Development and validation of the Maladaptive Eating Behavior Questionnaire for Chinese patients after bariatric surgery

Development and validation of the Maladaptive Eating Behavior Questionnaire for Chinese patients after bariatric surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and validation of the Maladaptive Eating Behavior Questionnaire for Chinese patients after bariatric surgery Hongxia Hua, Ruiping Liu, Kang Zhao, Hui Liang, Ningli Yang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7875279/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 16 You are reading this latest preprint version Abstract Introduction: It was challenging to accurately measure the maladaptive eating behavior after bariatric surgery. Our study was aimed to develop and validate the Maladaptive Eating Behavior Questionnaire after Bariatric Surgery (MEBQBS). Methods: The initial questionnaire was developed through concept clarification, literature review, focus group discussion, and pilot study. Its reliability and validity were also examined in 457 patients after bariatric surgery. Results: The final 53-item MEBQBS comprised 8 factors, including emotional eating (negative emotion, positive emotion sub-domain), grazing behavior, food craving (positive outcome expectancy, emotional craving, preoccupation with food sub-domain), uncontrolled eating (cognition, behavior sub-domain). Exploratory factor analysis revealed a cumulative variance contribution rate of 69.54%. Confirmatory factor analysis revealed that the indices of c 2 /df, goodness-of fit index, normed fit index, incremental fit index, Tucker-Lewis index, confirmatory fit index and root mean-square error of approximation were 1.868, 0.804, 0.884, 0.943, 0.934, 0.942, and 0.050, indicating the model fit well. Additionally, significant correlations were observed between the total score of MEBQBS and the Three-Factor Eating Questionnaire-R21 ( P <0.05). The Cronbach's α and Guttman split-half coefficient of MEBQBS were 0.966 and 0.790, respectively. Conclusion: The MEBQBS is a valid and reliable instrument for identifying unhealthy eating behavior of patients after bariatric surgery, offering potential utility in evaluating the effect of tailored interventions. Figures Figure 1 Figure 2 Key points This study firstly developed and validated the Maladaptive Eating Behavior Questionnaire for Bariatric Surgery (MEBQBS). The final 53-item MEBQBS encompasses 8 factors across 4 core dimensions, including emotional eating, grazing behavior, food craving, and uncontrolled eating. MEBQBS is a valid and reliable tool for early identification of unhealthy eating patterns, facilitating timely and tailored interventions for patients undergoing bariatric surgery. Introduction In recent years, the global incidence of obesity has been on the rise year by year[ 1 ]. Bariatric surgery has been considered as the most effective intervention for severe obesity and associated comorbidities. The minimally invasive alteration of gastrointestinal anatomy lead to food restriction and nutrient malabsorption, which may help patients achieve sustained weight loss and metabolic improvement[ 2 , 3 ]. However, the effect of weight loss among patients vary significantly, with some patients experiencing weight regain within 1 ~ 2 years or even 6 months after surgery[ 4 ]. Studies showed that the incidence of weight regain within 2 years after bariatric surgery can reach 27.6%, which is mainly associated with the maladaptive eating behavior[ 5 , 6 ]. Most of the obese patients have unhealthy eating behavior before surgery, and some patients may still develop unhealthy eating behavior after bariatric surgery. So it is extremely important to accurately assess and timely improve the maladaptive eating behavior of patients undergoing bariatric surgery. At present, the concept of maladaptive eating behavior after bariatric surgery has not been unified, and it is often mixed up with terms such as “eating disorder after bariatric surgery” or “poor dietary adherence after bariatric surgery”. In 2023, our study found that these three concepts are distinct from each other. Maladaptive eating behavior after bariatric surgery means the unhealthy eating behavior that occurs after the surgery, characterized by uncontrolled eating, grazing diet, emotional eating, food craving, food addiction, and compensatory behavior. However, eating disorder belong to mental disease, and the diagnosis is mainly based on the Diagnostic and Statistical Manual of Mental Disorders. Poor dietary adherence after bariatric surgery refers to the inability of patients to follow dietary recommendations given by doctors, including insufficient intake of protein, vitamins, and trace elements, as well as excessive intake of fats and carbohydrates, which can lead to a series of nutritional complications such as vitamin deficiency, anemia, osteoporosis, etc. Meanwhile, there are also some connections between these three concepts. When maladaptive eating behavior continues to develop, it can easily trigger eating disorder. Also there is a mutual influence between maladaptive dietary behavior and poor dietary adherence after bariatric surgery[ 7 ]. The conceptual relationship is shown in Fig. 1 . Besides, due to the altered gastrointestinal anatomy and hormonal changes induced by bariatric surgery, the eating pattern of patients after bariatric surgery should be different from the general population, such as changes in the amount and types of food intake, as well as increase in the frequency of meals[ 8 , 9 ]. At present, researchers usually use universal questionnaires to assess unhealthy eating behavior of patients after bariatric surgery, such as the Three-Factor Eating Questionnaire (TFEQ)[ 10 ], the Adult Eating Behaviour Questionnaire (AEBQ)[ 11 ], and the Dutch Eating Behavior Questionnaire (DEBQ)[ 12 ]. The theoretical basis and measurement dimensions of these scales are inconsistent, and they were designed according to the characteristics of eating behavior among general populations. Consequently, it is challenging to accurately measure the maladaptive eating behavior after bariatric surgery, because of the non-unification of its concept and unique eating characteristics of patients undergoing bariatric surgery. To bridge this knowledge gap, our study aimed to define and characterize the maladaptive eating behavior after bariatric surgery, also develop a scientific assessment tool and facilitate early intervention for unhealthy eating behavior after bariatric surgery. Materials and Methods The development of a reliable and valid measurement tool involved two phases. Phase 1 focused on developing the initial draft of MEBQBS by concept clarification, literature review, focus group discussion, and pilot study. Phase 2 included a cross-sectional survey to assess the reliability and validity of MEBQBS. Phase 1: Development of the initial draft of MEBQBS 1.Concept clarification Firstly, we clarified the concept of maladaptive eating behavior after bariatric surgery by using the Rodgers' concept analysis in 2023[7]. The conceptual framework of maladaptive eating behavior after bariatric surgery is shown in Fig2. We concluded that the conceptual attributes were composed of 6 aspects: uncontrolled eating, grazing behavior, emotional eating, food craving, food addiction and compensatory behaviors. Considering that food addiction and compensatory behaviors only occur in a small number of patients in the long term after bariatric surgery[13], so the initial dimensions of MEBQBS were set as: emotional eating (defined as “eating as a response to a range of negative and positive emotions”, including negative emotion, positive emotion sub-domain[14]), grazing behavior (defined as “repetitious, continuous and unplanned eating between mealtimes, where the amount of food at each intake may be small, but overall intake is relatively large”[15]), food craving (defined as “having a strong desire for specific food, such as high-fat food or desserts”, including positive outcome expectancy, emotional craving, preoccupation with food sub-domain[16]), and uncontrolled eating (defined as “lossing control over the amount and variety of food intake, without other features of binge eating disorder”, including cognition, behavior sub-domain[17]). Based on the above analysis, the measurement dimensions of MEBQBS was developed. Then, we searched databases from inception to September 2023. The search strategy keywords and the medical subject headings (MeSH) included "bariatric and metabolic surgery", "maladaptive eating behavior" and others in both Chinese and English. We thoroughly reviewed the relevant literature, compared the applicability of items in existing scales such as the Emotional Eating Scale (EES)[18], Repetitive Eating Questionnaire [Rep (eat)-Q][19], Eating Loss of Control Scale (ELOCS)[20], ect. An initial item pool comprising 4 dimensions and 90 items was developed. The response format for MEBQBS is a 5-point Likert scoring system, with the following scoring: never (0); rarely (1), sometimes (2), often (3), and always (4). The questionnaire instructions were as follows: “Please answer the following questions by reflecting on your performance over the past 28 days”. 2.Focus group discussion Then the focus group discussion was jointly organized by our team and 15 experts in nutrition, health behavior promotion and psychology fields. All items were analyzed, reviewed, and discussed one by one, in order to adjust the dimension, language expression and scoring criteria for each item. A total of 23 items were revised in terms of their language expression. 3.Pilot study 20 patients undergoing bariatric surgery who were followed up in a tertiary hospital were recruited by convenience sampling. They were asked to complete the initial draft of MEBQBS independently. After respondents completed the survey, we evaluated the clarity of items and overall format of the questionnaire. According to the feedback from participants, most of the items in MEBQBS were clearly expressed and easily understood, with only some items being expressed improperly. After discussion by our team, the following modifications were made: (1) change the interrogative expressions to declarative expressions, such as changing "how much faster my eating speed is than usual" to "my eating speed is faster than usual". (2) change the phrase "the food I crave/desire" in some items to "the food I want to eat". (3) change the word "You" in some items to "I" because MEBQBS is a self-report questionnaire. Phase 2: Reliability and validity test of MEBQBS 4.Participants Patients who underwent bariatric surgery and were followed up at a tertiary hospital from October 2023 to October 2024 were selected by convenience sampling. A total sample size of 457 participants successfully completed the survey. Inclusion criteria were as follows: (1) adhered to the surgical indications of the Chinese Guidelines for the Surgical Treatment of Obesity and Type 2 Diabetes[21]; (2) underwent initial bariatric surgery; (3) with normal cognition and communication ability; (4) voluntary participation. Exclusion criteria were: (1) experienced postoperative complications such as anastomotic leakage or bleeding; (2) filled out the questionnaire randomly; (3) had more than 20% of the content missing. The sample size was calculated according to the requirement of factor analysis, requiring 5~10 participants per item with minimum samples of 100 cases for exploratory factor analysis (EFA) and 150 cases for confirmatory factor analysis (CFA)[22]. Considering 20% of the invalid questionnaires and the formal draft of MEBQBS contains 53 items, the sample size was at least 318. 5.Measures The General Information Questionnaire was developed by our team, in order to collect the participants’ demographic information, including age, gender, education degree, marital status, type of surgery, postoperative time. MEBQBS including 53 items was applied to identify unhealthy eating behavior of patients after bariatric surgery. This self-report questionnaire utilized a 0-4 point for each item, with higher sores in each dimension reflecting more severe emotional eating, grazing behavior, food craving or uncontrolled eating. TFEQ-R21 was used to test the criterion validity of MEBQBS. This questionnaire was developed by ROSNAH[23], including 3 dimensions: emotional eating, restrictive eating, and uncontrolled eating. The total score of the scale is the sum of the scores from each dimension, with higher scores indicating more severe unhealthy eating behavior. 6.Data collection The General Information Questionnaire, MEBQBS and TFEQ-R21 were distributed face-to-face. Participants completed all questionnaires by themselves independently. If participants had any questions, researchers would explain it. Questionnaires were collected immediately after completion, and subsequently reviewed for the completeness. 7.Analysis Item analysis was used to select proper items of MEBQBS, and the following criteria were applied for item elimination: (1) non-significant difference in scores between high and low scorers ( P >0.05) or critical ratio<3; (2) item-total correlation coefficient0.05); (3) improvement in overall Cronbach’s α coefficient upon item deletion; (4) factor loading value<0.5 or communalities value<0.2. Construct validity was assessed through both EFA and CFA. Firstly, the Kaiser-MeyerOlkin ( KMO ) test for sampling adequacy and Bartlett’s test of sphericity were performed to examine the factorability. Then EFA was performed with principal component analysis and varimax rotation to identify the latent factor structure of MEBQBS, with factor extraction based on eigenvalue≥1. Subsequently, CFA was conducted with the maximum likelihood estimation to validate the factor structure identified by EFA. The construct validity of MEBQBS was considered as good when meeting the following criteria: c 2 /df<3, root mean-square error of approximation (RMSEA)<0.05, and goodness-of fit index (GFI), normed fit index (NFI), incremental fit index (IFI), Tucker-Lewis index (TLI), confirmatory fit index (CFI) all exceed 0.8[24]. For criterion validity, pearson correlation coefficients between the total score, scores of each dimension of MEBQBS and the total scores of TFEQ-R21 were calculated. The reliability was assessed by both internal consistency (Cronbach's α coefficients) and split-half reliability (Guttman split-half coefficients). We considered Cronbach's α and Guttman split-half coefficients higher than 0.7 as satisfactory reliability indicators[25]. All statistical analyses were performed by SPSS 22.0 and Amos 23.0 software. The continuous variables were presented by mean and standard deviation, with group comparisons examined by independent sample t-tests. The categorical variables were described by frequency and percentage. Pearson correlation analysis was used to examine variable associations. The data was randomly split into two subsamples. Sample 1 (n=133) was used for item analysis and EFA, and sample 2 (n=324) was used for CFA, criterion validity assessment, and reliability test. A significance threshold of α=0.05 was applied for all analyses. Results 1.Sample characteristics With 468 questionnaires distributed, 457 participants completed the survey successfully, yielding a high response rate of 97.6%. The general characteristics of 457 participants are shown in Table1. Table1 Characteristics of patients after bariatric surgery （ n=457 ） Characteristics Category n（%） Age (years) <18 17（3.70%） 18~<45 388（84.90%） ≥45 52（11.40%） Gender Men 165（36.10%） Women 292（63.90%） Education degree Junior school or less 64（13.90%） High school 101（22.20%） College or above 292（63.90%） Marital status Unmarried 205（44.80%） Married 233（51.00%） Divorce or widowhood 19（4.20%） Type of surgery Sleeve gastrectomy 262（57.30%） Sleeve gastrectomy plus jejunojejunal bypass 114（25.00%） Sleeve gastrectomy plus duodenal-jejunal bypass 32（7.00%） Roux-en-Y gastric bypass 49（10.70%） Postoperative time (months) <12 351（76.80%） 12~<24 90（19.70%） ≥24 16（3.50%） 2.Item analysis A total of 37 items did not meet the criteria of item analysis and were subsequently deleted. The final draft of MEBQBS with 4 dimensions, 8 sub-domains, and 53 items were developed. 3.Validity analysis Construct validity was confirmed by the KMO value of 0.86 and the significant Bartlett's sphericity test ( P 1 were identified, explaining 69.54% of the cumulative variance. According to our specialized knowledge, we found that the first and sixth factor reflected the negative and positive emotion sub-domain of emotional eating (including 21 items); the second factor described the frequency of grazing behavior (including 11 items); the third, fifth, and eighth factor reflected the positive outcome expectancy, emotional craving, and preoccupation with food sub-domain of food craving (including 13 items); the fourth and seventh factor reflected the cognition and behavior sub-domain of uncontrolled eating (including 8 items). Table 2 lists the factor loading of the MEBQBS based on EFA, which ranged from 0.56 to 0.92. The results of CFA revealed an optimal model with 53 items aligned to the previously identified 8 factors. The model demonstrated good fit indices: c 2 /df=1.87, GFI=0.80, NFI==0.88, IFI=0.94, TLI=0.93, CFI=0.94, and RMSEA=0.05, supporting the structural validity of the 8-factor MEBQBS. For criterion validity, the correlation coefficients between the total score of MEBQBS, as well as scores of emotional eating, grazing behavior, food craving, uncontrolled eating dimension and the total score of TFEQ-R21 were 0.67, 0.57, 0.40, 0.52, and 0.59 ( P <0.01). Table2 Factor loading of the MEBQBS based on the EFA （ n=133 ） Item Factor loading Factor1 Factor2 Factor3 Factor4 Factor5 Factor6 Factor7 Factor8 1.I desire to eat when I am resentful 0.88 2.I desire to eat when I am discouraged 0.86 3.I desire to eat when I am worn out 0.82 4.I desire to eat when I am excited 0.70 5.I desire to eat when I am rebellious 0.87 6.I desire to eat when I am blue 0.76 7.I desire to eat when I am sad 0.84 8.I desire to eat when I am irritated 0.90 9.I desire to eat when I am frustrated 0.89 10.I desire to eat when I am furious 0.90 11.I desire to eat when I am on edge 0.88 12.I desire to eat when I am nervous 0.86 13.I desire to eat when I am guilty 0.85 14.I desire to eat when I am helpless 0.79 15.I desire to eat when I am upset 0.79 16.I desire to eat when I am angry 0.87 17.I desire to eat when I am confused 0.88 18.I desire to eat when I am worried 0.92 19.I desire to eat when I am happy 0.74 20.I desire to eat when I am satisfied 0.74 21.I desire to eat when I am glad 0.77 22.I eat “off and on” all day 0.68 23.I eat small or modest amounts of food in a repetitive and unplanned manner 0.81 24.I “snack” on food without paying attention to what I am doing 0.80 25.I “snack” on food repetitively throughout the day 0.84 26.I eat without paying attention to the amount of food I am eating 0.79 27.I eat food items at random in between I planned meals and snacks 0.75 28.I do not want to eat, but feel that I can’t avoid eating 0.76 29.I can’t avoid going back to snack on food even if I am trying to resist 0.83 30.I have a hard time controlling my cravings to eat in between meals 0.85 31.I feel driven to eat 0.68 32.I feel upset after “snacking” 0.56 33.When I eat what I crave, I feel great 0.64 34.Sometimes, eating makes things seem just perfect 0.78 35.If I am to eat what I’m desiring, I am sure my mood will improve 0.85 36.Eating something tasty will make me feel wonderful 0.84 37.If I eat something, I won’t feel so sluggish and lethargic 0.79 38.Satisfying my appetite will make me feel less grouchy and irritable 0.75 39.I will feel more alert if I can satisfy my appetite 0.80 40.I crave foods when I feel bored, angry or sad 0.66 41.When I’m stressed out, I crave food 0.73 42.My emotions often make me want to eat 0.74 43.When I crave something, I know I won’t be able to stop eating once I start 0.73 44.I feel like I have food on my mind all the time 0.64 45.I find myself preoccupied with food 0.66 46.I feel disgusted, depressed, or very guilty while eating 0.63 47.I am afraid of losing control over eating 0.80 48.I feel upset by the feeling that I can’t stop eating 0.78 49.I feel hard to stop thinking about food I am craving 0.69 50.I feel out of control when I has eaten an unusually large amount of food 0.80 51.I ignore an interruption to keep eating 0.68 52.I eat much more rapidly than normal 0.78 53.I give in to an impulse to eat even though not hungry 0.65 Note: Factor 1refers to the negative emotion sub-domain of emotional eating; Factor 2 refers to grazing behavior; Factor 3 refers to the positive outcome expectancy sub-domain of food craving; Factor 4 refers to the cognition sub-domain of uncontrolled eating; Factor 5 refers to the emotional craving sub-domain of food craving; Factor 6 refers to the positive emotion sub-domain of emotional eating; Factor 7 refers to the behavior sub-domain of uncontrolled eating; Factor 8 refers to the preoccupation with food sub-domain of food craving. 4.Reliability analysis The Cronbach's α and the Guttman split-half coefficient for the MEBQBS were 0.97 and 0.79. The Cronbach's α for dimensions of emotional eating, grazing behavior, food craving, and uncontrolled eating were 0.97, 0.94, 0.93, and 0.86, respectively. The Guttman split-half coefficients for dimensions of emotional eating, grazing behavior, food craving, and uncontrolled eating were 0.93, 0.86, 0.74, and 0.82, respectively. Discussion Unhealthy eating behavior is an important reason for weight regain after bariatric surgery. So it is crucial for the early identification and effective management of unhealthy eating behavior among patients undergoing bariatric surgery[ 26 ]. At present, the assessment tools for unhealthy eating behavior after bariatric surgery mainly include specific and universal scales. Among them, specific scales such as the Rep (eat)-Q[ 19 ] can only measure a single type of unhealthy eating behavior among patients undergoing bariatric surgery. The universal scale such as TFEQ[ 10 ], AEBQ[ 11 ], and DEBQ[ 12 ] are comprehensive assessment tools. TEFQ includes 3 dimensions of uncontrolled, restrictive and emotional eating, while DEBQ contains 3 dimensions of emotional, extrinsic, and restrictive eating. They were widely used in clinic due to the multidimensional measurement advantages. However, TFEQ and DEBQ lack population specificity when applied to patients undergoing bariatric surgery, especially in the assessment of restrictive eating. Restrictive eating was defined as “an eating pattern that voluntarily limiting dietary intake by regularly weighing themselves”. After bariatric surgery, patients may experience a decrease in food intake because of the reduction in gastric capacity, which contradicts the concept of restrictive eating that "being influenced by one's own cognition rather than physiological mechanisms". Therefore, TFEQ and DEBQ are not entirely suitable for assessing unhealthy eating behavior for patients after bariatric surgery. Besides, some researchers suggested that TFEQ and DEBQ have not captured all specific characteristics of unhealthy eating behavior, and their measurement dimensions are still incomplete. Then, AEBQ was developed in 2016, which includes 8 dimensions: food reactivity, hunger, food enjoyment, emotional overeating, emotional insufficient eating, satiety, eating speed, and picky eating. The measurement dimensions of AEBQ are more comprehensive when compared with TFEQ and DEBQ. However, some dimensions such as hunger, food enjoyment, satiety and eating speed are still inapplicable to patients after bariatric surgery, because AEBQ was also not specially developed for the eating characteristics of patients after bariatric surgery. In order to address this gap, we have developed a 53-item MEBQBS, which integrated the measurement dimensions with dietary characteristics of patients after bariatric surgery closely, and assessed unhealthy eating behavior from multiple perspectives. When developing MEBQBS, we adopted a systematic approach in order to ensure the scientific process and robustness of the results. The measurement dimensions of MEBQBS were formulated by clarifying the definition of maladaptive eating behavior after bariatric surgery, which ensure the MEBQBS has a clear and reasonable structure. Then, literature review and focus group discussion were carried out to produce the item pool of MEBQBS. Besides, a pilot study was also conducted to improve its operability and acceptability. Our rigorous development procedure ensured that MEBQBS is a scientific and effective assessment tool. Construct validity refers to the degree that a questionnaire fully assess the construct of interest. In our study, EFA extracted 8 common factors, with a cumulative variance contribution rate of 69.54%. All item factor loadings were greater than 0.50, indicating that the structure of MEBQBS is acceptable. And the 8 common factors were divided into 4 dimensions and 8 sub-domains, named as emotional eating (negative and positive emotion sub-domain), grazing behavior, food craving (positive outcome expectancy, emotional craving, preoccupation with food sub-domain), uncontrolled eating (cognition and behavior sub-domain), respectively. The obtained dimensions were consistent with the theoretical hypotheses proposed in the previous stage of concept clarification. And the sub-domains among different types of unhealthy eating behavior could provide a convenient approach for accurately assessing the specific characteristics of unhealthy eating behavior. CFA further supported a 8-factor structure of MEBQBS, fit indices including χ 2 /df, GFI, NFI, IFI, TLI, CFI, and RMSEA suggested the data fit the model well. The finding further verified the consistency between the measurement structure and theoretical concept of MEBQBS, indicating that the scale has good structural validity. TFEQ-R21 is a widely used self-assessment scale for unhealthy eating behavior, with good reliability and validity[ 10 ]. Significant correlations were observed between the total score, scores of each dimension of MEBQBS and the total score of TFEQ-R21, indicating that the criterion validity of MEBQBS is good. The results of reliability analysis showed that the Cronbach's α of MEBQBS and each dimension were 0.86–0.97, which were higher than those of TEFQ-R21 (α: 0.76–0.89), DEBQ (α: 0.80–0.95) and AEBQ (α: 0.75–0.90). These results suggested that MEBQBS has better internal consistency, and the items are more conform to the characteristics of patients after bariatric surgery. Meanwhile, the Guttman split-half coefficient of MEBQBS and dimensions of emotional eating, grazing behavior, food craving, uncontrolled eating were 0.79, 0.93, 0.86, 0.74, and 0.82, indicating good homogeneity among items[ 24 ]. Therefore, MEBQBS has good reliability and stability, it also has great prospect for long-term follow-up and assessment of dietary intervention in patients after bariatric surgery. Some limitations still need to be acknowledged. On the one hand, convenient sampling method used in participant selection may affect the representativeness of the sample and the generalizability of the results. On the other hand, the predictive power of MEBQBS for clinical outcomes after bariatric surgery has not been explored, further research should be conducted to evaluate it’s predictive ability for clinical outcomes. Conclusion In summary, MEBQBS developed by our study, a self-report measure of unhealthy eating behavior in patients after bariatric surgery, is reliable and useful. It provides a basis for developing scientific and effective interventions for unhealthy eating behavior after bariatric surgery and helps promote the localization exploration of unhealthy eating behavior after bariatric surgery in China. Declarations Conflict of Interest The authors declare that they have no conflict of interest. Ethical Approval Ethical approval for our research was obtained from the Ethics Committee of *** (Approval Code: 2023-SR-581). Informed consent Informed consent was obtained by all individual participants included in the study. Funding This study was supported by *** (Grant Number: JSPH-NB-2022-14). Author Contribution H.HX. and Z.K. designed and wrote the main manuscript text. H.HX. and L.RP. acquired and analysed data. Y.Nl. and L.H. critical revised the manuscript; L.RP. and Z.K. prepared all figures and tables; Y.Nl. provided administrative, technical, or material support. 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1","display":"","copyAsset":false,"role":"figure","size":50700,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe conceptual relationship diagram of maladaptive eating behavior, eating disorder and poor dietary adherence after bariatric surgery\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7875279/v1/2caab6a7578848b8fd01766d.jpeg"},{"id":96399833,"identity":"f683f38a-eccd-4300-a28c-4e904ce94df9","added_by":"auto","created_at":"2025-11-20 16:02:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":167523,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe conceptual framework of maladaptive eating behavior after bariatric surgery\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7875279/v1/a666740e19e90407d88ded50.png"},{"id":96603347,"identity":"a84aa30a-e30f-4e91-b751-de40735d1f73","added_by":"auto","created_at":"2025-11-24 09:08:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1151741,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7875279/v1/9034eaf7-5f44-4825-bf80-2f185ba4044f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and validation of the Maladaptive Eating Behavior Questionnaire for Chinese patients after bariatric surgery","fulltext":[{"header":"Key points","content":"\u003cul start=\"50\"\u003e\n \u003cli\u003eThis study firstly developed and validated the Maladaptive Eating Behavior Questionnaire for Bariatric Surgery (MEBQBS).\u003c/li\u003e\n \u003cli\u003eThe final 53-item MEBQBS encompasses 8 factors across 4 core dimensions, including emotional eating, grazing behavior, food craving, and uncontrolled eating.\u003c/li\u003e\n \u003cli\u003eMEBQBS is a valid and reliable tool for early identification of unhealthy eating patterns, facilitating timely and tailored interventions for patients undergoing bariatric surgery.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eIn recent years, the global incidence of obesity has been on the rise year by year[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Bariatric surgery has been considered as the most effective intervention for severe obesity and associated comorbidities. The minimally invasive alteration of gastrointestinal anatomy lead to food restriction and nutrient malabsorption, which may help patients achieve sustained weight loss and metabolic improvement[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, the effect of weight loss among patients vary significantly, with some patients experiencing weight regain within 1\u0026thinsp;~\u0026thinsp;2 years or even 6 months after surgery[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Studies showed that the incidence of weight regain within 2 years after bariatric surgery can reach 27.6%, which is mainly associated with the maladaptive eating behavior[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Most of the obese patients have unhealthy eating behavior before surgery, and some patients may still develop unhealthy eating behavior after bariatric surgery. So it is extremely important to accurately assess and timely improve the maladaptive eating behavior of patients undergoing bariatric surgery.\u003c/p\u003e\u003cp\u003eAt present, the concept of maladaptive eating behavior after bariatric surgery has not been unified, and it is often mixed up with terms such as \u0026ldquo;eating disorder after bariatric surgery\u0026rdquo; or \u0026ldquo;poor dietary adherence after bariatric surgery\u0026rdquo;. In 2023, our study found that these three concepts are distinct from each other. Maladaptive eating behavior after bariatric surgery means the unhealthy eating behavior that occurs after the surgery, characterized by uncontrolled eating, grazing diet, emotional eating, food craving, food addiction, and compensatory behavior. However, eating disorder belong to mental disease, and the diagnosis is mainly based on the Diagnostic and Statistical Manual of Mental Disorders. Poor dietary adherence after bariatric surgery refers to the inability of patients to follow dietary recommendations given by doctors, including insufficient intake of protein, vitamins, and trace elements, as well as excessive intake of fats and carbohydrates, which can lead to a series of nutritional complications such as vitamin deficiency, anemia, osteoporosis, etc. Meanwhile, there are also some connections between these three concepts. When maladaptive eating behavior continues to develop, it can easily trigger eating disorder. Also there is a mutual influence between maladaptive dietary behavior and poor dietary adherence after bariatric surgery[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The conceptual relationship is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eBesides, due to the altered gastrointestinal anatomy and hormonal changes induced by bariatric surgery, the eating pattern of patients after bariatric surgery should be different from the general population, such as changes in the amount and types of food intake, as well as increase in the frequency of meals[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. At present, researchers usually use universal questionnaires to assess unhealthy eating behavior of patients after bariatric surgery, such as the Three-Factor Eating Questionnaire (TFEQ)[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], the Adult Eating Behaviour Questionnaire (AEBQ)[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and the Dutch Eating Behavior Questionnaire (DEBQ)[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The theoretical basis and measurement dimensions of these scales are inconsistent, and they were designed according to the characteristics of eating behavior among general populations. Consequently, it is challenging to accurately measure the maladaptive eating behavior after bariatric surgery, because of the non-unification of its concept and unique eating characteristics of patients undergoing bariatric surgery. To bridge this knowledge gap, our study aimed to define and characterize the maladaptive eating behavior after bariatric surgery, also develop a scientific assessment tool and facilitate early intervention for unhealthy eating behavior after bariatric surgery.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThe development of a reliable and valid measurement tool involved two phases. Phase 1 focused on developing the initial draft of MEBQBS by concept clarification, literature review, focus group discussion, and pilot study. Phase 2 included a cross-sectional survey to assess the reliability and validity of MEBQBS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePhase 1: Development of the initial draft of MEBQBS\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.Concept clarification\u0026nbsp;\u003c/strong\u003eFirstly, we clarified the concept of maladaptive eating behavior after bariatric surgery by using the Rodgers\u0026apos; concept analysis in 2023[7]. The conceptual framework of maladaptive eating behavior after bariatric surgery is shown in Fig2. We concluded that the conceptual attributes were composed of 6 aspects: uncontrolled eating, grazing behavior, emotional eating, food craving, food addiction and compensatory behaviors. Considering that food addiction and compensatory behaviors only occur in a small number of patients in the long term after bariatric surgery[13], so the initial dimensions of MEBQBS were set as: emotional eating (defined as \u0026ldquo;eating as a response to a range of negative and positive emotions\u0026rdquo;, including negative emotion, positive emotion sub-domain[14]), grazing behavior (defined as \u0026ldquo;repetitious, continuous and unplanned eating between mealtimes, where the amount of food at each intake may be small, but overall intake is relatively large\u0026rdquo;[15]), food craving (defined as \u0026ldquo;having a strong desire for specific food, such as high-fat food or desserts\u0026rdquo;, including positive outcome expectancy, emotional craving, preoccupation with food sub-domain[16]), and uncontrolled eating (defined as \u0026ldquo;lossing control over the amount and variety of food intake, without other features of binge eating disorder\u0026rdquo;, including cognition, behavior sub-domain[17]). Based on the above analysis, the measurement dimensions of MEBQBS was developed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThen, we searched databases from inception to September 2023. The search strategy keywords and the medical subject headings (MeSH) included \u0026quot;bariatric and metabolic surgery\u0026quot;, \u0026quot;maladaptive eating behavior\u0026quot; and others in both Chinese and English. We thoroughly reviewed the relevant literature, compared the applicability of items in existing scales such as the Emotional Eating Scale (EES)[18], Repetitive Eating Questionnaire [Rep (eat)-Q][19], Eating Loss of Control Scale (ELOCS)[20], ect. An initial item pool comprising 4 dimensions and 90 items was developed. The response format for MEBQBS is a 5-point Likert scoring system, with the following scoring: never (0); rarely (1), sometimes (2), often (3), and always (4). The questionnaire instructions were as follows: \u0026ldquo;Please answer the following questions by reflecting on your performance over the past 28 days\u0026rdquo;.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.Focus group discussion\u0026nbsp;\u003c/strong\u003eThen the focus group discussion was jointly organized by our team and 15 experts in nutrition, health behavior promotion and psychology fields. All items were analyzed, reviewed, and discussed one by one, in order to adjust the dimension, language expression and scoring criteria for each item. A total of 23 items were revised in terms of their language expression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.Pilot study\u0026nbsp;\u003c/strong\u003e20 patients undergoing bariatric surgery who were followed up in a tertiary hospital were recruited by convenience sampling. They were asked to complete the initial draft of MEBQBS independently. After respondents completed the survey, we evaluated the clarity of items and overall format of the questionnaire. According to the feedback from participants, most of the items in MEBQBS were clearly expressed and easily understood, with only some items being expressed improperly. After discussion by our team, the following modifications were made: (1) change the interrogative expressions to declarative expressions, such as changing \u0026quot;how much faster my eating speed is than usual\u0026quot; to \u0026quot;my eating speed is faster than usual\u0026quot;. (2) change the phrase \u0026quot;the food I crave/desire\u0026quot; in some items to \u0026quot;the food I want to eat\u0026quot;. (3) change the word \u0026quot;You\u0026quot; in some items to \u0026quot;I\u0026quot; because MEBQBS is a self-report questionnaire.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePhase 2: Reliability and validity test of MEBQBS\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.Participants\u0026nbsp;\u003c/strong\u003ePatients who underwent bariatric surgery and were followed up at a tertiary hospital from October 2023 to October 2024 were selected by convenience sampling. A total sample size of 457 participants successfully completed the survey. Inclusion criteria were as follows: (1) adhered to the surgical indications of the Chinese Guidelines for the Surgical Treatment of Obesity and Type 2 Diabetes[21]; (2) underwent initial bariatric surgery; (3) with normal cognition and communication ability; (4) voluntary participation. Exclusion criteria were: (1) experienced postoperative complications such as anastomotic leakage or bleeding; (2) filled out the questionnaire randomly; (3) had more than 20% of the content missing. The sample size was calculated according to the requirement of factor analysis, requiring 5~10 participants per item with minimum samples of 100 cases for exploratory factor analysis (EFA) and 150 cases for confirmatory factor analysis (CFA)[22]. Considering 20% of the invalid questionnaires and the formal draft of MEBQBS contains 53 items, the sample size was at least 318.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5.Measures\u0026nbsp;\u003c/strong\u003eThe General Information Questionnaire was developed by our team, in order to collect the participants\u0026rsquo; demographic information, including age, gender, education degree, marital status, type of surgery, postoperative time. MEBQBS including 53 items was applied to identify unhealthy eating behavior of patients after bariatric surgery. This self-report questionnaire utilized a 0-4 point for each item, with higher sores in each dimension reflecting more severe emotional eating, grazing behavior, food craving or uncontrolled eating. TFEQ-R21 was used to test the criterion validity of MEBQBS. This questionnaire was developed by ROSNAH[23], including 3 dimensions: emotional eating, restrictive eating, and uncontrolled eating. The total score of the scale is the sum of the scores from each dimension, with higher scores indicating more severe unhealthy eating behavior.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.Data collection\u0026nbsp;\u003c/strong\u003eThe General Information Questionnaire, MEBQBS and TFEQ-R21 were distributed face-to-face. Participants completed all questionnaires by themselves independently. If participants had any questions, researchers would explain it. Questionnaires were collected immediately after completion, and subsequently reviewed for the completeness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e7.Analysis\u0026nbsp;\u003c/strong\u003eItem analysis was used to select proper items of MEBQBS, and the following criteria were applied for item elimination: (1) non-significant difference in scores between high and low scorers (\u003cem\u003eP\u003c/em\u003e\u0026gt;0.05) or critical ratio\u0026lt;3; (2) item-total correlation coefficient\u0026lt;0.4 or did not reach a significant level (\u003cem\u003eP\u003c/em\u003e\u0026gt;0.05); (3) improvement in overall Cronbach\u0026rsquo;s \u0026alpha; coefficient upon item deletion; (4) factor loading value\u0026lt;0.5 or communalities value\u0026lt;0.2. Construct validity was assessed through both EFA and CFA. Firstly, the Kaiser-MeyerOlkin (\u003cem\u003eKMO\u003c/em\u003e) test for sampling adequacy and Bartlett\u0026rsquo;s test of sphericity were performed to examine the factorability. Then EFA was performed with principal component analysis and varimax rotation to identify the latent factor structure of MEBQBS, with factor extraction based on eigenvalue\u0026ge;1. Subsequently, CFA was conducted with the maximum likelihood estimation to validate the factor structure identified by EFA. The construct validity of MEBQBS was considered as good when meeting the following criteria:\u0026nbsp;c\u003csup\u003e2\u003c/sup\u003e/df\u0026lt;3, root mean-square error of approximation (RMSEA)\u0026lt;0.05, and goodness-of fit index (GFI), normed fit index (NFI), incremental fit index (IFI), Tucker-Lewis index (TLI), confirmatory fit index (CFI) all exceed 0.8[24]. For criterion validity, pearson correlation coefficients between the total score, scores of each dimension of MEBQBS and the total scores of TFEQ-R21 were calculated. The reliability was assessed by both internal consistency (Cronbach\u0026apos;s \u0026alpha; coefficients) and split-half reliability (Guttman split-half coefficients). We considered Cronbach\u0026apos;s \u0026alpha; and Guttman split-half coefficients higher than 0.7 as satisfactory reliability indicators[25]. All statistical analyses were performed by SPSS 22.0 and Amos 23.0 software. The continuous variables were presented by mean and standard deviation, with group comparisons examined by independent sample t-tests. The categorical variables were described by frequency and percentage. Pearson correlation analysis was used to examine variable associations. The data was randomly split into two subsamples. Sample 1 (n=133) was used for item analysis and EFA, and sample 2 (n=324) was used for CFA, criterion validity assessment, and reliability test. A significance threshold of \u0026alpha;=0.05 was applied for all analyses.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e1.Sample characteristics\u0026nbsp;\u003c/strong\u003eWith 468 questionnaires distributed, 457 participants completed the survey successfully, yielding a high response rate of 97.6%. The general characteristics of 457 participants are shown in Table1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable1 Characteristics of patients after bariatric surgery\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003en=457\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 286px;\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003en（%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 101px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003e\u0026lt;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e17（3.70%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003e18~\u0026lt;45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e388（84.90%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003e\u0026ge;45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e52（11.40%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 101px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e165（36.10%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e292（63.90%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 101px;\"\u003e\n \u003cp\u003eEducation degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003eJunior school or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e64（13.90%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e101（22.20%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003eCollege or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e292（63.90%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 101px;\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003eUnmarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e205（44.80%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e233（51.00%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003eDivorce or widowhood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e19（4.20%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 101px;\"\u003e\n \u003cp\u003eType of surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003eSleeve gastrectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e262（57.30%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003eSleeve gastrectomy plus jejunojejunal bypass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e114（25.00%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003eSleeve gastrectomy plus duodenal-jejunal bypass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e32（7.00%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003eRoux-en-Y gastric bypass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e49（10.70%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 101px;\"\u003e\n \u003cp\u003ePostoperative time (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003e\u0026lt;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e351（76.80%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003e12~\u0026lt;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e90（19.70%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 286px;\"\u003e\n \u003cp\u003e\u0026ge;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e16（3.50%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e2.Item analysis\u0026nbsp;\u003c/strong\u003eA total of 37 items did not meet the criteria of item analysis and were subsequently deleted. The final draft of MEBQBS with 4 dimensions, 8 sub-domains, and 53 items were developed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.Validity analysis\u0026nbsp;\u003c/strong\u003eConstruct validity was confirmed by the \u003cem\u003eKMO\u003c/em\u003e value of 0.86 and the significant Bartlett\u0026apos;s sphericity test (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01), indicating the suitability for EFA. Following principal component analysis and varimax rotation, 8 factors with eigenvalues\u0026gt;1 were identified, explaining 69.54% of the cumulative variance. According to our specialized knowledge, we found that the first and sixth factor reflected the negative and positive emotion sub-domain of emotional eating (including 21 items); the second factor described the frequency of grazing behavior (including 11 items); the third, fifth, and eighth factor reflected the positive outcome expectancy, emotional craving, and preoccupation with food sub-domain of food craving (including 13 items); the fourth and seventh factor reflected the cognition and behavior sub-domain of uncontrolled eating (including 8 items). Table 2 lists the factor loading of the MEBQBS based on EFA, which ranged from 0.56 to 0.92. The results of CFA revealed an optimal model with 53 items aligned to the previously identified 8 factors. The model demonstrated good fit indices:\u0026nbsp;c\u003csup\u003e2\u003c/sup\u003e/df=1.87, GFI=0.80, NFI==0.88, IFI=0.94, TLI=0.93, CFI=0.94, and RMSEA=0.05, supporting the structural validity of the 8-factor MEBQBS. For criterion validity, the correlation coefficients between the total score of MEBQBS, as well as scores of emotional eating, grazing behavior, food craving, uncontrolled eating dimension and the total score of TFEQ-R21 were 0.67, 0.57, 0.40, 0.52, and 0.59 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable2 Factor loading of the MEBQBS based on the EFA\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003en=133\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"770\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 340px;\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 430px;\"\u003e\n \u003cp\u003eFactor loading\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eFactor1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003eFactor2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003eFactor3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003eFactor4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003eFactor5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003eFactor6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003eFactor7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eFactor8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e1.I desire to eat when I am resentful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e2.I desire to eat when I am discouraged\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e3.I desire to eat when I am worn out\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e4.I desire to eat when I am excited\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e5.I desire to eat when I am rebellious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e6.I desire to eat when I am blue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e7.I desire to eat when I am sad\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e8.I desire to eat when I am irritated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e9.I desire to eat when I am frustrated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e10.I desire to eat when I am furious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e11.I desire to eat when I am on edge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e12.I desire to eat when I am nervous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e13.I desire to eat when I am guilty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e14.I desire to eat when I am helpless\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e15.I desire to eat when I am upset\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e16.I desire to eat when I am angry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e17.I desire to eat when I am confused\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e18.I desire to eat when I am worried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e19.I desire to eat when I am happy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e20.I desire to eat when I am satisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e21.I desire to eat when I am glad\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e22.I eat \u0026ldquo;off and on\u0026rdquo; all day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e23.I eat small or modest amounts of food in a repetitive and unplanned manner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e24.I \u0026ldquo;snack\u0026rdquo; on food without paying attention to what I am doing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e25.I \u0026ldquo;snack\u0026rdquo; on food repetitively throughout the day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e26.I eat without paying attention to the amount of food I am eating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e27.I eat food items at random in between I planned meals and snacks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e28.I do not want to eat, but feel that I can\u0026rsquo;t avoid eating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e29.I can\u0026rsquo;t avoid going back to snack on food even if I am trying to resist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e30.I have a hard time controlling my cravings to eat in between meals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e31.I feel driven to eat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e32.I feel upset after \u0026ldquo;snacking\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e33.When I eat what I crave, I feel great\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e34.Sometimes, eating makes things seem just perfect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e35.If I am to eat what I\u0026rsquo;m desiring, I am sure my mood will improve\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e36.Eating something tasty will make me feel wonderful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e37.If I eat something, I won\u0026rsquo;t feel so sluggish and lethargic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e38.Satisfying my appetite will make me feel less grouchy and irritable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e39.I will feel more alert if I can satisfy my appetite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e40.I crave foods when I feel bored, angry or sad\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e41.When I\u0026rsquo;m stressed out, I crave food\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e42.My emotions often make me want to eat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e43.When I crave something, I know I won\u0026rsquo;t be able to stop eating once I start\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e44.I feel like I have food on my mind all the time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e45.I find myself preoccupied with food\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e46.I feel disgusted, depressed, or very guilty while eating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e47.I am afraid of losing control over eating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e48.I feel upset by the feeling that I can\u0026rsquo;t stop eating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e49.I feel hard to stop thinking about food I am craving\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e50.I feel out of control when I has eaten an unusually large amount of food\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e51.I ignore an interruption to keep eating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e52.I eat much more rapidly than normal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e53.I give in to an impulse to eat even though not hungry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eNote:\u003c/em\u003e Factor 1refers to the negative emotion sub-domain of emotional eating; Factor 2 refers to grazing behavior; Factor 3 refers to the positive outcome expectancy sub-domain of food craving; Factor 4 refers to the cognition sub-domain of uncontrolled eating; Factor 5 refers to the emotional craving sub-domain of food craving; Factor 6 refers to the positive emotion sub-domain of emotional eating; Factor 7 refers to the behavior sub-domain of uncontrolled eating; Factor 8 refers to the preoccupation with food sub-domain of food craving.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.Reliability analysis\u0026nbsp;\u003c/strong\u003eThe Cronbach\u0026apos;s \u0026alpha; and the Guttman split-half coefficient for the MEBQBS were 0.97 and 0.79. The Cronbach\u0026apos;s \u0026alpha; for dimensions of emotional eating, grazing behavior, food craving, and uncontrolled eating were 0.97, 0.94, 0.93, and 0.86, respectively. The Guttman split-half coefficients for dimensions of emotional eating, grazing behavior, food craving, and uncontrolled eating were 0.93, 0.86, 0.74, and 0.82, respectively.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eUnhealthy eating behavior is an important reason for weight regain after bariatric surgery. So it is crucial for the early identification and effective management of unhealthy eating behavior among patients undergoing bariatric surgery[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. At present, the assessment tools for unhealthy eating behavior after bariatric surgery mainly include specific and universal scales. Among them, specific scales such as the Rep (eat)-Q[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] can only measure a single type of unhealthy eating behavior among patients undergoing bariatric surgery. The universal scale such as TFEQ[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], AEBQ[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and DEBQ[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] are comprehensive assessment tools. TEFQ includes 3 dimensions of uncontrolled, restrictive and emotional eating, while DEBQ contains 3 dimensions of emotional, extrinsic, and restrictive eating. They were widely used in clinic due to the multidimensional measurement advantages. However, TFEQ and DEBQ lack population specificity when applied to patients undergoing bariatric surgery, especially in the assessment of restrictive eating. Restrictive eating was defined as \u0026ldquo;an eating pattern that voluntarily limiting dietary intake by regularly weighing themselves\u0026rdquo;. After bariatric surgery, patients may experience a decrease in food intake because of the reduction in gastric capacity, which contradicts the concept of restrictive eating that \"being influenced by one's own cognition rather than physiological mechanisms\". Therefore, TFEQ and DEBQ are not entirely suitable for assessing unhealthy eating behavior for patients after bariatric surgery. Besides, some researchers suggested that TFEQ and DEBQ have not captured all specific characteristics of unhealthy eating behavior, and their measurement dimensions are still incomplete. Then, AEBQ was developed in 2016, which includes 8 dimensions: food reactivity, hunger, food enjoyment, emotional overeating, emotional insufficient eating, satiety, eating speed, and picky eating. The measurement dimensions of AEBQ are more comprehensive when compared with TFEQ and DEBQ. However, some dimensions such as hunger, food enjoyment, satiety and eating speed are still inapplicable to patients after bariatric surgery, because AEBQ was also not specially developed for the eating characteristics of patients after bariatric surgery. In order to address this gap, we have developed a 53-item MEBQBS, which integrated the measurement dimensions with dietary characteristics of patients after bariatric surgery closely, and assessed unhealthy eating behavior from multiple perspectives.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eWhen developing MEBQBS, we adopted a systematic approach in order to ensure the scientific process and robustness of the results. The measurement dimensions of MEBQBS were formulated by clarifying the definition of maladaptive eating behavior after bariatric surgery, which ensure the MEBQBS has a clear and reasonable structure. Then, literature review and focus group discussion were carried out to produce the item pool of MEBQBS. Besides, a pilot study was also conducted to improve its operability and acceptability. Our rigorous development procedure ensured that MEBQBS is a scientific and effective assessment tool. Construct validity refers to the degree that a questionnaire fully assess the construct of interest. In our study, EFA extracted 8 common factors, with a cumulative variance contribution rate of 69.54%. All item factor loadings were greater than 0.50, indicating that the structure of MEBQBS is acceptable. And the 8 common factors were divided into 4 dimensions and 8 sub-domains, named as emotional eating (negative and positive emotion sub-domain), grazing behavior, food craving (positive outcome expectancy, emotional craving, preoccupation with food sub-domain), uncontrolled eating (cognition and behavior sub-domain), respectively. The obtained dimensions were consistent with the theoretical hypotheses proposed in the previous stage of concept clarification. And the sub-domains among different types of unhealthy eating behavior could provide a convenient approach for accurately assessing the specific characteristics of unhealthy eating behavior. CFA further supported a 8-factor structure of MEBQBS, fit indices including χ\u003csup\u003e2\u003c/sup\u003e/df, GFI, NFI, IFI, TLI, CFI, and RMSEA suggested the data fit the model well. The finding further verified the consistency between the measurement structure and theoretical concept of MEBQBS, indicating that the scale has good structural validity. TFEQ-R21 is a widely used self-assessment scale for unhealthy eating behavior, with good reliability and validity[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Significant correlations were observed between the total score, scores of each dimension of MEBQBS and the total score of TFEQ-R21, indicating that the criterion validity of MEBQBS is good. The results of reliability analysis showed that the Cronbach's α of MEBQBS and each dimension were 0.86\u0026ndash;0.97, which were higher than those of TEFQ-R21 (α: 0.76\u0026ndash;0.89), DEBQ (α: 0.80\u0026ndash;0.95) and AEBQ (α: 0.75\u0026ndash;0.90). These results suggested that MEBQBS has better internal consistency, and the items are more conform to the characteristics of patients after bariatric surgery. Meanwhile, the Guttman split-half coefficient of MEBQBS and dimensions of emotional eating, grazing behavior, food craving, uncontrolled eating were 0.79, 0.93, 0.86, 0.74, and 0.82, indicating good homogeneity among items[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Therefore, MEBQBS has good reliability and stability, it also has great prospect for long-term follow-up and assessment of dietary intervention in patients after bariatric surgery.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSome limitations still need to be acknowledged. On the one hand, convenient sampling method used in participant selection may affect the representativeness of the sample and the generalizability of the results. On the other hand, the predictive power of MEBQBS for clinical outcomes after bariatric surgery has not been explored, further research should be conducted to evaluate it\u0026rsquo;s predictive ability for clinical outcomes.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eIn summary, MEBQBS developed by our study, a self-report measure of unhealthy eating behavior in patients after bariatric surgery, is reliable and useful. It provides a basis for developing scientific and effective interventions for unhealthy eating behavior after bariatric surgery and helps promote the localization exploration of unhealthy eating behavior after bariatric surgery in China.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflict of Interest\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eEthical approval for our research was obtained from the Ethics Committee of *** (Approval Code: 2023-SR-581).\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eInformed consent was obtained by all individual participants included in the study.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study was supported by *** (Grant Number: JSPH-NB-2022-14).\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eH.HX. and Z.K. designed and wrote the main manuscript text. H.HX. and L.RP. acquired and analysed data. Y.Nl. and L.H. critical revised the manuscript; L.RP. and Z.K. prepared all figures and tables; Y.Nl. provided administrative, technical, or material support.\u003c/p\u003e\n\u003ch2\u003eData availability statements\u003c/h2\u003e\n\u003cp\u003eData sets generated during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGlobal, regional, and national prevalence of adult overweight and obesity, 1990-2021, with forecasts to 2050: a forecasting study for the Global Burden of Disease Study 2021. Lancet. 2025;405(10481):813-838.\u003c/li\u003e\n\u003cli\u003eAngrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N. Bariatric surgery worldwide 2013. Obes Surg. 2015;25(10):1822-1832.\u003c/li\u003e\n\u003cli\u003eKissler HJ, Settmacher U. Bariatric surgery to treat obesity. Semin Nephrol. 2013;33(1):75-89.\u003c/li\u003e\n\u003cli\u003eHan Y, Jia Y, Wang H, Cao L, Zhao Y. Comparative analysis of weight loss and resolution of comorbidities between laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass: A systematic review and meta-analysis based on 18 studies. Int J Surg. 2020;76:101-110.\u003c/li\u003e\n\u003cli\u003eConcei\u0026ccedil;\u0026atilde;o E, Teixeira F, Rodrigues T, Lourdes M, Bastos AP, Vaz A, et al. Problematic eating behaviors after bariatric surgery: A national study with a Portuguese sample. Acta Med Port. 2018;31(11):633-640.\u003c/li\u003e\n\u003cli\u003eWilliams-Kerver GA, Steffen KJ, Mitchell JE. Eating pathology after bariatric surgery: an updated review of the recent literature. Curr Psychiatry Rep. 2019;21(9):86.\u003c/li\u003e\n\u003cli\u003eHua HX, Liang H, Xu XY, Xu Q, Song YT, Yang NL. Maladaptive eating behavior after bariatric surgery:a conceptual analysis. Chinese General Practice. 2023;26(07):783-789.\u003c/li\u003e\n\u003cli\u003eAhmed K, Penney N, Darzi A, Purkayastha S. Taste changes after bariatric surgery: A systematic review. Obes Surg. 2018;28(10):3321-3332.\u003c/li\u003e\n\u003cli\u003eZhu HF, Xu Q, Zhao K, Hua HX, Zhu SQ, Yang Nl,et al. The evidence for nutrition management of patients after bariatric surgery. Chinese Nursing Management. 2021;21(06):874-879.\u003c/li\u003e\n\u003cli\u003eStunkard AJ, Messick S. The three-factor eating questionnaire to measure dietary restraint, disinhibition and hunger. J Psychosom Res. 1985;29(1):71-83.\u003c/li\u003e\n\u003cli\u003eHunot C, Fildes A, Croker H, Llewellyn CH, Wardle J, Beeken RJ. Appetitive traits and relationships with BMI in adults: Development of the Adult Eating Behaviour Questionnaire. Appetite. 2016;105:356-363.\u003c/li\u003e\n\u003cli\u003eStrien TV, Frijters JER, Bergers GPA, Defares PB. The dutch eating behaviour questionnaire (DEBQ) for assessment of restrained, emotional, and external eating behaviour. International Journal of Eating Disorder. 1986;5(2).\u003c/li\u003e\n\u003cli\u003eMitchell JE, King WC, Courcoulas A, Dakin G, Elder K, Engel S, et al. Eating behavior and eating disorders in adults before bariatric surgery. Int J Eat Disord. 2015;48(2):215-222.\u003c/li\u003e\n\u003cli\u003eCanetti L, Berry EM, Elizur Y.. Psychosocial predictors of weight loss and psychological adjustment following bariatric surgery and a weight-loss program: the mediating role of emotional eating. Int J Eat Disord. 2009;42(2):109-117.\u003c/li\u003e\n\u003cli\u003eConcei\u0026ccedil;\u0026atilde;o EM, Mitchell JE, Engel SG, Machado PP, Lancaster K, Wonderlich SA. What is \u0026quot;grazing\u0026quot;? Reviewing its definition, frequency, clinical characteristics, and impact on bariatric surgery outcomes, and proposing a standardized definition. Surg Obes Relat Dis. 2014;10(5):973-982.\u003c/li\u003e\n\u003cli\u003eCrowley NM, LePage ML, Goldman RL, O\u0026apos;Neil PM, Borckardt JJ, Byrne TK. The food craving questionnaire-trait in a bariatric surgery seeking population and ability to predict post-surgery weight loss at six months. Eat Behav.2012;13(4):366-370.\u003c/li\u003e\n\u003cli\u003eMeany G, Concei\u0026ccedil;\u0026atilde;o E, Mitchell JE. Binge eating, binge eating disorder and loss of control eating: effects on weight outcomes after bariatric surgery. Eur Eat Disord Rev. 2014;22(2):87-91.\u003c/li\u003e\n\u003cli\u003eArnow B, Kenardy J, Agras WS. The emotional eating scale: the development of a measure to assess coping with negative affect by eating. Int J Eat Disord. 1995;18(1):79-90.\u003c/li\u003e\n\u003cli\u003eConcei\u0026ccedil;\u0026atilde;o E, Mitchell JE, Vaz AR, Bastos AP, Ramalho S, Silva C, et al. The presence of maladaptive eating behaviors after bariatric surgery in a cross sectional study: importance of picking or nibbling on weight regain. Eat Behav. 2014;15(4):558-562.\u003c/li\u003e\n\u003cli\u003eBlomquist KK, Roberto CA, Barnes RD, White MA, Masheb RM, Grilo CM. Development and validation of the eating loss of control scale. Psychol Assess. 2014;26(1):77-89.\u003c/li\u003e\n\u003cli\u003eWang Y, Wang CC, Zhu SH, Zhang P, Liang H. Chinese Guidelines for the Surgical Treatment of Obesity and Type 2 Diabetes (2019). Chinese Journal of Practical Surgery. 2019;39(4):301-306.\u003c/li\u003e\n\u003cli\u003eNorris M, Lecavalier L. Evaluating the use of exploratory factor analysis in developmental disability psychological research. J Autism Dev Disord. 2010;40(1):8-20.\u003c/li\u003e\n\u003cli\u003eRosnah I, Noor HI, Shafizah AS. A systematic translation and cultural adaptation process for three-factor eating questionnaire (TFEQ-R21). Med J Malaysia. 2013;68(5):424-434.\u003c/li\u003e\n\u003cli\u003eBolarinwa OA. Principles and methods of validity and reliability testing of questionnaires used in social and health science researches. Niger Postgrad Med J. 2015;22(4):195-201.\u003c/li\u003e\n\u003cli\u003eNymo S, B\u0026oslash;rresen SO, Aukan M, Finlayson G, Gr\u0026aelig;slie H, M\u0026aring;rvik R, et al. Suboptimal weight loss 13 years after roux-en-y gastric bypass: Is hedonic hunger, eating behaviour and food reward to blame? Obes Surg. 2022;32(7):2263-2271.\u003c/li\u003e\n\u003cli\u003eYao XY, Liu T, Li Y, Miao XX, Li YC, Li XD, et al. Development and psychometric testing of a gout patient self-management assessment scale. Chinese Journal of Nursing. 2020;55(2):261-265.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"obesity-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"obsu","sideBox":"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)","snPcode":"11695","submissionUrl":"https://submission.springernature.com/new-submission/11695/3","title":"Obesity Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7875279/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7875279/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eIt was challenging to accurately measure the maladaptive eating behavior after bariatric surgery. Our study was aimed to develop and validate the Maladaptive Eating Behavior Questionnaire after Bariatric Surgery (MEBQBS).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe initial questionnaire was developed through concept clarification, literature review, focus group discussion, and pilot study. Its reliability and validity were also examined in 457 patients after bariatric surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe final 53-item MEBQBS comprised 8 factors, including emotional eating (negative emotion, positive emotion sub-domain), grazing behavior, food craving (positive outcome expectancy, emotional craving, preoccupation with food sub-domain), uncontrolled eating (cognition, behavior sub-domain). Exploratory factor analysis revealed a cumulative variance contribution rate of 69.54%. Confirmatory factor analysis revealed that the indices of c\u003csup\u003e2\u003c/sup\u003e/df, goodness-of fit index, normed fit index, incremental fit index, Tucker-Lewis index, confirmatory fit index and root mean-square error of approximation were 1.868, 0.804, 0.884, 0.943, 0.934, 0.942, and 0.050, indicating the model fit well. Additionally, significant correlations were observed between the total score of MEBQBS and the Three-Factor Eating Questionnaire-R21 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05). The Cronbach's α and Guttman split-half coefficient of MEBQBS were 0.966 and 0.790, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe\u003cstrong\u003e \u003c/strong\u003eMEBQBS is a valid and reliable instrument for identifying unhealthy eating behavior of patients after bariatric surgery, offering potential utility in evaluating the effect of tailored interventions.\u003c/p\u003e","manuscriptTitle":"Development and validation of the Maladaptive Eating Behavior Questionnaire for Chinese patients after bariatric surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-20 16:02:05","doi":"10.21203/rs.3.rs-7875279/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-15T17:26:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-04T15:22:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-01T19:00:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-25T03:05:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"129993718495322805024949469586239858577","date":"2025-11-24T10:10:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"37192782178971316214076468321792648388","date":"2025-11-24T08:00:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265643963964134004352450317210791715422","date":"2025-11-23T18:03:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"276308162890512522651662363661566496730","date":"2025-11-12T18:06:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-12T08:59:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116688701001301329269848203254619164029","date":"2025-11-12T08:54:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147612730524800544254682041255318592597","date":"2025-11-11T17:34:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152875864087883191970980019780890774345","date":"2025-11-11T14:38:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-10T18:00:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-10T16:54:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-10T12:33:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Obesity Surgery","date":"2025-10-16T08:35:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"obesity-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"obsu","sideBox":"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)","snPcode":"11695","submissionUrl":"https://submission.springernature.com/new-submission/11695/3","title":"Obesity Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"d80cdba2-a4f7-4d9f-b145-e9588e3b48d3","owner":[],"postedDate":"November 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T22:08:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-20 16:02:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7875279","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7875279","identity":"rs-7875279","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}