Is the screening for celiac disease useful in anorexia nervosa?

Psychological, Psychiatric, and Organic Brain Manifestations of Celiac Disease

INTRODUCTION

Celiac disease is an autoimmune condition that affects approximately 1% of the population worldwide. Although its main impact often concerns the small intestine, resulting in villous atrophy and nutrient malabsorption, it can also cause systemic manifestations, particularly when undiagnosed or left untreated.

METHOD

Attention is directed to the possible psychological, psychiatric, and organic brain manifestations of celiac disease. Specific topics related to the influence and risk of such manifestations with respect to celiac disease are defined and discussed. Overall, eighteen main topics are considered, sifted from over 500 references.

RESULTS

The most often studied topics were found to be the effect on quality of life, organic brain dysfunction and ataxia, epilepsy, Down syndrome, generalized psychological disorders, eating dysfunction, depression, and schizophrenia. For most every topic, although many studies report a connection to celiac disease, there are often one or more contrary studies and opinions. A bibliographic analysis of the cited articles was also done. There has been a sharp increase in interest in this research since 1990. Recently published articles tend to receive more referencing, up to as many as 15 citations per year, suggesting an increasing impact of the topics. The number of manuscript pages per article has also tended to increase, up to as many as 12 pages. The impact factor of the publishing journal has remained level over the years.

CONCLUSION

This compendium may be useful in developing a consensus regarding psychological, psychiatric, and organic brain manifestations that can occur in celiac disease and for determining the best direction for ongoing research focus.

Five-Year Inpatient Management of Teenagers With Anorexia Nervosa: Focus on Nutritional Issues

OBJECTIVES

In patients with Anorexia Nervosa (AN) malnutrition can lead to life-long nutritional treatments. The refeeding process can combine natural feeding (NF) with specific nutritional strategies, including oral nutritional supplements (ONS) and nasogastric feeding (NGF). Aims of the present study were to assess the efficacy of hospital protocol and identify the most effective inpatient nutritional strategies for weight restoration.

METHODS

All patients hospitalized from April 2015 to April 2020 were enrolled. According to hospital protocol, NF was proposed to all patients; ONS were combined with NF if caloric intake was <70% of the requirements and NGF was added if caloric intake did not reach 30% in the first week from admission.

RESULTS

Overall, 186 patients [M = 20; median age 14 (interquartile range 1316)] were included. Nutritional issues were the main indication to admission (56.6%). A significant effect of combination treatment, with a shorter duration of hospitalization when using ONS with NGF in addition to NF was found (ß: -20.28 [95% confidence interval -34.92:-5.65], P  < 0.001). Only one patient showed a significant but limited increase of liver enzymes.

CONCLUSIONS

We provide a safe and effective standardized protocol to treat the malnutrition of teenagers with AN in an inpatient setting. Malnutrition was the most important cause of admission, and more than half of the patients admitted were severely malnourished. The combination of NF, ONS, and NGF was the most effective strategy to achieve the weight restoration; however, this result should be validated on larger series of patients treated with NGF and NF.

A systematic review and meta-analysis of the prevalence and odds of eating disorders in patients with celiac disease and vice-versa

OBJECTIVES

In the present systematic review and meta-analysis study, we aimed to review studies that assessed the prevalence and risk of eating disorders (EDs) in patients with celiac disease (CD) and vice-versa.

METHOD

We conducted a systematic search in PubMed, Embase, Scopus, and Web of Science for studies that assessed the prevalence and risk of AN in patients with CD and vice-versa. Joanna Briggs Institute tools were used for critical appraisal. The STATA software was used for the meta-analysis of the random-effect model.

RESULTS

In this study, 23 observational studies were included. The results of the meta-analysis indicated that the pooled prevalence of EDs and bulimia nervosa in patients with CD was 8.88% [95% CI: 6.4, 11.7] and 7.26% [95% CI: 0.23, 21.57], respectively. Moreover, the risk of anorexia nervosa in patients with CD was significantly higher than in the healthy population (relative risk [RR]: 1.48 [95% CI: 1.32, 1.64]). The rates of CD in patients with AN and EDs were 0.96% [95% CI: 0.15, 2.31] and 0.90% [95% CI: 0.56, 1.31], respectively. Moreover, the overall risk of CD in patients with AN was significantly higher compared with healthy adults (RR: 2.35 [95% CI: 1.27-3.44]).

DISCUSSION

The result of the present meta-analysis showed the high prevalence of EDs in patients with CD. Moreover, there was a significant bidirectional association between CD and EDs.

Epidemiology and risk of psychiatric disorders among patients with celiac disease: A population-based national study

BACKGROUND AND AIM

Celiac disease (CD) is a chronic disorder resulting from an immune reaction to gluten in genetically predisposed individuals. Although several studies have linked CD to psychiatric diseases, there are limited data on this topic. Using a large database, we sought to describe the epidemiology of several psychiatric disorders in CD.

METHODS

We queried a multicenter database (Explorys Inc), an aggregate of electronic health record data from 26 major integrated healthcare systems from 2016 to 2020 consisting of 360 hospitals in the USA. A cohort of patients with a Systematized Nomenclature Of Medicine - Clinical Terms diagnosis of CD was identified. Multivariate analysis was performed using Statistical Package for Social Sciences version 25.

RESULTS

Of the 37 465 810 patients in the database between 2016 and 2020, there were 112 340 (0.30%) individuals with CD. When compared with patients with no history of CD, patients with CD were more likely to have a history of anxiety (odds ratio [OR]: 1.385; 95% confidence interval [CI]: 1.364-1.407), depression (OR: 1.918; 95% CI: 1.888-1.947), bipolar (OR: 1.321; 95% CI: 1.289-1.354), attention-deficit hyperactivity disorder (OR: 1.753; 95% CI: 1.714-1.792), eating disorder (OR: 15.84; 95% CI: 15.533-16.154), and childhood autistic disorder (OR: 4.858; 95% CI: 3.626-6.508). Patients with CD and psychiatric conditions were more likely to be smokers, with history of alcohol and substance abuse as well as a history of personality disorder.

CONCLUSIONS

In this large database, patients with CD are at increased risk of having multiple psychiatric diseases including anxiety, depression, bipolar, attention-deficit hyperactivity disorder, eating disorder, and childhood autism. Individual care and referral to psychiatry when appropriate are warranted while taking care of this group of patients.

The intersect of gastrointestinal symptoms and malnutrition associated with anorexia nervosa and avoidant/restrictive food intake disorder: Functional or pathophysiologic?-A systematic review

OBJECTIVE

Although multiple pathophysiologic changes develop within the gastrointestinal (GI) system in the setting of malnutrition, the etiology of the reported multitude of symptoms in those with anorexia nervosa and avoidant restrictive intake disorder, as well as their contribution toward disordered eating, remain poorly understood. This systematic review seeks to better understand how these physiologic changes of malnutrition of the esophagus, stomach, intestines, and pancreas contribute toward the reported GI symptoms, as well as better understand how celiac disease, inflammatory bowel disease, pelvic floor dysfunction, and Ehlers-Danlos syndrome contribute toward disordered eating.

METHODS

Studies of any design exploring the pathogenesis of complications and treatment strategies were included. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used to structure and complete the review.

RESULTS

A total of 146 articles were used for the review. The majority of studies were observational or case reports/case series.

DISCUSSION

Pathophysiologic changes of the esophagus, stomach, and intestines develop with malnutrition, although these changes do not consistently correlate with expressed GI symptoms in patients with restrictive eating disorders. Celiac disease and inflammatory bowel disease also contribute to disordered eating through the associated somatic GI complaints, while pelvic floor dysfunction and Ehlers-Danlos syndrome contribute through both somatic symptoms and functional symptoms. Indeed, functional GI symptoms remain problematic during the course of treatment, and further research is required to better understand the extent to which these symptoms are functional in nature and remit or remain as treatment ensues.

Disordered eating behaviors in adolescents with celiac disease

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.

Psychiatric Manifestations of Coeliac Disease, a Systematic Review and Meta-Analysis

Background: Coeliac disease (CD) is increasingly prevalent and is associated with both gastrointestinal (GI) and extra-intestinal manifestations. Psychiatric disorders are amongst extra-intestinal manifestations proposed. The relationship between CD and such psychiatric disorders is not well recognised or understood. Aim: The aim of this systematic review and meta-analysis was to provide a greater understanding of the existing evidence and theories surrounding psychiatric manifestations of CD. Methodology: An online literature search using PubMed was conducted, the prevalence data for both CD and psychiatric disorders was extracted from eligible articles. Meta analyses on odds ratios were also performed. Results: A total of 37 articles were included in this review. A significant increase in risk was detected for autistic spectrum disorder (OR 1.53, 95% CI 1.24–1.88, p < 0.0001), attention deficit hyperactivity disorder (OR 1.39, 95% CI 1.18–1.63, p < 0.0001), depression (OR 2.17, 95% CI 2.17–11.15, p < 0.0001), anxiety (OR 6.03, 95% CI 2.22–16.35, p < 0.0001), and eating disorders (OR 1.62, 95% CI 1.37–1.91, p < 0.00001) amongst the CD population compared to healthy controls. No significant differences were found for bipolar disorder (OR 2.35, 95% CI 2.29–19.21, p = 0.43) or schizophrenia (OR 0.46, 95% CI 0.02–10.18, p = 0.62). Conclusion: CD is associated with an increased risk of depression, anxiety, eating disorders as well as ASD and ADHD. More research is required to investigate specific biological explanations as well as any effect of gluten free diet.

An update on gastrointestinal disturbances in eating disorders

Eating disorders, namely anorexia nervosa, bulimia nervosa and binge eating disorder are frequent diseases and often complicated by comorbidities, e.g. psychiatric or cardiovascular comorbidities. It is to note that also gastrointestinal symptoms/complications are frequently observed in patients with eating disorders. These diseases will be presented in the current review along with - where known - possible underlying mechanisms. Lastly, gaps in knowledge will be highlighted.

Psychological Comorbidities in Childhood Celiac Disease: A Systematic Review

OBJECTIVES

Mental health disorders comorbid to chronic illness are associated with higher medical care utilization and costs for adults and children. Celiac disease (CD) has a substantial perceived treatment burden and is associated with higher rates of psychopathology in adults. However, establishing the risk for psychological comorbidities in children with CD is still needed. This study aimed to review existing research on mental health concerns in pediatric CD and propose an initial psychosocial research and clinical agenda.

METHODS

Databases, including Scopus and PubMed. Additional publications were accessed and reviewed from the references provided by initially identified publications. Two investigators screened studies using predetermined criteria (peer-reviewed, published in English, electronically available, inclusive of child participants, and examining CD). One investigator initially extracted data, with subsequent review by the second investigator.

RESULTS

Twenty-six publications met criteria for the current review (16 case-control, 9 observational, and 1 clinical trial). Publications were heterogeneous in symptoms examined, methodology, and population characteristics. Several studies found elevated risk for psychological comorbidities and poorer quality of life in children with CD. However, many studies were limited by small sample sizes and inconsistent or nonvalidated approaches to measuring psychological symptoms.

CONCLUSIONS

Many existing studies have found increased prevalence of comorbid CD and psychological symptoms or diagnoses. Therefore, screening for psychological symptoms in CD and also screening for CD in psychological clinic populations is needed. We have identified the importance for further study of mechanisms and risk, and identify preliminary priorities for psychosocial research and clinical care in pediatric CD.

Differential Diagnoses of Food-Related Gastrointestinal Symptoms in Patients with Anorexia Nervosa and Bulimia Nervosa: A Review of Literature

OBJECTIVES

The present review investigates the prevalence and medical causes of food-related gastrointestinal symptoms in eating disorder (ED) patients and recommends a diagnostic algorithm based on the current literature.

METHODS

A literature search was conducted, which included publications from January 2000 until January 2017 Results: Over 90% of ED patients suffer from food-related symptoms. There is no evidence for a higher prevalence of immunological or structural gastrointestinal disorders in ED patients compared to the healthy population. Most food-related symptoms in ED patients are likely to be functional.

CONCLUSIONS

Diagnostic work-up of food-related symptoms in ED patients needs to be based on clinical history. Only if timing and quality of symptoms point towards a disorder independent from the ED is a comprehensive diagnostic work-up necessary.

Increased prevalence of disordered eating in the dual diagnosis of type 1 diabetes mellitus and celiac disease

BACKGROUND

Disordered eating behaviors (DEBs) may lead to full blown eating disorders. Both type 1 diabetes mellitus (T1DM) and celiac disease (CD) have been linked to DEBs.

OBJECTIVE

To compare the presence of DEBs between adolescents and young adults with a dual diagnosis of T1DM and CD, and individuals with only one of the diagnoses.

METHODS

Individuals with a dual diagnosis of T1DM and CD ("T1DM + CD group" n = 39), with a diagnosis of T1DM only ("T1DM group" n = 97) and with a diagnosis of CD only ("CD group" n = 267) filled the Eating Attitude Test-26 (EAT-26) questionnaire. Those with T1DM completed in addition to the Diabetes Eating Problem Survey-Revised (DEPS-R).

RESULTS

The study population comprised of 403 individuals, of whom 65% were females. There were no statistically significant differences among the groups in distribution of sex, age, hemoglobin A1c (HbA1c) levels, age of disease diagnosis and duration. The prevalence of DEBs in the T1DM + CD group was 3-fold higher (26.0%) than in the T1DM (8.2%) and CD (8.2%) groups (P = .003). This trend was observed for both females and males. Multivariate analysis demonstrated that the T1DM + CD group had an increased risk for DEBs (odds ratio, OR: 4.7, 95% confidence interval, CI: 1.9-11.2, P = .001) after adjustment for age, sex, and body mass index. Additionally, being female, older and overweight increased the risk for DEBs. HbA1c values were not associated with an increased DEBs rate.

CONCLUSIONS

Individuals with the dual diagnoses of T1DM and CD have an increased likelihood to develop DEBs compared to those with only one of these diagnoses.

Are children with chronic illnesses requiring dietary therapy at risk for disordered eating or eating disorders? A systematic review

OBJECTIVE

Pediatric chronic illnesses (CI) can affect a child's mental health. Chronic illnesses with treatment regimens that specify a therapeutic diet may place the child at increased risk for disordered eating and specific eating disorders (ED). The aim of this review is to examine the relation between diet-treated CI and disordered eating and to determine the order of onset to infer directionality. Diet-treated CI is hypothesized to precede and to be associated with disordered eating.

METHOD

A comprehensive search of empirical articles that examine the relation between diet-treated CI (diabetes, cystic fibrosis, celiac disease, gastrointestinal disorders, and inflammatory bowel diseases) and disordered eating was conducted in Medline and PsycINFO using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A table of the sample's characteristics, ED measures, major pertinent findings, and the onset of CI in relation to ED were provided.

RESULTS

Diet-treated CI was associated with disordered eating and ED. Diet-treated CI had onset prior to disordered eating in most studies, except for inflammatory bowel diseases. Disordered eating and unhealthy weight management practices put children at risk for poor medical outcomes.

DISCUSSION

Interventions for diet-treated CI require a focus on diet and weight, but may increase the risk for disordered eating. Future research is needed to elucidate the mechanisms that transform standard treatment practices into pathological eating, including characteristics and behaviors of the child, parents/care providers, family, and treatment providers.

Celiac disease and anorexia nervosa: a case report

The relationship between anorexia nervosa and celiac disease remains an area of ongoing research. Identification of celiac disease in patients with restricted nutritional intake can be challenging since abdominal complaints are a common comorbidity associated with eating disorders and since diagnosis of celiac disease requires a duodenal biopsy while on a gluten containing diet. In this report, we present a 12-year-old female who developed anorexia nervosa and was thereafter diagnosed with celiac disease. The latter diagnosis occurred after a 2-year period of persistent abdominal complaints and duodenal biopsies on three separate occasions. Our case highlights the diagnostic challenge, which may include initially missing the diagnosis, associated with celiac disease in patients who are restricting their nutritional intake, and also the importance of re-testing in patients where gastrointestinal complaints are persistent for extended time periods after refeeding.

Celiac Disease and Anorexia Nervosa: A Nationwide Study

BACKGROUND AND OBJECTIVE

Previous research suggests an association of celiac disease (CD) with anorexia nervosa (AN), but data are mostly limited to case reports. We aimed to determine whether CD is associated with the diagnosis of AN.

METHODS

Register-based cohort and case-control study including women with CD (n = 17 959) and sex- and age-matched population-based controls (n = 89 379). CD (villous atrophy) was identified through the histopathology records of Sweden's 28 pathology departments. Inpatient and hospital-based outpatient records were used to identify AN. Hazard ratios for incident AN diagnosis were estimated by using stratified Cox regression with CD diagnosis as a time-dependent exposure variable. In the secondary analyses, we used conditional logistic regression to estimate odds ratios for being diagnosed with AN before CD.

RESULTS

Median age of CD diagnosis was 28 years. During 1 174 401 person-years of follow-up, 54 patients with CD were diagnosed with AN (27/100 000 person-years) compared with 180 matched controls (18/100 000 person-years). The hazard ratio for later AN was 1.46 (95% confidence interval [CI], 1.08-1.98) and 1.31 beyond the first year after CD diagnosis (95% CI, 0.95-1.81). A previous AN diagnosis was also associated with CD (odds ratio, 2.18; 95% CI, 1.45-3.29). Estimates remained largely unchanged when adjusted for socioeconomic characteristics and type 1 diabetes.

CONCLUSIONS

The bidirectional association between AN diagnosis and CD warrants attention in the initial assessment and follow-up of these conditions because underdiagnosis and misdiagnosis of these disorders likely cause protracted and unnecessary morbidity.

Gastrointestinal comorbidities which complicate the treatment of anorexia nervosa

Patients with anorexia nervosa often voice a multitude of symptoms in regards to their gastrointestinal tract. These complaints can complicate the treatment of their eating disorder as they distract attention from the important goal of weight restoration. Moreover, the restricting of certain food groups also makes the task of weight restoration substantially more difficult, or may result in binging. Therefore a working knowledge of common gastrointestinal comorbidities, such as celiac disease, irritable bowel syndrome, inflammatory bowel disease, and gastroparesis, is useful when treating a patient who has anorexia nervosa.

Anorexia nervosa of the restrictive type and celiac disease in adolescence

BACKGROUND

Anorexia nervosa (AN) is usually present in adolescence with symptoms partially overlapping celiac disease (CD), but the relationship between these two conditions has received little attention in the literature. The aim of this work was to explore this relationship, considering if CD could be associated with specific baseline AN-related clinical features.

METHODS

In this retrospective study, 82 adolescent female out- and inpatients with AN of the restrictive type (ANr), according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria, were recruited. CD diagnosis and related serology were recorded, including tissue transglutaminase type-2 antibodies, endomysial antibodies, and antibodies against deamidated forms of gliadin peptides. Eating disorder inventory-3, Children's Depression Inventory, body mass index, age, and disease duration data recorded at the time of blood withdrawal were also obtained from each patient.

RESULTS

Five (6.1%) subjects presented a CD disorder associated with AN: none of the collected psychometric measures was significantly correlated with any CD-related parameter or characterized as a specific subgroup.

CONCLUSION

CD diagnosis or serology does not relate to ANr clinical or demographic characteristics. However, a slight increase in prevalence with respect to the general population might be hypothesized and possibly elucidated by further studies with an appropriate design.

Screening for celiac disease in patients with eating disorders

PURPOSE

Celiac disease (CD) affects approximately 1% of the population, and although it remains largely underdiagnosed, can have considerable long-term morbidity. Common presenting symptoms include gastrointestinal complaints and weight loss, which are also symptoms seen in patients with eating disorders (EDs). Because of this overlap, and the importance of early diagnosis of CD and identifying possible complicating factors in patients with EDs, screening in our program has become part of an initial assessment during the past 4 years.

METHODS

A retrospective chart review of all patients ages 7-22 years seen in our Division of Adolescent Medicine for an ED evaluation from 2011 to 2014 were reviewed. Screening for CD was done with tissue transglutaminase IgA antibody (TTgAb) and anti-endomysial IgA antibody (aEAb). Immunoglobulin A (IgA) was also measured.

RESULTS

There were 1160 patients evaluated for an ED between 2011 and 2014, and 42.6% (494) were screened for CD during this time. Of those patients screened for CD the mean age was 16.0, compared to a mean age of 15.6 for those that were not screened, and 87.7% were female, compared to 84.7% of the unscreened group. Of the 494 screened, 10 (2%) screened positive with a TTgAb IgA EIA >20. Of the 10 who screened positive via blood test, four had biopsy confirmed CD via endoscopy, for an overall 0.8% prevalence in this cohort. Of the 457 patients who were also screened for IgA deficiency (92%), 5 (1.1%) had low IgA levels.

CONCLUSION

In this cohort of patients being evaluated for an ED, 0.8% had biopsy confirmed CD. This is similar to the reported prevalence in the general population, suggesting that routine screening of patients with EDs for CD is not indicated. We still need to be vigilant, however, for subtle symptoms that may indicate underlying CD in a small percentage of patients with EDs.

Patients with eating disorders showed no signs of coeliac disease before and after nutritional intervention

AIM

This study assessed the presence of specific antibodies for coeliac disease in outpatients suffering from eating disorders before and after nutritional intervention. We also evaluated whether those patients should undergo regular screening for coeliac disease.

METHODS

The sample consisted of 154 patients with a mean age of 16.7 years - ranging from one to 19 years of age - suffering from eating disorders. Serology screening for coeliac disease and total immunoglobulin A (IgA) levels was evaluated in the 154 children before the nutritional intervention and in 104 patients after the intervention. The patients consumed an adequate amount of gluten in both phases.

RESULTS

Postintervention evaluation revealed that 92 patients (88.5%) achieved a normal body weight, while the remaining 12 (11.5%) became obese. Postprandial abdominal discomfort and pain were resolved. The serology tests were negative in all patients, before and after intervention. None displayed IgA deficiency.

CONCLUSION

To the best of our knowledge, this was the first prospective study where patients underwent a screening serology for coeliac disease before and after nutritional intervention. No indication of the coexistence of eating disorders and coeliac disease was documented, and the patients in our study were unlikely to require regular screening for coeliac disease.