Perfectionism and disordered eating in overweight woman

    Perfectionism and Disordered Eating in Overweight Woman Catarina Peixoto, Maria Jo˜ao Soares, Ant´onio Macedo, Ana Telma Pereira PII: DOI: Reference:

S1471-0153(15)00041-0 doi: 10.1016/j.eatbeh.2015.03.009 EATBEH 917

To appear in:

Eating Behaviors

Received date: Revised date: Accepted date:

26 August 2014 27 January 2015 19 March 2015

Please cite this article as: Peixoto, C., Soares, M.J., Macedo, A. & Pereira, A.T., Perfectionism and Disordered Eating in Overweight Woman, Eating Behaviors (2015), doi: 10.1016/j.eatbeh.2015.03.009

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ACCEPTED MANUSCRIPT Perfectionism and Disordered Eating in Overweight Woman

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Authors:

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Catarina Peixoto1,2, Maria João Soares1, António Macedo1, Ana Telma Pereira1 Psychological Medicine Department, Faculty of Medicine, Coimbra, Portugal;

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Epidemiology Unit, Institute of Preventive Medicine, Faculty of Medicine, Lisbon,

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Portugal.

Address:

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Rua Larga, 3004-504 Coimbra

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Serviço de Psicologia Médica, Faculdade de Medicina da Universidade de Coimbra,

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Correspondent Author:

Catarina Peixoto, Serviço de Psicologia Médica da Faculdade de Medicina de

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Coimbra, Rua Larga, 3004-504 Coimbra, Portugal 00351-239857759 (voice) 00351-239823170 (fax) [email protected]

ACCEPTED MANUSCRIPT Abstract Introduction: Perfectionism constitutes a risk factor for the development of eating

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disorders. In overweight women, knowledge about the nature of this association is

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scarce.

affect in overweight women. The

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versions

of

the

Eating

Disorders

Examination

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Methods:

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Objectives: To investigate the relationship between perfectionism, eating behaviors and

Questionnaire/EDEQ, the Multidimensional Perfectionism Questionnaire and the

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Profile of Mood States were administered to an outpatient sample of 276 women (Mean age=43.85±11.89years; Mean BMI=32.82±5.43kg/m2).

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Results: Correlations between Social Prescribed Perfectionism/SPP, EDEQ total (T)

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and its dimensional scores (Weigh and Shape Concern and Dissatisfaction/WSCD,

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Eating Concern/EC, Dietary Restraint/DR) were significant (r>.30;p>.001). SelfOriented Perfectionism/SOP was significantly correlated with EDEQ-T, WSCD and DR (r=.20). Participants with high (>M+SD) vs. low (
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significantly higher means in EDEQ-T, WSCD, EC and DR (p<.001). Linear regression showed that SPP was predictor of EDEQ-T and EC (p<.001). Conclusions: SPP and SOP are related to disordered eating in overweight women.

Keywords: PERFECTIONISM, EATING BEHAVIORS, AFFECT, OVERWEIGHT WOMEN

ACCEPTED MANUSCRIPT 1.1. INTRODUCTION During the last decades there has been an increasing interest in the topic of

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perfectionism. Many studies have shown that perfectionism plays an integral role in the

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etiology, maintenance and course of a wide range of psychopathologic conditions such

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as depression, obsessive-compulsive disorder, social phobia, suicidal behavior, eating disorders (ED) (Egan, Wade, & Shafran, 2011; Shafran & Mansell, 2001) and sleep

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problems (Azevedo et al., 2009; Azevedo et al., 2010; Bos et al., 2013). Perfectionism has been identified as a specific risk factor for the development of ED,

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defined by the Statistical Manual of Mental Disorders (APA, 2012), in large-scale community studies that examined risk factors for patients with bulimia nervosa (BN),

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anorexia nervosa (AN), and binge eating disorder (BED) (Fairburn et al., 1999;

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Fairburn, Cooper, Doll, & Welch, 1999). Prospective studies have also shown that perfectionism constitute a risk factor for the

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development of disordered eating attitudes (abnormal behaviors associated with eating disorders e.g restraint eating; emotional eating; night eating; weight, shape, and eating

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concerns (Quick, Byrd-bredbenner, & Neumark-sztainer, 2013) along a continuum at the extreme end of which we have eating disorders as AN and BN (Soares et al., 2009; Egan et al., 2011).

The early view of perfectionism focused exclusively in the intrapersonal aspects (ex. Hamachek, 1978), evolved to a multidimensional perspective encompassing the intrapersonal and interpersonal facets of this trait, and also emphasizing that some of its dimensions can have an negative impact on psychological health (Hewitt & Flett, 1991). In the majority of the reviewed studies (Stoeber & Otto, 2006), the perfectionism dimensions found to be associated with psychopathology were concerns over mistakes and doubts about actions from the Frost-Multidimensional Perfectionism Scale (F-

ACCEPTED MANUSCRIPT MPS) (Frost et al, 1990) and SPP from the Hewitt & Flett Multidimensional Perfectionism Scale (H&F-MPS) (Hewitt & Flett, 1991). However, it is important to

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note that the distinction between the positive and negative aspects of perfectionism is

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not clear-cut. (Broman-Fulks, Hill, & Green, 2008),

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In non-clinical samples studies, results from our group confirm that high levels of both SPP and SOP are associated with abnormal eating behaviors (Macedo et al., 2007; Soares et al. 2009; Bento, 2010). All these data suggests that perfectionism is a

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significant predictor of psychological maladjustment in the context of these clinical

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conditions, plays an important role in the maintenance of ED (Macedo et al., 2007; Fairburn, Cooper, & Shafran, 2003) and is a persistent trait even in periods of symptom remission (Macedo et al., 2007) that should be managed.

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To date, the majority of studies focusing in this relation have been restricted to AN and BN and to our knowledge no studies in overweight women with disordered eating

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behavior have been performed. Thus, our aim was to investigate the relationship

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between perfectionism, eating behaviors and affect in overweight women.

ACCEPTED MANUSCRIPT 1.2. MATERIALS AND METHODS This study was approved by the Medical Ethics Review Committee of Faculty of

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Medicine of the Coimbra University.

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The sample was composed by women attending a nutritional appointment for weight loss treatment in a public hospital care setting (Figueira da Foz Hospital, Portugal), between July and December 2011. Overweight (BMI higher than 24.9kg/m2) women

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between 18 and 65 years who were not pregnant were invited to participate in the study, while waiting for their appointments. The nature and objectives of the investigation

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were explained, data confidentially was guaranteed and the ones who agree to participate gave their written consent. After that, each subject completed a questionnaire

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with demographic questions and a battery of validated self-report instruments including

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Multidimensional Scale of Perfectionism (H&F-MPS) (Hewitt & Flett, 1991; Soares

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et al. 2003), Eating Disorders Examination Questionnaire (EDEQ; (Fairburn & Beglin, 1994; Machado, Machado, Gonçalves, & Hoek, 2007; Peixoto et al., 2013), and Profile of Mood States (POMS; McNair, Lorr, & Droppleman, 1971; Azevedo et al,

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1991); their weight and height was measured. 300 Questionnaires were distributed, of which 270 (90%) were returned. Weight was measured using an electronic scale (TANITA® Body Composition Analyzer TBF-300), and registered to the nearest 0.1 kg and height was also measured with a stadiometer (SECA®) with the women in a Frankfurt plan, and the values registered to the nearest 0.1 cm. Body mass index (BMI) in kilograms per square meter was calculated from weight (kg) and height (m). The mean age was 43.85±11.89 years and the mean BMI was 32.82±5.43 Kg/m2. The majority of the participants were married (76.3%), 16% were single and the other 8.2% had other marital status. 62.2% of the woman were employed, 20.0% were unemployed and 13.7% were retired.

ACCEPTED MANUSCRIPT 1.2.1. Instruments In this study the Portuguese version of the H&F-MPS (Hewitt & Flett, 1991) translated

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and validated in Portugal (Soares, Gomes, Macedo, & Azevedo, 2003) was used to

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measure 2 dimensions of perfectionism: SOP (unrealistic self-imposed standards) and

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SPP (perceiving that others have unrealistically high standards are require perfection from oneself). It is a self-report questionnaire, of which we used 32-items, rated on a 7-

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point Likert scale, ranging from strongly disagree (score 1) to strongly agree (score 7). The psychometric properties of the Portuguese version of MPS have been described

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elsewhere (Macedo et al., 2007).

EDEQ (Machado et al., 2007; Peixoto et al, 2013), is a self-report measure consisting

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of 28 items designed to assess eating disorder symptoms. It yields a global score and

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subscales dimensional scores. We used a three factors structure analyzed by our team

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(Peixoto et al, 2013): Weigh and Shape Concern and Dissatisfaction (WSCD), Eating Concern (EC) and Dietary Restraint (DR).

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We used a shorter version of POMS (Azevedo, Silva, & Dias, 1991) with 36 items (Bos et al. 2013) to assess positive affect (PA) and negative affect (NA). This instrument is a commonly used measure of psychological distress. Following each adjective the subject is required to respond how she has been feeling on a 5 point scale which varies from «not at all» (value 0) to «extremely» (value 5), considering the previous month, and not the last week as it was originally requested. This modification enabled to assess affectivity instead of transitory mood states.

ACCEPTED MANUSCRIPT 1.2.2. Statistical Analyses SPSS 20.0 for Windows was used. Spearman correlation coefficients were used. Mean

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scores of continuous variables were compared using the One-way Analysis of Variance

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linear (hierarchical) regressions were performed.

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(ANOVA) (followed by the adequate Post hoc multiple comparisons tests). Multiple

ACCEPTED MANUSCRIPT 1.3.RESULTS 1.3.1. Correlations

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The total mean EDE-Q was 2.36 ± 1.07, with a range from 0 to 5.33. For the three

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dimensions the mean scores was WSCD 3.64 ± 1.70, EC 0.78 ± 0.91 and DR 2.65 ±

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1.51. To investigate the relationship between each perfectionism dimension and Eating Behaviors dimensions and total score, Pearson moment-product correlations were

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computed. In general, correlations between SPP and EDEQ-T and its dimensional scores (WSCD, EC, DR) were moderate (r>.30) and significant (p>.001). SOP was also

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significantly correlated with EDEQ-T, WSCD and DR but not with EC and affect dimensions. PA was negatively correlated and NA was positively correlated with

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EDEQ-T and dimensional scores (p>.001). SPP, but not SOP, was significantly

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(Introduce here table 1)

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correlated with PA (r=-.27) and NA (r=.34) (Table 1).

1.3.2. Mean comparisons

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In order to analyze the differences in eating behavior dimensions between groups with distinct perfectionism levels, the total sample was subdivided in three groups based on the MPS dimensions scores, using the cut-off criterion of one standard deviation below and above the mean. Subjects who scored in the SOP measures one standard deviation above the mean (>M+SD; n=45; 17.3%), were considered as having high levels of perfectionism; subject who scored in the SOP one standard deviation below the mean (
ACCEPTED MANUSCRIPT attitudes and behaviors, by groups of perfectionism we applied the One-way ANOVA test, followed by PostHoc tests for specific group’s comparisons.

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(Introduce here table 2)

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Participants with high vs. low SOP and SPP had significantly higher mean scores in

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EDEQ-T, WSCD, EC and DR (all p< .05). In general, results showed that subjects with higher levels of perfectionism particularly with high levels of SPP had more disordered

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eating behaviors. The groups with low total perfectionism had significantly less WSCD, EC and DR when compared with the low and moderate total perfectionism groups

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(MPS – Total score). Similar results were obtained with SPP, as the group with low SSP had less WSCD, EC and DR as well as less NA and more PA. Groups with different

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1.3.3. Linear regression

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levels of SOP did not show significant differences in the dimensional scores.

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To evaluate if SOP and SPP significantly explain the eating behaviors variance a linear regression analysis was applied. Eating behaviors variables EDEQ-T, WSCD, EC and

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DR were taken as dependent variables and all variables showing significant associations with the dependent variables were entered in the models as potential independent variables.

Results indicated that: SPP, PA and NA were significant predictors of EDEQ and jointly explained 22.1% of the total variance of the total score of EDEQ; [R2=.221 / Adjusted R2=.209; F(4, 250)=17.766, p<.001]. SOP, NA and PA were significant predictors of WSCD and jointly explained 17.8% of the total variance of the total score WSCD; [R2=.178 / Adjusted R2=.165; F(4, 251)=13.583, p<.001].

ACCEPTED MANUSCRIPT SPP and NA were predictors of EC and jointly explained 20.6% of the total variance of the total score of EC; [R2=.206 / Adjusted R2=.197; F(3, 254)=22.006, p<.001].

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There was no significant predictors of DR [R2=.079 / Adjusted R2=.064; F(3,

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255)=18.518, p<.001]. (Table 3)

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(Introduce here table 3) 1.3.4. Hierarchic regression

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Controlling for NA/PA, SPP still being a significant predictor of EDEQ-T, [R2=.221 /

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Adjusted R2=.203; F(3, 252)= 22.639, p<.001] and EC [R2=.206 / Adjusted R2=.197; F(3, 254)= 22.006, p<.001], accounting for significant increments of variance (4.0% and

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3.1%, respectively; p<.001) and SOP still being a significant predictors of WSCD

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[R2=.170 / Adjusted R2=.161; F(3, 254)= 17.402, p<.001] (significant increment of

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2.6% of explained variance).

ACCEPTED MANUSCRIPT 1.4. DISCUSSION One of the strengths of the present work is that, to our knowledge, the first to study the

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relationship between perfectionism and disordered eating in overweight women. Other

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strong points include the large sample size, the focus on multidimensional perfectionism

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and the inclusion of positive and negative affect. The weaknesses are that the sample was drawn from a hospital population and thereby may not be representative of

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overweight women in the community and the women evaluated were in different phases of treatment. Related to this, we cannot exclude that higher levels of perfectionism may

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have selected women who are more motivated to seek help. Study results confirm that higher levels of perfectionism are associated with disordered

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eating attitudes and behavior in overweight women. These results are similar to

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previous findings in samples with normal range of weight (Davis, Holland, & Keel, 2014), namely college female students (Macedo et al., 2007; Soares et al., 2009) and

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high school girls (Bento et al., 2010). This information is relevant to a clearer understanding of the relationship between perfectionism and disordered eating behavior

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across a full range of body weight, but also to look at which of the different perfectionism dimensions are predominantly associated with these eating problems. Studies focusing in SOP and SPP suggest that both are associated with AN. In which to other disordered eating the evidence is less strong and mixed. (Bardone-Cone et al., 2007; Lethbridge, Watson, Egan, Street, & Nathan, 2011). Many authors argue for a «maladaptive» dimension of perfectionism, essentially motivated by a morbid inability to tolerate failure, which is associated with emotional distress, and an «adaptive» dimension of perfectionism defined as striving for realistic standards and goals (Terry-Short, Owens, Slade, & Dewey, 1995). In this dichotomy,

ACCEPTED MANUSCRIPT SOP has been considered mostly as adaptive, and SPP as maladaptive (e.g. Hewitt & Flett, 1991; Stoeber & Otto, 2006).

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In contrast with this appealing, but simplistic view, our results provided support for SPP

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as a maladaptive dimension, given its relationship with eating behaviors and EC, being

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in accordance with other studies that have examined the relationship between perfectionism dimensions and bulimic symptoms in non-clinical samples (Hewitt, Flett, & Ediger, 1995; Pearson & Gleaves, 2006).

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However, the findings also demonstrated that SPP is not alone, SOP also proved to be a

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significant predictor of WSCD, even after controlling for affect. These are new results that lead us to think that even in overweight women the SOP dimension could be expressed in life domains, like body image, with negative consequences, showing that it

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was a significant predictor of weight and shape concerns in these women. Thus, overweight women continue to be perfectionists in the domain of weight and body

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image and feel the pressure to have a perfect body (Urquhart & Mihalynuk, 2011), as suggested by Steele et. al. the relation between «benign» perfectionism and ED maybe

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mediated by self-esteem (Steele, Corsini, & Wade, 2007). Though, we should consider that the positivity or negativity of a specific behavior or trait may be context-dependent. Some would argue that a perfectionist driven behavior to be thinner may be helpful in obese individuals, acting as a driving force in the right way (i.e. losing weight). However, we must not forget that this hypothetic «positive» effect of a so-called positive perfectionism may come at some cost, namely higher levels of stress perception and its association with negative affect (Pereira et al., 2014; Macedo et al., 2015). According to the affect regulation model (McCarthy, 1990), people binge eat in an effort to provide comfort and distraction from adverse emotions. Negative affect is a predictor of increase in eating pathology (Stice, 2002) and may act as a precipitant

ACCEPTED MANUSCRIPT factor implicated in dieting loss of control and in the initiation of episodes of excessive eating. Thus, negative affect may counteract any potential positive effect that SOP could

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have in motivating overweight women to lose weight.

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1.5.CONCLUSION

The implications of the findings from the present study are that psychological variables, such as dysfunctional personality traits (eg. negative perfectionism) and negative affect

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should be addressed in nutritional/ weight loss interventions with overweight women in

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order to prevent the development of pathological eating behavior. Further research is warranted in order to examine whether perfectionism dimensions predict change in disordered eating and if perfectionism dimensions are mediators and moderators of

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disordered eating in overweight women. Additionally, it will be also important to

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determine if these findings replicate in males and in more racially diverse samples.

ACCEPTED MANUSCRIPT ACKNOWLEDGE We are deeply grateful to all women who participated in the present study. To personnel

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of nutrition service of Figueira da Foz Hospital we would equally like to thank their

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collaboration

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ACCEPTED MANUSCRIPT Table 1: Pearson Correlation between MPS Total Score and subscales and other variables of

SOP

EDEQ

Total

EDEQ

EDEQ

Positive

F1

F2

F3

Affect

.880**

Socially prescribed perfectionism (SPP)

.798**

.416**

EDEQ Score Total

.304**

.189**

.343**

.267**

.175**

.285**

EDEQ F2 - Eating Concern

.193**

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EDEQ F3 - Dietary Restraint

.240**

Positive Affect

-.137*

Negative Affect

.235**

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Self-oriented perfectionism (SOP)

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EDEQ F1 - Weight and Shape Concern and Dissatisfaction

EDEQ SPP

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MPS

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interest

.912**

.667**

.437**

.81**

.227**

.681**

.447**

NS

-.272** -.267** -.296** -.151*

NS

NS

.337**

.184**

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.303**

.389**

.317**

.261**

.418**

-.335**

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**Correlation is significant at the 0.01 level; *Correlation is significant at the 0.05 level; MPS, Multidimensional Perfectionism Scale; SOP, Self-Oriented Perfectionism; SPP, Socially Prescribed Perfectionism; EDEQ, Eating Disorders Examination Questionnaire.

ACCEPTED MANUSCRIPT Table 2: Mean scores by groups of Perfectionism (MPS)

Low (n=44) M±DP

Medium (n=171) M±DP

Hight (n=45) M±DP

One-Way ANOVA F p

Post Hoc

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Multidimensional Perfectionism Total Score (MPS) 33.65±14.942

EDEQ F2 - Eating Concern

3.22±4.275

6.55±7.177

7.13±8.546

4.496

.012

EDEQ F3 - Dietary Restraint

10.95±7.918

13.11±7.581

16.38±6.879

5.967

.003

EDEQ- Total

39.52±23.877

53.41±23.667

59.27±21.436 8.782

.000

Positive Affect

19.48±6.903

18.09± 6.469

17.24± 6.205

1.360

.259

Negative Affect

18.84±16.907

32.53±22.444

33.31±25.160 7.175

.001

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EDEQ F1 – Weight and Shape 25.34±16.562 Concern and Dissatisfaction

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35.76±13.546 6.566

.002

   



1<2,3 1<2,3 1<3 2<3 1<2,3

1<2,3

Self-Oriented Perfectionism (SOP)

12.13 ± 7.497 12.83 ± 7.89

TE

EDEQ F3 - Dietary Restraint

33.94 ±15.351

D

EDEQ F1 - Weight and Shape 27.37 ± Concern and Dissatisfaction 16.146

33.87 ± 13.416

3.540

.030q

1<2,3

16.06 ± 6.243

4.017

.019d

1<3 2<3

Socially Prescribed Perfectionism (SPP) 33.79±14.560 40.18 ± 11.733

8.729

<.001d 1<2,3

EDEQ F2 - Eating Concern

2.36 ± 3.712

6.67 ± 3.037

9.35 ± 10.822

9.201

<.001d

1<2

EDEQ F3 - Dietary Restraint

11.05 ± 7.637

13.33 ± 7.554 19.12 ± 5.644

7.171

<.001q

EDEQ Score Total

38.39 ± 24.428

53.82±22.978 68.65 ± 17.913

12.834 <.001q

1<2 2<3 1<2,3 2<3

Positive Affect

20.69 ± 6.815

17.92 ±6.403

5.423

Negative Affect

17.49 ± 17.709

32.20±21.904 43.00 ± 28.664

AC

CE P

EDEQ F1 - Weight and Shape 25.00 ± 17.047 Concern and Dissatisfaction

Only significant results are shown; Questionnaire.



LSD;



15.24 ± 4.956

.005q

1>2,3

11.467 <.001d 1<2,3

Tamhane, EDEQ, Eating Disorders Examination

ACCEPTED MANUSCRIPT Table 3: Linear Regression, predictors of EDEQ total score and subscales

Weigh and Shape Concern and Dissatisfaction

EDEQ Total Partial Correlat.

Beta

p

Partial Beta Correlat.

Partial Correlat.

p

Partial Correlat.

Beta

SOP

0.099 0.112

0.1

0.123

0.055

0.121

-

-

-

0.127

0.061

0.118

SPP

0.171 0.011

0.159

0.108

0.117

0.099

0.19

0.002

0.193

0.125

0.087

0.108

NA

0.281 <.001

0.277

0.205

0.001

0.2

0.367 <.001

0.35

0.124

0.064

0.117

PA

-0.124 0.043

-0.127

-0.199

0.002

-0.197

0.036 0.557

0.037

-0.026 0.698

-0.024

IP

p

SC R

p

Dietary Restraint

T

Indep. Beta Variables

Eating Concern

AC

CE P

TE

D

MA

NU

SOP, Self-Oriented Perfectionism; SPP, Socially Prescribed Perfectionism; EDEQ, Eating Disorders Examination Questionnaire. NA, Negative Affect, PA, Positive Affect.

ACCEPTED MANUSCRIPT Highlights Perfectionism related to eating behaviors also in overweight women. Social Prescribed Perfectionism is a predictor of disordered eating.

CE P

TE

D

MA

NU

SC R

IP

T

Self-Oriented Perfectionism is a predictor of Weigh and Shape Concern and Dissatisfaction

AC

-