Disordered Eating and the Management of Disorders of the Gut Brain Axis by Ursula Philpot

Added: 2026-05-22

[00:00:00]so next up Ursula Philpot is a free reversala I'm not the only one timing's up um Ursula is a freelance consultant dietitian and Senior lecturer in nutrition and dietetics providing specialist nutrition consultancy to the media companies and individuals she has extensive experience and NH NHS settings specialist eating disorder services and runs her own practice she specializes in producing guidelines Pathways and consensus statements within the area of eating disorders and mental health thank you thanks thanks for inviting me today and I have to say that really I'm speaking on behalf of myself and Nick so we've been involved in a a project that started very small and around a shared interest and sort of grew and grew and grew really over the last few years we're almost at the finishing points we felt it was a good idea to come and speak to you about it today um so I'm speaking I feel like I'm preaching just converted here really I've got a few slides you know really trying to sell the fact that GI symptoms coexist in patients with disordered eating and eating disorders but I you know I very much think that you know this already um I've got a couple of um a you know a couple of quotes there that I just think are really important so for me I see a huge amount of delayed gastric emptying in my patients with anorexia and bulimia you know they they're either weight suppressed they've lost a little bit of weight or they're restricting what they're eating they're under fueling and that results in in GI GI symptoms and we have a lovely quote there from Helen Burton's paper as well you know the growing evidence for the dubai-directional relationship between eating disorders and GI symptoms and you know really thinking about the role of gastroenterology providers in in their awareness of historic Eating Disorders current eating disorders and the potential obviously for making things worse if we treatments so um again another few statistics here around the overlap and the characterization of eating disorders and ngi symptoms um you know the bottom one there patients with chronic constipation you know they're within that particular cohort 19 had clinically significant eating disorder Psychopathology so this is a problem I think I don't need to sell it to you but um we have a lovely table here a bit small you might not be able to see so much but I think what you'll see at the top um you can see that down the left we have a huge amount of GI symptoms and look at all the ticks across all of Eating Disorders at the top there but anorexia Rosa where you have a low level of energy intake you know a huge amount of ticks there so we know it's a problem as an eating disorders dietitian I've you know increasingly felt like I didn't know enough to help my patients with their GI problems I don't know much about gastro so I approached Nick and he said well yeah I see patients with gastro problems and eating disorders and I don't really know what to do either so we thought okay this is a really difficult complex patient population um we could do something on this you know there's no guidance out there you know what what are dietitians supposed to do with this population so rather than leave that to someone else we thought in our spare time because we've both got the so much spare time we would try and come up with something so what we've done is similar to the previous speaker and some from this morning we got together an expert group um you know we get from Gastro and from eating disorders um and Nick and I put something together around what we thought might be sensible suggestions for this patient population and then we put it out to the group so there's some of the group members there that's not exclusive there are a lot more group members that's just who we could find photos of mainly we also want to thank our um our colleagues in psychology as well we've had two brilliant psychologists look at the paper as well so we've got some consensus from dietitians in the field around some do's and don'ts some places to start with this patient population so um what the key things I suppose that we came up with uh the key points that we need to really think about in this Patron population are obviously screening for historically eating disorders and current disordered eating habits and really thinking about well how do we do that accurately it was one of the questions we had earlier on I suppose the overlap between Eating Disorders disordered eating and Trauma or adverse childhood experiences we know that adverse childhood experiences can lead to you know clusters of disease States both physical and psychological and gut symptoms are part and parcel of that and also within easy disorders we have significant overlap with autism as well you know a very high percentage of our patients have autism we also felt quite strongly I think it's been talked about a lot today that weight in BMI should not be the only metrics or or red flags just because somebody presents with a normal BMI does not mean they don't have an eating disorder or that they're under fueling or under eating so we've considered really weight loss as being really important but also weight suppression you know somebody who has dieted down to a lot what's still in within a normal BMI range but eats very little to stay there and that would be typical of the type of patient that I would see you know they may present as a normal BMI but actually they're quite they're very restrictive and under fueled there certainly the role of under fueling and not just not having enough energy on board or the meal pattern you know whether it goes associated with that where people are not eating in the morning saving up all their calories for later in the day we also thought about things like hybrid fruit and vegetable intake in my eating disorder patients um High intakes of things like sorbitolin in chewing gum and um non-sugar drinks um and we also considered the role of anxiety which has been mentioned a lot today and Hyper vigilance of interoceptive signaling which we see a lot in eating disorders and we see a lot in autism so we had a lot to think about within our paper we don't have all the answers is the is the um where we got to really one of the issues we had was that the common screening tools that we'd use here things like the edq which I would use in Eating Disorders or maybe the short R feed or the scoff haven't been you know they haven't been validated within this population and certainly for things like the um you know you're going to get false positives you know if you start asking someone about restricting their eating and they're restricting their eating because of their IBS and they're in pain you know that it could overlap and look like an eating disorder when it wasn't so one of the things that we have within the paper is thinking about in clinic assessments for dietitians you know what what sorts of things should be thinking about both psychologically and physiologically to ensure that you have more of a holistic idea about this patient and can characterize perhaps some of those features of um rules rigid thinking or under fueling so we typically thought about um you know food being associated with guilt or anxiety preoccupation with food difficulty making everyday decisions which tends to happen when you're when you're under fueling you tend to become quite anxious Pace a lot and have trouble sleeping and have trouble making everyday decisions so we also obviously thought about patients being quite focused on numbers or rules you know typically using things like MyFitnessPal to track calories or to having a certain amount of calories over the day physiologically you know we just wanted people to expand out the IR ideas about asking about physiological responses to anxiety or under fueling which might include things like skin picking feeling very cold particularly hands and feet and that's a really easy one to pick up you know somebody's under fueling in the day they're going to get cold and they're going to get tired and that's quite easy to pick up with just a few a few simple questions in clinic assessments we've got something some examples here you know do you pretentions prevent you eating you know how much time do you spend planning your food you know tell me about your relationship with food so we've got some ideas about questions dietitians can ask on their assessments we have a lovely algorithm and I have to credit Nick with this because I'm absolutely no good with um with putting boxes into into um PowerPoints Etc so Nick's done done some brilliant work on this we're not sure it's exactly right but we're going to go out and try it and get some feedback on you know seeing whether it helps with people it's not the full algorithm there we're just showing you a little a little bit of it um I guess where does this take us in terms of treatments well obviously usually as it's been discussed today dietary treatments would be at the Forefront of treatments for GI symptoms but actually what we're asking you to do is be a bit cautious particularly rushing in with anything like a FODMAP approach in this population so there's a quote there from one of the papers at the bottom that says recommending elimination diets to patients with eating disorders can have devastating consequences equally from any you know from my perspective as an eating disordered dietitian we can't leave people without treatment you know if if chronic pain bloating you know GI symptoms are really interfering with their recovery and their relationship with food we can't not treat them either so where does that leave us so one of the things you absolutely can do is address energy intake really dig into are they fueling adequately it might look like it on paper um you know but actually do they need more than they think they do you know are they cold and tired in the day are they really fueling properly across the day and we can also use the modified first-line IBS treatment approaches most of the treatment approaches are fine with patients reading disorders you know making sure you're drinking things don't drink fizzy drinks um don't have too much caffeine the only two I've put little red crosses on are cut down fatty foods obviously that's a bit of a No-No in eating disorders and making meals smaller because they're probably already quite small what can we do for non-dietary treatments perhaps we need to dump into those earlier and certainly with our in our paper that's what we're recommending you know if somebody has constipation can we use pharmacology you know can we jump in and use that to relieve some of those symptoms um in a sensible way sometimes people are a bit reluctant when they hear the word eating disorders and they think about laxative use but actually it you can be you can use these very appropriately in most patients the only exclusion would be if somebody's had a history of laxative misuse it just needs to be thought about a little bit more carefully what we definitely can do I use got directed hypnotherapies anxiety management psychological therapies and also um something that we use we're beginning to use a lot more which is thinking about polyvagal Theory and getting people out of that if you have a look up there getting people out of that middle Zone which is the fight flight response and down into that um safer safer Zone at the bottom and using lots of strategies to help people achieve that so as I said non-pharmacologic pharmacological approaches can be used much earlier you know this is your traditional way of doing things but what we're suggesting is that you go here first rather than using dietary interventions first we then obviously thought about the early use of psychological therapies and perhaps you know the things that got directed hypnotherapies as well the sorts of things Rosie talked about this morning we then thought well sometimes patients may need a low FODMAP approach and in my my experience has been that some patients because if they're very high fruit and vegetable intake do need to reduce their FODMAP load but actually they don't need a traditional full-on you know exclusion diet and a reintroduction phase because that's going to be a disaster if you have an eating disorder if you have autism you're going to get very very negative outcomes in that case so from the consensus of talking to patients per dietitians who work in eating disorders and Nick and his colleagues um what we decided was things you could do safely would be to replace lactose with lactose free products in an isocalorific way and it's the iso calorific that you've really got to work on with these patients you know if you're substituting milk for oat milk that's not ISO calorific it needs you need to be thinking about other substitutes definitely we can reduce fructose fructose load because people have tend to have quite a lot of fruits particularly things like apples for example and we can reduce some of the obvious fructans particularly things like onions and garlic and those won't necessarily negatively impact on somebody's um already quite restricted diet you also need to think about um considering how you talk to patients about this information you know they kind of you cannot instill any fear around foods that you know what will make the fears that they have any worth so it's really thinking about you know about doing it in a slightly different way and obviously talking about the reintroduction of these as well perhaps to tolerance so really the take home messages are you know there is emerging evidence to demonstrate the association between these gut disorders and these maladaptive eating behaviors that we have dietary approaches for for this population group you know if you go dive in and start using something like you know a gluten-free diet or FODMAP approach with somebody with an eating disorder you are going to get compromised Nutritional Health um you're definitely going to get Negative it's like a social domains affected you're all you're probably and very likely to exacerbate disordered eating or eating disorder behaviors or delay recovery what you can do though as a dietitian is screen talk to people about their relationship with food you know find out if they're tracking calories find out if they've got any food rules you can then assess patients suitability for these treatments we've talked about the personalized approach earlier we've talked about you know not necessarily going straight in with that those dietary approaches for everybody and so you we've already had some of discussion around this and I think it's really appropriate to think about first Do no harm with this patient group and obviously as dietitians you can modify or uh you know or find alternative treatments for dietary approaches when required and I've just put on the right there um you know B my key things are first Do no harm be curious and collaborate with your friendly eating disorder dietitian colleagues because Nick and I working together has been really great and we've learned a huge amount from each other I think the end was 26 seconds to go okay that was an excellent talk thank you I really appreciate your approach about you know if food hurts how do you navigate that and just dismiss it completely you calm right yeah so what do you do do you I just I feel patience hear FODMAP and they're going to go online and Google so do you use the word FODMAP like what do you think the best or do you just say we're gonna try let's try lactose free milk yeah what I do is explain that there is an approach that's usually quite restrictive and actually has lots of rules attached to it and actually if we go and have a look at that approach together that's likely to be make things worse not better so we have to do it in a very modified way so depending on the patient I would either use something like the Monash app and just get them to have a look at the food guide with some of the red Amber and green Foods or I would do some of the printouts from that around red Amber and green foods and say or I would some patients I wouldn't even go that far I would simply look at their diet and say look you're eating loads of apples you know reduce those you're having loads of chewing gum reduce that can we think about maybe not having onions and garlic as you've already said you feel a bit weird after pasta with tomato sauces so it very much depends on the patient I think um you know I think we could one of the things we need to do in future is develop some more resources you know the one you've talked about with the pictures on is great you know we could have a sort of level of resources couldn't we for patients that want something very simple and actually would just get too too caught up in those more in those you know the more detailed approaches so I I and I guess we would always do one thing at a time so I start with probably usually start with lactose or fructose depending on the diet and we would try one thing and then we would go and try another thing you know when we would build up that restriction if needs be the last thing I would do would be put them on a gluten-free diet and I so far never had to do that all of my patients have responded by reducing fruit and vegetables um you know and a few key fructans really yeah yeah excellent stop it thank you so much I look forward to where Earthworks gonna go