Appetite 114 (2017) 391e397

Contents lists available at ScienceDirect

Appetite
journal homepage: www.elsevier.com/locate/appet

Turkish version of the Intuitive Eating Scale-2: Validity and reliability

among university students
Murat Bas*, Kezban Esen Karaca 1, Duygu Saglam 2, Gozde Arıtıcı 3, Ecem Cengiz 4,
€ ksal 5, Aylin Hasbay Buyukkaragoz 6
Selen Ko
Acıbadem University, Health Sciences Faculty, Department of Nutrition and Dietetics, Istanbul, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Intuitive Eating is defined as "the dynamic process-integrating attunement of mind, body, and food". The
Received 26 July 2016 purpose of this study was, therefore, adapt the IES-2 to the Turkish language and reliability and validity
Received in revised form of IES-2 among Turkish populations. We also examined the instrument's internal consistency and test-
24 March 2017
retest reliability and analysed the relationships between the IES-2 and several variables so as to eval-
Accepted 12 April 2017
Available online 18 April 2017
uate the convergent and discriminant validity. Three hundred seventy-seven undergraduate and post-
graduate women and men between the ages of 19e31 years (mean 22.3, SD ¼ 3.53) attending two large
private universities in Istanbul, Turkey. The best solution from the principal factors analysis of the 23
Keywords:
Intiutive eating
items of the IES-2 revealed four factors corresponding to the four subscales (F1: Eating for physical rather
Psychometric properties than emotional reasons; F2: Unconditional permission to eat; F3: Reliance on hunger and satiety cues;
Dietary behavior F4: Body-food choice congruence), as reported by the authors of the questionnaire. Bartlett's test of
Validation sphericity gave X2 ¼ 9043.49 (p < 0.001), while the Kaiser-Meyer-Olkin index was 0.87 (KMO were 0.89
Turkish for women and 0.83 for men). The test-retest reliability of the IES-2 was 0.88 for the IES-2 total score. The
IES-2 had a ¼ 0.82. These findings support the notion that intuitive eating is a viable concept for uni-
versity students and the IES can be used to examine adaptive eating behaviors in this population.
© 2017 Published by Elsevier Ltd.

1. Introduction adaptive, independent behavioral process. Tylka (2006) examined

these adaptive eating processes through the development of the
Current approaches to eating behaviors have emphasized pa- Intuitive Eating Scale (IES) in college women, which was the first
thology, and research has begun to focus on exploring the causes, scale to provide clinicians and researchers with a way to adequately
prevalence, and factors associated with the occurrence of disor- measure this concept.
dered eating rather than on determining what contributes to the Intuitive eating is a type of non-diet approach to health that was
development of healthy, adaptive eating (Burrows & Cooper, 2002; first popularized in 1995 by Evelyn Tribole and Elyse Resch, both of
Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011; whom are registered dietitians. Tribole and Resch founded this
Wilksch & Wade, 2010). When healthy eating is argued, healthy method as a bridge between a traditional non-diet approach and
eating generally has been described simply as the lack of eating the typical health community approach, which includes dieting to
disorder symptoms (Tylka & Subich, 1999), rather than as an achieve ideal body weight. The traditional non-diet approach re-
quires full body acceptance regardless of size or shape but often
does not address health risks. On the other hand, the health com-
* Corresponding author. Acıbadem University, Health Sciences Faculty, Depart- munity's approach stresses the importance of minimizing health
_
ment of Nutrition and Dietetics, Içerenk € y Mahallesi Kayışdag
o ı Caddesi No:32, risks, including BMI, without mentioning the acceptance of the
Istanbul, Turkey. Tel.: þ90 216 500 42 30; Fax: þ90 216 577 51 35.
personal weight and shape differences. Tribole and Resch attempt
E-mail address: murat.bas@acibadem.edu.tr (M. Bas).
1
Tel.: þ90 216 500 42 39; Fax: þ90 216 577 51 35.
to mesh these two polar ideas into a single program in intuitive
2
Tel.: þ90 216 500 42 33; Fax: þ90 216 577 51 35. eating (Tribole & Resch, 2003).
3
Tel.: þ90 216 500 42 38; Fax: þ90 216 577 51 35. Intuitive eating, which is a restrictive eating or diet alternative,
4
Tel.: þ90 216 500 42 34; Fax: þ90 216 577 51 35. encourages individuals to consume calories only when they are
5
Tel.: þ90 216 500 41 79; Fax: þ90 216 577 51 35.
6 physically hungry (Gast & Hawks, 1998). This paradigm also focuses
Tel.: þ90 216 500 4231; Fax: þ90 216 577 51 35.

http://dx.doi.org/10.1016/j.appet.2017.04.017
0195-6663/© 2017 Published by Elsevier Ltd.
392 M. Bas et al. / Appetite 114 (2017) 391e397

on an individual's eating whatever is desired, theorizing that it is While Hawk's IES encompasses a four-factor structure (intrinsic
the body's natural way of telling it what it needs, avoiding food eating, extrinsic eating, antidieting, self-care), Tylka's IES embraces
consumption for emotional, social, or environmental cues, being a three-factor model (unconditional permission to eat, eating for
mindful of the body's satiety level, and supports the notion that physical rather than emotional reason, and reliance on internal
acceptance of body size is just as important as the food we consume hunger and satiety cues to determine when and how much to eat)
(Gast & Hawks, 2000). Many diets fail because of restrictive food (Cadena-Schlam & Lo  pez-Guimera , 2015). Nevertheless, most re-
intake and the ensuing disruption of homeostasis (Van Dyke & searchers preferred Tylka's IES to better assess intuitive eating style,
Drinkwater, 2014). Many professional organizations endorse calo- and have been using it widely in subsequent studies (Denny, Loth,
rie restricted diets as the best method for weight loss and weight Eisenberg, & Neumark-Sztainer, 2013; Dockendorff, Petrie, Green-
maintenance (Academy of Nutrition and Dietetics, 2009; Jensen leaf, & Martin, 2012; Tylka & Kroon Van Diest, 2013). Moreover,
et al., 2014). However, previous study has shown that dieting is building on Tylka's work, new scales have emerged. In 2012,
not a successful long-term tool for weight loss in all individuals; Dockendorff et al. developed Intuitive Eating Scale-Adolescents
one study estimated that less than 20% of individuals who attempt (IES-A) to assess intuitive eating in the adolescent population
to lose weight with dieting are successful and only 10% of people (Dockendorff et al., 2012).
who are initially successful are able to maintain that weight loss for Recently, Tylka and Kroon Van Diest (2013) developed and
more than one year (Kraschnewski et al., 2010). validated the Intuitive Eating Scale-2 (IES-2) in order to address
In contrast, intuitive eating offers a non diet approach to weight some limitations of the IES (Tylka & Kroon Van Diest, 2013). Two
management by eating according to physiological hunger and main changes have been presented that make the second version of
satiety cues (Augustus-Horvath & Tylka, 2011; Gast, Madanat, & the intuitive eating scale, by Tylka and Kroon Van Diest (2013),
Nielson, 2012; Hawks, Merrill, & Madanat, 2004; Tylka & Kroon more representative of adaptive eating behaviour. First, the
Van Diest, 2013; Wirtz & Madanat, 2013). Intuitive eating posits construct has now been validated in both women and men uni-
that the body can self-regulate caloric need by sending signals to versity/college population. Second, is the addition of the body food
eat the types and quantities of food to maintain health and weight; choice congruence subscale. The addition of the body-food choice
these physiological cues are commonly referred to as eat when you congruence subscale is important because the subscale provides
are hungry and stop when you are full (Van Dyke & Drinkwater, insight into the decisions that individuals make regarding their
2014). Intuitive eating shifts attention away from the negative nutrition focused food choices. The IES-2 re-phrases the four major
processes of dieting, restrictive eating, energy monitoring, sub-scales that relate to intuitive eating from the original IES to: (1)
increased physical activity for the purpose of calorie deficit, and eating for physical rather than emotional reasons (2) unconditional
weight loss towards the positive processes of increased body signal permission to eat, which assesses restraint in eating (3) reliance on
awareness, improved emotional wellbeing, improved self-worth, hunger and satiety cues, and (4) body-food choice congruence. The
reduced negative self-talk, and reduced preoccupation with food tool contains 23 items and is scored on a five point Likert scale with
choice (Cole & Horacek, 2010). Intuitive Eating is defined as “the higher scores representing greater adherence to intuitive eating
dynamic process-integrating attunement of mind, body and food” behaviors. The possible range for total IES score is 1e5, where a
(Tribole & Resch, 2003). It refers to an adaptive form of eating higher total score corresponds to more intuitive eating. The IES-2
essentially based on hunger and satiety cues to regulate food provides to be valid and reliable in both male and female college
intake. Thus, a strong connection with internal body signals, known students in U.S.
as interoceptive awareness, is fundamental to this process (Cadena- The IES-2 validity and realiability are not known among the
Schlam & Lo  pez-Guimera , 2015). Intuitive eating relies upon 10 Turkish population. The purpose of this study was, therefore, to
principles to teach body wisdom. Included in these principles are, adapt the IES-2 into the Turkish language and the reliability and
“reject the diet mentality,” “respect your fullness,” “Challenge the validity of IES-2 among Turkish population. We also examined the
Food Police“,”Discover the Satisfaction Factor”, “Honor Your Health instrument's internal consistency and test-retest reliability. In
“and, “honor your feelings without using food”. It should be addition, and in order to determine the construct validity, we
emphasized that the purpose of intuitive eating is not to facilitate analysed the relationship between the IES-2 and several variables
weight loss (Tribole & Resch, 2003). (Body Mass Index, Eating AttitudesTest, Eating Disorder Examina-
A large popular literature has accumulated that supports in- tion Questionnaire, Body Appreciation Scale) so as to evaluate the
dividuals in developing intuitive eating skills (Hirschmann & convergent and discriminant validity.
Munter, 1995; Matz & Frankel, 2006; Tribole & Resch, 2003).
There is considerable evidence that intuitive eating skills can be 2. Methods
learned (Bacon, Stern, Van Loan & Keim, 2005; Mensinger, Close &
Ku, 2009), and that intuitive eating is associated with improved 2.1. Participants and procedures
nutrient intake (Smith & Hawks, 2006), reduced eating disorder
symptomatology (Kristeller & Hallett, 1999; Tylka, 2006) and not Three hundred seventy-seven undergraduate and postgraduate
with weight gain (Provencher et al., 2009; Rapoport, Clark, & women and men between the ages of 19e31 years attending two
Wardle, 2000). Also, several studies have found intuitive eating to large private universities in Istanbul, Turkey.
be associated with lower body mass (Hawks, Madanat, Hawks, & This study utilized a cross-sectional design with participants
Harris, 2005; Weigensberg, Shoar, Lane, & Spruijt-Metz, 2009). assessed at the one-time point. Questionnaires were completed
In order to be able to measure the above-mentioned features, during a normal class time in groups under the supervision of
self-report questionnaires had to be developed. In the literature, teachers and the authors. The questionnaires were applied during
there are only two validated questionnaires that measure intuitive the elective couses of the students. Among the participants, nobody
eating. Both of the questionnaires are referred to as Intuitive Eating showed any comprehension and/or language difficulties. Partici-
Scale (IES). The first of these was developed by Steven Hawks et al., pants responded to typical socio-demographic questions regarding
in 2004 (Hawks et al., 2004). And the latest scale was developed by their age, gender, current health status, dieting behaviours, and
Tracy Tylka in 2006 (Tylka, 2006). Despite the fact that both seem to height and weight, which were then used to calculate BMI using the
measure intuitive eating features, (but) they do not share the same following formula: weight (kg.)/[height (m)]2 (Centers for Disease
factor structure. Control, 2015). The initial number of 425 participants was
 M. Bas et al. / Appetite 114 (2017) 391e397 393

subsequently reduced to 377 after some incomplete protocols were 2.4. Test-retest
rejected. Regarding the IES-2, total in 48 cases (11.29%) the ques-
tionnaires were incomplete and they were rejected. After rejecting The testeretest was conducted 2e4 weeks after the initial sur-
the incomplete protocols 215 women (57,03%) and 162 men vey to establish reliability. The randomly selected 100 participants
(42,97%) remained. The participants' mean age was 21.1 (SD ± 3.2) completed the Intuitive Eating Questionnaire - 2 at baseline and
years. Women's mean BMI was 22.5 (SD ± 3.6; range: 17.1e29.4) after 4 weeks to provide evidence of testeretest reliability and the
and men's average BMI was 23.9 (SD ± 3,5; range: 17.2e31.5). In all, Pearson Correlation Analysis was performed for this.
16 subjects (4.2%) were obese, 260 (69.0%) normal-weight, 70
(18.6%) overweight and 30 (8.2%) underweight. Current dieters are 3. Measures
not included in this study.
3.1. Eating Disorder Examination-Questionnaire (EDE-Q)
2.2. Turkish adaptation protocol
The Eating Disorder Examination Questionnaire (EDE-Q) was
The IES-2 is a 23-item, 5-point Likert scaled instrument that used as an indicator of the participants' eating psychopathology.
addresses the four major components of intuitive eating: uncon- The EDE-Q (Fairburn & Beglin, 1994) is a widely used 28-item
ditional permission to eat (UPE; 6 items; e.g., “If I'm craving a measure of disordered eating attitudes and behaviors. It was
certain food, I allow myself to have it”), eating for physical reasons translated into Turkish by Yücel et al. (2011). Items are rated on a 7-
(EPR; 8 items; e.g., “I mostly eat foods that make my body perform point Likert scale with higher scores indicating greater disordered
efficiently (well)”), reliance on hunger and satiety cues (RHSC; 6 eating. The questionnaire contains four subscales Restraint (present
items; e.g., “I rely on my hunger signals to tell me when to eat”), and Cronbach's a ¼ 0.85), Eating Concern (present Cronbach's a ¼ 0.80),
body-food choice congruence (B-FCC; 3 items) (e.g., “I mostly eat Shape Concern (present Cronbach's a ¼ 0.88), and Weight Concern
foods that give my body energy and stamina” (Tylka & Kroon Van (present Cronbach's a ¼ 0.83), as well as a Global Score (present
Diest, 2013). Responses range from 1 (strongly disagree) to 5 Cronbach's a ¼ 0.93) representing an average of scores on the four
(strongly agree). To score the IES-2 negative items are reverse subscales.
coded and then added together to a composite score, which is then
divided by the number of items to produce a mean score. A 5-point 3.2. The Eating Attitudes Test (EAT-26)
Likert scale was used in the IES-2 scoring as it was on the original
IES-2 scale. In addition, the inverse and negative questions in the The Eating Attitudes Test (EAT-26) is a widely used self-report
measure were used as in the original scale. Both cases were tested measure for eating disorders. It was developed by Garner and
in the pilot study. Garfinkel (1979) to measure symptoms of anorexia nervosa. The
Permission to use the IES-2 was obtained from the scale EAT-26 is based on an original Eating Attitudes Test (EAT-40). Total
developer in June 2016. The back translation techniques were scores on the EAT-26 are derived as a sum of the composite items,
employed to develop language-specific versions of the IES-2. The ranging from 0 to 53, with the score of 20 on the EAT-26 was used
translation techniques followed a standardized procedure sug- as the cut-off (Garner, Olmstead, Bohr & Garfinkel, 1982). The EAT-
gested by Brislin (1986) in which the inventory items and scale 26 consist of three-factor scores: (F1) dieting-the degree of avoid-
were translated from English to the target language by a bilingual ance of fattening foods and preoccupation with being thinner; (F2)
researcher. Thereafter, the translated inventory was back- bulimia and preoccupation with food; and (F3) oral control the
translated by a jury of independent and proficient bilingual aca- degree of self-control around food and the perception of pressure
demics at the institutions of the authors. The back-translated ver- from others to gain weight. The Turkish version of EAT-40 (Savaşır
sions were then compared with the original English version and & Erol, 1989) measures disturbance in eating attitudes and be-
any inconsistencies, errors, biases and incongruences highlighted. haviors. The reliability of EAT-26 was also determined by Bas, Asci,
These inconsistencies were removed in a further translation and Karabudak, and Kiziltan (2004).
the back-translation comparison process was repeated until the
versions were identical, as recommended by Bracken and Barona 3.3. Body Appreciation Scale-2
(1991). The final versions exhibited no discrepancies with the
original English version of the IES-2 when back-translated. As an Participants completed the Body Appreciation Scale-2 (Tylka &
additional check, the translated instruments were independently Wood-Barcalow, 2015), a 10-item measure of positive body image
reviewed by the jurors to confirm whether each item served the (sample item: “I respect my body”). Items on the BAS-2 are rated on
purpose of the instrument (Brislin, 1993). The reviewers affirmed a 5-pointscale, ranging from 1 (Never) to 5 (Always). Items were
that the items from the translated instrument were satisfactory in averaged, with higher scores reflecting greater body appreciation.
representing the items from the original English version. The pre- The reliability and validity evidence of BAS-2 for Turkish adults was
sent study was approved by the Human Research Ethics Committee €
determined by Anlı, Akın, Eker, and Ozçelik (2015). The internal
at the University of Acıbadem. consistency reliability coefficients of the scale were found as 0.88.
(Cronbach's alpha). Also, The reliability and validity evidence of
2.3. Cultural adaptation BAS-2 for Turkish university student was determined by Bakalım
and Taşdelen-Karçkay (2016). The Turkish version of the BAS
The IES-2 was pilot tested on 40 participants. The participants demonstrated adequate internal consistency and composite reli-
found the questionnaire easy to understand and applicable to their ability. In that study, BAS-2 was concluded to be one-dimensional
conditions. Subsequent review and discussion found most of the as in Western societies.
questionnaire translated without difficulty, but some discrepancies
were present due to linguistic and cultural differences. Changes 3.4. Data analysis
were made through finer adjustments to wording that enabled a
final consensus agreed format from all translators with changes The factorial structure of IES-2 was examined by exploratory
compared to the English version. The final IES-2 consensus version factor analysis. The Principal Component Factor Analysis with
was brought into use for the validity and reliability study. Varimax Rotation was conducted. The reliability was tested using
394 M. Bas et al. / Appetite 114 (2017) 391e397

Cronbach's alpha. Confirmatory factor analysis (CFA) with a diag- evaluating model fit. Chi-square statistic is affected very quickly by
onally weighted least squares estimation method was used to sample size, and the normed chi-square (NC) was used. In this
assess the construct validity of the Turkish version of the food model, the NC value was 4.237 (949.148/224), indicating a
choice questionnaire (FCQ). Model fit of the 9-factor structure was reasonable fit to the data. In addition, Adjusted Goodness Of Fit
examined using c 2/df, root mean square error of approximation Index-AGFI was found to be 0.96. If this value is over 0.90, it shows
(RMSEA), and two goodness of fit indices such as comparative fit that the model is well compatible. Same way, if the Root Mean
index (CFI) and non-normed fit index (NNFI). The criteria for an Square Residual-RMR is below 0.05 (RMR ¼ 0.045) and the Root
acceptable model fit was identified as c2/df (degrees of Mean Square Error of Approximation-RMSEA is less than 0.08
freedom)  5, CFI  0.90, NNFI  0.90, and RMSEA 0.06, and also (RMSEA ¼ 0.078), the model shows good fit. The values set at this
the good model fit was identified as c2/df  2, CFI  0.95 and scale show the acceptability and applicability of the Turkish version
NNFI  0.95. RMSEA 0.80 indicates excellent test-retest agreement. of the IES-2 scale.
Internal consistency of the scale was evaluated using Cronbach's
alpha. A criteria for Cronbach's alpha was selected as 0.70 (Field,
4.2. Internal consistency reliability
2009). Test-retest reliability was examined by intraclass correla-
tion coefficient (ICC). ICC>0.80 indicates excellent test-retest
The internal consistency of the IES-2 and its subscales was
agreement. Pearson correlation coefficients were used to investi-
determined by calculating Cronbach's alpha coefficient. The un-
gate associations between intuitive eating, body appreciation,
conditional permission to eat factor gavea ¼ 0.97, the eating for
disordered eating, and BMI. All statistical analyses were performed
physical rather than emotional reasons factor gave a ¼ 0.95, the
using SPSS software.
reliance on hunger and satiety cues factor gave a ¼ 0.92, while the
body-food choice congruence factor yielded a ¼ 0.86. Overall, the
4. Results IES-2 had a ¼ 0.82. Eventually, the total and subscales scores of IES-
2 are internally reliable (Table 2).
4.1. Confirmatory factor analysis Table 1 shows the rotated factor loadings. A factor analysis was
conducted using principal components extraction with varimax
For the confirmatory construct validity of the IES-2 scale, a 4- rotation. Various indicators of the high degree of interrelationship
factorial structure was tested based on the original in the study. between the variables confirmed the suitability of the analysis:
The desired model fit of the collected data was analysed with the Bartlett's test of sphericity gave X2 ¼ 9043.49 (p < 0.001), while the
AMOS Structural Equation Model. Different indexes can be used in Kaiser-Meyer-Olkin index was 0.87 (KMO were 0.89 for women and

Table 1
Factor structure and standardized loadings for the original IES-2.

Factor 1: Eating for Factor 2: Unconditional Factor 3: Reliance Factor 4: Body-Food

Physical Rather Than Permission to Eat on Hunger and Choice Congruence
Emotional Reasons Satiety Cues

Women Men Women Men Women Men Women Men

2. I find myself eating when I'm feeling emotional (e.g., anxious, 0.81 0.77
depressed, sad), even when I'm not physically hungry.
5. I find myself eating when I am lonely, even when I'm not 0.65 0.64
physically hungry.
10. I use food to help me soothe my negative emotions. 0.85 0.89
11. I find myself eating when I am stressed put, even when I'm 0.92 0.83
not physically hungry.
12. I am able to cope with my negative emotions (e.g., anxiety, 0.94 0.71
sadness) without turning to food for comfort.
13. When I am bored, I do NOT eat just for something to do. 0.92 0.69
14. When I am lonely, I do NOT turn to food for comfort. 0.93 0.83
15. I find other ways to cope with stress and anxiety 0.93 0.91
than by eating
1. I try to avoid certain foods high in fat, carbohydrates, 0.96 0.95
or calories.
3. I find myself eating when I'm feeling emotional (e.g., 0.87 0.82
anxious,depressed, sad), even when I'm not physically
hungry.
4. If I am craving a certain food, I allow myself to have it. 0.94 0.94
9. I get mad at myself for eating something unhealthy. 0.95 0.94
16. I use food to help me soothe my negative emotions. 0.95 0.94
17. I find myself eating when I am stressed out, even 0.91 0.89
when I'm not physically hungry.
6. I trust my body to tell me when to eat. 0.96 0.93
7. I trust my body to tell me what to eat. 0.74 0.76
8. I trust my body to tell me how much to eat. 0.80 0.82
21. I rely on my hunger signals to tell me when to eat. 0.96 0.69
22. I rely on my fullness (satiety) signals to tell me 0.86 0.86
when to stop eating.
23. I trust my body to tell me when to stop eating. 0.78 0.75
18. Most of the time, I desire to eat nutritious foods. 0.92 0.93
19. I mostly eat foods that make my body perform 0.88 0.75
efficiently (well).
20. I mostly eat foods that give my body energy and stamina. 0.76 0.88
 M. Bas et al. / Appetite 114 (2017) 391e397 395

Table 2
Descriptive statistics, internal consistency estimates of IES-2 subscales and correlation between total and subscales of IES-2 scores, and BMI, EAT-26 and BAS-2.

Mean ± S.D. Range Internal Correlation coefficients

consistency
BMI EAT-26 EDEQ-Restraint EDEQ-Eating EDEQ-Shape EDEQ-Weight EDE-Q BAS
Concern Concern Concern Global Score

IES-2 3.08 ± 0.49 1e5 0.817a 0.277** 0.482** 0.362** 0.384** 0.508** 0.467** 0.393** 0.263**
UPE 2.98 ± 1.12 1e5 0.965a 0.103* 0.313** 0.130* 0.095 0.248** 0.258** 0.165** 0.020
EPR 2.93 ± 0.99 1e5 0.946a 0.274** 0.303** 0.364** 0.357** 0.379** 0.333** 0.298** 0.252**
RHSC 3.54 ± 0.67 1e5 0.915a 0.089 0.007 0.326** 0.327** 0.344** 0.290** 0.260** 0.033
B-FCC 2.72 ± 1.03 1e5 0.864a 0.092 0.292** 0.240** 0.291** 0.401** 0.347** 0.304** 0.318**

BMI ¼ body mass index; EAT-26 ¼ Eating Attitudes Test; BAS-2 ¼ Body Appreciation Scale-2.
UPE: Unconditional permission to eat; EPR: Eating for physical rather than emotional reasons; RHSC: Reliance on hunger and satiety cues; B-FCC: Body-food choice
congruence; EDE-Q: Eating Disorder Examination-Questionnaire.
**p < 0.01; *p < 0.05.
a
Standardized Cronbach's alpha.

0.83 for men). The best solution from the principal factors analysis factor structure of Tylka and Kroon Van Diest (2013). In other
of the 23 items of the IES-2 revealed four factors corresponding to words, these Turkish data indicated strong support for the domi-
the four subscales (UPE: Unconditional permission to eat; EPR: nant four-factor structure originally proposed by Tylka and Kroon
Eating for physical rather than emotional reasons; RHSC: Reliance Van Diest (2013), with the resultant four factors explaining
on hunger and satiety cues; B-FCC: Body-food choice congruence), 77.53% of the variance.
as reported by the authors of the questionnaire. The first factor, Eating for Physical rather than Emotional Rea-
The first factor, which explains 30.89% of the total variance, sons, consisted of 8 items that reflect the ability to use food to
groups together the 6 items of the unconditional permission to eat satisfy hunger rather than as a way to cope with emotional distress.
sub-scale of the IES-2. The second factor explains 22.48% of the total The second factor, Unconditional Permission to Eat, which reflects a
variance and groups together the remaining 8 items, those from the willingness to eat in response to internal hunger cues and the food
eating for physical rather than emotional reasons sub-scale. The that may be desired, consisted of 6 items in the original study. The
third factor explains 15.96% of the total variance and groups third factor, Reliance on Internal Hunger/Satiety Cues, consisted of
together the remaining 6 items, those from the reliance on hunger 6 items and reflected an awareness of internal hunger and satiety
and satiety cues sub-scale. The fourth factor explains 9.19% of the cues and a trust in those cues to guide eating behaviors. The orig-
total variance and groups together the remaining 3 items, those inal fourth factor, Body-food Choice Congruence consists in using
from the body-food choice congruence sub-scale. The analysis of gentle nutrition to guide food choices that meet both physical and
data revealed seven factors that in total explain 77.53% of the sensory needs, consisted of 3 items in the original study (Tylka &
variance among the scale items. Kroon Van Diest, 2013). The Turkish data supported that all fac-
tors of IES-2 were same factor structure originally proposed by
4.3. Construct validity Tylka and Kroon Van Diest (2013). In contrast, in the French study,
Camilleri et all. (2015) adapted the IES-2 to the French language and
Criterion-related validity is shown in Table 2. For testing crite- population. In their study, the scale of IES-2 included three di-
rion reliability, the Pearson product-moment correlation co- mensions: Eating for Physical Rather than Emotional Reasons,
efficients were computed among the IES-2 scores, BMI, EAT-26, Reliance on Hunger and Satiety Cues and Unconditional Permission
EDE-Q and subscales of EDE-Q and BAS-2 scores for participants. to Eat.
Also, the results of the correlation analyses showed significant The acceptable minimum point was 0.40 for factor loading (Polit
correlation of the IES-2 score of participants with BMI(r ¼ 0.277; & Beck, 2004). Factor analysis yielded that all of the factor loadings
p < 0.01), EAT-26 (r ¼ 0.482; p < 0.01) and BAS-2(r ¼ 0.263; were above 0.40 and factor loading of the items in the scale ranged
p < 0.01). IES-2 score were significant inversely correlated with from 0.69 to 0.96 in our study. Factor loadings were reported to
eating-disorder related behaviours and cognitions in participants. range from 0.50 to 0.98 on the original scale Tylka and Kroon Van
The results of the correlation analyses were the significant corre- Diest (2013). Similarly, Carbonneau et al. (2016) found that the 23
lation with IES-2 total scores and restraint eating (r ¼ 0.362; items had loadings ranging from 0.51 to 0.93 onto their respective
p < 0.01), eating concern (r ¼ 0.384; p < 0.01), shape concern factor, indicating that each item has a satisfactory association with
(r ¼ 0.508; p < 0.01) and weight concern (r ¼ 0.165; p < 0.01). the score of its subscale and, the results of the CFA showed that the
Results from the Turkish samples indicated that the IES-2 subscales fourfactorstructure of the French-Canadian version of the IES-2
have a high internal consistency and test-retest reliability coeffi- fitsthe data well.
cient. The test-retest reliability of the IES-2 was 0.80 for the un- In a recent review by Bruce and Ricciardelli (2016), they showed
conditional permission to eat subscale score, 0.87 for eating for that the Unconditional Permission to Eat subscale demonstrated
physical rather than emotional reasons subscale score, 0.84 for the highest correlation with disordered eating, the Eating for
reliance on hunger and satiety cues subscale score, 0.90 for body- Physical Reasons subscale and the Reliance on Hunger/Satiety Cues
food choice congruence subscale score and 0.88 for the IES-2 to- subscale demonstrated small to medium correlations with disor-
tal score. dered eating, while the Body-Food Choice Congruence subscale was
unrelated with disordered eating, thus suggesting that these three
5. Discussion aspects of intuitive eating are more conceptually distinct from
disordered eating. In our study, EDE-Q global score was inversely
The current study first translated and then validated the Turkish correlated with all of IES-2 subscales. Also, the IES-2 total score
version of the IES-2 instrument in the Turkish sample. Factor showed strong inverse correlations with restraint eating, eating
analysis results for determining the validity of the IES-2 indicated concern, shape concern and weight concern of subscales of EDE-Q
four main factors. These four factors were the same as the four- in our study. The French study indicated that IES-2 total score and
396 M. Bas et al. / Appetite 114 (2017) 391e397

subscales were negatively related to cognitive restraint, emotional internal consistency values that were obtained in this study were
eating, uncontrolled eating and depressive symptoms (Camilleri lower than the results of Tylka and Kroon Van Diest (2013). In
et al., 2015). Also, Carbonneau et al. (2016) showed that all four addition, the obtained internal consistency was lower than the one
IES-2 subscales showed moderate to strong negative associations obtained in the French version (Camilleri et al., 2015). Alpha co-
with the four EDI-2 subscales. Results indicated that highly disor- efficients are affected by many factors and therefore may be un-
dered eating of participants was related to lower intuitive eating satisfactory in some study groups. According to some authors, the
behaviour in our study. Similarly, Tylka and Kroon Van Diest (2013) values of Cronbach's alpha 0.90 should be considered as optimal,
and Camilleri et al. (2015) reported that the correlations were 0.80 as good, 0.70 as acceptable, 0.60 as questionable, 0.50 as
negative and significant between disordered eating and intuitive poor, and <0.50 as unacceptable (Beaton, Bombardier, Guillemin, &
eating behaviour. Ferraz, 2007). In our study, the obtained Cronbach's alpha coeffi-
A fundamental premise of intuitive eating is accurately inter- cient was above the cut-off values for an adequate consistency of
preting and adhering to instinctive feedback regarding the required 0.80 for each subscale. These results suggest that no major prob-
content and volume of food consumption. Therefore, regardless of lems were caused by translating the original IES-2 into Turkish. In
whether intuitive eating explicitly includes the goal of normalising other words, all individual items contributed to the functioning of
weight, eating intuitively should correlate with a lower weight/BMI their subscale and language differences appeared not to compro-
(Tribole & Resch, 2003). Intuitive eating has been associated with mise the effectiveness of items. The test-retest reliability co-
lower body mass index (BMI) in numerous cross-sectional surveys. efficients with one month were acceptable ranges. According to
Cross-sectional evidence from non-clinical populations also sug- Bloxom and Knapp, the acceptable test-retest reliability correlation
gests that increased intuitive eating relates to lower body mass was within the range 0.55e0.85 (as cited in Waite, Gansneder, &
index (Denny et al., 2013; Hawks et al., 2005). Similarly, our study Rotella, 1990). The obtained test-retest reliability values for the
supports that high intuitive eating was correlated with lower BMI. IES-2 in this study fell within that range. If the items in the Turkish
Van Dyke and Drinkwater published a review about intuitive eating scale were compared with the original scale, the scale was found to
and health indicators on 2014. They indicated that the intuitive be the same as the original scale. This result also questions the
eating is negatively associated with BMI, positively associated with procedure of the KMO, which was 0.87 in this study. These results
various psychological health indicators, and possibly positively indicated that the sample was average enough for performing a
associated with improved dietary intake and/or eating behaviours, satisfactory factor analysis and that further validation (factor so-
but not associated with higher levels of physical activity. In addi- lution) could proceed with a similar sample size in the current
tion, the New Zealand survey study supports the idea that intuitive study. The sample size in this study was adequate for factor
eating promotes a healthy BMI. The study's subjects who had analysis.
higher intuitive eating scores on the IES also had lower BMI. The This study has some limitations. The validity study requires a
majority of mid-aged women had stable IES scores over three years representative sample but in this study Turkish sample is not
in their study. They found that intuitive eating was inversely related representative and did not represent distribution in Turkey for sex,
to BMI with an increase in IES score over three years associated ethnicity, religion, social class and region. The present study was
with lower BMI at three years. The New Zealand study suggests that only conducted with relatively well educated, middle class partic-
learning IE skills may be most beneficial for those who are binge ipants from urban area and convenience sample of university stu-
eaters, and for those who are trying to lose weight. These findings dents. Thus, the results cannot necessarily be generalized to other
highlight the fact that IE has clinical relevance and may be bene- groups. That's why this study provides preliminary evidence about
ficial to improving eating behaviours and promoting weight loss in the validity and reliability of IES-2 for Turkish sample.
overweight individuals. In contrast, Anglin (2012), Alberts, As a conclusion, The Turkish version of the IES-2 has shown
Thewissen, and Raes (2012), Bacon, Stern, Loan, and Keim (2005) statistically acceptable levels of reliability and validity and the
and Gravel et al. (2014) studies indicate that BMI is not affected original research that validated the IES-2, the present study ob-
by the introduction of intuitive eating type approaches. tained four factors corresponding to the unconditional permission to
Concepts of the body appreciation is not the same for every eat, eating for physical rather than emotional reason, reliance on
culture in respect to conceptual and factorial. There are similar hunger and satiety cues and body-food choice congruence subscales,
cultural structures to be seen in Turkey, despite the impact of with 6, 8, 6 and 3 items, respectively. The reliability analysis
globalization, modernization and social media. Turkey starts to showed that both the total IES-2 and its four subscales have
import the social habits of Western societies but the traditional adequate internal consistency. However, it should be noted that the
family structure still maintains (Bakalım & Taşdelen-Karçkay, Turkish version of IES-2 indicates a same reliability coefficient
2016). when it is compared to its original English version. Also, in terms of
Previous studies were supported that there was a correlation construct validity, there is equivalence between the English and
between intuitive eating and body appreciation. (Augustus- Turkish versions of IES-2, both versions indicate a near identical
Horvath & Tylka, 2011; Oh, Wiseman, Hendrickson, Phillips, & factor loadings on items and factor structure. Initial analyses pro-
Hayden, 2012; Tylka & Kroon Van Diest, 2013). The body dissatis- vided support for their validity in relation to body mass index, body
faction (EDE-Q-shape concern) and BAS-2 scores was strongly appreciation and disordered eating behaviours. These findings
correlated with IES-2 scores in our study. The strong inverse cor- support the notion that intuitive eating is a viable concept for
relation between body dissatisfaction and intuitive eating is in young adults and the IES can be used to examine adaptive eating
agreement with the findings of Tylka, who reported a correlation behaviors in this population. Future studies are needed to examine
of 0.53, significant at the p < 0.001 level. Also, in the current study the Turkish version of IES-2 in a representative sample of adults.
which showed us that intuitive eating correlated with aspects of
positive body image such as body appreciation. The Bruce and References
Ricciardelli’s (2016) studies indicated that intuitive eating corre-
lated with body appreciation in a positive direction, and was Academy of Nutrition and Dietetics. (2009). Position of the American Dietetics
consistent for total scores and subscale scores of intuitive eating. Association: Weight management. Journal of the American Dietetics Association,
109(2), 330e346.
For women and men, respectively, Cronbach's coefficient alphas Alberts, H. J. E. M., Thewissen, R., & Raes, L. (2012). Dealing with problematic eating
were 0.85 and 0.74 for the total 23-item IES-2 in our study. The behavior. The effects of a mindfulness-based intervention on eating behavior,
 M. Bas et al. / Appetite 114 (2017) 391e397 397

food, cravings, dichotomous thinking and body image concerns. Appetite, 58, Academy of Nutrition and Dietetics, 114(1), 99e106.
847e851. Hawks, S., Madanat, H., Hawks, J., & Harris, A. (2005). The relationship between
Anglin, J. C. (2012). Assessing the effectiveness of intuitive eating for weight loss- intuitive eating and health indicators among college women. American Journal
pilot study. Nutrition and Health, 21, 107e115. of Health Education, 36, 331e336.
€
Anlı, G., Akın, A., Eker, H., & Ozçelik, B. (2015). The validity and reliability of Tuskish Hawks, S., Merrill, R. M., & Madanat, H. N. (2004). The intuitive eating Scale:
version of the body appreciation scale. International Journal of Social Science, 36, Development and preliminary validation. American Journal of Health Education,
505e511. 35(2), 90e99.
Augustus-Horvath, C. L., & Tylka, T. L. (2011). The acceptance model of intuitive Hirschmann, J. R., & Munter, C. H. (1995). When women stop hating their bodies:
eating: A comparison of women in emerging adulthood, early adulthood, and Freeing yourself from food and weight obsession (1 edition). New York: Fawcett
middle adulthood. Journal of Counseling Psychology, 58, 110e125. Columbine.
Bacon, L., Stern, J. S., Van Loan, M. D., & Keim, N. L. (2005). Size acceptance and Jensen, M. D., Ryan, D. H., Apovian, C. M., Ard, J. D., et al. (2014). 2013 AHA/ACC/TOS
intuitive eating improve health for obese, female chronic dieters. Journal of the Guidelines for the management of overweight and obesity in adults. Obesity,
American Dietetic Association, 105(6), 929e935. 22(S2), 1e410.
Bakalım, O., & Taşdelen-Karçkay, A. (2016). Body appreciation Scale: Evaluation of Kraschnewski, J. L., Boan, J., Esposito, J., Sherwood, N. E., Lehman, E. B.,
the factor structure and psychometric properties among male and female Kephart, D. K., et al. (2010). Long-term weight loss maintenance in the United
Turkish university students. Mersin University Journal of the Faculty of Education, States. International Journal of Obesity, 34(11), 1644e1654.
12(1), 410e422. Kristeller, J., & Hallett, C. (1999). An exploratory study of a meditation-based
Bas, M., Asci, H., Karabudak, E., & Kiziltan, G. (2004). Eating attitudes and their intervention for binge eating disorder. Journal of Health Psychology, 4, 357e363.
psychological correlates among Trukish adolescents. Adolescence, 39(155), Matz, J., & Frankel, E. (2006). The diet Survivor's handbook: 60 lessons in eating,
593e599. acceptance and self-care naperville, IL: Sourcebooks.
Beaton, D., Bombardier, C., Guillemin, F., & Ferraz, M. B. (2007). Recommendations for Mensinger, J., Close, H., Ku, J. (2009). Intuitive eating: A novel health promotion
the cross-cultural adaptation of the DASH & QuickDASH outcome measures. Tor- strategy for obese women. Paper presented at American Public Health Associa-
onto, Canada: Institute for Work & Health. tion. Philadelphia, PA.
Bracken, B. A., & Barona, A. (1991). State of the art procedures for translating, Oh, K. H., Wiseman, M. C., Hendrickson, J., Phillips, J. C., & Hayden, E. W. (2012).
validating and using psychoeducational tests in cross-cultural assessment. Testing the acceptance model of intuitive eating with college women athletes.
School Psychology International, 12, 119e132. Psychology of Women Quarterly, 36, 88e98.
Brislin, R. W. (1986). The wording and translation of research instruments. In Polit, D. F., & Beck, C. T. (2004). Nursing research: Principles and methods (7th ed.).
W. J. Lonner, & J. W. Berry (Eds.), Field methods in educational research (pp. Philadelphia: Lippincott Williams & Wilkins.
137e164). Newbury Park, CA, USA: Sage. Provencher, V., Begin, C., Tremblay, A., Mongeau, L., Corneau, L., Dodin, S., et al.
Brislin, R. W. (1993). Understanding culture's influence on behavior. Fort Worth, TX: (2009). Health-at-every-size and eating behaviors: 1-year follow-up results of a
Harcourt, Brace and Johanovich. size acceptance intervention. Journal of American Dietetic Association, 109,
Bruce, L. J., & Ricciardelli, L. A. (2016). A systematic review of the psychosocial 1854e1861.
correlates of intuitive eating among adult women. Appetite, 96, 454e472. Rapoport, L., Clark, M., & Wardle, J. (2000). Evaluation of a modified cognitive-
Burrows, A., & Cooper, M. (2002). Possible risk factors in the development of eating behavioural programme for weight management. International Journal of
disorders in overweight pre-adolescent girls. International Journal of Obesity, 26, Obesity, 24, 1726e1737.
1268e1273. Savaşır, I., & Erol, N. (1989). Yeme Tutum Testi. Anoreksiya nevroza belirtileri
Cadena-Schlam, L., & Lo pez-Guimer a, G. (2015). Intuitive eating: An emerging indeksi. Psikoloji Dergisi, 7, 19e25.
approach to eating behavior. Nutricio n Hospitalaria, 31(3), 995e1002. Smith, T., & Hawks, S. (2006). Intuitive eating, diet composition and the meaning of
Camilleri, G. M., Mejean, C., Bellisle, F., Andreeva, V. A., Sautron, V., Hercberg, S., food in healthy weight promotion. American Journal of Health Education, 37,
et al. (2015). Cross-cultural validity of the Intuitive Eating Scale-2. Psychometric 130e136.
evaluation in a sample of the general French population. Appetite, 84, 34e42. Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J., & Merikangas, K. R. (2011).
Carbonneau, E., Carbonneau, N., Lamarche, B., Provencher, V., Be gin, C., Bradette- Prevalence and correlates of eating disorders in adolescents: Results from the
Laplante, M., et al. (2016). Validation of a French-Canadian adaptation of the national comorbidity survey replication adolescent supplement. Archives of
Intuitive Eating Scale-2 for the adult population. Appetite, 105, 37e45. General Psychiatry, 68, 714e723.
Centers for Disease Control. (2015). About adult BMI. Retrieved from http://www. Tribole, E., & Resch, E. (2003). Intuitive eating (2nd ed.). New York, N.Y.: St. Martin's
cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html. Griffin.
Cole, R. E., & Horacek, T. (2010). Effectiveness of the “my body knows when” Tylka, T. L. (2006). Development and psychometric evaluation of a measure of
intuitive eating pilot program. American Journal of Health Behavior, 34(3), intuitive eating. Journal of Counseling Psychology, 53(2), 226e240.
286e297. Tylka, T. L., & Kroon Van Diest, A. M. (2013). The Intuitive Eating Scalee2: Item
Denny, K. N., Loth, K., Eisenberg, M. E., & Neumark-Sztainer, D. (2013). Intuitive refinement and psychometric evaluation with college women and men. Journal
eating in young adults. Who is doing it, and how is it related to disordered of Counseling Psychology, 60(1), 137e153.
eating behaviors? Appetite, 60(1), 13e19. Tylka, T. L., & Subich, L. M. (1999). Exploring the construct validity of the eating
Dockendorff, S., Petrie, T., Greenleaf, C., & Martin, S. (2012). Intuitive eating scale: An disorder continuum. Journal of Counseling Psychology, 46, 268e276.
examination among early adolescents. Journal of Counseling Psychology, 59(4), Tylka, T. L., & Wood-Barcalow, N. L. (2015). The body appreciation Scale-2: Item-
604e611. refinement and psychometric evaluation. Body Image, 12, 53e67.
Fairburn, C. G., & Beglin, S. J. (1994). Assessment of eating disorders: Interview or Van Dyke, N., & Drinkwater, E. J. (2014). Relationships between intuitive eating and
self-report questionnaire? The International Journal of Eating Disorders, 16, health indicators: Literature review. Public Health Nutrition, 17, 1757e1766.
363e370. Waite, B. T., Gansneder, B., & Rotella, R. J. (1990). Sport specific measure of self-
Field, A. (2009). Discovering statistics using SPSS. London: SAGE Publications. acceptance. Journal of Sport and Exercise Psychology, 12, 264e279.
Garner, D. M., & Garfinkel, P. E. (1979). The EAT. An index of the symptoms of Weigensberg, M., Shoar, Z., Lane, C., & Spruijt-Metz, D. (2009). Intuitive eating (IE) Is
anorexia. Psychological Medicine, 9, 273e279. associated with decreased adiposity and increased insulin sensitivity (Si) in obese
Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The eating attitudes Latina female adolescents. DiabetesPro.
test: Psychometric features and clinical correlates. Pscyhological Medicine, 12, Wilksch, S. M., & Wade, T. D. (2010). Risk factors for clinically significant importance
871e878. of shape and weight in adolescent girls. Journal of Abnormal Psychology, 119,
Gast, J., & Hawks, S. R. (1998). Weight loss education: The challenge of a new 206e215.
paradigm. Health Education & Behavior, 25, 464e473. Wirtz, A. L., & Madanat, H. N. (2013). Westernization, intuitive eating, and BMI: An
Gast, J., & Hawks, S. R. (2000). Examining intuitive eating as a weight loss program. exploration of Jordanian adolescents. International Quarterly of Community
Healthy Weight Journal, 14, 42e44. Health Education, 33(3), 275e287.
Gast, J., Madanat, H., & Nielson, A. C. (2012). Are men more intuitive when it comes _
Yücel, B., Polat, A., Ikiz, T., Düşgo € S. (2011). The Turkish
€ r, B. P., Yavuz, A. E., & Berk, O.
to eating and physical activity? American Journal of Men’s Health, 6(2), 164e171. version of the eating disorder examination questionnaire: Reliability and val-
Gravel, K., Deslaurier, A., Watiez, M., Dumont, M., Bouchard, A. A., & Provencher, V. idity in adolesecents. European Eating Disorders Review, 19, 509e511.
(2014). Sensory-based nutrition pilot intervention for women. Journal of the