Abstract
Objective:
Preoccupation (excessive and constant thoughts) about shape/weight and food/eating are thought to be prominent in individuals with eating disorders but have received much less research than overt behavioral features. This study examined the significance and distinctiveness of different foci of preoccupation in individuals categorized with different forms of eating disorders and in individuals with higher weight.
Method:
Participants (N=1363) completed a web-based survey with established measures of eating-disorder psychopathology and depression. The current study compared preoccupation among individuals with core features of bulimia nervosa (BN; n=144), binge-eating disorder (BED; n=576), anorexia nervosa (AN; n=48), and higher body weight (BMI≥25) without eating-disorder features (HW; n=595). Associations of each type of preoccupation with other eating-disorder psychopathology and depression were examined both between and within study groups.
Results:
Preoccupation with shape/weight and with food/eating showed a graded pattern of statistically significant differences: AN and BN had higher preoccupation than BED, which was higher than HW. Within BN, BED, and AN study groups, correlation magnitudes of shape/weight and food/eating preoccupation with eating-disorder psychopathology and depression did not differ significantly. Within the HW group, shape/weight preoccupation was significantly more strongly correlated than food/eating preoccupation with overvaluation, body dissatisfaction, and depression.
Discussion:
The preoccupation cognitive style, as well as focus, appears associated with other facets of eating-disorder psychopathology and depression. If results are confirmed among individuals with formal diagnoses, clinicians addressing maladaptive cognitions in CBT should consider the role of preoccupation. Future research should investigate whether preoccupation predicts or moderates eating disorder treatment outcomes.
Keywords: bulimia nervosa, binge-eating disorder, eating disorders, anorexia nervosa, obesity, body image, weight, cognitive, preoccupation
INTRODUCTION
Preoccupation is a form of cognition that involves constant and excessive thoughts and can cause impairment in daily functioning, such as being unable to focus on a conversation. Other forms of cognition, such as overvaluation (excessive self-evaluation based on weight or shape) are considered core features of eating disorders, but preoccupation has received much less attention in the literature. Among individuals with eating-disorder psychopathology, the content of preoccupied thoughts often focuses on body image (shape and weight) and food/eating. The limited work on preoccupation with shape/weight has shown that among individuals with AN, preoccupation with shape/weight is associated with impaired work and social functioning, poorer general psychopathology, and slower improvement in cognitive-behavioral therapy (Calugi, El Ghoch, Conti, & Dalle Grave, 2018). In a clinical sample of patients with BED, preoccupation with shape/weight was more strongly associated with eating concerns than body dissatisfaction, overvaluation, or fear of weight gain (Lydecker, White, & Grilo, 2017). Among those with BN, preoccupation with shape/weight was central to eating-disorder psychopathology and highly associated with depressive and anxious symptomatology (Levinson et al., 2017). Among adolescent girls, preoccupation with shape/weight was more strongly associated with dietary restraint and binge eating than other body-image constructs (Mitchison et al., 2017). Longitudinally, among individuals with heterogenous eating-disorder diagnoses, preoccupation with shape/weight was associated with global eating-disorder psychopathology and fasting (Askew et al., 2020).
These findings suggest that preoccupation with shape/weight is associated consistently with eating concerns and disordered eating behaviors as well as broader eating-disorder psychopathology. An additional focus of preoccupation is food and eating. Much less is known about preoccupation with food/eating than preoccupation with shape/weight, and the two preoccupation constructs have not been examined in the context of the other nor compared, despite being administered in parallel on eating disorder measures such as the Eating Disorder Examination interview and questionnaire (Fairburn & Beglin, 1994; Fairburn & Cooper, 1993). Most of the existing literature on preoccupation with food/eating examines its relationship to food restriction and dieting (Jones & Rogers, 2003; King, Herman, & Polivy, 1987; Polivy, 1996). A study comparing women engaged in dieting with women engaged in binge eating found that in both groups, women with higher levels of preoccupation with food/eating also had higher levels of dietary restraint (Timmerman & Gregg, 2003). These findings suggest the need to examine preoccupation with shape/weight and preoccupation with food/eating together in their relationship with eating-disorder psychopathology.
The current study compared preoccupation with shape/weight and preoccupation with food/eating among individuals with core features of BN, BED, AN, and those without eating-disordered features with higher weight (HW) in terms of associations with eating-disorder psychopathology and depression, both within and between study groups. We selected these groups because shape/weight preoccupation has been examined in eating disorder samples, and food/eating preoccupation has been examined in samples of individuals engaging in restriction or weight loss.
METHOD
Participants
Participants were 1363 individuals from a larger group of 3283 individuals who completed an internet-based survey advertised as a study on weight, eating, dieting, and health-related behaviors. Data from this study have been used previously, including in a study that compared different body image constructs, including preoccupation, with select clinical variables (Grilo, Ivezaj, Lydecker, & White, 2019). Respondents who met criteria for one of the study groups (BN, BED, AN, or HW) were included in the current study. All participants provided electronic informed consent prior to surveys. Data are available from the corresponding author upon reasonable request.
Participants included 159 (11.7%) men and 1199 (88.3%) women (5 participants did not report gender). Participants self-reported race/ethnicity: 80.5% White (n=1091), 6.3% Black (n=85), 6.1% Latinx/Hispanic (n=83), 3.6% Asian (n=49), 3.5% “other” (n=48; 7 participants did not report race/ethnicity). Mean age was 36.20 (SD=12.52) years. Mean BMI was 32.85 (SD=9.14) kg/m2.
Measures
Body Mass Index (BMI).
Participants reported their height and weight, which were used to calculate BMI.
Questionnaire on Eating and Weight Patterns—Revised (QEWP-R).
The QEWP-R measures eating disorder psychopathology that aligns with DSM-IV eating-disorder diagnostic criteria over the past 6 months (Yanovski, 1993). The presence of each eating-disorder behavior is first assessed as “yes” or “no” and then frequency is assessed. Frequency items are scored on a five-point scale from “Less than once a week” through “More than five times a week”.
Eating Disorder Examination Questionnaire (EDE-Q).
The EDE-Q measures eating-disorder psychopathology over the past 28 days using a seven-point scale for items (Fairburn & Beglin, 1994). The EDE-Q assesses the frequency of binge eating and various purging behaviors (vomiting, laxative misuse, diuretic misuse frequency); these were used in the algorithms to create the four study groups. The EDE-Q also assesses associated eating-disorder psychopathology, including the preoccupation with food/eating and preoccupation with shape/weight constructs. Rather than relying on the original EDE-Q subscales, we employed the brief alternative version of the EDE-Q, which consists of seven items comprising three subscales (Restraint [3 items], Overvaluation [2 items], and Dissatisfaction [2 items]), for two reasons. First, this version shows superior psychometric properties than the original full EDE-Q structure in both clinical and non-clinical studies (Grilo et al., 2010; Grilo, Reas, Hopwood, & Crosby, 2015; Machado, Grilo, & Crosby, 2018). Second, the brief factor structure does not include the preoccupation items in subscales, thereby eliminating any problem with item overlap in the analyses. In the current study, the three subscales from the brief version were internally consistent, α=.87–.96.
For descriptive purposes, given the paucity of research on preoccupation, we also examined the proportion of individuals meeting a clinical threshold for preoccupation of food and eating, and a clinical threshold for preoccupation of shape and weight. The clinical threshold used the convention of a score of 4 (“moderate”) on the EDE-Q item.
Beck’s Depression Inventory (BDI).
The BDI measures depressive features and symptoms on a 4-point scale (0 through 3) (Beck, Steer, & Brown, 1987). Items cover a wide range of negative affect associated with depression, and the total score is strongly correlated with both self-reported depression and anxiety (Beck, Steer, & Carbin, 1988; Watson & Clark, 1984). In the current study, the items yielded an internally consistent total score, α=.91.
Creation of Study Groups
Study groups were created using items from the QEWP-R and EDE-Q. Participants with core features of BN reported at least weekly binge eating (eating an unusually large amount of food and experiencing a loss of control while eating) over the past 6 months (“1 episode per week” through “14 or more episodes per week” endorsed on QEWP-R), at least weekly purging (vomiting, laxative misuse, and diuretic misuse total minimum frequency of at least 4 in the past 28 days on the EDE-Q), at least moderate overvaluation of shape or weight (“moderate” score of 4 or greater on either overvaluation of weight or overvaluation of shape on EDE-Q), and a BMI at least 18.5 kg/m2. Note that the BN group required the presence of overvaluation of shape/weight, thereby creating a restricted range of scores above the clinical threshold for this one specific body-image variable. We used the overvaluation continuous composite score (mean of overvaluation of weight and overvaluation of shape) in correlations, but the clinical threshold in the creation of study groups. The BED study group had at least weekly binge eating, at least moderate distress about loss of control (“moderate” score of 3 or greater on the EDE-Q), less than weekly purging (vomiting, laxative misuse, and diuretic misuse total minimum frequency fewer than 4 in the past 28 days on the EDE-Q), and a BMI at least 18.5 kg/m2. Participants with core features of AN had a BMI below 18.5 kg/m2 and endorsed a clinical level (“moderate” score of 4 or greater) on restraint over eating, food avoidance, or dietary rules. The HW study group had a minimum BMI of 25 kg/m2, less than weekly binge eating, and less than weekly purging.
Statistical Analyses
Analyses of variance (ANOVAs) and chi-square tests compared the four study groups (BN, BED, AN, HW) on demographic variables, preoccupation with food/eating, and preoccupation with shape/weight. Post-hoc tests using a Tukey correction for multiple comparisons examined pairwise differences. Pearson correlation coefficients examined associations between clinical characteristics and preoccupation (food/eating and shape/weight) within each study group. Fisher’s r-to-z test compared the magnitude of correlations within and between study groups when correlations were significant. Regression models compared the individual contributions of preoccupation with food/eating and preoccupation with shape/weight for each clinical characteristic with each study group.
RESULTS
Table 1 summarizes demographic characteristics of BN, BED, AN, and HW study groups. The HW group had a significantly higher mean age than the BED and BN groups (who did not differ significantly from each other) and compared with the AN group (who was also significantly younger than BED and BN groups). There were some group differences in race/ethnicity, as shown in Table 1. The BN and AN groups had significantly higher proportions of women compared to the BED and HW groups (but the BN and AN groups did not differ significantly from each other). Table 2 describes the clinical characteristics of each study group. The mean BMI of the BN group was significantly lower than the HW and BED groups (who did not differ significantly from each other). The mean BMI of the AN group was significantly lower than all other groups.
Table 1:
Demographic characteristics by study group
| BN (n=144) | BED (n=576) | AN (n=48) | HW (n=595) | |||||
|---|---|---|---|---|---|---|---|---|
| F | Total df | p | ηp2 | |||||
| Age, M (SD) | 33.63 (11.50)c,d | 35.65 (12.65)c,d | 27.10 (9.73)a,b,d | 38.05 (12.36)a,b,c | 13.58 | 1185 | <.001 | .033 |
| χ 2 | N | p | φ | |||||
| Sex | 11.12 | 1358 | .011 | .090 | ||||
| Male, n (%) | 8 (5.6%)b,d | 76 (13.2%)a,c | 1 (2.1%)b,d | 74 (12.5%)a,c | ||||
| Female, n (%) | 135 (94.4%)b,d | 498 (86.8%)a,c | 47 (97.9%)b,d | 519 (87.5%)a,c | ||||
| Race/Ethnicity | 37.62 | 1356 | <.001 | .167 | ||||
| White, n (%) | 103 (72.0%)b,d | 475 (82.8%)a | 38 (80.9%) | 475 (80.2%)a | ||||
| Black, n (%) | 8 (5.6%) | 29 (5.1%)d | 1 (2.1%) | 47 (7.9%)b | ||||
| Asian, n (%) | 5 (3.5%) | 24 (4.2%) | 4 (8.5%)d | 16 (2.7%)c | ||||
| Hispanic, n (%) | 21 (14.7%)b,d | 33 (5.7%)a | 3 (6.4%) | 26 (4.4%)a | ||||
| Other, n (%) | 6 (4.2%) | 13 (2.3%)d | 1 (2.1%) | 28 (4.7%)b |
Note. HW=individuals with non-eating-disordered higher body weight (BMI>25 kg/m2); BN=core features of bulimia nervosa; BED=core features of binge-eating disorder.
Significantly different from BN at p<.05.
Significantly different from BED at p<.05.
Significantly different from AN at p<.05.
Significantly different from HW at p<.05.
Table 2:
Clinical characteristics by study group
| BN (n=144) | BED (n=576) | AN (n=48) | HW (n=595) | |||||
|---|---|---|---|---|---|---|---|---|
| F | Total df | p | ηp2 | |||||
| Preoccupation with food and eating, M (SD) | 3.72 (2.17) | 2.25 (2.20) | 3.61 (2.36) | 1.11 (1.74) | 86.17 | 1339 | <.001 | .162 |
| Preoccupation with shape and weight, M (SD) | 4.31 (2.03) | 2.71 (2.30) | 3.67 (2.34) | 1.51 (2.04) | 80.23 | 1339 | <.001 | .153 |
| BMI, M (SD) | 30.83 (9.62) | 33.59 (9.63) | 16.85 (2.65) | 33.92 (7.45) | ||||
| Restraint, M (SD) | 4.15 (1.72) | 2.98 (1.86) | 4.63 (1.32) | 2.88 (1.97) | ||||
| Overvaluation, M (SD) | 5.50 (0.80) | 4.71 (1.45) | 4.32 (1.59) | 3.66 (1.93) | ||||
| Dissatisfaction, M (SD) | 5.51 (0.87) | 5.24 (1.19) | 3.63 (1.94) | 4.67 (1.56) | ||||
| BDI, M (SD) | 25.02 (10.97) | 18.77 (10.21) | 19.94 (12.74) | 13.05 (9.20) | ||||
| χ 2 | N | p | φ | |||||
| Clinical level of preoccupation with food and eating, n (%) | 82 (57.3%)b,d | 162 (28.6%)a,c,d | 27 (57.4%)b,d | 70 (11.8%)a,b,c | 163.24 | 1347 | <.001 | .348 |
| Clinical level of preoccupation with shape and weight, n (%) | 100 (69.4%)b,c,d | 218 (38.3%)a,c,d | 25 (53.2%)a,b,d | 116 (19.6%)a,b,c | 148.30 | 1353 | <.001 | .331 |
Note. HW = individuals with non-eating-disordered higher body weight (BMI>25 kg/m2); BN = core features of bulimia nervosa; BED = core features of binge-eating disorder; AN = core features of anorexia nervosa; BMI= body mass index; BDI = Beck Depression Inventory; EDE-Q = Eating Disorder Examination – Questionnaire. Restraint, Overvaluation, and Dissatisfaction are subscales calculated from the EDE-Q brief version and Preoccupation with food and eating and Preoccupation with shape and weight are items on the EDE-Q; possible scores range from 0 through 6 with higher scores indicating greater psychopathology.
Significantly different from BN at p<.05.
Significantly different from BED at p<.05.
Significantly different from AN at p<.05,
Significantly different from HW at p<.05.
There was a significant, graded relationship in both shape/weight preoccupation (F(3, 1335)=80.23, p<.001, ηp2=.153) and food/eating preoccupation (F(3,1335)=86.17, p<.001, ηp2=.162). BN and AN (which did not differ significantly from each other) were higher on both forms of preoccupation than BED, which was in turn higher on both forms of preoccupation than HW. Similarly, proportions of individuals with BN, BED, AN, and HW who endorsed clinical levels of preoccupation with shape/weight (χ2(3, N=1353)=148.30, p<.001, φ=.331) and preoccupation with food/eating (χ2(3, N=1347)=163.24, p<.001, φ=.348) followed a similar graded pattern (see Table 2). A significantly greater proportion of individuals with AN had clinical levels of shape/weight preoccupation (53.2%) than all other groups. A significantly greater proportion of individuals with AN had clinical levels of food/eating preoccupation (57.4%) than BED and HW but did not differ significantly from BN. A significantly greater proportion of individuals with BN had clinical levels of both forms of preoccupation (shape/weight preoccupation: 69.4%, food/eating preoccupation: 57.3%) than individuals with BED (shape/weight preoccupation: 38.3%, food/eating preoccupation: 28.6%), who had in turn a significantly greater proportion than individuals categorized with HW (shape/weight preoccupation: 19.6%, food/eating preoccupation: 11.8%).
Across study groups, the correlation of shape/weight preoccupation with food/eating preoccupation was higher for AN (r=.85; p<.01 for all correlation comparisons) but other groups had similar magnitudes (BN r=.64, BED r=.68, HW r=.63, p>.05 for all correlation comparisons). Correlations of each form of preoccupation with eating-disorder psychopathology and depression, as well as significant differences in correlation magnitudes, are summarized in Table 3. Within the BN study group, there were no significant differences in the magnitude of associations of shape/weight preoccupation and food/eating preoccupation and dietary restraint, dissatisfaction with shape/weight, or depression. Likewise, there were no significant differences in correlation magnitudes within the BED and AN study groups. However, within the HW study group, overvaluation had a significantly stronger association with shape/weight preoccupation than food/eating preoccupation (Z=−2.02, p=.04). In the HW group, dissatisfaction was significantly more strongly associated with shape/weight preoccupation than food/eating preoccupation (Z=−2.35, p=.02), and depression also had a significantly stronger association with shape/weight preoccupation than food/eating preoccupation (Z=−2.34, p=.02). Other correlation magnitudes did not differ significantly.
Table 3:
Associations between clinical characteristics and preoccupation by study group
| Preoccupation with Food/Eating | Preoccupation with Shape/Weight | Within Group Correlation Comparison (PFE vs PSW) | Between Group Correlation Comparison (BN vs BED vs AN vs HW) | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| BN | BED | AN | HW | BN | BED | AN | HW | |||
| Preoccupation with shape and weight | 0.64*** | 0.68*** | 0.85*** | 0.63*** | - | - | - | - | - | BN<AN BED<AN HW<AN |
| Preoccupation with food and eating | - | - | - | - | 0.64*** | 0.68*** | 0.85*** | 0.63*** | - | - |
| Restraint | 0.40*** | 0.36*** | 0.62*** | 0.36*** | 0.21* | 0.27*** | 0.72*** | 0.27*** | ns | BNPSW<ANPSW; BEDPFE<ANPFE; BEDPSW<ANPSW; HWPFE<ANPFE; HWPSW<ANPSW |
| Overvaluation | 0.04 | 0.34*** | 0.46** | 0.31*** | 0.14 | 0.36*** | 0.48*** | 0.41*** | PFEHW<PSWHW | ns |
| Dissatisfaction | 0.10 | 0.20*** | 0.62*** | 0.23*** | 0.29*** | 0.24*** | 0.71*** | 0.36*** | PFEHW<PSWHW | BEDPSW<HWPSW; BNPSW<ANPSW; BEDPFE<ANPFE; BEDPSW<ANPSW; HWPFE<ANPFE; HWPSW<ANPSW |
| BMI | −0.07 | 0.02 | −0.26 | 0.05 | 0.03 | 0.02 | −0.25 | 0.07 | - | - |
| BDI | 0.23** | 0.31*** | 0.60*** | 0.21*** | 0.23** | 0.31*** | 0.56*** | 0.34*** | PFEHW<PSWHW | BNPFE<ANPFE; BEDPFE<ANPFE; BNPSW<ANPSW; HWPFE<ANPFE |
Note. HW= individuals with non-eating-disordered higher body weight (BMI>25 kg/m2); BN = core features of bulimia nervosa; BED = core features of binge-eating disorder; AN = core features of anorexia nervosa; PFE = preoccupation with food/eating; PSW = preoccupation with shape/weight; ns = no significant differences; BMI = body mass index; BDI = Beck Depression Inventory; EDE-Q = Eating Disorder Examination – Questionnaire. Correlations were only compared when correlations were significant. All listed correlation comparisons are significant, p<.05. Restraint, Overvaluation, and Dissatisfaction are subscales calculated from the EDE-Q brief version and PFE and PSW are items on the EDE-Q; possible scores range from 0 through 6 with higher scores indicating greater psychopathology.
Significant at p<.05.
Significant at p<.01.
Significant at p<.001.
Significant differences in correlation magnitudes between study groups are also summarized in Table 3. Between study groups, the correlation of shape/weight preoccupation and overvaluation did not differ significantly between BED, AN, and HW. The association of shape/weight preoccupation and dietary restraint was significantly stronger in the AN study group than all other study groups (BN: Z=3.95, p<.001, BED: Z=3.99, p<.001, HW: Z=3.99, p<.001). The association of food/eating preoccupation and dietary restraint was significantly stronger in the AN study group than BED (Z=2.24, p=.025) and HW (Z=2.27, p=.023) but did not differ significantly from BN. The association of shape/weight preoccupation and dissatisfaction was significantly stronger in the AN study group than all other study groups (BN: Z=3.43, p<.001, BED: Z=4.10, p<.001, HW: Z=3.31, p<.001). In addition, the association of shape/weight preoccupation and dissatisfaction was significantly stronger in the HW study group than the BED study group (Z=−2.13, p=.03). The association of food/eating preoccupation and dissatisfaction was significantly stronger in the AN study group than BED (Z= 3.29, p<.001) and HW (Z= 3.09, p=.002). The association of shape/weight preoccupation and depression was significantly stronger in the AN study group than BN (Z= 2.14, p=.033) but did not differ significantly from BED or HW. The association of food/eating preoccupation and depression was significantly stronger in the AN study group than all other study groups (BN: Z=2.52, p=.012, BED: Z= 2.31, p=.021, HW: Z= 2.95, p=.003). The correlation magnitudes for shape/weight preoccupation and other variables did not differ significantly between groups. The correlation magnitudes for food/eating preoccupation and other variables did not differ significantly between groups.
Regression models showed similar patterns as correlations, with some notable differences (see Table 4 for all regression models). All regression models were significant for dietary restraint, body dissatisfaction, and depression, for each study group. The regression model of overvaluation was significant in AN, BED, and HW study groups but not BN. No regression models were significant for BMI, in any study group. Food/eating preoccupation accounted for a significant proportion of variance in BN, BED, and HW study groups but not AN; shape/weight preoccupation was only significant in the AN study group. For body dissatisfaction, shape/weight preoccupation accounted for a significant amount of variance in dissatisfaction in all study groups, but food/eating preoccupation was not significant.
Table 4:
Regression models of clinical characteristics and preoccupation by study group
| BN | BED | AN | HW | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| F | R 2 | β | F | R 2 | β | F | R 2 | β | F | R 2 | β | |
| Restraint | 13.97 *** | 16.6% | 42.21 *** | 13.1% | 21.53 *** | 50.0% | 44.44 *** | 13.2% | ||||
| Shape/weight preoccupation | −.077 | .051 | .671 ** | .076 | ||||||||
| Food/eating preoccupation | .453 *** | .326 *** | .042 | .310 *** | ||||||||
| Overvaluation | 1.58 | 2.2% | 47.57 *** | 14.7% | 6.62 ** | 24.0% | 59.18 *** | 17.3% | ||||
| Shape/weight preoccupation | - | .223 *** | .380 | .366 *** | ||||||||
| Food/eating preoccupation | - | .196 *** | .124 | .072 | ||||||||
| Dissatisfaction | 7.30 *** | 9.4% | 17.66 *** | 6.0% | 21.26 *** | 50.3% | 40.85 *** | 12.6% | ||||
| Shape/weight preoccupation | .376 *** | .194 *** | .651 ** | .352 *** | ||||||||
| Food/eating preoccupation | −.136 | .067 | .068 | .004 | ||||||||
| BMI | 1.17 | 1.6% | 0.144 | 0.1% | 1.63 | 7.1% | 1.29 | 0.4% | ||||
| Shape/weight preoccupation | - | - | - | - | ||||||||
| Food/eating preoccupation | - | - | - | - | ||||||||
| BDI | 4.52 * | 6.7% | 31.54 *** | 11.1% | 10.59 *** | 35.2% | 33.65 *** | 11.6% | ||||
| Shape/weight preoccupation | .141 | .176 ** | .166 | .359 *** | ||||||||
| Food/eating preoccupation | .144 | .187 ** | .444 | −.028 | ||||||||
Note. HW= individuals with non-eating-disordered higher body weight (BMI>25 kg/m2); BN = core features of bulimia nervosa; BED = core features of binge-eating disorder; AN = core features of anorexia nervosa; PFE = preoccupation with food/eating; PSW = preoccupation with shape/weight; ns = no significant differences; BMI = body mass index; BDI = Beck Depression Inventory; EDE-Q = Eating Disorder Examination – Questionnaire. Restraint, Overvaluation, and Dissatisfaction are subscales calculated from the EDE-Q brief version and PFE and PSW are items on the EDE-Q; possible scores range from 0 through 6 with higher scores indicating greater psychopathology.
Significant at p<.05.
Significant at p<.01
Significant at p<.001.
DISCUSSION
Our findings add to our understanding of the relatively understudied construct of preoccupation among individuals with core features of eating disorders. To our knowledge, this is the first study to examine how preoccupation with two targets—shape/weight and food/eating—compare among individuals categorized with BN, BED, AN, and non-eating-disordered HW. One important finding is that the two forms of preoccupation are more strongly associated in the AN study group compared with other study groups. We also found that for the AN group, both forms of preoccupation were, overall, more strongly associated with psychopathology than for the BN, BED and HW groups. While there were no significant within-group differences in these two preoccupation targets and clinical characteristics among individuals categorized with BN, BED, and AN, there were some significant within-group differences among individuals in the HW study group. Additionally, the pattern of whether each form of preoccupation accounted for a significant amount of variance in each clinical characteristic showed overall similarities across groups.
Preoccupation with both content areas was highest in AN and greater in the BN study group than in BED, and both preoccupations in BED were in turn greater than in HW. Prior studies have identified shape/weight preoccupation as a distinct body-image construct that is strongly correlated with eating concerns in BED and is a central feature to the severity and maintenance of symptoms in BN (Askew et al., 2020; Grilo et al., 2019; Levinson et al., 2017; Lydecker et al., 2017). Preoccupation with food/eating has been associated with higher levels of dietary restraint in women engaging in dieting or binge eating (Timmerman & Gregg, 2003). Our findings extend this work by showing evidence that both types of preoccupation are part of the psychopathology of BN, BED, and AN, not just shape/weight preoccupation.
Notably, correlations and regressions with BMI did not have significant associations with either form of preoccupation in any of the study groups. In contrast, overvaluation, dissatisfaction, and dietary restraint had significant correlations with both forms of preoccupation in BED, AN, and HW study groups. In the BN study group, overvaluation and dissatisfaction were not associated significantly with food/eating preoccupation and overvaluation was not associated significantly associated with shape/weight preoccupation. However, this pattern may have been partly due to the requirement of clinical overvaluation of shape or weight in the categorization of the BN study group. The non-significance of BMI with shape/weight preoccupation and food/eating preoccupation highlights that eating-disorder psychopathology, including maladaptive body-image and eating cognitions, occurs across the weight spectrum. In addition to eating-disorder psychopathology, depression was significantly associated with both types of preoccupation in all study groups. The strong relationship between depression and both types of preoccupation indicates that preoccupation is associated with negative affect not only in individuals with core features of eating disorders, but in individuals without eating disorders as well.
Correlations between preoccupation items and other eating-disorder psychopathology did not differ in magnitude within BN, BED, or AN study groups, although there were some differences within the non-eating-disordered HW group. These findings suggest there may be a greater distinction between shape/weight preoccupation and food/eating preoccupation in their relation to aspects of eating-disorder psychopathology in individuals without core features of eating disorders. Differences within the HW group suggested that shape/weight preoccupation was more strongly associated with psychopathology than food/eating preoccupation, which highlights the particular importance of body image in non-eating-disordered groups. Our findings contribute to the existing literature by providing evidence that within BN, BED, and AN groups, preoccupation with shape/weight and preoccupation with food/eating are not differentially associated with other clinical characteristics, as they occur with comparably high associations.
As a complement to these findings regarding the magnitude of correlations within groups, we also compared the magnitude of correlations between groups and whether each form of preoccupation accounted for a significant amount of variance. Both forms of preoccupation had stronger associations with most clinical variables in the AN group compared with other study groups. This suggests that preoccupation (with both content forms) has particular relevance for individuals with core features of AN. In contrast, we observed a pattern in the regression models suggesting that the content of the preoccupation had a greater role than the study group, per se. That is, food/eating preoccupation accounted for a significant amount of variance in dietary restraint in BN, BED, and HW but not AN. The reverse was true for dissatisfaction, where shape/weight preoccupation accounted for a significant amount of variance in dissatisfaction but food/eating preoccupation was not significant. Findings for the HW group for the other variables showed the same pattern as correlation magnitudes: shape/weight preoccupation was more strongly associated with overvaluation and depression than food/eating preoccupation.
Taken together, these findings suggest the potential utility of future work considering how the content of preoccupation, when present, relates to psychopathology. If replicated and extended in future studies, such findings would suggest greater focus on the cognitive style of preoccupation might potentially enhance interventions for eating disorders. For example, the recommended treatment for eating disorders, cognitive-behavioral therapy (CBT) (Agras, 2019; Grilo, 2017; National Institute for Health and Care Excellence, 2017), focuses on overvaluation of shape/weight as the central maladaptive cognitive process conceptualized to maintain behavioral, emotional, and other cognitive features of eating disorders (Fairburn, Cooper, & Shafran, 2003). Prior work has additionally emphasized the importance of considering preoccupation with shape/weight as part of treatment planning and delivery, particularly in relation to eating concerns and dietary restraint (Askew et al., 2020; Lydecker et al., 2017; Mitchison et al., 2017). Our findings suggest that preoccupation as a cognitive style (i.e., both food/eating and shape/weight preoccupation) could be helpful to address for those patients who experience these types of thoughts. However, this should be interpreted within the context of the study’s limitations, detailed below, and should be tested prior to applying in clinical treatment.
Our findings should be considered in the context of the study’s strengths and limitations. The study design was cross-sectional and examined associations, so no conclusions about causality of differences in forms of preoccupation can be determined. An important extension of our work in light of these findings would be to examine shape/weight preoccupation and food/eating preoccupation prospectively and in treatment-seeking samples to understand whether the content of the preoccupation is associated with clinical characteristics or treatment outcomes, as well as whether specific interventions targeting preoccupation improve treatment outcomes. Notably, participants were categorized into study groups based on self-report measures, rather than clinical interviews or observational data, and are therefore subject to reporting biases. However, it is possible that self-report might facilitate more honest reporting, particularly when anonymous and when subject matter is sensitive, as was the case with these data. Our findings should be confirmed in samples that have clinical diagnoses of BN, BED, and AN before applying findings to clinical treatment. Lastly, our sample was primarily White and female. Future research examining whether these findings are more broadly generalizable to the important groups not well-represented in our sample is essential.
The current study contributes to the existing literature by examining preoccupation with shape and weight alongside preoccupation with food and eating in individuals with core features of BN, BED, AN, and non-eating-disordered HW. The results indicate that both types of preoccupation are significantly higher in AN and BN than BED and in turn HW, but that some individuals in all study groups reported clinically significant levels of both preoccupation with shape/weight and preoccupation with food/eating. These findings hold important implications for treatment research, including developing and testing interventions for preoccupation. It is also recommended that CBT clinicians and clinical-researchers think more broadly about the importance of preoccupied cognitions across eating disorders, in thought logs, cognitive restructuring interventions, and treatment formulation.
Funding:
This research was supported, in part, by National Institutes of Health grant K23 DK115893 and UL1 TR001863. Funders played no role in the content of this paper.
Footnotes
Potential conflicts of interest: The authors (Lydecker, Simpson, Smith, White, Grilo) report no conflicts of interest.
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