- Email: [email protected]
The Dutch Eating Behaviour Questionnaire (DEBQ). Assessment of eating behaviour in an aging French population
Appetite 59 (2012) 853–858
Contents lists available at SciVerse ScienceDirect
Appetite journal homepage: www.elsevier.com/locate/appet
Research report
The Dutch Eating Behaviour Questionnaire (DEBQ). Assessment of eating behaviour in an aging French population Nathalie Bailly a,⇑, Isabelle Maitre b, Marion Amanda c, Catherine Hervé a, Daniel Alaphilippe a a
University François Rabelais, E.A. 2114, «Psychologie des Ages de la Vie», Department of Psychology, 3 rue des Tanneurs, 37041 Tours Cedex, France PRESS L’UNAM - UPSP GRAPPE – GROUPE ESA-55 Rue Rabelais BP30748 – 49007 Angers cedex 01, France c ONIRIS, rue de la Géraudière, 44322 Nantes, France b
a r t i c l e
i n f o
Article history: Received 29 August 2012 Accepted 31 August 2012 Available online 7 September 2012 Keywords: Dutch Eating Behaviour Questionnaire Eating behaviour Elderly Older people Validation
a b s t r a c t The aim of the study was to develop a French version of the Dutch Eating Behaviour Questionnaire (DEBQ) in order to provide a self-report measure for French people in the field of gerontology. A short version of the DEBQ was administered to 262 participants aged 65 years and older. Single and multigroup confirmatory analyses were carried out. The fit measures for the three-factor model and the factorial invariance models with respect to age, sex and BMI status were satisfactory. Three subscales of DEBQ had satisfactory internal consistency. Regarding age, the results showed significant differences in emotional eating and restrained eating. Concerning sex, women had higher mean scores for emotional eating and restrained eating than men. Finally, the overweight older people had higher scores for emotional eating than the normal-weight participants. The short version of DEBQ should provide a useful measure for researchers and clinicians who are interested in exploring eating behaviours among the elderly. Ó 2012 Elsevier Ltd. All rights reserved.
Introduction Population aging is now a worldwide phenomenon. In the more developed regions, the proportion of the population 60 years and older is estimated to increase from 19% to 32% between 2000 and 2050, with those 80 years and older constituting more than one out of four of the elderly in 2050 (United Nations, 2003). This aging of the population has raised important questions concerning the specific nutrition of aging systems, changes in food preferences and overall quality of life (Elsner, 2002). Decreased physical activity and decreased energy expenditure with ageing predispose to fat accumulation and redistribution. According to several studies in developed countries, the early phase of aging (55–65 years) is often associated with a positive energy balance and an increase in body fat which is linked to excess morbidity, mortality, and health care costs (Andreyeva, Sturm, & Ringel, 2004; Calle, Teras, & Thun, 2005; Cornoni-Huntley et al., 1991). In the subsequent phase of aging (after 65–75 years), body fat and lean body mass decrease and continue to decline with a negative energy balance (Wilson & Morley, 2003). Age-related physiological changes contribute to the development of malnutrition in older adults (Chapman, 2010; Chen, Schilling, & Lyder, 2001). Eating is not an automatic process but is influenced to a large extent by cultural, social, and psychological pressures felt by each of us. Over the last 30 years, theories have been developed to as⇑ Corresponding author. E-mail address: [email protected] (N. Bailly). 0195-6663/$ - see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.appet.2012.08.029
sess various aspects of the motivation to eat which could impair adequate food intake and body weight control. Based on psychological theories, Van Strien et al. (Van Strien, Frijters, Bergers, & Defares, 1986) defined three different eating behaviours. The ‘‘psychosomatic theory’’ (Bruch, 1973; Kaplan & Kaplan, 1957) emphasizes the role of ‘‘emotional eating’’. It refers to eating in response to negative emotions in order to relieve stress while disregarding internal physiological signals of hunger. The ‘‘externality theory’’ (Rodin, 1981; Schachter, Goldman, & Gordon, 1968) refers to eating in response to food-related stimuli (sight or smell of food) regardless of the internal state of hunger and satiety. The theory of ‘‘restrained eating’’ (Herman & Polivy, 1975) reflects the degree of conscious food restriction (attempts to refrain from eating in order to lose or maintain a particular weight). Most studies have indicated that these three eating behaviours are linked to the body mass index (BMI) (Baños et al., 2011; Bozan, Bas, & Hulya Asci, 2011; Porter & Johnson, 2011; Ricca et al., 2009; Van Strien, Herman, & Verheijden, 2009), nature of food consumption (Baños et al., 2011; Burton, Smit, & Lightowler, 2007; Ouwens, Van Strien, & Van Der Staak, 2003; Porter & Johnson, 2011; Snoek, Van Strien, Janssens, & Engels, 2007) and psychological outcomes such as depression, anxiety or body-esteem (Flament et al., 2012; Goossens, Braet, Van Vlierberghe, & Mels, 2009; Porter & Johnson, 2011). The three types of eating behaviour can be reliably and validly measured using the Dutch Eating Behaviour Questionnaire (DEBQ: Van Strien et al., 1986). The DEBQ consists of 33 items with answers on a 5-point Likert scale (ranging from ‘‘never’’ to ‘‘very often’’). The English version of the original DEBQ (Wardle, 1987)
854
N. Bailly et al. / Appetite 59 (2012) 853–858
has been translated into many languages: Portuguese (Viana & Sinde, 2003), Turkish (Bozan et al., 2011), Spanish (Baños et al., 2011), French (Lluch et al., 1996) and Swedish (Halvarsson & Sjoden, 1998). All these versions show good factorial validity (reporting a stable factor solution for the total DEBQ and for the three subscales) and reliability, and also satisfactory internal consistency. The DEBQ has a stable factor structure across genders, weight categories, and random samples (Allison, Kalinsky, & Gorman, 1992; Van Strien & Oosterveld, 2008). Different versions have been adapted for adults and adolescents (Lluch et al., 1996; Van Strien et al., 1986; Wardle, 1987) for children (Halvarsson & Sjoden, 1998: 9–10 years old; Van Strien & Oosterveld, 2008: 7–12 years old) and for clinical populations (Baños et al., 2011; Lluch et al., 1996). A version of the questionnaire for parents (DEBQ-P) has been validated in the Italian population (Caccialanza et al., 2004). However to date, no version adapted for an older and oldest-old population has been developed. Given the specific nutritional problems linked to an aging population, it seems important to have a reliable and valid tool to provide a better understanding of eating behaviours in aging, which can be used by public health nutrition practitioners and researchers. The aims of the present study were to test the factorial validity and internal consistency of a short version of the DEBQ in an older people population. Further aims were to test the factorial validity and the similarity of the factorial structure for men and women, older and the oldest-old, and for those who were or were not overweight (BMI-status). The final purpose was to obtain basic data concerning the DEBQ in an older population.
Methods Participants Data presented in this study were obtained from the Aupalesens project: ‘‘Improving pleasure of elderly people for better aging and for fighting against malnutrition’’ (http://www2.dijon.inra.fr/aupalesens/).1 A sample of 559 older French adults aged 65 years and older replied to a multidisciplinary questionnaire on food preferences, social factors and food context, sensory abilities, medical status and nutritional status of individuals aged 65 years and older (the survey contained a total of more than 400 items). French older adults were recruited and stratified by age, gender and marital status in four towns in France. Volunteers were screened for cognitive impairment using the French adaptation of Folstein’s Mini Mental Status Examination (MMSE; Desrosiers & Hébert, 1997) and were excluded if they scored less than 25. The Aupalesens project was funded by the French National Research Agency (ANR); the experimental protocols were approved by the local research ethics committee (CPP). The present study concerns only older people living independently (the first category of the Aupalesens Project). The total sample included 262 French adults aged 65 and older living in their own homes. The mean age of the participants was 73.49 years (SD = 5.46, 65–90) with 178 women (67.9%, M age = 73.75, SD = 5.4) and 84 men (32.1%, M age = 72.95, SD = 5.4). Regarding marital situation, 51% (n = 134) were married or had a partner and 49% (n = 128) lived alone. Regarding previous occupational status, the main categories were office workers (42.74%, n = 112), executives (33.6%, n = 88) and middle managers (21%, n = 55). 1 The Aupalesens project aims to investigate food preferences and behaviour associated with the desire to eat and the pleasure of eating in older people during aging. Four categories were identified: (1) people living at home without any assistance, (2) people living at home with assistance, except for meal preparation, (3) people living at home with assistance for meal preparation or meal delivery and (4) people living in a nursing home.
BMI was calculated from height and weight measurements. International cut-off scores were used to determine whether a participant was overweight or obese. Participants with scores above 25 were considered overweight or obese. There were no underweight participants (BMI < 18.50) in our sample. A total of 34.44% (n = 90) of the participants had a normal weight status and 65.56% (n = 172) were overweight or obese. The distribution of BMI obtained for our sample was close to the percentages for the French population. In 2009, in France, 1.9% of people over 65 years of age were underweight and 60.2% were overweight or obese (ObEpi, 2009). Instrument: the DEBQ The DEBQ was assessed using the French version of Van Strien’s scale (Lluch et al., 1996). The DEBQ consists of 33 items answered on a 5-point Likert scale (ranging from ‘‘never’’ to ‘‘very often’’). Considering the aims of the Aupalesens project, the DEBQ could be used on less autonomous populations including those loosing physical autonomy living in nursing homes. However, due to the fatigue and annoyance effect specific to this older population (oldest-old) and further comparison with them, we decided to shorten the DEBQ scale. To this end, a group of experts in gerontology and eating behaviours met to identify strategies for selecting items. Attention was focused both on the results of the French validation study (Lluch et al., 1996) and on the validation of the questionnaire in an adult population. Firstly, we examined the factorial loadings of the 33 items from previous research. Items such as ‘‘Eat less if you have put on weight’’or ‘‘Desire to eat when bored or restless’’ were removed because of their lower factorial loadings when validated in French adults (Lluch et al., 1996). Secondly, the pertinence of the items in relation to an aging population was examined. For example items such as ‘‘Tempted when food is being prepared’’ and ‘‘Tempted by snack bar/ fast food store’’ were removed due to their lack of relevance for an aging population. Indeed, older adults may have difficulty performing basic activities of daily living, such as eating or preparing meals. Some of them require personal assistance services, assistive technology, help from others or all three to perform activities of daily living, and receive home delivery of meal trays (Davin, Paraponaris, & Verger, 2009). As a result of this review, 16 items (Table 1) were selected to represent the three eating behaviour patterns: restrained eating (5 items), external eating (5 items) and emotional eating (6 items). This adapted scale was then pilot-tested with ten older people. All the participants stated that they had no difficulty understanding the items and expressed their willingness to complete all the items. Data analysis First we carried out a factor and item analysis on the DEBQ. A Kaiser–Meyer–Olkin (KMO) value of 0.82 indicated a good sampling adequacy for the factor analysis. Bartlett’s test of sphericity yielded a chi-square value of 1752 (p = 0.000), indicating that the model is appropriate. The factor analysis was performed by means of a principal component factor analysis with varimax rotation. Criteria for item selection were (1) a factor loadings above 0.40 on the appropriate factors and (2) factor loadings not exceeding 0.20 on non-appropriate factors. To test whether the three-factor structure was an adequate representation of the older adult responses, a confirmatory factor analysis (CFA – Joreskog & Sorbom, 1998) was performed on the total sample of participants. CFA was chosen over exploratory factor analysis (EFA) because it can be used (1) to test first whether the hypothesized factor structure for the set of measures fits the data
855
N. Bailly et al. / Appetite 59 (2012) 853–858 Table 1 Varimax rotated 3-factor solution of the DEBQ (16 items) for older subjects. Emotional eating 30.27% 1 – Desire to eat when irritated
Restrained eating 13.39%
External eating 10.37%
.675 .131
.100
2 – Eat more when see others eat
.061
.499
3 – Desire to eat when watch others eat
.345
.048
4 – Eat less after eating too much
.133
.510
.684 .077
5 – Eat less than you would like
.118
6 – Desire to eat when walk past the baker
.239
.634 .047
7 – Eat less to avoid weight gain become heavier
.137
8 – Desire to eat when something unpleasant is about to happen
.872
9 – Desire to eat when feeling lonely
.707 .051
10 – Watch what you eat
.793 .011
.187
.152 .461 .033 .078
.167
.199
.646 .101
-.103 .215
11 – Desire to eat when depressed or discouraged
.791
12 – Desire to eat when things go wrong
.037
.100
13 – Desire to eat when see or smell food
.892 .003
.049
14 – Eat slimming foods
.187
.724 -.096
.738 -.048
15 – Eat more if food tastes good 16 – Desire to eat when emotionally upset Cronbach’s Alpha
.021 .881 .90 (6 items)
.015
.696 .085
.71 (5 items)
.70 (5 items)
As the DEBQ is protected by copyrightÓ (Berne convention), only abbreviated items are given. Underlined values: factor loadings > .40.
and, if this is the case, (2) to examine how similarly the model fits across the different sub-samples (Bryant & Yarnold, 1995). Firstly, we investigated whether the three-factor model was an adequate representation of the relationship between the items. Secondly, we investigated whether this model was appropriate for several subsamples by fitting multigroup models. Hence, a number of models were fitted for which equality constraints on parameters over the groups were gradually imposed, i.e., first the three-factor model was fitted for each group (Model 0), then equality constraints were imposed on the factor correlations (Model 1), then additional equality restrictions were imposed on the factor loadings (Model 2) and, finally, equality restrictions were imposed on the unique variances (Model 3). Model fit was examined using the ratio of v2 and degree of freedom (v2/df), and the root mean square error of approximation (RMSEA). The ratio should not exceed 2; the RMSEA should not exceed the 0.05 level. The RMSEA is accompanied by the test of close fit, which should not reach significance. For multigroup models, a v2 difference test can be used to test whether imposing additional restrictions leads to a significant drop in fit. Multigroup tests were performed for age, sex and BMI-status. The test on factorial invariance for age was conducted on two age groups (based on the median): 65–73 yearsold (n = 141) and 73 years-old and older (n = 121). Finally, scores for each of the three scales were obtained by dividing the sum of the item-scores by the total number of items on that scale. For each scale, means and standard deviations (SD) were calculated and compared according to sex, BMI-status and age. All analyses were conducted with AMOS-SPSS.
Results The factorial structure of the shorter form was examined using exploratory factor analysis on the 262 older people of 65 years and older. The screen-test suggested that a three-factor solution was the best fit for the data (Table 1). The three factors explained 54% of the variance among the scale items (30.27%, 13.39%, and 10.37%). Factor 1 included the six emotional eating items (eigenvalue = 4.8). Factor 2 included the five restrained eating items (eigenvalue = 2.1). Factor 3 included the five externality eating items (eigenvalue = 1.66). In line with the results of Van strien et al., our findings thus support a three-factor model in an older population. Cronbach’s alpha value was .90 for emo-
tional eating, .71 for restrained eating and .70 for externality eating, indicating satisfactory internal consistencies in our study.
Factor structure and factorial invariance Table 2 shows the fit measures of the three-factor model in the total sample and the multigroup models for the test of factorial invariance. First, a baseline model was examined involving three correlated latent factors (emotion, restriction and externality) with six items loading for emotion, five items each loading for restriction and externality. The v2/df was just above 2 and the RMSEA was higher than .05. The indices were acceptable but not good. If the initial model to be tested did not provide an adequate representation of the data, the modification indices (MIs) and standardized expected parameter changes (SEPCs) were used to modify the model, as recommended by Kaplan (1989). MIs and SEPCs suggested error covariances between (1) items 13 and 15 (external dimension), (2) items 1 and 8 (emotion dimension) and (3) items 9 and 16. The model was modified to incorporate these additional parameters; the fit indices associated with this model are presented in Table 2 as Model (a). Analysis revealed that the model now provided a better fit to the data as evidenced by the low RMSEA and higher v2/df. The second section of Table 2 contains the fit measures of the multigroup models for testing factorial invariance for age. Model 0 – the model specifying that the three-factor model is adequate for both groups with varying parameter values for the groups – had adequate fit measures. Thus, the three-factor model was applicable for older and the oldest-old participants. The results were basically the same for Model 1 and the v2 difference test showed that the difference in fit for Model 0 and 1 is not significant. The results were the same for Model 1 and Model 2. This was not the case for Model 3: the v2 difference test showed that adding equality restrictions on the unique variance led to a significant difference in fit. The third section of Table 2 contains the fit measures of the multigroup model for testing factorial invariance for sex. All the models had acceptable fit measures and the differences between the models are not significant indicating that the three-factor model was applicable for the older men and women. However, in Model 3, the v2 difference test showed that adding equality restrictions on the unique variances led to a significant difference in fit. The fourth section of Table 2 contains the results for the factorial invariance test in relation to BMI status. The results indicate
856
N. Bailly et al. / Appetite 59 (2012) 853–858
Table 2 Fit measures for the DEBQ three-factor models and the multigroup models for age, sex and BMI status.
v2 difference test
Fit measures 2
2
df
p
210 157
101 98
.000 .000
2.07 1.63
.064 .049
.031 .52
Test for age (multigroup model) Model 0 281 Model 1 291 Model 2 297 Model 3 332
192 205 211 232
.000 .000 .000 .000
1.47 1.42 1.41 1.43
.043 .040 .04 .04
.89 .94 .95 .94
9.5 6.3 34.4
13 6 21
.73 .39 .03
Test for sex (multigroup model) Model 0 Model 1 Model 2 Model 3
266 283 291 352
192 205 211 232
.000 .000 .000 .000
1.39 1.38 1.38 1.51
.039 .038 .038 .045
.96 .96 .97 .82
17.6 7.6 60.7
13 6 21
.17 .27 .00
Test for BMI (multigroup model) Model 0 282 Model 1 291 Model 2 298 Model 3 332
192 205 211 232
.000 .000 .000 .000
19.6 2,71 74,49
13 6 21
,11 .84 .00
Three-factor Model Three-factor Model(a)
v /df
v2
v
1,40 1,41 1,38 1,58
RMSEA
,039 ,040 ,038 ,047
p
,95 ,95 ,97 ,68
df
p
Table 3 Means, Standard deviations (SD) for restrained, emotional and external eating in the total sample and the sub-sample of younger-old and older-older, women and men, normal weight and overweight participants. Restrained eating
Emotional eating
External eating
All sample (n = 262)
2.87 (.92)
2.02 (.97)
2.48 (.73)
Age Younger-old (141) Older-old (121)
2.98 (.92) 2.74 (.90)
2.14 (1.09) 1.88 (.90)
2.54 (.73) 2.42 (.74)
Sex Women (178) Men (84)
2.98 (.88) 2.64 (.96)
2.23 (1.01) 1.58 (.71)
2.50 (.74) 2.44 (.73)
BMI-status Normal weight (90) Overweight (172)
2.82 (.97) 2.90 (.90)
1.83 (.90) 2.12 (1)
2.49 (.64) 2.48 (.76)
that the three-factor structure was applicable for ‘‘normal weight status’’ and ‘‘overweight status’’, while Model 3, the most restricted model, led to a significant difference in fit. Eating behaviours in relation to age, sex and BMI-status Table 3 shows the means and standard deviations of the scales obtained in the total sample and sub-sample (younger-old/olderold, men/women, and normal weight/ overweight). In all the samples, restrained eating was the most prevalent type of eating behaviour, followed by external eating and emotional eating. Regarding age, results show significant differences in emotional eating (t(260) = 2.14 , p = .033) and restrained eating (t(260) = 2.12 , p = .035). The younger-old had higher mean scores for restriction and emotion than the older-old. Similarly, regarding sex, women had higher mean scores for emotional eating (t(260) = 5.31 , p = 0.000) and restrained eating (t(260) = 2.80 , p = 0.006) than men. The DEBQ responses showed no significant age and gender interactions (restrained eating: F(1,257) = 0.04; NS – emotional eating: F(1,257) = 0.19; NS and external eating: F(1.257) = 0.23; NS). Finally, regarding BMI status, overweight older people had higher scores for emotional eating than normalweight participants (t(260) = 2.24 , p = .026). No differences for external eating were observed between groups in the subsamples. Discussion The aim of this study was to validate a short version of the DEBQ to measure restrained, emotional and external eating in an
older adult population. A confirmatory factor analysis was performed to assess (1) the construct validity for the measure of eating behaviour dimensions, and (2) whether the factorial structure is invariant for age, sex and BMI-status. An additional objective was to provide some basic data for this first validation study among people aged 65 years and older. A tool of 16 items (6 for emotional eating, 5 for external eating and 5 for restrained eating) was drawn up which selected items according to their appropriateness for older people and their previous factor loadings in adults. A three-factor model showed acceptable fit indicating that this short version represents three dimensional factors. These three factors correspond to those of the original work of Van Strein et al. (1986) and the different language adult versions (Lluch et al., 1996; Wardle, 1987). To our knowledge, the CFA method has been used in only two previous studies (Baños et al., 2011; Van Strien & Oosterveld, 2008). The CFA was chosen in preference to exploratory factor analysis (EFA) because it can be used on models which have a well-developed underlying theory and to examine how similarly a model fits across diverse sub samples. In this study, the tests for factorial invariance showed that the three-factor model was applicable for the younger-old and oldest-old, men and women and the two groups of BMI status. Adding equality constraints on the factor correlations (Model 1) and on the factor loadings (Model 2) did not lead to a significant increase in v2 values. Nonetheless, the more restrictive model (Model 3), where equality restrictions were imposed on the unique variances, led to a significant difference in fit. Although the internal consistency values of DEBQ are good, they are lower than those reported in the original version of DEBQ (Van
N. Bailly et al. / Appetite 59 (2012) 853–858
Strien et al., 1986 – alpha between .80 and .95) and those reported in an adult French population (Lluch et al., 1996 – alpha between .82 and .91). The absence of previous data on an older population makes comparison difficult (the maximum age was 41 years in Llutch’s French validation). For a better understanding of these first results a larger sample of older people needs to be investigated. Nonetheless, regarding the structure and the psychometric properties of the DEBQ, this shorten scale appears to be a good self-report screening instrument that measures eating behaviours and attitudes to eating in an older adult population. Examination of the subsample scores on restrained, emotional and external eating reveals that restrained eating was the most prevalent type of reported eating behaviour, followed by emotional and external eating. The importance of restrained eating behaviour in the older people suggests that this population is particularly aware of food intake. In response to the prevalence of malnutrition in the older people, France has developed health awareness campaigns directed towards seniors and set up specific controlling bodies (PNNS: ‘‘National Nutritional Health Programme’’; HAS: French ‘‘National Authority for Health’’). These health recommendations can discourage older people from eating food considered unhealthy by social medical science. In addition, diabetes, cholesterol and other common diseases in older people can also lead to restrained food intake, for example reducing the consumption of cured meats and high-sugar content foods. This observed restrained eating behaviour would therefore be linked to a desire to remain healthy. Concerning age, our results indicate that restrained eating is higher in the younger-old group (65–73 years old) than in the oldest-old (over 73 years old). According to the restrained theory, restrained eaters attempt to control their eating but with age, uncontrollable and irreversible events occur (bereavement, death of close friends, role loss, etc.) which put considerable strain on one’s perceived control (Infurna, Gerstorf, & Zarit, 2011; Skaff, 2007). This perceived loss of control can explain the difference on restrained eating between younger-old and the oldest-old. It could also be postulated that the sensorial, physical and social losses among the oldest-old would lead individuals to put the pleasure of eating before health recommendations. This is clearly summarised by one of the interviewees in the Aupalesens project who said ‘‘eating is the only pleasure left!’’ (Sulmont-Rossé, Maître, & Issanchou, 2010). Thus, this loss of control on restrained eating may be a deliberate choice. In addition, our results indicate higher scores for emotional eating in the younger-old than for the oldest-old. Younger-old are more prone to eat in response to negative emotions to relieve stress. Gerontological research suggests a decline in negative emotions with age (Carstensen, Fung, & Charles, 2003). In particular, socio-emotional selectivity theory (Carstensen et al., 2003) suggests that elders improve in affect optimization, i.e., the ability to maximize positive emotion and dampen negative emotion. The oldest-old would thus have less need for emotion eating. However, to investigate this further it would be interesting to introduce a positive emotion item (e.g., ‘‘Desire to eat when happy’’) in the DEBQ scale to understand better the role of both positive and negative emotions on eating behaviour. Our study indicates that women scored higher in restrained and emotion eating than men. Regarding restrained eating, our results are similar to those observed in previous studies in young adult and adult populations (Wardle, 1987). It has been suggested that higher scores for dietary restraint in women could be explained by the fact that women are more likely to diet than men. Therefore, women express restrained behaviours in response to greater awareness and concern about food and fear of gaining weight (de Castro, 1995). In addition, current societal standards for female beauty emphasize the desirability of thinness (Wiseman, Gray, Mosimann, & Ahrens, 1992) leading women to be more concerned than men about the effects of aging on their appearance (Gupta &
857
Schork, 1993). Several authors highlight a ‘‘standard of aging’’ whereby older women are judged much more harshly than older men (Tiggemann, 2004; Wilcox, 1997). With regard to emotional eating, older women are more prone to this than older men. Gerontological literature indicates that older women experience depression and anxiety more often than older men (Schoevers, Beekman, Deeg, Jonker, & van Tilburg, 2003). This suggests emotion-oriented coping among older women is used to alleviate negative emotional states (Konttinen, Männistö, Sarlio-Lähteenkorva, Silventoinen, & Haukkala, 2010; Spoor, Bekker, Van Strien, & van Heck, 2007). Finally, concerning the BMI status, our study indicates that emotional eating is more important for the overweight participants. Our results are in line with previous studies (Greeno & Wing, 1994; Van Strien, Frijters, Roosen, Knuiman-Hijl, & Defares, 1985) which support the idea that overweight individuals are more likely to use food as an emotional defence to cope with a negative event, which causes overconsumption which, in turn, leads to obesity (Kaplan & Kaplan, 1957). However, contrary to previous results (Baños et al., 2011; Snoek et al., 2007; Wardle, 1987), BMI status did not influence restrained eating in the older group. This could be related to the body mass index (BMI) used to measure body fat. Many authors consider BMI to be unsuitable and not to take into account the age-related changes in body fat distribution. Some claim that ‘‘the BMI thresholds for overweight and obesity are overly restrictive for older people’’ (Flicker et al., 2010). Recent evidence indicates that in older people, obesity is paradoxically associated with a lower rather than higher, mortality risk (Chapman, 2010). Evidence from practice, in addition to literature reviews, does not support the use of BMI when assessing nutritional issues in individual older subjects. Furthermore, this could also explain the high rate of overweight participants in our sample (65.56%). Our study has several limitations. Given the characteristics of our sample (younger-old, living independently with no cognitive impairment, previously have high-level professional occupations, etc.), we can assume that our participants have not yet had to deal with major health or social problems. The high functioning level of our sample could have biased certain results. A study involving a more representative sample of the older French population would improve understanding of eating behaviour in old age. Further research should involve less autonomous and older people. These first results among younger-old should be compared with those for the oldest-old. Indeed, the loss of control in preparing meals and food choice for people with assistance for meal preparation or meal delivery will change eating behavior in terms of restrained, emotional and external eating. The DEBQ scale also needs to be tested for its concurrent, discriminant and predictive validity. To improve prevention and treatment strategies, factors that influence eating behaviours among older people need to be investigated. In particularly, social eating networks, body self-esteem, general eating habits, health status (misfitting or unclean dentures, lack of dentition) and mental health (anxiety, depression) undoubtedly impact on the motivation to eat among older people. Nonetheless, this first study shows that the French adaptation of the shorten scale has satisfactory psychometric properties and may therefore be a valuable instrument for researchers and clinicians who are interested in exploring the motivation to eat in older people.
References Allison, D. B., Kalinsky, L. B., & Gorman, B. S. (1992). The comparative psychometric properties of three measures of dietary restraint. Psychological Assessment, 4, 391–398. Andreyeva, T., Sturm, R., & Ringel, J. S. (2004). Moderate and severe obesity have large differences in health care costs. Obesity Research, 12, 1936–1943. Baños, R. M., Cebolla, A., Etchemendy, E., Felipe, S., Rasal, P., & Botella, C. (2011). Validation of the Dutch Eating Behavior Questionnaire for Children (DEBQ-C) for use with Spanish children. Nutrición Hospitalaria, 26(4), 890–898.
858
N. Bailly et al. / Appetite 59 (2012) 853–858
Bozan, N., Bas, M., & Hulya Asci, F. (2011). Psychometric properties of Turkish version of Dutch Eating Behaviour Questionnaire (DEBQ). A preliminary results. Appetite, 56(3), 564–566. Bruch, H. (1973). Eating disorders. Obesity, anorexia nervosa, and the person within. New York: Basic Books, pp. 44–65. Bryant, F. B., & Yarnold, P. R. (1995). Principal-components analysis and exploratory and confirmatory factor analysis. In L. G. Grimm & P. R. Yarnold (Eds.), Reading and understanding multivariate statistics (pp. 99–136). Washington, DC: American Psychological Association. Burton, P., Smit, H. J., & Lightowler, H. J. (2007). The influence of external eating behavior on overeating. Mediation by food cravings. Appetite, 49, 191–197. Caccialanza, R., Nicholls, D., Cena, H., Maccarini, L., Rezzani, C., Antonioli, L., et al. (2004). Validation of the Dutch Eating Behaviour Questionnaire Parent version (DEBQ-P) in the Italian population. European Journal of Clinical Nutrition, 58, 1217–1222. Calle, E. E., Teras, L. R., & Thun, M. J. (2005). Obesity and mortality. The New England Journal Medicine, 353, 2197–2199. Carstensen, L. L., Fung, H. H., & Charles, S. T. (2003). Socioemotional selectivity theory and the regulation of emotion in the second half of life. Motivation and Emotion, 27(2), 103–123. Chapman, I. M. (2010). Obesity paradox during aging. Interdisciplinary Topics in Gerontology, 37, 20–23. Chen, C. C., Schilling, L. S., & Lyder, H. (2001). A concept analysis of malnutrition in the elderly. Journal of Advanced Nursing, 36(1), 131–142. Cornoni-Huntley, J. C., Harris, T. B., Everett, D. F., Albanes, D., Micozzi, M. S., Miles, T. P., & Feldman, J. J. (1991). An overview of body weight of older persons, including the impact on mortality. The National Health and Nutrition Examination Survey I – Epidemiologic Follow-up Study. Journal of Clinical Epidemiology, 44(8), 743–753. Davin, B., Paraponaris, A., & Verger, P. (2009). Socioeconomic determinants of the need for personal assistance reported by community-dwelling elderly. Empirical evidence from a French national health survey. Journal of SocioEconomics, 38(1), 138–146. De Castro, J. M. (1995). The relationship of cognitive restraint to the spontaneous food and fluid intake of free-living humans. Physiology and Behavior, 57, 287–295. Desrosiers, J., & Hébert, R. (1997). Principaux outils d’évaluation en clinique et en recherche. In M. Arcand & R. Hébert (Eds.), Précis Pratique de Gériatrie (pp. 77–107). Edisem. Elsner, R. J. (2002). Changes in eating behavior during the aging process. Eating Behaviours, 3, 15–43. Flament, M. F., Hill, E. M., Buchholz, A., Henderson, K., Tasca, G. A., & Goldfield, G. (2012). Internalization of the thin and muscular body ideal and disordered eating in adolescence. The mediation effects of body esteem. Body Image, 9(1), 68–75. Flicker, L., McCaul, K. A., Hankey, G. J., Jamrozik, K., Brown, W. J., Byles, J. E., & Almeida, O. P. (2010). Body mass index and survival in men and women aged 70 to 75. Journal of the American Geriatrics Society, 58(2), 234–241. Goossens, L., Braet, C., Van Vlierberghe, L., & Mels, S. (2009). Loss of control over eating in overweight youngsters. The role of anxiety, depression and emotional eating. European Eating Disorders Review, 17(1), 68–78. Greeno, C., & Wing, R. (1994). Stress-induced eating. Psychological Bulletin, 115(3), 444–464. Gupta, M. A., & Schork, N. J. (1993). Aging-related concerns and body image. Possible future implications for eating disorders. International Journal of Eating Disorders, 14, 481–486. Halvarsson, K., & Sjoden, P. O. (1998). Psychometric properties of the Dutch Eating Behaviour Questionnaire (DEBQ) among 9–10-year-old Swedish girls. European Eating Disorders Review, 6, 115–125. Herman, C. P., & Polivy, J. (1975). Anxiety, restrained and eating behavior. Journal of Abnormal Psychology, 84(6), 666–672. Infurna, F. J., Gerstorf, D., & Zarit, S. H. (2011). Examining dynamic links between perceived control and health. Longitudinal evidence for differential effects in midlife and old age. Developmental Psychology, 47(1), 9–18. Joreskog, K., & Sorbom, J. (1998). LISREL 8. User’s reference guide. Hillsdale, NJ: Lawrence Erlbaum. 1998. Kaplan, D. (1989). Model modification in covariance structure analysis. Application of the expected parameter change statistic. Multivariate Behavioral Research, 24, 285–305.
Kaplan, H. L., & Kaplan, H. S. (1957). The psychosomatic concept of obesity. Journal of Nervous and Mental Diseases, 125(2), 181–201. Konttinen, H., Männistö, S., Sarlio-Lähteenkorva, S., Silventoinen, K., & Haukkala, A. (2010). Emotional eating, depressive symptoms and self-reported food consumption. A population-based study. Appetite, 54(3), 473–479. Lluch, A., Kahn, J. P., Stricker-Krongrad, A., Ziegler, O., Drouin, P., & Méjean, L. (1996). Internal validation of a French version of the Dutch Eating Behaviour Questionnaire. European Psychiatry, 11, 198–220. ObEpi (2009). Enquête épidémiologique nationale sur le surpoids et l’obésité. Inserm, TNS HealthCare Sofres/Roche. Ouwens, M. A., Van Strien, T., & Van Der Staak, C. P. F. (2003). Tendency toward overeating and restraint as predictors of food consumption. Appetite, 403, 291–298. Porter, K. N., & Johnson, M. A. (2011). Obesity is more strongly associated with inappropriate eating behaviors than with mental health in older adults receiving congregate meals. Journal of Nutrition in Gerontology and Geriatrics, 30(4), 403–415. Ricca, V., Castellini, G., Lo Sauro, C., Ravaldi, C., Lapi, F., Mannucci, E., Rotella, C. M., & Faravelli, C. (2009). Correlations between binge eating and emotional eating in a sample of overweight subjects. Appetite, 53, 418–421. Rodin, J. (1981). Current status of the internal-external hypothesis for obesity. What went wrong? American Psychologist, 36, 361–372. Schachter, S., Goldman, R., & Gordon, A. (1968). Effects of fear, food deprivation, and obesity on eating. Journal of Personality and Social, Psychology, 10, 91–97. Schoevers, R. A., Beekman, A. T., Deeg, D. J., Jonker, C., & van Tilburg, W. (2003). Comorbidity and risk-patterns of depression, generalised anxiety disorder and mixed anxiety-depression in later life. Results from the AMSTEL study. International Journal of Geriatrics, 18(11), 994–1001. Skaff, M. M. (2007). Sense of control and health. A dynamic duo in the aging process. In C. M. Adlwin, C. L. Park, & R. Spiro (Eds.), Handbook of health psychology and aging (pp. 186–209). New York: Guilford. Snoek, H. M., Van Strien, T., Janssens, J. M. A. M., & Engels, M. C. M. E. (2007). Emotional, external, restrained eating and overweight in Dutch adolescents. Scandinavian Journal of Psychology, 48(1), 23–32. Spoor, S. T. P., Bekker, M. H. J., Van Strien, T., & van Heck, G. L. (2007). Relations between negative affect, coping, and emotional eating. Appetite, 48, 368–376. Sulmont-Rossé, C., Maître, I., & Issanchou, S. (2010). Âge, perception chimiosensorielle et préférences alimentaires. Gérontologie et Société. Cahiers de la Fondation Nationale de Gérontologie, 134, 87–106. Tiggemann, M. (2004). Body image across the adult life span. Stability and change. Body Image, 1, 29–41. United Nations (2003). World population prospects. The 2002 revision. New York: United Nations. Van Strien, T., & Oosterveld, P. (2008). The children’s DEBQ for assessment of restrained, emotional and external eating in 7 to 12-year-old children. International Journal of Eating Disorders, 41(1), 72–81. Van Strien, T., Frijters, J. E. R., Bergers, G. P. A., & Defares, P. B. (1986). The Dutch Eating Behaviour Questionnaire (DEBQ) for assessment of restrained, emotional and external eating behaviour. International Journal of Eating Disorders, 5, 747–755. Van Strien, T., Frijters, J. E. R., Roosen, R. G., Knuiman-Hijl, W. J., & Defares, P. B. (1985). Eating behavior, personality traits and body mass in women. Addictive Behavior, 10, 333–343. Van Strien, T., Herman, C. P., & Verheijden, M. W. (2009). Eating style, overeating, and overweight in a representative Dutch sample. Does external eating play a role? Appetite, 52(2), 380–387. Viana, V., & Sinde, S. (2003). Estilo Alimentar. Adaptaceo e validacao do quuestionario Holandes do comportamento alimentar (Eating style. A validation study of the Dutch Eating Behavior Questionnaire for the Portugese population). Psicologia—Teoria-Investigaca-e-Practica, 8, 59–71. Wardle, J. (1987). Eating style. A validation study of the Dutch Eating Behaviour Questionnaire in normal weight subjects and women with eating disorders. Journal of Psychosomatic Research, 31, 161–169. Wilcox, S. (1997). Age and gender in relation to body attitudes. Is there a double standard of aging? Psychology of Women Quarterly, 21, 549–565. Wilson, M. M. G., & Morley, J. E. (2003). Aging and energy balance. Journal of Applied Physiology, 95, 1728–1736. Wiseman, C. V., Gray, J. J., Mosimann, J. E., & Ahrens, A. H. (1992). Cultural expectations of thinness in women. An update. International Journal of Eating Disorders, 11, 85–89.
Contents lists available at SciVerse ScienceDirect
Appetite journal homepage: www.elsevier.com/locate/appet
Research report
The Dutch Eating Behaviour Questionnaire (DEBQ). Assessment of eating behaviour in an aging French population Nathalie Bailly a,⇑, Isabelle Maitre b, Marion Amanda c, Catherine Hervé a, Daniel Alaphilippe a a
University François Rabelais, E.A. 2114, «Psychologie des Ages de la Vie», Department of Psychology, 3 rue des Tanneurs, 37041 Tours Cedex, France PRESS L’UNAM - UPSP GRAPPE – GROUPE ESA-55 Rue Rabelais BP30748 – 49007 Angers cedex 01, France c ONIRIS, rue de la Géraudière, 44322 Nantes, France b
a r t i c l e
i n f o
Article history: Received 29 August 2012 Accepted 31 August 2012 Available online 7 September 2012 Keywords: Dutch Eating Behaviour Questionnaire Eating behaviour Elderly Older people Validation
a b s t r a c t The aim of the study was to develop a French version of the Dutch Eating Behaviour Questionnaire (DEBQ) in order to provide a self-report measure for French people in the field of gerontology. A short version of the DEBQ was administered to 262 participants aged 65 years and older. Single and multigroup confirmatory analyses were carried out. The fit measures for the three-factor model and the factorial invariance models with respect to age, sex and BMI status were satisfactory. Three subscales of DEBQ had satisfactory internal consistency. Regarding age, the results showed significant differences in emotional eating and restrained eating. Concerning sex, women had higher mean scores for emotional eating and restrained eating than men. Finally, the overweight older people had higher scores for emotional eating than the normal-weight participants. The short version of DEBQ should provide a useful measure for researchers and clinicians who are interested in exploring eating behaviours among the elderly. Ó 2012 Elsevier Ltd. All rights reserved.
Introduction Population aging is now a worldwide phenomenon. In the more developed regions, the proportion of the population 60 years and older is estimated to increase from 19% to 32% between 2000 and 2050, with those 80 years and older constituting more than one out of four of the elderly in 2050 (United Nations, 2003). This aging of the population has raised important questions concerning the specific nutrition of aging systems, changes in food preferences and overall quality of life (Elsner, 2002). Decreased physical activity and decreased energy expenditure with ageing predispose to fat accumulation and redistribution. According to several studies in developed countries, the early phase of aging (55–65 years) is often associated with a positive energy balance and an increase in body fat which is linked to excess morbidity, mortality, and health care costs (Andreyeva, Sturm, & Ringel, 2004; Calle, Teras, & Thun, 2005; Cornoni-Huntley et al., 1991). In the subsequent phase of aging (after 65–75 years), body fat and lean body mass decrease and continue to decline with a negative energy balance (Wilson & Morley, 2003). Age-related physiological changes contribute to the development of malnutrition in older adults (Chapman, 2010; Chen, Schilling, & Lyder, 2001). Eating is not an automatic process but is influenced to a large extent by cultural, social, and psychological pressures felt by each of us. Over the last 30 years, theories have been developed to as⇑ Corresponding author. E-mail address: [email protected] (N. Bailly). 0195-6663/$ - see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.appet.2012.08.029
sess various aspects of the motivation to eat which could impair adequate food intake and body weight control. Based on psychological theories, Van Strien et al. (Van Strien, Frijters, Bergers, & Defares, 1986) defined three different eating behaviours. The ‘‘psychosomatic theory’’ (Bruch, 1973; Kaplan & Kaplan, 1957) emphasizes the role of ‘‘emotional eating’’. It refers to eating in response to negative emotions in order to relieve stress while disregarding internal physiological signals of hunger. The ‘‘externality theory’’ (Rodin, 1981; Schachter, Goldman, & Gordon, 1968) refers to eating in response to food-related stimuli (sight or smell of food) regardless of the internal state of hunger and satiety. The theory of ‘‘restrained eating’’ (Herman & Polivy, 1975) reflects the degree of conscious food restriction (attempts to refrain from eating in order to lose or maintain a particular weight). Most studies have indicated that these three eating behaviours are linked to the body mass index (BMI) (Baños et al., 2011; Bozan, Bas, & Hulya Asci, 2011; Porter & Johnson, 2011; Ricca et al., 2009; Van Strien, Herman, & Verheijden, 2009), nature of food consumption (Baños et al., 2011; Burton, Smit, & Lightowler, 2007; Ouwens, Van Strien, & Van Der Staak, 2003; Porter & Johnson, 2011; Snoek, Van Strien, Janssens, & Engels, 2007) and psychological outcomes such as depression, anxiety or body-esteem (Flament et al., 2012; Goossens, Braet, Van Vlierberghe, & Mels, 2009; Porter & Johnson, 2011). The three types of eating behaviour can be reliably and validly measured using the Dutch Eating Behaviour Questionnaire (DEBQ: Van Strien et al., 1986). The DEBQ consists of 33 items with answers on a 5-point Likert scale (ranging from ‘‘never’’ to ‘‘very often’’). The English version of the original DEBQ (Wardle, 1987)
854
N. Bailly et al. / Appetite 59 (2012) 853–858
has been translated into many languages: Portuguese (Viana & Sinde, 2003), Turkish (Bozan et al., 2011), Spanish (Baños et al., 2011), French (Lluch et al., 1996) and Swedish (Halvarsson & Sjoden, 1998). All these versions show good factorial validity (reporting a stable factor solution for the total DEBQ and for the three subscales) and reliability, and also satisfactory internal consistency. The DEBQ has a stable factor structure across genders, weight categories, and random samples (Allison, Kalinsky, & Gorman, 1992; Van Strien & Oosterveld, 2008). Different versions have been adapted for adults and adolescents (Lluch et al., 1996; Van Strien et al., 1986; Wardle, 1987) for children (Halvarsson & Sjoden, 1998: 9–10 years old; Van Strien & Oosterveld, 2008: 7–12 years old) and for clinical populations (Baños et al., 2011; Lluch et al., 1996). A version of the questionnaire for parents (DEBQ-P) has been validated in the Italian population (Caccialanza et al., 2004). However to date, no version adapted for an older and oldest-old population has been developed. Given the specific nutritional problems linked to an aging population, it seems important to have a reliable and valid tool to provide a better understanding of eating behaviours in aging, which can be used by public health nutrition practitioners and researchers. The aims of the present study were to test the factorial validity and internal consistency of a short version of the DEBQ in an older people population. Further aims were to test the factorial validity and the similarity of the factorial structure for men and women, older and the oldest-old, and for those who were or were not overweight (BMI-status). The final purpose was to obtain basic data concerning the DEBQ in an older population.
Methods Participants Data presented in this study were obtained from the Aupalesens project: ‘‘Improving pleasure of elderly people for better aging and for fighting against malnutrition’’ (http://www2.dijon.inra.fr/aupalesens/).1 A sample of 559 older French adults aged 65 years and older replied to a multidisciplinary questionnaire on food preferences, social factors and food context, sensory abilities, medical status and nutritional status of individuals aged 65 years and older (the survey contained a total of more than 400 items). French older adults were recruited and stratified by age, gender and marital status in four towns in France. Volunteers were screened for cognitive impairment using the French adaptation of Folstein’s Mini Mental Status Examination (MMSE; Desrosiers & Hébert, 1997) and were excluded if they scored less than 25. The Aupalesens project was funded by the French National Research Agency (ANR); the experimental protocols were approved by the local research ethics committee (CPP). The present study concerns only older people living independently (the first category of the Aupalesens Project). The total sample included 262 French adults aged 65 and older living in their own homes. The mean age of the participants was 73.49 years (SD = 5.46, 65–90) with 178 women (67.9%, M age = 73.75, SD = 5.4) and 84 men (32.1%, M age = 72.95, SD = 5.4). Regarding marital situation, 51% (n = 134) were married or had a partner and 49% (n = 128) lived alone. Regarding previous occupational status, the main categories were office workers (42.74%, n = 112), executives (33.6%, n = 88) and middle managers (21%, n = 55). 1 The Aupalesens project aims to investigate food preferences and behaviour associated with the desire to eat and the pleasure of eating in older people during aging. Four categories were identified: (1) people living at home without any assistance, (2) people living at home with assistance, except for meal preparation, (3) people living at home with assistance for meal preparation or meal delivery and (4) people living in a nursing home.
BMI was calculated from height and weight measurements. International cut-off scores were used to determine whether a participant was overweight or obese. Participants with scores above 25 were considered overweight or obese. There were no underweight participants (BMI < 18.50) in our sample. A total of 34.44% (n = 90) of the participants had a normal weight status and 65.56% (n = 172) were overweight or obese. The distribution of BMI obtained for our sample was close to the percentages for the French population. In 2009, in France, 1.9% of people over 65 years of age were underweight and 60.2% were overweight or obese (ObEpi, 2009). Instrument: the DEBQ The DEBQ was assessed using the French version of Van Strien’s scale (Lluch et al., 1996). The DEBQ consists of 33 items answered on a 5-point Likert scale (ranging from ‘‘never’’ to ‘‘very often’’). Considering the aims of the Aupalesens project, the DEBQ could be used on less autonomous populations including those loosing physical autonomy living in nursing homes. However, due to the fatigue and annoyance effect specific to this older population (oldest-old) and further comparison with them, we decided to shorten the DEBQ scale. To this end, a group of experts in gerontology and eating behaviours met to identify strategies for selecting items. Attention was focused both on the results of the French validation study (Lluch et al., 1996) and on the validation of the questionnaire in an adult population. Firstly, we examined the factorial loadings of the 33 items from previous research. Items such as ‘‘Eat less if you have put on weight’’or ‘‘Desire to eat when bored or restless’’ were removed because of their lower factorial loadings when validated in French adults (Lluch et al., 1996). Secondly, the pertinence of the items in relation to an aging population was examined. For example items such as ‘‘Tempted when food is being prepared’’ and ‘‘Tempted by snack bar/ fast food store’’ were removed due to their lack of relevance for an aging population. Indeed, older adults may have difficulty performing basic activities of daily living, such as eating or preparing meals. Some of them require personal assistance services, assistive technology, help from others or all three to perform activities of daily living, and receive home delivery of meal trays (Davin, Paraponaris, & Verger, 2009). As a result of this review, 16 items (Table 1) were selected to represent the three eating behaviour patterns: restrained eating (5 items), external eating (5 items) and emotional eating (6 items). This adapted scale was then pilot-tested with ten older people. All the participants stated that they had no difficulty understanding the items and expressed their willingness to complete all the items. Data analysis First we carried out a factor and item analysis on the DEBQ. A Kaiser–Meyer–Olkin (KMO) value of 0.82 indicated a good sampling adequacy for the factor analysis. Bartlett’s test of sphericity yielded a chi-square value of 1752 (p = 0.000), indicating that the model is appropriate. The factor analysis was performed by means of a principal component factor analysis with varimax rotation. Criteria for item selection were (1) a factor loadings above 0.40 on the appropriate factors and (2) factor loadings not exceeding 0.20 on non-appropriate factors. To test whether the three-factor structure was an adequate representation of the older adult responses, a confirmatory factor analysis (CFA – Joreskog & Sorbom, 1998) was performed on the total sample of participants. CFA was chosen over exploratory factor analysis (EFA) because it can be used (1) to test first whether the hypothesized factor structure for the set of measures fits the data
855
N. Bailly et al. / Appetite 59 (2012) 853–858 Table 1 Varimax rotated 3-factor solution of the DEBQ (16 items) for older subjects. Emotional eating 30.27% 1 – Desire to eat when irritated
Restrained eating 13.39%
External eating 10.37%
.675 .131
.100
2 – Eat more when see others eat
.061
.499
3 – Desire to eat when watch others eat
.345
.048
4 – Eat less after eating too much
.133
.510
.684 .077
5 – Eat less than you would like
.118
6 – Desire to eat when walk past the baker
.239
.634 .047
7 – Eat less to avoid weight gain become heavier
.137
8 – Desire to eat when something unpleasant is about to happen
.872
9 – Desire to eat when feeling lonely
.707 .051
10 – Watch what you eat
.793 .011
.187
.152 .461 .033 .078
.167
.199
.646 .101
-.103 .215
11 – Desire to eat when depressed or discouraged
.791
12 – Desire to eat when things go wrong
.037
.100
13 – Desire to eat when see or smell food
.892 .003
.049
14 – Eat slimming foods
.187
.724 -.096
.738 -.048
15 – Eat more if food tastes good 16 – Desire to eat when emotionally upset Cronbach’s Alpha
.021 .881 .90 (6 items)
.015
.696 .085
.71 (5 items)
.70 (5 items)
As the DEBQ is protected by copyrightÓ (Berne convention), only abbreviated items are given. Underlined values: factor loadings > .40.
and, if this is the case, (2) to examine how similarly the model fits across the different sub-samples (Bryant & Yarnold, 1995). Firstly, we investigated whether the three-factor model was an adequate representation of the relationship between the items. Secondly, we investigated whether this model was appropriate for several subsamples by fitting multigroup models. Hence, a number of models were fitted for which equality constraints on parameters over the groups were gradually imposed, i.e., first the three-factor model was fitted for each group (Model 0), then equality constraints were imposed on the factor correlations (Model 1), then additional equality restrictions were imposed on the factor loadings (Model 2) and, finally, equality restrictions were imposed on the unique variances (Model 3). Model fit was examined using the ratio of v2 and degree of freedom (v2/df), and the root mean square error of approximation (RMSEA). The ratio should not exceed 2; the RMSEA should not exceed the 0.05 level. The RMSEA is accompanied by the test of close fit, which should not reach significance. For multigroup models, a v2 difference test can be used to test whether imposing additional restrictions leads to a significant drop in fit. Multigroup tests were performed for age, sex and BMI-status. The test on factorial invariance for age was conducted on two age groups (based on the median): 65–73 yearsold (n = 141) and 73 years-old and older (n = 121). Finally, scores for each of the three scales were obtained by dividing the sum of the item-scores by the total number of items on that scale. For each scale, means and standard deviations (SD) were calculated and compared according to sex, BMI-status and age. All analyses were conducted with AMOS-SPSS.
Results The factorial structure of the shorter form was examined using exploratory factor analysis on the 262 older people of 65 years and older. The screen-test suggested that a three-factor solution was the best fit for the data (Table 1). The three factors explained 54% of the variance among the scale items (30.27%, 13.39%, and 10.37%). Factor 1 included the six emotional eating items (eigenvalue = 4.8). Factor 2 included the five restrained eating items (eigenvalue = 2.1). Factor 3 included the five externality eating items (eigenvalue = 1.66). In line with the results of Van strien et al., our findings thus support a three-factor model in an older population. Cronbach’s alpha value was .90 for emo-
tional eating, .71 for restrained eating and .70 for externality eating, indicating satisfactory internal consistencies in our study.
Factor structure and factorial invariance Table 2 shows the fit measures of the three-factor model in the total sample and the multigroup models for the test of factorial invariance. First, a baseline model was examined involving three correlated latent factors (emotion, restriction and externality) with six items loading for emotion, five items each loading for restriction and externality. The v2/df was just above 2 and the RMSEA was higher than .05. The indices were acceptable but not good. If the initial model to be tested did not provide an adequate representation of the data, the modification indices (MIs) and standardized expected parameter changes (SEPCs) were used to modify the model, as recommended by Kaplan (1989). MIs and SEPCs suggested error covariances between (1) items 13 and 15 (external dimension), (2) items 1 and 8 (emotion dimension) and (3) items 9 and 16. The model was modified to incorporate these additional parameters; the fit indices associated with this model are presented in Table 2 as Model (a). Analysis revealed that the model now provided a better fit to the data as evidenced by the low RMSEA and higher v2/df. The second section of Table 2 contains the fit measures of the multigroup models for testing factorial invariance for age. Model 0 – the model specifying that the three-factor model is adequate for both groups with varying parameter values for the groups – had adequate fit measures. Thus, the three-factor model was applicable for older and the oldest-old participants. The results were basically the same for Model 1 and the v2 difference test showed that the difference in fit for Model 0 and 1 is not significant. The results were the same for Model 1 and Model 2. This was not the case for Model 3: the v2 difference test showed that adding equality restrictions on the unique variance led to a significant difference in fit. The third section of Table 2 contains the fit measures of the multigroup model for testing factorial invariance for sex. All the models had acceptable fit measures and the differences between the models are not significant indicating that the three-factor model was applicable for the older men and women. However, in Model 3, the v2 difference test showed that adding equality restrictions on the unique variances led to a significant difference in fit. The fourth section of Table 2 contains the results for the factorial invariance test in relation to BMI status. The results indicate
856
N. Bailly et al. / Appetite 59 (2012) 853–858
Table 2 Fit measures for the DEBQ three-factor models and the multigroup models for age, sex and BMI status.
v2 difference test
Fit measures 2
2
df
p
210 157
101 98
.000 .000
2.07 1.63
.064 .049
.031 .52
Test for age (multigroup model) Model 0 281 Model 1 291 Model 2 297 Model 3 332
192 205 211 232
.000 .000 .000 .000
1.47 1.42 1.41 1.43
.043 .040 .04 .04
.89 .94 .95 .94
9.5 6.3 34.4
13 6 21
.73 .39 .03
Test for sex (multigroup model) Model 0 Model 1 Model 2 Model 3
266 283 291 352
192 205 211 232
.000 .000 .000 .000
1.39 1.38 1.38 1.51
.039 .038 .038 .045
.96 .96 .97 .82
17.6 7.6 60.7
13 6 21
.17 .27 .00
Test for BMI (multigroup model) Model 0 282 Model 1 291 Model 2 298 Model 3 332
192 205 211 232
.000 .000 .000 .000
19.6 2,71 74,49
13 6 21
,11 .84 .00
Three-factor Model Three-factor Model(a)
v /df
v2
v
1,40 1,41 1,38 1,58
RMSEA
,039 ,040 ,038 ,047
p
,95 ,95 ,97 ,68
df
p
Table 3 Means, Standard deviations (SD) for restrained, emotional and external eating in the total sample and the sub-sample of younger-old and older-older, women and men, normal weight and overweight participants. Restrained eating
Emotional eating
External eating
All sample (n = 262)
2.87 (.92)
2.02 (.97)
2.48 (.73)
Age Younger-old (141) Older-old (121)
2.98 (.92) 2.74 (.90)
2.14 (1.09) 1.88 (.90)
2.54 (.73) 2.42 (.74)
Sex Women (178) Men (84)
2.98 (.88) 2.64 (.96)
2.23 (1.01) 1.58 (.71)
2.50 (.74) 2.44 (.73)
BMI-status Normal weight (90) Overweight (172)
2.82 (.97) 2.90 (.90)
1.83 (.90) 2.12 (1)
2.49 (.64) 2.48 (.76)
that the three-factor structure was applicable for ‘‘normal weight status’’ and ‘‘overweight status’’, while Model 3, the most restricted model, led to a significant difference in fit. Eating behaviours in relation to age, sex and BMI-status Table 3 shows the means and standard deviations of the scales obtained in the total sample and sub-sample (younger-old/olderold, men/women, and normal weight/ overweight). In all the samples, restrained eating was the most prevalent type of eating behaviour, followed by external eating and emotional eating. Regarding age, results show significant differences in emotional eating (t(260) = 2.14 , p = .033) and restrained eating (t(260) = 2.12 , p = .035). The younger-old had higher mean scores for restriction and emotion than the older-old. Similarly, regarding sex, women had higher mean scores for emotional eating (t(260) = 5.31 , p = 0.000) and restrained eating (t(260) = 2.80 , p = 0.006) than men. The DEBQ responses showed no significant age and gender interactions (restrained eating: F(1,257) = 0.04; NS – emotional eating: F(1,257) = 0.19; NS and external eating: F(1.257) = 0.23; NS). Finally, regarding BMI status, overweight older people had higher scores for emotional eating than normalweight participants (t(260) = 2.24 , p = .026). No differences for external eating were observed between groups in the subsamples. Discussion The aim of this study was to validate a short version of the DEBQ to measure restrained, emotional and external eating in an
older adult population. A confirmatory factor analysis was performed to assess (1) the construct validity for the measure of eating behaviour dimensions, and (2) whether the factorial structure is invariant for age, sex and BMI-status. An additional objective was to provide some basic data for this first validation study among people aged 65 years and older. A tool of 16 items (6 for emotional eating, 5 for external eating and 5 for restrained eating) was drawn up which selected items according to their appropriateness for older people and their previous factor loadings in adults. A three-factor model showed acceptable fit indicating that this short version represents three dimensional factors. These three factors correspond to those of the original work of Van Strein et al. (1986) and the different language adult versions (Lluch et al., 1996; Wardle, 1987). To our knowledge, the CFA method has been used in only two previous studies (Baños et al., 2011; Van Strien & Oosterveld, 2008). The CFA was chosen in preference to exploratory factor analysis (EFA) because it can be used on models which have a well-developed underlying theory and to examine how similarly a model fits across diverse sub samples. In this study, the tests for factorial invariance showed that the three-factor model was applicable for the younger-old and oldest-old, men and women and the two groups of BMI status. Adding equality constraints on the factor correlations (Model 1) and on the factor loadings (Model 2) did not lead to a significant increase in v2 values. Nonetheless, the more restrictive model (Model 3), where equality restrictions were imposed on the unique variances, led to a significant difference in fit. Although the internal consistency values of DEBQ are good, they are lower than those reported in the original version of DEBQ (Van
N. Bailly et al. / Appetite 59 (2012) 853–858
Strien et al., 1986 – alpha between .80 and .95) and those reported in an adult French population (Lluch et al., 1996 – alpha between .82 and .91). The absence of previous data on an older population makes comparison difficult (the maximum age was 41 years in Llutch’s French validation). For a better understanding of these first results a larger sample of older people needs to be investigated. Nonetheless, regarding the structure and the psychometric properties of the DEBQ, this shorten scale appears to be a good self-report screening instrument that measures eating behaviours and attitudes to eating in an older adult population. Examination of the subsample scores on restrained, emotional and external eating reveals that restrained eating was the most prevalent type of reported eating behaviour, followed by emotional and external eating. The importance of restrained eating behaviour in the older people suggests that this population is particularly aware of food intake. In response to the prevalence of malnutrition in the older people, France has developed health awareness campaigns directed towards seniors and set up specific controlling bodies (PNNS: ‘‘National Nutritional Health Programme’’; HAS: French ‘‘National Authority for Health’’). These health recommendations can discourage older people from eating food considered unhealthy by social medical science. In addition, diabetes, cholesterol and other common diseases in older people can also lead to restrained food intake, for example reducing the consumption of cured meats and high-sugar content foods. This observed restrained eating behaviour would therefore be linked to a desire to remain healthy. Concerning age, our results indicate that restrained eating is higher in the younger-old group (65–73 years old) than in the oldest-old (over 73 years old). According to the restrained theory, restrained eaters attempt to control their eating but with age, uncontrollable and irreversible events occur (bereavement, death of close friends, role loss, etc.) which put considerable strain on one’s perceived control (Infurna, Gerstorf, & Zarit, 2011; Skaff, 2007). This perceived loss of control can explain the difference on restrained eating between younger-old and the oldest-old. It could also be postulated that the sensorial, physical and social losses among the oldest-old would lead individuals to put the pleasure of eating before health recommendations. This is clearly summarised by one of the interviewees in the Aupalesens project who said ‘‘eating is the only pleasure left!’’ (Sulmont-Rossé, Maître, & Issanchou, 2010). Thus, this loss of control on restrained eating may be a deliberate choice. In addition, our results indicate higher scores for emotional eating in the younger-old than for the oldest-old. Younger-old are more prone to eat in response to negative emotions to relieve stress. Gerontological research suggests a decline in negative emotions with age (Carstensen, Fung, & Charles, 2003). In particular, socio-emotional selectivity theory (Carstensen et al., 2003) suggests that elders improve in affect optimization, i.e., the ability to maximize positive emotion and dampen negative emotion. The oldest-old would thus have less need for emotion eating. However, to investigate this further it would be interesting to introduce a positive emotion item (e.g., ‘‘Desire to eat when happy’’) in the DEBQ scale to understand better the role of both positive and negative emotions on eating behaviour. Our study indicates that women scored higher in restrained and emotion eating than men. Regarding restrained eating, our results are similar to those observed in previous studies in young adult and adult populations (Wardle, 1987). It has been suggested that higher scores for dietary restraint in women could be explained by the fact that women are more likely to diet than men. Therefore, women express restrained behaviours in response to greater awareness and concern about food and fear of gaining weight (de Castro, 1995). In addition, current societal standards for female beauty emphasize the desirability of thinness (Wiseman, Gray, Mosimann, & Ahrens, 1992) leading women to be more concerned than men about the effects of aging on their appearance (Gupta &
857
Schork, 1993). Several authors highlight a ‘‘standard of aging’’ whereby older women are judged much more harshly than older men (Tiggemann, 2004; Wilcox, 1997). With regard to emotional eating, older women are more prone to this than older men. Gerontological literature indicates that older women experience depression and anxiety more often than older men (Schoevers, Beekman, Deeg, Jonker, & van Tilburg, 2003). This suggests emotion-oriented coping among older women is used to alleviate negative emotional states (Konttinen, Männistö, Sarlio-Lähteenkorva, Silventoinen, & Haukkala, 2010; Spoor, Bekker, Van Strien, & van Heck, 2007). Finally, concerning the BMI status, our study indicates that emotional eating is more important for the overweight participants. Our results are in line with previous studies (Greeno & Wing, 1994; Van Strien, Frijters, Roosen, Knuiman-Hijl, & Defares, 1985) which support the idea that overweight individuals are more likely to use food as an emotional defence to cope with a negative event, which causes overconsumption which, in turn, leads to obesity (Kaplan & Kaplan, 1957). However, contrary to previous results (Baños et al., 2011; Snoek et al., 2007; Wardle, 1987), BMI status did not influence restrained eating in the older group. This could be related to the body mass index (BMI) used to measure body fat. Many authors consider BMI to be unsuitable and not to take into account the age-related changes in body fat distribution. Some claim that ‘‘the BMI thresholds for overweight and obesity are overly restrictive for older people’’ (Flicker et al., 2010). Recent evidence indicates that in older people, obesity is paradoxically associated with a lower rather than higher, mortality risk (Chapman, 2010). Evidence from practice, in addition to literature reviews, does not support the use of BMI when assessing nutritional issues in individual older subjects. Furthermore, this could also explain the high rate of overweight participants in our sample (65.56%). Our study has several limitations. Given the characteristics of our sample (younger-old, living independently with no cognitive impairment, previously have high-level professional occupations, etc.), we can assume that our participants have not yet had to deal with major health or social problems. The high functioning level of our sample could have biased certain results. A study involving a more representative sample of the older French population would improve understanding of eating behaviour in old age. Further research should involve less autonomous and older people. These first results among younger-old should be compared with those for the oldest-old. Indeed, the loss of control in preparing meals and food choice for people with assistance for meal preparation or meal delivery will change eating behavior in terms of restrained, emotional and external eating. The DEBQ scale also needs to be tested for its concurrent, discriminant and predictive validity. To improve prevention and treatment strategies, factors that influence eating behaviours among older people need to be investigated. In particularly, social eating networks, body self-esteem, general eating habits, health status (misfitting or unclean dentures, lack of dentition) and mental health (anxiety, depression) undoubtedly impact on the motivation to eat among older people. Nonetheless, this first study shows that the French adaptation of the shorten scale has satisfactory psychometric properties and may therefore be a valuable instrument for researchers and clinicians who are interested in exploring the motivation to eat in older people.
References Allison, D. B., Kalinsky, L. B., & Gorman, B. S. (1992). The comparative psychometric properties of three measures of dietary restraint. Psychological Assessment, 4, 391–398. Andreyeva, T., Sturm, R., & Ringel, J. S. (2004). Moderate and severe obesity have large differences in health care costs. Obesity Research, 12, 1936–1943. Baños, R. M., Cebolla, A., Etchemendy, E., Felipe, S., Rasal, P., & Botella, C. (2011). Validation of the Dutch Eating Behavior Questionnaire for Children (DEBQ-C) for use with Spanish children. Nutrición Hospitalaria, 26(4), 890–898.
858
N. Bailly et al. / Appetite 59 (2012) 853–858
Bozan, N., Bas, M., & Hulya Asci, F. (2011). Psychometric properties of Turkish version of Dutch Eating Behaviour Questionnaire (DEBQ). A preliminary results. Appetite, 56(3), 564–566. Bruch, H. (1973). Eating disorders. Obesity, anorexia nervosa, and the person within. New York: Basic Books, pp. 44–65. Bryant, F. B., & Yarnold, P. R. (1995). Principal-components analysis and exploratory and confirmatory factor analysis. In L. G. Grimm & P. R. Yarnold (Eds.), Reading and understanding multivariate statistics (pp. 99–136). Washington, DC: American Psychological Association. Burton, P., Smit, H. J., & Lightowler, H. J. (2007). The influence of external eating behavior on overeating. Mediation by food cravings. Appetite, 49, 191–197. Caccialanza, R., Nicholls, D., Cena, H., Maccarini, L., Rezzani, C., Antonioli, L., et al. (2004). Validation of the Dutch Eating Behaviour Questionnaire Parent version (DEBQ-P) in the Italian population. European Journal of Clinical Nutrition, 58, 1217–1222. Calle, E. E., Teras, L. R., & Thun, M. J. (2005). Obesity and mortality. The New England Journal Medicine, 353, 2197–2199. Carstensen, L. L., Fung, H. H., & Charles, S. T. (2003). Socioemotional selectivity theory and the regulation of emotion in the second half of life. Motivation and Emotion, 27(2), 103–123. Chapman, I. M. (2010). Obesity paradox during aging. Interdisciplinary Topics in Gerontology, 37, 20–23. Chen, C. C., Schilling, L. S., & Lyder, H. (2001). A concept analysis of malnutrition in the elderly. Journal of Advanced Nursing, 36(1), 131–142. Cornoni-Huntley, J. C., Harris, T. B., Everett, D. F., Albanes, D., Micozzi, M. S., Miles, T. P., & Feldman, J. J. (1991). An overview of body weight of older persons, including the impact on mortality. The National Health and Nutrition Examination Survey I – Epidemiologic Follow-up Study. Journal of Clinical Epidemiology, 44(8), 743–753. Davin, B., Paraponaris, A., & Verger, P. (2009). Socioeconomic determinants of the need for personal assistance reported by community-dwelling elderly. Empirical evidence from a French national health survey. Journal of SocioEconomics, 38(1), 138–146. De Castro, J. M. (1995). The relationship of cognitive restraint to the spontaneous food and fluid intake of free-living humans. Physiology and Behavior, 57, 287–295. Desrosiers, J., & Hébert, R. (1997). Principaux outils d’évaluation en clinique et en recherche. In M. Arcand & R. Hébert (Eds.), Précis Pratique de Gériatrie (pp. 77–107). Edisem. Elsner, R. J. (2002). Changes in eating behavior during the aging process. Eating Behaviours, 3, 15–43. Flament, M. F., Hill, E. M., Buchholz, A., Henderson, K., Tasca, G. A., & Goldfield, G. (2012). Internalization of the thin and muscular body ideal and disordered eating in adolescence. The mediation effects of body esteem. Body Image, 9(1), 68–75. Flicker, L., McCaul, K. A., Hankey, G. J., Jamrozik, K., Brown, W. J., Byles, J. E., & Almeida, O. P. (2010). Body mass index and survival in men and women aged 70 to 75. Journal of the American Geriatrics Society, 58(2), 234–241. Goossens, L., Braet, C., Van Vlierberghe, L., & Mels, S. (2009). Loss of control over eating in overweight youngsters. The role of anxiety, depression and emotional eating. European Eating Disorders Review, 17(1), 68–78. Greeno, C., & Wing, R. (1994). Stress-induced eating. Psychological Bulletin, 115(3), 444–464. Gupta, M. A., & Schork, N. J. (1993). Aging-related concerns and body image. Possible future implications for eating disorders. International Journal of Eating Disorders, 14, 481–486. Halvarsson, K., & Sjoden, P. O. (1998). Psychometric properties of the Dutch Eating Behaviour Questionnaire (DEBQ) among 9–10-year-old Swedish girls. European Eating Disorders Review, 6, 115–125. Herman, C. P., & Polivy, J. (1975). Anxiety, restrained and eating behavior. Journal of Abnormal Psychology, 84(6), 666–672. Infurna, F. J., Gerstorf, D., & Zarit, S. H. (2011). Examining dynamic links between perceived control and health. Longitudinal evidence for differential effects in midlife and old age. Developmental Psychology, 47(1), 9–18. Joreskog, K., & Sorbom, J. (1998). LISREL 8. User’s reference guide. Hillsdale, NJ: Lawrence Erlbaum. 1998. Kaplan, D. (1989). Model modification in covariance structure analysis. Application of the expected parameter change statistic. Multivariate Behavioral Research, 24, 285–305.
Kaplan, H. L., & Kaplan, H. S. (1957). The psychosomatic concept of obesity. Journal of Nervous and Mental Diseases, 125(2), 181–201. Konttinen, H., Männistö, S., Sarlio-Lähteenkorva, S., Silventoinen, K., & Haukkala, A. (2010). Emotional eating, depressive symptoms and self-reported food consumption. A population-based study. Appetite, 54(3), 473–479. Lluch, A., Kahn, J. P., Stricker-Krongrad, A., Ziegler, O., Drouin, P., & Méjean, L. (1996). Internal validation of a French version of the Dutch Eating Behaviour Questionnaire. European Psychiatry, 11, 198–220. ObEpi (2009). Enquête épidémiologique nationale sur le surpoids et l’obésité. Inserm, TNS HealthCare Sofres/Roche. Ouwens, M. A., Van Strien, T., & Van Der Staak, C. P. F. (2003). Tendency toward overeating and restraint as predictors of food consumption. Appetite, 403, 291–298. Porter, K. N., & Johnson, M. A. (2011). Obesity is more strongly associated with inappropriate eating behaviors than with mental health in older adults receiving congregate meals. Journal of Nutrition in Gerontology and Geriatrics, 30(4), 403–415. Ricca, V., Castellini, G., Lo Sauro, C., Ravaldi, C., Lapi, F., Mannucci, E., Rotella, C. M., & Faravelli, C. (2009). Correlations between binge eating and emotional eating in a sample of overweight subjects. Appetite, 53, 418–421. Rodin, J. (1981). Current status of the internal-external hypothesis for obesity. What went wrong? American Psychologist, 36, 361–372. Schachter, S., Goldman, R., & Gordon, A. (1968). Effects of fear, food deprivation, and obesity on eating. Journal of Personality and Social, Psychology, 10, 91–97. Schoevers, R. A., Beekman, A. T., Deeg, D. J., Jonker, C., & van Tilburg, W. (2003). Comorbidity and risk-patterns of depression, generalised anxiety disorder and mixed anxiety-depression in later life. Results from the AMSTEL study. International Journal of Geriatrics, 18(11), 994–1001. Skaff, M. M. (2007). Sense of control and health. A dynamic duo in the aging process. In C. M. Adlwin, C. L. Park, & R. Spiro (Eds.), Handbook of health psychology and aging (pp. 186–209). New York: Guilford. Snoek, H. M., Van Strien, T., Janssens, J. M. A. M., & Engels, M. C. M. E. (2007). Emotional, external, restrained eating and overweight in Dutch adolescents. Scandinavian Journal of Psychology, 48(1), 23–32. Spoor, S. T. P., Bekker, M. H. J., Van Strien, T., & van Heck, G. L. (2007). Relations between negative affect, coping, and emotional eating. Appetite, 48, 368–376. Sulmont-Rossé, C., Maître, I., & Issanchou, S. (2010). Âge, perception chimiosensorielle et préférences alimentaires. Gérontologie et Société. Cahiers de la Fondation Nationale de Gérontologie, 134, 87–106. Tiggemann, M. (2004). Body image across the adult life span. Stability and change. Body Image, 1, 29–41. United Nations (2003). World population prospects. The 2002 revision. New York: United Nations. Van Strien, T., & Oosterveld, P. (2008). The children’s DEBQ for assessment of restrained, emotional and external eating in 7 to 12-year-old children. International Journal of Eating Disorders, 41(1), 72–81. Van Strien, T., Frijters, J. E. R., Bergers, G. P. A., & Defares, P. B. (1986). The Dutch Eating Behaviour Questionnaire (DEBQ) for assessment of restrained, emotional and external eating behaviour. International Journal of Eating Disorders, 5, 747–755. Van Strien, T., Frijters, J. E. R., Roosen, R. G., Knuiman-Hijl, W. J., & Defares, P. B. (1985). Eating behavior, personality traits and body mass in women. Addictive Behavior, 10, 333–343. Van Strien, T., Herman, C. P., & Verheijden, M. W. (2009). Eating style, overeating, and overweight in a representative Dutch sample. Does external eating play a role? Appetite, 52(2), 380–387. Viana, V., & Sinde, S. (2003). Estilo Alimentar. Adaptaceo e validacao do quuestionario Holandes do comportamento alimentar (Eating style. A validation study of the Dutch Eating Behavior Questionnaire for the Portugese population). Psicologia—Teoria-Investigaca-e-Practica, 8, 59–71. Wardle, J. (1987). Eating style. A validation study of the Dutch Eating Behaviour Questionnaire in normal weight subjects and women with eating disorders. Journal of Psychosomatic Research, 31, 161–169. Wilcox, S. (1997). Age and gender in relation to body attitudes. Is there a double standard of aging? Psychology of Women Quarterly, 21, 549–565. Wilson, M. M. G., & Morley, J. E. (2003). Aging and energy balance. Journal of Applied Physiology, 95, 1728–1736. Wiseman, C. V., Gray, J. J., Mosimann, J. E., & Ahrens, A. H. (1992). Cultural expectations of thinness in women. An update. International Journal of Eating Disorders, 11, 85–89.