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Psychol Assess. Author manuscript; available in PMC 2017 October 01. Published in final edited form as: Psychol Assess. 2016 October ; 28(10): 1319–1324. doi:10.1037/pas0000246.
Black Patients with Binge-Eating Disorder: Comparison of Different Assessment Methods Janet A. Lydecker, Marney A. White, and Carlos M. Grilo Department of Psychiatry, Yale School of Medicine
Abstract Author Manuscript Author Manuscript
The Eating Disorder Examination (EDE) is a well-established assessment instrument, but requires substantial training and administration time. The Eating Disorder Examination Questionnaire (EDE-Q) is the corresponding self-report survey, which does not have these demands. Research has shown concordance between these two assessment methods, but samples have lacked racial diversity. The current study examined the concordance of the EDE-Q and EDE in a sample of Black patients with binge-eating disorder (BED) and a matched sample of White patients. Participants were 238 (Black n=119, White n=119) treatment-seeking adults with DSM-IV-TRdefined BED. Participants completed the EDE-Q and trained doctoral-level clinicians assessed participants for BED and eating-disorder psychopathology using the Structured Clinical Interview for DSM-IV Disorders and the Eating Disorder Examination (EDE) interview. The EDE-Q and EDE yielded significantly correlated frequencies of binge-eating and eating-disorder psychopathology subscales. The EDE-Q yielded significantly lower frequencies of binge-eating and higher scores on three of four subscales (not dietary restraint). Similar patterns of concordance between the EDE-Q and EDE were found for an alternative brief version of the instruments. Patterns of convergence and divergence between the EDE-Q and EDE observed in Black patients with BED are generally consistent with findings derived from the matched White sample: overall, scores are correlated but higher on the self-report compared with interview assessment methods. Clinicians assessing patients with BED should be aware of this overall pattern, and aware that this pattern is similar in Black patients with BED with the notable exception of dietary restraint.
Keywords binge-eating disorder; race; concordance; eating disorders
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Binge-eating disorder (BED) is the most prevalent eating disorder (Hudson, Hiripi, Pope, & Kessler, 2007). BED is defined by recurrent binge-eating (i.e., eating unusually large amounts of food while experiencing a subjective sense of loss of control over eating) without the weight compensatory behaviors that define bulimia nervosa (American Psychiatric Association, 2013). In contrast to other eating disorders, BED is unique in that there is less racial disparity in prevalence and treatment-seeking rates than other eating disorders
Correspondence should be addressed to Janet A. Lydecker, Yale University School of Medicine, 301 Cedar Street, New Haven, CT 06519. [email protected]. The authors report no conflicts of interest.
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(Marques et al., 2011). Assessment of binge-eating and associated eating-disorder psychopathology can be challenging but is a critical component of diagnosis and treatment planning. To date, BED-related assessment research has been primarily with samples underrepresented by racial minorities (Berg, Peterson, Frazier, & Crow, 2011). Parallel research is needed to expand our understanding of BED-related assessment in racial minorities, such as individuals who identify as Black, to improve multicultural competence in assessment and inform clinicians and researchers about how to assess efficiently yet comprehensively. To date, much research has been done using the Eating Disorder Examination (EDE) interview and questionnaire version (EDE-Q), but this line of research warrants extension to more diverse patient samples including racial minorities.
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The EDE is an investigator-based, semi-structured interview that assesses eating-disorder psychopathology comprehensively (Fairburn & Cooper, 1993). The EDE assesses eatingdisorder psychopathology (dietary restraint, eating concern, weight concern, and shape concern) and the frequency of binge-eating, overeating, and extreme weight compensatory behavior (e.g., purging). The EDE is considered the best-established interview method for the assessment of eating-disorder psychopathology, but it requires significant clinical training and administration time. A self-report survey version of the EDE, the Eating Disorder Examination Questionnaire (EDE-Q), was designed to decrease these interviewbased measurement barriers while maintaining the comprehensiveness of the assessment (Fairburn & Beglin, 1994).
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The EDE-Q and EDE have matched item content and scoring procedures for subscales (dietary restraint, eating concern, weight concern, shape concern), global score, and diagnostic items, including binge-eating frequency (Fairburn & Beglin, 1994). This allows for the direct comparison of scores and frequencies, which can provide insight into how similar the self-report and interview scores are, and help clinicians conceptualize data based on the different methods. Several studies have evaluated the concordance of the EDE-Q and EDE (Berg et al., 2011). Berg and colleagues (2011), in a review and meta-analysis of results of studies performed across various clinical and non-clinical samples, showed that subscale scores were significantly correlated, with significantly higher scores generated by the EDE-Q than the EDE across diagnostic groups. Meta-analytic results for binge-eating frequencies, however, were inconclusive across the studies with some subjects reporting higher frequencies on the self-report questionnaire than interview (Fairburn & Beglin, 1994) whereas a different pattern was observed for other subjects (Wilfley, Schwartz, Spurrell, & Fairburn, 1997).
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To date, four small studies have evaluated the concordance of the EDE-Q and EDE in patients with BED (Barnes, Masheb, White, & Grilo, 2011; Grilo, Masheb, & Wilson, 2001a, 2001b; Wilfley et al., 1997). Across these studies, binge-eating frequencies were fewer on the EDE-Q compared with the EDE, all EDE-Q and EDE subscales were significantly correlated with each other (ranging from .33 to .69 across studies), and all scores on the EDE-Q subscales were significantly higher than corresponding EDE scores. One study found that binge-eating frequency was not significantly correlated between the EDE-Q and EDE (Wilfley et al., 1997), but the other three studies found significant correlations (Barnes et al., 2011; Grilo et al., 2001a, 2001b). Reported binge-eating episodes
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were fewer on the EDE-Q than the EDE in two studies (Barnes et al., 2011; Wilfley et al., 1997) and not significantly different in two other studies (Grilo et al., 2001a, 2001b).
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Whereas research has begun to establish that the self-report EDE-Q does produce reasonably concordant findings to the EDE interview, the variable findings also point to the necessity of understanding the nature and sources of variability that characterize the different assessment methods. To date, assessment research with BED has had overwhelmingly White samples, which have been small: 91% White (N=82; Grilo et al., 2001b), 89% White (N=46; Grilo et al., 2001a), and 92% White (N=52; Wilfley et al., 1997). One study had 33% Black individuals (N=66; Barnes et al., 2011), but did not examine EDE-Q and EDE concordance by race. There is a clear need for EDE-Q/EDE concordance research that includes racial minorities, particularly because BED has comparable prevalence rates and mental health service utilization across racial groups (Marques et al., 2011) while showing complex patterns of similarities and differences in clinical presentation by race (Lydecker & Grilo, 2015). Therefore, the goal of the current study was to examine the concordance of the two assessment methods (self-report and interview versions of the EDE) in a sample of Black participants who met criteria for BED. Additionally, to place these concordance findings in the context of the larger literature, we examined how the concordance in the Black sample compared with a matched (by sex, education, age) White sample. Understanding how bingeeating frequencies and eating-disorder psychopathology scores on the EDE-Q and EDE relate to each other in the Black sample will help inform decisions about which instrument fits clinical or research needs, and will help improve interpretation of scores with accuracy and confidence that the tools are culturally appropriate for diverse individuals.
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Participants
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Participants (N = 238) responded to advertisements for treatment studies for BED at an urban, medical-school based program located in the northeastern United States. These participants were selected from a larger series of treatment-seeking patients with BED, which has been previously described (Lydecker & Grilo, 2015). Participants were between 18 and 65 years old and met full criteria for BED in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition – Text Revision (DSM-IV-TR; American Psychiatric Association, 2004). Participants were excluded for medical conditions influencing eating or weight (e.g., diabetes), severe mental illness that could interfere with clinical assessment (e.g., psychosis), concurrent treatment for eating/weight concerns, or pregnancy. Participants were included in the current analyses if they self-identified as Black (n = 119). Additionally, we created a comparison sample taken from the larger sample of White participants (n = 119) by matching to the Black participants on sex, education, then age. Overall, the 238 participants in the current study had a mean age of 45.07 years (SD = 10.16) and a mean BMI of 38.45 kg/m2 (SD = 6.90). Participants were primarily female (n = 198, 83.2%), and had varying levels of education: high school/less than high school (n = 64, 26.9%), some college/associate’s degree (n = 102, 42.9%), or a college degree (n = 72, 30.3%). This study received approval from the university’s ethical review board; all enrolled participants provided written informed consent.
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Measures
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Participants were evaluated by doctoral-level research clinicians who were trained and monitored to maintain reliability. Research clinicians administered the Structured Clinical Interview for DSM-IV Axis I Disorders (First, Spitzer, Gibbon, & Williams, 1997) to determine DSM-IV-TR-based BED diagnosis. Research clinicians measured participants’ height and weight and calculated BMI (kg/m2). The self-report EDE-Q was completed by participants prior to the EDE interview (thus providing a test of its concordance less biased by learning effects). Inter-rater reliability, examined in 113 cases from the larger series of BED patients, was excellent: intra-class correlation coefficients were .94 for OBEs and .92 for EDE global score, .92 for Restraint, .78 for Eating Concern, .91 for Weight Concern, and .94 for Shape Concern.
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Eating Disorder Examination (EDE)—The EDE evaluates eating-disorder psychopathology (dietary restraint, eating concern, weight concern, and shape concern) in the past 28 days, and over longer intervals as they correspond with diagnostic criteria (Fairburn & Cooper, 1993). The interview also assesses objective bulimic episodes (objective BEs, consuming an unusually large amount of food and perceiving a loss of control over eating; this corresponds to the DSM-IV-TR-based definition of binge-eating episodes), subjective bulimic episodes (subjective BEs, eating a small or typical amount of food yet perceiving a loss of control over eating) and objective overeating episodes (objective OEs, eating an unusually large amount of food without perceiving a loss of control over eating). The EDE is a well-established assessment tool with good inter-rater and test-retest reliability in BED (Grilo, Masheb, Lozano-Blanco, & Barry, 2004). Overall, in the current study, Cronbach’s α was .82 for the EDE global score and as follows for subscales: restraint α = .60, eating concern α = .63, weight concern α = .51, shape concern α = .71.
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Eating Disorder Examination Questionnaire, version 5.2 (EDE-Q)—The EDE-Q is the self-report survey version of the EDE (Fairburn & Beglin, 1994). Like the EDE, the EDE-Q measures eating-disorder psychopathology in the past 28 days, and over longer intervals for diagnostic items. The EDE-Q yields scores on the same subscales (dietary restraint, eating concern, weight concern, and shape concern), global score, and binge-eating frequency variables. Overall, in the current study, Cronbach’s alpha for the EDE-Q global score was .89 and as follows for the subscales: restraint α = .78, eating concern α = .76, weight concern α = .61, shape concern α = .78. Statistical Analyses
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To evaluate the concordance of EDE-Q and EDE for subscale and global scores and for binge-eating and other eating behaviors, we compared scores using Pearson’s productmoment correlations and paired t-tests. Parallel analyses also compared an alternative, brief structure proposed for the EDE-Q and EDE. The alterative, brief version of the EDE-Q and EDE uses seven items to generate a global score and three subscales: dietary restraint, shape/ weight overvaluation, and body dissatisfaction (Grilo et al., 2015). We include analyses with these brief versions because psychometric studies have suggested they have advantages over the full EDE-Q and EDE for BED (Grilo et al., 2010), and their much briefer formats would decrease time required to assess patients (Grilo et al., 2010; Grilo et al., 2015). Psychol Assess. Author manuscript; available in PMC 2017 October 01.
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To evaluate the concordance of binge-eating and overeating frequencies (objective BE, subjective BE, and objective OE variables), we compared monthly episodes using Pearson’s product-moment correlations and paired t-tests. Variables that were not normally distributed were evaluated using Kendall’s τb instead of Pearson’s correlation and the Wilcoxon signedrank Z-test instead of paired t-test. We also compared the magnitude of independent correlation coefficients in the Black and White samples using Fisher’s r-to-z transformation. Finally, we sought to replicate earlier work examining the concordance of the EDE-Q and EDE in BED by including a sample of White participants matched with the sample of Black participants. Participants were matched by sex and education level, and then by age. Frequencies of Black and White participants for sex and education were identical. The mean age for Black participants was 45.34 (SD=9.80), and for White participants was 44.80 (SD=10.55).
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Results Comparison of EDE-Q and EDE eating episodes
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Table 1 summarizes correlations and mean difference tests for eating episodes and weight variables. In the Black sample, frequencies reported on the EDE-Q and EDE had significant, large correlations for objective BEs, but not subjective BEs or objective OEs. Objective BEs were fewer on the EDE-Q than the EDE, and objective OEs were higher on the EDE-Q than the EDE; subjective BEs did not significantly differ. In the matched White sample, frequencies for objective and subjective BEs were significantly correlated, but not objective OEs. The subjective BE correlation was significantly stronger in the White sample than the Black sample, although this difference became nonsignificant using a Bonferroni correction for multiple comparisons. Objective BEs were significantly fewer on the EDE-Q than the EDE, and objective OEs were significantly higher on the EDE-Q than the EDE; subjective BE mean differences were not significant. Comparison of EDE-Q and EDE eating-disorder psychopathology variables
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Table 2 summarizes findings for eating-disorder psychopathology subscales and global score. In the Black sample, scores on the EDE-Q and EDE subscales and global scores had significant, large correlations, ranging from .49 to .65. The brief versions of the EDE-Q and EDE were also significantly correlated, with τb ranging from .37 to .56. Means were significantly higher on the EDE-Q than EDE subscales and global scores, except the restraint scale, which did not significantly differ. The restraint subscale had a significantly stronger correlation in the White sample than the Black sample, although this difference became nonsignificant using a Bonferroni correction for multiple comparisons; all other correlations did not significantly vary in magnitude between the Black and White samples. The brief versions performed similarly; only the restraint subscale did not significantly differ between the brief EDE-Q and brief EDE. In the matched White sample, scores on the EDEQ and EDE subscales and global scores all had significant, large correlations ranging from . 56 to .76. The brief versions were also all correlated, with τb ranging from .27 to .69. All scores on EDE-Q and EDE subscales and global scores were significantly higher on the EDE-Q than the EDE; brief versions had parallel significance patterns.
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Conclusions
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The goal of the current study was to evaluate the concordance of the EDE-Q and EDE in treatment-seeking Black patients with BED. Patterns of convergence and divergence in the matched White sample in the present study replicated earlier BED research, derived from primarily White samples, on the concordance of the EDE-Q and EDE (Barnes et al., 2011; Grilo et al., 2001a, 2001b; Wilfley et al., 1997). Patterns in the Black sample were also generally consistent with earlier findings. In both samples, objective BEs were significantly correlated and less frequent on the EDE-Q than the EDE. All eating-disorder psychopathology variables had significant, large correlations between the EDE-Q and EDE. In the Black sample, three of the four subscales were higher on the EDE-Q than the EDE, although restraint did not significantly differ on the EDE-Q and EDE. All four subscales were higher on the EDE-Q than the EDE in the White sample. These results are consistent with the larger literature on self-reported versus interview assessment scores (e.g., Eaton, Neufeld, Chen, & Cai, 2000),
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The findings regarding the degree of concordance between the EDE-Q and EDE for bingeeating frequencies have clinical implications. Binge-eating, as defined by DSM-IV-TR and DSM-5 criteria, is a complex concept that may not correspond to how the term “binge” is used colloquially. In the current study, EDE interviews were administered by trained research clinicians with expertise in eating disorders after participants had completed the EDE-Q. Administration order is important because the interview can result in a participant learning how to answer items based on perceptions of how the interviewer rated answers. By administering the EDE-Q prior to the EDE, the observed correlations and mean differences can be attributed to the instruments rather than biases patients might have acquired during the interview. Additionally, this order of administration is consistent with using a survey as part of clinical intake paperwork, which would then inform the clinical interview. The significant correlation and significant mean difference in objective BEs is of particular clinical importance because it shows that when definitions of binge-eating are presented, patients and expert clinicians may view this key diagnostic feature in a significantly different way. These results suggest that clinicians should gather detailed information about objective BEs when making a BED diagnosis when relying on information provided in survey format. Research on prospective and retrospective self-reported frequency of binge-eating has shown nonsignificant differences, suggesting that patients consistently underreport on self-report surveys compared with interviews (Grilo et al., 2001a, 2001b). Future research could explore whether results are similar across different levels of clinician expertise, which may be an important factor in interpreting objective BEs reported in interview.
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Consistent with past research on primarily White samples and our results in a matched White sample (Barnes et al., 2011; Grilo et al., 2001a, 2001b; Wilfley et al., 1997), our findings for Black patients suggest that items on the EDE-Q and EDE are correlated on binge-eating, eating-disorder psychopathology scales, and weight variables, and these correlations do not differ in magnitude between Black and White patients. Yet, with the exception of Restraint in the Black sample, subscale scores were consistently higher on the EDE-Q than the EDE, which suggests that data from the self-report and interview versions cannot be used interchangeably, and scores need to be understood in the context of the
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assessment tool. That is, it is important for clinicians and researchers to understand how the assessment was done, and to use appropriate norms for the specific technique. Our findings that scores derived from the survey version were higher than those from the interview version of the EDE is consistent with research on assessment methods in other fields, including depressive disorders (e.g., Eaton et al., 2000), panic disorder (e.g., Scupi, Maser, & Uhde, 1992) and personality disorders (e.g., Zimmerman & Coryell, 1990), among others. Of note, however, is the size of the significant differences between the EDE-Q and EDE. Black patients’ reported binge-eating frequency on the EDE-Q would fit the DSM-5 definition of “Mild” BED (i.e., 1–3 binge episodes per week), but binge-eating frequency on the EDE would fit the DSM-5 definition of “Moderate” BED (i.e., 4–7 binge episodes per week); both the EDE-Q and EDE binge-eating frequencies in the matched White sample would fit the DSM-5 definition of “Moderate” BED. If these mean differences reflect differences in BED severity, this could impact treatment prioritization and planning. Evaluation based on objectively measured psychopathology could clarify whether differences are due to measurement or psychopathology. The size of differences on other variables is smaller, and more meaningful in the context of the pattern of the results than taken individually. This study also adds information on the concordance of a recently-suggested alternative, brief version of the EDE-Q and EDE (Grilo et al., 2015). In the current study, the concordance pattern parallels findings observed for the full versions in that Restraint, in the sample of Black patients, is the only subscale with nonsignificant mean differences. This again suggests that although clinicians and researchers need to keep in mind the assessment used, the brief version of the EDE-Q and EDE are clinical tools that may be useful when time is limited.
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The results of our study pertain to Black adults with BED who were treatment-seeking at an urban, northeastern setting and who chose to participate in research at an academic medical hospital. These results might not generalize to individuals who do not seek treatment, choose not to participate in research, or live in other geographical areas. Additionally, both the EDE-Q and EDE rely on retrospective data that, despite the additional probes and opportunities to clarify responses embedded in the EDE, are ultimately reported by patients rather than objectively observed. Further research should seek to evaluate the concordance of these instruments with data collected from participants with shorter latency between bingeeating and reporting, such as ecological momentary assessment. Furthermore, although a major strength of the current study is its focus on Black individuals, race was assessed through participant self-identification based on a list of possible options including an openresponse format “other” option. Future research could evaluate the extent to which individuals identify with a racial group using continuous measures to explore whether eating disorder assessment varies by extent of racial identification rather than racial group identification. This study was also limited to a BED sample; evaluation of binge-eating in individuals who do not meet threshold diagnostic criteria might be different than it is for patients who have experienced regular objective BEs. It is also important to note that there are likely substantial and important differences among individual Black patients, even though differences between assessment techniques suggest assessments are comparable. For
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example, individuals’ histories with healthcare providers and sociocultural attitudes about eating and body shape may influence how they respond to survey and interview questions.
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Examining the eating disorder assessment process in patients with BED who are Black provides important information for both clinicians and clinical researchers. BED shows similar prevalence rates among racial groups, unlike other eating disorders that show a higher prevalence of anorexia and bulimia among White individuals (Marques et al., 2011). This highlights the need for valid assessment tools to evaluate patients presenting with symptoms of BED. In addition, two of the more commonly used eating-disorder assessment instruments, the EDE-Q and EDE, have profound differences in the training requirements and clinical administration time, and evidence of EDE-Q validity in Black patients could decrease these burdens without compromising clinical care. The current study shows a pattern of overall significant correlations between the EDE-Q and EDE, and overall higher scores on the EDE-Q than the EDE. Additional research is needed to improve understanding of why these mean differences occur, that is, whether there may be underreporting in interview, over-reporting on surveys, or an alternative explanation. Future research should also use longitudinal design to evaluate change in behaviors and attitudes on the EDE-Q and EDE subscales and items, particularly in response to clinical intervention. Our results add evidence to the emerging literature that suggests Black patients with BED can be evaluated in the same way as White patients with BED, even though assessment tools were developed on samples underrepresented by Black individuals, and add evidence that race-based differences are minimal in BED patients.
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This research was supported, in part, by National Institutes of Health grants K24 DK070052 and R01 DK49587 (Dr. Grilo).
References
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Author Manuscript Psychol Assess. Author manuscript; available in PMC 2017 October 01.
Author Manuscript
Author Manuscript
Author Manuscript 15.45 (10.66)
Objective OEs
6.10 (8.59) 16.38 (10.33)
Subjective BEs
Objective OEs
3.94 (9.37)
8.43 (13.05)
17.87 (11.84)
3.37 (6.59)
9.22 (15.99)
21.20 (16.29)
EDE M (SD)
.033
.231
.301
.019
.065*
.270
τb
.646
.001
Psychol Assess. Author manuscript; available in PMC 2017 October 01. Published in final edited form as: Psychol Assess. 2016 October ; 28(10): 1319–1324. doi:10.1037/pas0000246.
Black Patients with Binge-Eating Disorder: Comparison of Different Assessment Methods Janet A. Lydecker, Marney A. White, and Carlos M. Grilo Department of Psychiatry, Yale School of Medicine
Abstract Author Manuscript Author Manuscript
The Eating Disorder Examination (EDE) is a well-established assessment instrument, but requires substantial training and administration time. The Eating Disorder Examination Questionnaire (EDE-Q) is the corresponding self-report survey, which does not have these demands. Research has shown concordance between these two assessment methods, but samples have lacked racial diversity. The current study examined the concordance of the EDE-Q and EDE in a sample of Black patients with binge-eating disorder (BED) and a matched sample of White patients. Participants were 238 (Black n=119, White n=119) treatment-seeking adults with DSM-IV-TRdefined BED. Participants completed the EDE-Q and trained doctoral-level clinicians assessed participants for BED and eating-disorder psychopathology using the Structured Clinical Interview for DSM-IV Disorders and the Eating Disorder Examination (EDE) interview. The EDE-Q and EDE yielded significantly correlated frequencies of binge-eating and eating-disorder psychopathology subscales. The EDE-Q yielded significantly lower frequencies of binge-eating and higher scores on three of four subscales (not dietary restraint). Similar patterns of concordance between the EDE-Q and EDE were found for an alternative brief version of the instruments. Patterns of convergence and divergence between the EDE-Q and EDE observed in Black patients with BED are generally consistent with findings derived from the matched White sample: overall, scores are correlated but higher on the self-report compared with interview assessment methods. Clinicians assessing patients with BED should be aware of this overall pattern, and aware that this pattern is similar in Black patients with BED with the notable exception of dietary restraint.
Keywords binge-eating disorder; race; concordance; eating disorders
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Binge-eating disorder (BED) is the most prevalent eating disorder (Hudson, Hiripi, Pope, & Kessler, 2007). BED is defined by recurrent binge-eating (i.e., eating unusually large amounts of food while experiencing a subjective sense of loss of control over eating) without the weight compensatory behaviors that define bulimia nervosa (American Psychiatric Association, 2013). In contrast to other eating disorders, BED is unique in that there is less racial disparity in prevalence and treatment-seeking rates than other eating disorders
Correspondence should be addressed to Janet A. Lydecker, Yale University School of Medicine, 301 Cedar Street, New Haven, CT 06519. [email protected]. The authors report no conflicts of interest.
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(Marques et al., 2011). Assessment of binge-eating and associated eating-disorder psychopathology can be challenging but is a critical component of diagnosis and treatment planning. To date, BED-related assessment research has been primarily with samples underrepresented by racial minorities (Berg, Peterson, Frazier, & Crow, 2011). Parallel research is needed to expand our understanding of BED-related assessment in racial minorities, such as individuals who identify as Black, to improve multicultural competence in assessment and inform clinicians and researchers about how to assess efficiently yet comprehensively. To date, much research has been done using the Eating Disorder Examination (EDE) interview and questionnaire version (EDE-Q), but this line of research warrants extension to more diverse patient samples including racial minorities.
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The EDE is an investigator-based, semi-structured interview that assesses eating-disorder psychopathology comprehensively (Fairburn & Cooper, 1993). The EDE assesses eatingdisorder psychopathology (dietary restraint, eating concern, weight concern, and shape concern) and the frequency of binge-eating, overeating, and extreme weight compensatory behavior (e.g., purging). The EDE is considered the best-established interview method for the assessment of eating-disorder psychopathology, but it requires significant clinical training and administration time. A self-report survey version of the EDE, the Eating Disorder Examination Questionnaire (EDE-Q), was designed to decrease these interviewbased measurement barriers while maintaining the comprehensiveness of the assessment (Fairburn & Beglin, 1994).
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The EDE-Q and EDE have matched item content and scoring procedures for subscales (dietary restraint, eating concern, weight concern, shape concern), global score, and diagnostic items, including binge-eating frequency (Fairburn & Beglin, 1994). This allows for the direct comparison of scores and frequencies, which can provide insight into how similar the self-report and interview scores are, and help clinicians conceptualize data based on the different methods. Several studies have evaluated the concordance of the EDE-Q and EDE (Berg et al., 2011). Berg and colleagues (2011), in a review and meta-analysis of results of studies performed across various clinical and non-clinical samples, showed that subscale scores were significantly correlated, with significantly higher scores generated by the EDE-Q than the EDE across diagnostic groups. Meta-analytic results for binge-eating frequencies, however, were inconclusive across the studies with some subjects reporting higher frequencies on the self-report questionnaire than interview (Fairburn & Beglin, 1994) whereas a different pattern was observed for other subjects (Wilfley, Schwartz, Spurrell, & Fairburn, 1997).
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To date, four small studies have evaluated the concordance of the EDE-Q and EDE in patients with BED (Barnes, Masheb, White, & Grilo, 2011; Grilo, Masheb, & Wilson, 2001a, 2001b; Wilfley et al., 1997). Across these studies, binge-eating frequencies were fewer on the EDE-Q compared with the EDE, all EDE-Q and EDE subscales were significantly correlated with each other (ranging from .33 to .69 across studies), and all scores on the EDE-Q subscales were significantly higher than corresponding EDE scores. One study found that binge-eating frequency was not significantly correlated between the EDE-Q and EDE (Wilfley et al., 1997), but the other three studies found significant correlations (Barnes et al., 2011; Grilo et al., 2001a, 2001b). Reported binge-eating episodes
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were fewer on the EDE-Q than the EDE in two studies (Barnes et al., 2011; Wilfley et al., 1997) and not significantly different in two other studies (Grilo et al., 2001a, 2001b).
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Whereas research has begun to establish that the self-report EDE-Q does produce reasonably concordant findings to the EDE interview, the variable findings also point to the necessity of understanding the nature and sources of variability that characterize the different assessment methods. To date, assessment research with BED has had overwhelmingly White samples, which have been small: 91% White (N=82; Grilo et al., 2001b), 89% White (N=46; Grilo et al., 2001a), and 92% White (N=52; Wilfley et al., 1997). One study had 33% Black individuals (N=66; Barnes et al., 2011), but did not examine EDE-Q and EDE concordance by race. There is a clear need for EDE-Q/EDE concordance research that includes racial minorities, particularly because BED has comparable prevalence rates and mental health service utilization across racial groups (Marques et al., 2011) while showing complex patterns of similarities and differences in clinical presentation by race (Lydecker & Grilo, 2015). Therefore, the goal of the current study was to examine the concordance of the two assessment methods (self-report and interview versions of the EDE) in a sample of Black participants who met criteria for BED. Additionally, to place these concordance findings in the context of the larger literature, we examined how the concordance in the Black sample compared with a matched (by sex, education, age) White sample. Understanding how bingeeating frequencies and eating-disorder psychopathology scores on the EDE-Q and EDE relate to each other in the Black sample will help inform decisions about which instrument fits clinical or research needs, and will help improve interpretation of scores with accuracy and confidence that the tools are culturally appropriate for diverse individuals.
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Participants
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Participants (N = 238) responded to advertisements for treatment studies for BED at an urban, medical-school based program located in the northeastern United States. These participants were selected from a larger series of treatment-seeking patients with BED, which has been previously described (Lydecker & Grilo, 2015). Participants were between 18 and 65 years old and met full criteria for BED in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition – Text Revision (DSM-IV-TR; American Psychiatric Association, 2004). Participants were excluded for medical conditions influencing eating or weight (e.g., diabetes), severe mental illness that could interfere with clinical assessment (e.g., psychosis), concurrent treatment for eating/weight concerns, or pregnancy. Participants were included in the current analyses if they self-identified as Black (n = 119). Additionally, we created a comparison sample taken from the larger sample of White participants (n = 119) by matching to the Black participants on sex, education, then age. Overall, the 238 participants in the current study had a mean age of 45.07 years (SD = 10.16) and a mean BMI of 38.45 kg/m2 (SD = 6.90). Participants were primarily female (n = 198, 83.2%), and had varying levels of education: high school/less than high school (n = 64, 26.9%), some college/associate’s degree (n = 102, 42.9%), or a college degree (n = 72, 30.3%). This study received approval from the university’s ethical review board; all enrolled participants provided written informed consent.
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Measures
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Participants were evaluated by doctoral-level research clinicians who were trained and monitored to maintain reliability. Research clinicians administered the Structured Clinical Interview for DSM-IV Axis I Disorders (First, Spitzer, Gibbon, & Williams, 1997) to determine DSM-IV-TR-based BED diagnosis. Research clinicians measured participants’ height and weight and calculated BMI (kg/m2). The self-report EDE-Q was completed by participants prior to the EDE interview (thus providing a test of its concordance less biased by learning effects). Inter-rater reliability, examined in 113 cases from the larger series of BED patients, was excellent: intra-class correlation coefficients were .94 for OBEs and .92 for EDE global score, .92 for Restraint, .78 for Eating Concern, .91 for Weight Concern, and .94 for Shape Concern.
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Eating Disorder Examination (EDE)—The EDE evaluates eating-disorder psychopathology (dietary restraint, eating concern, weight concern, and shape concern) in the past 28 days, and over longer intervals as they correspond with diagnostic criteria (Fairburn & Cooper, 1993). The interview also assesses objective bulimic episodes (objective BEs, consuming an unusually large amount of food and perceiving a loss of control over eating; this corresponds to the DSM-IV-TR-based definition of binge-eating episodes), subjective bulimic episodes (subjective BEs, eating a small or typical amount of food yet perceiving a loss of control over eating) and objective overeating episodes (objective OEs, eating an unusually large amount of food without perceiving a loss of control over eating). The EDE is a well-established assessment tool with good inter-rater and test-retest reliability in BED (Grilo, Masheb, Lozano-Blanco, & Barry, 2004). Overall, in the current study, Cronbach’s α was .82 for the EDE global score and as follows for subscales: restraint α = .60, eating concern α = .63, weight concern α = .51, shape concern α = .71.
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Eating Disorder Examination Questionnaire, version 5.2 (EDE-Q)—The EDE-Q is the self-report survey version of the EDE (Fairburn & Beglin, 1994). Like the EDE, the EDE-Q measures eating-disorder psychopathology in the past 28 days, and over longer intervals for diagnostic items. The EDE-Q yields scores on the same subscales (dietary restraint, eating concern, weight concern, and shape concern), global score, and binge-eating frequency variables. Overall, in the current study, Cronbach’s alpha for the EDE-Q global score was .89 and as follows for the subscales: restraint α = .78, eating concern α = .76, weight concern α = .61, shape concern α = .78. Statistical Analyses
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To evaluate the concordance of EDE-Q and EDE for subscale and global scores and for binge-eating and other eating behaviors, we compared scores using Pearson’s productmoment correlations and paired t-tests. Parallel analyses also compared an alternative, brief structure proposed for the EDE-Q and EDE. The alterative, brief version of the EDE-Q and EDE uses seven items to generate a global score and three subscales: dietary restraint, shape/ weight overvaluation, and body dissatisfaction (Grilo et al., 2015). We include analyses with these brief versions because psychometric studies have suggested they have advantages over the full EDE-Q and EDE for BED (Grilo et al., 2010), and their much briefer formats would decrease time required to assess patients (Grilo et al., 2010; Grilo et al., 2015). Psychol Assess. Author manuscript; available in PMC 2017 October 01.
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To evaluate the concordance of binge-eating and overeating frequencies (objective BE, subjective BE, and objective OE variables), we compared monthly episodes using Pearson’s product-moment correlations and paired t-tests. Variables that were not normally distributed were evaluated using Kendall’s τb instead of Pearson’s correlation and the Wilcoxon signedrank Z-test instead of paired t-test. We also compared the magnitude of independent correlation coefficients in the Black and White samples using Fisher’s r-to-z transformation. Finally, we sought to replicate earlier work examining the concordance of the EDE-Q and EDE in BED by including a sample of White participants matched with the sample of Black participants. Participants were matched by sex and education level, and then by age. Frequencies of Black and White participants for sex and education were identical. The mean age for Black participants was 45.34 (SD=9.80), and for White participants was 44.80 (SD=10.55).
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Results Comparison of EDE-Q and EDE eating episodes
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Table 1 summarizes correlations and mean difference tests for eating episodes and weight variables. In the Black sample, frequencies reported on the EDE-Q and EDE had significant, large correlations for objective BEs, but not subjective BEs or objective OEs. Objective BEs were fewer on the EDE-Q than the EDE, and objective OEs were higher on the EDE-Q than the EDE; subjective BEs did not significantly differ. In the matched White sample, frequencies for objective and subjective BEs were significantly correlated, but not objective OEs. The subjective BE correlation was significantly stronger in the White sample than the Black sample, although this difference became nonsignificant using a Bonferroni correction for multiple comparisons. Objective BEs were significantly fewer on the EDE-Q than the EDE, and objective OEs were significantly higher on the EDE-Q than the EDE; subjective BE mean differences were not significant. Comparison of EDE-Q and EDE eating-disorder psychopathology variables
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Table 2 summarizes findings for eating-disorder psychopathology subscales and global score. In the Black sample, scores on the EDE-Q and EDE subscales and global scores had significant, large correlations, ranging from .49 to .65. The brief versions of the EDE-Q and EDE were also significantly correlated, with τb ranging from .37 to .56. Means were significantly higher on the EDE-Q than EDE subscales and global scores, except the restraint scale, which did not significantly differ. The restraint subscale had a significantly stronger correlation in the White sample than the Black sample, although this difference became nonsignificant using a Bonferroni correction for multiple comparisons; all other correlations did not significantly vary in magnitude between the Black and White samples. The brief versions performed similarly; only the restraint subscale did not significantly differ between the brief EDE-Q and brief EDE. In the matched White sample, scores on the EDEQ and EDE subscales and global scores all had significant, large correlations ranging from . 56 to .76. The brief versions were also all correlated, with τb ranging from .27 to .69. All scores on EDE-Q and EDE subscales and global scores were significantly higher on the EDE-Q than the EDE; brief versions had parallel significance patterns.
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Conclusions
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The goal of the current study was to evaluate the concordance of the EDE-Q and EDE in treatment-seeking Black patients with BED. Patterns of convergence and divergence in the matched White sample in the present study replicated earlier BED research, derived from primarily White samples, on the concordance of the EDE-Q and EDE (Barnes et al., 2011; Grilo et al., 2001a, 2001b; Wilfley et al., 1997). Patterns in the Black sample were also generally consistent with earlier findings. In both samples, objective BEs were significantly correlated and less frequent on the EDE-Q than the EDE. All eating-disorder psychopathology variables had significant, large correlations between the EDE-Q and EDE. In the Black sample, three of the four subscales were higher on the EDE-Q than the EDE, although restraint did not significantly differ on the EDE-Q and EDE. All four subscales were higher on the EDE-Q than the EDE in the White sample. These results are consistent with the larger literature on self-reported versus interview assessment scores (e.g., Eaton, Neufeld, Chen, & Cai, 2000),
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The findings regarding the degree of concordance between the EDE-Q and EDE for bingeeating frequencies have clinical implications. Binge-eating, as defined by DSM-IV-TR and DSM-5 criteria, is a complex concept that may not correspond to how the term “binge” is used colloquially. In the current study, EDE interviews were administered by trained research clinicians with expertise in eating disorders after participants had completed the EDE-Q. Administration order is important because the interview can result in a participant learning how to answer items based on perceptions of how the interviewer rated answers. By administering the EDE-Q prior to the EDE, the observed correlations and mean differences can be attributed to the instruments rather than biases patients might have acquired during the interview. Additionally, this order of administration is consistent with using a survey as part of clinical intake paperwork, which would then inform the clinical interview. The significant correlation and significant mean difference in objective BEs is of particular clinical importance because it shows that when definitions of binge-eating are presented, patients and expert clinicians may view this key diagnostic feature in a significantly different way. These results suggest that clinicians should gather detailed information about objective BEs when making a BED diagnosis when relying on information provided in survey format. Research on prospective and retrospective self-reported frequency of binge-eating has shown nonsignificant differences, suggesting that patients consistently underreport on self-report surveys compared with interviews (Grilo et al., 2001a, 2001b). Future research could explore whether results are similar across different levels of clinician expertise, which may be an important factor in interpreting objective BEs reported in interview.
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Consistent with past research on primarily White samples and our results in a matched White sample (Barnes et al., 2011; Grilo et al., 2001a, 2001b; Wilfley et al., 1997), our findings for Black patients suggest that items on the EDE-Q and EDE are correlated on binge-eating, eating-disorder psychopathology scales, and weight variables, and these correlations do not differ in magnitude between Black and White patients. Yet, with the exception of Restraint in the Black sample, subscale scores were consistently higher on the EDE-Q than the EDE, which suggests that data from the self-report and interview versions cannot be used interchangeably, and scores need to be understood in the context of the
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assessment tool. That is, it is important for clinicians and researchers to understand how the assessment was done, and to use appropriate norms for the specific technique. Our findings that scores derived from the survey version were higher than those from the interview version of the EDE is consistent with research on assessment methods in other fields, including depressive disorders (e.g., Eaton et al., 2000), panic disorder (e.g., Scupi, Maser, & Uhde, 1992) and personality disorders (e.g., Zimmerman & Coryell, 1990), among others. Of note, however, is the size of the significant differences between the EDE-Q and EDE. Black patients’ reported binge-eating frequency on the EDE-Q would fit the DSM-5 definition of “Mild” BED (i.e., 1–3 binge episodes per week), but binge-eating frequency on the EDE would fit the DSM-5 definition of “Moderate” BED (i.e., 4–7 binge episodes per week); both the EDE-Q and EDE binge-eating frequencies in the matched White sample would fit the DSM-5 definition of “Moderate” BED. If these mean differences reflect differences in BED severity, this could impact treatment prioritization and planning. Evaluation based on objectively measured psychopathology could clarify whether differences are due to measurement or psychopathology. The size of differences on other variables is smaller, and more meaningful in the context of the pattern of the results than taken individually. This study also adds information on the concordance of a recently-suggested alternative, brief version of the EDE-Q and EDE (Grilo et al., 2015). In the current study, the concordance pattern parallels findings observed for the full versions in that Restraint, in the sample of Black patients, is the only subscale with nonsignificant mean differences. This again suggests that although clinicians and researchers need to keep in mind the assessment used, the brief version of the EDE-Q and EDE are clinical tools that may be useful when time is limited.
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The results of our study pertain to Black adults with BED who were treatment-seeking at an urban, northeastern setting and who chose to participate in research at an academic medical hospital. These results might not generalize to individuals who do not seek treatment, choose not to participate in research, or live in other geographical areas. Additionally, both the EDE-Q and EDE rely on retrospective data that, despite the additional probes and opportunities to clarify responses embedded in the EDE, are ultimately reported by patients rather than objectively observed. Further research should seek to evaluate the concordance of these instruments with data collected from participants with shorter latency between bingeeating and reporting, such as ecological momentary assessment. Furthermore, although a major strength of the current study is its focus on Black individuals, race was assessed through participant self-identification based on a list of possible options including an openresponse format “other” option. Future research could evaluate the extent to which individuals identify with a racial group using continuous measures to explore whether eating disorder assessment varies by extent of racial identification rather than racial group identification. This study was also limited to a BED sample; evaluation of binge-eating in individuals who do not meet threshold diagnostic criteria might be different than it is for patients who have experienced regular objective BEs. It is also important to note that there are likely substantial and important differences among individual Black patients, even though differences between assessment techniques suggest assessments are comparable. For
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example, individuals’ histories with healthcare providers and sociocultural attitudes about eating and body shape may influence how they respond to survey and interview questions.
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Examining the eating disorder assessment process in patients with BED who are Black provides important information for both clinicians and clinical researchers. BED shows similar prevalence rates among racial groups, unlike other eating disorders that show a higher prevalence of anorexia and bulimia among White individuals (Marques et al., 2011). This highlights the need for valid assessment tools to evaluate patients presenting with symptoms of BED. In addition, two of the more commonly used eating-disorder assessment instruments, the EDE-Q and EDE, have profound differences in the training requirements and clinical administration time, and evidence of EDE-Q validity in Black patients could decrease these burdens without compromising clinical care. The current study shows a pattern of overall significant correlations between the EDE-Q and EDE, and overall higher scores on the EDE-Q than the EDE. Additional research is needed to improve understanding of why these mean differences occur, that is, whether there may be underreporting in interview, over-reporting on surveys, or an alternative explanation. Future research should also use longitudinal design to evaluate change in behaviors and attitudes on the EDE-Q and EDE subscales and items, particularly in response to clinical intervention. Our results add evidence to the emerging literature that suggests Black patients with BED can be evaluated in the same way as White patients with BED, even though assessment tools were developed on samples underrepresented by Black individuals, and add evidence that race-based differences are minimal in BED patients.
Acknowledgments Author Manuscript
This research was supported, in part, by National Institutes of Health grants K24 DK070052 and R01 DK49587 (Dr. Grilo).
References
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Author Manuscript Psychol Assess. Author manuscript; available in PMC 2017 October 01.
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Author Manuscript 15.45 (10.66)
Objective OEs
6.10 (8.59) 16.38 (10.33)
Subjective BEs
Objective OEs
3.94 (9.37)
8.43 (13.05)
17.87 (11.84)
3.37 (6.59)
9.22 (15.99)
21.20 (16.29)
EDE M (SD)
.033
.231
.301
.019
.065*
.270
τb
.646
.001
