Celiac Disease Study Reveals Link Between Over-Restriction and Depression

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Avoiding additional foods beyond gluten in adults with celiac disease is linked to lower quality of life (QoL) and higher rates of depression, highlighting the psychological toll of overly restrictive diets.

Previous research has shown a possible link between following a gluten-free diet and reduced QoL as well as harmful eating habits.

“The potential for eating disorder development is present in celiac disease, as well as other gastrointestinal disorders, due to subtle but pervasive maladaptive eating behaviors associated with restrictive diet therapies,” wrote a team of investigators led by Anne R. Lee, RDN, LD, an instructor in nutrition medicine associated with the Celiac Disease Center at Columbia University. “These behaviors include fasting, excessive physical activity, hypervigilance, and preoccupation with meals and food preparation. These, in turn, may disrupt daily life, manifesting as avoidance of social events, dining out, and travel, and may even promote social isolation.”

This cross-sectional study highlighted the impact of food avoidance behaviors in adults with celiac disease who follow a gluten-free diet by analyzing 50 patients with biopsy-confirmed disease who completed surveys that assessed demographics — such as age, gender, ethnicity, race, education, marital status, income, weight, height and years since diagnosis — QoL, food avoidance and eating pathology. Disease-related symptoms and adherence to a gluten-free diet were measured using the Celiac Disease Symptom Diary (CDSD) and Celiac Dietary Adherence Test (CDAT). Depression was assessed using the Center for Epidemiologic Studies Depressive Scale (CESD), and anxiety was measured using the State-Trait Anxiety Inventory (STAI).

Investigators assessed food avoidance (beyond the gluten-free diet) by asking participants if they avoided certain foods, who advised them to avoid the food and whether they had a formal allergy diagnosis regarding that food.

Among the cohort, overall celiac disease QoL scores were considered good, with a mean score of 62.7 out of 100 (higher scores are associated with better QoL). The mean CDAT adherence score was 11.9, with greater than 13 indicating inadequate adherence to a gluten-free diet. The mean state anxiety score was 37.4 (within normal range), and the mean trait anxiety score was 39.8, just past the cutoff point for clinical anxiety. One out of 4 respondents was considered to be in an anxious state and/or have anxious traits.

Over half (58%) of the participants avoided additional foods, which was linked to lower QoL scores (57.4 versus 70.2, respectively) and higher rates of depression (16.0 versus 13.6, respectively) compared with those who only avoided gluten. Only 36.6% of the foods were avoided due to dietitian or clinician suggestion, and approximately half (49.3%) were avoided by self-evaluation or information found online. Only 21.1% of people who reported avoiding additional foods had a formal diagnosis or allergy. The most commonly avoided foods were oats (22%), dairy/casein/milk protein (22%), lactose (20%), sugar (16%) and soy (12%).

Clinical depression was observed in 77% of those avoiding more than gluten, as indicated by scoring above the CESD cutoff point of 15.

Patients who only avoided gluten had better QoL and lower depression scores, suggesting that self-imposed dietary restrictions beyond gluten may exacerbate psychological and emotional challenges for individuals with celiac disease.

“Adherence to a gluten-free diet for an individual with celiac disease is imperative but must be encouraged with mindfulness of the individual’s emotional state,” investigators concluded. “Concern over comorbidities and healing, as well as continued symptoms, may increase anxiety around dining out, chance gluten exposure, or checking ingredients. Fixation on these concerns can lead to hypervigilance, which has been associated with more restrictive behavior, potentially leading to further restriction of intake and food.”