Crohn's disease and disordered eating: What to know

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Disordered eating is a spectrum that includes behaviors such as:

• restricting foods to an extreme degree, though simply restricting one’s diet to avoid gluten or dairy, for example, is not disordered eating on its own
• purging, either by self-inducing vomiting or by misusing laxatives, enemas, or diuretics
• binge eating, which refers to eating unusually large amounts of food within short periods

Some people with disordered eating meet the criteria for specific eating disorders, such as:

• anorexia nervosa
• bulimia nervosa
• avoidant restrictive food intake disorder (ARFID)
• binge eating disorder

However, it is possible to display disordered eating behaviors without having an eating disorder.

Current research on eating disorders often relies on standardized questionnaires. These questionnaires can lack nuance surrounding the eating behaviors of people with IBD, such as restricting foods, which might inadvertently inflate eating disorder rates among this community. Some medical professionals question whether labeling IBD patients with eating disorders medicalizes an understandable response to chronic illness.

Disordered eating can lead to malnutrition, psychological distress, and other complications.

Some research suggests that Crohn’s disease may actually increase the risk of certain eating disorders. For example, a 2018 study links Crohn’s disease to an increased incidence of disordered eating behavioral traits.

The authors of a case report also warn that doctors might mistake the symptoms of Crohn’s disease for an eating disorder.

A key takeaway from research on disordered eating in people living with Crohn’s disease is that it’s complicated and what may look disordered to a physician may seem perfectly reasonable to a patient, even if the eating has become disordered.

There are many reasons people with Crohn’s disease may change their eating habits.

Typically when a person experiences digestive upset, they first thing they do is either skip meals or eat “safe” foods. This is acceptable in the short term, but in a chronic situation like Crohn’s disease, making severe diet adjustments can lead to unintended problems.

Also, people looking to manage the symptoms of Crohn’s disease may sometimes become hypervigilant about what they eat and how it affects their body. They may restrict foods so much that it starts to impact other areas of their life, including their mood, ability to socialize, or even their nutrition. Without proper dietary guidance, some people develop disordered eating.

“Some research shows that individuals with Crohn’s disease have higher anxiety and depression, greater emotional eating, greater binge eating, and more cravings for highly palatable food,” Shaun Riebl, Ph.D., told Medical News Today. Riebl is the director of nutrition for Within Health, a virtual eating disorder treatment program.

“These symptoms make sense if an individual is restricting foods and trying to eat ‘perfectly,’ based on rhetoric about ‘clean eating’ and ‘anti-inflammatory’ foods. Unfortunately, these food beliefs and behaviors can put you at risk for disordered eating or an eating disorder,” he said.

When Crohn’s disease is active, the symptoms may reduce a person’s appetite and cause unintentional weight loss. Anecdotal evidence has linked some treatments for Crohn’s disease to weight gain, although it is unclear whether this is because of the medications themselves or a person’s improved ability to eat with treatment.

Weight changes may negatively affect a person’s perception of their body weight or their satisfaction with their body image. This may also contribute to disordered eating.

Anorexia nervosa

People with anorexia nervosa, known as anorexia, restrict the amount of food they eat, often to the point that it causes low body weight. They fear weight gain, even though they are underweight.

Some people have atypical anorexia, which means that they are not underweight but otherwise meet the criteria for the eating disorder.

According to one small study of 95 people with IBD, 24.3 % of these met the criteria for an eating disorder (encompassing anorexia nervosa, bulimia nervosa, or binge eating disorder) based on the questionnaire Eating Disorders Diagnostic Scale. This rate was higher when compared to prevalence in the general population (2.7%).

Conversely, a 2021 study in Denmark found that people who had a past diagnosis of anorexia were more likely than average to develop Crohn’s disease later on. However, the study did not find that Crohn’s disease raised the risk of anorexia.

The study authors note that research suggests that anorexia might raise the risk of Crohn’s disease by increasing inflammation and disrupting the balance of bacteria and other microbes in the digestive system.

All in all, more research is necessary to study the link between anorexia and Crohn’s disease.

ARFID

ARFID is a relatively new diagnosis. People with this condition restrict the amount or type of food they eat to the point that it causes significant weight loss, malnutrition, or psychological and social challenges. Unlike with anorexia, research has not linked this condition to distress relating to body shape or size.

In a 2021 study involving 161 adults with IBD, 17% scored positive for ARFID on a screening test. Participants who scored positive for ARFID had an increased risk of malnutrition. Many participants in the study reported avoiding certain foods or entire food groups, even when their IBD was in remission.

Another pilot study of 100 adults with IBD found that 10.2% of participants met the clinical cutoff for ARFID. Further to this, patients with more severe Crohn’s symptoms were more likely to have ARFID.

However, some researchers argue that the screening test often used to measure ARFID, known as the Nine Item Avoidant/Restrictive Food Intake disorder screen (NIAS), may overestimate its prevalence in people with gastrointestinal conditions, such as IBD. This is due to overlapping symptoms between gastrointestinal conditions and ARFID.

Newer questionnaires, such as the Fear of Food Questionnaire, may be better suited to evaluating the complex relationship between Crohn’s disease and disordered eating.

Ultimately, more research is necessary to study the link between ARFID and Crohn’s disease.

Binge eating

When a person binge eats, they eat an unusually large amount of food in a relatively short time window. They feel a lack of control over what or how much they eat.

A 2018 study found that moderate-severity binge eating affected 29% of people with Crohn’s disease, compared with 3% of people without Crohn’s disease.

People with Crohn’s disease reported greater cravings for both sweet and savory foods, as well as lower levels of control over these cravings.

These individuals also had lower mood scores. Psychological distress may help account for higher rates of binge eating in people with this condition.

It can sometimes be difficult to distinguish between the signs and symptoms of an eating disorder and those of Crohn’s disease. Eating disorders and Crohn’s disease can both affect someone’s eating and bowel habits. Both can cause gastrointestinal symptoms, weight loss, and malnutrition.

MNTconnected with Jennifer Diggs to learn how to recognize a potential eating disorder in people with Crohn’s disease. She is a registered dietitian at Mymee, an organization that provides specialized care for people with autoimmune diseases.

Diggs shared the following warning signs of an eating disorder:

• poor eating during meals
• excessive restriction of food, beyond what is beneficial for managing Crohn’s disease
• fixation on a certain food or food group, to the neglect of others
• excessive trips to the bathroom following meals
• avoidance of social or celebratory meals with family or friends
• hiding or lying about eating habits
• taking medication or smoking to suppress the appetite

Although some fluctuations in body weight often occur during flare-ups or remissions of Crohn’s disease, continued weight loss or gain is another potential sign of an eating disorder.

Excessive concern about body shape, weight, or both is also common in people with eating disorders. However, a person with ARFID or binge eating disorder might not have this symptom.

A person should speak with a gastroenterologist and registered dietitian before restricting their diet to manage Crohn’s disease. These specialists can help them learn how to adjust their diet safely to meet their nutritional needs. They can also monitor the person for signs of disordered eating.

“Working with qualified medical professionals and a registered dietitian with experience in treating Crohn’s disease will help you to discern what works for you and your body,” Riebl told MNT.

“There is no evidence that food can cause or cure Crohn’s disease or even cause flare-ups. However, food might affect symptoms,” he said. “Modifications for Crohn’s disease are individualized, tailored to each patient’s needs.”

Anyone who thinks that they may have developed an eating disorder should talk with a doctor as soon possible. The doctor will refer them to an eating disorder specialist for treatment. In severe cases, a person may require inpatient treatment in a hospital or residential treatment program.

“It is important to get specialized help with an eating disorder treatment team,” Angela Fish told MNT. She is the clinical nutrition manager at UC San Diego Health Eating Disorders Center for Treatment and Research in California.

“Eating disorder treatment is offered at many levels of care, including outpatient, partial hospitalization, and residential,” she added.

Below are some commonly asked questions about Crohn’s disease and eating disorders.

Can Crohn’s disease cause eating disorders?

Some research suggests Crohn’s disease may lead to an increased risk of specific eating disorders. Indeed, one 2018 study supports this by linking Crohn’s disease to an increased incidence of disordered eating behavioral traits.

However, these studies may lack nuance surrounding the eating behaviors of people with Crohn’s disease.

Ultimately, what may appear disordered to a physician, such as restricting food intake, may seem perfectly reasonable to a person with Crohn’s disease.

How does Crohn’s disease influence an affected person’s food intake?

Crohn’s disease may influence a person’s food intake. They may restrict certain foods, eat smaller amounts, or skip meals entirely as a means to alleviate their symptoms. A survey of people with active IBD symptoms showed that 92% avoided one or more foods.

Making dietary adjustments may help people with Crohn’s disease manage symptoms of the condition. However, some people with Crohn’s disease restrict their diet more than necessary to manage the symptoms. Some people binge eat or engage in other forms of disordered eating.

Those who wish to learn how to manage Crohn’s disease safely and effectively should speak with a gastroenterologist. They may also find it helpful to connect with a registered dietitian. These specialists can help them learn which dietary modifications may work well for them.

If a person suspects that they might have an eating disorder, they should speak with a doctor as soon as possible. The doctor can refer them to an eating disorder specialist for treatment.