Translation of the nine item avoidant/restrictive food intake disorder screen (NIAS) questionnaire in French (NIAS‐Fr)

Abstract

Background
The Nine Item Avoidant/Restrictive Food Intake Disorder (ARFID) Screen (NIAS) questionnaire is originally available in English. Given the significant overlap of ARFID‐like symptoms in gastrointestinal (GI) diseases, ARFID screening becomes crucial in these patient populations. Consequently, the translation of the NIAS questionnaire into French is necessary for its utilization in French‐speaking countries.

Methods
Clinical experts in neuro‐gastroenterology and dietetics from four medical centres in two French‐speaking countries (France and Belgium) took part in a well‐structured questionnaire translation procedure. This process involved six steps before final approval: translation from English to French, backward translation, comparison between the original and retranslated versions, testing the translated version on patients, making corrections based on patient feedback, and testing the corrected version on an additional sample of patients.

Key Results
The NIAS questionnaire in French (NIAS‐Fr) was tested on 18 outpatients across the involved centres. For the majority of native French‐speaking patients, the translated questionnaire was well understood and clear. After incorporating two relevant modifications suggested by the patients, the translated questionnaire was approved through testing on an additional sample of patients.

Conclusions and Inferences
The involvement of two French‐speaking countries was crucial for the harmonization and cultural adaptation of the questionnaire. As a result, the NIAS‐Fr is now available for use in 54 French‐speaking countries, serving approximately 321 million French speakers across five continents for screening ARFID, for both clinical and research purposes.

Full text

Neurogastroenterology & Motility. 2024;36:e14757.  
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https://doi.org/10.1111/nmo.14757
wileyonlinelibrary.com/journal/nmo
Received:14Decembe r2023
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Revised:18J anuar y2024
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Accepted :22Januar y2024
DOI : 10.1111/nm o.14757
TECHNICAL NOTE
Translation of the nine item avoidant/restrictive food intake
disorder screen (NIAS) questionnaire in French (NIAS- Fr)
Pauline Van Ouytsel1 | Hiba Mikhael- Moussa2 | François Mion3 | Sabine Roman3 |
Guillaume Gourcerol2,4 | Rachel Marion- Letellier2 | Hubert Piessevaux5 |
Hubert Louis1 | Chloé Melchior2,6
This is an op en access arti cle under the ter ms of the CreativeCommonsAttribution-NonCommercial License, which permits use, distribution and reproduction
in any medium, provided the original work is properl y cited an d is not use d for comm ercial purposes.
©2024TheAut hors.Neurogastroenterology & Motilityp ublish edbyJohnW iley&SonsLtd.
1Universi té libre de Bruxelles (ULB),
Hôpital Univer sitai re de Bru xelles (H.U.B),
CUB Hôpital Erasme, Department of
Gastroenterology, Hepatopancreatology
and Digestive On colog y, Brussels, Belg ium
2UnivRoue nNorma ndie,INSERM,
Norman dieUniv,AD ENUMR1073,
Nutrit ion,Inf lammat ionandmicrobiota-
gut-brainaxis ,Rouen,France
3Hospice s Civils de Lyon, Unive rsité Lyon
1, Digestive Physiology Department,
HôpitalEdouard-Herriot,Lyon,Fran ce
4Department of Physiology, CHU Rouen,
CIC-CRB1404,Rouen,Fr ance
5Depar tmentofHepato-
Gastroenterology, Cliniques universitaires
Saint-Luc(UCLouvain),B russe ls,Belgium
6Department of Gastroenterology, CHU
Rouen,CIC-CRB1404,Rouen,France
Correspondence
HibaMikhael-Mous sa,UMRI NSERM
1073 – 22 Boulevard Gamb etta, Rouen
76183,France.
Email: hiba.mikhael-moussa@univ-rouen.fr
Abstract
Background: The Nine Item Avoidant/Restrictive Food Intake Disorder (ARFID)
Screen (NIA S) questionnaire is or iginally available in English . Given the significant
overlapofARFID-likesymptomsingastrointestinal(GI)diseases,ARFIDscreeningbe-
comescrucialinthesepatientpopulations.Consequently,thetranslationoftheNIAS
questionnaireintoFrenchisnecessaryforitsutilizationinFrench-speakingcountries.
Methods: Clinic al experts i n neuro-gast roenterology an d dietetics from four m ed-
ical centre s in two French-sp eaking countries (Fran ce and Belgium) took par t in a
well-structuredquestionnaire translation procedure.This processinvolvedsixsteps
beforefinalapproval:translationfromEnglishtoFrench,backwardtranslation,com-
parison between the original and retranslated versions, testing the translated version
on patients, making corrections based on patient feedback, and testing the corrected
version on an additional sample of patients.
Key Results: TheNIASquestionnaireinFrench(NIAS-Fr)wastestedon18outpatients
acrosstheinvolvedcentres.ForthemajorityofnativeFrench-speakingpatients,the
translatedquestionnairewaswellunderstoodandclear.Afterincorporatingtworel-
evant modifications suggested by the patients, the translated questionnaire was ap-
proved through testing on an additional sample of patients.
Conclusions and Inferences: TheinvolvementoftwoFrench-speakingcountrieswas
crucialfortheharmonizationandculturaladaptationofthequestionnaire.Asaresult,
theNIAS-Frisnowavailableforusein54French-speakingcountries,servingapproxi-
mately 321 million French speakers across five continents for screening ARFID, for
both clinical and research purposes.
KEYWORDS
ARFID,functionalGastrointestinalDisorders,NIAS,questionnaire,screening

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1 | INTRODUCTIO N
According to the Diagnostic and Statistical Manual, 5th Edition
(DSM-5), Avoidant/Restrictive Food Intake Disorder (ARFID) is
classified as an eating disorder which can be applied to children,
adolescents and adults.1Unlikeothereatingdisorders,ARFIDisnot
characterized by disturbances relatedtobody weightor shape.As
a consequence of their restrictive and avoidant eating behaviors,
ARFIDpatient shaveatleast one ofthefollowing conditions: asig-
nificant weight loss, a significant nutritional deficiency, a depend-
ence on enteral feeding or oral nutritional supplement s, or a marked
interference with psychosocial functioning.2
TheNineItemARFIDScreen(NIAS)isa9-itemself-reportques-
tionnaire used as an assessment tool for detecting avoidant/restric-
tive eating patterns. This questionnaire includes three subscales:
picky eating, appetite, and fear of aversive consequences, which
are intended to align with the three presentations that are currently
includedintheDSM-5diagnostic criteria.3 Whenused alongside a
negative screening on a measure of symptoms related to other eat-
ingdisorders,such astheSCOFF,theNIAScan beused for ARFID
screening.4 In the end, the diagnosis remains clinic ally based.
StudieshaveshownthatARFIDmayco-occurwithanxiet ydisor-
dersandneurodevelopmentaldisorders,includingattention-deficit/
hyperactivity disorder and autism spectrum disorder.5 In addition,
ARFIDsymptomsarecommoningastroenterology,especiallyinpa-
tientswithdisordersofgut-braininteraction(DGBI).6 In a subgroup
ofpatients withIrritablebowel syndrome (IBS), severefood avoid-
ance has been repor ted, and these symptoms may be indicative of
ARFID.7 Whilerestrictivediets are oneaspectof IBS management,
itisimpor tanttoscreenthesepopulationsforARFIDtopreventthe
prescription of such restrictive diets to patients who might be at risk
for nutritional deficiencies and disordered eating.8
To date, the NIAS has been originally available in English.
Therefore,thereisaneedforavalidatedFrenchversionoftheNIAS
for research and clinical purposes. Henceforth, a collaborative work
wasinitiatedinvolvingtwoFrenchandtwoBelgianmedicalcentres.
Inthispaper,wereportthestructuredtranslationoftheNIASfrom
EnglishtoFrench(NIAS-Fr)anditssubsequentvalidation.
2 | MATERIALS AND METHODS
The tra nslation proce ss was initiated by c linical exp erts in neu ro-
gastroenterology (C.M., F.M., H.L., H.P.,S.R., G.C.) and indietetics
(P.V.O.)fromFrance(Rouen,Lyon)andBelgium(Brussels).Theorigi-
nal version of the questionnaire used for the translation process was
in English.
2.1 | Structures and roles
Roles were defined at the beginning of the process. There was a
coordinator who managed the whole process and communication
between all members (C.M.). Three translators, nativespeakers of
thetargetlanguage(French)andfluentinEnglish(P.V.O.,H.L.,F.M.),
translatedtheoriginalquestionnaireintoFrench.Theyworkedinde-
pendently from each other, then compared and combined the 3 ver-
sionsinone.AbackwardtranslatorhighlyexperiencedinEnglish,as
wellasnativeFrenchspeaker,translatedthefinalFrenchtranslation
back into the original language, i.e. English(R. M-L.).Two external
reviewers compared all original version with the backward versions
attheendoftheprocess(C.M.,G.C.).
2.2 | Translation procedure
First,theoriginalNIASquestionnairewastranslatedfromEnglishto
Frenchindependentlybythethreetranslators,whothencompared
their versions. Identified differences were confronted and combined
intoonecommonFrench-translatedversion.Second,thebackward
translator translated this first French version back into English.
Third,arevisionwasperformedtocomparetheoriginalNIASques-
tionnaireanditsbackwardtranslatedversion.Somesentenceswere
therefore revisedin the French version when discrepancies were
identif ied. Then, a pre-final vers ion of the NIAS ques tionnaire in
French (NIA S-Fr) was a pproved by the clinic al expert s. The com-
prehension of this version was tested on patients in French and
Belgian centers. Patients anonymously completed a form to assess
whether they perceived the questionnaire easy to understand, un-
ambiguousandclearona6-pointsscale(Stronglydisagree,disagree,
slightly disagree, slightly agree, agree, strongly agree). At no point
werehealth-relateddatacollected.Thepatientswerefinallyasked
if some queries should be modified (“yes” or “no”) and had the op-
portunity to add suggestions. Based on the patient s' feedback and
expertise of the clinicians, it was decided whether modifications
ofthequestionnairewereneededto obtain a final,clear and well-
understoodversionofthetranslatedNIASquestionnaireinthetar-
getedlanguage (NIAS-Fr)allwhilepreservingtheoriginalmeanings
fromtheEnglishversion.ThecorrectedversionoftheNIAS-Frwas
therefore evaluated on an additional sample of patients in order to
be approved. (Figure 1).
Key points
• A well-structured translation procedure of the NIA S
questionnairefromEnglishtoFrenchwasconductedby
clinicalexpertsintwoFrench-speakingcountries.
• Cultural adaptation and the identification of shared
termsandmeaningsinFrancophonecountrieswerees-
sentialinthetranslationprocesstocreateaharmonized
Frenchversion.
• TheNIAS-Frcan now be usedforclinical andresearch
purposesinallFrench-speakingcountries.

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3 | RESULTS
TheFrenchtranslatedversionofthequestionnaire(NIAS-Fr)was
submittedto 18outpatients whohadaschedule visit atthehos-
pital for a c arbohydrate hydrogen breath test in the three centres
involved (n = 8 in Brussels, n = 5 in Lyon, n = 5 in Rouen). Eighty-
three percent of the patients found that the questionnaire was
easy to understand (7/18 “strongly agree”; 7/18 “agree”; 1/18
“slightlyagree”).Thir teenoutof18patientsagreedthattheques-
tions were clear and without ambiguity, while 4 patients disagreed
on this point and one patient did not answer. Half of the patients
(10/18)suggestedtodosomemodificationsofquestionnumber1
(7/18),andques tionnumber3(2/18).Su ggestedm odificationsfor
the first question were related to misunderstanding of the terms
used, particularly concerning “je fais la fine bouche”, which trans-
latesto“Iamapickyeate r”inFrench.Eventh oughthetranslation
was correct, an explanation was added in brackets “je suis difficile
avec la nourriture”, translating to “I am picky with food”, since “je
fais la fine bouche” might also be understood as someone demand-
ing (not only with food). Concerning Question 3, it was related to
a redaction mistake. Corrections were made for those two que-
ries. Thefinal version of theNIAS-Frquestionnaire is presented
in Table 1,withthesamecut-offscoresutilized as intheoriginal
English version (Table 1).4Thisversionunderwenttestingon18
other outpatients across the three centres (n = 5inBrussels,n = 8
in Lyon, n = 5inRouen).Nearly allpatients,withtheexceptionof
FIGURE 1 ProcessforvalidationoftheFrenchversion.
1.
NIAS translaon
from English to
French
2.
NIAS backward
translaon from
French to
English
3.
Comparison
between
original English
version and
retranslated
English version :
consensus
4.
Tesng the
paents'
comprehension
of the
quesonnaire
5.
Correcon of
the French
version based
on paents'
comments and
clinicians'
experse
6.
Evaluaon of
the corrected
version on an
addional
sample of
paents
7.
Final version of
the NIAS-Fr
TAB LE 1 TranslatedFrenchversionoftheNIASquestionnaire(NIAS-Fr)(Dépistagedestroublesderestriction/évitementdelaprise
alimentaire(NIAS–Fr)).
Pas du tout
d'accord
Pas
d'accord
Légèrement
pas d'accord
Légèrement
d'accord D'accord
Tout à fait
d'accord
Mangeur d ifficile (échelle positive si score ≥ 10)
1Jefaislaf inebouche(jesuisdif ficileaveclanourriture)
2Jen'aimepasl aplupartdesaliment squelesa utres
personnes mangent.
3 La liste des aliments qu e j'aime et que je mange est plus
courte que la liste des aliments que je ne man ge pas.
Petit appétit (échel le positive si score ≥ 9)
4Mangernem' intéressepasparticulièrement:j'ail'impression
d'avoir un plus petit a ppétit que les autres personnes.
5Jedoismefo rceràmangerdesre pasrégu lierspendant
lajournéeouàmangerunequantitésuffisantede
nourriture pendant le repas.
6Mêmequa ndjemangedesalim entsquej'aimevraiment,
c'est dif ficile pour mo i d'en manger une qua ntité
suffisante lors des repas.
Peur de man ger (échel le positive si score ≥ 10)
7J'évitedem angeroujem'arrêtedemangerparcequej'ai
peur d'avoir un inconfort digestif, de m'étouffer ou de
vomir.
8 Jemelimiteàcert ainsalimentsparcequej'aipeurque
d'autres aliments décl enchent un inconfort digestif, un
étouffement ou un vomissement.
9 Jemangede spetitesportionspa rcequej'aip eurd'avoirun
inconfort digestif, de m'étouffer o u de vomir.
Note:Interprétationduscore:lesréponsesàchaquequestioncorrespondentàunscoreentre0(«Pas du tout d'accord»)et5(«Tout à fait d'accord
»).Ilya3sous-échelles(«mangeurdifficile»,questions1à3;«petitappétit»,questions4à6;«peurdemanger»,questions7à9)pourchaque
présentationdel'ARFID,chacunescoréeentre0et15.Lesvaleursseuilpourlessous-échellessont :diff icile≥10,appétit≥9,peur≥10.Ilest
importantdenoterquecesvaleur sseuilscorrespondentàcellesdelaversionoriginaleduNIAS(enanglais)etontétévalidéesenconjonc tionavec
undépistagenégatifsurl' EDE-Q8(BurtonMurr ayHetal.4).Lesvaleursseuilsn'ontpasencoreétéétabliespourleNIAS-FR.Ainsi,undépistagede
l'ARFIDdoitêtreaccompagnéd'undépistagenégatifd'autrestroublesducompor tementalimentaire.

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one, found thequestionnaire easytounderstand(7/18 “strongly
agree”; 10/18 “agree”; 1/18 “strongly disa gree”) and clear w ith-
outambiguity (8/18“strongly agree”;5/18“agree”;4/18“slightly
agree”;1/18“stronglydisagree”).
4 | DISCUSSION
Theaimofthiscollaborativeworkwastohave a French-translated
versionoftheNI ASfo rs creen in gA RFIDincl inica la nd re searc hcon-
textsamongpatientswithdisordersofgut-braininteraction(DGBI).
Up to 40% of DGBI patients meet criteria for symptoms of
ARFID,9 particularly those with a history of restrictive diets.10While
ARFID-likesymptomsarecommonamongDGBIpatients,wefound
onlyeightpapersthatmeetkeywordsforbothARFIDandDGBIon
PubMed to d ate.9,11 –17 Inaddition,sinceARFIDhasbeenfirstde-
scribedby the DSM-5in 2013,thecurrentliterature on this eating
disorderamongadultpopulationisverylimited.Studiesarehetero-
geneouswithregardtotheir methodology.Wefoundonly12stud-
iesincluding the use of theNIAS questionnaire published sinceits
validationin2018.
GiventhatthenumberofnativeFrenchspeakersisestimatedto
321 millionworldwide,havingavalidatedFrenchversionoftheNIAS
will be crucial for a better understanding of the association bet ween
DGBIandARFID.Ontheonehand,aFrenchversionoftheNIASis
necessary for advancing clinical research. On the other hand, the
clinicalpurpose of the NIAS,when used in combination with other
detectionmethodssuchastheEDE-Q8ortheSCOFFquestionnaire,
is to screen the risk of eating disorders.4 The identification of eating
disorders,namelyARFID,willhelptodeliveranadapteddieteticap-
proach.18Indeed,restrictivediets such aslowFODMAPs areoften
partoftheclinicalmanagementinDGBI,especiallyIBS.19Screening
these patientsforthepresenceof ARFID isthereforeimportantto
prevent the risk of developing or exacerbating eating disorders.
SimilartotheSCOFFquestionnaire,20aback-translationmethod
was also used to obtain a French version of theNIAS.The French
translated version of the NIAS questionnaire (NIAS-Fr) was well
understood andclear for a majority of the native French speaking
patients. The inclusion of two different French-speaking coun-
tries (France and Belgium) was important for harmonization, ac-
knowledging cultural differences, and identifying shared terms and
meaningsinallFrancophonecountries.Thetranslationprocesswas
well-structured, and the final version incorporated two relevant
patient-suggestedmodifications,resultinginanimprovedquestion-
naire understood by a majority of the patients.Without a rigorous
and sta ndardized translating process, the q uestionnaire c an have
deleterious effects on results, especially in the absence of cultural
adaptation.21
In conclusion, a French translated version of the NIAS ques-
tionnair e (NIAS-Fr) has been tested and approve d among French
and Belgi an patients. This struc tured translat ion of the NIAS ex-
pandsitsuseto the54French-speakingcountries(membersofthe
Internat ional Organiz ation of La Franco phonie) with an es timated
321 millionFrenchspeakers acrossfivecontinentstoscreenARFID
for clinical and research purposes.
AUTHOR CONTRIBUTIONS
C.M. and F.M.initiatedthe study.C.M.,F.M.,H.L., H.P.,S.R.,G.C.,
and P.V.O planned the study. P.V.O. collated the information. P.V.O.
andH.M.M.draftedthe manuscript.Eachauthor has approvedthe
final draft submitted.
FUNDING INFORMATION
There was no funding for this study.
CONFLICT OF INTEREST STATEMENT
CMhas served as a consultant/advisoryboard member for Kyowa
Kirin,Norgine,Biocodex,MayolySpindler,Tillots,Ipsen,andNestlé
HealthScience. FM has servedasa consultant/speakerforLaborie,
Medtronic,DrFalkPharma. HLhasservedas aconsultant/speaker
forJohnson&Johnson,DrFalkPharma,Ipsen,MenariniandTakeda.
SRhasservedasaconsultantforDrFalkPharma,Sanofi,Medtronic
and rese arch suppor t from Medtr onic and Diver satek Health care.
GG has ser ved as a consultant/speaker for Laborie, Medtronic,
KyowaKirin,LillyandEnterra medical.Otherauthorshavenocon-
flicts of interest.
DATA AVAIL AB ILI T Y STAT E MEN T
The data that support the findings of this study are available from
the corresponding author upon reasonable request.
ORCID
François Mion https://orcid.org/0000-0002-2908-1591
Sabine Roman https://orcid.org/0000-0002-7798-7638
Guillaume Gourcerol https://orcid.org/0000-0001-8220-9155
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MionF,etal.Translationofthenineitemavoidant/restrictive
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doi:10.1111/nmo.14757