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J Child Psychol Psychiatry. 2019 Jul;60(7):803-812. doi: 10.1111/jcpp.12958. Epub 2018 Sep 3.

Bidirectional relationship between eating disorders and autoimmune diseases.

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Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
Department of Psychology, George Mason University, Fairfax, VA, USA.
Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
Department of Computer and Information Science, Linköping University, Linköping, Sweden.
Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, & Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden.
School of Medical Sciences, Örebro University, Örebro, Sweden.
Department of Pediatrics, Örebro University Hospital, Örebro, Sweden.
Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
Pediatric Allergy and Pulmonology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.



Immune system dysfunction may be associated with eating disorders (ED) and could have implications for detection, risk assessment, and treatment of both autoimmune diseases and EDs. However, questions regarding the nature of the relationship between these two disease entities remain. We evaluated the strength of associations for the bidirectional relationships between EDs and autoimmune diseases.


In this nationwide population-based study, Swedish registers were linked to establish a cohort of more than 2.5 million individuals born in Sweden between January 1, 1979 and December 31, 2005 and followed up until December 2013. Cox proportional hazard regression models were used to investigate: (a) subsequent risk of EDs in individuals with autoimmune diseases; and (b) subsequent risk of autoimmune diseases in individuals with EDs.


We observed a strong, bidirectional relationship between the two illness classes indicating that diagnosis in one illness class increased the risk of the other. In women, the diagnoses of autoimmune disease increased subsequent hazards of anorexia nervosa (AN), bulimia nervosa (BN), and other eating disorders (OED). Similarly, AN, BN, and OED increased subsequent hazards of autoimmune diseases.Gastrointestinal-related autoimmune diseases such as, celiac disease and Crohn's disease showed a bidirectional relationship with AN and OED. Psoriasis showed a bidirectional relationship with OED. The previous occurence of type 1 diabetes increased the risk for AN, BN, and OED. In men, we did not observe a bidirectional pattern, but prior autoimmune arthritis increased the risk for OED.


The interactions between EDs and autoimmune diseases support the previously reported associations. The bidirectional risk pattern observed in women suggests either a shared mechanism or a third mediating variable contributing to the association of these illnesses.


anorexia nervosa; autoimmunity; bulimia nervosa; cox regression; hazard; immune system; risk


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