Letter: Eating Disorders in Inflammatory Bowel Disease‐Are We Asking the Right Questions?

We congratulate Goddard et al. on their comprehensive systematic review and meta-analysis examining the prevalence of eating disorders and eating disorder risk in patients with inflammatory bowel disease (IBD) [1]. This work confirms that disordered eating may be more prevalent in individuals with IBD than in the general population. Disordered eating lies at the intersection of gastroenterology, nutrition and mental health, yet access to specialist dietetic and psychological care remains variable. Integrated interdisciplinary models that include dietetic and psychological expertise improve outcomes and health-related quality of life [2, 3]. Disordered eating likely contributes to the high burden of malnutrition in IBD, which is associated with poorer disease control, reduced response to advanced therapies, increased peri-operative morbidity and higher mortality [4, 5]. Routine identification of patients at risk is therefore essential, particularly before prescribing dietary therapies such as exclusive enteral nutrition (EEN) or the Crohn's Disease Exclusion Diet (CDED). The substantial variation in prevalence reported in this review is notable, with physician-diagnosed eating disorders reported in 2.8% of patients compared with 13.6% identified through patient-completed questionnaires. These pooled figures must be interpreted cautiously given limitations in the original data, and we welcome the authors' acknowledgement of these, including lack of stratification by eating disorder subtype, uncertainty surrounding recruitment and response rates and significant heterogeneity amongst questionnaires. Whilst clinician-diagnosed eating disorders likely underestimates the true burden, questionnaire-based tools may overestimate risk in IBD populations for several reasons. As acknowledged, existing screening tools are not validated for use in IBD, and it remains difficult to determine whether disordered eating precedes, follows or parallels disease activity. Furthermore, questionnaire items may yield false-positive responses due to lifestyle changes from disease activity or prescribed dietary interventions rather than pathological eating behaviours; for example, food-related anxiety, avoidance and weight loss may be due to active disease, whilst food preoccupation or prolonged meal times may arise from adherence to prescribed diets such as a modified-fibre diet, EEN or the CDED [6]. Although disease activity was not associated with disordered eating prevalence, this analysis is limited by sparse objective biochemical, sonographic and endoscopic data. The absence of difference by gender, contrary to non-IBD populations, also contrasts with prior IBD studies, further highlighting heterogeneity and potential limitations in detecting disordered eating in IBD cohorts [7, 8]. We commend Goddard and colleagues for their comprehensive review, which suggests a considerable burden of disordered eating amongst individuals with IBD and highlights important gaps in the current evidence. In particular, the validity of non–IBD-specific eating disorder screening tools in this population remains uncertain. The discrepancy between clinician-diagnosed and questionnaire-based prevalence emphasises the need for validated IBD-specific screening tools. Until such tools are developed, screening outcomes should be interpreted cautiously and incorporated within a broader interdisciplinary assessment. Jacoba C van Wees: writing – original draft, conceptualization. Robert D Little: conceptualization, writing – review and editing. Sarah L Melton: conceptualization, writing – review and editing. The authors have nothing to report. The authors declare no conflicts of interest. This article is linked to Goddard et al. papers. To view this article, visit https://doi.org/10.1111/apt.70492. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.