Protocol - Questionnaire on Eating and Weight Patterns - Adult

QUESTIONNAIRE ON EATING AND WEIGHT PATTERNS-5

(QEWP-5)©

Last name ____________________________

First name _______________ M.I ____

Date _________________________________

I.D Number ______________________

Thank you for completing this questionnaire.
Please circle or check the appropriate number or response, and write in information where asked. You may skip any question you do not understand or do not wish to answer.

1. Age ___ years

2. Sex:

1[ ]Male

2[ ]Female

3. What is your ethnic/racial background?

a. Are you Latino, Hispanic, or of Spanish origin?

(Please check Yes or No).

[ ] Yes (Please continue with question 3b)

[ ] No (Please continue with question 3b)

b. Which of the following best describes you?

(You may check more than one.)

[ ] African American/Black

[ ] American Indian/Native American/Alaskan Native

[ ] Asian

[ ] Pacific Islander

[ ] White

[ ] Other (please specify): _______________________________

4. How far did you go in school?

1[ ]Some high school or less

2[ ]High school graduate or equivalent (GED)

3[ ]Some college or associate degree

4[ ]Completed college

5[ ]Advanced degree

5. How tall are you?

____ feet ___ ___ inches

6. How much do you weigh now (if you are unsure, please provide your best guess)?

________ pounds

7. What has been your highest adult weight ever (for women, when not pregnant)?

________ pounds

8. During the past three months, did you ever eat, in a short period of time? For example, a two hour period. What most people would think was an unusually large amount of food?

1[ ]Yes

2[ ]No → IF NO, SKIP TO QUESTION 21

9. During the times when you ate an unusually large amount of food, did you ever feel you could not stop eating or control what or how much you were eating?

1[ ]Yes

2[ ]No → IF NO, SKIP TO QUESTION 21

10. During the past three months, how often, on average, did you have episodes like this? That is, eating large amounts of food plus the feeling that you’re eating was out of control?

(There may have been some weeks when this did not happen, just average those in.)

1[ ]Less than 1 episode per week

2[ ]1 episode per week

3[ ]2-3 episodes per week

4[ ]4-7 episodes per week

5[ ]8-13 episodes per week

6[ ]14 or more episodes per week

11. Did you usually have any of the following experiences during these episodes?

a. Eating much more rapidly than normal?	Yes	No
b. Eating until feeling uncomfortably full?	Yes	No
c. Eating large amounts of food when not feeling physically hungry?	Yes	No
d. Eating alone because of feeling embarrassed by how much you were eating?	Yes	No
e. Feeling disgusted with yourself, depressed, or feeling very guilty afterward?	Yes	No

12. Think about a typical episode when you ate this way (That is, when you ate a large amount of food and felt your eating was out of control):

a. What time of day did the episode start?

1[ ](8 AM to 12 Noon)

2[ ](12 Noon to 4 PM)

3[ ](4 PM to 8 PM)

4[ ](8 PM to 12 Midnight)

5[ ](12 Midnight to 8 AM)

b. Approximately how long did this episode of eating last? hours_____ minutes_____

c. As best you can remember, please list everything you ate and drank during that episode. Please list the foods eaten and liquids consumed during the episode. Be specific - include brand names where possible, and amounts or portion sizes as best you can estimate.

d. At the time this episode started, how long had it been since you had previously finished eating a meal or snack?

hours_____ minutes_____

13. In general, during the past three months, how upset were you by these episodes?

(When you ate a large amount of food and felt your eating was out of control)?

1[ ]Not at all

2[ ]Slightly

3[ ]Moderately

4[ ]Greatly

5[ ]Extremely

14. During the past three months, did you ever make yourself vomit in order to avoid gaining weight after episodes of eating like you described (when you ate a large amount of food and felt your eating was out of control)?

1[ ]Yes

2[ ]No

IF YES: How often, on average, was that?

1[ ]Less than 1 episode per week

2[ ]1 episode per week

3[ ]2-3 episodes per week

4[ ]4-7 episodes per week

5[ ]8-13 episodes per week

6[ ]14 or more episodes per week

15. During the past three months, did you ever take more than the recommended dose of laxatives in order to avoid gaining weight after episodes of eating like you described (when you ate a large amount of food and felt your eating was out of control)?

1[ ]Yes

2[ ]No

IF YES: How often, on average, was that?

1[ ]Less than 1 time per week

2[ ]1 time per week

3[ ]2-3 times per week

4[ ]4-5 times per week

5[ ]6-7 times per week

6[ ]8 or more times per week

16. During the past three months, did you ever take more than the recommended dose of diuretics (water pills) in order to avoid gaining weight after episodes of eating like you described (when you ate a large amount of food and felt your eating was out of control)?

1[ ]Yes

2[ ]No

IF YES: How often, on average, was that?

1[ ]Less than 1 time per week

2[ ]1 time per week

3[ ]2-3 times per week

4[ ]4-5 times per week

5[ ]6-7 times per week

6[ ]8 or more times per week

17. During the past three months, did you ever fast - for example, not eat anything at all for at least 24 hours -- in order to avoid gaining weight after episodes of eating like you described (when you ate a large amount of food and felt your eating was out of control)?

1[ ]Yes

2[ ]No

IF YES: How often, on average, was that?

1[ ]Less than 1 day per week

2[ ]1 day per week

3[ ]2 days per week

4[ ]3 days per week

5[ ]4-5 days per week

6[ ]More than 5 days per week

18. During the past three months, did you ever exercise excessively for example, exercised even though it interfered with important activities or despite being injured, specifically in order to avoid gaining weight after episodes of eating like you described. (When you ate a large amount of food and felt your eating was out of control)?

1[ ]Yes

2[ ]No

IF YES: How often, on average, was that?

1[ ]Less than 1 time per week

2[ ]1 time per week

3[ ]2-3 times per week

4[ ]4-7 times per week

5[ ]8-13 times per week

6[ ]14 or more times per week

19. During the past three months, did you ever take more than the recommended dose of a diet pill in order to avoid gaining weight after episodes of eating like you described. (When you ate a large amount of food and felt your eating was out of control)?

1[ ]Yes

2[ ]No

IF YES: How often, on average, was that?

1[ ]Less than 1 time per week

2[ ]1 time per week

3[ ]2-3 times per week

4[ ]4-5 times per week

5[ ]6-7 times per week

6[ ]8 or more times per week

20. During the past three months, on average, how important has your weight or shape been in how you feel about or evaluate yourself as a person as compared to other aspects of your life, such as your performance at work or as a parent, or how you get along with other people?

1[ ]Weight and shape were not very important

2[ ]Weight and shape played a part in how you felt about yourself

3[ ]Weight and shape were among the main things that affected how you felt about yourself

4[ ]Weight and shape were the most important things that affected how you felt about yourself.

Continue here after completing question 20 OR if you skipped to question 21 from question 8 or 9.

21. During the past three months, did you ever have episodes during which you felt you could not stop eating or control what or how much you were eating but in which you did not consume what most people would think was an unusually large amount of food?

1[ ]Yes

2[ ]No → IF NO, SKIP TO QUESTION 26

22. During the past three months how often did you have episodes like this -- the feeling that your eating was out of control, but you did not consume what most people would think was an unusually large amount of food? (There may have been some weeks when this did not happen -- just average those in.)

1[ ]Less than 1 episode per week

2[ ]1 episode per week

3[ ]2-3 episodes per week

4[ ]4-7 episodes per week

5[ ]8-13 episodes per week

6[ ]14 or more episodes per week

23. Did you usually have any of the following experiences during these episodes?

a. Eating much more rapidly than normal?	Yes	No
b. Eating until feeling uncomfortably full?	Yes	No
c. Eating large amounts of food when not feeling physically hungry?	Yes	No
d. Eating alone because of feeling embarrassed by how much you were eating?	Yes	No
e. Feeling disgusted with yourself, depressed, or feeling very guilty afterward?	Yes	No

24. Think about a typical episode when you ate this way (that is, when you felt you could not stop eating or control what or how much you were eating) but in which you did not consume an unusually large amount of food):

a. What time of day did the episode start?

1[ ](8 AM to 12 Noon)

2[ ](12 Noon to 4 PM)

3[ ](4 PM to 8 PM)

4[ ](8 PM to 12 Midnight)

5[ ](12 Midnight to 8 AM)

b. Approximately how long did this episode of eating last?

hours_____ minutes_____

c. As best you can remember, please list everything you ate and drank during that episode. Please list the foods eaten and liquids consumed during the episode. Be specific - include brand names where possible, and amounts or portion sizes as best you can estimate.

d. At the time this episode started, how long had it been since you had previously finished eating a meal or snack?

hours_____ minutes_____

25. In general, during the past three months, how upset were you by these episodes (that is, when you felt you could not stop eating or control what or how much you were eating but in which you did not consume an unusually large amount of food)?

1[ ]Not at all

2[ ]Slightly

3[ ]Moderately

4[ ]Greatly

5[ ]Extremely

Continue here after completing question 25 OR if you skipped to question 26 from question 21.

26. Please take a look at these silhouettes. Put a circle around the silhouettes that most resemble the body builds of your biological father and mother at their heaviest.

If you have no knowledge of your biological father and/or mother, don’t circle anything for that parent.

Scoring:

DECISION RULES FOR SCREENING FOR POSSIBLE DIAGNOSIS OF BINGE EATING DISORDER

(BED) USING THE QUESTIONNAIRE ON EATING AND WEIGHT PATTERNS - 5

(FOR RATER’S USE ONLY)

POSSIBLE DIAGNOSIS OF BED
QUESTION NUMBER	RESPONSE
8 AND 9	1 (BINGE EATING)
10	2, 3, 4, 5, OR 6 (AT LEAST 1 EPISODE PER WEEK FOR THREE MONTHS)
11 a through e	3 OR MORE ITEMS MARKED "YES" (AT LEAST 3 ASSOCIATED SYMPTOMS DURING BINGE EATING EPISODES)
13	4 0R 5 (MARKED DISTRESS REGARDING BINGE EATING)

POSSIBLE DIAGNOSIS OF BED REQUIRES ALL OF THE ABOVE ALONG WITH THE ABSENCE OF INAPPROPRIATE COMPENSATORY BEHAVIORS AS SEEN IN BULIMIA NERVOSA, AS DEFINED BELOW.

POSSIBLE DIAGNOSIS OF BULIMIA NERVOSA
QUESTION NUMBER	RESPONSE
8 AND 9	1 (BINGE EATING)
10	2, 3, 4, 5, OR 6 (AT LEAST 1 EPISODE PER WEEK FOR THREE MONTHS)
14,15,16,17,18, OR 19	ANY RESPONSE 2, 3, 4, 5, OR 6 (INAPPROPRIATE COMPENSATORY BEHAVIOR AT LEAST 1 TIME PER WEEK FOR THREE MONTHS)
13	4 0R 5 (MARKED DISTRESS REGARDING BINGE EATING)

QUESTIONS FOR RESEARCH PURPOSES ONLY (NOT TO BE USED FOR DIAGNOSIS OF BED OR BULIMIA NERVOSA)
QUESTION NUMBER	RESPONSE
12 a through d	EXAMINER’S JUDGMENT THAT AMOUNT OF FOOD DESCRIBED IS UNUSUALLY LARGE GIVEN CIRCUMSTANCES (I.E., TIME OF DAY, HOURS SINCE PREVIOUS MEAL) Yes _____ NO____ UNSURE
21	1 (SUBJECTIVE BULIMIC EPSIODE/LOSS OF CONTROL EATING)
24 a through d	EXAMINER’S JUDGMENT THAT AMOUNT OF FOOD DESCRIBED IS UNUSUALLY LARGE GIVEN CIRCUMSTANCES (I.E., TIME OF DAY, HOURS SINCE PREVIOUS MEAL) Yes _____ NO____ UNSURE
26	SILHOUETTES MAY BE USED TO ESTIMATE PARENTAL HISTORY OF OBESITY