Cross-Cultural Testing of Dietary Restraint
Restrained eating refers to the intention to restrict food intake deliberately in order to prevent weight gain or to promote weight loss. Research on restrained eating started in the 1970s and, thus, it now encompasses more than 40 years of investigation. This chapter provides a brief overview of the historical development of the concept, describes the most commonly used measures for the assessment of restrained eating, and reviews cross-cultural differences in dietary restraint.
KeywordsRestrained eating Dietary restraint Dieting Weight concern Cross-cultural
The hypothesis that differences in the pattern of eating behavior correspond to two theoretically distinct classes of individuals, obese and normal (as measured by degree of overweight), no longer seems tenable, at least in its most elementary form. Within the population of normal weight individuals, fairly sizable differences exist with respect to concern with weight and eating behavior—in our terminology, restraint […]. Herman and Mack (1975, p. 657)
In environments in which highly caloric and palatable food is cheap, constantly available, and easily accessible, eating more calories than the body can expend is easy. Thus, it seems that most people (except maybe endurance athletes) need to be conscious about their food decisions and the amount they eat instead of mindlessly indulging in eating. Yet, while it seems necessary to regulate one’s eating to prevent becoming overweight, such intentional restriction is also notorious for causing further weight gain or increasing the risk for eating disorders (Schaumberg et al. 2016).
Research on this topic was heavily influenced — or in fact started off — by the works of C. Peter Herman and Janet Polivy (1975, 1983; Herman et al. 1978). In a seminal study (Herman and Mack 1975), participants were instructed to drink either none, one, or two milkshakes followed by a bogus ice cream taste test. It was found that participants scoring low on a measure of dietary restraint ate less ice cream when they before had to drink the milkshakes than in the no milkshake condition. Strikingly, participants scoring high on a measure of dietary restraint — so-called restrained eaters — showed the opposite pattern: they even ate more ice cream in the milkshake conditions than in the no milkshake condition (in which they actually ate less than the unrestrained eaters). Thus, this study indicated that when people restrain their eating behavior, this restriction can easily be disinhibited under certain circumstances (e.g., by consumption of a high-calorie preload).
In the decades that followed, several other manipulations were identified that similarly induce disinhibited eating in restrained eaters, for example, negative mood inductions (Evers et al. 2018). Yet, several limitations of the original conception of restrained eating have been noted in the past decades as well. For example, the Restraint Scale as employed by Herman and Polivy includes questions on weight fluctuations. While it was noted that participants (particularly unrestrained eaters) find these questions hard to answer (Wardle 1986), the items also confound a higher body weight as well as past dieting failures and restraint. As a consequence, Stunkard and Messick (1985) and van Strien et al. (1986) developed alternative measures in order to capture more “pure” cognitive control of eating behavior.
Regardless of which questionnaire is used, however, it seems that scores of dietary restraint scales do not relate to actual reduced food consumption (Stice et al. 2004, 2007, 2010). Thus, restrained eating cannot be equated with dieting, that is, actual caloric restriction. As most restrained eaters are not currently on a diet but are concerned about their weight and try to limit their food intake, restrained eating can rather be defined as the intention to restrict food intake deliberately in order to prevent weight gain or to promote weight loss.
Dietary restraint has been implicated as a risk factor for the development of eating disorders. Furthermore, because of the finding that restrained eating behavior can easily be disinhibited under certain circumstances and because higher restraint scores typically relate to higher body mass index, dietary restraint has a bad reputation for being a rather dysfunctional, unsuccessful strategy to control food intake. Yet, it seems that this deserves a more nuanced view as dietary restraint has also been linked to positive outcomes, particularly in conjunction with weight management programs (Schaumberg et al. 2016).
Measures of Restrained Eating
Psychometric instruments for the assessment of restrained eating
Arabic (Madanat et al. 2007)
Czech (Bernatova and Svetlak 2017)
Dutch (Jansen et al. 1988)
Estonian (Tiggemann and Rüütel 2001)
French (Mobbs et al. 2008)
German (Dinkel et al. 2005)
Greek (Kkeli et al. 2018)
Japanese (Madanat et al. 2011)
Spanish (Silva and Urzúa-Morales 2010)
Three-Factor Eating Questionnaire (Stunkard and Messick 1985)
Chinese (Chong et al. 2016)
Dutch (Ouwens et al. 2003)
Finnish (Anglé et al. 2009)
French (Lesdéma et al. 2012)
German (Pudel and Westenhöfer 1989)
Greek (Kavazidou et al. 2012)
Italian (Boschi et al. 2001)
Japanese (Adachi et al. 1992)
Malay (Ismail et al. 2015)
Persian (Mostafavi et al. 2017)
Portuguese (Moreira et al. 1998)
Spanish (Jáuregui-Lobera et al. 2014)
Swedish (Karlsson et al. 2000)
Thai (Chearskul et al. 2010)
Turkish (Bas et al. 2008)
Dutch Eating Behavior Questionnaire (van Strien et al. 1986)
aDutch (van Strien et al. 1986)
French (Lluch et al. 1996)
German (Grunert 1989)
Greek (Zeeni et al. 2013)
Italian (Dakanalis et al. 2013)
Korean (Kim et al. 1996)
Malay (Subramaniam et al. 2017)
Maltese (Dutton and Dovey 2016)
Persian (Nejati et al. 2018)
Portuguese (Viana and Lourenço 2003)
Spanish (Cebolla et al. 2014)
Turkish (Bozan et al. 2011)
Eating Disorder Examination—Questionnaire (Fairburn and Beglin 1994)
Chinese (Leung et al. 2009)
Dutch (Aardoom et al. 2012)
Fijian (Becker et al. 2010)
French (Carrard et al. 2015)
German (Hilbert and Tuschen-Caffier 2016)
Greek (Giovazolias et al. 2013)
Italian (Calugi et al. 2017)
Japanese (Nakai et al. 2014)
Norwegian (Rø et al. 2010)
Persian (Mahmoodi et al. 2016)
Portuguese (Machado et al. 2014)
Spanish (Elder and Grilo 2007)
Swedish (Welch et al. 2011)
Turkish (Yucel et al. 2011)
In the early studies by Herman and Polivy, different versions of the Restraint Scale were used (Herman and Mack 1975; Herman and Polivy 1975). The final version of the Revised Restraint Scale has 10 items (Herman et al. 1978; Polivy et al. 1978). The scale includes different response options. For example, some items are scored from 0 = never to 3 = always but other response categories include different ranges of pounds (e.g., for the question “What is the maximum amount of weight you have ever lost within 1 month?”). The scale can be further separated into two subscales: concern for dieting and weight fluctuations (Blanchard and Frost 1983).
Three-Factor Eating Questionnaire (TFEQ)
The TFEQ (sometimes also referred to as Eating Inventory) was developed by Stunkard and Messick (1985). It has 51 items with different response formats. The scale can be separated into three subscales: cognitive restraint of eating, disinhibition, and hunger. The restraint subscale consists of 21 items. Yet, it has been suggested that the restraint subscale is also not uniform but can be further divided with some items assessing a more rigid control of eating and some items assessing a more flexible control of eating (Westenhoefer 1991). A short version of the TFEQ with 18 items has also been developed (Karlsson et al. 2000). Yet, the three-factor structures of both the original and the short version have received mixed support in subsequent studies (Cappelleri et al. 2009; Mazzeo et al. 2003).
Dutch Eating Behavior Questionnaire (DEBQ)
The DEBQ was developed by van Strien et al. (1986). It has 33 items that are scored from 1 = never to 5 = very often. The scale can be separated into three subscales: restrained eating, emotional eating, and external eating. The restraint subscale consists of 10 items. The three-factor structure has generally received good support in other studies (Barrada et al. 2016).
Eating Disorder Examination—Questionnaire (EDE—Q)
The EDE–Q was developed by Fairburn and Beglin (1994). It has 28 items of which 6 items assess the frequency of key behaviors such as binge eating and self-induced vomiting in the past 28 days. The remaining 22 items have different response options (e.g., 0 = no days to 6 = every day) and can be separated into four subscales: restraint, eating concern, weight concern, and shape concern. Yet, this four-factor structure has received limited support in the literature (Rand-Giovannetti et al. in press).
Cross-Cultural Differences in Restrained Eating
Although some of these studies only investigated women, studies that included participants of both sexes suggest that differences in restrained eating between countries seem to be primarily driven by restraint scores of women. Specifically, women usually display higher restrained eating than men do in North American, Australian, and European samples. This sex difference resonates with a large body of research showing than women are more concerned about their weight and shape and have a higher prevalence of disordered eating behaviors than men have. In countries with lower restrained eating scores, however, there seems to be no such difference between sexes (Cogan et al. 1996; Dolan and Ford 1991; Fig. 1).
Besides these cross-cultural differences, however, several studies found similar levels of restrained eating between different countries. For example, no differences in dietary restraint were found between UK versus Israel women during or after pregnancy (Shloim et al. 2015, in press), Lebanon versus Cyprus female students (Zeeni et al. 2013), Japan versus Jordan versus USA female students (Madanat et al. 2011), and Greece versus UK students (Tapper et al. 2008).
Thus, it seems that no broad conclusions regarding different world regions can be drawn as differences in restrained eating can be observed within the same continent (e.g., China vs. Japan; Madanat et al. 2011) or scores are sometimes similar across countries in different continents (e.g., Jordan vs. USA; Madanat et al. 2011). Furthermore, differences in dietary restraint can also be observed between different ethnic groups within one country. For example, lower restrained eating has been reported in Afro-American versus Caucasian female students in the USA (Abrams et al. 1993; Rucker III and Cash 1992). Thus, it seems necessary for future research to not only compare scores of participants in different countries but also to consider other factors (e.g., ethnicity, migration background) within each country.
Given these cross-cultural differences — although inconsistent — an interesting line of research pertains to the question of acculturation. Does moving to another country lead to increases or decreases in restraint scores because the new environment changes one’s attitudes towards eating and body weight? Although there are not many studies on this, is seems that levels of restrained eating can be quite stable. For example, Abdollahi and Mann (2001) tested Iranian women living in Iran and Iranian women living in the USA and found no differences in restrained eating between groups. Furthermore, a recent study by Westenhoefer et al. (2018) found that seafarers from Kiribati had higher TFEQ disinhibition scores (and these were more strongly related to body mass index) than seafarers from Europe. Although disinhibited eating is not equivalent to (but is positively correlated with) restrained eating, this study suggests that cultural background can still account for differences in eating behavior in the same food environment.
Even if two cultures exhibit similar levels of restrained eating, its predictors and consequences might still be culture-specific. In a recent study by Shagar et al. (2019), for example, body dissatisfaction was linked to restrained eating only in Australian but not in Malaysian women. Furthermore, family influence related to internalization of the thin ideal only in Malaysian but not in Australian women. Although these differences were found, however, the authors also highlighted that overall there were more similarities than differences across cultures. For example, higher internalization of the thin ideal was linked to higher restrained eating in both Australian and Malaysian women.
In conclusion, studies that examined cross-cultural differences in restrained eating tend to show highest levels of dietary restraint in the USA, followed by European countries and Australia, and lowest levels in African and Asian countries such as Ghana, Egypt, Iran, and China. However, this conclusion is based only on a handful of studies and, therefore, findings need to be interpreted cautiously. Interestingly, it seems that studies that reported similar levels of restrained eating across different countries are more recent while research that reported differences between certain countries includes studies from the 1980s and 1990s. Thus, it might be speculated that there is an overall trend towards an alignment of restraint scores across countries, which may be due to changes in diet (e.g., Westernization of traditional Eastern diets) and other factors (e.g., media exposure, thin ideal internalization).
Challenges in Cross-Cultural Testing of Dietary Restraint
It is usually assumed that differences in restrained eating between countries or ethnic groups are due to cultural differences such as eating traditions, social interactions, or media exposure. However, there are also methodological and anthropometrical issues that need to be considered. For example — as discussed below — higher restrained eating scores can result from having a higher body weight. Thus, it may be that cross-cultural differences in restraint may be partially attributable to general differences in mean body mass index between countries. That is, higher restraint scores in a country may simply be the result of people being heavier there instead of reflecting dietary restriction. This may be particularly relevant for the Restraint Scale as answers to the weight fluctuations questions are highly correlated with body mass index.
Furthermore, the response categories of the weight fluctuations questions may not be equally applicable to all ethnic groups because of different body build. Asian populations, for example, have lower body mass index and different associations between body mass index and body fat than non-Asian populations (WHO Expert Consultation 2004). For instance, some Asian groups have higher percent body fat at a low body mass index than Caucasians due to differences in trunk-to-leg length and slenderness (Deurenberg et al. 2002).
Such differences in body build and body composition may also influence the relationship between body mass index and restrained eating. Specifically, higher restrained eating — particularly when assessed with the Restraint Scale — is usually positively correlated with body mass index. That is, most restrained eaters have a higher body weight than unrestrained eaters. This relationship is likely bidirectional: restrained eating may predict weight gain (van Strien et al. 2014), but having a high body weight may also lead to higher restraint scores as the desire for losing weight (and, thus, the intention to restrict food intake) increases with increasing body weight (Snoek et al. 2008). Surprisingly, however, restrained eating scores were unrelated to body mass index in some studies from China, even when participants were explicitly classified as successful and unsuccessful restrained eaters (Meule 2016).
Finally, it may be that differences in nutrition can account for differences in the relationship between body weight and restrained eating. For example, the traditional Chinese diet is healthier (i.e., less energy dense) than the typical North American diet (Lv and Cason 2004). Thus, it might be that rather unsuccessful restrained eaters living in countries with a healthier diet may still have a healthier weight than those living in countries with an unhealthier diet because — although they might consider themselves unsuccessful — they still do not consume large amounts of calories. Yet, as typical diets in many countries are more and more “Westernized,” it may be that this will also lead to a decrease of cross-cultural differences in the relationship between body weight and restrained eating.
Restrained eating or dietary restraint refers to cognitive effort exerted by an individual to eat less than they would like. Higher restrained eating scores have been related to instances of disinhibited eating and higher body weight. However, as Schaumberg et al. (2016) have noted, “dietary restraint cannot be categorized as entirely healthy or unhealthy, but rather could be health promoting or detrimental depending on the circumstances under which it is employed” (p. 96). Although some studies point towards highest levels of restrained eating in North America followed by European countries and Australia and then African, Arabic, and Asian regions, the extant literature on cross-cultural differences in dietary restraint does not provide a consistent overall picture. This may be partially due to methodological and anthropometric issues that need to be considered in cross-cultural testing of dietary restraint.
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