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Eating disorders and celiac disease: A case report

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Basak Yucel at İstanbul University- İstanbul Faculty of Medicine
Basak Yucel
  • İstanbul University- İstanbul Faculty of Medicine
Nese Ozbey
Nese Ozbey
Nese Ozbey
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Kadir Demir at Istanbul University
Kadir Demir
Aslihan Polat at Kocaeli University Medical School
Aslihan Polat
  • Kocaeli University Medical School
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Abstract

Although chronic physical illness may be associated coincidentally with an eating disorder, some clinicians may overlook the possibility that another medical illness may coexist and contribute concurrently to symptoms such as peculiar eating behaviors, restrictive eating, and/or vomiting accompanied by body dissatisfaction. We present a 31-year-old single woman initially diagnosed with an atypical eating disorder. After a gastroenterology consultation prompted by the atypical characteristics of her eating disturbance, the diagnosis of celiac disease was established. Cause-and-effect relationships between anorexia nervosa and celiac disease are unclear, and celiac disease may lead to confusion in the differential diagnosis of anorexia nervosa. Particularly in atypical cases, and in cases where nausea and bloating are prominent complaints, workup for celiac sprue may reveal the presence of this condition. In such instances, patients may achieve additional relief through the implementation of gluten-free diets.
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Eating Disorders and Celiac Disease: A Case Report
Basak Yucel, MD
1
*
Nese Ozbey, MD
2
Kadir Demir, MD
3
Aslihan Polat, MD, MSc
4
Joel Yager, MD
5
ABSTRACT
Objective:
Although chronic physical ill-
ness may be associated coincidentally with
an eating disorder, some clinicians may
overlook the possibility that another medi-
cal illness may coexist and contribute con-
currently to symptoms such as peculiar
eating behaviors, restrictive eating, and/or
vomiting accompanied by body dissatisfac-
tion. We present a 31-year-old single
womaninitiallydiagnosedwithanatypical
eating disorder.
Method:
After a gastroenterology con-
sultation prompted by the atypical charac-
teristics of her eating disturbance, the
diagnosis of celiac disease was established.
Results:
Cause-and-effect relationships
between anorexia nervosa and celiac dis-
ease are unclear, and celiac disease may
lead to confusion in the differential diag-
nosis of anorexia nervosa.
Conclusion:
Particularly in atypical
cases, and in cases where nausea and
bloating are prominent complaints,
workup for celiac sprue may reveal the
presence of this condition. In such
instances, patients may achieve addi-
tional relief through the implementation
of gluten-free diets.
V
V
C
2006 by Wiley
Periodicals, Inc.
Keywords:
anorexia nervosa; atypical
eating disorder; celiac disease; gluten
enteropathy
(Int J Eat Disord 2006; 39:530–532)
Introduction
Chronic physical illness may be associated coinci-
dentally with an eating disorder. Eating disorders
may mimic virtually many types of other medical
diseases, and patients with eating disorders may
present to physicians with abnormalities in almost
any organ system.
1
Alternatively, some clinicians
may overlook the possibility that another medical
illness may coexist and contribute concurrently to
symptoms such as peculiar eating behaviors,
restrictive eating, and/or vomiting accompanied by
body dissatisfaction. For clinicians who are not
attuned to its psychological features, anorexia nerv-
osa may masquerade as a number of other medical
illnesses, with clinical and laboratory findings simi-
lar to those observed in disease states associated
with malabsorption and/or hypogonadotropic
hypogonadism.
Along these lines, celiac disease (gluten sensitive
enteropathy) has protean manifestations; patients
may present with classical findings of malabsorp-
tion; isolated micronutrient deficiencies in the
absence of any gastrointestinal symptom; atypical
gastrointestinal findings, such as abdominal bloat-
ing and discomfort; and/or growth alteration and
delayed puberty in children.
2
Associations between
anorexia nervosa and celiac disease have been
reported previously.
3,4
We present a new case ini-
tially diagnosed with an atypical eating disorder in
whom the diagnosis of celiac disease was subse-
quently established.
Case Report
A 31-year-old single woman was referred to the
Psychiatry Department of Istanbul Medical Faculty.
She was underweight and complained of restrictive
eating, nausea, and occasional vomiting after
meals. She had seen several physicians with similar
complaints for the prior 2 years. At 167 cm tall and
weighing 42 kg (body mass index [BMI]¼15.7 kg/
m
2
), she had not been amenorrheic, and denied
fear of gaining weight, self-induced vomiting, and
misuse of laxatives or diuretics. Because of these
features, negative laboratory test results and a nor-
mal gastroscopic examination, most of the examin-
1
Department of Psychiatry, Istanbul Medical Faculty, Istanbul
University, Istanbul, Turkey
2
Department of Endocrinology, Istanbul Medical Faculty,
Istanbul University, Istanbul, Turkey
3
Department of Gastroenterology, Istanbul Medical Faculty,
Istanbul University, Istanbul, Turkey
4
Department of Psychiatry, Kocaeli University Faculty of
Medicine, Kocaeli, Turkey
5
Department of Psychiatry, School of Medicine, The University
of New Mexico, Albuquerque, New Mexico
Accepted 18 January 2006
*Correspondence to: Basak Yucel, MD, Istanbul Universitesi,
Istanbul Tip Fakultesi, Psikiyatri AD, Capa Istanbul, Turkey 34390.
E-mail: byucel@superonline.com
Published online 19 May 2006 in Wiley InterScience
(www.interscience.wiley.com). DOI: 10.1002/eat.20294
V
V
C
2006 Wiley Periodicals, Inc.
530
International Journal of Eating Disorders 39:6 530–532 2006—DOI 10.1002/eat
CASE REPORT
ing physicians had diagnosed her as having an Eat-
ing Disorder Not Otherwise Specified and sug-
gested psychological treatment.
During the initial psychiatric interview in our
department, the patient reported that she was eat-
ing her meals in small pieces and very slowly,
thinking about food very much, feeling anxious
and tense before eating and bloated after meals,
and weighing herself several times a day. She
described having unpleasant feelings about her
body. She was uncomfortable with her physical
appearance, did not feel herself to be an attractive
woman, and further described difficulties in her
relationships with boyfriends.
Results of projective psychological testing by
means of the Rorschach and Draw-a-Person tests
were interpreted as showing ambivalence about
and feelings of being defective with respect to her
feminity, possible problems in her relationship with
her mother early in life along with current ongoing
conflicts in this relationship, needs for love and
approval, and an hysterical personality structure
accompanied by depressive characteristics.
Despite her low BMI and pecularities in eating
behaviors, she did not describe experiencing a real
body image distortion, fear of gaining weight, or
amenorrhea during the previous several years.
Her past medical history included a thyroidec-
tomy due to a thyroid nodule 10 years previously,
for which she was taking L-thyroxine replacement
therapy (100 mg/day), and breast augmentation sur-
gery performed 8 years previously. Her menstrual
periods were regular.
The physical examination revealed a 2 2-cm
nodule in the left thyroid lobe area and was other-
wise unremarkable. Her secondary sexual charac-
teristics were normal. The laboratory test results
were within normal limits except for a high total
iron binding capacity (TIBC): 429 mg/dL (normal
range, 250–410) and a low ferritin level: 10.28 ng/dL
(normal range 13–50 for woman). Her serum thy-
roid-stimulating hormone (TSH) concentration
was within normal range (1.38 mU/mL; normal
range, 0.4–4.0). A fine-needle aspiration biopsy of
the thyroid nodule revealed benign findings.
On the basis of this initial psychiatric evaluation,
we confirmed her psychiatric diagnosis as Eating
Disorder NOS According to the DSM-IV. Because of
the atypical characteristics of her eating disturb-
ance, vomiting attacks, and an increase in the fre-
quency of her complaints of abdominal bloating in
the previous 3 months, despite a normal gastros-
copy examination 1 year earlier, we arranged for
another gastroenterology consultation at our hos-
pital. Upper gastrointestinal endoscopic evaluation
revealed gastric mucosal hyperemia and edema, as
well as duodenal mucosal edema. Tissue biopsy
from the distal part of the duodenum revealed find-
ings compatible with celiac disease. Histopatholog-
ical examination of the biopsy specimen showed
an increased number of intraepithelial lympho-
cytes (IEL; 50 lymphocytes per 100 epithelial cells)
with crypt hyperplasia and partial villous atrophy.
Antiendomysium IgA antibodies were positive. The
diagnosis of celiac disease was made on the basis
of increased IEL with crypt hyperplasia and villous
atrophy (diagnosed according to the Marsh spec-
trum, Marsh IIIa).
3
Endoscopy with biopsy of the distal duodenum
repeated 5 months after the initiation of a gluten-
free diet revealed a decreased number of intraepi-
thelial lymphocytes (15 lymphocytes per 100 epi-
thelial cells) with improvement in villous atrophy
and crypt hyperplasia. After starting a gluten-free
diet, the patient gained 3 kg. Although she contin-
ued to weigh herself every day, she felt calmer and
more comfortable both before and after meals, and
she no longer complained of nausea or vomiting.
She continued in insight-oriented therapy for her
ongoing psychological concerns.
Conclusion
In this patient, the diagnosis of celiac disease was
established after an initial diagnosis of atypical
eating disorder. Cause-and-effect relationships,
if they exist at all, between anorexia nervosa
and celiac disease remain unclear. In previously
described cases in which both diagnoses were
made,
3,6
the diagnosis of celiac disease was
established either before or after the diagnosis of
anorexia nervosa. The restriction of food choice
in celiac disease is thought potentially to add to
factors that might promote psychological fea-
tures of eating disorders.
In our patient, the problem was rather compli-
cated. Given that she was considered to have an
atypical eating disorder, searching for alternative
medical conditions that might be contributing to
weight loss or inability to gain weight becomes
more imperative. The presence of iron deficiency
anemia with an otherwise normal biochemical pro-
file was important in our case. Bottaro et al.
7
indi-
cated that in 1,026 consecutive patients with sub-
clinical/silent celiac disease, iron deficiency ane-
mia was the most prevalent extraintestinal finding,
followed by short stature in children and dermatitis
herpetiformis lesions in adults.
EATING DISORDERS AND CELIAC DISEASE
International Journal of Eating Disorders 39:6 530–532 2006—DOI 10.1002/eat
531
In the classical form of the disease many adults
demonstrate the clinical picture of episodic/noc-
turnal diarrhea, flatulence, and weight loss.
8,9
How-
ever, celiac disease may have subclinical presenta-
tion, delaying the diagnosis. The prevalence of cel-
iac disease in the United States and Europe has
been reported as approaching 1%.
10
Furthermore,
the diagnosis of subclinical forms of celiac disease
is reported to be on the increase.
11
Subclinical
forms may present with abdominal discomfort,
bloating, malaise, anxiety and depression, recur-
rent apthous stomatitis, and/or evidence of deple-
tion of a single nutrient. In addition, associated
psychiatric syndromes and neurological abnormal-
ities are sometimes observed
8
. A previous study
indicated schizophrenic symptoms and Single
Photon Emision Computed Tomography (SPECT)
abnormalities in a celiac patient that reversed after
a gluten-free diet.
12
First-degree relatives of celiac
patients; patients with short stature; anemia; ame-
norrhea without any explanation; or patients with
immunological abnormalities with no obvious
cause are all candidates for investigation of poten-
tial celiac disease.
11
The spectrum may also com-
prise patients with atypical eating disorders.
To conclude, celiac disease may cause confusion
in the differential diagnosis of anorexia nervosa
and/or atypical eating disorders because these dis-
orders may have overlapping symptoms and clini-
cal findings. Especially in atypical cases, and in
cases where nausea and bloating are prominent
complaints, workup for celiac sprue may reveal the
presence of this condition or a subclinical variant,
and in such instances patients may achieve addi-
tional relief through the implementation of gluten-
free diets.
References
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YUCEL ET AL.
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International Journal of Eating Disorders 39:6 530–532 2006—DOI 10.1002/eat
... There are sparse data on the associations of CD with EDs and even less on that the between CD and DEBs. Studies examining the connection between CD with EDs consisted mainly of case reports [10][11][12][13][14] and two population-based works: one that comprised of only hospitalized CD patients [15], and a second nationwide study that described the link between CD and anorexia nervosa [16]. Reports that specifically explored the possible association of CD with DEBs consisted of structural psychological assessments [17] and/ or questionnaires [18,19]. ...
... To our knowledge, this is the first study to examine the occurrence of DEBs in adolescents with CD not performed in a hospital setting. Our results strengthen the supposition of an increased prevalence of DEBs in CD, a subject for which available information is scarce [10][11][12][13][14][15][16]19]. ...
... Second, "strict adherence" to a GFD may reduce anxiety levels and increase general psychosocial functioning. This was suggested by other studies that presented comparable findings [14,18]. Third, our study group comprised a relatively small number of "non-adherers" (12.4%). ...
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Purpose Celiac disease (CD) is a chronic immune-mediated systemic disease characterized by inflammation and villous atrophy of the small intestine. A strict, lifelong gluten-free diet (GFD) is the only treatment for CD. Disordered eating behaviors (DEBs) prevail in adolescence and young adulthood, and confer a risk of developing into full-blown eating disorders. The aims of the current study were to assess the incidence and risk factors for DEBs among individuals with CD, and to examine an association between adherence to GFD and DEBs. Methods A cohort of 136 individuals with CD responded to a web-mediated survey that assessed DEBs and adherence to a GFD. The survey included demographic data (gender, age, weight, disease duration) and two self-rating questionnaires: the Eating Attitudes Test-26 and the gluten-free diet questionnaire. Results DEBs were found in 19% of female and 7% of male responders. These individuals were characterized by being overweight (p = 0.02), of an older age (p = 0.04) and female sex (p = 0.06). Strict adherence to a GFD was reported by 32% of the responders and was not correlated with age, disease duration, age at diagnosis of CD and with being overweight. Conclusions Caregivers should be aware of the increased occurrence of DEBs in adolescents with CD, especially those who are overweight, older and of a female gender. Level of evidence Level V, cross-sectional descriptive study.
View
... Numerous studies have found that individuals with GI disease, most notably celiac disease, are at an increased risk of developing psychiatric disorders in general (9)(10)(11)(12)(13)(14)(15). However, this literature is mostly composed of case series, small studies, or self-reported population surveys (12,(16)(17)(18). European population-based studies by Zerwas et al and Raevuori et al have shown increased eating disorder development in autoinflammatory conditions, which included diseases with GI involvement (6,19). ...
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Background Previous national registry studies have reported an increased risk of eating disorders in immune-mediated conditions (inflammatory bowel disease [IBD] and celiac disease). Our objective was to examine the association between immune-mediated GI diseases and incident eating disorders in Ontario. Methods This was a retrospective matched cohort study of individuals <50 years of age with a diagnosis of an immune-mediated GI disease between 2002 and 2020 (“cases”). Those with a pre-existing eating disorder were excluded. Cases (n=83,920) were matched with controls (n=167,776) based on birth year, sex, and region of residence. Incidence rate ratio and hazard ratio were estimated using Poisson regression model and adjusted Cox proportional models, respectively. Results Over the follow-up period (up to January 31, 2022), 161 cases and 160 controls were identified with eating disorders. The overall incidence rate ratio (95% CI, p-value) of eating disorders in immune-mediated GI disease was 1.99 (1.6–2.5, p<0.001). The adjusted hazard ratios for eating disorder in cases with immune-mediated GI diseases was 1.98 (1.6–2.5, p<0.001). In the pediatric group of incident cases (≤18 years of age), overall adjusted hazard ratio was 2.62 (1.9–3.7, p<0.001)) compared to 1.56 (1.02–2.4, p=0.041) for adults (>18 years of age). The largest hazard ratio of 4.11 (1.6–10.3, p=0.003) was observed for pediatric incident cases of ulcerative colitis. Conclusion IBD and celiac disease are associated with the development of eating disorders. The magnitude of the association was stronger in the pediatric age group, underscoring the need for early screening and detection.
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... Recent studies have investigated the association between CeD and ED. Several cases of EDs have been reported in patients with CeD, signifying that ED may be a comorbidity related to CeD [14,15], and a few studies have investigated the association between the two disorders [4,14,16]. However, the presence of DE attitudes and behaviors was not investigated; neither was the association with the rigid nature of the GFD, the burden of dietary adherence and the constant vigilance needed to avoid chance gluten exposure [4,12]. ...
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Background The only treatment for celiac disease (CeD) is strict lifelong adherence to a gluten-free diet (GFD). In some individuals the demands of a GFD may contribute to maladaptive eating attitudes and behaviors that impair quality of life (QOL). The Celiac Disease Food Attitudes and Behaviors (CD-FAB) is an easily administered and scored 11-item tool querying potentially maladaptive food attitudes and behaviors resulting from beliefs around gluten exposures and food safety. Objectives To assess the usefulness of the CD-FAB in establishing the presence of maladaptive food attitudes and behaviors among adults with CeD and to explore the relationship between these attitudes and behaviors and other factors including QOL, anxiety, depression, CeD symptoms and personality traits. Methods The study is a cross-sectional pilot of 50 adults (mean age 29.6 years) with biopsy-proven CeD who followed a GFD for at least one year and had no self-reported eating disorder diagnosis. High scores on the CD-FAB tool suggest higher disordered eating attitudes and beliefs. Results Compared to lower scores (mean 20.2), higher (worse) CD-FAB scores (mean 54.5) were positively associated with recency of diagnosis, number of CeD-related gastrointestinal symptoms, and the personality trait of neuroticism. Higher CD-FAB scores were statistically and clinically significantly associated with diminished QOL (p < 0.001). The relationship with anxiety and depression was less clear but trended in the expected direction. Conclusion The CD-FAB may be a useful tool for dietitians who wish to monitor maladaptive food attitudes and behaviors among their CeD patients, especially in the first-year post-diagnosis.
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... 17 CD has also been linked to DEBs. However, until recently, the relevant studies were mainly case reports [18][19][20][21][22][23] and one population-based study 24 that included only hospital admitted CD patients, which might have amplified the reported risk. A recent nationwide study conducted in Sweden showed a positive bidirectional association between CD and anorexia nervosa. ...
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This article examines associations between gluten, polymorphisms of the major histocompatibility complex, and mucosal pathology representative of the spectrum of gluten sensitivity. Sequences of wheat, rye, and barley prolamins contain recurring tetrapeptide motifs that are predicted to have beta-reverse-turn secondary structure and that, with in vitro assays, appear active. Structural polymorphisms of major histocompatibility complex subloci identify codon switches within the second exon that control the third hypervariable region in the outer domain of the beta chain. Observations of the intestinal response to gluten reveal five interrelated lesions (preinfiltrative, infiltrative, hyperplastic, destructive, and hypoplastic) that are interpretable as cell-mediated immunologic responses. These responses originate in the lamina propria, where a series of antigen-specific inflammatory processes has now been identified. There is no evidence that celiac sprue is a disease of jejunal enterocytes. Furthermore, the role of intraepithelial space lymphocytes in pathogenesis, if relevant, needs further experimental dissection. Also awaiting further definition are polymorphisms of the celiac lymphocyte antigen receptor and their relationship to gliadin oligopeptide(s) and predisposing genes. The nature and basis of nonresponsive celiac sprue require more thoughtful initiatives to elucidate the immunologic mechanism(s) of unresponsiveness and evaluate possible means of reversal. Finally, a more sensible definition of gluten sensitivity (unhampered by qualitative morphological imagery) is ultimately called for in order to accommodate the biomolecular advances addressed in this review.
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Anorexia nervosa and celiac disease: Two case reports
Article
  • Feb 2000
  • INT J EAT DISORDER
Objective Anorexia nervosa (AN) has been reported to be associated with several chronic medical illnesses. In this study, we report two cases of women suffering from AN and celiac disease. The former received the diagnosis of celiac disease before the onset of the eating disorder. For the latter, the diagnosis of celiac disease followed that of AN. Authors discuss the complex relationships between celiac disease and AN. They suggest that in the first case the dietary restriction could act as a trigger for the eating disorder, whereas in the second case, the onset of celiac disease could have exacerbated the clinical symptoms of AN. © 2000 by John Wiley & Sons, Inc. Int J Eat Disord 27: 119–122, 2000.
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Organic Diseases Mimicking Atypical Eating Disorders
Article
  • Jul 1990
The authors present three case studies of patients referred to Children's Hospital and Medical Center, Seattle, Washington, for evaluation of possible eating disorders. The atypical manifestations of the cases warranted further investigation, which revealed an organic basis for their weight loss. The authors summarize the typical findings of bulimia and anorexia nervosa and discuss the clues from the case studies that mandated further evaluation.
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Subclinical Celiac Sprue
Article
  • Feb 1993
We have reviewed the clinical records of 226 consecutive adult patients with celiac sprue diagnosed in our department from 1972 to 1989. The study period has been divided into three subperiods of 6 years each (1972-1977, 1978-1983, 1984-1989). From the first to the third subperiod a significant increase in the number of new diagnoses and of the proportion of patients recognized by minor symptoms has been observed. These patients represent 50% of our series in the last 3 years of the study and 70% in 1989. Diagnosing subclinical forms of celiac sprue has significantly lowered the mean age at diagnosis and the female/male ratio. First-degree relatives of celiac patients; subjects who had a gluten-free diet for a period during childhood; patients with short stature, anemia, or amenorrhea of no obvious cause; or patients with unexplained immunological abnormalities are the groups in which most patients with subclinical celiac sprue have been found and in which potential patients should be sought. Helpful diagnostic tools include antigliadin antibody testing and the observation of absent or reduced Kerckring folds in the descending duodenum in the course of upper gastrointestinal endoscopy.
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Schizophrenic symptoms and SPECT abnormalities in a coeliac patient: Regression after a gluten-free diet
Article
  • Dec 1997
De Santis A, Addolorato G, Romito A, Caputo S, Giordano A, Gambassi G, Taranto C, Manna R, Gasbarrini G (Catholic University, Rome, Italy). Schizophrenic symptoms and SPECT abnormalities in a coeliac patient: regression after a gluten-free diet (Case Report). J Intern Med 1997; 242: 421–23. A 33-year-old patient, with pre-existing diagnosis of ‘schizophrenic’ disorder, came to our observation for severe diarrhoea and weight loss. Use of single photon emission computed tomography, (99mTc)HMPAO SPECT, demonstrated hypoperfusion of the left frontal brain area, without evidence of structural cerebral abnormalities. Jejunal biopsy showed villous atrophy. Antiendomysial antibodies were present. A gluten-free diet was started, resulting in a disappearence of psychiatric symptoms, and normalization of histological duodenal findings and of (99mTc)HMPAO SPECT pattern. This is the first case in which, in an undiagnosed and untreated coeliac patient with psychiatric manifestations, the (99mTc)HMPAO SPECT demonstrated a dysfunction of frontal cortex disappearing after a gluten-free diet.
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The clinical pattern of subclinical silent celiac disease: An analysis on 1026 consecutive cases
Article
  • Mar 1999
The demographic, clinical, and epidemiological features of subclinical/silent celiac disease in Italy were analyzed in a multicenter study carried out with the participation of 42 centers, in the years between 1990 and 1994. One thousand twenty-six subclinical/silent patients (644 children and 382 adults, 702 women and 324 men) were considered eligible for the study. The prevalence of the subclinical/silent form increased significantly during the study both in adults (p < 0.001) and in children (p < 0.005), but its prevalence was always lower (p < 0.001) in children than in adults. This increase appears more likely due to a greater diagnostic awareness and to a better use of screening than to a higher number of subclinical/silent cases. Whereas in 1990 a significantly higher proportion (p < 0.001) of subclinical/silent celiac patients was diagnosed in Northern Italy rather than in Southern-Insular Italy, both in adults (46.7% vs 17.2%) and in children (22.0% vs 9.0%), in 1994 such a difference was no longer conspicuous. Both in children and in adults, iron-deficiency anemia appeared to be the most frequent extraintestinal symptom, followed by short stature in children and cutaneous lesions of dermatitis herpetiformis in adults. In 25.9% of the cases another disease was present, with a significantly higher frequency (p < 0.05) in adults (30.1%) than in children (20.7%). Diabetes and atopy appeared to be the most frequently associated conditions both in children and in adults. This study has provided an analysis of the largest series of subclinical/silent celiac disease reported to date. In Italy, this form is most frequently recognized in adults, and prospective studies will clarify whether the lower frequency observed in children is a real or apparent phenomenon.
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