Associations between body checking and disordered eating behaviors in nonclinical women

Examining the momentary relationships between body checking and eating disorder symptoms in women with anorexia nervosa

Body checking is common among individuals with anorexia nervosa (AN) and increases risk for dietary restriction. However, no study has examined whether body checking increases the immediate risk for engaging in other harmful weight loss behaviors, or whether this relationship is moderated by person-level traits. The current study utilized ecological momentary assessment (EMA) to examine whether (a) body checking predicted rapid use of weight loss behaviors, and (b) whether eating-related obsessionality/compulsivity moderated this relationship. Women with full or subthreshold anorexia nervosa (N = 118) completed a measure of eating-related obsessionality/compulsivity at baseline, followed by a 14-day EMA protocol during which they reported on body checking and weight loss behaviors (i.e., exercise, self-induced vomiting, laxative use, skipping meals, and increasing fluid intake). In a series of generalized linear mixed models, within-person effects indicated that momentary body checking significantly predicted subsequent meal skipping and using fluids to curb appetite. Between-person effects indicated that individuals who engage in more frequent body checking also engage in a higher frequency of self-induced vomiting, meal skipping, and use of fluids to curb appetite. An individual's degree of eating-related obsessionality/compulsivity did not moderate any of these relationships. Findings highlight body checking as an immediate precursor of dangerous weight loss behaviors among individuals with AN, and underscore the need for clinicians to address body checking during treatment.

Revisiting the Postulates of Etiological Models of Eating Disorders: Questioning Body Checking as a Longer-Term Maintaining Factor

Body checking (BC) is not only inherent to the maintenance of eating disorders but is also widespread among healthy females. According to etiological models, while BC serves as an affect-regulating behavior in the short term, in the longer term it is assumed to be disorder-maintaining and also produces more negative affect. The present study therefore aimed to empirically examine the proposed longer-term consequences of increased BC. In an online study, N = 167 women tracked their daily amount of BC over a total of 7 days: Following a 1-day baseline assessment of typical BC, participants were asked to check their bodies in an typical manner for 3 days and with a 3-fold increased frequency for 3-days. Before and after each BC episode, the impact of BC on affect, eating disorder symptoms, general pathology and endorsement of different functions of BC was assessed. Participants showed longer-term consequences of increased BC in terms of increased negative affect and general pathology, while eating disorder symptoms remained unaffected. In the case of typical BC, participants showed decreased general pathology and anxiety. Furthermore, the endorsement of a higher number of BC functions led to increased negative affect and an increased amount of typical BC. The findings support the theoretically assumed role of maladaptive BC in maintaining negative emotion in the longer term. However, though requiring replication, our finding of positive effects of typical BC calls into question the overall dysfunctionality of BC among non-clinical women who are not at risk of developing an eating disorder.

Predicting the restrictive eating, exercise, and weight monitoring compulsions of anorexia nervosa

PURPOSE

Compulsions surrounding restrictive eating, exercise, and weight monitoring are thought to maintain abnormal eating behaviour in individuals with anorexia nervosa (AN). This study aimed to determine if AN psychopathology and trait anxiety explain the presence of restrictive eating, exercise, and weight monitoring compulsions in a mixed sample.

METHODS

Participants were 31 females with AN and 31 age and gender-matched healthy individuals (HC). Restrictive eating, exercise and weight monitoring compulsion presence was compared between AN and HC groups. Multivariable poisson regression analyses, adjusted for diagnostic status, were conducted to assess the association of both AN psychopathology and trait anxiety with compulsions across the mixed group.

RESULTS

Individuals with AN endorsed a greater number of restrictive eating, exercise and weight monitoring compulsions compared to HC. In adjusted poisson regression analyses neither AN psychopathology nor trait anxiety predicted compulsion presence: incidence rate ratio (IRR) for AN psychopathology = 1.15 [95% CI 0.84, 1.57], p = 0.39; IRR for trait anxiety = 1.01 [95% CI 0.97, 1.06], p = 0.50.

CONCLUSIONS

Greater presence of restrictive eating, exercise and weight monitoring compulsions was reported by individuals with AN, supporting the conceptualisation of disorder behaviours as compulsive. The study was underpowered to robustly evaluate the association between predictors of interest and the compulsions outcome, largely owing to the small sample size. Further investigation is required, ideally using methods able to identify causal and mediation effects.

LEVEL OF EVIDENCE

Level V, cross-sectional study.

Factor structure and psychometric properties of the Spanish version of the Body Image Avoidance Questionnaire (BIAQ)

PURPOSE

The main objective of this study was to analyse the factor structure and psychometric properties of a Spanish validation of the Body Image Avoidance Questionnaire (BIAQ) in a community sample of adolescents.

METHODS

A total of 4283 people (55.9% girls, aged 12-18) participated.

RESULTS

Confirmatory factor analysis corroborated four first-order factors related to a second-order factor including the total BIAQ score, with excellent fit and invariance across sex. The total internal consistency of the questionnaire was adequate, although two factors showed low reliability. Strong relationships were found with scales evaluating preoccupation with weight and dysmorphic concerns, and moderate correlations with dissatisfaction and investment in appearance. It was found that 24.06% of adolescents with body image disturbance could be at risk of developing a body image disorder.

CONCLUSIONS

The results of this study support the use of the Spanish translation of the BIAQ for assessing behavioural characteristic of body image disturbance.

LEVEL OF EVIDENCE

V, cross-sectional descriptive study.

Racial differences in overeating, loss of control eating, and binge eating: Extending core tenets of the Cognitive Behavioral Theory of Eating Disorders

PURPOSE

The present study examined racial differences in associations among body dissatisfaction, body checking, and dietary restraint relative to overeating, loss of control eating, and binge eating outcomes among college women.

METHOD

Young adult women (N = 903) at three Mid-Atlantic US institutions completed measures assessing negative body image and eating pathology via an online survey. Structural equation modeling was used to test a model examining associations among body dissatisfaction, body checking, dietary restraint, and disinhibited eating behaviors. Multigroup analyses examined whether these associations differed for women who identified as White (n = 432) versus Black (n = 359).

RESULTS

More frequent body checking explained associations between elevated body dissatisfaction and more frequent use of all three disinhibited eating outcomes for White and Black women, whereas restraint solely mediated an association between body dissatisfaction and overeating. The assessed constructs generally operated in a similar manner across racial groups. However, stronger associations among body dissatisfaction, restraint, and overeating, and between body checking and loss of control eating were identified for women who identified as White versus Black.

CONCLUSIONS

Eating disorder programming efforts targeting body checking behavior may prove useful in decreasing White and Black women's disinhibited eating.

Gender Dysphoria, Eating Disorders and Body Image: An Overview

Background::

Gender dysphoria is a clinical condition in which a state of inner suffering, stress and anxiety is detected when biological sex and a person's gender identity do not coincide. People who identify themselves as transgender people are more vulnerable and may have higher rates of dissatisfaction with their bodies which are often associated with a disorderly diet in an attempt to change the bodily characteristics of the genus of birth and, conversely, to accentuate the characteristics of the desired sexual identity.

Aim::

The purpose of this work is to examine the association between dissatisfaction with one's own body and eating and weight disorders in people with gender dysphoria.

Results::

Gender dysphoria and eating disorders are characterized by a serious discomfort to the body and the body suffers in both conditions. The results of our study suggest that rates of pathological eating behaviors and symptoms related to a disordered diet are high in patients with gender dysphoria and that standard screening for these symptoms must be considered in both populations at the time of evaluation and during the course of the treatment.

Conclusions::

In light of this evidence, clinicians should always investigate issues related to sexuality and gender identity in patients with eating disorders, to develop more effective prevention measures and better strategies for therapeutic intervention..

How do you feel when you check your body? Emotional states during a body-checking episode in normal-weight females

PURPOSE

Cognitive-behavioral theories posit that body checking decreases negative emotions, but increases levels of arousal. However, few studies have investigated the effects of body checking on the course of emotional states. Therefore, the current study examined how normal-weight females with higher and lower eating, weight, and shape concerns feel during a checking episode of their most-liked and least-liked body parts.

METHODS

In an online design, levels of negative emotions and arousal were retrospectively assessed before, during, immediately after, and 15 min after an individually remembered body-checking episode. Participants (N = 355) also rated their subjective satisfaction with specific body parts.

RESULTS

Levels of negative emotions were lower 15 min after the checking episode of most-liked and least-liked body parts than before the episode. However, negative emotions increased during the checking episode of least-liked body parts, but subsided thereafter. The levels of arousal increased during the checking episodes of most-liked and least-liked body parts and decreased afterwards, and females with higher concerns reported greater levels of arousal than females with lower concerns. Furthermore, females with higher concerns reported more body checking than those with lower concerns.

CONCLUSIONS

The results support the assumptions of the cognitive-behavioral theories, as body checking led to a decrease in negative emotions in the longer term, and levels of arousal increased during the checking episode. The greater levels of arousal in females with higher concerns, and their pronounced body-checking behavior, might enhance their existing concerns and increase the risk of disordered eating.

LEVEL OF EVIDENCE

Level V, descriptive study.

The influence of gender and body dissatisfaction on body-related attentional bias: An eye-tracking and virtual reality study

OBJECTIVE

In the attentional bias (AB) phenomenon, eating disorder (ED) patients show a tendency to pay more attention to self-attributed unattractive body parts than to other body parts. However, little research has focused on gender differences in body-related attention, controlling for body dissatisfaction (BD). This study aimed to assess gender differences in AB toward specific weight- or nonweight-related body parts using a virtual reality (VR)-based embodiment technique and an eye-tracking AB assessment.

METHOD

Forty-five women (23 with high BD and 22 with low BD) and 40 men (20 with high BD and 20 with low BD) were subsequently embodied in three virtual avatars, the first based on the participant's actual measurements, the second being larger than the participant, and the third being the same as the first avatar. The number of fixations and complete fixation time on weight-related areas of interest (W-AOIs) and nonweight-related areas of interest (NW-AOIs) were recorded for the three assessment time/avatars.

RESULTS

The results showed a statistically significant interaction between gender and time for total fixation time and number of fixations (p < .05). BD levels did not significantly affect the results. Overall, women paid more attention to the W-AOIs than men, who in turn paid more attention to the NW-AOIs. Furthermore, preliminary evidence was found for an AB toward muscular-related AOIs among men.

CONCLUSIONS

This study provides new information about gender differences and BD in gaze pattern behaviors. Future psychological ED assessments and treatments could take advantage of the possibilities of VR while real-time AB is objectively measured.

Disentangling relations between the desirability of the thin-ideal, body checking, and worry on college women's weight-loss dieting: A self-regulation perspective

The study used self-regulation theory to elucidate the relationships between the desirability of the thin-ideal goal, dispositional worry, body checking and weight-loss dieting (WLD) in college women. We hypothesized that body checking would mediate the relationship between the desirability of the thin-ideal goal and WLD: the desire to be thin would be associated with more WLD through more frequent body checking. We also hypothesized that dispositional worry would moderate this mediation pathway, such that the mediation pathway would be stronger for those higher in worry. Finally, all effects were expected to occur when controlling for self-reported body size. A paper and pencil survey was conducted on a convenience sample of 237 college women who completed measures of: thin-ideal desirability, dispositional worry, body checking, WLD, as well as providing height and weight. A bootstrap analysis using PROCESS (Hayes, 2013) supported the hypothesized moderated mediation model. Findings add to current knowledge by elucidating the nature and function of body checking, and by so doing may provide insight into the prevention and treatment of disordered eating.

Psychometric Properties of the Body Checking Questionnaire (BCQ) and of the Body Checking Cognitions Scale (BCCS): A Bifactor-Exploratory Structural Equation Modeling Approach

This research sought to assess the psychometric properties of the French versions of the Body Checking Questionnaire and the Body Checking Cognitions Scale among community samples. A total sample of 922 adolescents and adults was involved in a series of two studies. The results from the first study supported factor validity and reliability of responses obtained on these two measures, and showed that both measures were best represented by a bifactor-exploratory structural equation modeling representation of the data. The results from the second study replicated these conclusions, while also supporting the measurement invariance of the bifactor-exploratory structural equation modeling solution and the equivalence of the correlations among the two measures (i.e., convergent validity) across samples. This second study also supported the criterion-related validity of ratings on both measures with measures of global self-esteem, physical appearance, social physique anxiety, fear of negative appearance evaluation, and disturbed eating attitudes and behaviors. Finally, the results of this last study also supported the measurement invariance and lack of differential item functioning of both measures in relation to sex, age, diagnosis of eating disorders, and body mass index.

Gender Differences in Affective and Evaluative Responses to Experimentally Induced Body Checking of Positively and Negatively Valenced Body Parts

Body checking (BC) is defined as behavior aimed at gaining information on body shape, size, or weight. Besides its occurrence as a transdiagnostic symptom in eating disorders (EDs), BC is widespread in non-clinical populations. It is associated with body dissatisfaction and the development of body image disturbances and ED. Males and females differ in terms of body dissatisfaction and associated BC strategies. However, the question of a gender-related intensity of negative affect and state body satisfaction as reactions to BC remains open. Therefore, the present experimental study aimed to examine gender differences in affective and evaluative responses to BC. We tested n = 60 women and n = 60 men in a crossover design, implementing two experimental conditions and one control condition. In the negative body checking condition (NBC), participants received standardized instructions to check negatively valenced body parts. In the positive body checking condition (PBC), by contrast, participants were asked to check positively valenced body parts. The control condition (CBC) consisted of playing a computer game. Before and after checking of one’s own body, participants rated negative body-related affect, i.e., guilt, shame, and disgust, and state body satisfaction. The results indicate that both NBC and PBC led to an increase in negative affect for men and women. Eating pathology predicted negative affect after checking in NBC for both genders. Men reported a significantly higher state body satisfaction in all conditions, whereas only women showed decreased body satisfaction in NBC. These findings suggest that BC of any body part (i.e., positively or negatively valenced) leads to increased negative affect for both genders. Eating pathology significantly influences the affective responses to BC for both genders. Changes in state body satisfaction, however, only occur in females. An explanation might be that men generally report higher body satisfaction, resulting in a more stable body image. Females and males with pathological eating behavior seem to be more vulnerable to changes in negative affect. As negative affect is equally increased after NBC and PBC for both genders, BC might play a central role in the maintenance of body image disturbances in males and females.

The Mediating Effect of Specific Social Anxiety Facets on Body Checking and Avoidance

Objective: Body checking (BC) and avoidance (BA) form the behavioral component of body image disturbance. High levels of BC/BA have often been documented to hold a positive and potentially reinforcing relationship with eating pathology. While some researchers hypothesize, that patients engage in BC/BA to prevent or reduce levels of anxiety, little is known about the mediating factors. Considering the great comorbidity between eating disorders (ED) and in particular social anxieties, the present study investigated whether socially relevant types of anxiety mediate the relationship between eating pathology and BC/BA.

Methods: 83 participants reporting an eating disorder and 323 healthy participants (14–25 years) took part in an online survey. Eating pathology was measured with the Eating Disorder Examination Questionnaire and Body Checking and Avoidance Questionnaire. Trait and social anxiety were assessed by means of the State Trait Anxiety Inventory (STAI-T), the Fear of Negative Evaluation (FNE) and the Social Appearance and Anxiety Scale (SAAS). Separate mediation analyses were carried out with eating pathology as independent variable, BC/BA as dependent variable and STAI, FNE, and SAAS as mediating variables.

Results: Anxieties correlated highly positive with eating pathology in both groups. SAAS mediated the relationship between ED pathology and BC/BA in participants with ED and mediated the relationship between ED pathology and BA in healthy participants. FNE mediated the relationship between eating pathology and BA for participants with eating pathology.

Discussion: SAAS mediated the relationship between eating pathology and BC/BA. Being afraid of bodily evaluations may represent a particular relevant fear that triggers safety behaviors.

Body Covering and Body Image: A Comparison of Veiled and Unveiled Muslim Women, Christian Women, and Atheist Women Regarding Body Checking, Body Dissatisfaction, and Eating Disorder Symptoms

Although Islam is the fastest growing religion worldwide, only few studies have investigated body image in Muslim women, and no study has investigated body checking. Therefore, the present study examined whether body image, body checking, and disordered eating differ between veiled and unveiled Muslim women, Christian women, and atheist women. While the groups did not differ regarding body dissatisfaction, unveiled Muslim women reported more checking than veiled Muslim and Christian women, and higher bulimia scores than Christian. Thus, prevention against eating disorders should integrate all women, irrespective of religious affiliation or veiling, with a particular focus on unveiled Muslim women.

Effects of the exposure to self- and other-referential bodies on state body image and negative affect in resistance-trained men

Previous body image research suggests that first, exposure to body stimuli can negatively affect men's body satisfaction and second, body concerns are associated with dysfunctional gaze behavior. To date, however, the effects of self- vs. other-referential body stimuli and of gaze behavior on body image in men under exposure conditions have not been investigated. Therefore, 49 weight-trained men were presented with pictures of their own and other bodies of different builds (i.e., normal, muscular, hyper-muscular) while being eye-tracked. Participants completed pre- and post-exposure measures of body image and affect. Results indicated that one's own and the muscular body negatively affected men's body image to a comparable degree. Exposure to one's own body also led to increased negative affect. Increased attention toward disliked own body parts was associated with a more negative post-exposure body image and affect. These results suggest a crucial role of critical self-examination in maintaining body dissatisfaction.

Enhancing empowerment in eating disorder prevention: Another examination of the REbeL peer education model

Previously validated eating disorder (ED) prevention programs utilize either a targeted or universal approach. While both approaches have shown to be efficacious, implementing either style of program within a school setting remains a challenge. The current study describes an enhanced version of REbeL, a module based, continuous ED prevention program which utilizes a self-selection model of prevention in high school settings. The purpose of this study was to determine if an enhanced empowerment model of REbeL could increase feelings of empowerment and reduce eating disorder risk. We also aimed to assess the feasibility and acceptability of the intervention. High school peer-educators self-selected into the semi-manualized dissonance based intervention. Following feedback from a pilot trailed, enhanced peer-led group activities, designed to critique the thin ideal and designed to empower macro-changes in societal structures that emphasize the thin ideal, were added. The study (N=83) indicates that the program appears to be effective at reducing eating disorder risk factors and increasing empowerment. Participants reported reductions in body checking and internalization of the thin ideal.

Psychometric properties of the Body Checking Questionnaire in college women

While the Body Checking Questionnaire (BCQ; Reas et al., 2002) is the most commonly-used measure of body checking behaviors, findings on the factor structure in nonclinical samples are mixed. This study investigated the factor structure and psychometric properties of the BCQ among nonclinical college women. In Study 1 (n=326), an exploratory factor analysis indicated factors corresponding to (a) behavioral and (b) visual checking. In Study 2 (n=1013), a confirmatory factor analysis revealed adequate fit for these factors, better than the original or total score solutions. Scales based upon the two factors demonstrated good internal consistency, convergent validity with measures of eating pathology, and sensitivity for detecting at-risk eating pathology. Results suggest an alternate two-factor solution that differs from the original three-factor solution.

The influence of social anxiety on the body checking behaviors of female college students

Social anxiety and eating pathology frequently co-occur. However, there is limited research examining the relationship between anxiety and body checking, aside from one study in which social physique anxiety partially mediated the relationship between body checking cognitions and body checking behavior (Haase, Mountford, & Waller, 2007). In an independent sample of 567 college women, we tested the fit of Haase and colleagues' foundational model but did not find evidence of mediation. Thus we tested the fit of an expanded path model that included eating pathology and clinical impairment. In the best-fitting path model (CFI=.991; RMSEA=.083) eating pathology and social physique anxiety positively predicted body checking, and body checking positively predicted clinical impairment. Therefore, women who endorse social physique anxiety may be more likely to engage in body checking behaviors and experience impaired psychosocial functioning.

Body checking and body image avoidance: construct validity and norms for college women

The current study explored the prevalence of body checking and body image avoidance behaviors in a large sample of undergraduate women (N=1011). The factor structures of two relevant measures, the Body Checking Questionnaire and the Body Image Avoidance Questionnaire, were compared with factor structures proposed by the development studies. Subscales are described, and the influence of race on responses examined. Results suggest these scales are valid in White and African American samples with a modified factor structure. Findings can inform clinical and research use of these measures, although additional experimental research is needed.

An initial psychometric evaluation and exploratory cross-sectional study of the body checking questionnaire among Brazilian women

Body checking is considered an expression of an excessive preoccupation with appearance. The first aim of this study was to evaluate the psychometric properties of a Brazilian Portuguese version of the Body Checking Questionnaire (BCQ). Additionally, we wanted to examine the questionnaire’s associations with body avoidance behaviour, body mass index, dietary habits, and the intensity, frequency, and length of physical exercise. Finally, we also examined the differences between the total BCQ score and the individual BCQ factor scores. Differences between active and sedentary persons and between non-dieters and those on weight-loss diets were also analyzed. For the psychometric study, 546 female public university students from four different courses were surveyed. Two minor samples of university students and eating disorders women were also recruited. In the second part of the study, 403 women were recruited from weight-loss programs, gyms, and a university. All participants were verbally invited to participate in the research and voluntarily took part. Confirmatory factor analysis showed a good fit to the original model of the Brazilian BCQ that retained all 23 items. Satisfactory evidence of construct validity and internal consistency were also generated through analysis of factor loadings, t-values, Cronbach’s alpha, and construct reliability tests. The results also showed associations among body checking and body avoidance, body satisfaction, social anxiety, body mass index, and the frequency and intensity of physical exercise. Significant differences were found between non-dieters and weight-loss dieters for all BCQ factors and the total BCQ score. For physically active and sedentary persons, a significant difference was only observed for idiosyncratic checking behaviour. In conclusion, the BCQ appears to be a valid and reliable scale for Brazilian research, and the associations and differences found in this study suggest that women at gyms and especially in weight-loss programs should be targeted for future body checking studies.

Body checking and avoidance in ethnically diverse female college students

Although body checking and avoidance behaviors are common in women with eating disorders, minimal research has examined the nature or correlates of these behaviors in ethnically diverse female college students without eating disorders. Self-identified European American (n=268), Asian American (n=163), Latina (n=146), and African American (n=73) women completed self-report measures of body checking and avoidance, thin-ideal internalization, eating pathology, and clinical impairment. Results indicated that European and Asian American women reported significantly more body checking and avoidance than African American and Latina women. Generally, correlates of body checking and avoidance were consistent across ethnic groups: Regression analyses indicated that type of ethnicity predicted body checking and avoidance; and ethnicity, body checking, and body avoidance predicted eating pathology and clinical impairment. These associations suggest that body checking and avoidance are not benign behaviors in diverse nonclinical women.

A naturalistic examination of body checking and dietary restriction in women with anorexia nervosa

Body checking has been conceptualized as a behavioral manifestation of the core overvaluation of eating, shape, and weight concerns underlying eating disorder psychopathology. Cognitive-behavioral theories suggest that body checking behaviors may function to maintain dietary restriction. The current study examined the association between body checking frequency and dietary restriction among women with anorexia nervosa (AN) in the natural environment. Women (N = 118) with full or partial AN completed baseline clinical interviews and a two-week ecological momentary assessment protocol, during which they reported on body checking behaviors (i.e., checking whether one's thighs touch; checking joints/bones for fat) and dietary restriction (i.e., 8 waking hours without eating; consuming less than 1200 calories per day). Average daily body checking frequency was positively associated with baseline eating disorder symptoms and body mass index. Daily body checking frequency was associated with both forms of dietary restriction on the same day, as well as the following day. Results support the theorized association between body checking and overvaluation of shape and weight, and suggest that targeting such behaviors in treatment may have utility in reducing dietary restriction.

Body checking and avoidance in women: associations with mental and physical health-related quality of life

Body checking and body avoidance have demonstrated clinical significance in a number of populations. However, the associations between these behaviors and mental and physical health-related quality of life have not been examined. This study investigated the associations between body checking and avoidance and quality of life in 214 community women. Body checking and body avoidance were significantly correlated with mental and physical quality of life, as well as with eating disturbances. Frequency of body checking significantly predicted impairment in mental quality of life, and frequency of body avoidance significantly predicted impairment in physical quality of life, over and above the contributions of depressive symptoms and related demographic characteristics. Targeting checking and avoidance in prevention and treatment programs may improve quality of life and reduce health-related functional impairment.