Development and Validation of the Coeliac Disease Food Attitudes and Behaviours Scale

Abstract

Objectives
Previous studies on coeliac disease suggest that attitudes towards the gluten-free diet may contribute to the development of disordered eating. This study describes the development and validation of the Coeliac Disease Food Attitudes and Behaviours scale (CD-FAB) to measure these behaviours in coeliac disease.

Research Methods and Procedures
Focus groups were used to develop 33 potential questionnaire items. These items were reviewed by service users and then distributed online to 157 adults with coeliac disease. Items were removed based on ceiling/floor effects, high interitem correlations (>0.7) and factor analysis. 11 items were retained. Exploratory factor analysis was then conducted. The psychometric properties of the final version of the CD-FAB were assessed via using an online platform.

Results
The CD-FAB had 11 items distributed across one factor assessing attitudes and behaviours towards food. These factors explained 44.1% of the variance in responding. The CD-FAB and its subscales had high internal consistency (Cronbach's alpha > 0.7) and psychometric validation indicated good convergent and discriminant validity. High scores on the CD-FAB are associated with psychological distress and an impaired quality of life.

Conclusions
The CD-FAB is a reliable and valid measure of food attitudes and behaviours in coeliac disease. As a new disease-specific instrument, it may be a useful tool for evaluating food concerns in individuals with coeliac disease in a clinical setting and for further exploring the development of disordered eating patterns in coeliac disease. Further research is required to assess the full potential of the CD-FAB.

Full text

Research Article
Development and Validation of the Coeliac Disease Food Attitudes
and Behaviours Scale
Rose-Marie Satherley ,
1
Ruth Howard,
2
and Suzanne Higgs
2
1
School of Populations Sciences and Health Services Research, Guy’s Campus, King’s College London, 5th Floor Addison House,
London SE1 1UL, UK
2
School of Psychology, University of Birmingham, 52 Pritchatts Road, Edgbaston, Birmingham B15 2SB, UK
Correspondence should be addressed to Rose-Marie Satherley; rose-marie.satherley@kcl.ac.uk
Received 20 April 2018; Accepted 1 August 2018; Published 19 August 2018
Academic Editor: Luca Elli
Copyright © 2018 Rose-Marie Satherley et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.
Objectives. Previous studies on coeliac disease suggest that attitudes towards the gluten-free diet may contribute to the development
of disordered eating. This study describes the development and validation of the Coeliac Disease Food Attitudes and Behaviours
scale (CD-FAB) to measure these behaviours in coeliac disease. Research Methods and Procedures. Focus groups were used to
develop 33 potential questionnaire items. These items were reviewed by service users and then distributed online to 157 adults
with coeliac disease. Items were removed based on ceiling/floor effects, high interitem correlations (>0.7) and factor analysis. 11
items were retained. Exploratory factor analysis was then conducted. The psychometric properties of the final version of the
CD-FAB were assessed via using an online platform. Results. The CD-FAB had 11 items distributed across one factor assessing
attitudes and behaviours towards food. These factors explained 44.1% of the variance in responding. The CD-FAB and its
subscales had high internal consistency (Cronbach’s alpha >0.7) and psychometric validation indicated good convergent and
discriminant validity. High scores on the CD-FAB are associated with psychological distress and an impaired quality of life.
Conclusions. The CD-FAB is a reliable and valid measure of food attitudes and behaviours in coeliac disease. As a new disease-
specific instrument, it may be a useful tool for evaluating food concerns in individuals with coeliac disease in a clinical setting
and for further exploring the development of disordered eating patterns in coeliac disease. Further research is required to assess
the full potential of the CD-FAB.
1. Introduction
Coeliac disease (CD) is managed by a strict, life-long gluten-
free diet (GFD), which leads to improvement in the majority
of CD-related symptoms [1]. However, following the GFD
may harm some individuals’relationship with food, increas-
ing the risk of disordered eating [2]. Disordered eating
describes a spectrum of eating behaviours, ranging from clin-
ical eating disorders, including anorexia and bulimia nervosa
[3], to skipping meals and restricting certain foods [4].
A two-pathway model of disordered eating has been used
to understand disordered eating attitudes and behaviours in
CD [2]. The first pathway describes those who experience
distress around weight change associated with diagnosis that
triggers disordered eating attitudes and behaviours. The sec-
ond pathway describes a hypervigilance around food that
triggers disordered eating attitudes and behaviours. Case
studies of comorbid CD and disordered eating, although lim-
ited by small sample sizes, are concordant with systematic
studies suggesting that 22–29% of individuals with CD score
above clinical cut-offs for disordered eating [5–7]. However,
evidence for clinically diagnosed eating disorders is mixed.
Evidence from Sweden and the UK had demonstrated an
increased risk of anorexia nervosa in CD [8, 9], whereas
Babio et al. [10] found no greater risk for eating disorder in
individuals with CD when compared to healthy controls.
Following the GFD requires vigilance around food and
knowledge of food preparation and so current disordered
Hindawi
Gastroenterology Research and Practice
Volume 2018, Article ID 6930269, 9 pages
https://doi.org/10.1155/2018/6930269

eating measures may incorrectly classify behaviours essential
for the management of CD as disordered. The binge eating
scale (BES) [11] and the Eating Attitudes Test (EAT-26)
[12] have been used to identify disordered eating CD [6].
However, some individuals with CD who score below the
clinical cut-offon these measures describe apparent disor-
dered eating attitudes and behaviours, with a cognitive focus
on fears about cross-contamination and food safety [13].
Although control around food is essential for those follow-
ing a GFD, these beliefs about food may result in disordered
eating attitudes and behaviours [13]. To better understand
how these beliefs develop from adaptive coping mecha-
nisms to disordered attitudes and behaviours, they must
be measureable in CD.
This article reports the development of a CD Food Atti-
tudes and Behaviours Scale (CD-FAB) to identify disordered
eating attitudes and behaviours resulting from beliefs around
cross-contamination and food safety, including the psycho-
metric properties comprising subscale structure, reliability
and validity, and psychosocial correlates.
2. Methods
A mixed methods approach using three studies was used to
develop the CD-FAB (Figure 1).
3. Study 1: Item Generation
Online focus groups, moderated by the first author, were
used to generate CD-FAB items. Individuals with a self-
reported, biopsy-confirmed diagnosis of CD (18–69 years)
were recruited from online forums. Individuals reporting
CD diagnosis via blood test, physician report, or self-report,
without intestinal biopsy, were excluded from the analyses.
Interested individuals emailed the first author to complete
a screening questionnaire and to confirm focus group
attendance. Verbal consent, over the phone, and online
consent was provided before attending the focus group.
Participants experiencing other dietary-controlled condi-
tions (e.g., cystic fibrosis and diabetes mellitus) or food
allergies were excluded.
Eight open-ended questions were designed to answer the
key questions of the study: (1) the construct of food attitudes
in CD and (2) the everyday interactions with food in CD. The
five stages in the two-pathway model of disordered eating in
gastrointestinal disease (diagnosis of CD, adaptation to diag-
nosis, illness beliefs, dietary management, and eating pat-
terns) were used to frame questions [2]. Closure of the
focus group was based on data saturation, by repeatedly com-
paring data across participants, which occurred when no new
information was obtained from the focus group.
3.1. Data Analysis. Thematic analysis identified key themes
related to food attitudes, concerns, and eating behaviours
[14]. The first author (experienced in qualitative analysis
and under the supervision of experienced academics) read
through the transcripts noting initial thoughts; transcripts
were reread allowing data immersion. Subsequently, the cod-
ing phase began. Codes identified characteristics related to
food attitudes, concerns, and eating behaviours; similar codes
were grouped, creating themes. Emerging themes were used
to develop items for the CD-FAB. Each item was transformed
into a 7-point Likert scale (strongly agree to strongly dis-
agree). Questions were phrased so that higher scores indi-
cated greater food concerns; four items were reverse scored
to minimise response bias. Individuals from the focus group
rated the 33 pilot items on clarity, adequacy, and relevance to
the focus group discussion. Three service users with CD,
recruited via email from the Birmingham Coeliac UK com-
mittee who did not take part in the focus groups, commented
on the clarity, adequacy, and relevance of the questions.
These questions were rated on a 5-point scale (1: strongly
agree to 5: strongly disagree); those items that consistently
scored low were removed.
4. Results of Item Generation
Twelve individuals took part in the focus group (10 females,
mean age = 29.1 years, SD = 8.16; mean time since diagno-
sis = 6.2 years, SD = 4.69). Three had a CD diagnosis for over
10 years (see Table 1).
4.1. Thematic Analysis. Four themes were identified: handling
of food,trust,risk-taking, and food safety. Handling of food
refers to feelings around gluten-containing products, includ-
ing preparing gluten-containing food for others, having glu-
ten in the home, and touching gluten-containing foods.
Some participants said that they would prepare gluten-
containing foods for others and had no concerns being
around gluten, as long as they did not consume gluten.
Other participants described a fear around food that was
attributed to their need to be vigilant about food content;
gluten was not allowed in the home and feelings of anxiety
increased when they were in close proximity to gluten. “I
get concerned in supermarkets when the gluten-free bread is
next to the normal bread. I know they’re all wrapped up but
it scares me”(Ashley).
The second theme, trust, described the need for control
during food preparation, especially where others were
involved. Concerns stemmed from the belief that others
may not be vigilant around cross-contamination. To reduce
concerns around eating food prepared by others, trust in
the individual preparing food was needed. “I don’t let him
prepare my food. I like to be in control of my food, I can’t trust
others to do it”Charlie). Clem described the impact of trust
on the ability to eat outside the home “Going out for a meal
I always have to double check. If they (the restaurant) sound
unsure I won’t go. I need to trust them”(Clem).
Risk-taking reflects the ability to consume foods in new
environments. Twelve participants indicated that an element
of risk was necessary to live a normal life. A lack of risk-
taking led to isolation from events involving food. “I have
to take small risks if I want to have a normal life!”(Jamie).
Food safety describes the eating strategies employed to
manage food concerns. Although most participants were
willing to try new gluten-free foods, some viewed food as
the enemy. These individuals experienced anxiety around
food and felt safer not eating. A limited range of food was
2 Gastroenterology Research and Practice

consumed, or long periods of food restriction to promote
safety and prevent gastrointestinal symptoms were reported.
“I cope with my fear of getting glutened by not eating.”(Ash-
ley). These attitudes were related to the participant’s ability
to recall their symptoms and adverse food experiences prior
to diagnosis. “I don’t go to restaurants. They remind me of
being ill. I didn’t like that, so I don’t eat much”(Alex).
4.2. Item Development. The identified themes were used to
generate 33 items for the CD-FAB. After the review, 13 items
were reworded and 3 items were removed to create the 30
items in the pilot CD-FAB to be used in study two.
5. Study 2: Item Analysis and Exploratory
Factor Analysis
Study two identified items for the final scale. The pilot CD-
FAB was distributed to a new sample of people with CD
recruited from our research database (November–December
2015). This database consists of 157 adults (18–69 years) with
self-reported biopsy confirmed diagnosis of CD, recruited
from online forums, who had previously volunteered to take
part in research. As in study 1, individuals reporting CD
diagnosis via blood test, physician report, or self-report,
without intestinal biopsy, were excluded from the analyses.
All 157 individuals were approached and directed to an
online questionnaire, which included demographic informa-
tion (age and years with diagnosis) and the pilot CD-FAB.
5.1. Data Analysis. Only items that contributed to the ques-
tionnaire’s explanatory power were retained (see Table 2
for removal criteria) [15]. One theoretically relevant item
was retained due to its salience during the focus group,
“I am afraid to touch gluten-containing foods,”despite the
removal criteria.
Principle component analysis with orthogonal rotation
was used to identify loading patterns within the CD-FAB.
The scree plot and factor eigenvalues >1 identified the most
appropriate factor solution.
6. Results of Item Analysis and Exploratory
Factor Analysis
One hundred and two individuals (96 females) completed the
pilot stage (mean age = 8.6 years; SD = 16.73; 9.6 years with
Phase 1: 12 participants
recruited for online focus
groups
Interim phase: items developed
from focus group data and
reviewed by service users
Phase 2: pilot CD-FAB
distributed to 157 individuals
with CD; item analysis and
exploratory factor analysis
Phase 3 (time 1): CD-FAB and
validating measures completed
by 203 individuals with CD;
psychometrics and
conrmatory factor analysis
(CD-FAB 11 items)
Phase 3 (time 2): CD-FAB
completed by 67individuals
with CD; test-retest reliability,
predictive validity, and
psychosocial correlates
(CD-FAB 11 items)
Pilot CD-FAB (33 items)
CD-FAB (13 items)
Figure 1: Flow chart of the CD-FAB development and validation process.
Table 1: Participant characteristics for focus groups (study 1: item
generation).
Pseudonym Gender Age (years) Years since diagnosis
Alex Male 36 1
Ari Female 23 4
Ashley Female 19 2
Charlie Female 26 3
Clem Female 47 2
Eddie Female 28 3
Frances Female 24 13
Jamie Female 31 12
Sam Female 29 4
Sean Female 27 7
Tyler Male 20 9
Wren Female 39 14
3Gastroenterology Research and Practice

CD diagnosis; SD = 18.24; response rate = 65%). Twelve were
excluded, as they did not report a biopsy-confirmed diagno-
sis of CD.
6.1. Content and Internal Reliability. The CD-FAB was
reduced from 30 to 13 items based on the criteria described
in Table 1. The Cronbach’s alpha for the overall scale was
acceptable (0.89).
6.2. Exploratory Factor Analysis. The Kaiser-Meyer-Olkin
and Bartlett’s test of sphericity assumptions were met. A
three-factor solution was extracted. Given the high intercor-
relations among the three factors, a stricter eigenvalue of 2
was used, producing a one-factor solution explaining 44.1%
of the variance (Table 3).
7. Study 3: Confirmatory Factor Analysis,
Psychometrics, and Psychosocial Correlates
Study three assessed the feasibility, reliability, and psycho-
metric properties of the CD-FAB and validated the
underlying factor structure. The psychosocial correlates of
the CD-FAB were also explored (see Table 4 for CD-FAB).
Recruitment posters in food outlets across the University
of Birmingham, UK, directed interested individuals to an
online survey (January–March 2016). Individuals were asked
not to complete the questionnaire if they had completed
study one. All participants who completed the questionnaire
(time 1) were invited to complete the CD-FAB and items
assessing predictive validity four weeks later (time 2). Online
questionnaires to assess the psychosocial correlates were
distributed at time 2 with the CD-FAB. Two hundred
individuals with self-reported, biopsy-confirmed CD were
targeted, as this is a sufficient sample size for confirmatory
factor analysis (CFA) [16]. The inclusion/exclusion criteria
were as described in study one.
7.1. Data Analysis. Floor and ceiling effects determined feasi-
bility of the CD-FAB score; these were considered when
more than 15% of respondents achieved the lowest/highest
possible score.
Table 2: Removal criteria for CD-FAB items.
Spread of responses across options
High endorsement of a single item suggests poor discriminatory power.
Items were considered for removal if >80% or <20% were an agree-type
statement or a disagree-type statement
16 removed
Internal consistency Items with a corrected item-domain total correlation <0.3 or in a domain
with a poor Cronbach’s alpha <0.7 were considered for removal 1 removed
Timing of administration of questionnaire
Needs to be applicable to people from the point of coeliac disease
diagnosis onwards, so all individuals with coeliac disease can
complete the scale
2 reworded
Clarity and relevance of items Difficult to understand items were reworded or considered for removal 13 reworded
Items deemed theoretically important These items were retained despite meeting the above criteria because
they were deemed theoretically important 1 retained
Table 3: Factor loadings for CD-FAB items.
Item
number
Factor
loading
Cronbach’s alpha for scale
I am afraid to eat outside my home 2 0.78
I am comfortable eating gluten-free food from other people’s kitchens∗11 0.77
I am afraid to touch gluten-containing foods 3 0.75
I get concerned being near others when they are eating gluten 1 0.73
My concerns about cross-contamination prevent me from going to social events involving food 8 0.71
I get worried when eating with strangers 5 0.70
I enjoy going out for meals as much as I did before my diagnosis∗10 0.69
Being contaminated by gluten in the past has not stopped me from enjoying restaurants∗12 0.69
I will only eat food that I have prepared myself 7 0.65
If I ask questions, I can normally find gluten-free food to eat∗13 0.64
I will happily prepare gluten for others 9 0.58
Ifind it hard to eat gluten-free foods that look like the gluten-containing foods that have made me ill in the past 6 0.45
I have a lack of variety in my diet 4 0.35
∗represents items that are reverse scored. Numerical values represent factor loadings.
4 Gastroenterology Research and Practice

CFA was used to confirm the one factor model found in
study two, based on the goodness fit and assessed using sev-
eral indices: the comparative fit index (CFI; >0.95 indicates
acceptable fit), Tucker-Lewis index (TLI; >0.95 indicates
acceptable fit), and root mean square errors of approxima-
tion (RMSEA; <0.08 indicates acceptable fit) [17]. Modifica-
tion indices determined changes made to improve model fit.
CD-FAB scores were calculated by summing the responses
on each item. CD-FAB scores ranged between 13 and 91,
with higher scores indicating greater CD-related food con-
cerns and compensatory behaviours.
Correlation coefficients were used to assess test-retest
reliability of the CD-FAB scores; for 50 participants, a corre-
lation coefficient >0.7 is indicative of strong reliability [18].
Psychosocial correlates were explored by applying a tertiary
split to CD-FAB scores, dividing individuals into high,
medium, and low scorers basedonthe33rdand66thpercen-
tiles. Analysis of variance was used to compare psychosocial
outcomes across the three groups, and t-tests were used to com-
pare the means across the low and high scorers on the CD-FAB.
7.2. Measures
7.2.1. Food Neophobia Scale (FNS) [19]. Convergent validity
was assessed using the FNS, as this has previously been used
to assess food anxieties in CD
6
. The FNS measures willing-
ness to try new food, with lower scores indicating a greater
willingness to try new foods. The scale consists of 10 items
and is the standard measure of food nephobia [19]. Correla-
tions were sought to determine the degree to which the
CD-FAB score reflected a fear of trying new foods. We
anticipated a moderately positive relationship between total
CD-FAB score and FNS scores, as individuals with high
CD-FAB scores may also be fearful of trying new foods.
7.2.2. Depression, Anxiety, Stress Scale 21 (DASS-21) [20].
The Anxiety subscale from the DASS-21 was used to assess
convergent validity. This subscale measures behavioural feel-
ings of anxiety over the last four weeks with higher scores
indicating greater anxiety. The DASS-21 has strong psycho-
metric properties; with higher scores indicating greater anxi-
ety [21]. To demonstrate convergent validity, total scores on
the CD-FAB should correlate with scores on the Anxiety sub-
scale. At time 2, all subscales of the DASS-21 were distributed
to explore the relationship between CD-FAB scores, depres-
sion, anxiety, and stress.
7.2.3. CD Quality of Life Scale (CD-QoL) [22]. The Treatment
subscale was used to assess discriminative validity. This sub-
scale assesses satisfaction with one’s treatment (the GFD). No
relationship between these scores was anticipated. At time 2,
all subscales of the CD-QoL were distributed to explore the
relationship between CD-FAB scores and quality of life.
Table 4: The Coeliac Disease Food Attitudes and Behaviours scale (CD-FAB). Instructions: this questionnaire is designed to explore food
attitudes and beliefs in coeliac disease. Some questions may not apply to you; this is because we are trying to assess a range of beliefs about
coeliac disease and managing the gluten-free diet. Please fill out the form below as accurately, honestly, and completely as possible. There
are no right or wrong answers. All of your responses are confidential. Please tick the box that best describes your response to the question.
Strongly
agree (7)
Agree
(6)
Somewhat
agree (5)
Neither agree
nor disagree (4)
Somewhat
disagree (3)
Disagree
(2)
Strongly
disagree (1)
Because of my coeliac disease…
I get concerned being near others when they
are eating gluten
I am afraid to eat outside my home
I am afraid to touch gluten-containing foods
I get worried when eating with strangers
Ifind it hard to eat gluten-free foods that
look like the gluten-containing foods that
have made me ill in the past
I will only eat food that I have prepared myself
My concerns about cross-contamination prevent
me from going to social events involving food
Despite having coeliac disease…
I enjoy going out for meals as much as I did
before my diagnosis∗
I am comfortable eating gluten-free food from
other people’s kitchens∗
Being contaminated by gluten in the past has
not stopped me from enjoying restaurants∗
If I ask questions, I can normally find
gluten-free food to eat∗
Reverse items with ∗and add all scores to make total score.
5Gastroenterology Research and Practice

7.2.4. Behavioural Item. Known groups discriminant validity
was assessed using the behavioural item, “Do you consider
yourself to be anxious around food?”This item was rated
yes/no. A further behavioural item “How many times have
you eaten outside the home over the last month?”was assessed
at time 2, to assess predictive validity. We anticipated that
individuals scoring high on the total CD-FAB score at time
1 would eat outside the home less than those with lower
CD-FAB scores at time 2.
7.2.5. Gluten-Free Management. Gluten-free dietary man-
agement was rated on a 5-point Likert scale, in response
to the question “In general, how strictly do you maintain
a gluten-free diet?”ranging from ‘1) All of the time’;
2) ‘Most of the time’;3)‘Some of the time’;4)‘Now and
then’;5)‘Not at all’[23].
8. Results of Confirmatory Factor Analysis
and Psychometrics
8.1. Participants at Time 1. 203 (35 males, 2 “other”) partici-
pants took part in the validation stage with a mean age of 30.9
years (SD = 11.4) and 6.2 years with CD diagnosis (SD = 8.4).
Nineteen participants were excluded as they reported a
self-diagnosis and not a biopsy-proven diagnosis of CD.
This sample was older than the participants recruited for
study two (t (1, 285) = −4.21, p<0 001). No difference was
found in years since the diagnosis across the two samples
(t (1, 286) = −1.81, p=0 072). 56.1% of participants with
CD reported following their GFD “all of the time.”Of the
remainder, 1% were completely nonadherent, and 42.9%
were partially adherent to the GFD.
8.2. Participants at Time 2. 112 of those recruited at time
1 consented to be contacted at time 2; of these, 67 completed
the second questionnaire (54 females; mean age = 32.8,
SD = 16.51; mean years with diagnosis = 7.5, SD = 11.42;
response rate = 60%).
When comparing participant contact details to those
recruited in study one, there was a 3% overlap across the
samples. These individuals were removed from the analysis.
8.2.1. Reliability and Feasibility. Floor and ceiling effects
ranged between 0.5 and 1%. The CD-FAB total score showed
good internal consistency (Cronbach’s alpha = 0.89).
8.2.2. Confirmatory Factor Analysis. All items loaded onto
the total CD-FAB score (Figure 2). Figure 2 shows the struc-
tural equation model containing the standardised path esti-
mates between the items and factors for the final model.
Items 4 (I have a lack of variety in my diet) and 9 (I will hap-
pily prepare gluten for others) were removed from the model
due to low factor loadings and improved model fit after
removal. Despite item 6 (Ifind it hard to eat gluten-free foods
that look like the gluten-containing-foods that have made me
ill in the past) having a low factor loading (0.56), this item
was retained, as removal did not improve model fit. Model
fit could be improved by covarying the errors on items 1
and 3, 1 and 5, 7 and 8, and 10 and 12. The resulting model
fit was acceptable (TLI = 0.95; CFI = 0.93; RMSEA = 0.08).
The resulting CD-FAB contained 11 items with total scores
ranging from 11 to 77 (Cronbach’s alpha for 11-item
CD-FAB remained at 0.89). These calculations were used
in subsequent analyses.
8.3. Convergent Validity. Total CD-FAB positively correlated
with the FNS (r=274,p<0001) and the Anxiety subscale of
the DASS-21 (r=0188,p=0016). Correlation coefficients
were <0.7, indicating a weak relationship.
8.4. Discriminant Validity. Beliefs about the effectiveness of
the GFD were not related to CD-FAB scores (r=−0002,
p=098), indicating good discriminant validity.
8.5. Known Groups Validity. 37.2% of participants consid-
ered themselves to feel anxious around food. These individ-
uals had significantly higher CD-FAB scores (m=482,
SD = 6.3) than those who were not anxious around food
(m=406, SD = 7.5, p<0 001)
8.5.1. Predictive Validity. CD-FAB scores taken at time 1
were associated with responses to the item “How many times
have you eaten outside the home over the last month?”taken
at time 2 (r=−037,p=0048),
8.5.2. Test-Retest Reliability. Test-retest correlation coeffi-
cients between the total CD-FAB scores at time 1 and time
2 were strong (r=092,p<0001).
8.5.3. Psychosocial Correlates. The top third of CD-FAB
scores were associated with increased psychological distress
and a more impaired quality of life when compared to low
scores (p<001). No significant differences were found
between medium and high scorers (Table 5).
Low CD-FAB scorers were in the “normal”ranges for
DASS-21, whereas the medium and high scorers were within
the “mild”and “moderate”ranges [20]. No differences were
found across age and BMI for CD-FAB scores.
9. General Discussion
The recent research has highlighted the association between
disordered eating and CD [5–9]. Qualitative studies suggest
that existing measures of disordered eating do not identify
all atypical eating patterns reported in CD [13]. Beliefs
around cross-contamination and food safety have been
implicated in the development of disordered eating attitudes
and behaviours in CD [13], but there are no tools to measure
these factors. We developed and validated a self-report food
attitudes and behaviours measure for adults with CD.
The CD-FAB set out to measure the four themes identi-
fied in focus groups, which explored underlying food atti-
tudes, concerns, and eating behaviour themes (i.e., handling
of food,trust,risk-taking,and food safety). One factor
emerged but items targeting each of the themes were retained
within this factor. This factor explained 44.1% of the variance
in scores. High scores described greater concerns around
food alongside avoidance and changes in the diet to cope
with these concerns.
The CD-FAB has a high Cronbach’s alpha (0.89), indi-
cating strong psychometric properties and good predictive
6 Gastroenterology Research and Practice

validity. Test-retest reliability over 4 weeks was excellent.
This may indicate that CD food attitudes and behaviours
are a stable trait, supporting previous literature highlighting
this issue [24]. Additionally, the CD-FAB has good discrim-
inant validity, showing no correlation with the CD-QoL
Treatment subscale. The direction and magnitude of the
correlations between the CD-FAB and the FNS and Anxiety
subscale of the DASS-21 were weak, indicating limited con-
vergent validity. However, the use of the DASS-21 to assess
trait anxiety may be problematic if the CD-FAB assessed
situational concerns, future research should explore the
use of a state measure of anxiety alongside the CD-FAB
to further explore convergent validity claims of the CD-
FAB. Individuals with high CD-FAB scores felt more
socially limited and concerned about their CD and its
health consequences compared to low scorers, suggesting
high scores on the CD-FAB indicate impaired psychosocial
well-being.
A strength of this study lies in the use of participant
involvement to create the CD-FAB. This information along-
side a priori themes, including a framework developed by
Satherley, Howard, and Higgs [2], was used to make these
items relevant to participant experiences. Constructs
identified by respondents related to social settings, gastroin-
testinal symptoms, and eating behaviours are measured for
the first time by the CD-FAB. Pertinent examples of this
are that eating at social events is less enjoyable after a CD
diagnosis as the GFD can lead to feelings of embarrassment,
isolation, and a fear of gastrointestinal symptoms, [24] for
some, this fear of symptoms and anxiety around food may
lead to disordered eating attitudes and behaviours [13].
Despite the strengths of the current study, future research
needs to examine long-term changes in CD-FAB scores,
particularly during the first year of diagnosis, to explore
typical and atypical adaptation to CD and the GFD. The
high dropout rate between time 1 and time 2 completion
of the CD-FAB is a further limitation of this study. Given
this high dropout, future investigations should consider
recruiting a larger subject population for follow-up analy-
ses. Furthermore, participants in the developmental stages
of the CD-FAB were predominantly female, which reflects
the higher prevalence of both eating concerns and CD in
females [25, 26]. However, further validation of the CD-
FAB should reflect a better balance between males and
females. Additionally, despite the exclusion of participants
who did not report a biopsy confirmation of their CD
Tot al sc ore
CDFAB1 e1
e2
e3
e4
e5
e6
e7
e8
e9
e10
e11
1.25
2.05
1.39
1.84
0.55
2.01
1.83
3.36
2.27
2.50 0.57
1.00
1.52
2.63
0.61
CDFAB2
CDFAB3
CDFAB5
CDFAB6
CDFAB7
CDFAB8
CDFAB10
CDFAB11
CDFAB12
CDFAB13
1.89
1.00
1.07
1.00
0.93
0.56
0.74
0.91
0.88
1.02
0.96
0.63
1
1
1
1
1
1
1
1
1
1
1
Figure 2: Confirmatory factor analysis with standardised item loadings onto the one CD-FAB factor. The numbers shown on the diagram
from right to left are (1) covariance of the errors, (2) error terms (E), and (3) path coefficients of indicators.
7Gastroenterology Research and Practice

diagnosis throughout the procedures, self-report is not suf-
ficient to ensure CD diagnosis. Given the confusion
among CD diagnosis and symptomatic overlap with non-
coeliac gluten sensitivity and irritable bowel syndrome, it
is possible that individuals without a biopsy-confirmed
diagnosis of CD could have been included in these studies.
Given this limitation, further validation is needed in a
sample of biopsy-confirmed individuals with CD recruited
from clinical settings.
Measurement of symptom severity needs to be conducted
alongside further assessment of the CD-FAB to control for
impact of symptom severity on associated behaviours, affect,
and cognition. In addition, a more thorough assessment of
GFD adherence and an exploration of eating disorder history
would aid in further understanding scores on the CD-FAB.
Finally, expert review was not used to assess content validity,
but the involvement of service users with CD in generating
the items and providing feedback on the overall CD-FAB
provides evidence for content validity.
These limitations do not detract from the clinical util-
ity of the CD-FAB. The instrument may be used as an
outcome measure in clinical research, enabling a greater
understanding of CD-related eating patterns that are not
currently captured by current tools. There is a need to
establish clinical cut-offpoints; further guidance regarding
the interpretation of CD-FAB scores (e.g., referral to dieti-
cian, clinical psychologist, or specialist eating disorder ser-
vice) can be given following the identification of population
norms and health implications.
The CD-FAB is a brief, self-report questionnaire that
shows good reliability and validity in measuring disordered
eating attitudes and behaviours in CD. The measure may be
a useful tool to help understand eating attitudes and behav-
iours in adults with CD.
Abbreviations
BES: Binge eating scale
CD: Coeliac disease
CD-FAB: Coeliac Disease Food Attitudes and Behaviours
scale
CD-QoL: Coeliac disease quality of life scale
CFI: Comparative fit index
DASS-21: Depression anxiety stress scale
EAT-26: Eating attitudes test
FNS: Food Neophobia Scale
GFD: Gluten-free diet
RMSEA: Root mean square of errors approximation
TLI: Tucker-Lewis index.
Data Availability
The data used to support the findings of this study are
available from the corresponding author upon request.
Ethical Approval
The Psychology Research Ethics Committee, University
of Birmingham, UK, granted ethical approval (ERN_15-
0370A). All work was conducted in accordance with the
Declaration of Helsinki (1964), with individuals’understand-
ing and consent.
Conflicts of Interest
Rose-Marie Satherley is an employee at Kings College
London; Ruth Howard and Suzanne Higgs are employees at
the University of Birmingham. There are no conflicts of
interest to report.
Authors’Contributions
Rose-Marie Satherley collected and analysed data and wrote
the initial draft. Suzanne Higgs and Ruth Howard reviewed
analyses, advised on interpretation, and contributed to the
final version of this article. Rose-Marie Satherley is the guar-
antor of this paper. All authors approved the final version of
the manuscript.
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9Gastroenterology Research and Practice