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Testing the Measurement Invariance of the Body Image Acceptance and Action Questionnaire Between Women With and Without Binge-Eating Disorder Symptomatology: Further Evidence for an Abbreviated Five-Item Version

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Jake Linardon
Jake Linardon
Jake Linardon
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Mariel Messer at Deakin University
Mariel Messer
Sohee Lee at Stanford University
Sohee Lee
Matthew Fuller-Tyszkiewicz at Deakin University
Matthew Fuller-Tyszkiewicz
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Abstract

The Body Image Acceptance and Action Questionnaire (BI-AAQ), a measure designed to assess body image flexibility, was originally developed for and psychometrically investigated with nonclinical populations, but it has been recently administered to people with binge-eating disorder (BED) symptomatology. Tests of measurement invariance are needed to understand whether the BI-AAQ operates in the same way for BED and non-BED populations, thereby ensuring meaningful comparison across these groups. We thus tested the measurement invariance of the BI-AAQ in participants with and without clinically significant BED symptomatology. Data were analyzed from 358 community-based participants. Participants were either classified as with (n = 179) or without (n = 179) "probable BED" based on self-reported symptom frequency. An unacceptable model fit was found across both groups, indicating that the unidimensional structure of the BI-AAQ was not replicated. We then sought to confirm the unidimensional structure of a recently proposed five-item version of the BI-AAQ. A unidimensional structure of this abbreviated version was replicated, and tests of measurement variance were upheld. Internal consistency, convergent validity, and incremental validity were documented for both the original and abbreviated BI-AAQ across individuals with and without BED symptomatology. Present findings provide further psychometric support for an abbreviated five-item BI-AAQ, although it is important for future research to replicate both the full and abbreviated BI-AAQ in more diverse samples. Overall, an abbreviated BI-AAQ may be an attractive alternative for researchers studying body image flexibility. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Testing the Measurement Invariance of the Body Image Acceptance and
Action Questionnaire Between Women With and Without Binge-Eating
Disorder Symptomatology: Further Evidence for an Abbreviated
Five-Item Version
Jake Linardon and Mariel Messer
Deakin University
Sohee Lee
Arizona State University
Matthew Fuller-Tyszkiewicz
Deakin University
The Body Image Acceptance and Action Questionnaire (BI-AAQ), a measure designed to assess body
image flexibility, was originally developed for and psychometrically investigated with nonclinical
populations, but it has been recently administered to people with binge-eating disorder (BED) symp-
tomatology. Tests of measurement invariance are needed to understand whether the BI-AAQ operates in
the same way for BED and non-BED populations, thereby ensuring meaningful comparison across these
groups. We thus tested the measurement invariance of the BI-AAQ in participants with and without
clinically significant BED symptomatology. Data were analyzed from 358 community-based partici-
pants. Participants were either classified as with (n⫽179) or without (n⫽179) “probable BED” based
on self-reported symptom frequency. An unacceptable model fit was found across both groups, indicating
that the unidimensional structure of the BI-AAQ was not replicated. We then sought to confirm the
unidimensional structure of a recently proposed five-item version of the BI-AAQ. A unidimensional
structure of this abbreviated version was replicated, and tests of measurement variance were upheld.
Internal consistency, convergent validity, and incremental validity were documented for both the original
and abbreviated BI-AAQ across individuals with and without BED symptomatology. Present findings
provide further psychometric support for an abbreviated five-item BI-AAQ, although it is important for
future research to replicate both the full and abbreviated BI-AAQ in more diverse samples. Overall, an
abbreviated BI-AAQ may be an attractive alternative for researchers studying body image flexibility.
Public Significance Statement
This study enhances our understanding on the assessment of body image flexibility in binge-eating
disorder. Suggestions for using this measure in an abbreviated form in clinical and nonclinical
populations are provided.
Keywords: body image flexibility, binge eating, eating disorder, psychometric properties
Body image has been thought of as a multidimensional construct
comprised of both positive and negative features with behavioral,
perceptual, and attitudinal components (Smolak & Cash, 2011).
Research has traditionally focused on describing, explaining, and
predicting negative body image in the absence of considering
positive body image (e.g., Cash, 2012;Kearney-Cooke & Tieger,
2015). For example, several theoretical models have garnered
support in understanding precipitating and perpetuating factors of
negative body image, and more recent research demonstrates that
distinct negative components of body image differentially predict
various ill-health outcomes (Linardon, Fuller-Tyszkiewicz, de la
Piedad Garcia, Messer, & Brennan, 2019;Linardon et al., 2018a,
2018b;Lydecker, White, & Grilo, 2017). Such work has helped
inform effective prevention and intervention strategies for negative
body image (Alleva, Sheeran, Webb, Martijn, & Miles, 2015).
However, focusing on minimizing negative body image without
considering how to promote positive body image is a limitation, as
it said to have limited a comprehensive understanding of body
image, and may have prevented the development of more potent
interventions (Tylka & Wood-Barcalow, 2015). Thus, the impor-
This article was published Online First July 25, 2019.
XJake Linardon and Mariel Messer, School of Psychology, Deakin
University; Sohee Lee, Department of Psychology, Arizona State Univer-
sity; Matthew Fuller-Tyszkiewicz, School of Psychology, Deakin Univer-
sity.
Correspondence concerning this article should be addressed to Jake
Linardon, School of Psychology, Deakin University, 221 Burwood, High-
way, Burwood, VIC 3125, Australia. E-mail: jake.linardon@deakin.edu.au
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Psychological Assessment
© 2019 American Psychological Association 2019, Vol. 31, No. 11, 1368–1376
ISSN: 1040-3590 http://dx.doi.org/10.1037/pas0000761
1368
... The BI-AAQ has a unidimensional structure and has consistently yielded reliable scores across a relatively wide range of populations. Internal consistency estimates have fluctuated around 0.90 to 0.95 across samples of college students, men, women, and participants clinically diagnosed with an eating disorder (e.g., Lee et al., 2017;Linardon et al., 2019Linardon et al., , 2020Sandoz et al., 2013;Timko et al., 2014). The BI-AAQ has also passed several tests of convergent and incremental construct validity, with BI-AAQ total scores consistently emerging as a unique predictor of general psychological flexibility/inflexibility, body image, and eating disorder symptoms (Linardon et al., 2020;Sandoz et al., 2013;Timko et al., 2014). ...
... The BI-AAQ has been translated and validated into at least three languages: Portuguese, both in Portugal (Ferreira et al., 2011) andBrazil (Lucena-Santos et al., 2017), Greek (Karekla et al., 2020) and Chinese (He et al., 2021). Overall, the unidimensional factor structure of the BI-AAQ has held, not perfectly, but reasonably well across a diversity of samples that include college students (Sandoz et al., 2013), male and female adults (Linardon et al., 2020), heterosexual women and women with other sexual orientations (Soulliard & Vander Wal, 2022), and participants with eating disorders (e.g., Lee et al., 2017;Linardon et al., 2019). The most common findings across studies that examine the psychometric properties of the BI-AAQ are that the one-factor structure is supported by adequate to excellent fit indices (e.g., Ferreira et al., 2011;Sandoz et al., 2013;He et al., 2020), that in many instances eliminating "item 6" substantively improves fit (e.g., Linardon et al., 2019Linardon et al., , 2020Lucena-Santos et al., 2017), and that multi-group analyses often find weak to strong measurement invariance across disparate samples (e.g., Linardon et al., 2019Linardon et al., , 2020Lucena-Santos et al., 2017). ...
... Overall, the unidimensional factor structure of the BI-AAQ has held, not perfectly, but reasonably well across a diversity of samples that include college students (Sandoz et al., 2013), male and female adults (Linardon et al., 2020), heterosexual women and women with other sexual orientations (Soulliard & Vander Wal, 2022), and participants with eating disorders (e.g., Lee et al., 2017;Linardon et al., 2019). The most common findings across studies that examine the psychometric properties of the BI-AAQ are that the one-factor structure is supported by adequate to excellent fit indices (e.g., Ferreira et al., 2011;Sandoz et al., 2013;He et al., 2020), that in many instances eliminating "item 6" substantively improves fit (e.g., Linardon et al., 2019Linardon et al., , 2020Lucena-Santos et al., 2017), and that multi-group analyses often find weak to strong measurement invariance across disparate samples (e.g., Linardon et al., 2019Linardon et al., , 2020Lucena-Santos et al., 2017). ...
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... Subsequently, the BI-AAQ-5, an abbreviated form of the BI-AAQ, was created by Basarkod et al. [21] using genetic algorithms. Both the comprehensive and shortened versions of the BI-AAQ have exhibited robust psychometric properties when applied to assess clinical and non-clinical samples of adults [11,22,23]. Moreover, translations of the English-language BI-AAQ have been completed for a multitude of languages, such as Mandarin Chinese [24], Greek [25], Portuguese [26], and Spanish [27]. ...
Validation of the Chinese Version of the Body Image Flexibility and Inflexibility Scale among Chinese College Students
Article
Full-text available
  • Oct 2024
Body image flexibility is a specific type of psychological flexibility relevant to body image. The development of the Body Image Flexibility and Inflexibility Scale (BIFIS) expands the concept and structure of body image flexibility and provides more detailed measurement indicators for theoretical research and clinical practice. However, the tool’s applicability to the Chinese population is still unclear. This study aims to test the reliability and validity of the BIFIS among Chinese college students. A total of 1446 Chinese college students were surveyed and completed a series of scales, including the Chinese version of the BIFIS (i.e., C-BIFIS). A total of 99 participants were retested one month later. Confirmatory factor analysis supported the second-order factor structure of the BIFIS. The C-BIFIS showed measurement invariance across genders. The scale also exhibited good internal consistency and test–retest reliability. The higher-order body image flexibility and inflexibility factors were significantly correlated with unidimensional body image flexibility, body satisfaction, body appreciation, intuitive eating, and life satisfaction. Incremental validity tests indicated that two higher-order factors remained unique predictors of intuitive eating and life satisfaction. In conclusion, the Chinese version of the BIFIS has good psychometric properties and could be used to study body image flexibility in Chinese college student populations.
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... The original BIAAQ-12 and the abbreviated BIAAQ-5 showed adequate and excellent model fit, respectively, in the full sample and in men and women (see Table 1). The BIAAQ-5 was retained for subsequent analyses given its superior model fit, which is aligned with previous validation studies (Linardon et al., 2019(Linardon et al., , 2020. ...
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... The Body Image-Acceptance and Action Questionnaire-5 (BI-AAQ-5) [22] was used to evaluate participants' body image flexibility. The BI-AAQ-5 was an abbreviated version of the original version [3] with comparable performance [22,23]. It contained 5 items rated on a 7-point Likert-type scale (1 = never true to 7 = always true). ...
Association between Body Image Flexibility and Intermittent Fasting in Chinese Medical Students: A Cross-Sectional Study
Article
Full-text available
  • Oct 2023
Unhealthy dietary behaviors and body dissatisfaction are becoming increasingly common among college students. Understanding the association between body image flexibility and intermittent fasting is particularly meaningful, especially for medical college students. This study aimed to investigate the association between body image flexibility and intermittent fasting among medical students. We conducted a cross-sectional study with 5138 medical college students at Jitang College of North China University of Science and Technology. Univariate and multivariate logistic regression were used to evaluate the association between body image flexibility and intermittent fasting. Subgroup analysis and interaction tests were further used to examine the possible interaction between body image flexibility and intermittent fasting. In this study, 1329 (25.87%) students had intermittent fasting behavior. After adjustment for confounding factors, there was a negative association between body image flexibility and intermittent fasting (OR = 0.94, 95%CI = 0.93 to 0.95, p < 0.001). A significant interaction between body image flexibility and intermittent fasting was found in gender, academic year, major, and monthly living expenses (p for interaction < 0.05). E-value analysis suggested there was unlikely to be an unmeasured confounding. This association could contribute to the establishment of personalized health intervention strategies and provide recommendations for promoting the physical and mental health of medical students.
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... Based on structural equation modeling, the BI-AAQ-5 performed comparably to the original 12-item version as evidenced by a positive association with self-compassion, and negative associations with body dissatisfaction, weight stigma, internalization of physical appearance norms in society, and poorer mental health. A recent study of the BI-AAQ-5 among women with and without binge eating symptoms supported the BI-AAQ-5′s unidimensional factor structure and psychometric properties (Linardon, Messer, Lee, & Fuller-Tyszkiewicz, 2019). Another study also found support for its unidimensional factor structure and invariance between predominantly White women and men (Linardon, Messer, Lisboa, Newton, & Fuller-Tyszkiewicz, 2020); interestingly, the researchers examined the factor structure of the full version of the BI-AAQ and did not find support for its unidimensional factor structure, further suggesting benefits in using the BI-AAQ-5. ...
Measurement invariance and psychometric properties of three positive body image measures among cisgender sexual minority and heterosexual women
Article
  • Mar 2022
  • BODY IMAGE
Positive body image is a multidimensional construct consisting of various facets including body appreciation, body image flexibility, and functionality appreciation measured via the Body Appreciation Scale-2 (BAS-2), Body Image-Acceptance and Action Questionnaire-5 (BI-AAQ-5), and Functionality Appreciation Scale (FAS), respectively. Research has supported the unidimensional factor structure of these measures; however, invariance testing based on sexual identity has yet to be conducted. The study’s primary aim was to assess the measurement invariance of the BAS-2, BI-AAQ-5, and FAS between sexual minority and heterosexual women. The secondary aim was to assess the psychometric properties of each positive body image measure among each sample. Participants were predominantly White, cisgender women who identified as a sexual minority (n = 310) or heterosexual (n = 360) and completed online questionnaires of positive body image, eating behaviors, and mental and physical health. Results supported invariance with no differences in BAS-2 or BI-AAQ-5 scores. A significant difference with a small effect size was found in FAS scores, with sexual minority women reporting lower FAS scores. Findings supported the BI-AAQ-5 and FAS’s incremental validity on perceived mental health. Overall, results suggest that the BAS-2, BI-AAQ-5, and FAS scores can be compared among women of varying sexual identities.
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Reciprocal associations between intuitive eating and positive body image components: A multi-wave, cross-lagged study
Article
  • Jul 2022
  • APPETITE
Intuitive eating is an adaptive style of eating that has gained substantial research attention. However, possible predictors and outcomes of intuitive eating are poorly understood, as prospective study designs addressing this are missing. Since theoretical research indicates that positive body image might enhance – and be enhanced by – intuitive eating, the present study tested for possible reciprocal associations between three components of positive body image (body appreciation, functionality appreciation, and body image flexibility) and intuitive eating. Adult women (n = 3039) were invited to complete study measures at baseline (T1), four (T2), and eight month (T3) follow-up. Cross-lagged panel analyses were computed to test for possible reciprocal relationships between intuitive eating and positive body image components. Results showed that intuitive eating and both body appreciation and functionality appreciation were reciprocally related. Higher intuitive eating levels at T1 predicted greater increases in these two positive body image components at T2 (and vice versa). Similarly, higher intuitive eating levels at T2 predicted greater increases in these two positive body image components at T3 (and vice versa). Only unidirectional effects were observed between intuitive eating and body image flexibility: higher intuitive eating levels predicted greater increases in body image flexibility at the subsequent time-point. Findings suggest that intuitive eating and certain components of positive body image might serve to enhance each other over time. Intervention strategies designed to cultivate intuitive eating may also result in concomitant improvements in certain indices of positive body image.
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Short forms of the Body Appreciation Scale-2 (BAS-2SF): Item selection and psychometric evaluation
Article
  • Jun 2022
  • BODY IMAGE
The 10-item Body Appreciation Scale-2 (BAS-2; Tylka & Wood-Barcalow, 2015) is a widely used contemporary measure of positive body image that assesses one’s love for, acceptance and appreciation of, and respect for their body. Given the need for abbreviated measures to reduce participant burden and study cost, we aimed to generate a short form of the BAS-2 (BAS-2SF). Two versions of the BAS-2SF emerged: a 3-item version derived deductively from theory (items selected based on their unique contribution to the body appreciation construct), and a 2-item version generated empirically (items selected based on a genetic algorithm approach). Psychometric evidence was garnered across five studies, totaling 3114 participants. Both BAS-2SF versions correlated highly (rs = .93–.97) with the original 10-item BAS-2 and demonstrated internally consistent and stable scores. Factor analyses revealed high item-factor loadings, unidimensionality, and gender invariance of the 3-item BAS-2SF. Correlations with construct validity measures, as well as model pathways, were similar between both BAS-2SF versions and the 10-item BAS-2. BAS-2SF versions also evidenced incremental validity. Both BAS-2SF versions retain the psychometric integrity of the BAS-2 and are recommended for use; however, the 3-item BAS-2SF is an ideal option for researchers who wish to estimate a body appreciation latent factor.
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Screening for Eating Disorders in Adolescents and Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force
Article
Full-text available
  • Mar 2022
Importance: Eating disorders are associated with adverse health and social outcomes. Objective: To review the evidence on screening for eating disorders in adolescents and adults to inform the US Preventive Services Task Force. Data sources: MEDLINE, Cochrane Library, PsycINFO, and trial registries through December 19, 2020; surveillance through January 1, 2022. Study selection: English-language studies of screening test accuracy, randomized clinical trials (RCTs) of screening or interventions for eating disorders in populations with screen-detected or previously untreated eating disorders (trials limited to populations who are underweight were ineligible). Data extraction and synthesis: Dual review of abstracts, full-text articles, and study quality. Meta-analysis of test accuracy studies and intervention trials. Main outcomes and measures: Test accuracy, eating disorder symptom severity, quality of life, depression, and harms. Results: Fifty-seven studies were included (N = 10 773); 3 (n = 1073) limited to adolescents (mean or median age, 14-15 years). No study directly evaluated the benefits and harms of screening. Seventeen studies (n = 6804) evaluated screening test accuracy. The SCOFF questionnaire (cut point ≥2) had a pooled sensitivity of 84% (95% CI, 74% to 90%) and pooled specificity of 80% (95% CI, 65% to 89%) in adults (10 studies, n = 3684). Forty RCTs (n = 3969) evaluated interventions for eating disorders; none enrolled a screen-detected population. Lisdexamfetamine for binge eating disorder (4 RCTs; n = 900) was associated with larger reductions in eating disorder symptom severity on the Yale-Brown Obsessive Compulsive Scale modified for binge eating (YBOCS-BE) than placebo (pooled mean difference, -5.75 [95% CI, -8.32 to -3.17]). Two RCTs (n = 465) of topiramate for binge eating disorder found larger reductions in YBOCS-BE scores associated with topiramate than placebo, from -6.40 (95% CI, -8.16 to -4.64) to -2.55 (95% CI, -4.22 to -0.88). Nine pharmacotherapy trials (n = 2006) reported on harms. Compared with placebo, lisdexamfetamine was associated with higher rates of dry mouth, headache, and insomnia, and topiramate was associated with higher rates of paresthesia, taste perversion, confusion, and concentration difficulty. Twenty-four trials (n = 1644) assessed psychological interventions. Guided self-help for binge eating disorder improved eating disorder symptom severity more than control (pooled standardized mean difference, -0.96 [95% CI, -1.26 to -0.67]) (5 studies, n = 391). Evidence on other interventions was limited. Conclusions and relevance: No studies directly assessed the benefits and harms of screening. The SCOFF questionnaire had adequate accuracy for detecting eating disorders among adults. No treatment trials enrolled screen-detected populations; guided self-help, lisdexamfetamine, and topiramate were effective for reducing eating disorder symptom severity among referred populations with binge eating disorder, but pharmacotherapies were also associated with harms.
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Positive body image, intuitive eating, and self‐compassion protect against the onset of the core symptoms of eating disorders: A prospective study
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  • Oct 2021
Objective Establishing factors that protect against the onset of eating disorder symptoms is needed to identify critical intervention targets to inform the design of more potent prevention programs. Knowledge of robust protective factors is lacking, which might account for the limited effectiveness of existing prevention programs. As positive body image, intuitive eating, and self-compassion show protective potential, the present study tested whether these factors protect against the onset of a range of different eating disorder symptoms. Method Data were analyzed from 1,270 women who completed study measures at baseline and 8 months. Logistic regressions tested whether, among initially asymptomatic women, baseline and changes in positive body image components (body appreciation, body image flexibility, and functionality appreciation), intuitive eating, and self-compassion predicted the continued absence versus onset of seven core eating disorder symptoms at follow-up. Results Each of the five factors at baseline was associated with a lower odds of symptom onset for each outcome in univariate analyses. Baseline body appreciation and intuitive eating scores remained consistent, unique predictors of a lower odds of experiencing symptom onset in multivariate models. Greater increases in intuitive eating and body appreciation over time were the two factors consistently associated with a lower odds of symptom onset across several outcomes. Discussion This study provides strong evidence for the protective influence of positive body image components, intuitive eating, and self-compassion against several eating disorder symptoms. Building these factors within established prevention programs may, in the longer term, help reduce the incidence of eating disorder syndromes and symptoms.
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Confirmatory Validation and Measurement Equivalence of the Eating Loss of Control Scale in Binge Eating and Non-Clinical Samples
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Full-text available
  • Sep 2018
  • J PSYCHOPATHOL BEHAV
Although Loss of Control (LOC) is a transdiagnostic factor in eating pathology, there are few standalone assessments of LOC. The objective of this study was to evaluate the uni-dimensionality and measurement equivalence of the Eating Loss of Control Scale (ELOCS). Confirmatory factor analyses were used to achieve a well-fitting uni-dimensional model in clinical (N = 226) and non-clinical (N = 476) samples. Measurement equivalence was tested in a factor analytic framework, and effect sizes were computed to evaluate the impact of non-equivalence. A well-fitting model was achieved in both samples after the removal of 4 items. The instrument showed configural equivalence but not metric equivalence. Results suggest that the ELOCS is a reliable and valid measure of LOC in clinical and non-clinical samples. However, while the nature of the LOC construct is similar across binge eating and non-clinical participants, comparisons of ELOCS across these groups are affected by measurement non-equivalence. This research also revealed novel insights into the relative sensitivity of model fitting and effect size approaches to investigating measurement equivalence.
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Form and Formulation: Examining the Distinctiveness of Body Image Constructs in Treatment-Seeking Patients With Binge-Eating Disorder
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Objective: Body-image disturbance is a core aspect of eating disorders, yet the clinical manifestations of individuals’ weight and shape concerns are complex, vary considerably, and are poorly understood by clinicians and researchers. This study aimed to distinguish different aspects of body-image disturbance—including weight/shape dissatisfaction, weight/shape overvaluation, weight/shape preoccupation, and fear of weight gain—in patients with binge-eating disorder (BED). Examining how each specific body image construct relates to biopsychosocial features of BED could contribute to the refinement of conceptualization and treatment planning. Method: The current study assessed body-image disturbance and eating-disorder psychopathology in 748 treatment-seeking patients with BED using established investigator-based interviews reliably administered by doctoral clinicians. Results: The 4 body image constructs, although related to one another, showed some important similarities in associations with biopsychosocial clinical features, as well as some important distinctions. The relation between overvaluation and self-esteem was, as conceptualized, more strongly negative than for other body image variables, and preoccupation was more associated than other body image variables with eating concerns. Biopsychosocial features of BED were associated with different forms of body-image disturbance, but associations of body image variables with body mass index (BMI) were not significant and associations with binge-eating frequency did not differ across body image variables. Conclusion: Manifestations of body-image disturbance in BED are complex and understanding the distinctions between different body image constructs can contribute to treatment formulation.
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Meta-analysis of the effects of third-wave behavioural interventions on disordered eating and body image concerns: implications for eating disorder prevention
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  • Oct 2018
  • Cognit Behav Ther
Third-wave behavioural interventions are increasingly popular for treating and preventing mental health conditions. Recently, researchers have begun testing whether these interventions can effectively targeting eating disorder risk factors (disordered eating, body image concerns). This meta-analysis examined whether third-wave behavioural interventions (acceptance and commitment therapy; dialectical behaviour therapy; mindfulness-based interventions; compassion-focused therapy) show potential for being effective eating disorder prevention programs, by testing their effects on eating disorder risk factors in samples without an eating disorder. Twenty-four studies (13 randomized trials) were included. Most studies delivered selective prevention programs (i.e. participants who reported elevated risk factor). Third-wave interventions led to significant pre–post (g = 0.59; 95% CI = 0.43, 0.75) and follow-up (g = 0.83; 95% CI = 0.38, 1.28) improvements in disordered eating, and significant pre–post improvements in body image (g = 0.35; 95% CI = 0.13, 0.56). DBT-based interventions were associated with the largest effects. Third-wave interventions were also significantly more efficacious than wait-lists (g = 0.39; 95% CI = 0.09, 0.69) in reducing disordered eating, but did not differ to other interventions (g = 0.25; 95% CI = –0.06, 0.57). Preliminary evidence suggests that third-wave interventions may have a beneficial effect in ameliorating eating disorder risk.
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A systematic review of the roles of body image flexibility as correlate, moderator, mediator, and in intervention science (2011–2018)
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  • BODY IMAGE
The emergence of body image flexibility into the positive body image nomenclature has innovatively expanded the conceptualization of how individuals may adaptively respond to body image threats. Given the notable growth of interest in researching this construct over nearly the past decade, the present analysis provides a systematic and critical review of evidence examining the roles of body image flexibility as correlate, mediator, moderator, and in intervention research. Results indicated that body image flexibility tended to demonstrate a pattern of relationships with correlates in directions predicted by its conceptualization and showed promise in functioning as both effect modifier and as an explanatory variable in the associations evaluated. Multiple studies demonstrated susceptibility to change following intervention. Although the current state of the literature is bound by notable limitations, the results of this review point to pertinent future steps in advancing the theory and application of body image flexibility scholarship.
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Body image flexibility: A predictor and moderator of outcome in transdiagnostic outpatient eating disorder treatment
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  • Jan 2018
Objective: Predictors of attrition and predictors and moderators of outcome were explored in a transdiagnostic sample of patients who received ten-session cognitive behavioral therapy (CBT-T) for nonunderweight eating disorders. Body image flexibility, a protective positive body image construct, was hypothesized to be a significant moderator. Method: Data from two case series were combined to form a sample of 78 participants who received CBT-T. Baseline measures of body image, negative affect, personality, and motivation (readiness to change and self-efficacy) were included as potential predictors. Global eating disorder psychopathology at each assessment point (baseline, mid- and post-treatment, 1- and 3-month follow-up) was the outcome variable. Predictors of attrition were assessed using logistic regression, and multilevel modeling was applied for predictors and moderators of outcome. Results: Body image flexibility emerged as the strongest predictor and moderator of global eating disorder psychopathology, followed by body image avoidance. Body checking, negative affect, personality beliefs, and self-efficacy were significant predictors of global eating disorder psychopathology. Discussion: Higher body image flexibility predicted lower global eating disorder psychopathology at every assessment point. Further research is required to replicate findings and explore the benefit of focusing on positive body image in treatment.
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Indicators of clinical significance among women in the community with binge‐eating disorder symptoms: Delineating the roles of binge frequency, body mass index, and overvaluation
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  • INT J EAT DISORDER
Objective: This study aimed to investigate the relative contributions of binge eating, body image disturbance, and body mass index (BMI) to distress and disability in binge-eating disorder (BED). Method: A community sample of 174 women with BED-type symptomatology provided demographic, weight, and height information, and completed measures of overvaluation of weight/shape and binge eating, general psychological distress and impairment in role functioning. Correlation and regression analyses examined the associations between predictors (binge eating, overvaluation, BMI), and outcomes (distress, functional impairment). Results: Binge eating and overvaluation were moderately to strongly correlated with distress and functional impairment, whereas BMI was not correlated with distress and only weakly correlated with functional impairment. Regression analysis indicated that both overvaluation and binge eating were strong and unique predictors of both distress and impairment, the contribution of overvaluation to variance in functional impairment being particularly strong, whereas BMI did not uniquely predict functional impairment or distress. Discussion: The findings support the inclusion of overvaluation as a diagnostic criterion or specifier in BED and the need to focus on body image disturbance in treatment and public health efforts in order to reduce the individual and community health burden of this condition.
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The empirical status of the third-wave behaviour therapies for the treatment of eating disorders: A systematic review
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  • Oct 2017
  • CLIN PSYCHOL REV
Although third-wave behaviour therapies are being increasingly used for the treatment of eating disorders, their efficacy is largely unknown. This systematic review and meta-analysis aimed to examine the empirical status of these therapies. Twenty-seven studies met full inclusion criteria. Only 13 randomized controlled trials (RCT) were identified, most on binge eating disorder (BED). Pooled within- (pre-post change) and between-groups effect sizes were calculated for the meta-analysis. Large pre-post symptom improvements were observed for all third-wave treatments, including dialectical behaviour therapy (DBT), schema therapy (ST), acceptance and commitment therapy (ACT), mindfulness-based interventions (MBI), and compassion-focused therapy (CFT). Third-wave therapies were not superior to active comparisons generally, or to cognitive-behaviour therapy (CBT) in RCTs. Based on our qualitative synthesis, none of the third-wave therapies meet established criteria for an empirically supported treatment for particular eating disorder subgroups. Until further RCTs demonstrate the efficacy of third-wave therapies for particular eating disorder subgroups, the available data suggest that CBT should retain its status as the recommended treatment approach for bulimia nervosa (BN) and BED, and the front running treatment for anorexia nervosa (AN) in adults, with interpersonal psychotherapy (IPT) considered a strong empirically-supported alternative.
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