Nutritional Rehabilitation-Why is it so painful?

Tuesday, Feb 20  •  


Chad Speth
Primary Care Provider

I have the unique opportunity at Avalon Hills to watch our clients make tremendous changes in their lives. This is one of my favorite parts of doing this kind of work. I see patients, both adolescents and adults come from all parts of the country and many parts of the world. The treatment team and I at Avalon, are able to see the triumph over the most deadly of all psychiatric illnesses. Eating disorders are complicated and require a team approach in order for treatment to be effective. Treating eating disorders is complicated and challenging for providers from therapists to dietitians to the medical staff. The challenges to treatment providers pale in comparison to the struggles, pain and challenges experienced by the patient’s themselves. I often tell my patients that treatment and the road to true recovery is some of the most difficult work they will likely do in their life. Despite it being a painful and difficult road it also will be one of the most rewarding things they will ever do as well. In this post I want to address some of medical reasons why this road to recovery can be so challenging.

Much of the life-threatening effects of an eating disorder come from the behaviors themselves and the effects of those behaviors on the body. These behaviors, including dietary restriction, purging and laxative abuse cause the body to be in a state of malnutrition and can cause fluid and electrolyte imbalances, structural or anatomical changes and hormone imbalances, etc. The effects of malnutrition including fluid and electrolyte imbalances can lead to potentially life threatening problems. Malnutrition is a whole body illness, literally affecting every organ system of the body.

One of the most challenging and difficult phases of treatment comes at the beginning. This is an overwhelming time -both emotionally and physically. The strong urge to use symptoms can tempt them to want to quit the recovery process and give up. It can be a very difficult journey. I want to explain why this process can be so painful physically.

The solution to many of the effects of the eating disorders on the body is cessation of the eating disorder behavior, or symptom interruption. The next step is correcting the behavior through adequate nutritional rehabilitation and weight restoration if needed. Medications and other medical and therapeutic interventions are often needed to support this process as it can be very difficult for patients. Those with eating disorders should go through the nutritional restoration phase of treatment being monitored and supported by a medical provider, dietitian and therapist who understand eating disorders and the dangers as well as the difficulties experienced by patients. Our role is to help offer support and interventions to ease the pain of this already challenging time.

One area that is difficult for patients is the potential for refeeding syndrome. If patients are severely underweight or there has been rapid, significant weight loss, they are at risk for this life-threatening condition. Refeeding Syndrome refers to complications that come from refeeding that result in fluid and electrolyte shifts in the body. This can have a potentially fatal impact on the heart and other vital organs. Patients should be started out at a conservative amount of food and calories and be gradually increased throughout the process of weight restoration. Weight gain and dietary intake should be monitored closely by a competent medical provider. Frequent lab draws are done, sometimes as much as daily or more. Patients may be supplemented with electrolytes such as potassium, phosphorus, magnesium and vitamins such as thiamine to prevent problems associated with refeeding.

Low blood sugars is commonly seen in patients who are malnourished. Low blood sugar or blood glucose can put a patient at risk for a seizure. Monitoring this requires frequent finger sticks and or blood draws to monitor blood glucose. Patients are often supplemented with snacks to bring this up to normal levels. Ultimately the “cure” for this problem is weight restoration and consistent, adequate dietary intake.

Another area that is particularly difficult for patients during the refeeding process is stomach and abdominal complaints. This area is referred to as the Gastrointestinal (GI) system. In my experience these are some of the most common complaints that patients have going while going through the refeeding process. Complaints include stomach or abdominal pain, cramping, bloating, increased or early fullness, bloating, increased gas, heartburn, reflux, nausea, vomiting, constipation, painful bowel movements, hemorrhoids, rectal bleeding and diarrhea. Eating disorder behaviors such as dietary and fluid restriction, laxative abuse, binging and purging all contribute to the damage to the GI tract. These behaviors lead to decreased motility (movement) through the entire GI tract, injury to the muscles and nerves of the gut, tissue damage of the gut, impaired digestion and malabsorption of food and nutrients, altered bacterial flora in the gut as well as damage to the liver, pancreas and gallbladder. Thankfully most if not all of these symptoms get better if not completely resolve with weight restoration. Abdominal complaints can be triggers to engage in eating disordered behavior such as further restricting, purging or laxative use. Patients should be supported along the way as these symptoms can be very distressing and can trigger intense emotional distress and cause them to want to quit and give up. They should be given reassurance that these symptoms are temporary. There is much that can be done medically, psychiatrically, dietarily and therapeutically to support patients and alleviate the pain and suffering during this time.

Lastly, an area of concern is that of weight distribution and redistribution. When patients who have been severely underweight begin to gain weight the body often puts weight first around the areas of the vital organs. Often one of the place patients will notice weight gain is in their abdomen and the face and neck. This is the body’s way of protecting and preserving vital organ function. Though this too, is quite distressing to patients who are already struggling with intense body image issues as they are trying to move in a direction of recovery. These intense emotions can be painful and cause patients to want to lose weight, likely triggering a relapse of eating disorder symptoms. As with the above-mentioned problems with weight gain and nutritional restoration; if given time the body will redistribute this weight. The body will begin to restore muscle in the arms and legs and the feelings of excess weight in the abdomen and distention will decrease. Providers need to be aware of this process and be able to evaluate and educate patients about this and give reassurance where needed.

In summary, recovery from eating disorders is very difficult. The process of weight restoration and nutritional rehabilitation is one of the more difficult parts of the journey to recovery. Patients need to be supported through and monitored closely during this time by a team who understands and is experienced with eating disorders. Education should be given to patients and loved ones that healing is possible and is worth the pain and struggle.