When intuitive eating isn’t enough: Addressing disordered eating patterns with patients

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By Carolina Brooks, BA, IFMCP

It’s difficult to scroll through social media or read a consumer publication without mention of intuitive eating. Touted as a solution to disordered eating patterns affecting so many of our patients, the phrases “listen to your body,” or “eat until full,” are thought to simplify the eating process, which can be challenging for someone struggling with disordered eating. It’s a far cry from the more conventional approach to eating disorder management, where a patient may face regular weigh-ins, force-feeding under strict observation, or referral to a psychiatrist. Through my clinical experience, these approaches do not work.

A 2017 study in Academic Psychiatry looked at the knowledge of eating disorders and attitudes toward patients with eating disorders amongst physician residents and fellows and concluded that participants demonstrated both limited knowledge and minimal comfort levels treating this subset of patients. Knowledge of nutrition is often poor, and the focus tends to be on offering therapy. One area that is often overlooked is the neurochemistry of binge eating, and this is the area I focus on when I work with patients with disordered eating issues who are also working interactively alongside a therapist with a special interest in this area, and these are the patients who do not respond to intuitive eating exercises, and whose behaviors around food do not stem from environmental or social factors.

I see a greater prevalence of women with disordered eating habits who are vegetarian or vegan. A 2019 study in Nutrients concluded that risk of insufficient protein intake through diet was low in vegans and vegetarians, but I believe the issue stems from poor stomach acid production negatively impacting assimilation of protein. Hypochlorhydria is often present due to stress, medications, or high alcohol intake. Hydrochloric acid production also decreases dramatically with age. Practitioners might also see low levels of zinc in the diet, and this might be due to stress, intense exercise, the oral contraceptive pill, or high levels of phytic acid-containing foods in the diet, such as legumes, nuts, and seeds.

Zinc is required to make hydrochloric acid in the stomach. Hydrochloric acid is required to assimilate zinc and which plays a key role in numerous physiological processes, including neurotransmitter breakdown and production. Vitamin B12 levels may be sub-optimal if there is hypochlorhydria, as stomach acid is required to utilize vitamin B12. I prefer to use a hydroxocobalamin or adenosylcobalamin form for supplementation to avoid the possibility of methyl-trapping, starting with a small dose and where appropriate, using lithium orotate alongside vitamin B12 to facilitate entry into the cell.

We also need to consider the impact of neurotransmitter activity, particularly if there is suspected tryptophan or phenylalanine depletion. Vitamin B6 and folate levels also play a key role , as well as vitamin D, which is the rate-limiting step in serotonin synthesis. Nutrient deficiencies and medications such as antihistamines, antipsychotics, and corticosteroid medications can exacerbate disordered eating patterns because they can increase feelings of hunger and impair satiety.

Case Study

A 41-year-old patient with a long history of disordered eating and addiction came to see me for depression, weight gain, cognitive dysfunction, severe fatigue, binge eating, menorrhagia, and dysmenorrhea. She had a history of addictive behaviors, having spent three months in a rehabilitation facility to address a dependence on alcohol, which had been very successful. She was too exhausted to exercise, but she managed to cook for the family every day. She had seen multiple therapists for her disordered eating patterns, but had not found them helpful. She had been taught cognitive behavioral therapy and intuitive eating, and had been put on metformin and antidepressants, but nothing had worked for her. Nobody had previously looked at her nutrient status and biochemical behavioral triggers. She was no longer taking antidepressants, but was still taking metformin.

The patient’s stipulations were that she had three children in the house and was not prepared to remove her binge foods from the house as they were foods her children, and she did not wish to eat different food to her children. I avoid dietary exclusions as much as possible with disordered eating patients, as often restriction can aggravate symptoms.

We did some bloodwork and a stool test, and found her fat-soluble vitamins, B vitamins, zinc, immunoglobulins and proteins were all suboptimal, which had a subsequent impact on immune and thyroid function. Her iron markers were some of the lowest I had ever seen, and iron-deficiency anemia was impacting everything from energy levels and metabolism to liver detoxification pathways.

A 2013 review article in Frontiers in Aging Neuroscience discussed the role of iron metabolism in the brain and how deficiency can adversely affect neurological function. The patient’s stool test demonstrated gut permeability with high levels of zonulin present, moderately high calprotectin levels indicating inflammation, and poor pancreatic elastase activity.

Her commensal bacteria looked good, however high levels of Prevotella copri and Bacteroides vulgatus were present, which a 2016 paper in Nature demonstrated as driving increased levels of branch-chain amino acids in the gut driving insulin resistance.

I immediately supplemented the patient with iron, a good multivitamin, S-Adenosyl methionine (SAMe), zinc, iron, digestive enzymes, omega-3 fatty acids, short-chain fatty acids,  prebiotic fibers to support better blood sugar regulation, and amino acids between meals. I also prescribed a herbal blend to be taken when menstruated started at a high, frequent dose every few hours to address the dysmenorrhea, menorrhagia and poor uterine tone, using herbs like Capsella bursa-pastoris (shepherd’s purse), Achillea millefolium (yarrow), and Rubus ideaus (raspberry leaf) for their hemostatic, anti-inflammatory, and astringent properties. The patient was instructed to reduce the dose to just three times a day when the bleeding had reduced by fifty percent. We focused on how she could improve her phytonutrient intake and macronutrient balance, rather than foods to be excluded.

Within a month, the patient felt a little more energized, and no longer had to nap in the afternoons. She had managed to shift the family over to healthier cereals and snacks but had not yet managed to stop bingeing. Since the patient tended to binge in the early evenings when her husband was picking the children up from their after-school activities, I proposed that the patient should involve herself in these journeys and take her amino acid supplement in one larger dose at this time.

It has now been five months since I started working with this patient. Her most recent blood work indicated that her nutrient status and blood sugar regulation had improved, and she was no longer anemic. She has tapered off metformin, is now energized enough to exercise and is finally losing weight. At the time of writing, she has not had a bingeing episode in two months and is feeling very positive about her progress.

References

Anderson, K., Accurso, E. C., Kinasz, K. R., and Le Grange, D. (2017) Residents’ and Fellows’ Knowledge and Attitudes About Eating Disorders at an Academic Medical Center. Academic Psychiatry: The Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry. Retrieved from: https://doi.org/10.1007/s40596-016-0578-z

Hare, D., Ayton, S., Bush, A., and Lei, P. (2013) A delicate balance: Iron metabolism and diseases of the brain. Frontiers in Aging Neuroscience, 5, 34. Retrieved from: https://doi.org/10.3389/fnagi.2013.00034

Mariotti, F. and Gardner, C. D. (2019) Dietary Protein and Amino Acids in Vegetarian Diets-A Review. Nutrients. Retrieved from: https://doi.org/10.3390/nu11112661

Pedersen, H. K., Gudmundsdottir, V., Nielsen, H. B., Hyotylainen, T., Nielsen, T., Jensen, B. A., Forslund, K., Hildebrand, F., Prifti, E., Falony, G., Le Chatelier, E., Levenez, F., Doré, J., Mattila, I., Plichta, D. R., Pöhö, P., Hellgren, L. I., Arumugam, M., Sunagawa, S., Vieira-Silva, S., and Pedersen, O. (2016) Human gut microbes impact host serum metabolome and insulin sensitivity. Nature. Retrieved from: https://doi.org/10.1038/nature18646