Psychology in gastrointestinal disorders: addressing food concerns

09 Apr 2024
by Dr Rose-Marie Satherley, Imogen Hughes, Alice Drake

Dr Rose-Marie Satherley looks at the interplay between food concerns, restrictive eating and gastrointestinal disorders.

Gastrointestinal disorders encompass a broad spectrum of conditions involving the digestive tract. For many gastrointestinal disorders, for example irritable bowel syndrome or coeliac disease, dietary interventions like the low FODMAP or gluten-free diet are recommended.

At first, a dietary change may seem straightforward, but adhering to these dietary interventions can pose significant challenges. Many patients develop concerns around food because what they eat may trigger unpleasant symptoms like stomach pain, bloating or constipation.1 When these concerns start impacting their ability to meet their nutritional needs, mental wellbeing, or quality of life, greater multidisciplinary support is warranted.

Understanding and validating food concerns in gastrointestinal disorders

Food concerns affect 13%-55% of patients, leading to avoidance behaviours like skipping meals or restricting food intake beyond the needs of their dietary intervention.2 Concerns about the consequences of eating may increase the risk of avoidant/restrictive food intake disorder (ARFID), characterised by persistent avoidance or restriction of food intake, resulting in significant weight loss, nutritional deficiencies and impaired psychosocial functioning.

ARFID prevalence varies across gastrointestinal disorders, and research suggests that ARFID is not uncommon. One study found that up to 53% of participants with gastrointestinal disorders (achalasia, coeliac disease, eosinophilic esophagitis and inflammatory bowel disease) met ARFID criteria.3 Understanding these concerns involves considering the brain–gut axis and the role of anxiety in fostering dietary vigilance.

The gut–brain axis is a network of neurons, neurotransmitters, and signalling molecules facilitating communication between the intestines and the brain.4 The brain moderates these signals to maintain comfort, but disruptions can arise due to prolonged stress or intense emotions, leading to heightened perceptions of sensations and disturbances in intestinal function. Heightened food concerns may also lead to misinterpreting normal bodily sensations as signs of food contamination, though some sensations may stem from disruptions in the gut–brain connection rather than actual contamination. Nonetheless, it’s crucial to note that food contamination does still occur.

Secondly, concerns can be beneficial, helping patients to adhere to dietary interventions. While not explicitly outlined for patients with gastrointestinal diseases, the ‘Goldilocks principle’5 refers to an optimum level of caution that enables effective dietary management while minimising anxiety and potentially unsafe behaviour. For example, we might expect heightened concerns around food before diagnosis, where uncertainty about symptoms may lead some patients to avoid food, or during periods of increased gastrointestinal symptoms. Furthermore, transition periods, like navigating new environments while away from home, may heighten concerns around food. While exercising caution around food may be helpful during these phases, persistent food concerns may require further support, prompting dietitians to screen patient wellbeing.

Asking about food preferences and changes since diagnosis

Understanding the interplay between food concerns, ARFID and gastrointestinal disorders is crucial for advancing dietetic practice. Even when patients appear to adhere well to dietary interventions, these behaviours may mask deeper struggles and present significant challenges to their overall wellbeing.

Initiating discussions about food concerns can be done informally, for example, “How does your diet intake affect your daily activities and routines?” or “If any, what changes have you noticed about yourself around mealtimes, both in and outside of the home?” By asking these questions, dietitians can better understand the challenges patients face in managing their condition, and tailor dietary interventions accordingly.

Importantly, there is no evidence to suggest that discussing food concerns causes distress. On the contrary, it signifies a commitment to holistic care by acknowledging the intricate relationship between diet, symptoms and overall wellbeing, an approach endorsed by patients.6 For patients who express significant diffculties with food concerns and/or ARFID, explain that, while supporting diet is within your scope of practice, multi-disciplinary collaboration and referral to other team members may be necessary to better meet their needs.

Another strategy involves the use of screening tools for food concerns or ARFID. However, using measures that were developed in populations without gastrointestinal symptoms, like the Nine-item ARFID screen (NIAS) questionnaire, can present significant challenges.7 Scores on the NIAS may not accurately reflect the concerns of patients with gastrointestinal disorders. For instance, patients may endorse avoiding food due to gastrointestinal discomfort, which might be a part of their dietary intervention rather than a symptom of ARFID. Consequently, patients with gastrointestinal disorders may exhibit higher scores on the NIAS due to recommended condition management strategies.

Dietitians should familiarise themselves with validated measures for food concerns and ARFID and exercise caution in interpreting scores in gastrointestinal settings. For more accurate assessment, dietitians may consider utilising validated gastrointestinal-specific measures for food concerns, with examples including the Food-related Quality of Life in Inflammatory Bowel Disease Measure,8 the Coeliac Disease Food Attitudes and Behaviours Scale9 and the Esophageal Hypervigilance and Anxiety Scale.10

Referring to specialist support when needed

Multidisciplinary support is crucial in gastrointestinal settings, with the inclusion of practitioner psychologists playing a key role. They offer consultation to colleagues and can provide protected spaces to patients with additional needs regarding ARFID and food concerns. Although current NICE guidelines do not cover psychological interventions for food concerns in gastrointestinal disorders, psychologists can adapt evidence-based approaches with the aim of improving patient wellbeing. For example, cognitive behavioural therapy (CBT) focuses on understanding the relationship between thoughts, emotions, physical symptoms and behaviour, suggesting techniques to reduce distress cycles. CBT interventions have been effective in improving condition management, reducing depression and anxiety in gastrointestinal disease and a range of other chronic health conditions.11

Similarly, the acceptance and commitment therapy (ACT) approach focuses on a patient’s personal values, accepting thoughts and fostering psychological flexibility. ACT shows promise in gastrointestinal disorders, helping patients to adapt to the unpredictable nature of gastrointestinal symptoms and the wider impact on the body and consider ways to live meaningfully with any changes in physical health.12

Currently, no rigorously evaluated psychological interventions target food concerns in gastrointestinal disease. However, a pilot study has examined the feasibility of an eight-session behavioural intervention for ARFID symptoms in adults with disorders of gut–brain interaction.13 Qualitative feedback from patients indicated high treatment satisfaction, and improvements were observed in select clinical outcomes, though caution is warranted due to the study’s small sample size.

Despite the potential benefits of addressing food concerns psychologically, the availability of psychologists in gastrointestinal settings remains limited. Those seeking to advocate for psychologists in these roles are encouraged to consult the British Psychological Society guidelines on optimal recruitment practices.14 While the ideal scenario would involve psychologists as integral members of every gastroenterology multidisciplinary team, dietitians may integrate psychological-informed approaches, albeit at a lower intensity level, into existing clinical services through several steps:

a. Understand and validate food concerns

Providing a safe and empathetic environment for patients to explore their identity, values and ability to find meaning in life can aid in adapting to and accepting life with a gastrointestinal disorder. Continuing professional development to improve psychological understanding and knowledge enables dietitians to better address these complex issues. Offering some level of validation, normalisation and psychoeducation to patients on anxiety and the gut–brain axis may be beneficial. Resources like the Rome Foundation’s psychogastroenterology section provide training and support for healthcare professionals.15

b. Ask about food preferences and changes since diagnosis

Take time to explore and comprehend patients’ food relationships, including preferences, aversions and postdiagnosis alterations, in addition to attitudes and support within the home and social

network. This information helps tailor dietary recommendations aligned with individual needs and preferences. Validated screening tools designed for gastrointestinal disorders can aid in identifying any food concerns patients may harbour. However, such measures should be supplementing discussions and not replacing personalised dietetic consultation. Additionally, dietitians ought to keep in mind the overlap of gastrointestinal disorder and eating disorder symptoms. If uncertain, seek support from the multidisciplinary team.

c. Seek specialist support when needed

While dietitians play a crucial role in addressing dietary concerns in gastrointestinal disorders, some patients may require additional, focused support from a specialised psychologist, especially if food concerns are significantly impacting their wellbeing and quality of life. Developing a business case for including a psychologist in the multidisciplinary team may be necessary, drawing on growing evidence for psychological support in gastrointestinal settings. Don’t hesitate to request consultation or supervision or refer patients to appropriate specialists for further evaluation and treatment when necessary.


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