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Low Cholesterol and Mental Disorders in Children and Adolescents With Celiac Disease

TO THE EDITOR: We suggest that low plasma cholesterol levels might be a plausible mechanism involved in the etiology and pathogenesis of mental and behavioral disorders related to celiac disease.

Celiac disease (CD) is an underdiagnosed autoimmune disorder that occurs in genetically-susceptible individuals after the ingestion of gluten, a protein found in wheat and some other cereals. The immunologically-based inflammation induces atrophy of the villous structure of the jejunum, leading to malabsorption of variable severity. Early detection of the disease represents a key factor in the prevention of later complications. However, it has now become evident that the clinical presentations of the disease may not only be related to the classic malabsorption syndrome, but also that subclinical and nonspecific forms have been found to be increasingly common.

Behavioral disorders such as schizophrenia, depression, and obsessional neurosis have been described in children with CD for a long time. In a large screening study of patients age 6–16 years, most of the detected CD cases showed illness of low-grade intensity that was often associated with "decreased psychophysical well-being."¹ Furthermore, a recent study found that CD was associated with increased prevalence of depressive and disruptive behavioral disorders in adolescents, particularly in the phase before diet-based treatment.² Of note, in some cases, psychiatric symptoms appeared to improve after the patients started a gluten-free diet.²

The mechanisms involved in the etiology and pathogenesis of mental and behavioral disorders related to CD remain poorly understood. We suggest that low plasma cholesterol levels might have a role in this detrimental association.

Lower cholesterol concentration is a frequent finding in children with malabsorption and steatorrhea due to CD. Moreover, low plasma cholesterol has also been found in CD without signs of overt malabsorption,³ and cholesterol levels in the normal-to-high range have been shown to have a high predictive power to exclude CD.³

On the other hand, it is well known that low cholesterol may be associated with mental disorders. In particular, a statistically significant association has been shown between low cholesterol and aggressive behaviors among non-African American children from a national sample of noninstitutionalized, school-age children.⁴ Low cholesterol has also been associated with the onset of conduct disorder during childhood among male criminals.⁵

Therefore, screening for CD should be considered in children and adolescents with mental disorders and low cholesterol.

REFERENCES

1. Catassi C, Fabiani E, Rätsch IM, et al: The coeliac iceberg in Italy: a multicentre anti-gliadin antibodies screening for coeliac disease in school-age subjects. Acta Paediatr Suppl 1996; 412:29–35[Medline]
2. Pynnönen PA, Isometsä ET, Aronen ET, et al: Mental disorders in adolescents with celiac disease. Psychosomatics 2004; 45:325–335[CrossRef][Medline]
3. Ciacci C, Cirillo M, Giorgetti G, et al: Low plasma cholesterol: a correlate of nondiagnosed celiac disease in adults with hypochromic anemia. Am J Gastroenterol 1999; 94:1888–1891[CrossRef][Medline]
4. Zhang J, Muldoon MF, McKeown RE, et al: Association of serum cholesterol and history of school suspension among school-age children and adolescents in the United States. Am J Epidemiol 2005; 161:691–699[Abstract/Free Full Text]
5. Repo-Tiihomen E, Halonen P, Tiihonen J, et al: Total serum cholesterol level, violent criminal offences, suicidal behavior, mortality, and the appearance of conduct disorder in Finnish male criminal offenders with antisocial personality disorder. Eur Arch Psychiatry Clin Neurosci 2002; 252:8–11[Medline]

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