Eating Disorders & Celiac Disease

NothingToEat Do adults with untreated celiac disease have more than just gastrointestinal symptoms like pain, bloating and diarrhea affecting how they eat? This may seem in some ways like a question that may not need an answer. People with gastrointestinal symptoms would be expected to alter their eating habits. It would also not be surprising if people who had been diagnosed but not yet treated might have feelings of anxiety or depression before they got used to the treatment and its benefits.

Yet there have been small studies suggesting the possibility of a link between eating disorders and untreated celiac disease, so a group of Italian researchers designed a larger study to try and answer the question, “Does something about celiac disease lead to any psychological conditions that could be considered eating disorders?”

To do this, they compared 100 people with diagnosed but untreated celiac disease with 100 normal subjects without CD who were similar in age and other specifics. They were careful to exclude people with known psychiatric issues, pregnancy, use of many prescribed or recreational drugs, other intestinal illnesses or anything else that might be associated with abnormal eating behavior. Patients with CD had to be conclusively diagnosed, meaning positive antibody tests and intestinal biopsies. They had to be experiencing gastrointestinal symptoms and still be eating gluten.

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The investigators used a number of questionnaires, either self administered or given by a researcher, to look for evidence of abnormal eating behavior and/or psychological stress. They also looked to see if findings of abnormal eating were related to the experiencing of intestinal symptoms.

Psychologists evaluated study participants. In addition, researchers used the following questionnaires, some administered by an investigator and the others done by the participants themselves and turned in:

  • EPIC Food Frequency Questionnaire – this uses pictures of food for participants to use to try and reproduce the foods they are eating and portion sizes.
  • Binge Eating Staircases – these measures both the behaviors related to binge eating as well thoughts and feelings common to people who binge eat.
  • Eating Attitudes Test (EAT 26) – this looks at thoughts that indicate an individual might have distorted perception of their appearance, and also asks questions about anxiety and bulimia.
  • Eating Disorder Inventory (EDI-2) – this questionnaire is filled out by each person, not given by a psychologist. It asks about symptoms that are known to be present in people with anorexia nervosa or bulimia.
  • Zung Self-Rating Depression Scale (M-SDS) – this is an Italian version of a scale looking for symptoms of depression.
  • State Trait Anxiety Inventory Forma Y (STAI-Y1 and STAI-Y2) – these look primarily for symptoms of anxiety.
  • Symptom Check List (SCL-90) – this is also done by the participants themselves, and includes 90 questions designed to find evidence of a variety of psychological or psychiatric problems, from depression and anxiety to phobias and sleep disturbances.
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The results of all of these questionnaires were totaled and analyzed. Data was examined to look for differences between the people with CD and the people without it. The EAT-26 scores showed significantly higher scores in people with CD compared to healthy individuals in the study. The EDI-2 scores were also higher in CD patients than healthy controls. The M-SDS, STAY-1 and STAY-2, and SLC-90 also all showed higher scores in a variety of areas among the people with untreated CD as opposed to healthy participants.

Combining and analyzing the data led the authors to conclude that there was a statistically significant difference in the amount of altered eating behavior in both men and women with untreated celiac disease, as well as more bulimic behavior, but only in the men with CD compared to the healthy men. The altered eating behaviors did not correlate with symptoms, according to the tests.

An interesting discovery unrelated to the reasons for the study was that people with celiac disease ate 30% more pasta and bread than those without CD. The authors of the study speculated that this adds weight to the theory that increased gluten intake is the cause for the increase in celiac disease. It could be argued, however, that people who like gluten-containing foods but have the genetic tendency to develop CD might have more symptoms and get diagnosed more frequently than people who don’t eat a lot of gluten.

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The study did not evaluate whether or not these behaviors and feelings changed on a gluten-free diet. The researchers noted that what they learned means more study is necessary. It is always important to identify people with eating disorders, and if they are more common in some people with untreated CD, this may complicate treatment.

If you have celiac disease and any suspicions that your eating behavior is not normal either before or after starting a gluten-free diet, discuss it with your doctor.


V. Passananti, M. Siniscalchi, F. Zingone, C. Bucci, R. Tortora, P. Iovino, C. Ciacci. Prevalence of Eating Disorders in Adults with Celiac Disease. Gastroenterology Research and Practice. Volume 2013, Article ID 491657, 7 pages.

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