Content warning: This story contains sensitive details about eating disorders.

Dianne Chungs eating issues started in middle school. Like many girls at that age, the medias fixation on women with very specific body types (read: skinny) put pressure on Dianne to look a certain way. But there was more: She describes herself as a sickly child who always had trouble eating and digesting food. A lot of my early memories are of me throwing up because I was sick or had stomach pain, which was pretty traumatic, so I didnt exactly enjoy eating once I got older, she says. It became common for Dianne to skip lunch at school, not only because of her struggles with food but because she wanted to save money too. Dianne grew up with a single mom in a low-income household. Since eating was such a pain to me physically, I thought, oh, its better to save money and have that help out with expenses at home, she says.

In middle school and high school, Dianne says her emotional and mental state crossed into eating-disorder territory. Because her mother was often at work, Dianne was in charge of her own meals and in addition to lunch she often skipped dinner, as no one was around to tell her otherwise. She began exercising constantly, up to six hours a day. After school, shed have something small to eat if she couldnt resist the hunger pains but usually she worked out or went to bed early and slept until the following day. This went on for years.

Dianne, now 25, is Korean and says that both because of her cultural background and her low-income upbringing, she didnt grow up going to the doctorthe concept of health care wasnt even really a thing in her family. Even if I had pain, it wasnt normalized to go to the doctor, she says. I would just drink water or sleep it off.

By the time Dianne arrived at the University of California, Berkeley, as a college freshman, shed grown so nervous about the idea of the Freshman 15 that she ended up losing 15 pounds. It wasnt until Dianne began experiencing nausea and dizzy spells, which she worried could affect her school work, that she decided to see a doctor. I didnt want to fail out of school, she remembers.

Diannes initial visits to the campuss primary care physicians were intimidating: I didnt understand U.S. healthcare or what it meant to communicate your symptom. For the first three visits, it wasnt even clear to Dianne when or how she should talk about her problems. There was a standard blood draw and then theyd say, Is there anything else you want to talk about? And I would feel so stuck trying to explain why I was there. My mind would just go blank.

Yet Dianne was determined to get help, so ahead of a fourth visit, she tapped into her academic training and made a list of what she wanted to discuss. That was a turning point. As soon as I walked in with my agenda, the doctor responded with a series of follow-up questions, like what my diet looked like and if Id ever been to a dietitian, she says. From there, Dianne was diagnosed with anorexia nervosa with symptoms of binge eating, and visited a gastroenterologist, who told her she had irritable bowel syndrome (IBS). She also met with a dietitian to set her on a course toward healthy eating habits as well as a therapist to help her get to the root of her eating disorders. She says cognitive behavior therapy played a huge role in her recovery: That was really about changing the mindset behind my IBS symptoms and relationship with food, where now Im no longer ashamed.

Its almost shockingly common for people with eating disorders to also experience gut disorders. According to a 2019 study published in Nutrients, 98 percent of eating disorder patients meet the criteria for at least one functional gastrointestinal disorder (FGIDs) with the most common one being IBS. But one doesnt necessarily cause the other. Alexandra Fuss, PhD, a psychologist who specializes in digestive health at Yale New Haven Hospital says its a chicken or egg situation depending on the patients presentation. Disordered eating behaviors can place a great deal of strain on the body through significant nutritional deficits, and physical strain from compensatory behaviors such as vomiting, overuse of laxatives or over-exercising which can in turn lead to GI motility complications, erosions of the esophagus, increased inflammation, and so on, she explains.

On the other hand, some people, like Dianne, develop IBS symptoms such as stomach pains or difficulty digesting food firstand change their eating habits accordingly. When people begin to equate food with their symptoms, that can lead to a fear of eating, restricting certain food groups, and resulting in avoidance of certain foods altogether or binge eating, says Lynn O'Connor, MD, director of Colon and Rectal Surgery of New York. This type of relationship with food can cause anxiety around eating and psychological stress, which can lead to changes in the gut, even changing the makeup of the bacteria in the gut, which can contribute to IBS. In other words, disordered eating habits can up your chances of developing a gastro health issue, and the reverse is also true.

John Damianos, MD, an internal medicine physician focusing on gastroenterology at Yale New Haven Hospital, says this is, in a way, quite a natural response. If any of us had a stimulus that was bothering us, then we would avoid it, he says. But with sustained abnormal eating patterns, that can eventually develop into actual eating disorders such as anorexia nervosa, bulimia nervosa, and avoidant/restrictive food intake disorder (ARFID)."

Disordered eating behaviors can place a great deal of strain on the body.

In the case of anorexia, defined as an abnormally low body weight due to an intense fear of gaining weight and/or a distorted idea of weight, people often experience constipation, gas, and bloating as a result of decreased gut activity and delayed emptying from not eating enough for prolonged periods of time, explains Jenna Volpe, a registered dietitian based in Round Rock, Texas. Food is not being ingested in volumes large enough to simulate the digestive system and smooth muscles responsible for digestion and gut motility, so the gut slows down. For those with bulimia, which can entail purging of food in the form of self-induced vomiting, laxative abuse, and over-exercise, the food that does get ingested either isnt making its way all the way through the entire digestive tract (in the case of self-induced vomiting), or its being rushed through the system too quickly (in the case of laxatives) which can disrupt natural digestive biochemistry. Dr. Damianos adds that orthorexia nervosa, or a pathologic obsession with healthy eating, has been suggested as an emerging disorder, and it can also lead to IBS symptoms.

Just ask Erin Decker, 31. While she isnt sure which started first, her disordered eating habits or her IBS symptoms, she calls them a natural consequence of being a relatively anxious, high-stress person. Studying to become a registered dietitian reinforced her orthorexia nervosa, and she decided to seek help once it started affecting her relationship with friends and family. Today, as a registered dietitian who works with clients with eating disorders, she says, It is so important to consider my own self care. Im a new mom as well, so its easy to lose track of time and forget to eat regular meals or ask for help. I notice my IBS symptoms act up more when these needs are not being met. She adds that the mantra Dont let perfect get in the way of better helps too.

Emily R., 28, says her disordered eating habits started first, as shes struggled with anorexia on and off for 12 years. Along the way, she began experiencing sustained periods of constipation. I started to realize how much time and space thinking about food and my bowel movements were taking upso much that I couldnt be a friend or partnerand I knew I needed to seek help, she recalls. Emily was told she has IBS-C, a type of IBS where constipation is the primary symptom. She now actively sees both a therapist and dietitian who specialize in eating disorders, in addition to limiting stress, taking a magnesium supplement and drinking spearmint tea, and, no joke, telling her stomach nice things. It sounds hokey, but dont knock it till you try it, she adds.

Dianne says through the combination of her own therapy and work with a dietitian, she now considers herself a foodie. I think about the time Ive lost out on enjoying different foods from different cultures, and now Im always looking for recommendations. Its become an adventure to try new things with my partner and friends. I wouldve never believed this back in grade school, but now, food is a form of art that I actually enjoy.

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How Eating Disorders and IBS Are Connected - Cosmopolitan