shape and weight concern and self-esteem as mediators of externalized self-perception, dietary...

European Eating Disorders ReviewEur. Eat. Disorders Rev. 12, 129–136 (2004)

Shape and Weight Concern andSelf-esteem as Mediatorsof Externalized Self-perception,Dietary Restraint and UncontrolledEating

Melanie Ross and Tracey D. Wade*School of Psychology, Flinders University of South Australia, Australia

Objective: This study investigated mediational processes bywhich variables may work together to increase the likelihood ofdietary restraint and uncontrolled eating, guided by the frame-work suggested by the cognitive model.Method: Female university students aged between 18 and 25years (N¼ 111) completed the Silencing the Self Scale, andmeasures of self-esteem, weight concern, shape concern anddietary restraint, as well as a measure of uncontrolled eating.Results: Self-esteem partially mediated the relationship betweenexternalized self-perception and a combined measure of weightand shape concern, which in turn fully mediated the relationshipbetween self-esteem and both dietary restraint and uncontrolledeating. Dietary restraint did not mediate the relationship betweenweight and shape concern and uncontrolled eating.Discussion: The results support the validity of the cognitivemodel of bulimia nervosa and are consistent with externalizedself-perception being an early risk factor for disturbed eatingpatterns, in line with earlier theorizing. Copyright # 2003 JohnWiley & Sons, Ltd and Eating Disorders Association.

Keywords: shape and weight concern; externalized self-perception; dietary restraint; uncontrolled eating

INTRODUCTION

The cognitive model of bulimia nervosa has beeninfluential in guiding treatment of the disorder. Thismodel focuses on the centrality of overvalued ideasabout body weight and shape, to which the initiationand maintenance of bulimic symptomatology areattributed (Cooper & Fairburn, 1993; Fairburn &

Cooper, 1989; Vitousek, 1996; Vitousek & Hollon,1990). Individuals possessing overvalued ideas aboutbody weight and shape equate their self-worth interms of their body appearance, placing great impor-tance on exerting self-control over dietary restraintand losing weight. In turn, bingeing episodes can betriggered by this dietary restraint which can lead tovarious compensatory behaviours such as vomitingand the use of laxatives in order to avoid gainingweight (Stice, 2001). The cognitive model also sug-gests low self-esteem is the most proximal risk factorfor overvalued ideas about body weight and appear-ance (Meijboom, Jansen, Kampman, & Schouten,1999). Longitudinal research has supported the role

Copyright # 2003 John Wiley & Sons, Ltd and Eating Disorders Association.

Published online 25 May 2003 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/erv.531

* Correspondence to: Dr T. Wade, School of Psychology,Flinders University of South Australia, GPO Box 2100,Adelaide, South Australia, 5001, Australia. Tel: þ61-8-8201-3736. Fax: þ61-8-8201-3877.E-mail: [email protected]

of weight concern as a risk factor for the developmentof an eating disorder (Killen et al., 1996).

Few studies exist that evaluate the cognitivemodel of bulimia nervosa. A recent study (Byrne &McLean, 2002) provided some qualified support forthe cognitive model but measured body dissatisfac-tion and drive for thinness as components of weightand shape concern, despite the suggestion that theseare distinct constructs (Cooper & Fairburn, 1993).Another recent cross-sectional study (Wade &Lowes, 2002) found that overvalued ideas aboutbody weight and shape mediate the relationshipbetween low self-esteem and behavioural bulimicsymptomatology, as implied in the cognitive model.However, this latter study did not separate out diet-ary restraint from the bulimic symptoms, which isthe most common approach in the testing of eatingdisorder models (e.g. Ricciardelli & McCabe, 2000;Stice, 2001).

Less well-defined in the cognitive model are thespecific types of variables whose effect may bemediated by self-esteem in order to increase risk foran eating disorder as opposed to some other psycho-pathology. Cross-sectional studies have identifiedsome possible risk factors including perfectionismand conflict between parents while growing up(Wade & Lowes, 2002; Wade, Bulik, & Kendler,2001). More recently there has been a focus on the‘self-silencing’ interpersonal style, which is charac-terized by suppression of feelings, judging the selfby external standards, attempting to secure attach-ments by putting the needs of others before the self,and presenting an outer compliant self (Zaitsoff,Geller, & Srikameswaran, 2002). This interpersonalstyle is typically measured using the Silencing theSelf Scale (STSS; Jack & Dill, 1992), and is based onJack’s theory (1991) which postulates that the lackof expression of the true self in relationships leadsto decreased self-esteem. Self-silencing behavioursmay be of particular relevance to women and candevelop during adolescence (Brown & Gilligan,1992). The relevance of this interpersonal style to eat-ing disorders is consistent with both clinical observa-tions and research. Bruch (1978) described patients asstriving to conform to their parents’ expectations andnot expressing their feelings in order to avoid criti-cism, or discontentment. In addition, in comparisonto controls, women with bulimia nervosa report agreater need for acceptance and need to please othersaround them (Jacobson & Robins, 1989; Katzman& Wolchik, 1984), avoid uncomfortable communi-cation involving negative affect (Strober, 1991)and express greater externalized self-perception(Striegel-Moore, Silberstein, & Rodin, 1993).

Two studies currently exist that examine the rela-tionship of the self-silencing interpersonal style toeating disorders. Geller, Cockell and Goldner (2000)considered silencing the self in a group of womenwith anorexia nervosa, a psychiatric control group(comprising of depression and bipolar disorderpatients), and a normal control group, matched onage and education. The anorexia nervosa groupscored higher on suppressing feelings and puttingothers’ needs before self in comparison to both con-trol groups when age, depression, self-esteem andglobal functioning were controlled for. In contrast, astudy of adolescent females found that only higherlevels of judging self by external standards predictedboth behavioural and cognitive eating disordersymptoms when controlling for shape and weightconcern (Zaitsoff, Geller, & Srikameswaran, 2002).When controlling for self-esteem, suppression of feel-ings predicted behavioural eating disorder symp-toms and judging self by external standardspredicted eating disorder cognitions.

The aim of the present study is therefore twofold.The first is to examine the relevance of the cognitivemodel with respect to late adolescent and early adultwomen, focusing on both dietary restraint anduncontrolled eating as outcome variables. The sec-ond aim is to further examine the self-silencing inter-personal style and its relation to the othercomponents of the cognitive model. In particular,this cross-sectional study seeks to investigate media-tional processes by which variables may worktogether to increase the likelihood of dietaryrestraint and uncontrolled eating, guided by the fra-mework suggested by the cognitive model.

METHOD

Participants

The study sample consisted of 111 female, universitystudents aged between 18 and 25 years, with a meanage of 19.8 years (SD¼ 1.89 years). This age groupreflects the age range in which bulimic sympto-matology typically develops (Wade et al., 1996;Woodside & Garfinkel, 1992). Approval for thestudy was received from the Flinders UniversitySocial and Behavioural Research Ethics Committee.

Measures

The Silencing the Self Scale (STSS; Jack & Dill, 1992)is comprised of 30 items which make up four scales:Externalized Self-Perception, Care as Self-Sacrifice,Silencing the Self and the Divided Self. Each item

130 M. Ross and T. D. Wade

Copyright # 2003 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 12, 129–136 (2004)

is measured using a 5-point Likert scale (1¼ stronglydisagree, 5¼ strongly agree), where higher scoresindicate greater silencing of the self beliefs and beha-viours. The scale has demonstrated good test–retestreliability and construct validity in relation to differ-ent social contexts (Jack & Dill, 1992). Item 20 wasexcluded from analysis due to the lack of loadingon the Silencing the Self dimension, as indicated inDuarte and Thompson (1999) and Stevens andGalvin (1995). The internal consistency for the totalSTSS score in this sample was good (Cronbach’s�¼ 0.88). Three of the scales had acceptable internalconsistency: externalized self-perception (�¼ 0.71),silencing the self (�¼ 0.86) and divided self(�¼ 0.72). The care as self-sacrifice had a less accep-table internal consistency with �¼ 0.61.

Self-esteem was assessed using the State Self-Esteem Scale (SSES; Heatherton & Polivy, 1991), asensitive measure for fluctuating changes in self-esteem (Heatherton & Polivy, 1991; Linton &Marriott, 1996). Participants were asked to indicate,on a 5-point Likert scale (1¼not at all,5¼ extremely), the answer which was true for themat that particular moment in time. Lower scores areindicative of lower self-esteem. The SSES hasdemonstrated good concurrent validity with theRosenberg Self-Esteem Scale (Rosenberg, 1989),r¼ 0.72, p< 0.05 (Heatherton & Polivy, 1991). Discri-minant validity for the SSES has also been demon-strated in relation to emotional changes producedby academic performance. Only the total self-esteemscore was examined in this study and internal con-sistency for the total score in this sample was moder-ately good (Cronbach’s �¼ 0.83).

Concerns about weight and shape were measuredusing the combined Weight Concern and ShapeConcern scales of the Eating Disorders Examina-tion–Questionnaire (EDE-Q; Fairburn & Beglin,1994). The EDE-Q is designed to measure the pre-sence and degree of specific psychopathology asso-ciated with bulimia nervosa and anorexia nervosaover the previous 4 weeks and the two scales focuson the degree to which self-worth and acceptanceare defined in terms of weight or shape. These scaleswere combined since they were found to be highlycorrelated (r¼ 0.91, p< 0.01). Scored using a 7-pointLikert format (0¼not at all, 6¼marked), higherscores indicate a higher degree of overvalued ideasabout body weight and shape. The Weight Concernand Shape Concern scales have demonstrated goodconcurrent validity with the scales in the Eating Dis-orders Examination (Fairburn & Cooper, 1993) andhave excellent test–retest reliability (Black & Wilson,1996; Luce & Crowther, 1999). In this study over-

valued ideas about body weight and shape measurehad high internal consistency (Cronbach’s �¼ 0.94).

Dietary restraint was measured using the DietaryRestraint scale from the EDE-Q (Fairburn & Beglin,1994) which is comprised of five items measuredusing a 7-point Likert scale (0¼no days, 6¼ everyday), where higher scores are indicative of a higherdegree of restrained eating behaviour. The subscalehas demonstrated good concurrent validity withdietary restraint subscale in the Eating DisordersExamination (Black & Wilson, 1996) and good test–retest reliability (Luce & Crowther, 1999). The inter-nal consistency for the dietary restraint subscale inthis sample was 0.77.

Uncontrolled eating was measured using the Buli-mia subscale from the Eating Disorders Inventory-2(EDI-2; Garner, 1990), which comprises seven itemsrated using a 6-point Likert format (0¼never,5¼ always). Participants indicate how often eachsentence is true for them e.g. ‘I think about bingeing(overeating),’ with a higher score indicative of ahigher degree of uncontrolled eating behaviour.The Bulimia subscale has been found to differentiatebetween body dissatisfaction and eating disordergroups, supporting its construct validity (Klemchuk,Hutchinson, & Frank, 1990) and has demonstratedexcellent test–retest reliability in a non-clinicallyeating disordered sample (Wear & Pratz, 1987).The EDI, however, has been shown to have limita-tions in assessing bulimic behaviour when com-pared to direct observation reports (Gross, Rosen,Leitenberg, & Willmuth, 1986). The Bulimia subscaledemonstrated good internal consistency in thisstudy sample (�¼ 0.78).

Body mass index (BMI) was calculated from theself-reported height and weight. BMI was investi-gated as a potential covariate due to its influenceon bulimic symptomatology as indicated in pre-vious studies (Patton, 1988; Stice, Nemeroff, & Shaw,1996) where a higher BMI was associated with ahigher degree of bulimic symptomatology.

Procedure

A ‘Self-image Questionnaire’ was distributed to stu-dents during tutorial time. The questionnaire, whichrequired approximately 20 min to complete, wascompleted in the tutorial time.

RESULTS

Descriptive Analyses

Only the Bulimia measure was significantly skewedand it was therefore transformed to its log value.

Self-perception and Dietary Restraint 131


Multicollinearity was not detected and data werefound to be both linear and homoscedastic intendency.

The mean BMI of the sample was in the normalrange at 22.43 (SD¼ 3.43). The sample representedunderweight, normal weight and overweight witha minimum BMI of 16.71 and a maximum BMI of35.38.

The mean item score for overvalued ideas aboutbody weight and shape was 2.70 (SD¼ 1.45), belowthe clinical cut-off score of 4 (Fairburn & Beglin,1994). However, the sample reflected both scaleextremes, ranging from 0 to 5.67. The mean dietaryrestraint item score of 1.32 (SD¼ 1.32) indicated that,on average, participants had dieted for 1–12 days outof the previous 4 weeks. The mean uncontrolled eat-ing item score of 1.00 (SD¼ 0.72) indicated that themajority of participants rarely displayed this formof behaviour. Higher levels of dietary restraint wascorrelated with higher levels of uncontrolled eating(r¼ 0.44, p< 0.001).

The mean total STSS score of 9.59 (SD¼ 2.15) wassimilar to that found previously using a female,undergraduate sample (Jack & Dill, 1992). The meantotal self-esteem score for this sample was 7.57(SD¼ 1.38), slightly lower than scores from a femaleundergraduate sample in a previous study(Heatherton & Polivy, 1991).

As self-reported BMI was significantly, positivelycorrelated to overvalued ideas about body weightand shape (r¼ 0.26, p< 0.01) and no other variable,it was controlled for in any regression analysis inwhich overvalued ideas was an outcome variable.

Strength of Associations between STSS andOther Variables

In order to assess the relevance of the self-silencinginterpersonal style to other variables in the currentstudy, the associations between the silencing the selfscales and the other measures were investigatedusing Pearson correlations (see Table 1). A greatertendency toward self silencing behaviour was corre-

lated with lower self-esteem and greater levels ofweight and shape concern and dietary restraint. Agreater degree of uncontrolled eating was weaklycorrelated with a higher level of self-silencingbehaviours.

The Relationship between STSS and Self-esteem

Using simultaneous multiple regression to furtherinvestigate the relationship between the STSS scalesand self-esteem, the first hypothesized relationshipin the model, we entered all of the STSS scales at step1 (R2¼ 0.34, p< 0.01). However, only externalizedself-perception contributed significantly to this equa-tion, with a standardized regression coefficient (�) of�0.56 (p< 0.01), explaining 31.4 per cent of the var-iance of the outcome variable. In the interests of par-simony only this scale rather than the full score wasfurther investigated in our model building process.

Self-esteem as the Mediator betweenExternalized Self-perception and Weightand Shape Concern

The investigation of the mediational relationshipwas carried out in accordance with the three criteriafor mediation outlined by Baron and Kenny (1986).First, multiple regression analysis (MRA) was usedto investigate whether the independent variable pre-dicted the mediator. Second, the relationship of themediator to the dependent variable was examined. Ifthese two relationships were significant, hierarchi-cal MRA was used to investigate whether the rela-tionship between the independent and dependentvariable was reduced when the mediator was con-trolled. In order to test whether this reduction wassignificant, the formula derived by Sobel (1982)was used, producing a z value.

In the first test of mediation (see Table 2), externa-lized self-perception demonstrated a significantrelationship with self-esteem, and self-esteem alsosignificantly predicted weight and shape concern.Externalized self-perception also significantly pre-dicted the overvalued ideas about body weight

Table 1. Correlations between the STSS total and its subscales with the other model variables

STSS scale Self-esteem Weight and Dietary Uncontrolledshape concern restraint eating

Externalized self-perception �0.58** 0.58** 0.30** 0.34**Care as self-sacrifice �0.27** 0.31** 0.33** 0.25**Silencing the self �0.28** 0.30** 0.28** 0.08Divided self �0.30** 0.23* 0.12 0.19*STSS total �0.47** 0.47** 0.33** 0.28**

*p< 0.05; **p< 0.01.



and shape (R2¼ 0.39, F(2, 108)¼ 34.92, p< 0.01).After controlling for self-esteem, externalized self-perception continued to significantly predict shapeand weight concern, (R2�¼ 0.06, F(3, 108)¼ 12.94,p< 0.01) although this contribution was signifi-cantly reduced. BMI, externalized self-perceptionand self-esteem together accounted for 54.9 per centof the variance in overvalued ideas about bodyweight and shape. It was concluded that state self-esteem partially mediated the relationship betweenexternalized self-perception and weight and shapeconcern.

Weight and Shape Concern as the Mediatorbetween Self-esteem and Bulimic Behaviour

The mediational relationship was tested for two out-come variables, dietary restraint and uncontrolledeating (Table 2). Self-esteem significantly predictedweight and shape concern and this variable in turnsignificantly predicted dietary restriction. Therewas a significant relationship between self-esteemand dietary restraint (R2¼ 0.18, F(1, 109)¼ 23.85,p< 0.01) which disappeared when controlling forweight and shape concern (R2�¼ 0.00, F(2,108)¼ 0.00, p> 0.97), representing a significantreduction in the variance explained by self-esteem.Self-esteem and weight and shape concern togetheraccounted for 38.1 per cent of the variance in dietaryrestraint. It was concluded that weight and shapeconcern fully mediated the relationship betweenstate self-esteem and dietary restraint.

With respect to uncontrolled eating, there was alsoa significant relationship between this self-esteemand uncontrolled eating (R2¼ 0.12, F(1, 107)¼14.96,p< 0.01). There was no significant relationshipbetween these two variables when the impact ofweight and shape concern was controlled for

(R2�¼ 0.00, F(2, 107)¼ 0.00, p> 0.75), representinga significant reduction in the variance explained byself-esteem. Self-esteem and weight and shape con-cern together accounted for 30.2 per cent of the var-iance in uncontrolled eating. It was concluded thatweight and shape concern fully mediated the rela-tionship between state self-esteem and uncontrolledeating.

Dietary Restraint as the Mediator betweenWeight and Shape Concern andUncontrolled Eating

Implicit in the cognitive model is the idea that higherlevels of weight concern lead to increased dietaryrestraint which in turn leads to binge eating. Therewere significant relationships between weight andshape concern and dietary restraint, between dietaryrestraint and uncontrolled eating (F(1, 107)¼ 25.94,p< 0.001), and between weight and shape concernand uncontrolled eating. However, the size of thislatter relationship was not significantly reducedwhen dietary restraint was controlled for, indicatingthat mediation was not present.

Path Analysis

In order to gain some overview of how the variableswere related to each other, a path analysis was con-ducted using a series of simultaneous MRAs work-ing backwards through the model (Cohen & Cohen,1983). In each step, BMI was entered at step 1 inorder to control for its influence. Dietary restraintwas used as the first outcome variable for the firstMRA, and the remaining variables (except uncon-trolled eating) were entered as independent vari-ables. Each variable continuing down through themodel was entered as an outcome variable, with

Table 2. Results from testing for mediation, reporting the standardized regression coefficient (�) and its associatedsignificance

Mediational chain IV!MV MV!DV IV!DV IV!DV|MV Z (p)Independent variable � � � �(IV)!mediation variable t ( p) t ( p) t ( p) t ( p)(MV)!dependent variable (DV)

Externalized self-perception! �0.58 �0.66 0.57 0.29 6.23self-esteem!weight & shape �7.41 (<0.001) �9.55 (<0.001) 7.61 (<0.001) 3.60 (<0.001) (<0.0001)concernSelf-esteem!weight & shape �0.66 0.62 �0.42 �0.004 6.45concern!dietary restriction �9.55 (<0.001) 8.19 (<0.001) �4.88 (<0.001) �0.04 (0.97) (<0.0001)Self-esteem!weight & shape �0.66 0.55 �0.35 0.04 8.80concern!uncontrolled eating �9.55 (<0.011) 6.80 (<0.001) �3.87 (<0.001) 0.32 (0.75) (<0.0001)Weight & shape concern!dietary 0.62 0.44 0.55 0.45 0.15restraint!uncontrolled eating 8.19 (<0.001) 5.09 (<0.001) 6.80 (<0.001) 4.36 (<0.001) (>0.05)



the variables to its left being entered as independentvariables. Uncontrolled eating was also examined asan outcome variable in the absence of dietaryrestraint. The final model, using all the significantstandardized regression coefficients (�) as path coef-ficients, is presented in Figure 1. For the overallmodel with dietary restraint as the outcome vari-able, R2¼ 0.39, p< 0.01, and for the overall modelwith uncontrolled eating as the outcome variable,R2¼ 0.31, p< 0.01.

DISCUSSION

This study represents only the third cross-sectionalexamination of the cognitive model. To date, nolongitudinal studies exist. In line with the predic-tions of the model, the relationship between self-esteem and both dietary restraint and uncontrolledeating were fully mediated by weight and shapeconcern, as measured by the EDE-Q (Beglin &Fairburn, 1994). Weight and shape concern is shownto be a pivotal variable within this model, sharing 44per cent, 30 per cent and 24 per cent of its variancewith dietary restraint, uncontrolled eating and self-esteem respectively. Our model cannot inform us asto the directional nature of the relationships betweenthese variables, and they may indeed be bi-direc-tional as suggested by an earlier study (Byrne &McClean, 2002).

Unlike a previous examination of the cognitivemodel (Byrne & McClean, 2002), we found that diet-ary restraint and uncontrolled eating were posi-tively and significantly correlated. However, wedid not find that dietary restraint (attempts or inten-tions to restrict intake) mediated the relationshipbetween weight and shape concern and uncon-trolled eating, suggesting that dieting is not a neces-sary pathway to uncontrolled eating. Previously, intests of the dual pathway model of eating disorders,it has been found that dieting mediates body

dissatisfaction and bulimic symptoms in females(Ricciardelli & McCabe, 2000; Stice, 2001). Thismay further support the notion that body dissatis-faction and weight and shape control are distinctbut overlapping concepts (Cooper & Fairburn,1993) and therefore have different mechanisms ofaction. However, definition of the dietary restraintconstruct continues to be debated in this area ofresearch, and may also be a reason for different find-ings across different studies. A recent study hasshown that dietary intake of dieting girls may besimilar to that of non-dieting girls, where respon-dents in the study interpreted healthy eating as diet-ing (Roberts et al., 2001). Dieting has also beendefined as a negative energy balance between calorieintake and expenditure and differentiated from diet-ary restraint, defined as the oscillation betweenrestriction and overeating (Stice, 2001). In terms ofa cognitive conceptualization, dieting can be seenas a set of cognitive rules that guide eating andwhich, when broken, result in permissive thoughtswhich can lead to binge eating (Cooper, Todd, &Wells, 2000). Further research into the way in whichdietary restraint works together with other variablesin the model will require a closer investigation ofwhat is actually being measured by the variety ofdietary measures available and how these differentmeasures behave in relation to uncontrolled eating.

In concordance with another study of adolescentgirls (Zaitsoff et al., 2002), externalized self-percep-tion (judging the self by external standards) seemsto be the most pertinent aspect of self-silencing beha-viour to influence self-esteem and weight and shapeconcern, which in turn influence eating behaviour.This type of behaviour is likely to be related to a lackof interoceptive awareness, defined by Bruch (1973)as the tendency to ‘believe that neither their bodiesnor their actions are self-directed, or not even theirown’ (p. 39), and postulated to be fundamental toanorexia nervosa. This external view of self hasalso been highlighted in other models of disturbed

Figure 1. Path analysis results: significant pathways (standardized regression coefficients) in the integrative model



eating, including the dual pathway model whichlinks thin ideal internalization to body dissatisfac-tion (Stice, 2001), and the self-objectification modelwhere acceptance of the thin cultural ideal leads tobody shame (Noll & Frederickson, 1998). It is ofinterest to note that about one-third of the varianceof self-esteem can be accounted for by externalizedself-perception and that externalized self-percep-tion also has an independent relationship withweight and shape concern, accounting for 8 per centof the variance of this variable. One of the benefits ofmodel building is the ability to suggest areas forintervention in prevention work. While the cross-sectional limitations of this research prevent us frombeing able to make conclusions about causality orthe direction of the relationships, we suggest that itmay be fruitful to further investigate the impact ofchallenging the acceptance of external opinions ofself on risk factors for eating disorders. This maybe especially relevant with respect to media con-structs of person and body, in line with the approachpromoted in media literacy prevention work (Irving& Berel, 2001). Indeed, there is some evidence to sug-gest that this type of approach can result in a short-term decrease in levels of weight concern (Wade,Davidson, & O’Dea, 2003), as would be predictedby the findings of the current paper.

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