5. Refeeding Risks: Cow’s Milk Based Supplements, Autoimmune Conditions and Hormonal Health

The journey of recovery from anorexia nervosa (AN) involves not only regaining physical health but also addressing complex disruptions in the gut-brain axis and hormonal systems. While nutritional rehabilitation is central to treatment, emerging research highlights the need for a more nuanced approach to ensure recovery is both effective and sustainable. Understanding the intricate relationship between gut health, hormonal balance, and mental well-being sheds light on potential pitfalls of conventional refeeding practices, such as the risks posed by cow’s milk-based supplements. These common strategies, while designed to promote weight restoration, may inadvertently fuel the growth of harmful bacteria, exacerbate inflammation, and hinder long-term healing.

This post explores how recovery strategies can be refined to better support the body’s needs, reduce inflammatory risks, and promote comprehensive healing. 

Adressing Pitfalls in Current Refeeding Practices for Anorexia Recovery

Elevated Autoimmune Development Risks

Research consistently indicates that individuals with anorexia nervosa (AN) face a significantly elevated risk for autoimmune diseases, including inflammatory bowel disease (IBD), autoimmune thyroid disease, and type 1 diabetes (1). The weakened immune system and altered microbiome in AN appears to predispose individulas to these conditions.

However, while nutritional rehabilitation is essential for recovery, refeeding practices must be carefully managed to avoid exacerbating autoimmune risks and triggering bacterial imbalances.

Potential Triggers in Refeeding Practices

1. Dairy and Cow's Milk-Based Supplements

Many refeeding programs rely on cow's milk-based supplements due to their high-calorie content and nutrient density. However, these products can promote harmful bacteria, such as Bilophila wadsworthia, which has been linked to inflammation and autoimmune conditions, including inflammatory bowel disease (IBD) (2).

Links to Autoimmune Conditions

• Individuals with anorexia are already at a heightened risk for autoimmune disorders due to compromised gut barriers and chronic inflammation (3). Reintroducing inflammatory foods too rapidly can exacerbate this risk.

Gastrointestinal Distress

• Lactose intolerance is common among individuals in recovery, leading to bloating, discomfort, and diarrhea, which may discourage food intake (1).

The increase in bacterial dysbiosis highlights the need for gradual dietary reintroduction and close microbial monitoring.

2. Saturated Fats in Early Refeeding

High-saturated fat foods, including dairy products and fatty meats, can fuel pro-inflammatory bacteria, like Bilophila wadsworthia, worsening gut dysbiosis and triggering inflammation (4).

Refeeding Shock

• Sudden reintroduction of saturated fats can overwhelm the compromised digestive system, leading to symptoms like nausea and cramping (1).

3. Increased Gut Permeability (''Leaky Gut'')

Malnutrition weakens the intestinal lining, allowing harmful bacteria and toxins to enter the bloodstream and exacerbate systemic inflammation (1).

Refeeding Risks

• Rapid dietary changes without sufficent adaptation of the gut can worsen permeability, triggering immune dysregulation (4).

Personalized Refeeding Plans

To reduce autoimmune risks and promote gut health during recovery:

Gradual Dietary Reintroduction

• Slowly increase caloric intake and nutrient diversity to allow gut microbiota adaptation and minimize dysbiosis risks.

Avoid High Risk Foods Early

• Limit cow's milk-based supplements and saturated fats in initial stages, prioritizing anti-inflammatory alternatives like plant-based yoghurts, fermented vegetables, and unsaturated fats from nuts, seeds and olive oil (3).

Microbial Monitoring

• Regular assessments of gut health and microbial diversity to guide dietary adjustments.

Psychological and Emotional Support

Addressing fears around food reintroduction is essential in promoting successful recovery and reducing autoimmune complications:

• Cognitive-Behavioural Therapy (CBT): Helps manage food-related anxieties and reinforces positive eating behaviours.

• Mindfulness Strategies: Support emotional regulation and gut-brain axis balance.

By acknowledging the heightened autoimmune risks and the pitfalls of traditional refeeding practices, adopting personalized and mindful recovery strategies becomes critical. Balancing gut health with psychological well-being ensures comprehensive healing and lowers the likelihood of relapse or long-term health complications.

Refeeding and Immune Dysregulation and Strategies to Mitigate Autoimmune Risk During Recovery

Activation of Pro-Inflammatory Pathways

The process of reintroducing nutrients during recovery from anorexia nervosa (AN) is crucial but presents challenges for immune system regulation. Rapid refeeding has been linked to elevated inflammatory markers, including cytokines such as tumor necrosis factor-alpha (TNF-α) and interleukins (IL-6, IL-1β), which are associated with autoimmune activation and systemic inflammation (2,1).

• Gut-Associated Lymphoid Tissue (GALT) Response: The sudden exposure to new or increased dietary components can trigger immune overreactions as the weakened intestinal lining struggles to regulate bacterial and toxin translocation into the bloodstream.

• Mircobial Shift Contributions: The rapid shift in microbiome composition during refeeding may contribute to heightened immune responses, perpetuating inflammation and autoimmunity risks (4).

• Clinical Manifestations: This inflammatory response may present as gastrointestinal distress, joint pain, or even exacerbation of existing autoimmune conditions.

Strategies to Mitigate Inflammatory Activation

• Gradual Nutritional Rehabilitation: Slow and measured increases in food intake help limit sudden pro-inflammatory surges.

• Anti-Inflammatory Dietary Components: Early-phase diets rich in omega-3 fatty acids (e.g., flaxseeds, walnuts, salmon), and green leafy vegetables can help counteract inflammation.

• Probiotic and Prebiotic Supplementation: These can aid in regulating the immune system by promoting beneficial bacterial growth and reducing dysbiosis-associated inflammation (1).

Metabolic and Endocrine Responses

Maladapted refeeding strategies may increase susceptibility to metabolic disorders such as insulin resistance, further complicating immune regulation and inflammation control (Marzola). This is attributed to:

• Altered Insulin Sensitivity: The sudden reintroduction of carbohydrates during refeeding can trigger hyperinsulinemia and rapid glucose fluctuations, straining an already compromised endocrine system.

• Cortisol Dysregulation: High cortisol levels from chronic malnutrition can persist during early recovery, impairing glucose metabolism and contributing to metabolic imbalance (5).

• Leptin and Ghrelin Imbalances: Hormonal dysregulation during recovery affects hunger and satiety signals, complicating the refeeding process and potentially increasing inflammatory responses.

Strategies for Managing Metabolic Stress

• Balanced Macronutrient Ratios: Gradual increases in carbohydrate and protein intake help maintain glycemic stability and reduce insulin resistance risks.

• Healthy Fats Focus: Prioritizing unsaturated fats (e.g., olive oil, avocados, and nuts) supports metabolic function and hormone regulation while minimizing inflammation.

• Endocrine Monitoring: Regular assessments of glucose levels, insulin sensitivity, and hormone balance can help tailor nutritional interventions to individual needs.

By carefully balancing nutritional intake and adressing inflammatory and metabolic risks during refeeding, practitioners can support comprehensive recovery while minimizing immune dysregulation and endocrine complications.

Key Concerns in Nutritional Rehabilitation

Risks of Cow's Milk-Based Supplements

Cow's milk-based nutritional supplements are a common component of refeeding strategies due to their high caloric density and ease of consumption. However, emerging research highlights potential risks associated with their use:

Promotion of Harmful Gut Bacteria

• Studies (4,1) link excessive consumption of cow's milk-based products to the proliferation of Bilophila wadsworthia, a bacterial strain associated with gut inflammation and dysbiosis.

Inflammatory Pathways

• Increased B. wadsworthia levels have been implicated in conditions such as inflammatory bowel disease (IBD) and autoimmune disorders, particularly in individuals recovering from anorexia (5).

Gut-Brain Axis Disruption

Disruptions in gut microbiota contribute to hormonal imbalances and neuroinflammation, exacerbating anxiety and cognitive challenges common in anorexia (2). Recovery strategies must prioritize microbiome restoration to mitigate these effects.

Alternative Nutritional Approaches for Rehabilitation

Recommendation

• Slowly reintroduce saturated fats through cultured food sources, such as cultured grass-fed butter and dairy alternatives, while priortizing unsaturated fats like olive oil, avocados, nuts and seeds during the initial phases of recovery (5). Gradual incorporation helps prevent feeding harmful bacteria like Bilophila wadsworthia, known to thrive on saturated fats and potentially contribute to gut inflammation and autoimmune risks (2).

Cultured Food Sources and Dairy Alternatives for Saturated Fats:

Cultured Grass-Fed Butter

• Rich in beneficial fats and probiotics when cultured, it is more digestable than regular butter for some individuals.

• Ideal for small amounts during early stages of reintroduction.

Coconut Yoghurt

• A plant-based probiotic-rich option, with naturally occuring saturated fats.

Tempeh

• Fermented soy products with high protein content and gut-friendly properties.

• Provides moderate fat content and beneficial probiotics.

Nut-Based Cheese Alternatives

• Cashew and almond- based cheeses often cultured for probiotic content.

• Free from lactose, making them gentler on digestion.

Sources of Unsaturated Fats for Initial Recovery

Olive oil

• High in monounsaturated fats and antioxidants, olive oil supports cardiovascular health and reduces inflammation.

• Best consumed raw in dressings or drizzled over cooked vegetables (4).

Avocados

• Rich in monounsaturated fats and fibre, supporting heart health and satiety.

• Easily digestible and versatile in meals or snacks.

Nuts and Seeds

• Include almonds, walnuts, flaxseeds, and chia seeds for a balance of unsaturated fats and omega-3s.

• Soaking or lightly roasting them can improve digestibility during early recovery.

Fatty fish

• Salmon, mackerel, and sardines provide omega-3 fatty acids critical for brain and inflammatory health.

• Recommended as a key protein and fat source (1).

By carefully balalncing the reintroduction of fats and emphasizing anti-inflammatory food choices, nutritional rehabilitation can better support gut healing, hormone regulation, and long-term recovery.

Anti-Inflammatory Diet Focus

Successful recovery from anorexia requires thoughtful nutritional strategies that go beyond simply increasing caloric intake. Emphasis on gut health, anti-inflammatory foods, and hormone-supportive nutrients can facilitate healing while avoiding exacerbation of autoimmune or digestive issues.

Omega-3 Sources for Anti-Inflammatory Support

Omega-3 fatty acids play a critical role in reducing inflammation and supporting brain function. These essential fats can also help stabilize mood and promote cognitive recovery (4). Key dairy-free sources include:

• Fatty fish: Salmon, mackerel, sardines, anchovies.

• Plant based sources: Chia seeds, flaxseeds, hemp seeds, walnuts.

• Algae oil: a vegan alternative rich in DHA, an omega-3 fatty acid.

Leafy Greens and Colourful Vegetables fo Nutrient Density

Vegetables rich in vitamins, minerals, and antioxidants help repair damaged tissues, support immune function, and provide essential nutrients for gut health (1).

Recommended vegetables include

• Leafy Greens: Spinach, kale, collard greens, Swiss chard.

• Colourful Vegetables: Carrots, capsicum, beets, zucchini, purple cabbage, broccoli, sweet potato.

Fermented Foods and Drinks for Gut Microbiome Support

Fermented foods provide beneficial bacteria (probiotics) that help restore gut microbial balance disrupted by prolonged malnutrition (3).

Non-dairy fremented options include

• Kimchi

• Sauerkraut

• Fermented vegetables (e.g., carrots, beets)

• Kombucha (low-sugar varieties)

• Miso and tempeh

High-Fibre Foods That Are Easy on Digestion

Dietary fibre is essential for gut health, but during early recovery, gentler forms of fibre are recommended to minimise bloating and discomfort (2).

Recommended high-fibre foods

• Cooked vegetables: Squash, carrots, green beans

• Fruits: Bananas, peeled apples, pears, blueberries

• Whole grains: Oats, quinoa and brown rice

• Seeds: Ground flaxseeds and chia seeds (soaked before consumption).

• Legumes: Lentils and chickpeas (in moderate amounts initially).

Foods Rich in L-Glutamine for Gut Barrier Repair

L-Glutamine is an amino acid that plays a key role in strengthening the gut lining and improving its function (5). Including foods high in this nutrient supports recovery from gut permeability issues (1).

Dairy-free sources include

• Bone Broth

• Spinach

• Cabbage

• Beets

• Asparagus

• Chicken, turkey, and fish

• Nuts and seeds

Maintaining a diverse diet with nutrient-dense foods aids in restoring overall health and hormonal balance. Recovery strategies should be tailored to individual tolerance levels and gradually introduce more challenging foods over time to build gut resilience and support comprehensive healing (6).

Hormonal Imbalance in Anorexia Recovery

1. Sex Hormones (Estrogen, Progesterone, and Testosterone)

Women

• Prolonged energy deficiency due to restricted caloric intake leads to a suppression of the hypothalamic- pituitary-gonadal (HPG) axis, resulting in reduced secretion of gonadotropins (luteinizing hormone and follicle-stimulating hormone) (5).

• This suppression decreases estrogen and progestorone production, leading to amenorrhea (loss of menstration) (2).

• The lack of estrogen not only affects fertility but also conrtibutes to bone density loss, increasing the risk of osteopenia and osteoporosis (4).

Men

• Energy deprivation also inhibits testosterone production in men by supressing the HPG axis.

• Symptoms include reduced libido, erectile dysfunction, decreased muscle mass, and chronic fatigue (6).

• The long term effects can mirror those seen in women, including bone density loss and reduced cardiovascular health (1).

2. Thyroid Hormones (T3 and T4)

• Malnutrition and chronic stress from AN reduce the production of active thyroid hormones (triiodothyronine (T3) and thyroxine (T4)) while increasing reverse T3, a biologically inactive form (6).

• This adaptive response, known as "euthyroid sick syndrome," is the body's attempt to conserve energy but leads to: Cold intolerance, slowed metabolism, hair thinning, dry skin, fatigue and lethargy (5).

3. Cortisol (Stress Hormone)

• Elevated cortisol levels in AN are linked to prolonged malnutrition and psychological stress (2).

• Chronic stress elevates cortisol levels, contributing to musle breakdown, anxiety, and disrupted sleep cycles (2).

• Elevated cortisol levels may also perpetuate anxiety and depression, complicating psychological recovery (1).

4. Hunger Hormones (Leptin and Ghrelin)

Leptin

• Low body fat stores result in decreased leptin levels, which signal the brain to supress reproductive functions and maintain energy conservation modes (5).

• Reduced leptin levels also disrupt appetite regulation, making it difficult to feel full during refeeding (4).

Ghrelin

• Ghrelin levels, responsible for signaling hunger, may become dysregulated, leading to unpredictable hunger cues during recovery (6).

• Over time, these imbalances can make it challenging for individuals to reconnect with natural hunger and fullness signals.

5. Insulin and Blood Sugar Regulation

• Chronic energy deprivation causes increased insulin sensitivity, which can lead to dangerously low blood sugar levels (hypoglycemia) during periods of fasting (4).

• During refeeding, sudden spikes in glucose levels can trigger insulin dysregulation, contributing to fatigue and mood instability (1).

Strategies to Address Hormonal Imbalances

1. Gradual Nutritional Rehabilitation

• A steady increase in caloric intake supports the restoration of the HPG axis and hormone production.

• Gradually introducing healthy fats is essential for synthesizing sex hormones (2).

2. Targeted Nutrient Support

Proper micronutrient intake is crucial for hormonal production and balance (6).

Vitamin D: Supports bone health and hormone regulation.

• Sources: Fortified foods, fatty fish, sunlight exposure.

Zinc: Essential for reproductive health and hormone production (4).

• Sources: Pumpkin seeds, shellfish, legumes.

B Vitamins: Key in stress management, neurotransmitter synthesis, and energy production (5).

• B1 (Thiamine): Helps the body turn food into energy (whole grains, nuts, poultry).

• B6 (Pyridoxine):Important for mood regulation (bananas, chickpeas).

• B9 (Folate): Crucial for cellular repair and hormone function (leafy greens, avocado).

• B12 (Cobalamin):For nerve and brain function as well as production of DNA and red blood cells (fortified foods, dairy and plant-based alternatives).

3. Medical Interventions

• Hormone replacement therapy (HRT) may be necessary for severe cases to restore mentrual cycles or support testosterone levels in men (5).

4. Stress Reduction Practices

High cortisol levels from stress can supress reproductive hormones (3). Managing stress and sleep is critical for restoring hormonal health during recovery (5).

• Techniques such as mindfulness, meditation, yoga and gentle activities like, walking and tai chi can help lower cortisol levels and support overall endocrine balance (6).

• Quality sleep (9-10 hours per night) aids in cortisol regulation and supports hormonal health.

The Role of Hormonal Health in Long-Term Recovery

Addressing hormonal imbalances plays a critical role in holistic recovery, offering benefits such as:

• Enhanced mood stability and reduced anxiety (6).

• Improved fertility and reproductive health outcomes (5).

• Stronger bone density and reduced fracture risk (1).

• Stabilized metabloic function for long-term well-being (2).

By refining and carefully tailoring refeeding strategies, and monitoring gut health, immune and hormonal function, recovery approaches can be optimized to minimize the risk of developing or exacerbating autoimmune conditions, fostering a smoother path to long-term recovery.

A Personal Note:

I want to remind readers that I am not a medical professional. I am someone who has experienced anorexia and is currently in recovery. This article is not intended to provide medical advice, but rather to share the insights and information I have gathered during my own journey. My hope is that by exploring the complexities of this disorder and the recovery process, I can help raise awareness and offer support to others who may be going through similar struggles. Please consult with a qualified healthcare provider for guidance and treatment if you or someone you know is struggling with anorexia.

References:

1. Zhao, W., Kodancha, P., Das, S, 2022, Gut microbiome changes in anorexia nervosa: a comprehensive review, Pathophysiology, acessed 10 January 2025, https://www.mdpi.com/1873-149X/31/1/6
2. Herpertz-Dahlmann, B., Seitz, J., Baines, J, 2017,  Food matters: how the microbiome and gut-brain interaction might impact the development and course of anorexia nervosa,  Eur Child Adolesc Psychiatry, accessed 10 January 2025, https://link.springer.com/article/10.1007/s00787-017-0945-7?fromPaywallRec=false
3. Ghenciulescu, A., Park, R. J., Burnet, P. W. J., 2021, The Gut Microbiome in Anorexia Nervosa: Friend or Foe?, Journal of Psychopharmacology, accessed 10 January 2025, https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2020.611677/full
4. Ruusunen, A., Rocks, T., Jacka, F., Loughman, A., 2019, The gut microbiome in anorexia nervosa: relevance for nutritional rehabilitation, Psychopharmacology (Berl), acessed 10 January 2025, https://pubmed.ncbi.nlm.nih.gov/30612189/
5. Haines, M. S., 2022, Endocrine Complications of Anorexia Nervosa, Journal of Eating Disorders, accessed 10 January 2025, https://link.springer.com/article/10.1186/s40337-023-00744-9
6. Marzola, E., Nasser, J. A., Hashim, S. A., Shih, P. A. B., Kaye, W. H, 2013, Nutritional rehabilitation in anorexia nervosa: review of the literature and implications for treatment, BMC Psychiatry, accessed 10 January 2025, https://link.springer.com/article/10.1186/1471-244x-13-290