Cross-cultural adaptation and translation into Brazilian Portuguese of the instruments Sick Control One Stone Fat Food Questionnaire (SCOFF), Eating Disorder Examination Questionnaire (EDE-Q) and Clinical Impairment Assessment Questionnaire (CIA)

Abstract Introduction Eating disorders (EDs) affect up to 13% of young people and are associated with significant morbidity and mortality. Nevertheless, important, internationally recognized instruments for brief ED screening (Sick Control One Stone Fat Food Questionnaire [SCOFF]), symptom severity assessment and diagnosis (Eating Disorder Examination Questionnaire [EDE-Q]) and assessment of ED-associated psychosocial impairment (Clinical Impairment Assessment Questionnaire [CIA]) were not yet available in Brazilian Portuguese. Our objective was to perform the cross-cultural adaptation and translation into Brazilian Portuguese of the instruments SCOFF, EDE-Q and CIA. Method The process involved a series of standardized steps, as well as discussions with experts. First, the relevance and adequacy of the scales’ items to our culture and population were extensively discussed. Then, two independent groups translated the original documents, creating versions that were compared. With the participation of external ED experts (i.e., who did not take part in the translation process), synthesized versions were produced. The syntheses were then applied to a focal group of patients with ED (n = 8). After that step, a preliminary version of the three scales in Brazilian Portuguese was produced and sent for back-translation by two English native speakers, who worked independently. A synthesis of the back-translations, along with the preliminary versions in Brazilian Portuguese, were sent to the original authors. Results The Brazilian Portuguese versions of SCOFF, EDE-Q and CIA were approved by the original authors and are now available for use. Conclusion This study provides important tools for the ED research field in Brazil.


Introduction
Eating disorders (EDs) are considered serious mental illnesses that affect thousands of individuals worldwide regardless of age, ethnicity, skin color, nationality or gender. These conditions are associated with high personal, family and social costs. 1 According to diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), EDs affect up to 13% of young women 2 and are characterized by chronicity, relapse, functional impairment, future risk of obesity, depression, suicide attempts, anxiety disorders, psychoactive substance abuse and morbidity. [3][4][5] Moreover, EDs have the highest mortality rate among all mental illnesses. 6 Mortality risk is high even in individuals who have access to specialized treatment. Standardized mortality ratio ranges from 1.9 up to 6.2 (90 up to 520% more cases of death than in the general population). 7,8 Despite the severity and impairments associated with EDs, only 20% of individuals with these disorders receive any treatment, which is partly due to an overall failure to recognize and identify cases. 9 The psychopathology of ED can be divided into general and specific components. The general psychopathology consists of traits observed in many psychiatric disorders, the most common ones being depression and anxiety symptoms. 10  The objective of this study was to perform the cross-cultural adaptation and translation into Brazilian Portuguese of the instruments SCOFF, EDE-Q and CIA.

Method
The study was approved by the research ethics Below we present a brief description of the three instruments.

Questionnaire 19,20
The SCOFF is an ED screening questionnaire that comprises five yes/no questions. Each yes response equals 1 point; a score of 2 indicates a likely diagnosis of anorexia nervosa or bulimia nervosa.

Eating Disorder Examination Questionnaire (EDE-Q 10 )
The EDE-Q is a 28-item self-report measure adapted from the Eating Disorder Examination (EDE), an investigator-based interview developed by Fairburn & Cooper. 21 The EDE-Q focuses on the past 28 days and measures the core pathology of EDs, i.e., excessive importance of weight and shape in determining self-worth as well as frequency of core ED behaviors, including binge eating and compensatory behaviors. The instrument yields a global score as well as four subscale scores: eating concern, shape concern, weight concern and restraint. Clinical Impairment Assessment Questionnaire (CIA) 22 The CIA is a 16-item self-report measure developed to assess psychosocial impairment secondary to ED features, covering the past 28 days. It is designed for use immediately after the administration of the EDE-Q or other measure of current ED features. The items are scored on a 4-point Likert scale, which are summed to yield a single, global score that is indicative of the severity of secondary impairment as long as at least 12 of the items have responses.

Results
The Brazilian Portuguese versions of SCOFF, EDE-Q and CIA were approved by the original authors and are available as online-only supplementary material.

Discussion
This study provides the scientific community with internationally recognized instruments for ED screening (SCOFF), symptom severity and diagnosis (EDE-Q) and psychosocial impairment associated with the condition (CIA), now translated and adapted to Brazilian Portuguese through a very rigorous process. Therefore, it is our belief that it will contribute to ED research in Brazil.