We had the pleasure to have an exclusive interview with Ms. Gallagher, the co-founder and nutrition director of the BeginWithin Center for nutritional and psychological wellness. She holds a Master’s degree in Nutrition and Physical Fitness from NYU, she is a master’s level registered dietician (RD#724400), and has a Certification in Applied Positive Psychology, and is a Certified Eating Psychology Counselor. She is currently pursuing a Doctorate of Clinical Nutrition (DCN) at the School of Health Professions Rutgers University in Newark.
Prior to having her own practice, Ms. Gallagher worked at Monmouth Medical Center, Robert Wood Johnson University Hospital- Somerset, and Department of Nursing at Monmouth University in West Long Branch, New Jersey. She has several publications (listed at the end of this page) and she has also been a guest speaker at Rutgers University School of Health Professions in Newark, New Jersey.
Beyond her impressive educational and professional background, Ms. Gallagher shared with us her expertise in Nutrition and Psychological wellness from over thirty years’ experience in treating individuals with eating disorders, body image issues, and other types of nutritional concerns on individuals of all backgrounds including athletes and individuals with learning disabilities such as ADD, ADHD, and autism spectrum disorders.
We asked Ms. Gallagher some questions about anorexia nervosa to help bring awareness to this eating disorder and ways we can help provide support to someone with this disorder.
Q: Can you explain what anorexia nervosa is and how it differs from other eating disorders?
A: Anorexia nervosa is a mental illness just like other mental illnesses such as anxiety, depression, PTSD, and other eating disorders. The main differences between anorexia nervosa and other eating disorders are the medical complications that can be associated with it. Some of these can be completely reversed through weight restoration and nutrition management, but others cannot. For example, anorexia nervosa has numerous gastrointestinal comorbidities such as irritable bowel syndrome, SIBO, gastroparesis, and abdominal pain. There are also cardiovascular complications such as hypotension and bradycardia which can often be reversed. Medical complications such as osteoporosis may not be reversed over time.
Q: How does anorexia nervosa affect a person’s physical health?
A: Anorexia nervosa affects a person’s physical and psychological health and well-being. Psychologically, it can cause anxiety, depression, obsessive compulsive behaviors, and interference with the overall quality of life. Physically, it is associated with numerous medical complications as mentioned above. Anorexia nervosa can affect every organ system causing gastrointestinal, cardiac, endocrine, bone metabolism, and biochemical abnormalities.
Q: Can you describe the short-term and long-term consequences of anorexia nervosa on the body?
A: Short-term complications can include biochemical abnormalities, micronutrient and macronutrient deficiencies, gastrointestinal symptoms, anemia, hypoglycemia, electrolyte imbalances, bradycardia, hypotension, muscle, and fat loss. Long-term complications can include osteoporosis, cardiac scarring, long-standing malnutrition, and other severe cardiac complications.
Q: How does anorexia nervosa affect a person’s metabolism?
A: The metabolic changes that occur with anorexia nervosa depend on the various points or stages of the illness. During the early restrictive phases and the duration of restriction, the metabolism goes down as an attempt to conserve energy. According to our expert Donna Gallagher, she has seen using a reliable and valuable tool called indirect calorimetry that shows sometimes the metabolism can be reduced down to 65% of normal. Once somebody starts refeeding, there is a short-term when they are hypermetabolic, where the metabolism could go up to 150% or more of normal. Clients are at high risk during this time in recovery due to the person is susceptible to “refeeding syndrome” which causes electrolyte abnormalities and potential cardiac involvement.
Q: What are some common nutritional deficiencies associated with anorexia nervosa?
A: The nutritional deficiencies in anorexia nervosa come from both macronutrient deficiencies as well as micronutrient deficiencies. Macronutrient deficiencies, including protein, carbohydrates, and fat can cause weight loss and muscle and fat wasting. This is particularly dangerous because the body’s organs are made out of muscle and they become smaller and weaker. Micronutrient deficiencies, including vitamin and mineral deficiencies can be seen in multiple ways, often in abnormalities in skin, hair, nails, and the mouth. A common deficiency is iron deficiency anemia which can be seen in pale skin as well as nail deformities. B vitamin deficiencies can often be seen in the mouth, presenting with red cracked lips and tongue abnormalities.
Q: How does anorexia nervosa affect bone health, and what can be done to prevent bone loss?
A: Anorexia can cause bone loss in the form of osteopenia and osteoporosis. This is caused by a combination of low levels of estrogen as well as the lack of intake of calcium containing foods. A way to try to prevent bone loss is to supplement with an estrogen type of medication, take calcium supplements, and try to increase the amount of calcium in foods. It has been shown the most common medical co-morbidity in women with anorexia nervosa is bone loss, with over 85% of women having bone mineral density values more than one standard deviation below an age comparable mean. The low bone mass in anorexia nervosa is due to multiple hormonal adaptations to under nutrition, including hypothalamic amenorrhea and growth hormone resistance. Importantly, this low bone mass is also associated with a seven-fold increased risk of fracture. Therefore, strategies to effectively prevent bone loss and increase bone mass are critical.
Q: Can anorexia nervosa affect the menstrual cycle, and if so, what are the implications of this?
A: Anorexia nervosa reduces the amount of hormones in the body. Estrogen, progesterone, and testosterone are all reduced and due to the reduction in these hormones, the menstrual cycle is often either light or absent. The long-term implications of this can be infertility. Concerning individuals that are taking hormones as they are transitioning gender, to date there is limited information specifically addressing the interaction between hormone therapy and anorexia nervosa. Body composition, metabolism, and overall physical changes may be affected by hormone therapy, combined with preexisting body image concerns that are typical with anorexia nervosa which can lead to additional challenges and complexities for individuals who are transitioning.
Q: Does anorexia nervosa affect more women than men, does it affect men at all?
A: Although anorexia nervosa is more commonly seen in women it does affect men as well. As a result much of the focus on eating disorders has been centered on females which has led to potential misdiagnosis or underdiagnoses in males. Awareness efforts recently have been aimed to address this in an effort to try and shed more light on the experiences of males with anorexia nervosa. A study has shown that Anorexia is seen in roughly 0.35% of all women and seen in roughly 0.1% of all men (“Statistics & Research on Eating Disorders,” 2019). Roughly 1% to 2% of all females will have anorexia at least once in their lifetime, while it is around .1% to .3% in males (“Statistics & Research on Eating Disorders,” 2019). Males contribute to 25% of the anorexic population but actually have higher chances of dying to the disease due to getting treatment at later stages.
Q: Can you explain the cardiovascular risks associated with anorexia nervosa?
A: There are numerous cardiovascular risks associated with anorexia nervosa. The most common ones are slow heart rate which is known as bradycardia, and low blood pressure which is known as hypotension. Hypertension can either be orthostatic or relative hypotension. Orthostatic hypotension is when there is a reduction in blood pressure from lying down to a sitting or standing position. These are usually normalized through weight restoration and nutrition rehabilitation. There are other more complicated cardiovascular risks associated with electrolyte imbalances. Electrolyte imbalances can contribute to cardiac arrest which is one of the number one reasons why individuals die of anorexia nervosa. Anorexia nervosa can also cause structural changes in the heart chambers, and weakening and reduction in size. Another serious cardiac complication is the prolongation of the QTC interval which can also increase the risk of sudden cardiac death. Pericardial effusions, the build-up of too much fluid around the heart are also common. Lastly, malnutrition can cause scar tissue of the heart which could also increase risk for sudden cardiac death.
Q: How does anorexia nervosa affect the immune system and overall health?
A: Anorexia nervosa decreases the immune system in part due to the lack of nutrients taken in. The lack of nutrients taken in causes moderate to severe malnutrition which increases the risk for immunological problems.
Q: Can you discuss the role of nutrition therapy in treating anorexia nervosa and supporting recovery?
A: Nutrition therapy with an eating disorder specialist can help a client with anorexia nervosa challenge their fears associated with eating, can help them work on body image issues, and can help to slowly rehabilitate their nutritional health and weight. The recovery process often takes a long time, due to the eating disorder serves underlying functions and addressing the underlying psychological aspects of an eating disorder, needs to be done in tandem with nutritional guidance in order to help the person make a full recovery.
Q: How is condition started (age/early signs/social/emotional environment) and can it be prevented?
A: The origins of an eating disorder are very complicated and multifaceted. The origins can be a combination of temperament, genetics, environment, and physiological complications or malnutrition. Examples of temperament that are conducive to the development of an eating disorder are perfectionism, hypersensitivity, and emotional instability. Genetic factors that can contribute to the predisposition of an eating disorder are epigenetic nutritional and environmental factors. Environmental factors are ones that are modifiable and these are large contributors to the development of an eating disorder. These can include things such as social and cultural norms, idealizing thinness, pressure from media and social media, pressure to be thin within the family home, a toxic home environment, and dieting family members. The last category of medical or malnutrition related factors are things such as gastrointestinal illnesses that can predate an eating disorder, psychiatric instability, and malnutrition. It’s hard to prevent all of these, and not everyone who experiences these things will develop an eating disorder. Changes in environmental factors such as the influence of social media, and having a more positive and safe home environment, can be very helpful. Given that anorexia nervosa can occur at any age parental awareness is important during all stages of childhood. Noticing body image or nutritional changes that could be due to anorexia nervosa is crucial for parents not only to become aware but also vigilant about their involvement starting as soon as early adolescence which is typically around 12 to 14 years of age. It is during adolescence in particular the early to mid-teen years that is considered to be a high-risk period for the development of anorexia nervosa.
Q: How does the condition affect their professional and personal life?
A: An interesting factor associated with people with anorexia nervosa is that they are often very highly functioning. Often, it takes people by surprise that they have this illness. It ultimately will have a negative impact on their professional and personal life because it is extremely time-consuming and causes so many psychological and medical complications. In the long term, it will negatively affect the way someone can perform in their professional and personal life. In their personal life, it can cause people to become withdrawn and avoid situations that they are uncomfortable with.
Q: Are there any signs a loved one is going through this, and what is the appropriate way to support them?
A: Unfortunately, some of the early signs of anorexia nervosa are praised by others. Since weight loss in our society is revered as a positive thing, when someone initially loses weight, people often aren’t alarmed. In fact, they will often praise the person for losing weight and the person may also get numerous compliments from friends and family. Some of the signs that someone is developing or has anorexia nervosa are distinct and more rigid changes in eating behaviors. Often times, overall calorie level is reduced and certain food groups are taken out. This often starts with sweet foods, snack foods, higher fat foods, and carbohydrate containing foods. The person then becomes inflexible and will not try a lot of these “forbidden” foods that is a huge red flag. Also, someone may increase their exercise and feel as though they cannot take a day off. Another red flag would be if someone is using the bathroom immediately after meals, this could indicate that they are purging. It is very difficult to approach someone who has anorexia if they are not ready to change. Oftentimes a loved one is met with anger, defensiveness, fear and resentment. It is important to be very validating of the individual who has this illness and show them understanding, love, and kindness. Also, being controlling around food is not helpful. It may cause the person to want to control their food even stronger. Lastly, and most importantly, it would be important to get that individual into treatment for the eating disorder as soon as possible. The treatment provider should be an expert in the field of eating disorders in order to provide the best help possible.
Q: What should a loved one (family or friend) do or not do to help someone with this condition?
A: First and foremost, a loved one cannot be the treatment provider, the therapist or the dietitian. They need to just focus on being a supportive family member or friend. It’s very helpful when the loved one asks the person who has the eating disorder what they need. They may not know exactly what they need, but it is better to start there and find out what specific type of support the person wants. They may need full mealtime support, or they may just need to check in with people periodically, this is very individual. As mentioned previously, what a loved one or friend should not do is try to control the person’s food or exercise patterns by being the “food or exercise police”. It’s also important not to express any type of judgment of the person. It’s essential to remember that an eating disorder is an illness, not a choice. The person is in emotional and perhaps physical pain, and needs emotional support.
Q: Are there any other topics/signs/symptoms etc. that you feel are important for someone to know about anorexia nervosa, that you would like people to be aware of?
A: Standout topics/signs/symptoms to be on high alert for include severe weight loss, restrictive eating patterns, excessive exercise, distorted perception of body shape and size, social withdrawal and isolation, physical complications, both emotional and psychological factors, obsessive thoughts about food, meal planning, and strict rituals, and lastly the importance of early detection and intervention.
We thank Ms. Gallagher for sharing her expertise in expertise in anorexia nervosa and eating disorders. During our time together Donna and I really dove deep into discussion about anorexia nervosa which studies have shown has the highest mortality rate of all psychiatric illnesses. For many years Ms. Gallagher has been treating and helping clients who struggle with this disorder so it was a true privilege to gain such informed and valuable answers from an expert in the field.
To learn more about Ms. Gallagher or the BeginWithin Center where Ms. Gallagher performs initial nutrition assessments and nutrition counseling for individuals with eating disorders, performs family counseling to educate patients’ loved ones on how to support the individual with the eating disorder, co-facilitates support groups for individuals with eating disorders and adult women with binge eating/emotional eating issues as well as various other responsibilities, please visit:
Ms. Gallagher’s publications include:
Gallagher D, Parker A, Samavat H, Zelig R. Prophylactic supplementation of phosphate, magnesium, and potassium for the prevention of refeeding syndrome in hospitalized individuals with anorexia nervosa. Nutrition in Clinical Practice. 2022;37(2):328-343.
Gallagher D. Behind the Mask: Our Secret Battle. North Charleston, NC: CreateSpace; 2012.
Gallagher DR, Geliebter A, Melton PM, McCray R S, Gage D, Hashim S A. Gastric capacity, gastric emptying, and test-meal intake in normal and bulimic women. The American Journal of Clinical Nutrition. 1992; 56(4):656–661.
