents both a lack of research and not enough time spent parking prejudices and extending the effort towards understanding the true complexity of these interwoven issues.

This Nutritionist’s entire brand message is all about minimising so-called “Nutri-Bollocks”… But, at least in this instance, she has herself cherry-picked her science - and in so doing, made countless people feel deeply devalued in terms of how it feels to live inside a body which reacts badly to foods. So let's look a little deeper at the science behind the thing she's accusing of being bollocks: 'leaky gut'...

What's In A Name? 

Now, I’ll admit, ‘leaky gut’ is an unfortunate phrase. But no professional would use it now without qualifying it by saying that this expression is layman's terms for "Intestinal Permeability". I have made several references to language above, and just like I can ridicule the words "Non-Diet" for its technical inaccuracy, I actually went to great pains to explain the concepts behind this poorly chosen phrase.

Seems this Nutritionist didn't give the same treatment to 'leaky gut', or "Intestinal Permeability" (the posh way of saying it, a bit like her jazzing things up with the word "Nocebo").

Just throw Intestinal Permeability into PubMed and you won't just find one study - you'll find literally thousands. You will find mechanism identified, health outcomes and consequences detailed and in-depth explanations of the effect on the gastrointestinal mucosa and epithelial cell wall. You will find gut health linked to countless conditions. And all of that is just in the first result - a British Medical Journal of Gastroenterology review article from 2014 in which these terms were clarified and explained. The abstract doesn’t conclude that it’s nutri-nonsense. Instead it states, “In summary, intestinal permeability, which is a feature of intestinal barrier function, is increasingly recognized as being of relevance for health and disease, and therefore, this topic warrants more attention.”

Hmmm... this condition - according to proper, published research scientists - warrants more attention. Not a rolling eye emoji.

Looking at the paper fully (yup, no PhD and I can still read science) its conclusion mentions a whole host of further investigations necessary in order to really identify "the effect of the translocation of luminal components" and how to fix, heal and repair the gut lining. 

And for those who weren’t keeping up with the phrase “translocation of luminal components”... yup, that pretty much equates to “leaky gut”, however posh you want to make your language...

So… looks like PubMed (i.e. proper research) thinks this gut health condition is a real thing…

And more than this, Intestinal Permeability is being increasingly indicated as playing a role in mental health disorders. Of which, ironically, an eating disorder is one.

To dismiss a concept due to terminology or language is easy to do. But it shows a lack of respect for the topic (whatever happened to an inclusive attitude?!) and for concepts that you don't want to engage with fully. It’s easy to jump before fully evaluating something - and we’ve all done it. It’s just not something you’d expect from someone who claims to “know (her) s**t” and be across all science.

Dismissing Intestinal Permeability allows you both to defend the consumption of EVERYTHING, eating intuitively of course, ignoring the fact that in some individuals, some of the time, there are states and foods which can exacerbate Intestinal Permeability. Instead, by cherry picking (and not linking to or referencing any of) the science this Nutritionist concluded that food intolerances - in particular to gluten - were entirely "Nocebo" effects.

Now, Nocebo and placebo exist. Nocebo is where you react because you think that something is going to be harmful. And yes, there are studies which have shown that with gluten the Nocebo effect can play a role in individuals' reactions. But there are equally many, many studies which provide mechanistic data for the effect of gluten's Gliadin protein on the gut, studies surrounding the impact of impaired endothelial barrier function in chronic inflammatory diseases, objective studies about the effects of gluten (in those that don't have coeliac disease) on the intestinal wall, research into the effect of the transfer of microbial populations across the gut wall due to impaired intestinal barriers and even randomised controlled trial evidence for the presence of non-coeliac-gluten-sensitivity in those who have gastrointestinal symptoms - not in everybody, and yes, some patients had a "Nocebo" response (14%) ... but other patients had a genuine response to the ingestion of gluten and a worsening of symptoms, WITHOUT the presence of coeliac disease.

So yes, Intestinal Permeability really does exist, really can be due to ingestion of proteins such as Gliadin and yes, it really can exist without frank coeliac diagnosis and yes, it is linked to systemic inflammation and neuro-inflammation.

Which Brings Us Back to That Eating Disorder - Which is A Mental Health Issue

So if Intestinal Permeability exists, which it looks like it does, and it contributes to neuroinflammation and systemic inflammation, which also looks likely, it's not beyond the realms of possibility that gut health issues can literally create the anxiety and depressive conditions which contribute to disordered eating behaviours.

Moreover, if the gut health issue itself causes pain and gastrointestinal discomfort, the natural consequence is an alteration in eating behaviours and a sense of unease around meals and eating - which equals disordered eating behaviours.

Now, don't mistake me - the discomfort we feel around eating can emanate out of a deep psychological resistance to the result of eating (i.e. irrational fears of weight gain, distress over body image). But it actually doesn't have to. Moreover, even if a physical issue with food begins mentally - it can very quickly become physical.

This is because our ability to effectively process and metabolise food, thereby NOT having food intolerances, sensitivities or an impaired gastrointestinal tract can be affected for many reasons - the biggest of which is stress.

Yes, that's right - anxiety and excess stress are the biggest contributors to intestinal permeability and food reactivity - and the mechanism for this can either be through the stress itself increasing sympathetic nervous system activity which decreases blood flow to the gastrointestinal tract and makes the gut itself more vulnerable to permeability, or it can be down to stress, as the body feels under threat, causing a physiological protective response which equals an up-regulation in immune activity and thereby an overreaction to things that aren't true antigens. In plain English - stress causes leaky gut and creates food intolerances. Or it can. In some people, some of the time.

So, it is true, that having an emotional conflict around eating and body size, weight, shape etc. can literally cause a gut health issue - but the means by which it does this are through the stress impacts on our nervous system and hence our gut.

The parasympathetic branch of the nervous system is the counterbalance to the sympathetic branch - and these are a seesaw in opposition. They both affect the digestive tract - with the parasympathetic needing to be 'on' or 'active' in order to allow for digestion to occur effectively, and the sympathetic which creates a rapid emptying and freezing of digestion whilst the organism (us) is under threat. This means that in states of high stress the sympathetic nervous system rules, halting peristalsis (the movement of food through the gastrointestinal tract) and preventing the release of gastric juices and enzymes. Human beings just aren't meant to be eating in times of stress and distress. We also will break down foods less, thereby absorbing less from the nutrition we take in.

When in a state of stress, food is less well digested and so there are larger food molecules passing through the intestines. Stress is also inflammatory and creates intestinal permeability - so these larger molecules pass into the immune tissue surrounding the GI tract and... you have a recipe for food intolerance.

It doesn't matter where the stress emanates from - whether it's from being anxious at work, self-conscious about your body and weight, whether you're struggling in relationships or whether you have serious health issues which are, in and of themselves, stressful. The stress can also be chemical, toxin overload, under-nutrition, starvation, over-nutrition, sugar-based calories which are low in nutrients. Stress can be viral, bacterial or due to seasonal allergies.

All of these stresses will affect digestive function. They won't all lead to intestinal permeability and food intolerances. However, over the long term, this is a possible outcome. And if the major stress is concern over the physical body, this doesn't just have to come from societal pressures around weight and body size. Instead, if you have a chronic illness and you feel as if your body has failed you on every level, this is enough stress to create gastrointestinal issues and food sensitivities which compound the issues and pile body anxieties on top of body anxieties. Here's where chronic illness and gut health become an ever-compounding web of suffering.

And there are some for whom physical anxieties were not at all part of the picture but their bodies really suffer eating certain foods. These people experience suffering even when they don't know they've eaten some of those foods. These people feel ill even when they were totally fine about eating something. That's not nocebo, it's not reactivity based in fear - it's a body with any number of inflammatory or immune conditions which genuinely is intolerant or reactive to whatever has been eaten.

How To Deal With Gut-Health-Disordered-Eating Clients 

The solution to the compounding of gastrointestinal and emotional/psychological health, however, is absolutely NOT to completely dismiss (rolling eye emoji and all) the notion that GI compromise exists and might be contributing to someone's condition and illness. It's not right, fair or conscientious to say that people are using food intolerances as an excuse to avoid food.

Quite the contrary, it's essential that an understanding of any underlying gastrointestinal comorbidities (coexisting conditions) is understood in order to actually help any patient properly heal.

Telling someone that their reactions are all in their head, or created by their head, or exacerbated by the head is not helpful, it's judgemental. It alienates those for whom a desire to be thin was never a part of their issues with their body - though a desire not to feel so rubbish internally may have been. Moreover, it alienates those for whom emotional conflicts absolutely did create a disordered way of eating, but who are now battling recovery whilst facing the consequences of the physical compromise that came as a result of their restrictive or stressed eating behaviours.

Suggesting that the route to healing the body is through eating everything can, for some, be a toxic attitude and may do more harm than good. Indeed, for some there is the very real fate that our bodies really cannot digest and thrive eating absolutely every food imaginable - whether we would desire to or not. Our relationship with food is an area where we make daily choices which are reflective of how well we are able to care for ourselves. It is not self-care to mainline gluten and sugar if you have intestinal permeability due to excess stress - even if the stress started because of how you feel your body looks. It is also not self-care to try and continue to eat foods that you feel rubbish eating.

Is it Ever OK to Dismiss Gut Health & Food Intolerances - Even if They Were Created Through Disordered Eating & Emotional Food Issues?

I personally don't care where my clients' anxieties arise from. So many mental health patients come towards me because they feel utterly anxious and they are craving a biochemical explanation for their situation. The truth is that there usually are biochemical reasons, genetic reasons, life experience and case history reasons, emotional reasons - they all cascade into one end result which is the patient in my clinic.

What surprises me, every time I come to explain my complex attitude towards and understanding of the interrelationship between physical health and mental/emotional wellbeing is that so often I cannot put one before the other. There really doesn't seem to be a 'cause' and 'effect' that we can isolate.

Sometimes, though it's more rare than you would think, it is clear to see that something specific caused a symptom.

More often, however, the reality is that a constellation of issues cascade into the reality which my clients face today. 

My one challenge is to not endorse psychological fear - even when I am recommending dietary restriction. The real challenge is making the complexity about the patient and to minimise the power and the control that the client may have placed on the food itself.

 I don't do this by insisting that all foods are equal - I do this by explaining that all foods can be fine in everyone, but at times of physical compromise there are routes to wellbeing which do involve care and restriction. I always stress that the purpose of this is an end result of a broad and inclusive diet, but I am never neglectful or accusatory that if certain foods never make it back onto the table then that client is disordered.

Food relationships are complex and rooted in much history, memory, physiology and biochemistry. They are worthy of our respectful attention to unwind - and they are never dismissible as nonsense. Cutting foods out of your diet and your life might be necessary - in both the short and the long term. Sometimes our biology and structural integrity is damaged so much by our experience that we really do have to watch what we eat for the rest of our lives.

Food intolerances can be very real, no matter where they come from. No, they are not as widespread as you would believe if you judged everything by social media. But they are certainly not as inconsequential as a rolling eye emoji and an intuitive eating hashtag.

If you have, or think you have, food intolerances - my suggestion would be to work with someone who can help you navigate through them. Never take them at face value. Never trust a test you got off the internet which told you you were intolerant to something and never decide you're intolerant to something because the science papers or the mass media say you might be. Experiment with your body and learn your own answers - and take the time to understand the reasons behind why you might struggle with certain foods.

Cutting stuff out because you want to be thin is a 'diet', and I'd agree with this Nutritionist on this one - there are better ways to direct your energy and live inside your life and your body.

But cutting foods out because you feel negatively affected every time you eat them and you choose not to do that to yourself is a choice that it is entirely your privilege to make. If it changes the health and vitality you feel inside your body then it doesn't matter what science or practitioners say.

It is no-one else's right to criticise your choice (just as I won't criticise this Nutritionist for her Vegan, Non-Diet Diet). It is your role to ask yourself the why's and wherefore's of your dietary choices (and never do anything because the internet tells you to) - but if you do the self-work and realise your choice comes from a desire to feel good inside your body, rather than from a desire to control your body, then whatever you choose to not eat is entirely your decision.