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Body image flexibility moderates the association between disordered eating cognition and disordered eating behavior in a non-clinical sample of women: A cross-sectional investigation
Eating Behaviors 15 (2014) 664–669
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Eating Behaviors
Body image flexibility moderates the association between disordered eating cognition and disordered eating behavior in a non-clinical sample of women: A cross-sectional investigation Makeda Moore, Akihiko Masuda ⁎, Mary L. Hill, Bradley L. Goodnight Department of Psychology, Georgia State University, USA
a r t i c l e
i n f o
Article history: Received 6 January 2014 Received in revised form 21 May 2014 Accepted 21 August 2014 Available online 28 September 2014 Keywords: Disordered eating Body image flexibility Mindfulness Psychological inflexibility
a b s t r a c t Body image flexibility, a regulation process of openly and freely experiencing disordered eating thoughts and body dissatisfaction, has been found to be a buffering factor against disordered eating symptomatology. The present cross-sectional study investigates whether body image flexibility accounts for disordered eating behavior above and beyond disordered eating cognition, mindfulness, and psychological inflexibility in a sample of nonclinical women, and whether body image flexibility moderates the associations between these correlates and disordered eating behavior. Participants were 421 women, age 21 ± 5.3 years old on average, who completed a web-based survey that included the self-report measures of interest. Results demonstrate the incremental effects of body image flexibility on disordered eating behavior above and beyond disordered eating cognition, mindfulness, and psychological inflexibility. Women with greater body image flexibility endorse disordered eating behavior less so than those with lower body image flexibility. Body image flexibility moderates the association between disordered eating cognition and disordered eating behavior; for women with greater body image flexibility, disordered eating cognition is not positively associated with disordered eating behavior. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Recently, there has been a growing interest in emotion and behavior regulation processes in understanding and treating disordered eating behavior (Anestis, Selby, Fink, & Joiner, 2007). Findings in this line of research suggest that, in addition to disordered eating cognitions, the way an individual interprets, relates, and reacts to unwanted internal events (e.g., fear of gaining weight and body dissatisfaction) plays a central role in the onset and maintenance of disordered eating (Aldao, Nolen-Hoeksema, & Schweizer, 2010; Anestis et al., 2007). Research has also shown that disordered eating behaviors, such as restricted or excessive dieting, binge eating and purging, and preoccupation with caloric intake, often function as maladaptive emotion and behavior regulation strategies (Schmidt & Treasure, 2006; Wedig & Nock, 2010). Given these findings, some recent cognitive behavioral therapies (CBTs) for disordered eating, especially acceptance- and mindfulnessbased CBTs (Hayes, Villatte, Levin, & Hildebrandt, 2011), explicitly target the reduction of maladaptive regulation strategies and the promotion of adaptive regulation strategies. Examples of these CBTs are Dialectical Behavior Therapy (DBT; Safer, Telch, & Chen, 2009), Mindfulness-Based Eating Awareness Training (MB-EAT; Kristeller & Wolever, 2011) and
Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 2012). Two major emotion and behavior regulation processes that are the focus of these CBTs include mindfulness and psychological inflexibility. 1.1. Mindfulness Mindfulness is often defined as an emotion and behavior regulation process of openly attending to and becoming aware of the present moment and accompanying experiences. When defined in this way, it is best captured by the Mindfulness Attention and Awareness Scale (MAAS; Brown & Ryan, 2003). From an acceptance- and mindfulnessbased CBT standpoint, mindfulness has shown much promise in its role in understanding and treating disordered eating pathology (Baer, Fischer, & Huss, 2005; Kristeller & Wolever, 2011), partially because of its health-promoting effects (Brown, Ryan, & Creswell, 2007). Crosssectional investigations with nonclinical samples of men and women have shown that, when measured by the MAAS, mindfulness is inversely related to bulimic symptoms (Lavender, Jardin, & Anderson, 2009) as well as disordered eating behavior (Masuda, Price, & Latzman, 2012). 1.2. Psychological inflexibility
⁎ Corresponding author at: Department of Psychology, Georgia State University, Atlanta, GA 30303, USA. E-mail address: [email protected] (A. Masuda).
http://dx.doi.org/10.1016/j.eatbeh.2014.08.021 1471-0153/© 2014 Elsevier Ltd. All rights reserved.
The construct of psychological inflexibility is derived from a basic behavioral account of complex human behavior, called relational frame
M. Moore et al. / Eating Behaviors 15 (2014) 664–669
theory (RFT; Hayes, Barnes-Holmes, & Roche, 2001), and its applied extension ACT (Hayes et al., 2012). Psychological inflexibility, often measured using the Acceptance and Action Questionnaire-II (AAQ-II; Bond et al., 2011), refers to a general regulation tendency to rigidly attempt to control and down-regulate unwanted psychological experiences, combined with excessive investment in the literal content of thoughts. From an ACT perspective, the process of psychological inflexibility is at the core of diverse psychopathologies (Hayes, Luoma, Bond, Masuda, & Lillis, 2006), including disordered eating (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996; Juarascio et al., 2013). Cross-sectional investigations have shown that this rigid and inflexible regulation tendency is positively related to a range of disordered eating symptoms in nonclinical samples of men and women (Cowdrey & Park, 2012; Manlick, Cochran, & Koon, 2013; Masuda, Boone, & Timko, 2011; Merwin et al., 2011), including disordered eating behavior (Masuda et al., 2012). Conceptually, mindfulness is often theorized to be part of psychological inflexibility (Hayes et al., 2006), as its inverse psychological flexibility is a multifaceted construct involving the dimension of open awareness of the present moment experience. Nevertheless, previous cross-sectional studies have demonstrated that mindfulness and psychological inflexibility are related, but distinct from each other especially when measured by the MAAS and AAQ, respectively (Masuda, Mandavia, & Tully, in press; Masuda & Tully, 2012). More specifically, while mindfulness as measured by the MAAS reflects present moment awareness, the construct of psychological inflexibility measured by the AAQ-II primarily reflects the maladaptive regulation of psychological distress (Latzman & Masuda, 2013). Recent evidence also suggests that the construct of psychological inflexibility is too general to adequately capture behavior and emotion regulation patterns specific to the context of disordered eating (Sandoz, Wilson, Merwin, & Kellum, 2013). For example, preliminary crosssectional studies have shown that the association between psychological inflexibility and disordered eating behavior is small in non-clinical samples, ranging from r = .18 to r = .19 (Cowdrey & Park, 2012; Masuda et al., 2012). Furthermore, the positive association is no longer significant when controlling for other key psychological and demographic variables, such as depression and rumination specific to eating disorder symptoms (Cowdrey & Park, 2012), or disordered eating cognitions and mindfulness (Masuda et al., 2012). 1.3. Body image flexibility Body image flexibility refers to psychological flexibility specific to the context of disordered eating and body dissatisfaction (Sandoz et al., 2013). Specifically, body image flexibility is defined as the capacity to openly and freely experience body dissatisfaction and other relevant disordered eating thoughts without making efforts to avoid or change them (Sandoz et al., 2013). Several notable cross-sectional investigations have demonstrated body image flexibility to be negatively correlated to a range of disordered eating pathology, including body dissatisfaction (Hill, Masuda, & Latzman, 2013; Sandoz et al., 2013), disordered eating cognitions (Wendell, Masuda, & Le, 2012), general eating pathology (Ferreira, Pinto-Gouveia, & Duarte, 2011; Sandoz et al., 2013; Wendell et al., 2012), and disordered eating behavior (Hill et al., 2013). Studies also suggest that body image flexibility is particularly fit to capture emotion and behavioral regulation processes specific to disordered eating behavior more so than general psychological inflexibility and body dissatisfaction (Sandoz et al., 2013). 1.4. Moderating and protective role of body image flexibility Literature also suggests that body image flexibility serves as a protective factor against disordered eating and attenuates the association between risk factors and disordered eating. For example, among individuals with greater body image flexibility, the strength of the positive
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relationship between body dissatisfaction and disordered eating symptoms is weaker, relative to that of individuals low in body image flexibility (Sandoz et al., 2013). Among women with lower body mass index (BMI), greater body image flexibility is also found to be a protective factor against disordered eating behaviors (Hill et al., 2013). As such, it seems plausible to speculate that greater body image flexibility weakens the link between emotional and cognitive risk factors (e.g., psychological inflexibility, body dissatisfaction) and disorder eating behavior. Similarly, it is possible to speculate that body image flexibility may promote the inverse link between protective factors (e.g., mindfulness) and disordered eating behaviors. This speculation is based on pertinent literature demonstrating synergistic and interactional relationship between adaptive regulation processes on distress variables (EisenlohrMoul, Walsh, Charnigo, Lynam, & Baer, 2012; Peters, Eisenlohr-Moul, Upton, & Baer, 2013). For example, in a study proposed by Peters et al. (2013), the strength of the association between acting with awareness and distress variables in a non-clinical college sample depends on nonjudging, another protective and health-promoting process. More specifically, the study shows that the inverse associations between acting with awareness and distress variables are stronger among individuals with greater nonjudgmental mindsets. Given these findings, it seems worthwhile to explore whether body image flexibility moderates previously established links between disordered eating cognition and disordered eating behavior, between psychological inflexibility and disordered eating behavior, and between mindfulness and disordered eating behavior (Masuda et al., 2012). In establishing these contributing roles of body image flexibility, we hope to gain greater understanding of how this construct best targets the underlying processes that promote and maintain disordered eating behavior. 1.5. Present study Following extant findings, the present study first investigates whether body image flexibility accounts for unique variance in disordered eating behavior above and beyond disordered eating cognition, mindfulness, and psychological inflexibility in women. We focus on a nonclinical sample of women as the present research questions are based on evidence which is drawn from nonclinical female samples. The study then examines whether body image flexibility moderates the association between these potential predictors and disordered eating behaviors. 2. Methods 2.1. Participants All participants were recruited from undergraduate psychology courses using a web-based research participant pool. The initial sample included 457 women. Those who did not provide self-report height and weight (n = 18), and those who represented outliers based on a BMI 34.75 (n = 18) were excluded from the study. The final investigated sample consisted of 421 non-clinical undergraduate college women with a mean age of 21.21 years (SD = 5.58). The sample presented an ethnically diverse composition with 35% (n = 148) identifying as “European American”, 32% (n = 134) identifying as “African American/Black”, 17% (n = 72) identifying as “Asian”, 7% (n = 27) identifying as “Hispanic”, 5% (n = 20) identifying as “Biracial”, b 1% (n = 2) identifying as “Native American”, and 4% (n = 18) identifying as “Other”. BMI scores ranged from 13.39 to 34.74, with a mean of 22.92 (SD = 4.02). 2.2. Procedure The current study was approved by the Institutional Review Board of the participating university. Participants completed an anonymous
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web-based survey. Prior to the survey, the purpose of the study and instructions for responding were presented to the participants. The following measures were administered to assess disordered eating behaviors, disordered eating cognition, mindfulness, general psychological inflexibility, and body image flexibility. 2.3. Measures 2.3.1. Disordered eating behaviors Based on previous findings (Anderson-Fye & Lin, 2009; Miller, Vaillancourt, & Hanna, 2009), the sum of nine behavioral items in the 26-item version of the Eating Attitudes Test (EAT-26; Garner, Olmsted, Bohr, & Garfinkel, 1982) was used to measure behavioral symptoms of disordered eating. These items clearly capture the behavioral symptoms of disordered eating (e.g., “I avoid eating when I am hungry” and “I vomit after I have eaten”). All items are scored on a 6-point Likert scale: never (0), rarely (0), sometimes (0), often (1), very often (2), or always (3). The total score of the behavioral scale (EAT-26 Behavior) ranges from 0 to 27, and higher scores denote more disordered eating behavior. In a previous study conducted with a non-clinical college sample, Cronbach's alpha for the scale was .72 (Masuda et al., 2012). Cronbach's alpha was .75 in the present study. 2.3.2. Disordered eating cognition The Mizes Anorectic Cognitions Questionnaire — Revised (MAC-R; Mizes et al., 2000) is a 24-item self-report questionnaire designed to assess distorted cognitions related to all eating disorders. These cognitions are the fear of weight gain (e.g., “When I see someone who is overweight, I worry that I will be like him/her”), the importance of being thin or attractive to be socially accepted (e.g., “No one likes fat people; therefore, I must remain thin to be liked by others”), and self-esteem based on controlled eating habits and weight gain (e.g., “If my weight goes up, my self-esteem goes down”). Each item is scored on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree), with a total score derived from the sum of all responses. Total scores range from 24 to 120 with higher scores indicating greater disordered eating-related dysfunctional cognitions. In a previous study conducted with a non-clinical college sample, Cronbach's alpha for the MAC-R total was .89 (Masuda, Price, Anderson, & Wendell, 2010). In the current study, Cronbach's alpha of this measure was .87.
2.3.5. Body image flexibility The Body Image Acceptance and Action Questionnaire (BI-AAQ; Sandoz et al., 2013) is a 12-item scale designed to measure psychological flexibility in the context of body dissatisfaction and disordered eating. Specifically, the self-report scale measures the extent to which one is entangled with difficult body image beliefs, the degree to which one avoids or is affected by body image-related negative psychological experiences, and the extent to which one's values-consistent activities are interrupted by body dissatisfaction. All items are rated on a 7-point Likert-like scale ranging from 1 (Never true) to 7 (Always true) and are reverse-scored. Total scores for BI-AAQ range from 12 to 84, with higher scores representing higher body image flexibility. The BI-AAQ has shown good internal consistency (Cronbach's alpha = .92), as well as concurrent, criterion-related, and incremental validity in an undergraduate population (Sandoz et al., 2013). In the present study, Cronbach's alpha of the measure was .96. 2.4. Data analysis In the present set of analyses, we first examined zero-order correlations among all study variables. Then a hierarchical multiple regression was conducted to examine whether body image flexibility accounted for unique variance in disordered eating behavior above and beyond disordered eating cognition, mindfulness, and psychological inflexibility, and whether body image flexibility moderated the associations between these three predictors and disordered eating behavior. In the first step of the regression, age, gender, BMI, and ethnicity were entered as covariates. In the second step, disordered eating cognition, mindfulness, and psychological inflexibility were entered into the model. In the third step, body image flexibility was entered into the model in order to investigate its main effect. Finally, the two-way interactions of body image flexibility × disordered eating cognitions, body image flexibility × mindfulness, body image flexibility × psychological inflexibility were entered into the model to examine the moderating role of body image flexibility. Disordered eating cognition, mindfulness, psychological inflexibility, and body image flexibility scores were standardized (i.e., z-scored) and these scores were used to calculate interaction terms used for these analyses. 3. Results 3.1. Associations among study variables
2.3.3. Mindfulness The Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003) is a 15-item, self-report measure, which is designed to assess the frequency of mindlessness, the opposite of the construct of mindfulness, over time (e.g., “It seems I am running automatic without much awareness of what I'm doing”). Participants rate the extent to which they function mindlessly in daily life, using a 6-point Likert-type scale ranging from 1 (almost always) to 6 (almost never). Total scores range from 15 to 90, with higher scores denoting greater mindfulness. The MAAS has good internal consistency (i.e., Cronbach's α), ranging from .82 to .87 (Brown & Ryan, 2003). Cronbach's alpha in the present study was .90. 2.3.4. Psychological inflexibility The Acceptance and Action Questionnaire (AAQ-II; Bond et al., 2011) is a 7-item questionnaire designed to assess unwillingness to experience undesirable thoughts and feelings (e.g., “I'm afraid of my feelings”) and interference by these internal events in daily functioning (e.g., “My painful experiences and memories make it difficult for me to live a life that I would value”). Participants rate the extent to which statements are true or not true of themselves on a 7-point Likert-type scale, ranging from 1 (Never true) to 7 (Always true). Total scores range from 7 to 49, with higher scores denoting greater inflexibility. Previous research has found AAQ-II to have good psychometric properties (Bond et al., 2011) with internal consistencies (Cronbach's alphas) ranging from .78 to .88. Cronbach's alpha of this measure in the present study was .93.
Descriptive statistics and correlations among study variables are presented in Table 1. Disordered eating behavior was positively associated with disordered eating cognition and psychological inflexibility, and negatively associated with mindfulness and body image flexibility. Body image flexibility was negatively associated with disordered eating cognition and psychological inflexibility, and positively associated with mindfulness. 3.2. Roles of disordered eating cognitions, psychological inflexibility, mindfulness, body image flexibility on disordered eating behavior Results of the hierarchal regression revealed that after controlling for age, BMI, and ethnicity (Step 1; R2 = .01), disordered eating cognition (β = .39, p b .001), but not mindfulness (β = −.06, p = .23) or psychological inflexibility (β = .03, p = .59), was associated with disordered eating behavior (Step 2; R2 = .18). Body image flexibility (β = − .43, p b .001) was found to account for unique variance in disordered eating behavior above and beyond other study variables (Step 3; R2 = .27). 3.3. Moderating effect of body image flexibility The final step of the hierarchal regression (Step 4; R2 = .28) showed a significant interaction effect for disordered eating cognition × body image flexibility (β = −.12, p b .05), but not psychological
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Table 1 Means, standard deviations, coefficient alphas, and zero-order relations between all variables. 1 1. Disordered Eating Behaviors (EAT-26 B) 2. Disordered Eating Cognition (MAC-R) 3. Psychological Inflexibility (AAQ-II) 4. Mindfulness (MAAS) 5. Body Image Flexibility (BI-AAQ) 6. Age 7. BMI 8. Ethnicity M SD α
2
3
4
5
6
7
8
–
.41⁎⁎⁎ .21⁎⁎⁎ −.22⁎⁎⁎ −.46⁎⁎⁎ −.04 −.05 −.09 2.37 3.56 .75
–
.39⁎⁎⁎ −.38⁎⁎⁎ −.62⁎⁎⁎ −.08⁎ .08 −.15⁎
62.72 14.85 .87
– −.49⁎⁎⁎ −.57⁎⁎⁎ −.16⁎⁎ −.07 −.05 20.78 9.44 .93
–
.36⁎⁎ .19⁎⁎ .06⁎
.08 57.83 12.78 .90
– .09 −.20⁎⁎ .11⁎ 63.20 18.06 .96
–
.28⁎⁎ −.05 21.20 5.58
– –
.07 22.91 4.09
Note: N = 573, EAT-26 = Eating Attitudes Test-26 item, B = Behavior, MAC-R = Mizes Anorectic Cognition Questionnaire — Revised, AAQ-II = Acceptance and Action Questionnaire-II, MAAS = Mindfulness Attention Awareness Scale, BI-AAQ = Body Image Acceptance and Action Questionnaire; BMI = Body Mass Index. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.
inflexibility × body image flexibility (β = .04, p N .40) or mindfulness × body image flexibility (β = −.00, p N .97). The positive association between disordered eating cognition and disordered eating behavior is therefore smaller in women high (+ 1 SD) in body image flexibility compared to those low (− 1 SD) in body image flexibility (see Fig. 1). This interaction was probed using simple slopes analysis, revealing that for high (+1 SD) values of body image flexibility the relationship between disordered eating cognition and disordered eating behavior was non-significant (β = .11, p = .13), but at low (− 1 SD) levels of body image flexibility the relationship between disordered eating cognition and disordered eating behavior was statistically significant (β = .31, p b .001) (Table 2). 4. Discussion The present study has demonstrated that body image flexibility is a useful construct in understanding disordered eating behavior in nonclinical women for several reasons. First, body image flexibility accounts for additional variance in disordered eating behavior (i.e., 8% in the present study) above and beyond mindfulness, disordered eating cognitions, psychological inflexibility, and key demographic variables combined (i.e., 17% of variance). As shown elsewhere (Hill et al., 2013; Sandoz et al., 2013; Wendell et al., 2012), those high in body image flexibility tend to have lower levels of disordered eating behavior than those low in body image flexibility. Second, these findings support a conceptual framework employed in acceptance and mindfulness-based CBTs (Hayes et al., 2006, 2011). The
Disordered Eating Behavior
8 7 6 5 4
Low Body Image Flexibility
3
High Body Image Flexibility
2 1 0 Low Disordered Eating Cognition
High Disordered Eating Cognition
Fig. 1. Body image flexibility moderates the association between disordered eating cognitions and disordered eating behaviors. High and low values correspond to ±1 SD from the mean.
conceptual model states that both context specific cognition and regulation processes account for a given psychopathology. In accordance with the model, our findings suggest that disordered eating cognitions and body image flexibility, but not mindfulness and psychological flexibility, are uniquely associated with disordered eating behavior possibly due to their disordered eating specific nature. Regarding mindfulness and psychological inflexibility, their significant associations with disordered eating behavior observed in the zero-order correlational analyses disappear probably because of their generic nature. Once their shared features with other disordered eating specific variables are removed, their remaining features result in a non-significant association with disordered eating behavior or a significant, but conceptually inconsistent association. Finally, body image flexibility interacts with disordered eating cognition and moderates the association between the cognition and disordered eating behavior. Previous cross-sectional studies have shown that disordered eating cognition and other relevant factors, such as body dissatisfaction, are uniquely associated with disordered eating behaviors (Hill et al., 2013; Masuda et al., 2012). However, our findings suggest that the strength of these positive associations may depend on body image flexibility, a protective factor that attenuates the associations between risk factors and disordered eating symptoms. More Table 2 Final step of a hierarchical linear regression examining the role of disordered eating cognition, psychological inflexibility, mindfulness, and body image flexibility on disordered eating behaviors. Disordered eating behaviors (EAT-26-B) Intercept Direct effects Age BMI Ethnicity Disordered Eating Cognitions (MAC-R) Psychological Inflexibility (AAQ-II) Mindfulness (MAAS) Body Image Flexibility (BI-AAQ) Moderating effects MAC-R × BI-AAQ AAQ-II × BI-AAQ MAAS × BI-AAQ
b
SE
β
4.89
1.08
.04 −.15⁎⁎ .02 .73⁎⁎ −.47⁎ −.20 −1.40⁎⁎
.03 .04 .32 .20 .20 .18 .24
.05 −.17 .00 .21 −.13 −.06 −.39
−.36⁎ −.13 −.01
.16 .15 .18
−.12 −.04 .00
Note: N = 421; EAT-26-B = Eating Attitudes Test-26 item version Behavior Subscale; BMI = Body Mass Index; MAC-R = Mizes Anorectic Cognition Questionnaire — Revised; AAQ-II = Acceptance and Action Questionnaire II; MAAS = Mindfulness Attention Awareness Scale; BI-AAQ = Body Image-Acceptance and Action Questionnaire; First step, F (3, 417) = 1.57, R2Δ = .01, p = .197; Second step, F (3, 414) = 29.27, p b .001, R2Δ = .17, p b .001; Third step, F (1, 413) = 47.17, p b .001, R2Δ = .08, p b 001; Fourth step, F (3, 410) = 1.93, p b .001, R2Δ = .01, p = 124. ⁎ p b .05. ⁎⁎ p b .01.
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specifically, at least in the current study, for women with greater body image flexibility, disordered eating cognition is not positively associated with disordered eating behavior. Although it is beyond the scope of present cross-sectional study, these findings among women with greater body image flexibility may be explained by their greater openness to disordered eating cognitions without acting on them via disordered eating behaviors. Regarding applied implications, our study may suggest the importance of repeatedly assessing and perhaps promoting body image flexibility in the context of targeting disordered eating concerns, especially for non-clinical samples of women. This applied implication is in line with acceptance- and mindfulness-based CBT models (Manlick et al., 2013; Safer et al., 2009) postulating that emotion and behavior regulations are at the core of eating pathology as well as recovery from disordered eating. Although this is beyond the scope of the present study, given that disordered eating cognition interacts with body image flexibility, simply targeting disordered eating cognition without considering body image flexibility may not effectively target the disordered eating behavior. More specifically, for individuals with lower body image flexibility, interventions that focus on modifying disordered eating cognition may not effectively decrease disordered eating behavior (Sandoz et al., 2013). Findings of the present study should be interpreted in light of limitations. These include the exclusive use of self-report measures in that the constructs of interest are bound to these measures. In the same regard, as the set of disordered eating behaviors measured in the present study is limited to 9 items listed in the EAT-26, this may not fully capture disordered eating behaviors that are not included in the scale. Furthermore, some BMI values in the present sample were extreme even after exclusion of outliers. The great range of BMI in the present sample might have been attributed to intentional and unintentional errors that can occur with the self-report of height and weight. The investigated sample is likely to compromise the external validity of the present findings as it consisted of only female college undergraduates from an urban area university in the southeastern United States. Relatedly, participants were recruited in a non-clinical setting, thus our findings may not be generalized to a clinical population with disordered eating behavior or eating disorders. Finally, the present study is crosssectional, and the analytic strategy used in the present study does not permit drawing causal inferences or inferences about functional associations among the variables of interest. 4.1. Conclusion Limitations aside, this study added further validation for body image flexibility as a promising construct in understanding disordered eating behavior in a non-clinical sample of women. This study demonstrated the unique nature of body image flexibility and its significant role in disordered eating behavior that extends beyond other regulation patterns not specific to disordered eating. Body image flexibility also moderates the association between disordered eating cognition and disordered eating behavior, adding further understanding of disordered eating behavior. It seems worthwhile to continue to investigate body image flexibility and its evident role in disordered eating and relevant factors. Role of funding sources There were no funding sources for this study. Contributors The first author designed the study, collected the data, conducted the literature review, conducted the statistical analysis, and wrote and revised the manuscript. The second author mentored the first author, helping her in the areas of developing research questions, conducting statistical analysis, revising and finalizing the manuscript. The third authors mentored the first author for conducting data analyses, interpreting findings, and manuscript writing. All authors have approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest.
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Contents lists available at ScienceDirect
Eating Behaviors
Body image flexibility moderates the association between disordered eating cognition and disordered eating behavior in a non-clinical sample of women: A cross-sectional investigation Makeda Moore, Akihiko Masuda ⁎, Mary L. Hill, Bradley L. Goodnight Department of Psychology, Georgia State University, USA
a r t i c l e
i n f o
Article history: Received 6 January 2014 Received in revised form 21 May 2014 Accepted 21 August 2014 Available online 28 September 2014 Keywords: Disordered eating Body image flexibility Mindfulness Psychological inflexibility
a b s t r a c t Body image flexibility, a regulation process of openly and freely experiencing disordered eating thoughts and body dissatisfaction, has been found to be a buffering factor against disordered eating symptomatology. The present cross-sectional study investigates whether body image flexibility accounts for disordered eating behavior above and beyond disordered eating cognition, mindfulness, and psychological inflexibility in a sample of nonclinical women, and whether body image flexibility moderates the associations between these correlates and disordered eating behavior. Participants were 421 women, age 21 ± 5.3 years old on average, who completed a web-based survey that included the self-report measures of interest. Results demonstrate the incremental effects of body image flexibility on disordered eating behavior above and beyond disordered eating cognition, mindfulness, and psychological inflexibility. Women with greater body image flexibility endorse disordered eating behavior less so than those with lower body image flexibility. Body image flexibility moderates the association between disordered eating cognition and disordered eating behavior; for women with greater body image flexibility, disordered eating cognition is not positively associated with disordered eating behavior. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Recently, there has been a growing interest in emotion and behavior regulation processes in understanding and treating disordered eating behavior (Anestis, Selby, Fink, & Joiner, 2007). Findings in this line of research suggest that, in addition to disordered eating cognitions, the way an individual interprets, relates, and reacts to unwanted internal events (e.g., fear of gaining weight and body dissatisfaction) plays a central role in the onset and maintenance of disordered eating (Aldao, Nolen-Hoeksema, & Schweizer, 2010; Anestis et al., 2007). Research has also shown that disordered eating behaviors, such as restricted or excessive dieting, binge eating and purging, and preoccupation with caloric intake, often function as maladaptive emotion and behavior regulation strategies (Schmidt & Treasure, 2006; Wedig & Nock, 2010). Given these findings, some recent cognitive behavioral therapies (CBTs) for disordered eating, especially acceptance- and mindfulnessbased CBTs (Hayes, Villatte, Levin, & Hildebrandt, 2011), explicitly target the reduction of maladaptive regulation strategies and the promotion of adaptive regulation strategies. Examples of these CBTs are Dialectical Behavior Therapy (DBT; Safer, Telch, & Chen, 2009), Mindfulness-Based Eating Awareness Training (MB-EAT; Kristeller & Wolever, 2011) and
Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 2012). Two major emotion and behavior regulation processes that are the focus of these CBTs include mindfulness and psychological inflexibility. 1.1. Mindfulness Mindfulness is often defined as an emotion and behavior regulation process of openly attending to and becoming aware of the present moment and accompanying experiences. When defined in this way, it is best captured by the Mindfulness Attention and Awareness Scale (MAAS; Brown & Ryan, 2003). From an acceptance- and mindfulnessbased CBT standpoint, mindfulness has shown much promise in its role in understanding and treating disordered eating pathology (Baer, Fischer, & Huss, 2005; Kristeller & Wolever, 2011), partially because of its health-promoting effects (Brown, Ryan, & Creswell, 2007). Crosssectional investigations with nonclinical samples of men and women have shown that, when measured by the MAAS, mindfulness is inversely related to bulimic symptoms (Lavender, Jardin, & Anderson, 2009) as well as disordered eating behavior (Masuda, Price, & Latzman, 2012). 1.2. Psychological inflexibility
⁎ Corresponding author at: Department of Psychology, Georgia State University, Atlanta, GA 30303, USA. E-mail address: [email protected] (A. Masuda).
http://dx.doi.org/10.1016/j.eatbeh.2014.08.021 1471-0153/© 2014 Elsevier Ltd. All rights reserved.
The construct of psychological inflexibility is derived from a basic behavioral account of complex human behavior, called relational frame
M. Moore et al. / Eating Behaviors 15 (2014) 664–669
theory (RFT; Hayes, Barnes-Holmes, & Roche, 2001), and its applied extension ACT (Hayes et al., 2012). Psychological inflexibility, often measured using the Acceptance and Action Questionnaire-II (AAQ-II; Bond et al., 2011), refers to a general regulation tendency to rigidly attempt to control and down-regulate unwanted psychological experiences, combined with excessive investment in the literal content of thoughts. From an ACT perspective, the process of psychological inflexibility is at the core of diverse psychopathologies (Hayes, Luoma, Bond, Masuda, & Lillis, 2006), including disordered eating (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996; Juarascio et al., 2013). Cross-sectional investigations have shown that this rigid and inflexible regulation tendency is positively related to a range of disordered eating symptoms in nonclinical samples of men and women (Cowdrey & Park, 2012; Manlick, Cochran, & Koon, 2013; Masuda, Boone, & Timko, 2011; Merwin et al., 2011), including disordered eating behavior (Masuda et al., 2012). Conceptually, mindfulness is often theorized to be part of psychological inflexibility (Hayes et al., 2006), as its inverse psychological flexibility is a multifaceted construct involving the dimension of open awareness of the present moment experience. Nevertheless, previous cross-sectional studies have demonstrated that mindfulness and psychological inflexibility are related, but distinct from each other especially when measured by the MAAS and AAQ, respectively (Masuda, Mandavia, & Tully, in press; Masuda & Tully, 2012). More specifically, while mindfulness as measured by the MAAS reflects present moment awareness, the construct of psychological inflexibility measured by the AAQ-II primarily reflects the maladaptive regulation of psychological distress (Latzman & Masuda, 2013). Recent evidence also suggests that the construct of psychological inflexibility is too general to adequately capture behavior and emotion regulation patterns specific to the context of disordered eating (Sandoz, Wilson, Merwin, & Kellum, 2013). For example, preliminary crosssectional studies have shown that the association between psychological inflexibility and disordered eating behavior is small in non-clinical samples, ranging from r = .18 to r = .19 (Cowdrey & Park, 2012; Masuda et al., 2012). Furthermore, the positive association is no longer significant when controlling for other key psychological and demographic variables, such as depression and rumination specific to eating disorder symptoms (Cowdrey & Park, 2012), or disordered eating cognitions and mindfulness (Masuda et al., 2012). 1.3. Body image flexibility Body image flexibility refers to psychological flexibility specific to the context of disordered eating and body dissatisfaction (Sandoz et al., 2013). Specifically, body image flexibility is defined as the capacity to openly and freely experience body dissatisfaction and other relevant disordered eating thoughts without making efforts to avoid or change them (Sandoz et al., 2013). Several notable cross-sectional investigations have demonstrated body image flexibility to be negatively correlated to a range of disordered eating pathology, including body dissatisfaction (Hill, Masuda, & Latzman, 2013; Sandoz et al., 2013), disordered eating cognitions (Wendell, Masuda, & Le, 2012), general eating pathology (Ferreira, Pinto-Gouveia, & Duarte, 2011; Sandoz et al., 2013; Wendell et al., 2012), and disordered eating behavior (Hill et al., 2013). Studies also suggest that body image flexibility is particularly fit to capture emotion and behavioral regulation processes specific to disordered eating behavior more so than general psychological inflexibility and body dissatisfaction (Sandoz et al., 2013). 1.4. Moderating and protective role of body image flexibility Literature also suggests that body image flexibility serves as a protective factor against disordered eating and attenuates the association between risk factors and disordered eating. For example, among individuals with greater body image flexibility, the strength of the positive
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relationship between body dissatisfaction and disordered eating symptoms is weaker, relative to that of individuals low in body image flexibility (Sandoz et al., 2013). Among women with lower body mass index (BMI), greater body image flexibility is also found to be a protective factor against disordered eating behaviors (Hill et al., 2013). As such, it seems plausible to speculate that greater body image flexibility weakens the link between emotional and cognitive risk factors (e.g., psychological inflexibility, body dissatisfaction) and disorder eating behavior. Similarly, it is possible to speculate that body image flexibility may promote the inverse link between protective factors (e.g., mindfulness) and disordered eating behaviors. This speculation is based on pertinent literature demonstrating synergistic and interactional relationship between adaptive regulation processes on distress variables (EisenlohrMoul, Walsh, Charnigo, Lynam, & Baer, 2012; Peters, Eisenlohr-Moul, Upton, & Baer, 2013). For example, in a study proposed by Peters et al. (2013), the strength of the association between acting with awareness and distress variables in a non-clinical college sample depends on nonjudging, another protective and health-promoting process. More specifically, the study shows that the inverse associations between acting with awareness and distress variables are stronger among individuals with greater nonjudgmental mindsets. Given these findings, it seems worthwhile to explore whether body image flexibility moderates previously established links between disordered eating cognition and disordered eating behavior, between psychological inflexibility and disordered eating behavior, and between mindfulness and disordered eating behavior (Masuda et al., 2012). In establishing these contributing roles of body image flexibility, we hope to gain greater understanding of how this construct best targets the underlying processes that promote and maintain disordered eating behavior. 1.5. Present study Following extant findings, the present study first investigates whether body image flexibility accounts for unique variance in disordered eating behavior above and beyond disordered eating cognition, mindfulness, and psychological inflexibility in women. We focus on a nonclinical sample of women as the present research questions are based on evidence which is drawn from nonclinical female samples. The study then examines whether body image flexibility moderates the association between these potential predictors and disordered eating behaviors. 2. Methods 2.1. Participants All participants were recruited from undergraduate psychology courses using a web-based research participant pool. The initial sample included 457 women. Those who did not provide self-report height and weight (n = 18), and those who represented outliers based on a BMI 34.75 (n = 18) were excluded from the study. The final investigated sample consisted of 421 non-clinical undergraduate college women with a mean age of 21.21 years (SD = 5.58). The sample presented an ethnically diverse composition with 35% (n = 148) identifying as “European American”, 32% (n = 134) identifying as “African American/Black”, 17% (n = 72) identifying as “Asian”, 7% (n = 27) identifying as “Hispanic”, 5% (n = 20) identifying as “Biracial”, b 1% (n = 2) identifying as “Native American”, and 4% (n = 18) identifying as “Other”. BMI scores ranged from 13.39 to 34.74, with a mean of 22.92 (SD = 4.02). 2.2. Procedure The current study was approved by the Institutional Review Board of the participating university. Participants completed an anonymous
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web-based survey. Prior to the survey, the purpose of the study and instructions for responding were presented to the participants. The following measures were administered to assess disordered eating behaviors, disordered eating cognition, mindfulness, general psychological inflexibility, and body image flexibility. 2.3. Measures 2.3.1. Disordered eating behaviors Based on previous findings (Anderson-Fye & Lin, 2009; Miller, Vaillancourt, & Hanna, 2009), the sum of nine behavioral items in the 26-item version of the Eating Attitudes Test (EAT-26; Garner, Olmsted, Bohr, & Garfinkel, 1982) was used to measure behavioral symptoms of disordered eating. These items clearly capture the behavioral symptoms of disordered eating (e.g., “I avoid eating when I am hungry” and “I vomit after I have eaten”). All items are scored on a 6-point Likert scale: never (0), rarely (0), sometimes (0), often (1), very often (2), or always (3). The total score of the behavioral scale (EAT-26 Behavior) ranges from 0 to 27, and higher scores denote more disordered eating behavior. In a previous study conducted with a non-clinical college sample, Cronbach's alpha for the scale was .72 (Masuda et al., 2012). Cronbach's alpha was .75 in the present study. 2.3.2. Disordered eating cognition The Mizes Anorectic Cognitions Questionnaire — Revised (MAC-R; Mizes et al., 2000) is a 24-item self-report questionnaire designed to assess distorted cognitions related to all eating disorders. These cognitions are the fear of weight gain (e.g., “When I see someone who is overweight, I worry that I will be like him/her”), the importance of being thin or attractive to be socially accepted (e.g., “No one likes fat people; therefore, I must remain thin to be liked by others”), and self-esteem based on controlled eating habits and weight gain (e.g., “If my weight goes up, my self-esteem goes down”). Each item is scored on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree), with a total score derived from the sum of all responses. Total scores range from 24 to 120 with higher scores indicating greater disordered eating-related dysfunctional cognitions. In a previous study conducted with a non-clinical college sample, Cronbach's alpha for the MAC-R total was .89 (Masuda, Price, Anderson, & Wendell, 2010). In the current study, Cronbach's alpha of this measure was .87.
2.3.5. Body image flexibility The Body Image Acceptance and Action Questionnaire (BI-AAQ; Sandoz et al., 2013) is a 12-item scale designed to measure psychological flexibility in the context of body dissatisfaction and disordered eating. Specifically, the self-report scale measures the extent to which one is entangled with difficult body image beliefs, the degree to which one avoids or is affected by body image-related negative psychological experiences, and the extent to which one's values-consistent activities are interrupted by body dissatisfaction. All items are rated on a 7-point Likert-like scale ranging from 1 (Never true) to 7 (Always true) and are reverse-scored. Total scores for BI-AAQ range from 12 to 84, with higher scores representing higher body image flexibility. The BI-AAQ has shown good internal consistency (Cronbach's alpha = .92), as well as concurrent, criterion-related, and incremental validity in an undergraduate population (Sandoz et al., 2013). In the present study, Cronbach's alpha of the measure was .96. 2.4. Data analysis In the present set of analyses, we first examined zero-order correlations among all study variables. Then a hierarchical multiple regression was conducted to examine whether body image flexibility accounted for unique variance in disordered eating behavior above and beyond disordered eating cognition, mindfulness, and psychological inflexibility, and whether body image flexibility moderated the associations between these three predictors and disordered eating behavior. In the first step of the regression, age, gender, BMI, and ethnicity were entered as covariates. In the second step, disordered eating cognition, mindfulness, and psychological inflexibility were entered into the model. In the third step, body image flexibility was entered into the model in order to investigate its main effect. Finally, the two-way interactions of body image flexibility × disordered eating cognitions, body image flexibility × mindfulness, body image flexibility × psychological inflexibility were entered into the model to examine the moderating role of body image flexibility. Disordered eating cognition, mindfulness, psychological inflexibility, and body image flexibility scores were standardized (i.e., z-scored) and these scores were used to calculate interaction terms used for these analyses. 3. Results 3.1. Associations among study variables
2.3.3. Mindfulness The Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003) is a 15-item, self-report measure, which is designed to assess the frequency of mindlessness, the opposite of the construct of mindfulness, over time (e.g., “It seems I am running automatic without much awareness of what I'm doing”). Participants rate the extent to which they function mindlessly in daily life, using a 6-point Likert-type scale ranging from 1 (almost always) to 6 (almost never). Total scores range from 15 to 90, with higher scores denoting greater mindfulness. The MAAS has good internal consistency (i.e., Cronbach's α), ranging from .82 to .87 (Brown & Ryan, 2003). Cronbach's alpha in the present study was .90. 2.3.4. Psychological inflexibility The Acceptance and Action Questionnaire (AAQ-II; Bond et al., 2011) is a 7-item questionnaire designed to assess unwillingness to experience undesirable thoughts and feelings (e.g., “I'm afraid of my feelings”) and interference by these internal events in daily functioning (e.g., “My painful experiences and memories make it difficult for me to live a life that I would value”). Participants rate the extent to which statements are true or not true of themselves on a 7-point Likert-type scale, ranging from 1 (Never true) to 7 (Always true). Total scores range from 7 to 49, with higher scores denoting greater inflexibility. Previous research has found AAQ-II to have good psychometric properties (Bond et al., 2011) with internal consistencies (Cronbach's alphas) ranging from .78 to .88. Cronbach's alpha of this measure in the present study was .93.
Descriptive statistics and correlations among study variables are presented in Table 1. Disordered eating behavior was positively associated with disordered eating cognition and psychological inflexibility, and negatively associated with mindfulness and body image flexibility. Body image flexibility was negatively associated with disordered eating cognition and psychological inflexibility, and positively associated with mindfulness. 3.2. Roles of disordered eating cognitions, psychological inflexibility, mindfulness, body image flexibility on disordered eating behavior Results of the hierarchal regression revealed that after controlling for age, BMI, and ethnicity (Step 1; R2 = .01), disordered eating cognition (β = .39, p b .001), but not mindfulness (β = −.06, p = .23) or psychological inflexibility (β = .03, p = .59), was associated with disordered eating behavior (Step 2; R2 = .18). Body image flexibility (β = − .43, p b .001) was found to account for unique variance in disordered eating behavior above and beyond other study variables (Step 3; R2 = .27). 3.3. Moderating effect of body image flexibility The final step of the hierarchal regression (Step 4; R2 = .28) showed a significant interaction effect for disordered eating cognition × body image flexibility (β = −.12, p b .05), but not psychological
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Table 1 Means, standard deviations, coefficient alphas, and zero-order relations between all variables. 1 1. Disordered Eating Behaviors (EAT-26 B) 2. Disordered Eating Cognition (MAC-R) 3. Psychological Inflexibility (AAQ-II) 4. Mindfulness (MAAS) 5. Body Image Flexibility (BI-AAQ) 6. Age 7. BMI 8. Ethnicity M SD α
2
3
4
5
6
7
8
–
.41⁎⁎⁎ .21⁎⁎⁎ −.22⁎⁎⁎ −.46⁎⁎⁎ −.04 −.05 −.09 2.37 3.56 .75
–
.39⁎⁎⁎ −.38⁎⁎⁎ −.62⁎⁎⁎ −.08⁎ .08 −.15⁎
62.72 14.85 .87
– −.49⁎⁎⁎ −.57⁎⁎⁎ −.16⁎⁎ −.07 −.05 20.78 9.44 .93
–
.36⁎⁎ .19⁎⁎ .06⁎
.08 57.83 12.78 .90
– .09 −.20⁎⁎ .11⁎ 63.20 18.06 .96
–
.28⁎⁎ −.05 21.20 5.58
– –
.07 22.91 4.09
Note: N = 573, EAT-26 = Eating Attitudes Test-26 item, B = Behavior, MAC-R = Mizes Anorectic Cognition Questionnaire — Revised, AAQ-II = Acceptance and Action Questionnaire-II, MAAS = Mindfulness Attention Awareness Scale, BI-AAQ = Body Image Acceptance and Action Questionnaire; BMI = Body Mass Index. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.
inflexibility × body image flexibility (β = .04, p N .40) or mindfulness × body image flexibility (β = −.00, p N .97). The positive association between disordered eating cognition and disordered eating behavior is therefore smaller in women high (+ 1 SD) in body image flexibility compared to those low (− 1 SD) in body image flexibility (see Fig. 1). This interaction was probed using simple slopes analysis, revealing that for high (+1 SD) values of body image flexibility the relationship between disordered eating cognition and disordered eating behavior was non-significant (β = .11, p = .13), but at low (− 1 SD) levels of body image flexibility the relationship between disordered eating cognition and disordered eating behavior was statistically significant (β = .31, p b .001) (Table 2). 4. Discussion The present study has demonstrated that body image flexibility is a useful construct in understanding disordered eating behavior in nonclinical women for several reasons. First, body image flexibility accounts for additional variance in disordered eating behavior (i.e., 8% in the present study) above and beyond mindfulness, disordered eating cognitions, psychological inflexibility, and key demographic variables combined (i.e., 17% of variance). As shown elsewhere (Hill et al., 2013; Sandoz et al., 2013; Wendell et al., 2012), those high in body image flexibility tend to have lower levels of disordered eating behavior than those low in body image flexibility. Second, these findings support a conceptual framework employed in acceptance and mindfulness-based CBTs (Hayes et al., 2006, 2011). The
Disordered Eating Behavior
8 7 6 5 4
Low Body Image Flexibility
3
High Body Image Flexibility
2 1 0 Low Disordered Eating Cognition
High Disordered Eating Cognition
Fig. 1. Body image flexibility moderates the association between disordered eating cognitions and disordered eating behaviors. High and low values correspond to ±1 SD from the mean.
conceptual model states that both context specific cognition and regulation processes account for a given psychopathology. In accordance with the model, our findings suggest that disordered eating cognitions and body image flexibility, but not mindfulness and psychological flexibility, are uniquely associated with disordered eating behavior possibly due to their disordered eating specific nature. Regarding mindfulness and psychological inflexibility, their significant associations with disordered eating behavior observed in the zero-order correlational analyses disappear probably because of their generic nature. Once their shared features with other disordered eating specific variables are removed, their remaining features result in a non-significant association with disordered eating behavior or a significant, but conceptually inconsistent association. Finally, body image flexibility interacts with disordered eating cognition and moderates the association between the cognition and disordered eating behavior. Previous cross-sectional studies have shown that disordered eating cognition and other relevant factors, such as body dissatisfaction, are uniquely associated with disordered eating behaviors (Hill et al., 2013; Masuda et al., 2012). However, our findings suggest that the strength of these positive associations may depend on body image flexibility, a protective factor that attenuates the associations between risk factors and disordered eating symptoms. More Table 2 Final step of a hierarchical linear regression examining the role of disordered eating cognition, psychological inflexibility, mindfulness, and body image flexibility on disordered eating behaviors. Disordered eating behaviors (EAT-26-B) Intercept Direct effects Age BMI Ethnicity Disordered Eating Cognitions (MAC-R) Psychological Inflexibility (AAQ-II) Mindfulness (MAAS) Body Image Flexibility (BI-AAQ) Moderating effects MAC-R × BI-AAQ AAQ-II × BI-AAQ MAAS × BI-AAQ
b
SE
β
4.89
1.08
.04 −.15⁎⁎ .02 .73⁎⁎ −.47⁎ −.20 −1.40⁎⁎
.03 .04 .32 .20 .20 .18 .24
.05 −.17 .00 .21 −.13 −.06 −.39
−.36⁎ −.13 −.01
.16 .15 .18
−.12 −.04 .00
Note: N = 421; EAT-26-B = Eating Attitudes Test-26 item version Behavior Subscale; BMI = Body Mass Index; MAC-R = Mizes Anorectic Cognition Questionnaire — Revised; AAQ-II = Acceptance and Action Questionnaire II; MAAS = Mindfulness Attention Awareness Scale; BI-AAQ = Body Image-Acceptance and Action Questionnaire; First step, F (3, 417) = 1.57, R2Δ = .01, p = .197; Second step, F (3, 414) = 29.27, p b .001, R2Δ = .17, p b .001; Third step, F (1, 413) = 47.17, p b .001, R2Δ = .08, p b 001; Fourth step, F (3, 410) = 1.93, p b .001, R2Δ = .01, p = 124. ⁎ p b .05. ⁎⁎ p b .01.
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specifically, at least in the current study, for women with greater body image flexibility, disordered eating cognition is not positively associated with disordered eating behavior. Although it is beyond the scope of present cross-sectional study, these findings among women with greater body image flexibility may be explained by their greater openness to disordered eating cognitions without acting on them via disordered eating behaviors. Regarding applied implications, our study may suggest the importance of repeatedly assessing and perhaps promoting body image flexibility in the context of targeting disordered eating concerns, especially for non-clinical samples of women. This applied implication is in line with acceptance- and mindfulness-based CBT models (Manlick et al., 2013; Safer et al., 2009) postulating that emotion and behavior regulations are at the core of eating pathology as well as recovery from disordered eating. Although this is beyond the scope of the present study, given that disordered eating cognition interacts with body image flexibility, simply targeting disordered eating cognition without considering body image flexibility may not effectively target the disordered eating behavior. More specifically, for individuals with lower body image flexibility, interventions that focus on modifying disordered eating cognition may not effectively decrease disordered eating behavior (Sandoz et al., 2013). Findings of the present study should be interpreted in light of limitations. These include the exclusive use of self-report measures in that the constructs of interest are bound to these measures. In the same regard, as the set of disordered eating behaviors measured in the present study is limited to 9 items listed in the EAT-26, this may not fully capture disordered eating behaviors that are not included in the scale. Furthermore, some BMI values in the present sample were extreme even after exclusion of outliers. The great range of BMI in the present sample might have been attributed to intentional and unintentional errors that can occur with the self-report of height and weight. The investigated sample is likely to compromise the external validity of the present findings as it consisted of only female college undergraduates from an urban area university in the southeastern United States. Relatedly, participants were recruited in a non-clinical setting, thus our findings may not be generalized to a clinical population with disordered eating behavior or eating disorders. Finally, the present study is crosssectional, and the analytic strategy used in the present study does not permit drawing causal inferences or inferences about functional associations among the variables of interest. 4.1. Conclusion Limitations aside, this study added further validation for body image flexibility as a promising construct in understanding disordered eating behavior in a non-clinical sample of women. This study demonstrated the unique nature of body image flexibility and its significant role in disordered eating behavior that extends beyond other regulation patterns not specific to disordered eating. Body image flexibility also moderates the association between disordered eating cognition and disordered eating behavior, adding further understanding of disordered eating behavior. It seems worthwhile to continue to investigate body image flexibility and its evident role in disordered eating and relevant factors. Role of funding sources There were no funding sources for this study. Contributors The first author designed the study, collected the data, conducted the literature review, conducted the statistical analysis, and wrote and revised the manuscript. The second author mentored the first author, helping her in the areas of developing research questions, conducting statistical analysis, revising and finalizing the manuscript. The third authors mentored the first author for conducting data analyses, interpreting findings, and manuscript writing. All authors have approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest.
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