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Hi all! I would like to share this research study with you all because I think it's important but mostly we all need to know the dieting is a form of disordered eating. Here is some of the research.
Disordered eating, perfectionism, and food rules
Amanda Joelle Brown ⁎, Kortney M. Parman, Deirdre A. Rudat, Linda W. Craighead Emory University Psychological Center, 36 Eagle Row, Atlanta, GA 30322, USA
Received 17 September 2011 Received in revised form 25 April 2012 Accepted 31 May 2012 Available online 9 June 2012
Perfectionism Food rules Disordered eating
The identification of factors that contribute to the development and maintenance of eating disorders has been the focus of significant research effort in recent years. The etiology of anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS) appears to involve a combination of genetic, familial, person- ality, developmental, and socio-cultural influences (Klein & Walsh, 2003). A strong relationship has been found between trait perfection- ism and disordered eating, but potential mediating variables affecting this relationship remain largely unknown (Bardone-Cone et al., 2007). One hypothesized mechanism at play in this relationship is adherence to rules regarding what, when, and how one must eat or not eat. Perfec- tionistic traits may lead individuals to adhere rigidly to such “food rules,” which, in turn, may increase vulnerability to developing eating disorder symptoms. This study aims to explore the role of food rules in understanding the relationship between perfectionism and disor- dered eating attitudes and behaviors.
The construct of perfectionism involves placing excessive empha- sis on organization and preciseness, holding idealistic personal expec- tations, critically self-evaluating when expectations are not met, and doubting the quality of personal accomplishments (Hewitt & Flett, 1991). Hewitt and colleagues (Hewitt, Flett, Turnbull-Donovan, & Mikail, 1991) propose that perfectionism has three dimensions: self-oriented, other-oriented, and socially prescribed. Self-oriented perfectionism involves critical self-scrutiny and holding to unrealistic,
⁎ Corresponding author. Tel.: +1 908 507 7209; fax: +1 404 727 1284. E-mail address: firstname.lastname@example.org (A.J. Brown).
1471-0153/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.eatbeh.2012.05.011
Clinically significant trait perfectionism is often characteristic of individuals exhibiting symptoms of eating disorders. The present study reports on a measure developed to assess the use of food rules and evaluates the hypothesis that adherence to food rules may be one mechanism through which trait perfectionism exac- erbates risk for developing eating disorder symptoms. Forty-eight female college students completed a bat- tery of questionnaires, and multiple regression analyses were used to test a mediational model. Results indicated that adherence to food rules mediated the relationship between self-oriented perfectionism and three indices of disordered eating in this sample. This relationship was specific to self-oriented perfectionism and did not hold for other-oriented or socially prescribed perfectionism. These findings may have implica- tions for designing early interventions for disordered eating and may be useful in tailoring treatment for individuals with disordered eating who also report high levels of perfectionism.
© 2012 Elsevier Ltd. All rights reserved.
self-imposed personal standards, whereas other-oriented and socially prescribed perfectionism are based on a need to achieve high stan- dards imposed by other people or by society at large (Hewitt, Flett, Besser, Sherry, & McGee, 2003). While some degree of adherence to personal and socially constructed standards of behavior is adaptive and healthy, perfectionistic tendencies become clinically relevant when high standards are pursued despite significant adverse conse- quences (Shafran, Cooper, & Fairburn, 2002).
Perfectionism has been identified as both a risk factor and a maintaining variable for disordered eating symptoms. In a prospective study, individuals with severe anorexia nervosa who scored highly on perfectionism at pretest had poorer prognoses, as indicated by assess- ments 5–10 years later (Bizeul, Sadowsky, & Rigaud, 2001). In a correla- tional study designed to investigate the relationship between eating disorders and both adaptive and maladaptive dimensions of perfection- ism, women in treatment for an eating disorder scored significantly higher than healthy controls on the maladaptive perfectionism factor (Ashby, Kottman, & Schoen, 1998). More recent findings suggest that this difference may be specific to self-oriented perfectionism (Castro- Fornieles et al., 2007); individuals with eating disorders appear to hold themselves to exceptionally high personal standards but may be less concerned about living up to socially prescribed ideals.
In Fairburn and colleagues’ influential transdiagnostic cognitive– behavioral theory of the development and maintenance of eating dis- orders (Fairburn, Cooper, & Shafran, 2003), over-evaluation of eating, weight, and shape interacts with perfectionistic standards for achieve- ment and self-control to drive the development and maintenance of eat- ing disorder symptoms. Fairburn (Fairburn, 2008) recently introduced a “clinical perfectionism” module into standard cognitive–behavioral therapy for eating disorders, which specifically addresses this dysfunc- tional scheme for self-evaluation.348 A.J. Brown et al. / Eating Behaviors 13 (2012) 347–353
While the relationship between perfectionism and disordered eat- ing behaviors is well-supported by the existing literature, the specific mechanisms by which perfectionism exerts its influence on eating pa- thology have yet to be identified. The pursuit of unrealistic standards regarding eating, weight, and shape may encourage the development of overly rigid food rules. To date, little empirical research has been conducted on the development of and adherence to food rules among individuals with eating disorders. The following section briefly reviews research related to food rules and disordered eating and sug- gests that food rules may mediate the relationship between perfec- tionism and eating disorder symptoms.
1.1. Food rules
Many individuals with AN, BN, and subclinical forms of disor- dered eating subscribe to personal food rules that can be quite rigid and restrictive (Eiber, Mirabel-Sarron, & Urdapilleta, 2005). For some, it is a matter of taking generally sound recommendations for healthy eating to the extreme. Others have received unhealthy mes- sages about food in the past and experience greater distortion in their thoughts about food as their disorder progresses. Many individ- uals with eating concerns avoid foods that either predispose them to binge eating or they consider unhealthy (Klein & Walsh, 2003). By denying themselves certain foods and only eating those foods con- sidered to be safe, the food intake of individuals with eating concerns can be very restrictive and lacking in variety and nutrients, which may lead to a state of physiological deprivation and heightened risk for binge eating (Eiber et al., 2005; Mathes, Brownley, Mo, & Bulik, 2009). Food rules specifically, and rigid thought patterns about food more generally, are associated with heightened emotion- al responsiveness and cognitive disruption, including excessive fo- cusing on food as well as eating in excess, which further compound eating concerns (Polivy, 1996).
Self-imposed food rules may increase preoccupation with “for- bidden” foods, setting the stage for more rigid adherence to these rules in an effort to maintain self-control and increasing the likeli- hood of binge eating when the temptation to consume “off-limits” foods becomes too strong (Lingswiler, Crowther, & Stephens, 1989; Mann & Ward, 2001). Mann and Ward (2001) assigned par- ticipants to one of three groups; the first group was prohibited from eating a target food, the second group was encouraged to avoid it, and the third group was given no instruction related to the target food. The researchers found that in an absence of prohi- bition on eating, individuals’ thoughts about a food decreased over time. However, when dietary restraint from an appealing food was enforced or chosen, individuals experienced increased preoccupa- tion with the forbidden foods. Such preoccupation may strengthen commitment to food rules as the forbidden food becomes more tempting and salient for the individual, who may feel a need to exert more control over his or her behavior to resist consuming the off-limits food.
To date, little research has evaluated the degree to which adher- ence to food rules may contribute to disordered eating. Additionally, the current literature is limited by a lack of validated measures spe- cifically assessing adherence to food rules. This study aims to fill both voids by testing the psychometric properties of a new Food Rules Measure (FRM) in a sample of healthy female undergraduates and exploring the relationship between perfectionism, adherence to food rules, and disordered eating in this sample. Adherence to food rules is hypothesized to mediate the relationship between perfec- tionism and disordered eating. Support for this hypothesis would suggest that specific interventions targeting distorted cognitions about and commitment to following rigid food rules might be partic- ularly efficacious for treating eating pathology in highly perfectionis- tic individuals.
The current investigation was part of a larger study investigating the role of self- and other-compassion in body dissatisfaction (Rudat, 2010). The specific measures used for this study (described below) were included among the questionnaires that were complet- ed as a part of the parent study.
Forty-eight female undergraduate students completed the study. All students were enrolled in the Psychology Research Pool at a private uni- versity. Only participants over age 18 were enrolled in the study. The ages of participants ranged from 18 to 35 (M = 19.2, SD = 2.5). The par- ticipants were racially diverse; 66.7% identified as Caucasian, 18.8% as Asian, 8.3% as Black or African-American, 4.2% as Mixed Race or Other. Further, 10.4% of the participants identified as Hispanic or Latino. One participant did not report her race or ethnicity. This study was approved by the Emory University Institutional Review Board.
The measures used for this study were included within a larger set of questionnaires that were completed at a single time point. This cross-sectional correlational design was used to provide an initial investigation of potential relationships among concurrent levels of perfectionism, eating disorder symptoms, and adherence to food rules. Other measures assessing depression, self-esteem, and self- and other-compassion were used to investigate the construct validity of the new measure of adherence to food rules that had been developed specifically to evaluate hypotheses for this study. As adherence to food rules was hypothesized to reflect attitudes and judgments about one's own eating, it was expected that the new measure would be moderately correlated with depression, self-esteem, and self-compassion but not significantly correlated with compassion towards others.
2.3.1. Food rules
Due to the lack of adequate measures to assess adherence to food rules, the authors developed a novel measure assessing the degree to which participants endorse the use of food rules. The Food Rules Mea- sure (FRM) is a 14-item self-report measure designed to assess the content of food rules, the frequency of rule enforcement, and the predicted consequences of breaking the rule. A team of experts, including a registered dietician and two Masters-level psychologists, collaboratively generated the items for the FRM and pilot-tested the measure to ensure its clarity and coherence. FRM items are rated on a four-point scale ranging from “Always” to “Never.” Lower scores in- dicate greater adherence to food rules. An example item from this measure is, “I feel disappointed in myself when I ‘splurge’ on a food I typically do not eat or avoid.” Reliability and validity statistics relat- ed to the FRM are presented in the Results section.
The Multidimensional Perfectionism Scale is a 45-item self-report measure that assesses perfectionism using seven-point Likert scales (Hewitt et al., 1991). The measure captures three domains of perfec- tionism: self-oriented perfectionism, other-oriented perfectionism, and socially prescribed perfectionism. Hewitt et al. (1991) found this measure to have good internal consistency (Cronbach's alpha = 0.87), test–retest reliability (0.91 and 0.86 for self-oriented and socially prescribed perfectionism, respectively), and concurrent validity.
2.3.3. Eating pathology
Stice's Eating Screen (SES) was used to determine current eating disorder pathology. Stice, Telch, and Rizvi (2000) found this measure to be a reliable and valid brief screening measure for eating disorders. The measure is comprised of 26 questions related to the symptoms of anorexia, bulimia, and binge-eating disorder and can be used to indi- cate the likelihood of a current diagnosis according to DSM-IV criteria (Stice et al., 2000). Participants were not asked to report if they had ever been diagnosed with or received treatment for an eating disor- der, and participants were not screened out on the basis of likely eat- ing disorder diagnosis.
2.3.4. Eating-related cognitions
The Preoccupation with Eating, Weight, and Shape Scale (PEWS; Niemeier, Craighead, Pung, & Elder, 2002) is an eight-item self- report measure that was adapted from the Modifying Distressing Thoughts Questionnaire (Clark, Feldman, & Channon, 1989). It re- quires respondents to rate the percentage of the day (0–100%) they spend thinking about food/eating and about weight/shape, and also to indicate on a scale of one to six how distressing the thoughts were, how difficult they were to stop, and how much they interfered with concentration. Percentage is averaged across both domains, and the six Likert scores are averaged to provide an overall Distress score. Preliminary analyses have revealed adequate convergent and dis- criminant validity, sensitivity to change, and internal consistency (co- efficient alpha=.84;(Niemeier et al., 2002).
2.3.5. Intuitive eating
The Intuitive Eating Scale (IES; Tylka, 2006) is a 21-item question- naire that assesses three aspects of eating: unconditional permission to eat when hungry, eating for physical instead of emotional reasons, and relying on internal hunger and satiety cues when determining when to eat and how much to eat. The measure has good internal consistency (coefficient alpha = .89) and good construct validity, correlating strongly in the negative direction with measures of body dissatisfaction, interoceptive awareness, pressure for thinness, and thin-ideal internalization (Tylka, 2006).
2.3.6. Body dissatisfaction
Participants’ body dissatisfaction was measured by the Body Shape Questionnaire (BSQ; Cooper, Taylor, Cooper, & Fairburn, 1987), a 34-item, self-report questionnaire that assesses body shape concerns through six-point Likert scale forced-choice answers. Items include questions such as, “Have you felt ashamed of your body?” Higher scores indicate greater body dissatisfaction. Internal consis- tency (0.97), test–retest reliability (0.88) and concurrent validity (0.66) have been shown to be satisfactory (Rosen, Jones, Ramirez, & Waxman, 1996).
The Beck Depression Inventory, Second Edition (BDI-II), like its predecessor the Beck Depression Inventory (BDI), was constructed by selecting items that consistently discriminated between depressed and nondepressed psychiatric patients (Beck, Steer, Ball, & Ranieri, 1996; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961; Steer, Ball, Ranieri, & Beck, 1999). The BDI-II is a 21-item multiple-choice self- report measure that assesses emotional, cognitive, motivational, and physical symptoms of depression. The coefficient alpha for the BDI- II is approximately .91, and it correlates highly with mood disorder diagnosis (Beck, Ward et al., 1996).
The Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965) consists of 10 items related to feelings about oneself that are answered on a four-point Likert scale ranging from “Strongly agree” to “Strongly disagree.” Total scores range from 0 to 30, with scores below 15
suggesting significantly low self-esteem. The RSES has been validated with many culturally diverse and international samples (Hatcher & Hall, 2009; Martin, Thompson, & Chan, 2006).
The Self-Compassion Scale (SCS; Neff, 2003) was used to deter- mine levels of compassion toward the self. The 26-item, self-report questionnaire includes three factors: self-kindness, common human- ity, and mindful awareness. Items include statements such as, “I try to be understanding and patient towards those aspects of my personal- ity I don't like,” and the respondent's level of agreement is rated on a five-point Likert scale. Higher scores indicate a higher degree of self- compassion. Internal consistency (0.92), test–retest reliability (0.93), and discriminant validity are satisfactory (Neff, 2003).
The Other-Compassion Scale (OCS) is a modified version of the Self-Compassion Scale, designed to assess compassion toward other people. The OCS was created for the parent study, which was designed in part to investigate the relationship between self- and other-compassion. The 26 items of the Self-Compassion Scale were modified to refer to others instead of the self; for example, “I try to be understanding and patient towards those aspects of other people's personality that I don't like.” Like the Self-Compassion Scale, the Other-Compassion Scale is a self-report measure that uses a five- point Likert scale. Reliability and validity of this measure have not yet been determined.
Participants were recruited through the Introductory Psychology subject pool. Participants were told that the study was about “attitudes towards self, appearance, and others.” When participants arrived, they were given a brief verbal description of the study and signed a consent form explaining the nature of the study. Participants then completed the questionnaire packet. Prior to their departure, each participant re- ceived a debriefing form with additional information about the study and referral information for local counseling services.
2.5. Data analysis
Based on the Baron and Kenny model for testing mediational hypoth- eses, a four-step procedure for data analysis was followed (Baron & Kenny, 1986). A series of regression analyses were carried out to deter- mine the extent to which the variance in a potential mediator variable accounts for the statistical relationship between an independent variable and dependent variable(s). Mediation is demonstrated when the effect of the independent variable on a given outcome variable is attenuated or non-existent when controlling for the mediating variable. The Sobel test (Sobel, 1982) was conducted to test the significance of the mediator's impact on the relationship between the independent and de- pendent variable. An alpha level of .05 was used to determine statistical significance for all analyses. SPSS was used for all statistical analyses.
3.1. Descriptive statistics
All 48 participants completed the required questionnaires and were included in the analyses. Table 1 displays participants’ mean scores on each of the measures.
3.2. Psychometric properties of the FRM
The FRM was found to have good internal consistency (Cronbach's alpha = .85) suggesting that the items create a coherent measure. In
A.J. Brown et al. / Eating Behaviors 13 (2012) 347–353 349
350 A.J. Brown et al. / Eating Behaviors 13 (2012) 347–353
Correlations between FRM and measures related to eating pathology.
Measure Correlation with FRM
SES IES PEWS % PEWS Distress BSQ
−.54⁎⁎ .78⁎⁎ −.59⁎⁎ −.59⁎⁎ −.69⁎⁎
FRM=Food Rules Measure. SES=Stice's Eating Scale. IES=Intuitive Eating Scale. PEWS=Preoccupation with Eating, Weight, and Shape Scale.
BSQ=Body Shape Questionnaire.
order to test for construct validity, correlations were calculated between the FRM and other measures included in the parent study. Convergent validity was demonstrated by the large effect sizes of the correlations be- tween the FRM and all other measures assessing eating pathology (Table 2). Moderately strong correlations were found between the FRM and four non-eating-specific measures (Table 3): the BDI-II, RSES, SCS, and the Self-Oriented subscale of the MPS. Other-oriented perfectionism, socially oriented perfectionism, and compassion towards others were not correlated with adherence to food rules.
3.3. Mediator analyses
A series of regression analyses (Baron & Kenny, 1986) was carried out to test whether adherence to food rules acted as a mediator of the rela- tionship between perfectionism (three subscales) and the three primary indices of eating pathology, the SES, PEWS, and IES. Table 4 depicts the outcome of these statistical tests. To test the first criterion for mediation, that the independent variable affects the mediator, scores on the FRM were regressed on each of the three subscales of the MPS. The results in- dicated that adherence to food rules was significantly related to self- oriented perfectionism but not related to other-oriented or socially ori- ented perfectionism. Therefore, the subsequent steps in the mediator analyses were conducted only with self-oriented perfectionism.
To test the second criterion for mediation, that the independent variable affects the dependent variable, SES, PEWS and IES scores were regressed on MPS-Self scores. Self-oriented perfectionism was significantly related to global eating pathology (as measured by the SES), preoccupation with eating, weight, and shape (PEWS) and intu- itive eating (IES).
The third criterion for mediation is that the mediator affects the dependent variable. To test this criterion, SES, PEWS, and IES scores were each regressed on FRM scores. Results of Step 3 analyses indi- cated that the adherence to food rules was significantly related to all three eating-related outcome measures.
In order to be considered a mediating variable according to Baron and Kenny's (1986) criteria, the effect of the independent variable on the dependent variable must be significantly less when controlling for the mediator than when the mediator is not controlled. To test this final criterion, SES, PEWS, and IES scores were regressed on self- oriented perfectionism, as in Step 2. In Step 4, FRM scores were entered into block 1 of the regression analysis to control for their influence on the relationship between perfectionism and eating disorder symptoms. The Sobel test was performed (http://www.people.ku.edu/~preacher/ sobel/sobel.htm) to test the strength of the mediator.
The results indicated that adherence to food rules significantly mediated the relationship between self-oriented perfectionism and all three outcome variables: global eating disorder symptoms (Sobel test statistic=2.41, p=.02), preoccupation with food and weight (Sobel test statistic=2.50, p=.01) and intuitive eating (Sobel test
statistic=−3.80, p=.00). Due to the strong statistical relationship between the MPS-self, FRM, and all three outcome variables, the achieved power for these regression analyses was consistently high (.96 and above). The two nonsignificant Step 1 regression analyses had lower power, which may have been related to the weaker corre- lations between the measures of other-oriented and socially pre- scribed perfectionism and the FRM, the small sample size, or both (achieved power: MPS-other=.22; MPS-social=.14).
In this study, adherence to food rules mediated the relationship between self-oriented perfectionism and three indices of eating pa- thology: global eating disorder symptoms, preoccupation with eating and weight, and intuitive eating. Notably, mediation was specific to self-oriented perfectionism and was not demonstrated for other- oriented or socially oriented perfectionism. These data support the notion that disordered eating attitudes and behaviors may be largely driven by individuals’ self-imposed high standards. High levels of self- oriented perfectionism may lead individuals to rigidly interpret guide- lines for healthy eating and to adhere strictly to these guidelines. Once established, rigid food rules likely become more restrictive and prohib- itive, leading to greater preoccupation with food and eating, less intui- tive eating, and increased symptoms of disordered eating. While the current data do not address the developmental trajectory of perfection- ism, food rules, and disordered eating, they support the hypothesis that adherence to food rules may be a key mechanism by which self- oriented perfectionism leads to eating pathology.
As the first measure to specifically assess adherence to food rules, the FRM provides a promising contribution to the field of eating dis- orders assessment. In this study, the FRM showed good internal
Correlations between FRM and non-eating-related measures.
Measure Correlation with FRM
BDI-II −.34⁎ RSES .40⁎⁎ SCS .34⁎ OCS .06 MPS-Self −.58⁎⁎ MPS-Other −.23 MPS-Social −.17
BDI-II=Beck Depression Inventory. RSES=Rosenberg Self-Esteem Scale. SCS=Self-Compassion Scale. OCS=Other-Compassion Scale. MPS-Self=Self-Oriented Perfectionism. MPS-Other=Other-Oriented Perfectionism. MPS-Social=Socially Prescribed Perfectionism.
⁎ pb.05. ⁎⁎
Possible Observed Mean Standard range range deviation
Food Rules Measure Self-Oriented Perfectionism Other-Oriented Perfectionism Socially Prescribed Perfectionism Stice's Eating Scale Preoccupation with Eating, Weight,
and Shape Scale Intuitive Eating Scale Body Shape Questionnaire Beck Depression Inventory Rosenberg Self-Esteem Scale Self-Compassion Scale Other‐Compassion Scale
14–84 15–105 15–105 15–105 0–22
34–204 0–63 10–40 26–130 26–130
26–75 35–103 40–86 25–80 0–17 0–5.3
1.9–4.4 34–174 0–24
15–40 41–128 62–104
51.5 37–86 71.9 16.6 63.4 10.3 52.2 13.1
9.2 4.8 2.2 1.5
3.0 0.54 92.1 33.7 9.8 6.7
32.3 5.1 77.3 17.7 90.9 9.1
A.J. Brown et al. / Eating Behaviors 13 (2012) 347–353 351
Results of mediator analyses.
R2 change F change P value β Meets criteria?
Step 1: Independent variable affects the mediator IV: MPS-self
FRM .33 IV: MPS-other
FRM .05 IV: MPS-social
22.7 .00 −.58 Yes
2.5 .12 −.23
FRM .03 Step 2: Independent variable affects the dependent variable
No; stop here No; stop here
IV: MPS-self SES .19 PEWS .31 IES .16
10.1 .00 21.0 .00 8.3 .01
.44 Yes .56 Yes −.40 Yes
−.54 Yes −.59 Yes .76 Yes
Step 3: Mediator affects the dependent variable IV: FRM
1.4 .25 −.17
SES .29 PEWS .35 IES .57
Step 4: IV affects than when it is IV: MPS-self
SES .03 PEWS .07 IES .00
17.7 .00 24.4 .00 60.5 .00
the DV to a lesser degree when the mediator is controlled not
1.6 .21 5.7 .02 .32 .57
.19⁎ Yes .33⁎ Yes −.07⁎ Yes
^pb.10 compared with Step 2 value (Sobel test). ⁎
pb.05 compared with Step 2 value (Sobel test).
consistency and construct validity. The strong correlations between the FRM and other measures assessing characteristics of eating disor- ders indicate that the measure has good convergent validity and may be useful as a more specific index of this aspect of disordered eating. The FRM may also be useful in a clinical setting for the purposes of screening or treatment planning. For example, the FRM may be useful for individualizing treatment by helping to identify the specific rules that individuals adhere to and the ways in which these rules may be exacerbating or causing disordered eating behaviors.
The medium effect sizes of the correlations between the FRM and the BDI-II, SCS, and Self-Oriented subscale of the MPS also offer evi- dence of convergent validity, as depression (Casper, 1998), low self- compassion (Adams & Leary, 2007), and self-oriented perfectionism (Castro-Fornieles et al., 2007) have all been found at higher levels among individuals showing symptoms of disordered eating. The lack of significant correlation between FRM and the other-oriented and socially prescribed subscales of the MPS suggests that adherence to food rules is associated with holding oneself to high self-standards, but not seeking to achieve goals set by others and by society at large. The FRM also proved to have adequate discriminant validity, as it was not significantly correlated with measures assessing constructs for which there is no empirical evidence or theoretical basis for a rela- tionship with disordered eating (e.g., compassion for others).
4.1. Relevance for treatment
The present findings suggest that an explicit focus on changing rule-bound cognitions and behaviors may increase the efficacy of treatments for eating disorders, at least for individuals with high levels of self-oriented perfectionism. It may be helpful for therapists and dietitians to identify clients’ rigid food rules early in treatment and to work towards modifying those rules through such techniques as cognitive restructuring and exposure and response prevention. Cognitive restructuring strategies, already commonly used in cognitive- behavioral therapy for eating disorders (Fairburn et al., 2003) are easily applicable to rigid rules about food. For example, the “downward arrow” technique can be used to help clients understand what lies at the heart of their food rules, such as fear of weight gain or an aversion to appearing weak or self-indulgent. Those maladaptive cognitions can then be challenged and attenuated.
Behavioral interventions such as exposure and response preven- tion can also be used to challenge clients’ rigid adherence to food rules. In vivo exposure to rule breaking (without the option of restricting or purging) may lessen the rigidity of clients’ beliefs that rule breaking will have a negative outcome (e.g. weight gain). With repeated exposure, the rule is likely to lose its potency, allowing the client increased flexibility in both cognitions and behaviors.
4.2. Study limitations
The main limitations of this questionnaire-based study include sam- ple characteristics, aspects of study design, and the use of a newly devel- oped measure to assess adherence to food rules. This study was conducted in a single geographic location in a developed nation at an elite, private university. Further research will be needed to determine if the findings are representative of the national college population, and be- yond this, a clinical population with significant eating pathology. Further, the cross-sectional nature of the study design did not allow for analysis of the development of eating disorder pathology, perfectionism, or sub- scription to food rules. Specifically, this study did not investigate if there is an age or life stage at which these variables most often appear and in- teract. Further research will be necessary to determine if there are critical developmental periods in which food rules emerge or are more likely to exacerbate disordered eating.
As the FRM was developed by the authors for the purposes of this study, its reliability and validity can only be preliminarily suggested on the basis of the study results. Data analyses indicated that the measure had good internal consistency and correlated strongly with indicators of eating pathology and perfectionism. Further investiga- tion is needed to determine the utility of the FRM as an assessment tool for determining the extent to which adherence to food rules is problematic or interferes with response to intervention. However, the mean FRM score reported in this study can serve as an initial nor- mative value for female college undergraduates.
Rigid adherence to food rules is characteristic of many individuals with eating concerns. Perfectionism is also common in this population, and the results of this investigation suggest that adherence to food rules may be one mechanism by which perfectionistic tendencies contribute to the development and maintenance of eating disorder symptoms. Ad- herence to food rules was found to be a mediator of the relationship be- tween self-oriented perfectionism and three indicators of disordered eating in a nonclinical sample of female undergraduates. Thus, use of food rules may need to be targeted in prevention and early intervention programs designed to reduce risk factors for eating disorders. Further work is needed to confirm this finding within clinical populations. If confirmed, therapeutic interventions for eating disorders might be strengthened by individualized assessment of and attention to clients’ levels of trait perfectionism and adherence to food rules.
Role of funding sources
No external funding was provided for this study.
Authors 1, 2, 3, and 4 were involved in designing the study. Authors 1 and 2 con- ducted all statistical analyses and wrote the manuscript collaboratively. Authors 2 and 3 were directly involved in data collection. All authors contributed to and have ap- proved the final manuscript.
Conflict of interest All authors declare that they have no conflicts of interest.
352 A.J. Brown et al. / Eating Behaviors 13 (2012) 347–353 Appendix A.
Food Rules Measure
Directions for participants: For each item, please check the answer that best characterizes your beliefs or behaviors. Do you have any dietary restrictions based on a medical condition or food allergy?
□ Yes □ No Briefly describe: ____________________________________
1. I choose to eat what I consider to be healthy foods when those foods are available. □ Always □ Usually □ Often □ Sometimes □ Rarely □ Never
2. I don't eat at certain times during the day because I believe those times are not helpful for my body's metabolism (e.g. after 7 p.m. or first thing in the morning). □ Always □ Usually □ Often □ Sometimes □ Rarely □ Never
3. I avoid certain foods or food groups for reasons other than an allergy or dislike of the taste or texture. □ Always □ Usually □ Often □ Sometimes □ Rarely □ Never
4. I tend to snack between meals. □ Always □ Usually □ Often □ Sometimes □ Rarely □ Never
5. I eat what I believe to be the right portion size, even when it's not satisfying. □ Always □ Usually □ Often □ Sometimes □ Rarely □ Never
6. I feel disappointed in myself when I “splurge” on a food I typically do not eat or avoid. □ Always □ Usually □ Often □ Sometimes □ Rarely □ Never
7. I feel the need to follow food rules or diet plans that dictate what, when, and/or how much to eat. □ Always □ Usually □ Often □ Sometimes □ Rarely □ Never
8. I avoid eating “junk food” and sweets because they are not good choices. □ Always □ Usually □ Often □ Sometimes □ Rarely □ Never
9. I feel comfortable eating any food in all locations with anyone, including at home, in a restaurant, and at social functions. □ Always □ Usually □ Often □ Sometimes □ Rarely □ Never
10. I feel I need to compensate, such as through exercise or eating less at another time, when I eat certain foods or a certain amount of food.
□ Always □ Usually □ Often □ Sometimes □ Rarely □ Never 11. I find myself preoccupied with thoughts about food and what to eat or not eat.
□ Always □ Usually □ Often □ Sometimes □ Rarely □ Never 12. I eat exactly what I want, regardless of what kind or quantity of food is available, or what time of day it is.
□ Always □ Usually □ Often □ Sometimes □ Rarely □ Never 13. I avoid foods high in carbohydrates, fat, and/or calories.
□ Always □ Usually □ Often □ Sometimes □ Rarely □ Never 14. I avoid thinking of foods as either “good” or “bad” based on their nutritional content.
□ Always □ Usually □ Often □ Sometimes □ Rarely □ Never
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