Reliability and Validity of the Malay Mindful Eating Questionnaire (MEQ-M) among Overweight and Obese Adults

1 Dietetic Program and Centre for Healthy Aging and Wellness, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Aziz, Kuala Lumpur 50300, Malaysia; moc.liamg@risabludba.harinumitis (S.M.A.B.); ym.ude.mku@rahahs.anazus (S.S.)

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Zahara Abdul Manaf

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Mahadir Ahmad

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Nor Ba’yah Abdul Kadir

3 Centre for Research in Psychology and Human Well-being, Faculty of Social Sciences and Humanities, Universiti Kebangsaan Malaysia, Selangor, Bangi 43600, Malaysia; ym.ude.mku@hayabnka (N.B.A.K.); moc.liamg@182liamsiasin (W.N.K.I.)

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4 Biomedical Science Program and Centre for Healthy Aging and Wellness, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Aziz, Kuala Lumpur 50300, Malaysia; ym.ude.mku@irtifimira

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Suzana Shahar

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Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

Associated Data

The data presented in this study is a part of an ongoing doctoral research of S.M.AB. Hence, we could not publicly release the data. However, it is available upon request from the corresponding author (Z.A.M.).

Abstract

The Mindful Eating Questionnaire is a reliable tool for the assessment of mindful eating behavior among the general population. This study aimed to determine the reliability and validity of The Malay Mindful Eating Questionnaire (MEQ-M) in a sample of overweight and obese adults. This is a cross-sectional survey which involved 144 overweight and obese adults in a selected public university. After linguistic validation of the Malay version of the MEQ, exploratory factor analysis (EFA) with varimax rotation was performed on the scale constructs. The psychometric properties of the MEQ were assessed through Cronbach’s alpha and intraclass correlation coefficient (ICC) analysis. The EFA of the MEQ produced a seven-dimensional model (58.8% of overall variances). The concurrent validity analysis between total MEQ scores and total Mindfulness Attention Awareness Scale (MAAS) scores indicated a weak non-significant correlation (p = 0.679). The internal consistency reliability of the MEQ was reasonable (Cronbach’s α = 0.64). The agreement stability of the MEQ over eight weeks was poor (ICC = 0.10). In conclusion, the psychometric properties of the Malay-translated MEQ are acceptable through construct validity and internal consistency reliability tests. This instrument may be used for assessing mindful eating habits in the Malaysian population, especially among overweight and obese adults.

Keywords: mindfulness, obesity, MEQ, reliability, validity

1. Introduction

Mindfulness is commonly understood as the ability of being open, accepting, and present in the moment [1]. Mindfulness trainings such as Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), Acceptance and Commitment Therapy (ACT), and Dialectical Behavioral Therapy (DBT) are often described as interventions that focus to promote non-judgmental and moment-to-moment awareness of the present experience. The role of mindfulness in encouraging behaviors related to healthy body weight maintenance and reducing overweight and obesity has gained attention among scholars [2]. This practice has been beneficial to control food cravings, portion size, body mass index, and body weight [3]. Mindful eating refers to being conscious of physical sensation and emotion while eating or in a food-related environment [1]. It helps in improving one’s sensitivity to the physical cues of hunger, satiety, eating speed, and the food atmosphere [3]. These cues are crucial to self-regulate one’s desire to consume high-calorie foods. Studies have shown that mindful eating helps in reducing negative eating behaviors, sweets consumption, and serving sizes of energy-dense foods [4,5,6].

There are many factors associated with eating behaviors, such as physiological (i.e., chronotype), social (i.e., coworker influence), environmental, and psychological (i.e., stress, mood) [7,8,9]. It has been hypothesized that obesity-related eating behaviors are partially associated with the inability to identify and respond to internal cues of hunger and satiety [10,11] (pp. 75–91), [12] (pp. 913–933). This lack of response to internal cues is correlated with increased overeating episodes and a greater risk for weight gain [13,14,15]. In addition, emotional dysregulation has been associated with emotional and stress eating [16,17,18,19]. Studies have shown that compulsive overeating and higher preference for high calorie, fat, sugar, and/or high sodium foods are the result of negative emotions and acute stress [20,21,22]. Emotional eating has been shown to be a strong indicator of obesity and is negatively associated with weight loss and its maintenance [23,24,25]. Furthermore, a restricted diet and increased physical activity can result in physiological discomforts that may impose an added barrier to long-term weight loss [24].

There are several tools available in measuring eating behaviors such as Night Eating Syndrome Questionnaire (NEQ), Three-Factor Eating Questionnaire (TFEQ) and Binge Eating Scale (BES). The Mindful Eating Questionnaire (MEQ) is the first scale developed by Framson and colleagues that measures mindful eating [1]. It is a 28-item self-report instrument that consists of five mindful eating domains: awareness, disinhibition, distraction, emotional response, and external cues. This questionnaire has been validated previously among healthy adults aged 18 to 80 years old. The study showed good internal consistency with a reliability of 0.64 for the MEQ score [1]. In addition, each subscale had internal consistency ranging from 0.64 to 0.83. It was also reported that there were modest (0.14) to moderate (0.47) correlation among all subscales with the exception of correlation between external cues and emotional response. Another validation study among overweight and obese pregnant women yielded the same five domains of the MEQ [26]. It was found that the MEQ has poor internal consistency reliability of the summary score (0.56). As for the subscales, only the external cues subscale was not internally consistent with Cronbach’s alpha of 0.31. Its reliability was further supported by test-retest analysis, where the total and subscale scores were ranged between 0.62 to 0.85. To add, positive correlations were also observed between the MEQ subscales and the Mindful Attention Awareness Scale (MAAS) [26]. Another study of the Persian version of MEQ among women seeking weight loss reported satisfactory internal consistency for the total score and the subscales (0.73–0.81) and satisfactory test-retest reliability ranging from 0.73 to 0.91. [27]. Its construct validity analysis resulted in five domains which were similar to the original study. Contrary, the Italian version of the MEQ resulted in a 20-item pool where only two domains emerged; awareness and recognition [28]. Clementi et al. also found that both domains have satisfactory internal and test-retest reliability, and were associated with general mindfulness. Meanwhile, the MAAS is a standard tool used to assess mindfulness in everyday life among the general population [29]. It consists of a 15-item self-reported single-factor scale that focused on the mindfulness construct’s attention awareness component.

The prevalence of overweight and obesity had significantly increased between 1976 and 2016 globally, in which half of them (52%) were adults over 18 years of age [30]. In Malaysia, the National Health and Morbidity Survey (NHMS) reported that the prevalence of overweight and obesity among adults increased by 5% from 2011 to 2015 [31,32]. Moreover, the prevalence by age in 2015 showed an increasing trend from 34.8% among 18–29 years to 60.2% among 50–59 years. Obesity is associated with increased risk of many non-communicable diseases (NCDs), including diabetes, cardiovascular disease, depression, some cancers, and respiratory disease [33,34,35,36,37]. Moreover, it negatively impacts bone health, quality of life, and functional capacity [38,39,40]. Consequently, obesity is also associated with expensive health care costs [41,42,43]. One study suggested that obese adults have difficulty in reflecting on the impact of obesity on their social and relational functioning despite having psychological difficulties [44]. Considering the increasing trend in obesity prevalence in Malaysia, a locally validated instrument is essential in conducting research and intervention activities. To the best of our knowledge, no measure has been carried out to assess mindful eating behavior in Malaysia’s overweight and obese adults. Moreover, there is currently no instrument measuring mindful eating (in general) in the Malaysian context using its local language. Several studies have shown that eating mindfully was associated with a lower BMI [45,46] and reduced body weight [47]. Thus, the objective of our present study was to determine the reliability and validity of the MEQ-M in a sample of overweight and obese adults. This is the first study to examine the reliability and validity of the Mindful Eating Questionnaire (MEQ) among this population. We hypothesized that the MEQ would have similar results to a previous study [40] where the questionnaire would be valid and reliable among overweight and obese Malaysian adults. As mindful eating was generally associated with general mindfulness in previous studies, we hypothesized that the MEQ-M total score would be positively correlated with the Mindful Attention Awareness Scale (MAAS).

2. Materials and Methods

2.1. The Questionnaire

The MEQ contains five subscales: awareness (seven items), distraction (three items), disinhibition (eight items), emotional responses (four items), and external cues (six items). The eating behaviors are rated on a four-point Likert scale; 1—never/rarely, 2—sometimes, 3—often, and 4—usually/always. Reverse scoring was applied to questions 1, 2, 6, 7, 9, 11, 17, 18, 19, 27, and 28.

2.2. Translating the Questionnaire

A back-translation method was used to create the Malay-translated version of the MEQ [48]. The original version of the MEQ was first translated into the Malay language by two authors who are bilingual (English and Malay). The translated version was then piloted to 10 university staff members to test for clarity. Some unclear terms and phrases were noted. The questionnaire was then carefully checked for clarity, accuracy, the language’s suitability, and linguistic errors by two independent researchers. Once clarity and accuracy had been established, the questionnaire was then back-translated from the Malay version to English by an independent translator. The revised and modified translated items are available in the Appendix A.

2.3. Data Collection

This study was a cross-sectional survey to assess the psychometric properties of the Malay version of MEQ conducted on 144 overweight and obese working adults conveniently recruited in a selected public university. These participants were recruited by our researcher from a health screening program held by the university among the staff. The sample size was determined based on a 5:1 ratio, where the sample size is expected to be a least five times the total number of items in the questionnaire [49] (pp. 86–99). Respondents were eligible if they met each of the following criteria: BMI ≥ 25.0 kg/m 2 , age 18–59 years, and no chronic diseases, such as cancer, kidney diseases, or heart diseases. Exclusion criteria were pregnant and/or breastfeeding women, having any severe mood disorder controlled by pharmaceuticals, and the use of pharmaceutical weight control. The socio-demographic information of the participants’ age, gender, educational level, monthly household income, and types of work were collected through a questionnaire. The BMI of the participants were measured using the TANITA Body Composition Analyzer (model TBF 300, Tanita Corporation, Tokyo, Japan). The Malay-translated MEQ was distributed via a Google Form. Ethical approval was obtained before data collection from the Universiti Kebangsaan Malaysia Medical Research Ethics Committee (UKM PPI.800-1/1/5/JEP-2019-391). Respondents were briefed on the purpose of the study and written consent was obtained.

2.4. Validation of MEQ-M

2.4.1. Construct Validity

Factor analysis enables the determination of the underlying subdomains of a questionnaire [50]. Exploratory factor analysis (EFA) was recommended for establishing equivalence and factor structure validation of the translated and adapted questionnaires performed in different sample populations [51]. In this study, the MEQ factor structure was determined by using principal component analysis with varimax rotation [52]. This rotation produces a simpler solution and uncomplicated interpretation while maximizing the total variances of the squared loadings correlation between variables and factors. An eigenvalue of >1, a factor loading of ≥0.4 and a scree plot were applied for this study ( Figure 1 ) [26].