Eating Disorder or Celiac Disease?

...Or Both?

What if a high-achieving young woman you care about, maybe a high school or college student, claims to have no appetite? She’s way too thin, but she says she’s not hungry, and you know she's vomiting after meals. In fact, she is showing some of the typical signs of an eating disorder such as anorexia nervosa or bulimia. Would you think that maybe she has an eating disorder, or celiac disease... or both?

At a college in Florida, the coaches were faced with just this problem. During a preseason conditioning program, one of their elite athletes, a National Collegiate Athletics Association Division I female volleyball player, began to lose a lot weight. She lost her appetite and was having diarrhea and vomiting. She became very tired. She fell asleep at meals, in the team van or bus, and before and during practices in which she was not participating. Her athletic performance suffered. She also struggled with fatigue during her classes and began to beg off from social engagements.

Because this athlete was under a lot of pressure from her coach, her teammates, and herself to improve her skills, the training staff believed that she might be trying to increase her fitness and performance beyond normal expectations, and that she had developed an eating disorder as an escape from the pressure and an attempt to meet these expectations. In fact, athletes have a higher rate of eating disorders than the general public.

But guess what? She didn’t have anorexia nervosa or bulimia – she had celiac disease. Luckily for her, the coaches sent her to a gastroenterologist, who quickly recognized her celiac disease. After she began following a gluten-free diet, her appetite improved, she gained weight, and she rejoined the volleyball team. According to her coaches and teammates, her athletic performance improved and even exceeded that of her pre-illness status.

As it turned out, this girl did not have an eating disorder -- but celiac disease and eating disorders can co-exist in the same individual more often than people realize. Dr. Daniel Leffler and colleagues from The Celiac Center at Beth Israel-Deaconess Medical Center in Boston published a report on this topic. Over a 5-year period, 2.3% of the female patients they treated either had celiac disease and an eating disorder, or they had celiac disease that was masquerading as an eating disorder.

The Boston doctors described 10 such patients in detail. In only one patient did recognizing and treating the celiac disease lead to outright improvement in the eating disorder. In others, the restrictions of the gluten-free diet made it difficult (but not impossible) for doctors to treat the eating disorder. For some patients, finding out that they had celiac disease and gaining weight on the gluten-free diet caused their eating disorder to worsen. And finally, it turned out that one patient didn’t have any eating disorder at all – her weight loss and poor appetite were due only to celiac disease.

Thus, in most of the patients, there were important interactions between their celiac disease and their eating disorder. In the small group of patients that Dr. Leffler and his colleagues reported on, 80% were able to achieve or maintain remission from their celiac disease and their eating disorder.

The bottom line? Celiac disease and eating disorders can sometimes be difficult to distinguish. Patients with either or both conditions need to be evaluated from a variety of perspectives: primary care, gastroenterology, nutrition, and psychiatry/psychology. That’s the only way to make sure the individual is not suffering from complicated interactions between physical and mental health problems.

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Article Sources

  • Leffler DA et al. The interaction between eating disorders and celiac disease: an exploration of 10 cases. European Journal of Gastroenterology & Hepatology 2007;19:251-255.
  • Lindsey E Eberman and Michelle A Cleary. Celiac Disease in an Elite Female Collegiate Volleyball Athlete: A Case Report. Journal of Athletic Training 2005 Oct–Dec; 40(4): 360–364.