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. Author manuscript; available in PMC: 2022 Sep 1.
Published in final edited form as: Women Health. 2021 Aug 25;61(8):791–799. doi: 10.1080/03630242.2021.1970082

Associations among weight suppression, self-acceptance, negative body image, and eating disorder behaviors among women with eating disorder symptoms

Kelly A Romano a, Kristin E Heron a,b, Deborah Ebener c
PMCID: PMC8440428  NIHMSID: NIHMS1736427  PMID: 34433381

Abstract

The present study aimed to clarify existing research that has inconsistently shown that weight suppression (differences between individuals’ highest and current body weights) is associated with worse eating disorder (ED) behaviors and negative body image among women with lifetime EDs, by examining whether an understudied client-supported protective factor for ED pathology—self-acceptance—moderates these associations. Currently symptomatic women with lifetime EDs (N=108) completed measures assessing self-acceptance and ED symptoms via an online survey. Moderated regressions examined whether self-acceptance moderated associations between weight suppression and both body image (weight/shape preoccupation, overvaluation, dissatisfaction) and ED behavior (dietary restraint, compensatory behaviors, binge eating) outcomes. Results indicated that weight suppression was associated with more severe negative body image and dietary restraint, but not compensatory behaviors or binge eating. In contrast, self-acceptance consistently emerged as a protective factor relative to all negative body image and ED behavior indices. This protective effect did not offset apparent risk factor associations between weight suppression, and negative body image and ED behavior outcomes. These results support further assessment of self-acceptance as an understudied protective factor for women’s ED symptoms and as a mechanism of change in EDs intervention research. Women’s weight suppression should be assessed during ED prevention initiatives.

Keywords: Eating Disorders, Weight Suppression, Self-Acceptance, Body Dissatisfaction, Women’s Health

Eating disorders (EDs) such as anorexia nervosa, bulimia nervosa, and binge eating disorder are common adverse mental health concerns that present at high rates among women. Current point prevalence estimates from a systematic review that included studies from around the world suggest that clinical EDs present in 5.7%, and sub-clinical EDs in 19.4%, of women (Galmiche et al. 2019). Further, EDs are associated with multiple adverse physiological and psychosocial outcomes, including mental health concerns (e.g., anxiety and depressive disorders, substance use disorders), somatic symptoms (e.g., cardiovascular disease, electrolyte imbalances), and psychosocial impairment (Udo and Grilo 2018, 2019). Improving the understanding of risk and maintenance factors for women’s ED pathology that can be identified via brief screening methods in routine healthcare can serve as an important first step in connecting at-risk individuals with treatment and deterring these adverse outcomes. Weight suppression, the difference between one’s highest and current body weight, has recently been identified as one factor that could serve this purpose (Stice et al. 2020). However, the current understanding of weight suppression is limited by various factors that make it difficult to gauge its full theoretical and practical importance.

First, findings from existing research examining associations between weight suppression and ED symptoms are inconsistent. For example, among women with EDs and non-clinical women, greater weight suppression has been associated with greater binge eating (Goodman et al. 2018; Van Son et al. 2013), compensatory behaviors (e.g., excessive exercise, self-induced vomiting; Schaumberg et al. 2016), dietary restraint (Burnette et al. 2017, 2018; Goodman et al. 2018; Schaumberg et al. 2016; Van Son et al. 2013), and ED severity (Burnette et al. 2018; Schaumberg et al. 2016). In contrast, other research among women has found non-significant associations between weight suppression and binge eating (Carter et al. 2015; Keel et al. 2017; Schaumberg et al. 2016), compensatory behaviors (Burnette et al. 2018; Carter et al. 2015; Goodman et al. 2018; Keel et al. 2017), and ED severity (Keel et al. 2017).

Second, although previous research has found that higher weight suppression is associated with worse body dissatisfaction and weight/shape concerns in clinical and non-clinical samples of women (Burnette et al. 2018; Zanetti et al. 2013), little is known about associations between weight suppression and theoretically important components of body image implicated in the pathogenesis of EDs. The cognitive behavioral theory of EDs (CBT-ED), for example, posits that weight/shape preoccupation (placing a large amount of attention on one’s body weight or shape) and overvaluation (believing that one’s body weight or shape are central components of one’s character) are risk and maintenance factors for increased ED severity (Fairburn et al. 2003). In the only existing study in this area, higher weight suppression was associated with greater weight/shape overvaluation among community women over 50 years old (Goodman et al. 2018). Whether this finding extends to younger women with ED symptoms and generalizes to weight/shape preoccupation, a construct shown to be more consistently associated with ED pathology than weight/shape overvaluation and dissatisfaction among individuals with EDs (Askew et al. 2020), is unknown.

In contrast to risk factor associations identified between weight suppression and ED symptoms, self-acceptance—the extent to which individuals accept all negative and positive aspects of themselves (Ryff 1989)—has been considered a protective factor. Although qualitative research shows that women who have recovered from EDs consider self-acceptance to be central to promoting ED recovery (de Vos et al. 2017), few studies have examined this construct via quantitative methods. Results from this limited evidence base suggest that individuals with EDs exhibit less self-acceptance than individuals without EDs (Tomba et al. 2014, 2017). Further, among individuals with lifetime EDs, those with better ED recovery statuses have exhibited greater self-acceptance than individuals in less favorable recovery classifications (Romano and Ebener 2019).

As a notable gap in the EDs evidence base, self-acceptance has not previously been assessed as a direct correlate of ED symptoms or as a moderator of weight suppression-ED symptom associations. Yet, support for self-acceptance’s potential moderating role in these interrelations stems from the psychobiological/biobehavioral bind hypothesis of weight suppression (Butryn et al. 2006; Lowe et al. 2018). The psychobiological bind is based upon the notion that women with ED symptoms commonly exhibit poor self-perceptions (including poor self-acceptance) and fear weight gain (Fairburn et al. 2003). When women with ED symptoms are also weight suppressed, biological responses to these weight losses (e.g., decreased leptin/satiety) promote weight regain (Keel et al. 2019). In turn, weight regain is believed to further perpetuate adverse cognitive (body dissatisfaction, poor self-perceptions/acceptance) and behavioral (binge eating, restriction) ED symptoms.

Given that this process involves an interplay between psychological (poor self-perceptions/acceptance) and physiological (weight suppression) influences, it is plausible that the psychological and physiological components of the psychobiological bind may interact among women with ED symptoms and map onto their ED symptoms. However, these interrelations have not been assessed to date. Thus, to advance the understanding of how theoretically and clinically-relevant risk (weight suppression) and protective (self-acceptance) factors individually and multiplicatively influence ED symptoms, the present study aimed to examine associations among weight suppression, self-acceptance, and body image and ED behavior outcomes, as well as whether self-acceptance moderates associations between weight suppression, and body image and ED behavior outcomes. It was hypothesized that: (1) weight suppression would be positively, and self-acceptance negatively, associated with more adverse levels of the assessed body image and ED behavior outcomes; (2) higher levels of self-acceptance would decrease the strength of positive associations between higher levels of weight suppression and worse body image and ED behavior outcomes.

Method

Participants and Procedures

Institutional review board approval was obtained and all procedures were performed in accordance with the ethical standards in the 1964 Declaration of Helsinki and its amendments. Prospective respondents were recruited through online ED support groups, organizations, and websites run by ED treatment centers throughout the U.S. to complete a study on “Eating Disorder Recovery” from April to August 2016. After electronically providing informed consent, 123 women aged 18 or older with self-reported lifetime ED diagnoses made by qualified professionals (medical doctor, psychiatrist, psychologist, counselor) completed an online survey. At the time of assessment, 15 participants (12.2%) met validated criteria for full ED recovery (Bardone-Cone et al. 2010). To increase the homogeneity of participants’ symptom severity, the analytic sample included the remaining 108 women with current ED symptoms. Participants’ demographic characteristics are reported in Table 1.

Table 1.

Participant Characteristics

M (SD) n (%)
Age 30.07 (10.76)
Current Body Mass Index 24.05 (8.53)
Race
 African American 1 (0.93%)
 European American or Caucasian 98 (90.74%)
 Asian American or Pacific Islander 2 (1.85%)
 Native American or Alaskan Native 2 (1.85%)
 Other Race 4 (3.70%)
Hispanic or Latinx 4 (3.70%)
Highest Level of Education
 Less than High School 3 (2.78%)
 High School Graduate 5 (4.63%)
 Some College 22 (20.37%)
 2-year Degree (e.g., associates) 5 (4.63%)
 4-year Degree (e.g., bachelors) 43 (39.81%)
 Professional Degree (e.g., masters, JD, MD, etc.) 28 (25.93%)
 Doctorate 2 (1.85%)
Sexual Identity
 Heterosexual 79 (73.15%)
 Bisexual 9 (8.33%)
 Gay 0 (0%)
 Lesbian 9 (8.33%)
 Queer 1 (0.93%)
 Questioning 3 (2.78%)
 Other Sexual Identity 6 (5.56%)
 Prefer Not to Say 1 (0.93%)
Lifetime Eating Disorder Diagnoses
 Anorexia Nervosa, Restrictive Subtype 67 (62.04%)
 Anorexia Nervosa, Binge/Purge Subtype 22 (20.37%)
 Bulimia Nervosa 29 (26.85%)
 Binge Eating Disorder 18 (16.67%)
 Other Specified Feeding or Eating Disorder (e.g., purging disorder, atypical anorexia) 23 (21.30%)
 Unspecified Feeding or Eating Disorder 5 (4.63%)
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Note. N = 108

Measures

Weight Suppression

Per recommendations (Schaumberg et al. 2016), relative weight suppression1 was calculated based on participants’ self-reported lifetime highest weights at their current heights minus their present weights, and that value was divided by participants’ lifetime highest weights. Positive values indicate that individuals’ current weights are lower than their lifetime highest weights and a value of 0 indicates that individuals are currently at their highest weights.

Self-Acceptance

The 14-item Self-Acceptance Scale of Ryff’s Scales of Psychological Well-Being (RSPWB) was used to assess women’s self-acceptance (Ryff 1989). Items are endorsed on a 6-point response scale (strongly disagree, strongly agree); higher scores reflect greater self-acceptance. This measure has exhibited good internal consistency and test-retest reliability in previous studies (Ryff 1989). In the present sample, α=.942.

Eating Disorder Examination Questionnaire (EDE-Q)

The EDE-Q (Fairburn and Beglin 2008) is a widely-used measure of ED symptoms. Items are rated on a 7-point response scale, and higher scores reflect worse ED symptoms. In line with recent procedures (Askew et al. 2020), the present study used select EDE-Q items and subscales, shown in Table 2, to assesses negative body image and ED behaviors.

Table 2.

Eating Disorder Behavior and Negative Body Image Covariates from the Eating Disorder Examination Questionnaire

Construct Item or Scale and Coding
Weight/Shape Preoccupation “On how many of the past 28 days has thinking about shape or weight made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)?” (0=no days, 6=every day)
Weight/Shape Overvaluation Averaged composite of (asked with respect to the 28 days prior to assessment):

  1. “Has your WEIGHT influenced how you think about (judge) yourself as a person?” (0=not at all, 6=markedly)

  2. “Has your SHAPE influenced how you think about (judge) yourself as a person?” (0=not at all, 6=markedly)
Weight/Shape Dissatisfaction Averaged composite of (asked with respect to the 28 days prior to assessment):

  1. “How dissatisfied have you been with your WEIGHT?” (0=not at all, 6=markedly)

  2. “How dissatisfied have you been with your SHAPE?” (0=not at all, 6=markedly)
Dietary Restraint Restraint subscale
Compensatory Behavior Due to data non-normality, a dichotomous composite was created that reflected no (0) versus any (1) use of ≥1 of the following compensatory behaviors:

  1. “Over the past 28 days, how many TIMES have you made yourself sick (vomit) as a means of controlling your shape or weight?”

  2. “Over the past 28 days, how many TIMES have you taken laxatives as a means of controlling your shape or weight?”

  3. “Over the past 28 days, how many TIMES have you exercised in a "driven" or "compulsive" way as a mean of controlling your weight, shape or amount of fat, or to burn off calories?”
Binge Eating Binge eating is defined as episodes of overeating (captured via item 1 below) plus concurrent loss of control over eating during those episodes. Item 2 was consequently used to capture binge eating in the present study:

  1. “Over the past 28 days, how many TIMES have you eaten what other people would regard as an UNUSUALLY LARGE amount of food given the circumstances”

  2. “Over the past 28 days, on how many of these times did you have a sense of having lost control over your eating (at the time you were eating)?”
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Statistical Analyses

Analyses were conducted using Mplus 8.4. First, bivariate correlations among study variables were conducted. Subsequently, six moderated regressions with 5,000 bootstrapped samples were run. Each model controlled for current BMI and assessed associations among self-acceptance, weight suppression, and a self-acceptance X weight suppression interaction, relative to body image (weight/shape preoccupation, overvaluation, dissatisfaction) and ED behavior (dietary restraint, compensatory behaviors, binge eating) outcomes in separate models. Self-acceptance and weight suppression covariates were centered before creating the interaction. An a priori power analysis suggested that N=105 was needed to detect small-medium effects (f2=0.12; α=.05; power=.80). There were ≤3.7% missing data. Maximum likelihood estimation was used in all analyses except the model that included the dichotomous compensatory behavior variable for which the WLSMV estimator was used.

Results

Table 3 presents descriptive statistics and bivariate correlations. The results of regressions that examined whether self-acceptance moderated associations between weight suppression and body image and ED behavior outcomes, controlling for women’s current BMIs, are presented in Table 4. Across the multivariate models, greater self-acceptance was associated with less negative body image (β=−0.42 to −0.60) and ED behaviors (β=−0.28 to −0.39). In contrast, higher weight suppression was associated with more weight/shape preoccupation, overvaluation, and dissatisfaction (β=0.18 to 0.27) and dietary restraint (β=0.45), but not compensatory behaviors or binge eating. Interactions between self-acceptance and weight suppression relative to body image and ED behavior outcomes were all non-significant.

Table 3.

Descriptive Statistics and Bivariate Correlations

M (SD) or
n (%)		 1 2 3 4 5 6 7 8 9
1. Current BMI 24.05 (8.53) -
2. Self-Acceptance 44.51 (16.73) .080 -
3. Relative Weight Suppression 13.74% (9.64%) −.248* −.027 -
4. W/S Preoccupation 3.17 (2.21) −.202* −.431*** .307** -
5. W/S Overvaluation 4.48 (1.80) .017 −.609*** .235* .654*** -
6. W/S Dissatisfaction 4.57 (1.81) .089 −.555*** .129 .616*** .814*** -
7. Dietary Restraint 2.93 (1.92) −.294** −.417*** .503*** .744*** .690*** .574*** -
8. Compensatory Behavior (Any) 76 (70.37%) −.294** −.238* .223* .437*** .385*** .315** .491*** -
9. Binge Eating 2.85 (7.03) .074 −.252* .079 .267** .187 .227* .217* .113 -
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Note. N=108; BMI = body mass index; W/S = weight or shape.

*

p < .05

**

p < .01

***

p < .001

Table 4.

Moderated Regression Analyses Predicting Body Image Concerns and Eating Disorder Behaviors

Weight and Shape
Preoccupation		 Weight and Shape
Overvaluation		 Weight and Shape
Dissatisfaction
b(SE) p β b(SE) p β b(SE) p β
Current BMI −0.02 (0.03) .347 −0.09 0.02 (0.01) .109 0.10 0.03 (0.02) .032 0.15
Self-Acceptance −0.06 (0.01) <.001 −0.42 −0.07 (0.01) <.001 −0.60 −0.06 (0.01) <.001 −0.57
Weight Suppression 0.06 (0.02) .001 0.26 0.05 (0.02) .001 0.27 0.03 (0.01) .018 0.18
Self-Acceptance X Weight Suppression −0.001 (0.001) .288 −0.08 0.001 (0.001) .179 0.12 0.001 (0.001) .128 0.11
Model R2 0.29 (0.08) <.001 0.44 (0.08) <.001 0.37 (0.08) <.001
Dietary Restraint Compensatory Behaviors Binge Eating
b(SE) p β b(SE) p β b(SE) p β
Current BMI −0.03 (0.02) .105 −0.15 −0.04 (0.02) .033 −0.29 0.10 (0.11) .385 0.12
Self-Acceptance −0.05 (0.01) <.001 −0.39 −0.02 (0.01) .049 −0.30 −0.12 (0.05) .014 −0.28
Weight Suppression 0.09 (0.02) <.001 0.45 0.03 (0.02) .128 0.24 0.06 (0.05) .235 0.08
Self-Acceptance X Weight Suppression 0.000 (0.001) .648 −0.03 0.000 (0.001) .708 0.06 −0.002 (0.01) .684 −0.04
Model R2 0.43 (0.07) <.001 0.27 (0.12) .018 0.09 (0.07) .186
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Note. N=108; BMI = body mass index; covariates were centered prior to creating the interaction terms.

Discussion

The present study aimed to improve the understanding of a factor recently suggested to uphold an influential role in the pathogenesis of EDs, weight suppression, via associations between this construct and self-acceptance, ED behaviors, and understudied components of negative body image among currently symptomatic women with lifetime EDs. Whereas weight suppression was associated with greater negative body image and dietary restraint, self-acceptance emerged as a protective factor relative to all assessed negative body image and ED pathology outcomes. However, this protective effect did not offset apparent risk factor associations between weight suppression, and negative body image and ED behavior indices.

First, although self-acceptance did not moderate associations between weight suppression and either ED behavior (restraint, compensatory behavior, binge eating) or body image (weight/shape preoccupation, overvaluation, dissatisfaction) outcomes, greater self-acceptance was consistently associated with less severe ED behaviors and negative body image across the assessed models. These findings extend initial evidence that greater self-acceptance is associated with better ED recovery statuses (Romano and Ebener 2019). Notably, self-acceptance exhibited more robust inverse correlations with the assessed negative body image constructs (β=−0.42 to −0.60) than ED behaviors (β=−0.28 to −0.39), suggesting that self-acceptance may serve as a more proximal protective factor relative to cognitive-affective body image indices than behavioral ED symptoms. Given that this is the first study to examine associations between self-acceptance and distinct ED symptoms among symptomatic women, despite the centrality of this construct in promoting ED recovery from clients’ perspectives (de Vos et al. 2017), examining associations between self-acceptance and behavioral and cognitive-affective ED symptoms via longitudinal studies is an important area of future inquiry.

In contrast to protective associations found between self-acceptance and negative body image and ED behavior covariates, higher weight suppression was associated with greater weight/shape preoccupation, overvaluation, and dissatisfaction, and stronger associations were identified for weight/shape preoccupation and overvaluation than dissatisfaction. These findings extend results from the only existing study in this area, which demonstrated that higher weight suppression was associated with greater weight/shape overvaluation among women over 50 years old (Goodman et al. 2018). This suggests that this previous finding extends to younger women with ED symptoms and emerges relative to weight/shape preoccupation.

Further, it is noteworthy that there were trivial to small associations between women’s current BMIs and each of the assessed negative body image and ED behavior covariates, particularly when compared to the notably larger magnitude of associations between weight suppression and these ED symptom outcomes. These findings are consistent with evidence that one’s body weight (or BMI) at a given point in time may be a less salient correlate of poor ED-related health outcomes when compared to differences between one’s current weight status and one’s past highest weight (i.e., weight suppression; Lowe et al. 2018). Additional research examining potential psychobiological explanations (e.g., the interplay among poor self-perceptions, biological responses to weight loss, subsequent weight regain, and adverse cognitive and behavioral ED symptoms associated with weight regain) for these differential associations could prove useful as this evidence base continues to advance.

The present results have various implications that can inform ED programming efforts. First, women’s weight suppression should be assessed during community-based ED prevention initiatives and by healthcare providers. This evidence can serve as an informative supplement to data on other known risk factors for ED onset and maintenance that are commonly assessed in these contexts (e.g., body dissatisfaction, BMI). Second, although clinical intervention research is needed, these initial data suggest that augmenting women’s self-acceptance could serve as a useful target in ED prevention and treatment initiatives.

Although the present study includes multiple strengths, including the focus on a theoretically and clinically important topic that can help improve ED outcomes, study limitations warrant attention. First, although it was specified that participants must have been diagnosed with EDs by a qualified professional to participate, some may not have received such diagnoses. However, strictly including participants with active symptoms in the analytic sample may decrease the impact of this limitation. Second, the present study was cross-sectional and study findings warrant confirmation via longitudinal research. Third, all participants identified as women, and most also identified as White and heterosexual. It will prove useful to determine whether the present findings extend to more diverse samples of participants.

That higher weight suppression was associated with greater dietary restraint, but not binge eating or compensatory behaviors, adds to an inconsistent literature identifying positive or null associations between weight suppression and ED behaviors among women. To clarify this evidence base, future research should examine whether weight suppression moderates associations among women’s cyclical ED behavior use via ecological momentary assessment, and also assess whether there are any differences in these patterns of results between women with sub-clinical versus clinical ED symptoms. For example, in line with the CBT-ED (Fairburn et al. 2003), momentary dietary restraint may promote subsequent binge eating and, in turn, additional restraint and/or compensatory behaviors among women with greater weight suppression. Such nuanced interconnectivity may be masked via between-person research methods that have strictly been used in this area to date.

Conclusions

The present study aimed to improve the understanding of associations among weight suppression, self-acceptance, ED behaviors, and understudied components of negative body image. Results demonstrated that weight suppression was associated with greater negative body image and dietary restraint, but not binge eating or compensatory behaviors. In contrast, self-acceptance emerged as a protective factor for all assessed negative body image and ED pathology outcomes. Weight suppression should be consistently assessed as an ED risk factor in healthcare. Self-acceptance warrants further examination as an understudied protective factor for women’s ED symptoms.

Funding acknowledgement:

This work was completed in part with support from the National Institute of Mental Health of the National Institutes of Health under award number F31MH120982 to Kelly A. Romano. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

1

Results using the traditional weight suppression measurement approach (i.e., lifetime highest weight minus current weight) did not differ from those using the relative weight suppression conceptualization. Data using the former approach are available upon request.

Disclosures: Institutional Review Board approval was obtained from the participating institution. All participants gave informed consent before taking part in this study.

Conflict of Interest

All authors declare that they have no conflicts of interest.

Data Availability:

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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