Gastrointestinal Issues Which Impede Successful Weight Restoration in Anorexia Nervosa and ARFID – part 3
By Philip S. Mehler, MD, FACP, FAED, CEDS
(Please note: The following article is Part III of a 3-part series with each part addressing a major GI issue that impairs refeeding. Part I can be found by clicking here. Part II can be found by clicking here)
An additional gastrointestinal factor which can impede and frustrate the refeeding plan, for patients with AN and ARFID, is the advent of diarrhea during the early stages of refeeding. Certainly in this day and age, first and foremost, an infectious etiology must be excluded. Parasites, such as Giardia, are the most common infectious agents causing diarrhea of 1 week or less and must also be excluded. Parasitic diarrhea is much less common in industrialized countries. C. difficile causes recurrent diarrhea among patients taking antibiotics in health care settings and must always be considered, especially with its increasing virulence worldwide.
Once infectious causes have been thoughtfully ruled out, other noninfectious pathologies to consider include celiac disease, irritable bowel syndrome and other forms of functional bowel disease. The evaluation for persistent diarrhea early on in the refeeding period includes a complete history and physical examination and diagnostic testing for infectious and noninfectious etiologies responsible for the patients’ symptoms. But, in the end a common additional cause to consider, which is really a diagnosis of exclusion, is a malabsorption state which accompanies marked weight loss in patients with A.N. Basically, it is directly caused by the weight loss and subsequent loss of small intestinal absorptive surface. Therefore, in essence, a new state of short-gut syndrome ensues due to the reduced intestinal absorptive area from villous atrophy, wherein calories are normally absorbed. There is actually one blood test which can be done to confirm the diagnosis, called a diamine oxidase level; it will be abnormally low in patients with AN, if the diarrhea is due to malabsorption. The treatment for this malabsorption state, which ultimately will correct itself with weight gain and nutritional rehabilitation, is to alter the diet so that the reduced absorptive area does not adversely impact weight restoration. Once again, this requires a close working relationship with an informed registered dietician to add more complex carbohydrates, to increase the protein content of the diet to reduce the amount of liquid ingested during the meal and to substitute six smaller meals instead of the traditional larger breakfast, lunch and dinner meals.
Suggested reading: Takinoto Y, et al. Diamine oxidase activity levels in anorexia nervosa. Int’l Journal of Eating Disorders, 2014; [47:20]3-205. Trees N., et al. Gastrointestinal complications of refeeding in anorexia nervosa. Journal of Nutritional Biology, 2016;[1:49]-60.
About the author:
As President of Eating Recovery Center, Dr. Philip Mehler is the designated head of medical services across Eating Recovery Center’s full National treatment spectrum. Dr. Mehler began his career at Denver Health more than 30 years ago and was formerly its Chief of Internal Medicine. He was Denver Health’s Chief Medical Officer (CMO) for 10 years until he was promoted to its Medical Director, a position he held until his retirement in 2014. He is also the Glassman Professor of Medicine at the University of Colorado School of Medicine, and has conducted research into the optimal medical treatment of the most severe cases of Anorexia Nervosa and Bulimia. He founded ACUTE at Denver Health, the country’s center of excellence for those with the most extreme forms of Anorexia nervosa, and continues to serve as its Executive Medical Director. Dr. Mehler has authored 425 scientific publications, including 3 textbooks, Medical Complications of Eating Disorders, published by Johns Hopkins University Press and is now in its third edition. His newest book was just released in November 2017. Dr. Mehler was the recipient of the Academy of Eating Disorders 2012 Outstanding Clinician Award, has been recognized among the “Best Doctors in America” for the past 22 years in a row, and was voted the “Top Internal Medicine physician in Denver” multiple times by 5280 Magazine. Dr. Mehler is a member and fellow of the Eating Disorders Research Society and the Academy of Eating Disorders, as well as a member of the editorial board of the International Journal of Eating Disorders. He has lectured extensively on a national and international level as the world’s leading medical expert on the topic of the medical complications of eating disorders.