Investigating Perceptions of the Eating Disorder Examination‐Questionnaire Among Undergraduate Students: A Qualitative Approach

ABSTRACT

Objective

Quantitative methods that have evaluated the Eating Disorder Examination Questionnaire (EDE‐Q) have found consistent evidence that the original four‐factor structure does not replicate across diverse samples and genders. Emerging evidence in the broader psychology literature shows that qualitative methods can provide nuanced insight into how participants interpret, understand, and respond to self‐report survey items. Qualitative methods may also help illuminate patterns of Likert responses and variation in respondents of different genders. Thus, this study used qualitative methods to explore how lay participants perceive and interpret EDE‐Q items.

Method

Undergraduate students (N = 97, M _age = 20.55 years, SD = 1.30, 48 men, 48 women, 1 transgender man) responded to the 22 attitudinal EDE‐Q items using the Likert‐type scale and provided open‐ended reflections on their thought processes, interpretations, and relevant contexts for selecting their response. Open‐ended responses were analyzed using content analysis to explore understanding of the items and response scales (e.g., confusion, misinterpretation, validity, gendered experiences).

Results

Most responses did not have issues; however, (a) shape and weight items were often conflated and participants expressed confusion about them, (b) higher ratings did not consistently reflect greater eating psychopathology, and (c) men described eating psychopathology geared toward gaining weight and muscularity even when selecting low Likert responses.

Discussion

Qualitative insights from this study complement concerns stemming from quantitative research on the structural validity of the EDE‐Q and suggest potential avenues to clarify essential yet misunderstood concepts.

Summary

• Quantitative research has consistently shown that the original four‐factor structure of The Eating Disorder Examination Questionnaire (EDE‐Q) is unstable and does not replicate across samples.

• Moving beyond quantitative methods, this study used a qualitative approach to explore how participants interpreted EDE‐Q items and chose their Likert responses.

• Findings showed confusion, misinterpretations, and misaligned responses relative to proposed EDE‐Q factors, along with distinct gendered experiences in responding.

• By integrating qualitative insights, findings contribute to broader discussions on refining the measure and potential reasons for structural validity issues.

1. Introduction

The reliability, validity, and generalizability of psychological measures have been increasingly questioned (Flake and Fried 2020), including commonly used eating disorder instruments such as the Eating Disorder Examination‐Questionnaire (EDE‐Q; Fairburn and Beglin 1994, 2008; see Jenkins and Rienecke 2022). The EDE‐Q was developed as a self‐report version of the Eating Disorder Examination (EDE; Fairburn et al. 2008) and is arguably the most widely used self‐report measure of eating pathology. Despite this, concerns remain regarding the reliability and validity of the original proposed four‐factor structure of the EDE‐Q (Dietary Restraint, Eating Concern, Shape Concern, and Weight Concern) Jenkins and Rienecke (2022) that is derived from the 22 “attitudinal” items (i.e., not the behavioral frequency items).

Many researchers and clinicians continue to use the EDE‐Q with its original four‐factor structure, including by reporting norms at the population level and within treatment studies (e.g., Hilbert et al. 2012; Karapatsia et al. 2024; Rienecke et al. 2024), even though there is severely limited psychometric support (Jenkins and Rienecke 2022). This is problematic because an unstable factor structure may misclassify eating psychopathology or mischaracterize treatment outcomes. As such, use of the EDE‐Q must be part of ongoing discussions about defining and measuring with accuracy what is being studied in psychological science to increase confidence in study conclusions (Flake and Fried 2020; Jenkins and Rienecke 2022).

1.1. Methods to Improve Psychological Measures

To address ongoing concerns about self‐report psychological instruments, primarily quantitative methods have assessed structural validity across samples (Flake and Fried 2020; Jenkins and Rienecke 2022). Emerging qualitative research methods can complement this work by investigating how participants understand assessment items, their nuanced reasons for selecting Likert responses, and whether these reasons align with what the item and its overarching factor intend to measure (Lundmann and Villadsen 2016; Mason et al. 2023). For example, in an investigation of cognitive processes when responding to a personality survey, qualitative analysis showed that items often did not correspond to anticipated factors, and participants varied significantly in interpreting items (Lundmann and Villadsen 2016). For example, participants often selected the same response (e.g., “disagree”) but described opposing experiences with different interpretations.

Similarly, a qualitative study exploring lay participants' perceptions regarding commonly used psychological instruments (e.g., Rosenberg Self‐Esteem Scale) used think‐aloud methodology with cognitive interviewing to capture perceptions and reasons for their response selection while they completed each item (Mason et al. 2023). Participants were challenged in interpreting and responding to some items and did not universally understand what the items asked of them. Collectively, these studies highlight a disconnection between participant and researcher interpretations of self‐report psychological measures. Notably, these qualitative methods have concentrated on personality assessments and have not been extended to assessments of psychopathology.

1.2. Eating Disorder Examination‐Questionnaire (EDE‐Q)

In a systematic review of the EDE‐Q's structural validity, the original four‐factor structure received little empirical support (Jenkins and Rienecke 2022). Of many alternative factor structures proposed (Jenkins and Rienecke 2022), a seven‐item version showed the most robust support across samples (Grilo et al. 2013; Jenkins and Davey 2020). Validity issues may stem from several sources. First, the items on the EDE‐Q were developed based on “rational rather than empirical grounds” (Cooper et al. 1989), meaning the items were grouped based on theory, clinical insights, and established etiological models, rather than a structured empirical design process (Goel et al. 2022).

Second, the EDE‐Q was initially developed with a focus on young, cisgender, White women from predominantly Western backgrounds, which limits applicability and interpretability for other individuals. For example, EDE‐Q scores are less effective at predicting disordered eating in Black women compared to White women, likely because the EDE‐Q fails to consider factors such as racial and cultural differences in body ideals (Goel et al. 2022). Additionally, the EDE‐Q incorporates items that center the thin ideal (Jenkins and Rienecke 2022), and potentially misses muscularity‐oriented body image concerns and psychopathology more common in men (Laskowski et al. 2023).

Finally, we propose that validity may be impaired if individuals interpret and respond to items differently. Consistent with prior qualitative investigations (Lundmann and Villadsen 2016; Mason et al. 2023), we anticipate that identical Likert responses to an item could represent different qualities and experiences. We also anticipate that participants may be confused by and/or misinterpret items. In sum, understanding participants' subjective experiences while completing the EDE‐Q may aid in its refinement.

1.3. The Present Study

In this study, we examined how lay participants perceived, interpreted, and made meaning of EDE‐Q items. Specifically, we considered whether participants were confused by items, whether they misinterpreted items, whether Likert responses matched qualitative descriptions, whether responses aligned with associated subscales, whether item interpretations were consistent across participants, and whether interpretations varied by gender. Our goal was to provide evidence about the face validity of EDE‐Q items, describe whether items accurately reflect scales from the original four‐factor structure, and describe whether items are consistently and clearly understood by participants. As such, our research question was based on past research (Lundmann and Villadsen 2016; Mason et al. 2023), but our approach was exploratory without a priori hypotheses.

2. Method

2.1. Participants

We used convenience sampling to recruit lay participants unselected for prior specialized training or in‐depth knowledge related to eating disorders. Participants were undergraduate psychology students from McGill University. Participants were eligible if they identified as a man or woman, were at least 18 years old, and were fluent in English. We recruited 100 participants (50 men and 50 women) to analyze response patterns between genders. Due to the online format and completion of the study for extra course credit, we expected data loss due to insufficient written responses. Thus, we recruited a larger sample than prior studies using a similar methodological approach (Ns = 20–23; Lundmann and Villadsen 2016; Mason et al. 2023).

2.2. Measures

2.2.1. Sociodemographics

Participants reported age, sex assigned at birth, gender identity, sexual orientation, native language, visible minority group status, parental socioeconomic status, height, and weight.

2.2.2. EDE‐Q 6.0

Participants completed the 28‐item EDE‐Q 6.0 (Fairburn 2008). Participants were instructed to answer items based on the past 4 weeks (28 days). Participants were presented with each item and its corresponding 7‐point Likert scale (i.e., 0 = No days to 7 = Everyday for frequency items; 0 = Not at all to 7 = Markedly for severity items). The 22 items that comprise the four EDE‐Q subscales (dietary restraint, eating concern, shape concern, and weight concern) and the Global Score were coded; participants were not prompted for feedback on behavioral frequency items. Subscale and Global scores were calculated.

2.3. Procedure

The project received ethical approval from McGill University's Research Ethics Board‐II (#24‐09‐067). Students in the psychology participant pool signed up for the study, which involved an online Qualtrics survey consisting of informed consent, sociodemographic questions, and the EDE‐Q. Participants first selected their Likert response to EDE‐Q items (i.e., traditional administration) and then provided detailed descriptions of their thought processes, reasoning, and additional context for selecting their answer (see Supporting Information). Upon completing the study, participants received 1.0 units of extra credit in their course. Time to complete the survey with outliers removed (n = 11) was M = 48.35 min (SD = 2.45).

All participants had the option to select “Prefer not to say” for each EDE‐Q item. Participants who selected “Prefer not to say” were not prompted to supply a text response. Upon completing the study, participants received 1.0 credits toward extra credit in the course. Time to complete the survey with outliers removed (n = 11) was M = 48.35 min (SD = 2.45).

2.4. Data Analytic Plan

2.4.1. Quantitative Analyses

Descriptive statistics and internal consistency estimates (Cronbach's alpha) were computed for the whole sample and within men and women for the Global and four subscale scores of the EDE‐Q. Independent samples t‐tests compared mean scores on the Global and subscale scores between genders.

2.4.2. Qualitative Analyses

All open‐ended responses were coded using content analysis (Elo and Kyngäs 2008). An a priori codebook was constructed based on prior work (Mason et al. 2023; Lundmann and Villadsen 2016). This codebook was pilot tested and refined to include two additional codes: (1) accounting for responses when participants did not write enough to code (insufficient responding), and (2) distinguishing item misinterpretation from item confusion (see Table 1 for the final codebook). Five participants selected “Prefer not to say” (0.002%) which was coded as insufficient responding. EDE Interview guidelines, which contain descriptions of how the interviewer should evaluate responses for alignment with what the item intends to assess, were used to evaluate item misinterpretation and whether the item corresponded to its proposed factor (Fairburn et al. 2008). Thus, the content analysis was mainly deductive but included some inductive components to account for ambiguities and insufficient responses.

TABLE 1.

Coding categories for analysis of item responses in the EDE‐Q.

Response category	Description	Coder response options
Confusion with item	Participant explicitly notes confusion about what the item is asking or about terminology within the item.	Yes/No
2Misinterpretation of an item	Participants do not answer what the item intends to assess in combination with their Likert selection.	Yes/No
3Item corresponds to subscale to which it was originally designed to relate (i.e., face validity)	Participants' response to the item reflects the subscale it should relate to (e.g., restraint).	Yes/No
4Insufficient responding	Participant selected “Prefer not to say” and there was no text to code, or participant did not write enough detail to evaluate their response.	Yes/No

We followed the precedent set by Lundmann and Villadsen (2016), who structured their qualitative analysis with the concepts of equifinality and multifinality. Equifinality refers to how different processes can lead to the same outcome (Sato et al. 2009; von Bertalanffy 1968), and multifinality refers to how similar states can lead to different outcomes (Cicchetti and Rogosch 1996; Sroufe 1997). An example of equifinality would be participants who select the same response to an item (e.g., “Not at all”), but their qualitative elaborations to that item are not consistent with each other. An example of multifinality would be participants who give similar qualitative elaborations to an item but select different response options (e.g., “Not at all” vs. “Markedly”).

Finally, we explored gendered experiences in item responses. We considered participants' self‐reported gender and examined whether qualitative responses reflected overarching sociocultural body ideals and/or eating patterns consistent with gendered body ideals in Western culture, whereby men are subjected to a lean, muscular body ideal (Ricciardelli and McCabe 2015) and women are subjected to a thin and/or fit body ideal (Ata et al. 2015). We acknowledge that these sociocultural expectations are reflective of binary, cisgender, and heteronormative expectations, and that gendered experiences can vary significantly among gender‐ and sexual‐minority individuals (Richburg and Stewart 2024). For the one participant who identified as intersex and transgender, responses were coded similarly, whereby we considered whether their qualitative response reflected grappling with these ideals in relation to their gender identity.

Each item response was coded in an iterative fashion using the codebook that was constructed a priori for the codes in Table 1, and illustrative excerpts were collected to demonstrate each code in the results. Equifinality, multifinality, and gendered experiences were evaluated across all item responses. Specifically, responses to each item (in conjunction with Likert responses) were compared in pairs across participants to evaluate whether different qualitative elaborations corresponded to the same Likert response (equifinality), whether similar elaborations corresponded to different Likert responses (multifinality), and whether responses in that item across participants reflected gendered sociocultural body ideals. Evidence of equifinality, multifinality, or gendered experiences was then coded (yes/no) for each item, and illustrative excerpts were identified to demonstrate these concepts in the results.

In total, 2134 text responses (including insufficient responses) were coded from 97 participants. Author SO coded the first 20 responses based on the categories in the coding manual. Author KLH independently coded these first 20 items, and initial inter‐rater agreement was calculated using Cohen's kappa (Cohen 1968). Because inter‐rater reliability was sufficient, SO independently coded the remaining responses, and KLH reviewed codes. Questions that arose during review were discussed and resolved in an iterative fashion. If questions were not resolved, SER provided a third opinion. See Supporting Information for information on researcher positionality and reflexivity.

3. Results

3.1. Quantitative Findings

The final sample included 97 (M _age = 20.55 years, SD = 1.30) participants. Participants' assigned sex at birth was male (n = 47, 48.4%), female (n = 49, 50.5%), or intersex (n = 1, 0.1%). Participants' gender identity was man (n = 48, 50.5%), woman (n = 48, 49.4%), or transgender man (0.01%). Most (n = 61, 62.9%). Participants did not identify as members of visible minority groups, and most were heterosexual (n = 72, 74.2%). Mean BMI was 22.54 (SD = 3.68; Range = 16.83–35.90).

The EDE‐Q's Global score and subscales (Restraint, Eating Concern, Weight Concern, and Shape Concern) mostly exhibited acceptable‐to‐high internal consistency (Cronbach's alpha 0.70–0.93) except for the Eating Concern subscale, which exhibited poor internal consistency in men (α = 0.60), but acceptable internal consistency in women (α = 0.73). Mean scores for women were significantly higher for all EDE‐Q subscales and Global score compared to men (ds = 0.49–0.62), except for Restraint (d = 0.02; see Table 2).

TABLE 2.

Means, standard deviations, and internal consistencies.

Subscale	Overall		Men		Women		Independent samples t‐test
	M (SD)	α	M (SD)	α	M (SD)	α	t	d
Restraint	2.26 (1.30)	0.74	2.23 (1.41)	0.77	2.27 (1.19)	0.73	0.15	0.03
Eating concern	1.78 (0.98)	0.71	1.53 (0.77)	0.60	2.05 (1.11)	0.73	−2.78**	−0.56
Weight concern	2.69 (1.38)	0.76	2.32 (1.28)	0.81	3.02 (1.39)	0.70	−2.62*	−0.53
Shape concern	2.97 (1.44)	0.87	2.46 (1.34)	0.88	3.42 (1.37)	0.85	−3.07**	−0.62
Global score	2.43 (1.08)	0.92	2.13 (0.99)	0.89	2.69 (1.11)	0.93	−2.41*	−0.49

Note: *p < 0.05. **p < 0.01.

Abbreviations: α, Cronbach's alpha; d, Cohen's d effect size; M, mean; SD, standard deviation; t, t‐statistic.

3.2. Qualitative Findings

Inter‐rater reliability for the first 20 items was 87.0%, indicating high agreement. Across items, most participants selected “No days” or “Not at all” (n = 1039, 49%) as a response. In total, 0.9% (n = 19) of item responses had confusion, 5.2% (n = 112) of responses had misinterpretation, 1.4% (n = 31) of responses were insufficient to code, and 3.4% (n = 72) of responses contained content that did not correspond to the proposed factor. Patterns of equifinality, multifinality, and gendered experiences were observed across most items (see Table 3). Avoidance of eating (item 2; n = 11), Eating in secret (item 19; n = 10), Dietary rules (item 4; n = 10), Feeling fat (item 11; n = 10), Desire to lose weight (item 12; n = 10), and Avoidance of exposure (item 28; n = 10) were the most misinterpreted, caused confusion, and were least likely to correspond with their proposed factor. Exemplar content is included in Table 4 (confusion, misinterpretation, item correspondence to original subscale) and Table 5 (equifinality, multifinality, gendered experiences).

TABLE 3.

Types of issues with item responses and evidence of equifinality, multifinality, and gendered experiences across item responses for N = 97 participants.

Item	Subscale	1. Issue with item	2. Issues in understanding an item	3. Misinterpretation of item	4. Insufficient responding	5. Item corresponds to factor to which it should relate	(A) Equifinality	(B) Multifinality	(C) Gendered experiences
1. Restraint overeating	Restraint	Yes (n = 3) No (n = 94)	Yes (n = 0) No (n = 97)	Yes (n = 3) No (n = 94)	Yes (n = 0) No (n = 97)	Yes (n = 96) No (n = 1)	Yes	Yes	Yes
2. Avoidance of eating	Restraint	Yes (n = 11) No (n = 97)	Yes (n = 1) No (n = 95) N/A (n = 1)	Yes (n = 10) No (n = 86) N/A (n = 1)	Yes (n = 1) No (n = 96)	Yes (n = 91) No (n = 5) N/A (n = 1)	Yes	Yes	No
3. Food avoidance	Restraint	Yes (n = 7) No (n = 90)	Yes (n = 1) No (n = 96)	Yes (n = 6) No (n = 91)	Yes (n = 0) No (n = 97)	Yes (n = 97) No (n = 2)	Yes	Yes	Yes
4. Dietary rules	Restraint	Yes (n = 10) No (n = 86) N/A (n = 1)	Yes (n = 1) No (n = 95) N/A (n = 1)	Yes (n = 8) No (n = 88) N/A (n = 1)	Yes (n = 1) No (n = 96)	Yes (n = 90) No (n = 6) N/A (n = 1)	Yes	Yes	Yes
5. Empty stomach	Restraint	Yes (n = 6) No (n = 91)	Yes (n = 1) No (n = 94) N/A (n = 2)	Yes (n = 4) No (n = 91) N/A (n = 2)	Yes (n = 2) No (n = 95)	Yes (n = 91) No (n = 4) N/A (n = 2)	Yes	Yes	Yes
6. Flat stomach	Shape concern	Yes (n = 7) No (n = 90)	Yes (n = 2) No (n = 93) N/A (n = 2)	Yes (n = 3) No (n = 92) N/A (n = 2)	Yes (n = 2) No (n = 95)	Yes (n = 94) No (n = 1) N/A (n = 2)	Yes	Yes	Yes
7. Preoccupation with food, eating, or calories	Eating concern	Yes (n = 9) No (n = 88)	Yes (n = 2) No (n = 95)	Yes (n = 8) No (n = 89)	Yes (n = 0) No (n = 97)	Yes (n = 91) No (n = 6)	Yes	No	No
8. Preoccupation with shape or weight	Shape/weight concern	Yes (n = 4) No (n = 93)	Yes (n = 1) No (n = 96)	Yes (n = 3) No (n = 94)	Yes (n = 0) No (n = 97)	Yes (n = 94) No (n = 3)	Yes	Yes	Yes
9. Fear of losing control over eating	Eating concern	Yes (n = 6) No (n = 91)	Yes (n = 2) No (n = 93) N/A (n = 2)	Yes (n = 2) No (n = 93) N/A (n = 2)	Yes (n = 2) No (n = 95)	Yes (n = 95) No (n = 0) N/A (n = 2)	Yes	Yes	Yes
10. Fear of weight gain	Weight concern	Yes (n = 5) No (n = 92)	Yes (n = 0) No (n = 97)	Yes (n = 5) No (n = 92)	Yes (n = 0) No (n = 97)	Yes (n = 96) No (n = 1)	Yes	Yes	Yes
11. Feeling fat	Shape concern	Yes (n = 11) No (n = 86)	Yes (n = 0) No (n = 95) N/A (n = 2)	Yes (n = 9) No (n = 86) N/A (n = 2)	Yes (n = 2) No (n = 95)	Yes (n = 91) No (n = 4) N/A (n = 2)	Yes	Yes	Yes
12. Desire to lose weight	Weight concern	Yes (n = 10) No (n = 87)	Yes (n = 1) No (n = 94) N/A (n = 2)	Yes (n = 8) No (n = 86) N/A (n = 2)	Yes (n = 2) No (n = 95)	Yes (n = 89) No (n = 8) N/A (n = 2)	Yes	No	Yes
19. Eating in secret	Eating concern	Yes (n = 10) No (n = 87)	Yes (n = 3) No (n = 92) N/A (n = 2)	Yes (n = 5) No (n = 90) N/A (n = 2)	Yes (n = 2) No (n = 95)	Yes (n = 90) No (n = 5) N/A (n = 2)	Yes	Yes	No
20. Guilt about eating	Eating concern	Yes (n = 5) No (n = 92)	Yes (n = 1) No (n = 93) N/A (n = 3)	Yes (n = 1) No (n = 93) N/A (n = 3)	Yes (n = 3) No (n = 94)	Yes (n = 93) No (n = 1) N/A (n = 3)	Yes	Yes	Yes
21. Social eating	Eating concern	Yes (n = 3) No (n = 94)	Yes (n = 1) No (n = 95) N/A (n = 1)	Yes (n = 2) No (n = 95)	Yes (n = 2) No (n = 95)	Yes (n = 95) No (n = 1) N/A (n = 1)	Yes	No	No
22. Importance of weight	Weight concern	Yes (n = 7) No (n = 90)	Yes (n = 0) No (n = 95) N/A (n = 2)	Yes (n = 5) No (n = 90) N/A (n = 2)	Yes (n = 2) No (n = 95)	Yes (n = 92) No (n = 3) N/A (n = 2)	Yes	Yes	No
23. Importance of shape	Shape concern	Yes (n = 7) No (n = 90)	Yes (n = 1) No (n = 96)	Yes (n = 7) No (n = 90)	Yes (n = 0) No (n = 97)	Yes (n = 92) No (n = 5)	Yes	Yes	Yes
24. Reaction to prescribed weighing	Weight concern	Yes (n = 6) No (n = 91)	Yes (n = 0) No (n = 96) N/A (n = 1)	Yes (n = 5) No (n = 91) N/A (n = 1)	Yes (n = 1) No (n = 96)	Yes (n = 92) No (n = 4) N/A (n = 1)	Yes	Yes	No
25. Dissatisfaction with weight	Weight concern	Yes (n = 6) No (n = 91)	Yes (n = 0) No (n = 95) N/A (n = 2)	Yes (n = 4) No (n = 91) N/A (n = 2)	Yes (n = 2) No (n = 95)	Yes (n = 91) No (n = 4) N/A (n = 2)	Yes	No	Yes
26. Dissatisfaction with shape	Shape concern	Yes (n = 6) No (n = 91)	Yes (n = 0) No (n = 94) N/A (n = 3)	Yes (n = 2) No (n = 92) N/A (n = 3)	Yes (n = 4) No (n = 93)	Yes (n = 93) No (n = 0) N/A (n = 4)	Yes	Yes	Yes
27. Discomfort seeing body	Shape concern	Yes (n = 7) No (n = 90)	Yes (n = 1) No (n = 93) N/A (n = 3)	Yes (n = 4) No (n = 90) N/A (n = 3)	Yes (n = 2) No (n = 95)	Yes (n = 91) No (n = 3) N/A (n = 3)	Yes	No	No
28. Avoidance of exposure	Shape concern	Yes (n = 10) No (n = 87)	Yes (n = 0) No (n = 96) N/A (n = 1)	Yes (n = 9) No (n = 86) N/A (n = 1)	Yes (n = 1) No (n = 96)	Yes (n = 90) No (n = 6) N/A (n = 1)	Yes	Yes	Yes

TABLE 4.

Exemplary quote examples of responses to EDE‐Q items.

	Quote	Item	Likert response	Factor
Confusion
	“I didn't know what furtively meant.” (P89, man)	Eating in secret	No days	Eating concern
	“I'm questioning if I am not suited for this study because a lot of this is about body image which for the most part I am good with. My food relationship really has to do with my chronic nausea so its always thinking about if the food to nausea ratio is worth it.” (P21, woman)	Preoccupation with food, eating, or calories	13–15 days	Eating concern
	“I have, though not because of weight rather because of a skin condition I have. The question might want to specify because of weight/fat, as I have noticed a lot of other surveys I've done, they ask about insecurity relate to our body but in my case its only to do with skin and surveys may incorrectly assume due to weight or body type.” (P51, man)	Discomfort seeing body	3	Shape concern
Misinterpretation
	“I selected 1–4 only because sometimes there are days when I forget to bring food to school and periods of the day where food is not accessible (e.g., during commute to school, if I'm late to class and can't pick up something, etc.)” (P19, woman)	Avoidance of eating	1–5 days	Restraint
	“I normally avoid saturated fats like animal fat, and I don't eat a lot of sodium. Sometimes I feel guilty if I do because I am so anxious about my health.” (P42, man)	Food avoidance	Everyday	Restraint
	“I feel like it's more my body image than my weight that bothers me. I understand weight is just a random number…therefore I'm not that concerned about my weight.” (P14, woman)	Importance of weight	2	Weight concern
	“This question feels the same as the one before. I have a hard time distinguishing between my weight and shape.” (P12, woman)	Importance of shape	4	Shape concern
	“Yes I sometimes don't know what I would do if I gained a lot of weight. It is too scary a thought.” (P2, woman)	Importance of shape	3	Shape concern
	“It's hard to be short in big crowds.” (P21, woman)	Importance of weight	2	Weight concern
Item corresponds to factor to which it should relate
	“Not a calorie limit but a calorie minimum. I try to eat a minimum amount of calories to ensure I can gain some weight.” (P9, man)	Dietary rules	Everyday	Restraint
	“I always wonder where I am going to get lunch, and getting lunch has been the biggest regular inconvenience in my residence life. It does not help that the dining halls prohibit taking food to go. The fact that lunch closes at 2 PM was the primary reason I chose the class schedule I did.” (P26, man)	Preoccupation with food, eating, or calories	Everyday	Eating concern
	“I do feel uncomfortable when strangers see my body because I am more of a conservative person when it comes to my body. It has nothing to do with my shape or figure.” (P18, woman)	Avoidance of exposure	Moderately	Shape concern
	“It would feel weird to have someone monitor my weight, even if it's stable. Feels like an invasion of privacy.” (P20, man)	Reaction to prescribed weighing	3	Weight concern

TABLE 5.

Exemplary quote examples of equifinality, multifinality, and gendered experiences on EDE‐Q Items.

	Example quote	Comparison quote	Item	Factor
Equifinality
	“I have had 1 or 2 days that I have not eaten anything within 8 waking hours, but it is not for the reason above. It is usually when I wake up around 10 a.m. and I have some assignments due, I will not get up, stay in bed and do my assignment until my dinner time which is around 8 p.m.” (P41, man, Likert response: 1–5 days)	“I practice intermittent fasting sometimes to help regulate my eating patterns and support a body shape that aligns with my fitness goals. This approach allows me to manage my calorie intake while promoting discipline and balance in my lifestyle.” (P30, man, Likert response: 1–5 days)	Avoidance of eating	Eating concern
	“Sometimes when I have to work longer shifts with small breaks, I realize I am hungry and sometimes symptoms kick in and I feel more exhausted and so less prompted to focus at work.” (P10, woman, Likert response: 1–5 days)	“Especially planning spring break where I know I will be in a bikini has made this more prevalent and affected my daily life. This question brought up how I don't like that I am thinking about my body this much and letting it interrupt my life.” (P12, woman, Likert response: 1–5 days)	Preoccupation with food, eating, or calories	Eating concern
	“When I look at my arms I feel fat. When I look at my legs or face, I feel too skinny.” (P94, woman, Likert response: 16–22 days)	“Realistically I know I'm not. Even when I was very anorexic I thought I was fat and looking back on photos, I obviously was very thin. Now that I am healthy, I still have these thoughts, especially when comparing myself to my friends and influencers.” (P12, woman, Likert response: 16–22 days)	Feelings of fatness	Shape concern
Multifinality
	“No I have not tried to include diet items, but in general, I do try to eat healthy foods and reduce my sugar intake and not eat too many carbs and that's just for my personal health because my family has a history of diabetes.” (P23, woman, Likert response: No days)	“I won't feel good about myself if I don't think the food I am eating is healthy, because I know that cheap carbs, trans fats, UPFs, salt, cholesterol, and added sugars are bad for you. I think about these things a lot because I'm interested in medicine and learning about how the human body works.” (R26, woman, Likert response: Everyday)	Food avoidance	Eating concern
	“I think this question is very interesting and links with many dimensions, including one's values and conception of self‐worth. I answered 5, which is relatively high because I am proud of my weight and my body, and this influences positively how I think about myself.” (P17, woman, Likert response: 5)	“My weight has always been something I am confident in. I feel comfortable in my body and this has not influenced my insecurities.” (P4, woman, Likert response: 0)	Importance of weight	Weight concern
	“Kind of just worried that I'll gain unnecessary weight and ruin my shape. I wouldn't go as far as calling it a fear though.” (P58, man, Likert response: No days)	“I would say that it is a moderate thought that crosses my mind, but I don't think I would call it a fear.” (P11, woman Likert response: 6–12 days)	Fear of weight gain	Shape concern
Gendered Experiences
	“I have been doing the opposite actually. I'm trying to gain weight so I ‘force myself’ to eat food.” (P9, man, Likert response: No days)	“I put no days because I am content with my body and weight, I eat mindfully naturally so I did not have to limit my intake per say.” (P39, woman, Likert response: No days)	Restraint over eating	Restraint
	“I'm very wishy washy when it comes to losing weight. Sometimes I wish I was skinnier, but generally when I feel bad about my body I wish I was big and strong.” (P1, man, Likert response: 6–12 days)	“Though I always have the desire to lose weight, the thought has been bothering me more lately and especially since I saw that I had gained some weight. If I can, I always want to be lighter.” (P32, woman, Likert response: 13–15 days)	Desire to lose weight	Weight concern
	“I honestly would like to have more muscles and seem like a strong person. I look a little bit too skinny, and I do not like that.” (P55, man, Likert response: 4)	“My shape bothers me more than my weight as stated before and although I like aspects of my body I do wish I had a flatter stomach, more defined waist, and wider hips.” (P54, woman, Likert response: 3)	Dissatisfaction with shape	Shape concern
	“I have never felt guilty for not eating. I sometimes feel guilty of not eating enough.” (P40, man, Likert response: None of the times)	“I feel disappointed in myself when I eat. I feel this way because I make it so far by holding off, and then when I do, I feel like I should've and could've gone longer without eating.” (P25, woman, Likert response: Most of the time)	Guilt about eating	Eating concern

3.2.1. Confusion and Misinterpretation

When participants misunderstood or misinterpreted items on the EDE‐Q, they noted confusion of terminology within the items and expressed concern as to whether their experiences could be appropriately applied to the question (Table 4). For example, participants described experiences with body discomfort due to insecurities related to their general appearance and skin; preoccupation with and avoidance of food due to certain health conditions and/or concerns; and restricting and avoiding food for reasons unrelated to shape and/or weight. For many of these items, participants selected Likert responses alongside their written responses that were greater than 0, suggesting that scores on the EDE‐Q would be inflated due to item confusion and misinterpretation. Some participants were confused about how shape and weight were different concepts and expressed this by either commenting on it directly or by describing weight concerns that were clearly related to shape and vice versa.

3.2.2. Items Corresponding to Factors

Findings from the content analysis suggested that participants' responses included content that did not correspond to the item's original subscale. For the Restraint subscale, although some written responses aligned with what the question was asking (e.g., 4. Dietary rules), the response did not reflect the broader concept of Restraint. For example, some participants described imposing calorie minimums rather than limits to gain weight and build muscle, a response that was mainly endorsed by men but also some women. While calorie minimums do reflect a dietary rule pertaining to shape and/or weight, they do not reflect dietary restraint (alongside a high Likert selection) like other items on the Restraint subscale. Further, some participants selected responses greater than 0 for calorie minimums as a dietary rule while others did not, reflecting inconsistencies in responding and multifinality (see below). Across all subscales, some participants selected high Likert responses with elaborations that were clearly unrelated to the subscale. For example, participants described hiding their body due to modesty, discomfort with prescribed weighing because they felt it would be creepy or unnecessary, and feelings of food and body preoccupation due to inconveniences (e.g., busy schedule) or lack of food availability (e.g., store/dining hall closures).

3.2.3. Equifinality

Data suggested there was variation in participants' responses despite selecting the same Likert response (i.e., equifinality). While some participants described eating pathology and body image concerns, others described inconveniences (busy work/school schedules) or normal hunger cues when selecting the same Likert response. As such, examples of equifinality often also reflected participant misinterpretation. As an example, for Avoidance of eating (item 2), two participants selected “1–5 days,” but one participant described avoiding food because they were too busy to eat, while the other participant described avoiding food and intermittent fasting to influence body shape (see Table 5). In other cases of equifinality, one participant's response reflected what the item intended to measure (according to the EDE; Fairburn et al. 2008), while the other response did not. As shown in Table 5, two participants selected 16–22 days for Feeling fat (item 11), but one participant described only feeling fat with respect to a specific body part while the other described feeling fat in general. This former response contrasts with EDE Interview guidelines, which state that feelings of fatness should be in general and not in respect to a particular body part (Fairburn et al. 2008). Overall, evidence of equifinality highlights a key issue: the same Likert scale rating may reflect both normative and problematic experiences depending on interpretation, making it difficult to distinguish between them based on the score alone.

3.2.4. Multifinality

Other participants understood and responded to an item in similar ways but selected opposing Likert responses (i.e., multifinality). Similar responses but opposing Likert responses involved descriptions of restricting, avoiding, or being preoccupied with food due to health concerns as well as different interpretations of item terminology. For the Importance of weight (item 22), two participants described feeling proud of and confident with their weight, but one participant selected “5” while the other selected “0” (Table 5). One participant interpreted the word “judge” in the item positively while the other participant interpreted the word “judge” negatively. For Food avoidance (item 3), two participants described avoiding foods for health reasons, but one participant selected “No days” while the other selected “Everyday.” Even though neither participant described avoiding foods for shape or weight reasons, they selected Likert responses on opposite ends of the scale. For Fear of weight gain (item 10), two participants described feelings of concern, but not fear, around weight gain, but selected opposing Likert responses (Table 5). Evidence of multifinality throughout responses demonstrates that even when individuals have the same underlying reasoning for their responses, ratings can vary significantly.

3.2.5. Gendered Experiences

Men and women described problematic eating behaviors and body concerns in varying ways due to gendered and binary sociocultural expectations of the body. For Restraint overeating (item 1), a woman described eating mindfully and naturally, while a man described forcefully eating food to gain weight (Table 5). While both participants selected “No days,” the man was actively trying to alter his weight, highlighting how gender‐related motivations can lead to the same rating being selected, but for different reasons. Men also tended to describe imposing calorie minimums across items while women described imposing calorie maximums. Further, men sometimes described feelings of wanting to lose weight but mainly described wanting to get bigger and stronger. In contrast, women tended to describe wanting to lose weight and become thinner. Gendered experiences also extended to Guilt about eating (item 20), where one man described feeling guilty for “not eating enough” while a woman described “always” feeling guilty when eating. Although both participants described guilt related to eating, the man selected “None of the times” while the woman selected “Most of the time.” In sum, qualitative responses demonstrated that EDE‐Q items might fail to account for the nuanced and complex ways gender intersects with sociocultural pressures related to body weight, shape, eating, and self‐image.

4. Discussion

Quantitative research to date has not fully captured the nuances of how participants interpret and respond to specific EDE‐Q items. Consistent with previous qualitative research (Lundmann and Villadsen 2016; Mason et al. 2023), there was evidence of participant confusion, misinterpretation, mismatches between responses and subscales, and diverse patterns of equifinality, multifinality, and gendered experiences between respondents. Taken together, this highlights the need to address ongoing validity issues with the EDE‐Q and underscores the importance of incorporating qualitative approaches into the development and ongoing use of eating disorder measures to ensure they accurately measure what is being studied (Flake and Fried 2020).

Our qualitative findings support the argument that self‐report measures, including the EDE‐Q, are not inherently objective (Lundmann and Villadsen 2016). We identified several issues with EDE‐Q items that may partially explain why they do not consistently load onto the original four subscales. First, many EDE‐Q items assess multiple constructs (i.e., double‐ or triple‐barreled), which confused participants and may contribute to cross‐loading in quantitative studies. For example, items showing the most misinterpretation and confusion (e.g., 2. Avoidance of eating, 4. Dietary rules) combined weight, shape, and eating concerns/behaviors. Although the EDE Interview instructs clinicians to distinguish between weight and shape, the EDE‐Q contains no definitions of these concepts, and several participants explicitly stated they did not understand the difference. Taken together with the idea that some participants may understand the difference but experience weight and shape similarly, this may explain why some proposed alternative factor structures have found support for combining weight and shape items (Jenkins and Rienecke 2022).

Second, some participants provided “health” rather than weight or shape reasons in their responses. These participants did not view their behaviors as problematic but described strictly eating “healthy” foods, avoiding certain foods/food groups, or increasing food intake to build muscle in targeted areas (e.g., glutes) to influence health, yet these responses were provided for items asking about weight and shape. Research on fitspiration suggests that evolving body ideals promote the pursuit of a sculpted physique through restrictive, highly controlled, and/or orthorexic eating patterns, which may partially explain these findings (Jerónimo and Carraça 2022; Wu et al. 2022; Scheiber et al. 2023). While participants misinterpreted these items in the EDE‐Q according to EDE Interview guidelines (Fairburn et al. 2008), we note that the EDE‐Q has limited flexibility in accounting for diverse presentations of eating‐disorder psychopathology and adopts a thin‐centric model (Reilly et al. 2025). As such, participants' responses may reflect eating psychopathology related to orthorexia, excessive preoccupation with muscularity, and/or food avoidance that could indicate avoidant/restrictive food intake disorder but is nonetheless inconsistent with the intent of the items.

Third, since many people conflate BMI, weight, and shape with health (Krems and Neuberg 2022; Tomiyama et al. 2016; Wright et al. 2006), individuals may respond inconsistently due to an inability to distinguish between the concepts. Other research suggests that individuals who perceive themselves as overweight/obese report greater eating‐disorder psychopathology and poorer perceived health (Hamilton et al. 2023), suggesting that eating‐disorder behaviors may be motivated by health for individuals of higher weight. Alternatively, some participants may present pathological eating behaviors as desirable health behaviors because of pervasive social bias that pursuing health (including weight loss) is a moral responsibility (Conrad 1994; Jean Marks et al. 2020).

Fourth, the EDE‐Q has been criticized for using a female‐centric model, which overlooks the experiences of men, non‐binary, and/or trans individuals (Laskowski et al. 2023; Nagata et al. 2020). Indeed, our findings revealed gendered experiences in how participants respond to EDE‐Q items. On items that were designed to measure restraint, men discussed deliberately increasing their food intake and imposing calorie minimums to gain weight and strength. Although men would select “Not at all” for these items, their qualitative responses indicated muscularity‐oriented disordered eating. Further, the wording of some items may be problematic for men who idealize a muscular physique if they presume that the participant desires a thin physique. Some shape items ask about overall dissatisfaction (which may be interpreted as muscularity dissatisfaction for men), while others ask about fear of weight gain (which some men described as a desire to build muscle). This was evident in the gendered inconsistencies we observed. Overall, these findings indicate that eating‐disorder psychopathology, particularly among cisgender and heterosexual men, may be underreported using the EDE‐Q, and researchers should consider if other measures are more suitable for men.

Finally, previous research emphasizes the value of integrating qualitative feedback into the refinement of psychological instruments (Mason et al. 2023). Our findings suggest several potential refinements. First, items could be updated to emphasize (bold, underline, italicize) key words to underscore that participants should only consider weight and/or shape reasons when selecting their response. Second, items that ask about discomfort with seeing the body should specify for weight and/or shape reasons, since some participants reported discomfort for other reasons (e.g., modesty, conservativeness). Third, certain concepts tended to be misinterpreted, like shape, weight, feeling fat, and overvaluation. Since researchers have explored shortened versions of the EDE‐Q that use these items and found that these items have good internal consistency and predict more severe eating‐disorder psychopathology (Dufour et al. 2025; Jenkins and Davey 2020), one recommendation is to provide more detailed definitions of these concepts in lieu of additional items. Additionally, we stress that further qualitative research, especially in clinical samples, should be conducted to better understand how to refine EDE‐Q items.

5. Limitations and Future Directions

This study is not without limitations. First, the sample was comprised of undergraduate psychology students, and additional findings may arise in a more diverse sample. For example, individuals of diverse body sizes and cultural, ethnic, or socioeconomic backgrounds may have different body weight and shape ideals (Kambanis et al. 2022) and disordered eating behaviors (Hamilton et al. 2023; Henrich et al. 2010). Future research should incorporate participants' open‐ended responses alongside their sociodemographic information to gain insight into how cultural body ideals and socioeconomic factors influence the way eating disorders are experienced. Individuals of other gender identities (e.g., non‐binary, transgender) may also have different ideals and underlying motivations for pursuing these ideals (Richburg and Stewart 2024). Additionally, given the non‐clinical nature of the sample and the finding that almost half the sample selected “No days” or “0” as a Likert response, there is likely more variability in clinical samples. Relatedly, participants with lived eating disorder experience may have more in‐depth knowledge of eating disorders, which may influence their responses, but we did not assess eating‐disorder psychopathology with an independent measure. Ultimately, future research should explore qualitative responses to EDE‐Q items using more diverse and clinical samples to better understand how participants interpret items beyond college students.

Second, the interpretation of qualitative data may be influenced by the researcher's perspective and varying levels of expertise in eating‐disorder psychopathology. We acknowledge this potential bias and emphasize the importance of replication to strengthen the validity of our findings. Third, a minority of responses were insufficient to code due to limited text. The length of the EDE‐Q, coupled with participant fatigue, may exacerbate this issue and miss the cognitive processes of participants who do not respond adequately. Future research could use in‐person think‐aloud protocols, which could provide additional complementary insights into participants' cognitive processes in real time (Mason et al. 2023).

6. Conclusion

This study provided qualitative evidence that there is variation in how individuals interpret and respond to items on the EDE‐Q, which clinicians and researchers have described anecdotally. Qualitative methodology provided deeper insight into how respondents engage with the EDE‐Q. A minority of responses reflected confusion, misinterpretation, gendered patterns of responding, and Likert‐scale selections that did not always align with participants' qualitative explanations. Overall, findings have important implications for refining the EDE‐Q, which could enhance its clinical and research utility. Moving forward, refining questionnaire items based on qualitative insights could help ensure that the EDE‐Q more accurately captures eating‐disorder psychopathology across diverse populations.

Author Contributions

Katarina L. Huellemann: conceptualization, methodology, project administration, data collection, data analysis, writing – original draft, writing – review and editing, supervision of SO. Safia Ouédraogo: data collection, data analysis, methodology, writing – original draft, writing – review and editing. Janet A. Lydecker: writing – review and editing, conceptualization, methodology. Sarah E. Racine: supervision, writing – review and editing, resources.

Lived Experience Involvement Statement

No specific efforts were undertaken to involve persons with lived experience in the study design or execution, or in the preparation of this manuscript.

Funding

This research was supported by a Social Sciences and Humanities Research Council Postdoctoral Research Award to Katarina L. Huellemann and the Canada Research Chairs Program awarded to Sarah E. Racine.

Ethics Statement

Data collection for this project was granted ethical approval by the McGill University Research Ethics Board‐II (#24‐09‐067).

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1: Supporting Information 1.

Data S2: Supporting Information 2.

Huellemann, K. L. , Ouédraogo S., Lydecker J. A., and Racine S. E.. 2026. “Investigating Perceptions of the Eating Disorder Examination‐Questionnaire Among Undergraduate Students: A Qualitative Approach.” International Journal of Eating Disorders 59, no. 8: 1673–1686. 10.1002/eat.70102.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.