Abstract
Feeling fat and fear of weight gain are key cognitive-affective symptoms that are theorized to maintain eating disorders (EDs). Little research has examined the dynamic relationships among feeling fat, fear of weight gain, emotions, cognitions, and ED behaviors. Furthermore, it is unknown if these relations vary by ED diagnosis (e.g., anorexia nervosa (AN) vs other ED). The current study (N=94 ED participants; AN n=64) utilized ecological momentary assessments collected four times a day for 18 days (72 timepoints) asking about feeling fat, fear of weight gain, emotions (i.e., anxiety, guilt), cognitions (i.e., feelings of having overeaten, thoughts about dieting), and ED behaviors (i.e., vomiting, diuretic/laxative use, excessive exercise, body checking, self-weighing, binge-eating, restriction) at stressful timepoints (contemporaneous [mealtime], and prospective/temporal [next-meal]). Multilevel modeling was used to test for between and within-person associations. Higher feeling fat and fear of weight gain independently predicted higher next-meal emotions (i.e., anxiety, guilt), cognitions (i.e., feelings of having overeaten, thoughts about dieting, fear of weight gain, feeling fat), and ED behaviors (i.e., body checking, self-weighing [feeling fat]). There were relationships in the opposite direction, such that some emotions, cognitions, and ED behaviors prospectively predicted feeling fat and fear of weight gain, suggesting existence of a reciprocal cycle. Some differences were found via diagnosis. Findings pinpoint specific dynamic and cyclical relationships among feeling fat, fear of weight gain, and specific ED symptoms, and suggest the need for more research on how feeling fat, fear of weight gain and cognitive-affective-behavioral aspects of ED operate. Future research can test if treatment interventions targeted at feeling fat and fear of weight gain may disrupt these cycles.
Keywords: eating disorders, anorexia nervosa, feeling fat, fear of weight gain, cognitive-affective symptoms, ecological momentary assessment
1. Introduction
Eating disorders (ED) carry one of the highest mortality rates of all psychiatric illnesses, with up to a 50% relapse rate, and often co-occur with dysfunctional cognitive-affective processes (Arcelus et al., 2011; Ralph-Nearman & Filik, 2018; Ralph-Nearman et al., 2021; Walsh et al., 2021). The transdiagnostic theory of EDs uniquely conceptualizes similar underlying cognitive (overvaluation of weight/shape and their control) and affective (anxiety, guilt) mechanisms of eating disorder pathology which drive ED behaviors (vomiting, diuretics/laxative use, excessive exercise, body checking, self-weighting, binge eating, restriction) and ED severity (Fairburn et al., 2003). Many studies point toward impaired cognitive-affective mechanisms, such as the experience of feeling fat (i.e., bodily experience of being overweight), and the fear of weight gain (i.e., intense fear of rapidly gaining significant amounts of weight and associated negative consequences), underlying the development and/or maintenance of an ED (Anderson et al., 2022; Levinson et al., 2020). Individuals with an ED diagnosis may utilize ED compensatory behaviors such as vomiting, exercise, and weighing, as well as binge eating, to regulate or escape intense negative cognitive-mediated emotions and distress (e.g., Engel et al., 2013; Lavender et al., 2015). Guilt and anxiety are particularly salient distressful emotions in EDs, as guilt has been implicated as a central feature of EDs (Levinson et al., 2022; Sanftner et al., 1995), and anxiety co-occurs in ≥85% of individuals diagnosed with EDs (Galmiche et al, 2019). Importantly, feeling fat and fear of weight gain are two very common, but distinct cognitive-affective symptoms and key ED diagnostic criteria (Linardon et al., 2018a; Stice et al., 2021), which suggests greater insight is needed on how these understudied cognitive-affective symptoms operate across time.
1.1. Feeling Fat.
Feeling fat is widely discussed in Cognitive-Behavioral Therapy (CBT) theoretical models of EDs, such as the Transdiagnostic Theory (Fairburn et al., 2003), which proposes that feeling fat is an expression that arises from placing an overemphasis upon one’s weight or shape and intensified ED behaviors and symptoms (Messer & Linardon, 2022). Feeling fat affects individuals with and without a clinical ED diagnosis (Mehak & Racine, 2021), but is highest in individuals diagnosed with an ED (Fairburn, 2008). Further, a cross-sectional study found that feeling fat is an independent mechanism from body-related concerns and body dissatisfaction (Linardon et al., 2018a). Specifically, feeling fat had significant unshared variance with body-related concerns (i.e., weight and shape over-evaluation) and affective symptoms, supporting that it is a unique construct.
Feeling fat may not be explained by objective body mass index, but is an interoceptive feeling of carrying extra weight (Messer & Linardon, 2022). Feeling fat is not related to larger objective body mass index (BMI), but lower levels of feeling fat at baseline and 6-month follow-up have been shown to be associated with attaining a normal BMI (≥18.5) for individuals diagnosed with AN (Calugi et al., 2018). Furthermore, higher feeling fat at baseline predicts slower BMI percentile improvements over time for adolescents with AN (Calugi & Dalle Grave, 2019), and is related to negative emotions and distress (Cooper et al., 2007). In CBT-E, patients learn that the experience of feeling fat fluctuates while their actual body weight remains relatively stable across treatment (Mehak & Racine, 2021). Over the course of treatment, patients are also taught to identify emotions and physical sensations often misinterpreted as feeling fat. Thus, feeling fat is not merely an expression of overvaluation with shape and weight but a maintainer of these ED symptoms.
Feeling fat may be the mislabeling of intense negative bodily experiences or emotions, such as depression or disgust. Recent research supports this idea, finding that depression makes up a unique amount of variance of feeling fat and that depression prospectively predicts higher feeling fat (Fairburn et al., 2003; Levinson, et al., 2020; McGregor et al., 2020). However, feeling fat has rarely been investigated in prospective or causal models and therefore there is very little evidence-based research investigating feeling fat in relation to emotions, cognitions, and ED behaviors. For example, the one experimental study to date found, in a nonclinical sample, that high body checking behaviors were associated with temporary, possibly contemporaneous (i.e., occurring within the same measurement window), increases in feelings of fatness, body dissatisfaction, and self-critical thoughts, with only low body checking behaviors associated with non-significant decreases in feelings of fatness (Shafran et al., 2007). As up to 100% of individuals diagnosed with an ED endorse feelings of fatness (Levinson et al., 2020), more research on prospective associations between feeling fat and cognitions, emotions, and ED behaviors is needed.
1.2. Fear of weight gain.
Fear of weight gain is a core feature of EDs and an indicator of ED severity, particularly in AN (American Psychiatric Association [APA], 2013). There is also support for fear of weight gain as a maintaining ED symptom in bulimia nervosa (BN; e.g., Carter & Bewell-Weiss, 2011; Levinson et al., 2017). One cross-sectional study reported that after accounting for the variance of other common body-related concerns (i.e., both dissatisfaction, over-evaluation of weight and shape, and body preoccupation) fear of weight gain was the strongest predictor of AN illness severity (Linardon et al., 2018b). Fear of weight gain is also a primary feature included in ED models, such as the Transdiagnostic Theory for EDs (Fairburn et al., 2003). Fears around weight gain may lead to negative affect, such as guilt and anxiety, and ED behaviors (e.g., restriction, vomiting, etc.) may then serve to temporarily relieve these distressing emotions and cognitions (Fairburn et al., 2003; Lavender et al., 2013; Zerwas et al., 2013). Data shows that decreasing fear of weight gain is pivotal in decreasing ED behaviors, such as dietary restraint in clinical samples during treatment, and is also implicitly linked to drive for thinness in AN (Calugi et al., 2018). Similar to feeling fat, fear of weight gain is a unique cognitive-affective mechanism that is highly prevalent (Linardon et al., 2018a). Specifically, fear of weight gain is endorsed within 73.6 percent of women in community samples (Slof-Op’t Landt et al., 2017), though it is especially heightened in individuals with an ED. For instance, fear of weight gain has been shown to be endorsed more in individuals with ED than the fear of public speaking; the most commonly endorsed human fear (Brown & Levinson, 2022).
1.3. AN vs Other ED.
Overall, feeling fat and fear of weight gain are considered transdiagnostic maintaining factors of EDs (Fairburn et al. 2003), and may be related differently to AN compared with other-ED diagnoses (Stice et al., 2021). However, in individuals with an AN diagnosis, more intense fear of weight gain is significantly related to heightened illness severity (e.g., Santonastaso et al., 2009; Thomas et al., 2009). Fear of weight gain is most often examined in AN, but may also be a key maintaining symptom in binge eating spectrum EDs, such as BN and BED (Levinson et al., 2017; Manasse et al., 2022; Wang et al., 2019). Fear of weight gain has been shown to be predictive of the onset of AN and is a diagnostic feature of AN, while both fear of weight gain and feeling fat were predictive of other EDs (e.g., BN and BED) (Stice et al., 2021). These results suggest there may be differences in cognitive and affective profiles between AN and other types of EDs (e.g., BN and BED). Feeling fat has rarely been examined, and mainly in cross-sectional community or ED samples. It is suggested that individuals with AN are more vulnerable to fear conditioning than healthy comparisons, and that this susceptibility may explain why intense fear of weight gain often develops just after engaging in dieting (Steinglass et al., 2011). However, it is unknown if diagnoses (AN vs. other ED) moderates fear of weight gain’s or feeling fat’s relationship with negative emotions, cognitions, and ED behaviors.
1.4. Current study.
In the current study, we tested dynamic relations among feeling fat, fear of weight gain and emotions, cognitions, and ED behaviors temporally, during specifically stressful times (i.e., at mealtime and next-meal) across three weeks. Specifically, the present study aims to investigate if increased mealtime feeling of fatness and/or fear of weight gain independently predict increased mealtime and next-meal negative affect (i.e., anxiety, guilt) and ED behaviors (i.e., vomiting, compensatory behaviors, exercise, restriction, body checking, weighing, and binge eating). We also examined whether higher feelings of fatness, and emotions, cognitions, and ED behaviors prospectively predict more intense fear of weight gain at the next-meal, as well as whether higher fears of weight gain, emotions, cognitions, and ED behaviors prospectively predict higher feelings of fatness at the next-meal. Finally, we examined if ED diagnoses (AN vs. other ED) moderated these relationships. We hypothesized that feeling fat and fear of weight gain would be overlapping, but unique cognitive-affective mechanisms. Specifically, we hypothesized that fear of weight gain would predict anxiety and guilt, and ED cognitions/behaviors. As fear of weight gain has been associated with dietary restriction and feared consequences of weight gain have been shown to predict drive for thinness over time (Levinson et al., 2017), we predicted that fear of weight gain would uniquely be associated with and prospectively predict restriction, thoughts about dieting, and ED cognitions/behaviors. As little is known about feeling fat, we explored which specific cognitions and behaviors feeling fat would relate to.
2. Methods
2.1. Participants
Participants were 94 women diagnosed with an ED (AN n = 64 [Restricting n = 44; Binge-Purge n = 20]; other ED n = 30 [BN Purge n = 13; BN Non-Purge n = 4; BED n = 4; Atypical BN-Purge n = 5; Atypical BN Non-Purge n = 4]). Ages ranged from 18–62 years old (M = 28.99; SD = 8.93). Ethnicity reported were as follows: American Indian or Alaskan Native n = 1 (1.1%); Asian/Asian American n = 6 (6.4%); Non-Hispanic Black n = 3 (3.2%); Hispanic n = 6 (6.4%); Multiracial n = 3 (3.2%); Non-Hispanic White n = 75 (79.8%). The age of participants in the AN group (M = 28.05, SD = 8.13) was not significantly different from the age of participants in the other ED group (M = 31.00, SD = 10.30; t(92) = 1.504, p = 0.136). However, the BMI of participants in the AN group (M = 20.01, SD = 4.43) was significantly lower than the BMI of participants in the other ED group (M = 25.86, SD = 5.88; t(89) = 5.269, p < 0.001, d = 1.19). Participants were divided into AN vs. other ED groups in order to test if ED diagnosis moderated relationships of interest.
Procedure
After approval from the University of Louisville Institutional Review Board (#16.1077), participants were recruited from across the United States from treatment alumni lists, social media, and the local community as an online paid study using an app on their iPhone to answer questions about meals and snacks four times a day. Participants’ diagnoses were determined by highly trained interviewers, followed by the agreement of four independent raters (96% agreement between raters). After baseline measures, participants completed ecological momentary assessments (EMA) collected four times a day for 18 days (72 timepoints) asking about feeling fat, fear of weight gain, emotions/cognitions and ED behaviors at stressful timepoints (i.e., mealtimes) through a mobile-application.
2.2. Measures
2.2.1. Diagnostic Measures
The ED modules were used from the Structured Clinical Interview for DSM-5 ED Module (SCID-5-RV; First et al., 2015) to determine participants’ DSM-5 ED diagnoses. Participants’ exclusion criteria (suicidality, psychosis, and mania/hypomania) were determined by utilizing these modules from the Mini-International Neuropsychiatric Interview 5.0 (MINI 5.0; Sheehan et al., 1998). The MINI 5.0 has shown excellent test-retest and inter-rater reliability to assess DSM-5 diagnoses through a semi-structured interview (Sheehan et al., 1997).
2.2.2. Mobile Application Assessment
Daily Habits Questionnaire (DHQ; Levinson et al., 2018) consists of 47 items rating emotions (e.g., I felt anxious during the meal or snack), cognitions (e.g., I felt fat during the meal) and behaviors (e.g., Please rate how much you have engaged in the following behaviors since your last meal or snack from 1-not at all to 6 - a lot: vomiting) in the context of meals from 1 (not at all) to 6 (a lot/extreme). The DHQ was used in four-hour semi-fixed intervals sent to participants smartphone to assess feeling fat, fear of weight gain, emotions (i.e., anxiety, guilt), cognitions and ED behaviors (i.e., feelings of having overeaten, vomiting, compensatory behaviors, exercise, restriction, body checking, weighing, and binge eating), from 1 (none) to 6 (a lot/extreme). The DHQ has been utilized in multiple EMA research studies previously (e.g., Levinson et al., 2018; Sala et al., 2019).
2.3. Statistical Analyses
Data were analyzed with R, using the nlme package for multilevel modeling (MLM; Pinheiro et al., 2020). Participants completed four EMA surveys per day for 18 days, or a total of 72 within-person observations. MLM is robust to missing data (Brown, 2021; Quene & Van den Bergh, 2004), and as such, we were able to include all participants. MLM allows for examination of the relationship between variables both within-individuals (level one) and between-individuals over time (level two). Level one data consisted of repeated measures collected at each survey, which were nested within level two units (i.e., participants). As suggested by prior research (Hamaker et al., 2015), time-varying predictors (i.e., predictor variables administered via EMA; TVPs) were disaggregated into participants’ average trait levels of variables across all 72 surveys (i.e., TVPmean) and their state fluctuations of variables at each survey (TVPdeviation; TVPraw – TVPmean).
In separate models we examined the relationships among state independent fluctuations in feeling fat and fears of weight gain during mealtimes (contemporaneous or cross-sectional) and next-meal (prospective: lag of four hours) emotions and cognitions (e.g., anxiety, guilt, feelings of having overeaten). We also examined the relationships among state fluctuations in feelings of fatness and fears of weight gain during momentary mealtimes (contemporaneous or cross-sectional) and next-meal (prospective: lag of four hours) ED behaviors (i.e., vomiting, other compensatory behaviors, exercise, body checking, weighing, binge eating, and restriction). These relationships were also examined in the opposite direction to determine whether state fluctuations in emotions, cognitions and ED behaviors were associated with feelings of fatness and fears of weight gain during mealtimes (contemporaneous or cross-sectional) and at the next-meal (prospective: lag of four hours). We then examined whether these relationships were moderated by diagnosis (i.e., AN vs. other ED). We examined these constructs separately for feeling fat and fear of weight gain, while adjusting for BMI. The contemporaneous models examined these relationships across the same time window to investigate how feeling fat, fears of weight gain, emotions, cognitions, and ED behaviors are related at the same measurement period (i.e., momentary mealtime). The prospective models examined whether feeling fat, fears of weight gain, emotions, cognitions, and ED behaviors at a prior time point predict each other at a later time point (lag of four hours).
Random effects were specified based on the results of likelihood ratio tests comparing models with increasingly more complex random effects (Snijders & Bosker, 2012). In addition, we used an AR1 covariance structure. Effect sizes were calculated by transforming the t-statistics associated with the regression coefficients from the models into Cohen’s d. In the results detailed below, we only report TVPdeviation effects, as these effects represent causal effects of the predictor on the outcome and allow us to understand how changes in the predictor variable influence changes in the outcome variable (Hamaker et al., 2015). We included both TVPmean and TVPdeviation effects in the regression model, as this is necessary to assess TVPdeviation effects (Hamaker et al., 2015).
3. Results
3.1. Feeling Fat
3.1.1. Contemporaneous (i.e., momentary mealtime).
3.1.1.1. Emotions and Cognitions.
Higher feeling fat was associated with higher anxiety and guilt, and higher feeling fat was also associated with higher feelings of having overeaten, thoughts about dieting, and fears of weight gain.
3.1.1.2. Behaviors.
Mealtime feelings of fatness were associated with more vomiting, diuretic/laxative use, excessive exercise, body checking, self-weighing, and binge eating. Interestingly, feeling fat was not significantly associated with restriction (p = .972) (See Table 1, Model 1).
Table 1.
Regression Coefficients for Feeling Fat on Emotions, Cognitions, and ED Behaviors
| Dependent Variable | Model 1 Contemporaneous | Model 2 Temporal | ||||
|---|---|---|---|---|---|---|
|
|
||||||
| B | SE | d | B | SE | d | |
|
| ||||||
| Emotions | ||||||
|
| ||||||
| Anxiety | 0.44*** | 0.03 | 0.49 | 0.06* | 0.03 | 0.08 |
| Guilt | 0.53*** | 0.03 | 0.57 | 0.10*** | 0.03 | 0.13 |
|
| ||||||
| Cognitions | ||||||
|
| ||||||
| Feelings of having overeaten | 0.56*** | 0.03 | 0.57 | 0.09** | 0.03 | 0.11 |
| Thoughts about dieting | 0.28*** | 0.03 | 0.32 | 0.05* | 0.02 | 0.09 |
| Fear of weight gain | 0.19*** | 0.03 | 0.26 | 0.03* | 0.02 | 0.08 |
|
| ||||||
| Behaviors | ||||||
|
| ||||||
| Vomiting | 0.06*** | 0.02 | 0.12 | 0.04 | 0.02 | 0.07 |
| Diuretic/laxative use | 0.06*** | 0.02 | 0.12 | 0.00 | 0.01 | 0.01 |
| Excessive exercise | 0.04* | 0.02 | 0.08 | 0.02 | 0.01 | 0.07 |
| Body checking | 0.16*** | 0.03 | 0.21 | 0.06*** | 0.02 | 0.13 |
| Self-weighing | 0.05** | 0.02 | 0.09 | 0.03* | 0.02 | 0.08 |
| Binge eating | 0.15*** | 0.03 | 0.18 | 0.00 | 0.02 | 0.01 |
| Restriction | 0.00 | 0.03 | 0.00 | 0.01 | 0.02 | 0.02 |
Note. We examined the impact of feeling fat on contemporaneous emotions, cognitions, and ED behaviors while controlling for diagnostic status (i.e., AN vs. other ED). In Model 1, we examined the impact of feeling fat on concurrent emotions, cognitions, and ED behaviors. In Model 2, we examined the temporal impact of feeling fat on emotions, cognitions, and ED behaviors at the next meal.
p < .05
p < .01
p<.001
3.1.1.3. Reciprocal Relationships With Feeling Fat.
Conversely, higher mealtime anxiety, guilt, feelings of having overeaten, thoughts about dieting, fears of weight gain, vomiting, diuretic/laxative use, body checking, self-weighing, and binge-eating were associated with higher feelings of fatness. Excessive exercise and restriction were not associated with feelings of fatness (ps > .562) (See Table 2, Model 1).
Table 2.
Regression Coefficients for Emotions, Cognitions, and ED Behaviors on Feeling Fat
| Independent Variable | Model 1 Contemporaneous | Model 2 Temporal | ||||
|---|---|---|---|---|---|---|
|
|
||||||
| B | SE | d | B | SE | d | |
|
| ||||||
| Emotions | ||||||
|
| ||||||
| Anxiety | 0.42*** | 0.04 | 0.37 | 0.08** | 0.03 | 0.10 |
| Guilt | 0.44*** | 0.03 | 0.43 | 0.09*** | 0.02 | 0.15 |
|
| ||||||
| Cognitions | ||||||
|
| ||||||
| Feelings of having overeaten | 0.31*** | 0.02 | 0.42 | 0.04** | 0.01 | 0.11 |
| Thoughts about dieting | 0.38*** | 0.04 | 0.33 | 0.08* | 0.04 | 0.08 |
| Fear of weight gain | 0.38*** | 0.05 | 0.27 | 0.08** | 0.03 | 0.11 |
|
| ||||||
| Behaviors | ||||||
|
| ||||||
| Vomiting | 0.07** | 0.02 | 0.10 | 0.04 | 0.03 | 0.05 |
| Diuretic/laxative use | 0.09** | 0.03 | 0.09 | 0.03 | 0.04 | 0.02 |
| Excessive exercise | 0.01 | 0.02 | 0.02 | 0.01 | 0.03 | 0.02 |
| Body checking | 0.17*** | 0.03 | 0.20 | 0.05* | 0.02 | 0.09 |
| Self-weighing | 0.05** | 0.02 | 0.10 | 0.00 | 0.02 | 0.01 |
| Binge eating | 0.25*** | 0.05 | 0.18 | 0.05* | 0.02 | 0.08 |
| Restriction | 0.00 | 0.02 | 0.01 | −0.01 | 0.02 | 0.02 |
Note. We examined the impact of emotions, cognitions, and ED behaviors on contemporaneous feeling fat while controlling for diagnostic status (i.e., AN vs. other ED). In Model 1, we examined the impact of emotions, cognitions, and ED behaviors on concurrent feeling fat. In Model 2, we examined the temporal impact of emotions, cognitions, and ED behaviors on feeling fat at the next meal.
p < .05
p < .01
p<.001
3.1.2. Prospective (i.e., next-meal).
3.1.2.1. Emotions and Cognitions.
Higher mealtime feelings of fatness prospectively (i.e., at next meal) predicted higher anxiety, guilt (emotions) and feelings of having overeaten, thoughts about dieting, and worries about weight gain (cognitions) at the next meal (see Table 1, Model 2).
3.1.2.2. Behaviors.
Mealtime feelings of fatness also prospectively predicted more body checking and self-weighing (behaviors) at the next meal. Feeling fat did not prospectively predict vomiting, diuretic/laxative use, excessive exercise, binge eating, or restriction (ps ≥ .075) at the next meal (see Table 1, Model 2).
3.1.2.3. Reciprocal Relationships With Feeling Fat.
Conversely, higher mealtime anxiety, guilt, feelings of having overeating, thoughts about dieting, worries about weight gain, body checking and binge eating prospectively predicted feelings of fatness at the next meal. Vomiting, diuretic/laxative use, excessive exercise, self-weighing, and restriction did not prospectively predict feelings of fatness (ps ≥ .159) at the next meal (See Table 2, Model 2).
3.2. Fear of Weight Gain
3.2.1. Contemporaneous (i.e., momentary mealtime).
3.2.1.1. Emotions and Cognitions.
Higher fear of weight gain was associated with higher anxiety and guilt (emotions), and higher fear of weight gain was associated with higher feelings of having overeaten, thoughts about dieting, and feelings of fatness (cognitions).
3.2.1.2. Behaviors.
Mealtime fear of weight gain was associated with more diuretic/laxative use, body checking, self-weighing, binge eating, and restriction. Higher fear of weight gain was not significantly associated with vomiting (p = .153) or excessive exercise (p = .327) (See Table 3, Model 1).
Table 3.
Regression Coefficients for Fear of Weight Gain on Emotions, Cognitions, and ED Behaviors
| Dependent Variable | Model 1 Contemporaneous | Model 2 Temporal | ||||
|---|---|---|---|---|---|---|
|
|
||||||
| B | SE | d | B | SE | d | |
|
| ||||||
| Emotions | ||||||
|
| ||||||
| Anxiety | 0.36*** | 0.04 | 0.30 | 0.06* | 0.03 | 0.08 |
| Guilt | 0.40*** | 0.04 | 0.31 | 0.08** | 0.03 | 0.10 |
|
| ||||||
| Cognitions | ||||||
|
| ||||||
| Feelings of having overeaten | 0.51*** | 0.05 | 0.34 | 0.10** | 0.04 | 0.10 |
| Thoughts about dieting | 0.48*** | 0.04 | 0.42 | 0.07* | 0.03 | 0.09 |
| Feeling Fat | 0.38*** | 0.05 | 0.27 | 0.08** | 0.03 | 0.11 |
|
| ||||||
| Behaviors | ||||||
|
| ||||||
| Vomiting | 0.03 | 0.02 | 0.05 | 0.01 | 0.02 | 0.01 |
| Diuretic/laxative use | 0.04** | 0.02 | 0.10 | 0.01 | 0.02 | 0.01 |
| Excessive exercise | −0.02 | 0.02 | 0.03 | 0.02 | 0.02 | 0.03 |
| Body checking | 0.26*** | 0.04 | 0.25 | 0.07** | 0.03 | 0.10 |
| Self-weighing | 0.07** | 0.02 | 0.10 | −0.01 | 0.03 | 0.01 |
| Binge eating | 0.06** | 0.02 | 0.09 | −0.01 | 0.02 | 0.02 |
| Restriction | 0.09** | 0.03 | 0.11 | 0.03 | 0.03 | 0.04 |
Note. We examined the impact of fear of weight gain on contemporaneous emotions, cognitions, and ED behaviors while controlling for diagnostic status (i.e., AN vs. other ED). In Model 1, we examined the impact of fear of weight gain on concurrent emotions, cognitions, and ED behaviors. In Model 2, we examined the temporal impact of fear of weight gain on emotions, cognitions, and ED behaviors at the next meal.
p < .05
p < .01
p<.001
3.2.1.3. Reciprocal Relationships With Fear of Weight Gain.
Conversely, higher anxiety, guilt, feelings of having overeaten, thoughts about dieting, and feelings of fatness were significantly associated with higher fear of weight gain. More diuretic/laxative use, body checking, self-weighing, binge-eating, and restriction were also significantly associated with greater fear of weight gain. Vomiting (p = .124) and excessive exercise (p = .280) were not significantly associated with fear of weight gain (See Table 4, Model 1).
Table 4.
Regression Coefficients for Emotions, Cognitions, and ED Behaviors on Fears of Weight Gain
| Independent Variable | Model 1 Contemporaneous | Model 2 Temporal | ||||
|---|---|---|---|---|---|---|
|
|
||||||
| B | SE | d | B | SE | d | |
|
| ||||||
| Emotions | ||||||
|
| ||||||
| Anxiety | 0.13*** | 0.02 | 0.21 | 0.01 | 0.01 | 0.02 |
| Guilt | 0.16*** | 0.02 | 0.26 | 0.03 | 0.02 | 0.06 |
|
| ||||||
| Cognitions | ||||||
|
| ||||||
| Feelings of having overeaten | 0.14*** | 0.02 | 0.26 | 0.00 | 0.01 | 0.00 |
| Thoughts about dieting | 0.28*** | 0.03 | 0.28 | 0.02 | 0.02 | 0.04 |
| Feeling Fat | 0.19*** | 0.03 | 0.26 | 0.03* | 0.02 | 0.08 |
|
| ||||||
| Behaviors | ||||||
|
| ||||||
| Vomiting | 0.02 | 0.02 | 0.05 | −0.01 | 0.02 | 0.03 |
| Diuretic/laxative use | 0.05* | 0.02 | 0.09 | 0.03 | 0.02 | 0.05 |
| Excessive exercise | −0.02 | 0.02 | 0.04 | 0.00 | 0.02 | 0.00 |
| Body checking | 0.13*** | 0.02 | 0.23 | 0.02 | 0.01 | 0.06 |
| Self-weighing | 0.04** | 0.01 | 0.11 | −0.01 | 0.01 | 0.02 |
| Binge eating | 0.03** | 0.01 | 0.09 | 0.01 | 0.01 | 0.03 |
| Restriction | 0.04* | 0.02 | 0.09 | 0.01 | 0.01 | 0.02 |
Note. We examined the impact of emotions, cognitions, and ED behaviors on contemporaneous fear of weight gain while controlling for diagnostic status (i.e., AN vs. other ED). In Model 1, we examined the impact of emotions, cognitions, and ED behaviors on concurrent fear of weight gain. In Model 2, we examined the temporal impact of emotions, cognitions, and ED behaviors on fear of weight gain at the next meal.
p < .05
p < .01
p<.001
3.2.2. Prospective (i.e., next-meal).
3.2.2.1. Emotions, Cognitions, and Behaviors.
Fear of weight gain prospectively predicted anxiety, guilt (emotions), feelings of having overeaten, thoughts about dieting, feeling fat (cognitions), and body checking (behaviors) at the next meal. Fear of weight gain did not prospectively predict vomiting, diuretic/laxative use, excessive exercise, self-weighing, binge eating, or restriction (ps ≥ .293). (Table 3, Model 2).
3.2.2.2. Reciprocal Relationships With Fear of Weight Gain.
In turn, higher mealtime feeling fat prospectively predicted fear of weight gain at the next meal. Anxiety, guilt, feelings of having overeating, thoughts about dieting, vomiting, diuretic/laxative use, excessive exercise, body checking, self-weighing, binge eating, and restriction did not prospectively predict fear of weight gain (ps ≥ .100) at the next meal (see Table 4, Model 2).
3.3. Moderation by Diagnosis
Moderation analyses (i.e., AN vs. other ED) are presented in Tables 5–8 and Figure 1.
Table 5.
Regression Coefficients for the Interaction between Feeling Fat and Diagnosis on Emotions, Cognitions, and ED Behaviors
| Dependent Variable | Model 1 Contemporaneous | Model 2 Temporal | ||||
|---|---|---|---|---|---|---|
|
|
||||||
| B | SE | d | B | SE | d | |
|
| ||||||
| Emotions | ||||||
|
| ||||||
| Anxiety | −0.05 | 0.07 | 0.03 | −0.17** | 0.05 | 0.12 |
| Guilt | −0.06 | 0.07 | 0.03 | −0.13 | 0.07 | 0.07 |
|
| ||||||
| Cognitions | ||||||
|
| ||||||
| Feelings of having overeaten | −0.03 | 0.07 | 0.01 | −0.15* | 0.07 | 0.08 |
| Thoughts about dieting | −0.01 | 0.06 | 0.01 | −0.06 | 0.03 | 0.07 |
| Fear of weight gain | 0.03 | 0.06 | 0.02 | −0.05 | 0.04 | 0.06 |
|
| ||||||
| Behaviors | ||||||
|
| ||||||
| Vomiting | −0.06 | 0.04 | 0.05 | −0.10* | 0.04 | 0.09 |
| Diuretic/laxative use | −0.09* | 0.04 | 0.08 | 0.00 | 0.02 | 0.00 |
| Excessive exercise | −0.03 | 0.04 | 0.03 | −0.01 | 0.03 | 0.01 |
| Body checking | −0.04 | 0.06 | 0.02 | −0.07 | 0.04 | 0.07 |
| Self-weighing | −0.04 | 0.04 | 0.03 | −0.07 | 0.03 | 0.07 |
| Binge eating | −0.32*** | 0.05 | 0.23 | 0.01 | 0.03 | 0.01 |
| Restriction | −0.05 | 0.06 | 0.03 | −0.01 | 0.04 | 0.01 |
Note. We examined whether the impact of feeling fat on contemporaneous emotions, cognitions, and ED behaviors varies by ED diagnosis (i.e., AN vs. other ED). In Model 1, we examined the impact of feeling fat on concurrent emotions, cognitions, and ED behaviors and whether the effects varied by AN vs. other ED participants. In Model 2, we examined the temporal impact of feeling fat on emotions, cognitions, and ED behaviors at the next meal and whether the effects varied by AN vs. other ED participants.
p < .05
p < .01
p<.001
Table 8.
Regression Coefficients of the Interaction between Emotions, Cognitions, and ED Behaviors and Diagnostic Status on Fear of Weight Gain
| Dependent Variable | Model 1 Contemporaneous | Model 2 Temporal | ||||
|---|---|---|---|---|---|---|
|
|
||||||
| B | SE | d | B | SE | d | |
|
| ||||||
| Emotions | ||||||
|
| ||||||
| Anxiety × Diagnosis | 0.07 | 0.04 | 0.05 | −0.03 | 0.03 | 0.04 |
| Guilt × Diagnosis | 0.07 | 0.04 | 0.06 | −0.02 | 0.04 | 0.02 |
|
| ||||||
| Cognition | ||||||
|
| ||||||
| Feelings of having overeaten × Diagnosis | 0.06 | 0.04 | 0.06 | 0.01 | 0.02 | 0.03 |
| Thoughts about dieting × Diagnosis | 0.06 | 0.08 | 0.03 | 0.09** | 0.03 | 0.10 |
| Fear of weight gain × Diagnosis | 0.03 | 0.06 | 0.02 | −0.05 | 0.04 | 0.06 |
|
| ||||||
| Behaviors | ||||||
|
| ||||||
| Vomiting × Diagnosis | −0.01 | 0.03 | 0.01 | −0.03 | 0.03 | 0.04 |
| Diuretic/laxative use × Diagnosis | 0.00 | 0.04 | 0.00 | −0.08 | 0.04 | 0.07 |
| Excessive exercise × Diagnosis | 0.00 | 0.04 | 0.00 | −0.02 | 0.04 | 0.02 |
| Body checking × Diagnosis | 0.06 | 0.04 | 0.05 | −0.01 | 0.03 | 0.01 |
| Self-weighing × Diagnosis | 0.06* | 0.03 | 0.08 | −0.02 | 0.03 | 0.03 |
| Binge eating × Diagnosis | −0.01 | 0.03 | 0.01 | 0.03 | 0.03 | 0.04 |
| Restriction × Diagnosis | −0.03 | 0.04 | 0.02 | 0.01 | 0.03 | 0.02 |
Note. We examined whether the impact of emotions, cognitions, and ED behaviors on contemporaneous fear of weight gain varies by ED diagnosis (i.e., AN vs. other ED). In Model 1, we examined the impact of emotions, cognitions, and ED behaviors on concurrent fear of weight gain and whether the effects varied by AN vs. other ED participants. In Model 2, we examined the impact of emotions, cognitions, and ED behaviors on fear of weight gain at the next meal and whether the effects varied by AN vs. other ED participants.
p < .05
p < .01
p<.001
Figure 1.
Moderation by diagnosis (i.e., AN vs. other ED) results
3.3.1. Contemporaneous (i.e., momentary mealtime) feeling fat.
3.3.1.1. Emotions and Cognitions.
There were no significant interactions between feeling fat and diagnosis on emotions (ps > .411) or cognitions (ps > .545).
3.3.1.2. Behaviors.
Diagnosis moderated the relationship between feeling fat and diuretic/laxative use, such that higher feeling fat was associated with elevated diuretic/laxative use for those with other ED diagnoses (b = 0.14, SE = 0.04, p = .001, d = 0.21), and not for those with an AN diagnosis (p = .318). Similarly, diagnosis moderated the relationship between feeling fat and binge eating, such that higher feeling fat was associated with elevated binge eating for those with other ED diagnoses (b = 0.37, SE = 0.06, p < .001, d = 0.37) compared to those with an AN diagnosis (b = 0.05, SE = 0.02, p = .007, d = 0.11) (See Table 5, Model 1, and Figure 1). Diagnosis did not moderate the relationship between feeling fat and vomiting, excessive exercise, body checking, self-weighing, and restriction (ps > .137).
3.3.2. Prospective (i.e., next mealtime) feeling fat.
3.3.2.1. Emotions.
Diagnosis moderated the relationship between feeling fat and prospective anxiety, such that higher feeling fat led to elevations in anxiety at the next time point for those with other ED diagnoses (b = 0.17, SE = 0.06, p = .003, d = 0.21) and not for those with an AN diagnosis (p = .953). Diagnosis did ont moderate the effect of feeling fat on prospective feelings of guilt (p = 0.051) (See Table 5, Model 2, and Figure 1).
3.3.2.2. Cognitions.
Diagnosis moderated the relationship between feeling fat and prospective feelings of having overeaten, such that higher feeling fat led to elevated feelings of having overeaten for those with other ED diagnoses (b = 0.22, SE = 0.07, p = .003, d = 0.22), but not for those with an AN diagnosis (p = .220) (See Table 5, Model 2, and Figure 1). Diagnosis did not moderate the effect of feeling fat on prospective thoughts about dieting and fears of weight gain (ps > .060).
3.3.2.3. Behaviors.
While diagnosis moderated the prospective relationship between feeling fat and vomiting (p = 0.019) and the relationship between feeling fat and vomiting was stronger in the other ED diagnoses (b = 0.11, SE = 0.06, p = .065, d = 0.13) than the AN diagnosis (p = 0. 868), these relationships were not significant within the individual groups (See Table 5, Model 2, and Figure 1). Diagnosis did not moderate the effect of feeling fat on prospective diuretic/laxative use, excessive exercise, body checking, self-weighing, binge eating, and restriction (ps > .051).
3.4.3. Contemporaneous (i.e., momentary mealtime) fear of weight gain.
3.4.3.1. Emotions.
Diagnosis moderated the relationship between fear of weight gain and anxiety, such that those with an AN diagnosis had higher anxiety (b = 0.40, SE = 0.04, p < .001, d = 0.37) vs. those with other ED diagnoses (b = 0.19, SE = 0.08, p = .012, d = 0.16). Similarly, diagnosis moderated the relationship between fear of weight gain and guilt, such that higher fear of weight gain was associated with elevated guilt for those with an AN diagnosis (b = 0.45, SE = 0.04, p < .001, d = 0.43) compared to those with other ED diagnoses (b = 0.22, SE = 0.09, p = .016, d = 0.156) (See Table 7, Model 1, and Figure 1).
Table 7.
Regression Coefficients of the Interaction between Fear of Weight Gain and Diagnostic Status on Emotions, Cognitions, and ED Behaviors
| Dependent Variable | Model 1 Contemporaneous | Model 2 Temporal | ||||
|---|---|---|---|---|---|---|
|
|
||||||
| B | SE | d | B | SE | d | |
|
| ||||||
| Emotions | ||||||
|
| ||||||
| Anxiety | 0.21* | 0.09 | 0.08 | −0.08 | 0.06 | 0.05 |
| Guilt | 0.24** | 0.09 | 0.09 | 0.06 | 0.07 | 0.03 |
|
| ||||||
| Cognitions | ||||||
|
| ||||||
| Feelings of having overeaten | 0.16 | 0.11 | 0.05 | 0.02 | 0.09 | 0.01 |
| Thoughts about dieting | 0.00 | 0.09 | 0.00 | 0.10 | 0.07 | 0.05 |
| Feeling Fat | 0.02 | 0.11 | 0.01 | 0.01 | 0.07 | 0.01 |
|
| ||||||
| Behaviors | ||||||
|
| ||||||
| Vomiting | −0.05 | 0.04 | 0.04 | 0.00 | 0.05 | 0.00 |
| Diuretic/laxative use | −0.05 | 0.04 | 0.05 | −0.01 | 0.04 | 0.01 |
| Excessive exercise | 0.00 | 0.04 | 0.00 | −0.02 | 0.05 | 0.02 |
| Body checking | 0.09 | 0.08 | 0.04 | 0.08 | 0.06 | 0.05 |
| Self-weighing | 0.08 | 0.05 | 0.05 | −0.03 | 0.08 | 0.01 |
| Binge eating | −0.16** | 0.05 | 0.10 | 0.05 | 0.06 | 0.03 |
| Restriction | −0.04 | 0.07 | 0.02 | 0.02 | 0.07 | 0.01 |
Note. We examined whether the impact of fear of weight gain on contemporaneous emotions, cognitions, and ED behaviors varies by ED diagnosis (i.e., AN vs. other ED). In Model 1, we examined the impact of fear of weight gain on concurrent emotions, cognitions, and ED behaviors and whether the effects varied by AN vs. other ED participants. In Model 2, we examined the temporal impact of fear of weight gain on emotions, cognitions, and ED behaviors at the next meal and whether the effects varied by AN vs. other ED participants.
p < .05
p < .01
p<.001
3.4.3.2. Cognitions.
Diagnosis did not moderate the relationship between fear of weight gain and any cognitions (ps > .1648).
3.4.3.3. Behaviors.
Diagnosis moderated the relationship between fear of weight gain and binge eating, such that higher fear of weight gain was associated with elevated binge eating only for those with other ED diagnoses (b = 0.18, SE = 0.07, p = .009, d = 0.17), and not for those with an AN diagnosis (p = .1526) (See Table 7, Model 1, and Figure 1). Diagnosis did not moderate the relationship between fear of weight gain and vomiting, diuretic/laxative use, excessive exercise, body checking, self-weighing, and restriction (ps > .12184).
3.4.4. Prospective Fear of Weight Gain.
3.4.4.1. Emotions, Cognitions, and Behaviors.
Diagnosis did not moderate any relationships among fear of weight gain and prospective emotions, cognitions, ED behaviors, and fear of weight gain (ps ≥ .18147) (See Table 7, Model 2).
3.5. Moderation by Diagnosis - Reciprocal Relationships
3.5.1. Contemporaneous (i.e., momentary mealtime) feeling fat.
3.5.1.1. Emotions and Cognitions
did not moderate the relationship between any emotions or cognitions with feeling fat (ps > 0.138).
3.5.1.2. Behaviors.
Diagnosis moderated the relationship between diuretic/laxative use and feeling fat, such that higher diuretic/laxative use was associated with higher feelings of fatness for those with other ED diagnoses (b = 0.18, SE = 0.05, p < .001, d = 0.24), but not for those with an AN diagnosis (p = 0.453) (See Table 6, Model 1, and Figure 1). Diagnosis moderated the relationship between excessive exercise and feeling fat, however, the relationship between feeling fat and excessive exercise was not significant for those with other ED diagnoses (p = 0.066) or for those with an AN diagnosis (p = 0.624).
Table 6.
Regression Coefficients for the Interaction between Emotions, Cognitions, and ED Behaviors and Diagnosis on Feeling Fat
| Independent Variable | Model 1 Contemporaneous | Model 2 Temporal | ||||
|---|---|---|---|---|---|---|
|
|
||||||
| B | SE | d | B | SE | d | |
|
| ||||||
| Emotions | ||||||
|
| ||||||
| Anxiety × Diagnosis | −0.11 | 0.08 | 0.05 | −0.13* | 0.06 | 0.08 |
| Guilt × Diagnosis | −0.11 | 0.08 | 0.05 | −0.08 | 0.05 | 0.06 |
|
| ||||||
| Cognitions | ||||||
|
| ||||||
| Feelings of having overeaten × Diagnosis | −0.02 | 0.05 | 0.01 | −0.06 | 0.03 | 0.07 |
| Thoughts about dieting × Diagnosis | −0.01 | 0.09 | 0.00 | −0.07 | 0.05 | 0.05 |
| Fear of weight gain × Diagnosis | 0.02 | 0.11 | 0.01 | 0.01 | 0.07 | 0.01 |
|
| ||||||
| Behaviors | ||||||
|
| ||||||
| Vomiting × Diagnosis | 0.00 | 0.05 | 0.00 | −0.02 | 0.05 | 0.02 |
| Diuretic/laxative use × Diagnosis | −0.17* | 0.07 | 0.09 | −0.06 | 0.09 | 0.02 |
| Excessive exercise × Diagnosis | −0.13* | 0.06 | 0.07 | −0.10 | 0.06 | 0.06 |
| Body checking × Diagnosis | −0.04 | 0.07 | 0.02 | −0.05 | 0.05 | 0.04 |
| Self-weighing × Diagnosis | −0.03 | 0.04 | 0.02 | −0.04 | 0.04 | 0.04 |
| Binge eating × Diagnosis | −0.03 | 0.10 | 0.01 | −0.04 | 0.05 | 0.03 |
| Restriction × Diagnosis | −0.02 | 0.04 | 0.02 | −0.02 | 0.04 | 0.02 |
Note. We examined whether the impact of emotions, cognitions, and ED behaviors on contemporaneous feeling fat varies by ED diagnosis (i.e., AN vs. other ED). In Model 1, we examined the impact of emotions, cognitions, and ED behaviors on concurrent feeling fat and whether the effects varied by AN vs. other ED participants. In Model 2, we examined the impact of emotions, cognitions, and ED behaviors on feeling fat at the next meal and whether the effects varied by AN vs. other ED participants.
p < .05
p < .01
p<.001
3.5.2. Prospective feeling fat
3.4.2.1. Emotions.
Diagnosis also moderated the relationship between anxiety and prospective feelings of fatness, such that higher anxiety led to elevations in feeling fat at the next time point for those with other ED diagnoses (b = 0.17, SE = 0.06, p = .006, d = 0.20), but not for those with an AN diagnosis (p = .150) (See Table 6, Model 2, and Figure 1). Diagnosis did not moderate the relationship between guilt and feeling fat (p = .133).
3.5.2.2. Cognitions, and Behaviors.
Diagnosis did not moderate the relationship between any cognitions or behaviors with feeling fat (ps > .065).
3.5.3. Contemporaneous (i.e., momentary mealtime) fear of weight gain.
3.5.3.1. Emotions and Cognitions.
Diagnosis did not moderate the relationship between anxiety or guilt or cognitions and fears of weight gain (ps > .091).
3.5.3.2. Behaviors.
Diagnosis moderated the relationship between self-weighing and fear of weight gain, such that higher self-weighing was associated with higher fear of weight gain for those with an AN diagnosis (b = 0.06, SE = 0.02, p < 0.001, d = 0.15), but not for those with other ED diagnoses (p = 0.991; See Table 8). Diagnosis did not moderate any other reciprocal relationships (ps ≥ 0.091).
3.5.4. Prospective fear of weight gain.
3.5.4.1. Emotions.
Diagnosis did not moderate the relationship between anxiety or guilt and fears of weight gain (ps ≥ 0.286).
3.5.4.2. Cognitions.
Diagnosis also moderated the relationship between thoughts about dieting and prospective fears of weight gain, such that more thoughts about dieting led to higher fears of weight gain at the next time point for those with an AN diagnosis (b = 0.13, SE = 0.02, p < 0.001, d = 0.28) compared to those with other ED diagnoses (b = 0.03, SE = 0.02, p = 0.027, d = 0.08).
3.5.4.3. Behaviors.
Diagnosis did not moderate the relationship between any behaviors and fears of weight gain (ps > 0.05)
4. Discussion
Feeling fat and fear of weight gain are hallmark features of EDs, but little is known about how these cognitive-affective symptoms operate momentarily and across time and how those dynamics impact ED behaviors, especially during stressful situations for those with ED (i.e., at mealtime and next-meal). By pinpointing how feeling fat and fear of weight gain operate we can develop interventions to disrupt cycles of specific emotions, cognitions, and ED behaviors. This study used EMA collected four times a day for 18 days (72 timepoints) to measure feeling fat, fear of weight gain, emotions (anxiety, guilt), cognitions (feelings of having overeaten, thoughts about dieting), and ED behaviors (vomiting, diuretic/laxative use, excessive exercise, body checking, self-weighing, binge eating, and restriction) both contemporaneously (i.e., momentary mealtime) and prospectively (i.e., next-meal). We also tested if ED diagnosis (AN vs. other ED) moderated these relationships. Our findings suggest that feeling fat and fear of weight gain are part of dynamical systems of cognitive-behavioral-affective aspects of EDs. Furthermore, feeling fat and fear of weight gain, while having some overlap in how they impact other symptoms, also have unique and specific impacts on cognitive-behavioral symptoms of ED. Finally, some of these relationships are moderated by diagnosis.
4.1. Contemporaneous (i.e., momentary mealtime) Findings.
Overall, we found that feeling fat and fear of weight gain experienced during mealtimes were both significantly associated with elevations of emotions (i.e., anxiety and guilt), cognitions (feelings of having overeaten, thoughts of dieting, fear of weight gain/feeling fat), and ED behaviors (diuretic/laxative use, body checking, self-weighing, binge eating). These findings suggest that feeling fat and fear of weight gain are possibly part of dynamical systems of cognitive-behavioral-affective aspects of EDs and begin to pinpoint how they operate both uniquely and in concert. For example, though both feeling fat and fear of weight gain were similarly related to anxiety, guilt, and ED cognitions, results showed that feeling fat and fear of weight gain differed with respect to specific ED behaviors (i.e., vomiting, excessive exercise, and dietary restriction) in contemporaneous models. These results are in line with prior research (Calugi et al., 2018; Garner & Bemis, 1985; Linardon et al., 2018a; Ralph-Nearman et al., 2021), as higher fear of weight gain was associated with increased restriction in our contemporaneous model. However, higher feeling fat at mealtime was not related to restriction but, unlike fear of weight gain, feeling fat was associated with more vomiting and excessive exercise contemporaneously. Unlike feeling fat, fear of weight gain did not relate to vomiting or excessive exercise in our contemporaneous model. The results which found no relationship contemporaneously nor prospectively between fear of weight gain and excessive exercise support prior literature which also found that there was no effect of fear of weight gain on subsequent exercise engagement (Lampe et al., 2022). To speculate, perhaps individuals may use these compensatory behaviors of vomiting or excessive exercise in an attempt to stop feeling fat during the meal, but as fear of gaining weight is a fear of a future experience, it is plausible that vomiting and excessive exercise may not be as commonly utilized for fear of gaining weight as it is used for the current experience of feeling fat during the meal. These results are important because they shed light on which behaviors could be reduced by intervening on feeling fat versus fear of weight gain.
Conversely, anxiety, guilt, feelings of having overeaten, thoughts of dieting, diuretic/laxative use, body checking, self-weighing, and binge eating were significantly associated with both feeling fat and fear of weight gain contemporaneously. Alternatively, vomiting was contemporaneously associated with feeling fat but not fear of weight gain, and restriction was related to fear of weight gain but not feeling fat. These unique cyclical relationships may distinguish feeling fat from fear of weight gain and suggests that feeling fat may be more associated with specific compensatory behaviors (i.e., vomiting), whereas fear of weight gain is associated with restrictive ED behaviors during mealtimes. These models show how reciprocal relationships among ED cognitions, behavior, and affect may operate.
4.2. Prospective Models.
Feeling fat and fear of weight gain prospectively predicted each other and some overlapping and unique emotions, cognitions, and ED behaviors. Specifically, results suggest that both feeling fat and fear of weight gain may lead to feeling anxious, guilty, fullness (i.e., having overeaten), thoughts of how to reduce feeling fat/fear of weight gain, such as dieting, and monitoring ED behaviors (i.e., body checking). These results extend prior research, which found that high body checking behaviors were associated with temporary, possibly contemporaneous increases in feeling fat (Shafran et al., 2007), to include cyclical relationships between body checking and both feeling fat and fear of weight gain contemporaneously and prospectively.
Only feeling fat prospectively predicted self-weighing. It is possible that, unlike fear of weight gain, feeling fat during meals may lead to monitoring ED behaviors (i.e., self-weighing). Specifically, self-weighing may be used to relieve feeling fat, and self-weighting may be an attempt to temporarily relieve distress. Further, current findings may differ from prior cross-sectional findings, as the current study pinpoints these momentary and prospective relationships around mealtimes. Similarly, neither feeling fat nor fear of weight gain prospectively predicted more vomiting, diuretic/laxative use, excessive exercise, binge eating or restricting ED behaviors. While prior literature has found cross-sectional associations between fear of weight gain and dietary restriction (Calugi & Ghoch, 2018; Garner & Bemis, 1985; Linardon et al., 2018a; Ralph-Nearman et al., 2021), fear of weight gain did not prospectively predict restriction in our study. Thus, our findings highlight the importance of examining these relationships both contemporaneously and prospectively. It will be important for future research to further examine whether these relationships may change or remain constant over a longer period than 18 days.
Interestingly, only higher feeling fat prospectively predicted next-meal fear of weight gain, while all emotions (i.e., anxiety and guilt), cognitive symptoms (i.e., feelings of having overeaten, thoughts of dieting, fear of weight gain), and two ED behaviors (i.e., body checking and binge eating) prospectively predicted next-meal feeling fat. It is possible that body checking could be used in an attempt to alleviate interoceptive feelings of fatness from binge eating, thus body checking may have a dynamic cyclical relationship with feeling fat. Our findings partially corroborate the transdiagnostic cognitive behavioral theory of EDs which posits that feeling fat drives engagement in certain ED behaviors to compensate for or alleviate these negative emotions (Fairburn et al., 2003; Levinson et al., 2020), but was not found for fear of weight gain.
4.3. Moderation Findings.
We also found that diagnosis (AN vs other ED) moderated some of the relationships among feeling fat and fear of weight gain and emotions, cognitions, and ED behaviors. Specifically, relative to AN, higher feeling fat was associated with elevated binge eating in both AN and other ED diagnoses, but more so in the other ED diagnoses, whereas higher fear of weight gain was associated with elevated binge eating ED behaviors only for those with other ED diagnoses. These findings suggest that the relationships between feeling fat and fear of weight gain with more binge eating and compensatory ED behaviors are more strongly associated contemporaneously for other ED diagnoses (e.g., BN), than for AN. As our group of AN consisted of two-thirds restricting subtype, and our other ED group consisted of a little over half of either non-purge BN or BED, these results support prior literature that shows that binge eating leads to feelings of fatness (Anderson et al., 2022; Mussell et al., 1996). In contrast, relative to other ED diagnoses, higher fear of weight gain was contemporaneously more strongly associated with elevated anxiety and guilt for those with AN. Although intense fear of weight gain is a significant and common fear among the majority of individuals with an ED (e.g., Brown & Levinson, 2022), AN is the only diagnosis that includes fear of weight gain in its diagnostic criteria. These findings show that higher fear of weight gain is more strongly related to elevated anxiety and guilt in those with AN (relative to those with other ED diagnoses), which suggests that weight gain fears and intense negative emotions may be especially important to address in AN to alleviate guilt and anxiety.
Prospective moderation results indicate that, relative to those with an AN diagnosis, higher feeling fat led to higher elevations in anxiety, feelings of having overeaten, and vomiting at the next time point for those with other ED diagnoses. This effect was not present in the opposite direction, except for anxiety. Again, results point to feeling fat intensifying anxiety, feelings of having overeaten, and these compensatory ED behaviors (i.e., vomiting) that are often used in other ED diagnoses to reduce negative emotions and feelings of overeating, such as in BN (APA, 2013). Overall, these findings may shed light on areas for future intervention (such as just-in-time interventions) research that could reduce ED symptoms in the moment.
4.4. Limitations.
This research has limitations, which may inform next steps. First, while these data began to explore how diagnoses may moderate feeling fat and fear of weight gain relationships with emotions, cognitions, and ED behaviors, our sample sizes for each ED group only allowed for us to compare AN vs. other ED diagnoses in the current study. Larger, more well-powered samples are needed in future studies, to compare AN with other more specific diagnostic groups (i.e., BN, BED, etc.). Second, the current study sample consisted mostly of non-Hispanic white women clinically diagnosed with an ED. Thus, future studies may investigate a wider range of ED diagnoses more specifically and recruit a more diverse sample for generalization.
4.5. Conclusion.
Momentary feeling fat and fear of weight gain prospectively predict emotions, cognitions and ED behaviors, and vice-versa. These findings begin to pinpoint dynamic and cyclical relationships among feeling fat, fear of weight gain, emotions, cognitions, and specific ED behaviors. These data begin to show how cycles of ED symptoms may maintain EDs. Findings suggest that more ED treatment intervention research is needed on feeling fat and fear of weight gain, as such interventions might disrupt cycles of specific emotions, cognitions, and ED behaviors.
Highlights.
Feeling fat (FF)/fear of weight gain (FOWG) are key eating disorder (EDs) symptoms
Momentary FF and FOWG prospectively predict emotions, cognitions and ED behaviors
ED symptoms and behaviors prospectively predict momentary FF and FOWG
These data begin to show how cycles of ED symptoms may maintain EDs
Interventions on FF/FOWG may disrupt cycles of specific ED symptoms and behaviors
Acknowledgements:
Thank you to all of our participants that made this research possible, and for our EAT Lab team.
Funding Statement:
CRN and CAL are funded by grant P20GM103436–20 (KY-INBRE) from the National Institute of General Medical Sciences, and by grant R15 MH121445 from the National Institute of Mental Health, National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.
Footnotes
Conflicts of Interest: Authors have no conflicts of interest to declare.
Credit authorship contribution statement: CRN wrote original writing and contributed to conducting the formal analyses. MH mainly conducted formal analyses with contribution from RH and CRN, and MH created Tables and Figures. CAL provided supervision of the project. All authors contributed to editing of writing and approved the final version of the manuscript.
Ethical Statement: This study has been approved by the UofL Institutional Review Board (#16.1077). The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
References
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 10.1176/appi.books.9780890425596 [DOI] [Google Scholar]
- Anderson LM, Hall LM, Crosby RD, Crow SJ, Berg KC, Durkin NE, Engel SG, Peterson CB 2022. “Feeling fat,” disgust, guilt, and shame: Preliminary evaluation of a mediation model of binge-eating in adults with higher-weight bodies. Body Image. 42, 32–42. 10.1016/j.bodyim.2022.05.008 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Arcelus J, Mitchell AJ, Wales J, Nielsen S 2011. Mortality rates in patients with Anorexia Nervosa and other eating disorders. Archives of General Psychiatry. 68, 724–731. doi: 10.1001/archgenpsychiatry.2011.74 [DOI] [PubMed] [Google Scholar]
- Brown VA 2021. An Introduction to Linear Mixed-Effects Modeling in R. Advances in Methods and Practices in Psychological Science, 4. 10.1177/2515245920960351 [DOI] [Google Scholar]
- Brown ML, Levinson CA 2022. Core eating disorder fears: Prevalence and differences in eating disorder fears across eating disorder diagnoses. International Journal of Eating Disorders. 10.1002/eat.23728 [DOI] [PubMed] [Google Scholar]
- Calugi S, Dalle Grave R 2019. Body image concern and treatment outcomes in adolescents with anorexia nervosa. International Journal of Eating Disorders. 52, 582–585. 10.1002/eat.23031 [DOI] [PubMed] [Google Scholar]
- Calugi S, El Ghoch M, Conti M, Dalle Grave R 2018. Preoccupation with shape or weight, fear of weight gain, feeling fat and treatment outcomes in patients with anorexia nervosa: A longitudinal study. Behaviour Research and Therapy. 105, 63–68. 10.1016/j.brat.2018.04.001 [DOI] [PubMed] [Google Scholar]
- Carter JC, Bewell-Weiss CV 2011. Nonfat phobic anorexia nervosa: clinical characteristics and response to inpatient treatment. International Journal of Eating Disorders. 44, 220–224. 10.1002/eat.20820 [DOI] [PubMed] [Google Scholar]
- Cooper MJ, Deepak K, Grocutt E, & Bailey E (2007). The experience of ‘feeling fat’in women with anorexia nervosa, dieting and non-dieting women: an exploratory study. European Eating Disorders Review: The Professional Journal of the Eating Disorders Association, 15(5), 366–372. [DOI] [PubMed] [Google Scholar]
- Engel SG, Wonderlich SA, Crosby RD, Mitchell JE, Crow S, Peterson CB, Le Grange D, Simonich HK, Cao L, Lavender JM, Gordon KH 2013. The role of affect in the maintenance of anorexia nervosa: Evidence from a naturalistic assessment of momentary behaviors and emotion. Journal of Abnormal Psychology. 122, 709–719. 10.1037/a0034010 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Fairburn CG, Cooper Z, Shafran R 2003. Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. Behaviour Research and Therapy. 41, 509–528. [DOI] [PubMed] [Google Scholar]
- Fairburn CG 2008. Cognitive behavior therapy and eating disorders. New York, NY: Guilford Press. [Google Scholar]
- First MB, Williams JB, Karg RS, Spitzer RL 2015. Structured clinical interview for DSM-5—Research version (SCID-5 for DSM-5, research version; SCID-5-RV). Arlington, VA: American Psychiatric Association. 1–94. [Google Scholar]
- Galmiche M, Déchelotte P, Lambert G, Tavolacci MP (2019). Prevalence of eating disorders over the 2000–2018 period: a systematic literature review. Am J Clin Nutr, 109(5):1402–1413. doi: 10.1093/ajcn/nqy342 [DOI] [PubMed] [Google Scholar]
- Garner D Bemis K. 1985. Cognitive therapy for anorexia nervosa in: Garfinkel, G.P.E. (Ed.), Handbook of psychotherapy for anorexia nervosa and bulimia, Guilford Press, New York: New York. [Google Scholar]
- Hamaker EL, Kuiper RM, Grasman RP 2015. A critique of the cross-lagged panel model. Psychological Methods. 20, 102–116. 10.1037/a0038889. [DOI] [PubMed] [Google Scholar]
- Lampe EW, Wons O, Taylor LC, Juarascio AS, & Manasse SM (2022). Associations between fear of weight gain and exercise in binge-spectrum eating disorders. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 27(6), 2121–2128. doi: 10.1007/s40519-022-01361-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Lavender JM, De Young KP, Anestis MD, Wonderlich SA, Crosby RD, Engel SG, Mitchell JE, Crow SJ, Peterson CB, & Le Grange D (2013). Associations between retrospective versus ecological momentary assessment measures of emotion and eating disorder symptoms in anorexia nervosa. Journal of Psychiatric Research, 47(10), 1514–1520. 10.1016/j.jpsychires.2013.06.021 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Lavender JM, Wonderlich SA, Engel SG, Gordon KH, Kaye WH, Mitchell JE 2015. Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa: A conceptual review of the empirical literature. Clinical Psychology Review. 40, 111–122. 10.1016/j.cpr.2015.05.010 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Levinson CA, Brosof LC, Ma J, Fewell LK, Lenze EC 2017. Fear of food prospectively predicts drive for thinness in an eating disorder sample recently discharged from intensive treatment. Eating Behaviors. 27, 45–51. 10.1016/j.eatbeh.2017.11.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Levinson CA, Hunt RA, Christian C, Williams BM, Keshishian AC, Vanzhula IA, & Ralph-Nearman C (2022). Longitudinal group and individual networks of eating disorder symptoms in individuals diagnosed with an eating disorder. Journal of Psychopathology and Clinical Science, 131(1), 58–72. 10.1037/abn0000727 [DOI] [PubMed] [Google Scholar]
- Levinson CA, Sala M, Fewell L, Brosof LC, Fournier L, Lenze EJ 2018. Meal and snack-time eating disorder cognitions predict eating disorder behaviors and vice versa in a treatment seeking sample: A mobile technology based ecological momentary assessment study. Behaviour Research and Therapy, 105, 36–42. 10.1016/j.brat.2018.03.008 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Levinson CA, Williams BM, Christian C 2020. What are the emotions underlying feeling fat and fear of weight gain?. Journal of Affective Disorders, 277. 146–152. 10.1016/j.jad.2020.08.012 [DOI] [PubMed] [Google Scholar]
- Linardon J, Phillipou A, Castle D, Newton R, Harrison P, Cistullo LL, Griffiths S, Hindle A, Brennan L 2018a. Feeling fat in eating disorders: Testing the unique relationships between feeling fat and measures of disordered eating in anorexia nervosa and bulimia nervosa. Body Image. 25, 163–167. 10.1016/j.bodyim.2018.04.001 [DOI] [PubMed] [Google Scholar]
- Linardon J, Phillipou A, Castle D, Newton R, Harrison P, Cistullo LL, Griffiths S, Hindle A, Brennan L 2018b. The relative associations of shape and weight over-evaluation, preoccupation, dissatisfaction, and fear of weight gain with measures of psychopathology: An extension study in individuals with anorexia nervosa. Eating Behaviors, 29, 54–58. 10.1016/j.eatbeh.2018.03.002 [DOI] [PubMed] [Google Scholar]
- Manasse SM, Lampe EW, Srivastava P, Payne-Reichert A, Mason TB, & Juarascio AS (2022). Momentary associations between fear of weight gain and dietary restriction among individuals with binge-spectrum eating disorders. International Journal of Eating Disorders, 55(4), 541–552. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Mehak A, Racine SE 2021. ‘Feeling fat’ is associated with specific eating disorder symptom dimensions in young men and women. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. 1–7. [DOI] [PubMed] [Google Scholar]
- Messer M, & Linardon J (2022). Exploring the role of feeling fat in individuals categorized with bulimia nervosa, binge-eating disorder and overweight/obesity. Eating and Weight Disorders, 26(8), 2617–2623. 10.1007/s40519-021-01119-2 [DOI] [PubMed] [Google Scholar]
- Mussell MP, Peterson CB, Weller CL, Crosby RD, De Zwaan M, & Mitchell JE (1996). Differences in body image and depression among obese women with and without binge eating disorder. Obesity Research, 4(5), 431–439. 10.1002/j.1550-8528.1996.tb00251.x [DOI] [PubMed] [Google Scholar]
- Pinheiro J, Bates D, DebRoy S, Sarkar D, R Core Team. 2020. nlme: Linear and Nonlinear Mixed Effects Models. R package version 3.1–148, <URL: https://CRAN.R-project.org/package=nlme>. [Google Scholar]
- Quene H, Van den Bergh H 2004. On multi-level modeling of data from repeated measures designs: A tutorial. Speech Communication. 43, 103–121. 10.1016/j.specom.2004.02.004. [DOI] [Google Scholar]
- Ralph-Nearman C, Filik R 2018. Eating disorder symptomatology and body mass index are associated with readers’ expectations about character behavior: Evidence from eye-tracking during reading. International Journal of Eating Disorders. 51, 1070–1079. 10.1002/eat.22961 [DOI] [PubMed] [Google Scholar]
- Ralph-Nearman C, Arevian AC, Moseman S, Sinik M, Chappelle S, Feusner JD, Khalsa SS 2021. Visual mapping of body image disturbance in anorexia nervosa reveals objective markers of illness severity. Scientific Reports. 11, 1–12. 10.1038/s41598-021-90739-w [DOI] [PMC free article] [PubMed] [Google Scholar]
- Sala M, Brosof LC, Levinson CA 2019. Repetitive negative thinking predicts eating disorder behaviors: A pilot ecological momentary assessment study in a treatment seeking eating disorder sample. Behaviour Research and Therapy. 112, 12–17. 10.1016/j.brat.2018.11.005 [DOI] [PubMed] [Google Scholar]
- Sanftner JL, Barlow DH, Marschall DE, & Tangney JP (1995). The Relation of Shame and Guilt to Eating Disorder Symptomatology. Journal of Social and Clinical Psychology, 14(4), 315–324. 10.1521/jscp.1995.14.4.315 [DOI] [Google Scholar]
- Santonastaso P, Bosello R, Schiavone P, Tenconi E, Degortes D, Favaro A (2009). Typical and atypical restrictive anorexia nervosa: weight history, body image, psychiatric symptoms, and response to outpatient treatment. International Journal of Eating Disorders. 42, 464–470. [DOI] [PubMed] [Google Scholar]
- Shafran R, Lee M, Payne E, Fairburn CG 2007. An experimental analysis of body checking. Behaviour Research and Therapy. 45, 113–121. 10.1016/j.brat.2006.01.015 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar GC, 1998. The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD- 10. Journal of Clinical Psychiatry. 59, pp.22–33. [PubMed] [Google Scholar]
- Sheehan DV, Lecrubier Y, Sheehan KH, Janavs J, Weiller E, Keskiner A, Schinka J, Knapp E, Sheehan MF, Dunbar GC 1997. The validity of the Mini International Neuropsychiatric Interview (MINI) according to the SCID-P and its reliability. European Psychiatry, 12, pp.232–241. [Google Scholar]
- Slof-Op’t Landt MC, van Furth EF, van Beijsterveldt CE, Bartels M, Willemsen G, de Geus EJ, Ligthart L, Boomsma DI 2017. Prevalence of dieting and fear of weight gain across ages: a community sample from adolescents to the elderly. International Journal of Public Health. 62, 911–919. 10.1007/s00038-017-0948-7 [DOI] [PubMed] [Google Scholar]
- Snijders TA, Bosker RJ 2012. Multilevel analysis: An introduction to basic and advanced multilevel modeling. London, UK: Sage. [Google Scholar]
- Steinglass JE, Sysko R, Glasofer D, Albano AM, Simpson HB, Walsh BT 2011. Rationale for the application of exposure and response prevention to the treatment of anorexia nervosa. International Journal of Eating Disorders. 44, 134–141. doi: 10.1002/eat.20784 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Stice E, Desjardins CD, Rohde P, & Shaw H (2021). Sequencing of symptom emergence in anorexia nervosa, bulimia nervosa, binge eating disorder, and purging disorder and relations of prodromal symptoms to future onset of these disorders. Journal of Abnormal Psychology, 130(4), 377–387. 10.1037/abn0000666 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Thomas JJ, Vartanian LR, Brownell KD 2009. The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: Meta-analysis and implications for DSM. Psychological Bulletin. 135, 407–433. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Walsh BT, Xu T, Wang Y, Attia E, Kaplan AS 2021. Time course of relapse following acute treatment for anorexia nervosa. American Journal of Psychiatry. 178, 848–853. 10.1176/appi.ajp.2021.21010026 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Wang SB, Jones PJ, Dreier M, Elliott H, & Grilo CM (2019). Core psychopathology of treatment-seeking patients with binge-eating disorder: a network analysis investigation. Psychological Medicine, 49(11), 1923–1928. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Zerwas S, Lund BC, Von Holle A, Thornton LM, Berrettini WH, Brandt H, Crawford S, Fichter MM, Halmi KA, Johnson C, Kaplan AS, La Via M, Mitchell J, Rotondo A, Strober M, Woodside DB, Kaye WH, & Bulik CM (2013). Factors associated with recovery from anorexia nervosa. Journal of Psychiatric Research, 47(7), 972–979. 10.1016/j.jpsychires.2013.02.011 [DOI] [PMC free article] [PubMed] [Google Scholar]