Understanding "feeling fat" and its underlying mechanisms: The importance of multimethod measurement

Experiential Avoidance During Mealtimes Among Individuals With Eating Disorders

The relationship between negative emotions and avoidance is widely theorized as a bidirectional cycle implicated in a range of psychopathology. Historically, research on this cycle has examined one type of negative emotion: anxiety. Yet, a broader range of internal experiences may be implicated in the maintenance of unhealthy avoidance cycles in psychopathology. This study examines prospective relationships among anxiety, guilt, physical discomfort, and experiential avoidance during mealtimes for individuals with eating disorders (EDs). Participants (N = 108) completed ecological momentary assessments four times a day for 25 days. We computed multilevel models to examine between- and within-person effects of negative emotions and physical discomfort on experiential avoidance. When including guilt and anxiety in one model, guilt, but not anxiety, explained the significant variance in experiential avoidance at the next meal. Mealtime physical discomfort and experiential avoidance evidenced reciprocal prospective relationships. Future research should test whether interventions targeting experiential avoidance and physical discomfort at mealtimes disrupt guilt.

A naturalistic examination of feeling fat: Characteristics, predictors, and the relationship with eating disorder behaviors

OBJECTIVE

Although literature implicates feeling fat in the maintenance of binge-spectrum eating disorders (EDs; e.g., bulimia nervosa, binge-ED), research in this area is small, nascent, and relies on retrospective self-report. The current study sought to understand the temporal pattern of feeling fat and its role as a precipitant and consequence of ED behaviors.

METHODS

Totally 106 treatment-seeking adults with binge-spectrum EDs completed 7-14-day ecological momentary assessments. They rated feeling fat, negative affect states, and reported on ED behaviors six times per day. Multilevel models evaluated whether feeling fat mediates prospective links between negative affect states and ED behaviors, assessed if negative affect states mediate the prospective association of feeling fat on ED behaviors, and examined the bidirectional prospective association between feeling fat and ED behaviors.

RESULTS

Feeling fat was highest in the early morning (6-8:59 a.m.). Individuals with binge-ED-spectrum EDs demonstrated greater variability in feeling fat than those with bulimia nervosa-spectrum EDs who had stable and high levels of feeling fat. Guilt, sadness, anxiety, and the overall NA at Time 2 mediated the prospective associations between at Time 1 feeling fat and Time 3 dietary restraint, actual dietary restriction, and compensatory exercise. There was a bidirectional prospective association between feeling fat and binge eating.

DISCUSSION

Feeling fat serves as a proximal predictor and mediator of the prospective association between guilt and binge eating. Feeling fat and binge eating mutually reinforce each other.

PUBLIC SIGNIFICANCE

Little is understood regarding the experience of feeling fat in natural environments among individuals with binge-spectrum eating disorders. We found that the risk for having the experience of feeling fat is high in the morning and evening. Feeling fat triggers guilt, anxiety, and sadness which in turn, increases engagement in dietary restraint/restriction and compensatory exercise. Feeling fat also triggers binge eating, and binge eating leads to feelings of fatness.

Perceptual Dysfunction in Eating Disorders

Eating disorders (EDs) are characterized by abnormal responses to food and weight-related stimuli and are associated with significant distress, impairment, and poor outcomes. Because many of the cardinal symptoms of EDs involve disturbances in perception of one's body or abnormal affective or cognitive reactions to food intake and how that affects one's size, there has been longstanding interest in characterizing alterations in sensory perception among differing ED diagnostic groups. Within the current review, we aimed to critically assess the existing research on exteroceptive and interoceptive perception and how sensory perception may influence ED behavior. Overall, existing research is most consistent regarding alterations in taste, visual, tactile, and gastric-specific interoceptive processing in EDs, with emerging work indicating elevated respiratory and cardiovascular sensitivity. However, this work is far from conclusive, with most studies unable to speak to the precise etiology of observed perceptual differences in these domains and disentangle these effects from affective and cognitive processes observed within EDs. Further, existing knowledge regarding perceptual disturbances in EDs is limited by heterogeneity in methodology, lack of multimodal assessment protocols, and inconsistent attention to different ED diagnoses. We propose several new avenues for improving neurobiology-informed research on sensory processing to generate actionable knowledge that can inform the development of innovative interventions for these serious disorders.

The roles of negative affect and emotion differentiation in the experience of 'feeling fat' among undergraduate students: An ecological momentary assessment study

'Feeling fat' is the somatic experience of being overweight not fully explained by objective body mass. According to the body displacement hypothesis, 'feeling fat' occurs when diffuse negative emotions are projected onto the body in lieu of adaptive emotion regulation. Emotion differentiation, the ability to experience and label discrete emotions, is an important skill for adaptively addressing emotion that may reduce 'feeling fat.' We hypothesized that individuals with better negative emotion differentiation would be less likely to report 'feeling fat' when experiencing high negative emotion. We collected ecological momentary assessment data from 198 undergraduate students (52.24% female). Multilevel modeling revealed that both within-person increases in negative emotions and the tendency to experience greater negative emotion were associated with greater 'feeling fat.' Of the specific types of negative emotion, guilt and sadness predicted 'feeling fat.' Contrary to hypotheses, individuals with better emotion differentiation were more likely to report 'feeling fat' after experiencing elevated negative affect. These findings contradict the primary clinical conceptualization of 'feeling fat,' suggesting that factors beyond displacement of negative emotions onto the body may be responsible for 'feeling fat'. Results in a sample with pronounced shape/weight concern may better support the traditional clinical understanding of 'feeling fat.'

Exposure to thin and non-thin bodies elicits 'feeling fat': Validation of a novel state measure

'Feeling fat' refers to the subjective experience of carrying excess weight and relates to severity of eating pathology. Despite research suggesting that 'feeling fat' fluctuates across contexts, this construct is almost exclusively assessed in terms of frequency or as a trait. Examining state 'feeling fat' in response to external stimuli can inform us of the nature of this construct. In an experimental study, 290 community women were exposed to five categories of affective (pleasant, aversive, and neutral) and body (thin and non-thin) images in quasi-random order. Self-Assessment Manikin (SAM) valence and arousal rating scales as well as a novel SAM 'feeling fat' scale were rated for each image. Theoretically-relevant constructs (i.e., trait 'feeling fat', thin-ideal internalization, body dissatisfaction, eating pathology) were also measured. Body images elicited greater state 'feeling fat' than affective images, with images of non-thin bodies producing higher state 'feeling fat' than thin bodies. Positive correlations were observed between state 'feeling fat' in response to thin and all variables of interest, whereas associations between these variables and 'feeling fat' in response to non-thin images were small or non-significant. The development of a state measure of 'feeling fat' allows for the investigation of triggers of this bodily experience and will facilitate future research.

The structure of eating disorder and somatic symptoms

Individuals with eating disorders (EDs) often present with somatic concerns in treatment, such as bloating, fullness, and feeling tight clothes on skin. However, most research generally focuses on general interoception (e.g., heartbeat) rather than sensations relevant to EDs (e.g., sensations related to the gastrointestinal system or body movement). In the current study (N = 181), we used network analysis to model the structure of ED symptoms and somatic concerns among individuals with anorexia nervosa, bulimia nervosa, and other specified feeding and eating disorder. Results showed that heightened sensitivity to somatic concerns had the highest strength centrality within a symptom network comprising ED and somatic symptoms. Exploratory graph analysis identified four symptom dimensions: cognitive-affective ED symptoms, behavioral ED symptoms, general interoception, and ED-specific proprioception. Findings suggest that heightened sensitivity to somatic concerns may maintain ED symptoms and mutually reinforce other somatic concerns. Implications concerning assessment and treatment of EDs are discussed.

Exploring the contributions of affective constructs and interoceptive awareness to feeling fat

PURPOSE

Feeling fat, a subjective feeling of being overweight that does not always correspond to actual body weight, is commonly reported in patients with an eating disorder. Research suggests that feeling fat relates to deficits in interoceptive awareness, the perception and integration of signals related to body states. Relatedly, recent work has linked feeling fat to affective constructs, such as depressive symptoms and guilt. The current study explores the unique relationships between feeling fat, self-reported, and objective IA, guilt, alexithymia, and depressive symptoms.

METHOD

Female undergraduates (N = 128) completed the 11th item of the Eating Disorder Examination Questionnaire, the Toronto Alexithymia Scale, the Guilt subscale of the Positive and Negative Affect Schedule, and the Beck Depression Inventory-II. Participants also completed two IA measures: a heartbeat perception task and the Multidimensional Assessment of Interoceptive Awareness.

RESULTS

All collected measures explained 56% of the variability in feeling fat. Depressive symptoms, self-reported IA, and BMI accounted for significant variability in feeling fat. Relative weights analyses revealed that depressive symptoms accounted for the most variability in feeling fat (19%). This finding remained significant after controlling for BMI, which also accounted for significant variability in feeling fat (25%).

CONCLUSIONS

Our results replicate previous findings that depressive symptoms relate significantly to feeling fat and extend this work by incorporating the role of interoceptive awareness, guilt, and alexithymia. Endorsement of feeling fat during an intake assessment may alert clinicians to assess for depressive symptoms, and focusing on depressive symptoms in treatment may improve feeling fat.

LEVEL OF EVIDENCE

Level I Evidence obtained from an experimental study.

Conceptualizing eating disorder recovery research: Current perspectives and future research directions

BACKGROUND

How we research eating disorder (ED) recovery impacts what we know (perceive as fact) about it. Traditionally, research has focused more on the "what" of recovery (e.g., establishing criteria for recovery, reaching consensus definitions) than the "how" of recovery research (e.g., type of methodologies, triangulation of perspectives). In this paper we aim to provide an overview of the ED field's current perspectives on recovery, discuss how our methodologies shape what is known about recovery, and suggest a broadening of our methodological "toolkits" in order to form a more complete picture of recovery. BODY: This paper examines commonly used methodologies in research, and explores how incorporating different perspectives can add to our understanding of the recovery process. To do this, we (1) provide an overview of commonly used methodologies (quantitative, qualitative), (2) consider their benefits and limitations, (3) explore newer approaches, including mixed-methods, creative methods (e.g., Photovoice, digital storytelling), and multi-methods (e.g., quantitative, qualitative, creative methods, psycho/physiological, behavioral, laboratory, online observations), and (4) suggest that broadening our methodological "toolkits" could spur more nuanced and specific insights about ED recoveries. We propose a potential future research model that would ideally have a multi-methods design, incorporate different perspectives (e.g., expanding recruitment of diverse participants, including supportive others, in study co-creation), and a longitudinal course (e.g., capturing cognitive and emotional recovery, which often comes after physical). In this way, we hope to move the field towards different, more comprehensive, perspectives on ED recovery.

CONCLUSION

Our current perspectives on studying ED recovery leave critical gaps in our knowledge about the process. The traditional research methodologies impact our conceptualization of recovery definitions, and in turn limit our understanding of the phenomenon. We suggest that we expand our range of methodologies, perspectives, and timeframes in research, in order to form a more complete picture of what is possible in recovery; the multiple aspects of an individual's life that can improve, the greater number of people who can recover than previously believed, and the reaffirmation of hope that, even after decades, individuals can begin, and successfully continue, their ED recovery process.

Body image as a multidimensional concept: A systematic review of body image facets in eating disorders and muscle dysmorphia

Body image disturbance is core to the psychopathology of eating disorders (EDs), and related disorders such as muscle dysmorphia (MD). Global measures of body image fail to quantify specific aspects of body image disturbance that characterizes EDs, and may be differentially associated to outcomes. The aim of this systematic review was to provide an overview of specific body image facets and synthesize findings from controlled studies that compared clinical ED/MD and control-comparison groups in body image disturbance. One-hundred sixty-seven studies met inclusion criteria, and reported on comparisons among 30,584 individuals in 28 body image facets, which were more broadly grouped into evaluative, perceptual, cognitive-affective and motivational categories for the purpose of the present review. Effect sizes were calculated as Cohen's d for every comparison between ED and control groups. Body dissatisfaction (evaluative category) was the most prevalent facet assessed across studies (62 %), and differences between clinical and control groups were the largest in this category, especially for bulimia nervosa (d = 1.37). Scarcity of studies with male and MD clinical samples, and use of single-item and non-validated measures, should encourage development of instruments for body image facets pertinent to EDs and MD that can be validly applied across gender.

Relationships between paranoia and body image concern among community women

Previous research has indicated that lifetime body image concerns are associated with increased odds of paranoid ideation. In this study, we sought to replicate and extend this finding by exploring how paranoia relates to different aspects of body image concern using a comprehensive, cross-sectional design. Women without a mental health diagnosis (n = 119) completed online questionnaires assessing paranoia, shape and weight concerns, and figure ratings for how they "think" their body looks and how they "feel" in their body. Participant's "actual" figure ratings were estimated from height and weight; discrepancy scores were then calculated for "actual-think" and "actual-feel" figure ratings. Correlational analyses, and mediation models testing paranoia as a mediator between "actual-feel" and shape and weight concerns, were conducted. Paranoia was significantly correlated with increased shape and weight concerns, and with "feeling" larger. Paranoia significantly mediated paths from feeling larger to increased shape or weight concerns. There were no significant associations of paranoia with "actual-think" ratings. Limitations include that height and weight data could not be objectively confirmed, and only women were included in the study. Further research is needed to understand mechanisms by which paranoia may influence shape and weight concerns and vice versa, and how "feeling" larger may feed paranoia. Future research should investigate these relationships among clinical eating disorder groups.

'Feeling fat' amid the COVID-19 pandemic: Examining the role of emotion dysregulation in the body displacement hypothesis

'Feeling fat,' the somatic experience of being overweight not entirely explained by objective weight, may occur due to the projection of negative affect onto the body. Individuals may manage 'feeling fat' via eating pathology (e.g., binge eating or dietary restriction) rather than address the source of negative affect. Thus, 'feeling fat' may occur in the absence of adaptive emotion regulation strategies. The COVID-19 pandemic has increased negative affect widely and may potentially contribute to the experience of 'feeling fat' and eating pathology among individuals with emotion dysregulation. This study examined whether emotion dysregulation moderates 'feeling fat's' role as a mechanism underlying the relationship between COVID-19-related distress and eating pathology. This uniqueness of this model to eating pathology was investigated by comparing effects for binge eating and dietary restriction versus anxiety, depression, and problematic alcohol use. Structural equation modelling was used to analyze questionnaire data from 877 participants (77.3% women). 'Feeling fat' explained significant variance in the relationship between COVID-19-related distress and both binge eating and restriction. Emotion dysregulation modulated the strength of these relationships. However, 'feeling fat's role in the relationship between pandemic-related distress and negative psychological outcomes was not unique to eating pathology and did not vary based upon emotion dysregulation. Individuals with elevated emotion dysregulation are more likely to report eating pathology, but not other outcomes, in the context of 'feeling fat'. In contrast, 'feeling fat' underlies the relationship between COVID-19-distress and transdiagnostic psychological outcomes, meaning 'feeling fat' should be considered in risk for psychopathology beyond eating disorders.

Exploring the role of feeling fat in individuals categorized with bulimia nervosa, binge-eating disorder and overweight/obesity

PURPOSE

Despite featuring in prominent theoretical models, the role of "feeling fat" in certain eating and weight disorder presentations remains poorly understood. This study compared levels of feeling fat between people categorized with referable bulimia nervosa (BN) symptoms, binge-eating disorder (BED) symptoms, and overweight/obesity, and examined the unique associations of feeling fat on measures of eating pathology and functional impairment within each of these subgroups.

METHODS

Data were analyzed from 977 participants who met criteria referable to BN symptoms (n = 419), BED symptoms (n = 346), or overweight/obesity without ED psychopathology (n = 212) based on self-report symptom frequency.

RESULTS

Analysis of variance revealed that feeling fat levels were highest in the referable BN group, followed by the referable BED group, and then the overweight/obese subgroup. Multiple regressions revealed that feeling fat contributed additional variance to functional impairment and key cognitive (e.g., eating concerns) and behavioural (e.g., dietary restraint) symptoms only among those who met criteria referable to BN.

CONCLUSION

Overall, findings suggest that the experience of feeling fat may be an important component of body image particularly among individuals with BN-type symptoms. Present findings may also have implications for the assessment and treatment of feeling fat among different eating and weight disorder presentations.

LEVEL OF EVIDENCE

Cross-sectional descriptive study, Level V.

Extending the scope of the interpersonal psychotherapy model of eating disorders: Integrating the role of 'feeling fat'

The interpersonal psychotherapy model of eating disorders (IPT-ED) argues that interpersonal problems result in negative affect, and that an inability to cope with this negative affect triggers ED symptoms. Relatedly, it is theorized that 'feeling fat' (i.e., the somatic experience of being overweight not entirely explained by one's body mass) results from shifting negative affect onto one's body, which can then be controlled via ED symptoms. Research has yet to identify why negative affect caused by interpersonal problems may trigger ED symptoms as opposed to other maladaptive behaviours. Integrating 'feeling fat' into the IPT-ED may help to explain this relationship. This study examined whether interpersonal problems positively related to ED symptoms via negative affect and 'feeling fat' in 190 undergraduate women (mean age [SD] = 19.05 [1.23]; mean BMI [SD] = 21.76 [3.17]; 72.8% Caucasian). Using both cross-sectional and longitudinal path analyses, we tested the indirect effects of ostracism and peer victimization on binge eating and restricting via negative affect and 'feeling fat' using serial indirect effects analyses. Cross-sectional path analysis revealed significant indirect effects of ostracism on both binge eating and restricting sequentially via negative affect and 'feeling fat', such that ostracism related to negative affect, which related to 'feeling fat', which was ultimately associated with disordered eating behaviours. Longitudinal path analysis replicated the significant indirect effects of ostracism on binge eating sequentially via negative affect and 'feeling fat'. Results suggest that individuals may displace negative feelings that result from ostracism onto their body, triggering 'feelings of fatness' and prompting ED symptoms. Future research should examine 'feeling fat' within the IPT-ED in a sample of individuals with EDs to determine its clinical utility beyond an undergraduate sample.

Manipulating the sensation of feeling fat: The role of alexithymia, interoceptive sensibility and perfectionism

OBJECTIVE

Feeling fat reflects difficulties in processing emotions and is an important aspect of body image and eating disorders. The current study aimed to develop a novel social comparison manipulation to induce feeling fat and to explore personality traits that may increase an individual's vulnerability.

METHODS

At time 1254 healthy females (24.14 years, BMI = 23.77) completed the feeling fat subscale of the Body Attitudes Questionnaire, as well as self-report measures of alexithymia, interoceptive sensibility, physical appearance comparison and perfectionism online.

RESULTS

Greater tendency to feel fat was significantly associated with difficulty identifying and describing feelings (alexithymia), poorer interoceptive sensibility, higher socially-prescribed perfectionism, and greater engagement in physical appearance comparisons. At time 2, a subset of 107 participants (22.39 years, BMI = 23.85) were randomly assigned to a condition: negative social comparison, positive social comparison, negative general, or neutral (as a control). Participants in the negative social comparison condition reported significantly greater increases in feeling fat compared to the control condition, but only when they were also high in alexithymia or socially-prescribed perfectionism.

DISCUSSION

Current findings provide new insights into the potential mechanisms underpinning feeling fat and highlight how a novel social comparison manipulation can be used to induce the sensation of feeling fat.