Validation of the Greek version of the Salzburg Stress Eating Scale in adults

Abstract

BACKGROUND:

It is widely known that excessive or prolonged stress in humans, can negatively affect eating behavior.

OBJECTIVE:

The aim of the study was to validate the Salzburg Stress Eating Scale (SSES) in the Greek language and to examine its psychometric properties, in a sample of adults, in Greece.

METHODS:

An online survey was conducted. The Perceived Stress Scale (PSS), the three-factor eating questionnaire (TFEQ) R-18 and two subscales of the Dutch Eating Behavior questionnaire (DEBQ) were used, together with the SSES. Certain sociodemographic and lifestyle characteristics were also assessed. Exploratory Factor analysis (EFA), Cronbach’s α and Spearman’s rho were used.

RESULTS:

The sample consisted of 368 participants (51.1% women) and the mean age of the participants was 35 years. EFA indicated one factor in SSES with Eigenvalues > 1, which explained the 54.6% of total variance. The Cronbach’s Alpha was 0.920. SSES was significantly positively correlated with the subscales of the DEBQ (for the Restrained Eating subscale r = 0.147 and for the Emotional Eating subscale r = 0.615, p < 0.001) and was significantly negatively correlated with two subscales of the TEFQ (for the TFEQ1 r = – 0.233 and for the TFEQ2 r = – 0.562, p < 0.001).

CONCLUSIONS:

The Greek version of SSES is a reliable tool for assessing changes in eating behavior, in relation to stress.

Keywords

Overeating emotional eating eating habits external eating restrained eating

1 Introduction

There is good evidence that, prolonged mental stress seems to negatively affects psychosomatic health, in humans [1, 2]. More specifically, metal stress has been linked with lower sense of wellbeing, depression, age related comorbidities and with negative health behaviors [3, 4]. There is solid proof that stress and anxiety can affect eating behavior in humans [5] with women and individuals with excess body weight, being more likely to report emotional eating in response to stress [4, 6]. Studies indicate that people who alter their food behavior in response to stress, usually, fall into two categories, those who increase their food intake and those who decrease their food intake [7].

It has been previously reported that, specific types of eating behaviors which are usually employed to cope with a stressful situation, include emotional eating, where an individual overeats due to alterations in their emotions, restrained eating, where the individual purposely controls/limits daily food intake, in order to lose or maintain body weight [8] and external eating, which manifests itself with increased tendency to eat in the absence of hunger, in response to external cues [9].

Measuring the effect of psychological stress on eating behavior in the general adult population, is of paramount importance. A number of useful tools have been developed, in the past, to assess changes in eating behaviors due to stress or emotions: i) the Dutch Eating behavior questionnaire (DEBQ) is a tool comprising 33 questions that assess changes in eating behaviors (mostly overeating) and it has beentranslated and used in numerous studies in Greece [10]; ii) the Three Factor Eating Questionnaire Revised-18 (TFEQ-R-18), is a tool consisting of 18 questions aiming at detecting behaviors related to overeating, restrained eating and emotional eating and it has been validated in Greek in a sample of general population [11–13]; iii) the Salzburg Emotional Eating Scale (SEES) is a self-reported 20-item tool with four subscales, investigating alterations in eating habits with respect to different emotions and it has been validated in a sample of general population and the participants had either German or Austrian citizenship [14]; iv) the Salzburg Stress Eating Scale (SSES) is a tool comprising of ten questions that measure changes in eating behaviors related to overeating or to undereating and overall eating behavior alterations, that might be stress-triggered, theSSES was originally developed and validated in English and German, in a sampleof the general population [15]; SSES evaluates the effects of stress in eating habits and measures stress related eating and comparatively to other tools has the following advantage of detecting both overeating and undereating behaviors.

The aim of the present study is the validation of the “Salzburg Stress Eating Scale” in the Greek language in a sample of the general Greek adult population, The Salzburg Stress Eating Scale, as stated above, is a very useful instrument because it measures simultaneously possible overeating or undereating, related to mental stress. The secondary aim of the study was to assess possible correlations of SSES with certain sociodemographic and lifestyle characteristics of the participants.

2 Materials, Methodology & techniques

2.1 Tool’s description

The Salzburg Stress Eating Scale (SSES) was originally developed by Reichenberger, Blechert & Meule and it was firstly validated in 2018 in the German and the English languages, in 2018. Its main purpose was to appropriately assess changes in eating behaviors, in general, and not only eating changes leading to overeating [15]. The instrument has also been validated and used in the Netherlands and in Brazil [16, 17]. Moreover, SSES was developed based on some items of the Perceived Stress Scale 14 (PSS-14) [18]. Also, it was administered along with the PSS-14, or shorter versions of it [19, 20].

The SSES consists of 10 questions, with each question scoring from 1–5, without reverse coded variables. The total score is calculated as an average of the participant’s responses. When the total score of the responder is less than 3 (score < 3), then the participant, in a period of stress, eats less. When the responder’s score is equal to 3 (score = 3), then his/her eating habits do not changed in stressful periods. Finally, when the responder’s total score exceeds 3 (score >3), the participant eats more during periods of stress.

2.2 Translation procedure

After obtaining permission from the original authors of the instrument, the rules of the backward-forward translation method were applied:

Stage 1: Two independent individuals with certified excellent knowledge of the English language, translated the Salzburg Stress Eating Scale from English to Greek, resulting in two translations(T1 & T2) (forward translation).

Stage 2: Comparisons between T1 and T2 resulted in one final version of the scale.

Stage 3: This scale was then translated back into English by a Greek-English bilingual individual (backward translation).

Stage 4: The backward translation was discussed by the expert committee review, for any discrepancies to the original scale.

Stage 5: When the translation procedure was finalized, the final instrument was piloted to assess clarity and other possible issues in a group of 5 adult volunteers

2.3 Participants & Procedures

An online survey was conducted, spanning from November 2021 to January 2022. The study sample consisted of a total of 368 participants (51.1% women). Exclusion criteria included participants being officially diagnosed with an eating disorder, such as anorexia and/or bulimia nervosa and inability to understand or read in Greek. These criteria were applied after the completion of the questionnaire. The questionnaire was available in a fully encrypted online platform and the link was promoted through social media platforms such as Facebook and Instagram. Convenience sampling was employed. Eighteen out of 368 participants, who wished to participate in the repeatability measurement, provided their email address, so that the researchers could re-administer the tool for a second time, after a 15 day period.

2.4 Ethical considerations

The protocol of the study was approved by the Bioethics Committee of the Medical School of the National and Kapodistrian University of Athens (protocol number 670/12.08.2022). The participants were fully informed in the first page of the online questionnaire about the aim of the study and that, by completing the questionnaire, they provided their informed consent to participate in the study. The questionnaire was anonymous. Participants were also informed that they could withdraw from the study at any point, if they wished to do so.

2.5 Measures

2.5.1 Sociodemographic and anthropometric variables

Participants completed questions about age, height, and body weight. They were also asked about their nationality, employment status, education level, pre-existing medical conditions and certain eating habits.

2.5.2 Dutch Eating Behavior Questionnaire (DEBQ):

DEBQ is a tool consisting of 33 questionsaiming at measuring: emotional overeating, restrained eating and external eating. DEBQ is frequently used to reveal eating habits and behaviors that are linked to obesity. The questions are structured as follows: 1–10 restrained eating, 11–23 emotional overeating & 24–33 external eating. The DEBQ is scored on a Likert scale, ranging from 1 (never) to 5 (very often). The higher the score, the greater the tendency of overeating. The subscales related to emotional overeating and restrained eating were used, in the present study [10]. This tool has been translated in the Greek language and used in numerous studies, in the past [21–24].

2.5.3 Three Factor Eating Questionnaire R-18 (TFEQ R-18):

TFEQ R-18 is a revised edition of the TEFQ [11] that consists of 18 questions [13]. It is structured to investigate tendencies to restrained eating, uncontrollable overeating and emotional overeating. Nine questions are associated with uncontrollable overeating (1, 4, 5, 7, 8, 9, 13, 14, 17), six of them, are associated with restrained eating (2, 11, 12,15, 16, 18) and three of them, are associated with emotional eating (3,6,10). For each question, the score ranges from 1–4. Then the score of each question is summed up resulting in the overall score of each subscale. The initial scores of the three subscales are modeled on a scale of 0–100 [(initial score – lowest possible initial score)/possible range of initial score)×100]. The total score ranges from 18–72. The higher the score, the more frequent the occurrence of each behavior. This tool has also been validated in the Greek language in the past [12].

2.5.4 Perceived Stress Scale (PSS):

The PSS is a widely used tool measuring perceived stress and it has been validated in the Greek language, in the past [18, 25]. This tool was developed to assess whether a person perceives his/her life as unpredictable, “overloaded” or uncontrollable. It is related with the personal evaluation of stress and with the perception of situations as stressful. The PSS consists of 14 questions, seven “positive” and seven “negative” ones. Each question ranges from 0 (never) to 4 (very often). Negative questions are associated with lack of control and positive questions are associated with someone’s ability to cope with stressful events. Possible range varies from 0 to 56 and is resulting from the sum of all questions, having first reversed the positive and converted the negative questions. The higher the score, the higher the levels of perceived stress.

2.6 Statistical analysis

Data are presented as N (%) for categorical variables and Mean (SD), Median and (IQR) for quantitative variables. Exploratory factor analysis was used to extract the factors of SSES. To assess sample’s adequacy, the Kaiser-Meyer-Olkin (KMO) measure and Bartlett’s test of sphericity were used. The varimax rotation method was used to maximize the loadings of items. Eigenvalues greater than 1 showed the appropriate number of factors and items with loadings greater than 0.3 were assigned to the factors. Cronbach’s alpha was calculated to examine internal consistency. Due to the skewed distribution of the numeric variables Spearman’s rho coefficient was used to assess correlations between SSES and other variables. Wilcoxon signed-rank test and the Spearman correlation coefficient were used to test for differences and to estimate the rank agreement between the test and the retest estimates, in order to assess repeatability. The non-parametric tests Mann-Whitney U and Kruskal-Wallis tests were used to evaluate between group differences. For the statistical analysis SPSS v26, for windows, was used [26] and the level of significance was set at p≤0.05.

3 Results

The study’s sample consisted of 368 adults. The baseline characteristics of the participants, together with the scores of the tools used, are presented in Table 1. In total, the median age was 35 years (IQR = 11.97), with 51.1% women. Most of the participants (97.6%) had Greek Nationality. Among the 368 responders, 228 (59.1%) were unmarried, 232 (66%) had a bachelors’ degree and 51 (13.9%) of them had a chronic health condition. Finally, almost 47% of the participants were categorized as overweight and obese. All the above information was self reported by the participants.

Table 1
Samples’ Sociodemographic characteristics and study’s measurements (N=368)

Variables N (%) or Median (IQR)

Gender

Women 188 (51.1)

Men 180 (48.9)

Nationality

Greek 359 (97.6)

Other 9 (2.4)

Smoking

Yes 121 (32.9)

No 205 (55.7)

Ex-smoker 42 (11.4)

Alcohol consumption

Yes 301 (81.8)

No 67 (18.2)

Exercise

Yes 279 (75.8)

No 89 (24.2)

Chronic condition

Yes 51 (13.9)

No 317 (86.1)

Marital Status

Unmarried 228 (59.1)

Married 122 (31.6)

Divorced/Widowed 36 (9.3)

Educational level

Secondary Education 59 (16)

Tertiary Education 232 (66)

Advanced Tertiary Education 77 (20.9)

Age (years) 30.00 (19.00)

BMI (kg/m2) 24.61 (5.25)

BMI categories

Underweight 11 (3)

Normal Weight 185 (50.3)

Overweight 127 (34.5)

Obese 45 (12.2)

SSES Total 2.80 (1.00)

SSES Categories

Eat less 212 (57.6)

No change 43 (11.7)

Eat more 113 (30.7)

PSS Total 39.00(10.00)

Restrained eating (DEBQ) 2.80 (1.28)

E motional eating (DEBQ) 2.38 (1.23)

TFEQ1 60.00 (24.00)

TFEQ2 61.11 (16.67)

TEFQ3 55.56 (44.44)

Variables	N (%) or Median (IQR)
Gender
Women	188 (51.1)
Men	180 (48.9)
Nationality
Greek	359 (97.6)
Other	9 (2.4)
Smoking
Yes	121 (32.9)
No	205 (55.7)
Ex-smoker	42 (11.4)
Alcohol consumption
Yes	301 (81.8)
No	67 (18.2)
Exercise
Yes	279 (75.8)
No	89 (24.2)
Chronic condition
Yes	51 (13.9)
No	317 (86.1)
Marital Status
Unmarried	228 (59.1)
Married	122 (31.6)
Divorced/Widowed	36 (9.3)
Educational level
Secondary Education	59 (16)
Tertiary Education	232 (66)
Advanced Tertiary Education	77 (20.9)
Age (years)	30.00 (19.00)
BMI (kg/m2)	24.61 (5.25)
BMI categories
Underweight	11 (3)
Normal Weight	185 (50.3)
Overweight	127 (34.5)
Obese	45 (12.2)
SSES Total	2.80 (1.00)
SSES Categories
Eat less	212 (57.6)
No change	43 (11.7)
Eat more	113 (30.7)
PSS Total	39.00(10.00)
Restrained eating (DEBQ)	2.80 (1.28)
E motional eating (DEBQ)	2.38 (1.23)
TFEQ1	60.00 (24.00)
TFEQ2	61.11 (16.67)
TEFQ3	55.56 (44.44)

BMI = Body Mass Index; SSES TOTAL = Salzburg Stress Eating Scale total; PSS TOTAL =P erceived Stress Scale total; DEBQ restrained/emotional = Dutch Eating Behavior Questionnaire Restrained/emotional; TFEQ 1/2/3 = Three Factor Eating Questionnaire 1 (Uncontrollable eating) / 2 (Restrained eating) / 3 (Emotional eating).

The KMO value was 0.911 and the significance of the Bartlett’s test of sphericity was p < 0.001. The results of the exploratory factor analysis (EFA) of the ten items of SSES, are presented in Table 2. Exploratory Factor Analyses (EFA) indicated one factor in SSES with Eigenvalues > 1 (all loadings > 0.422), which explained the 54.6% of total variance. The Cronbach’s a coefficient for this factor was 0.920, indicating that there is satisfactory internal consistency. All item– total correlations were > 0.408. Finally, test-retest repeatability revealed that there was no difference between 1^st and 2^nd measurement for the SSES (p = 0.247) and the Spearman correlation coefficient was high (r = 0.688, p = 0.001) (results not presented but available upon request).

Table 2

Rotated factor loadings of the exploratory factor analysis (EFA) for the 10 items of the SSES, item-total correlation and Cronbach’s alpha coefficients

	SSES	Item-total correlations
When I am overwhelmed with things I have to do, …	0.772	0.739
During periods of great stress, …	0.782	0.749
When I feel things are out of control, …	0.867	0.826
On days where everything seems to go wrong, …	0.783	0.749
While preparing for a strenuous task, …	0.422	0.408
When I am under pressure, …	0.673	0.659
When I feel nervous and stressed, …	0.754	0.719
When I feel that I have no influence over the important things in my life, …	0.747	0.709
When I feel that I am not really on top of things, …	0.714	0.681
When I feel difficulties have been piling up so high that I cannot overcome them, …	0.789	0.748
% of Variance	54.614	–
Eigenvalues	6.461	–
Alpha of scale	0.920	–

In Table 3 correlations (Spearmans’ rho) between SSES and other variables and measurements, are presented. SSES was significantly positively correlated with the subscales of the DEBQ (for the Restrained subscale r = 0.147, p < 0.001 and for the Emotional subscale r = 0.615, p < 0.001) and significantly negatively correlated with two subscales of the TEFQ (for the TFEQ1 r = – 0.233, p < 0.001 and for the TFEQ3 r = – 0.562, p < 0.001).

Table 3

Correlations (Spearman’s rho) between SSES and other variables and measurements

SSES TOTAL
Age	– 0.080
BMI	0.178^**
PSS TOTAL	0.089
DEBQ(RESTRAINED)	0.147^**
DEBQ(EMOTIONAL)	0.615^**
TFEQ1 (uncontrollable eating)	– 0.233^**
TFEQ2 (restrained eating)	– 0.038
TFEQ3 (emotional eating)	– 0.562^**

^**Correlation is significant at the 0.01 level (2-tailed). BMI = Body Mass Index; SSES TOTAL = Salzburg Stress Eating Scale total; PSS TOTAL =P erceived Stress Scale total; DEBQ restrained/emotional = Dutch Eating Behavior Questionnaire Restrained/emotional; TFEQ 1/2/3 = Three Factor Eating Questionnaire 1/2/3. 1 (Uncontrollable eating) / 2 (Restrained eating) / 3 (Emotional eating).

The study also aimed at investigating possible links between the SSES score and certain socioeconomic and lifestyle characteristics of the participants, which are shown on Table 4. Significant differences were observed between gender and the SSES categories, as well as, physical exercise and SSES categories. More specifically, more men reported no changes in eating behaviors in stressful periods, in comparison to women, and more women reported eating more in stressful periods, in comparison to men (p = 0.001). As for physical exercise, those who were physically active reported eating less in stressful periods, in contrast to those who are not as physically active (p = 0.016). Finally, obese participants reported that in stressful periods, either they were eating less, or more (42.2%, respectively). Underweight, normal weight and overweight participants reported that they were eating less, in stressful periods. This finding was statistically significant (p = 0.044). No other significant differences were observed.

Table 4

Differences in sociodemographic characteristics and lifestyle characteristics with respect to eating categories (SSES questionnaire)

Study measurements	Categories	EAT LESS N%	NO CHANGE N%	EAT MORE N%
Gender	Men	105 (58.3)	31 (17.2)	44 (24.4)
	Women	107 (56.9)	12 (6.4)	69 (36.7)
	p-value		0.001
Marital status	Unmarried	126 (55.3)	22 (9.6)	80 (35.1)
	Married	76 (62.3)	18 (14.8)	28 (23.0)
	Divorced / Widowed	10 (55.6)	3 (16.7)	5 (27.8)
	p-value		0.151
Nationality	Greek	205 (57.1)	42 (11,7)	112 (31.2)
	Other	7 (77.8)	1 (11.1)	1 (11.1)
	p-value		0.405
Education level	Secondary education	38 (64.4)	5 (8.5)	16 (27.1)
	Tertiary education	136 (58.6)	32 (13.8)	64 (27.6)
	Advanced Tertiary education	38 (49.4)	6 (7.8)	33 (42.9)
	p-value		0.075
BMI Categories	Underweight	7 (63.6)	0 (0)	4 (36.4)
	Normal weight	121 (65.4)	17 (9.2)	47 (25.4)
	Overweight	65 (51.2)	19 (15)	43 (33.9)
	Obese	19 (42.2)	7 (15.6)	19 (42.2)
	p-value		0.044
Smoking	Yes	72 (59.5)	13 (10.7)	36 (29.8)
	No	116 (56.6)	24 (11.7)	65 (31.7)
	Ex-smoker	24 (57.1)	6 (14.3)	12 (28.6)
	p-value		0.961
Alcohol consumption	Yes	166 (55.1)	37 (12.3)	98 (32.6)
	No	46 (68.7)	6 (9.0)	15 (22.4)
	p-value		0.128
Exercise	Yes	171 (61.3)	33 (11.8)	75 (26.9)
	No	41 (46.1)	10 (11.2)	38 (42.7)
	p-value		0.016
Chronic Condition	Yes	29 (56.9)	7 (13.7)	15 (29.4)
	No	183 (57.7)	36 (11.4)	98 (30.9)
	p-value		0.883

4 Discussion

The current study was set out to validate the “Salzburg Stress Eating Scale” in the Greek Language in adults. Validating a tool like SSES is a helpful contribution for further research in the field of human eating behavior and stress. The results indicate that the SSES is a valid and reliable instrument. More specifically, exploratory Factor Analyses (EFA) indicated one factor in SSES with Eigenvalues > 1 (all loadings > 0.422), which is in line with the results of the original paper and other validation studies published in the past [15, 17]. Internal consistency was also very good with Cronbach’s alpha = 0.920, which is consistent with the original research paper (a1 = 0.89) [15], and similar validations in other languages too (a = 0.94 women, a = 0.91 men) [16]. Also, test-retest repeatability revealed that there was no difference between 1st and 2nd measurement for the SSES (p = 0.247) and the Spearman correlation coefficient was high (r = 0.688, p = 0.001).

It is important to note that, in the current study, the SSES had a significant positive correlation with both subscales of the DEBQ, which is in contrast with the study by Verbiest, (2021), where the SSES did not correlate significantly with the restrained eating subscale of the DEBQ [17]. However, the study by Verbiest (2021), validated the SSES in children and adolescents, not in adults. Unfortunately, there is a lack of validation studies in adult populations using the same tools with the current study, hence, no further comparison can be made.

No correlation between the SSES and the PSS was observed in this study. This finding is in accordance to a similar study by Meule Adrian et al., 2018 (15). To an extent the above lack of correlation between SSES and PSS was unexpected, since, usually, emotional eating and disordered eating are positively correlated with levels of perceived stress [17, 27]. One explanation could be that the SSES assesses stress-related eating without incorporating emotion-related items. It is also highly likely that the perception of levels of stress and its relation to eating behaviors, are two unrelated constructs.

With respect to the TFEQ, SSES had a significant negative correlation, with two out of the three subscales of TFEQ. It was significantly negatively correlated with uncontrollable eating and emotional eating, which was anticipated, given the fact SSES assesses stress-related eating without incorporating specific emotion-related items [15].

In agreement with Santos et al. 2021, there was a significant correlation between BMI and SSES [16]. More specifically, in the current study participants with higher BMI reported to eat more during stressful periods. In addition, more men in comparison to women, reported no changes in their eating behaviors during stressful periods. Women on the other hand, seem to eat more during stressful periods, in comparison to men (p = 0.001). These gender differences have also been reported in the past by other investigators [15, 16].

It is noteworthy that in the current study, participants who reported that they are physically active, tend to eat less in stressful situations, in contrast to those who are not physically active (p = 0.016). In a recent study, a potential protective role of physical activity with emotional eating during the COVID-19 pandemic, has been reported [28, 29]. There is indeed good evidence that, people who are physically active, are more efficient, in general, in coping with stress, in comparison to sedentary people [30].

Finally, the findings of this study should be considered in the light of a few methodological limitations including: the self-reported nature of the data and the convenience sampling recruitment of the participants, which led to a non-representative sample, with respect to the general adult population.

5 Conclusion

The ability to identify individuals who overeat or undereat in response to stress, using appropriate tools, is of paramount importance. The Greek version of the SSES appears to be a reliable instrument and can be used to assess eating behaviors in relation to stress.

Footnotes

Acknowledgments

The authors would like to thank everyone who participated in this research.

Funding

The authors report no funding.

Conflict of interest

The authors have no conflict of interest to report.

Author contribution

PN: conception, performance of work, interpretation of data, writing the article; MM: conception, performance of work, interpretation of data, writing the article; XT: conception, performance of work, interpretation of data, writing the article; CKG: conception, performance of work, interpretation of data, editing the article; VC: conception, performance of work, interpretation of data, writing the article.

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