To our knowledge this is the first study to examine the factor structure of the questionnaire EDE-Q, contrasting the findings with the EDE interview in a representative university sample of Spanish men to establish a cut-off point for optimal ED detection in this population.
In the present study, the EDE-Q shows good internal consistency, with high Omega coefficient values for both the total scale and the two subscales of the EDE-Q, similar to those obtained in other studies [5, 17]. Therefore, the EDE-Q is shown to be a valid and reliable instrument for use as a screening tool in Spanish males.
Consistent with other studies [42, 7], the original 4-factor structure of the EDE-Q was not confirmed. For the Spanish male sample, the EDE-Q showed a better fit in a two-factor solution with a Restraint subscale and a Weight-Shape-Eating Concern subscale without removing any items . Both the EDE interview and the EDE-Q were constructed on a rational basis to represent the key psychopathology of eating disorders. Subsequent factor studies, however, mostly do not support the initial structure . These first theoretical approaches are based on a female-centric approach that may not fit the male perspective in which cognitive aspects seem to belong to a single dimension of body image concern.
Given the dual nature of male body dissatisfaction and its associated behaviors, it is suggested that the EDE-Q be used in males in conjunction with more specific measures of male body reality . The EDE-Q shows moderate to high convergence with the MDDI, indicating overlap between ED and MD symptomatology, except for the Restraint subscale which shows a lower association with the Drive For Size subscale of the MDDI. This difference is not surprising, as this subscale is aimed at exploring the desire for muscle mass gain, for which dietary restriction is counterproductive [11, 9].
The EDE-Q mean scores observed in our sample are consistent with those obtained in research with similar samples of men in Spain [16, 19] and in other countries [44, 42, 43, 45, 46]. In general, men score lower than women in studies using the EDE-Q [15, 20, 47, 44, 46]. However, this does not necessarily imply that there is no ED symptomatology in males, so it is systematically questioned whether the cut-off points established for the questionnaires imply a risk of under-diagnosis [9, 45]. This risk is particularly salient when exploring male samples, where body image concerns and behaviors differ from those of women and the difficulty of detecting at-risk cases is greater [9, 11]. The use of a proposed initially cut-off ≥ 4  as a marker of clinical significance has been criticized in the literature, suggesting downward rectification for both female  and male samples . In fact, studies using ROC curve analyses contrasting EDE-Q scores with EDE interview scores point in this direction. In female samples there is a variability of cut-off proposals for the EDE-Q (EDE-Q-Global Score range: 1.98-2.80) [15, 48, 49, 50], all below the Carter et al.  proposal, including the cut-off ≥ 3.10 proposed by Mond et al.  for overweight individuals. For male samples, the cut-off ≥ 1.68 proposed by Schaefer et al.  is also far from the original proposal. The analysis performed in the present study suggests that, for the Spanish male sample, a cut-off ≥ 1.09 for at-risk of ED cases and ≥ 2.41 for clinical cases presents an optimal balance between sensitivity and specificity.
In conclusion, there are gender differences in levels of eating pathology that are indicative of clinical concern . However, most research using the EDE-Q, including many in recent years, continues to use cut-off ≥ 4 in males [3, 5], leaving significant numbers of potentially at-risk participants undetected and therefore untreated. In men, body image and eating pathology is more complex and the EDE-Q is limited in detecting muscle-oriented eating risk behaviours. In this sense, the development and further examination of a modified muscle-oriented version of the EDE-Q  that captures the domains of disordered eating relevant to males may be promising.
Strenght and limits
The main strength of the study is its big sample size and the representativeness of the sample of undergraduate men students of Spain. Conducting clinical interviews in research is an indispensable requirement to contrast the results of the questionnaires and establish a correct diagnosis. However, its high cost makes it difficult to carry out, so the high number of clinical interviews conducted is another important strength of the study. However, results of this study should consider some limitations. Although the sample provided level-sport data, no invariance studies have been carried out in this respect. Also, no data was collected on the ethnic or sexual diversity of the participants, so the results obtained in university students do not allow generalization of the results to other samples of males.
What is already known on this subject?
The factor structure of the EDE-Q has been explored in different samples with contradictory results. Particularly in the male population, the interview-based cut-off point is not sensitive for males, aggravating the problem of underdiagnosis.
What does this study add?
Our study explores the factor structure of the EDE-Q in a large representative sample of males, who also participated in a clinical interview. Our results provide the scientific community with a sensitive and specific cut-off point of the EDE-Q for males and represent a potential advance in the detection of ED in Spanish-speaking males.