If you visit your GP for help with being overweight, the advice is often the same. ‘Initially, the focus is always on a simple mantra: eat less, exercise more,’ explains Tatjana van Strien, professor emeritus of psychology at Radboud University. ‘But that standard treatment doesn’t always work.’ With the Dutch Eating Behaviour Questionnaire (Nederlandse Vragenlijst voor Eetgedrag, or NVE, in Dutch), a healthcare professional can easily determine whether there might be other factors at play.
This is done using 33 questions covering three types of eating behaviour. The first: emotional eating, triggered by negative emotions. This includes statements such as “Do you have a desire to eat when you are approaching something unpleasant to happen?”. The second type, external eating, based on external food cues, includes questions such as: “If you walk past a snackbar or a café, do you have the desire to buy something delicious?” Diet-oriented eating is assessed with questions such as: “Do you deliberately eat less in order not to become heavier?”
The questions can be answered on a scale of 1 (never) to 5 (always). A total score is then calculated for each type of eating behaviour which, after comparison with that of the best reference group, can be classified as 1) very low to 7) very high. The NVE has separate reference groups for boys and girls, and for men and women. Using the qualification score, the appropriate treatment strategy can be determined via a decision tree.
Tailored treatment
Van Strien: ‘Emotional eating is eating in response to negative emotions or stress. From an evolutionary perspective, this is deviant behaviour: our distant ancestors had to fight or flee when they felt threatened; they had no time to eat then. And even now, many people can’t swallow a bite when stressed. But some people actually do start eating then, probably because they have little awareness of signals from their own body and emotional cues – this is also known as emotional blindness.’
‘An external eater is someone who is sensitive to food cues from their surroundings. Think, for example, of the smell of a chip shop you walk past, or seeing your colleagues eating at lunch. That’s behaviour we all exhibit from time to time, but for some people it’s just a bit more intense.’
And diet-oriented eaters are people who consciously eat less in order to lose weight. At first, most of them lose weight, but because these people are constantly hungry, it only takes the slightest thing to happen for the diet to fail again, and ultimately they often end up heavier than before the diet.’
We now know that emotional eating in particular requires specialised treatment. As well as issues surrounding emotion regulation, it is also linked to binge eating disorder. For instance, we have just completed a new study at a Dutch eating disorder clinic where dialectical behaviour therapy (DBT) worked better for patients with binge eating disorder and a high degree of emotional eating than standard cognitive behaviour therapy, because DBT focuses more on emotion regulation and thus on emotional eating. It also appears that emotional eating is the connecting link between depression and obesity, which makes the NVE highly relevant for psychologists and psychiatrists.
Simplicity supports success
The questionnaire is seemingly simple, but according to Van Strien, that is precisely why, forty years later, it is still frequently used by professionals in the field. ‘All sorts of new questionnaires have been developed, but people keep coming back to the three eating styles outlined in the NVE. It gives the GP, for example, a direct tool: should I refer this patient to a dietitian, or to a psychologist?’
The questionnaire originated in the 1980s. At the time, Van Strien was completing her PhD at Wageningen University on research into eating styles and was involved in a large multidisciplinary study on obesity. As a psychologist, she was asked to develop a questionnaire on eating behaviour. ‘At the time, there were three theories on eating behaviour: one concerning the role of upbringing and negative emotions, one regarding external food stimuli, and one focusing on diet-oriented eating, each with its own corresponding therapy. A good theory-driven questionnaire that measured the three types of eaters separately did not yet exist. We were able to establish that with the NVE.’
After Wageningen, Van Strien moved to Nijmegen. There she continued her research into the underlying causes of eating behaviour. Among other things, she worked at the Institute for Gender Studies, where she focused on depression in women and the role of gender in health. Yet research into eating behaviour continued to hold her interest. Just before her retirement, for instance, she was involved in a large-scale longitudinal project, in which babies were followed from fourteen months of age through to adolescence. That project (‘the crowning glory of my work’, according to Van Strien) demonstrated that emotional eating does indeed develop as early as the early childhood years.
Eating behaviour appears to know no bounds
Notably, the questionnaire is also proving successful abroad. ‘The three types of eaters transcend cultural differences. The questionnaire has been translated into Japanese, Spanish, Chinese, Farsi, Hindi and numerous other languages. I was even recently approached by someone who wanted to produce a Ukrainian translation: I was very pleased about that. And in all those translations, the questions have essentially remained the same. That shows that, regardless of your country and your background, the same factors can determine your eating behaviour.’