ABSTRACT

Eating disorder diagnoses are becoming increasingly common in Australia, with new types of eating disorders being recognised in recent times. Research on the bidirectional gut–brain axis suggests that food, mood and mental health are interconnected. This case study reviews the improvement in mood and progress in weight gain/management in a young Australian woman following changes in eating patterns, food quality and increased caloric intake.

INTRODUCTION

Eating disorders (EDs) are a complex group of disorders with a number of drivers, often different for each person, and are difficult to treat for mental health providers and nutrition-based practitioners alike [1,2]. EDs are generally considered to be triggered by both personal and environmental issues such as (but by no means limited to) body dysmorphia, trauma and the impact of peer pressure and social media, which lead to a disordered relationship to food [3].

A young woman aged 26, Sophie (name changed for privacy), presented to clinic following a referral from her treating psychologist.

The psychologist advised that Sophie was undertaking cognitive behaviour therapy for suicidal ideation, an ED (type unspecified), relationship issues and a traumatic family history and, as Sophie states, “just living” – all of which are commonly reported foundations for the development of EDs [3,4].

There is evidence to suggest deranged eating behaviours that include severe restriction can alter the gut microbiota [4] and trigger dysfunction of the gut–brain axis, leading to the development of anxiety and/or depression [5]. Furthermore, research now suggests that EDs too may be a result of a dysbiosis (an imbalance of commensal and pathogenic microbiota) [4, 6, 7]. Questions remain, however, as to the order of development of the conditions – did the ED appear first, causing microbiome disruption, or does a disrupted microbiome trigger the ED? [4] Additionally, consideration needs to be given to the impact of each condition on the other.

During the first appointment, Sophie disclosed she was underweight and experiencing a number of health issues related to severely restricted eating, a deranged eating pattern and, possibly, undiagnosed coeliac disease. Nutritional counselling commenced in September 2021 and continues at the time of writing. The following is a discussion of the case presentation, background, treatment and the positive impact of increased food intake and quality on her mood, mental and general health and wellbeing.

While Sophie is still on the road to recovery, and experiences occasional relapses in deranged eating behaviours and weight loss, she no longer purposefully restricts her caloric intake. She states that these relapses occur when she feels overwhelmed by life. Sophie has not dropped back down to her lowest weight since commencing nutritional counselling, but has not yet reached her goal weight.

She had some disruption to her psychological therapy due to her psychologist moving to another intrastate practice, and she was distressed by the loss of that therapeutic relationship. She now attends therapy with a new counsellor/psychotherapist.

CASE PRESENTATION

A 26-year-old Caucasian Australian female, Sophie, presented via teleconference to discuss strategies for overcoming an ED. She weighed 44 kilograms and was 1.64 metres tall. Her body mass index (BMI) was 16.36, indicating that she was underweight. She stated that her goal weight was 50kg so that she would be able to donate blood.

Family history

Sophie has a traumatic family history with both parents – “addicts and alcoholics” – and she stated that her mother had “relapsed a whole bunch of times”. Her mother abandoned Sophie’s younger brother and sister, and Sophie was required to parent them at a young age. Her parents later became immersed in the church, but her mother relapsed again. Sophie left home at age 16 and is now estranged from her parents.

Coming from a low socioeconomic background, Sophie states that she was malnourished and was always very thin. When her parents did provide meals, they was poor quality, low in vegetables and fruit and often deep fried. Sophie subsequently underwent a cholecystectomy to remove her gallbladder at age 17.

When we met, Sophie was in a relationship with her partner of three years and was the stepmother to his two children from an earlier relationship. She was mostly responsible for food preparation for the family.

Presenting symptoms

Significant and long-term food restriction had negative impacts on Sophie’s health. Her symptoms included:

■ eating disorder (self-diagnosed anorexia nervosa);

■ low body weight;

■ experiencing post-prandial cramps, vomiting (not purging), bloating and borborygmi;

■ constipation, but also postprandial diarrhoea;

■ daily headaches requiring two paracetamol tablets two to three times daily;

■ dyspnoea on exertion;

■ chest pain and palpitations (cardiovascular diagnoses eliminated);

■ insufficient sleep (five and a half hours);

■ constantly anxious and stressed;

■ rumination;

■ deep joint and bone pain;

■ easy bruising and broken capillaries;

■ amenorrhoea;

■ negative voices in her head that she believed to be her mother telling her to restrict food;

■ suicidal ideation; and

■ self-medicating – smoking marijuana twice daily.

Existing diet

Sophie’s existing diet was restrictive and repetitive, and generally did not meet the recommended daily allowances of all micronutrients. Sophie did not eat breakfast, lunch, morning tea or afternoon tea. She ate an entire supermarket frozen spinach pizza (always the same) in bed each night, away from the family. The entire pizza provided only 858 calories (3586.44 kilojoules) and only 26 grams of protein – both significantly under her daily requirement.

The only beverages she consumed were 1.25 litres of water, which she consumed only at night with her pizza, and instant coffee without milk or sugar. She stated that she would consume a medium jar of instant coffee fortnightly.

Photo: Pexels

Sophie had a limited list of ‘safe’ foods and an extensive list of ‘unsafe’ foods that she wanted to eat but would not allow herself. She would cook healthy and fun meals for her young stepdaughters, but would not share the meals. Sophie had been restricting her diet and eating in bed for 18 months prior to her initial consultation.

MANAGEMENT AND OUTCOME

It was apparent in the initial consultation that Sophie feared food because of the post-prandial digestive discomfort, and that her relationship with food had been dysfunctional for some time. She was fearful of significant changes in her diet, and only very small changes were implemented in the first few sessions.

Initially, Sophie was asked to sip her 1.25L of water during the day to improve hydration to reduce constipation, improve digestive function, reduce headaches and reduce reliance on paracetamol [8]. She was initially resistant until it was explained that this change to her water consumption pattern meant no increase in her daily energy intake.

Two other small changes were discussed in the first session. These were to eat a tiny portion of breakfast that she made for her stepdaughters, and to have a small salad with her pizza in the evening.

Sophie adopted all three recommendations and reported improvements in sleep, reduction of headaches (using paracetamol only four to five times in the previous fortnight), and enjoyed improved connection with her stepdaughters, and she had introduced a 600-millilitre smoothie (banana, strawberries, blueberries and almond milk) for morning tea of her own volition. Sophie was pleased to feel more alert, more energised, less sad and more connected.

At the second session, Sophie reported that despite improvements, she still experienced digestive issues. She noted that her mother had been diagnosed with coeliac disease and that Sophie herself was lactose intolerant. Sophie had not undergone any investigations for coeliac disease. We agreed to assume that Sophie was also coeliac and removed gluten from her diet. Lactose was also removed. This meant that going forward, Sophie would need to make her own pizza and that she could experiment with different toppings and flavour profiles.

The removal of gluten and lactose from her diet significantly reduced her digestive symptoms, allowing Sophie to expand her list of ‘safe’ foods. She started to eat three main meals plus snacks on a daily basis, and she began eating with family at the dining table. Despite these improvements she had lost 1.6kg, decreasing her weight to 42.4kg (BMI 15.76) after six weeks. This may have been due to ongoing relationship issues. She did report that she was no longer experiencing headaches.

After three months, Sophie had no further digestive disturbances, she was experiencing hunger and attending to it appropriately, had increased her portion sizes, expanded her ‘safe’ food list, felt less guilt for eating and was able to go out to a café for breakfast for the first time in two years.

Following eight months of nutritional counselling, Sophie reached a weight of 48.9kg (BMI 18.18) – just 900g under a healthy BMI of 18.5 and 1.1kg short of her 50kg goal. At the time of writing, Sophie’s weight has decreased to 45.9kg (BMI 17.07). This decline in weight followed disruption to the therapeutic relationship, as two replacement psychologists had been unavailable or unhelpful, and ongoing relationship difficulties with her partner. She advises that she appreciates and trusts her current counsellor, and that she and her partner are discussing next steps.

Sophie remains positive about recovery but has fallen into some previous eating behaviours during this time of stress. With continuing development of the therapeutic relationship with both nutritionist and new counsellor, it is considered that Sophie will continue to recover [9].

DISCUSSION

A combination of dietary modification and therapy has proven to be helpful with Sophie’s recovery. A key observation through this process with Sophie is the significant interaction between gut health and her mental wellbeing and improved resilience.

There is a strong connection between the role of food on mental health, and the impact of mental health on food choices.

Key roles of the gut microbiota include neurotransmitter development and efficacy, modulation of the hypothalamicpituitary-adrenal axis, and inhibition of neuroinflammation and neural oxidative stress [10, 11]. Additionally, gut microbiota plays a role in the production of brain-derived neurotrophic factor, which acts as a growth hormone for the brain, allowing neuroplasticity and thought patterns to change [11]. The gut microbiota require fibre as fuel, amino acids from ingested protein and other co-factors to build mood-enhancing and moodstabilising neurotransmitters such as serotonin, acetylcholine, dopamine, oxytocin and gammaaminobutyric acid [5,12].

Sophie’s initial presentation of poor gut health was representative of a level of dysbiosis or gut microbiome disturbance due to possible coeliac disease [5]. This suggests that Sophie’s ED and co-morbid anxiety and depression may have been triggered by an imbalance to her gut microbiota. Conversely, her deranged pattern of eating, poor nutritional status and low-protein and low-fibre diet may have disrupted her gut microbiome balance and her supply of moodstabilising neurotransmitters [5].

While this might seem like a question of chicken and egg, the important observation is that Sophie’s mood improved, her suicidal ideation diminished (today she states that “there’s a lot to live for”), and her stress resilience improved, as has her self-efficacy following her change of diet. This is likely the result of increased food consumption leading to greater energy intake, more food variety, a healthier gut, greater microbiome diversity and better nutritional status.

Many counsellors, psychotherapists and psychologists receive little training in nutrition and the role of food on microbiome balance and health, and how this impacts the gut–brain axis [13].

Nutritionists and dietitians receive little training on supporting clients in times of psychological need [14]. There is a strong connection between the role of food on mental health, and the impact of mental health on food choices. Additionally, there is an opportunity for synergistic interfaces between mental health providers and nutrition-based practitioners to support clients living with mental health disorders generally, not only those presenting with EDs.

References

1. Anderson, L.K., Claudat, K., Cusack, A., Brown, T.A., Trim, J., Rockwell, R., Nakamura, T., Gomez, L., Kaye, W.H. Differences in emotion regulation difficulties among adults and adolescents across eating disorder diagnoses. Journal of Clinical Psychology. 2018 Oct;74(10):186773.

2. Hay, P., Touyz, S. Classification challenges in the field of eating disorders: can severe and enduring anorexia nervosa be better defined?. Journal of Eating Disorders. 2018 Dec;6(1):1-3.

3. Woerwag-Mehta, S., Treasure, J. Causes of anorexia nervosa. Psychiatry. 2008 Apr 1;7(4):147-51.

4. Reed, K.K., Abbaspour, A., Bulik, C.M., Carroll, I.M. The intestinal microbiota and anorexia nervosa: Cause or consequence of nutrient deprivation. Current Opinion in Endocrine and Metabolic Research. 2021 Aug 1;19:46-51.

5. Du, Y., Gao, X.R., Peng, L., Ge, J.F. Crosstalk between the microbiota-gut-brain axis and depression. Heliyon. 2020 Jun 1;6(6):e04097.

6. Marx, W., Lane, M., Hockey, M., Aslam, H., Berk, M., Walder, K., Borsini, A., Firth, J., Pariante, C.M., Berding, K., Cryan, J.F. Diet and depression: exploring the biological mechanisms of action. Molecular Psychiatry. 2021 Jan;26(1):134-50.

7. Berding, K., Vlckova, K., Marx, W., Schellekens, H., Stanton, C., Clarke, G., Jacka, F., Dinan, T.G., Cryan, J.F. Diet and the microbiota– gut–brain axis: sowing the seeds of good mental health. Advances in Nutrition. 2021 Jul;12(4):1239-85.

8. Popkin, B.M., D’Anci, K.E., Rosenberg, I.H. Water, hydration, and health. Nutrition Reviews. 2010 Aug 1;68(8):439-58.

9. Ramjan, L.M., Fogarty, S. Clients’ perceptions of the therapeutic relationship in the treatment of anorexia nervosa: qualitative findings from an online questionnaire. Australian Journal of Primary Health. 2019 Mar 5;25(1):37-42.

10. Butler, M.J., Perrini, A.A., Eckel, L.A. The role of the gut microbiome, immunity, and neuroinflammation in the pathophysiology of eating disorders. Nutrients. 2021 Feb 3;13(2):500.

11. Keeler, J.L., Patsalos, O., Chung, R., Schmidt, U., Breen, G., Treasure, J., Hubertus, H., Dalton, B. Serum levels of brain-derived neurotrophic factor and association with pro-inflammatory cytokines in acute and recovered anorexia nervosa. Journal of Psychiatric Research. 2022 Jun 1;150:34-9.

12. Navarro-Tapia, E., Almeida-Toledano, L., Sebastiani, G., Serra-Delgado, M., García-Algar, Ó., Andreu-Fernández, V. Effects of microbiota imbalance in anxiety and eating disorders: probiotics as novel therapeutic approaches. International Journal of Molecular Sciences. 2021 Feb 26;22(5):2351.

13. Downer, S., Berkowitz, S.A., Harlan, T.S., Olstad, D.L., Mozaffarian, D. Food is medicine: Actions to integrate food and nutrition into healthcare. The BMJ. 2020 Jun 29;369.

14. Notaras, S., Mak, M., Wilson, N. Advancing practice in dietitians’ communication and nutrition counselling skills: a workplace education program. Journal of Human Nutrition and Dietetics. 2018 Dec;31(6):725-33.

Permissions

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