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Factor structure and psychometric properties of the TFEQ in morbid obese patients, candidates to bariatric surgery.

Factor structure and psychometric properties of the TFEQ in morbid obese patients, candidates to bariatric surgery

Obesity is a metabolic disorder that has reached epidemic proportions in developed countries throughout the last century (WHO, 2000, 2003). One of the most frequently used questionnaires for the measurement of behavioral and cognitive components of food intake in obesity is the Three Factor Eating Questionnaire (TFEQ; Stunkard & Messick, 1985), also known as the Eating Inventory (EI; Stunkard & Messick, 1988). The TFEQ is based on Herman and Mack's Restraint Theory (Herman et al., 1975) and on the boundary model of food regulation (Herman & Polivy, 1984). It was created to improve some of the psychometric issues found in the predictive and construct validity of the Restraint Scale and to promote the study of restraint in obesity (Ruderman, 1986). It was developed, via factorial analysis, from responses to the Restraint Scale (Herman & Polivy, 1980), the Latent Obesity Questionnaire (Pudel, Metzdorff, & Oetting, 1975) and some new items based on clinical practice. Three factors were extracted, "Cognitive Restraint of Eating", "Disinhibition of Eating Control" and "Susceptibility to Hunger". The internal consistency indexes were .93, .91 and .85, respectively.

Some studies have tried to confirm the factorial structure of the TFEQ. Ganley (1988) found, in a mixed sample of women, a four-factor design, with the factors Restraint, Hunger and the original Disinhibition factor divided into Weight Lability and Emotional Eating, in relation to the loss of control over eating when associated with negative emotional states . Hyland, Irvine, Thaker, Dann, and Dennis (1989) found a three-factor organization (Disinhibition and Hunger joined in a single factor, Restraint, and Emotional Eating) in a similar sample. These factorial solutions were analyzed by a confirmatory factor analysis conducted by Mazzeo, Aggen, Anderson, Tozzi, and Bulik (2003) in a population sample of female twins, finding a poor fit of the factor structure in their sample.

In 2000, Karlsson, Persson, Sjostrom, and Sullivan carried out the "Swedish Obese Subjects (SOS)" study (N= 4.377), in which obese subjects undergoing treatment were assessed. The resulting scale had a three-factor structure: Cognitive Restriction, Uncontrolled Eating--which includes most of the Disinhibition and Hunger items--and Emotional Eating. In their reduced version of the TFEQ (TFEQ R-18), they proposed to change the scoring method, switching from dichotomous responses to a 4-point Likert scale. Some studies using the TFEQ R-18 have shown good internal consistency in the general population (Angle et al., 2009; de Lauzon et al., 2004). Tholin, Rasmussen, Tynelius, and Karlsson (2005) added 3 items in order to avoid floor and ceiling effects in the Emotional Eating factor in a twin male sample. They found a strong genetic influence in the three factors that could not be confirmed for females (Mazzeo et al., 2003; Neale, Mazzeo, & Bulik, 2003).

In Spain, the only adaptation of the original TFEQ was carried out on a non-clinical sample of university female students (Sanchez-Carracedo, Raich, Figueras, Torras, & Mora, 1999). Nevertheless, no validation has been made to date with a clinical obese Spanish sample, despite that questionnaire has proven particularly useful among this population (Gade, Rosenvinge, Hjelmesaeth, & Friborg, 2014). The TFEQ is a sensitive tool to describe changes in the dysfunctional eating behavior of obese patients undergoing surgery (Laurenius et al., 2012), to choose between different bariatric techniques (Apovian et al., 2013), to adapt interventions to reduce weight based on eating behavior (Bryant, Caudwell, Hopkins, King, & Blundell, 2012), to test the effectiveness of psychotherapeutic interventions focused on dysfunctional eating (Gade, Hjelmesaeth, Rosenvinge, & Friborg, 2014) and for webbased weight loss programs (Svensson et al., 2014).

Thus, the objective of the present research was to study the factorial structure and psychometric properties of the original TFEQ among a Spanish sample of morbidly obese patients (defined as those with a BMI of 40 or more and those with a BMI [greater than or equal to] 35 with other medical comorbidities), candidates for bariatric surgery (BS). Following Karlsson's work, the reduction of items was aimed, as a secondary objective, in order to yield more efficient scales.

Methods

Participants

The sample was composed of 222 outpatients (66 men and 156 women) with morbid obesity (BMI mean: 45.16; SD: 7.26. Range: 30-80) that had already initiated the previous assessment process for BS according to the criteria defined in the World Guide to Obesity (WHO,2000). From a total sample of 230 patients, 3.5% (8 candidates) refused to participate in the study.

Mean age for participants was 41.84 years (SD: 11.11; Range: 18-75), mean years of education was 10.97 (SD: 3.31; Range: 2-22), one third of the sample only had primary education (35.1%). Patients were part of a Public Financial study where clinical and neuropsychological features of morbidly obese patients with and without binge eating disorder were obtained. The TFEQ, together with two other self-applied questionnaires, were administered to patients as part of the psychiatric evaluation protocol. The sample was recruited from two National Public Health Hospitals in Madrid: The "Hospital Universitario 12 de Octubre" (78% of the total sample), and the "Hospital Universitario de la Paz" (22% of the sample). The study was approved by the Research Ethics Committee and all patients completed an informed consent before the assessment.

Instruments

The Three-Factor Eating Questionnaire (Stunkard & Messick, 1985) is a 51-item self-applied questionnaire divided in two parts: the first part is composed of 36 items with two-option answers (truefalse) and the second part is composed of 15 items with 4-choice answers. The 0-1 responses are added to yield a total score. Higher scores reflected greater levels of Cognitive Restraint (21 items), Disinhibition (16 items) and Hunger (14 items).

Procedure

Direct translation and adaptation from the original questionnaire was conducted by a senior Psychiatrist (PhD) and a Psychologist (MSc, proficiency English level) specialized in eating disorders and obesity. It was subsequently compared with the adaptation carried out by Sanchez-Carracedo in order to discuss and solve the differences found between the two versions. Due to the particular cultural levels in the present study's recruitment area, some items were adapted in order to facilitate their comprehension, favoring the use of colloquial expressions commonly used to describe eating behaviors in daily life (Table 1).

Data analyses

A multi-trait/multi-item analysis was conducted to study the psychometric properties of the original scales of the TFEQ (Ware, 1983). The item-scale correlation matrices were calculated, comparing each item across the three scales. The items' convergent validity (Criterion 1) was appropriate when every item considerably correlated with the scale it represented (r [greater than or equal to] 0.40, corrected overlap) (Howard & Forehand, 1962).

Discriminant validity of items (criterion 2) was considered appropriate when the items highly correlated with the scale they represented in comparison with the other two scales. The significant difference between the item/scale correlations was determined using the standard matrix error of correlations (1/[check]n). The significant criterion used was 2 standard errors. Alpha coefficients (KR- 20) were also calculated to estimate the internal consistency of the scales' scores (reliability) (Kuder & Richardson, 1937).

A principal components factor analysis was conducted to study the TFEQ's factor structure (Gorsuch, 1983). Orthogonal (varimax) and oblique (promax) rotations were explored. A sediment tree was used to determine the number of factors. Items with a minimum loading of 0.40 were selected for each factor. Every extracted factor was renamed after a content analysis. With the purpose of studying the unidimensionality and homogeneity of the original scales of the TFEQ, factor analyses of every original scale were performed separately.

To analyze the stability and generality of the new factor structure, analyses of subgroups by age, sex and BMI were conducted (items with loadings <0.40 were excluded). The psychometric properties of new scales were studied with a multitrait/multi-item analysis.

Finally, to examine the prognostic value of the newly revised scales, correlations (Pearson) of new scales with BMI in the moment of assessment and the percentage of weight lost 20 months after surgery were performed. Results of those scales were considered among two subgroups of patients, depending on the presence or absence of binge eating disorder at the moment of evaluation, using a one-way ANOVA.

Results

Multitrait/multi-item scaling analyses

In Table 2, the Multitrait/multi-item scaling analyses are presented. The reliability coefficients (KR-20) for every scale were over the 0.70 standard, but under the 0.90 limit recommended for individual evaluation. The item-scale correlation analysis showed a weak internal consistency of items, especially in the Cognitive Restraint and Disinhibition scales. Seven of the 21 items of Restraint, 9 out of 16 from the Disinhibition and 7 of the 14 items of the Hunger factor exceeded the minimum desired level (r [greater than or equal to] 0.40, corrected overlap) of convergent validity of items. The discriminant validity analyses showed clear difficulties in the assignment of the designated items to the Disinhibition and the Hunger factors. Many items were related to both scales, mainly the ones corresponding to the Disinhibition factor. Items assigned to Cognitive Restraint demonstrated a strong discriminative capacity. Correlations between those items and the other two scales were low (r<0.32) and only one item could not overcome discriminate validity criteria. In sum, 7 out of 21 items from the Cognitive Restraint, 5 out of 16 from the Disinhibition and 5 out of 14 items from the Hunger scales fulfilled discriminant and convergent validity criteria in this study's sample.

Factor structure of the TFEQ

Following the scree test indications, a 3- factor solution was inforced. Item loadings of 0.40 or higher are represented in Table 3. The solution explained a 32% of the total variance. It was not possible to differentiate between the concepts of Disinhibition and Hunger, as was observed in the scalar multi-trait analysis above. The first factor contained 8 items from the Disinhibition and 12 from the Hunger scales with moderate loadings (ranging from 0.42 to 0.64). Item number 15 showed the highest loading (0.64). This factor included a wide range of items related to an extreme appetite, a failure of control over eating and the items about emotional eating with loadings around 0.60. Renaming this factor as "Dysregulated Eating" was considered so as to include diverse aspects such as appetite or lack of control over eating associated to any type of trigger. Patients who scored in this scale described an elevated intensity of the hunger sensation and a frequent loss of control over food intake in any daily situation.

The second factor comprised 10 items from the Cognitive Restraint scale. Item number 28 yielded the highest loading (0.68). In this factor, items related to active behaviors of restraint were observed, and was consequently labeled as "Restrained Behavior". Patients scoring in this scale stated that they usually employed behavioral strategies for the self-control of their daily food intake.

The third factor included 4 items from the Restraint scale and 1 from Disinhibition (item number 25), related to motivation and concern over intake and weight, and therefore was designated as "Predisposition to Restraint". Patients scoring in this scale showed an elevated disposition to perform restraint behaviors and showed evidences of being concerned about food intake and body weight.

Unidimensionality of the original TFEQ scales

The analysis of each original scale led to the confirmation of the division into two factors of the Cognitive Restraint scale (according to the scree test) where, in the first factor, items related to restraint behaviors were grouped, and in the second factor, items associated with "Predisposition to Restraint" were found. The analysis of the 12 items of Hunger showed factor loadings of 0.40 and higher. Only one factor was identified. The Disinhibition scale revealed the possibility of two factors, although when forcing the two-factor solution, the saturations in both scales were above 0.40 on 33% of the items, leaving 2 items from the original scale out of the solution. Correlations of factorial scores (after oblique rotation) showed a moderate association (r = 0.33).

Multitrait/ multi-item analyses of the revised scales

Factors derived from the factor analysis, "Dysregulated Eating" (DE), "Restrained Behavior" (RB) and "Predisposition to Restraint" (PR) were examined and organized into different subgroups. The factor structure was studied for the men and women subgroups, in patients under 45 years of age and in patients of 45 or older, and in subjects with a BMI<45 vs a BMI [greater than or equal to] 45. The only items contributing with over a 0.40 for one factor in every subgroup were included. The items that compose the final scales are listed in Table 1. A total of 23 items: 13 assigned to "Dysregulated Eating" (DE-13), 6 items to "Restrained Behavior" (RB-6) and 4 items to "Predisposition to Restraint" (PR-4). The estimated internal consistency (KR-20) was appropriate for the revised scales: DE-13 (0.85) and RB-6 (0.73) and PR-4 (0.60), which showed the poorest adjustment.

As can be observed in Table 4, the new scales fulfilled the discriminant validity criteria suggested, except for the item "I eat anything I want, any time I want" (inverse punctuation) from the RB-6 scale, whose correlation with the PR-4 scale did not reach two standard errors as significant difference (0.12<0.13 of established minimum value of difference between correlations). The same case is found in item number 10 "Life is too short to worry about dieting" (inverse punctuation) (0.11<0.13).

Convergent validity criteria (corrected overlap) presented moderated levels of correlation. In the DE-13 scale, all the items yielded correlations above 0.40, excluding item 8 "Since I am often hungry, I sometimes wish that while I am eating, an expert would tell me that I have had enough or that I can have something more to eat" which presented a correlation of 0.37, close to the recommended standard. Furthermore, at a clinical level, it was considered appropriate to maintain this item due to its conceptual characteristics. It was certainly related to the maladjustment of the satiety signal response and the need of an external measure as a way to control overeating, which is characteristic in a high percentage of morbidly obese patients. In the RB-6, only item 37 "How often are you dieting in a conscious effort to control your weight?", with a correlation of 0.36, did not reach the proposed condition. Its inclusion was considered as it represented a nuclear characteristic of the scale. The PR-4 scale presented a level of correlations of 0.32-0.44 between its items. Item 46: "How likely are you to consciously eat slowly in order to cut down on how much you eat?" was the only item presenting a correlation higher than 0.40, and item 10 (r= 0.32) was the only item correlating under 0.38.

Correlations between the original scales, derived factors and revised scales

In Table 5, the degrees of association between the original scales of the TFEQ are presented, with the scores for the derived factors and the revised scales. Strong associations between revised scales and their corresponding factors were obtained: DE-13 vs Factor 1/DE (r= 0.97), RB-6 vs. Factor 2 /RB (r= 0.94), and PR-4 vs Factor 3/PR (r= 0.96). Factor 1 and Factor 2 showed a light inverse correlation (r= -0.21). A positive association between Factor 2 and Factor 3 was observed (r= 0.36), while Factor 1 and Factor 3 were not related (r= 0.05). The DE-13 scale presented high correlations with the original scales of Disinhibition (r= 0.84) and Hunger (r= 0.91), and a weak inverse correlation with Cognitive Restraint (r= -0.16). At the same time, the original scale of Cognitive Restraint strongly correlated with the revised RB-6 scale (r= 0.87) and moderately correlated with PR-4 (r= 0.48).

Preliminary results of the predicted values of revised scales in a subgroup of the sample (n= 22) allowed to point out that scores in the revised PR-4 scale showed a small positive association with BMI (r= 0.17; p= 0.012) and the revised RB-6 scale was positively associated with the percentage of weight lost (mean= 37.74; SD= 10.44) about 18 months (Mean:18.27; DT: 5.05) after BS (r= 0.54; p= 0.009).

Moreover, the performance of the scales was analyzed according to the presence or absence of binge eating. The revised DR-13 and PR-4 scales yielded a significantly different effect for both groups. Results are shown in Table 6.

Discussion

The factor structure of the original TFEQ was not replicated among this study's sample of patients with morbid obesity. This research obtained the following factors: "Dysregulated Eating", "Restraint Behavior" and "Predisposition to Restraint". Moreover, the removal of items that did not sufficiently represent those factors in the different subgroups of the sample, yielded 3 reduced scales (DE-13, RB-6 and PR-4) that maintained appropriate psychometric properties.

The factor explaining most of the variability of the data, containing almost the complete sum of items from the original factors of Hunger and Disinhibition, was the factor labeled "Dysregulation Eating" (DE). The failure to replicate both factors was already stated by Karlsson et al. (2000), who referred that these factors were sustained in the hypothesis of the internalexternal model of obesity: obese patients would be more sensible to environmental temptations (items representing disinhibition) and less sensible to internal signs of hunger and satiety (items representing hunger). The studies aimed at confirming such hypothesis have shed inconsistent results, related mainly to the difficulties in distinguishing between internal and external eating stimuli. The psychometric analysis in this research verified the strong association between the items from the Hunger and Disinhibition scales, supporting the idea of a lack of differentiation between internal and external triggers.

In the DE factor, the items referring to emotional eating were included, contrary to previous studies that supported the presence of a differentiated factor for it (Angle et al., 2009; Ganley, 1988; Karlsson et al., 2000; Tholin et al., 2005). The differences can be explained by the disparity of size and characteristics from the studied samples. In this study, the sample was fairly homogenous (severe to extreme obesity, resistance to traditional treatments of weight reduction, elevated percentage of patients with binge eating) compared to previous studies that included different ranges of weight (normal weight, overweight and obesity), non-clinical samples, and obese patients under weight reduction treatment, etc.

Chronicity and severity of obesity were considered as determinant factors in the absence of item differentiation related to emotional eating. Following the psychosomatic theory of obesity, emotional eating is at the base of the development of obesity (Kaplan & Kaplan, 1957). The continuous association between physiological activation and comfort-searching through food intake, observed in some dysphoric states, could result in a cognitive reattribution of those signs of activation into perceived hunger signs, leading to a cognitive overlap between the physiologic hunger sensation and the state of emotional dysphoria.

In this study's sample, the original Restraint factor was clearly divided in two factors. The first factor was related to behaviors of active restraint (RB) and the second factor was associated with cognitive aspects of restraint (worry about eating and motivation for restraint) (PR). Previous research has found similar results in this tendency (Fairburn & Beglin, 1994; White, Masheb, & Grilo, 2009). One of such studies, the White et al. (2009) study, found a two-factor solution (Regimented Restraint and Lifestyle Restraint). However, Bond, McDowell and Wilkinson (2001) obtained three factors from the original Restraint scale (Strategic Dieting Behavior, Attitude to Self-Regulation, Avoidance of Fattening Foods); and Westenhoefer (1991) found a division: Rigid Control and Flexible Control, associated respectively with higher or lower scores in Disinhibition.

In this study's model, the presence of strategies of control over eating behaviors (RB) was associated with a lower intensity of lack of control over eating (DE). Therefore, in patients with morbid obesity, the employment of behavioral resources for the control of food intake would reduce the probability of overeating episodes, as was reported in studies of obese patients in treatment (Foster et al., 1998).

Contrasting with prior researches that could not find any relation between the basal TFEQ scores and weight reduction (Bocchieri-Ricciardi et al., 2006; Burgmer et al., 2005), the preliminary results of patients' follow-up after surgery indicated a clear association between basal punctuations in the RB-6 and the percentage of weight lost in a medium term post-surgery. This confirmed that the acquisition and the implementation of control over eating habits before surgery were translated into better objective achievements after the procedure. Those findings were especially relevant to development of behaviorcognitive treatments before surgery. They could contribute to decrease the intensity of the symptoms of lack of control over eating after the procedure, since it is the principal predictive factor of the long term response to surgery (Kalarchian et al., 2002; White, Kalarchian, Masheb, Marcus, & Grilo, 2010).

Nevertheless, the cognitive component of Restraint (PR), that is, the worries related with eating or the focused attention to restraint, was associated with a higher BMI and with the presence of binge eating. In this study's sample, being evaluated as candidates for BS could act as a positive bias, increasing the probability of answering positively in this scale, because patients with higher levels of BMI (and presumably greater presence of comorbidities) BS could be their last chance of treatment. The association of the PR-4 with binge eating was consistent with the alteration of cognitive patterns in patients with BED,which implied a great concern over eating and weight, but a persistent incapability to manage or control their eating over time (Hsu et al., 2002; Kalarchian, Wilson, Brolin, & Bradley, 1998).

The factor structure derived from the sample showed appropriate statistical values of validity and reliability. To our knowledge, this was the first study that has analyzed the performance of TFEQ on a Spanish clinical population with severe obesity. The purpose of reducing the number of items included in the scales allowed the identification of the items that represented the relevant information in men and women, in different ranges of ages and in different levels of severe obesity.

The adaptations carried out previously, with Spani sh and Mexican women, showed different factor structures (2-factorsolutions) (Lopez-Aguilar et al., 2011; Sanchez-Carracedo, Raich, Figueras, Torras, & Mora, 1999). Comparing these results with the ones obtained in the present study, it is difficult to substantiate differences among sex distribution, mean age or educational level in the different samples. The next goal should be to increase the sample number with normal-weight participants for comparison with general population.

The principal issue of the study was the lack of equity in the sex distribution and the limited number of patients' follow-up in two years, thus it would be convenient to replicate the results obtained in greater samples. Moreover, the sample showed very homogeneous clinical features, which means that the scales derived from the analysis could result in a useful and easy-to-manage instrument in BS and endocrinology offices, where the evaluation process for surgery normally / generally starts, allowing for a better detection of successful candidates for BS and providing specific adaptations to treatments performed before procedures.

doi: 10.7334/psicothema2014.46

Acknowledgements

This study was supported by the Institute of Health Carlos III, ISCIII (PI07/224) and the Fundacion Mutua Madrilena (MUTUA 2007/80).

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Diana Tabeada (1), Mercedes Navio (1), Rosa Jurado (1), Vanesa Fernandez (1), Carmen Bayon (2), Ma Jose Alvarez (1), Isabel Morales (1), Guillermo Ponce (1), Gabriel Rubio (1), Jose Carlos Mingote (1), Felipe Cruz (1), Miguel Angel Jimenez (1)

(1) Hospital Universitario 12 de Octubre and (2) Hospital Universitario La Paz

Received: February 24, 2014 * Accepted: January 21, 2015

Corresponding author: Diana Taboada Denia

Servicio de Psiquiatria

Hospital Universitario 12 de Octubre

28045 Madrid (Spain)

e-mail: taboada.diana@gmail.com
Table 1
Original TFEQ and Spanish adaptation

Part I (True or False)

1. When I smell a sizzling steak or see a juicy piece of meat,
I find it very difficult to keep from eating, even if I have
just finished a meal.

2. I usually eat too much at social occasions like parties
and picnics.

3. I am usually so hungry that I eat more than                   DE-13
three times a day.

4. When I have eaten my quota of calories, I am usually
good about not eating any more.

5. Dieting is so hard for me because I just get too hungry.        DE

6. I deliberately take small helpings as a means of              RB-6
controlling my weight.

7. Sometimes things just taste so good that I keep on eating
even when I am no longer hungry.                                   DE

8. Since I am often hungry, I sometimes wish that while I am
eating, an expert would tell me that I have had enough or        DE-13
that I can have something more to eat.

9. When I feel anxious, I find myself eating.                    DE-13

10. Life is too short to worry about dieting.                    PR-4

11. Since my weight goes up and down, I have gone on
reducing diets more than once.

12. I often feel so hungry that I just have to eat something.      DE

13. When I am with someone who is overeating, I usually            DE
overeat too.

14. I have a pretty good idea of the number of calories
in common food.

15. Sometimes when I start eating, I just can't seem to stop.    DE-13

16. It is not difficult for me to leave something on my plate.

17. At certain times of the day, I get hungry because
I have gotten used to eating then.

18. While on a diet, if I eat food that is not allowed,
I consciously eat less for a period of time to make up for it.

19. Being with someone who is eating often makes me hungry       DE-13
enough to eat also.

20. When I feel blue, I often overeat.                           DE-13

21. I enjoy eating too much to spoil it by counting                RB
calories or watching my weight.

22. When I see a real delicacy, I often get so hungry that         DE
I have to eat right away.

23. I often stop eating when I am not really full as a           RB-6
conscious means of limiting the amount that I eat.

24. I get so hungry that my stomach often seems like             DE-13
a bottomless pit.

25. My weight has hardly changed at all in the last                PR
ten years.

26. I am always hungry so it is hard for me to stop eating       DE-13
before I finish the food on my plate.

27. When I feel lonely, I console myself by eating.              DE-13

28. I consciously hold back at meals in order not to             RB-6
gain weight.

29. I sometimes get very hungry late in the evening or             DE
at night.

30. I eat anything I want, any time I want.                      RB-6

31. Without even thinking about it, I take a long time to eat.

32. I count calories as a conscious means of controlling my weight.

33. I do not eat some foods because they make me fat.              RB

34. I am always hungry enough to eat at any time.                DE-13

35. I pay a great deal of attention to changes in my figure.       RB

36. While on a diet, if I eat a food that is not allowed,        DE-13
I often then splurge and eat other high calorie foods.

Part II

Please answer the following questions by circling the number
above the response that is appropriate to you.

37. How often are you dieting in a conscious effort to control
your weight?

1. Rarely; 2. Sometimes; 3. Usually; 4. Always                   RB-6

38. Would a weight fluctuation of 5 lbs affect the way you
live your life?

1. Not at all; 2. Slightly; 3. Moderately; 4. Very much

39. How often do you feel hungry?

1. Only at mealtimes; 2. Sometimes between meals;                DE-13
3. Often between meals; 4. Almost always

40. Do your feelings of guilt about overeating help you to
control your food intake?

1. Never; 2. Rarely; 3. Often; 4. Always                         RB-6

41. How difficult would it be for you to stop eating halfway
through dinner and not eat for the next four hours?

1. Easy; 2. Slightly difficult; 3. Moderately difficult;         DE
4. Very difficult

42. How conscious are you of what you are eating?

1. Not at all; 2. Slightly; 3. Moderately; 4. Extremely          PR-4

43. How frequently do you avoid 'stocking up' on tempting foods?

1. Almost never; 2. Seldom; 3. Usually; 4. Almost always

44. How likely are you to shop for low calorie foods?

1. Unlikely; 2. Slightly unlikely; 3. Moderately likely;
4. Very likely

45. Do you eat sensibly in front of others and splurge alone?

1. Never; 2. Rarely; 3. Often; 4. Always

46. How likely are you to consciously eat slowly in order to
cut down on how much you eat?

1. Unlikely; 2. Slightly unlikely; 3. Moderately likely;         PR-4
4. Very likely

47. How frequently do you skip dessert because you are no
longer hungry?

1. Almost never; 2. Seldom; 3. At least once a week;
4. Almost every day

48. How likely are you to consciously eat less than you want?

1. Unlikely; 2. Slightly unlikely; 3. Moderately likely;         PR-4
4. Very likely

49. Do you go on eating binges though you are not hungry?

1. Never; 2. Rarely; 3. Sometimes; 4. At least once a week       DE-13

50. On a scale of 0 to 5, where 0 means no restraint in eating
(eating whatever you want, whenever you want it) and 5 means total
restraint (constantly limiting food intake and never 'giving in'),
what number would you give yourself?

0. Eat whatever you want, whenever you want it

1. Usually eat whatever you want, whenever you want it

2. Often eat whatever you want, whenever you want it

3. Often limit food intake, but often 'give in'

4. Usually limit food intake, rarely 'give in'

5. Constantly limiting food intake, never 'giving in'            RB

51. To what extent does this statement describe your eating
behavior? 'I start dieting in the morning, but because of any number
of things that happen during the day, by evening I have given up and
eat what I want, promising myself to start dieting again tomorrow.'

1. Not like me; 2. Little like me; 3. Pretty good description
of me; 4. Describes me perfectly

Parte I (Verdadero o Falso)

l.Cuando me llega el olor de la carne en la sarten, o veo un buen
filete jugoso me resulta dificil retenerme y no comermelo, incluso
habiendo terminado de comer

2. Suelo comer demasiado en reuniones sociales, como fiestas y
picnics

3. Suelo tener tanta hambre que como mas de tres veces al dia

4. Cuando he tomado mi cuota de calorias, entonces dejo de comer.

5. Me resulta muy dificil seguir una dieta porque me muero de
hambre.

6. Me sirvo deliberadamente poco como medida para controlar el peso

7. A veces las cosas saben tan bien que no puedo remediar seguir
comiendo aun sin tener hambre

8. Puesto que tengo hambre a menudo, a veces desearia que, cuando
como, un experto me dijera que ya comi suficiente o que todavia
puedo comer algo mas

9. Cuando me siento ansioso/a, me encuentro a mi mismo/a comiendo .

10. La vida es demasiado corta para preocuparse de seguir una dieta
(inv)

11. Me he puesto a dieta mas de una vez porque mi peso sube y baja.

12. A menudo tengo tanta hambre que tengo que comer algo.

13. Cuando estoy con alguien que come demasiado, normalmente yo
tambien lo hago.

14. Se bastante bien la cantidad de calorias que tienen los mas
comunes.

15. A veces, cuando empiezo a comer, parece como si no pudiera
parar.

16. No es dificil para mi dejarme algo en el plato.

17. Hay algunos momentos del dia en los que tengo hambre porque me
he acostumbrado a comer a esa hora.

18. Cuando sigo una dieta, si como algo que me esta prohibido, como
conscientemente menos, durante un cierto periodo de tiempo, para
compensarlo.

19. Estar con alguien que esta comiendo, a menudo, me pone lo
bastante hambriento para comer yo tambien.

20. Cuando me siento triste, a menudo como demasiado.

21. Me gusta demasiado comer como para estropearlo contando
calorias o controlando el peso (Inv)

22. Cuando veo una verdadera exquisitez, a menudo me entra tanta
hambre que tengo que comer de inmediato.

23. A menudo dejo de comer cuando todavia no estoy lleno como una
medida consciente de limitar la cantidad de comida que tomo.

24. Tengo tanta hambre que mi estomago, a menudo, parece un pozo
sin fondo.

25. Mi peso casi no ha cambiado en los ultimos diez anos (inv).

26. Siempre tengo hambre, asi que me es dificil dejar de comer
hasta que no he terminado todo lo que tengo en el plato.

27. Cuando me siento solo me consuelo comiendo.

28. Me controlo conscientemente en las comidas para no ganar peso.

29. A veces me entra mucha hambre a ultimas horas de la tarde o por
la noche.

30. Como lo que quiero, todas las veces que lo deseo. (inv)

31. Incluso sin darme cuenta me paso mucho tiempo comiendo. (inv)

32. Cuento las calorias como un modo consciente de controlar mi
peso

33. Algunos alimentos no los tomo porque engordan.

34. Siempre tengo suficiente hambre para comer a cualquier hora.

35. Presto mucha atencion a los cambios que se producen en mi
figura.

36. Cuando sigo un regimen, si tomo algo que me esta prohibido, a
menudo me suelto y tomo mas alimentos altamente caloricos.

Parte II

Por favor, responde a las siguientes preguntas marcando el numero
correspondiente a la respuesta que describe tu comportamiento.

37. ?Con que frecuencia esta a dieta en un esfuerzo consciente por
controlar su peso?

1. Raramente; 2. A veces; 3. Normalmente; 4. Siempre

38. ?Le afectaria a su forma de vida un cambio de peso de 2 kg?

1. Nada; 2. Ligeramente; 3. Moderadamente; 4. Mucho

39. ?Con que frecuencia tiene hambre?

1. En las comidas; 2. A veces entre horas; 3. Frecuentemente entre
horas; 4. Casi siempre

40. ?Su sentimiento de culpa por comer demasiado le ayuda a
controlar lo que come?

1. Nunca; 2. Raramente; 3. A menudo; 4. Siempre

41. ?Le seria dificil interrumpir su comida a la mitad y no comer
durante las 4 horas siguientes?

1. Facil; 2. Un poco dificil; 3. Moderadamente dificil; 4. Muy
dificil

42. ?Es usted consciente de lo que come?

1. Nada; 2. Un poco; 3. Bastante; 4. Mucho

43. ?Con que frecuencia evita comprar comidas tentadoras?

1. Casi nunca; 2. A veces; 3. Normalmente; 4. Casi siempre

44. ?Suele comprar alimentos bajos en calorias?

1. No; 2. Alguna vez; 3. Normalmente; 4. Siempre

45. ?Come sensatamente delante de los demas y se atiborra solo?

1. Nunca; 2. Raramente; 3. A menudo; 4. Siempre

46. ?Le seria posible comer despacio conscientemente para comer
menos?

1. Imposible; 2. Poco posible; 3. Posible; 4. Muy posible

47. ?Con que frecuencia no toma postre porque ya no tiene mas
hambre?

1. Casi nunca; 2. A veces; 3. Al menos una vez por semana; 4. Casi
cada dia

48. ?Estaria dispuesto a comer conscientemente menos de lo que
desea?

1. Imposible; 2. Poco posible; 3. Posible; 4. Muy posible

49. ?Continua comiendo lo que encuentra aunque no tenga hambre?

1. Nunca; 2. Raramente; 3. A veces; 4. Al menos una vez por semana

50. En una escala del 0 al 5, donde 0 significa "ninguna
restriccion para comer" (comer lo que uno quiere y cuando quiere),
y 5 significa "restriccion total" (limitarse constantemente la
comida y no ceder nunca). ?Que puntuacion se daria a si mismo?

0. Como lo que quiero, cuando quiero

1. Normalmente como lo que quiero, cuando quiero

2. A menudo como lo que quiero, cuando quiero

3. A menudo limito lo que como, pero cedo frecuentemente

4. A menudo limito lo que como y cedo rara vez

5. Constantemente limito lo que como, no cediendo nunca

51. ?Hasta que punto describe su habito alimentario lo siguiente?:
"Empiezo a seguir un regimen por la manana pero, a causa de
numerosas circunstancias que suceden durante el dia, al final de la
tarde ya lo he dejado y como lo que me apetece prometiendome a mi
mismo que volvere a empezar el regimen al dia siguiente"

1. Nada; 2. Un poco; 3. Bastante; 4. Perfectamente

Table 2

Summary of the results of multitrait/multi-item scaling tests of
the TFEQ and Reliability estimates

                              Multitrait/multi-item scaling tests

                                        Item-scale
                                    convergent validity

                          Range of r             Criterion 1

                                             Number of item-scale
                          Item-scale      correlations [greater than
Scales (a)             correlations (b)      or equal to]0.40 (c)

Sample (n = 222)
Cognitive restraint      0.03 - 0.59                 7/21
Disinhibition            0.03 - 0.51                 9/16
Hunger                   0.12 - 0.56                 7/14

                             Multitrait/multi-item scaling tests

                                        Item-scale
                                   discriminant validity

                           Range of r             Criterion 2

                       Correlations with        Number of items
Scales (a)              other scales (d)    significantly higher (e)

Sample (n = 222)
Cognitive restraint       0.00 - 0.31                20/21
Disinhibition             0.01 - 0.53                 8/16
Hunger                    0.01 - 0.49                 8/14

                                   Reliability

                               Scaling fulfilment

                       Number of items that
                        meet both criteria
Scales (a)                 1 and 2 (f)        KR-20

Sample (n = 222)
Cognitive restraint            7/21            0.75
Disinhibition                  5/16            0.70
Hunger                         5/14            0.79

(a) Cognitive restraint (21 items), Disinhibition (16 items) and
Hunger (14 items).

(b) Pearson correlations between items and scales (corrected for
overlap).

(c) Item-scale correlations that meet the standard for convergent
validity (r [greater than or equal to]0.40)/ Number of
correlations.

(d) Range of correlations between items and competing scales.

(e) Correlations significantly higher between items and original
scale in comparison with all other scales (by 2 standard errors or
more / total number of correlations.) The standard error of the
correlation matrix was 0.067.

(f) Items in each scale that met criteria for both convergent
(Criterion 1) and discriminant (Criterion 2) validity

Table 3

Factor structure (three-factor solution) of the TFEQ, Reliability
estimates, Means, Standard Deviations (SD) and Ranges of each factor

Factor loadings[greater than or equal to] 0.40 (orthogonal rotation)

     Factor 1                                     Factor 3
  "Dysregulated        Factor 2 "Restraint    "Predisposition
    eating" (a)             behaviour"          to restraint"

Item (b)             Item                   Item

DI15        0.64     CR28         0.68      DI25        0.59
HU3         0.63     CR6          0.63      CR10        0.58
HU24        0.62     CR23         0.63      CR46        0.53
DI9         0.61     CR40         0.61      CR48        0.52
HU26        0.61     CR30         0.53      CR42        0.49
DI27        0.60     CR37         0.52
HU34        0.60     CR33         0.46
HU20        0.59     CR50         0.46
DI49        0.59     CR21         0.43
DI19        0.55     CR35         0.42
HU39        0.54
DI13        0.53
DI7         0.52
DI36        0.50
HU22        0.50
HU8         0.46
HU29        0.45
HU12        0.44
HU5         0.44
H41         0.42

KR-20       0.88     KR-20        0.78      KR-20       0.64

Mean (SD)   Range    Mean (SD)    Range     Mean (SD)   Range

9.85        0-20     4.09         0-10      3.52        0-5
(5.54)               (2.78)                 (1.45)

(a) Eigenvalues were 7.89 for Factor 1; 4.67 for Factor 2;
and 3.5 for Factor 3.

(b) Letters and item numbers refer to the original placement
in StunKard and Messick (9): Cognitive Restraint (CR),
Disinhibition (DI) and Hunger (HU)

Table 4 Summary of results of multitrait/multi-item scaling tests
for revised and reduced scales and Reliability estimates

                             Multitrait/multi-item scaling tests

                               Item-scale convergent validity

                          Range of r             Criterion 1

                                             Number of item-scale
                          Item-scale      correlations [greater than
Revised scales (a)     correlations (b)      or equal to]0.40 (c)

Sample (n = 222)
Dysregulated eating       0.37-0.58                 12/13
Restraint behaviour       0.36-0.53                  5/6
Predispostion             0.32-0.44                  1/4
  to restraint

                       Multitrait/multi-item scaling tests

                         Item-scale discriminant validity

                          Range of r         Criterion 2

                                           Number of items
                       Correlations with    significantly
Revised scales (a)     other scales (d)       higher (e)

Sample (n = 222)
Dysregulated eating        0.00-0.31            13/13
Restraint behaviour        0.00-0.29             5/6
Predispostion              0.01-0.20             3/4
  to restraint

                                  Reliability

                              Scaling fulfilment

                       Number of items that
                        meet both criteria
Revised scales (a)         1 and 2 (f)        KR-20

Sample (n = 222)
Dysregulated eating           12/13           0.85
Restraint behaviour            5/6            0.73
Predispostion                  1/4            0.60
  to restraint

(a) Dysregulaedt eating (14 items), Restraint behaviour (6 items)
and Predisposition to Restraint (4 items).

(b) Pearson correlations between items and scales (corrected for
overlap).

(c) Item-scale correlations that meet the standard for convergent
validity (r [greater than or equal to]0.40)/ Number of
correlations.

(d) Range of correlations between items and competing scales.

(e) Correlations significantly higher between items and original
scale in comparison with all other scales (by 2standard errors or
more/ total number of correlations.) The standart error of the
correlation matrix= 0.067

(f) Items in each scale that meet criteria for both convergent
(Criterion 1) y discriminant (Criterion 2) validity

Table 5
Intercorrelations between the original TFEQ scale scores, derived
factor scores (three factors) and revised-reduced scale
scores (n = 222)

                                    Pearson correlations (r)

                                      TFEQ original scales

                                CR-21        DI-16         HU-14

TFEQ original scales

Cognitive restraint (CR-21)

Disinhibition (DI-16)         -0.120
                              0.074

Hunger (HU-14)                -0.187(**)   0.716(**)
                              0.005        0.000

Derived factors

Factor 1                      -0.193(**)   0.867(**)    0.939(**)
(Dysregulation eating)        0.004        0.000        0.000

Factor 2                      0.924(**)    -0.157(*)    -0.189(**)
(Restraint behaviour)         0.000        0.020        0.005

Factor 3 (Predisposition      0.420(**)    0.065        -0.124
to Restraint)                 0.000        0.338        0.065

Revised-scales

Dysregulated eating (DE-13)   -0.164(*)    0.838(**)    0.910(**)
                              0.014        0.000        0.000

Restraint behaviour (RB-6)    0.872(**)    -0.111       -0.119
                              0.000        0.098        0.077

Predisposition to             0.478(**)    -0.010       -0.165(*)
Restraint (PR-4)              0.000        0.876        0.014

                                     Pearson correlations (r)

                                         Derived factors

                               Factor 1     Factor 2     Factor 3

TFEQ original scales

Cognitive restraint (CR-21)

Disinhibition (DI-16)

Hunger (HU-14)

Derived factors

Factor 1
(Dysregulation eating)

Factor 2                      -0.212(**)
(Restraint behaviour)         0.001

Factor 3 (Predisposition      0.047        0.357(**)
to Restraint)                 0.487        0.000

Revised-scales

Dysregulated eating (DE-13)   0.972(**)    -0.186(**)    -0.051
                              0.000        0.005         0.446

Restraint behaviour (RB-6)    -0.140(*)    0.939(**)     0.254(**)
                              0.037        0.000         0.000

Predisposition to             -0.115       0.315(**)     0.957(**)
Restraint (PR-4)              0.089        0.000         0.000

                                 Pearson correlations (r)

                                     Derived factors

                               DE-13      RB-6      PR-4

TFEQ original scales

Cognitive restraint (CR-21)

Disinhibition (DI-16)

Hunger (HU-14)

Derived factors

Factor 1
(Dysregulation eating)

Factor 2
(Restraint behaviour)

Factor 3 (Predisposition
to Restraint)

Revised-scales

Dysregulated eating (DE-13)

Restraint behaviour (RB-6)    -0.106
                              0.115

Predisposition to             -0.097    0.292(**)
Restraint (PR-4)              0.149     0.000

** Statistical significant correlation at 0.01 (bilateral).

* Statistical significant correlation at 0.05 (bilateral)

Table 6

Means, Standard Deviations (SD) and 95% Confidence Index (CI(95%)
of the revised scales in an obese group suffering from Binge
Eating (BE-Group) and those without Binge Eating (N BE-Group).
Difference between groups (one way ANOVA)

                       BE-Group
                       (n = 89)
Revised
scales (a)    Mean (SD)       CI (95%)

DE-13        9,20 (3,15)    8,54 - 9,87
RB-6         2,15 (1,71)    1,78 - 2,51
PR-4         3,09 (0,92)    2,89 - 3,28

                      N BE-Group
                      (n = 132)
Revised
scales (a)    Mean (SD)       CI (95%)     F(1,219)     P-value

DE-13        5,33 (3,08)    4,80 - 5,86      82,29       0,000
RB-6         2,56 (1,94)    2,23 - 2,89      2,66        0,104
PR-4         2,61 (1,36)    2,37 - 2,84      8,60        0,004

(a) DE-13 (Dysregulated eating); RB-6 (Restraint behaviour);
PR-4 (Predisposition to Restraint)
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Title Annotation:articulo en ingles; Three Factor Eating Questionnaire
Author:Tabeada, Diana; Navio, Mercedes; Jurado, Rosa; Fernandez, Vanesa; Bayon, Carmen; Alvarez, Ma Jose; M
Publication:Psicothema
Date:Apr 1, 2015
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