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University of Louisiana at Lafayette, Psychology Department, Girard 202-A, P.O. Box 43131, Lafayette, LA 70504, USA
University of Mississippi, USA
c
Duke University Medical Center, USA
b
art ic l e i nf o
a b s t r a c t
Article history:
Received 1 August 2012
Received in revised form
8 February 2013
Accepted 17 March 2013
Acceptance and mindfulness components are increasingly incorporated into treatment for eating
disorders with promising results. The development of measures of proposed change processes would
facilitate ongoing scientic progress. The current series of studies evaluated one such instrument, the
Body Image-Acceptance and Action Questionnaire (BI-AAQ), which was designed to measure body image
exibility. Study one focused on the generation and reduction of items for the BI-AAQ and a
demonstration of construct validity. Body image exibility was associated with increased psychological
exibility, decreased body image dissatisfaction, and less disordered eating. Study two demonstrated
adequate internal consistency and testretest reliability of BI-AAQ. Study three extended ndings related
to structural and construct validity, and demonstrated an indirect effect of body image dissatisfaction on
disordered eating via body image exibility. Research and clinical utility of the BI-AAQ are discussed. The
BI-AAQ is proposed as a measure of body image exibility, a potential change process in acceptanceoriented treatments of eating disorders.
& 2013 Published by Elsevier Inc. on behalf of Association for Contextual Behavioral Science.
Keywords:
Body image
Psychological exibility
Acceptance
Mindfulness
Eating
Assessment
1. Introduction
A number of cognitive behavior therapies (CBTs) focus on
teaching clients to behave effectively in the presence of disturbing
thoughts and feelings (Hayes, 2004). This is particularly well
suited for clinical populations which tend to be cognitively rigid
(and therefore have thoughts that are difcult to change) or for
whom cognitions are consistent with a preferred self-image
(despite being harmful), such as in eating disorders like anorexia
nervosa. Acceptance and Commitment Therapy (ACT; Sandoz,
Wilson, & DuFrene, 2011), Dialectical Behavior Therapy (DBT; e.
g., Safer, Telch, & Chen, 2009), Mindfulness Based Cognitive
Therapy (MBCT; e.g., Baer, Fischer, & Huss, 2005b), and Mindfulness Based Stress Reduction (MBSR; e.g., Kristeller & Hallet,
1999) have all been adapted for treatment of disordered eating.
Common to each of these approaches is an emphasis on building
awareness and openness toward experience (for example, cues for
hunger and satiation and dissatisfaction with the body) while
replacing automatic or reactive eating behavior with more intentional, committed behaviors.
This emphasis seems to be particularly well suited for treating
disordered eating (see Baer, Fischer, and Huss (2005a), Kristeller,
2212-1447/$ - see front matter & 2013 Published by Elsevier Inc. on behalf of Association for Contextual Behavioral Science.
http://dx.doi.org/10.1016/j.jcbs.2013.03.002
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Table 1
Correlations between body image exibility, psychological exibility, and eatingrelated difculties.
Body image exibility
Study 1
rpartial
Study 3
r
0.48nnn
0.73nnn
0.70nnn
0.69nnn
0.60nnn
0.09
0.30nnn
0.80nnn
0.70nnn
0.61nnn
0.27nnn
Note: Study 1 correlations were calculated after controlling for Body Mass Index.
n
p o0.05, nnp o0.01, nnnp o 0.001..
Fig. 2. Predicated disordered eating from body image dissatisfaction by body image
exibility.
Table 2
Hierarchical regression model predicting disordered eating (EAT-26 total) from body shape dissatisfaction and body image exibility after controlling for BMI.
Std. beta
R2
R2
BMI
0.030
0.391 (0.149)
0.001
0.001
BMI
Body image dissatisfaction
0.184
0.761
3.571 (0.102)
14.750 (0.015)nnnn
0.556
0.555nnnn
BMI
Body image dissatisfaction
Body image exibility
0.184
0.537
0.309
3.743 (0.097)nnnn
7.633 (0.020)nnnn
4.437 (0.041)nnnn
0.601
0.045nnnn
BMI
Body image dissatisfaction
Body image exibility
Body image dissatisfaction body image exibility
0.172
1.121
0.107
0.434
3.591
5.996
0.758
3.357
(0.094)nnnn
(0.054)nnnn
(0.083)
(0.001)nnn
0.626
0.025nnn
44
Table 3
Hierarchical regression equation predicting disordered eating (EAT-26 scores) from body image dissatisfaction and body image exibility.
Std. beta
R2
R2
0.712
16.834 (0.013)nnn
0.507
0.507nnn
0.392
0.401
nnn
5.972 (0.021)
6.104 (0.046)nnn
0.565
0.059nnn
1.417
0.320
0.667
7.910 (0.057)nnn
2.399 (0.094)n
6.093 (0.001)nnn
0.617
0.052nnn
p o 0.05,
nnn
p o0.001.
7.2. Measures
In study two, the Demographic Questionnaire and the twelveitem BI-AAQ developed in study one were included in a packet of
measures of psychological exibility and related constructs (e.g.,
mindfulness). None of the other measures are of interest to the
reliability of the BI-AAQ and will not be described further.
7.3. Procedure
After consenting to participation, participants completed the
battery of 12 brief questionnaires including the Demographic
Questionnaire and 12-item BI-AAQ. This took participants no
longer than 60 mins. Participants returned between two and three
weeks later and completed a shorter battery of three questionnaires including the BI-AAQ. This took participants no longer than
20 min. Participants received a debrieng form upon completion,
providing more detailed information regarding the study's hypotheses and references for supplementary information and mental
health services.
7.4. Study two results
7.4.1. Calculation and descriptive statistics
The distributions of scores were examined for central tendency
and spread. For the rst administration, BI-AAQ scores ranged
from 15 to 84, with a mean of 59.9 and a standard deviation of
17.4. For the second administration, BI-AAQ scores ranged from 22
to 84, with a mean of 63.3 and a standard deviation of 16.1.
Consistent with study one, both distributions were negatively
skewed, indicating a trend toward body image exibility.
7.5. Reliability
7.5.1. Internal consistency
The 12-item version of the BI-AAQ was examined for internal
consistency in both administrations. For the rst administration,
all item-total correlations were over 0.54. Cronbach's alpha was
0.92, and decreased if any one item was deleted. For the second
administration, most item-total correlations were over 0.62, with
one item (If I start to feel fat, I try to think of something else)
correlating with the total 0.39. Cronbach's alpha was 0.93. Cronbach's alpha decreased if any item except this item was deleted, in
which case it stayed the same.
7.2.2. Testretest reliability
The Pearson productmoment correlation between the two
administrations of the BI-AAQ was 0.80 (p o0.01). Correlations
between administrations for individual items ranged from 0.30 for
one item (I will have better control over my life if I can control
45
Table 4
Logistic regression equation predicting eating disorder risk (EAT-2611) from body image exibility and body shape dissatisfaction.
Predictor
Std. beta
SE
Wald's 2
Odds ratio
Constant
0.672
0.127
28.066
N/A
Constant
Body image exibility
5.483
0.096
0.775
0.012
50.057
64.125nnn
N/A
0.908
Constant
Body image exibility
Body image dissatisfaction
2.021
0.036
0.040
1.565
0.016
0.008
1.668
5.384nn
25.158nnn
N/A
0.964
1.041
Constant
Body image exibility
Body image dissatisfaction
Body image exibility body image dissatisfaction
3.087
0.113
0.007
0.001
3.199
0.046
0.026
0.000
0.931
6.018nn
0.069
3.307n
N/A
0.893
0.993
1.001
128.254nnnn
131.179nnnn
6.392
p o 0.10.
p o 0.05.
nnn
po 0.01.
nnnn
p o 0.001.
nn
model, including the body image exibility body image dissatisfaction interaction, was also signicant, 2(2) 128.254,
po 0.001. The full factorial model correctly classied 92.6% of
those with eating disorder risk and 63.6% without, for a total of
72.7% correct classication. Interestingly, body image dissatisfaction was not a signicant predictor once the interaction term was
included.
9. Discussion
The current series of studies attempted to develop and provide
initial psychometric support for a brief self-report measure of
body image exibility, the Body Image-Acceptance and Action
Questionnaire (BI-AAQ). To be useful, such an instrument would
need to demonstrate both that it does, indeed, measure body
image exibility (validity), and that it does so consistently
(reliability).
9.1. Reliability
The twelve-item BIAAQ was found to assess body image
exibility with good reliability between items and administrations. Internal consistency was high (0.920.93) in all four administrations across three different samples. Temporal stability was
good (0.80) for overall BI-AAQ scores.
8.2. Validity
Body image exibility was dened as the capacity to experience
the perceptions, sensations, feelings, thoughts, and beliefs about the
body fully and intentionally while pursuing effective action in other
life domains. Although conceptually, body image exibility could be
distinguished into different capacities (e.g., capacity to experience
body image vs. capacity to pursue effective action), each item was
generated to refer to both acceptance and action. In other words,
the BI-AAQ was intended to measure body image exibility as a
unidimensional construct. Results of principal factor analysis in the
rst study supported the retention of 12 items that loaded on a
single factor with a conservative retention criterion. Studies 2 and
3 replicated a single, highly homogenous factor. Since data were
rst collected for these studies, the item selection and
46
Appendix. BI-AAQ
Directions: Below you will nd a list of statements. Please rate the
truth of each statement as it applies to you. Use the following rating
scale to make your choices. For instance, if you believe a statement is
Always True, you would write a 7 next to that statement.
Never Very
Seldom Sometimes Frequently Almost Always
true seldom true
true
true
always true
true
true
1
47
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