Differences in the Factor Structure of the Eating Attitude Test-26 (EAT-26) in Different Cultures in Israel: Jews, Muslims, and Christians

The optimal cut-off score of the Eating Attitude Test-26 for screening eating disorders in Japan

PURPOSE

The Eating Attitude Test-26 (EAT-26) is a screening tool for eating disorders (EDs) in clinical and non-clinical samples. The cut-off score was suggested to be varied according to target population. However, no studies have examined the appropriateness of the originally proposed score of 20 for screening DSM-5 eating disorders in Japan. This study aimed to identify an appropriate cut-off score to better differentiate clinical and non-clinical samples in Japan for EDs.

METHODS

The participants consisted of 54 patients with anorexia nervosa restricting type, 58 patients with anorexia nervosa binge-eating/purging type, 37 patients with bulimia nervosa diagnosed according to DSM-5 criteria, and 190 healthy controls (HCs). Welch's t test was used to assess differences in age, body mass index (BMI), and total EAT-26 scores between HCs and patients with EDs. Receiver operating characteristic (ROC) analysis was conducted to identify the optimal cut-off score.

RESULTS

The HCs had significantly higher BMI and lower total EAT-26 mean scores than patients with EDs. The area under the ROC curve was 0.925, indicating that EAT-26 had excellent performance in discriminating patients with EDs from HCs. An optimal cut-off score of 17 was identified, with sensitivity and specificity values of 0.866 and 0.868, respectively.

CONCLUSIONS

The result supports the suggestions that optimal cut-off score should be different according to target populations. The newly identified cut-off score of 17 would enable the identification of patients with EDs who have been previously classified as non-clinical samples in the EAT-26 test.

LEVEL OF EVIDENCE

III: evidence obtained from case-control analytic study.

Risk and resilience in eating disorders: differentiating pathways among psychosocial predictors

OBJECTIVE

Eating disorders (EDs) represent a rising global health concern. The current study takes a multivariate approach to examine psychological (i.e., perfectionism, anxiety sensitivity [AS], emotion dysregulation) and sociocultural factors (i.e., body dissatisfaction) that may relate to risk and resilience in EDs.

METHODS

Participants were 698 undergraduate students (Mage = 21, SDage = 4.02), mainly female (71%) and Hispanic (61.6%), who participated in an online survey assessing perfectionism, emotion dysregulation, AS, body dissatisfaction, and eating behaviors.

RESULTS

The results from structural equation model analyses revealed differential associations with disordered eating (DE) outcomes. Self-oriented perfectionism and dysmorphic appearance concerns were associated with increased dieting/carb restriction, desire for thinness, and binging tendencies. Specifically, emotional nonacceptance and lack of emotional awareness showed associations with elevated risk for dieting/carb restriction and purging tendencies, respectively. Conversely, lack of emotional clarity showed a protective pathway to these risk behaviors. Anxiety sensitivity cognitive concerns related to higher purging tendencies, while AS social concerns related to lower purging and binging tendencies.

DISCUSSION

Findings highlight the differential pathways of psychosocial risk and resilience for EDs. Subscales of emotional dysregulation and AS showed risk as well as resilience associations with DE outcomes. This information is key for advancing transdiagnostic prevention and intervention to reduce the rising rates of EDs.

Psychometric properties of the Eating Attitudes Test-26 in Spanish schoolchildren

INTRODUCTION

Disordered Eating Attitudes and Behaviours (DEABs) can impact both the mental and physical health of children. Early detection is crucial to prevent complications and improve outcomes. The Eating Attitudes Test-26 (EAT-26) is a widely used, cost-effective tool for assessing DEABs.

OBJECTIVE

To evaluate the psychometric properties of the EAT-26 by analysing its factor structure, internal consistency, convergent validity, and measurement invariance across sexes in Spanish schoolchildren.

METHOD

Validation study in a sample of 718 schoolchildren. The sample was randomly divided into 2 groups, each with 359 participants, and we carried out an exploratory factor analysis (EFA) and a confirmatory factor analysis (CFA) of the instrument. Subsequently, we assessed the internal consistency by means of the ordinal alpha, the convergent validity with the SCOFF questionnaire and the measurement invariance across the sexes.

RESULTS

The results of the EFA and CFA supported a multidimensional structure of the EAT comprising 6 factors and 21 items. These factors underlie a second-order model of DEABs. The internal consistency was adequate for most factors. The SCOFF questionnaire showed a moderate convergent validity for most of the EAT-21 factors. We found measurement invariance across the sexes.

CONCLUSIONS

The abbreviated EAT-21 scale exhibited modest and promising psychometric properties, making it a suitable instrument for assessing DEABs in both sexes in educational settings.

Evidence-Based Assessments for Transdiagnostic Eating Disorder Symptoms: Guidelines for Current Use and Future Directions

Eating disorders are severe and often chronic mental illnesses that are associated with high impairment and mortality rates. Recent estimates suggest that eating disorder prevalence rates are on the rise, indicating an increased need for accurate assessment and detection. The current review provides an overview of transdiagnostic eating disorder assessments, including interview, self-report, health and primary care screeners, and technology-based and objective assessments. We focused on assessments that are transdiagnostic in nature and exhibit high impact in the field. We provide recommendations for how these assessments should be used in research and clinical settings. We also discuss considerations that are crucial for assessment, including the use of a categorical versus dimensional diagnostic framework, assessment of eating disorders in related fields (i.e., anxiety and depression), and measurement-based care for eating disorders. Finally, we provide suggestions for future research, including the need for more research on short transdiagnostic screeners for use in health care settings, standardized assessments for ecological momentary assessment, development of state-based assessment of eating disorder symptoms, and consideration of assessment across multiple timescales.

Energy drinks and waterpipe smoking associated with disordered eating habits among male Palestinian refugees

This cross-sectional study highlights the concerning relationship between stimulants, alcohol use, and weight-related problems among Palestinian refugee men in the West Bank. Self-administered questionnaires were used to gather data on stimulants and alcohol use and eating attitudes and behaviors (EAT-26). The findings revealed that many refugee men were daily cigarette (61.4%) and waterpipe smokers (15.5%), while 30.6% and 2.3% were daily energy drink and alcohol users, respectively. Moreover, most refugee men (67.3%) were obese, and 23.5% were terrified about being obese. They had disordered eating habits, including the impulse to vomit after meals (63.3%). Moreover, 30.7% scored ≥20 using EAT-26 scale, and 44.4% scored at least one positive behavior, including binge eating (40.4%), purging (10.0%), using laxatives or diet pills (8.3%), excessive exercise (30.9%), and losing weight (24.6%). The results of the adjusted binary logistic regression indicated that risk factors associated with self-induced vomiting were daily (OR = 2.71, p-value = 0.004) and weekly energy drink intake (OR = 2.41, p-value = 0.023), weekly alcohol intake (OR = 10.83, p-value = 0.036), and obesity (OR = 2.57, p-value = 0.002), while inversely associated with weekly waterpipe smoking (OR = 0.297, p-value = 0.007). Obesity was inversely associated with daily (OR = 0.146, p-value < 0.01) and weekly waterpipe smoking (OR = 0.259, p-value = 0.002), and weekly cigarette smoking (OR = 0.251, p-value < 0.01). The study underscores the urgent need for community awareness, professional evaluation, and treatment for obesity and disordered eating habits among Palestinian refugee men. It is essential to address the detrimental effects of alcohol and energy drink intake and tobacco smoking to improve the health outcomes of this vulnerable population.

Structure and factorial invariance of a brief version of the Eating Attitudes Test in Peruvian university students

Background

University students often experience significant changes in their eating habits, which can increase the risk of developing eating disorders (ED). This situation calls for the creation of brief assessment tools to identify college students who may be most at risk. The aim of the study was to determine the psychometric properties of the Eating Attitudes Test-8 (EAT-8) in a Peruvian university population; additionally, the possible differences in the scores of the instrument according to sociodemographic variables, such as gender and age, were examined.

Methods

A psychometric study was conducted on 610 participants (M = 24.3, SD = 2.16, and 61.5% female), aged 19 to 31 years, belonging to four universities of different professional careers.

Results

The unidimensional eight-item model was found to have fit indices that confirm acceptable factorial validity (X2/df = 3.23, CFI = 0.984, TLI = 0.977, RMSEA = 0.061, SRMR = 0.049) and an internal consistency of 0.833 for the Cronbach's alpha coefficient and 0.838 for the McDonald's omega coefficient. In addition, the EAT-8 was reported to be invariant according to gender and age; likewise, there were no significant differences in the age and gender categories.

Conclusion

The EAT-8 has solid psychometric properties, including validity, reliability, and invariance, in the Peruvian university population, which supports its ability to assess the risk of developing ED in this specific group.

Assessing the factor structure of the Eating Attitude Test-26 among undergraduate students in Malaysia

The objective of this study was to assess the factor structure of the 26-item Eating Attitude Test (EAT-26) through confirmatory factor analysis (CFA) among 1,084 undergraduate students in Malaysia. The initial findings indicated a lack of support for the proposed three-factor structure. Model modifications were made due to the inadequate initial fit. The fit of the model was significantly improved by excluding items with factor loadings below 0.40 and integrating residual covariances. In conclusion, it is necessary to make contextual modifications to the EAT-26 in order to effectively utilize it among Malaysian undergraduates. This highlights the significance of cultural adaptations in psychological instruments.

Beyond generalized anxiety: the association of anxiety sensitivity with disordered eating

BACKGROUND

Anxiety and eating disorders (EDs) are rising at alarming rates. These mental health disorders are often comorbid, yet the factors associated with their comorbidity are not well understood. The present study examined a theoretical model of the pathways and relative associations of anxiety sensitivity (AS) with different dimensions of ED risk, controlling for generalized anxiety.

METHODS

Participants (N = 795) were undergraduate students with an average age of 21 (SD = 4.02), predominantly female (71%), and Hispanic (71.8%). Participants completed an online survey with established measures of AS (i.e., Anxiety Sensitivity Index-3; ASI-3), general anxiety (i.e., Beck Anxiety Inventory; BAI), and eating behaviors (i.e., Eating Attitudes Test-26; EAT-26).

RESULTS

The results of our structural equation models indicated that AS subscales were significantly associated with dimensions of the EAT-26, even when controlling for generalized anxiety. Specifically, the ASI-3 factors reflecting cognitive and social concerns provided the most consistent significant associations with EDs. Whereas reporting higher cognitive concerns was associated with higher ED symptoms (e.g., reporting the urge to vomit after a meal), reporting higher social concerns was associated with fewer ED symptoms. These differential results may suggest risk and resilience pathways and potential protective or buffering effects of social concerns on ED risk.

DISCUSSION

Findings advance understanding of the role of AS in the comorbidity of anxiety and EDs, demonstrating the strong association of AS with ED pathology. These findings provide cognitive indicators for transdiagnostic therapeutic intervention in order to reduce the risk of EDs.

Omega-3 as an adjuvant in the treatment eating and psychological symptoms in patients with anorexia nervosa: a systematic review and meta-analyses

BACKGROUND

This study was carried out to assess the effects of omega-3 supplementation as an adjunct treatment for eating and psychological symptoms in patients with anorexia nervosa.

METHODS

We conducted a systematic review of the literature using the terms 'anorexia nervosa' AND 'Fatty Acids, Omega-3'. Five randomised controlled trials with a total of 144 participants, published between 2003 and 2022, were included.

RESULTS

The effects of supplementation of omega-3 on anxiety were standardised mean difference (SMD) 0.79, 95% confidence interval (CI) -0.08 to 1.66; p = 0.08; I² = 3%; two studies, 33 participants; moderate quality of evidence. For depression, the supplementation of omega-3 was SMD: 0.22, 95% CI: -0.50 to 0.93; p = 0.18; I² = 45%; two studies, 33 participants; moderate quality of evidence. For obsessive-compulsive disorder, the supplementation of omega-3 was SMD: -0.22, 95% CI: -0.70 to 2.25; p = 0.36; I² = 0%; three studies, 32 participants; low quality of evidence.

CONCLUSION

This research showed that regardless of dose, time or, if associated with other components, the use of omega-3 supplementations as an adjuvant treatment showed no evidence of effect in eating and psychological symptoms in patients with anorexia nervosa.

Differences in the Factor Structure of the Eating Attitude Test-26 (EAT-26) among Clinical vs. Non-Clinical Adolescent Israeli Females

In recent years, the diagnostic definitions of eating disorders (EDs) have undergone dramatic changes. The Eating Attitudes Test-26 (EAT-26), which is considered an accepted instrument for community ED studies, has shown in its factorial structure to be inconsistent in different cultures and populations. The aim of the present study was to compare the factor structure of the EAT-26 among clinical and non-clinical populations. The clinical group included 207 female adolescents who were hospitalized with an ED (mean age 16.1). The non-clinical group included 155 female adolescents (mean age 16.1). Both groups completed the EAT-26. A series of factorial invariance models was conducted on the EAT-26. The results indicate that significant differences were found between the two groups regarding the original EAT-26 dimensions: dieting, bulimia and food preoccupation, and oral control. Additionally, the factorial structure of the EAT-26 was found to be significantly different in both groups compared to the original version. In the clinical group, the factorial structure of the EAT-26 consisted of four factors, whereas in the non-clinical sample, five factors were identified. Additionally, a 19-item version of the EAT-26 was found to be considerably more stable and well suited to capture ED symptoms in both groups, and a cutoff point of 22 (not 20) better differentiated clinical samples from non-clinical samples. The proposed shortening of the EAT from 40 to 26 and now to 19 items should be examined in future studies. That said, the shortened scale seems more suited for use among both clinical and non-clinical populations. These results reflect changes that have taken place in ED psychopathology over recent decades.

Prevalence and Associated Factors of Eating Disorders Among Female Students at Jazan University, Kingdom of Saudi Arabia: A Survey Study

BACKGROUND AND OBJECTIVE

Concerns about the incidence of eating disorders (EDs) among university students are spreading throughout the world. In Saudi Arabia, little is known about the prevalence and associated factors of EDs among female university students. Thus, this study investigated the prevalence, common types, and potential associated factors of EDs among female students of Jazan University.  Methods: A cross-sectional survey was conducted between August 31, 2020, and November 2, 2020. The snowball technique was used to recruit female students via an electronic survey distributed in Arabic. The survey collected information about demographic characteristics, and SCOFF (Sick, Control, One, Fat, Food) and Eating Attitudes Test (EAT-26) scales. Cronbach's alpha for the SCOFF and EAT-26 scales was calculated to be 0.78 and 0.58, respectively, in this study.

RESULTS

A total of 566 female students participated in the survey, with a mean age of 22.12 ± 2.93 years. The results showed that 47.9% of participants were at risk for EDs based on SCOFF scores, while 26.5% were at risk based on EAT-26 scores. The most common types of EDs were bulimia nervosa and binge eating disorder. Furthermore, the study identified several sociodemographic characteristics, including year of study (p = 0.042), college type (p = 0.004), body weight (p = 0.001), and BMI (p = 0.001), that are significantly associated with EDs. However, no significant relationships were observed between marital status (p = 0.103), age (p = 0.147), and height (p = 0.509) with SCOFF scores. Some students reported frequent binge eating, purging, or laxative/diet pill misuse.

CONCLUSIONS

The study revealed a moderate to high prevalence of risk for EDs among female university students in Jazan, Saudi Arabia, associated with higher study years, college majors, and body weight and BMI. Dangerous ED behaviors reported by some students signal an urgent need for resources to identify and support those suffering from these disorders. Targeted interventions and services may help address this critical issue on campuses and support vulnerable students in need. Continued research and public health action are needed to curb the spread of these disorders.

The Tamil version of Eating Attitudes Test-26: Reliability and factor structure among persons with schizophrenia

Background

Disordered eating behaviors (DEBs) among persons with schizophrenia (PwS) have been reported widely in the literature, with very few studies in India. Robust tools to assess DEB are needed in the vernacular language to capture symptoms of disordered eating accurately. No such tools are available in the Tamil language. Globally, the Eating Attitudes Test (EAT-26) is widely used to assess DEB among PwS.

Aim

This study aimed to translate and study the factor structure and reliability of EAT-26 among Tamil-speaking PwS.

Materials and Methods

EAT-26 was translated into Tamil following the Oxford linguistic validation process. Experts evaluated its face validity and content validity. One hundred and fifty PwS, aged between 18 and 65 years, who attended the outpatient department of a psychiatric facility, and consented to participate, completed the Tamil version of EAT-26. Test-retest reliability of EAT-26 was assessed by readministering the tool to 30 PwS after two weeks. Data were analyzed using Stata 16.1. Internal consistency and test-retest reliability were computed using Cronbach's alpha and intraclass coefficients, respectively. The factor structure of EAT-26 was explored using principal component analysis (PCA). Spearman's rho was calculated to understand the correlation between the factors.

Results

EAT-26 had an internal consistency of 0.71 and test-retest reliability of 0.896. Factor analysis revealed nine latent factors consisting of 21 of the original 26 items on EAT-26. These 21 items could explain a variance of 63.63%.

Conclusions

The Tamil version of the EAT-26 is a reliable tool to assess DEB among Tamil-speaking PwS. It can be used to screen PwS for eating disorder risk.

The 26-Item Eating Attitudes Test (EAT-26): Psychometric Properties and Factor Structure in Vegetarians and Vegans

The eating disorder screener, Eating Attitudes Test (EAT), has been used widely; however, its usability in specific dietary groups such as vegetarians and vegans remain unknown. Considering the rising popularity of vegetarianism and veganism, the current study aimed to assess the psychometric properties and theoretical assumptions of the 26-item EAT in separate groups of vegetarians (n = 278), vegans (n = 580), and omnivores (n = 413). Confirmatory factor analysis of four models from previous literature revealed inadequate fit of the data, with the exception of a 16-item four-factor model in vegetarians and vegans. Further assessment of the original three-factor model and 16-item four-factor model demonstrated poor psychometric properties. The primarily inadequate test-retest reliability discovered in this study, independent of whether a shortened version was used, raises concerns around the utility and stability of the EAT-26 in vegetarians and vegans. Future research should potentially investigate novel ways of measuring eating disorder pathology in these groups.

An investigation of the factor structure of a German version of the Eating Disorder Symptom Impact Scale (EDSIS) among parents of adolescents and young adults with anorexia nervosa

The aim of this study was to explore the factor structure, scale characteristics and convergent validity of a German version of the Eating Disorder Symptom Impact Scale (EDSIS). A total of 335 parents of adolescents and young adults with anorexia nervosa in inpatient or outpatient treatment completed the 24-item German translation of the EDSIS and other measures of caregiving burden and psychological distress. We tested a 4 vs. 6-factor model of the EDSIS using confirmatory factor analyses. The 6-factor model treating items as ordinal variables showed the best fit to the data (CFI = 0.949, RMSEA = 0.064). Strong invariance of this model was shown between the sample of mothers and fathers. Internal consistencies of the EDSIS scales were in the acceptable-to-good range. Bottom effects were observed for the 'Binge-Purge-Impacts' subscale only. Mothers had significantly higher EDSIS scores compared to fathers. The EDSIS total score and most of the subscores showed substantial positive correlations with caregivers' psychological distress, level of depression, anxiety and expressed emotion as well as negative associations with the level of perceived caregiving skills. The German version of the EDSIS is a useful tool to assess caregiving burden in mothers and fathers of patients with anorexia nervosa.

The Prevalence of "at Risk" Eating Disorders among Athletes in Jordan

Eating disorders (EDs) are addressed as one of the expanding mental health problems worldwide. While an ED is a clinical psychiatric diagnosis that can only be established after a psychiatric assessment, it is important to note that "at-risk" refers to people who will exhibit aberrant eating patterns but do not fully meet the requirements for an ED diagnosis. This study was designed to address the ED symptoms (i.e., "at-risk") in Jordanian athletes and their association with age, sex, body mass index (BMI), and type of sport. A convenient, cross-sectional study was conducted among 249 athlete participants by answering the Eating Attitude Test (EAT-26). The EAT-26 results indicated an ED prevalence of 34% among Jordanian athletes. Within "at-risk" ED athletes, sex, age, and BMI had no significant differences in the rates of EDs. Outdoor sports had the least effect on EDs, while the highest was amongst gymnastics. EDs prevalence is alarming among Jordanian athletes. Gymnastics is a risk factor for increasing EDs. Our results should be taken into consideration by physicians, mental health professionals, sports nutritionists, coaches, and sport medicine specialists. We recommend establishing strategies pertaining to mental health, especially EDs in sports centers, along with screening programs for those who demand additional assessment and supervision.

Prevalence of High-Risk Disordered Eating Amongst Adolescents and Young Adults in the Middle East: A Scoping Review

High-risk disordered eating (HRDE) negatively affects physical, mental, and social wellbeing. This scoping review aimed to estimate the prevalence of HRDE amongst adolescents and young adults in the Middle East. MEDLINE database was searched for studies published in English or Arabic from 1 January 2000 to 30 September 2020, estimating HRDE prevalence (using the Eating Attitudes Test 26 or 40 item questionnaire) in the Middle East. Two reviewers independently screened abstracts and full texts of potentially eligible records, followed by data extraction from eligible studies. Nineteen studies (n = 16,288; 65.8% female) from Egypt, Iran, Israel, Jordan, Kuwait, Libya, Oman, Palestine, Saudi Arabia, Syria, Turkey, and the United Arab Emirates were included. Prevalence of HRDE varied considerably across countries and was lowest amongst adolescents in Israel (F 8.2%; M 2.8%) and highest amongst university students in Egypt (F 75.8%; M 69.6%). Prevalence of high-risk for anorexia nervosa ranged from 0.0% in Jordan to 9.5% in Oman; high-risk for bulimia nervosa from 0.6% in Jordan to 1.0% in the United Arab Emirates; and high-risk for binge eating disorder was 1.0% and 1.8% in Turkey and Jordan, respectively. Future studies should employ a standardized two-stage design with clinical diagnosis to verify the prevalence of abnormal eating behaviours in the Middle East.

A Plea for Diversity in Eating Disorders Research

Eating disorders (EDs) are often stereotyped as affecting the SWAG, that is, as affecting mostly skinny, White, affluent girls. Over the last decade, however, significant progress has been made toward increasing diversity in ED research. There is consensus that EDs affect individuals of all genders, ages, sexual orientations, ethnic, and socio-economic backgrounds, with recent studies exploring social determinants of ED etiology, ED presentation, and developing diversity-affirming ED assessments. This article provides a brief summary of current developments related to diversity as a research theme, and proposes different perspectives toward further improving diversity in ED research. Specifically, we argue for exploring the role of diversity in ED treatment settings and outcomes, for pursuing diversity-oriented research pro-actively rather than as a reaction to issues of under-representation, and for integrating diversity across different areas of medical education and trainings in psychotherapy. Limitations with respect to the paucity of research, and the link between diversity as a research theme and ED-related workforce diversity are discussed.