Psychometric evaluation of the “Body Checking and Avoidance Questionnaire — BCAQ” adapted to Brazilian Portuguese

Vol. 16: e293-e299, December 2011

e293

INSTRUMENTS

Key words:Body checking,psychometrics, validity,eating disorders.Correspondence to:Adriana Trejger Kachani,Rua Bahia, 945 apto 71 -01244-001, São Paulo, Brasil.E-mail: [email protected]: January 13, 2011Accepted: April 15, 2011

Psychometric evaluation of the“Body Checking and AvoidanceQuestionnaire – BCAQ” adaptedto Brazilian Portuguese

INTRODUCTION

Eating disorders (ED) are a group of con-ditions that include anorexia nervosa,bulimia nervosa and eating disorders nototherwise specified; they are characterizedby severely disturbed eating-related behav-iors, misperception of body shape and con-sequent pathological weight control (1).Body dissatisfaction is one of the manifesta-tion of a misperception of body shape, andis often described as a core symptom of aneating disorder (2). It is defined as a self-perception disturbance influenced by one’sown experience about body weight andshape. Body dissatisfaction can influence apatient’s self esteem, as individuals with EDoften judge themselves almost exclusivelyby their physical appearance, with whichthey are constantly dissatisfied (2, 3). Bodychecking magnifies perceived imperfec-tions, sustaining concerns with body sizeand a fear of losing control, which in turnfuels dietary restrictions (4).

To control their bodies and in an attemptto reach a satisfactory body image, patients

with ED repeatedly engage in body check-ing behaviors such as constantly weighingthemselves, looking in the mirror, trying onclothes to check for tightness, pinchingbody parts and comparing their own bodyto that of other people, among others (5).These behaviors may take a few seconds orseveral minutes several times a day (6).Other patients engage in body avoidance,absolutely refusing to weigh themselves,covering mirrors and avoiding any reflec-tive surface, or wearing baggy clothes tocover up their body (7). Shafran et al. (7)studied patients with ED and found thatmore than half of them reported that bodychecking behaviors affect the way they liveand eat and that they alternate betweenbody checking and avoidance. Theseauthors found a positive associationbetween severity of ED and frequency ofbody checking or avoidance.

Body checking behaviors can becomecompulsive in patients with ED as theirdaily lives revolve around body image andbody checking to overcome or relieve theiranxiety over their body (5). Treatment

A. Trejger Kachani1, P. Brunfentrinker Hochgraf1, S. Brasiliano1, A.L. RodriguesBarbosa1, T.A. Cordás2, and M.A. Conti2

1PROMUD, Women Drug Dependent Treatment Center at the Institute of Psychiatry, Hospital das Clinicas,University of São Paulo School of Medicine, 2Eating Disorders Program at the Institute of Psychiatry, Hospi-tal das Clinicas, University of São Paulo School of Medicine, São Paulo, Brasil

ABSTRACT. OBJECTIVE: Adapt and validate the Brazilian Portuguese version of the BodyChecking and Avoidance Questionnaire (BCAQ). METHODS: The study consisted of: trans-lation and back translation; technical review and assessment of semantic equivalences, factoranalysis and discriminant and concurrent validity in a sample of subjects with and withouteating disorders. RESULTS: The instrument was adapted and was found to be easy tounderstand (mean scores higher than 3.4; maximum score: 5.0) and showed excellent con-cordance (Cronbach’s alpha: 0.94). Factor analysis identified five components with eigenval-ues greater than 1. It was able to discriminate the two groups (p<0.001) and correlated withthe Eating Attitudes Test (EAT) (r=0.50), body shape questionnaire (BSQ) (r=0.68) and BeckDepression Inventory (BDI) scales (0.51). DISCUSSION: The Brazilian Language versionshowed suitable internal consistency and external validation, and was easy to understand.The results were similar to the original version and its use is recommended for evaluation ofbody checking in the Brazilian population in subjects with or without eating disorders.(Eating Weight Disord. 16: e293-e299, 2011). ©2011, Editrice Kurtis

A. Trejger Kachani, P. Brunfentrinker Hochgraf, S. Brasiliano, et al.

should focus on body checking as it is a corebehavior in ED and can take up much of apatient’s time and energy (8).

Although body checking behaviors are clini-cally relevant in ED, few studies have attempt-ed to measure and describe these behaviorswithin this context (7-10). The Body Checkingand Avoidance Questionnaire (BCAQ) wasdeveloped in an attempt to quantify this phe-nomenon (7). However, it has not been translat-ed, culturally adapted or validated for the pop-ulation in Brazil, and thus cannot be used byresearchers in this country.

Cultural adaptation of scales already validat-ed for other populations, followed by the psy-chometric assessment of the adapted scalesensures that the findings are reliable for theresearch group and enable comparative studiesbetween countries and cultures (11). Currentlythere are a number of centers for the treatmentof eating disorders in Brazil, but only a fewbody image scales have been adapted and vali-dated for the Brazilian population. Amongthem are the Body Shape Questionnaire (12),Stunkard’s Body Figure Rating Scale (13), BodyAttitudes Questionnaire (14) and the BodyChecking and Cognitions Scale (9).

As far as we know, this is the first culturaladaptation of the BCAQ, although it has beenused in its country of origin. A recent articleinvestigated if constant body checking influ-ences body satisfaction among non clinicalpopulations (15). The objective of the presentstudy is to describe the process of translationand transcultural adaptation of the BCAQ intoBrazilian Portuguese, and check its internalconsistency, as well as its factor, discriminantand concurrent validity for the Brazilian popu-lation.

METHODS

SubjectsEighty-five female patients meeting DSM-IV

(1) criteria for clinical ED participated in thepsychometric evaluation of this study. All of thepatients included in the study were under treat-ment at the Eating Disorders Program (AMBU-LIM) at the Psychiatry Institute of Clinicas Hos-pital of Medical School – São Paulo’s University(IPQ-HC-FMUSP) in 2009. Forty-four met thediagnostic criteria for anorexia nervosa and 41for bulimia nervosa. The control group wasmade up of 40 randomly selected patients fromthe gynecology clinic of Clínicas Hospital atFMUSP associated with this same medicalschool. The controls were matched by age andlevel of education to ensure matched study

groups. Exclusion criteria included psychiatricdisorders, the use of psychoactive drugs, preg-nancy, and clinical impediments such as painor post operative status. At each new interviewthe researcher asked the subject about theseconditions. A secondary objective of simultane-ously applying the other related scales was toidentify undiagnosed ED or depression. Noneof the participants refused to participate in thestudy and all signed an informed consent form.

Measures and ProcedureThe process of translation, back translation

and verbal comprehension review consisted offive steps: translation of the original Englishtool into Brazilian Portuguese by a nutritionistfluent in English, back translation by a linguist,technical review and assessment of semanticequivalences, evaluation of the tool by expertsand, finally, approval by the authors of theoriginal tool. In this case, the panel of expertsconsisted of 3 psychiatrists, 3 psychologists, 4nutritionists and 48 psychology students whoused an adapted verbal numeric rating scale(11).

A nutritionist, PhD student, took all anthro-pometric measurements used to calculate thebody mass index (BMI) of all participants(patients and controls). Measurements weremade using a Tanita brand digital scaleequipped with a stadiometer and a non-elasticmeasuring tape. In addition to the BCAQ, studyparticipants also completed the followingforms and questionnaires:- Personal information form: prepared by the

research team to collect information aboutage, level of education and desired weight;

- Eating Attitudes Questionnaire (EAT) (16): a26-item self-report questionnaire that assess-es attitudes and behaviors typical of patientswith anorexia nervosa;

- Body Shape Questionnaire (BSQ) (17): a 34-item self-report questionnaire that assessesconcerns with body shape and self-deprecia-tion related to physical appearance and thesensation of “being overweight”;

- Beck Depression Inventory (BDI) (18): a 21-item self-report questionnaire that assessesdepressive symptoms.BCAQ is a self-administered questionnaire

that takes only a few minutes to be completed(7). It assesses body checking behaviors andsome body parts using a Likert scale: “not at all– I’m not interested,” “at least once a week,”“every day,” “1 to 2 times a day,” “more thanthree times a day, “not at all – I avoid beingupset.” The BCAQ score is calculated by addingup the score for each answer and will varybetween 0 and 110, with higher scores indicat-

e294 Eating Weight Disord., Vol. 16: N. 4 - 2011

Psychometric evaluation of “BCAQ”

ing more severe body checking (7). In the validi-ty study, the BCAQ proved to have excellentinternal consistency (Cronbach’s alpha=0.9).Component variance was 0.49 (p>0.5), calculat-ed using oblique rotation. The BCAQ was alsoable to distinguish clinical from nonclinical pop-ulations since those with ED had higher scoresthan those without eating disorders (7).

This study was approved by the Ethics andResearch Committee at HC-FMUSP (ProtocolNo. 0029/09) and complies with National Boardof Health Standard # 196 dated 10-Oct-1996. Itshould be noted that the lead author of theoriginal scale approved the BCAQ validationfor the Brazilian population.

Statistical analysisQuantitative variables (age, BMI, desired

weight and scale results) were described asmeans, standard deviations and interquartileranges. Principal component factor analysis (19)with Varimax rotation (20) was performed on thedata. Internal consistency was assessed usingCronbach’s Alpha (21). Discriminant validity wasassessed by Student’s t-test and concurrentvalidity was assessed by Pearson’s or Spear-man’s correlation, depending on the fit with anormal distribution. Kolmogorov-Smirnov’s testwas used to verify the assumption of normalityfor this data. A 5% significance level was set.

RESULTS

Translation and cultural adaptation of theBCAQ – Brazilian Portuguese version(See Appendix)

Translation required adapting the word stom-ach and explaining what clavicle means, as bothcan be interpreted differently in Brazilian Por-tuguese. We sought to make sure that connota-tive and denotative meanings were preserved in

the transfer of word meanings between sourceand target languages.

The instrument’s questions were easilyunderstood by both the experts and the Brazil-ian population at large, with mean scores high-er than 3.4 (SD: 1.68); 40.55% of the questionswere scored (5.0) or 4.6 (SD: 1).

Psychometric properties of the BCAQ –Brazilian Portuguese version

Table 1 describes the study sample. No statis-tically significant difference in age or BMI wasfound between the groups. The results of Stu-dent’s t-test showed the groups to be homoge-neous.

The internal consistency of the BCAQ wasvery good, with satisfactory Cronbach’s alphas.All coefficients were larger than 0.89 for sub-scale, and 0.4 for the overall scale.

Factor analysis identified five principal com-ponents, all with eigenvalues larger than 1. Thevariation of the scale is explained on 72% by aset of factors indicating they are strongly repre-sented.

Varimax rotation of the factor loadingsrevealed which factors were associated with thescale’s questions. Thus, questions 1, 2, 3, 4 wereassociated with the fourth principal component;questions 5 through 8 with the second compo-nent; questions 9 through 14 with the first com-ponent; questions 15, 16 and 17 with the thirdprincipal component, and questions 18 to 22with the fifth component (Table 2).

Student’s t-test showed higher mean BCAQscores in ED patients (45.38, SD=24.35) than incontrol subjects (21.52, SD=13.40), p-value<0.001.No correction was required as only two groupswere used.

Correlation analyses of BCAQ with other eat-ing disorder screening scales showed a directrelationship between them. In other words,comparisons were significant and the correla-

e295Eating Weight Disord., Vol. 16: N. 4 - 2011

VariableEating Disorder (N=85) Control (N=40)

Mean Standard Interquartile Mean Standard Interquartile p-valuedeviation range deviation range

Age (years) 27.87 7.928 21.0-33.0 29.18 9.086 23.0-34.0 0.415

BMI (kg/m2) 21.49 5.512 17.9-24.5 23.10 4.224 20.3-25.0 0.104

Weight expect (kg) 48.71 9.961 9.961-49.0 57.39 6.646 56.0 <0.001

EAT 34.51 16.744 21.5-49.0 8.32 6.996 3.0-11.8 <0.001

BSQ 144.48 44.253 115.5-180.5 70.18 24.542 50.5-87.5 <0.001

Beck 25.64 13.837 16.5-34.5 5.92 5.526 1.0-7.0 <0.001

BCAQ 45.38 24.351 26.5-62.0 21.52 13.401 11.3-29.0 <0.001

TABLE 1Comparison of age, body mass index (BMI), desired weight and scores of the scales between the two groups studied. São Paulo, 2009.


tion coefficient positive. Thus the correlationbetween BCAQ and EAT was 0.50 (p<0.001) andbetween BCAQ and BSQ was 0.68 (p<0.001).The correlation between BCAQ and BDI, amajor indicator of depressive symptoms, was0.51 (p<0.001). The correlation between BMI andBCAQ was 0.32 (p=0.003) in patients with EDand 0.11 in control subjects (p=0.489). In thecontrol group, the correlation between BCAQand EAT was 0.11 (p=0.501), between BCAQ andBDI was 0.21 (p=0.19) and between BCAQ andIMC was 0.11 (p=0.489). According to the Kol-mogorov-Smirnov test, the BDI scale does not fita normal distribution (p=0.046), thus in thisinstrument Spearman’s Correlation was used.

DISCUSSION

The BCAQ is a valuable instrument for bodyimage studies as it evaluates image-related bodychecking behaviors (7). The objective of the pre-sent study was to translate and adapt the BCAQto the Brazilian population and evaluate its psy-chometric properties. Several authors have

stressed the importance of conducting valida-tion studies after translation and transculturaladaptation, such as we have done in this article.A well translated and validated scale can reduceresearch errors and ensure that the informationcollected from the subjects is reliable. In addi-tion, validated scales can be administrated in dif-ferent contexts such as in epidemiological orclinical studies, or in health prevention and well-being (11, 22).

The results of this study revealed that thetranslated version of the BCAQ performed wellat all levels: internal consistency, factor, discrim-inant and concurrent analysis. The BrazilianPortuguese language version showed consisten-cy and discrimination between subjects with andwithout ED similar to those reported in the orig-inal validation study (7). The original validationstudy was conducted with 55 patients with EDand 55 control subjects, while the Brazilian vali-dation study used a slightly larger sample ofpatients (N=85) but a smaller control group(N=40). This difference in the number of subjectsin the control and ED groups in no way compro-mises the results obtained, as it is recommended


Rotated factor loadingsComponent

1 2 3 4 5

1. Pinched your thighs 0.348 0.045 0.224 0.777 0.216

2. Pinched your belly 0.209 0.295 0.071 0.803 0.133

3. Pinched your bottom 0.260 0.233 0.104 0.767 0.076

4. Pinched your face 0.173 0.313 0.118 0.753 0.169

5. Looked in the mirror at your overall appearance 0.170 0.721 0.168 0.178 0.142

6. Looked in the mirror at your thighs 0.353 0.742 0.167 0.190 0.190

7. Looked in the mirror at your belly 0.220 0.772 0.112 0.194 0.140

8. Looked in the mirror at your face 0.244 0.638 0.001 0.256 0.162

9. Touched your thighs 0.747 0.359 0.230 0.176 0.146

10. Touched your stomach 0.726 0.322 0.117 0.223 0.192

11. Touched your bottom 0.742 0.439 0.134 0.149 0.118

12. Touched your face 0.577 0.271 0.042 0.230 0.132

13. Touched your hip bones 0.665 0.106 0.282 0.305 0.326

14. Touched your collar bone 0.658 0.007 0.212 0.259 0.246

15. Used a tape measure around your thighs 0.187 0.140 0.892 0.123 0.214

16. Used a tape measure around your stomach 0.193 0.112 0.899 0.119 0.212

17. Used a tape measure around your hips 0.225 0.114 0.871 0.136 0.265

18. Have you used the fit of your clothes to judge your body size? 0.288 0.030 0.129 0.153 0.764

19. Have you compared your own body size to other people? 0.167 0.168 0.208 0.079 0.825

20. Have you monitored the spread of your thighs when you sit down? 0.348 0.199 0.176 0.137 0.683

21. Measured your wrist? 0.147 0.346 0.380 0.195 0.593

22. Weight yourself? -0.036 0.301 0.358 0.189 0.501

TABLE 2Factor loadings and correlation with BCAQ components.


that, in cases where there is concern that bothgroups be homogeneous along a given charac-teristic, the number of cases be larger than thenumber of controls. Age and level of educationwere used to balance the sample. The ratio ofcase to control subjects was 2.125, i.e., abouttwo cases per control (23, 24).

The psychometric properties of the Brazilianversion were found to be satisfactory. Internalconsistency was similar to that of the originalscale. The original validation study did notinclude factor analysis, but it is a useful tool as itassesses the most common body checkingbehavior.

Discriminant analysis showed that, consistentwith the original scale, the Brazilian version ofthe BCAQ can be used in both clinical and non-clinical populations. This result is consistentwith the original scale, and suggests thatpatients with ED check their bodies more oftenthan women without ED (7), probably becauseovervaluation of shape and weight is a coreaspect of ED (6, 7). Women who are unhappywith their body may make an effort to diet andexercise, and likely check their body to a rea-sonable extent. However, for women with ED,body image and diet are at the core of their life.They repeatedly check their body in an attemptto assess their size and weight, and to checkthe effectiveness of their (often inappropriate)weight loss practices in an unsuccessfulattempt to reduce their body image anxiety (10,25).

This study also assessed the associationbetween the BCAQ and the EAT, BSQ and EDIquestionnaires, as body checking and its avoid-ance directly determine these women’s eatingpatterns, weight changes and mood (2, 7, 25-28).We were able to demonstrate that this instru-ment can distinguish between the two groups.Thus, unlike the results of the control group, inthe patient group we found a moderate associa-tion between them. Patients with ED, who nor-mally score high in the EAT, BSQ and EDI ques-tionnaires, also tend to have high scores in theBCAQ, which suggests it can also be used toscreen for eating disorders, just as BSQ and EATscores can indicate a need for greater attentionand clinical interview in symptomatic women.

Those with higher scores in EAT often engagein more restrictive dieting, presumably becausethey are dissatisfied with their bodies and bodychecking may be a way to check how effectivetheir weight loss is (10). High BSQ scores, on theother hand, are indicative of body dissatisfac-tion, and it is reasonable to believe that individu-als who are more dissatisfied with their bodieswould engage in more frequent body checkingto confirm their weight or to take appropriate

action to lose weight as discussed earlier. A highBMI score had a positive association with theBCAQ for ED patients, but not for other women,although there was no statistical difference inmean BMI of patients and controls. The fact thatthe two groups have different weight expecta-tions (Table 1), with ED patients expecting thelower weights, could explain the higher level ofbody checking anxiety among these subjects asdesired target is harder to achieve.

Another interesting finding is the relationshipfound between BDI and BCAQ in patients withED. It is known that comorbid mood disordersin ED patients are a risk factor for binging andpurging, which would require more frequentlybody checking/avoidance to confirm weightgain and the impact of dieting and purgingbehaviors (27).

A limitation of this study is that, as far as theauthors are aware, there are no other validatedscales in Brazilian Portuguese that could be usedas the "gold standard”. Thus this study had torely on the objectivity of established body imagescales or other related scales such as EAT, BSQand EDI, a criterion often used in validationstudies (11, 12, 13, 22).

Finally, we must remember that body imageis one of the most difficult aspects to address inpatients with eating disorders, and mainte-nance of body dissatisfaction after treatmentmay be a predictor of poor prognosis (2, 29). Itis known that frequent body checking leadsindividuals to focus on the dimensions of theirbodies, exacerbating their self-criticism andincreasing their body dissatisfaction (7, 8, 25,29). This is why several authors (7, 8, 25) arguethat body checking/avoidance is an expressionof the core psychopathology of ED. In this waythe BCQA might also be used as a scale to trackthe disease, as are EAT, BITE and BSQ.

CONCLUSIONS

The Brazilian Portuguese language version ofthe BCAQ showed good verbal understandingand agreement between items. This instrumentshowed adequate validity and reliability, andgood sensitivity and specificity for the Brazilianpopulation.

ACKNOWLEDGEMENTS

We would like to thank nutritionists Marcela SalimKotait, Fernanda Pisciolaro and Esther Soares Fas-sarella for their help in administering the question-naires to patients. We also thank the Department ofObstetrics and Gynecology at FMUSP for facilitatingdata collection in the control group.




APPENDIXBRAZILIAN PORTUGUESE VERSION OF THE BODY CHECKING

AND AVOIDANCE QUESTIONNAIRE – BCAQ.

Este questionário é sobre comportamentos que você tem (ou evita ter) para verificar seu corpo.NAS ÚLTIMAS QUATRO SEMANAS, você…

Nenhumavez –não meinteresso

Pelo menosuma vez nasemana

Todosos dias

1-2 vezespor dia

Mais de 3vezes ao dia

Nenhumavez – evitopara nãome chatear

Beliscou ...

… suas coxas

… sua barriga

… seu bumbum

… seu rosto

Olhou no espelho para conferir …

… sua aparência geral

… suas coxas

… sua barriga

… seu rosto

Apalpou …

… suas coxas

… sua barriga

… seu bumbum

… seu rosto

… suas costelas (para verificaro quanto estão salientes)

… seus ossos da clavícula(“saboneteira”)

Usou uma fita métrica em volta ...

… das suas coxas

… sua barriga

… seu quadril

Você…

… usou o número de suas roupas parajulgar o tamanho de seu corpo?

… comparou o tamanho de seucorpo com o de outras pessoas?

… ao sentarse, monitorou o quantosuas coxas se esparramam?

… mediu a circunferência de seupulso (com os dedos ou pelotamanho do relógio)?

… se pesou?



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Psychometric evaluation of the “Body Checking and Avoidance Questionnaire — BCAQ” adapted to Brazilian Portuguese