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Titre: Measurement of disordered eating in bariatric surgery candidates: A systematic review of the literature
Auteur: Katrina Parker

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ORCP-366; No. of Pages 14

ARTICLE IN PRESS

Obesity Research & Clinical Practice (2014) xxx, xxx.e1—xxx.e14

REVIEW

Measurement of disordered eating in
bariatric surgery candidates: A
systematic review of the literature
Katrina Parker a,b, Leah Brennan a,c,∗
a

Centre for Obesity Research and Education (CORE), Monash University, Melbourne,
Victoria, Australia
b School of Psychology and Psychiatry, Monash University, Melbourne, Victoria,
Australia
c School of Psychology, Australian Catholic University, Melbourne, Victoria, Australia
Received 29 August 2013 ; received in revised form 9 January 2014; accepted 25 January 2014

KEYWORDS
Eating disorder;
Obesity;
Bariatric surgery;
Systematic review

Summary Symptoms of disordered eating are common among patients seeking
bariatric surgery, and assessment of eating pathology is typical in pre-surgical evaluations. A systematic review was conducted to evaluate the definitions, diagnostic
criteria and measures used to assess disordered eating in adults seeking bariatric
surgery. The review identified 147 articles featuring 34 questionnaires and 45 interviews used in pre-surgical assessments. The Questionnaire on Eating and Weight
Patterns Revised and the Structured Clinical Interview for DSM were the most frequently used questionnaire and interview respectively. Variations to pre-surgical
diagnostic criteria included changes to the frequency and duration criteria for binge
eating, and inconsistent use of disordered eating definitions (e.g., grazing). Results
demonstrate a paucity of measures designed specifically for an obese sample, and
only 24% of questionnaires and 4% of interviews used had any reported psychometric
evaluation in bariatric surgery candidates. The psychometric data available suggest
that interview assessments are critical for accurately identifying binge episodes and
other diagnostic information, while self-report questionnaires may be valuable for
providing additional information of clinical utility (e.g., severity of eating, shape and
weight-related concerns). Findings highlight the need for consensus on disordered
eating diagnostic criteria and psychometric evaluation of measures to determine
whether existing measures provide a valid assessment of disordered eating in this
population. Consistent diagnosis and the use of validated measures will facilitate



Corresponding author at: School of Psychology, Australian Catholic University, 115 Victoria Parade/Locked Bag 4115, Melbourne,
VIC 3450, Australia. Tel.: +61 3 9953 3662; fax: +61 3 9953 3205.
E-mail address: leah.brennan@acu.edu.au (L. Brennan).
1871-403X/$ — see front matter © 2014 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.orcp.2014.01.005

Please cite this article in press as: Parker K, Brennan L. Measurement of disordered eating in
bariatric surgery candidates: A systematic review of the literature. Obes Res Clin Pract (2014),
http://dx.doi.org/10.1016/j.orcp.2014.01.005

ORCP-366; No. of Pages 14

ARTICLE IN PRESS

xxx.e2

K. Parker, L. Brennan
accurate identification of disordered eating in the pre-surgical population to enable
assessment of suitability for surgery and appropriate targeting of treatment for disordered eating to optimise treatment success.
© 2014 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd.
All rights reserved.

Contents
Introduction..................................................................................................
Methods......................................................................................................
Search strategy ..........................................................................................
Inclusion criteria ........................................................................................
Data extraction and synthesis ...........................................................................
Results .......................................................................................................
Assessment methods.....................................................................................
Reliability ...............................................................................................
Validation ...............................................................................................
Content validity ...................................................................................
Construct validity .................................................................................
Criterion validity ..................................................................................
Criteria for defining eating disorders ....................................................................
Other disordered eating ...........................................................................
No eating disorder.................................................................................
Amendments to assessments.............................................................................
Discussion ....................................................................................................
Key findings .............................................................................................
Clinical and research recommendations .................................................................
Interviews.........................................................................................
Questionnaires ....................................................................................
Strengths and limitations of this review .................................................................
Conclusion ...................................................................................................
Conflict of interest ...........................................................................................
Appendix A. Supplementary data.............................................................................
References ...................................................................................................

Introduction
Obesity is a multifactorial condition requiring targeted intervention across numerous domains [1,2].
In Australia, the use of weight loss surgery to
treat obesity has increased dramatically, rising from
about 500 hospitalisations in 1998 to 17,000 in
2007—2008 [3]. Similar increases have been documented in the United States, from 8597 bariatric
procedures in 1993 to 112,999 in 2006 [4]. While
bariatric surgery is the most effective weight
loss intervention [5,6], not everyone succeeds
in achieving and sustaining clinically significant
weight loss. Psychological factors, specifically
disordered eating, can impair adherence to recommendations regarding food and eating patterns.
Disordered eating is highly prevalent among candidates presenting for bariatric surgery [7]. Eating
disturbances may include eating disorders such as

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Binge Eating Disorder (BED), Bulimia Nervosa (BN)
or Eating Disorder Not Otherwise Specified (EDNOS;
clinically significant eating disturbances that do not
meet criteria for the aforementioned eating disorders), as well as disordered eating symptoms that
do not reach the clinical significance required to
be classified as an eating disorder. Prevalence rates
for BED vary widely depending on the population
and assessment method, from 0.7% to 4% in community samples [8], 1% to 30% in patients seeking
non-surgical weight-loss treatment [9], and 2% to
49% in bariatric surgery candidates [10,11]. In a
recent Australian study, 13.5% of bariatric surgery
candidates met the Diagnostic and Statistical Manual (DSM-IV) [8] criteria for BED assessed using a
structured clinical interview [12]. Prevalence of
other forms of disordered eating in bariatric surgery
candidates also varies depending on the definition
and method of assessment. Reported rates of Night

Please cite this article in press as: Parker K, Brennan L. Measurement of disordered eating in
bariatric surgery candidates: A systematic review of the literature. Obes Res Clin Pract (2014),
http://dx.doi.org/10.1016/j.orcp.2014.01.005

ORCP-366; No. of Pages 14

ARTICLE IN PRESS

Measuring disordered eating pre-bariatric surgery
Eating Syndrome (NES; lack of appetite and excessive evening eating) range from 2% in interviews
using a strict definition [13] to 31% in self-report
questionnaires that were confirmed by interview
[14]; grazing (continuously eating small amounts of
food with associated loss of control) ranges from
26% when confirmed by interview [14] to 60% when
self-reported [15]; and prevalence of uncontrolled
eating (loss of control experienced at least once a
week) is reported as 14% [14]. This suggests that
while rates of BED are increased in the pre-surgical
population, rates of subthreshold disordered eating
are likely to be even higher. However, the measures
used to assess these behaviours are yet to be validated in bariatric surgery candidates, therefore the
accuracy of measurement is unknown.
Given the relationship between binge eating and
obesity [6,16,17] and the increased prevalence of
binge eating in surgery candidates, the bariatric
surgery literature has typically focused on bingeing
to a greater extent than other forms of disordered
eating. Systematic reviews examining pre-surgical
binge eating as a predictor of post-surgical weight
loss have ultimately concluded that most evidence does not support this relationship [7,18,19].
However, BED and disordered eating pre-surgery
are related to an increased risk of post-surgical
disordered eating [14,20—23], which has been consistently related to poorer weight loss outcomes,
more post-surgical complications and greater psychological distress [7,11,14,18,19,24—26]. This
indicates that bariatric surgery does not directly
address potential underlying psychological contributors to disordered eating that may continue to
negatively impact weight loss efforts following
surgery. While some countries require a presurgical evaluation of disordered eating, guidelines
for assessment and how to proceed when eating
pathology is identified are limited and inconsistent [27—29]. This was highlighted in a survey of
150 American Society for Bariatric Surgery (ASBS)
members in which respondents advised that for
patients with binge eating, 20.0% proceeded with
surgery, 2.7% recommended against surgery, 27.3%
postponed surgery, and 50.0% reported that management was varied [28].
Inconsistency in the pre-surgical literature is
evident in the range in prevalence rates, which
is attributed to the variability in disordered eating criteria and measures used across studies. This
raises questions regarding the reliability and validity of disordered eating assessment, and whether
measures used for this purpose are appropriate
and valid in bariatric surgery candidates. Due to
the increased risk of disordered eating in this population (e.g., binge eating, grazing, night eating

xxx.e3
and uncontrolled eating) and its re-emergence following surgery [14,20—23], accurate assessment
is critical to inform assessment of suitability
for surgery, identify individuals who may benefit from treatment for disordered eating, and
identify factors that may impact surgical outcomes.
The aim of the current review is to identify and
critically evaluate the assessment of disordered
eating in bariatric surgery candidates. Considerations include the diagnostic criteria applied
to disordered eating, any amendments to measures or diagnostic criteria for this population, the
psychometric properties of measures in bariatric
surgery candidates, and the strengths and limitations of measures. The review offers a critique
of current assessment methods and identifies
opportunities for future research where improvements to assessment are indicated. The findings
will be valuable for informing the choice of
existing measures and the development of new
measures to facilitate the accurate assessment
of disordered eating in bariatric surgery candidates.

Methods
This review was conducted and reported according to the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) statement
[30].

Search strategy
Articles were identified through a comprehensive
electronic search of Medline, PsycINFO, Cochrane
Library, Web of Knowledge, EMBASE, and CINAHL
using combinations of terms synonymous with disordered eating, overweight/obesity and surgery
(Figure SI). Additional limits of peer-reviewed,
English language, human, and adult population
were used (Figure SII). Additional relevant papers
were also extracted from reference lists of the
retrieved articles.

Inclusion criteria
Papers were included in the qualitative analysis if
they were original studies that incorporated the
measurement of disordered eating in adults (≥18
years) before any form of bariatric surgery (Fig. 1).
Studies of children and adolescents or those with
a mean age >65 years were excluded given that
bariatric surgery is predominantly performed in
adults and that adolescents and older adults may

Please cite this article in press as: Parker K, Brennan L. Measurement of disordered eating in
bariatric surgery candidates: A systematic review of the literature. Obes Res Clin Pract (2014),
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ORCP-366; No. of Pages 14

ARTICLE IN PRESS
K. Parker, L. Brennan

Iden fica on

xxx.e4
Records identified through database
searching
(n = 1604)

Additional records identified
through other sources
(n = 4)

Screening

Records after duplicates removed
(n = 950)

Records excluded as did
not meet inclusion criteria
(e.g., non-English articles,
not human studies,
participant age <18 years)
(n = 636)

Records screened
(n = 950)

Eligibility

Full-text articles assessed
for eligibility
(n = 314)

Full-text articles excluded
(e.g., non-peer reviewed,
review articles, abstract
only, not original studies,
out of the specified age
range)
(n = 134)

Full-text articles excluded:
post-surgery samples only
(n=33)

Included

Studies included in
qualitative synthesis
(n = 147)

Figure 1 Flowchart of literature search performed.

represent a distinct sample that is not directly comparable to the adult population.

Data extraction and synthesis
Type of disordered eating assessment method and
instrument, diagnostic criteria, psychometric validation, study sample characteristics and surgery
type were extracted using standardised extraction
matrices developed by the authors. In studies with
comparisons to non-surgical weight loss interventions, only data relevant to the bariatric surgery
sample was extracted.

Results
From a total of 950 articles identified by the search
strategy (once duplicate records removed), 147
papers met the inclusion criteria and reported the
pre-surgical assessment of disordered eating (Table
SI). Study sample sizes varied from 13 [31] to 1001
[32]. In all but one study [33], the predominant gender of participants was female (M = 79.3%; 0—100%).
In the majority of studies the predominant ethnicity was Caucasian, although generally only studies
based in the United States reported ethnicity
(Table SI).

Please cite this article in press as: Parker K, Brennan L. Measurement of disordered eating in
bariatric surgery candidates: A systematic review of the literature. Obes Res Clin Pract (2014),
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ORCP-366; No. of Pages 14

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Measuring disordered eating pre-bariatric surgery

Assessment methods
Self-report questionnaires were used 178 times,
with some studies administering more than one
questionnaire, and interviews were used 72 times.
The use of questionnaires included 34 unique tools,
16 of which were only used on a single occasion.
Forty-five unique interview tools were used, with
39 only used on a single occasion. Of the 147
studies reporting the use of a disordered eating
assessment, 75 (51.0%) used more than one measure of disordered eating, and 46 reported the use
of at least one self-report questionnaire and one
interview. The most frequently used methods of
assessing disordered eating in prospective bariatric
surgery candidates are presented in Table 1. The
full range of questionnaires and interviews and a
description of the constructs measured, eating disorder criteria utilised, strengths and limitations,
and reported psychometric properties are reported
in the supplementary Table SII. Due to the large
number of studies and the lack of consistency in
assessment it was not possible to provide a quantitative synthesis, therefore this review presents a
qualitative summary of the available data.

Reliability
Reliability evaluation of disordered eating measures in bariatric surgery candidates has been
extremely limited; all available data is reported
here. The Eating Disorder Examination Questionnaire (EDE-Q) was used in 22 studies yet only one
assessed reliability of the subscales and reported
undesirable [34] (˛ = 0.61; Weight Concern) to
respectable (˛ = 0.78; Shape Concern) internal
consistency [35]. The Binge Eating Scale (BES) was
employed in 17 studies, yet the only evaluation
was of a Dutch version of the scale by Larsen et al.
[36], who reported very good internal consistency
(˛ = 0.87) and satisfactory factor loadings for all
items (>0.3). Of the less frequently used questionnaires, internal consistency was very good for the
three subscales of the Emotional Eating Scale (EES)
(Depression, ˛ = 0.83; Anxiety, ˛ = 0.88; Anger,
˛ = 0.92) [37], which was used in three studies.
Two additional measures were evaluated, although
each was only employed in one study. Internal
consistency was very good for the Emotional Eating
questionnaire (˛ = 0.85) [38] and respectable for
the Eating Behaviour Self-efficacy Scale of the
Obesity Psychosocial State Questionnaire (˛ = 0.73)
[39]. The only reported test—retest reliability
was for the Eating Disorders in Obesity (EDO)
questionnaire, which was used in four studies
and demonstrated good test—retest concordance

xxx.e5
for binge eating (k = 0.65) [40]. Combined, these
results indicate adequate reliability for most of the
tested scales. However, the limited number of measures assessed and the lack of evaluation of some
of the most frequently used measures (e.g., Three
Factor Eating Questionnaire, Eating Disorder Inventory, Eating Disorder Examination) are of concern.

Validation
As there is no established gold standard measure in
the bariatric surgery population, we made an a priori decision to label the comparison of measures to
clinician led structured clinical interviews providing eating disorder diagnoses (e.g., Eating Disorder
Examination, EDE; Structured Clinical Interview for
DSM, SCID) as criterion validity, and comparisons
between other measures as construct validity. Definitions of reliability and validity considered in
this review are presented in Table 2. The results
of the most frequently used measures are outlined below; additional results are reported in
Table SII.
From the 34 questionnaires identified, only the
EDO was specifically constructed for weight-loss
treatment seeking adults. This modified version of
the Survey for Eating Disorders (SEDs) [41] was only
used in four of the reviewed papers and no information on the validity of the scale development
process was reported. The only interview developed specifically for bariatric surgery candidates
was the Rhode Island Bariatric Surgery Interview,
which was used once [42]. While it briefly assesses
eating and dieting history, it is primarily focused on
patients’ motivations and understanding of surgery
and there are no reports of its psychometric evaluation.
The only interviews evaluated for use with
bariatric surgery candidates were the SCID and EDE.
The SCID was employed in 14 studies and evaluated as a criterion in one study [43]; the EDE was
employed in 9 studies and was evaluated as a criterion in two studies [40,44]. The SCID has been shown
to generate lower rates of full BED diagnoses compared to the QEWP-R [43]. This finding highlights a
discrepancy between self-report and interview data
in the identification of binge eating behaviours.
Content validity
Not reported in any published papers.
Construct validity
Evaluation of construct validity was limited to the
BES, QEWP-R and EDE-Q [15,45]. There was a significant relationship between high scores on the
BES and bingeing behaviour on the QEWP, and

Please cite this article in press as: Parker K, Brennan L. Measurement of disordered eating in
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ORCP-366; No. of Pages 14

xxx.e6

K. Parker, L. Brennan

Table 1 Most frequently used methods of assessing disordered eating in the pre-operative bariatric surgery
population.
Instrument

Items/
duration

Description

Questionnaires
QEWP and QEWP-R [99]

28

TFEQ (EI) [100]

51

EDE-Q [101]

28

EDI and EDI-II [102]

91

BES [103]

16

Assesses symptoms and
history of ED
behaviours and weight
history
3 scales:
Cognitive restraint,
Disinhibition, Hunger
Adapted from the EDE
Global + 4 subscales:
Restraint, Eating
Concern, Shape
Concern, Weight
Concern
Assesses current eating
disorders
11 scales:
Drive for thinness,
Bulimia, Body
dissatisfaction,
Ineffectiveness,
Perfectionism,
Interpersonal distrust,
Interoceptive
awareness, Maturity
fears, Asceticism,
Impulse regulation, and
Social insecurity
Total score reflecting
severity of binge
behaviours

Interviews
SCID-I [104]

60 min

EDE [105]

45—75 min

Assesses current and
lifetime eating
disorders
Global + 4 subscales:
Restraint, Eating
Concern, Shape
Concern, Weight
Concern
Assesses current eating
disorders

Assess ED
behaviours

Validated in
BS

Obese






























Frequency

36

32

22

18

17

14

9

BES: Binge Eating Scale; BS: Bariatric Surgery; ED: Eating Disorder; EDE: Eating Disorder Examination; EDE-Q: Eating Disorder
Examination Questionnaire, EDI Eating Disorder Inventory; QEWP and QEWP-R: Questionnaire on Eating and Weight Patterns
(Revised); SCID: Structured Clinical Interview for DSM; TFEQ: Three Factor Eating Questionnaire.

between a high BES score and grazing behaviour
questions added to the QEWP [15]. Elder et al.
[45] reported that agreement between the QEWPR and EDE-Q was poor (k = 0.05) in identifying
twice-weekly binge eating, and fair (k = 0.26) in

identifying recurrent binge eating. The EDE-Q
better differentiated between those who binge ate
once a week versus no or infrequent bingeing,
and was better for identifying those with elevated shape and weight concerns than the QEWP-R.

Please cite this article in press as: Parker K, Brennan L. Measurement of disordered eating in
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Measuring disordered eating pre-bariatric surgery
Table 2

The measurement of reliability and validity [97].

Construct
Reliability
Internal consistency
Temporal
Validity
Content

Construct

Criterion

xxx.e7

Definition

Measurement

Homogeneity of the items. The degree to which the
scale items are measuring the same construct.
Test—retest reliability, the degree to which the
results are consistent over time.

Cronbach’s coefficient alpha;
inter-item correlations
Correlation

Adequacy with which a scale samples from the
intended universe of content. Typically considered
during the developmental phase (e.g., seeking advice
from experts in the field, receiving feedback on
scale).
Demonstrating the scale performs in line with its
conceptual definition, by exploring its relationship
with other constructs. Encompasses convergent (i.e.,
that measures of constructs that theoretically should
be related, are in fact related) and discriminant
(i.e., that measures of constructs that theoretically
should not be related, are not related) validity,
known groups validity and factorial validity.
Relationship with a specified, measurable criterion.
Also known as predictive validity.

Qualitative

All EDE-Q subscales except the Restraint scale
were moderately to strongly significantly correlated with measures of body image (Body Shape
Questionnaire) and general psychopathology (Beck
Depression Inventory and Rosenberg Self-Esteem
Scale) [45], demonstrating convergence with similar constructs. Taken together, the correlations
between conceptually-related scales indicate convergent validity for the BES, QEWP and EDE-Q,
although concordance between measures for identification of binge eating and the frequency of binge
behaviours is poor.
Criterion validity
The only reported criterion validity was between
the Night Eating Questionnaire (NEQ) and a clinical interview [46], the QEWP-R and SCID [43],
and the EDE-Q, EDO and EDE [40,44]. The NEQ
demonstrated the ability to differentiate between
candidates with and without NES as classified by
interview [46]. A comparison of the QEWP-R and
SCID found concordance for BED diagnosis was fair
(k = 0.37), with 41% of those who met full criteria
for BED using the QEWP-R also meeting criteria with
the SCID, and 71% of those who met full criteria
on the SCID also meeting criteria on the QEWPR [43]. There were significant strong correlations
(0.60—0.77) between the EDE-Q and EDE interview
for the four subscales, although scores were significantly lower on the EDE [44]. There was no

Correlations; T tests

Correlation; logistic
regression

significant difference in the number of Objective
Binge Episodes (OBEs) identified on the EDE-Q and
EDE, and the measures were moderately correlated
(Kendall’s tau-b = 0.46). Furthermore, agreement
on classification of participants binge eating at least
twice weekly was moderate (k = 0.45) [44]. The
EDO currently has the highest reported rates of
agreement with the EDE, with substantial concordance for classification of eating disorders (k = 0.67)
and binge eating (k = 0.63) [40]. Combined, these
results indicate that overall agreement between
measures for identification of binge eating is moderate at best.

Criteria for defining eating disorders
For diagnosis of BED, DSM criteria specify the
requirement of recurrent episodes of binge eating; that is, eating an objectively large amount
of food in a discrete period of time, with a sense
of lack of control over eating during the episode
[8,47]. This was the predominant criteria for classifying binge eating in the 147 reviewed studies.
An observed variation was to change the frequency
and duration requirements for a binge episode.
Five studies reduced the frequency to at least
one episode per week for six months [48—52],
while seven studies defined recurrent/regular binge
eating as at least one OBE per week, without specifying duration [45,53—58]. Five studies

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ORCP-366; No. of Pages 14

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xxx.e8
decreased the binge eating requirement to at least
one episode per week for three months [59—63]
(which aligns with the DSM-5 [47] criteria for
binge eating). Modifications to frequency were
based on studies that have demonstrated few psychological or behavioural differences and similar
functional impairment between people bingeing
once a week compared to those bingeing at
least twice per week [45,52,56,58,62,64—66], and
that these groups are at similar risk for obesity and psychiatric distress [67]. Diagnosis of
Eating Disorder Not Otherwise Specified (EDNOS)
was reported in twelve studies when the DSMIV frequency and duration criteria for bingeing
were not met yet the features of disordered eating resulted in clinically meaningful impairment
[10,40,50,59,61,68—74].
Other disordered eating
Other disordered eating pathology included nibbling, grazing, emotional eating, NES and subthreshold bingeing. Nibbling was classified in two
studies [75,76]. It was differentiated from grazing, which was classified in seven studies and
required a sense of loss of control while eating
[10,14,15,74,77—79]. There was variation in the
three definitions of emotional eating used across
interviews, such as whether it was defined as eating or overeating, and whether it was present
solely in response to negative emotions, or to both
negative and positive emotions [80—82]. NES classification was observed in nine studies and was
also inconsistent, with criteria including morning lack of appetite and excessive evening eating
(e.g., 50% or more of total energy intake after
7 pm) [13,14,46,79,82—86]. Some studies identified disordered eating behaviours similar to those
reported as EDNOS but did not use the EDNOS
diagnosis, instead using terms such as subthreshold bingeing [14,25,32,40,43,63,78,79,84,87,88].
This creates further inconsistency in labelling
and diagnosis and reduces comparability across
studies.
No eating disorder
The absence of an eating disorder was defined
in eleven studies. Definitions were inconsistent,
ranging from never binge eating [25,89—91], binge
eating less than once per week [51,62,63], no OBEs
and no more than one overeating episode per week
[60,61], to no experiences of loss of control while
eating [87] or a score of less than 18 on the BES
[36]. Consequently, there is also a lack of consensus on what constitutes the absence of disordered
eating.

K. Parker, L. Brennan

Amendments to assessments
Content amendments to questionnaires and interviews were observed in seven studies and included
the use of abbreviated measures, such as only
assessing for OBEs and subjective binge episodes
(SBEs, i.e., a sense of lack of control over eating when consuming amounts of food that would
not be regarded by others as objectively large)
on the EDE [60], or excluding items pertaining
to Anorexia Nervosa (AN) [13,40,59,74,92]. Other
modifications included adding items to the EDE to
assess for the additional behavioural features indicated in the DSM criteria [40,93], adding items
assessing grazing to the QEWP [15,77], and adding
questions about grazing and night eating to the
EDO [94]. These content and methodological variations were not psychometrically evaluated and
add further inconsistency to the assessment of
disordered eating in bariatric surgery candidates
(Table SII).

Discussion
This is the first systematic review to evaluate the
assessment of disordered eating in obese adults
seeking bariatric surgery. This review considers
disordered eating definitions, diagnostic criteria,
amendments and rationale for changes to measures
or diagnostic criteria, psychometric evaluation of
measures, and strengths and limitations of measures.

Key findings
Considerable variability was evident in the number of disordered eating measures and the range of
diagnostic criteria. A variety of disordered eating
constructs were assessed across different measurement tools, including behavioural (e.g., bingeing,
restriction), cognitive (e.g., dietary restraint, negative body image), and emotional (e.g., emotional
eating) factors. The inconsistency of assessment
likely accounts for the range in disordered eating prevalence rates and highlights the lack of a
standardised assessment approach. As such, findings between measures and across studies are
unlikely to be directly comparable, which limits the conclusions that can be drawn from this
review.
The review highlights the paucity of psychometric evaluation of disordered eating measures
in bariatric surgery candidates. This is of concern
given that obese persons who have accepted a surgical option for weight loss treatment likely represent

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Measuring disordered eating pre-bariatric surgery
a different population to those seeking lifestyle
or medical treatment, and to general eating disorder patients who may present at the opposite
end of the weight spectrum or with different areas
of pathology. A key limitation to validation of
disordered eating measures in bariatric surgery candidates is the lack of well-validated ‘gold-standard’
criterion measures in this sample. Validation is
dependent on the population of interest and purpose of assessment; therefore, a measure validated
for one population may not necessarily be valid for
another population [95]. As there is no established
criterion for pre-surgical assessment, measures are
being compared against other measures that are
also yet to be comprehensively validated in this
population. The lack of psychometric evaluation
means it is unclear whether measures designed
for traditional eating disorder populations (i.e.,
Anorexia Nervosa and Bulimia Nervosa) accurately
assess the relevant domains of eating attitudes,
cognitions and behaviours that are of concern for
the bariatric surgery population. Further research
is required to assess the psychometric properties
of existing measures, and to systematically revise
these measures and/or develop new tools designed
specifically for reliably and validly assessing disordered eating in this population. Any new measures
developed will also require thorough psychometric
evaluation.
There is an identified need for consensus on the
definitions and criteria applied to disordered eating
in bariatric surgery candidates. It is notable that
no adaptations were made to the definition for the
size of a binge in any of the measures used (e.g., to
consider SBEs instead of OBE criteria). The differentiation of SBEs accounts for the change in a patient’s
capacity to consume objectively large amounts of
food in a discrete period of time following surgery,
and highlights loss of control as the central clinical
symptom [87]. Thus the distinction between OBEs
and SBEs is likely to be of critical importance for
comparisons of disordered eating between pre- and
post-surgical samples. It is recommended that different approaches to the amount of food criteria
are considered to ensure comprehensive evaluation
of the range of disordered eating behaviours and
impairment experienced by patients, as well as the
potential changes following surgery.

Clinical and research recommendations
Recommendations from this review are based on
the limited evidence available from the use of
disordered eating measures in bariatric surgery
candidates. Until evidence regarding best practice
disordered eating assessment exists in the bariatric

xxx.e9
surgery population, clinical recommendations will
continue to be informed by data from non-surgical
samples.
To be clinically useful and psychometricallysound for research purposes, at minimum a measure
should meet four criteria: (i) internal consistency
(˛ = 0.65 minimum acceptable) [95,96]; (ii) temporal (test—retest) reliability (no clear minimum
guideline as dependent on nature of construct and
duration of retest period) [95]; (iii) evidence of
construct validity (convergent and divergent validity with conceptually similar/dissimilar constructs)
[97]; and (iv) evidence of criterion validity (relationship with a specified criterion) [97]. Of the
147 papers reviewed employing 34 questionnaires
and 45 interviews, no measures met all criteria in
bariatric surgery candidates. The EDE-Q has been
evaluated for all criteria except temporal reliability, although it failed to meet adequate internal
consistency for one scale and demonstrated only
moderate criterion validity [35,44,45]. The QEWP-R
is not comprised of construct scales and therefore internal consistency is not applicable, however
construct validity with the EDE-Q [45] and criterion validity with the SCID [43] were fair at best.
Based on this evidence, the aforementioned measures should be used with caution as they are likely
to have limited utility in this setting, particularly
for identification of disordered eating. The BES
has been reported to meet internal consistency
and construct validity criteria [15,36], although
evaluation of criterion validity is required to determine its utility. Three questionnaires that were
infrequently used met the internal consistency
criterion [37—39], and the NEQ demonstrated criterion validity [46]. The EDO showed the strongest
concordance with the EDE for identification of binge
eating and good temporal reliability [40]. Therefore
these measures have the potential to be useful if
additional psychometric testing is completed and
deemed adequate.
Investigator-based interviewing (e.g., the EDE)
is recommended as the most rigorous method for
assessing complex behaviours and based on the
available evidence is critical to obtaining accurate diagnoses [13,43—45]. This is also the method
recommended in non-bariatric surgery populations
[98]. The most comprehensive assessments used
an investigator-based interview complemented by
self-report questionnaire(s) to verify eating pathology and/or provide additional clinical information.
This approach was observed in 43 studies and
balances the diagnostic data obtained from an
interview with the opportunity to obtain data
on associated eating pathology via less resource
intensive means. While self-report assessments are

Please cite this article in press as: Parker K, Brennan L. Measurement of disordered eating in
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xxx.e10
dependent on insight and motivation to respond
truthfully and may be impeded by poor recall
or poor discrimination of specific binge episodes,
investigator-based interviews are able to minimise
some of these potential confounds as the interviewer (rather than the respondent) makes the
rating for each item and is able to revisit any
discrepancies in responses. This is particularly
advantageous when working with complex concepts, such as overeating or loss of control [43].
Interviews
From the interviews currently available, the
investigator-based, structured EDE is recommended as the assessment of choice as it is one of
only two interviews validated in bariatric surgery
candidates [44]. The EDE provides diagnostic information, and in contrast to the SCID it also provides
a comprehensive assessment of the severity of
eating-related pathology. Consequently, the EDE is
recommended as the criterion against which to
compare the validity of other measures.
Questionnaires
Screening: From the available evidence the BES
may be used with caution for screening of binge
severity. It was developed specifically for identifying binge eating behaviours in obese individuals,
although further evidence is required to establish
its criterion validity. The NEQ also requires further
psychometric evaluation in the bariatric surgery
population but evidence suggests it may be used
for screening of night eating behaviours [46].
Diagnosis: Although questionnaires cannot be
used to establish a diagnosis, they are often
employed as indicators of diagnostic symptomatology. The QEWP-R and EDE-Q both provide data on
frequency and duration of bingeing. However, the
EDE-Q does not assess the full duration required
for a DSM diagnosis and is not recommended for
identification of binge eating behaviour due to the
high potential for misclassification and its moderate agreement with the EDE in bariatric surgery
candidates [44,45]. Limitations for the QEWP-R are
similar, demonstrated by its fair concordance with
the SCID [43]. As a result, these questionnaires are
only recommended as secondary diagnostic indicators to an investigator-based interview.
Associated eating pathology: Although use of the
EDE-Q as a diagnostic indicator is cautioned, its subscales are recommended for assessing the severity
of eating-related pathology, with the understanding
that scale scores on the questionnaire are typically
higher than the interview [44] and the proviso that
the Weight Concern scale is interpreted with caution due to its undesirable internal consistency in

K. Parker, L. Brennan
bariatric surgery candidates [35]. The TFEQ was
frequently used but has not undergone any psychometric evaluation in bariatric surgery candidates,
therefore its utility is unknown.

Strengths and limitations of this review
This is the only review to systematically examine the criteria and methods used to identify and
assess disordered eating in bariatric surgery candidates. All information relating to disordered eating
definition, diagnostic criteria, measures, and reliability and validity data were extracted, from which
information was integrated and recommendations
provided based on available data. This paper highlights the heterogeneity of diagnostic criteria and
measures and the resultant lack of comparability.
Conclusions drawn from this review are limited by
inconsistent reporting in the identified literature,
the variability in assessments, and the paucity of
psychometric evaluation. Findings provide essential
information to guide researchers and clinicians in
the selection of assessment measures and inform
the development and psychometric evaluation of
future measures to ensure evidence-based assessment in bariatric surgery candidates.

Conclusion
This review highlights the need for consensus on
disordered eating criteria and further psychometric
evaluation of measures in bariatric surgery candidates. The recommended assessment approach is
the use of a structured investigator-based interview
(ideally the EDE), with complementary questionnaires selected based on the purpose of the
evaluation. Psychometric evaluation will provide an
evidence base for the use of existing measures and
inform the development of new measures where
required. Reliable and valid assessment and diagnosis of pre-surgical disordered eating is critical
to a comprehensive evaluation of patient characteristics and symptom severity, enabling accurate
identification and diagnosis prior to surgery. Further, it ensures the ability to evaluate the impact
of pre-surgical eating psychopathology on surgical
outcomes, and provides an opportunity to direct
disordered eating intervention to at-risk patients,
potentially preventing the (re)-emergence of postsurgical eating pathology.

Conflict of interest
The Centre for Obesity Research and Education
(CORE) received a grant from Allergan for research

Please cite this article in press as: Parker K, Brennan L. Measurement of disordered eating in
bariatric surgery candidates: A systematic review of the literature. Obes Res Clin Pract (2014),
http://dx.doi.org/10.1016/j.orcp.2014.01.005

ORCP-366; No. of Pages 14

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Measuring disordered eating pre-bariatric surgery
support. The grant was not tied to any specified
research projects and Allergan have no control of
the research protocols, analysis or reporting of any
studies.

Appendix A. Supplementary data
Supplementary data associated with this article can
be found, in the online version, at http://dx.doi.
org/10.1016/j.orcp.2014.01.005.

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Please cite this article in press as: Parker K, Brennan L. Measurement of disordered eating in
bariatric surgery candidates: A systematic review of the literature. Obes Res Clin Pract (2014),
http://dx.doi.org/10.1016/j.orcp.2014.01.005

ORCP-366; No. of Pages 14

ARTICLE IN PRESS

xxx.e14

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Available online at www.sciencedirect.com

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Please cite this article in press as: Parker K, Brennan L. Measurement of disordered eating in
bariatric surgery candidates: A systematic review of the literature. Obes Res Clin Pract (2014),
http://dx.doi.org/10.1016/j.orcp.2014.01.005


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