Appendix A

Questionnaire on eating and weight patterns

Last name_______________    First name_______________

Date____________________

ID Number_______________

Thank you for completing this questionnaire. Please circle the appropriate number or response, or 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?

1. Black (not Hispanic)

2. Hispanic

3. White (not Hispanic)

4. Asian

5. Other ( Please specify) _____

4. How far did you get in school?

1. Grammar school, junior high school or less

2. Some high school

3. High school graduate or equivalency (GED)

4. Some college or associate degree

5. Completed college

5. How tall are you?

____ feet ___ ____ in.

6. How much do you weigh now?

______ lbs.

7. What has been your highest weight ever (when not pregnant)?

______lbs.

8. Have you ever been overweight by at least 10 lbs. as a child or 15 lbs as an adult (when not pregnant)?

   1 Yes                                              2 No or not sure

If Yes: How old were you when you were first overweight (at least 10 lbs as a child or 15 lbs as an adult?) If you are not sure, what is your best guess?

____ ___ years

9. How many times (approximately) have you lost 20 lbs or more when you weren't sick - and then gained it back?

1 Never

2 Once or twice

3 Three or four times

4 Five times or more

10. During the past six months, did you often eat within any two-hour period what most poeple would regard as an unusually large amount of food?

   1 Yes                                           2 No

If No: Skip to Question 15

11. During the times when you ate this way, did you often feel you couldn't stop eating or control what or how much you were eating?

   1 Yes                                               2 No

If No: Skip to Question 15

12. During the past six months, how often, on average, did you have times when you ate this way - that is, large amounts of food plus the feeling that your eating was out of control? (There may have been some weeks when it was not present - just average those in.)

1 Less than one day a week

2 One day a week

3 Two or three days a week

4 Four or five days a week

5 Nearly every day

13. Did you usually have any of the following experiences during these occasions?

14. Think about a typical time when you ate this way_that is, large amounts of food plus the feeling that your eating was out of control.

a. What time of day did the episode start?

1 Morning (8 AM to 12 Noon)

2 Early afternoon (12 Noon to 4 PM)

3 Later afternoon (4 PM to 7 PM)

4 Evening (7 PM-10 PM)

5 Night (After 10 PM)

b. Approximately how long did this episode of eating last, from the time you started to eat to when you stopped and didn't eat again for at least two hours

 

______hours ______minutes

c. As best you can remember, please list everything you might have eaten or drunk during that episode. If you ate for more than two hours, describe the foods eaten and liquids drunk during the two hours that you ate the most. Be specific - include brand names where possible and amounts as best you can estimate. (For example: 7 ounces Ruffles potato chips; 1 cup Breyer's chocolate ice cream with 2 teaspoons hot fudge; 2 8-ounce glasses of Coca-Cola, 1 1/2 ham and cheese sandwiches with mustard.)

 

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

 

_____hours _____minutes

15. In general, during the past six months, how upset were you by overeating (eating more than you think is best for you)?

1 Not at all

2 Slightly

3 Moderately

4 Greatly

5 Extremely

16. In general, during the past six months, how upset were you by the feeling that you couldn't stop eating or control what or how much you were eating?

1 Not at all

2 Slightly

3 Moderately

4 Greatly

5 Extremely

17. During the past six months, 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 how you do at work, 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.

18. During the past three months, did you ever make yourself vomit in order to avoid gaining weight after binge eating?

   1 Yes                                            2 No

If Yes: How often, on average, was that?

1 Less than once a week

2 Once a week

3 Two or three times a week

4 Four or five times a week

5 More than five times a week

19. During the pest three months, do you ever take more than twice the recommended dose of laxatives in order to avoid gaining weight after binge eating?

   1 Yes                                             2 No

If Yes: How often, on average, was that?

1 Less than once a week

2 Once a week

3 Two or three times a week

4 Four or five times a week

5 More than five times a week

20. During the past three months, did you ever take more than twice the recommended dose of diuretics (water pills) in order to avoid gaining weight after binge eating?

   1 Yes                                            2 No

If Yes: How often, on average, was that?

1 Less than once a week
2 Once a week
3 Two or three times a week
4 Four or five times a week
5 More than five times a week

21. During the past three months, did you ever fast—not eat anything at all for at least 24 hours —in order to avoid gaining weight after binge eating?

   1 Yes                                                   2 No

If Yes: How often, on average, was that?

1 Less than one day a week

2 One day a week

3 Two or three days a week

4 Four or five days a week

5 Nearly every day

22. During the past three months, did you ever exercise for more than an hour specifically in order to avoid gaining weight after binge eating?

   1 Yes                                             2 No

If Yes: How often, on average, was that?

1 Less than once a week

2 Once a week

3 Two or three times a week

4 Four or five times a week

5 More than five times a week

23. During the past three months, did you ever take more than twice the recommended dose of a diet pill in order to avoid gaining weight after binge eating?

   1 Yes                                          2 No

If Yes: How often, on average, was that?

1 Less than once a week

2 Once a week

3 Two or three times a week

4 Four or five times a week

5 More than five times a week

24. During the past six months, did you go to any meetings of an organized weight control program? (e.g.,Weight Watchers, Optifast, Nutrisystem) or a self-help group (e.g., TOPS, Overeaters Anonymous)?

   1 Yes                                            2 No

If Yes: Name of program

________________________________________________

25. Since you have been an adult—18 years old— how much of the time have you been on a diet, been trying to follow a diet, or in some way been limiting how much you were eating in order to lose weight or keep from regaining weight you had lost? Would you say...?

1 None or hardly any of the time

2 About a quarter of the time

3 About half of the time

4 About three-quarters of the time

5 Nearly all of the time

26. Skip this question if you never lost at least 10 lbs. by dieting:

How old were you the first time you lost at least 10 lbs by dieting, or in some way limiting how much you ate? If you are not sure, what is your best guess?

______  years

27. Skip this question if you've never had episodes of eating unusually large amounts of food along with the sense of loss of control:

How old were you when you first had times when you ate large amounts of food and felt that your eating was out of control? If you are not sure, what is your best guess?

______  years

DIAGNOSIS OF NON-PURGING BULIMIA NERVOSA

DIAGNOSIS OF BED

Diagnosis of BED requires all of the above along with the absence of purging or non-purging bulimia nervosa, as defined below.

DIAGNOSIS OF PURGING BULIMIA NERVOSA