Hunger

Generation of items: The 35 items from the CEBQ were changed from the “My child …” format to a self-complete “I ...” format (e.g. “My child loves food” was changed to “I love food”) and the original response options (‘never’, ‘rarely’, ‘sometimes’, ‘often’ and ‘always’) were retained. Ten researchers working in the area of Energy Balance completed the self-report version of the CEBQ and discussed their experiences. The researchers described how the Desire to Drink scale was difficult to complete. Items from the CEBQ such as “My child is always asking for a drink” had been adapted to “I am always asking for a drink” for the AEBQ and it became unclear what type of drink (i.e. alcoholic versus non-alcoholic) was being referred to. Additionally, the item “My child is always asking for food” from the FR construct in the CEBQ, which became “I am always asking for food” in the AEBQ, was difficult for adults to relate to. It was therefore agreed that the 3 items from the Desire to Drink scale, and the “I am always asking for food item” from the FR scale should be eliminated.
Further refinement of the questionnaire took place in 3 group discussions with a panel of clinical psychologists, behavioural scientists, dieticians, and authors of the original CEBQ. The panel initially reviewed the remaining items from the original CEBQ for any obvious gaps or additional problem areas. It was suggested that a measure of hunger experience (H), which could not be captured by the CEBQ because parents are unable to accurately determine their child’s experienced level of hunger, should be added (Wardle et al., 2013 ). It was also agreed that aspects of Food Responsiveness that related to food cues a parent would not have been able to comment on should also be included. Following this discussion, potential items for the Hunger scale were identified for review, and additional items for the Food Responsiveness scale were developed by the authors for piloting. Finally the panel reviewed all included and excluded items to ensure no further additions/removals were felt to be required. A group consensus was reached and the total number of items following these additions, and the removal of the Desire to Drink scale, was 49.
Piloting. The extended version of the AEBQ was piloted online in an opportunity sample of 49 adults (21–73 years old), 36 women (79.6%) and 13 men (20.4%). Colleagues at University College London were asked to circulate a link to the questionnaire to their friends and family from a range of professional backgrounds. Participants were invited to comment on each individual item and on the questionnaire as a whole. Piloting led to changes in the response options from ‘never’, ‘rarely’, ‘sometimes’, ‘often’ and ‘always’, to ‘strongly disagree’, ‘disagree’, ‘neither agree not disagree’, ‘agree’ and ‘strongly agree’ because participants commented that the original response options did not fit with the questions. The new response options were tested with a small convenience sample (two females and three males, aged 31 ± 7 years). This answer format appeared to be more meaningful and better understood by this sample.
Piloting also led to the deletion of the item “Given the choice, I would always have food in my mouth” because several participants commented that it “sounded a bit odd” or was “over the top”. A second item (“I am interested in food”) was eliminated because participants reported they found the meaning ambiguous. The remaining 47 item version of the AEBQ was included in the Principal Component Analysis (PCA).

Repeated experiences of domestic abuse were apparent in the biographies of almost all women though it was not always perceived as such. Relationships were often idealised in the first few months then quickly descended into abuse:

You think you find the right person, you think they’re so nice and everything’s perfect for the first 6 to 12 months and then after 12 months it just goes pfffft. Like woah. And by the time that’s happened you’re just too far involved. And then you end up the one that’s out on the street (Rosa).

One of the most harmful aspects of domestic abuse is detachment from social networks, thus further deepening exclusion. Here, Sally describes being isolated her from family and friends and eventually her children: Nobody knew what was going on. So I eventually left, and unknown to me … I was made out to be the bad person, like a complete weirdo (Sally).
Several women described long term physical and mental health impact resulting from injuries caused by their partner. Dee was using heroin to manage chronic pain caused by physical injuries as well as trauma from abuse: “I was married once. And I’d never do it again. He was a woman batterer. Steel plate in my head. He was so violent” (Dee).
Other women described how their partner provided resources but also perpetuated further trauma:

he used to say “you’ve got nobody. You’ll never go hungry if you stay with me...” And it’s just hard like. I struggle every day. So it’s like I’m either, it’s easier for food, I’d get lifts if I needed to go to places or I’m not being with that person and struggle. Erm, but not arguing and not fighting. It’s just hard (Sienna).

Michelle describes how her relationship commands a lot of her attention and energy, with expressions of affection interspersed with mental turmoil and uncertainty:

Me partner who lives with me, [name], he’s really well known here. He got kicked out of a hostel a while ago and that’s how I met him... he’s playing us [me] along saying he loves me and wants to be with me, and it’s ripping me to bits, my head’s battered. … he doesn’t have a good word for us. Constantly puts us down. I don’t know. But he walked away a couple of month ago when he got paid, spent £750 left me with not a penny and went away for a week and come back when he had nothing. I knew then, he didn’t love me. No-one who loved someone would do that to them. You know. I couldn’t see the lad on the streets, I just couldn’t (Michelle).

Amongst the women who had exited homelessness, many chose to live alone: “I mean I just don’t intend getting into a relationship to discover how to have one. I’m done. I’ve had enough bad ones. I’ve loved, and I’ve been loved back a couple of times. But it hurts even harder when they’re the ones that try to kill you” (Tracy).
Most of the women who had successfully exited homelessness actively avoided situations where they might meet a new partner and expressed no desire for intimate relationships. This perhaps relates to not only their overwhelmingly bad experiences of relationships, but provides context to their perception of relationships primarily driven by necessity to obtain shelter, protection and resources.

We assessed socio-demographic characteristics for men and women, including, age, current marital status, and education. All studies except Indashyikirwa in Rwanda asked whether participants had worked in the past three months. Food insecurity was assessed using the three questions of the Household Hunger Scale [20 ]: in the past four weeks, how often was there no food to eat of any kind in your house because of a lack of money?; how often did you or any member of your household go to sleep hungry because of a lack of food?; how often did you or any of your household go a whole day and night without eating because of lack of food? The latter question was asked in all studies except Rwanda. The items were recoded as none / little, moderate and severe. This is an easy-to-use, well-validated measure [20 ]. Three level and binary measures of food insecurity were derived from the mean value of the three food insecurity items. As recommended by the scale developers, the following cut-offs were used for the 3-level food insecurity measure: 0 to 0.7 = no / little food insecurity; > = 0.7 to 1.7 = moderate food insecurity; > = 1.8 to 3.0 = severe food insecurity [20 ]. For the binary exposure, we combined moderate and severe food insecurity. The measures of IPV and NPSV are described in Table 2. We did not ask about NPSV in Rwanda because it was not a target of the intervention, nor in Afghanistan because of concerns about the particular sensitivity of the questions in that context.

Time variables, especially in the form of circles and distinct times of day, have been shown to be highly predictive in everyday life [41 (link)]. EMA studies have even found peak times for certain binge-eating antecedents (ie, food cravings or hunger; [42 (link)]) and binge eating itself [43 (link)-45 (link)]. Thus, as temporal data are passively collected in the EMA setting via timestamps, without additional participant input, we decided to include different temporal predictors that could detect a single high-risk time per day (24-hour oscillation) or several times per day (sub-24 hour oscillation).
Variables representing 8-, 12- and 24-hour sinusoidal and cosinusoidal cycles were computed based on the cumulative sum of time differences between assessments (eg, 10:30 AM-8 AM, 1 PM-10:30 AM=2.5, 5, 7.5...). For example, a 24-hour sinusoid cycle was calculated using the following formula: sin24h = sin(2π : 24 * Δ_t), where ∆_t is the difference between assessment points in hours (here: 2.5). Finally, dummy-coded variables representing the time of day were calculated for each signal (morning, late morning, early afternoon, afternoon, evening, and late evening). This allows for identifying a daytime when binge eating is particularly likely for a given participant (eg, when returning from work) that could not be well captured by the cyclical predictors.