Eating Competence among a Select Sample of Brazilian Adults: Translation and Reproducibility Analyses of the Satter Eating Competence Inventory

A systematic review of observational studies exploring the relationship between health and non-weight-centric eating behaviours

Eating behaviour that does not centralise weight, otherwise known as weight-neutral, is associated with improved physical and psychological health, and greater health promoting behaviours. However, consolidated evidence is lacking. This study aimed to systematically evaluate 'health-centric' eating behaviour reflective of weight-neutral approaches, and their relationship with health (physical and mental) and health promoting behaviours. A systematic search was performed, identifying observational studies with adult populations, ≥1 physical/mental health outcome(s), and ≥1 validated measure(s) of health-centric eating behaviour. Study design, sample characteristics and outcomes were extracted and characterised into four domains. Our search identified 8281 records, with 86 studies, 75 unique datasets, and 78 unique exposures including 94,710 individuals. Eating behaviours included intuitive eating (n = 48), mindful eating (n = 19), and eating competence (n = 11). There were 298 outcomes identified for body composition, size, and physical health (n = 116), mental health and wellbeing (n = 123), health promoting behaviours (n = 51) and other eating behaviour (n = 8). Higher levels of intuitive eating, mindful eating and eating competence were significantly related to a lower BMI, better diet quality and greater physical activity. Higher intuitive and mindful eating were significantly related to lower levels of disordered eating, and depressive symptoms, and greater body image, self-compassion, and mindfulness. Greater eating competence and intuitive eating were significantly related to higher fruit and vegetable intake, and greater eating competence to higher fibre intake and better sleep quality. Our results demonstrate that 'health-centric' eating behaviours are related to a range of favourable health outcomes and engagement in health promoting behaviours. These findings help to enhance our understanding of eating behaviours that do not centre around body weight, providing support for health-centric eating behaviour in healthcare. Future research should focus on intervention studies and more diverse population groups.

Validation of the French-Canadian Translation of the ecSatter Inventory 2.0 in an Adult Sample

OBJECTIVE

Evaluate the psychometric proprieties of the French-Canadian translation of the Satter Eating Competence Inventory (FrCanada ecSI 2.0).

DESIGN

Cross-sectional validation study.

PARTICIPANTS AND SETTING

424 French-Canadian adult Facebook users (61.8% women, 96.0% White).

VARIABLES MEASURED

Eating competence and variables related to eating or body image.

ANALYSIS

Factor analyses to assess the structural validity. Cronbach α and intraclass correlation coefficient to estimate reliability. Chi-square test of independence, Student t test, and Pearson's correlations to assess construct validity.

RESULTS

The mean eating competence score was 33.0 ± 7.8; 62.0% of participants were considered competent eaters (total score ≥ 32/48). The original 4-factor structure was not reproduced (unsatisfactory fit indices and/or factor loadings). Therefore, it is recommended to use the global score-but not the subscale scores-of the FrCanada ecSI 2.0. The questionnaire showed good internal consistency (Cronbach α = 0.86) and test-retest reliability (intraclass correlation = 0.81). Competent and noncompetent eaters differed according to gender (39.5% vs 27.3% male; P = 0.03), age (49.3 ± 13.6 vs 42.7 ± 14.2 years; P < 0.01), education (62.3% vs 50.6% with a university degree; P = 0.03), intuitive eating (3.6 ± 0.5 vs 3.1 ± 0.6; P < 0.001), cognitive restraint (12.3 ± 3.3 vs 13.8 ± 3.7; P < 0.001), and body esteem (3.3 ± 0.8 vs 2.5 ± 0.8; P < 0.001).

CONCLUSION AND IMPLICATIONS

Results suggest that the FrCanada ecSI 2.0 is a valid and reliable tool to measure eating competence in French-Canadian adults.

Division of Responsibility in Child Feeding and Eating Competence: A Cross-Sectional Study in a Sample of Caregivers of Brazilian Children with Celiac Disease

The objective of this cross-sectional study was to assess eating competence (EC) and the adherence to the division of responsibility in child feeding (sDOR) of Brazilian caregivers of children with celiac disease (CD). It also examined the association between EC and sDOR, children's adherence to a gluten-free diet, and sociodemographic data. This study administered a survey set that included sociodemographic data, health-related data, eating habits, and the instruments ecSI2.0TMBR and sDOR.2-6yTM BR, validated for a Brazilian population. The sample comprised 50 caregivers of children with CD (between 24 and 72 months of age). The participants following a gluten-free diet (GFD) presented higher scores for all EC domains and the total EC. The total EC scores were higher for the participants over 40 y/o, frequently having meals as a family, with their children consuming more than three servings of fruit and at least one serving of vegetables daily and complying with a GFD. Different from the EC, the sDOR.2-6yTM scores did not differ between the participants complying with a GFD. The sDOR.2-6yTM mealtime structure domain scores were significantly associated with the EC eating attitude, food acceptance, contextual skills, and total. These findings support the need for greater attention to exploring the division of responsibility in feeding and EC in pediatric celiac disease, potentially enhancing intervention strategies for patients and their families.

Eating competence in caregivers of celiac children: A cross-sectional study performed in Brazil

OBJECTIVES

Eating competence is an intraindividual approach to eating, behaviors, and attitudes related to eating, with repercussions on the individual and family. In pediatric celiac disease, the family is involved in the gluten-free diet management, the only treatment available. A gluten-free diet might affect eating competence because gluten-free diet compliance requires knowledge about food, meal planning, and attention to food choices. The objective is to access eating competence in caregivers of children with celiac disease and the association between caregivers' eating competence, children's adherence to a gluten-free diet, and sociodemographic data of participants.

METHODS

This cross-sectional study used a snowball spread method by applying a questionnaire, including sociodemographic data, data related to health, eating habits, and the Satter Eating Competence Inventory version validated for the Brazilian population. The sample consisted of 220 Brazilian parents or caregivers of celiac disease children. The scores of the Satter Eating Competence Inventory version validated for the Brazilian population were described in terms of means, SDs, medians, and interquartile range. Student's t test and analysis of variance followed by Tukey's post hoc tests were applied, and the association with the variables of interest was analyzed using Pearson χ2 tests. The tests were conducted considering bilateral hypotheses and a 5% significance level.

RESULTS

Participants' sex, schooling level, and income did not affect their eating competence. Competent eaters were mostly those with normal weight, following a gluten-free diet, with children complying with a gluten-free diet, and who have meals with family and prepare them at home. Different from vegetable consumption, participants' eating competence did not differ considering the frequency of children's fruit consumption.

CONCLUSIONS

The caregivers of children with celiac disease have greater eating competence scores than general Brazilian adults, and caregivers of children with celiac disease who comply with the gluten-free diet have higher eating competence scores.

Psychometric Properties of the Dutch Version of the Eating Competence Satter Inventory (ecSI 2.0TM) in Community Adolescents

Eating competence can help adolescents navigate their food choices and attitudes toward eating in a healthy and balanced way. In the present study, we investigated the psychometric properties of the Dutch translation of the Eating Competence Satter Inventory 2.0TM (ecSI 2.0TM), which was developed to assess eating attitudes and behaviors. A sample of 900 Flemish adolescents completed the ecSI 2.0TM DUTCH and two self-report measures on eating disorder symptoms and identity functioning (i.e., confusion and synthesis). Confirmatory factor analysis confirmed the four-factor structure of the ecSI 2.0TM DUTCH, and the resulting four subscales (i.e., Eating Attitudes, Food Acceptance, Internal Regulation, and Contextual Skills) showed acceptable-to-excellent reliability (αs ranging from 0.69 to 0.91). The ecSI 2.0TM DUTCH also demonstrated scalar invariance across sex and age (<17 years, ≥17 years). Males reported significantly higher ecSI 2.0TM DUTCH scores than females on the four subscales and the total scale. The two age groups did not significantly differ on the ecSI 2.0TM DUTCH scales. Finally, scores on the ecSI 2.0TM DUTCH subscales showed non-significant or small negative correlations with adolescents' Body Mass Index (BMI), large negative correlations with eating disorder symptoms and identity confusion, and large positive associations with identity synthesis. The Dutch translation of the ecSI 2.0TM is a valid and reliable instrument to assess eating competence skills in male and female adolescents.

Translation of the Satter's Division of Responsibility in Feeding Questionnaire into Brazilian Portuguese: A Cross-Sectional Study

This cross-sectional study aimed to translate and perform a psychometric analysis (evaluation of reproducibility and internal consistency) of the sDOR.2-6y™ into Brazilian Portuguese. The translation and back-translation followed the protocol required by the NEEDs Center, and the approved version was called "sDOR.2-6y™-Português-Brasil". The approved version was submitted to a test-retest round to verify its reproducibility through the Intraclass Correlation Coefficient (ICC). A pilot study was performed to assess the internal consistency of the instrument. The reproducibility analysis (n = 23) showed a total ICC of 0.945. With the data from the pilot study (n = 384), the internal consistency evaluation was analyzed through Cronbach's alpha coefficient, and the instrument obtained an overall Cronbach's alpha of 0.301. The translation of the sDOR.2-6y™ into Brazilian Portuguese is the first and only tool available for the Brazilian population to exclusively assess the division of responsibility in feeding, which is essential to the academic community, health professionals, and research on child feeding. Therefore, this instrument in Brazilian Portuguese will allow future research on the division of responsibility in feeding among those responsible for children in Brazil.

Nutrition Literacy Level in Bank Employees: The Case of a Large Brazilian Company

Nutrition Literacy (NL) positively impacts diet quality and has the potential to promote health and prevent nutrition-related chronic diseases. Brazil is one of the countries with the highest rates of nutrition-related chronic diseases. Nevertheless, in Brazil, few studies have explored the NL levels of its population. To provide remote access to the Nutrition Literacy Assessment Instrument for Brazilians (NLit-Br) and assess Brazilian bank employees, we conducted a study to estimate the validity of the NLit-Br online and to investigate whether bank employees have an adequate NL level. In the first step, we randomly assigned 21 employees from three financial institution branches to two groups to complete NLit-Br paper and online versions. After an interval period, both groups completed the NLit-Br with an opposite delivery method (paper vs. online). We compared the validity of the digital and paper versions of the NLit-Br by the Intraclass Correlation Coefficient (ICC), and the reliability by Kuder-Richardson formula 20. Second, we evaluated 1174 bank employees using the NLit-Br online version. We found an excellent absolute agreement (ICC ≥ 0.75) between the paper and online versions. The questionnaire had good internal consistency (KR-20 = 0.64). The sample was characterized as mostly male (61.0%), married/cohabitant (73.8%), and white (69.8%), with high household income (85.2%), and graduated or postgraduate (97.4%). The mean age of the population was 42.1 (SD = 7.6) years. Subjects predominantly had possibly inadequate NL (62.3%). The online NLit-Br total score was significantly associated with gender, age, and household income (p < 0.05). Women and individuals with higher incomes had a higher degree of NL. Subjects over 50 years old had a lower degree of NL. There was no significant association between the NLit-Br score and the participants' education. The NLit-Br online is a valid instrument to assess NL remotely. The population studied showed a high prevalence of inadequacy of the NL. Therefore, there is a need for targeted actions to improve the NL of bank employees.

Division of Responsibility in Child Feeding and Eating Competence among Brazilian Caregivers

This cross-sectional study aimed to assess Brazilian child caregivers' eating competence (EC) and their adherence to the division of responsibility (sDOR) in child feeding. The research had national coverage in all Brazilian regions. The sample comprised 549 caregivers of Brazilian children (24 up to 72 months) recruited by social media (snowball method). Data on sDOR and EC were collected using the sDOR.2-6y^TM Portuguese-Brazil (sDOR.2-6y-BR) and ecSI2.0^TMBR, both instruments validated to the Brazilian population. The scores of the sDOR.2-6y-BR were described in terms of means, standard deviations (SD), medians, and interquartile range. Student's t-test and analysis of variance (ANOVA) followed by Tukey's post hoc tests were used to compare the scores of sDOR.2-6y-BR and ecSI2.0^TMBR with interest variables. The association between the sDOR.2-6y-BR and ecSI2.0^TMBR scores was verified by Pearson's correlation coefficient. Most of the participants were female (n = 88.7%), 37.8 ± 5.1 y/o, had a high schooling level (70.31%), and high monthly income (more than 15 minimum wages-MW) (31.69%). The children for whom the participants were responsible were mostly girls (53.19%), with an average age of 3.6 ± 1.3 y/o. The instrument presented good responsiveness (floor and ceiling effects = 0%). Cronbach's Alpha = 0.268. There was no statistical difference in sDOR.2-6y-BR scores between caregiver's gender, age, level of education, number of people living in the household, or by gender or age of the child. Caregivers who reported (n = 100) that their children had some medical diagnosis (e.g., food allergy, autism, or Down syndrome) had lower sDOR adherence scores than caregivers who indicated their children had no medical diagnosis (p = 0.031). There was no statistical difference in ecSI2.0^TMBR scores between the categories of caregiver's gender, age, occupancy, and child's gender and age. Caregivers with income higher than 10 MW, living in houses with more than 3 people, and with graduate schooling showed higher EC scores. Caregivers considered competent eaters by ecSI2.0^TMBR scores differed only for educational level, which was more frequent among graduate participants. The total EC score was positively associated with total and mealtime structure (D1), how food is available to the child (D3), and the parent gives respect to the child's autonomy in eating (D4) sDOR.2-6y^TM domains. There was a negative association with the what is available to the child (D2) sDOR.2-6y^TM domain. In general, the sDOR.2-6y-BR had a positive association with the ecSI2.0^TMBR in all domains and total, with a low but significant correlation. This study enables the investigation of the division of responsibility in feeding and EC of a sample of caregivers of children in Brazil. This is the first study to apply the translated and validated version of the sDOR.2-6y-BR and showed good results, where competent eaters' caregivers adhere more to the principles of sDOR.

Eating Competence among Brazilian College Students

Eating competence (EC) is a biopsychosocial concept related to a healthier eating pattern. Studies have shown that weight gain and body shape and weight dissatisfaction are typical among college students, contributing to low self-esteem, risky eating behaviors, and a propensity to develop eating disorders. As eating habits are determinant factors for food choices that can be modified by eating behavior, this study aimed to evaluate EC in college students from Brazil, using the Brazilian version of the EC Satter Inventory (ecSI2.0™BR), and EC's association with health data. This cross-sectional study was conducted using an online survey spread using the snowball method. The self-report instrument was divided into three parts (socioeconomic and demographic data; health data; and ecSI2.0™BR). Recruitment took place through social networks, and 593 students from public and private universities from all five regions of Brazil participated in the survey. The EC average was 29.46 ± 8.67, and 46.2% of the sample were considered competent eaters. Total EC did not differ among gender and Brazilian region. Younger participants (up to 20 y/o) presented higher scores for total EC, contextual skills and food acceptance. The total EC and contextual skills of health sciences students did not differ from those of students in other areas, except for agricultural sciences in which students had lower total EC. Obese individuals and the participants who perceived themselves to be overweight had low scores for EC. This study confirmed the hypothesis that college students have low EC, causing worse health outcomes related to BMI, perceived body weight, and occurrence of hypertension and dyslipidemia.

Changes in Depressive Symptoms, Perceived Stress, and Food Security Among Study Participants With Metabolic Syndrome During a COVID-19-Mandated Research Pause

INTRODUCTION

We explored how depressive symptoms, perceived stress, and food security of people with metabolic syndrome (MetS) changed during the COVID-19 pandemic.

METHODS

An online survey was administered from October 2019 through March 2020, to participants in a 2-year lifestyle intervention trial to reverse MetS; the survey was repeated during the COVID-19 pandemic. Outcomes were a change in depressive symptoms, perceived stress, and food security as measured by the Patient Health Questionnaire-8 (PHQ-8), Perceived Stress Scale, and US Department of Agriculture's 10-item Adult Food Security Module. We analyzed changes in outcomes with measures of association, paired t tests, repeated measures, and independent t tests.

RESULTS

Survey respondents (N = 132) were mostly female (67%), White (70%), and middle-aged, with a median income of $86,000. Frequency of depressive symptoms increased from baseline to follow-up and the increase was related to lower mean (SD) baseline vitality (44.4 [20.7] vs 60.3 [18.9]; P = .01) and mental health decline (71.0 [14.3] vs 82.0 [10.4]; P = .002). Mean (SD) perceived stress was significantly higher at baseline than follow-up (18.5 [6.4] vs 14.9 [7.2]; P < .001). Food security increased from 83% at baseline to 90% at follow-up (P < .001). Movement to or continued food insecurity (n = 13) tended to be associated with a racial or ethnic minority group (P = .05).

CONCLUSION

A sample at high risk for COVID-19 did not experience increased stress or food insecurity, but demonstrated increased depressive symptoms after the onset of the COVID-19 pandemic, with some baseline susceptibility.

The Nutrition Literacy Assessment Instrument for Brazilians, NLit-Br: An Exploratory Cross-Cultural Validity Study

This study aimed to test the validity of the cross-cultural adapted Nutrition Literacy Assessment Instrument for Brazilians (NLit-Br). An observational cross-sectional study was performed in chronic disease clinics from the Brazilian Public Health System in two phases: (1) linguistic and cultural adaptation and (2) validity testing. Six registered dietitians and thirty adult patients diagnosed with at least one chronic disease participated in the study using the nutrition literacy assessment instrument (NLit-Br) and the short assessment of health literacy for Portuguese-speaking adults (SAHLPA-18). Sample descriptive variables: age, sex, race, income, education, and occupation. To adapt the instrument to the Brazilian Portuguese and Brazilian culture, we tested cognitive interviewing and the Scale Content Validity Index (S-CVI) with a group of dietitians and patients. To test the tool’s validity, health literacy (SAHLPA-18) was used as a construct that presents similarities and differences with nutrition literacy (NLit-Br). The correlation of NLit-Br and the SAHLPA-18 was tested (Spearman’s Rho). Internal consistency was measured by Kuder−Richardson Formula 20 (KR-20). The NLit-Br content validity (S-CVI = 0.85) and internal consistency (KR-20 = 0.868) were confirmed. Additionally, NLit-Br presented a significant and robust correlation with SAHLPA-18 (r = 0.665, p < 0.001). Therefore, the NLit-Br was considered a linguistic, cultural, and valid instrument to measure Brazilian’s nutrition literacy.

Eating Competence and Aspects Related to a Gluten-Free Diet in Brazilian Adults with Gluten-Related Disorders

This cross-sectional study aims to assess eating competence (EC—an intra-individual approach to food, behaviors, and attitudes related to food) and aspects related to a gluten-free diet (GFD) in Brazilian adults with gluten-related disorders (GRDs). The research was conducted using an online survey with a self-reported instrument consisting of 40 items, organized into three parts: (I) Socioeconomic and demographic data; (II) the Brazilian version of the Eating Competence Satter Inventory (ec-SI2.0™BR); and (III) questions about adherence and difficulties in following the gluten-free diet. EC was measured by the ecSI2.0™BR instrument, with scores ≥32 were considered competent eaters. The instrument was applied nationwide through the GoogleForms® platform from 14 February 2022 to 30 March 2022. The publicity for the recruitment was supported by Brazilian celiac local and national associations (Acelbras and Fenacelbra), pages of food services or personal pages of tips and posts about gluten-related disorders, and specialized stores that offer gluten-free foods. The recruitment occurred through social networks (emails, Facebook groups, WhatsApp, and Instagram). A total of 1030 Brazilians with GRDs answered the questionnaire. Most participants were female, aged 40 years or older, with an income >R$3000, and a high education level. The main difficulty regarding adherence to GFD was the high cost of gluten-free foods. Individuals younger than 40 years old had lower EC scores, with no differences between men and women. Increasing socioeconomic status, schooling, and culinary practices increased the total score. Participants who “never/almost never” felt socially judged because their diet had higher scores for total EC. Competent eaters GRD individuals (EC ≥ 32) were mostly individuals aged ≥40 y/o; with income > R$3000; following a GFD; satisfied with purchased gluten-free products; consuming gluten-free products prepared at home, mainly by themselves; who do not feel judged because of the GRD and who feel that they can live a normal life with GRD. Our study showed that individuals who strictly adhere to the GFD have higher scores on eating competence than those who sometimes follow the treatment.

Eating Competence, Food Consumption and Health Outcomes: An Overview

Eating Competence (EC) is one behavioral perspective of eating practices that has been associated with a healthy lifestyle. It emphasizes eating pleasure, self-regulation of eating, body weight satisfaction, and regular meal frequency that includes food variety without focusing on dietary guidelines. EC is composed of four components (Eating Attitude, Food Acceptance, Internal Regulation, and Contextual Skill), and its assessment is performed using the Eating Competence Satter Inventory (ecSI2.0™), developed and validated in English for an adult population. EC has been associated with diet quality and health indicators for various population groups and the development of skills that increase EC might be a strategy to improve nutritional health, and prevent obesity and other chronic diseases. In this sense, this study presents an overview of the background, concepts, features, and possible associations among EC, food consumption, and health outcomes. The high prevalence of diseases associated with food/nutrition draws attention to the necessity to broaden the view on food and its relationship with health and well-being, considering not only nutrients and food combinations but also the behavioral dimensions of eating practices. Healthy nutritional recommendations that take into account attitudes and behaviors are in accordance with the EC behavioral model. Studies on eating behavior emphasize the need to better understand attitudes towards food and eating in the general population using validated instruments. In this context, measuring EC and its association with health outcomes seems to be relevant to nutritional health. The complexity of food choices has been examined in social, behavioral, and biological sciences, representing a great challenge for applying unique and simple theoretical models. Multiple methods are required, as no single theory can fully explain food selection.

Eating Competence among Brazilian Adults: A Comparison between before and during the COVID-19 Pandemic

The coronavirus pandemic started a worldwide emergency, and tight preventive actions were necessary to protect the population, changing individuals' daily habits. Dwelling and working at home can change dietary habits, affect food choice and access, as well as the practice of physical activity. In this regard, this study's goal was to compare eating competence (EC) among Brazilian adults before and during the coronavirus pandemic, using the Brazilian version of the eating competence Satter inventory (ecSI2.0™BR) with the "retrospective post-then-pre" design. This cross-sectional study was performed from 30 April to 31 May 2021 among a convenience sample of the Brazilian adult population using an online platform (Google® Forms). In the studied sample (n = 302 in which 76.82% were females), EC total score lowered during the pandemic (31.69 ± 8.26 vs. 29.99 ± 9.72; p < 0.005), and the decrease was worst after the beginning of the pandemic among those who reported weight gain, decreased the consumption of fruit and vegetables, and increased the consumption of sugary beverages. The contextual skill component seems relevant in this scenario, where our life and routines were changed entirely, demonstrating that the ability to manage the food context is essential, especially when sanitary and economic situations represent a new challenge.

Eating Competence Associated with Food Consumption and Health Outcomes among Brazilian Adult Population

This study aimed to associate Eating Competence (EC) with food consumption and health outcomes in the Brazilian adult population. Researchers developed a questionnaire to associate EC with sociodemographic information, health outcomes, and food consumption. Data on body weight and height was referred to by participants in the questionnaire, and body mass index (BMI) was calculated and classified. A question to evaluate the perception of body size was included. After constructing the questionnaire items, content validation and semantic evaluation were performed following the Delphi method with a group of judges composed of 26 health professionals. The judges evaluated the sociodemographic information, health outcomes, and food consumption items associated with the eating competence instrument (previously validated in Brazilian-Portuguese). The final version of the questionnaire was composed of 33 items. Our results confirmed good reliability, responsiveness, and internal consistency. A total of 1810 Brazilians answered the questionnaire. Most of the participants were female, up to 40 years old, with a high education level and high income. Most of the participants did not report diabetes or hypertension. The EC total score did not differ among males and females. Individuals up to 40 years old presented a lower total score. The increase in educational level and income also increased EC total score. Excess weight individuals showed lower EC compared to the normal weight/underweight. Individuals who consumed fruits and/or vegetables five or more days/week presented the best scores for total EC.