Body Acceptance, Mindfulness, and Healthy Eating Behaviors among Women

Anushree Belur

A Dissertation Submitted to the Faculty of

The Chicago School of Professional Psychology

In Partial Fulfillment of the Requirements

For the Degree of Doctor of Psychology

June 23, 2016





ProQuest Number: 10829697




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 Body Acceptance, Mindfulness, and Healthy Eating Behaviors among Women

A Dissertation Submitted to the Faculty of

The Chicago School of Professional Psychology

In Partial Fulfillment of the Requirements

For the Degree of Doctor of Psychology

Anushree Belur

2016

Approved By:

Mekel Harris, Ph.D., Chairperson

Department Faculty, The Chicago School of Professional Psychology

Guy Balice, Ph.D., Reader

Department Faculty, The Chicago School of Professional Psychology
 Acknowledgements

I would not have been able to complete this dissertation without the encouragement,

patience, support, and enthusiasm of both my Chair, Dr. Mekel Harris, and Reader, Dr. Guy

Balice. Dr. Harris inspired me to aim for the best and taught me the importance of self-

compassion when I made mistakes. She helped me believe in myself and provided much needed

encouragement through humor and thought-provoking questions. Dr. Balice’s unerring

commitment to help students, no matter how late the hour, served as inspiration to be curious and

made me a better researcher. Thank you.

I also want to extend my heartfelt thanks to my friend and colleague, Kit Hoffman. Her

unconditional support kept me grounded and helped me complete this dissertation. Her kindness,

compassion, keen insight, and passion for psychotherapy inspires me to do my best. I also want

to thank my friends, Natalie, Liz, and Darlene – they were my voices of motivation. Thank you.
 Dedication

I would like to dedicate this dissertation to my family. I have been blessed with strong

role models in my family, starting with my Thatha, who nurtured my love for learning, and my

Ajji, who has unconditionally supported me in all my endeavors. My mother’s strong sense of

commitment to family, friends, and her work ethic, showed me that strength encompasses

dedication, love, and compassion. My father instilled a strong sense of wonder in me: I am

curious because of his loving support and encouragement to question things and pursue answers

with passion. My sister, Meera, taught me not to take life too seriously – her playfulness, endless

support, affection, and friendship inspires me every day. I am also fortunate to have a second set

of parents in my aunt Shantha and Kumar Uncle – they, along with my cousin, Anjana, have

always supported me. Thank you.

 Abstract

Research on weight management practices have become paramount given the rising rates of

overweight and obesity in the U.S. population (World Health Organization [WHO], 2008).

Despite widespread agreement that the etiology of obesity is multifaceted, societal norms that

idealize thinness promotes stigma that is often internalized by women. Internalization of fat

stigma is associated with unhealthy behaviors and mental health problems (Vartanian & Novak,

2011). Therefore, it is imperative to understand various aspects of body perception (e.g., body

satisfaction, information affecting perception process, etc.) and eating habits when tailoring

treatments aimed at helping women modify eating behaviors and manage their weight. The

current study examined the relationship between body acceptance, mindfulness, and eating

behaviors among women. A total of 73 participants were administered measures on mindfulness,

intuitive eating, maladaptive eating, and body acceptance. Multiple regression and factor

analyses were conducted to study the relationships between the variables. The results indicated

that high body acceptance significantly, but only slightly predicted higher intuitive eating (i.e.,

healthier eating). Examination of factors influencing eating behaviors revealed three factors: (1)

Physical Reasons for Eating; (2) Control of Eating Behaviors; and (3) Awareness of Emotional

States. The factors indicate that treatments can promote healthy eating by emphasizing

awareness of emotional states while eating, and awareness of physical sensations of hunger and

satiety. The findings also suggested that other than relationship status and education level, other

demographic variables (i.e., ethnicity, immigration/acculturation, etc.) did not predict body

acceptance. Clinical and research implications of these findings regarding are also addressed.
 Table of Contents

Table of Contents ............................................................................................................................. i

List of Tables .................................................................................................................................. v

Chapter 1: Introduction ................................................................................................................... 1

Obesity ........................................................................................................................................ 1

Health Risks Associated with Obesity ................................................................................ 2

Costs Associated with Obesity............................................................................................ 3

Socioeconomic and Other Influencers of Obesity .............................................................. 4

Impulsivity Model of Obesity ............................................................................................. 5

Body Acceptance......................................................................................................................... 6

Treatment Approaches ................................................................................................................ 7

Traditional Treatments ........................................................................................................ 7

Mindfulness-based Treatments ........................................................................................... 8

Gap in Literature ......................................................................................................................... 9

Future Clinical Implications ...................................................................................................... 10

Summary ................................................................................................................................... 10

Chapter 2: Literature Review ........................................................................................................ 11

Stigma as a Barrier to Weight Management ............................................................................. 11

Attitudes towards Body Image.......................................................................................... 13

Racial and Ethnic Differences in Body Perception........................................................... 16

Treatment Approaches for Weight Management ...................................................................... 18

Traditional Treatments ...................................................................................................... 18

Mindfulness-Based Treatment Approaches for Weight Management.............................. 19

i
 Importance of Culturally Relevant Treatment Approaches .............................................. 31

Research Questions ................................................................................................................... 34

Hypotheses ........................................................................................................................ 34

Chapter 3: Research Design and Method...................................................................................... 36

Research Design ........................................................................................................................ 36

Population and Sample .............................................................................................................. 36

Exclusion Criteria ............................................................................................................. 36

Inclusion Criteria .............................................................................................................. 37

Procedures ................................................................................................................................. 37

Instrumentation.......................................................................................................................... 39

Screeners ........................................................................................................................... 39

Mindfulness....................................................................................................................... 40

Body Acceptance .............................................................................................................. 41

Eating Behavior ................................................................................................................ 41

Data Processing ......................................................................................................................... 42

Ethical Considerations............................................................................................................... 43

Informed Consent.............................................................................................................. 43

Privacy and Confidentiality .............................................................................................. 44

Chapter 4: Findings ....................................................................................................................... 45

Introduction ............................................................................................................................... 45

Sample Characteristics .............................................................................................................. 45

Inclusion and Exclusion .................................................................................................... 45

Descriptive Statistics of Measures ............................................................................................ 49

ii
 Mindfulness....................................................................................................................... 49

Body Acceptance .............................................................................................................. 51

Eating Behavior ................................................................................................................ 52

Inferential Statistics ................................................................................................................... 54

Hypothesis 1...................................................................................................................... 54

Hypothesis 2...................................................................................................................... 57

Hypothesis 3...................................................................................................................... 58

Hypothesis 4...................................................................................................................... 60

Hypothesis 5...................................................................................................................... 60

Hypothesis 6...................................................................................................................... 61

Hypothesis 7...................................................................................................................... 69

Summary of Results .................................................................................................................. 74

Chapter 5: Discussion and Conclusions........................................................................................ 75

Overview of Study .................................................................................................................... 75

Findings ..................................................................................................................................... 77

Mindfulness....................................................................................................................... 77

Healthy Eating .................................................................................................................. 79

Body Acceptance .............................................................................................................. 81

Limitations ................................................................................................................................ 84

Sample Size....................................................................................................................... 84

Generalizability and Sample Characteristics .................................................................... 84

Study Design ..................................................................................................................... 85

Implications of Findings............................................................................................................ 86

iii
 Clinical Implications ......................................................................................................... 86

Research Implications ....................................................................................................... 87

Directions for Future Research ................................................................................................. 87

References ..................................................................................................................................... 89

Appendix A: Informed Consent .................................................................................................. 111

Appendix B: Advertisement for Research – Online Recruitment .............................................. 113

Appendix C: Advertisement for Research – Flyers .................................................................... 114

Appendix D: Advertisement for Research – Recruiting Face-to-Face ....................................... 115

Appendix E: Demographics ........................................................................................................ 116

Appendix F: Screener – Eating Disorder .................................................................................... 118

Appendix G: Screener – Patient Health Questionnaire - 9 (PHQ-9) .......................................... 119

Appendix H: Five Facet Mindfulness Questionnaire (FFMQ) ................................................... 120

Appendix I: Body Appreciation Scale – 2 (BAS-2) ................................................................... 122

Appendix J: Intuitive Eating Scale-2 (IAS-2) ............................................................................. 123

iv
 List of Tables

Table 1. Participants age, ethnicity, marital status, education, income …………. 46

Table 2. Geographic location of family of origin ……………………………….. 47

Table 3. Participants’ BMI ……………………………………………………… 48

Table 4. Past and current participation in weight loss program ………………… 48

Table 5. Mindfulness element in weight loss program ………………………….. 49

Table 6. Importance of spirituality ………………………………………………. 49

Table 7. FFMQ descriptive statistics ……………………………………………. 50

Table 8. FFMQ subscale descriptive statistics ………………………………….. 50

Table 9. BAS – 2 descriptive statistics ………………………………………….. 51

Table 10. EAT – 26 descriptive statistics ………………………………………… 52

Table 11. EAT – 26 subscale descriptive statistics – pre- and post-logarithmic

transformation ………………………………………………………….. 53

Table 12. IES – 2 descriptive statistics …………………………………………… 53

Table 13. IES – 2 subscales descriptive statistics ………………………………… 54

Table 14. Correlations between FFMQ and IES-2 ……………………………….. 55

Table 15. Correlations between IES-2 and EAT-26 ……………………………… 56

Table 16. Correlations between FFMQ and EAT-26 ……………………………... 57

Table 17. Correlations between BMI and IES-2 ………………………………….. 58

Table 18. Correlations between BMI and EAT-26 ……………………………….. 58

Table 19. Correlations between BAS-2 and IES-2 ……………………………….. 59

Table 20. Correlations between BAS-2 and EAT-26 …………………………….. 60

Table 21. Correlations between BAS-2 and BMI ………………………………… 60

v
Table 22. Correlations between BAS-2 and FFMQ ………………………………. 61

Table 23. Model summary ………………………………………………………... 62

Table 24. ANOVA ………………………………………………………………... 62

Table 25. Coefficients …………………………………………………………….. 62

Table 26. KMO and Bartlett’s test ………………………………………………... 64

Table 27. Communalities …………………………………………………………. 64

Table 28. Total Variance Explained ……………………………………………… 67

Table 29. Rotated Component Matrix ……………………………………………. 65

Table 30. KMO and Bartlett’s test ………………………………………………... 66

Table 31. Communalities …………………………………………………………. 66

Table 32. Total Variance Explained ……………………………………………… 68

Table 33. Rotated Component Matrix ……………………………………………. 69

Table 34. Model summary ………………………………………………………... 71

Table 35. ANOVA ………………………………………………………………... 71

Table 36. Coefficients …………………………………………………………….. 72

vi
 1

Chapter 1: Introduction

Obesity

Nearly 69.4% of adults in the United States are overweight or obese (World Health

Organization [WHO], 2008); Fryar, Carroll, and Ogden (2014) analyzed data from Center for

Disease Control’s (CDC) National Health and Nutrition Examination Survey (NHANES) of

adults over 20 years of age, and found that 33.9% adults are overweight, 35.1% are obese, and

6.4% of the United States population are estimated to be extremely obese. Baum and Ruhm

(2009) further analyzed the NHANES data and found age to be positively correlated with the

prevalence of obesity, while socioeconomic status (SES) to be inversely related to obesity

prevalence (i.e., individuals from lower SES had higher levels of obesity). Other analyses from

NHANES data revealed that prevalence rates for non-Hispanic White individuals was lower than

the combination of the prevalence for non-Hipanic White, non-Hispanic Black, and Mexican

American ethnicities, while the prevalence rates for non-Hispanic Black and Mexican American

individuals was significantly higher than non-Hispanic White individuals (Hedley et al., 2004).

Gender comparisons revealed that men had higher rates of overweight and obesity than women;

however, the ethnicity breakdown was similar to that of both sexes, with non-Hispanic Black and

Mexican American women having higher rates of overweight and obesity than non-Hispanic

White men and women (Hedley et al., 2004).

Obesity is caused by a combination of genetic, environmental, and psychological factors

(Devlin, Yanovski, & Wilson, 2000). The levels of obesity is often determined by the body mass

index (BMI), which measures the fat storage in the body by considering the height and weight

ratio, and is calculated by the weight in kilograms divided by the height in meters squared

(kg/m2; Lewis et al., 2009; WHO, 1995). Although the use of BMI is seen as controversial in

recent years (Burkhauser & Cawley, 2008; Poirier, 2007), the WHO (1995) Expert Committee
 2

recommended the following classification of overweight individuals through the use of BMI:

grade 1 overweight (i.e., BMI between 25.00 kg/m2 and 29.99 kg/m2), grade 2 overweight (i.e.,

BMI between 30.00 kg/m2 and 39.99 kg/m2), and grade 3 overweight (i.e., BMI of 40 kg/m2 or

greater). In general, the WHO (2014) classifies anyone with a BMI of 25 kg/m2 or greater as

overweight, and anyone with a BMI of 30 kg/m2 and greater as obese.

Health Risks Associated with Obesity

In a study examining the relationship between overweight, obesity, and mortality, Adams

et al. (2006) found both overweight and obesity to be associated with high risks for mortality in

adults between the ages of 50 and 71 years old. Large meta-analytic studies have found

correlations between obesity and several chronic health conditions (Guh, Zhang, Bansback,

Amarsi, Birmingham, Anis, 2009). Although researchers utilized different methods to determine

overweight or obesity in these studies (e.g., using BMI, waist circumference instead of waist to

hip ratio), they found overweight and obesity to be a risk factor in developing diabetes and

hypertension (Nyamdorj et al., 2008; Vazquez, Duval, Jacobs, & Silventoinen, 2007).

Overweight and obesity was also found to be predictive of the level of risk for cardiovascular

diseases (de Koning, Merchant, Pogue, & Anand, 2007) and coronary disease (Bogers et al.,

2007); Bogers et al. (2007) found that even moderate overweight and obesity are associated with

higher rates of blood pressure and cholesterol. Beuther and Sutherland's (2007) meta-analytic

study also found strong a strong association between an increase in asthma incidents and higher

BMIs in both men and women. Furthermore, research found overweight and obesity to be linked

to various types of cancer (Renehan, Tyson, Egger, Heller, & Zwahlen, 2008), including ovarian

(Olsen, Green, Whiteman, Sadeghi, Kolahdooz, & Webb, 2007) and colorectal cancer

(Moghaddam, Woodward, & Huxley, 2007).

 3

Overweight and obesity has also been found to be correlated with mental health

conditions (McElroy, Kotwal, Malhotra, Nelson, Keck, & Nemeroff, 2004). In a cross-sectional

study examining the relationship between weight and depression, Carey et al. (2014) found a “U”

shaped pattern – underweight and overweight participants had a greater likelihood of

experiencing depression than normal weight participants. The stigma associated with overweight

and obesity also affects the mental health of individuals; in an extensive review of the literature,

Puhl and Heuer (2009) explained that weight stigma impacts several domains of mental health,

including depression, low self-esteem, body dissatisfaction, and maladaptive coping skills. The

study by Wang, et al. (2004), which found that people who are overweight and obese view other

obese and overweight individuals as lazy, indicated that overweight and obese individuals may

be internalizing the stigma associated with their weight. The social stigma of overweight and

obesity affects individuals in healthcare, education, and employment settings, and consequently,

affect the costs associated with obesity (Puhl & Heuer, 2009).

Costs Associated with Obesity

The medical expenditure, loss of productivity, transportation, and human capital are some

of the costs attributed to obesity (Hammond & Levine, 2010). The estimates of medical

expenditures associated with obesity are reported to be $147 billion per year (Finkelstein,

Trogdon, Cohen, & Dietz, 2009), $209.7 billion per year (Cawley & Meyerhoefer, 2012), or

even up to $300 billion per year (Behan, Cox, Lin, Pedersen, & Yi, 2010). Furthermore, nearly

$11.7 billion is lost in productivity every year (Hammond & Levine, 2010); Finkelstein,

Strombotne, & Popkin (2013) estimate that nearly $73.1 billion is lost annually due to

absenteeism, presenteeism (i.e., being present at work, but not attending to the tasks), and

medical expenses in the workplace.

 4

Socioeconomic and Other Influencers of Obesity

SES, often measured by education level and family income, has been correlated with

overweight and obesity; individuals from low SES were likely to have higher rates of overweight

and obesity and they are less likely to have lower quality of life perceptions (Burkert, Rásky,

Großschädl, Muckenhuber, & Freidl, 2013; Sobal & Stunkard, 1989). However, longitudinal

research from 1971 and 2000 revealed that the discrepancy of prevalence rate for obesity in

regards to SES decreased from nearly 50% to 14% by 2000; however, the inverse relationship

between SES and obesity rates still prevailed by 2000 (Zhang & Wang, 2004).

Researchers also found that overweight and obese women from low SES generally pay

less attention to their weight, engage less in healthy behaviors, and perceive decreased social

support than their higher SES counterparts (Jeffery & French, 1996). Wardle, Waller, and Jarvis

(2002) further found that men and women from low SES both are at higher risk for obesity;

however, they found that women’s risk for obesity was mediated through higher occupational

positions. The relationship between low SES and higher obesity rates is also observed in

developing countries, and the relationship is particularly observed in women earlier in their lives

(Monteiro & Moura, 2004).

Kirby, Liang, Chen, and Wang (2012) explored the complexity of environmental factors;

they found that the obesity prevalence was higher in predominantly Hispanic neighborhoods, and

that the risk for obesity increased for Hispanics, as well as Caucasians. The study also found that

obesity prevalence, as well as the risk for obesity decreased for Caucasians living in

predominantly Asian neighborhoods. One explanation for this disparity may be due to the

availability of healthy food choice in their respective neighborhoods, as research indicates the

presence of more grocery stores and supermarkets in wealthier neighborhoods in comparison to

 5

poorer neighborhoods (K. Morland, Wing, Diez Roux, & Poole, 2002). Block, Scribner, &

DeSalvo (2004) also observed a similar phenomenon and found that 2.4 fast food restaurants

were present per square mile in low income Black communities in Louisiana in comparison to

1.5 fast food restaurants in White neighborhoods. Other factors, such as health beliefs (Blixen,

Singh, & Thacker, 2006) and perception of overweight and obesity (Dorsey, Eberhardt, &

Ogden, 2009; Paeratakul, White, Williamson, Ryan, & Bray, 2002), impact the prevalence of

obesity in communities.

Impulsivity Model of Obesity

While there are many environmental and genetic factors that influence obesity, the

impulsivity model of obesity examines the aspects of eating behavior that contribute to obesity.

The impulsivity model is derived from the five-factor model of personality and has four major

components: urgency, (lack) of premeditation, (lack) of perseverance, and sensation seeking

(Whiteside & Lynam, 2001). Whiteside & Lynam (2001) conducted an extensive factor analysis

utilizing various measures of impulsivity in order to provide a unified and comprehensive view

of the psychological processes that lead to impulsive behavior. They defined that urgency as “a

tendency to commit rash or regrettable actions as a result of intense negative affect,”

premeditation as “the tendency to delay action in favor of careful thinking and planning,”

perseverance as “the ability to remain with a task until completion and avoid boredom,” and

sensation seeking as “the tendency to seek excitement and adventure” (p. 677).

Claes, Vandereycken, & Vertommen (2005) used the impulsivity model to explain the

eating disorders and found that individuals with bulimia were more likely to exhibit urgency and

sensation seeking, rather than demonstrate lack of perseverance and premeditation. Mobbs,

Crépin, Thiéry, Golay, & Van der Linden (2010) applied the impulsive model to obesity and
 6

defined the four psychological processes of impulsivity in obesity as follows: urgency as the

“difficulty in refraining from eating when feeling strong emotions,” lack of perseverance as the

“mind [being] occupied with thoughts about food and body shape,” lack of premeditation as

eating “without taking consequences and complications into account,” and sensation seeking as

having “high sensitivity to reward, including eating” (p. 374). Mobbs et al. (2010) also portray a

bi-directional relationship between these four components and explain that the combination of

these four processes result in maladaptive eating behaviors. They further recommended that

introducing psychological flexibility may help individuals regulate their emotions and develop

adaptive eating behaviors (Mobbs et al., 2010).

Body Acceptance

Rumination about body image and body size play a key role in the maintenance of

unhealthy eating habits and weight loss challenges (Parham, 1999; Ruggiero, Hannover,

Mantero, & Raffaelo, 2000; Stewart, 2004). Body acceptance is the ability to recognize one’s

“strengths, beauty, and abilities of one’s body even while dispassionately recognizing the

weaknesses, unattractive features, and awkwardness. It involves expanding one’s perceptions to

go beyond the weaknesses into the whole experience of one’s body” (Parham, 1999, p. 922).

Body acceptance is often associated with higher body image satisfaction and higher self-esteem,

as related to body image and shape (e.g., Rubin, Fitts, & Becker, 2003; Snooks & Hall, 2002).

Furthermore, body acceptance, or positive body image is a separate phenomenon from negative

body image and involves rejecting media portrayals of ideal body images (Tylka & Wood-

Barcalow, 2015; Wood-Barcalow, Tylka, & Augustus-Horvath, 2010).

Research has consistently indicated that a significant discrepancy exists among women

from various ethnic and socioeconomic backgrounds in how they perceive body image (e.g.,
 7

Forbes & Frederick, 2008; Snooks & Hall, 2002). This discrepancy is particularly apparent while

studying the body size attitudes of Caucasian and African American women; Caucasian women

are more likely to have lower body satisfaction and self-esteem in comparison to African

American women (Forbes & Frederick, 2008; Molloy & Herzberger, 1998). Difference in body

image attitudes also exist between ethnic and racial subgroups; for example, Chinese-American

women have higher body satisfaction than Japanese-American women (Yates, Edman, &

Aruguete, 2004). Researchers point out the importance of understanding these nuances in body

image attitudes in relation to eating behaviors and weight management (e.g., Gordon, Castro,

Sitnikov, & Holm-Denoma, 2010; Wildes, Emery, & Simons, 2001).

Treatment Approaches

Traditional Treatments

Behavioral treatments have been consistently used to assist with weight loss (Devlin et

al., 2000), and studies have shown that people lost about 8-10% of their body weight in the initial

six months of treatment (Foster, Makris, & Bailer, 2005). The behavioral interventions include

the self-monitoring component (e.g., food logs), as well as nutrition education, cognitive

restructuring, and physical activity (Foster, et al., 2005). However, five-year follow-up studies

show that individuals gain back most of the weight and even may weigh more than when they

started the behavioral treatment (Devlin et al., 2000; Stalonas, Perri, & Kerzner, 1984).

Pharmacotherapy has been utilized as means to help individuals manage their weight loss

(Devlin et al., 2000). Although medications have shown to aid with weight loss in the first year

of treatment, long-term effects (i.e., greater than 1-year period) of pharmacotherapy has to be

studied (Padwal, Li, & Lau, 2003). Low-calorie dietary programs have also been widely used to

aid in weight loss; however, similar to behavioral treatments, long-term studies indicate that low-
 8

calorie diet programs do not result in sustained weight loss for overweight and obese individuals

(Atkinson et al., 1993).

Mindfulness-based Treatments

Recent research has focused on developing mindfulness-based interventions for weight

loss in overweight and obese individuals (e.g., Bernstein, Bar, Ehrman, Golubic, & Roizen,

2013; Daubenmier et al., 2011; Lillis, Hayes, Bunting, & Masuda, 2009). Mindfulness is a

metacognitive skill with two main components: the ability to self-regulate attention and the

ability to experience the present moment through acceptance, openness, and curiosity (Bishop et

al., 2004). The ability to self-regulate attention includes being aware of the present moment

through sustained attention (i.e., the ability to maintain thoughts on the experience of the present)

and inhibition of elaborative thought processes (i.e., mindfulness practice allows a person to

acknowledge intrusive thoughts as part of the experience, but does not emphasize on dwelling on

these thoughts – this inhibits the elaboration of the thought process; Bishop et al., 2004). The

second component of mindfulness involves what Bishop et al. (2004) describe as “orientation

towards experience;” this aspect of mindfulness requires a person to take a curious stance

towards their thoughts and accept these thoughts without judgment, which ultimately results in

emotional distress being experienced “as less unpleasant and threatening.”

Mindfulness-based interventions have been preliminarily applied to various health

conditions, including depression, chronic stress, and other physical ailments (Baer, 2006).

Mindfulness-based interventions for weight loss focus on developing greater non-judgmental

self-regulation and higher distress tolerance through the creation of increased awareness of

sensations in the body in the present moment (Caldwell, Baime, & Wolever, 2012; Dalen et al.,

2010; Lillis et al., 2009; O’Reilly, Cook, Spruijt-Metz, & Black, 2014). Mindfulness-based
 9

interventions have been shown to impact the eating behaviors associated with obesity (O’Reilly

et al., 2014), as well as result in weight loss, greater psychological flexibility (i.e., ability to

tolerate distress), and increase overall physical and mental health quality of life of overweight

and obese individuals (Lillis et al., 2009). Furthermore, mindfulness has been associated with

greater body acceptance and healthy eating behaviors (Alberts, Thewissen, & Raes, 2012;

Stewart, 2004).

Gap in Literature

Body acceptance and mindfulness are considered to be aspects of healthy eating

behaviors (Bacon, Stern, Van Loan, & Keim, 2005; O’Reilly et al., 2014). Research on body

acceptance indicated that a discrepancy in body satisfaction exists between various ethnic groups

(e.g., Fitzgibbon, Blackman, & Avellone, 2000; Forbes & Frederick, 2008; Rubin et al., 2003),

with Caucasian women often endorsing greater body dissatisfaction than women from other

groups. Furthermore, research showed that disparity in body satisfaction and body image

perception exists even within groups ( e.g., Asian subgroup differences, acculturation differences

within immigrant populations, etc.; e.g., Perez, Voelz, Pettit, & Joiner, 2002; Sussman, Truong,

& Lim, 2007; Yates, et al., 2004).

While many mindfulness-based interventions for weight management are still in their

infancy, the results of these interventions appear to be promising in cultivating greater

mindfulness, body acceptance, and healthier eating habits (e.g., Alberts et al., 2012; Dalen et al.,

2010; Lillis et al., 2009; O’Reilly et al., 2014; Tapper, Shaw, Ilsey, Hill, Bond, & Moore, 2009).

However, most of these studies included mostly Caucasian participants, and therefore, the

effectiveness of mindfulness-based treatments for weight management is not completely known

for other minority groups or for low SES populations (Lillis et al., 2009; Tapper et al., 2009).
 10

Furthermore, the attrition rates in studies that had more diverse sample sizes indicated that

women from minority groups were more likely to drop out of the study (e.g., Forman, Butryn,

Hoffman, & Herbert, 2009).

Although body acceptance or positive body image is related to healthy eating behaviors

(e.g., Alberts et al., 2012; Bacon et al., 2005), and increased mindfulness is also associated with

healthy eating behaviors and body acceptance (e.g., Alberts et al., 2012; Lillis et al., 2009), the

role of culture and socioeconomic background in relation to body acceptance has not been

widely studied. Given the wide cultural discrepancies in attitudes towards body image, it is

imperative to understand how cultural and socioeconomic variables influence body acceptance,

mindfulness, and healthy eating behaviors, while tailoring treatment for overweight and obese

women.

Future Clinical Implications

A study focusing on understanding the sociocultural influencers of body acceptance,

especially as they relate to mindfulness and healthy eating behaviors, would enhance the

literature on tailoring culturally relevant treatments for women. This would be particularly

important for clinicians who provide services to women in low SES or underserved communities.

Furthermore, the exploration of the relationship between mindfulness and body acceptance may

also promote strength-based treatments for women. This body of literature would also help

illuminate the barriers low SES populations may face with particular interventions and could

inspire more explanations for attrition and treatment non-adherence.

Summary

Although obesity is a multifaceted phenomenon, societal perceptions on obesity remain

unidimensional and perpetuate stigma. Contemporary treatments for weight management and
 11

changing eating behaviors have begun to integrate mindfulness and have produced promising

results (e.g., Lillis et al., 2009). However, most of the research on mindfulness-based treatments

and eating behaviors are conducted with college-age Caucasian women (e.g,. Bacon et al., 2005;

Bruce & Ricciardelli, 2016; Dalen et al., 2010), and represents a gap in literature in regards to

the relationships between mindfulness, body acceptance, and eating behaviors among diverse

populations.

Chapter 2 highlights literature on stigma associated with obesity, as well as explore

mindfulness-based treatments in depth. Chapter 2 will also explain the research questions that

guided the exploration of the relationship between mindfulness, body acceptance, and eating

behaviors. Chapter 3 presents the methodology used to investigate the research questions, and

provides information on the inclusion and exclusion criteria. Chapter 4 provides detailed analysis

of results, and explains the correlations found between mindfulness, body acceptance, eating

behaviors, and BMI. Chapter 5 summarizes the findings, as well as explores the limitations of the

results, especially in relation to the generalizability of the findings. Implications for clinical

practice, including recommendations to incorporate a more holistic body image model (Wood-

Barcalow et al., 2010) are discussed.

Chapter 2: Literature Review

Stigma as a Barrier to Weight Management

Majority of the population view obesity as an individual’s problem, rather than a societal

problem (e.g., Puhl, Moss-Racusin, Schwartz, & Brownell, 2008; Wang et al., 2004). The

attributional theory of obesity stigma revolves around controllability beliefs; Hegarty and Golden

(2008) found that a person affected by uncontrollable events is viewed with sympathy, while a

person affected by controllable events are viewed negatively. When applying this attributional
 12

model to obesity stigma, the general population view obesity as a controllable condition, and

therefore are less likely to sympathize with individuals who are overweight and obese (Puhl &

Brownell, 2001).

The pervasiveness of obesity stigma and controllability beliefs was observed even among

children in grade school. Tiggemann and Anesbury (2000) conducted a study with children

between grades 4 and 6 regarding their attitudes towards obesity; they administered surveys to

children regarding their perception of weight in children and adults. The study found a

significant relationship between the children’s negative stereotyping of overweight and their

controllability beliefs. Furthermore, the study found that children stereotyped other overweight

children and adults as lazy, less attractive, less confident, less healthy, and less hard-working

(Tiggemann & Anesbury, 2000).

Wang et al. (2004) aimed to study the effects of stigma of being obese in overweight and

obese individuals. The researchers conducted two studies to examine the implicit and explicit

stigma and utilized the Implicit Association Test (IAT) in both studies. The participants were

college aged individuals in a weight loss program with BMIs greater than 30 (i.e., categorized as

obese). The first study results indicated that obese individuals were more likely to view other

overweight and obese indiviudals as “bad.” The second study results demonstarted that obese

individuals explicity veiwed other obese individuals as “lazy” and “unmotivated” in comparison

to thin people.

Similarly, Puhl, Moss-Racusin, & Schwartz (2007) found that overweight and obese

women who believed the negative stereotypes regarding obesity had more binge eating episodes.

Overweight and obese women endorsed negative stereotypes, inlucing that overweight and obese

individuals are lazy, unintelligent, unattractive, lack hygeine and willpower, and are worthless.
 13

Furthermore, women who believed in these negative stereotypes were more likely to use

avoidance as a coping skill (e.g., refusing dieting behavior). Vartanian and Novak (2011) also

found similar avoidance coping skills; the study found that individuals who had high internalized

stigma regarding obesity were more motivated to avoid exercising if they also experienced

stigma. In contrast, individuals with lower levels of internalized weight stigma were more likely

to engage in exercise (Vartanian & Novak, 2011). The clinical implication of these research

studies are that overweight and obese individuals are more likely to internalize the stigma, and

therefore, may be more prone to depression and other mental health conditions (Puhl et al.,

2007).

Drury, Aramburu, and Louis (2002) further examined the adverse effects of stigma in

healthcare settings. They studied the health avoidance behavior of obese women by surveying

their experiences with a health care professional. Their study was aimed at nursing professionals,

and highlighted the stigma health officials often hold against overweight and obese individuals.

The study included over 200 participants who were recruited from churches in Las Vegas. The

study found that women were more likely to avoid going to their physicians in fear of being

weighed, or even their discomfort for changing into medical gowns. The limitation of this study

may stem from the homogeneity of the sample size; the majority of women included in this study

were Caucasian, and therefore, it is unclear if women from other ethnic and racial backgrounds

would hold similar views.

Attitudes towards Body Image

Social cues influence body image satisfaction; in a study examining social influencers on

body image among undergraduate college women, Salk and Engeln-Maddox (2011) found that

women who engaged in fat talk (i.e., women engaging in negative talk about their bodies) with
 14

their peers more frequently had higher rates of body dissatisfaction. Furthermore, the study

found that women who engaged in fat talk were more likely to internalize the ideal beauty

standards of being thin. Similarly, Stice, Maxfield, and Wells (2003) conducted a study with

college women to examine how social cues affect fat talk and body satisfaction. The participants

assigned to the experiment group interacted with a confederate who was thin but engaged in fat

talk. The results indicated that the women in the experiment group had higher levels of body

dissatisfaction and internalization of the ideal thin body. However, most of the women included

in these studies were Caucasian; studies examining body perception and satisfaction among

women from various ethnic and racial backgrounds reveal a discrepancy in how women perceive

themselves (e.g., Dorsey et al., 2009; Yates et al., 2004).

Holistic body image model. A review of literature suggests that body image is a

complex phenomenon that involves many sociocultural factors. Wood-Barcalow et al. (2010)

developed a model to conceptualize body image in a holistic manner by conducting a qualitative

study. The holistic body image model highlights “the unique process by which women interpret

and analyze information about their bodies” (Wood-Barcalow et al., 2010, p. 111). The model

includes three processes: reciprocity, filtering, and fluidity. These processes interact with four

structures of the model: sources, filter, body investment, and body evaluation. Sources are the

various elements that influence body image (e.g., health, developmental history, education,

community, spirituality, culture, society, interpersonal relationships, etc.). Reciprocity is the bi-

directional process in which the individual and the source influence one another. An example of

this is when women interact with other women with positive body image and unconditional

positive acceptance, these women influence one another through the process of reciprocity.
 15

Filtering is the process in which individuals choose to accept or reject the information

(Wood-Barcalow et al., 2010, p.111). “The filter consists of current affect (positive and

negative), beliefs (rational and irrational), and perceptions (accurate and inaccurate) shaped from

previous information that passed through the filter” (Wood-Barcalow et al., 2010, p.111).

Fluidity is the process in which the structures of the model (i.e., sources, filter, body investment,

and body evaluation) interact. The sources can influence each other (e.g., culture influencing

spirituality and lifestyle). Similarly, the body investment structure can interact with the filter, as

the body investment increases or decreases depending on the type of information that is being

filtered. Fluidity is also evidenced by the interaction between body investment and body

evaluation; body evaluation can be positive or negative and can influence an individual’s body

investment. Body evaluation does not need to be completely positive or negative, and in fact, the

researchers point out that the body evaluation can shift from positive to negative as new

information is filtered into an individual’s awareness (Wood-Barcalow et al., 2010).

The holistic model accounts for the various sociocultural phenomenon that influence

body acceptance, as well as account for how that information is perceived and interact with one

another. Based on this model, Wood-Barcalow et al. (2010) defined positive body image as

…an overarching love and respect for the body that allows individuals to (a) appreciate

the unique beauty of their body and the functions that it performs for them; (b) accept and

even admire their body, including those aspects that are inconsistent with idealized

images; (c) feel beautiful, comfortable, confident, and happy with their body, which is

often reflected as an outer radiance, or a ‘‘glow;’’ (d) emphasize their body’s assets

rather than dwell on their imperfections; (e) have a mindful connection with their body’s

needs; and (f) interpret incoming information in a body-protective manner whereby most
 16

positive information is internalized and most negative information is rejected or

reframed. (p. 112)

Their definition of positive body image closely resembles the definition of body acceptance put

forth by Parham (1999), which also emphasized the ability to accept the strengths of beauty, as

well as acknowledge the unattractive features objectively.

Racial and Ethnic Differences in Body Perception

As the holistic body image model theorizes, sociocultural factors appear to influence

body image. Dorsey et al. (2009) analyzed NHANES data from 1999-2006 and reported on the

trends in self-perception as they related to obesity, race/ethnicity and gender. The study found

that individuals in ethnic minorities groups (e.g., non-Hispanic Blacks and Mexican Americans)

were more likely to be misperceived about their weight status than non-Hispanic White

individuals. Specifically, overweight and obese non-Hispanic Black and Mexican American

individuals were more likely to identify themselves as “healthy weight” than non-Hispanic White

individuals. The study also found that men were more likely to perceive themselves as “healthy

weight” than women, and that this finding was more pronounced in non-Hispanic Black men.

The study also found a negative correlation between education levels and obesity prevalence and

self-perception; that is, overweight and obese individuals with less education were more likely to

report that they were “healthy weight” than individuals with more education.

Differences in body perception and body acceptance are particularly observable among

Caucasian and African American women, with Caucasian women usually reporting higher levels

of body dissatisfaction than their African American counterparts (Roberts, Cash, Feingold, &

Johnson, 2006). African American women have also been observed to have higher self-esteem

than Caucasian women in regards to their body satisfaction (Molloy & Herzberger, 1998).
 17

Literature suggests that Latina or Hispanic women are more sensitive to change in their weight

than Caucasian or African American women; a study by Fitzgibbon et al. (2000) indicated that

Caucasian women are more likely to be dissatisfied at lower BMIs than African American or

Latina women. However, African American and Latina women’s body dissatisfaction was

correlated with overweight or obese BMIs.

Research also indicates that women from different sub-groups may also endorse different

levels of body acceptance. Various studies point out that Asian women tend to have the least

amount of body satisfaction in comparison to women from other ethnic minorities (e.g., Evans &

McConnel, 2003; Forbes & Frederick, 2008). A closer look at the sub-groups among Asian

women reveal that Japanese women exhibit higher levels of body dissatisfaction than their

Chinese counterparts (Yates et al., 2004). Acculturation also plays a key role in levels of body

acceptance; a study by Sussman et al. (2007) found that first generation Chinese immigrants had

the lowest body satisfaction rates; however, body satisfaction was positively correlated with

acculturation among the Chinese immigrants. In contrast, Eastern European immigrant women’s

body satisfaction decreased with acculturation (Sussman et al., 2007). Acculturative stress was

also found to be highly correlated with body dissatisfaction and unhealthy eating habits (i.e.,

bulimia) among women from ethnic minorities (Perez et al., 2002).

These discrepancies in body perceptions and body acceptance might be explained by the

standards of beauty women from different backgrounds adhere. In a qualitative study examining

body perception among African American and Latina women, Rubin et al. (2003) found that the

participants prescribed to a set of body ethics rather than aesthetic ideals. Body ethics are “values

and beliefs regarding care and presentation of the body” (Rubin et al., 2003, p. 55). African

American women discussed style and self-confidence as being more important than size of a
 18

woman; spirituality and treating one’s body with respect was also seen as key elements to

adhering to a different set of body ethics. Women also rejected the mainstream standards of

beauty, and explained that their rejection was associated with not connecting with the ideal

women being represented in the media (i.e., “white, thin, and young – I don’t see me”; Rubin et

al., 2003).

This rejection of the mainstream aesthetic standards of beauty may act as a protective

factor for African American women. However, research also indicates that regardless of these

high rates of body satisfaction of self-esteem, African American women are at-risk for

overweight and obesity (Dorsey et al., 2009; Flynn & Fitzgibbon, 1998). Particularly, as African

American women are more likely to perceive their weights as not being overweight or obese,

they are more likely to not engage in healthy behaviors to manage their weights (Flynn &

Fitzgibbon, 1998). This scenario demonstrates the importance of understanding the sociocultural

nuances when tailoring weight management treatments for specific populations.

Treatment Approaches for Weight Management

Traditional Treatments

Traditional treatments for obesity include behavioral interventions, pharmaceutical

interventions, dietary restrictions, and surgery. In a review of different bariatric surgery

procedures used as a treatment method for individuals who are morbidly obese, Brolin (2002)

also mentioned the accompanying long-term success and failure rates of bariatric surgery. The

outcomes of surgery suggest that the incidence co-morbid coditions (e.g., coronary,

cardiovascular, etc.) of obesity decrease in individuals who underwent surgery. However, Brolin

(2002) noted that many individuals reported comparatively minimal wieght loss after surgery, as
 19

failure of surgery is considered less than 50% of weight loss. However, Brolin (2002) pointed

out the benefits of the surgery (e.g., reduction in hypertention) and argued that surgery is one of

the best options to treat morbid obesity.

In contrast, Suter, Calmes, Paroz, and Giusti (2006) questioned the use of surgery as a

treatment for morbid obesity. Their study examined the long-term efficacy of gastric banding

surgery to treat morbid obesity (i.e., BMI > 40kg/m2, or BMI > 35kb/m2 for individuals with

severe co-morbidities). Suter et al. (2006) found that the failure rates (i.e., weight loss of less

than 20% of body weight or removal of band) of surgery increased throughout the follow-up

time period, indicating that individuals eventually gained back the weight after surgery.

Furthermore, they noted an increased presence of complications related to surgery at later time

points and reported their skepticism regarding the effectiveness of surgery as an option to treat

morbid obsity. These tradtional treatment appraoches to obesity fail to consider the underlying

attitudes towards body image and eating behaviors; moreover, the appropriateness of these

tradtional treatments is unknown when considering the various sociocultural variables (e.g.,

culture, ethnicity, SES, etc.).

Mindfulness-Based Treatment Approaches for Weight Management

Caucasian population. According to the NHANES data, 63.3% of non-Hispanic White

population is estimated to be overweight and obese, and 24.9% are considered to be obese ( i.e.,

BMI ≥ 30kg/m2;Hedley et al., 2004). Treatment approaches for obesity are often first piloted in

Caucasian population (e.g., Dalen et al., 2010; Lillis et al., 2009), and as a result, a

preponderance of literature exists on the applicability of treatments to this population.

Contemporary treatments. Recent research on weight management has focused on

integrating mindfulness-based interventions, as mindfulness is thought to help increase

 20

emotional distress tolerance (Lillis et al., 2009). As the impulsivity model of obesity suggests the

importance of emotion regulation in eating behaviors, the basis of mindfulness-based

interventions are utilized in the hopes of increasing mindful eating behaviors. Most research

studies are still in the preliminary stages of piloting and exploring the effectiveness of

mindfulness techniques, and most of these studies utilize predominantly Caucasian participants.

Lillis et al. (2009) conducted a study examining the effectiveness of a one-day

mindfulness workshop focusing on obesity stigma to overweight or obese women completing

weight-loss programs. The intervention was based on the acceptance and commitment therapy

(ACT) model of change, which includes utilizing mindfulness, driving value-based actions, and

accepting distress to increase psychological flexibility. The focus of the intervention was on

obesity stigma, as the researchers argued that stigma often reduces overall wellbeing and quality

of life and increases self-stigma and depressive symptoms. A randomized control trial was

utilized in this study, with the inclusion criteria being that all participants had undergone at least

a 6-month weight loss program in the last 2 years. The control group was the waitlist group,

while ACT group received the one-day intervention. All participants were Caucasian women

from the Midwest region of United States.

Multiple measures assessing participants’ overall quality of life, distress tolerance,

acceptance and commitment practices, weight management, and experience of self-initiated

weight stigma were provided at baseline and a 3-month follow-up period. Researchers found that

participants in the ACT group were able to lose more weight than the control group in addition to

reporting greater quality of life, reduced weight stigma, and decreased psychological distress.

Furthermore, the ACT group participants had greater weight-related acceptance and were able to

utilize ACT-specific coping skills (e.g., diffusion) when faced with stress.
 21

Limitations of the Lillis et al. (2009) study included the unknown psychometric

properties of the Weight Stigma Questionnaire, as this measure was created for the sole purpose

of this study. Furthermore, the participants of this study had already undergone about six months

of a structured weight loss program; therefore, the eating behavior change, as well as the reduced

experience of weight stigma may have been due to the weight loss intervention, rather than the

ACT intervention. The clinical implications of this study’s findings are still relevant, as this

study adds to the literature of other mindfulness-based interventions that reported similar

findings. Lillis et al. (2009) found that overall, short-term mindfulness-based interventions for

weight loss programs appear to be effective in increasing overall wellbeing and quality of life.

They also found that the mindfulness aspect of the interventions seems to help overweight or

obese women accept their weight (i.e., body acceptance) and develop higher distress tolerance,

which in turn helps women maintain health behavior changes (e.g., tolerating food cravings).

Tapper et al. (2009) also implemented an ACT-based mindfulness intervention for obese

or overweight women to help with weight loss. Their study utilized a randomized control trial

design, with a total of 62 women; the inclusion criterion for the study was for all women to be

attempting to lose weight on their own. The control group received no treatment, while the ACT

group attended three 2-hour weekly didactic style workshops and a fourth 2-hour workshop as a

follow-up after three months. The participants were given manuals outlining the key concepts of

ACT, as well as a CD to help guide them in mindfulness practices. The procedure also

specifically adhered to cultivating mindfulness and ensured that information regarding diet was

not disbursed to participants in the ACT group.

The researchers measured general mental health, BMI, diet adherence, eating habits, and

physical activity change. The researchers found that participants in the intervention group lost
 22

significant weight and had increased their physical activity at the six-month follow-up time

period. In fact, Tapper et al. (2009) pointed out that although the weight loss seen in this

intervention at a six-month follow-up time frame is slightly less than what is seen in traditional

CBT interventions for weight loss, the results from the short-term ACT intervention (i.e., total of

8 hours) are comparable to 20-40 hours of CBT intervention. However, the researchers noted that

since this was an exploratory trial, the relationships between mindful acceptance and eating

behaviors (i.e., emotional eating and external eating – eating when cued by food stimuli) were

not significant. Upon further qualitative analysis, the authors found that participants experienced

difficulty in differentiating acceptance and relaxation, which the authors speculated also led to

the non-significant relationship between the three variables.

One of the other limitations in this study includes the group-based approach to

disseminating the information; the workshops were didactics and may present some cluster

effects. The strengths of this study are that although this was an exploratory analysis, it had a

large sample size when compared to other similar studies; furthermore, the validity of this study

may be higher due to the randomized nature of the trial. Although this study did not show

indicate a significant relationship between emotion regulation, eating behavior, and mindfulness,

this study indicated the comparability of results of an 8-hour mindfulness intervention with a 20-

40-hour CBT intervention.

Bacon et al. (2005) also designed a study aimed at increasing self-acceptance and

increasing healthy behaviors among overweight and obese women through a six-month weekly

intervention. The study included two groups: a diet group and the experiment group that the

researchers called “health at every size.” The diet group received information on nutrition,

calorie restriction, and exercise. The health at every size group, in contrast, focused on body
 23

acceptance, eating behavior, nutrition, exercise, and social support. The intervention taught

women techniques to become more aware of internal cues of hunger and satiety in addition to

providing them with nutritional information. The results of the study showed that the

intervention group improved holistically (i.e., eating behavior, health, depression, body image,

etc.) in comparison to the diet group. At a 2-year follow-up, the intervention group held on to the

gains of their improvements, while the diet group did not. Furthermore, the attrition to the diet

group was high, while there was little to no attrition in the intervention group. This study

demonstrated the importance of including body acceptance as an integral component of weight-

loss treatments. The limitation, as with many studies, was the lack of diversity in the sample; all

participants in this study were White women; therefore, the results from this study are not

generalizable to other populations.

Alberts, Mulkens, Smeets, and Thewissen (2010) also utlized acceptance-based

interventions with a relatively small sample size in a study examining the effectiveness of

mindfulness on food cravings. They included a control group in which participants received

standard intervention with dietary information. The treatment group participated in a 7-week

program and were given an instruction guide. One of the limitationsof this study, however, was

that the participants were not blind to their condition. Participants’ weight, food cravings, and

participation were recorded as part of the study.

Alberts et al. (2010) found the largest difference in treatment group participants’ positive

outcome expectancy, which led researchers to suggest that the mindulness intervention helped

participants reduce the value they placed on immediate relief or gratification from food. In

contrast to the Tapper et al. (2009) study, Alberts et al. (2010) concluded that the acceptance-

based intervention was related to the change in eating behaviors. Alberts et al. (2010) also found
 24

that the treartment group’s participants experienced less preoccupation with food after the

intervention. These results indicate a connection between mindfulness practices and reduction in

perseveration, which is a component of impulsivty according the the impulsivity model of

obeisty.

Dalen et al. (2010) also implemented a mindfulness-based intervention to change eating

behaviors; specifically, the researchers examined the effectiveness of the mindfulness-based

intervention, Mindful Eating and Living (MEAL) for obese individuals. This study utilized a

quasi-experimental design, as it only had a treatment group of 10 participants (7 women, 3 men).

The intervention was based on the dysregulation model of obesity, which the authors explained

as the inability to “recognize and respond to internal cues of hunger, taste, satiety, and fullness”

(p. 264). This inability, the authors went on to explain, usually perpetuates “avoidance of

unpleasant emotions, and reduced coping skills” (p. 264). The dysregulation model Dalen et al.

(2010) utilized in their study can be compared to the impulsivity model of obesity, as the

urgency component of the impulsivity model refers to individuals eating when emotionally

aroused (Mobbs et al., 2010; Whiteside & Lynam, 2001).

The intervention consisted of six weekly 2-hour sessions that consisted of group sessions

on practicing mindfulness, meditating, yoga, brief didactics on nutrition and exercise, and

engaging in eating exercises; the participants were also given written material to help with

practicing mindfulness at home. The authors stressed that although didactics were offered on

nutrition and exercise, the majority of the intervention focused on being mindful of body

sensations and satiety. Researchers utilized multiple measures examining the physiological (i.e.,

oral glucose, protein markers, etc.), psychological (i.e., depression, distress tolerance, affect,

etc.), behavior changes, and mindfulness practices. Dalen et al. (2010) found that participants
 25

had greater control over their eating behaviors, lower psychological distress and depressive

symptoms, and lost weight at the end of the program. Although the lack of generalizability of the

results from this study is one of the limitations, this study had similar outcomes found in other

mindfulness-based interventions.

In a review of the Enhancing Mindfulness for the Prevention of Weight Regain

(EMPOWER) program, Caldwell et al. (2012) describe a mindfulness-based intervention

designed to help individuals maintain their weight loss by researchers at Duke Integrative and the

Penn Program for Mindfulness. The EMPOWER program utilized a mixture of individualized

treatment, as well as group discussions and didactics while helping individuals who had already

lost 10% of their body weight. The EMPOWER program focused on developing various

mindfulness techniques (i.e., at least 20) to help participants choose the technique that best fit

their lifestyle. Mindfulness was intended as a way for participants “to learn about themselves by

paying attention to their experience with a nonjudgmental spirit of curiosity; the idea that each

individual was the expert on his or her life was emphasized throughout the program” (Caldwell

et al., 2012, p. 273).

The researchers combined various mindfulness-based interventions (e.g., mindfulness-

based cognitive behavioral therapy, acceptance and commitment therapy, dialectical behavioral

therapy) while creating this program. The participants of the study were instructed to practice

mindfulness techniques for at least 30 minutes a day, in addition to coaching on the telephone on

a bi-monthly basis for 30-minute sessions. These coaching sessions helped participants set their

goals and develop action plans to implement mindfulness practices in their lives. The two-hour

weekly group discussions were held for 12 weeks, and participants were provided with booster

sessions at 4-week intervals after the 12 weeks. Each of the group discussions included
 26

psychoeducation on mindfulness techniques, as well as practice of the techniques; each group

meeting consisted homework to practice the mindfulness techniques on their own.

Caldwell et al. (2012) described how the participants were “introduced to the concept of

maintaining weight in the context of what they valued most in life” (p. 273). This was intended

to help individuals utilize their mindfulness skills while experiencing situations that would

undermine their efforts at eating healthily. Researchers found that participants appreciated the

wide range of mindfulness techniques the EMPOWER program covered; they also found that

participants had varying opinions on cultivating internal and external sources of accountability.

The EMPOWER program focused on cultivating an internal source accountability through the

practice of mindfulness; however, the group sessions also acted as an external source of

accountability for participants.

Caldwell et al.'s (2012) study and program relied heavily upon resources; the study

included individual telephone sessions, extensive group sessions, and mastery of an extensive list

of mindfulness practices. However, this program also highlighted the flexibility of mindfulness

practices, as it combined different mindfulness-based interventions and emphasized on the

commonality of each of the approaches, which was to “teach present moment awareness, self-

awareness, acceptance, and avoidance of judging—all processes that positively influence affect

regulation” (Caldwell et al., 2012, p. 272).

Coffey and Hartman (2008) examined the inverse relationship between mindfulness and

psychological distress. They administered measures assessing mindfulness, emotion regulation,

and psychological distress to non-clinical college students. They utilized two separate

independent samples, and used a structural equation model to analyze the relationship between

mindfulness, its relationship with emotion regulation, rumination, and nonattachment (i.e., the
 27

ability to attribute happiness to internal influencers, rather than external). Coffey and Hartman

(2008) found that mindfulness was positively correlated with increased emotional regulation, and

inversely related to psychological distress. Furthermore, they found that mindfulness was also

associated with decreased rumination, and increased nonattachment. Although some participants

from the EMPOWER program preferred external sources of accountability over internal sources

of accountability (Caldwell et al., 2012), the results of the study by Coffey and Hartman (2008)

indicate the possibility of participants experiencing fewer ruminative thoughts and psychological

distress due to the mindfulness practices they utilized in their daily lives.

It must also be noted that an inverse relationship was observed between women’s self-

compassion and disordered eating habits, and a positive relationship between self-compassion

and flexible body image (Kelly, Vimalakanthan, & Miller, 2014). Self-compassion is the ability

“to respond to personal distress and inadequacies with self-kindness rather than self-judgment,

an attitude of mindfulness rather than over- identification, and the perspective that suffering is

common to humanity rather than isolating” (Kelly et al., 2014, p. 446). Many of the mindfulness-

based treatments found that participants had higher levels of psychological wellbeing, healthier

eating habits, and higher levels of body acceptance. It can be speculated that mindfulness aided

participants to be more compassionate towards themselves, which in turn was related to higher

levels of body acceptance.

Non-Caucasian population. The analysis of the NHANES data between 1999 and 2002

indicated a significant difference between the prevalence rates for obesity and overweight among

Caucasian individuals and non-Caucasian individuals ( i.e., non-Hispanic Black and Mexican

American; Hedley et al., 2004). For example, while 63.3% of non-Hispanic population was

estimated to be overweight or obese, 70.7% of non-Hispanic Black individuals, and 72.5% of

 28

Mexican American individuals were found to be overweight or obese. The prevalence trends for

obesity alone (i.e., BMI ≥ 30kg/m2) followed a similar pattern; while 24.9% of non-Hispanic

White population was considered obese, 39.4% of non-Hispanic Black individuals, and 32.6% of

Mexican American individuals were estimated to be obese (Hedley et al., 2004).

Regardless of the discrepancies in the prevalence rates among Caucasian and non-

Caucasian individuals, most interventions for obesity are developed by piloting them on

Caucasian individuals. This can pose as a potential barrier to treatment for non-Caucasian

individuals, as treatments for obesity are not tailored to specific cultures and populations.

However, some researchers have made recommendations to better fit the cultural needs of

specific populations.

Contemporary treatments. Most preliminary studies on mindfulness-based interventions

for weight loss maintenance indicate promising results. However, these studies included

primarily Caucasian individuals, and therefore their effectiveness is unknown for non-Caucasian

populations. Below are a few studies that included non-Caucasian individuals in their research.

Forman et al. (2009) implemented the acceptance-based behavioral treatment (ABBT)

protocol to overweight and obese women. They conducted the study utilizing a single-group

design with 29 women and conducted a 6-month post-treatment follow-up to measure the

effectiveness of the treatment. The researchers combined traditional behavioral treatment

elements (i.e., LEARN) with the acceptance-based treatment (ACT) protocol, and offered a 12-

week course to women at their places of employment. This study’s strengths include the

diversity of the population ethnically (i.e., nearly half the participants were African American,

while the other half was Caucasian) and economically (i.e., the income ranged between $30,000

and $150,000).
 29

Forman et al. (2009) utilized measures to assess the effectiveness included treatment dose

(e.g., number of classes attended, assignment completions), motivation, disinhibition, cognitive

restraint, emotional eating, mindful awareness, and quality of life. The researchers noted that

some of the measures were modified to fit the study. Although the study had a high attrition rate,

the researchers found that participants lost weight, and had lost more weight at the follow-up.

Furthermore, they found that the participants’ ratings of quality of life had increase at post-

treatment and follow-up. The study also found a strong positive relationship between the

treatability (i.e., dose of treatment) and their weight loss outcomes.

While the strengths of Forman et al.'s (2009) study included the diversity of the sample

size, some limitations include the small sample size, the high attrition rates, and the modification

of the measures. Due to the exploratory nature of the study, the small sample size was expected;

however, the study found that the African American participants had higher rates of attrition than

their Caucasian counterparts. This discrepancy in the attrition rates introduces questions about

the cultural sensitivity of the treatment protocol and may also provide an opportunity for more

research in this area. Overall, the Forman et al. (2009) supported the findings of other

mindfulness-based intervention outcomes for weight loss in overweight and obese women.

Kristeller, Wolever, and Sheets (2013) explored the effectiveness of a mindfulness-based

eating awareness training (MB-EAT) to treat binge eating disorder. Due to the synonymous

nature between binge eating disorder and eating behaviors seen in obese individuals (Claes et al.,

2005), results from the study by Kristeller et al. (2013) could contribute to the knowledge on the

effectiveness of mindfulness-based interventions for obesity. The researchers implemented MB-

EAT and compared this treatment to two groups, psycho-education cognitive/behavioral (PECB)

group, and the waitlist group. The study had a total of 98 participants, with majority of the
 30

participants being Caucasian and female; however, the study did include about 13% minority and

12% men in the study. The researchers found that participants lost weight in both MB-EAT and

PECB groups in comparison to the waitlist group; however, there were no significant differences

between the two treatment groups.

The four-month follow-up indicated that MB-EAT and PECB group participants engaged

in smaller and fewer binge episodes in comparison to the control group. One of the main

distinguishing components between the two treatment groups was that the MB-EAT group had

larger effect sizes in decrease to food reactivity, and greater self-regulation and self-control (i.e.,

relatable to the urgency aspect of the impulsivity model). The limitations of this study include

the high attrition rate, the limited longitudinal data (i.e., follow-up), as well as the lack of

participants’ diversity. The broader implications of this study are that it supports the theory of the

underlying processes of mindfulness-based interventions; the participants in this study seemed to

develop greater distress tolerance, which ultimately helped them reduce undesired eating habits

and lose weight.

A promising study conducted in Portugal with overweight and obese women over a span

of one year included elements of body acceptance and developing internal regulation (Carraça et

al., 2011). The participants were randomly assigned to the control group (i.e., psychoeducation

on nutrition and exercise) or the intervention group. The intervention group received 30 group

sessions that addressed body acceptance, nutrition, psychoeducation on regulating food intake,

and increasing internal regulation. The researchers appreciated the difficulty in navigating the

body acceptance aspect of the treatment, as they realized the difficulty in targeting the body

evaluative element without affecting the body investment element of the intervention. The results

reflected that the intervention group’s participants’ body acceptance increased as the investment
 31

aspect decreased; furthermore, the increase in body acceptance predicted healthier eating

behaviors among the women in the intervention group. The implications of this study are

particularly relevant, as the study demonstrated the importance of including body acceptance as a

treatment element for overweight and obese women. Furthermore, this study is more culturally

sensitive and relevant, as it was community-based.

Importance of Culturally Relevant Treatment Approaches

The studies examining the effectiveness of mindfulness-based interventions reported high

rates of attrition among participants from ethnic minorities (Forman et al., 2009; Kristeller et al.,

2013). The high attrition rates pose a question regarding the effectiveness and relevancy of such

interventions for women from diverse backgrounds. Furthermore, it highlights the importance of

understanding cultural attitudes regarding eating habits, body perception, and health. A study by

Ward, Gray, and Paranjape (2009) examined attitudes of obese African American patients’

towards their physicians during their treatment for obesity. The researchers conducted eight

focus groups and one of the themes that consistently emerged was the necessity for

personalization of treatment. For example, while some patients responded well to scare tactics

their physicians used during consultations, other patients viewed scare tactics as a barrier

towards their treatment. Furthermore, many African American patients did not like the use of the

word “obese” to describe them; men and women discussed feeling more helpless when applying

the term “obese” to themselves. Some participants also questioned the classification of being

obese, as they stated not “feeling obese;” this discrepancy may indicate a differnece in body

ethics, rather than aesthetic body ideals, that has been observed in other studies (Rubin et al.,

2003).

Church-based interventions for African Americans in regards to weight management,

 32

healthy eating, and obesity have been effective (e.g., Cowart, Biro, Wasserman, Stein, Reider, &

Brown, 2010; McDowell, et al., 2011). Research indicates that church place a vital role in

providing support among African American communities (Chatters, et al. , 2002). McDowell et

al. (2011) implemented a large-scale 2-year church-based intervention for African Americans in

a metropolitan city. Their study included participants from 10 churches who were overweight or

had diabetes; the study included bimonthly nutritional classes, physical activity sessions where

participants could choose traditional or non-traditional forms of exercise, and bimonthly

motivational sessions that emphasized the role of faith while working towards their goals

(McDowell et al., 2011). The results of this large-scale study indicated that participants had

improved health and eating behaviors; overall, participants decreased their body weight by an

average of 4%, and their BMIs by 2.5%. Additionally, as this study was implemented for 2 years,

the researchers noticed that participants’ increased or maintained these positive lifestyle changes

from year 1 to year 2. McDowell et al. (2011) demonstrated the importance of considering

culturally sensitive elements for weight loss.

In a critical review of literature on existing weight loss interventions for the Hispanic

population, Lindberg and Stevens (2007) suggest that although many studies may use the words

“culturaly sensitive,” the studies do not encompass culturally sensitive elements beyond the bare

minimum (e.g., including information in Spanish, cultrally-related food, etc.). They observed that

studies looking at weight loss interventions did not account for accultration, education, SES, or

the country of origin. Cousins, Rubovitis, Dunn, Reeves, Ramirez, & Foreyt (1992) implemented

a family-based intervention for weight loss in the Hispanic population and compared it to

individual-based intervention, and a control group that received only flyers on nutrition. The

researchers found that participants in both family-based and individal-based interventions had
 33

significant weight reduction in comparison to the control group. Furthermore, although there was

not a significant difference in weight loss between the family-based and individual-based

interventions, the authors observed that individuals who received family-based interventions had

more weight reduction than those in individual-based intervention group. Similarly, in an

extensive review of literature of weight loss interventions for the Hispanic population, Mier, Ory,

and Medina (2010) found that successful interventions included family-based activities in

addtion to bi-lingual services; however, the authors pointed out the sparcity of research among

the subgroups in the Hispanic population (e.g., immigrants from Centeral America, South

America, etc.).

In an effort to target specific populations, Tyler, Johnston, Madhukar, and Foreyt (2005)

specifically focused their recommendations to treat obesity among Mexican Americans. Their

recommended strategies emphasized the role family and a sense of community plays in the

treatment of obeseity, and suggested the community and systems level of intervention may be

more effective than individual interventions. Additionally, the recomendations by Tyler et al.

(2005) made also included the use of behavioral interventions to help individuals with their

eating habits and physical activity. Tyler et al. (2005) explained that it was more important to

build “health awareness instead of focusing on appearance is important when treating Mexican

Americans” (p. 249). The suggestion by Tyler et al. (2005) to discriminate between health

awareness and body perception reflects the importance of tailoring interventions for specific

populations.

Research Questions

A review of literature suggests that a strong link exists between body acceptance,

mindfulness, and eating habits. However, research highlights the importance of understanding
 34

the sociocultural nuances while developing interventions for weight loss among overweight and

obese women from diverse backgrounds. Thus, based on the review of literature, the following

research questions and hypotheses were made regarding mindfulness, body acceptance, and

eating behaviors:

 What is the relationship between body acceptance, mindfulness, and eating habits among

women?

 Do body acceptance and mindfulness predict healthy eating behaviors among women?

 Do specific socioeconomic and cultural factors predict body acceptance?

Hypotheses

The following hypotheses were made in regards to the research questions:

1) As previous studies indicated a positive correlation between mindfulness and healthy

eating behaviors (e.g., Alberts et al., 2012; Kristeller et al., 2013; Lillis et al., 2009;

O’Reilly et al., 2014), it was hypothesized that in general, women who were more

mindful would have healthier eating habits.

2) It was hypothesized that women who were more mindful would have lower BMIs and

better control over their food cravings, as research indicates that individuals who

underwent different types of mindfulness-based interventions eventually lost some

weight and had increased their mindfulness (e.g., Alberts et al., 2010; Lillis et al.,

2009; Mobbs et al., 2010; Tapper et al., 2009).

3) It was hypothesized that women who have higher body acceptance will have healthier

eating behaviors, as research indicates that higher body acceptance is related with

healthier eating habits and weight control (Carraça et al., 2011).

4) Similarly, it was hypothesized that women with high levels of body acceptance would
 35

have lower BMIs, as research indicates the important moderating role self-

compassion plays in lowering BMIs through healthy eating behaviors (Kelly et al.,

2014) .

5) As previous studies indicated a positive correlation between mindfulness and body

acceptance (e.g., Alberts et al., 2012; Kelly et al., 2014 Stewart, 2004; Wood-

Barcalow et al., 2010), it was hypothesized that in general, women who were more

mindful would endorse higher body satisfaction and body acceptance.

6) A predictive relationship between body acceptance, mindfulness, and healthy eating

behaviors was made, as research indicates that individuals with high levels of

mindfulness and body acceptance have healthier eating habits (e.g., Kelly et al., 2014;

Lillis et al., 2009; Parham, 1999; Wood-Barcalow et al., 2010).

7) An a priori hypothesis was not made in regards to group differences by SES and

ethnicity; SES and other cultural factors were expected to predict body acceptance,

given the research in regards to the differences in attitudes towards body acceptance

by ethnicity and SES (e.g., Forbes & Frederick, 2008; Perez et al., 2002; Wildes et

al., 2001).
 36

Chapter 3: Research Design and Method

Research Design

The researcher sought to understand the relationship between mindfulness, body

acceptance, and eating behaviors among women from diverse backgrounds. As no variables were

be manipulated, a non-experimental correlational design was utilized to explore these

relationships (Gravetter & Wallnau, 2011), with mindfulness and body acceptance as predictor

variables, and eating behaviors as the criterion variable.

Population and Sample

Exclusion Criteria

Only women were included in this study, as the purpose of the study was to understand

the relationships between mindfulness, body acceptance, and healthy eating behaviors for this

population. Furthermore, women who have a BMI greater than 40 kg/m2 were excluded from the

analysis, as individuals who are morbidly obese may have unhealthy eating habits that may

affect the results of the study. Women who were diagnosed with an eating disorder were

similarly excluded from the analysis of results, as they may have unhealthy eating habits and

skewed body perceptions (Urgesi et al., 2013) that may influence the analysis of the results.

Similarly, participants who indicated that they have undergone bariatric surgery were excluded

from the analysis, as individuals who have undergone surgery may skew the analysis of the

results for weight and eating behaviors. Additionally, women who were experiencing moderately

severe depression were be excluded from the analysis, as depression is associated with appetite

and weight change. It must be noted that data from the measures for the exclusion criteria were

collected along with the measures for the study; participants who met the exclusion criteria were

excluded from the analysis after the data were collected.

 37

Inclusion Criteria

Women, over the age of 18 and with the ability to understand English, from diverse

backgrounds were included in this study. The diverse backgrounds include women of all ages

over 18, ethnicity, and marital status. Furthermore, women from different levels of education and

income were included in this study. Additionally, women who were part of, or have participated

in weight loss programs were included in this study.

Sample size. A G-power analysis (Erdfelder, Faul, & Buchner, 1996) was conducted to

calculate the sample size, and a sample size of 76 was determined to be necessary for this study.

The alpha level was set at .05, as standard guidelines in research dictate the practice of being

certain that only 5% of the results are due to chance. The effect size, as defined by Cohen’s f2 for

regression analysis was set at .15; effect sizes of .02, .15, and .35 are considered to be small,

medium, and large, respectively (UCLA: Statistical Consulting Group, n.d.). The statistical

power provides information on the probability of the null hypothesis being accurately rejected

(Meyers, Gamst, & Guarino, 2013); the statistical power was set at .85 (i.e., specifying that there

is 85% chance that an effect will be detected through analysis). As two predictor variables are

being studied, the G-power analysis revealed that a sample size of 76 would be sufficient for this

study.

Procedures

Prior to the recruitment process, The Chicago School of Professional Psychology’s

Institutional Review Board (IRB) permission was obtained to ensure that the data for this study

would be obtained in a legal and ethical manner. Once IRB approval was obtained, the

researcher recruited participants by posting messages on social media sites (i.e., LinkedIn and

Facebook), sending out emails through The Chicago School of Professional Psychology’s
 38

(TCSPP) listserv, and posting flyers at approved areas in the student lounges at TCSPP in Los

Angeles. The recruitment information in the social media postings and emails contained

information regarding the study and provided an online survey link for participants (see

Appendix B). The flyer at the student lounges included slightly different information to

emphasize that individuals will have the choice to either complete the survey online, or contact

the researcher to complete the survey on paper (see Appendix C). Other recruitment methods

included verbally presenting the information regarding the study to individuals and presenting

them with paper versions of the informed consent and the measures if they agree to participate in

the study (see Appendix D).

The online survey, as well as print version of the study materials first included the

informed consent and provide information on the study, addressed privacy and confidentiality

issues and inform participants the potential risks and benefits of the study (see Appendix A). The

information emphasized: (1) confidentiality (i.e., the study utilized non-identifiable information

and store the information in a safe and secure manner through password protected computer for

the database, and locked cabinet for paper forms); (2) voluntary nature of the survey

participation (i.e., reiterate that they may choose to discontinue their participation oat any given

time while taking the survey); (3) option of enrolling in a raffle for a $50 gift card; (4) contact

information regarding any questions or concerns; and (5) provide information (i.e., phone

numbers), in case they feel distressed by the questions they are answering.

After reviewing this information, the participants had the choice to consent by either

clicking on a link that specifies they understand and agree to participate in the study on online

surveys. Participants who filled out the paper version of the questionnaires initialed their names

to indicate that they understood and agreed to participate in the study. After acknowledging the
 39

informed consent, the participants had the chance to enter their email addresses into the raffle;

this was optional and participants had the chance to enter their email for the raffle and still

discontinue their participation in the study if they chose.

Instrumentation

Demographics

A demographic questionnaire (see Appendix E) was created for participants; the

following information was collected: age, ethnicity/race, country of origin, number of years lived

in the U.S., height, weight, education level, employment status, marital status, and income. The

height and weight measurements were used to calculate the BMI of participants during the

analysis. Furthermore, participants were asked if they currently were participating in, or have in

the past participated in weight loss programs. Participants were also asked questions regarding

their weight loss program (i.e., how long did they participate, was a mindfulness component

incorporated). Additionally, participants were asked questions regarding the importance of

spirituality in their lives, and also about what motivated them to participate in the current study.

The expected completion time for the demographic questionnaire was between 7-10 minutes.

Screeners

In order to assess if the participants meet the exclusion criteria for the study, the

participants were asked to answer questions about whether they have ever been diagnosed with

an eating disorder, or have undergone bariatric surgery (see Appendix F), and complete the

Patient Health Questionnaire – 9 (PHQ-9; see Appendix G). The expected completion time for

the screeners are about 5-10 minutes.

Eating disorder and BMI. The participants’ demographic data of their weight and

height was used to calculate their BMIs; participants with BMI greater than 40 kg/m2 were
 40

excluded from the analysis. Similarly, participants were asked whether they have been diagnosed

with any eating disorder as a dichotomous question (i.e., Yes/No answer choices); participants

who answer “Yes” were excluded from the analysis. Additionally, participants were asked about

whether they have undergone bariatric surgery as dichotomous question, and participants who

indicate they had were excluded from this study.

Patient Health Questionnaire – 9 (PHQ-9). The PHQ-9 is a brief 9-item screener used

to identify symptoms of depression (Kroenke, Spitzer, & Williams, 2001). All nine items are

rated on a Likert scale from 0 (i.e., Not at all) to 3 (i.e., Nearly every day); individuals are asked

to rate the frequency of the symptoms (e.g., low energy, loss of interest, difficulty concentrating,

suicidal ideation, etc.) in the past two weeks. The internal reliability is excellent, as the

Cronbach’s alpha falls between 0.84 and 0.89. Furthermore, the specificity and sensitivity of the

measure is also good, as the receiver operating characteristic (ROC) area under the curve was

0.95 for accurately identifying symptoms of major depressive disorder. The total scores from

PHQ-9 can be used to obtain the severity levels of the depressive symptoms; the severity levels

range from minimal (i.e., scores between 0-4), mild (5-9), moderate (10-14), moderately severe

(15-19), and severe (20-27). Individuals with a score of 15 or higher were excluded from this

study.

Mindfulness

As one of the predictor variables is mindfulness, the participants were administered the

Five Facet Mindfulness Questionnaire (FFMQ; Baer, Smith, Hopkins, Krietemeyer, & Toney,

2006; see Appendix H). The FFMQ measures five facets of mindfulness: observing, describing,

acting with awareness, non-judging of inner experience, and non-reactivity to inner experience;

the FFMQ also provides a global score of mindfulness. The FFMQ consists of 39 items that are
 41

rated on a 5-point Likert scale (1: Never or very rarely true; 5: Very often or always true), with

higher scores indicating greater mindfulness. The expected completion time for this measure was

about 10 minutes. This measure was developed by combining various mindfulness measures to

create a comprehensive survey of mindfulness experiences. The FFMQ has good psychometric

properties with Cronbach’s alpha for internal consistency ranging between .72 and .92) (Baer et

al., 2008).

Body Acceptance

The participants were administered the Body Appreciation Scale – Second Edition (BAS-

2; Tylka & Wood-Barcalow, 2015; see Appendix I). The BAS-2 consists of 10 items that focus

on individuals’ attitudes towards their bodies. The items are rated on a 5-point Likert scale (i.e.,

1: Never to 5: Always). It was expected to be completed in approximately 5 minutes. The BAS-

2 measures body acceptance attitudes among men and women, and has been shown to have good

psychometric properties with a Cronbach alpha of 0.97 for internal consistency. The BSI has also

been found to be valid and have high internal consistency in other countries and cultures (e.g.,

Swami & Chamorro-Premuzic, 2008; Swami, Stieger, Haubner, & Voracek, 2008). Furthermore,

the items on the BAS-2 correlates negatively with BMI, which the authors concluded was a sign

of validity (Tylka & Wood-Barcalow, 2015).

Eating Behavior

The participants were administered two measures of eating behavior: (1) the Eating

Attitudes Test (EAT-26), and (2) the Intuitive Eating Scale – 2 (IAS-2; see Appendix J). The

purpose for using both measures was to collect information on disordered eating in addition to

healthy eating habits.

 42

Eating Attitudes Test (EAT-26). The EAT-26 is a widely used assessment tool to

screen for unhealthy disordered eating habits (Garner, Olmsted, Bohr, & Garfinkel, 1982). The

EAT-26 consists of 26 items with three scales: dieting (i.e., restrictive eating habits and body

shape preoccupation), bulimia and food preoccupation (i.e., associated with higher BMI), and

oral control (i.e., awareness of social environment on eating behavior and predicts good

outcomes). The EAT-26 items are rated on a Likert scale from 0 (Never) to 3 (Always), and a

total score greater than 20 indicates tendencies towards disordered eating. The psychometric

properties of this measure are good (i.e., r = 0.98). The expected completion time for the EAT-

26 was between 10-15 minutes.

Intuitive Eating Scale – 2 (IAS-2). The IAS-2 is a 23-item questionnaire that measures

eating behaviors based on internal cues of satiety and hunger (Tylka & Kroon Van Diest, 2013).

The items are administered on a 5-point Likert scale (i.e., 1 – Strongly Disagree, to 5 – Strongly

Agree). This measure provides a global score, as well as scores for four subscales: (1)

unconditional permission to eat; (2) eating for physical rather than emotional reasons subscale;

(3) reliance on internal hunger/satiety cues subscale; and (4) body-food choice congruence

subscale (i.e., consuming healthy food that nourishes the body). The psychometric properties of

this measure are good, as the internal consistency reliability Cronbach’s alphas range between

0.85 to 0.87. Furthermore, this measure is negatively correlated with body dissatisfaction and

BMI, which the author suggested was a good indicator of construct validity (Tylka, 2006). The

IES-2 was expected to be completed in approximately 10 minutes.

Data Processing

In order to gain a more holistic understanding on the relationships between body

acceptance, mindfulness, and eating behaviors, a multiple regression analysis was conducted;
 43

multiple regression analysis allows researchers to capture more than one variable to explain

relationships (Meyers et al., 2013). The predictor variables in this study were mindfulness and

body acceptance, while the outcome variable was healthy eating behavior. Similarly, a multiple

regression was conducted with body acceptance as the dependent variable, and the demographic

information as the predictor variables.

However, prior to conducting the regression analyses, a test of multicollinearity was

conducted to ensure that the predictor variables were distinct enough and not confounding one

another (Meyers et al., 2013). The enter method (i.e., entering all the variables into the regression

equation at the same time) was be used initially to study the power of the predictors; a stepwise

method (i.e., only the most significant predictors are part of the regression model, as determined

by p values) was later be utilized to ensure that only the strongest variables are used to predict

the outcome variable (Meyers et al., 2013).

Ethical Considerations

Informed Consent

Participants were given a chance to read and acknowledge that they understood the

informed consent (see Appendix A) on online and paper versions of the survey. They were

informed of the potential risks and benefits of the study. The potential risks for participants the

current study included possible feelings of discomfort while being asked about height, weight,

and answering questions regarding their mental health, body acceptance, and eating behaviors.

Although there are no direct benefits to the participants in this study, the potential indirect

benefits of this study are that the results from this study will expand research literature on the

practice of mindfulness and body acceptance as they relate to weight management treatments.

The potential burdens for participants in this study include time constraints (i.e., 30-45 minutes
 44

to complete survey) and fatigue from completing the survey. Participants were allowed to

discontinue their participation in the study at any given time without any penalty. Given the

potential risks and benefits for this study, participants were informed about the nature of the

survey prior to the start of the survey process.

Privacy and Confidentiality

The participants were also informed about how their confidentiality and privacy will be

protected in this study. Participants’ identifiable information was not published throughout the

course of the study. The only potentially identifiable information that was collected were

participants’ email addresses for the purpose of the raffle. Participants were informed that they

have the option of entering the raffle for a chance to win a $50 gift card. In order to protect their

privacy and confidentiality, participants’ email addresses were separated after the survey period

concludes; the email addresses were stored separately from the data from measures. As mandated

by the professional ethical standards and guidelines (American Psychological Association,

2010), final data from the current study were stored in a secure manner in a locked cabinet at

TCSPP in the dissertation chair’s office. The electronic data was password protected and saved

on a password-protected computer. The records from the study will be destroyed seven years

after the collection of data.

 45

Chapter 4: Findings

Introduction

The researcher explored the relationship between body acceptance, mindfulness, and

eating behaviors through a non-experimental, correlational design. Various demographic

variables, including income, education level, geographic origin, immigration history, and

relationship status, were explored in relation to body acceptance.

Sample Characteristics

Inclusion and Exclusion

The researcher conducted a power analysis, which indicated that 76 participants were

required in order to have meaningful results. The researcher collected a total of 91completed

surveys, two of which the researcher administered via paper-based surveys, while 89 were

collected online via social media and email links to the survey. Eighteen surveys were excluded

due to these participants not meeting the inclusion criteria: three participants had BMIs over 40;

12 were diagnosed with eating disorders (three of these participants also endorsed moderately

severe to severe symptoms of depression, and one had a bariatric surgery); two were excluded

due to endorsing moderately severe to severe symptoms on the PHQ-9 (Kroenke et al., 2001);

and one was excluded due to undergoing bariatric surgery. Hence, a total of 73 completed

surveys were included in the final analysis.

Sample Demographics

The average age of the women who completed the surveys was 31.46 years old, and

ranged between ages 18 and 62. The majority of participants were Caucasian (46.6%), followed

by Asian (31.5%), Hispanic/Latino(a) (9.6%), Multiracial (5.5%), African American (4.1%), and

Native American (1.4%; Table 1). The majority of Caucasian women reported that their families
 46

of origin were from North America (i.e., Canada and United States) (41.1%), and nearly 22% of

women’s families originated from South Asia (i.e., India and Pakistan; Table 2). The relationship

status data indicated that 45% of women were married, 37% were single and had never married,

about 8% were in a committed relationship and but not living together, nearly 7% were divorced,

and nearly 3% were living together with their partner, but were not married.

The majority of women had pursued higher education, as over 98% of women indicated

that they had some college education or more, with a majority of women (31.5%) endorsing they

had their Master’s degrees, followed by women indicating they had their Bachelor’s degrees

(28.8%). Most participants reported earning less than $25,000 (37%), followed by women

reporting income ranging between $50,000 and $99,999 (26%); only 10% of the participants

reported earning more than $150,000 (see Table 1 for age, ethnicity, marital status, education,

and income).

Table 1

Participants Age, Ethnicity, Marital Status, Education, Income

Frequency Percent
Age Unknown 1 1.4
18-30 years 38 52.1
30-40 years 25 34.2
40-50 years 7 9.6
50-60 years 1 1.4
60-70 years 1 1.4

Ethnicity African American 3 4.1

Native American 1 1.4
Asian 23 31.5
Caucasian 34 46.6
Hispanic/Latino(a) 7 9.6
Multicultural 4 5.5

Marital Status Single, never married 27 37.0

Not married, but living with 2 2.7
partner
 47

In a committed relationship, but 6 8.2

not living together
Married 33 45.2
Divorced 5 6.8

Education High school graduate or GED 1 1.4

Some college education 11 15.1
Associate’s degree 6 8.2
Bachelor’s degree 21 28.8
Some post-graduate education 3 4.1
Master’s degree 23 31.5
Ph.D., law, or medical degree 6 8.2
Other advanced degree beyond 2 2.7
Master’s

Income Less than $25,000 27 37.0

$25,000 to $34,999 3 4.1
$35,000 to $49,999 7 9.6
$50,000 to $74,999 10 13.7
$75,000 to $99,999 9 12.3
$100,000 to $149,999 8 11.0
$150,000 or more 7 9.6
Other (e.g., earning in different 1 1.4
currency)

Table 2

Geographic Location of Family of Origin

Frequency Percent
Family of Origin Asia 1 1.4
Location Southeast Asia (e.g., Vietnam, 3 4.1
Cambodia)
South Asia (India, Pakistan) 16 21.9
Middle East 1 1.4
Africa 1 1.4
Eastern Europe 1 1.4
Western Europe (e.g., England, 6 8.2
Germany, etc.)
Caribbean Islands 1 1.4
North America (Canada, U.S.A) 30 41.1
Central America (Mexico) 7 9.6
South America 2 2.7
 48

Pacific Islands 2 2.7

Multiple (e.g., Middle East and 2 2.7
Western Europe)

The researcher excluded participants with BMIs over 40 from the study; nearly 59% of

participants’ BMIs ranged between 18.5 and 24.9, while nearly 29% of participants’ BMIs

ranged between 25 and 29.9. Few participants’ BMIs ranged between 20 and 29.9 (11%), or had

BMIs under 18.5 (1.4%) (see Table 3). The majority of women reported that they had not

participated in weight loss programs in the past (64.4%), and nearly all indicated that they were

not enrolled currently in weight loss programs (90.4%) (see Table 4). Of the women who had

participated in weight loss programs in the past, nearly 62% of women reported that their weight

loss program included elements of mindfulness, and of the few participants currently in a weight

loss program, nearly 86% of women reported that their weight loss program included elements of

mindfulness (see Table 5). Participants’ responses regarding how they regarded spirituality in

their lives showed that many (64%) rated spirituality as moderately to extremely important in

their lives, while others reported that it was only slightly important to not at all important (see

Table 6).

Table 3

Participants’ BMI
Frequency Percent
BMI Under 18.5 (Underweight) 1 1.4
18.5 – 24.9 (Normal) 43 58.9
25.0 – 29.9 (Overweight) 21 28.8
30.0 – 39.9 (Obese) 8 11.0

Table 4

Past and Current Participation in Weight Loss Program

Frequency Percent
Past No 47 64.4
 49

Yes 26 35.6

Current No 66 90.4
Yes 7 9.6

Table 5

Mindfulness Element in Weight Loss Program1

Frequency Percent
Past Program No 10 38.5
Yes 16 61.5

Current Program No 1 14.3

Yes 6 85.7
1
Note: Only women who participated in weight loss program in the past or were currently in
programs were included in this analysis.

Table 6

Importance of Spirituality
Frequency Percent
Spirituality Not important 14 19.2
Slightly important 12 16.4
Moderately important 22 30.1
Very important 15 20.5
Extremely important 10 13.7

Descriptive Statistics of Measures

Mindfulness

The researcher administered the Five Facet Mindfulness Questionnaire (FFMQ; Baer et

al., 2008) to measure five aspects of mindfulness: Observing, Describing, Acting with

Awareness, Taking a Non-judgmental Stance of Inner Experience, and Non-reactivity of Inner

Experience. The total score for FFMQ was derived by adding the scores of 39 questions on the

measure, and each of the five subscale scores are similarly calculated by adding the scores of the
 50

subscale items. The mean FFMQ total score was 129.82 (SD = 16.39, Table 7). FFMQ subscale

scores (see Table 8) reveal that mean score for the Observe subscale was 24.19 (SD = 5.69),

Describe subscale was 28.60 (SD = 5.26), Acting with Awareness was 27.67 (SD = 5.08), Non-

judgmental towards Inner Experience was 28.68 (SD = 5.49), and Non-reactivity to Inner

Experience was 21.11 (SD = 4.32).

Table 7

FFMQ Descriptive Statistics

N Valid 73
Mean 129.822
Std. Error of Mean 1.918
Median 128.000
Mode 119.00a
Std. Deviation 16.387
Skewness .364
Std. Error of
.281
Skewness
Kurtosis -.487
Std. Error of Kurtosis .555
Range 73
Minimum 100.000
Maximum 173.000
a. Multiple modes exist. The smallest value is shown.

Table 8

FFMQ Subscale Descriptive Statistics

Non-judgmental Non-reactivity
Acting with towards Inner to Inner
Observing Describing Awareness Experience Experience
N Valid 73 73 73 73 73
Missing 0 0 0 0 0
Mean 24.1918 28.6027 27.6712 24.6849 21.1096
Std. Error of Mean .66628 .61585 .59458 .64221 .50551
Median 24.0000 29.0000 28.0000 24.0000 22.0000
Mode 21.00a 25.00a 24.00 21.00a 22.00
Std. Deviation 5.69273 5.26186 5.08007 5.48705 4.31908
 51

Skewness -.199 -.256 -.402 -.162 -.269

Std. Error of Skewness .281 .281 .281 .281 .281
Kurtosis .544 .758 .263 -.448 -.546
Std. Error of Kurtosis .555 .555 .555 .555 .555
Range 28.00 29.00 26.00 23.00 19.00
Minimum 9.00 11.00 14.00 12.00 12.00
Maximum 37.00 40.00 40.00 35.00 31.00
a. Multiple modes exist. The smallest value is shown

Body Acceptance

The researcher administered the Body Appreciation Scale – Second Edition (BAS-2;

Tylka & Wood-Barcalow, 2015) to measure body acceptance. The BAS-2 has 10 items scored on

a Likert scale, and higher score on BAS-2 represents higher body appreciation. The total mean

score on BAS-2 (see Table 9) was 34.45 (SD = 8.52), with the ranges of scores between 14 and

50, and skewness and kurtosis were within acceptable ranges.

Table 9

BAS-2 Descriptive Statistics

N Valid 73
Missing 0
Mean 34.4521
Std. Error of Mean .99677
Median 35.0000
Mode 35.00
Std. Deviation 8.51639
Skewness -.205
Std. Error of
.281
Skewness
Kurtosis -.366
Std. Error of Kurtosis .555
Range 36.00
Minimum 14.00
Maximum 50.00
 52

Eating Behavior

The researcher measured participants’ eating habits through the Eating Attitudes Test-26

(EAT-26; Garner et al., 1982), as well as the Intuitive Eating Scale – Second Edition (IES-2;

Tylka & Kroon Van Diest, 2013). While the EAT-26 measures maladaptive eating habits, the

IES-2 measures adaptive eating habits.

EAT-26. The EAT-26 consists of 26 items and has three subscales: Dieting, Bulimia and

Food Preoccupation, and Oral Control (i.e., awareness of social environment on eating behavior

and predicts good outcomes). The mean total EAT-26 score was 10.36 (SD = 8.19), and the

scores ranged between 0 and 31 (see Table 10). All three subscales were positively skewed (see

Table 11); therefore, the scores were log transformed to reduce the skewness of the scores for

later analysis (see Table 11). The mean score for the Log transformed Dieting subscale was 0.74

(SD = 0.36), while the score for Bulimia and Food Preoccupation was 0.21 (SD = 0.33), and the

score for the Oral Control subscale was 0.31 (SD = 0.29).

Table 10

EAT-26 Descriptive Statistics

N Valid 73
Missing 0
Mean 10.3562
Std. Error of Mean .95830
Median 9.0000
Mode 2.00
Std. Deviation 8.18768
Skewness .930
Std. Error of Skewness .281
Kurtosis .085
Std. Error of Kurtosis .555
Range 31.00
Minimum .00
Maximum 31.00
 53

Table 11

EAT-26 Subscale Descriptive Statistics – Pre- and Post-Logarithmic Transformation

Bulimia and
Food Oral Dieting Bulimia and Food Oral Control
Dieting Preoccupation Control Log1 Preoccupation Log1 Log1
N Valid 73 73 73 73 73 73
Missing 0 0 0 0 0 0
Mean 6.4110 1.3151 1.5753 0.7441 0.2109 0.3091
Std. Error of Mean .64042 .29122 .22405 0.04158 0.03826 0.03446
Median 4.0000 .0000 1.0000 0.699 0 0.301
Mode 3.00 .00 .00 0.6 0 0
Std. Deviation 5.47173 2.48818 1.91426 0.35527 0.32691 0.29441
Skewness 1.125 2.248 1.634 -0.452 1.261 0.344
Std. Error of Skewness .281 .281 .281 0.281 0.281 0.281
Kurtosis .586 4.565 2.871 -0.143 0.234 -1.034
Std. Error of Kurtosis .555 .555 .555 0.555 0.555 0.555
Range 22.00 10.00 8.00 1.36 1.04 0.95
Minimum .00 .00 .00 0 0 0
Maximum 22.00 10.00 8.00 1.36 1.04 0.95
1
Note: Represents descriptive statistics based on Log transformation to reduce skewness.

IES-2. The IES-2 consists of 21 items and has four subscales: Unconditional Permission

to Eat, Eating for Physical rather than Emotional Reasons, Reliance on Internal Hunger and

Satiety Cues, and Body-Food Choice Congruence. The total mean IES-2 score was 3.33 (SD =

0.62) (see Table 12). The average score for the Unconditional Permission to Eat subscale was

3.40 (SD = 0.90), the mean for the Eating for Physical rather than Emotional Reasons was 3.04

(SD = 0.93), the mean score for the Reliance on Internal Hunger and Satiety Cues was 3.57 (SD

= 0.82), and the mean score for the Body-Food Choice Congruence subscale was 3.48 (SD =

0.86) (see Table 13).

Table 12

IES-2 Descriptive Statistics

N Valid 73
Missing 0
Mean 3.3307
Std. Error of Mean .07264
Median 3.2609
Mode 3.70
 54

Std. Deviation .62065

Skewness -.157
Std. Error of
.281
Skewness
Kurtosis -.201
Std. Error of Kurtosis .555
Range 3.09
Minimum 1.74
Maximum 4.83

Table 13

IES-2 Subscales Descriptive Statistics

Eating for
Unconditional Physical rather Reliance on Body-Food
Permission to than Emotional Internal Hunger Choice
Eat Reasons and Satiety Cues Congruence
N Valid 73 73 73 72
Missing 0 0 0 1
Mean 3.4041 3.0431 3.5658 3.4815
Std. Error of Mean .09461 .10486 .09599 .10105
Median 3.3333 3.1250 3.8333 3.5000
Mode 3.00 3.50 4.00 4.00
Std. Deviation .80838 .89596 .82010 .85742
Skewness -.083 .012 -.705 -.220
Std. Error of
.281 .281 .281 .283
Skewness
Kurtosis -.303 -.769 .712 -.077
Std. Error of Kurtosis .555 .555 .555 .559
Range 3.83 4.00 4.00 4.00
Minimum 1.17 1.00 1.00 1.00
Maximum 5.00 5.00 5.00 5.00
a. Multiple modes exist. The smallest value is shown.

Inferential Statistics

Hypothesis 1

The researcher hypothesized that there would be a positive correlation between

mindfulness and healthy eating behaviors. The inter-correlation analysis revealed that there was
 55

a significantly positive correlation between IES-2 total (i.e., measuring healthy eating behaviors)

and FFMQ total score (i.e., measuring mindfulness) r = .324 (p <. 01). FFMQ total score was

also positively correlated with IES-2 Eating for Physical rather than Emotional Reasons

subscale, r=.284 (p < .05), and Reliance on Hunger and Satiety Cues subscale, r=.236 (p < .05),

although these correlations were not large (Table 14).

Post-hoc analyses. Additionally, as expected, unhealthy eating behaviors was

significantly negatively correlated with intuitive eating habits; this was evidenced by r = -.522

for EAT-26 and IES-2 (p < .01) (Table 15). Mindfulness was not correlated with maladaptive

eating habits, as measured by EAT-26 total; however, specific aspects of mindfulness correlated

with some maladaptive eating habits (Table 16). This was evidenced by a significant negative

correlation between the FFMQ Describing subscale and EAT-26 total, r = -.302 (p < .01), as well

as EAT-26 subscales Dieting, r = -.249 (p < .05), and Bulimia and Food Preoccupation r = -.277

(p < .01). Additionally, FFMQ Observing subscale was positively correlated with EAT-26

Dieting subscale r = 244 (p < .05).

Table 14

Correlations between FFMQ and IES-2

IES IES Eating for
Unconditional Physical rather IES Reliance IES Body-
Permission to than Emotional on Hunger and Food Choice
IES-2 Total Eat Reasons Satiety Cues Congruence
FFMQ Total Pearson Correlation .324** .063 .284* .236* .469**
Sig. (2-tailed) .005 .594 .015 .044 .000
N 73 73 73 73 72

FFMQ Pearson Correlation .037 -.130 -.018 .040 .462**

Observing Sig. (2-tailed) .755 .272 .878 .734 .000
N 73 73 73 73 72

FFMQ Pearson Correlation .277* .122 .244* .233* .213

Describing Sig. (2-tailed) .017 .306 .038 .047 .073
 56

N 73 73 73 73 72

FFMQ Pearson Correlation .157 -.052 .201 .073 .265*

Awareness Sig. (2-tailed) .183 .664 .089 .538 .024
N 73 73 73 73 72

FFMQ Non- Pearson Correlation .370** .275* .292* .272* .220

judgmental Sig. (2-tailed) .001 .019 .012 .020 .063
Stance towards N 73 73 73 73 72
Inner
Experience
FFMQ Non- Pearson Correlation .097 -.094 .118 .066 .281*
reactivity to Sig. (2-tailed) .413 .427 .319 .579 .017
Inner N 73 73 73 73 72
Experience

Table 15

Correlations between IES-2 and EAT-26

EAT Bulimia and
Food
EAT-26 EAT Dieting Preoccupation EAT Oral Control
Total Log Log Log
IES-2 Total Pearson
-.522** -.489** -.614** .074
Correlation
Sig. (2-tailed) .000 .000 .000 .533
N 73 73 73 73

IES Unconditional Pearson -.576** -.539** -.497** -.274*

Permission to Eat Correlation
Sig. (2-tailed) .000 .000 .000 .019
N 73 73 73 73

IES Eating for Pearson -.331** -.357** -.476** .137

Physical rather Correlation
than Emotional Sig. (2-tailed) .004 .002 .000 .249
Reasons N 73 73 73 73

IES Reliance on Pearson -.397** -.355** -.485** .194

Hunger and Correlation
Satiety Cues Sig. (2-tailed) .000 .002 .000 .099
N 73 73 73 73
 57

IES Body-Food Pearson -.134 -.018 -.242* .183

Choice Correlation
Congruence Sig. (2-tailed) .263 .882 .040 .124
N 72 72 72 72

Table 16

Correlations between FFMQ and EAT-26

FFMQ Non-
judgmental FFMQ Non-
Stance towards reactivity to
FFMQ FFMQ FFMQ FFMQ Inner Inner
Total Observing Describing Awareness Experience Experience
**
EAT-26 Total Pearson -.077 .152 -.302 -.033 -.160 .148
Correlation
Sig. (2-tailed) .515 .200 .010 .785 .175 .212
N 73 73 73 73 73 73

EAT Dieting Pearson .013 .244* -.249* .049 -.165 .209

Log Correlation
Sig. (2-tailed) .916 .037 .034 .682 .162 .075
N 73 73 73 73 73 73

EAT Bulimia Pearson -.190 .025 -.277* -.133 -.143 -.035

and Food Correlation
Preoccupation Sig. (2-tailed) .108 .834 .018 .261 .227 .771
Log N 73 73 73 73 73 73

EAT Oral Pearson .083 .171 -.010 .099 -.075 .120

Control Log Correlation
Sig. (2-tailed) .485 .147 .932 .405 .530 .313
N 73 73 73 73 73 73

Hypothesis 2

The researcher hypothesized that BMIs would be negatively correlated with healthy

eating habits, as well as mindfulness. As predicted, BMI was significantly negatively correlated

with IES-2 total r = -434 (p < .01), as well as the IES-2 subscales of Eating for Physical rather
 58

than Emotional Reasons, r = -406 (p <. 01), Reliance on Hunger and Satiety Cues r = -323 (p <

.01), as well as the Body-Food Congruence subscale r = -329 (p < .01) (Table 17). However,

contrary to the hypothesis, the correlation analysis revealed that BMI was not significantly

correlated with any aspect of mindfulness.

Post-hoc analyses. Although BMI was not correlated with EAT-26 total, BMI was

significantly correlated with the specific aspect of maladaptive eating behavior (Table 18). This

was evidenced by a significant positive correlation between BMI and EAT-26 subscale, Bulimia

and Food Preoccupation, r = 251 (p < .05).

Table 17

Correlations between BMI and IES-2

IES IES Eating for IES Reliance IES Body-
Unconditional Physical rather on Hunger Food
Permission to than Emotional and Satiety Choice
IES-2 Total Eat Reasons Cues Congruence
BMI Pearson
-.434** -.188 -.406** -.323** -.329**
Correlation
Sig. (2-tailed) .000 .110 .000 .005 .005
N 73 73 73 73 72

Table 18

Correlations between BMI and EAT-26

EAT Bulimia
and Food
EAT-26 EAT Dieting Preoccupation EAT Oral
Total Log Log Control Log
BMI Pearson
.209 .201 .251* -.208
Correlation
Sig. (2-tailed) .077 .087 .032 .077
N 73 73 73 73

Hypothesis 3
 59

The researcher hypothesized that body acceptance and healthy eating behaviors would be

positively correlated. As predicted, BAS-2 total, which measures body acceptance, was

significantly positively correlated with IES-2 Total, r = .589 (p < .01). Furthermore, the analysis

revealed that body acceptance was significantly and positively correlated with all aspects of

healthy eating, as measured by the IES-2. BAS-2 total was significantly correlated with the

Eating for Physical Reasons rather than Emotional Reasons subscale, r = .547 (p < .01), and with

the Body-Food Congruence subscale, r = .473 (p < .01). BAS-2 total was correlated with the

IES-2 subscales, Unconditional Permission to Eat, r = .315 (p < .01), and with Reliance on

Hunger and Satiety Cues, r = .368 (p < .05) (Table 19).

Table 19

Correlations between BAS-2 and IES-2

IES IES Eating for IES Reliance
Unconditional Physical rather on Hunger IES Body-
IES-2 Permission to than Emotional and Satiety Food Choice
Total Eat Reasons Cues Congruence
BAS-2 Pearson
.589** .315** .547** .368** .473**
Total Correlation
Sig. (2-tailed) .000 .007 .000 .001 .000
N 73 73 73 73 72

Post-hoc analysis. Additionally, the analysis revealed negative correlations between

body acceptance and maladaptive eating behaviors (Table 20). BAS-2 total was significantly and

negatively correlated with EAT-26 total, r = .352 (p<.01). Body acceptance was also negatively

correlated with specific aspects of maladaptive eating habits, dieting behavior and bulimia and/or

preoccupation with food. This was evidenced by significant negative correlation between BAS-2

total and EAT-26 Dieting subscale, r = .303 (p < .01), and the Bulimia and Food Preoccupation

subscale, r = .343 (p < .01).

 60

Table 20

Correlations between BAS-2 and EAT-26

EAT-26 EAT EAT Bulimia and EAT Oral
Total Dieting Food Preoccupation Control
Log Log Log
BAS-2 Pearson
-.352** -.303** -.343** .077
Total Correlation
Sig. (2-tailed) .002 .009 .003 .517
N 73 73 73 73

Hypothesis 4

The researcher hypothesized that BMIs would be negatively correlated with body

acceptance. As predicted, the correlation analysis revealed that there was a significant negative

correlation between BMI and BAS-2 total, r = -.325 (p < .01) (Table 21).

Table 21

Correlations between BAS-2 and BMI

BMI

BAS-2 Total Pearson Correlation -.325**

Sig. (2-tailed) .005
N 73

Hypothesis 5

The researcher hypothesized that mindfulness would be positively correlated with body

acceptance. As predicted, mindfulness, as measured by FFMQ total score, was significantly

positively correlated with BAS-2 total, r = .583 (p < .01). Additionally, body acceptance was

positively and significantly correlated with all aspects of mindfulness (Table 22). BAS-2 total

was significantly positively correlated FFMQ’s subscales Observe, r = .343 (p < .01), Describe, r

= .354 (p < .01), Awareness, r = .296 (p < .01), FFMQ Non-judgmental Stance towards Inner
 61

Experience, r = .432 (p < .01), and FFMQ Non-reactivity to Inner Experience, r = .335 (p < .01).

Table 22

Correlations between BAS-2 and FFMQ

FFMQ Non-
judgmental FFMQ Non-
FFMQ FFMQ FFMQ FFMQ Stance towards reactivity to Inner
Total Observing Describing Awareness Inner Experience Experience
BAS-2 Pearson
.583** .343** .354** .296* .432** .335**
Total Correlation
Sig. (2-tailed) .000 .003 .002 .011 .000 .004
N 73 73 73 73 73 73

Hypothesis 6

The researcher hypothesized that there would be a predictive relationship between

mindfulness, body acceptance, and eating habits. The researched conducted a linear regression

analysis; however, the results from the regression analysis, although significant, had to be

interpreted with caution due to multicollinearity between BAS-2 (i.e., body acceptance), IES-2

(i.e., eating habits) measures (Tables 23, 24, and 25). The multicollinearity was evidenced by

high significant correlations (Table 19) between the two measures, r = .589 (p < .01), as well as

the collinearity statistic (BAS Total score, Tolerance =.660; FFMQ Total score, Tolerance =

.660). A problem with multicollinearity is indicated usually when the Tolerance statistic is more

than 1-R2 (Leech, Barrett, & Morgan, 2011), as R2 is .347, 1-R2 value is .653, which is similar to

the Tolerance statistic for both BAS-2 Total score and the FFMQ Total score. The researcher

hypothesized that one of the reasons for the multicollinearity between the variables may be due

to the similar natures of the constructs; in other words, intuitive eating was perhaps innately

related to mindfulness, and specific aspects of mindfulness was innately related to body
 62

acceptance. However, the researcher decided to cautiously interpret the results, as the VIF values

were under 5 (VIF values above 5 indicate multicollinearity).

The researcher cautiously interpreted the results of regression model as the following: the

model accounted for 32.9% of the variance (Adjusted R2 = .329) (Table 23), with BAS-2 as a

significant predictor (Table 25). Mindfulness, as measured by FFMQ, was not a significant

predictor variable. The model indicated that for every point increase on the BAS-2 measure, the

IES-2 total score increased by .044 (b = .044); that is, higher body acceptance among women

predicted slightly higher intuitive eating habits, which partially confirms the researcher’s

hypothesis.

Table 23

Model Summary
Std. Error Change Statistics
R Adjusted
Model R of the R Square Sig. F
Square R Square F Change df1 df2
Estimate Change Change

1 .589a .347 .329 .50846 .347 18.639 2 70 .000

a. Predictors: (Constant), BAS-2 Total, FFMQ Total

Table 24

ANOVAa
Sum of Mean
Model df F Sig.
Squares Square
Regression 9.638 2 4.819 18.639 .000b
1 Residual 18.097 70 .259
Total 27.734 72
a. Dependent Variable: IES-2 Total
b. Predictors: (Constant), BAS-2 Total, FFMQ Total

Table 25

Coefficients
 63

Unstandardized Standardized Collinearity

Correlations
Coefficients Coefficients Statistics

Std. Zero-
B Beta Partial Part Tolerance VIF
Model Error t Sig. order
1 (Constant) 1.95 .480 4.068 .000
4
FFMQ Total -.001 .005 -.030 -.248 .805 .324 -.030 -.024 .660 1.516
BAS-2 Total .044 .009 .606 5.099 .000 .589 .520 .492 .660 1.516

Factor analysis. The researcher employed factor analysis to understand the various

aspects of eating behaviors among women, as the linear regression model had to be interpreted

with caution due to the issue of multicollinearity. The researcher conducted the factor analysis

using the measures (i.e., FFMQ, BAS-2, IES-2, and EAT-26) and their subsequent subscales to

examine the specific variables linked with eating behaviors. Although factor analysis is usually

utilized with a large sample size, there is research that supports the use of factor analysis with a

small sample size, provided a high number of variables are considered in the analysis (de Winter,

Dodou, & Wieringa, 2009).

The initial analysis included all measures and their subscales; however, some subscales

were excluded from the final analysis due to low Kaiser-Meyer-Olkin (KMO) measure of

sampling adequacy values and low commonalities. A total of 10 variables were included in the

analysis: Overall mindfulness, FFMQ Awareness, FFMQ Non-judgmental Stance towards Inner

Experience, FFMQ Non-reactivity to Inner Experience, overall eating behaviors, EAT-26

Dieting, EAT-26 Bulimia and Food Pre-occupation, overall intuitive eating components, IES-2

Eating for Physical rather than Emotional Reasons, and IES-2 Reliance on Hunger and Satiety

Cues. The KMO measure of sampling adequacy was .614, with the Bartlett’s Test of Sphericity

indicating significance (2 (45) = 547.27, p < .001) (Table 26). The communalities ranged
 64

between .505 and .967, which indicated that the variables shared some variability across the

extracted factors (Table 27).

Table 26

KMO and Bartlett's Test

Kaiser-Meyer-Olkin Measure of Sampling Adequacy .614
Approx. Chi-Square 547.272
Bartlett's Test of df 45
Sphericity Sig. .000

Table 27

Communalities
Initial Extraction
FFMQ Total 1.000 .920
FFMQ Awareness 1.000 .576
FFMQ Non-judgmental Stance towards Inner
1.000 .564
Experience
FFMQ Non-reactivity to Inner Experience 1.000 .505
EAT-26 Total 1.000 .925
*EAT Dieting Log 1.000 .833
*EAT Bulimia and Food Preoccupation Log 1.000 .697
IES-2 Total 1.000 .967
IES Eating for Physical rather than
1.000 .760
Emotional Reasons
IES Reliance on Hunger and Satiety Cues 1.000 .763
Extraction Method: Principal Component Analysis.
*Used Logrithmic values for EAT-26 subscales

The principal component analysis extraction method indicated that the first three factors

explained about 75% of the variance, as seen by the initial Eigen values (Table 28). Based on a

Varimax rotation method, three factors were extracted, with the first factor including overall

intuitive eating component, as well as IES-2 Eating for Physical rather than Emotional Reasons,

and IES-2 Reliance on Hunger and Satiety Cues. The second factor included overall eating
 65

behaviors, as well as EAT-26 Dieting, and EAT-26 Bulimia and Food Pre-occupation. The third

factor included overall mindfulness, as well as FFMQ Awareness, FFMQ Non-judgmental

Stance towards Inner Experience, and FFMQ Non-reactivity to Inner Experience (Table 29).

Table 29

Rotated Component Matrix a

Component
1 2 3
IES-2 Total .904
IES Reliance on Hunger and Satiety Cues .844
IES Eating for Physical rather than Emotional Reasons .834
EAT-26 Total .935
EAT Dieting Log* .883
EAT Bulimia and Food Preoccupation Log* .707
FFMQ Total .943
FFMQ Awareness .753
FFMQ Non-judgmental Stance towards Inner Experience .707
FFMQ Non-reactivity to Inner Experience .612
Extraction Method: Principal Component Analysis.
Rotation Method: Varimax with Kaiser Normalization.a
a. Rotation converged in 5 iterations.
b. *Used Logrithmic values for EAT-26 subscales

FFMQ Non-reactivity to Inner Experience subscale was eliminated in the following

analysis. The resulting KMO measure of sampling adequacy was .642, with a significant of

Bartlett’s Test of Sphericity (2 (36) = 496.74, p < .001) (Table 30). The communalities ranged

between .626 and .972, which improved from the previous analysis (Table 31). The resulting

initial Eigen values indicated that the first three factors explained 79.47% of the variance (Table

32). The Varimax rotation component matrix indicated three factors, first one included overall

intuitive eating components, with emphasis on IES-2 Eating for Physical rather than Emotional

Reasons, and IES-2 Reliance on Hunger and Satiety Cues. The second factor included aspects of

maladaptive eating (EAT-26 total), specifically EAT-26 Dieting and Bulimia and Food
 66

Preoccupation subscales. The third factor included overall mindfulness, with emphasis on FFMQ

Awareness and Non-judgmental Stance on Inner Experience subscales. The factors were

categorized as Physical Reasons for Eating, Control of Eating Behaviors, and Awareness of

Emotional States, respectively. These results indicate that the emotional states, as well as

cultivating awareness of physical cues of hunger and satiety contribute to healthy and adaptive

eating habits, while being overly pre-occupied with eating habits contribute to maladaptive

eating.

Table 30

KMO and Bartlett's Test

Kaiser-Meyer-Olkin Measure of Sampling Adequacy .642
Approx. Chi-Square 496.742
Bartlett's Test of
df 36
Sphericity
Sig. .000

Table 31

Communalities
Initial Extraction
FFMQ Total 1.000 .863
FFMQ Awareness 1.000 .651
FFMQ Non-judgmental Stance towards Inner Experience 1.000 .626
EAT-26 Total 1.000 .946
EAT Dieting Log* 1.000 .835
EAT Bulimia and Food Preoccupation Log* 1.000 .721
IES-2 Total 1.000 .972
IES Eating for Physical rather than Emotional Reasons 1.000 .771
IES Reliance on Hunger and Satiety Cues 1.000 .767
Extraction Method: Principal Component Analysis
*Used Logrithmic values for EAT-26 subscales
BODY ACCEPTANCE, MINDFULNESS, AND EATING BEAHVIORS 67

Table 28

Total Variance Explained

Initial Eigenvalues Extraction Sums of Squared Loadings Rotation Sums of Squared Loadings
Component % of Cumulative % of Cumulative % of Cumulative
Total Total Total Variance %
Variance % Variance %
1 4.139 41.389 41.389 4.139 41.389 41.389 2.605 26.050 26.050
2 2.313 23.131 64.520 2.313 23.131 64.520 2.483 24.826 50.877
3 1.057 10.567 75.087 1.057 10.567 75.087 2.421 24.211 75.087
4 .779 7.792 82.879
5 .693 6.929 89.808
6 .442 4.422 94.230
7 .331 3.312 97.542
8 .120 1.196 98.738
9 .090 .896 99.634
10 .037 .366 100.000
BODY ACCEPTANCE, MINDFULNESS, AND EATING BEAHVIORS 68

Table 32

Total Variance Explained

Initial Eigenvalues Extraction Sums of Squared Loadings Rotation Sums of Squared Loadings
Component % of Cumulative % of Cumulative % of Cumulative
Total Total Total Variance %
Variance % Variance %
1 4.122 45.803 45.803 4.122 45.803 45.803 2.541 28.229 28.229
2 1.978 21.977 67.780 1.978 21.977 67.780 2.475 27.496 55.725
3 1.052 11.692 79.472 1.052 11.692 79.472 2.137 23.747 79.472
4 .693 7.705 87.176
5 .452 5.027 92.203
6 .368 4.091 96.294
7 .205 2.274 98.569
8 .092 1.025 99.594
9 .037 .406 100.000
Extraction Method: Principal Component Analysis.
 69

Table 33

Rotated Component Matrix a

Component
1 2 3
IES-2 Total .902
IES Reliance on Hunger and Satiety Cues .843
IES Eating for Physical rather than Emotional Reasons .839
EAT-26 Total .953
EAT Dieting Log .892
EAT Bulimia and Food Preoccupation Log .745
FFMQ Total .911
FFMQ Awareness .806
FFMQ Non-judgmental Stance towards Inner .752
Experience

Extraction Method: Principal Component Analysis.

Rotation Method: Varimax with Kaiser Normalization.a
a. Rotation converged in 5 iterations.

Hypothesis 7

The researcher expected to various demographic components to predict body acceptance,

but the researcher did not make any specific a priori hypothesis regarding the specific variables

that would predict body acceptance. Demographic variables were expected to predict body

acceptance, as research indicates significant differences in how body image is perceived in

various cultures (Grabe & Hyde, 2006; Jackson, Jiang, & Chen, 2016; Rubin et al., 2003) The

researcher first conducted a regression analysis with body acceptance (BAS-2) as the dependent

variable, with intuitive (IES-2) and maladaptive eating habits (EAT-26), as well as mindfulness

(FFMQ) as the predictor variables. The model, although significant, had multicollinearity issues

similar to the regression analysis conducted with IES-2 as the dependent variable (i.e., high

correlations between BAS-2, FFMQ, and IES-2 measures, in addition to low Tolerance values).
 70

The researcher then ran a separate multiple regression utilizing demographic variables to

understand the relationship between various aspects of socioeconomic status, as well as age,

ethnicity, and geographic origins on body acceptance attitudes. Additionally, spirituality, BMI

and relationship status was included as dependent variables; the relationship status was

condensed to one variable, as the sample size of each category of the relationship status (e.g.,

single, divorced, married, not married but living with partner, etc.) was low. The relationship

status of participants was considered to be single if participants indicated they were single or

divorced, and that they were in a relationship if they indicated that they were married, not

married but living with a partner, or if they were in a committed relationship but not living

together.

The researcher utilized the enter method for the initial regression analysis, and used all

demographic variables as predictor variables, with BAS-2 total score as the dependent variable.

The resulting model was not statistically significant, F(35,36) = 1.22, p = .149. One possible

explanation for the results could be that there were too many variables, especially through the

use of dummy variables (e.g., ethnicity, geographic origin, education, etc.), which could have

reduced the overall power of the model. The researcher conducted a step-wise regression

analysis next, as this type of analysis allows the exploration of the most significant predictor

variables, and provides information regarding the model with a good fit.

The step-wise regression analysis produced four statistically significant models (Tables

4.34, 4.35, and 4.36). The variables that determined a significant and best predictive model were

BMI, relationship status of participants, and education level. However, participants’ age,

ethnicity, geographic origin, immigration status, income, importance of spirituality did not

predict BAS-2 scores, and were excluded from all the models. Regardless, the researcher
 71

interpreted the results of the stepwise regression with caution, as there were some indications of

multicollinearity across the four models; the Tolerance values for all four models were greater

than 1-R2 (i.e., Tolerance values should generally be less than 1-R2) and their respective

Eigenvalues were low (i.e., Eigenvalues that are close to 1 are considered within norms; Leech et

al., 2011). However, the results were interpreted with caution, as the VIF values were under 5

(VIF values above 5 indicate multicollinearity).

The first model included the relationship status, (F(1,70) = 9.168, p < .01), and explained

10.3% of variance (R2 = .103). Being in a relationship predicted better body acceptance, as

evidenced by a 5.800 change in BAS-2 score when being in a relationship was endorsed by

participants (b = 5.800). This model excluded BMI and education level.

Table 34

Model Summary
Std. Error Change Statistics
R Adjusted of the R Square Sig. F
Model R Square R Square Estimate Change F Change df1 df2 Change
a
1 .340 .116 .103 8.07666 .116 9.168 1 70 .003
b
2 .468 .219 .197 7.64456 .103 9.137 1 69 .004
c
3 .529 .280 .248 7.39652 .060 5.705 1 68 .020
d
4 .584 .341 .302 7.12703 .061 6.240 1 67 .015
a. Predictors: (Constant), Relationship
b. Predictors: (Constant), Relationship, BMI
c. Predictors: (Constant), Relationship, BMI, Some College Education
d. Predictors: (Constant), Relationship, BMI, Some College Education, High School Degree or GED

Table 35

ANOVAa
Sum of
Model Squares df Mean Square F Sig.
1 Regression 598.044 1 598.044 9.168 .003b
Residual 4566.275 70 65.233
Total 5164.319 71
 72

2 Regression 1132.006 2 566.003 9.685 .000c

Residual 4032.313 69 58.439
Total 5164.319 71
3 Regression 1444.143 3 481.381 8.799 .000d
Residual 3720.177 68 54.708
Total 5164.319 71
4 Regression 1761.089 4 440.272 8.668 .000e
Residual 3403.231 67 50.794
Total 5164.319 71
a. Dependent Variable: BAS-2 Total
b. Predictors: (Constant), Relationship
c. Predictors: (Constant), Relationship, BMI
d. Predictors: (Constant), Relationship, BMI, Some College Education
e. Predictors: (Constant), Relationship, BMI, Some College Education, High
School Degree or GED

Table 36

Coefficientsa
Unstandardized Standardized
Coefficients Coefficients Correlations Collinearity Statistics

Std. Zero-
Model B Error Beta t Sig. order Partial Part Tolerance VIF
1 (Constant) 31.125 1.428 21.800 .000
Relationship 5.800 1.916 .340 3.028 .003 .340 .340 .340 1.000 1.000
2 (Constant) 48.158 5.795 8.311 .000
Relationship 5.850 1.813 .343 3.226 .002 .340 .362 .343 1.000 1.000
BMI -.697 .230 -.322 -3.023 .004 -.318 -.342 -.322 1.000 1.000
3 (Constant) 46.599 5.645 8.256 .000
Relationship 5.806 1.754 .341 3.309 .001 .340 .372 .341 1.000 1.000
BMI -.595 .227 -.275 -2.622 .011 -.318 -.303 -.270 .965 1.036
Some
College -5.892 2.467 -.250 -2.389 .020 -.305 -.278 -.246 .965 1.036
Education
4 (Constant) 48.065 5.470 8.786 .000
Relationship 5.239 1.706 .307 3.072 .003 .340 .351 .305 .982 1.018
BMI -.631 .219 -.291 -2.877 .005 -.318 -.332 -.285 .961 1.041
 73

Some
College -6.124 2.378 -.260 -2.575 .012 -.305 -.300 -.255 .963 1.038
Education
HS Degree
-18.150 7.266 -.251 -2.498 .015 -.257 -.292 -.248 .976 1.025
or GED
a. Dependent Variable: BAS-2 Total

The second model included relationship status and BMI, F(2, 69) = 9.685, p < .01), and

explained 19.7% of variance (R2 = .197). While relationship status predicted increase in body

acceptance, BMI had an inverse relationship and suggested that for every 1-point increase in

BMI, BAS-2 total score decreased by .705 (b = -.705). This suggests that women who are in

relationships, and have lower BMIs experience higher levels of body acceptance. High school

degree or GED, and women with some college education were excluded.

The third model included relationship status, BMI, and some college education, which

was a category of the education level variable. The model was significant, (F(3,68) = 8.799, p <

.01), and explained 24.8% of the variance (R2 = .248). While relationship status had a positively

predicted body acceptance, BMI and having some college level education predicted lower body

acceptance. In fact, BAS-2 total score decreased by 5.892 points with the endorsement of some

college education (b = -5.892), while the BAS-2 score decreased by .595 for every 1-point

increase in BMI (b = -.595).

The fourth model similarly included the education level variable, high school degree or

GED, (F(4,67) = 8.668, p < .01), 30.2% of variance explained (R2 = .302). However, the

researcher interpreted the results of the fourth model cautiously, as only one participant had

endorsed high school degree or GED as their education level. The results indicated that the third

model with relationship status, BMI, and some college education variables produced a good

statistically significant model. The third model indicated that women in a relationship, with
 74

lower BMIs, having an education level higher than some college education level had higher body

acceptance rates.

Summary of Results

Mindfulness, body acceptance, and healthy eating (i.e., intuitive eating) were all

positively correlated with one another. The regression analysis with intuitive eating as the

dependent variable, and mindfulness and body acceptance as predictor variables revealed that

high body acceptance slightly, but significantly, predicted better intuitive eating. However, this

finding was interpreted with caution due to concerns regarding multicollinearity. The factor

analysis conducted to understand facets of eating behavior revealed three factors contribute to

eating behaviors: Physical Reasons for Eating, Control of Eating Behaviors, and Awareness of

Emotional States. Exploration of demographic variables’ relationships with body acceptance

through a regression analysis revealed that relationship status, BMI, and education level

significantly predicted body acceptance. However, these findings were interpreted with caution

due to concerns regarding multicollinearity.

 75

Chapter 5: Discussion and Conclusions

Overview of Study

Research on weight management practices have become more paramount given the rising

rates of overweight and obesity in the U.S. population (WHO, 2008). The health risks associated

with overweight and obesity (e.g., cancer, asthma, metabolic syndromes, cardiovascular diseases,

etc.) further highlight the need for weight management strategies (e.g., Guh et al., 2009; Renehan

et al., 2008). The etiology of obesity is multifaceted, with environmental and psychological

factors significantly contributing to the development of obesity (Devlin et al., 2000). Overweight

and obesity is more prevalent in ethnic minority groups, particularly among African American

and Hispanic/Latina women in comparison to non-Hispanic White women (Hedley et al., 2004).

The differences in prevalence rates can be attributed to some of the environmental and

socioeconomic influencers; for example, healthy food resource in poorer neighborhoods,

particularly those that are predominantly Hispanic or African American, are more scarce in

comparison to neighborhoods with higher incomes (Coleman-Jensen, Rabbitt, Gregory, & Singh,

2015; Kirby et al., 2012). Furthermore, an inverse relationship exists between obesity rates and

socioeconomic status (Sobal & Stunkard, 1989; Zhang & Wang, 2004), with research indicating

that there are more grocery stores and supermarkets in wealthier neighborhoods than in poor

ones (Morland & Evenson, 2009).

Despite environmental factors playing a role in the development of obesity, significant

social stigma is associated with being overweight or obese. The negative stereotypes and stigma

with being overweight or obese were even observed in grade school children, where they

associated overweight and obese individuals as lazy, less hard-working, less attractive, less

confident, and less healthy (Tiggemann & Anesbury, 2000). Further, research indicates that
 76

overweight and obese individuals tend to internalize these stigmas, and as a consequence, can

adversely affect any healthy behaviors in which they desire to engage (Puhl et al., 2007; Wang et

al., 2004). Therefore, research on how people process information regarding their weight, body

perception (i.e., level of body acceptance and satisfaction), and their eating habits is relevant

when developing comprehensive weight management techniques.

The current study utilized the impulsivity model of obesity (Mobbs et al., 2010) to

understand eating behaviors. The impulsivity model highlights how emotion regulation is an

important aspect to eating behaviors; the experience of strong emotions trigger emotional eating,

in addition to having high sensitivity to reward, or eating behaviors. These emotional processes

are combined with cognitive processes of not thinking of long-term consequences when eating,

as well as being pre-occupied with thoughts about food and body shape, which in turn trigger

emotional eating. Given that body shape perception also played into eating behaviors, the study

utilized the holistic body image model (Wood-Barcalow et al., 2010) to conceptualize the factors

affecting body acceptance. The holistic body image model postulates that the sources of

information (e.g., social attitudes, spirituality, genetics, culture, etc.) regarding body image are

filtered and influence one’s body evaluation and body investment, and that this process is fluid

and reciprocal. This model explains how a person can shift between having positive and negative

body evaluation, as it is based on the type of information that the person chooses to filter. As the

sense of agency (i.e., what type of information is filtered), as well as emotion regulation play a

role in body acceptance and eating behaviors, the researcher also included mindfulness as an

important variable to the study. Contemporary treatments for eating and weight management

have started to include mindfulness in treatments, as it is associated with higher emotion

regulation and non-judgmental attitudes (e.g., Alberts et al., 2010; Caldwell et al., 2012; Lillis et
 77

al., 2009). The current study looked at the relationship between body acceptance, mindfulness,

and healthy eating behaviors in hopes to add to the literature on which aspects of these variables

are crucial when developing comprehensive weight management programs that consider internal

and external factors of weight and healthy eating habits.

Findings

Using inter-correlational statistics, as well as multiple regression and factor analysis, the

researcher studied the relationship between mindfulness, healthy eating or intuitive eating, and

body acceptance.

Mindfulness

Mindfulness was positively correlated with overall healthy eating (i.e., intuitive eating)

habits, and supported previously found results from other studies (Alberts et al., 2010; Dalen et

al., 2010; Daubenmier, Lin, & Blackburn, 2012; Kristeller et al., 2013; Taylor, Daiss, &

Krietsch, 2015). The results indicated that increased mindfulness particularly increased eating

habits such as eating for physical rather than emotional reasons, as well as relying more on

physical cues of hunger and satiety when eating. Increased levels of mindfulness, especially the

observing aspect (i.e., the ability to attend to internal experiences, such as thoughts or the

consciousness) of mindfulness was related to increased likelihood of making healthy food

choices. This is in line with research that indicates that mindfulness training can impact food

choices and impulsivity (i.e., mindfulness training decreased impulsivity and increased delay in

food choice; Hendrickson & Rasmussen, 2013). Bongers et al. (2015) found that overweight and

obese individuals are more impulsive and are prone to seeking out high-caloric foods.

Mindfulness training has been hypothesized to reduce the value individuals place on the

immediate gratification of food (Alberts et al., 2010) and can lead to individuals making healthy
 78

food choice. This suggests that mindfulness can address the sensation seeking (i.e., being highly

sensitive to food, which acts as a reward), as well as urgency (i.e., eating when emotionally

triggered) aspects of eating behaviors, as outlined by the impulsivity model of obesity (Mobbs et

al., 2010).

In line with another prediction, increased mindfulness was related to increased levels of

body acceptance. These results corroborate findings from studies that aimed at increasing body

satisfaction and self-acceptance (e.g., Bacon et al., 2005; Kelly et al., 2014; Lillis et al., 2009)

through mindfulness-based treatments, and found that mindfulness training did increase body

acceptance. The current study’s results indicated that the specific mindful aspect of taking a non-

judgmental stance towards the inner experience was particularly related to a heightened sense of

body appreciation. Sairanen et al. (2015) indicated that the ability to be non-judgmental towards

the inner experience is related to being more psychologically flexible and accepting of self.

Having the ability to be non-judgmental towards the self, especially in regards to body shape and

food choices, may increase perseverance (i.e., ability to not be pre-occupied with thoughts

regarding body shape or eating behaviors), as defined by impulsivity model of obesity (Mobbs et

al., 2010), and ultimately enhance healthy eating behaviors and body acceptance.

Based on the research that showed weight loss when individuals were enrolled in

mindfulness-based interventions for weight management and food cravings (e.g., Alberts et al.,

2010; Lillis et al., 2009; Tapper et al., 2009), the researcher had predicted that mindfulness

would be inversely related to participants’ BMI. However, the results from current study

indicated no relationship between BMI and mindfulness. One possible explanation for these

results is that the studies that showed weight loss actually had an active mindfulness training

component in the intervention, which may have led to increased mindfulness and decreased
 79

BMI; in contrast, the current research only studied the levels of mindfulness that already exists

among the population and did not provide an active mindfulness training program to study

whether the training impacted BMIs.

Healthy Eating

Intuitive eating (Tylka & Kroon Van Diest, 2013) was used as the basis for healthy eating

behaviors; intuitive eating is observed when individuals rely on physical cues of the body to eat

nutritious food when hungry, give oneself unconditional permission to eat, and allowing the

body’s satiety cues to stop eating. The results from this study indicated that the aspect of giving

oneself unconditional permission to eat was correlated with increased ability to take a non-

judgmental stance towards the inner experience; this suggests that cognitive strategies (i.e., not

being pre-occupied with food) and emotion regulation strategies (i.e., not assigning blame or

shame to eating behaviors) are linked to healthy eating behaviors. In fact, Teper et al. (2013)

proposed that increased mindfulness, especially the ability to take a non-judgmental stance and

being present-oriented, influences impulse control and improves emotion regulation. The

findings from this study suggests that eating intuitively can mediate the urgency and lack of

perseveration, facets of impulsivity (Mobbs et al., 2010) related to eating behaviors among obese

or overweight individuals.

Furthermore, as predicted, results indicated that individuals who engaged in healthy

eating behaviors had lower BMIs; particularly, the findings showed that individuals who ate for

eating for physical rather than emotional reasons had lower BMIs. This is in line with research

that indicated that focusing on intuitive eating, particularly the aspect of becoming aware of the

body’s signals for food, rather than weight loss alone, sustained long-term healthy eating

behaviors (Bacon et al., 2005). These results also corroborated findings from other studies that
 80

found high levels of intuitive eating was associated with lower BMIs (Herbert, Blechert,

Hautzinger, Matthias, & Herbert, 2013; Moor, Scott, & McIntosh, 2012; Smith & Hawks, 2006),

as well as higher interceptive sensitivity (i.e., awareness and processing of body signals; Herbert

et al., 2013).

The study results also corroborated other research findings regarding the link between

high intuitive eating behaviors and high body acceptance rates (Bacon et al., 2005; Oh,

Wiseman, Hendrickson, Phillips, & Hayden, 2012; Wood-Barcalow et al., 2010). Body

appreciation was especially related to eating for physical, rather than emotional reasons, and

choosing to eat healthy or nutritious food when hungry. Additionally, the results indicated that

high body acceptance slightly predicted higher intuitive eating behaviors; interestingly,

mindfulness did not predict intuitive eating behaviors. It must be noted that these findings were

interpreted with caution due to concerns regarding multicollinearity. These findings indicate that

being mindful does not necessary predict intuitive eating, but that having some level of body

acceptance may enhance healthy eating behaviors. In fact, these findings support the study by

Spoor and Madanat (2016), who found that individuals with greater body image discrepancy

(i.e., belief that body size is larger or smaller than ideal) are less likely to exhibit intuitive eating

(i.e., attending to physical cues of hunger and satiety). The findings from this study also suggest

that although mindfulness may be highly correlated with healthy eating behaviors, being mindful

does not necessarily predict intuitive eating. As the findings from this study were tentative in

regards to the predictive relationship, they suggest that a closer examination of the relationship

between mindfulness and healthy eating is necessary.

Important factors of eating behaviors. Findings indicated that three distinct factors

encompass eating behaviors: (1) Physical Reasons for Eating (PRE); (2) Control of Eating
 81

Behaviors (CEB); and (3) Awareness of Emotional States (AES). PRE included elements of

adaptive eating behavior, such as relying heavily on physical cues of the body when hungry and

when satiated. Another element of PRE included eating for physical, rather than emotional

reasons. CEB factors included maladaptive eating behaviors. The CEB elements comprised of

dieting behaviors (i.e., avoidance of food), as well as intense preoccupation with food and body

shape that is seen individuals with bulimia nervosa. The AES factor highlighted the ability to be

mindfully aware of the inner experience of the body and one’s emotions, and to take a non-

judgmental stance towards the inner experience. The PRE factor was derived from the IES-2

measure, while the CEB factor from the EAT-26 measure, and the AES from the FFMQ

measure. The distinct nature of the PRE and CEB factors corroborated findings from the study

by Tylka and Wilcox (2006), who found that intuitive eating included elements that are distinct

from disordered eating behaviors. The results from this study imply that being aware of

emotional states and the physical experience of the body while eating contribute to healthy eating

behaviors, while engaging in more restrictive eating behaviors and being excessively pre-

occupied by food and body shape contribute to more maladaptive eating behaviors.

Body Acceptance

High body acceptance was correlated with lower BMIs; these results corroborated

research about the relationship between BMI and body acceptance (Annis, Cash, & Hrabosky,

2004; Augustus-Horvath & Tylka, 2011). In fact, researchers found that self-esteem increases,

and body dissatisfaction decreases with weight loss, suggesting that even small decrease in

weight loss can improve body satisfaction (Annis et al., 2004; Foster, Wadden, & Vogt, 1997).

The findings from this study also indicated that individuals with higher body acceptance were

less likely to engage in maladaptive eating habits, such as restrictive eating and being overly
 82

preoccupied with food and body shape; the findings are similar to other studies that showed that

being more self-compassionate about body image was related to lower disordered eating

behaviors (Kelly & Stephen, 2016; Taylor et al., 2015).

Interestingly, relationship status, BMI, and education level tentatively predicted body

acceptance: women who are involved in romantic relationships, have lower BMIs, and have

more than some college education were more likely to have higher body acceptance. Although

this finding had to be interpreted with caution, this finding corroborates findings from past

studies that showed that college students in relationships had relatively higher body satisfaction

rates (Forbes, Jobe, & Richardson, 2006; Pettijohn, Naples, & McDermott, 2010).

Objectification theory may explain these findings; Fredrickson and Roberts (1997) proposed that

women are sexually objectified, where their bodies are evaluated by their body parts, be it

implicitly (e.g., media) or explicitly (i.e., evaluative gaze), and that women in turn internalize

these values and objectify themselves. The self-objectification can negatively impact women’s

mental health. Being involved in a romantic relationship may present opportunities for women to

positively evaluate themselves, and thereby have higher body acceptance rates. However, the

results from this study must be interpreted with caution, as BMI and education level also

predicted body acceptance. It could be that women who have ideal body shapes (i.e., lower

BMIs) are more likely to be in relationships than women who have higher BMIs; additionally,

women who have more education may have more opportunities to meet and socialize with

potential romantic partners. Furthermore, the findings from this study do not denote a causal

relationship between relationship status and body acceptance.

Given the vast literature on cultural and ethnic differences in body image and body

satisfaction, the researcher had expected other demographics, especially the following variables
 83

to predict body acceptance: (a) ethnicity, since multiple studies indicate differences among

various ethnicities, especially among African American women (i.e., have higher body

acceptance), Caucasian women (i.e., have lower body acceptance), and Asian women (i.e., have

lower body acceptance; e.g., Grabe & Hyde, 2006; Quick & Byrd-Bredbenner, 2011; Schooler,

Ward, Merriwether, & Caruthers, 2004); (b) income level (i.e., have higher BMIs and lower

body acceptance, depending on ethnicity; e.g., Breitkopf, Littleton, & Berenson, 2007); and (c)

immigration status (i.e., if participants had, or their family had immigrated to the U.S.) and

geographic origin of family, as research indicated that women who immigrated to the U.S. from

different countries had variations in their body satisfaction levels (Yates et al., 2004). However,

none of the other demographic variables significantly predicted body acceptance.

Globalization of westernized ideals of thinness may be one explanation for the lack of

findings in this study. In fact, results from the International Body Project (Swami et al., 2010)

showed that thinness is held as an ideal in developed to middle-income countries they surveyed,

with individuals in high SES preferring thinner bodies than their low SES counter-parts.

Furthermore, the study found that Western media exposure was linked to higher body

dissatisfaction rates. Exposure to Western media is not limited to traditional means (e.g., music,

television, movies, etc.), but also extends to social media; a recent study found that women who

perused fitness related information on Pinterest had more opportunities to engage in social

comparison, engage in extreme weight loss behaviors, and endorsed believing in thin ideal body

types (Lewallen & Behm-Morawitz, 2016). Exposure to thin ideal body types even at a young

age through toys (e.g., Barbie dolls) is associated with young girls expressing their desire to be

thin, as well as having lower body acceptance (Dittmar, Halliwell, & Ive, 2006). The

globalization of the thin body ideal also appears to promote more fat stigma; Brewis, Wutch,
 84

Falletta-Cowden, & Rodriguez-Soto (2011) conducted an anthropological study across 10

countries and found that fat stigma was more globalized, and that people were more likely to

attribute negative stereotypes to overweight and obese individuals (e.g., laziness). The findings

from the current study indicate that more research is required to understand the nuances of how

various social and cultural values impact body acceptance among women.

Limitations

Sample Size

One of the most significant limitations for this study was the sample size; although the G-

power (Erdfelder, Faul, & Buchner, 1996) analysis revealed that 76 participants were necessary

to for this study. After the application of exclusion and inclusion criteria, the researcher included

73 participants in this study. Furthermore, it can be speculated that even more participants were

necessary, given that many of the demographic variables’ categorical levels were converted into

dummy variables for the purposes of the regression analyses. Having more participants would

have yielded stronger findings and predictive models.

Generalizability and Sample Characteristics

Additionally, although an ethnically diverse population was represented in this study, the

study’s participants were primarily graduate school students recruited from The Chicago School

of Professional Psychology. This may have inherently skewed the data, as the majority of the

sample represents a sub-group with more education, but less income in general. College students

tend to have unhealthier eating habits (Brevard et al., 1996; Deshpande, Basil, & Basil, 2009)

that follow them later on in life (Racette, Deusinger, Strube, Highstein, & Deusinger, 2005). Low

SES is associated with higher rates of obesity (e.g., McLaren, 2007) and with decreased access to

healthy food (e.g., Powell, Slater, Mirtcheva, Bao, & Chaloupka, 2007); however, as more
 85

education is associated with higher SES, the sample size from this study represents a unique sub-

set of the population with higher education level, but low income. Therefore, the results from this

study are not generalizable to the population at large.

Additionally, the data collection method may have influenced the sample characteristics

and ultimately skewed the data. The researcher primarily used social media sites to advertise and

collect data, and as such, the characteristics of the sample represent the researcher’s social

network at first, second, or third degree connections. The people who chose to respond to the

questionnaires may have done so due to interest to help the researcher, or those who have an

interest in the topic of body acceptance. Furthermore, the participants may have been exposed

more to the variables of this study (i.e., have more knowledge on mindfulness or body

acceptance), as a proportion of the researcher’s social network represent graduate students

studying psychology. The participants’ prior knowledge on the variables and the psychological

constructs may have influenced their response style and ultimately skewed the results; as such

the results from this study are not generalizable to the larger population.

Study Design

The design of this study presents as a limitation in the interpretation of results. This study

utilized a non-experimental design and relied heavily on correlational statistics and multiple

regression to study the relationships between variables. Although the researcher was able to

ascertain the strength of the relationship between variables, no causal relationships could be

found; furthermore, as the results from the regression analyses were tentative at best, further

research is needed to confirm the predictive relationships between the variables.

 86

Implications of Findings

Clinical Implications

Patients tend to avoid healthcare settings due to fear of any stigma healthcare providers

may hold against overweight and obese women (Drury et al., 2002). In fact, Phelan, Burgess,

Yeazel, Hellerstedt, Gfiffen, & van Ryn. (2015) conducted a comprehensive narrative review and

found that healthcare providers are biased against overweight and obese patients, and that these

negative stereotypic beliefs adversely affect the quality of healthcare they provide. Davis-

Coelho, Waltz, and Davis-Coelho (2000) found that even therapists hold similar negative

perceptions regarding overweight and obese clients, with younger and less experienced therapists

exhibiting more bias. Therapists would benefit from assessing their biases, as well as from

seeking out more information on mental health issues related to obesity, and consider integrating

the holistic body image model (Wood-Barcalow et al., 2010) when conceptualizing and

treatment planning for clients seeking out help with their weight management. Integrating the

holistic body image model may also help clients understand their own beliefs, decrease their

internalized stigma about being overweight or obese, and move towards body acceptance.

Treatments that target eating behaviors, weight management, or size acceptance may find

it beneficial to include mindfulness as part of the interventions. Specifically, the findings from

this study suggest that cultivating the ability to simply observe the inner experience and

emotions, and to take a non-judgmental stance towards inner experience, may contribute to

healthy eating behaviors. Furthermore, it would be beneficial for treatment interventions to focus

on helping women become more aware of the physical sensations in their bodies when hungry or

satiated.

Additionally, clinicians can administer specific subscales from the IES-2, FFMQ, and the
 87

EAT-26 measures to monitor healthy eating behaviors during treatment. The three identified

factors of healthy eating from this study encompassed the following: the PRE factor highlighted

two IES-2 subscales Reliance on Hunger and Satiety Cues and Eating for Physical rather than

Emotional Reasons. The CEB factor emphasized two subscales of the EAT-26 measure: Dieting

and Bulimia and Food Preoccupation. The AES factor comprised of two subscales from the

FFMQ measure, Awareness and Non-judgmental Stance towards Inner Experience. In a

treatment setting, the ideal method to determine healthy eating would be to see if clients had high

IES-2 and FFMQ subscale scores, and low EAT-26 scores.

Research Implications

Previous research on intuitive eating has been done mostly on White college women

(Bruce & Ricciardelli, 2016), and therefore, the results could not be generalized. The current

study adds to the literature, as it had a more ethnically diverse population, and the results confirm

some of the findings from other studies regarding the relationships between intuitive eating, body

acceptance, and mindfulness. However, more research needs to be conducted to confirm the

findings from this study, particularly that of how strongly body acceptance predicts intuitive

eating, as the results from this study, although significant, had to be interpreted with caution.

Future research can also focus on exploring structured equation modeling, as it would add to the

discussion regarding the directionality of the relationships between the variables. Additionally,

more research would be helpful to understand how globalizing trends of valuing thin-body ideals

affect overall body perception among women from various backgrounds.

Directions for Future Research

This study did not include sexual orientation as a variable while studying body

acceptance and intuitive eating. There is emerging research on body acceptance among lesbian
 88

women (Markey & Markey, 2013), but more information is needed to understand the variables

contributing to body acceptance among lesbian and bisexual women. Furthermore, the findings

from the current study indicated that the objectification theory may explain some of the eating

behaviors and body acceptance among women; however, more research regarding the specific

aspects of relationship status (e.g., perception of partner’s preference of body type, relationship

satisfaction, years of involvement in relationship, etc.) would add to the literature and clarify if

the objectification theory is at play.

Given the link between mindfulness and spirituality (Lazaridou & Pentaris, 2016), it

would be interesting to study the influence spirituality would have on body acceptance and

healthy eating behaviors. In fact, integrating spirituality as a variable would have strong clinical

implications while conceptualizing and treatment planning with clients seeking out help for

weight management and eating behaviors. Additionally, it would be interesting to see if any

interventions on a public health level can be developed to promote size acceptance. Global trends

towards increased preference for thin ideal body types (Swami et al., 2010) and the

accompanying wide-spread negative stereotyping against overweight and obese individuals

(Brewis et al., 2011) indicate that awareness of the adverse effects of fat stigma would benefit

individuals who are struggling with body image, regardless of their size. Future research can

explore the development of public health literacy on body acceptance.

 89

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Appendix A: Informed Consent

Title: Body Acceptance, Mindfulness, and Healthy Eating Behaviors among Women
Investigators: Anushree Belur, M.A.
Mekel Harris, Ph.D.

I am a student at The Chicago School of Professional Psychology. This study is being conducted
as a part of my dissertation requirement for the Clinical Psychology Department.

I am asking you to participate in a research study. Please take your time to read the information
below and feel free to ask any questions before signing this document.

Purpose: The purpose of this study is to understand the relationship between attitudes towards
body acceptance, mindfulness, and eating behaviors among women from diverse backgrounds.

Procedures: Upon agreeing to participate in this study, you will have the option of entering your
email for a chance to win the raffle of a $50 gift card. After the raffle entry, you will begin the
survey; the survey will take about 30-45 minutes to complete and has approximately 114
questions. You will have the option of discontinuing the survey at any time you choose. Your
entry into the raffle will not be affected if you choose to discontinue the survey.

Compensation: You will have the option of enrolling in a raffle for a chance to win a $50 gift
card.

Risks to Participation: The questions on this survey pertain to your attitudes regarding your
eating habits, health, and body acceptance. Some of these questions may cause discomfort while
you consider their application to your life. If you feel distressed and want to speak to someone,
you can call the Crisis Support phone line at 1(800) 273-8255.

Benefits to Participation: You will not directly benefit from this. However, we hope the
information learned from this study may benefit society by providing a deeper understanding of
the factors that contribute to healthy eating behaviors. Particularly, we will be able to add to the
research on culturally relevant ways to help people cultivate healthy eating habits and maintain
healthy weights.

Alternatives to Participation: Participation in this study is voluntary. You may withdraw from
study participation at any time without any penalty.

Confidentiality: During this study, information will be collected about you for the purpose of
this research. This includes your email address for the purpose of the raffle. Your email address
and answers will be secured on a password-protected computer file and/or a locked cabinet at the
institution. The information will be destroyed after seven years, as dictated by APA guidelines.

Your research records may be reviewed by federal agencies whose responsibility is to protect
human subjects participating in research, including the Office of Human Research Protections
 112

(OHRP) and by representatives from The Chicago School of Professional Psychology

Institutional Review Board, a committee that oversees research.

Questions/Concerns: If you have questions related to the procedures described in this document
please contact Anushree (Annie) Belur at apb6533@[Link], or the
dissertation chair, Mekel Harris, Ph.D. via phone at (213) 615-7257.

If you have questions concerning your rights in this research study you may contact the
Institutional Review Board (IRB), which is concerned with the protection of subjects in research
project. You may reach the IRB office Monday-Friday by calling 312.467.2343 or writing:
Institutional Review Board, The Chicago School of Professional Psychology, 325 N. Wells,
Chicago, Illinois, 60654.
Consent to Participate in Research

Consent: I have read the above information and have received satisfactory answers to my
questions. I understand the research project and the procedures involved have been explained to
me. I agree to participate in this study.
Online surveys: My participation is voluntary and I do not have to click on the “submit”
button if I do not want to be part of this project.
By clicking “submit” I acknowledge reading and understanding the informed consent,
and agree to participate in this study.

Paper forms: My participation is voluntary and I do not have to initial this form if I do
not want to be part of this research project. I will receive a copy of this consent form for
my records.
By entering my initials below, I acknowledge reading and understanding the informed
consent, and agree to participate in this study. _____
 113

Appendix B: Advertisement for Research – Online Recruitment

Hi! I am working on a research study that involves women over the age of 18. It will examine
attitudes towards body acceptance and eating behaviors. The survey will take about 30-45
minutes, and you will have the option of entering a raffle for a $50 gift card. Please click on the
link below to find out more about the study! Thank you!

External Link to Survey

Text displayed after clicking on link:

My research study is looking at eating behaviors and attitudes towards body acceptance among
women over the age of 18. The whole survey will take about 30-45 minutes to complete, and you
will have the chance to enter a raffle for $50 gift card if you choose to participate. The winner of
the raffle will be notified via email.

What will I be asked to do?

You will have to answer questions on the online survey and submit your responses. You will also
have the option of entering your email address to win a raffle for $50 gift card.

How will I qualify for this study?

If you are a woman over the age of 18, and you can read, understand, and respond to questions in
English, you can take the survey.

How will my participation help?

Your participation in this study will help the field of psychology, as the intention of the study is
to understand the different aspects of eating behavior among women. The information from this
study can potentially help researchers further develop new culturally relevant interventions to
help women cultivate and maintain healthy eating behaviors and healthy weight.

How can I learn more about the study?

Please feel free to contact Anushree (Annie) Belur, M.A., at apb6533@[Link]
or Mekel Harris, Ph.D. at mekelharris@[Link] with any questions or concerns
regarding the study.

You can also click on <link> to learn more about the study and participate in the study.

Thank you for your time and interest.

Sincerely,
Anushree (Annie) Belur, M.A.
 114

Appendix C: Advertisement for Research – Flyers

Looking for Research Participants!

My research study is looking at eating behaviors and attitudes towards body acceptance among
women over the age of 18. The whole survey will take about 30-45 minutes to complete, and you
will have the chance to enter a raffle for $50 gift card if you choose to participate. The winner of
the raffle will be notified via email.

What will I be asked to do?

You will have to answer questions on the online survey and submit your responses. You will also
have the option of entering your email address to win a raffle for $50 gift card.

How will I qualify for this study?

If you are a woman over the age of 18, and you can read, understand, and respond to questions in
English, you can take the survey.

How will my participation help?

Your participation in this study will help the field of psychology, as the intention of the study is
to understand the different aspects of eating behavior among women. The information from this
study can potentially help researchers further develop new culturally relevant interventions to
help women cultivate and maintain healthy eating behaviors and healthy weight.

How can I learn more about the study?

Please feel free to contact Anushree (Annie) Belur, M.A., at apb6533@[Link]
or Mekel Harris, Ph.D. at mekelharris@[Link] with any questions or concerns
regarding the study.

How can I participate in this study?

You can contact the researcher, Anushree (Annie) Belur via email, or you can enter the
following link on your web browser to learn more about the study and participate in the study.

<Link to Survey>
Thank you for your time and interest!
Sincerely,
Anushree (Annie) Belur, M.A.
 115

Appendix D: Advertisement for Research – Recruiting Face-to-Face

Script to read:

Hello, my name is Anushree (Annie) Belur, and I am a graduate student at The Chicago
School of Professional Psychology. I am conducting a research study and would like to see if
you would be interested in participating in my study.
Just to give you a little bit of information, my study is looking for women over the age of
18. The purpose of the study is to examine attitudes towards body acceptance and eating
behaviors among women from various backgrounds. The study involves you answering a few
questionnaires, and will most likely take you 30-45 minutes to complete. You will also have the
option to enter your email address in the raffle to win a $50 gift card.
Your participation in this study will help the field of psychology, as the intention of the
study is to understand the different aspects of eating behavior among women. The information
from this study can potentially help researchers further develop new culturally relevant
interventions to help women cultivate and maintain healthy eating behaviors and healthy weight.
If you are interested in participating in the study in person, I have more information about
the study, and the questionnaires you will be asked to complete. Please let me know if you have
the time to complete the measures today, or would like to complete them at a later time.
Alternatively, you can also contact me via email to receive more information regarding
the study and get the online survey link. Please note that you can contact me, or my chair, Dr.
Mekel Harris via email regarding any questions or concerns you have about the study. I will
leave a flyer with the information I covered, as well as the contact information I mentioned
before. Thank you for your help!

Flyer: Same flyer as Appendix C

 116

Appendix E: Demographics

1. What is your age? _______

2. How would you identify yourself?

a. African American
b. Asian
c. Caucasian/White
d. Hispanic/Latino(a)
e. Pacific Islander
f. Native American
g. Multiracial
h. Other ________

3. What is your or your family’s country of origin? __________________

4. If you are an immigrant, how long have you been living in the U.S.? ___________

5. If you were born in the U.S., but your parents immigrated to the U.S., how long has your
family been living in the U.S.? ___________________

6. What is your level of education?

a. Completed some high school
b. High school graduate/GED
c. Some college education
d. Associate’s degree
e. Bachelor’s degree
f. Some post-graduate education
g. Master’s degree
h. Ph.D., law, or medical degree
i. Other advanced degree beyond Master’s

7. What is your marital status?

a. Single, never married
b. Married
c. Separated
d. Divorced
e. Widowed
f. Not married, but living with partner
g. In a committed relationship, but not living together

8. What is your income level?

a. Less than $25,000
b. $25,000 to $34, 999
c. $35,000 to $49,999
d. $50,000 to $74,999
e. $75,000 to 99,999
 117

f. $100,000 to $149,999
g. $150,000 or more

9. What is your weight? ________

10. What is your height? ________

11. Have you ever been participated in a weight loss program in the past?
a. Yes
b. No

12. How long did you participate in the weight loss program? ____________

13. Are you currently participating in a weight loss program?

a. Yes
b. No

14. Did/Does your weight loss program include elements of mindfulness?

a. Yes
b. No

15. Please indicate how important spirituality is in your life:

a. Extremely important
b. Very important
c. Moderately important
d. Slightly important
e. Not important

16. What made you want to participate in this study?

____________________________________
 118

Appendix F: Screener – Eating Disorder

1. Have you been diagnosed with an eating disorder?

a. Yes
b. No

2. Have you undergone bariatric surgery for weight loss?

a. Yes
b. No
 119

Appendix G: Screener – Patient Health Questionnaire - 9 (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Items Not at Several More than Nearly

all days half the days every day
1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling or staying asleep, or 0 1 2 3

sleeping too much
4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself — or that you 0 1 2 3

are a failure or have let yourself or your
family down
7. Trouble concentrating on things, such as 0 1 2 3
reading the newspaper or watching
television
8. Moving or speaking so slowly that other 0 1 2 3
people could have noticed? Or the
opposite — being so fidgety or restless
that you have been moving around a lot
more than usual
9. Thoughts that you would be better off 0 1 2 3
dead or of hurting yourself in some way

For office coding 0+ + +

= Total Score

If you checked off any problems, how difficult have these problems made it for you to do your
work, take care of things at home, or get along with other people?
Not difficult at all Somewhat difficult Very difficult Extremely difficult
 120

Appendix H: Five Facet Mindfulness Questionnaire (FFMQ)

Please rate each of the following statements using the scale provided. Write the number in the
blank that best describes your own opinion of what is generally true for you.

1 2 3 4 5
Never or very Rarely true Sometimes true Often true Very often or
rarely true always true

_____ 1. When I’m walking, I deliberately notice the sensations of my body moving.
_____ 2. I’m good at finding words to describe my feelings.
_____ 3. I criticize myself for having irrational or inappropriate emotions.
_____ 4. I perceive my feelings and emotions without having to react to them.
_____ 5. When I do things, my mind wanders off and I’m easily distracted.
_____ 6. When I take a shower or bath, I stay alert to the sensations of water on my body.
_____ 7. I can easily put my beliefs, opinions, and expectations into words.
_____ 8. I don’t pay attention to what I’m doing because I’m daydreaming, worrying, or
otherwise distracted.
_____ 9. I watch my feelings without getting lost in them.
_____ 10. I tell myself I shouldn’t be feeling the way I’m feeling.
_____ 11. I notice how foods and drinks affect my thoughts, bodily sensations, and emotions.
_____ 12. It’s hard for me to find the words to describe what I’m thinking.
_____ 13. I am easily distracted.
_____ 14. I believe some of my thoughts are abnormal or bad and I shouldn’t think that way.
_____ 15. I pay attention to sensations, such as the wind in my hair or sun on my face.
_____ 16. I have trouble thinking of the right words to express how I feel about things
_____ 17. I make judgments about whether my thoughts are good or bad.
_____ 18. I find it difficult to stay focused on what’s happening in the present.
_____ 19. When I have distressing thoughts or images, I “step back” and am aware of the
thought or image without getting taken over by it.
_____ 20. I pay attention to sounds, such as clocks ticking, birds chirping, or cars passing.
_____ 21. In difficult situations, I can pause without immediately reacting.
_____ 22. When I have a sensation in my body, it’s difficult for me to describe it because I can’t
find the right words.
_____ 23. It seems I am “running on automatic” without much awareness of what I’m doing.
_____24. When I have distressing thoughts or images, I feel calm soon after.
_____ 25. I tell myself that I shouldn’t be thinking the way I’m thinking.
_____ 26. I notice the smells and aromas of things.
_____ 27. Even when I’m feeling terribly upset, I can find a way to put it into words.
_____ 28. I rush through activities without being really attentive to them.
_____ 29. When I have distressing thoughts or images I am able just to notice them without
reacting.
_____ 30. I think some of my emotions are bad or inappropriate and I shouldn’t feel them.
_____ 31. I notice visual elements in art or nature, such as colors, shapes, textures, or patterns of
light and shadow.
 121

_____ 32. My natural tendency is to put my experiences into words.

_____ 33. When I have distressing thoughts or images, I just notice them and let them go.
_____ 34. I do jobs or tasks automatically without being aware of what I’m doing.
_____ 35. When I have distressing thoughts or images, I judge myself as good or bad, depending
what the thought/image is about.
_____ 36. I pay attention to how my emotions affect my thoughts and behavior.
_____ 37. I can usually describe how I feel at the moment in considerable detail.
_____ 38. I find myself doing things without paying attention.
_____ 39. I disapprove of myself when I have irrational ideas.
 122

Appendix I: Body Appreciation Scale – 2 (BAS-2)

Directions for participants: Please indicate whether the question is true about you never,
seldom, sometimes, often, or always.

Item Never Seldom Sometimes Often Always

1. I respect my body. ☐ ☐ ☐ ☐ ☐
2. I feel good about my body. ☐ ☐ ☐ ☐ ☐
3. I feel that my body has at least some good ☐ ☐ ☐ ☐ ☐
qualities.
4. I take a positive attitude towards my ☐ ☐ ☐ ☐ ☐
body.
5. I am attentive to my body’s needs. ☐ ☐ ☐ ☐ ☐
6. I feel love for my body. ☐ ☐ ☐ ☐ ☐
7. I appreciate the different and unique ☐ ☐ ☐ ☐ ☐
characteristics of my body.
8. My behavior reveals my positive attitude ☐ ☐ ☐ ☐ ☐
toward my body; for example, I hold my
head high and smile.
9. I am comfortable in my body. ☐ ☐ ☐ ☐ ☐
10. I feel like I am beautiful even if I am ☐ ☐ ☐ ☐ ☐
different from media images of attractive
people (e.g., models, actresses/actors).
 123

Appendix J: Intuitive Eating Scale-2 (IAS-2)

Directions for participants: For each item, please circle the answer that best characterizes your
attitudes or behaviors. (note to experimenter: use “check” in lieu of “circle” if survey is online)

1. I try to avoid certain foods high in fat, carbohydrates, or calories.

1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

2. I have forbidden foods that I don’t allow myself to eat.

1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

3. I get mad at myself for eating something unhealthy.

1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

4. If I am craving a certain food, I allow myself to have it.

1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

5. I allow myself to eat what food I desire at the moment.

1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

6. I do NOT follow eating rules or dieting plans that dictate what, when, and/or how much
to eat.
1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

7. I find myself eating when I’m feeling emotional (e.g., anxious, depressed, sad), even
when I’m not physically hungry.
1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

8. I find myself eating when I am lonely, even when I’m not physically hungry.
1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

9. I use food to help me soothe my negative emotions.

1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

10. I find myself eating when I am stressed out, even when I’m not physically hungry.
1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree
 124

11. I am able to cope with my negative emotions (e.g., anxiety, sadness) without turning to
food for comfort.
1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

12. When I am bored, I do NOT eat just for something to do.

1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

13. When I am lonely, I do NOT turn to food for comfort.

1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

14. I find other ways to cope with stress and anxiety than by eating.
1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

15. I trust my body to tell me when to eat.

1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

16. I trust my body to tell me what to eat.

1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

17. I trust my body to tell me how much to eat.

1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

18. I rely on my hunger signals to tell me when to eat.

1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

19. I rely on my fullness (satiety) signals to tell me when to stop eating.

1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

20. I trust my body to tell me when to stop eating.

1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

21. Most of the time, I desire to eat nutritious foods.

1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

22. I mostly eat foods that make my body perform efficiently (well).
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1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree

23. I mostly eat foods that give my body energy and stamina.
1 2 3 4 5
Strongly Disagree Disagree Neutral Agree Strongly Agree