Eating Disorders and Pelvic Health Rehabilitation

Eating disorders affect 2–5% of individuals worldwide, with a higher prevalence among females (Attia & Walsh, 2025). These disorders carry significant medical and psychiatric complications, high outpatient care costs, impaired daily functioning, and reduced quality of life (Attia & Walsh, 2025; Almeida et al., 2024).

Types of Eating Disorders
Anorexia Nervosa (AN):
A persistent restriction of food intake leading to low body weight, intense fear of weight gain, and distorted body image. AN has two subtypes:

• Restrictive (AN-R) – primarily limited intake.
• Binge-Eating/Purging (AN-BP) – restriction combined with purging behaviors.

AN can result in severe medical complications and even be life-threatening (Moore & Bokor, 2023; Uniake et al., 2020).

Binge Eating Disorder (BED):
Recurrent episodes of consuming unusually large amounts of food (within 2 hours or less) with a sense of loss of control. Unlike bulimia, BED does not involve compensatory behaviors such as purging. Episodes often lead to shame, guilt, and distress (Berkman et al., 2015).

Bulimia Nervosa (BN):
Characterized by recurrent binge eating followed by compensatory behaviors like vomiting, laxative use, diuretics, fasting, or excessive exercise. These behaviors aim to prevent weight gain and carry serious health risks (Jain & Yilanli, 2023).

Other Specified Feeding and Eating Disorders (OSFED):
A category for individuals who don’t fully meet criteria for AN, BN, or BED but still experience significant symptoms. Examples include atypical anorexia, purging disorder, sub-threshold bulimia, sub-threshold BED, and night eating syndrome. OSFED, however, can cause symptoms that result in the same severity, health risks, and distress (Attia and Guarda 2024)

Avoidant/Restrictive Food Intake Disorder (ARFID):
Marked by apparent lack of interest in eating or food low appetite, extreme avoidance based on the sensory characteristics of food (such as texture, appearance, color, or smell), or fear of negative consequences of eating (fear of choking, nausea, vomiting, constipation, allergic reactions). ARFID can lead to nutritional deficiencies, weight loss, impairments of psychosocial functioning, impaired growth in children, and the need for supplements or tube feeding. It often begins in childhood but can present at any age (Ramirez & Gunturu, 2025).

Gastrointestinal Symptoms and Eating Disorders;
Gastrointestinal symptoms are common in those with eating disorders, often caused by malnutrition, anxiety, somatization, or pre-existing GI conditions. Common complaints include:

• Nausea
• Abdominal bloating and pain
• Early satiety and prolonged fullness
• Constipation and straining
• Pelvic organ prolapse symptoms
• Fecal incontinence (Gibson et al., 2021; Almeida et al., 2024)

A systematic review by Gibson et al. (2021) found that GI symptoms not only result from eating disorders but can also perpetuate disordered eating behaviors.

Multiple factors may contribute to the onset or perpetuation of the continuation of eating disorders or eating disorder behaviors. Medical conditions with GI predominant conditions also may contribute to eating disorders or disordered eating patterns (Gibson et al, 2021). These conditions can include:

• Celiac
• Irritable bowel disease
• Disorders of Gut-Brain Interaction (DGBI) - also called functional gastrointestinal disorders (FGID) in past literature (Almeida, 2024).
• Pelvic dysfunction
• Ehlers-Danlos Syndrome also may contribute to eating disorders or disordered eating patterns (Gibson et al, 2021).

DGBI / FGIDs include disturbances of the microbiome, hypersensitivity of gut viscera, altered processing of the brain and the enteric nervous system, and/or altered immune and mucosal function (Gibson et al. 2021). In addition, GI-related symptoms may also be a result of the physiological and medical complications to malnutrition (Gibson, 2021). The process of nutritional rehabilitation can cause severe GI distress as food is introduced in larger or more frequent amounts to an impaired GI system.

Interestingly, in the conclusions of Gibson et al’s systematic review, the authors recommended that additional research is necessary to “investigate those therapeutic modalities” to treat the FGID components, such as pharmacologic agents to treat GI pathophysiologic changes. Rehabilitation-based strategies should be considered a first-line approach with these individuals.

Building on this, Almeida et al. conducted a retrospective cohort study (2010–2020) of 344 individuals with eating disorders who sought gastrointestinal care. More than 75% had an eating disorder diagnosis prior to their GI consultation, with functional and motility disorders being the most common findings. The study suggested that eating disorders may contribute to gastrointestinal symptoms through their effects on the enteric, central, and autonomic nervous systems.

Additionally, weight loss and malnutrition can create pathological changes in gastrointestinal function, further worsening symptoms (Almeida et al., 2024). In this cohort, more than half of the participants were diagnosed with IBS, functional dyspepsia/gastroparesis, or constipation. While the pathophysiology of Disorders of Gut-Brain Interaction (DGBIs) is still being clarified, current evidence suggests that dietary restriction and compensatory behaviors such as purging are likely contributing factors (Almeida et al., 2024).

Why Pelvic Rehabilitation Matters
Pelvic rehabilitation professionals bring a unique skillset to this population:

• Enhancing quality of life by addressing pelvic floor and GI dysfunction.
• Recognizing warning signs of eating disorders in patients referred for GI or pelvic symptoms.
• Facilitating referrals to appropriate medical and mental health professionals.

While we do not diagnose eating disorders, pelvic health clinicians can play a pivotal role within a multidisciplinary treatment team by supporting patients physically, identifying red/yellow flags, and advocating for integrated care.

Learn More
Join me on October 4–5, 2025 for Eating Disorders and Pelvic Health Rehabilitation, a comprehensive course on eating disorders and pelvic health. Together, we’ll explore:

• Signs, symptoms, and medical complications of eating disorders.
• Multidisciplinary treatment strategies.
• Pelvic rehabilitation techniques to support individuals living with eating disorders.

Register today for Eating Disorders and Pelvic Health Rehabilitation to expand your skills and make a difference in this complex, underserved population

References

1. Almeida, M. N., Atkins, M., Garcia-Fischer, I., Weeks, I. E., Silvernale, C. J., Samad, A., Rao, F., Burton-Murray, H., & Staller, K. (2024). Gastrointestinal diagnoses in patients with eating disorders: A retrospective cohort study 2010-2020. Neurogastroenterology and motility, 36(6), e14782. https://doi.org/10.1111/nmo.14782
2. Attia, E., & Guarda, A. S. (2024). OSFED Subtypes: The Need for Better Definitions. The International journal of eating disorders, 57(10), 2053–2055. https://doi.org/10.1002/eat.24275
3. Attia, E., & Walsh, B. T. (2025). Eating Disorders: A Review. JAMA, 333(14), 1242–1252. https://doi.org/10.1001/jama.2025.0132
4. Berkman ND, Brownley KA, Peat CM, et al. Management and Outcomes of Binge-Eating Disorder [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 Dec. (Comparative Effectiveness Reviews, No. 160.) Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK338301/
5. Jain A, Yilanli M. Bulimia Nervosa. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562178/
6. Gibson, D., Watters, A., & Mehler, P. S. (2021). The intersect of gastrointestinal symptoms and malnutrition associated with anorexia nervosa and avoidant/restrictive food intake disorder: Functional or pathophysiologic?-A systematic review. The International journal of eating disorders, 54(6), 1019–1054. https://doi.org/10.1002/eat.23553
7. Guarda A. (2023, February). What are eating disorders?org. https://www.psychiatry.org/patients-families/eating-disorders/what-are-eating-disorders
8. Moore CA, Bokor BR. Anorexia Nervosa. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from https://www.ncbi.nlm.nih.gov/books/NBK459148/
9. Ramirez Z, Gunturu S. Avoidant Restrictive Food Intake Disorder. [Updated 2024 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK603710/
10. Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 3.33, DSM-IV to DSM-5 Avoidant/Restrictive Food Intake Disorder Comparison. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t33/
11. Uniacke, B., Slattery, R., Walsh, B. T., Shohamy, D., Foerde, K., & Steinglass, J. (2020). A comparison of food-based decision-making between restricting and binge-eating/purging subtypes of anorexia nervosa.The International journal of eating disorders, 53(10), 1751–1756. https://doi.org/10.1002/eat.23359

AUTHOR BIO
Carole High Gross PT, DPT, PRPC

Carole High Gross, PT, MS, DPT, PRPC earned her Doctorate of Physical Therapy from Arcadia University in 2015, and her Master of Science in Physical Therapy in 1992 from Thomas Jefferson University. Carole earned her Pelvic Rehabilitation Practitioner Certification and enjoys working as a Pelvic Clinical Rehabilitation Specialist for Lehigh Valley Health Network.

Carole serves as a Lead Teaching Assistant for the Herman & Wallace Pelvic Rehabilitation Institute for pelvic floor education courses. She is also an instructor with the Herman and Wallace Institute for Eating Disorders and Pelvic Health Rehabilitation: The Role of a Rehab Professional. Carole serves on the Pelvic Workgroup of the Ehlers-Danlos International Consortium. Carole has a special interest in working with individuals living with eating disorders and hypermobility throughout the pregnancy and postpartum journey. In addition, Carole enjoys working with all genders with pelvic, bowel, bladder, and abdominal issues. Carole is passionate about lifelong learning. She resides in Bucks County, Pennsylvania, and enjoys spending time with her family and pups.