Comments by Margriet S. Westerterp-Plantenga, Ph.D. (Oct, 2020)

Characterization of the TFEQ
The publication titled: ‘The Three Factor Eating Questionnaire to measure dietary restraint, disinhibition and hunger’ by Stunkard and Messick (1985) describes the construction of a questionnaire to measure three dimensions of human eating behaviour in adults. Using factor analysis of the results of combining and revising previous questionnaires, a.o the Herman-Polivy (H-P) questionnaire (Herman and Polivy, 1984) three stable factors emerged: F1: ‘cognitive restraint of eating’, F2: ‘disinhibition’ and F3: ‘hunger.’ F1 was interpreted as ‘cognitive control of eating behavior,’ F2 as ‘disinhibition of control and emotional eating,’ and F3 as ‘susceptibility to hunger.’ Assessment of the homogeneity of the restraint construct revealed two sets of restraint behaviors and cognitions differentiating between high and low disinhibition (Westenhoefer, 1991). This resulted in two restraint subscales, one associated with increasing disinhibition (rigid control), the other with decreasing disinhibition (flexible control). In addition, more sub-factors have been suggested, relating to particular sets of questions of the TFEQ (Bryant et al., 2019).

Significance of TFEQ scores in body weight management
The significance of scores on the three factors of the TFEQ lies in the role the scores play in explaining eating behavior in relation to energy balance and body-weight management in the context of obesity. Cognitive dietary restraint has been repeatedly confirmed -using functional brain imaging- as an indicator of control of food-intake (Born et al., 2011, Drummen et al., 2018, 2019, Lemmens et al., 2010, Westerterp-Plantenga, 2010). Comparison of TFEQ-scores with scores on the H-P scale showed that the H-P scale primarily relates to body weight, whereas the TFEQ primarily relates to food intake. Healthy participants with normal weight scoring high on TFEQ cognitive restraint but not on the H-P scale were primarily food-concerned, and consequently were successful restrained eaters (Westerterp-Plantenga et al., 1991). Healthy participants with overweight or obesity scoring high on both TFEQ and H-P dietary restraint were primarily weight-concerned (Westerterp-Plantenga et al., 1991). Longer term success of their dieting strategies was reinforced by a combination of their TFEQ scores, in that F1 should be increasing and remaining at a higher level, while F2 and F3 scores should be decreasing and remaining low (Westenhoefer, 1991; Westerterp-Plantenga et al., 1991, 1998a, 1998b; Vogels et al., 2005a, 2005b, 2007, Keskitalo et al., 2008; Bryant et al., 2019). Examples of long-term life-style studies showing such effects include studies with low-fat diets, or high-protein diets (Westerterp-Plantenga et al., 1998a, 1998b, 2004, 2020, Lejeune et al., 2005, Soenen et al., 2011, 2012, 2013). Especially increasing cognitive dietary restraint was shown to counteract unfavourable effects of high-fat diets (Westerterp-Plantenga 1998b), and to promote body-weight maintenance irrespective of exercise training effects (Lejeune et al., 2003a). Lejeune et al (2003b) also showed that after similar body weight losses induced by leptin injections or dieting, subsequent body-weight maintenance was stronger in the dieting group, paralleled by increased dietary restraint, which was absent in the leptin group. On the other hand, as body mass index increases, disinhibition and hunger increase while cognitive restraint decreases (Bryant et al., 2019). Thus disinhibition and hunger may antagonize the favourable effects of increasing dietary restraint during body weight maintenance(Westenhoefer, 1991; Westerterp-Plantenga et al., 1991; Vogels et al., 2005a, 2005c, Bryant et al., 2019).

Genetic predisposition to eating behavior and body weight management
An overall genetic susceptibility to obesity may also extend to eating behaviors. The link between specific loci and obesity may be mediated by eating behavior. Genetic studies report that genes associated with increased BMI are positively associated with disinhibition and hunger scores, and inversely associated with cognitive restraint scores (Jacob et a., 2018; de Lauzon-Guillain B et al., 2017; Konttinen et al., 2015). The Genetic Risk Score was positively associated with emotional and uncontrolled eating. Here the BMI‐increasing variants of MTCH2, TNNI3K, and ZC3H4 were positively associated with emotional eating and those of TNNI3K and ZC3H4 were positively associated with uncontrolled eating (Cornelis et al., 2013). Additionally, the glucocorticoid receptor (GRL) gene has been found to underlie changes in TFEQ scores. Compared with the other 2 genotypes (CC and CG), the homozygous carriers of the G allele of the GRL gene had significant decreases over time in their disinhibition, emotional eating and hunger scores, which may result in decreased food intake (Vogels et al., 2005c).

Two sets of restraint behaviors and cognitions differentiating between high and low disinhibition
Successful dietary restraint in the context of body weight management largely depends on disinhibition scores (Westenhoeffer 1991). Opposite to flexible dietary restrained individuals, rigid dietary restrained individuals are not able to maintain body weight at a desired level due to their increased disinhibition. When the impact of disinhibition is potent in increasing energy intake and susceptibility to disturbed eating, the action of cognitive restraint produces differential results. The psychopathology of disturbed and disordered eating behaviors includes more binge eating, food craving, food addiction, resulting in a poorer diet. Disinhibition indicates loss of control over eating, followed by consumption of greater quantities of food, independent of their level of cognitive restraint (Ruddock et al., 2018). Individuals with a binge eating disorder (BED) diagnosis show higher disinhibition and hunger, a tendency to overeat, higher depression. neuroticism, anxiety, dysfunctional eating patterns, weight stigma, and weight bias internalization (Keeler et al., 2015; Cheng et al., 2014; Steinberg et al; 2014; Luo et al., 2014). Additionnally, disinhibition was related to weight regain over 10 years in patients who underwent Roux-enY gastric bypass surgery (Laurenius et al., 2011).

In conclusion, the significance of the change and magnitude of scores on the three factors of the TFEQ lies in their role in explaining eating behaviour in relation to energy balance and body-weight management in the context of obesity. In healthy individuals, increased flexible cognitive dietary restraint together with decreased disinhibition, emotional eating and hunger, may be affected by genetic predisposition and promotes body-weight maintenance. In individuals with eating disorders, increased disinhibition, emotional eating and hunger, irrespective of cognitive restraint, may be affected by genetic predisposition, and promotes body weight regain. Therefore, treatment of obesity may be directed not only towards increased dietary restraint but also towards prevention of disinhibition.

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