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Disordered Eating Attitudes and Behaviors in Individuals with Celiac Disease and The

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Disordered Eating Attitudes and Behaviors in Individuals with Celiac Disease and The Disordered Eating Attitudes and Behaviors in Individuals with Celiac Disease and the association with Quality of Life Yara Gholmie Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy under the Executive Committee of the Graduate School of Arts and Sciences COLUMBIA UNIVERSITY 2021 © 2021 Yara Gholmie All Rights Reserved Abstract Disordered Eating Attitudes and Behaviors in Individuals with Celiac Disease and the association with Quality of Life Yara Gholmie The only treatment for celiac disease (CeD), an autoimmune disorder triggered by the ingestion of gluten, is lifelong adherence to a gluten-free diet (GFD). CeD and the GFD have been shown to be associated with low quality of life (QoL). In some individuals, such a strict diet can lead to disordered eating attitudes and behaviors. The purpose of this study was to better understand the extent to which disordered eating attitudes and behaviors may be common in a sample of adults diagnosed with CeD, as well as the relationship with various factors and QoL measures, including anxiety and depression. The study is a cross sectional pilot study of 50 individuals with CeD. Patients between the ages of 18 to 45 years old (mean=29.56, SD=7.40) with a biopsy-proven CeD diagnosis, following a GFD for at least a year (mean=7.20, SD=5.31) with no previous or current eating disorder diagnosis were recruited. In this study, suggestive ED (based on EDDS) and DE (based on EPSI) were present, but low (2% suggestive diagnosis of BED, 12% suggestive diagnosis of OSFED as per DSM-V). The distribution of the self-reported food attitudes and behaviors measures (CD-FAB scores) were spread out around the mean 36.96 (15.30) with a maximum score of 66 out of a possible 77. The CD-FAB may have utility in identifying adults with CeD that may be at risk for disordered eating attitudes and behaviors, particularly those in the first few years after diagnosis. It likely has limited utility in identifying suggestive EDs (as per EDDS) and DE (as per EPSI). The main factors that were associated with higher CD-FAB scores were BMI, number of symptoms, years since diagnosis, diet adherence and personality characteristics. Seven years after diagnosis seems to be an important cut-point in how participants rated food attitudes, fear responses and adaptive responses on the CDFAB scales. Higher CD-FAB scores had a significant and meaningful association with QoL scores. Participants recruited during the COVID-19 pandemic had significantly lower CD-FAB scores and higher QoL scores compared to those recruited pre- pandemic; despite not having significant differences in any other demographic characteristics. Table of Contents List of Tables ............................................................................................................................... viii List of Figures ................................................................................................................................ xi Acknowledgements ....................................................................................................................... xii Dedication .................................................................................................................................... xiv Chapter 1 – Introduction ................................................................................................................. 1 1.1 Background & Rationale ....................................................................................................... 2 1.2 Purpose of Study ................................................................................................................... 8 1.3 Research Questions ............................................................................................................... 9 1.4 Significance and Implications ............................................................................................. 10 1.5 Scope and delimitations ...................................................................................................... 11 1.6 Definition of Terms ............................................................................................................. 11 Chapter 2 – Review of the Literature ............................................................................................ 13 2.1 Celiac Disease ..................................................................................................................... 13 2.1.1 Definition. .................................................................................................................... 13 2.1.2 Prevalence. ................................................................................................................... 13 2.1.3 Pathophysiology. .......................................................................................................... 14 2.1.4 Presentation and Risk Factors. ..................................................................................... 15 2.1.5 Guidelines for Diagnosis. ............................................................................................. 16 i 2.1.6 Diet and complications. ............................................................................................... 18 2.1.7 GFD adherence and burden. ........................................................................................ 19 2.1.8 Quality of life (QoL) in Individuals with CeD. ........................................................... 21 2.1.9 Depression and Anxiety in Individuals with CeD. ...................................................... 24 2.2 Eating Disorders and Disordered Eating Patterns in CeD .................................................. 25 2.2.1 Eating Disorders and Disordered Eating. ..................................................................... 25 2.2.2 Eating disorders. .......................................................................................................... 27 2.2.3 Psychological factors on Disordered eating attitudes and behaviors. .......................... 43 2.2.4 The link to ARFID. ...................................................................................................... 44 2.2.5 Factors associated with ED or DE in CeD. .................................................................. 46 2.2.6 Summary ...................................................................................................................... 47 Chapter 3- Methods ....................................................................................................................... 48 3.1 Overview of Study Design .................................................................................................. 48 3.2 Setting and Participants ....................................................................................................... 48 3.3 Inclusion & Exclusion Criteria ........................................................................................... 49 3.4 Enrollment & COVID-19 ................................................................................................... 50 3.5 Study Measures ................................................................................................................... 51 3.5.1 Anthropometric measures. ........................................................................................... 51 3.5.2 Demographic and Medical History variables. ............................................................. 51 3.5.3 Eating Disorder Diagnosis Tools. ................................................................................ 52 3.5.4 Disordered Eating Patterns detection tool. ................................................................... 53 ii 3.5.5 Disordered Eating Patterns Specific to CeD tool. ........................................................ 54 3.5.6 Measures related to celiac disease specific QoL. ......................................................... 57 3.5.7 Measures of anxiety and depression. ........................................................................... 58 3.5.8 CeD Symptoms. ........................................................................................................... 59 3.5.9 Diet Adherence. ........................................................................................................... 59 3.5.10 Personality traits. ........................................................................................................ 61 3.6 Other measures collected but not used in this study ........................................................... 65 3.6.1. Serology. ..................................................................................................................... 65 3.6.2 Stool samples and swabs. ............................................................................................. 65 3.6.3 24-hour dietary recalls. ................................................................................................ 65 3.6.4 Food Avoidance. .......................................................................................................... 66 3.7 Data Analysis Plan .............................................................................................................. 66 3.7.1 Statistical procedures. .................................................................................................. 66 3.7.2 Analysis of RQ1a and RQ1b .......................................................................................
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