An Evaluation of the Italian Version of the Yale Food Addiction Scale in Obese Adult Inpatients Engaged in a 1-Month-Weight-Loss Treatment

Abstract

Addiction is a compulsive need for and use of a specific substance leading to a habit, tolerance, and psychophysiological symptoms. Excessive food consumption is similar to that of substance addiction. Some individuals who have trouble losing weight display addictive eating symptoms. To investigate food addiction in a sample of obese adults referred to hospital for a 1-month-weight-loss treatment. The Italian version of the Yale Food Addiction Scale (YFAS-16) was used as a screening tool in 88 obese inpatients. The construct validity of the YFAS-16 was assessed by testing its correlations with measures of binge eating (Binge Eating Scale), impulsiveness (Barratt Impulsiveness Scale), and emotional dysregulation (Difficulties in Emotion Regulation Scale). 34.1% of our sample was diagnosed with YFAS food addiction. Such diagnosis was also supported by strong associations between FA and psychological and behavioral features, typically descriptive of classic addiction. Patients who endorsed the YFAS-16 criteria for food addiction (FA) had significantly higher binge eating levels, greater emotional dysregulation, and nonacceptance of negative feelings; they lacked goal-oriented behavior, had little impulse control, had difficulty in emotion recognition, and attentional impulsivity; and they were unable to concentrate and lacked inhibitory control behavior, unlike participants who did not meet the FA criteria. Further research is needed to support the reliability of the YFAS-16. This measure has the potential to be applied in epidemiological research, estimating the prevalence of FA within the Italian population and to assess new treatments' efficacy for obese patients with food addiction symptoms seeking weight-loss treatments.

Introduction

Addiction is a compulsive need for and regular repeated use of a specific substance leading to habit, tolerance, and well-defined physiological and psychological symptoms.¹ Addictive behavior can occur in various forms, including overeating.² In some obese people, compulsive overeating symptoms mirror those associated with other compulsive behaviors, like substance addiction.^3

–6 Evidence suggests that some obese individuals with no inherited metabolic vulnerabilities experience great weight-loss difficulties and may exhibit signs of food addiction (FA).^7
–9 Unlike drugs and alcohol, food consumption is necessary for survival. It is impossible to abstain from, although it can involve physiological and psychological aspects typically associated with substance dependence (i.e., tolerance, withdrawal, craving, loss of control, and impulsivity).⁵ In fact, appetizing junk food can activate the brain reward circuits through fast input sensors and postbinging effects (i.e., glucose concentration in the blood and brain).¹⁰ Psychotropic substances can activate the same circuit directly.¹¹

Gearhardtet al.,^8,9 have carried out relevant research on FA. The authors created and validated the Yale Food Addiction Scale (YFAS), the most accredited FA measure.⁸ The 25-item questionnaire investigates respondents' eating behavior with respect to certain types of food (i.e., high in fat and/or sugars) in the last 12 months. The YFAS assesses FA symptoms based on substance dependence diagnostic criteria of the Diagnostic Manual and Statistical of Mental Disorders.¹² Three or more symptoms indicate an FA diagnosis. In their validation study on 353 college students, 11.4% of the sample met the criteria for food dependence, as assessed by the YFAS, while 13.2% met suggested clinical cutoffs on the Binge Eating Scale (BES). Findings evidenced that the YFAS is a more reliable measure of binge eating compared to other eating pathology measures. The scale efficiently identifies eating patterns similar to the compulsive behavior of classic addictions, and it is able to discriminate between individuals with and without addictive tendencies toward food.⁸

Using magnetic resonance imaging activation, the YFAS was later used in a study on addictive processes implicated in the development and maintenance of obesity.⁶ The results found that high FA scores on the YFAS were associated with high reward circuitry activation in response to palatable food cues and reduced activation of inhibitory regions in response to food intake. This may suggest the existence of similar neural activation patterns in addictive-like eating and substance dependence, as highlighted in previous neuroendocrine and imaging studies.^{5,11,13

–19} Recently, Gearhardt et al. ⁹ administered the YFAS to obese inpatients with binge eating disorder (BED) enrolled in a weight-loss treatment. They found that 57% of participants met FA, as diagnosed by the YFAS, and had higher scores on measures of depression, negative emotional states, and emotional dysregulation. In addition, obese individuals with BED displaying YFAS FA symptoms showed greater eating psychopathology and lower self-esteem compared to obese individuals with BED not meeting the FA criteria. YFAS scores also predicted the binge-eating frequency and intensity better than other measures.⁹ Similar results were found in a study on YFAS FA diagnosis and weight loss in obese individuals who had undergone bariatric surgery.²⁰

Thus, among obese patients diagnosed with BED, there could be a subset of individuals classified as having YFAS FA symptoms with a more severe eating disorder.⁹ BED and FA may be related. Some authors found that patients with BED might have difficulty in delaying gratification from food, in countering cravings, and controlling overeating.²¹ Such aspects may parallel many features of substance use disorders, as some obese individuals with BED could experience a higher reward sensitivity compared to other obese individuals without BED and normal-weight people.²¹

Hence, the need to overeat may go beyond basic physiological hunger and may be related to the need to intensively and quickly stimulate pleasure circuits.²² Previous research has found that obesity, index, and specific cognitive correlates resulting from a dopamine shortage (i.e., pleasure neurotransmitter) may be linked.¹⁰ That is to say, the greater the BMI, the lower the number of dopamine receptors; this is a condition that has generally been associated with alcohol and drug dependence.¹¹ The dopamine receptor scarcity in some obese individuals could also account for their lower self-efficacy levels and their difficulty in continuing diets and long-term nutrition programs.²³ Obesity associated with BED may reflect the phenomenological dynamics of a more severe eating disorder.²⁴ Obese binge eaters often describe themselves as food dependent, easily distressed, and unable to manage emotions, despite being aware of postbinging adverse consequences. They also report food craving, as opposed to other obese individuals without BED.²⁵ The relationship among obesity, BED, and FA remains unclear. More research is needed to clarify the connection between FA and obesity with or without BED.⁹ Studies on FA prevalence are still rare, some are only descriptive, and the incidence of FA among obese individuals with or without BED is still uncertain.²⁶

In Italy, there is nearly no research on FA and its prevalence. The only Italian study was developed by Innamorati et al. ²⁷ who validated an Italian version of the YFAS, namely, the YFAS-16. They were administered the YFAS-16 and the BES.^28,29 The one-factor 22-item model of the original scale ⁵ did not fit the Italian data. Thus, five items with low factor loadings and low item–total correlations (item 10, 11, 22, 24, and 25) were removed, and a new one-factor model with 16 items provided a better fit to the data.²⁷ The results from Innamorati et al. ²⁷ are in line with those reported by Meule et al. ³⁰ who investigated the psychometric properties of the YFAS on obese patients attending bariatric surgery.

The following research intends to extend Innamorati et al.'s work²⁷ by testing the convergent validity of the Italian YFAS-16 with measures previously used in Gearhardt et al.'s original validation.⁹ Currently, no research in Italy has ever assessed FA, disordered eating,^28,28 impulsiveness (measured by the Barratt Impulsiveness Scale,^31,32), and emotional dysregulation (measured by the Difficulties in Emotion Regulation Scale.^33,34) The above-mentioned instruments measure variables which have generally been assessed in classic substance addiction.⁴ A further aim of the study was to estimate the FA prevalence in a sample of obese inpatients engaged in a 1-month-weight-loss treatment.

Methodology

Sample and procedures

A total of 88 men (N=25) and women (N=63) adult obese (BMI≥30) inpatients undergoing a 1-month-weight-loss treatment at the Saint Joseph Hospital, Istituto Auxologico Italiano, were recruited. The study sample size (N=88) was considered to be sufficient a priori to detect a correlation of 0.35 or above with an 80% of statistical power. Participants' index ranged from a minimum of 30 to a maximum of 73, with an average of 40.8 (SD=7.1). The age variable was measured on categorical scales according to the following age groups: (1) 18–24; (2) 25–34; (3) 35–44; (4) 45–54; (5) 55–64; (6) 65–74; and (7) 74 or over. Most participants were between 45 and 54 years of age and between 55 and 64 years of age, both comprising 25% of the sample. Over half of the participants (56, 8%) were married or cohabiting, while the rest were single or widowed. Most participants had siblings (62, 5%). Furthermore, 53, 4% were unemployed or retired and few were self-employed (13, 6%). Most participants had a high school diploma (43, 2%).

This study was conducted in accordance with the Declaration of Helsinki and respected legal, ethical, and practical research standards of the Saint Joseph Hospital. The authors provided participants with the study protocol and obtained informed consent from each participant. Fully trained doctoral-level clinicians performed the assessment. Participants initially completed a preliminary sheet assessing demographic information on gender, age, education, profession, marital status, siblings, previous body weight-loss programs carried out, and physical measures, such as height in cm and weight in kilograms. Patients self-reported their weight and height. Such self-reported data were later cross-checked with objective measures previously taken by front-line physicians at the obesity center. Body–mass index was calculated at baseline.

Patients were assessed for BED using the BES^28,29 and clinical interviews carried out by psychologists/psychotherapists at the center. During assessment, both behavioral manifestations (eating large amounts of food) and feelings/cognitions following a binge episode (guilt, fear of being unable to stop eating) were examined. Participants were then administered four self-report questionnaires: the Italian version of the Yale Food Addiction Scale (YFAS-16),²⁴ the Barratt Impulsiveness Scale (BIS-11),^7,26 the Difficulties in Emotion Regulation Strategies (DERS),^28,29 and finally, the BES.^30,31

This study used the Italian version of a 16-item YFAS scale proposed by Innamorati et al. ²⁷ measured on a 4-point Likert scale ranging from 0–never to 4–four or more times daily. In their validation study, authors administered the YFAS-16 and the BES to participants.^30,31 The one-factor model of the YFAS reported in previous studies did not fit the data (v2 209=466.7, p\0.001; RMSEA=0.07; 90% CI: 0.06/0.08; CFI=0.9; WRMR=1.4). Based on item analysis, five items (items: 10, 11, 22, 24, and 25) were removed from the scale, as they had low item–total correlations. A 16-item one-factor model revealed a better fit to the data (v2 104=174.6; p\0.001; RMSEA=0.05; 90% CI: 0.04/0.07; CFI=0.9, WRMR=1.0). The YFAS-16 turned out to have satisfactory internal consistency, ability to discriminate obese patients from controls, and a strong correlation with BES scores. The YFAS-16 yielded a lower percentage of FA diagnoses compared to the original questionnaire, although the scale assesses the same FA symptoms as the original YFAS [9], and it has satisfactory psychometric properties.

The Barratt Impulsiveness Scale (BIS-11) assesses personological traits and behavioral constructs of impulsiveness.³¹ The Italian validated version used in this study is a 30-item scale describing common impulsive or nonimpulsive (for reverse scored items) behaviors and preferences.³² Items are scored on a 4-point Likert scale ranging from 1 (Rarely/Never) to 4 (Almost Always/Always). The total score is based on six first-order factors (attention, motor, self-control, cognitive complexity, perseverance, and cognitive instability impulsiveness) and three second-order factors (attentional, motor, and nonplanning impulsiveness). The scale measures three types of impulsivity³²:

(1) Attentional impulsivity (inability to focus attention or concentrate)

(2) Motor impulsivity (acting without thinking)

(3) Nonplanning impulsivity (lack of future orientation or forethought)

The Difficulties in Emotion Regulation Scale (DERS) is a 36-item measure of emotion dysregulation.³³ The test subscales tap into six aspects of emotion dysregulation:

(1) Nonacceptance of emotional responses (Nonacceptance scale)

(2) Difficulties engaging in goal-directed behaviors (Goals scale)

(3) Impulse control difficulties (Impulse scale)

(4) Lack of emotional awareness (Awareness scale)

(5) Limited access to emotion regulation strategies (Strategies scale)

(6) Lack of emotional clarity (Clarity scale)

The Italian validated questionnaire has the same structure and uses a 5-point Likert scale scoring, with higher scores reflecting greater emotion dysregulation.³⁴

Finally, the BES is a 16-item questionnaire evaluating both behavioral manifestations (i.e., eating large amounts of food) as well as feelings and cognitions associated with binging (i.e., guilt, fear of being unable to stop eating). The measure successfully differentiates among absent, moderate, and severe binge eating tendencies.²⁸ The Italian validated BES was used in this study.²⁹

Data analysis

The Pearson's correlation index was used to test associations between the YFAS-16 symptom count scores and other measures. Independent sample t-tests and chi-square tests were then used to compare patients who met the food addiction criteria on the Italian YFAS with those who did not meet such criteria. SPSS Statistics software Version 20 was used to analyze the data. G-Power 3.1.3 Software was used to calculate statistical power.³⁵ The results showed that a sample size of 84 participants provides 80% of power to detect a moderate correlation of 0.3 or above at the 0.05 level (see sample section). Moreover, we adjusted the classic Critical Alphas (0.05) for multiple comparisons according to the number of tests performed only with the subscales of the DERS (alpha=0.008) and the BIS (alpha=0.016 for second-order factors and 0.008 for first-order factors). For the total scores of the BIS, the DERS, and the BES, the critical alpha was maintained at the nominal level of 0.05.

Results

Overall, 30 patients (34.1%; 95% Confidence Intervals: 24.3% to 43.9%) met the diagnostic threshold for FA according to the YFAS-16 criteria (three or more FA symptoms endorsed and a clinically significant impairment). The mean number of FA symptoms for participants diagnosed as not having YFAS-16 FA criteria was 2.7 (SD=1) with a median value of 2.5, a minimum of 0 and a maximum of 6. The mean number of FA symptoms in the YFAS-16 was 4 (SD=1.1) for those diagnosed with YFAS-16 FA criteria, with a median value of 4, a minimum of 3 and a maximum of 7. The difference between patients meeting YFAS-16 FA criteria and patients not meeting such criteria was statistically significant (P=<.01).

No statistically significant difference was found in weight, height, BMI, age, gender, employment, and scholar level between participants classified with and without FA on the YFAS-16. Statistically significant differences were found between patients with FA and those without in the BES, Difficulties in Emotion Regulation Scale (DERS) total scores, and “impulse” subscale of the latter (P=<0.01), with patients diagnosed with food addiction on the YFAS-16 showing higher mean scores (Table 1).

Table 1.

Independent Sample t-Test Table of Means

	Subjects without food addiction as assessed by the YFAS-16						Subjects with food addiction as assessed by the YFAS-16
Independent-sample t-test	N	Mean	SD	Median	Min	Max	N	Mean	SD	Median	Min	Max	P
BES total score	57	9,4	6,7	7,0	0	30,0	30	20,0	9,3	22,5	3,0	42,0	<.001
Nonacceptance	58	13,9	6,4	13,0	6,0	30,0	30	18,1	6,2	19,0	6,0	28,0	.005
Goals	58	11,6	4,3	10,0	5,0	23,0	30	15,0	4,7	15,5	7,0	24,0	.001
Strategies	58	16,5	6,2	16,0	8,0	35,0	30	20,7	5,6	20,5	9,0	30,0	.003
Impulse	58	10,7	4,7	9,5	6,0	27,0	30	15,8	6,6	15,0	6,0	26,0	<.001
Clarity	58	9,8	4,0	10,0	5,0	18,0	30	12,9	4,5	13,0	5,0	22,0	.002
Awareness	58	6,7	3,3	6,0	3,0	15,0	30	7,6	2,8	7,0	3,0	13,0	.227
DERS total score	58	69,3	21,0	67,0	33,0	130,0	30	90,1	23,7	92,0	44,0	132,0	<.001
Attention	57	9,5	2,6	9,0	5,0	15,0	30	10,5	2,8	10,5	5,0	17,0	.094
Motor impulsiveness	57	13,2	3,3	13,0	7,0	22,0	30	14,0	4,8	13,0	8,0	28,0	.361
Self-control	57	12,5	4,2	12,0	6,0	22,0	30	14,3	4,1	14,5	6,0	22,0	.061
Cognitive complexity	57	12,3	2,3	12,0	7,0	18,0	30	13,6	2,9	14,0	5,0	17,0	.033
Perseverance	57	7,2	1,8	7,0	4,0	11,0	30	7,8	1,9	8,0	4,0	11,0	.153
Cognitive instability	57	6,3	1,5	6,0	3,0	9,0	30	6,3	2,0	6,0	3,0	10,0	.922
Attentional impulsivity	57	15,7	3,0	16,0	9,0	23,0	30	16,8	4,2	17,0	10,0	26,0	.182
Motor impulsivity	57	20,4	3,8	20,0	14,0	29,0	30	21,8	5,4	20,5	14,0	37,0	.21
Nonplanning impulsivity	57	24,9	5,6	24,0	13,0	36,0	30	27,9	6,4	28,5	11,0	38,0	.026
BIS total score	57	61,0	9,7	60,0	38,0	86,0	30	66,5	13,5	68,0	35,0	95,0	.032

All significant values are indicated in bold.

BES, Binge Eating Scale; DERS, Difficulties in Emotion Regulation Strategies; BIS, Barratt Impulsiveness Scale.

The YFAS-16 symptom count positively correlated with participants' total scores on the BES, (r=0.33; P=<.01) and on the Difficulties in Emotion Regulation Scale (DERS) (r=0.31; P=<.01). Four subscales of the Difficulties in Emotion Regulation Scale (DERS) correlated positively and significantly with the YFAS-16 symptoms. These subscales were Nonacceptance (r=0.26; P=<.05), Goals (r=0.21; P=<.05), Impulse (r=0.38; P=<.01), and Clarity (r=0.24, P=<.05). Positive correlations were also found between the YFAS-16 symptoms and the Barratt Impulsiveness Scale (BIS-11) total score (r=0.26; P=<.05). Three subscales of the Barratt Impulsiveness Scale (BIS-11) were found to positively and significantly correlate with the YFAS-16 symptom count. The three subscales were Attention (r=0.261, P=<.05), Cognitive Instability (r=0.22, P=<.05), and Attentional Impulsivity (r=0.30, P=<.01). After applying critical adjusted alphas (see data analysis), only the DERS Impulse subscale (r=0.38; P=<.008) and the BIS Attentional Impulsivity subscale (r=0.30, P=<.016) maintained statistical significance. Cronbach's alpha was used to assess the internal consistency of the Italian YAFS-16 scale. The Alpha coefficient was 0.9.

Discussion

This study investigated the convergent validity of the Italian YFAS-16,²⁷ with measures assessing disordered eating. Also, our research examined the divergent validity of the YFAS-16 with measures assessing other psychopathology, which have previously been used in the original YFAS validation.⁹ The current research extended the validation of the YFAS-16 ²⁷ in Italy, where there is currently a lack of psychometric measures designed to assess food-addiction. Our study estimated the FA prevalence in a sample of obese adult inpatients engaged in a brief weight-loss program. Furthermore, this work assessed FA as measured by the YFAS-16, disordered eating, as well as impulsiveness and emotional dysregulation, which are often found in classic substance addiction.^4,36

In our sample, 34.1% of participants met the full YFAS-16 criteria for food addiction, while patients who did not meet such criteria endorsed on an average three symptoms (2.7). This result may imply a possible association between obesity and food-addiction symptoms, as diagnosed by the YFAS-16. In addition, some participants classified without FA on the YFAS-16 went over the threshold, reaching up to six symptoms, although without clinical significance. This may suggest the need to further investigate eating patterns that are similar to those found in classic substance addiction in obese individuals with and without BED, as suggested by previous research.^10,21,23,24

Moreover, the mean scores on the BES of patients who were diagnosed with food addiction on the YFAS-16 were significantly higher compared to those who did not meet the food addiction criteria. This could suggest the possible existence of a particular subset of obese patients with BED characterized by a greater eating psychopathology compared to those who do not have signs of food addiction, as evidenced in other studies.^9,21 Our findings may suggest the presence of obesity associated with BED, which may resemble psychological distress and behavioral manifestations typically related to substance dependence, as research already highlighted.^6,9,14,21,25 This could indicate that participants who met an FA diagnosis on the YFAS-16 might have more difficulty in losing weight and may be at a risk for future weight gain.⁶

Patients who met the YFAS-16 food addiction criteria in our sample paid greater attention to food as opposed to those who did not meet such criteria. This could somewhat resemble the biased attention toward psychotropic substances in substance use disorders.^11,17,18 Those classified as meeting the FA criteria on the YFAS-16 may be predisposed to experience emotional dysregulation, general emotional instability, and negative emotional states compared to those who did not endorse the YFAS-16 FA criteria. Thus, some individuals may find a strategy to regulate negative emotional effects and achieve more positive emotional states in a sort of self-healing attempt through excessive food consumption.^9,13,37 This behavior seems to echo classic substance use, which is triggered by negative mood and emotion dysregulation.³⁶

Patients who met the food addiction criteria, as measured by the YFAS-16, were more likely to experience nonacceptance of emotional responses, negative secondary emotions in response to primary negative emotions, or nonacceptance reactions to psychological discomfort, as revealed by their DERS scores. They also experienced greater difficulty in adopting a goal-oriented behavior, concentrating and carrying out a task when feeling negative emotions, and controlling impulses compared to those who did not display an FA criteria on the YFAS-16. Finally, a food addiction YFAS-16 diagnosis may be related to lower emotional lucidity and a greater difficulty in recognizing emotions. Our results suggest that in some cases of morbid obesity, investigating emotional deregulation may be relevant to gain a better understanding of binge eating triggers. Negative effect and mood dysregulation, rather than overly restrictive dieting,⁹ may drive some obese individuals to eat more, perhaps as a coping strategy for the heightened emotional distress.³⁸

Furthermore, we found a food addiction YFAS-16 diagnosis to be possibly associated with a higher tendency to act rapidly and instinctively in response to environmental/internal stimuli, without considering negative consequences, as demonstrated by the BIS scores. Hence, obese adults with YFAS-16 FA may show higher attentional impulsivity and inability to complete tasks as well as lower inhibitory control behavior compared to patients who were not diagnosed with food addiction on the YFAS-16. Such features are signs of addictive-like behavior, similar to those found in alcohol and drug misuse.⁴ Our findings suggest the need to further investigate obesity and FA to provide patients who meet the FA criteria with the best possible treatment. Specific weight-loss programs should consider the existence of a particular type of obesity in hospitalized patients, as promptly identifying FA symptoms may lead to more efficient weight-loss interventions.^16,23

If strong similarities existed between certain phenomenological and neurobiological correlates of food addiction in obesity and addictive disorders, ^7,8,13,14 the treatment of obesity associated with food addiction might need to utilize interventions, which are traditionally employed in treating substance addiction.¹¹ FA treatment should consider specific interventions aimed at diminishing the power of food reinforcing properties on the one hand and the development of more functional alternative reinforcers on the other.¹⁸ As Volkow and Wise⁵ suggested, FA interventions should contemplate treatment strategies and techniques that are generally successful in substance use disorders. Tailored interventions on morbid obesity associated with FA should also promote the functional inhibition of conditioned learned associations to enhance motivation for nonfood-related activities and the development of specific coping strategies to overcome stressful events, mood instability, low self-control, as well as low frustration tolerance.¹⁹

Overall, this research shows that the YFAS-16²⁷ has good construct validity with measures of disordered eating (BES), impulsiveness (BIS), and emotional dysregulation (DERS). In the light of our findings, it appears that future research on obesity and binge eating associated with food addiction should address emotional dysregulation and impulsiveness, as they may be directly influencing such conditions. This study could thus provide suggestions for future research to further explore the role of disinhibition, emotional eating, and loss of control in FA, as this could be relevant for early and efficient interventions and relapse prevention. Although this work has potential implications for improving weight-loss interventions in obesity associated with FA symptoms, it has some limitations.

First, the psychometric assessment was only carried out in a clinical setting with a convenience sample of participants engaged in a brief treatment program, and it is not representative of the original population from which it was drawn. Moreover, the sample comprised a relatively small number of participants, and the results may not be generalizable to other groups of patients (e.g., bariatric surgery patients). Second, the study did not include a control group, which could have been useful to make more accurate or precise conclusions on the YFAS-16 properties. In addition, the experimental design may not have been fully satisfactory as only self-reported measures were administered and these could be susceptible to social desirability bias.³⁷ Third, measures of depression, which have been found to be closely related to FA,⁹ were not administered. Finally, the diagnostic sensitivity and specificity of the YFAS-16 were not assessed, as at the time of this study, there was no other valid and reliable instrument for a FA diagnosis in Italy. Future assessments should investigate the appropriateness of the Italian YFAS-16 in relation to the new Diagnostic and Statistical Manual of Mental Disorders (5th edition)¹ substance dependence criteria, which this study could not include.

Considering the above, the results still have important implications for the food addiction problem by offering an evaluation of a specific tool, such as the YFAS-16. Future studies on obesity may benefit from the use of a measure that would identify dependence symptoms concerning certain types of food. Overall, the YFAS-16 demonstrated to be a sound measure for identifying FA symptoms in adult obese inpatients. More evaluations of this scale in Italy are strongly recommended, as they could provide further evidence of the reliability and validity of the scale. This could also provide crucial clinical and psychometric data on food addiction among Italian obese and nonobese individuals.

In conclusion, the present study suggests that FA, as assessed by the YFAS-16, is a condition that can affect obese adults engaged in weight-loss programs. The study also provides psychometric and clinical evidence that food addiction, as measured by YFAS-16, may be associated with binge eating, higher emotion dysregulation, lower self-control, and higher impulsivity. These findings may suggest that the clinical implications concerning the subset of obese individuals who meet the food addiction criteria, as defined by the YFAS-16, are not yet known. It is important to identify addiction to food in obese individuals to develop a well-tailored treatment for these patients. Future research should carefully explore the FA phenomenon using reliable and valid psychometric measures to better assess disordered eating and to fully understand psychological, emotional, and behavioral implications associated with such a condition.

Footnotes

Acknowledgments

M. Ceccarini proposed the study design, collected data, and carried out experiments. G. M. Manzoni analyzed the data. The first two authors, together with G. Castelnuovo and E. Molinari, contributed to data interpretation, literature search, and generation of tables. All authors were involved in writing the article and approved the final version. The SISDCA group (Società Italiana per lo Studio del Comportamento Alimentare), a multidisciplinary team in the field of obesity treatment interventions, and Prof. Nazario Melchionda, in particular, offered general support and inspiration for this study.

Author Disclosure Statement

The authors of this article declare no conflicts of interest as it relates to the subject of this article. Researchers of this study declare that no institution, financial holdings, or considerations, such as stocks, bonds, or donations of supplies, equipment, or third party influenced the objectivity of the report. Authors declare that they have complied with APA ethical standards in the treatment of their sample.

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