The Dutch Eating Behaviour Questionnaire (DEBQ)

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The Dutch Eating Behaviour Questionnaire (DEBQ)

• Tatjana van Strien

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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)

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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

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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

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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

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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

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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

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Psychosomatic theory

• Confusion of internal arousal states and hunger,
  probably because of early learning experiences
  (Hilde Bruch)
• Low interoceptive awareness (alexithimia)

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Psychosomatic theory Stress and satiety
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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).

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Restraint theory

• Dieting as a cause rather than a consequence of
  over eating (Peter Herman and Janet Polivy,
  Toronto, Canada)
• Natural weight homeostatically preserved

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Restraint theorymilkshake-ice-cream experiment
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Restraint theory

• Restraint eatingfysiological 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

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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 ones natural weight
  undieting

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DEBQ

• Assessment of an individuals 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.

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Psychometrics

• Excellent factorial validity
• Satisfacory to good reliability
• Satisfactory concurrent and discriminative
  validity
• Officially available in Dutch and English.

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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

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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 3the 33 DEBQ-items with 5 point Likert
  scale. p4 Table of raw scores and norm scores.
• Can be easily scored with scoring template.

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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.

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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

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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.

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DEBQ and therapyhigh 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.

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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.

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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.

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DEBQ and treatmenthigh 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.

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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.

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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.

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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?

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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.

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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).

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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.

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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.

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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.