The development and validation of the food craving acceptance and action questionnaire (FAAQ).

Abstract

Research has suggested that mindfulness and acceptance may be important factors in the development, maintenance and treatment of both obesity and eating disorders. However, very few scales exist that apply constructs of acceptance and mindfulness to eating behavior. A measure of acceptance about food related thoughts would be especially beneficial in investigating links between acceptance and problematic eating, and in better understanding mechanisms of action of effective treatments for obesity and eating disorders. The Food Acceptance and Awareness Questionnaire (FAAQ) was developed to measure acceptance of urges and cravings to eat or the extent to which individuals might try to control or change these thoughts. The FAAQ is a self-report questionnaire made up of ten items each rated on a seven-point Likert scale (1=very seldom true to 6=always true). Higher scores indicate greater acceptance of motivations to eat. The FAAQ was given to a sample of 463 undergraduate students along with several other measures of eating behavior and other psychological variables. Concurrent associations with variables theorized to be closely linked (Eating Attitudes Test, EAT; the Dutch Eating Behavior Questionnaire, DEBQ; body mass index, BMI) and not very closely linked (the Depression Anxiety Stress Scale, DASS) were evaluated in order to indicate the new scale's convergent and divergent validity. These results demonstrated highly significant correlations with these measures in the expected direction, with stronger correlations for the theoretically-consistent variables than the theoretically-inconsistent variables. Exploratory factor analyses confirmed a structural two-factor model. Factor 1 seems to measure one's ability to regulate eating despite urges and cravings, and Factor 2 seems to measure desire to maintain internal control over eating thoughts. The FAAQ was also administered to a separate sample of 29 overweight or obese women enrolled in a weight loss program, and found to be predictive of weight loss. Taken together, results suggest that the FAAQ is a psychometrically sound instrument which might be a valuable tool for assessing acceptance of food related thoughts and urges.

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The development and validation of the food craving acceptance and
action questionnaire (FAAQ)☆
Adrienne Juarascioa, Evan Formana,⁎, C. Alix Timkob, Meghan Butryna, Christina Goodwina
aDrexel University, Philadelphia, PA, USA
bUniversity of the Sciences, Philadelphia, PA, USA
a b s t r a c ta r t i c l e i n f o
Article history:
Received 30 September 2010
Received in revised form 9 March 2011
Accepted 14 April 2011
Available online 21 April 2011
Keywords:
Obesity
Acceptance
Psychological flexibility
Eating behaviors
Research has suggested that mindfulness and acceptance may be important factors in the development,
maintenance and treatment of both obesity and eating disorders. However, very few scales exist that apply
constructs of acceptance and mindfulness to eating behavior. A measure of acceptance about food related
thoughts would be especially beneficial in investigating links between acceptance and problematic eating,
and in better understanding mechanisms of action of effective treatments for obesity and eating disorders.
The Food Acceptance and Awareness Questionnaire (FAAQ) was developed to measure acceptance of urges
and cravings to eat or the extent to which individuals might try to control or change these thoughts. The FAAQ
is a self-report questionnaire made up of ten items each rated on a seven-point Likert scale (1=very seldom
true to 6=always true). Higher scores indicate greater acceptance of motivations to eat. The FAAQ was given
to a sample of 463 undergraduate students along with several other measures of eating behavior and other
psychological variables. Concurrent associations with variables theorized to be closely linked (Eating
Attitudes Test, EAT; the Dutch Eating Behavior Questionnaire, DEBQ; body mass index, BMI) and not very
closely linked (the Depression Anxiety Stress Scale, DASS) were evaluated in order to indicate the new scale's
convergent and divergent validity. These results demonstrated highly significant correlations with these
measures in the expected direction, with stronger correlations for the theoretically-consistent variables than
the theoretically-inconsistent variables. Exploratory factor analyses confirmed a structural two-factor model.
Factor 1 seems to measure one's ability to regulate eating despite urges and cravings, and Factor 2 seems to
measure desire to maintain internal control over eating thoughts. The FAAQ was also administered to a
separate sample of 29 overweight or obese women enrolled in a weight loss program, and found to be
predictive of weight loss. Taken together, results suggest that the FAAQ is a psychometrically sound
instrument which might be a valuable tool for assessing acceptance of food related thoughts and urges.
© 2011 Elsevier Ltd. All rights reserved.
1. Introduction
The World Health Organization, 2006 reports that the number of
obese individuals (BMIN30 kg/m2) is fast approaching two billion
worldwide (2006). Obesity is associated with numerous health risks
ranging from osteoarthritis to heart disease, diabetes, cancer and
death (Center for Disease Control & Prevention, 2009). Unfortunately,
despite our best efforts to promote weight loss, current gold standard
treatments produce only moderate weight loss and the weight is
typically regained (Brownell, 2010). In response to this ever-growing
epidemic, numerous attempts at increasing healthy eating behaviors
among the overweight and obese have increased. One potential way
of increasing healthy eating behaviors amongst this population is to
determine whether certain psychological variables are associated
with successful weight loss and maintenance. Weight loss interven-
tions designed to increase these psychological factors could poten-
tially help others with their weight loss goals.
Recent research suggests that psychological flexibility, which is a
concept targeted in many of the newer third generation cognitive
behavioraltherapies,playsanimportantroleineatingbehaviors(Byrne,
Cooper, & Fairburn, 2003; Fassino et al., 2002; Rydén et al., 2003).
Psychological flexibility refers to an ability to choose from a range of
behavioral options based on one's personal values as opposed to being
constrainedbyanunwillingnesstoexperienceunpleasantordistressing
thoughts and feelings (Hayes, Strosahl, & Wilson, 1999). As such it
depends on the related constructs of psychological acceptance (i.e., a
psychological stance of openness towards the full range of experience,
including difficult thoughts, emotions and physiological experiences
withoutattemptingto control, alter, suppress or avoid theexperiences)
and willingness (i.e., the ability to choose value or goal-consistent
behaviors even when they provoke distressing thoughts and feelings).
Willingness, a term used by third generation behavioral therapies such
Eating Behaviors 12 (2011) 182–187
☆ The authors wish to thank Stephanie Goldstein and Janice Chubski for their help in
collecting the data for this manuscript.
⁎ Corresponding author at: Department of Psychology, Drexel University, 245 N. 15th
Street, MS 515, Philadelphia, PA 19102, USA.
E-mail address: evan.forman@drexel.edu (E. Forman).
1471-0153/$ – see front matter © 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.eatbeh.2011.04.008
Contents lists available at ScienceDirect
Eating Behaviors

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asAcceptanceandCommitmentTherapy,referstotheabilitytoperform
a behavior even when doing so brings with it aversive internal
experience (Hayes & Strosahl, 2004).
Research has demonstrated that the extent to which an individual
is able to accept unpleasant thoughts and feelings without trying to
diminish the internal experience either mentally (e.g., suppression
and distraction) or behaviorally (e.g., by performing an action likely to
produce change in the experience, such as eating a desired food) is
predictive of health and psychological outcomes. Psychological
acceptance (sometimes referred to as its converse, experiential
avoidance) predicts treatment-related improvements in health
behaviors including binge eating (Kristeller, Baer, & Quillian-Wolever,
2006), alcohol abuse (Brown, Evans, Miller, Burgess, & Mueller, 1997;
Patten, Drews, Myers, Martin, & Wolter, 2002), smoking (Gifford et al.,
2004) and a range of other maladaptive health behaviors (Hayes,
Luoma, Bond, Masuda, & Lillis, 2006).
Although some previous research has investigated the relation-
ships between eating behaviors and psychological flexibility, the
literature is limited. Prior work has demonstrated that individuals
who are successful at maintaining weight loss have more flexible
strategies in terms of how they cope with food cravings; in contrast,
individuals who are unable to maintain weight loss have a reduced
ability to cope with stress or negative emotions, and over-rely on
avoidance or control behaviors, such as eating in response to
distressing affect (i.e., “emotional eating”; Byrne et al., 2003; Fassino
et al., 2002; Rydén et al., 2003). There are theoretical reasons and
empirical evidence that suggest that the inability to accept food
cravings/urges and subsequent efforts to control or reduce these
cravings is tied to overeating and weight gain. Emotional eating,
which can be conceptualized as a learned response aimed at
controlling undesirable internal states, has been linked to an inability
to lose weight in a sample of 187 overweight adults who participated
in a group weight loss treatment (Blair, Lewis, & Booth, 1990). Binge
eating, and overeating more broadly, is often motivated by a desire to
escape from an aversive emotional state or to decrease distressing
thoughts (Heatherton & Baumeister, 1991). Experiential avoidance, or
a desire to reduce or control distressing feelings and cognitions, more
generally has been associated with increased difficulty in maintaining
lost weight (Lillis, Hayes, Bunting, & Masuda, 2009). Therefore,
strategies designed to increase acceptance of distressing thought
and cognitions, and reduce problematic control or avoidance
strategies, could theoretically decrease episodes of overeating.
Current research has shown the promise of acceptance-based
interventionsat increasingphysical activity(Butryn,Forman,Hoffman,
Shaw,&Juarascio,2011),managingfoodcravings(Formanetal.,2007),
and maintaining weight loss (Forman, Butryn, Hoffman, & Herbert,
2009). Other work has shown that one of the strongest predictors of
reducing binge eating in obese adults was the amount of time spent
engaging in eating-related mindfulness (Kristeller et al., 2006).
However, despite the reported effectiveness of acceptance-based
interventions at improving eating-related and weight loss behaviors,
no reliable method exists for reliably measuring levels of acceptance
regarding thoughts and feelings that arise in a food rich environment.
Previous research has demonstrated that measures of acceptance that
arebettertargetedtothespecificconceptsofinterestaremoresensitive
than more generalized measures such as the Acceptance and Action
Questionnaire (AAQ; Gifford, Antonuccio, Kohlenberg, Hayes, &
Piasecki,2002;Piaseki;Lillis &Hayes, 2008; Sandoz, Wilson,& Merwin,
in progress; Shawyer et al., 2007; Westin, Hayes, & Andersson,
2008).While general acceptance measures do exist, a food-specific
measuremaybemoresensitive,aspreviousresearchhasindicatedthat
specific measures designed for other health-related behaviors (e.g.,
smoking and pain) are highly predictive of success in interventions for
those behaviors. A measure of psychological flexibility that assessed
acceptance and willingnessto experiencefood-related thoughts would
be especially beneficial in investigating links between acceptance and
problematic eating, and in better understanding mechanisms of action
of effective treatments for obesity. To address this need the Food
Craving Acceptance and Action Questionnaire (FAAQ) was developed.
TheFAAQwasdevelopedtomeasurepsychologicalflexibilityinafood-
rich environment by assessing psychological acceptance of, versus a
need to control, aspects of food-related experience (i.e., cravings and
urges to eat). The scale was designed to measure both acceptance of
distressing internal experiences and willingness to take action and eat
inahealthymannerevenwhendoingsobringswithitaversiveinternal
experience This paper will review three preliminary studies which
investigate the reliability and validity of the FAAQ.
2. Method and results
2.1. Scale creation
The FAAQ is based on Chronic Pain Acceptance Questionnaire
(CPAQ; McCracken, Vowles, & Eccleston, 2004), which is itself based
on the Acceptance and Action Questionnaire-2 (AAQ-II; Bond et al.,
submitted for publication). The CPAQ is a 20-item measure assessing
acceptance of chronic pain (McCracken et al., 2004) that has been
well-validated (Vowles, McCracken, Mcleod, & Eccleston, 2008).
Therefore, it appeared to be suitable for adaptation for use with
eating urges and eating behaviors. The items to be modified were
chosen by two of the authors (EMF, MLB) who had prior experience
with both third generation cognitive behavioral treatments and
weight loss treatment. The modified version, referred to as the
Food-related Acceptance and Action Questionnaire (F-AAQ) contains
10-items (e.g., “I need to concentrate on getting rid of my urges to eat
unhealthily,” reversed scored) which are rated on a 6-point Likert
scale (1=very seldom true to 6=always true). A summary score is
calculated by summing the ten items. Higher scores indicate greater
acceptance of motivations to eat.
2.2. Study 1
Study 1 was designed to examine convergent and divergent
validity. This was accomplished by administering the FAAQ and
several questionnaires that assessed variables that are theoretically
similar (general psychological acceptance, food susceptibility, disor-
dered eating, and body image dissatisfaction) and dissimilar (depres-
sion, self-esteem, and alexithymia) to the FAAQ.
2.2.1. Participants
Study 1 utilized a community (n=240) and undergraduate
student (n=705) sample of 955 participants. Community partici-
pants were recruited via a number of on-line web sites devoted to
psychological research; as such, participants wereanonymousand did
not receive compensation. The average BMI of community partici-
pants was 24.28 (SD=6.03) and the average age was 26.88
(SD=10.39). The mean age of the student sample was 19.38
(SD=4.32), with a mean BMI in the normal weight range
(M=25.09, SD=2.99). The total sample was 56.40% female and
primarily Caucasian (78.80%, African American: 8.60%, Hispanic:
3.00%, Asian: 6.50%, Other: 3.1%).
2.2.2. Measures
2.2.2.1. Acceptance and action questionnaire-II (AAQ-II, Bond et al.,
submitted for publication). The AAQ-II is a 10-item measure designed
to assess psychological flexibility and acceptance of internal experi-
ences. Higher scores for the total scale indicate a greater degree of
psychological flexibility. Cronbach's alpha in this sample was 0.84.
2.2.2.2. Body shape questionnaire (Cooper, Taylor, Cooper, & Fairburn,
1987). The BSQ is a 34-item questionnaire that measures the extent to
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which individuals are preoccupied with, or self-conscious about, their
weight and appearance. Individuals who receive a score above 129 are
likely to have clinically significant body image dissatisfaction,
although the scale is often used as a continuum. The measure has
acceptable validity and reliability (Cronbach's alpha=0.96).
2.2.2.3. Depression anxiety stress scale (DASS; Lovibond & Lovibond,
1995). The DASS is a widely used self-report instrument designed to
measure depression, anxiety and tension/stress. The 21-item version
was used for this study. Each of the three DASS scales contains 7 items,
divided into subscales of 2–5 items with similar content. Participants
use a 4-point scale to rate the extent to which they have experienced
each state over the past week. Scores for depression, anxiety and
stressare calculatedby summingthescoresfor therelevantitems.The
scale had good internal reliability in this sample (Cronbach's
alpha=0.97).
2.2.2.4. Dutch eating behaviors questionnaire (DEBQ; Van Strien, Frijters,
Bergers, & Defares, 1986). The DEBQ assesses emotional eating
(overeating in respond to emotions, 13 items, Cronbach's α=0.95),
external eating (eating in response to food-related stimuli, regardless
of the internal state of hunger and satiety, 10 items, Cronbach's
α=0.88), and restrained eating (attempts to refrain from eating, 10
items, Cronbach's α=0.93).
2.2.2.5. Eating attitudes test (EAT-26; Garner, Olmsted, Bohr, &
Garfinkel, 1982). This 26-item scale is commonly used to help
diagnose eating disorders and provides a reliable measure of the
frequency of disordered eating behaviors. Participants who receive a
score of 20 or greater are advised to seek professional treatment. The
EAT-26 has three subscales: Dieting (α=0.98), Bulimia and Food
Preoccupation (α=0.97), and Oral Control (α=0.98). The total scale
had high internal validity (Cronbach's α=0.99).
2.2.2.6. Power of food scale (PFS; Lowe et al., 2009). The PFS is a 15-item
measure designed to assess a predisposition toward being highly
responsive to a food plentiful environment in the absence of actual
food consumption. Higher scores on this scale indicate a higher level
of responsiveness to the food environment. Cronbach's α in this
sample was 0.93.
2.2.2.7. Rosenberg self-esteem scale (RSE; Rosenberg, 1965). The RSE is a
10-item scale designed to assess global self-esteem. The scale ranges
from 0 to 30. Scores between 15 and 25 are within normal range;
scores below 15 suggest low self-esteem. Cronbach's α in this sample
was 0.71.
2.2.2.8. Toronto alexithymia scale-20 (TAS, Bagby, Parker, & Taylor,
1994-II). The TAS-20 is a 20-item measured designed to assess
Alexithymia. It has 3 factors including: difficulty identifying feelings
and distinguishing them from bodily sensations, difficulty describing
feelings to others, and externally oriented thinking. The TAS-20 uses
cutoff scoring, with scores equal to or less than 51 suggesting non-
alexithymia, scores equal to or greater than 61 suggesting alexithymia
and cores of 52 to 60 suggesting possible alexithymia. The total score
had an internal reliability of 0.84.
2.2.3. Procedure
As part of a larger study, participants were administered a battery
of measures including those described above. Approximately 54.7% of
519 community members who began the questionnaires completed
them. Of the 284 completers, 44 were removed due to being under 18,
not providing weight or height, or for obvious response sets (e.g.,
always checking the first option on all questionnaires). Students were
provided with extra credit for completion of the measures. As such, all
students in eligible classes had the opportunity to choose from any
number of studies. Of those who signed up to participate in this study,
all students completed the measures.
2.2.4. Results
The mean score on the FAAQ was 42.42 (SD=8.5, range: 14–67).
Internal consistency was found to be satisfactory, with a Cronbach's
alpha score of .68. In order to assess how the FAAQ related to other
variables that were theoretically similar, a series of correlation
analyses were conducted. Significant moderate correlations were
found with all of the theoretically similar measures of eating behavior
and acceptance as well as BMI. See Table 1 for a correlation matrix of
these results. In order to assess divergent validity, correlations
between the FAAQ and theoretically-dissimilar measures were
examined. See Table 1 for this correlation matrix. Overall, the
correlationsbetweentheFAAQandthetheoreticallydissimilarvariables
were either not significant or were weaker than for the theoretically
similar measures: mean rinconsistent=.14, mean rconsistent=.28, Fishers
Z=3.24, pb.001). In addition to the FAAQ total scores, the subscale
scores of the FAAQ (identified below in Study 2; Acceptance and
Willingness), were compared to the theoretically similar and dissimilar
variables. These results can also be seen in Table 1. The correlations
betweentheFAAQ subscale Willingnessand thetheoretically dissimilar
variables were either not significant or were weaker than for the
theoretically similar measures (rinconsistent=.16, mean rconsistent=.31,
Fishers Z=3.47, pb.001). This was not true for the FAAQ subscale
Acceptance (rinconsistent=.04, mean rconsistent=.09, Fishers Z=1.1,
p=.27).
To identify the factor structure, exploratory factor analyses were
performed for the 955 participants who completed study one. The
exploratory factor analysis conducted for study one extracted factors
with generalized least squares estimation. Because the factors in this
questionnaire were likely to be correlated with each other, an oblique
rotation was applied to the solution rather than an orthogonal
rotation. The viability of solutions containing between one and five
factors were examined based on the number of eigenvalues greater
than 1, scree plots, and Kaiser's criterion. A one-factor solution was
rejected because it yielded a significantly poorer representation of the
data than a two-factor solution. Likewise, three, four, and five factor
solutions were rejected due to eigenvalues of significantly less than
Table 1
Bivariate correlations between FAAQ and psychological variables.
FAAQ totalAcceptanceWillingness
rprprp
Similar
EATtotal
EATdiet
EATbul
EAToral
BSQ
PFStotal
PFSfoodavailability
PFSfoodpresence
PFSfoodtaste
DEBQemotional
DEBQexternalization
DEBQrestraint
AAQ-II total
BMI
−.22
−.26
−.27
.05
−.42
−.37
−.26
−.39
−.19
−.34
−.27
−.21
.33
−.22
b.001
b.001
b.001
.13
b.001
b.001
b.001
b.001
b.01
b.001
b.001
b.001
b.001
b.001
.14
.17
.01
.30
.15
b.001
b.001
.91
b.001
b.01
.25
.33
.97
.32
.30
.96
b.001
.45
.40
.32
.38
.26
.19
.51
.37
.29
.36
.27
.38
.30
.33
b.001
b.001
b.001
b.05
b.001
b.001
b.001
b.001
b.001
b.001
b.001
b.001
b.001
.24
−.04
.06
.01
.07
.03
−.01
.32
.04
−.04
−.27
.20
Dissimilar
Rosenberg
TASdescribe
TASid
TASthink
DASStotal
DASSdepression
DASSanxiety
DASSstress
.11 .002
.053
b.001
.003
b.001
b.001
b.001
b.001
.08
b.01
.06
.97
.51
.49
.50
.25
.61
−.04
.09
.11
.18
.28
.22
.13
.22
.24
b.05
b.05
b.001
b.001
b.001
b.001
b.001
−.09
−.22
−.16
−.25
−.23
−.15
−.16
−.09
−.01
−.03
.03
−.02
−.04
.02
184
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1.0. The final two-factor model accounted for 62.48% of the variance,
and all eigenvalues were greater than 1.0. Factor 1, which contains 6
items, seems to measure one's willingness to regulate eating, despite
urges, cravings, or distressing emotions associated with eating in a
healthy manner (see Table 2; α: 0.84). Factor 1 was therefore labeled
“Willingness” in that it measures an individual's willingness to
regulate eating behavior despite cravings. Willingness was chosen
as the name for Factor 1 to correspond with the usage of the term
willingness in the Acceptance and Commitment therapy literature
(Hayes & Strosahl, 2004). Factor 2, labeled Acceptance, (4 items)
appears to measure how accepting an individual is towards his or her
distressing food-related thoughts (α: .84). The two factors were
significantly correlated, although the strength of the correlation was
only in themedium range(r=.33,pb.001). The presence ofthese two
factors suggests that the measure assesses both acceptance and
willingness, which are the two factors that comprise psychological
flexibility. Therefore, the FAAQ appears to be an adequate measure of
psychological flexibility about eating-related experiences and
behaviors.
2.3. Study 2
Study 2 was designed to examine test–retest reliability and
internal consistency. This was accomplished by administering the
FAAQ at two time points. At time point 1, the FAAQ was administered
online. At time two, the FAAQ was administered in person.
2.3.1. Participants
Study two used a separate sample of 40 undergraduate women
recruited through undergraduate psychology classes. The mean age of
this sample was 20.26 (SD=3.01), with a mean BMI in the normal
weight range (M=22.38, SD=3.00). The sample was 62% Caucasian,
16% Asian, 4% African American, 2% Latino, and 16% Other.
2.3.2. Procedure
Participants completed an online FAAQ, and then completed the
FAAQ for second time, online, 3–7 days later. An Intra Class
Correlation (ICC) was used to assess test–retest reliability.
2.3.3. Results
Internal consistency was found to be high, with a Cronbach's alpha
score of .93, and test–retest reliability was shown to be acceptable
(ICC=.72, CI=.531–.841). Test–retest reliability was also acceptable
for both subscales (Acceptance: ICC=.738, CI=.558–.852; Willing-
ness: ICC=.786, CI=.632–.880). BMI was again correlated with FAAQ
scores (r=−.31, pb.05).
2.4. Study 3
Study 3 was designed to assess how responses on the FAAQ might
change during a 12 week weight loss treatment and whether the
FAAQ could prospectively predict weight loss. The FAAQ was given at
pre- andpost-treatment, andits relation to weightloss was examined.
2.4.1. Participants
The final study used a sample of 29 overweight women who
participated in an acceptance-based behavioral weight loss program.
The age of the participants ranged from 23 to 58 (M=43.66,
SD=9.79), and 51.70% were Caucasian (48.30% African American).
BMI ranged from 25.61 to 48.69, with a mean of 35.77 (SD=5.44).
Among treatment completers (n=19; 34% attrition), weight loss
averaged 6.6% of body weight at post-treatment See Forman et al.
(2009) for more information on the participants in this study.
2.4.2. Procedures
The FAAQ was administered at both the pre- and post-treatment
assessments along with several other questionnaires. BMI was also
assessed at both assessment points.
2.4.3. Results
Cronbach's alpha for the total FAAQ scale at pre-treatment was .66
(Acceptance=.60, Willingness=.82). As reported in Forman et al.
(2009), the mean FAAQ score at baseline was 28.13 (SD=8.00). By the
end of treatment, the mean FAAQ score had increased to 34.47
(SD=7.71). This represented a significant increase in psychological
flexibility (t(17)=−4.05, p=.02). A residualized change score was
calculated by regressing the baseline score on the post-intervention
score. A regression analysis was then used to assess the relationship
between change in FAAQ total scores and weight loss at post-treatment.
Weight at pre-treatment was controlled for in the equation. The
residualized change scores on the FAAQ was found to be predictive of
weight loss (β=1.05, t(17)=−4.19, p=.04), with those who showed
greater increases in FAAQ scores experiencing the most weight loss. We
performed the same regression analyses with the two subscales of the
FAAQ. The acceptance subscale was not significantly related to weight
loss (β=.06, t(17)=0.73, p=.48). The willingness scale was signifi-
cantly related to weight loss (β=−6.06, t(17)=−3.25, pb.01),
suggestingthatwillingnesstoregulateeatingdespitedistressingcravings
or emotions is more predictive of weight loss than acceptance per se.
3. Discussion
Previous research has indicated that although acceptance and
willingness may be important factors in eating behavior, there is
currently no well-validated measure of this construct in the context of
responses to food. The current studies sought to investigate the
reliability and validity of the Food Craving Acceptance and Action
Questionnaire, which wasdesigned to measurepsychologicalflexibility
in a food rich environment, by assessing acceptance of distressing food
relatedthoughtsorcravingsandwillingnesstoengageinhealthyeating
despite these experiences.
Preliminary analyses suggest that the FAAQ measure has acceptable
reliability and validity. Amongst a sample of 955 undergraduates and
community members, the measure had satisfactory internal consisten-
cy, but amongst a separate sample of 40 undergraduates the measure
had excellent internal consistency, possibly due to the more homoge-
nous nature of the second sample, which consisted entirely of
undergraduate women. The measure also showed adequate test–retest
Table 2
Questions in Factor 1 and Factor 2.
FAAQ factors
FAAQ items Factor 1:
Willingness
Factor 2:
Acceptance
1. I continue to eat a healthy diet, even when I have
the desire to overeat or make poor eating choices.
2. It's OK to experience cravings and urges to overeat,
because I don't have to listen to them.
3. It's necessary for me to control my food urges in
order to control my eating.
5. I don't have to overeat, even when I feel like I want
to overeat.
8. Despite my cravings for unhealthy foods, I continue
to eat healthily.
10. Even if I have the desire to eat something
unhealthy, I can still eat healthily.
4. I need to concentrate on getting rid of my urges to
eat unhealthily.
6. Controlling my urges to eat unhealthily is just as
important as controlling my eating.
7. My thoughts and feelings about food must change
before I can make changes in my eating.
9. Before I can make any important dietary changes, I
have to get some control over my food urges.
.77.05
.79 .00
.59 .25
.73.17
.74 .13
.82 .13
−.03 .79
.34.74
.03.85
−.04 .87
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reliabilityamongstthesmallersampleofundergraduates.Theconstruct
validity of the measure was supported by its moderately strong
association with several theoretically similar measures and its signifi-
cantly weaker associations with theoretically dissimilar measures. The
relatively strong correlation with the PFS supports the specificity of the
FAAQ,asthePFS is designed tomeasurethe extentto whichindividuals
arestronglyaffectedbythefoodenvironmentandwhethertheyareable
to resists urges to consume highly palatable foods.
Amongst the larger sample of undergraduates, a Factor Analysis
supported a2-factorstructure,with Factor1measuringwillingness and
Factor 2 measuring acceptance. Both Factors has acceptable internal
consistency, which was typically higher than the internal consistency
for the total scale. This might suggest that the scale measures two
distinct constructs, and that the use of the subscales, rather than the
total scale may provide more information. Factor 1 can be conceptual-
ized as measuring the extent to which one is able to choose value or
goal-consistent behaviors for weight management and healthy eating
even when they provoke distressing thoughts and feelings such as
cravings, feelingsofhunger, etc. Factor 2appears tomeasure thedegree
to which an individual is open to experiencing cravings, emotions and
physiological experiences associated with food and eating without
attemptingtocontrol,alter,suppressoravoidtheexperiences.Although
both subscales appear to assess distinct constructs, it seems like the
Willingness subscale is more related to theoretically similar constructs,
and therefore might have better construct validity. The Willingness
subscale was also more predictive of weight loss, suggesting that this
scale might be driving most of the total scales predictive power.
However, the two subscales together appear to assess psychological
flexibility, that is, the extent to which an individual chooses behavioral
options that are consistent with their values of healthy eating and
weight control, even if they are experiencing distressing thoughts,
hunger, or cravings. Future research is needed to validate these
subscales and to replicate findings of convergent and divergent validity
with broader measures of eating behavior and other non-eating related
variables. Additionally, future research is needed to demonstrate
whether these sub-factors can be used independently, and how they
individually predict eating behavior.
Given that the measure had acceptable reliability and validity in a
non-clinical population, it was important to test this measure
amongst a sample where acceptance of and willingness to experience
food-related thoughts and feelings might be especially important.
Therefore, the predictive validity of the FAAQ was assessed by
administering the measure to a sample of overweight women in an
open trial of acceptance-based behavioral treatment for weight loss.
As expected, psychological flexibility did increase substantially over
the course of the intervention, and this increase was predictive of
weight loss. These findings further support how important the
constructs of psychological flexibility, acceptance, and willingness
are in determining eating behavior and therefore supports the
measurement of these constructs in weight loss trials.
Overall, the current studies indicate that the FAAQ is a valid and
reliable measure. However,there are several limitations to the current
studies and further investigation is needed before this measure can be
confidently used to assess the constructs of acceptance and willing-
ness. For instance, although undergraduate, community, and clinical
samples were utilized, only the undergraduate/community sample
was large enough to investigate reliability and validity. Future work
must test the FAAQ in other populations, especially in overweight or
obese samples. In addition, further tests of reliability and validity
would be beneficial to ensure that the psychometric properties of this
measure are well established and the current findings are replicable.
Taken together, previous work and current findings suggest that
the creation of the FAAQ is an important step in better understanding
how acceptance of distressing thoughts and feelings regarding food
can contribute to eating behaviors and weight. Prior research has
begun to investigate how psychological flexibility in general can
contribute to weight and eating behavior, but a specialized measure
such as the FAAQ may provide a greater understanding of the
relationship between acceptance of distressing food cravings and food
consumption. This measure could be utilized to predict whether
certain individuals will be able to lose or maintain a healthy weight,
and can be used to track changes in acceptance of food related
thoughts and cravings during weight loss trials. Future research with
this measure may provide a greater understanding of problematic
eating and mechanisms of action for effective treatments of obesity.
Role of funding sources
There was no external funding for this study.
Contributors
Evan Forman, Meghan Butryn, and C. Alix Timko designed the study and wrote the
protocol. Christina Goodwin conducted literature searches and provided summaries of
previous research studies. Adrienne Juarascio conducted the statistical analysis and
wrote the firstdraft of the manuscript and allauthors contributed to and have approved
the final manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
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