Eating disorder Archives

SCOFF Questionnaire

Background: The SCOFF questionnaire (Morgan, Reid and Lacey, 1999) is a five item measure, developed to serve as a simple, easy to remember screening tool for eating disorders. The instrument was designed for use by professionals and non-professionals alike and can be used in primary health care settings. The SCOFF items were developed via focus groups with eating disordered patients and specialists in the field (Morgan et al, 1999). Questions can be administered orally or in written format (Perry et al, 2002).

Population: Screening tool that can be used in general population to identify people who may be at risk or have an eating disorder.

Measurement: The SCOFF Questionnaire is a five-question screening tool designed to clarify suspicion that an eating disorder might exist rather than to make a diagnosis. The questions can be delivered either verbally or in written form.

S – Do you make yourself Sick because you feel uncomfortably full?

C – Do you worry you have lost Control over how much you eat?

O – Have you recently lost more than One stone (6.35 kg) in a three-month period?

F – Do you believe yourself to be Fat when others say you are too thin?

F – Would you say Food dominates your life?

An answer of ‘yes’ to two or more questions warrants further questioning and more comprehensive assessment. A further two questions have been shown to indicate a high sensitivity and specificity for bulimia nervosa. These questions indicate a need for further questioning and discussion.

Are you satisfied with your eating patterns?
Do you ever eat in secret?

Scoring: Each “yes” response to the five yes/no questions on the SCOFF is summed for the total score. Scores of 2 or greater were originally set a cut-off point for maximum sensitivity to detect anorexia and Bulimia nervosa (Morgan et al, 1999). A cut-off point of 3 has been suggested as the best compromise between sensitivity and specificity.

Psychometrics: A meta analyses of 15 studies examining the utility of the SCOFF found that the 5 questions of the SCOFF constitute a highly efficient tool for the detection of eating disorders, even by a non-specialist, in several languages. Its use as a screening tool is highly recommended.

Strengths: Readability, ease of use, time efficient, effective, available and validated in other languages.

Limitations: SCOFF is a Self-report measure, may be less effective for male and older people who may present with different symptomology, does not screen for excess exercise, past weight loss

Access: Free and easily accessible. The SCOFF was developed in the United Kingdom but items have been adapted for use in the United States (Morgan et al, 1999; Parker, Lyons and Bonner, 2005). German, Finnish, Spanish and Japanese translations of the SCOFF have also been developed.

References

Botella, J., Sepúlveda, A., Huang, H. and Gambara, H. (2013). A Meta-Analysis of the Diagnostic Accuracy of the SCOFF. The Spanish Journal of Psychology, 16. Doi:10.1017/sjp.2013.92

Garcia, F., Grigioni, S., Chelali, S., Meyrignac, G., Thibaut, F. and Dechelotte, P. (2010). Validation of the French version of SCOFF questionnaire for screening of eating disorders among adults. The World Journal of Biological Psychiatry, 11(7), pp.888-893. Doi:10.3109/15622975.2010.483251.

Garcia-Campayo, J., Sanz-Carrillo, C., Ibañez, J., Lou, S., Solano, V. and Alda, M. (2005). Validation of the Spanish version of the SCOFF questionnaire for the screening of eating disorders in primary care. Journal of Psychosomatic Research, 59(2), pp.51-55. Doi:10.1016/j.jpsychores.2004.06.005.

Lähteenmäki, S., Aalto-Setälä, T., Suokas, J., Saarni, S., Perälä, J., Saarni, S., Aro, H., Lönnqvist, J. and Suvisaari, J. (2009). Validation of the Finnish version of the SCOFF questionnaire among young adults aged 20 to 35 years. BMC Psychiatry, 9(1). Doi:10.1186/1471-244X-9-5.

Morgan, J., Reid, F. and Lacey, J. (1999). The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ, 319(7223), pp.1467-1468. Doi:10.1136/bmj.319.7223.1467.

Pannocchia, L., Fiorino, M., Giannini, M. and Vanderlinden, J. (2011). A Psychometric Exploration of an Italian Translation of the SCOFF Questionnaire. European Eating Disorders Review, 19(4), pp.371-373. Doi:10.1002/erv.1105.

Perry, L., Morgan, J., Reid, F., Brunton, J., O’Brien, A., Luck, A. and Lacey, H. (2002). Screening for symptoms of eating disorders: Reliability of the SCOFF screening tool with written compared to oral delivery. International Journal of Eating Disorders, 32(4), pp.466-472. Doi:10.1002/eat.10093.

Solmi, F., Hatch, S., Hotopf, M., Treasure, J. and Micali, N. (2014). Validation of the SCOFF questionnaire for eating disorders in a multiethnic general population sample. International Journal of Eating Disorders, 48(3), pp.312-316. Doi:10.1002/eat.22373.

Eating Disorder Diagnostic Scale (EDDS)

The Eating Disorder Diagnostic Scale (EDDS; Stice, Telch, & Rizvi, 2000) is a 22-item self-report questionnaire designed to measure Anorexia nervosa, Bulimia nervosa, and Binge-eating disorder symptomatology aligned with the DSM-IV diagnostic criteria.

The scale is comprised of a combination of Likert ratings, dichotomous scores, behavioural frequency scores, and open-ended questions asking for weight and height. The first four questions assess attitudinal symptoms of Anorexia and Bulimia within the past 3 months. The next four items measure the frequency of uncontrollable food consumption, with a focus on the number of days per week over the past 6 months (a criterion for Binge-eating disorder), and number times per week over the last 3 months (a criterion for Bulimia). The following four items measure frequency of compensatory behaviours. Lastly, individuals are asked to record their height, weight, presence of menstrual cycles and birth control pill use.

There are two further scales used in the EDDS that differentiate between eating disorders and deviance from healthy eating pathology. The diagnostic scale may be used to inform diagnosis of Anorexia, Bulimia and Binge-eating disorders. Stice et al. (2000) have developed a scoring algorithm to accompany this scale to determine score cut-offs. The symptom composite scale may be used to create a continuous composite score of disordered eating pathology.

Psychometric Development & Validation

The EDDS went through a rigorous development and validation process with careful adherence to a number of steps. The developers first generated a pool of items to assess DSM-IV eating disorder diagnostic criteria. These items were evaluated by a panel of 14 eating disorder experts, followed by revision to eventually produce the final EDDS to test for reliability and validity against an American female sample aged 13 to 65 years inclusive of those with and without eating disorders.

Results revealed excellent 1-week test-retest reliability for Anorexia (kappa = .95), and adequate test-retest coefficients for Bulimia (kappa = .71) and Binge-eating disorder (kappa = .75). The overall symptom composite test-retest reliability was also strong (kappa = .87). Likewise, internal consistency of the overall symptom composite score was robust (Cronbach’s α = .91). These reliability magnitudes reflect Shrout’s (1998) psychometric rule-of-thumb whereby kappa values above .8 represent high reliability, values between .4 and .8 indicate moderate agreement, and values less than .4 suggest poor reliability.

Content validity results generated by the 14 eating disorder experts revealed that items within the scale adequately reflected the DSM-IV diagnostic criteria for Anorexia, Bulimia, and Binge-eating disorder. Consistently, data also suggested that the EDDS possessed convergent validity by comparing participants with eating disorders with their non-diagnosis control counterparts; with higher scores reported for those with eating disorders than those without.

Strengths & Weaknesses

The EDDS has an abundance of strengths. It is short and quick to complete. With only 22 items, it takes only a few minutes to complete the entire instrument. It is sensitive to change over time; that is, the EDDS has the versatility of being used as a screening tool at the beginning stages of assessment, a diagnostic tool in supporting eating disorder diagnostic criteria, and lastly it may also be used for treatment monitoring and evaluation.

However, the EDDS is not without its limitations. In at least one study, the EDDS has been found to generate a large number of ‘false positives’ (Lee et al., 2007), indicating a weakness in specificity. Conversely, this may not necessarily be a negative drawback considering that when used as a screening tool it is preferable to be able to identify more people as false positives than run a risk of missing out on detecting potential cases of eating disorders. This is because eating disorders, though low in prevalence compared to other clinical disorders, has one the highest mortality rates amongst psychiatric conditions (Arcelus, Mitchell, Wales, & Nielsen, 2011). Additional weaknesses include gender and cultural insensitivity. Different attitudes towards food consumption for gender was found to be reinforced by differing cultural ideals–which were not adequately captured in the EDDS (Lee et al., 2007). Similarly, eating disorder pathology and risk factors were not invariant across Caucasian American women and African American women (Kelly et al., 2012).

Conclusion

Overall, the EDDS is a short and quick to complete self-assessment tool that is versatile to use as a screening measure, diagnostic instrument, and treatment evaluation and monitoring tool for the assessment of Anorexia, Bulimia, and Binge-eating disorder. Its tendency to detect more false positives need not necessarily be a weakness given the vulnerability of the eating disorder population as having some of the most severe mortality and prognosis rates amongst mental conditions. The lack of gender and cultural sensitivity warrants further modifications and refinements by researchers so that this tool can adequately capture the individual nuances that exist both within and between minority groups.

Access

The EDDS is freely available following this link: http://www.ori.org/files/Static%20Page%20Files/EDDS.pdf. Information regarding scoring and interpretation may be found here: http://www.ori.org/files/Static%20Page%20Files/SticeTelch00.pdf.

References

Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: A meta-analysis of 36 studies. Archives of General Psychiatry, 68(7), 724-731. doi:10.1001/archgenpsychiatry.2011.74

Kelly, N. R., Mitchell, K. S., Gow, R. W., Trace, S. E., Lydecker, J. A., Bair, C. E., & Mazzeo, S. (2012). An evaluation of the reliability and construct validity of eating disorder measures in white and black women. Psychological Assessment, 24(3), 608-617. doi:10.1037/a0026457

Lee, S. W., Stewart, S. M., Striegel-Moore, R. H., Lee, S., Ho, S-Y., Lee, P. W. H., …Lam, T-H. (2007). Validation of the eating disorder diagnostic scale for use with Hong Kong adolescents. International Journal of Eating Disorders, 40(6), 569-574. doi:10.1002/eat

Shrout, P. (1998). Measurement reliability and agreement in psychiatry. Statistical Methods in Medical Research, 7(3), 301-317. doi:10.1191/096228098672090967

Stice, E., Telch, C. F., & Rizvi, S. L. (2000). Development and validation of the eating disorder diagnostic scale: A brief self-report measure of anorexia, bulimia, and binge-eating disorder. Psychological Assessment, 12(2), 123-131. doi:10.1037//1040-3590.12.2.123

Eating Attitudes Test (EAT-26)

Background

Developed by Garner, Olmstedt, Bohr and Garfinkel (1982), The Eating Attitudes Test (EAT-26) is a widely used standardised self-report measure of disordered eating behaviours and attitudes toward food. The EAT-26 is a refinement of the original EAT-40 that was first published in 1979, following the low factorial loadings of 14 items which were subsequently removed to create the EAT-26. Designed as a screening tool to be used with at-risk populations (as well as non-clinical populations), the EAT-26 does not provide a specific diagnoses for an eating disorder, but rather, an instrument to help identify individuals who might be at risk for an eating disorder (Garner et al., 2009).

Population

The EAT-26 can be used in both clinical and non-clinical settings, with both adolescents and adults. The ch-EAT (Mahoney, McGuire & Daniels, 1988) has been developed for children aged 8 to 13.

Measurement

The EAT-26 is useful as a screening tool to assess ‘eating disorder risk’ in school, college, athlete populations (Garner et al., 1983). It has also been used in non-clinical samples to detect characteristics and concerns related to anorexia and bulimia (Garner et al., 1983). The EAT-26 contains the same three factors as the EAT-40, which include: dieting, bulimia and food preoccupation and oral control (pertains to self-control of eating and perceived pressure from others to gain weight; Garner et al., 1982). Individuals who score 20 or more on the test should be interviewed by a qualified professional to determine if they meet the diagnostic criteria for an eating disorder. Any screening process should be accompanied with an interview to obtain a comprehensive assessment of the individual (Garner et al., 2009).

Scoring

Completing the EAT-26 yields a “referral index” based on three criteria: 1) The total score based on the answers to the EAT-26 questions; 2) Responses to the behavioural questions related to eating symptoms and weight loss, and 3) the individual’s body mass index (BMI) calculated from their height and weight. Generally a referral is recommended if a respondent scores “positively” or meets the “cut off” scores on one or more sections.

Psychometrics

EAT-26 correlates highly with the original EAT-40 scale (r = 0-98).The reliability (internal consistency) of the EAT-26 is high (alpha = 0-90 for the AN group), even though this scale is much shorter than the original EAT-40 (Garner, et al., 1982). Test-retest reliability for EAT-26 ranged from .84 to .89 (Banasiak et al., 2001). Other studies have noted the low reliability in studies conducted from 2005 onward, which might reflect changing attitudes toward food and exercise since the establishment of the EAT. There have also been some issues around the factorial structure of the EAT. The original three factor structure established by Garner et al., (1983) has been replicated inconsistently, with some studies noting three factors and four factors in others (Periera et al., 2008; Ocker et al., 2007). In non-clinical populations, some studies have found four factors that differ from Garner’s original factor structure. As such, a notable concern in nonclinical populations is that the EAT factors represent multiple theoretical constructs within one dimension (Ocker, Lam, Jensen & Zhang, 2007).

However, the EAT-26 has been extensively validated across other clinical and non-clinical subgroups from various cultural backgrounds (Eastern/Western Europe, South America, Middle East, Asia; Garfinkel and Newman, 2001).

Access

You can access the EAT-40 and the EAT-26 by following this link: http://www.eat-26.com/. Information regarding scoring, interpretation and screening information.

References

Garfinkel, P. & Newman, A. (2001). The Eating Attitudes Test: Twenty-five years later. Eating and Weight Disorders — Studies on Anorexia, Bulimia and Obesity, 6(1), 1–21. http://dx.doi.org/10.1007/BF03339747.

Garner, D., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The Eating Attitudes Test: Psychometric features and clinical correlates. Psychological Medicine, 12(4), 871-878.

Garner, D. (2009). EAT-26 Self-Test. Retrieved from http://www.eat-26.com/index.php

Gleaves, D. H., Pearson, C. A., Ambwani, S., &Morey, L. C. (2014). Measuring eating disorder attitudes and behaviors: A reliability generalization study. Journal of Eating Disorders, 2(6), 1-12. doi: 10.1186/2050-2974-2-6.

Maloney, M.J., McGuire, J.B., Daniels, S.R. (1988). Reliability testing of a children’s version of the Eating Attitude Test. Journal of the American Academy of Children and Adolescent Psychiatry, 27, 541–543.

Ocker, L.B., Lam, E., Jensen, B. E., Zhang, J.J. (2007). Psychometric properties of the Eating Attitudes Test. Measurement in Physical Education and Exercise Science, 11(1), 25-48.

Pereira, A. T., Maia, B., Bos, S., Soares, M. J., Macques, M., & Macedo, A., et al. (2008). The Portuguese short form of the Eating Attitudes Test-40. European Eating Disorders Review,16, 319-325.

Rivas, T., Bersabe, R., Jimenez, M., & Berrocal, C. (2010). The Eating Attitudes Test (EAT-26): Reliability and validity in Spanish Female Samples. The Spanish Journal of Psychology, 13(2), 1044-1056.