The Dutch Eating Behaviour Questionnaire (DEBQ) Tatjana van Strien
Stunkards pessimistic verdict • Most obese persons will not stay in treatment for obesity. • Of those who stay in treatment most will not lose weight. • Of those who do lose weight most will regain it • (Stunkard, 1958)
Goal • Also new methods show no satisfactory maintenance of treatment effects(Wilson, 1994). • Reason: absence of fit between treatments and individuals • Goal: improve maintenance of treatment effects by fitting treatment and individuals
How to fit treatments and individuals? • There are different types of overeating: emotional, external and restraint eating. • Each type has its own aetiology (derived from: psychosomatic theory, externality theory and restraint theory) • Each type also has its own treatment • Thus: fitting treatments and individuals by assessment of eating behaviour
The three types of overeating • Emotional eating: eating in response to emotional arousal states such as fear anger or anxiety. • External eating: eating in response to external food cues such as sight and smell of food • Restraint eating: overeating after a period of slimming when the cognitive resolve to diet is abandoned
Three theories of overeating • Psychosomatic and externality theory attribute weight gain and obesity to overeating (emotional and external eating) • Restraint theory (paradoxically) attributes overeating and weight gain to dieting
Psychosomatic and externality theory • In both theories: Mispercepetion of internal state prior to eating is causal factor in development of obesity • Psychosomatic theory: emphasis on internal emotional factors • Externality theory: focus on external food environment
Psychosomatic theory • Confusion of internal arousal states and hunger, probably because of early learning experiences (Hilde Bruch): • Low interoceptive awareness (alexithimia)
Externality theory • External eating, that is, eating in response to food-related stimuli regardless of the internal state of hunger or satiety. • This is the result of externality as personality trait ( over-responsiveness to external stimuli in general (not only food, but also a movie, a sad story etc).
Restraint theory • Dieting as a cause rather than a consequence of over eating (Peter Herman and Janet Polivy, Toronto, Canada) • Natural weight; homeostatically preserved
Restraint theory • Restraint eating:fysiological defence mechanisms such as hunger and preference for sweets: overeating, weight gain and obesity • Restraint eating: loss of contact with hunger and satiety: overeating weight gain and obesity
The three theories and therapy • Psychosomatic theory: focus on evoking awareness of own impulses, feelings and needs • Externality theory: behavior therapy: stimulus control or cue exposure • Restraint theory :accept one’s natural weight: undieting
DEBQ • Assessment of an individual’s structure of eating behaviour may enable a better fit between treatments and the individuals type of eating behaviour. So, with this goal in mind the DEBQ was developed. • DEBQ has separate scales for emotional, external and restrained eating; the scale on emotional eating has two subscales 1) eating in response to diffuse emotions and 2) eating in response to clearly labelled emotions.
Psychometrics • Excellent factorial validity • Satisfacory to good reliability • Satisfactory concurrent and discriminative validity • Officially available in Dutch and English.
DEBQ • In individual and group settings • For adults and children as young as nine years old • Takes 10 minutes to complete • Norm groups are available
Administration and Scoring • Administration requires item-form and scoring template • Item-form: p1: demographic questions and questions on body weight and weight history; p2 and 3:the 33 DEBQ-items with 5 point Likert scale.; p4: Table of raw scores and norm scores. • Can be easily scored with scoring template.
Scoring • Raw scores are obtained by adding the scores of the items of the scales. These raw scores can be noted on the back page. • A score on the scale for emotional eating can be obtained by adding the raw scores of the two subscales for emotional eating. • To compare raw scores with norm scores, raw scores should be divided by the total number of endorsed items on the scale • The appropriate normgroup can be chosen on the basis of the questions on p1: age, sex, weight category etc.
Norms • DEBQ-scale scores are devided in the seven categories: very high, high, above mean, mean, below the mean, low and very low. • The intervals of the DEBQ-scale scores associated with the seven categories are available for the following norm-groups
Norms • a)subsamples of 1170 inhabitants of Ede(men, women, obese men, obese women, non-obese men; non-obese women) • A sample of 724 high school females • A sample of 492 female college students • A sample of 303 female eating disorder patients • For further smaller samples of subjects DEBQ-scale statistics are provided.
DEBQ and therapy:high emotional eating • A high degree of emotional eating points toward a deficient inner cognitive and affective structure and lack of interoceptive awareness. • An individual with a high degree of emotional eating may benefit best from therapy focusing on interoceptive awareness, low self esteem, feelings of social inadequacy and other psychological problems accompanying emotional eating, rather than focussing upon weight as the sole or most important causal factor.
DEBQ and therapyhigh external eating • A high degree of external eating, unsupported by a high degree of emotional eating, points to a sensitivity to external cues such as sight and smell of food. • Is often found in men. • Therapy should focus on sensitivity to food cues by means of behavioural methods such as stimulus control or food exposure.
DEBQ and therapyhigh restrained eating • A score on restrained eating should never be considered in isolation from scores on the other scales, but always in conjunction with them. • Also the weight history and current weight status of the patient should be taken into account as the tendency towards restraint breaking or bingeing.
DEBQ and treatment:high degree of restrained eating • Underweight in combination with severe dieting may point towards anorexia nervosa. • High weight fluctuation in combination with severe dieting and tendencies toward restraint breaking may point at bulimia nervosa.
DEBQ and treatmenthigh degree of restrained eating • High degree of restrained eating, but low degree of emotional and external eating: these individuals may require more accurate information concerning nutrition and caloric balance. • A high degree of restrained eating and a high degree of emotional or external eating: in this case strict restriction of food intake is not likely to result in lasting weight loss unless the underlying psychic problems are solved or the sensitivity to food stimuli is treated.
Final remark • If an individual has always been overweight, he or she may be better off accepting his or her heavy build, instead of continuously starving him or herself. • A more accepting social or medical attidude towards those who are overweight would alleviate many psychological problems faced by the overweight: social anxiety, low self esteem.
The two most asked questions • Can I, for reason of saving time, not also simply interview patients on their eating behaviour, for example by asking them the three questions: Do you diet, Do you eat when emotionally upset, or when seeing tempting food? • How can I administer the DEBQ to patients when I have only 10-minutes time for them?
Why not simply ask them? • High chance of social desirable response(all obese live on air and diet all the time). • Answer on a single question gives no indication on the relative frequency of the eating behaviour in question within a person. Only yes/no • The questions have not been tested for their reliability and validity. • Answer gives no indication on relative frequency with respect to reference group.
How can the DEBQ be administered? • Adminstration and scoring of the DEBQ can be done by a secretary or doctors assistent. • The DEBQ can be given to the patient to fill it out at home, but the patient can also complete it in the waiting room (10 minutes).
Administration • A secretary can then score the DEBQ by means of the scoring templates, fill out the table with raw scores and the norm scores at the back of the item-form, and also make a comparison of the scores and the appropriate norm-group (5 minutes). • The appropriate normgroup can be chosen on the basis of answers to questions on page 1 of the item-form.
Interpretation of the DEBQ • Also the interpretation of the DEBQ-outcome can be done by a assistent or secretary, provided they have been skilled for this. • Preferably the interpretation should be done by the GP, family doctor or the like.
Interpretation: high emotional eating • Always start with emotional eating. If this is high in a patient, restriction of food intake or behavioural methods focussing on sensitivity to food cues are not likely to result in permanent weight loss, unless the psychological probems accompanying the emotional eating, such as low interoceptive awareness and low self esteem are solved. So the therapy should focus on these problems and not upon weight. • So the therapy should focus on these problems and not upon weight.