Patients with inflammatory bowel diseases (IBD), namely Crohn’s disease (CD) and ulcerative colitis (UC), are at risk for behavioral health disorder such as eating disorders (ED) that include anorexia nervosa (AN), bulimia nervosa (BN) and binge eating. The prevalence and risk factors of ED among patients with IBD are poorly described in the existing literature. Early recognition and intervention may influence clinical outcomes in both physical and mental health. The primary aims of this study were to describe the prevalence and identify risk factors for ED among patients with IBD seen at a single tertiary referral center using a validated questionnaire, the Eating Attitudes Test-26 (EAT-26).
ED can reliably be diagnosed utilizing the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM V). While the list of diagnosable ED is constantly evolving, commonly recognized and distinct ED described in the DSM V include AN, BN, and avoidant/restrictive food intake disorder (ARFID) [1]. The majority of existing literature on ED comes from adolescent cohorts. In general, ED are described at a rate of 3.8% in female and 1.5% in male adolescents. These rates are even higher in adolescent populations with chronic illnesses such as type 1 diabetes mellitus, occurring in up to 37.9% in females and 15.9% in males [2]. In adults, up to 4% of women and 0.7% of men self-reported diagnosis of AN and/or BN [3].
Patients with ED have an increased risk of suicide and increased overall mortality when compared to the general population. One longitudinal study showed that even with access to treatment, the hazard ratios for all-cause mortality of AN was 6.51 (95% CI 3.46–12.26) and of BN was 2.97 (CI 1.90–4.65) [4]. While the most frequent causes of death from medical conditions in people with AN are circulatory collapse, cachexia and organ failure [5], suicide makes up a significant proportion of death in this population; as many as one in five people with AN who have died committed suicide [6]. It is crucial for medical providers to identify patients at risk for ED early and provide mental health resources and inter-professional referral in order to mitigate these risks.
ED behaviors have been studied in patients with other chronic conditions with primarily gastrointestinal symptomology, such as celiac disease or type 1 diabetes mellitus [7, 8] though literature on this topic in patients with IBD is scarce. While ED in patients with IBD has mostly been described in case reports [9], prevalence is poorly described and likely underdiagnosed. This may be, in part, due to a previously described phenomenon wherein the presenting symptoms of IBD were met with food avoidance, diet alteration and weight loss of the patient, leading to diagnostic confusion and delay of appropriate treatment [10]. A 2017 review of existing case reports found that comorbid ED and IBD are most commonly reported in young women, with CD and AN being the most commonly reported comorbid conditions [9]. Patients with IBD and ED have been reported to perpetuate weight loss by declining IBD therapies due to fear of weight gain [9]. Additionally, the weight gain from treatments like corticosteroids has been linked to the development or exacerbation of ED in patients with previously diagnosed IBD [11]. Yet another confounding factor in making the diagnosis of ED in patients with IBD is the increased cytokine release in active disease states affecting hunger and satiety signaling, leading to weight loss and anorexia outside of a diagnosable ED [12].
