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Assessing eating disorder symptoms in low and middle-income countries: a systematic review of psychometric studies of commonly used instruments

Journal of Eating Disorders volume 10, Article number: 124 (2022) Cite this article

Abstract

Background

Various well-validated interview and self-report instruments are available to assess eating disorder symptomatology. However, most psychometric studies have been conducted in high-income countries. The aim of the present study was to systematically review the available psychometric studies conducted in low- and middle-income countries on well-known measures for assessing eating disorder symptoms.

Methods

Psychometric studies with the following instruments were included: the Eating Disorder Examination (EDE), the Eating Disorder Examination Questionnaire (EDE-Q), the Eating Disorder Inventory (EDI), the Eating Attitudes Test (EAT), and the Children’s Eating Attitudes Test (ChEAT). Searches were conducted on August 30, 2021, in the following databases: MEDLINE, EMBASE, LILACS, Web of Science, PsycINFO, and CABI. The methodological quality of the studies was assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). The studies were considered to have conducted the minimum psychometric evaluation if they assessed at least the three types of validity (content, criteria, and construct) or diagnostic performance. The psychometric properties were also evaluated considering the cut-off points described in the literature for each of the analysis methods used to evaluate validity and reliability and two reviewers independently selected the studies and evaluated the quality criteria.

Results

A total of 28 studies were included. The studies were conducted in 13 countries (10 middle income and 3 low income). The instruments that were most used in the studies were the EAT and EDE-Q. According to the overall COSMIN assessment, in most (57%) of the studies the psychometric properties assessed were not described. Forty-three percent of the studies conducted the minimum psychometric evaluation. However, according to the described cut-off points, the results for the psychometric properties assessed showed, in general, acceptable validity and reliability.

Conclusion

The results of this review suggest a lack of studies with the recommended psychometric properties in low- and middle-income countries on these commonly used instruments. With the steady increase in the prevalence of eating disorders globally, psychometric investigations of instruments for measuring eating disorder symptoms in these countries should be encouraged to promote their early detection and treatment.

Plain English summary

The prevalence of eating disorders has increased worldwide. Various instruments are available to assess eating disorder symptomatology, but most psychometric studies have been conducted in high-income countries. The current study aimed to systematically review studies from low- and middle-income countries that have examined the psychometric properties of commonly used measures for assessing eating disorder symptoms. The findings of this study suggest a lack of research in low- and middle-income countries on the psychometric properties of commonly used eating disorder instruments. To promote the early detection and treatment of eating disorder symptoms, instruments with adequate psychometric properties must be available worldwide.

Background

Eating disorders (EDs) are psychiatric disorders characterized as disturbances in eating or eating-related behavior that lead to impaired consumption or absorption of food, which can compromise the physical and psychological health of the individuals affected [1,2,3]. EDs, particularly anorexia nervosa (AN), can in some cases lead to early mortality [4].

In a systematic review from 2019, the lifetime prevalence of EDs was estimated at 8.4% in women and 2.2% in men [5]. Although research has shown that the highest burden of EDs remains in high-income countries, prevalence studies have indicated that EDs have increased in other countries [6], specifically in East and South Asia [4, 7]. According to the results from the Global Burden of Disease Study 2017, low- and middle-income countries have shown an important increase in the age-standardized rate of ED prevalence, rising from 116.74 per 100,000 population in 1990 (95% UI: 92.25–548) to 156.96 in 2017 (95% UI: 123.42–194.26) [8]. However, the number of studies on the prevalence in low- and middle-income countries is limited [4]. Studies that help in identifying the local prevalence of eating disorders, such as in low- and middle-income countries, are very important; they can guide public health policies and help in implementing optimal and effective measures for the respective population to reduce the burden of this disease [8, 9].

The tools commonly used to evaluate EDs are the Eating Disorder Examination (EDE) [10], the Eating Disorder Examination Questionnaire (EDE-Q) [11], the Eating Disorder Inventory (EDI) [12], the Eating Attitudes Test (EAT) [13], the Children’s Eating Attitudes Test (ChEAT) [14], the Children’s Eating Disorder Examination (ChEDE) [15], and the Children’s Eating Disorder Examination Questionnaire (ChEDE-Q) [16]. Most studies that examine the psychometric properties of these instruments have been conducted in high-income countries and there is a scarcity of studies that show whether these instruments have been used in low- and middle-income countries. The use, in low- and middle-income countries, of instruments whose psychometric properties have not been evaluated prevents us from knowing whether the results of their measurements correspond to the actual state of the phenomenon being measured [17, 18] Therefore, the objective of the present study was to systematically review psychometric studies on instruments that assess ED symptomatology in low- and middle-income countries.

Methods

Protocol and registration

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines [19], and its protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under case number CRD42021219090 [20].

Eligibility criteria

This systematic review included psychometric studies from low and middle-income countries. According to the World Bank in 2020, countries with low-middle-income economies are a diverse group in terms of size, population, and income level and are defined as having a gross domestic product per capita of between US$1,046 and US$4,095 [21]. This study covered the use of the EDE, EDE-Q, EDI, EAT, ChEAT, ChEDE, and ChEDE-Q instruments for assessing ED symptomatology. Review articles and duplicate publications were excluded. Articles were considered duplicates if they were in different databases and had the same Digital Object Identifier (DOI) or if they were from the same study group with the same inclusion period and individual study participant characteristics. In this case, the one with the largest sample size and the most recent publication date was considered.

Information sources

A comprehensive search was conducted on August 30, 2021, in the following databases: MEDLINE (via PUBMED), EMBASE, Latin American & Caribbean Health Sciences Literature (LILACS via BIREME), Web of Science, PsycINFO (via APA PsycNET), and Commonwealth Agricultural Bureaux International (CABI). In addition, the references of the included studies and other systematic reviews were considered in the selection process.

Search strategy

The MEDLINE search strategy was created and adapted for the other databases. There were no restrictions on language and year of publication. For the complete search strategy is presented in the attached online file 1 (see Additional file 1).

Selection process

Two authors (COA and CMGD) independently scanned the abstract and title of each study from the search results. Next, all potentially relevant articles were read in full. In both phases, wherever there was a difference in opinion, a third author (RM), who did not initially evaluate the articles, reviewed them to reach a final decision.

Data collection process and data items

Two authors (COA and CMGD) independently extracted the data. Any disagreements were presented to the third reviewer (RM) to establish a consensus. The following information was extracted: first author; year of publication; country; questionnaire language; eligibility criteria for participants; number of participants included (sample size); sex and age; instrument names; mode of administration of the questionnaire (self-reported or interview); number of items; domains assessed; psychometric properties; type of study. In the original protocol, we planned to contact the authors if we could not identify any of the information that was to be collected from the articles. However, all necessary information was presented in the included articles.

Assessment of risk of bias in included studies

The methodological quality of individual studies was assessed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) [22]. The COSMIN checklist for assessing the methodological quality of individual studies contains ten sections, including translation process, content validity, hypotheses testing (or convergent and discriminant validity), structural validity (or construct validity), criterion validity (or diagnostic process), internal consistency, test–retest, measurement invariance, responsiveness, and, finally, the overall score for the COSMIN assessment. To classify the psychometric properties, a five-point scale with the following descriptors was used: “very good,” “adequate,” “doubtful,” “inadequate,” “not reported,” or “not applicable.” The overall score for the methodological quality of each measurement tool was determined considering the lowest classification for any one of the items evaluated. For example, for the structural validity criterion, if a confirmatory factor analysis (CFA) was conducted (implying a “very good” classification), but the sample size was < 5 times the number of items (meaning an “inadequate” classification), the general quality classification considered for that methodological property was “inadequate” [22].

We also considered that the studies conducted the minimum psychometric evaluation, according to international guidelines, if they assessed at least the three types of validity (content, criteria, and construct) or diagnostic performance was evaluated with a gold standard tool [23]. Psychometric studies that did not include a description of the translation process were considered as lacking content validity.

Evaluation of psychometric properties evaluated in articles

The psychometric properties evaluated in the articles were assessed considering the cut-off points described in the literature for each of the analysis methods used to evaluate validity and reliability (Additional file 2).

The methodological quality of individual studies was visualized using the robvis web app, which depicts the plots obtained from these analyses [24]. The methodological quality of individual studies was assessed independently by two review authors (CA and CS). When there were differences in opinion, the third author (RM), who did not initially evaluate the articles, reviewed them to decide.

We assessed the performance of the original studies that developed and validated the questionnaires according to the COSMIN tool, minimum psychometric evaluation, and cut-off points.

We also described the methodological quality of individual studies according to the COSMIN tool of most validated questionaries’ and compared the COSMIN results for the validated questionnaires that underwent the translation process with those that did not undergo the translation process.

Results

Study selection

The search identified 4745 articles in the databases used, and a further 18 articles were identified in the gray literature. A total of 1719 duplicate articles were removed, leaving 3044 articles for the title and abstract evaluation. In this phase, 2901 articles were excluded. A further 1699 articles were excluded because they did not validate the instruments, 1026 used instruments other than the ones that are the focus of our study, 89 were studies conducted in populations from high-income countries, and 87 were review studies. Thus, 143 articles remained to be read in full. A further 115 were excluded because they did not meet the inclusion criteria: 76 studies did not validate the instruments, 28 used other instruments, nine were duplicates, and two were reviews. Thus, a total of 28 studies were included in this review. The systematic study selection is described in Fig. 1.

Fig. 1
figure 1

PRISMA 2020 flow diagram of study selection process

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Studies characteristics

The 28 studies included in this review comprising the research on psychometric properties were all cross-sectional studies published between 1989 [25] and 2021 [26,27,28]. One study validated the Eating Disorder Examination [29], ten validated the Eating Disorder Examination-Questionnaire [26,27,28, 30,31,32,33,34,35,36], four validated the Eating Disorder Inventory [37,38,39,40], 12 validated the Eating Attitudes Test [25, 41,42,43,44,45,46,47,48,49,50,51], and one validated the Children’s Eating Attitudes Test [52]. No study validated the Children’s Eating Disorder Examination [15] or the Children’s Eating Disorder Examination Questionnaire [16], and thus these two questionnaires are not further described here. The characteristics of the included studies are summarized in Table 1.

Table 1 Characteristics of included studies in this review
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Results of individual studies

Eating disorder examination (EDE)

The EDE is a semi-structured interview. There are three versions. The first version (12th edition) consisted of 62 items [10], the second version (16th edition) has 41 items [53], and the newest one (17th edition) was created based on the latest Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) and has 40 items [54]. All versions contemplate four domains: restraint, eating concern, shape concern, and weight concern. The global EDE score represents the average for the four domains.

The 12th edition of the EDE was translated into Mandarin and the psychometric properties were evaluated by one study in China. The psychometric properties of the Chinese version of the EDE were assessed in a sample of 84 female and male participants, with a mean age of 19 years old. The participant inclusion criteria included having a current diagnosis of AN or bulimia nervosa (BN), according to the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria, and being admitted to the Wuhan Hospital for psychotherapy or Wuhan Mental Health Center for treatment. The control group consisted of undergraduate and graduate students from the China University of Geosciences in Wuhan who did not have any EDs, according to the author’s interview.

According to the COSMIN methodological quality classification of individual studies the translation process was considered “doubtful”; the hypotheses testing was considered “adequate”; the validity criterion was considered “adequate”; the internal consistency was considered “very good”; and the test–retest assessment was evaluated as “doubtful.” The content validity, structural validity, measurement invariance, and responsiveness were not assessed (see Fig. 2 and Additional file 3) [29]. The EDE instrument met the minimum psychometric criteria considered in this review, through the diagnostic performance evaluation.

Fig. 2
figure 2

COSMIN methodological quality classification of individual studies. The X-axis represents the percentage of identified studies. Note hypotheses testing considers criterion validity; structural validity considers construct validity; and criterion validity considers diagnostic performance

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The psychometric property results according to the described cut-off points were as follows: discriminant validity: the EDE showed a significant difference between individuals with and without EDs; diagnostic performance: the area under the curve (AUC) was not evaluated; internal consistency: the Cronbach’s alpha coefficient was good; and test–retest: the Spearman correlation coefficient showed a strong correlation [29] (see Table 2).

Table 2 Methodology and results of the validation process of the studies
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Eating disorder examination-questionnaire (EDE-Q)

The EDE-Q is a self-report version of the EDE. There are three versions of it: the EDE-Q 4.0 with 38 items [11], the EDE-Q 6.0 with 28 items [55], and the short version EDE-QS with 12 items [56]. The EDE-Q 4.0 and EDE-Q 6.0 have four domains: restraint, eating concern, shape concern, and weight concern. The global EDE-Q score represents the average of the four domains. Finally, the EDE-QS has 12 items and is the only version that is one-dimensional.

The included studies used the three versions of the EDE-Q: the EDE-Q 4.0 [30, 31], the EDE-Q 6.0 [22, 23, 25,26,27,28,29], and the EDE-QS [21]. The EDE-Q was translated by eight studies [26,27,28, 30,31,32, 34, 36]. Two did not carry out the translation process and used a version of the questionnaire that was already translated into Spanish [33, 35, 57]. Ten studies evaluated the psychometric properties [26,27,28, 30,31,32,33,34,35,36]. The studies were conducted in the following countries and languages: Mexico (in Spanish) [30, 35], Malaysia (in Malay) [27, 36], Fiji (in Fijian) [32], Argentina (in Spanish) [33], China (in Mandarin) [26], India (in English) [28], Iran (in Persian) [34], and Turkey (in Turkish) [31]. The number of participants in the studies varied from 298 [36] to 2,928 [35]. Six studies were conducted in female and male participants [26,27,28, 31, 35, 36], three studies in female participants [30, 32, 34], and only one study in male participants [33]. The mean age of the participants varied from 10 [36] to 26 [33] years old. The participant inclusion criteria varied according to the target population chosen in the studies. In one study, all participants were recruited through convenience sampling at a hospital among patients with an eating disorder diagnosis [30], in six studies the participants were chosen through convenience sampling at secondary schools [26, 28, 30,31,32, 35], in three studies they were recruited at universities [27, 33, 34], and in one study they were recruited at sports centers [33]. In three studies, the exclusion criterion was participants who did not answer three or more questionnaires [24, 30, 31]. One study excluded participants from vernacular schools or schools with a predominant ethnic group [36].

According to the COSMIN methodological quality assessment, the translation process of the EDE-Q was considered “very good or adequate” in 80% of the studies [26,27,28, 30,31,32, 34, 36]; the hypotheses testing process was classified as “very good or adequate” in 70% [26,27,28, 31, 32, 34, 35]; the structural validity was classified as “very good” in 60% [26, 28, 30, 33, 35, 36]; the internal consistency assessment was evaluated as “very good” in 100% [26,27,28, 30,31,32,33,34,35,36]; the test–retest assessment was classified as “very good” in 40% [26, 28, 32, 35] and “doubtful” in 20% [27, 31]; and the measurement invariance was assessed as “very good” in 20% [33, 35] and “inadequate” in 10% of the studies [28]. Content validity, criterion validity, and responsiveness were not described in any of the studies, (see Fig. 2 and Additional file 3). No study contemplated the minimum psychometric assessment (content, criterion, and construct validity) or diagnostic performance.

The psychometric property results according to the described cut-off points were as follows: discriminant validity: the EDE-Q showed a significant difference between individuals who are overweight, underweight, and have a normal weight [34]. Convergent validity showed a null [31] to strong correlation [35]. The construct validity results assessed through CFA were as follows: relative χ2: inadequate [28] to adequate fit [26, 28, 30, 33, 35]; comparative fit index (CFI): unacceptable fit [26, 35] to good fit [28, 30]; Tucker-Lewis index (TLI): unacceptable fit [26, 28, 33] to good fit [30]; root mean square error of approximation (RMSEA): marginal [33] to good fit; standardized root mean residual (SRMR): good fit [28, 30, 33]; factor loadings: minimum [35, 36] to high level [26, 30, 36]; Kaiser–Meyer–Olkin coefficient (KMO): good [36]. The exploratory factor analysis (EFA) results were: KMO and Bartlett’s test not evaluated [27, 32]; factor loadings: minimum [27] to high level [27, 28, 32]; relative χ2: adequate fit [28]; CFI: unacceptable fit [28] to good fit [28]; TLI: unacceptable fit [28]; RMSEA: acceptable [28] to good fit [28]; and SRMR: good fit [28]. The item response theory results were: explained variance: strong [26]; unexplained variance: good [26]; eigenvalue: acceptable [26]; infit: productive [26]; outfit: productive [26]; Person separation index: good [26]; Person separation reliability: good [26]; differential item functioning: intermediate to large [26]. The measurement invariance results were: equal factor loading χ2/df: adequate fit [35]; RMSEA: acceptable fit [35]; CFI: unacceptable adjustment [35]. The model equal intercepts were: χ2/df: inadequate fit [35]; RMSEA: acceptable fit [35]; CFI: unacceptable fit [35]; configural vs metric: ΔCFI: non invariance [33]; ΔRMSEA: non invariance [33]; ΔSRMR: strong invariance [33]; metric vs scalar: ΔCFI: non invariance [33]; ΔRMSEA: non invariance [33]; ΔSRMR: strong invariance [33]. In one study CFI RMSEA, and SRMR were not assessed [28]. The internal consistency results were: omega coefficient: good [33, 35] to excellent [33]; Cronbach’s alpha coefficient: moderate [32] to excellent [28, 30, 31, 34]. The test–retest results were: intraclass correlation coefficients (ICC): good [26, 35]; Cohen’s kappa coefficient: poor [32] to substantial [32]; and Pearson correlation coefficient: strong [27] to very strong [31] (see Table 2).

Eating disorder inventory (EDI)

The EDI is a self-report questionnaire and has three versions. The first version has 64 items grouped into eight domains: drive for thinness, bulimia, body dissatisfaction, perfectionism, ineffectiveness, interpersonal distrust, interoceptive awareness, and maturity fears [12]; the second version (EDI-2) has 91 items grouped into 11 domains: drive for thinness, bulimia, body dissatisfaction, perfectionism, ineffectiveness, interpersonal distrust, interoceptive awareness, maturity fears, asceticism, impulse regulation, and social insecurity [58]; and the third and most recent version (EDI-3) consists of 91 items distributed in 12 domains: drive for thinness, bulimia, body dissatisfaction, low self-esteem, emotional dysregulation, perfectionism, asceticism, interoceptive deficit, maturity fear, interpersonal insecurity, personal alienation, and interpersonal alienation [59].

The included studies used the three versions of the EDI: the EDI [37], the EDI-2 [38], and the EDI-3 [39, 40]. A translated version of the EDI was used by two studies [38, 40]. These two studies did not carry out the translation process but instead used the version of the questionnaire already available in Spanish [37, 39, 60, 61]. The studies were conducted in Mexico (in Spanish) [37, 38], Iran (in Persian) [40], and Argentina (in Spanish) [39]. The number of participants in the studies varied considerably, from 47 [38] to 725 [39]. Three studies included only female participants [37,38,39] and one study included female and male participants [40]. The mean age of the participants varied from 15 [39] to 22 [40] years old. The participant inclusion criteria varied according to the target population chosen in the studies. All participants were recruited through convenience sampling. Two studies included patients diagnosed with an eating disorder according to the DSM-IV criteria, who were recruited in hospitals [37, 38]; one study recruited participants in a secondary school setting [39]; and one study recruited participants at a university [40]. The latter study excluded participants who did not answer three or more items in the questionnaires [40], and another study excluded students who presented difficulties with communication and in understanding the questionnaire [39].

According to the COSMIN methodological quality assessment of the four studies, the translation process was considered “adequate” in 25% of the studies [40] and “inadequate” in 25% [38]; the content validation process was considered “very good” in 50% of the studies [35]; the structural validity assessment was “adequate” in 50% of the studies [37, 39]; and the internal consistency examination was considered “very good” in 100% of the studies [37,38,39,40]. Hypotheses testing, criterion validity, test–retest, measurement invariance, and responsiveness were not described in any of the studies [38,39,40] (see Fig. 2 and Additional file 3). Two studies contemplated the minimum psychometric assessment [37, 38], one by examining content, criterion, and construct validity (25%) [37], and the other by evaluating diagnostic performance (25%) [38].

The psychometric property results according to the described cut-off points were as follows: content validity: the validity index for the clarity, relevance, and comprehensiveness of the survey was acceptable [40]; convergent validity: null [37] to strong correlation [37]; construct validity through EFA: KMO: good [39] and Bartlett’s test not evaluated [37, 39]; factor loadings: high level [37]; diagnostic performance: AUC not evaluated [38]; internal consistency: Cronbach’s alpha coefficient: questionable [39, 40] to excellent [37, 39]; and test–retest: moderate ICC [40] (see Table 2).

Eating attitudes test (EAT)

The EAT is a self-report questionnaire and has two versions. The first version has 40 items [13] and the second and most recent version (EAT-26) has 26 items [62]. Both versions contemplate three domains: dieting, bulimia and food preoccupation, and oral control [13, 62].

The included studies used the two versions of the EAT: the EAT-40 [25, 41, 44] and the EAT-26 [42, 43, 45,46,47,48,49,50,51]. The EAT was translated by five studies [25, 42, 43, 47, 51] and seven studies did not carry out the translation process because they used the versions of the questionnaire already translated into Arabic, Spanish, Portuguese, and Mandarin, respectively [41, 44,45,46, 48,49,50, 63,64,65,66]. All studies evaluated the psychometric properties [25, 41,42,43,44,45,46,47,48,49,50,51]. The studies were conducted in Colombia (in Spanish) [49, 50], Brazil (in Portuguese) [45, 46], Turkey (in Turkish) [25, 51], Egypt (in Arabic) [41], Mexico (in Spanish) [44], Lebanon (in Arabic) [42], China (in Mandarin) [48], Thailand (in Thai) [47], and Iran (in Persian) [43]. The number of participants in the studies varied from 70 [47] to 1500 [51]. In eight studies, the questionnaire was administered to female participants [25, 41, 43,44,45, 47,48,49], two studies included only male participants [46, 50], and two studies were conducted in mixed samples of males and females [42, 51]. The mean age of the participants varied from 14 [46] to 27 [42] years old. All participants were recruited through convenience sampling. In five studies, a clinical group was recruited at a hospital for patients with an eating disorder diagnosis [44, 47,48,49,50]; in five studies, community participants were recruited from secondary schools [25, 41, 44, 46, 48]; and seven studies were conducted at universities [25, 43, 44, 48,49,50,51]. In two studies, the exclusion criterion was participants who did not answer three or more items of the questionnaires [43, 46]. Two studies excluded participants with stupors, depression, catatonia, schizophrenia, neoplasms, any severe medical illness related to malnutrition, and hypometabolism [49, 50]. One study excluded elementary school students [25] and another excluded participants who did not perform anthropometric measurements [46]. One study excluded participants who refused to complete the questionnaire and participants who had a cognitive impairment, as reported by a family member [51].

According to the COSMIN methodological quality assessment, the hypotheses testing was considered “very good or adequate” in 50%of the studies [43, 44, 46,47,48, 51]; the structural validity examination was classified as “very good or adequate” in 75% of the studies [25, 41,42,43,44, 46, 49,50,51]; the criterion validity assessment was classified as “very good” in 42% of the studies [45, 47,48,49,50] and “inadequate” in 8% [44]; the translation process was considered “not applicable” in58% [41, 44,45,46, 48,49,50] and of the ones that carried out the translation process, the content validation was “not reported” in 80% [25, 42, 43, 51]; the internal consistency assessment was classified as “very good” in96% [25, 41,42,43,44,45,46, 48,49,50,51]; and the test–retest was “not reported” in67% of the studies [25, 41, 42, 44, 45, 47, 49, 50]. Measurement invariance and responsiveness were not assessed in these studies (see Fig. 2 and Additional file 3). Seven studies contemplated the minimum psychometric assessment [44,45,46,47,48,49,50], six by testing diagnostic performance (50%) [44, 45, 47,48,49,50], and one study by examining content, criterion, and construct validity (8%) [46].

The psychometric property results according the described cut-off points were: content validity: content validity index: the total item coefficient was excellent [47]; discriminant validity: the EAT showed a significant difference between individuals with and without EDs [44, 47], between individuals who are low weight, normal weight, overweight, and obese [46], and between dieting individuals and those who have never been on a diet [43]; convergent validity: null [43] to strong correlation [48]; construct validity through CFA: χ2/df: adequate fit [42, 51]; CFI: unacceptable fit [51]; RMSEA: good fit; goodness-of-fit index: poor fit [42, 51]; adjusted goodness-of-fit index: poor fit [42]; factor loadings: middle to high level [41]. The EFA results were: Bartlett’s test: statistically significant [42, 43, 46, 49,50,51]; KMO: average [50] to very good [42, 46]; and Bartlett’s test and KMO not evaluated [25, 44]; factor loadings: minimum [25, 43, 46, 51] to high level [25, 41, 43, 44, 46, 49,50,51]. The diagnostic performance results were: the AUC was considered high [48] to excellent accuracy [47, 49, 50] and the AUC was not evaluated [44, 45]; internal consistency: Cronbach’s alpha coefficient: unacceptable [41] to excellent [44, 48, 49]; polychoric ordinal alpha: acceptable [43] to excellent [43]. The test–retest results were: Pearson correlation coefficient: null [43] to strong correlation [43, 51]; ICC: good [48] to excellent [46] (see Table 2).

Children's eating attitudes test (ChEAT)

The ChEAT is a self-report and 26-item instrument that contemplates three domains: dieting attitudes, oral control, and social pressure to restrict eating [14]. The ChEAT-26 was translated into Portuguese and its psychometric properties were evaluated in one study in Brazil. The instrument was validated in a sample of 346 female and male participants, with a mean age of 10 years old. The participant inclusion criteria was pre-adolescents from eight to 12 years old recruited from four private schools.

According to the COSMIN methodological quality assessment, the translation process was considered “doubtful”; the internal consistency assessment was classified as “very good”; and the structural validity examination was considered “adequate” [52]. The content validity, hypotheses testing, criterion validity, test–retest, measurement invariance, and responsiveness were “not reported” (see Fig. 2 and Additional file 3). This study did not contemplate the minimum psychometric assessment (content, criterion, and construct validity) or diagnostic performance.

The psychometric property results according to the described cut-off points were: construct validity: Bartlett’s test: statistically significant [52]; KMO: average [52]; factor loadings: minimum [52] to high level [52]; internal consistency: Cronbach’s alpha coefficient: moderate [52] (see Table 2).

Overall results

This review included 28 studies conducted in low- and middle-income countries on the psychometric properties of commonly used ED symptom measures. Of those countries, 10 were classified as middle-high income [25,26,27, 29,30,31,32,33, 35,36,37,38,39, 42, 44,45,46,47,48,49,50,51,52] and three were classified as lower-middle income [28, 34, 40, 41, 43].

According to the COSMIN assessment, most of the studies were considered as having: a “very good or adequate” (46%) or “doubtful” (10%) translation process; " “very good or adequate” (53%) hypotheses testing; a “very good or adequate” (71%) structural validity examination; and “very good” (96%) internal consistency. Most studies did not report content validity (88%), measurement invariance (89%), criterion validity (71%), or test–retest (57%). No studies reported responsiveness. Thus, according to this classification, most (57%) of the studies did not describe (“not reported”) the psychometric properties assessed (see Fig. 2 and Additional file 3).

Forty-three percent of the studies conducted the minimum psychometric evaluation. According to the described cut-off points, the psychometric properties assessed showed overall acceptable validity and reliability results (see Table 2).

Performance of original studies that developed and validated the questionnaires according to the COSMIN tool, minimum psychometric evaluation, and cut-off points.

Overall score, (40%) of the studies did not describe (“not reported”) the psychometric properties assessed in this tool [10,11,12, 14, 62] (see Additional Files 4 and 5). None of the studies conducted the minimum psychometric evaluation.

The following results were obtained according to the cut-off points described: convergent validity: weak [14] to strong [62] correlation; discriminant validity: the questionnaires showed a significant difference between individuals with AN [10, 12], individuals with BN [10], and control groups [10, 12]; construct validity though EFA: Bartlett’s test and KMO not evaluated [12, 14]; factor loadings: minimum [14] to high level [12]; internal consistency: Cronbach’s alpha coefficient: questionable [10] to excellent[12]; and test–retest: Pearson correlation coefficient: strong correlation [14], (see Additional file 6).

1.6 Description of individual studies of most validated questionnaires according to the COSMIN tool

Since the EAT and the EDE-Q were the instruments with the most evaluations, they were compared with their original versions to compare the impact of psychometric properties. Forty percent of the original studies did not describe the psychometric properties (Additional files 7 and 8).

Comparison between studies of validated questionnaires with translation process and those without this process

According to the overall COSMIN score, in both cases, more than 45% of the studies did not describe most of the psychometric properties (see Additional file 9).

Discussion

Most of the studies conducted in low- and middle-income countries on measures for assessing well-known eating disorder symptoms did not described psychometric properties according to the COSMIN methodological quality classification of the individual studies and they did not conduct the minimum recommended assessment of these properties. However, according to the described cut-off points, the psychometric properties evaluated showed overall acceptable validity and reliability results. In addition, most studies were conducted in middle-income countries.

The overall score for the methodological quality of each measurement according to the COSMIN procedure is determined considering the lowest classification of any one of the items evaluated. While a strength of the COSMIN procedure is that it has very rigid and specific criteria for evaluating psychometric properties, the result is that there is little flexibility in the tool. For example, in the test–retest evaluation, if researchers choose to report Pearson or Spearman correlations instead of the kappa coefficient or ICC, this property could be classified as doubtful [22]. The assessment of psychometric properties involves a vast field and there is still a lack of standardization in conceptual and methodological terms [23]. According to the general COSMIN assessment, most of the original studies also did not describe the psychometric properties evaluated. In addition, most of these studies did not meet the minimum criteria recommended for the evaluation of psychometric properties. These results reinforce the need to properly assess psychometric properties in the development of ED assessment tools.

We also considered the minimum criteria recommended for assessing psychometric properties, and most studies did not include these criteria either. For example, of the 17 studies that carried out the translation process, only two assessed the content validity for the cultural adaptation of the instrument [23]. However, the studies with and without the translation process showed great similarity in the evaluation of the psychometric properties according to the COSMIN score. All the validated tools were developed in English in high-income countries. Understanding the possible cultural difference between countries is crucial for an adequate assessment of the instruments [67, 68].

The psychometric properties were most frequently assessed in the EAT and EDE-Q instruments. A possible explanation for the greater use of these questionnaires may be that both instruments include important domains for the assessment of EDs, and they are already widely used and recognized in clinical practice [69,70,71]. As with original studies, the majority of the most used questionnaires did not describe the psychometric properties evaluated in COSMIN.

The EDE, one of the most frequently used instruments for measuring EDs, was only validated in China [29, 69]. The ChEDE and ChEDE-Q instruments were not validated in any of the low-and middle-income countries.

Of the 28 studies included in this review, only five received partial funding to develop their research. This emphasizes the scarcity of resources for developing ED research in low- and middle-income countries. A lack of resources can significantly compromise the feasibility of conducting studies according to methodological recommendations [72].

Regarding the limitations of this review, no country-specific databases were accessed. However, the search for evidence included six databases and gray literature and did not include any language or publication date restrictions. Another limitation is that this review included only the most commonly used instruments and did not cover all instruments. In addition, we did not compare the diagnostic performance of questionnaires in studies that evaluated psychometric properties. However, only six studies evaluated the diagnostic performance of three instruments.

Conclusion

The results of this review suggest a lack of studies in low- and middle-income countries on psychometric properties in commonly used instruments for measuring EDs. With the steady increase in the prevalence of EDs globally, psychometric investigations of instruments for measuring eating disorder symptoms in these countries should be encouraged to promote their early detection and treatment.

Availability of data and materials

The datasets analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

AN:

Anorexia nervosa

AUC:

Area under the curve

BN:

Bulimia nervosa

ChEAT:

Children's eating attitudes test

ChEDE:

Children's eating disorder examination

ChEDE-Q:

Children's eating disorder examination questionnaire

CABI:

Commonwealth agricultural Bureaux international

CFI:

Comparative fit index

CFA:

Confirmatory factor analysis

COSMIN:

Consensus-based standards for the selection of health measurement instruments

DSM-IV:

Diagnostic and statistical manual of mental disorders-IV

DSM-5:

Diagnostic and statistical manual of mental disorders-5

DOI:

Digital Object Identifier

EAT:

Eating attitudes test

EDs:

Eating disorders

EDE:

Eating disorder examination

EDE-Q:

Eating disorder examination-questionnaire

EDE-QS:

Eating disorder examination-questionnaire short

EDI:

Eating disorder inventory

EDs:

Eating disorders

EFA:

Exploratory factor analysis

Fig:

Figure

ICC:

Intraclass correlation coefficients

KMO:

Kaiser Meyer Olkin

LILACS:

Latin American & Caribbean Health Sciences Literature

PRISMA:

Preferred reporting items for systematic reviews and meta-analyses

PROSPERO:

International prospective register of systematic reviews

TLI:

Tucker Lewis index

SRMSR:

Standardized root mean square residual

RMSEA:

Root mean square error of approximation

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Acknowledgements

The authors thank Professor Linda Booij for her contributions in reviewing this manuscript, as well as the Research Support Foundation of Rio Grande do Sul (FAPERGS), the National Research Council of Brazil (CNPq), and the Coordination for the Improvement of Higher Education Personnel – Brazil (CAPES) (Finance Code 001).

Funding

Professor Paula A. Diaz Valencia received funds through the project entitled “Repository for the Surveillance of Chronic Disease Risk Factors in Colombia, the Caribbean, and the Americas,” financed by the Ministry of Science, Technology, and Innovation of Colombia—Minciencias (code 111584467754).

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Authors and Affiliations

  1. Pontificia Universidade Católica Do Rio Grande Do Sul, Porto Alegre, Brazil

    Camila Ospina Ayala, Camila Scarpatto, Tatiana Quarti Irigaray & Rita Mattiello

  2. Faculty of Nursing, Universidad de Antioquia, Medellín, Colombia

    Claudia Milena Garizábalo-Davila & Wilson Cañon-Montañez

  3. Epidemiology Group, National College of Public Health, Universidad de Antioquia, Medellín, Colombia

    Paula Andrea Diaz Valencia

  4. Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Rio Grande do Sul, Brazil

    Rita Mattiello

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Contributions

COA and RM conceptualized the review; COA and RM conducted the literature search; COA and CMGD screened studies for inclusion. All authors reviewed drafts of the manuscript. All authors contributed to, and have approved, the final manuscript.

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Correspondence to Rita Mattiello.

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Supplementary Information

Additional file 1

Database search strategy.

Additional file 2

Cut-off points for psychometric properties.

Additional file 3

COSMIN methodological quality classification of individual studies.

Additional file 4

COSMIN methodological quality classification of original studies.

Additional file 5

COSMIN methodological quality classification of original studies.

Additional file 6

Methodology and results of the validation process of the original studies.

Additional file 7

COSMIN classification of the methodological quality of the EAT from the original study versus the studies included in this review.

Additional file 8

COSMIN classification of the methodological quality of the EDE-Q from the original study versus the studies included in this review.

Additional file 9

COSMIN classification of the methodological quality of studies with and without a translation process.

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Ayala, C.O., Scarpatto, C., Garizábalo-Davila, C.M. et al. Assessing eating disorder symptoms in low and middle-income countries: a systematic review of psychometric studies of commonly used instruments. J Eat Disord 10, 124 (2022). https://doi.org/10.1186/s40337-022-00649-z

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  • DOI: https://doi.org/10.1186/s40337-022-00649-z

Keywords

Journal of Eating Disorders

ISSN: 2050-2974