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Anorexia diagnosis associated with celiac disease
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Researchers found a positive association between anorexia nervosa and celiac disease, both before and after celiac diagnosis, in a Swedish nationwide study.
“Clinical similarities between the two illnesses ... may lead to misclassification, delay in diagnosis, and improper treatment,” Karl Mårild, MD, PhD, of the Norwegian Institute of Public Health in Norway, and the Barbara Davis Center at the University of Colorado, and colleagues wrote. “This bidirectional association warrants attention in the initial medical assessment and follow-up of these conditions.”
Karl Mårild
Mårild and colleagues used national databases to identify 17,959 women with celiac disease (median age at diagnosis, 28 years) and compared their odds of being diagnosed with anorexia nervosa with 89,379 age- and sex-matched controls from the general population in Sweden. Follow-up spanned 1987 through 2009.
The investigators found that 54 of the patients with celiac disease were diagnosed with anorexia nervosa, corresponding to an incidence rate of 27 per 100,00 person-years of follow-up. In comparison, 180 controls were diagnosed with anorexia nervosa for a rate of 18 per 100,000 person-years.
Patients with celiac disease showed an increased risk for a subsequent anorexia nervosa diagnosis (HR = 1.46; 95% CI, 1.08-1.98), including beyond a year after celiac diagnosis (HR = 1.31; 95% CI, 0.95-1.81). Additionally, patients diagnosed with anorexia nervosa showed an increased risk for a subsequent diagnosis of celiac disease (OR = 2.18; 95% CI, 1.45-3.29). The investigators found similar results after adjusting for socioeconomic factors and type 1 diabetes.
A secondary analysis showed celiac patients with small-intestinal inflammation without villous atrophy, and those with normal small-intestinal mucosa but with positive celiac serology, both showed increased risk for anorexia nervosa. Further, a post hoc analysis showed no association between anorexia nervosa and celiac disease among men, but this analysis had low statistical power, the researchers noted.
Initial misdiagnosis, surveillance bias, or shared genetic risk factors may contribute to this association, they concluded.
While the “coexistence of eating disorders with autoimmune diseases, including [celiac disease], has been well documented, [this study] adds directionality by showing that in adults previously diagnosed with [celiac disease], the risk for developing [anorexia nervosa] increases twofold,” Neville H. Golden, MD, and K.T. Park, MD, MS, of Stanford University, wrote in a related editorial. “The present study suggests that excessive focus on diet in patients with [celiac disease] may lead to development of [anorexia nervosa] in susceptible individuals.”
Golden and Park also noted that research on associations between gluten-free diets and eating disorders is warranted, especially as more people without celiac disease are choosing to go on gluten-free diets.
“This important study only addresses the tip of the iceberg,” they concluded. – by Adam Leitenberger
Disclosures: One of the researchers reports he has received grants from and consulted for Shire. Golden and Park report no relevant financial disclosures.
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