Eating Disorders Common in Patients with Chronic Constipation

Individuals with eating disorders often complain of constipation and related symptoms such as bloating and abdominal pain. The opposite association—the frequency of eating disorders in patients with chronic constipation—has little research.

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Gastroenterologist Kyle Staller, MD, MPH, director of the Gastrointestinal Motility Laboratory at Massachusetts General Hospital, Helen Burton Murray, MS, clinical and research fellow, and colleagues recently identified eating disorders in 19% of adults presenting for physiologic evaluation of chronic constipation. In Clinical Gastroenterology and Hepatology, they explain the relevance of this and related findings for the treatment of patients with constipation.

Study Details

The researchers studied 279 adults who underwent anorectal manometry for the evaluation of chronic constipation at Mass General between June 2017 and September 2018 and completed the 26-item version of the Eating Attitudes Test (EAT-26), which screens for eating disorders. The average patient age was 47 and 79% were female.

Patients also completed the Patient Assessment of Constipation Symptom Questionnaire, the Hospital Anxiety and Depression Scale and the Visceral Sensitivity Index (a measure of gastrointestinal-specific anxiety).

EAT-26 Results

53 patients (19%) had a total EAT-26 score ≥20, indicating a possible clinically significant eating disorder. Results on the three EAT-26 subscales were also tallied:

• Dieting (e.g., shape/weight concern, attempts to control eating, feelings around eating)—100% of patients in the eating disorders group reported having impulses to vomit after meals and engaging in dieting behavior at least "sometimes"
• Oral Control (e.g., avoidance of food, overly cautious behaviors such as cutting food into small pieces)—23% to 56% endorsed items on this subscale at least "sometimes"
• Bulimia/Preoccupation (e.g., binge eating, purging, intrusive thoughts about food)—13% to 66% endorsed items on this subscale at least "sometimes"

EAT-26 also includes items that assess the presence and frequency, over the preceding six months, of:

• Binge eating—reported by 45% of the 53 patients who met the eating disorder symptom cut-off
• Self-induced vomiting for weight/shape control—reported by 14%
• Use of laxatives, diet pills or diuretics for weight/shape control—reported by 23%

Factors Associated with Eating Disorders

The researchers analyzed whether age, the severity of constipation, depression, anxiety or gastrointestinal-specific anxiety were associated with the presence of eating disorder symptoms. General anxiety and gastrointestinal-specific anxiety were the only variables independently associated.

However, the severity of constipation was associated with the severity of eating disorder pathology. This association appeared to be driven by abdominal-related symptoms rather than by rectal symptoms or stool symptoms.

Mediation Analysis

Greater gastrointestinal-specific anxiety could perpetuate eating disorder symptoms, which could perpetuate greater severity of constipation (e.g., through stimulant laxative abuse). However, when the researchers conducted a mediation analysis to investigate the temporal relationships of these variables, they found that was not the case in this cohort. Instead, gastrointestinal-specific anxiety fully explained the relationship between eating disorders and the severity of constipation.

The Need for Screening

The findings from this study imply that patients with chronic constipation should be screened for eating disorders, particularly those who describe worries or fears about gastrointestinal sensations and those who report abdominal-specific constipation symptoms such as bloating and abdominal pain.

Screening is especially important before prescribing dietary restriction (e.g., low FODMAP diet) for chronic constipation. Patients who have an unidentified eating disorder symptoms may appear to adhere well to such an intervention, but food restriction could further perpetuate the link between the eating disorder and constipation.

The Need for Complementary Treatment

It is important for clinicians to recognize that eating disorder symptoms lie along a spectrum and include disordered thinking as well as disordered behavior. For instance, feeling bloated can be misappraised as feeling fat, reinforcing fears of weight gain and lead to eating disordered behavior. Individuals with eating disorder symptoms may also be hypervigilant to gastrointestinal sensations and then experience heightened sensitivity to symptoms associated with constipation.

By identifying which patients with constipation have underlying eating disorder symptoms, clinicians will be better able to recommend appropriate care. Outpatient treatment of eating disorders typically includes cognitive–behavioral therapy with pharmacotherapy and nutritional support if needed.

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