Body image victimization and eating distress in young adult females

doi:10.21203/rs.3.rs-3131042/v1

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Body image victimization and eating distress in young adult females

https://doi.org/10.21203/rs.3.rs-3131042/v1

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Background

Eating distress syndrome (EDS) is characterized by distressing and conflicting thoughts about the body shape and eating behaviours accompanied by self-imposition of strict dietary and/or exercise regimes in the absence of any significant weight loss. EDS has prevalence of nearly 11% and is associated with psychological distress, internalizing and externalizing problems, lesser well-being, and reduced quality of life.

Methods

The study aimed to assess the relationship between eating-related messages, and body image victimization with eating distress syndrome in young adult females. Purposive sampling was employed to approach an estimated sample size of 151 young adults (18–26 years). The data was collected online by using e-consent through social media platforms such as Facebook, Twitter, Instagram, etc. via Google Form (GF). There was a total of 403 respondents to GF comprising of Caregiver Eating Messages Scale (CEMS), Body Image Victimisation Experience Scale (BIVES), Eating Disorder Examination - Questionnaire Short (EDE-QS). Total 151 were recruited from 403 as per defined criteria.

Results

Restrictive or critical messages (RCM) had a positive relationship and accounted 12% chance of occurrence of EDS. Frequency of experiences of body image victimization from peers (6%) had a greater predictive value than that from the parents (3%). Similarly, the impact of body image victimization by peers (9%) contributed more than that from the parents (4%) in the occurrence of EDS.

Conclusion

Remarks or comments related to eating and appearance tend to determine how an individual perceived oneself and the course of one’s food habits or choices.

Body image

eating distress

eating disorder

caregiver messages

eating

Eating behaviors encompass a broad spectrum of behaviors which include feeding practices, dieting, food choices, and motives, as well as eating patterns such as overeating or restrained eating that sometimes may lead to obesity, feeding disorders, and eating disorders (ED).^[1] The Eleventh Revision of the International Classification of Diseases (ICD-11) classifies feeding or eating disorders into 7 categories i.e., anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant-restrictive food intake disorder, pica, rumination-regurgitation disorder and other specified feeding or eating disorders.^[2] The extent of eating behaviors ranging largely from health-promoting eating behaviors to eating disorders also comprise a lesser explored subthreshold state of disordered eating. This section of a nonclinical yet vulnerable population that experiences disordered patterns of eating has been referred to as eating distress syndrome (EDS) in Indian literature. ^[3] Srinivasan et al described EDS to be characterized by distressing and conflicting thoughts about the body shape and eating behaviors accompanied by self-imposition of strict dietary and/or exercise regimes in the absence of any significant weight loss. However, individuals having EDS do not resort to severe measures such as diet pills, purging, or starvation as opposed to those diagnosed with ED though, episodes of binging might be present in some. ^[3] They conceptualized EDS to be an archaic form of the eating disorders prevalent in industrialized, and Western countries. ^[4]

However, this subthreshold population has largely remained under-researched in Indian literature despite the near 11% prevalence of EDS in the country. ^[5] The research showed that disordered eating behaviors could have both short-term as well as long-term consequences and deteriorated mental and physical health. This pattern of eating (EDS) was found to be associated with psychological distress, internalizing and externalizing problems, lesser well-being, and reduced quality of life. ^[6–8]

Existing literature indicated that early experiences particularly parental attitudes towards food, food choices made by them, and behaviors modeled as well as reinforced in children were likely to play an important role in the development of eating behaviors. ^{[9, 10]} Other important factors could be personal preferences, economic resources, health status, and socio-cultural environmental factors. ^[11] Socio-cultural factors of the early environment might contribute to women having a higher prevalence of ED – a finding observed by Bruch who stated that compliance to societal and parental expectations was reinforced in women hampered their ability to develop a sense of personal competence and inner-directedness. The preoccupation with body appearance, weight, and disordered eating patterns was a response to the powerlessness they experienced, and an attempt to develop a sense of control. ^[12] Early verbal and non-verbal messages conveying the child to restrict their eating contributed to the development of body dissatisfaction as well as disordered eating patterns in men and women.^[13] Furthermore, explicit body image victimization by family and peers through name-calling or comments regarding one's physical appearance, size, or weight also impacted the eating behaviors and self-identity of young females. ^[14]

The Indian studies either focused on studying the prevalence or identifying the correlates of eating disorders. However, not much has been explored or highlighted regarding the sub-syndromal population (EDS). The present study hypothesized that restrictive/critical caregiver eating messages along with the experience of body image victimization by family and peers during childhood and adolescence might lead to engagement in disordered eating behaviors referred to as the eating distress syndrome in young adult females.

The study aimed to assess the relationship between eating-related messages, and body image victimization with eating distress syndrome in young adult females. The study was exploratory research having correlational and cross-sectional design. ^[15] Purposive sampling was employed to approach an estimated sample size of 151 young adults. ^[16–18] The data was collected online by using e-consent through social media platforms such as Facebook, Twitter, Instagram, etc.^[19] Google Forms (GF) was prepared by the researcher to gather information on sociodemographic, health, and food intake details along with the standardized tools transferred to GF. ^[20]

Participants

There was a total of 403 respondents to GF, 1 declined to consent to participate and another was a male. Out of these 401, 151 young adults (18–26 years) with a minimum of 12 years of formal education and currently feeling dissatisfied with their eating behaviors and/or physical appearance due to shape, size, and/or weight of body were included in the study. The researcher manually filtered the data and excluded participants as per the defined exclusion criteria. Those who scored (52) above the cut-off on Eating Disorder Examination - Questionnaire Short (EDE-QS), reported (92) satisfaction with eating behavior and appearance and had received (3) a diagnosis of eating disorders or other psychiatric illnesses (19 had depression, 16 had anxiety, 13 had mixed anxiety & depression, 1 had adjustment disorder: 1, 2 had Bipolar affective disorder, 1 had attention deficit hyperactivity disorder, 1 had a borderline personality disorder, 17 checked 'yes' but did not disclose their diagnosis) were excluded from the study. Those who had undergone (4) cosmetic/bariatric surgery due to dissatisfaction with their physical appearance were also excluded. Additionally, to maintain the homogeneity of the sample, responses submitted by foreign residents (9) were excluded; to control for any extra-therapeutic benefits, the study also excluded those who had sought treatment (13) from a professional or had been a part of any support group for addressing their eating or weight-related issues or had sought any counseling/therapy (7) by a mental health professional for eating/body related issues in the past 6 months. ^[21]

Insert Fig. 1

Measures

Caregiver Eating Messages Scale (CEMS) is a 10-item self-report measure that assesses the perception of the messages one received from caregivers about what to eat when to eat, and how much to eat. ^[13] CEMS comprises two subscales - restrictive or critical messages and pressure to eat messages. The responses are recorded on a 6-point Likert-type scale, 1 (never) to 6 (always), with higher scores indicating greater perceived pressure to eat or criticalness or restriction of food choice/intake. The Cronbach's alpha for both pressure-to-eat messages as well as for restrictive/critical messages for women is 0.86, therefore, considered apt for the current study. ^[13]

Body Image Victimization Experience Scale (BIVES) is a 12-item self-report measure that assesses experiences of bullying and teasing by peers or caregivers during childhood or adolescence period due to physical appearance. ^[22] The participant responded to the items retrospectively on a 5-point Likert-type scale determining the frequency (part A) of being targeted for their physical appearance by peers or parents and the impact (part B) of such experiences on the individual. The response scale ranges from 1 = never to 5 = very frequently (part a) and from 1 = nothing to 5 = a lot (part B). The total score for both parts was derived from the mean of all item scores and ranges between 1 and 5. The Cronbach’s alpha of the scale is 0. ^[22]

Eating Disorder Examination - Questionnaire Short (EDE-QS) is a 12-item version of the Eating Disorder Examination – Questionnaire (EDE-Q) (Gideon et al., 2016). It assesses eating disorder symptoms over the preceding seven days rated on a 4-point scale ranging from 0 to 3. Higher scores indicate inflated symptoms of the eating disorder. Scores range from 0 to 36 and a score higher than 15 is considered to be indicative of ED. The Cronbach’s alpha of the scale is 0.91. ^[23] For the current study, a score below 15 on the questionnaire was conceptualized to be indicative of eating distress syndrome as it reflected a difficult relationship with eating behavior that is below the disordered level. The EDE-QS scale had been validated on the Chinese population befitting it for assessing the eating behaviors in the Asian population that reduced the recall bias by keeping a short time frame of the past 7 days. ^[24]

Procedure

The research proposal was submitted to the Institution Ethics Committee (IEC) with all annexures including the informed consent form, sociodemographic and clinical profile sheet, and assessment tools. In the meanwhile, the google form (GF) process ensued. ^{[20, 25]} GF was prepared over 4 hours across 2 days and comprised of various sections; section 1 contained the information sheet and informed consent; sections 2 and 3 sought information regarding socio-demographics and clinical details respectively; sections 4 to 6 comprised of the questionnaires i.e., CEMS, BIVES, and EDE-QS in that order. The last section thanked the participant for their interest and the time is taken out for the study. The contact details of the primary researcher, the first author, were shared in the message accompanying the GF uniform source locator (URL) as well as on the information sheet of the consent page. For ethical considerations, the e-consent section informed the participants about the process of reaching out to mental health professionals if required, and an option was given to contact the researcher to facilitate the same. Thereafter, the GF was ready to be accessed using the URL (https://forms.gle/3XFfZR7HMWf6GgaQ6).

The next step was to check the GF for any technical glitches, the link was first circulated among the authors filling in dummy responses with different scenarios such as declining the consent to participate resulted in the termination of participation, responding to the questionnaire but closing the browser without submitting the responses, feeding gender as ‘male’ etc. Next, the link to GF was shared with 3 fellow professionals, and 4 non-psychology peers of the researcher for review and feedback. The authors had 4 meetings over a period of one month to hold discussions on the feedback. Consequently, after final rectifications, the GF was then ready to be circulated among the target population.

By now, the approval letter from IEC (IEC/671R/2021/426) had been received and then the GF was first sent to five individuals. The authors looked into the Excel sheet adding a column that mentioned the status of inclusion or exclusion for each participant. Thereafter, the primary researcher identified platforms from which the target population could be approached, namely, WhatsApp (WA), WhatsApp Business (WA Bus), Instagram (IG), Email, and Facebook (FB). The messages having GF links and the primary researcher's contact details were circulated on the identified social media platforms. The link was shared through WA Bus among college students who had completed the Internship program run by the Department over the last 5 years so it could be sent out on WA further to reach the target population (67 posts) and they could post on the alumni college groups. It was also shared through email with two individuals from an undergraduate course in a metropolitan city (2 posts) and on 4 posts on WA Bus groups. A total of 4 posts on FB pages that catered to women's health and well-being were contacted to post the link on their page, out of which no engagement was observed in the form of either likes or responses. Thereafter, the GF link was never posted again. On IG, two business accounts dedicated to female sexual and mental health were contacted, and the message was sent out along with the GF URL; out of which one page did not show much engagement while the page on female sexuality was responsive. Therefore, the researcher requested them and reminded them once in 2 weeks to repost, and a total of 7 times it was posted on that IG account. Ten personal IG accounts of males were contacted through direct messages and they were requested to share the URL with female friends or college groups (10 posts). A total of 124 individuals as well as 8 academic groups were contacted via WA (124 + 8 = 132).

As a result, a total of 403 responses were recorded on the auto-generated Google sheet out of which one individual had declined consent. A master sheet had been created at the beginning of data collection on Microsoft Excel, all the responses were stored here and filtered as per the criteria. From the 402 responses, 251 responses were excluded based on the set exclusion criteria (Fig. 1). The remaining 151 constituted the study sample. The responses of these participants were further computed to attain individual scaled scores and finally, the data were coded for analysis.

Statistical analysis

Data were analyzed using Statistical Package for the Social Sciences version 26. Descriptive statistics were computed for demographic variables i.e., age, years of education, BMI, sex, education, and zone of residence, as well as the clinical variables. Pearson product-moment correlation was computed to interpret the relationship among the measures. ^[26] Further regression analysis was computed to determine the predictors of eating distress. ^[27]

The present study aimed to assess the relationship among eating-related messages, body image victimization, and eating distress syndrome in young adult females. The sociodemographic profile of the sample is shown in Table 1. The mean age was 21.48 ± 2.35 years with 15.29 ± 1.64 years of formal education. The GF was widely circulated so the sample was categorized as per the zones determined by the Government of India. ^[28]

Table 1

Characteristics of the participants (N = 151)
Variable		Mean (SD) / f (%)
Age		21.48 (2.35)
Sex		151 (100)
Education years		15.29 (1.64)
Education level	Diploma	6 (4)
	Graduation	86 (57)
	Post-Graduation	59 (39.1)
Body Mass Index		23.31 (14.27)
Zone	Northern	89 (58.9)
	Southern	23 (15.2)
	North Eastern	5 (3.3)
	Eastern	6 (4)
	Western	22 (14.6)
	Central	6 (4)
SD: Standard deviation, f: Frequency, %: Percentage

Insert Table 1

Table 2 depicts the mean and standard deviation (SD) of the scores on the assessment measures namely; CEMS, BIVES, and EDE-QS.

Table 2

Descriptive statistics of assessment measures (N = 151)
Measures		Mean	SD
CEM	PEM	3.45	1.02
CEM	RCM	2.03	1.07
BIVES	Frequency	1.91	0.78
	Impact	1.99	0.91
	Parent Frequency	1.86	1.04
	Parent Impact	1.92	1.14
	Peer Frequency	1.97	0.85
	Peer Impact	2.05	1.02
EDE-QS		8.02	3.95
SD: Standard deviation, CEM: Caregiver Eating Messages, PEM: Pressure to eat messages, RCM: Restrictive/ critical messages, BIVES: Body Image Victimisation Experience Scale, EDE-QS: Eating Disorder Examination - Questionnaire Short

Insert Table 2

The Pearson product-moment correlation coefficient was computed to determine the relationship between eating-related messages, and body image victimization with eating distress syndrome. Pressure to eat messages (PEM) and restrictive or critical messages (RCM) showed a significant positive correlation with frequency as well as the impact of body image victimization, but only restrictive or critical messages had a positive relationship with eating distress syndrome (EDS). The strength of the relationship ranged from negligible (r = .00 to .30) to low (r = .30 to .50) except the relationship between restrictive or critical messages and the impact of body image victimization from parents had a significant moderate correlation (r = .50 to .70). The frequency and impact of body image victimization from either parents or peers had negligible to low significant positive correlation with EDS.

Insert Table 3

Table 3

Pearson correlation of eating related messages, and body image victimisation with eating distress syndrome of the study sample (N = 151)
Measure		CEM		BIVES						EDE-QS
Measure		PEM	RCM	F	IM	Parent-F	Parent-IM	Peer-F	Peer-IM	EDE-QS
CEM	PEM	1	.15	0.32**	0.26**	0.28**	0.24**	0.26**	0.22**	.08
CEM	RCM	-	1	0.44**	0.47**	0.49**	0.53**	0.23**	0.25**	.36**
BIVES	F	-	-	1	.91**	.87**	.82**	.79**	.73**	.27**
	IM	-	-	-	1	.76**	.83**	.75**	.85**	.34**
	Parent-F	-	-	-	-	1	.93**	.38**	.38**	.19*
	Parent-IM	-	-	-	-	-	1	.38**	.42**	.23**
	Peer-F	-	-	-	-	-	-	1	.90**	.27**
	Peer-IM	-	-	-	-	-	-	-	1	.32**
EDE-QS										1
*:Correlation is significant at the 0.01 level (2-tailed), :Correlation is significant at the 0.05 level (2-tailed) CEM: Caregiver Eating Messages, PEM: Pressure to eat messages, RCM: Restrictive/ critical messages, BIVES: Body Image Victimisation Experience Scale, F: Frequency, IM: Impact, EDE-QS: Eating Disorder Examination - Questionnaire Short

The regression analysis (Table 4) was computed for significant correlations, it determined the coefficient of determination (R²), predicting the amount of change in the dependent variable (DV) EDS, contributed by the independent variables (IVs) CEM and BIVES. It was found that restrictive or critical messages from caregivers significantly accounted 12% chance of occurrence of eating distress syndrome. The frequency and impact of body image victimization had significant contributions of 6% and 11% respectively resulting in EDS. It was observed that the frequency of experiences of body image victimization from peers (6%) had a greater predictive value than that from the parents (3%). Similarly, the impact of body image victimization by peers (9%) contributed more than that from the parents (4%) in the occurrence of EDS.

Table 4

Simple linear regression model for EDE-QS as the outcome variable
IV		DV	B	SE	F	Adjusted R²	t	p	Beta
CEM	RCM	EDE-QS	1.32	0.28	22.07	0.12	4.69	0.000**	0.35
BIVES	Frequency		1.37	0.39	12.06	0.06	3.47	0.001**	0.27
	Impact		1.48	0.33	19.66	0.11	4.43	0.000**	0.34
	Parent-F		0.73	0.30	5.79	0.03	2.40	0.017*	0.19
	Parent-IM		0.80	0.27	8.61	0.04	2.935	0.004**	0.23
	Peer-F		1.26	0.27	11.95	0.06	3.45	0.001**	0.23
	Peer-IM		1.25	0.36	17.54	0.09	4.18	0.000**	0.27
* – p < .001; – p < .01; * – p < .05 IV: Independent variable, DV: Dependent variable, SE: Standard error, CEM: Caregiver Eating Messages, PEM: Pressure to eat messages, RCM: Restrictive/ critical messages, BIVES: Body Image Victimisation Experience Scale, F: Frequency, IM: Impact, EDE-QS: Eating Disorder Examination - Questionnaire Short

Insert Table 4

The study aimed to highlight the role of early life experiences such as eating messages received from caregivers and body image victimization by parents as well as peers in the development of eating distress syndrome among young adult females. The results indicated that on average the participants received more pressure to eat messages as opposed to restrictive/critical eating messages. Messages that pressurize the child to eat have been associated with lower body weight status and fussy eating habits, whereas restrictive/critical messages tend to be associated with high parental concern about a child becoming overweight. ^[29–31] When looking at the body image victimization experience scale, it was apparent that the impact of the experience on victimization had higher mean scores than the frequency of its occurrence. This was a consistent finding indicating that the personal meaning and impact of the victimization may have less to do with how frequently the person was body shamed or victimized. It implied the significance of isolated incidents of body image victimization and also focused on other factors which may influence the impact such as shame about body image, self-objectification behaviors on social media, self-compassion, etc. ^[32–34]

The participants of the study experienced body image victimization from peers and colleagues more frequently than they did from their parents and the impact of victimization by peers was much more than otherwise. This finding may be understood keeping in mind that the participants were asked to recall the experiences of body image victimization from their adolescence which is a period where peer influences and one's social image among their peers is a great source of validation. ^[35] Therefore, it would be expected that mockery and victimization at the hand of peers impacted the individual more significantly than parental commentary did.

The findings showed that pressure-to-eat messages were positively associated with body image victimization but did not have an association with EDS. Studies generally showed that parental messages which pressure to eat have an association with a lower preference for pressured food, fussy eating habits, low intake of fruits and vegetables, and lower weight but its role on BMI might be mediated by cultural factors. ^{[36, 37]} Therefore, individuals receiving pressure to eat messages may have varying body weights and shapes but may still experience body shaming and victimization.

On the other hand, restrictive/critical messages (RCM) were found to be positively associated with all measures of body image victimization and eating disorder examination – questionnaire short. The association between RCM and disordered eating patterns had been established by previous studies and the current study also had similar findings. ^[13] Individuals experiencing RCM might not learn to eat based on hunger and satiety signals rather they might eat based on the perceived familial body acceptance and pressure to be thin. ^[13] This indicated that body image victimization by parents may be mediating between receiving restrictive/critical eating messages and the development of disordered eating behaviors. Though restrictive/critical messages may be a significant predictor of eating distress, many other factors might be responsible as well for the development of disordered patterns of eating including internalized shame schema, drive for thinness, determining self-worth by physical appearance, peer-influenced weight-related attitudes and upward appearance comparison. ^[38–41]

When examining EDE-QS scores, the findings showed an association between EDE-QS and all subscales of BIVES which indicated that those who had experienced body image victimization were likely to develop eating distress. The association was stronger between EDE-QS and impact subscales than with frequency subscales which again pointed to the importance of the mediating factors as mentioned above. The overall impact of experiencing body victimization was an important predictor, a finding supported by the longitudinal studies as well.^[42] The personal impact of experiencing body shaming or victimization at the hand of one’s peers was a stronger predictor of distressed eating behavior than the mere frequency of body victimization by peers. Other studies also found that peer influence impacts the development of disordered eating patterns indicating that peer group experiences are a significant predictor of the development of distressed eating patterns. ^{[43, 44]} Criticality, body victimization, and bonding with parents were important predictors of disordered eating. ^{[45, 46]} Similar to the influence of peers, the personal impact of experiencing parental body victimization was a stronger predictor of disordered eating than the mere frequency of its occurrence. While body victimization by parents is an important factor, there might be other factors that may play a stronger role such as childhood trauma of violence, weight stigma, emotion dysregulation and impulsivity, and various other factors. ^[47–49]

On the whole, the findings of the current study highlighted some important predictors of disordered eating patterns among young adult females. Factors such as restrictive/critical eating messages by caregivers or parents while growing up and perceived impact of body image victimization by peers and colleagues are stronger predictors of developing eating distress syndrome which is characterized by dissatisfaction with one's body shape, size or weight along with unhealthy patterns of eating and dietary restraint. Other important predictors identified by the study were the frequency and impact of body image victimization by parents.

It can be concluded that early life experiences including remarks or comments related to eating and appearance tend to determine how an individual perceived oneself and the course of one’s food habits or choices. Consequently, some develop eating disorders and gain the attention of mental health professionals (MHP) while others may go unnoticed and continue to live with EDS without progressing to ED. Nylander’s hypothesis state that eating disturbances and eating disorders differ in severity but share the underlying psychological characteristics that need to be addressed in treatment as both are an attempt to develop a sense of control manifesting poor self-regulation. ^{[10, 12]} The study revealed that early experiences with significant others lay the foundation of coping mechanisms and regulation strategies in adolescence and adulthood.

The study had limitations of inherent cross-cultural differences as a confounding variable and reporting of symptoms over the preceding seven days on EDS-QS. The findings of the study hold significant clinical implications for individual, group, and family therapies in different age groups. Given the role of early experiences in eating psychopathology, future studies can explore if these messages (pressure to eat or restrictive/critical) act as a latent form of emotional abuse that requires resolution of cumulative beliefs for successful treatment outcome. Further research can compare eating messages with other forms of early experiences and observe gender differences.

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Body image victimization and eating distress in young adult females

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