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The Significance of Overvaluation of Shape and Weight in Binge
Eating Disorder
Andrea B. Goldschmidt, M.A.a, Anja Hilbert, Ph.D.b, Jamie L. Manwaring, Ph.D.a, Denise E.
Wilfley, Ph.D.c, Kathleen M. Pike, Ph.D.d, Christopher G. Fairburn, D.M.e, and Ruth H. Striegel-
Moore, Ph.D.f
a Department of Psychology, Washington University, 660 South Euclid Avenue, Campus Box 8134,
St. Louis, MO, 63110, USA; goldscha@psychiatry.wustl.edu (Ms. Goldschmidt);
manwaringj@psychiatry.wustl.edu (Ms. Manwaring)
b Department of Psychology, Philipps University of Marburg, Gutenbergstrasse 18, Marburg,
Germany; hilbert@staff.uni-marburg.de
c Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue,
Box 8134, St. Louis, MO, 63110, USA; wilfleyd@psychiatry.wustl.edu
d Department of Psychology, Temple University Japan Campus, Azabu Hall 6th Floor, Minami-
Azabu 2-8-12, Minato-ku, Tokyo, Japan, 106-0047; pike@tuj.ac.jp
e Department of Psychiatry, Oxford University, Warneford Hospital, Oxford OX3 7JX, England;
credo@medsci.ox.ac.uk
f Department of Psychology, Wesleyan University, 207 High Street, Middletown, CT 06459, USA;
rstriegel@wesleyan.edu
Abstract
As publication of DSM-V draws near, research is needed to validate the diagnostic scheme for binge
eating disorder (BED). Shape and weight overvaluation has stimulated considerable debate in this
regard, given associations with psychosocial impairment and poor treatment outcome in BED. This
study sought to further explore the convergent validity and diagnostic specificity of shape and weight
overvaluation in BED. A total of 160 women with BED, and 108 women with non-eating disordered
psychiatric disorders were recruited from the community. Women with BED were classified as more
or less severe based on a global measure of eating-related psychopathology; subsequent receiver
operating characteristics analysis determined that a threshold of at least “moderate” overvaluation
best predicted membership into a more severe group. BED participants with threshold overvaluation
exhibited poorer psychosocial functioning than those with subthreshold overvaluation, as well as
participants with other psychiatric disorders. Discriminant function analysis revealed that threshold
overvaluation predicted a diagnosis of BED versus other psychiatric disorder with 67.7% accuracy.
Results suggest that shape and weight overvaluation is a useful diagnostic specifier in BED.
Continued research is warranted to examine its predictive validity in natural course and treatment
outcome studies.
© 2009 Elsevier Ltd. All rights reserved.
Address correspondence to: Andrea Goldschmidt, University of Missouri Counseling Center, 119 Parker Hall, Columbia, MO, 65201;
phone: (573) 882-6601; fax: (573) 884-4936; goldscha@psychiatry.wustl.edu.
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Author Manuscript
Behav Res Ther. Author manuscript; available in PMC 2011 March 1.
Published in final edited form as:
Behav Res Ther. 2010 March ; 48(3): 187–193. doi:10.1016/j.brat.2009.10.008.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Keywords
Binge eating disorder; overvaluation of shape and weight; weight and shape concerns; classification
Binge eating disorder (BED) is currently included in the DSM-IV-TR as a provisional diagnosis
requiring further study (American Psychiatric Association, 2000). With the impending
publication of DSM-V, several questions regarding the validity of BED and its diagnostic
criteria remain (Latner & Clyne, 2008; Wilfley, Bishop, Wilson, & Agras, 2007; Wonderlich,
Gordon, Mitchell, Crosby, & Engel, in press). In particular, it has been suggested that
overvaluation of shape and weight be included in BED's diagnostic scheme in DSM-V, given
evidence that it reliably predicts elevated levels of psychosocial impairment (Grilo et al.,
2009; Grilo et al., 2008; Grilo, Masheb, & White, in press; Hrabosky, Masheb, White, & Grilo,
2007; Latner & Clyne, 2008; Mond, Hay, Rodgers, & Owen, 2007). Further research is needed
to establish the clinical utility of this construct in adults with BED.
Overvaluation of shape and weight denotes the undue importance of shape and weight in one's
scheme for self-evaluation (Fairburn, 2008). According to schema theory (Waller, Ohanian,
Meyer, & Osman, 2000) and the cognitive behavioral model of eating disorders (Fairburn,
2008), shape and weight overvaluation refers to higher-order cognitive content reflecting core
negative beliefs about the self (e.g., low self-esteem) that may manifest itself through automatic
negative thoughts or dysfunctional assumptions regarding shape and weight. In contrast to
body dissatisfaction, which may be contingent upon mood or current body size, and shape and
weight concerns, which broadly encompass many aspects of shape- and weight-related
attitudes, overvaluation of shape and weight represents a stable construct that is resistant to
change (P. J. Cooper & Fairburn, 1993; Fairburn, 2008). Indeed, shape and weight
overvaluation appears to be more closely related to changes in self-esteem over time, as
compared to fluctuations in depressive symptoms (P. J. Cooper & Fairburn, 1993; Masheb &
Grilo, 2003), and is at least partially responsible for persistence in bulimic symptoms over time
(Fairburn, Stice et al., 2003). Given evidence that it is typically present in individuals with
eating disorders, regardless of diagnostic group (Fairburn, Cooper, & Shafran, 2003), and
appears to be of critical importance in maintaining these disorders (Fairburn, Peveler, Jones,
Hope, & Doll, 1993; Fairburn, Stice et al., 2003), shape and weight overvaluation is considered
by some, but not all (Slade, 1982; Waller, 2008), investigators to mark the “core
psychopathology” of eating disorders (P. J. Cooper & Fairburn, 1993; Fairburn, 2008; Fairburn
& Garner, 1986). As such, shape and weight overvaluation is currently a diagnostic criterion
for both AN (i.e., “undue influence of body shape and weight on self-evaluation”) and BN (i.e.,
“self evaluation [that is] unduly influence by body shape and weight”; American Psychiatric
Association, 2000).
While recognized as a feature of BN even before the publication of DSM-III (Russell, 1979),
it was not until DSM-III-R that a construct approximating overvaluation of shape and weight
(i.e., “persistent overconcern with body shape and weight”) was included as a diagnostic
criterion for BN (American Psychiatric Association, 1987). DSM-IV's later refinement of this
criterion to the more stringent overvaluation of shape and weight criterion purportedly reflects
that the “critical disturbance is the undue influence of body shape and weight on self-
esteem” (Walsh, 1992). Indeed, this distinction is supported by evidence that overvaluation of
shape and weight discriminates individuals with eating disorders from healthy controls
(Goldfein, Walsh, & Midlarsky, 2000; McFarlane, McCabe, Jarry, Olmsted, & Polivy, 2001),
whereas body dissatisfaction and shape and weight concerns are less discriminating (Garfinkel
et al., 1992; Hadigan & Walsh, 1991).
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Although BED is a relatively new diagnostic entity, a great deal of empirical work has already
focused on the nature of body image disturbance in BED. Individuals with BED report levels
of shape and weight concerns that are commensurate to individuals with AN and BN, and
significantly higher than both normal-weight and overweight individuals without eating
disorders (Eldredge & Agras, 1996; Masheb & Grilo, 2000; Striegel-Moore et al., 2001;
Striegel-Moore, Dohm et al., 2000; Wilfley, Schwartz, Spurrell, & Fairburn, 1997). These
findings have stimulated research into the utility of including overvaluation of shape and weight
in the diagnostic scheme for BED, either as an individual criterion or as a diagnostic specifier
(i.e., a sub-category within a diagnosis that assists with treatment matching and/or prediction
of treatment outcome). Several studies have documented that overvaluation of shape and
weight among individuals with BED is associated with increased psychosocial impairment,
including eating-related and general psychopathology, functional impairments, and
decrements in quality of life (Grilo et al., 2009; Grilo et al., 2008; Grilo et al., in press; Hrabosky
et al., 2007; Mond et al., 2007), as well as treatment-seeking behavior and poorer treatment
response on some measures of outcome (Masheb & Grilo, 2008). Taken together, these findings
suggest that overvaluation of shape and weight is a clinically relevant construct associated with
elevated impairment and distress in BED.
According to research convention, overvaluation of shape and weight is considered to be
clinically significant when shape and weight are at least moderately important in one's scheme
for self-evaluation (Fairburn & Cooper, 1993). However, no research to date has validated the
use of this threshold value, relative to other threshold values, among individuals with eating
disorders. Several studies have demonstrated that individuals with full-syndrome and
subclinical eating disorders are indistinguishable on measures of impairment and distress
(Crow, Agras, Halmi, Mitchell, & Kraemer, 2002; Fairburn et al., 2007; Striegel-Moore, Dohm
et al., 2000; Striegel-Moore, Wilson, Wilfley, Elder, & Brownell, 1998); expounding on these
findings, it is possible that even less extreme overvaluation of shape and weight may
nevertheless be associated with psychopathology and decrements in quality of life. If shape
and weight overvaluation are to be included among BED's diagnostic criteria, it will be
necessary to establish a threshold rating on this construct that is clinically meaningful and
provides useful diagnostic information.
The purpose of the current study is to further examine the utility of including overvaluation of
shape and weight in the diagnostic scheme for BED. Specific aims are to: 1) determine a
threshold value of shape and weight overvaluation that is predictive of a more severe
psychological profile in BED; 2) compare BED participants with threshold shape and weight
overvaluation, BED participants with subthreshold overvaluation, and participants with other
psychiatric disorders on measures of psychosocial and interpersonal functioning, and health
care usage; and 3) examine how well the threshold value discriminates between women with
BED and those with other psychiatric disorders.
Method
Participants
Participants were 268 Caucasian or African-American women (69.8% Caucasian, 30.2%
African-American), aged 18-40 (M = 30.61; SD = 6.16). Participants were recruited from
Connecticut, the Boston area, New York City, and Los Angeles to participate in the New
England Women's Health Project (Striegel-Moore, Wilfley, Pike, Dohm, & Fairburn, 2000),
a community-based study examining risk factors for BED. The sample consisted of 160 women
diagnosed with BED, and 108 women diagnosed with a psychiatric disorder other than an
eating disorder (psychiatric controls; PC). Eight participants (4 from the BED group and 4 from
the PC group) did not respond to questionnaire items assessing overvaluation of shape and
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weight, and thus were excluded from all analyses. The final sample included 156 women with
BED, and 104 PC women. For full sample characteristics, see Table 1.
Procedures
Participants were recruited through community and media advertisements, and the use of
consumer databases. Individuals interested in participating were administered a brief telephone
screen and those who met basic eligibility criteria (i.e., age between 18 and 40; absence of
medical conditions influencing eating behavior or body weight; absence of a psychotic
disorder; being female, of black or white race, and born in the United States) were invited to
complete an in-person assessment. Written informed consent was obtained from all
participants. The study was approved by the IRBs at Wesleyan University and Columbia
University. Detailed descriptions of recruitment and screening procedures are provided
elsewhere (Pike, Dohm, Striegel-Moore, Wilfley, & Fairburn, 2001; Striegel-Moore, Dohm,
Pike, Wilfley, & Fairburn, 2002; Striegel-Moore et al., 2005).
Measures
Structured Clinical Interview for DSM-IV Axis I Disorders—All participants were
given the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID; First, Spitzer,
Gibbon, & Williams, 1997) to ascertain psychiatric diagnoses. The SCID (First et al., 1997) is
a well-established semi-structured interview assessing the full range of psychiatric disorders.
Presence of a comorbid SCID diagnosis was used as a validator in analyses comparing women
with BED reporting threshold and subthreshold overvaluation.
Eating Disorder Examination—Participants meeting diagnostic criteria for BED based on
the SCID were given an abbreviated diagnostic version of the Eating Disorder Examination
(EDE; Fairburn & Cooper, 1993) to confirm the diagnosis. The EDE is a semi-structured,
interviewer-based instrument with established reliability and validity (Z. Cooper, Cooper, &
Fairburn, 1989; Grilo, Masheb, Lozano-Blanco, & Barry, 2004; Rizvi, Peterson, Crow, &
Agras, 2000; Rosen, Vara, Wendt, & Leitenberg, 1990). EDE items assessing weekly
frequency of binge eating episodes (i.e., consumption of an unambiguously large amount of
food accompanied by loss of control over eating) and binge eating-related distress over the
past six months were used as validators in comparisons of women with BED reporting threshold
and subthreshold overvaluation.
Eating Disorder Examination-Questionnaire—For the assessment of eating disorder
psychopathology, all participants completed the Eating Disorder Examination-Questionnaire
(EDE-Q; Fairburn & Beglin, 1994). The EDE-Q is a self-report questionnaire version of the
EDE which generates a global index of eating-related pathology (including items measuring
restraint, eating concern, weight concern, and shape concern). The EDE-Q was used to measure
the independent variable of shape and weight overvaluation. For each participant, individual
items assessing overvaluation of shape and overvaluation of weight (i.e., “Over the past four
weeks, how much has your shape/weight influenced how you think about (judge) yourself as
a person?”) were averaged to form a composite “overvaluation of shape and weight” item;
responses ranged from 0 (not at all) to 6 (markedly). The EDE-Q global severity index was
used to derive more and less severe BED groups for the receiver operating characteristics
analysis. The EDE-Q subscales have demonstrated adequate internal consistency and retest
reliability (Luce & Crowther, 1999; Mond, Hay, Rodgers, Owen, & Beumont, 2004). The
measure has also shown convergent validity with the EDE across both eating disordered and
non-eating disordered samples in the measurement of eating-related attitudes, although the
EDE-Q tends to produce higher ratings across subscales than the EDE (Black & Wilson,
1996; Fairburn & Beglin, 1994; Grilo, Masheb, & Wilson, 2001).
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Brief Symptom Inventory—The Brief Symptom Inventory (BSI; Derogatis, 1991) was
used to assess general psychiatric functioning. The global severity index was included in
validation analyses comparing women with BED exhibiting threshold overvaluation, women
with BED exhibiting subthreshold overvaluation, and PCs. Scores on the BSI were converted
to T-scores ranging from 0 to 100, with higher scores indicating more severe psychiatric
symptoms. The BSI has good internal consistency and is highly correlated with the more
lengthy Symptom-Checklist-90-R (SCL-90-R) across measured domains of psychopathology
(Derogatis, 1991).
Social Adjustment Scale—The Social Adjustment Scale (SAS; Weissman & Bothwell,
1976) was used as a general measure of social functioning in a broad range of domains (e.g.,
role performance, interpersonal relationships, social and leisure activities). The SAS total score
was included in validation analyses comparing women with BED reporting threshold
overvaluation, women with BED reporting subthreshold overvaluation, and PCs. Scores on
the SAS range from 0 to 5, with higher scores indicating poorer social functioning. The SAS
has good reliability and validity (Goldman, Skodol, & Lave, 1992; Weissman, Prusoff,
Thompson, Harding, & Myers, 1978).
Healthcare utilization—Health care utilization was determined by whether participants
reported any participation in therapy/counseling in the year prior to assessment. This variable
was used as a validator in analyses comparing women with BED endorsing threshold
overvaluation, women with BED endorsing subthreshold overvaluation, and PCs.
Statistical Analyses
Preliminary descriptive analyses were conducted using ANOVA and chi-square tests. These
analyses included three groups: women with BED exhibiting threshold overvaluation, women
with BED exhibiting subthreshold overvaluation, and PCs.
In order to determine a threshold value of shape and weight overvaluation that best predicts
higher levels of eating-related psychopathology, women with BED were first categorized as
more or less severe using a median split of the EDE-Q global severity index (median = 3.38).
Next, the EDE-Q overvaluation of shape and weight composite variable was entered into a
receiver operating characteristics (ROC) analysis to determine an optimal value for predicting
membership into the more severe group. The purpose of this analysis was to establish a
clinically significant threshold of shape and weight overvaluation1.
In order to examine the construct validity of clinical overvaluation of shape and weight, first,
a MANCOVA of concurrent variables measuring current psychosocial functioning was
conducted. The BSI global severity index and SAS total score were included as dependent
variables in the MANCOVA, with group (BED threshold, BED subthreshold, PC) as the
independent variable. The model included BMI and race as covariates, given findings that both
of these variables are associated with body dissatisfaction in adults (Allaz, Bernstein, Rouget,
Archinard, & Morabia, 1998; McLaren & Kuh, 2004; Wildes, Emery, & Simons, 2001). Post-
hoc Tukey's honestly significant difference tests were used to examine pairwise differences in
the dependent variables.
1In order to minimize concerns about the overlap between the predictor (i.e., shape and weight overvaluation composite score) and state
(i.e., BED severity status based on EDE-Q global severity index median split) variables in the ROC analysis, an EDE-Q global severity
index was recalculated omitting overvaluation of shape and weight items. There was a high correlation between EDE-Q global severity
indices derived by including and excluding the overvaluation items (r = .99; p < .001). Moreover, ROC analyses yielded the same optimal
shape and weight overvaluation score of 4.5, whether the standard EDE-Q global severity index (i.e., including shape and weight
overvaluation items) or the recalculated EDE-Q global severity index (i.e., excluding shape and weight overvaluation items) was used
to classify a more severe BED group.
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Several additional statistical tests were conducted for further validation. First, a chi-square test
was used to compare the three aforementioned groups (i.e., BED threshold, BED subthreshold,
and PC) on the dichotomous dependent variable of healthcare utilization in the year before
assessment (i.e., whether participants did or did not participate in therapy/counseling in the
previous year). Next, two individual Mann-Whitney U-tests were used to compare women with
BED reporting threshold and subthreshold overvaluation on the dependent variables of EDE-
measured distress and weekly binge eating frequency. PCs were not included in these analyses
since they did not complete the EDE at the baseline assessment visit. Lastly, a separate chi-
square test was used to compare women with BED reporting threshold and subthreshold
overvaluation on the dependent variable of psychiatric comorbidity (i.e., whether participants
received a comorbid SCID diagnosis). PCs were not included in these analyses since all of
these participants had a psychiatric diagnosis, and thus their inclusion would have biased test
results.
Finally, a discriminant function analysis was performed to determine if the threshold value of
shape and weight overvaluation accurately predicts membership into the BED vs. PC group.
Results
Determining a Threshold of Shape and Weight Overvaluation
ROC analysis indicated that in predicting membership into the more severe BED group (i.e.,
those scoring above the median EDE-Q global severity index score; n = 78), the optimal
compromise between sensitivity and specificity was achieved at a score of 4.5 on the
overvaluation of shape and weight composite item (sensitivity = 0.82, specificity = 0.69; see
Figure 1). This score yielded a positive predictive value of 0.73 (i.e., the proportion of
individuals with threshold overvaluation who were classified as belonging to the more severe
BED group) and a negative predictive value of 0.79 (i.e., the proportion of individuals with
subthreshold overvaluation who were classified as belonging to the less severe BED group).
A score of 4.5 indicates that shape and weight are moderately important in one's scheme for
self-evaluation.
Construct Validity of Threshold Overvaluation of Shape and Weight
Demographic Variables—Among women with BED, the majority (n = 88 out of 156;
56.4%) endorsed levels of shape and weight overvaluation at or above the threshold value of
4.5. BED subthreshold women were comprised of a significantly greater proportion of African-
Americans relative to BED threshold and PC women (χ2(2, N = 260) = 25.07; p < .001). There
were also significant group differences in BMI (F(2, 258) = 31.13; p < .001). A post-hoc
Tukey's test indicated that BED threshold and subthreshold women had significantly higher
BMIs than PCs, but did not significantly differ from one another. The three groups did not
differ on age (F(2, 259) = 1.05; p = .35) or education level (χ2(4,N = 260) = 1.45; p = .84). See
Table 2 for a full description of demographic characteristics.
Current Psychosocial Functioning—The full MANCOVA model comparing BED
threshold, BED subthreshold, and PC women on measures of current psychosocial functioning
was significant (F(2, 232) = 13.12; p < .001), as were univariate tests for both BSI (F(2, 232)
= 10.05; p < .001) and SAS total scores (F(2, 232) = 10.53; p < . 001). Post-hoc Tukey's tests
demonstrated that BED threshold women had significantly higher levels of BSI global severity
than BED subthreshold (p < .001) and PC women (p < .001), whereas BED subthreshold and
PC women did not differ from one another (p = .93). Similarly, post-hoc Tukey's tests for SAS
total scores indicated that BED threshold women endorsed higher levels of interpersonal
dysfunction than BED subthreshold (p = .002) and PC women (p < .001), while BED
subthreshold and PC women did not significantly differ (p = .69).
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The chi-square test for healthcare utilization indicated that BED subthreshold women were
relatively less likely to have sought therapy or counseling in the year prior to assessment,
compared to BED threshold and PC participants (χ2(2, N = 246) = 6.14; p < .05), although the
standardized residual for BED subthreshold women fell within the critical values. A Mann-
Whitney U-test indicated that within the BED group, women with threshold overvaluation
reported greater distress over binge eating than those with subthreshold overvaluation (Z(156)
= 4.62; p < .001). The two groups did not differ in frequency of binge eating episodes over the
previous month (Z(156) = 0.65; p = .52). The chi-square test for psychiatric comorbidity
indicated that women with BED who reported threshold overvaluation were also significantly
more likely to have been diagnosed with a lifetime comorbid psychiatric disorder than women
with BED who reported subthreshold overvaluation (χ2(1, N = 156) = 16.53; p < .001), the
most common primary diagnosis being Major Depressive Disorder (n = 41 out of 88; 46.6%).
See Table 2 for group means and test statistics.
Predicting Diagnostic Status
Discriminant function analysis revealed that 67.7% of cases were correctly classified into their
respective diagnostic group (BED vs. PC) based on the overvaluation of shape and weight
cutoff score of 4.5. Specifically, among women reporting threshold levels of shape and weight
overvaluation, 84.6% (n = 88 out of 104) were correctly classified as having BED, versus just
15.4% (n = 16 out of 104) who were classified as PC. Among women with subthreshold
overvaluation of shape and weight, 56.4% (n = 88 out of 156) were correctly classified as PC,
versus 43.6% (n = 68 out of 156) who were classified as BED. The corresponding chi-square
value was highly significant (χ2(1, N = 260) = 43.76; p < .001).
Discussion
The purpose of the current study was to examine the construct and discriminant validity of
overvaluation of shape and weight in a large, community-based sample of women with BED
and other psychiatric disorders. Threshold shape and weight overvaluation was found to be
associated with impaired psychosocial functioning in women with BED, and to significantly
predict diagnosis of BED versus other disorders. Taken together, these findings highlight the
utility of overvaluation of shape and weight in the diagnostic scheme for BED.
Using ROC analysis, we were able to identify a value of shape and weight overvaluation that
best predicted a more severely impaired profile in women with BED. Consistent with research
convention (Fairburn & Cooper, 1993) and with previous studies examining this construct in
BED (Grilo et al., 2008; Grilo et al., in press; Hrabosky et al., 2007; Mond et al., 2007),
overvaluation of shape and weight scores corresponding to at least “moderate” importance of
shape and weight in one's scheme for self-evaluation best predicted a more severely impaired
subset of individuals with BED. Thus, results confirm the use of moderate overvaluation to
denote clinical significance.
Women with BED who endorsed threshold overvaluation reported significantly greater levels
of general psychopathology and social dysfunction than both women with BED who endorsed
subthreshold overvaluation, and women with other psychiatric disorders. Moreover, among
women with BED, those exhibiting threshold overvaluation reported greater levels of distress
related to their binge eating, greater rates of lifetime psychiatric comorbidity, and increased
healthcare utilization relative to those exhibiting subthreshold overvaluation. Threshold and
subthreshold women, however, did not differ with regard to frequency of binge eating, perhaps
reflecting that shape- and weight-related attitudes are less relevant triggers for binge eating
episodes in BED than other psychosocial stressors (e.g., negative affect). Overall, results
suggest that overvaluation of shape and weight is a clinically important construct that may be
a used as a marker of impairment and distress. Grilo and colleagues (2008) have proposed that
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overvaluation of shape and weight may be most useful as a diagnostic specifier in BED (i.e.,
a diagnostic sub-category that can be used to aid treatment planning), rather than as a diagnostic
criterion, the latter of which would exclude a significant portion of otherwise diagnosable
patients who nevertheless experience significant impairment and distress secondary to their
eating disorder. Indeed, in the current study, women with BED reporting subthreshold
overvaluation exhibited commensurate levels of psychosocial impairment relative to the
psychiatric control group, indicating that even without threshold levels of shape and weight
overvaluation, women with BED still demonstrate marked impairment in a range of domains.
Thus, current findings support including shape and weight overvaluation as a specifier rather
than a criterion for the diagnosis of BED. If included as a diagnostic specifier, overvaluation
of shape and weight could assist clinicians in case formulation for individuals with BED.
Discriminant function analysis revealed a modest proportion (15.4%) of PC women who
endorsed threshold levels of shape and weight overvaluation. This likely reflects the relatively
high levels of shape and weight concerns among women in Western societies in general (i.e.,
“normative discontent”; Rodin, Silberstein, & Striegel-Moore, 1985). Alternatively, even
though PCs were screened for the presence of significant eating disorder symptomatology, the
recruitment of a control group with psychiatric diagnoses could have inflated the rates of shape
and weight overvaluation in PC women given the association between disordered eating
attitudes and psychiatric disorders (Jackson & Grilo, 2002; Srebnik et al., 2003). Nevertheless,
future research should explore whether shape and weight overvaluation is related to
psychosocial impairment or poor treatment outcome in individuals with non-eating-related
psychiatric disorders.
Strengths of this study include the large and ethnically diverse sample, and the community-
based study design, which enhances generalizability of the current findings. Further, this was
the first study, to the authors' knowledge, to include a psychiatric comparison group when
examining shape and weight overvaluation, consequently allowing careful investigation of this
variable as a clinically significant construct unique to BED. Limitations include the use of a
self-report questionnaire to assess overvaluation of shape and weight. Further, PC women were
not matched to women with BED on BMI, thus, some of the current findings could be attributed
to increased body weight in women with BED. However, all analyses statistically controlled
for BMI, minimizing such concerns.
Overall, research supports overvaluation of shape and weight as a clinically important construct
in BED. Continued research on overvaluation of shape and weight in BED is warranted in order
to continue to improve intervention and prevention efforts. In particular, future studies should
seek to untangle timing with regards to the onset of shape and weight overvaluation relative
to eating disorder and other psychosocial symptoms. Healthcare providers are advised to assess
overvaluation of shape and weight in patients presenting with BED in order to obtain additional
information on psychosocial functioning, and to inform clinical decision-making. For example,
individuals with BED who exhibit threshold overvaluation may require interventions that
address the full range of psychosocial symptoms, in addition to symptoms of BED, in order
improve overall functioning and treatment outcome.
Acknowledgments
Funding sources for this study include NIH grants T32 HL007456 (Ms. Goldschmidt), K24 MH070446 (Dr. Wilfley),
and MH52348 (Dr. Striegel-Moore), and a supplemental grant from the Office for Research on Women's Health at
NIH. Dr. Fairburn is supported by a Principal Fellowship award from the Wellcome Trust, London (046386).
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Figure 1.
Receiver operating characteristics curve. Note: Receiver operating characteristics curve
predicting membership to the higher severity binge eating disorder subgroup based upon shape
and weight overvaluation mean score.
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Table 1
Full sample characteristics and comparisons between women with binge eating disorder and psychiatric controls on demographic variables (M ± SD, unless
otherwise indicated)
Variable Full Sample
(N = 260)aBED
(n = 156) PC
(n = 104) Test Statistic for
BED vs. PC
Comparison
Age, y 30.62 ± 6.19 31.04 ± 5.79 30.00 ± 6.73 t (258) = 1.29
Body mass index, kg/m231.01 ± 9.48 34.40 ± 9.48 25.96 ± 6.91 t (257) = 8.28*
White 70.4 (183) 62.8 (98) 81.7 (85)
Race, %
(n)Black 29.6 (77) 37.2 (58) 18.3 (19) χ2(1, N = 260) =
10.71*
Education
level, %
(n)
High school or less 20.4 (53) 19.2 (30) 22.1 (23)
Some college 47.7 (124) 50.0 (78) 44.2 (46) χ2(2, N = 260) =
0.85
College graduate or
higher 31.9 (83) 30.8 (48) 33.7 (35)
Note: BED = binge eating disorder; PC = psychiatric control
*p ≤ .001
aExcludes 8 participants missing data on questionnaire items assessing overvaluation of shape and weight
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Table 2
Demographic characteristics and psychosocial functioning of women with BED reporting threshold shape and weight overvaluation, women with BED
reporting subthreshold shape and weight overvaluation, and psychiatric controls (M ± SD, unless otherwise indicated)
Variable BED subthreshold
overvaluation
(n = 68)
BED threshold
overvaluation
(n = 88)
PC
(n = 104) Test Statistic
Demographics
Age, y 31.37 ± 6.28 30.78 ± 5.40 30.00 ± 6.73 F(2, 259) = 1.05
Body mass index, kg/m235.34 ± 9.82a33.66 ± 9.19a25.96 ± 6.91bF(2, 258) = 31.13**
Race, %
(n)†White 47.1 (32/68)a75.0 (66/88)b81.7 (85/104)bχ2(2, N = 260) =
25.07**
Black 52.9 (36/68)a25.0 (22/88)b18.3 (19/104) b
Education
level, %
(n)†
High school or less 22.1 (15/68) 17.0 (15/88) 22.1 (23/104) χ2(4, N = 260) = 1.45
Some college 48.5 (33/68) 51.1 (45/88) 44.2 (46/104)
College graduate or
higher 29.4 (20/68) 31.8 (28/88) 33.7 (35/104)
Psychosocial functioning
Full MANCOVA model --- --- --- F(2, 232) = 13.12**
BSI global severity index 57.56 ± 10.80a64.49 ± 8.93b58.18 ± 10.07aF(2, 236) = 10.05**
SAS total score 1.97 ± 0.48a2.27 ± 0.59b1.90 ± 0.44aF(2, 236) = 10.53 **
Any lifetime comorbid psychiatric
diagnosis, % (n)†66.2 (45/68) 92.0 (81/88) --- χ2(2, N = 156) =
16.53**
Sought therapy/counseling in past
6 months, % (n)†31.7 (19/60)a51.8 (43/83)b47.6 (49/103)bχ2(2, N = 246) = 6.14*
Note: BED = binge eating disorder; PC = psychiatric control; BSI = Brief Symptom Inventory (range = 0 to 100; higher scores indicate more severe psychopathology); SAS = Social Adjustment Scale (range
= 0 to 5; higher scores indicate lower social functioning). Differing superscript letters indicate significant between-group differences.
†Denominator indicates total number of available subjects
*p < .05
**p < .001
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