Intuitive Eating in Relation to Other Eating Patterns …dro.deakin.edu.au/.../bruce-intuitiveeating-2017.pdfAbstract Intuitive eating has been proposed as an eating style that fosters

Intuitive Eating in Relation to Other Eating Patterns

and Psychosocial Correlates

by

Lauren Jade Bruce

Bachelor of Arts, Graduate Diploma in Psychology

Submitted in partial fulfilment of the requirements for the degree of

Doctor of Psychology (Health)

Deakin University

August, 2017

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Acknowledgements

I would like to express my deepest gratitude to my supervisor, Professor Lina

Ricciardelli. Your continuous support and guidance have been invaluable in

completing this thesis. I have appreciated your wisdom, your encouragement, and

your patience throughout the last five years. I would also like to thank my associate

supervisor, Associate Professor Matthew Fuller-Tyszkiewicz. Your practical support

and advice in conducting my empirical study is very much appreciated. To Professor

Helen Skouteris, thank you for your support and understanding as I balanced

working on your projects with my doctoral studies. To my fellow colleagues and

students, thank you for being a significant source of motivation and for keeping me

focused. A heartfelt thank you to my family and friends who have supported me

throughout this journey. To my parents, I will be forever grateful for your support

during my academic pursuits. Your love and care have enabled me to reach this

milestone. Mum, I am certain I could not have achieved this without you. To my

dearest friends EJ and Rachel, without your support, the process of writing this thesis

would have been much more of a challenge. EJ, you walked this journey with me.

Thank you for holding me up in times I felt overwhelmed, for making me laugh, and

for celebrating those little milestones with me along the way. Rachel, thank you for

your encouragement and your thoughtfulness. Our coffee dates and spending time

with your girls were a welcome distraction, particularly in the final few months. To

Patrick and Ruby, you have been a much-needed source of comfort and humour.

Finally, I would like to dedicate this thesis to the memory of my Pop, Victor Barson.

Pop, you were my mentor. I am so grateful for the time I shared with you. Your

actions and your words inspired me to live a more meaningful and courageous life.

Abstract

Intuitive eating has been proposed as an eating style that fosters a positive

attitude towards food, the body, and physical activity. In contrast with disordered

eating, which encourages eating based on external cues for what, when, and how

much to eat, intuitive eating places emphasis on physical cues for hunger and satiety

to guide food intake. As assessed by the Intuitive Eating Scale (IES; Tylka, 2006),

intuitive eating comprises three components: unconditional permission to eat, eating

for physical rather than emotional reasons, and reliance on hunger and satiety cues.

However, the extent to which these aspects of intuitive eating overlap with

disordered eating and other eating patterns has yet to be fully established. The overall

aim of the thesis was to examine intuitive eating in relation to other eating patterns

and psychosocial correlates.

Firstly, a systematic review of intuitive eating literature was conducted to

summarise psychosocial factors that correlate with intuitive eating in adult women.

Twenty-four cross-sectional studies were included for review based on the following

eligibility criteria: examined females aged 18 years and older; used a measure of

intuitive eating; and assessed a psychosocial correlate of intuitive eating. The review

showed that higher levels of intuitive eating were associated with less dieting and

other aspects of disordered eating, greater emotional functioning, and a more positive

body image. Additional psychosocial factors that are components of the acceptance

model of intuitive eating (e.g., body acceptance by others), and the dual pathway

model of disordered eating (e.g., pressure for thinness, and internalisation of the thin-

ideal) were also related to intuitive eating. Another important finding of the review is

that the strength of association between intuitive eating and psychosocial factors

differed for each aspect of intuitive eating. In comparison to eating for physical

rather than emotional reasons and reliance on hunger/satiety cues, unconditional

permission to eat was more strongly correlated with disordered eating, body

dissatisfaction, societal pressure for thinness, and internalisation of the thin-ideal.

The review suggested that unconditional permission to eat may not be a distinct

pattern of eating, and instead may be assessing low levels of disordered eating.

Following the systematic review, an empirical study was conducted to: (1)

examine the factor structure of the IES in a community sample of adult women; (2)

to examine each of the three aspects of intuitive eating in relation to other eating

behaviours; and (3) to examine and compare the psychosocial correlates of the three

aspects of intuitive eating with other patterns of eating. These included: dieting,

restrained eating, bulimia/food preoccupation, emotional eating and external eating.

Psychosocial factors examined were those from the acceptance model of intuitive

eating (i.e., perceived social support, body acceptance by others, body function, and

body appreciation) and the dual pathway model of disordered eating (i.e., pressure

for thinness, internalisation of the thin-ideal, body dissatisfaction, and negative

affect). Participants were a community sample of 457 women aged 18 years and

older, who were English-speaking and lived in Australia.

The three-factor structure of the IES was supported in the community sample

of women. However, due to low factor loadings, five items across the three subscales

were removed. All three revised subscales demonstrated high levels of internal

consistency. Principal axis factoring was conducted to determine if the three aspects

of intuitive eating are distinct from the following eating behaviours: dieting,

restrained eating, bulimia/food preoccupation, emotional eating and external eating.

Unconditional permission to eat loaded onto the first factor with dieting, restrained

eating, and bulimia/food preoccupation. This eating factor was labelled ‘disordered

eating’. Eating for physical rather than emotional reasons loaded onto a second

eating factor with emotional eating and external eating. This eating factor was

labelled ‘eating for non-emotional/non-external reasons’. Reliance on hunger/satiety

cues did not load onto either eating factor, suggesting that it is more distinct from the

other eating behaviours.

A comparison of the psychosocial correlates of disordered eating, eating for

non-emotional/non-external reasons, and the reliance on hunger/satiety cues subscale

was conducted by examining bivariate correlations, the acceptance model of intuitive

eating, and a modified dual pathway model of disordered eating. As indicated by the

bivariate correlations and across both the acceptance model and dual pathway model,

body dissatisfaction/body satisfaction was the strongest direct predictor of each of

the three eating patterns.

All other psychosocial factors in the acceptance model and the modified dual

pathway model correlated significantly at the bivariate level with the three eating

patterns. However, when specifically testing the acceptance model, body function

was found to predict disordered eating and eating for non-emotional/non-external

reasons but it did not predict reliance on hunger/satiety cues. In addition, when

testing the modified dual pathway model, negative affect predicted disordered eating

and eating for non-emotional/non-external reasons but not reliance on hunger/satiety

cues. Societal pressure for thinness was directly associated with eating for non-

emotional/non-external reasons but not disordered eating; and internalisation of the

thin-ideal was directly associated with disordered eating but not eating for non-

emotional/non-external reasons.

Overall, findings from the systematic review and the empirical study of this

thesis demonstrated that only the reliance on hunger/satiety cues subscale of the IES,

is conceptually distinct from other eating patterns. Reliance on hunger/satiety cues

involves an awareness and trust in physical cues to guide food intake, instead of

emotional and external cues.

Longitudinal research is now needed to examine whether reliance on

hunger/satiety cues leads to more positive health outcomes than disordered eating,

emotional eating, and external eating. In addition, research is needed to examine how

the additional component of the revised IES, body-food choice congruence, which

was not examined in this thesis, is related to these other eating patterns.

Furthermore, other aspects of intuitive eating, such as body acceptance and respect,

and a positive attitude towards physical activity, which are not assessed by either the

original or the revised IES, also need to be considered in future research. Lastly,

additional psychosocial factors need to be examined and longitudinal research is

needed to evaluate whether these psychosocial factors are antecedents or

consequences of intuitive eating.

I

Table of Contents

CHAPTER ONE........................................................................................ 1

Thesis Overview ........................................................................................ 1

Overview of Thesis and Chapters ................................................................ 1

Chapter Two: An Introduction to Intuitive Eating ........................................ 2

Chapter Three: A Systematic Review of the Psychosocial Correlates

of Intuitive Eating among Adult Women ..................................................... 2

Chapter Four: Empirical Study: Introduction and Method............................ 3

Chapter Five: Empirical Study: Results and Discussion Part One ................ 3

Chapter Six: Empirical Study: Results and Discussion Part Two ................. 4

Chapter Seven: General Discussion ............................................................. 5

CHAPTER TWO ...................................................................................... 6

An Introduction to Intuitive Eating .......................................................... 6

Principles of Intuitive Eating ....................................................................... 6

Psychometric Scales Designed to Measure Intuitive Eating ....................... 13

CHAPTER THREE ................................................................................ 22

A Systematic Review of the Psychosocial Correlates of Intuitive

Eating among Adult Women................................................................... 22

Introduction ............................................................................................... 22

Methods .................................................................................................... 24

Search Strategy .............................................................................. 25

Eligibility Criteria ......................................................................... 25

Selection Process ........................................................................... 25

II

Data Extraction ............................................................................. 26

Assessment of Study Quality ........................................................... 26

Results ...................................................................................................... 27

Methodological Quality of Studies ................................................. 28

Summary of Included Studies ......................................................... 29

Eating Attitudes and Behaviours .................................................... 68

Body Image .................................................................................... 70

Emotional Functioning .................................................................. 72

Other Psychosocial Correlates ...................................................... 73

Discussion ................................................................................................. 76

Limitations and Recommendations for Future Research ................ 81

CHAPTER FOUR ................................................................................... 83

Empirical Study: Introduction and Method .......................................... 83

Factor Structure of IES .............................................................................. 84

The Association between Intuitive Eating and

Other Eating Behaviours ........................................................................... 85

Psychosocial Correlates of Intuitive Eating and

Other Patterns of Eating ............................................................................ 91

Method ...................................................................................................... 95

Participants ................................................................................... 95

Measures ....................................................................................... 98

Background Information .................................................... 98

Weight Status ..................................................................... 98

III

Intuitive eating ................................................................... 98

Dieting ............................................................................... 99

Bulimia and Food Preoccupation ..................................... 100

Restrained Eating ............................................................. 100

Emotional Eating ............................................................. 101

External Eating ................................................................ 101

Perceived Social Support ................................................. 102

Body Acceptance by Others .............................................. 102

Body Function .................................................................. 103

Body Appreciation ............................................................ 104

Pressure for Thinness ....................................................... 104

Thin-ideal Internalisation ................................................. 105

Appearance Evaluation .................................................... 105

Body Area Satisfaction ..................................................... 106

Negative Affect ................................................................. 107

Procedure .................................................................................... 107

Data Analyses .............................................................................. 108

CHAPTER FIVE ................................................................................... 110

Empirical Study: Results and Discussion Part One ............................. 110

Factor Structure of the IES ...................................................................... 110

Correlations between Eating Behaviours ................................................. 116

Exploratory Factor Analysis of Intuitive Eating and

Other Eating Behaviours ......................................................................... 118

IV

Discussion ............................................................................................... 120

CHAPTER SIX ..................................................................................... 127

Empirical Study: Results and Discussion Part Two............................. 127

Age, Education, and BMI ........................................................................ 128

Bivariate Correlations between Eating Patterns

and Psychosocial Variables ..................................................................... 129

Psychosocial Predictors of Disordered eating,

Eating for Non-emotional/Non-external Reasons, and

Reliance on Hunger/satiety Cues ............................................................. 132

Model Based on the Acceptance Model of Intuitive Eating ...................... 134

Model Based on the Dual Pathway Model of Disordered Eating .............. 146

Discussion ............................................................................................... 156

CHAPTER SEVEN ............................................................................... 162

General Discussion ................................................................................ 162

Summary of Aims and Main Findings ..................................................... 162

Assessing Principles of Intuitive Eating ................................................... 165

Other Psychosocial Factors...................................................................... 169

Intuitive Eating and Positive Health Outcomes ........................................ 171

Examining Intuitive Eating in Other Populations ..................................... 173

Study Limitations .................................................................................... 179

Conclusion .............................................................................................. 179

REFERENCES ...................................................................................... 181

APPENDICES ....................................................................................... 221

V

Appendix A ............................................................................................. 221

Ethics Approval Documentation ................................................... 221

Appendix B ............................................................................................. 223

Plain Language Statement and Consent Form ............................. 223

Appendix C ............................................................................................. 227

Principal Axis Factoring for Three Body Image Variables ........... 227

Appendix D ............................................................................................. 228

Authorship Statement ................................................................... 228

Licensing Agreement for Reproduction of Published Article......... 230

VI

List of Figures

Chapter Three Page

Figure 3.1 Search terms and search strategy ............................. 26

Figure 3.2 Flow diagram of included studies............................ 28

Chapter Five

Figure 5.1 Proposed first order model of the IES ................... 111

Figure 5.2 Re-specified model of the IES .............................. 114

Chapter Six

Figure 6.1 Model I – Modified acceptance model for the

three eating patterns: disordered eating, eating for

non-emotional and external reasons and reliance

on hunger/satiety cues ........................................... 132

Figure 6.2 Model II - Modified dual pathway model

for the three eating patterns: disordered eating,

eating for non-emotional and external reasons

and reliance on hunger/satiety cues ....................... 133

Figure 6.3 Re-specified Model I – Modified acceptance

model with disordered eating as the outcome ........ 136

Figure 6.4 Re-specified Model I - Modified acceptance

model with non-emotional/external reasons

as the outcome ...................................................... 140

Figure 6.5 Re-specified Model I - Modified acceptance

model with reliance on hunger/satiety cues

VII

as the outcome ...................................................... 144

Figure 6.6 Re-specified Model II – Modified dual pathway

model with disordered eating as the outcome ........ 148


model with eating for non-emotional/non-external

reasons as the outcome ......................................... 151


model with reliance on hunger/satiety cues

as the outcome ...................................................... 155

VIII

List of Tables

Chapter Three Page

Table 3.1 Summary of Cross-sectional Studies Examining

Psychosocial Correlates of Intuitive Eating ............. 31

Chapter Four

Table 4.1 Sample Characteristics ............................................ 96

Chapter Five

Table 5.1 Factor Loadings for Proposed First-order

Model of the IES .................................................. 113

Table 5.2 Covariances and Correlations between Factors

in the Proposed First-order Model of the IES ........ 114

Table 5.3 Estimates, Standard Error of Estimates

and p-values for Re-Specified Model .................... 115

Table 5.4 Covariances and Correlations between Factors

In the Re-Specified Model .................................... 116

Table 5.5 Mean (SD), Range, Internal Reliability for

Eating-related Scales ............................................ 117

Table 5.6 Correlations between Intuitive Eating

and Other Eating Patterns ..................................... 118

Table 5.7 Pattern Matrix with Rotated Factor Loadings ........ 120

Chapter Six

Table 6.1 Correlations between Eating Patterns, Age,

Education, and BMI .............................................. 128

IX

Table 6.2 Mean, Standard Deviation, and Bivariate

Correlations for Psychosocial Factors and

Eating Patterns ...................................................... 131

Table 6.3 Initial Estimates for Model I – Modified

Acceptance Model with Disordered Eating as

the Outcome ......................................................... 135

Table 6.4 Final Estimates for Model I – Modified

Acceptance Model with Disordered Eating as

the Outcome ......................................................... 137


Acceptance Model with Eating for

Non-emotional/external Reasons

as the Outcome ..................................................... 139


Acceptance Model with Eating for


as the Outcome ..................................................... 141


Acceptance Model with Reliance on

Hunger/satiety Cues as the Outcome ..................... 143


Acceptance Model with Reliance on

Hunger/satiety cues as the Outcome ...................... 145

X

Table 6.9 Initial Estimates for Model II – Modified

Dual Pathway Model with Disordered Eating

as the Outcome ..................................................... 147

Table 6.10 Final Estimates for Model II - Modified Dual

Pathway Model with Disordered Eating

as the Outcome ..................................................... 149

Table 6.11 Initial Estimates for Model II – Modified Dual

Pathway Model with Eating for


as the Outcome ..................................................... 150

Table 6.12 Final Estimates for Model II - Modified Dual

Pathway Model with Eating for


as the Outcome ..................................................... 152

Table 6.13 Initial Estimates for Model II – Modified Dual

Pathway Model with Reliance on

Hunger/satiety Cues as the Outcome ..................... 154

Table 6.14 Final Estimates for Model II – Modified Dual

Pathway Model with Reliance on Hunger/satiety

Cues as the Outcome ............................................ 156

1

CHAPTER ONE

Thesis Overview

Overview of the Thesis

Intuitive eating is an eating style proposed to foster a positive relationship

with food by encouraging a focus on physical hunger and satiety cues to guide food

intake. The eating approach is proposed to target disordered eating patterns by

removing the focus on emotional and external cues for eating, promoting body

acceptance rather than modifying weight and shape, and promoting a positive

relationship with exercise (Tribole & Resch, 1995, 2012). Intuitive eating has had an

increasing presence in the literature over the past decade, with the first study of

intuitive eating, as proposed by Tribole and Resch (1995), being published by Tylka

(2006). However, the relationship between intuitive eating and other patterns of

eating, and its association with psychosocial factors, as both predictors and/or

outcomes of intuitive eating is yet to be fully established.

This doctoral thesis investigated intuitive eating in relation to other eating

patterns and its psychosocial correlates in adult women. Intuitive eating research has

largely focused on adult women, particularly female university students. Firstly, a

systematic review of existing literature on the psychosocial correlates of intuitive

eating in adult women was conducted. An empirical study was then conducted to

examine the three aspects of intuitive eating in relation to other patterns of eating and

their psychosocial correlates in a community sample of adult women. This included

an examination of the three-factor structure of the Intuitive Eating Scale (IES; Tylka,

2006); an examination of the three IES subscales (unconditional permission to eat,

eating for physical rather than emotional reasons, reliance on hunger/satiety cues) in

relation to dieting, restrained eating, bulimia/food preoccupation, emotional eating

2

and external eating; and an examination and comparison of the psychosocial

correlates of the different eating patterns.

Chapter Two: An Introduction to Intuitive Eating

The second chapter provides an introduction to the intuitive eating approach,

as proposed by Tribole and Resch (1995, 2012). This includes an overview of the

principles of intuitive eating and the psychometric scales that have been developed to

assess intuitive eating.

Chapter Three: A Systematic Review of the Psychosocial Correlates of Intuitive

Eating among Adult Women

Chapter Three presents the systematic review that has been published in

Appetite1. The review was conducted to examine the psychosocial correlates that

have found to be associated with intuitive eating in adult women. This review set out

to provide a summary of findings and determine gaps in the literature. No systematic

reviews of intuitive eating had been published at the time the review had

commenced. Moreover, there had been no review of studies that had investigated the

association between intuitive eating and disordered eating patterns.

The systematic review demonstrated that a majority of intuitive eating studies

have investigated female university students living in the United States. The three

main correlates that have been examined are: eating attitudes and behaviours; body

image; and emotional functioning. Firstly, the review showed that intuitive eating

was negatively associated with aspects of disordered eating, including dieting, and

there were differences between IES subscales (i.e., unconditional permission to eat,

1 Bruce, L. J., & Ricciardelli, L. A. (2016). A systematic review of the psychosocial correlates of

intuitive eating among adult women. Appetite, 96, 454-472.

3

eating for physical rather than emotional reasons, reliance on hunger/satiety cues) in

the strength of their relationship with disordered eating. More specifically, the review

suggested that unconditional permission to eat may be less conceptually distinct from

disordered eating. Secondly, the review demonstrated that intuitive eating was

associated with a more positive body image, better emotional functioning, and other

psychosocial correlates such as body acceptance by others, perceived social support,

societal pressure for thinness, and internalisation of the thin-ideal.

Chapter Four: Empirical Study: Introduction and Method

Chapter Four provides an introduction to the empirical study of the thesis,

and details the aims and method. The introduction provides an overview of the

association between intuitive eating and other eating patterns, and the psychosocial

factors that have found to be related to intuitive eating. This is then followed with an

overview of two psychosocial models of eating: the acceptance model of intuitive

eating and the dual pathway model of disordered eating. The method section of this

chapter provides a description of the sample, the measures used to assess study

variables, and the procedure used to conduct the study.

Chapter Five: Empirical Study: Results and Discussion Part One

The fifth chapter provides a report of the findings for the first part of the

empirical study and is divided into two sections. The first section examined the

three-factor structure of the IES (Tylka, 2006). A confirmatory factor analysis

demonstrated that sixteen items loaded onto three factors of intuitive eating:

unconditional permission to eat (7 items); eating for physical rather than emotional

reasons (5 items); and reliance on hunger/satiety cues (4 items). Five items were

removed from the scale due to low factor loadings.

4

Following the examination of the IES (Tylka, 2006), the empirical study

examined the association between each of the IES subscales (unconditional

permission to eat, eating for physical rather than emotional reasons, and reliance on

hunger/satiety cues) and the following eating behaviours: dieting, restrained eating,

bulimia/food preoccupation, emotional eating and external eating. Principal axis

factoring was used to examine the overlap between the three intuitive eating factors

and these eating behaviours. Two eating factors emerged from the analyses.

Unconditional permission to eat loaded onto the first factor with dieting, restrained

eating, and bulimia/food preoccupation. This factor was labelled ‘disordered eating’.

Eating for physical rather than emotional reasons loaded onto the second factor with

emotional eating and external eating. This factor was labelled ‘eating for non-

emotional/non-external reasons’. Reliance on hunger/satiety cues did not load onto

either of the two factors. Findings suggest unconditional permission to eat is not a

distinct eating pattern and overlaps with aspects of disordered eating. Moreover,

eating for physical rather than emotional reasons is not a unique eating pattern and

overlaps with emotional eating and external eating. Finally, the third aspect of

intuitive eating, reliance on hunger/satiety cues, is a distinct pattern of eating,

separate from aspects of disordered eating, emotional eating and external eating.

Chapter Six: Empirical Study: Results and Discussion Part Two

Chapter Six provides a summary of the second part of the empirical study.

The second part of the study examined the psychosocial correlates of the three eating

patterns (disordered eating, eating for non-emotional/non-external reasons, reliance

on hunger/satiety cues), assessed by bivariate correlations and two psychosocial

models of eating: the acceptance model of intuitive eating and a modified version of

the dual pathway model of disordered eating. Two of the three eating patterns,

5

disordered eating and eating for non-emotional/non-external reasons, were eating

factors identified in Chapter Five. The third eating pattern was assessed using the

modified reliance on hunger/satiety cues subscale of the IES (Tylka, 2006).

Psychosocial factors included were those from the acceptance model of intuitive

eating (i.e., perceived social support, body acceptance by others, body function, and

body appreciation) and the modified dual pathway model of disordered eating (i.e.,

societal pressure for thinness, internalisation of the thin-ideal, body area satisfaction,

appearance evaluation, and negative affect). Overall, findings of the study

demonstrated there were more similarities than differences in the psychosocial

factors that predict each eating pattern. However, the differences found in the study

highlighted that reliance on hunger/satiety cues is more distinct from disordered

eating and eating for non-emotional/non-external reasons.

Chapter Seven: General Discussion

A summary of the main aims and findings of the thesis are provided.

Secondly, the chapter discusses reliance on hunger/satiety cues and other factors not

examined in this thesis that have been found to be related to this eating behaviour.

Thirdly, the chapter discusses the implications of findings of the empirical study for

the Intuitive Eating Scale (Tylka, 2006). Following this, limitations and

recommendations for future research are discussed, including the need for studies to

examine the positive health outcomes associated with reliance on physical hunger

and satiety cues for eating, and extending research to examine other populations,

including adult men, adolescents, and clinical populations.

6

CHAPTER TWO

An Introduction to Intuitive Eating

Intuitive eating is an eating approach that promotes a positive relationship

with food and eating. Coined by Tribole and Resch (1995), intuitive eating describes

eating based on physical hunger and satiety cues, eating that ignores emotional and

external cues. Overall, intuitive eating is an approach that promotes a positive

attitude towards food, the body, and physical activity (Tribole & Resch, 2012). This

introductory chapter first provides an overview of the principles of intuitive eating,

as proposed by Tribole and Resch (2012). Secondly, a review of the main

psychometric scales that have been developed to measure intuitive eating is

provided.

Principles of Intuitive Eating

Intuitive eating is described using a set of ten principles proposed by Tribole

and Resch (1995, 2012). While these principles have not been tested in empirical

studies, they were the basis for developing Tylka’s (2006) widely used psychometric

scale of intuitive eating. The first principle is focused on a rejection of the ‘dieting

mentality’. Dieting is considered to be maladaptive and ineffective in modifying

body weight and shape (Tribole & Resch, 2012), yet it is a common strategy used to

lose weight or prevent weight gain (National Task Force on the Prevention and

Treatment of Obesity, 2000; Ouwehand & Papies, 2010; Timmerman & Gregg,

2003). Research shows that dieting is ineffective for controlling weight in the longer-

term (Field, Austin, Taylor, Malspeis, Rosner, Rockett et al., 2003; Mann,

Tomiyama, Westling, Lew, Samuels, & Chatman, 2007; Neumark-Sztainer, Wall,

Story, & Standish, 2012; Sarlio-Lahteenkorva, Rosanne, & Kaprio, 2000). There is

also research to suggest that dieting is associated with a higher Body Mass Index

7

(BMI) (e.g., Enriquez, Duncan, & Schur, 2013; Van Strien, Herman, & Verheijden,

2014), and dieting interventions for weight loss have been found to be associated

with weight regain (Langeveld & DeVries, 2015; Lowe, Doshi, Katterman, & Freig,

2013; Mann et al., 2007; Pietiläinen, Saarni, Kaprio, & Rissanen, 2012; Ulen,

Huizinga, Beech, & Elasy, 2008). Two systematic reviews of weight loss

interventions that incorporated dieting and/or physical activity components have

found that almost 50% of weight lost during the intervention was regained one year

later (Barte, Ter Bogt, Bogers, Teixeira, Blissmer, Mori, & Bemelmans, 2010;

Curioni & Lourenco, 2005). In addition, dieting, which is often considered part of

disordered eating, has been associated with food preoccupation (Timmermen &

Gregg, 2003) and perceived food deprivation (Markowitz, Butryn, & Lowe, 2008;

Timmerman & Gregg, 2003), and is a risk factor for the development of other

disordered eating behaviours (Haines & Neumark-Sztainer, 2006; Neumark-Sztainer,

Wall, Guo, Story, Haines, & Eisenberg, 2006). Attending to physical cues for hunger

and fullness when eating is thought to reduce the likelihood of engaging in

overeating or binge eating; two eating practices that have been found to be related to

dieting (e.g., Andrés & Saldaña, 2014; Rideout & Barr, 2009; Zunker, Peterson,

Crosby, Cao, Engel, Mitchell et al., 2011).

The second principle of intuitive eating is attending to physical cues for

hunger. This involves identifying cues that signal physical hunger and responding to

these cues. Such cues might include: stomach gurgling or growling, low energy or

lethargy, light-headedness, poor concentration, irritability, headaches, and persistent

thoughts about food (Bacon & Matz, 2010; Tribole & Resch, 2012). Eating patterns

that ignore hunger are discouraged. This includes attending to external cues, such as

confining food intake to set meal times, dieting rules that specify an amount of food,

or only eating in the presence of other people who are eating. Ignoring physical cues

8

for hunger can lead to inadequate food intake, and eating in the absence of hunger

can result in overeating. These both have implications for managing a healthy

weight. Research to date suggests that intuitive eating is associated with being in a

healthier weight range (Van Dyke & Drinkwater, 2014) whereas eating for reasons

other than physical hunger has been associated with weight gain (Enriquez et al.,

2013; Hays, Bathalon, McCrory, Roubenoff, Lipman, & Roberts, 2002; Koenders &

Van Strien, 2011; Van Strien et al., 2014).

The third principle of intuitive eating is an unconditional permission to eat.

This principle involves not categorising foods according to acceptability (i.e., ‘good’

and ‘bad’ foods; ‘healthy’ versus ‘junk’ foods), which is often encouraged by dieting

practices. By removing such rules and having the freedom to choose whatever food

is desired, unconditional eating is believed to address feelings of deprivation,

cravings associated with restrictive eating, and food-related guilt (Tribole & Resch,

1995, 2012). An unconditional permission to eat is also thought to prevent periods of

overeating in response to perceived food deprivation. Research shows that more

flexible eating practices are associated with less disinhibited eating (Timko &

Perone, 2005; Westenhoefer, Stunkard, & Pudel, 1999). Moreover, difficulties in

regulating eating have been associated with a discrepancy between the desire to

enjoy palatable foods and a desire to control body weight (Stroebe, Mensink, Aarts,

Schut & Kruglanski, 2008).

The fourth principle of intuitive eating relates to managing self-critical

thoughts and distorted thinking in relation to food and eating (Tribole & Resch,

1995, 2012). The approach promotes a non-judgemental attitude towards eating, and

encourages individuals to manage negative or unhelpful thoughts. This includes

dichotomous thoughts in relation to food (e.g., categorising foods as either ‘good’ or

9

‘bad’), which have been found to be associated with eating, weight and shape

concerns (Byrne, Allen, Dove, Watt, & Nathan, 2008), and is a maintaining factor for

disordered eating (Fairburn, Cooper, & Shafran, 2003). Moreover, self-criticism has

been found to predict disordered eating in those diagnosed with an eating disorder

(Fennig, Hadas, Itzhaky, Roe, Apter, & Shahar, 2014), and increases in self-

compassion have been shown to reduce negative feelings and alleviate disordered

eating in highly restrictive eaters (Adams & Leary, 2007) and in those diagnosed

with an eating disorder (Kelly, Carter, & Borairi, 2014).

The fifth principle focuses on an awareness of internal cues of satiety and

eating to a comfortable degree of fullness. Eating mindfully to recognise feelings of

fullness and the absence of hunger is an aspect of this principle. This principle

includes resisting the ‘clean your plate’ mentality (i.e., eating to completion), eating

without distraction, and being prepared to respond in situations likely to involve

obligatory eating (Tribole & Resch, 2012). Tuning into bodily cues for satiety is said

to help prevent overeating, including emotional eating and binge eating.

Mindfulness-based eating interventions have been demonstrated to reduce emotional

eating, external eating, and binge eating (Alberts, Thewissen, & Raes, 2012;

Katterman, Kleinman, Hood, Nackers, & Corsica, 2014; Kristeller, Wolever, &

Sheets, 2014).

The sixth principle is focused on satisfaction during eating, and is closely

connected to the principles described above, particularly the second, third, and fifth

principles. Eating satisfaction is heightened by an unconditional permission to eat,

and eating when hungry and until comfortably full. The pleasure of eating has been

identified as an important factor in the effect dieting has psychological well-being.

Dieting and restrained eating have been associated with poorer psychological well-

10

being in individuals who experience more pleasure in eating (Appleton & McGown,

2006; Remick, Pliner, & McLean, 2009). Moreover, it has been argued that dieters

are unable to maintain their control over eating due to a conflict between their desire

to enjoy palatable food and their desire to control their body weight (Stroebe,

Mensink, Aarts, Schut, & Kruglanski, 2008).

The seventh principle of intuitive eating addresses emotional eating.

Emotional eating involves eating in response to negative emotions (Van Strien,

Frijters, Bergers, & Defares, 1986) and has been associated with emotional

difficulties, such as anxiety and depression (Evers, Stok, & de Ridder, 2010;

Konttinen, Männistö, Sarlio-Lähteenkorva, Silventoinen, & Haukkala, 2010;

Schneider, Appelhans, Whited, Oleski, & Pagoto, 2010; Schulz & Laessle, 2010).

Engaging in emotional eating behaviours has been associated with a loss of control

over eating (Goossens, Braet, Van Vlierberghe, & Mels, 2009; Groesz, McCoy, Carl,

Saslow, Stewart, Adler et al., 2012) and binge eating behaviours (Ricca, Castellini,

Sauro, Ravaldi, Lapi, Mannucci et al., 2009; Zeeck, Stelzer, Linster, Joos, &

Hartmann, 2011). To prevent periods of emotional eating, intuitive eating promotes

an awareness of emotions, identification of the role that food plays in relation to

emotions (e.g., comfort, distraction), and situations that trigger emotional eating

(e.g., boredom, procrastination, stress). In addition, intuitive eating encourages

alternative strategies to manage emotions that do not involve using food, including:

engaging in activities such as spending time with friends or pets and engaging in

hobbies that provide nurturance and a distraction from feelings; and managing

feelings through activities such as journaling, meditation, and talking to friends or a

therapist (Tribole & Resch, 2012).

11

The eighth principle of intuitive eating addresses body image. Respecting

body size and shape, and discouraging unrealistic expectations or being critical of

weight and shape, are the primary focus of this principle (Tribole & Resch, 1995;

2012). Engaging in intuitive eating to modify weight or shape is not the aim of the

eating style (Tribole and Resch, 1995; 2012). Respect and appreciation of the body,

regardless of size and shape, is promoted. Body appreciation has been studied in

samples of women of different ages (Tiggemann & McCourt, 2013), male and

female university students (Avalos, Tylka, & Wood-Barcalow, 2005; Tylka, 2013;

Tylka & Wood-Barcalow, 2015) and in women from non-western countries (Ng,

Barron, & Swami, 2015; Swami & Jaafar, 2012). Body appreciation is viewed as

being distinct from body satisfaction and appearance evaluation (Tylka, & Wood-

Barcalow, 2015), and has been found to be associated with lower levels of disordered

eating and higher levels of psychological well-being (Avalos et al., 2005; Tylka, &

Wood-Barcalow, 2015).

In addition to addressing body image, intuitive eating encourages a healthy

attitude towards physical activity. The ninth principle of intuitive eating promotes

exercise as a healthy and enjoyable activity, rather than an activity carried out for

weight control by expending calories (Tribole & Resch, 1995, 2012). An awareness

of how the body feels and responds to physical activity is part of this principle.

Research suggests that enjoyment received while engaging in physical activity is

associated with higher levels of participation (e.g., Hagberg, Lindahl, Nyberg, &

Hellénius, 2009), and exercising for intrinsic reasons (such as enjoyment, or for the

challenge) rather than extrinsic reasons (such as for weight and appearance-related

reasons) is associated with greater exercise adherence in the longer-term (Ryan,

Christina, Deborah, Rubio, & Kennan, 1997; Kilpatrick, Hebert, & Bartholomew,

2005). Two studies have examined intuitive eating in relation to exercise motivation

12

(Gast, Campbell Nielson, Hunt, & Leiker, 2015; Tylka & Homan, 2015). In the study

conducted by Gast and colleagues (2015), female university students who identified

as eating more intuitively reported greater intrinsic motivation (i.e., pleasure) for

regular physical activity, compared with students who did not eat as intuitively (Gast

et al., 2015). Moreover, lower levels of intuitive eating were associated with physical

activity motivation that was based on external pressures, or a sense of guilt or shame

(Gast et al., 2015). Tylka and Homan (2015) investigated intuitive eating in relation

to exercise motivation based on appearance (including weight control) or health and

enjoyment. Male and female university students reported that appearance-based

motivation for exercise (including weight control) was negatively associated with

intuitive eating (Tylka & Homan, 2015).

The tenth principle of intuitive eating emphasises making food choices that

contribute to body functioning and are nourishing, but are also satisfying in terms of

taste (Tylka & Wilcox, 2006). This includes a focus on body’s response to food and

eating, and using this to guide food choices. Another aspect of this principle is eating

for nutrition, including: eating a variety of foods; eating in moderation; and

considering the taste, quality and quantity of foods in making food choices. There is

some empirical support for the relationship between intuitive eating and increased

pleasure associated with food and eating, a greater diversity of diet, and less of a

focus on food in terms of its properties, such as calories and amount of fat (Smith &

Hawks, 2006). Moreover, some aspects of intuitive eating have been associated with

lower energy intake, less sweet and fatty foods, less dairy, meat and fish products,

and more grain foods (Camilleri, Mejean, Bellisle, Andreeva, Kesse-Guyot,

Hercberg et al., 2017), though the unconditional permission to eat has been

associated with increased energy intake and less fruit and vegetable intake (Camilleri

et al., 2017).

13

Taken as a whole, these ten principles describe the intuitive eating approach.

While these principles are yet to be individually empirically tested, two psychometric

scales (Hawks, Merril, & Madanat, 2004; Tylka, 2006) used to assess aspects of

intuitive eating were developed in part according to these principles.

Psychometric Scales Designed to Measure Intuitive Eating

In order to assess intuitive eating behaviours in adults, two psychometric

scales were initially developed using samples of university students living in the

United States. The first scale published was the 27-item Intuitive Eating Scale

developed by Hawks and colleagues (2004). This was followed by the 21-item IES

developed by Tylka (2006). Of the two scales, Tylka’s (2006) scale is a more widely

used measure, with more than 30 studies having used the scale to assess intuitive

eating (e.g., Augustus-Horvath & Tylka, 2011; Brown, Parman, Rudat, & Craighead,

2012; Herbert, Blechert, Hautzinger, Matthias, & Herbert, 2013; Homan &

Cavanaugh, 2013; Iannantuono & Tylka, 2012; Järvelä-Reijonen, Karhunen,

Sairanen, Rantala, Laitinen, Puttonen, 2016; Madden, Leong, Gray, & Horwath,

2012; Mensinger, Calogero, & Tylka, 2016; Oh, Wiseman, Hendrickson, Phillips, &

Hayden, 2012; Schoenefeld & Webb, 2013; Shouse & Nilsson, 2011; Tylka &

Homan, 2015; Wheeler, Lawrence, Chae, Paterson, Gray, Healey et al., 2016). These

studies have provided support for the scale’s reliability and validity. The systematic

review conducted as part of this thesis demonstrated that a majority of studies that

examined the psychosocial correlates of intuitive eating, including disordered eating,

used Tylka’s (2006) scale. For these reasons, the empirical study conducted as part of

the thesis used Tylka’s (2006) IES to examine intuitive eating in relation to other

eating behaviours and psychosocial correlates. An overview of the two main intuitive

eating scales is provided below, and given that it has been frequently used, more

14

emphasis is placed on the Tylka’s (2006) scale and its revised versions (Camilleri,

Méjean, Bellisle, Andreeva, Sautron, Hercberg et al., 2015; Carbonneau,

Carbonneau, Lamarche, Provencher, Bégin, Bradette-Laplante et al., 2016;

Dockendorff, Petrie, Greenleaf & Martin, 2012; Tylka & Kroon Van Diest, 2013;

van Dyck, Herbert, Happ, Kleveman, & Vogele, 2016).

The 27-item scale developed by Hawks et al. (2004) is comprised of four

subscales: intrinsic eating (four items), extrinsic eating (six items), anti-dieting (13

items) and self-care (four items). The intrinsic eating subscale assesses eating in

response to physical cues for hunger and satiety (e.g. “I seldom eat unless I notice I

am physically hungry”), in comparison to the extrinsic eating subscale, which

assesses external influences on the decision to eat (e.g. “I often turn to food when I

feel sad, anxious, lonely, or stressed out”). The anti-dieting subscale assesses the

level of disagreement with dieting practices (e.g. “I generally count calories before

deciding if something is OK to eat”) while the self-care subscale assesses the

preference for health and fitness over attractiveness (e.g. “The health and strength of

my body is more important to me than how much I weigh”).

The scale was validated using a sample of 391 male and female university

students in the United States. This involved an examination of the scale’s internal

consistency, test-retest reliability, and an examination of the scale’s construct

validity. A principal components analysis demonstrated that 27 items loaded onto

four factors: intrinsic eating, extrinsic eating, anti-dieting, and self-care (Hawks et

al., 2004). Poor internal consistency for the intrinsic subscale (α=.42) and the self-

care subscale (α=.59) was reported (Hawks et al., 2004). This has been replicated in

subsequent studies that have used this scale (Gast, Madanat, Nielson, 2012; Gast et

al., 2015; Wilson, 2014), though internal consistency for the scale overall (i.e., all 27

15

items) has been demonstrated to be satisfactory (e.g., Gast et al., 2012; Smith &

Hawks, 2006). Test-retest reliability for the scale was determined over a four-week

period and was found to be high (r=.85, p<.0001) (Hawks et al. 2004). Construct

validity was assessed by comparing the scale to a measure of current dieting for

weight loss (Martz, Sturgis & Gustafdon, 1996). Intrinsic eating was strongly and

negatively associated with current dieting (r=-.84, p<.0001). Extrinsic eating (r=-.42,

p<.0001), and anti-dieting (r=-.48, p<.0001) were moderately and negatively

associated with current dieting. However, self-care was not related to current dieting

(r=-.02, p<.66) (Hawks et al., 2004), which suggests that individuals with more of a

preference for health and fitness were less likely to be currently dieting.

The IES (Tylka, 2006) was developed using the principles of intuitive eating

proposed by Tribole and Resch (1995). The scale is comprised of three subscales:

unconditional permission to eat (nine items, e.g. “If I am craving a certain food, I

allow myself to have it”), eating for physical rather than emotional reasons (six

items, e.g. “I find myself eating when I am bored, even when I’m not physically

hungry”), and a reliance on hunger and satiety cues (six items, e.g. “I trust my body

to tell me when to eat”) (Tylka, 2006).

The scale was validated in four studies of 1260 female university students

aged 17 to 61, who lived in the United States. Exploratory and confirmatory factor

analyses were conducted and the scale’s internal consistency, test-retest reliability,

and construct validity was assessed. In the first study, an exploratory factor analysis

demonstrated that 25 items loaded onto three factors: unconditional permission to

eat, eating for physical rather than emotional reasons, and reliance on hunger/satiety

cues (Tylka, 2006). A confirmatory factor analysis conducted in the second study

verified the three-factor structure, however, four items were deleted due to low factor

16

loadings. The 21-item scale demonstrated high levels of internal consistency for the

total scale (α=.85) and each of the three subscales (unconditional permission to eat,

α=.87; eating for physical rather than emotional reasons, α=.85; reliance on

hunger/satiety cues, α=.78) (Tylka, 2006). Subsequent studies have supported the

internal consistency of the total IES and its subscales (e.g., Augustus-Horvath &

Tylka, 2011; Kroon Van Diest & Tylka, 2010; Tylka & Homan, 2015). Test-retest

reliability for the total scale was established over a three-week period and found to

be very high (r= .90, p<.001) (Tylka, 2006). Construct validity of the IES was

evaluated against measures of disordered eating (Garner, Olmsted, Bohr & Garfinkel,

1982), body dissatisfaction (Garner, 1991), interoceptive awareness (Garner, 1991),

pressure for thinness (Stice, Ziemba, Margolis & Flick, 1996), and thin-ideal

internalisation (Heinberg, Thompson, & Stormer, 1995). Intuitive eating was

moderately and negatively correlated with disordered eating, body dissatisfaction,

pressure for thinness and thin-ideal internalisation (Tylka, 2006). At the subscale

level, a strong correlation was demonstrated between unconditional permission to eat

and disordered eating symptoms (r= -.72, p<.001). All other correlations between

intuitive eating subscales and these measures were moderate in strength, ranging

from -.23 to -.44 (p<.001).

Since the IES was published, it has been adapted for use with adolescents

(Dockendorff et al., 2012), and a 23-item revised version of the IES has been

published (Tylka & Kroon Van Diest, 2013). Moreover, the revised scale has been

translated for use in French (Camilleri et al., 2015), French-Canadian (Carbonneau et

al., 2016), and German populations (van Dyck et al., 2016).

The adolescent version of the scale (Dockendorff et al., 2012) was developed

using items included in the original version of the scale, and was validated in a

17

sample of male and female adolescents aged 11 to 15 years. Six of the 21 items were

modified to be more appropriate for adolescents (e.g., “I don’t keep certain foods in

my house/apartment because I think I may lose control and eat them” was reworded

to “In my house, my family does not keep certain foods because they think that I may

lose control and eat them”). The scale was validated using factor analyses in two

samples of adolescents. Internal consistency and concurrent validity of the scale were

also assessed. Exploratory and confirmatory factor analyses resulted in the deletion

of four items from the scale. Seventeen items were retained and four factors were

extracted: unconditional permission to eat; eating for physical rather than emotional

reasons; trust in hunger/satiety cues; and awareness of hunger/satiety cues. However,

the confirmatory factor analysis did not support intuitive eating as a higher order

factor, therefore only subscale scores were calculated, not a total intuitive eating

score.

Internal consistency of the subscales across the two samples of adolescents

used in the study were satisfactory for the unconditional permission to eat (α=.78 to

.81), eating for physical rather than emotional reasons (α=.83 to .85), and trust in

hunger/satiety cues (α=.75 to .79). Internal consistency was poorer for the awareness

of hunger/satiety cues subscale across both samples (α=.60 to .65). More recent

studies have reported satisfactory levels of internal consistency for the total scale

(Andrew, Tiggemann, & Clark, 2015; Andrew, Tiggemann, & Clark, 2016). An

assessment of concurrent validity for the scale with adolescents demonstrated that

three of four intuitive eating subscales (unconditional permission to eat, eating for

physical rather than emotional reasons, trust in hunger/satiety cues) correlated

positively with body satisfaction and aspects of positive affect (e.g., happiness,

confidence), and correlated negatively with pressure for thinness, internalisation of

the thin-ideal, and aspects of negative affect (e.g., feeling sad/depressed, shameful,

18

guilty, worthless, anxious) (Dockendorff et al., 2012. However, the awareness of

hunger/satiety cues did not correlate with any of these constructs.

Following the modification of the IES for adolescents, the original IES was

revised to incorporate the tenth principle of intuitive eating (Tribole & Resch, 2003).

This principle describes honouring health and engaging in ‘gentle nutrition’, which

involves making food choices that not only contribute to body functioning, but are

satisfying to the taste buds and for health. The revised version of the scale, the

Intuitive Eating Scale-2 (IES-2), included a fourth subscale to capture this principle

of intuitive eating, and was labelled ‘body-food choice congruence’ (e.g., “I mostly

eat foods that give my body energy and stamina”). In addition, 16 positively-worded

items were included in the scale, compared to eight items in the original IES (Tylka,

2006). This was to focus on assessing the presence of rather than the absence of

intuitive eating behaviours. Exploratory and confirmatory factor analyses were

conducted with two samples of male and female university students. Internal

consistency, convergent validity and test-retest reliability were assessed. Eleven

items from the original scale were retained and 12 new items were included. The

internal consistency of the total scale and each of the four subscales were satisfactory

for both men and women (α ranging from .81 to .93). Convergent validity was

assessed by examining the correlation of scores on the IES-2 with scores on the

original IES (Tylka, 2006). Strong correlations were reported between the two

versions of the scale, for total scores and subscale scores in both men and women (r

ranging from .86 and .95). Test-retest reliability was assessed over a period of three

weeks. Total scores and subscale scores were found to be stable across the three-

week period, with correlations ranging from .75 to .92 (Tylka & Kroon Van Diest,

2013).

19

Following the publication of the IES-2 (Tylka & Kroon Van Diest, 2013), the

scale was adapted and translated into the French language and validated in a French

sample of adult men and women (Camilleri et al., 2015). Factor analyses resulted in a

total of 18 items loading onto three factors, as with the original IES (Tylka, 2006):

unconditional permission to eat, eating for physical rather than emotional reasons,

and a reliance on hunger/satiety cues. The fourth factor of the IES-2 (Tylka & Kroon

Van Diest, 2013), body-food choice congruence, was not retained in the French

translated version. Internal consistency, concurrent validity and test-retest reliability

were assessed. Internal consistency for the total scale and the three subscales were

adequate (α ranging from .70 to .92). Total intuitive eating scores correlated

negatively with cognitive restraint, emotional eating, uncontrolled eating, and

depressive symptoms. The total scale and two of three subscales (unconditional

permission to eat, eating for physical rather than emotional reasons) demonstrated

good test-retest reliability (r ranging from .71 to .81). The reliance on hunger/satiety

cues subscale demonstrated moderate test-retest reliability (r= .66) (Camilleri et al.,

2015).

In addition to the French adapted version of the IES-2, a study conducted by

Carbonneau and colleagues (2016) adapted the scale to assess intuitive eating in a

sample of French-Canadian women. This study tested the factor structure and content

validity of the translated scale and, unlike the study conducted by Camilleri et al.

(2015), the four factors of the original IES-2 were retained. The French-Canadian

scale reported good internal consistency for the total scale (α= .90) and all four

subscales (α= .74 to .92), and scores were stable over a four to seven-week period in

both women and men (r=.73 to .78), except for the body-food choice congruence

subscale (r=.68). Total scores correlated strongly and negatively with measures of

bulimia symptoms and body dissatisfaction (Carbonneau et al., 2016).

20

More recently, a German version of the IES-2 was validated in a sample of

primarily female university students living in Germany, and included adults who had

received an eating disorder diagnosis (van Dyck et al., 2016). A confirmatory factor

analysis was conducted with the four factors of the IES-2 (Tylka & Kroon Van Diest,

2013) that loaded onto a higher order factor (i.e., intuitive eating). The four-factor

structure and all items of the scale were retained, and good internal consistency was

reported for all four subscales (α ranging from .72 to .91). Total scores were strongly

and negatively correlated with disordered eating, body dissatisfaction, drive for

thinness and emotional eating, supporting the construct validity of the scale.

While Tylka’s (2006) and Hawks and colleagues’ (2004) intuitive eating

measures have coexisted in the literature, there has been no comparison of the scale

developed by Hawks et al. (2004) with the scale developed by Tylka (2006), or its

revised versions. However, examining the subscales’ content, there does appear to be

some overlap. Both scales include a subscale that captures eating in response to

physical cues of hunger and satiety (the intrinsic eating subscale of Hawks et al.,

2004; the reliance on hunger/satiety subscale of Tylka (2006) and revised versions).

These subscales relate to the second and fifth principles of intuitive eating (i.e.,

eating based on physical hunger cues, an awareness of satiety cues and eating to a

comfortable degree of fullness) (Tribole & Resch, 2012). In addition, both scales

include an assessment of eating in response to external or emotional cues (the

extrinsic eating subscale of the Hawks et al., 2004; the eating for physical rather than

emotional reasons subscale of Tylka, 2006). These subscales relate to the second and

seventh principles (i.e., eating based on physical hunger cues and ignoring external

cues, and avoiding the use of food to manage emotions). The anti-dieting subscale of

Hawks et al. (2004) and the unconditional permission to eat subscale of Tylka (2006)

are similar in so far as they assess eating patterns and cognitions associated with

21

dieting or restrained eating. These subscales include items that relate to the first,

third, and fourth principles of intuitive eating (i.e., rejecting the dieting mentality,

unconditional permission to eat, non-judgemental attitudes towards eating) (Tribole

& Resch, 2012). One notable difference between the two intuitive eating scales is

that the Hawks et al. (2004) scale includes items that make reference to weight

control, appearance, and physical fitness. The items are part of the self-care subscale,

and are related to the eighth and ninth principles of intuitive eating (i.e., body

appreciation/respect, and a positive attitude towards physical activity) (Tribole &

Resch, 2012). The IES (Tylka, 2006) and its revised versions only make reference to

elements associated with food and eating.

Research to date shows that for the IES (Tylka, 2006) and its revised

versions, the factor structure is the same with regards to the first three subscales:


and reliance on hunger/satiety cues. However, the fourth subscale of the revised IES,

body-food choice congruence, was retained in two of the three translated versions of

the scale (Carbonneau et al., 2016; van Dyck et al., 2016). The body-food choice

congruence subscale was not retained in a community sample of French adults

(Camilleri et al., 2015). This suggests that this aspect of intuitive eating may not be

valid in all adult populations. Additional research is needed to validate the four-

factor structure of the English version of the IES-2 (Tylka & Kroon Van Diest, 2013)

and its translated versions in other populations, including community samples of

adults, adolescents and clinical eating disorder populations.

22

CHAPTER THREE

A Systematic Review of the Psychosocial Correlates of Intuitive Eating Among

Adult Women2

Introduction

Extensive research shows that weight loss strategies that promote the

restriction of food intake are largely ineffective for long term weight loss and weight

maintenance (Field et al., 2003; Mann et al., 2007; Neumark-Sztainer et al., 2012).

Moreover, restrictive eating practices have been associated with a higher body mass

index (BMI) (Enriquez et al., 2013; Quick & Byrd-Bredbenner, 2012; Rideout &

Barr, 2009; Van Strien et al., 2014); weight gain (Field et al., 2003; Mann et al.,

2007; Pietiläinen et al., 2012; Ulen et al., 2008); an increased risk of disordered

eating (Appleton & McGowan, 2006; Goldschmidt, Wall, Loth, Le Grange, &

Neumark-Sztainer, 2012; Holmes, Fuller-Tyszkiewicz, Skouteris, & Broadbent,

2014; Kenardy, Brown, & Vogt, 2001; Neumark-Sztainer et al., 2006); and

psychological problems such as emotional difficulties, body image concerns and

reduced cognitive functioning (Appleton & McGowan, 2006; Hawks, Madanat, &

Christly, 2008; Kenardy et al., 2001).

Intuitive eating has been proposed as an eating style that encourages a

positive relationship with food, the body, and physical activity (Tribole & Resch,

2012). The principles of intuitive eating include: focusing on physical cues for

hunger and satiety; permitting an unconditional permission to eat; making food

2 The systematic review has been published in its complete form, as presented in this chapter. Bruce,

L. J., & Ricciardelli, L. A. (2016). A systematic review of the psychosocial correlates of intuitive

eating among adult women. Appetite, 96, 454-472.

23

choices for both health and eating satisfaction; not using food to cope with emotions;

respecting the body regardless of weight and shape; and being physically active for

the enjoyment and health rather than calorie-burning for weight loss (Tribole &

Resch, 2012). This approach discourages a focus on weight control, though the

emergence and maintenance of an individual’s natural weight and shape is

acknowledged as a potential outcome (Tribole & Resch, 2012). The Intuitive Eating

Scale (IES-T)3 is one scale, developed by Tylka (2006), to assess the principles

proposed by Tribole and Resch (2012). The scale assesses three key features: (1)

relying on internal hunger and satiety cues to guide food intake; (2) permitting

oneself to eat unconditionally; and (3) eating for physical rather than emotional

reasons. Tylka and Kroon Van Diest (2013) developed a revised version of the scale

and identified a fourth feature: making food choices to enhance body functioning. An

alternative measure is the Intuitive Eating Scale (IES-H; Hawks et al., 2004) which

also assesses four features: intrinsic eating (i.e., motivation to eat based on internal

cues of hunger); extrinsic eating (i.e., lack of eating based on external cues);

antidieting (i.e., disagreement with dieting behaviours); and self-care (i.e., focus on

health/fitness rather than appearance).

A review of the literature conducted by Van Dyke and Drinkwater (2014)

has shown that intuitive eating (defined as any eating approach based on hunger and

satiety that does not restrict food type, unless for medical reasons) is associated with

a lower BMI; weight maintenance but not weight loss; and factors such as body

image, self-esteem, affect, optimism, and life satisfaction. The relationship between

intuitive eating and health behaviours such as physical activity and dietary intake

3 In the published version of the systematic review, abbreviations of the two intuitive eating scales

were distinguished by the first author to avoid any confusion when referring to each scale. Tylka’s

(2006) Intuitive Eating Scale was abbreviated using ‘IES-T’. The Hawks et al. (2004) Intuitive Eating

Scale was abbreviated using ‘IES-H’.

24

was less clear (Van Dyke & Drinkwater, 2014). A major limitation of this previous

review is that it was not a systematic review and it did not examine intuitive eating in

relation to other eating attitudes and behaviours, such as disordered eating, dieting,

and other weight loss practices.

The aim of this study was to conduct a systematic review of the literature

with a focus on intuitive eating in adult women, in relation to other eating attitudes

and behaviours, body image, and emotional functioning. These are three of the main

domains that address the principles underlying the intuitive eating approach (Tribole

& Resch, 2012). In order to make a significant contribution to the field, the review

also systematically examined all other psychosocial correlates that have been studied

in relation to intuitive eating. This includes factors such as self-esteem, messages

received by women relating to eating and body size and shape, and motivation for

engaging in physical activity. Women were the focus of this review as a majority of

intuitive eating studies have been conducted with women. Women are also more

likely than men to engage in restrictive and disordered eating practices for the

purpose of managing their weight (Enriquez et al., 2013; Forrester-Knauss & Zemp

Stutz, 2012; French, Jeffery, & Wing, 1994) and are at greater risk of developing an

eating disorder (e.g., Elgin & Pritchard, 2006).

Method

The review of quantitative studies was conducted according to the guidelines

specified by the Preferred Reporting Items for Systematic Reviews and Meta-

Analyses (PRISMA) statement (Moher, Liberati, Tetzlaff, & Altman, 2010).

25

Search Strategy

A search was conducted between September, 2014 and September, 2015 of

the following bibliographic databases: Academic Search Complete, Cumulative

Index to Nursing and Allied Health Literature Complete (CINAHL Complete),

Health Source (Nursing and Academic Edition), Medline Complete, PsycINFO,

PsycARTICLES, Psychology and Behavioral Sciences Collection, PubMed and

Scopus. All databases were accessed using EbscoHost with the exception of the

PubMed and Scopus databases. Papers were limited to quantitative studies published

in peer-reviewed journals in the English language up until September 2015. An

example of the search strategy and search terms used is provided in Figure 3.1.

Eligibility Criteria

Eligible studies were those that included: (1) females aged 18 years and

older; (2) a measure of intuitive eating; and (3) assessed a psychosocial correlate of

intuitive eating. Studies were excluded for the following reasons: (1) sampled from

females under the age of 18 years; (2) sampled only from males; (3) sampled from

both males and females but findings were not analysed by gender; (4) examined the

effect of an intuitive eating intervention but did not include a measure of intuitive

eating; or (5) did not assess a psychosocial correlate of intuitive eating.

Selection Process

The first author independently screened the titles and abstracts of identified

citations for potential eligibility. If eligibility criteria could not be determined then

papers were read in their entirety. Both authors then examined the full texts of

potential papers for eligibility criteria. Figure 3.2 shows a flow diagram of the

processing of the initial literature review.

26

"Intuitive Eating" OR "intuitive eater" OR "eating intuitively" OR "Intuitive Eating

Scale"

Combined with each of the following:

psych* OR soci* OR emotions OR affect OR depression OR anxiety OR stress OR

body image OR body acceptance OR body satisfaction OR eating disorders OR

disordered eating OR eating behavior

correlat* OR predict* OR factor OR associat* OR determin*

Limiters: peer reviewed, English language, adult 18 years and older, female

349 articles found

Figure 3.1. Search terms and strategy.

Data Extraction

Data extracted from each study included: authors, date of publication, and

country; study design, sample size and participant characteristics; measure used to

assess intuitive eating; psychosocial correlates and measure used; and study findings.

These data were extracted to allow for comparison across studies. Where studies

reported multiple summary statistics, data extracted were limited to bivariate

analyses that were evaluated against Cohen’s criteria for strength of association

(Rosenthal, 1996).

Assessment of Study Quality

The Standard Quality Assessment Criteria for Evaluating Primary Research

Papers from a Variety of Fields (Kmet, Lee, & Cook, 2004) was used to assess the

quality of eligible studies. It is a widely used tool for assessing the quality of study

designs (e.g., Bukowska-Durawa & Luszczynska, 2014; Fiszer, Dolbeault, Sultan, &

Brédart, 2014; Satherley, Howard, & Higgs, 2015). Each study was scored according

to a set of criteria using 14 items. Items assessed criteria such as the inclusion of

27

study objectives, study design and method of subject selection, description of

analyses, and adequate reporting of results. Scores for each item were indicative of

the degree to which each paper met specific criteria (‘yes’ = 2, ‘partial’ = 1, ‘no’ = 0,

or ‘N/A’ = not applicable). Three criteria were not applicable for all 24 studies as

they related to randomised designs. A summary score was calculated for each study

by dividing the sum of each relevant item score by the total possible score.

Results

The initial search produced 349 records. After the removal of duplicates, 237

potential papers were identified, and of these, 200 abstracts did not meet eligibility

criteria. Authors then examined the full texts of 37 potential papers to determine

eligibility for inclusion in the review. A further 16 papers did not meet eligibility

criteria. Further information on reasons for exclusion is provided in Figure 3.2. This

resulted in 21 eligible papers published between 2006 and 2015, six of which

reported multiple studies (Avalos & Tylka, 2006; Dittmann & Freedman, 2009;

Kroon Van Diest & Tylka, 2010; Tylka, 2006; Tylka & Kroon Van Diest, 2013;

Tylka & Wilcox, 2006). All studies reported in each of the six papers met eligibility

criteria except two studies in Tylka (2006), two studies in Tylka and Kroon Van

Diest (2013), and one study each in Kroon Van Diest and Tylka (2010) and Dittmann

and Freedman (2009). Each study in the six papers mentioned previously was

assessed separately, resulting in a total of 24 studies that met eligibility criteria4.

4 Eleven eligible studies published between 2010 and 2015 were not examined in the review by Van

Dyke and Drinkwater (2014) (Brown et al., 2012; Carbonneau et al., 2015; Dittmann & Freedman,

2009; Galloway et al., 2010; Gast et al., 2015; Herbert et al., 2013; Homan & Cavanaugh, 2013;

Schoenefeld & Webb, 2013; Shouse & Nilsson, 2011; Tylka et al., 2015; Tylka & Homan, 2015).

Five cross-sectional studies reviewed by Van Dyke and Drinkwater (2014) were not eligible for

inclusion in this review due to the following reasons: (1) two studies included males in their sample

but findings were not analysed by gender (Hawks, Merrill, & Madanat, 2004; Hawks et al., 2004); (2)

two studies were not published in a peer-reviewed publication (Banks, 2008; Nielson, 2009); and (3)

one study assessed mindful eating, not intuitive eating (Framson et al., 2009).

28

Figure 3.2. Flow diagram of included studies.

Methodological Quality of Studies

Quality assessment criteria were applied to each of the 24 studies. Authors

used the cut-off recommended by Kmet et al. (2004) for article inclusion. Studies

meeting at least 75 percent of criteria were included for review. All 24 studies met

the recommended cut-off. The summary score for each study according to relevant

criteria is presented in Table 3.1. While the summary score was useful in assessing

the eligibility of studies based on methodological quality, authors also reported the

strengths and weaknesses according to the relevant criteria that were common across

29

studies. Methodological strengths of studies included: describing study objectives

and participant characteristics; describing analyses and results in sufficient detail;

and appropriate conclusions that are drawn from the results. All 24 studies gained

full scores for these criteria. Methodological weaknesses that were common across

studies included: method of subject selection and possible measurement bias in the

use of self-report measures. A majority of studies used convenience sampling

methods, such as recruiting university students who were part of an existing research

pool (e.g., Brown et al., 2012), or undergraduate psychology students who received

class credit for their participation in the study (e.g., Avalos & Tylka, 2006; Kroon

Van Diest & Tylka, 2010; Tylka & Wilcox, 2006). One exception was Madden et al.

(2012), who randomly selected the sample from electoral rolls in New Zealand. All

studies used self-report measures to assess intuitive eating and psychosocial

correlates, including the use of individual items (e.g., Denny, Neumark-Sztainer,

Loth, & Eisenberg, 2013; Dittmann & Freedman, 2009; Madden et al., 2012).

Additionally, a proportion of studies did not consider confounding factors in their

study, such as participant characteristics. Seventeen of 24 studies considered at least

one participant characteristic in their analyses, including: age, ethnicity, gender, body

mass index, socioeconomic status, relationship status and level of education. Overall,

studies had more methodological strengths than weaknesses.

Summary of Included Studies

Table 3.1 provides a summary of each of the 24 cross-sectional studies that

assessed at least one psychosocial correlate of intuitive eating. The most frequently

used measure of intuitive eating was the 21-item IES-T (Tylka, 2006): nineteen of

the 24 studies assessed intuitive eating using this measure (Augustus-Horvath &

Tylka, 2011; Avalos & Tylka, 2006; Brown et al., 2012; Dittmann & Freedman,

30

2009; Galloway, Farrow, & Martz, 2010; Herbert, Blechert, Hautzinger, Matthias, &

Herbert, 2013; Homan & Cavanaugh, 2013; Iannantuono & Tylka, 2012; Kroon Van

Diest & Tylka, 2010; Madden et al., 2012; Oh et al., 2012; Schoenefeld & Webb,

2013; Shouse & Nilsson, 2011; Tylka, 2006; Tylka & Homan, 2015; Tylka &

Wilcox, 2006). The remaining five studies used either the revised 23-item IES-2

(Carbonneau, Carbonneau, Cantin, & Gagnon-Girouard, 2015; Tylka, Calogero, &

Danielsdottir, 2015; Tylka & Kroon Van Diest, 2013); the 27-item IES-H developed

by Hawks et al. (2004) (Gast et al., 2015); or two individual items from the Tylka’s

(2006) IES-T (Denny et al., 2013).

The majority of studies included predominantly university students (n=17).

Other studies included: university athletes (Oh et al., 2012); members of an online

community (Tylka et al., 2015); women involved in a heterosexual relationship

(Carbonneau et al., 2015); women aged 40 to 50 years (Madden et al., 2012); women

in their mid-twenties (Denny et al., 2013); three groups of women aged between 18

and 25, 26 and 39, and 40 and 65 years (Augustus-Horvath & Tylka, 2011); and

women who regularly practice yoga (Dittmann & Freedman, 2009). All studies

except for three were conducted in the United States. One of the exceptions was

conducted in New Zealand (Madden et al., 2012), one in Canada (Carbonneau et al.,

2015), and the other in Germany (Herbert et al., 2013). Nine of 21 papers (12 of 24

studies) included Tylka as an author.

31

Table 3.1

Summary of Cross-sectional Studies Examining Psychosocial Correlates of Intuitive Eating

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)

Main findings Quality

Assessment

Sore (%)

Augustus-

Horvath &

Tylka (2011)

United States

Participants:

emerging, early and

middle adult females

Mean age: emerging:

19.47 years (SD

1.90); early: 32.63

years (SD 4.06);

middle: 51.38 years

(SD 7.07)

Age range: 18-65

years

Ethnicity: Caucasian

82.4%, African

American 6.2%,

Other 11.4%

IES-T

(Tylka,

2006)

Body acceptance

by others

Body appreciation

Resistance in

adopting the

observer

perspective of the

body

Perceived social

support

Body Acceptance

by Others Scale

(Avalos & Tylka,

2006)

Body Appreciation

Scale (Avalos et al.,

2005)

Body Surveillance

subscale,

Objectified Body

Consciousness

Scale (McKinley &

Hyde, 1996)

IE positively associated with body

acceptance by others in emerging

(r=.43, p<.001), early (r=.50,

p<.001), and middle adulthood

(r=.45, p<.05).

IE positively related to body

appreciation in emerging (r=.60,

p<.001), early (r=.56, p<.001) and

middle adulthood (r=.60, p<.05).

IE positively associated with

resisting an observer perspective of

the body (r=.52, p<.001), early

(r=.53, p<.001, and middle

adulthood (r=.52, p<.05).

90.91

32

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Mean BMI:

emerging, 23.95

kg/m2; early, 25.55

kg/m2; middle, 28.86

kg/m2

Sample size: 801

(emerging, 318;

early, 238; middle,

245)

Study design: cross-

sectional

Social Provisions

Scale (Cutrona &

Russell, 1987)

IE positively related to perceived

social support for emerging (r=.24,

p<.001), early (r=.35, p<.001), and

middle (r=.23, p<.05) adulthood.

Avalos &

Tylka (2006)

United States

Study One:

Participants: female

university students

Mean age: 20.24

years (SD 5.17)

IES-T

(Tylka,

2006)

Body acceptance

by others

Body function

Body appreciation

Body Acceptance

by Others Scale

(Avalos & Tylka,

2006)

Body Surveillance

Subscale,

Objectified Body

Study One:


acceptance by others (r=.45,

p<.001), body function, (r=.43,

p<.001) and body appreciation

(r=.58, p<.001), but not perceived

Study One:

90.00

33

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Age range: 17-55

years


82.2%, African

American 5%, Other

12.8%

Sample size: 181

Study design/method:

cross-sectional

Study Two:


university students

Mean age: 19.92

years (SD 4.60)

Perceived

unconditional

acceptance from

others

Consciousness

Scale (McKinley &

Hyde, 1996)

Body Appreciation


2005)

Barrett-Lennard

Relationship

Inventory (Claiborn

et al., 1983)

general unconditional acceptance

from others (r= .07, ns).

Study Two:

IE positively related to perceived

unconditional acceptance from

others (r=.19, p<.01), body


p<.001), body function (r=.50,

<.001), and body appreciation

(r=.64, p<.001).

Study Two:

90.00

34

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Age range: 17-50

years


American 77.6%,

African American

9.1%, Other 13.3%

Sample size: 416


sectional

Brown et al.

(2012)

United States


university students

Mean age: 19.2

years (SD 2.5)

Age range: 18-35

years

IES-T

(Tylka,

2006)

Self-oriented

perfectionism

Multidimensional

Perfectionism Scale

(Hewitt & Flett,

1991)

IE inversely associated with self-

oriented perfectionism (β =-.40,

p<.01)

85.00

35

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)


66.7%, African

American 4.2%,

Asian 18.8%, Other

10.3%

Sample size: 48


sectional

Carbonneau

et al. (2015)

Participants: French-

Canadian women in

a heterosexual

relationship

Mean age: 29.86

years (SD 6.57)

Age range: 20-45

years

IES-2

(Tylka &

Kroon

Van

Diest,

2013)

Mother’s

interpersonal style

(autonomy-

supported,

controlling)

Partner’s

interpersonal style

(autonomy-

Perceived Parental

Autonomy Support

Scale (Mageau et

al., 2015)

The 6-item

autonomy support

subscale (Koestner

et al., 2012)

IE positively correlated with the

autonomy-supportive interpersonal

style of the mother (r=.23, p<.001)

but not the partner (r=.09, ns), and

negatively correlated with the

controlling interpersonal style of

the mother (r=-.27, p<.001) but not

the partner (r=-.09, ns).

UPE subscale positively correlated

with the autonomy-supportive

90.00

36

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)


94.9%, Other 5.2%

Sample size: 272


sectional

supported,

controlling)

Eating regulation

(autonomous,

controlled)

Adapted version of

two scales to assess

partner’s

controlling

interpersonal style

(Bartholomew et

al., 2010; Moreau

& Mageau, 2012)

Regulation of

Eating Behaviors

Scale (Pelletier et

al., 2004).

interpersonal style of the mother

(r=.17, p<.01) but not the partner

(r=.12, ns), and negatively

correlated with the controlling


(r=-.20, p<.01) but not the partner

(r=-.07, ns).

EPR Subscale positively correlated

with the autonomy-supportive


(r=.16, p<.01) but not the partner

(r=.05, ns), and negatively

correlated with the controlling


(r=-.23, p<.01) but not the partner

(r=-.06, ns).

RHSC subscale positively

correlated with the autonomy-

supportive interpersonal style of

37

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

the mother (r=.19, p<.01) but not

the partner (r=.00, ns), and

negatively correlated with the

controlling interpersonal style of

the mother (r=-.20, p<.01) but not

the partner (r=-.09, ns).

B-FCC subscale positively

correlated with the autonomy-

supportive interpersonal style of

the mother (r=.17, p<.01) and the

partner (r=.19, p<.01), but did not

correlate with the controlling


(r=-.07, ns) or the partner (r=-.03,

ns).

IE positively correlated with

autonomous eating regulation

(r=.29, p<.001) and negatively

38

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

associated with controlled eating

regulation (r=-.47, p<.001).

UPE subscale negatively correlated

with both autonomous eating

regulation (r=-.15, p<.05) and

controlled eating regulation (r =-

.29, p<.001).

EPR subscale positively correlated

with autonomous eating regulation

(r =.20, p<.01) and negatively

associated with controlled eating

regulation (r =-.40, p<.001).


correlated with autonomous eating

regulation (r =.33, p<.001) and

negatively associated with


.36, p<.001).

39

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)


correlated with autonomous eating

regulation (r =.58, p<.001) and



.24, p<.001).

Denny et al.

(2013)

United States

.

Participants: young

adult males and

females

Mean age (males and

females): 25.3 years

(SD 1.7)

Age range: not

reported

Ethnicity(females):

Caucasian 45.6%,

African American

Two

items

from IES-

T (Tylka,

2006)

Chronic dieting

Unhealthy weight

control practices

(fasting, starvation,

food supplement,

skipping meals,

smoking)

Extreme weight

control practices

(diet pills,

laxatives, diuretics)

One item each

assessing chronic

dieting, unhealthy

weight control, and

extreme weight

control practices

Two items

assessing binge

eating

Women who reported trusting their

body to tell them how much to eat

reported lower odds of chronic

dieting (OR = .58, 95% CI = [.38,

0.87], p<.05), unhealthy (OR= .55,

CI = [.41, .72], p<.05) and extreme

(OR = .62, CI = [.45, .85], p<.05)

weight control practices, and binge

eating (OR= .45, [.31, .65] , p<.05)

than women who did not trust their

body to tell them how much to eat

(controlled for ethnicity, socio-

economic status and BMI).

86.36

40

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

21.2%, Asian 18.8%,

Other 14.4%

Mean BMI: not

reported. Females

classified as normal

weight (n=630),

overweight (n=297),

obese (n=305)

Sample size: 2287

(females, n=1257)


sectional

Binge eating Women who reported that they

stopped eating when full reported

lower odds of chronic dieting (OR=

.62, CI = [.41, .95], p<.05) and

binge eating (OR = .34, CI = [.23,

.48], p<.05), but not unhealthy (OR

= .75, CI= [.55, 1.02], ns) or

extreme weight control practices

(OR = .81, CI= [.58, 1.14], ns)

(controlled for ethnicity, socio-

economic status and BMI).

Dittmann &

Freedman

(2009)

United States

Participants: females

who regularly

practice yoga

IES-T

(Tylka,

2006)

Body satisfaction

Body awareness

Body

responsiveness

Single item

assessing body

satisfaction

Observe subscale,

Five Facet


satisfaction (r=.47, p<.01), body

awareness (r=.22, p<.01) and body

responsiveness (r=.415, p<.01), but

not spiritual readiness (r=.036, ns).

86.36

41

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Mean age: 47.4

years (SD 11.19)

Age range: 22-72

years

Ethnicity: majority

Caucasian

(proportion not

reported)

Mean BMI: 22.2

kg/m2

Sample size: 157


sectional

Spiritual readiness Mindfulness

Questionnaire (Baer

et al., 2006)

7-item scale

assessing body

responsiveness

(Daubenmier,

2005)

17-item scale

assessing spiritual

readiness

Galloway et

al. (2010)

Participants: male

and female

university students

IES-T

(Tylka,

2006)

Caregiver eating

messages (parent-

reported)

Child Feeding

Questionnaire for

Children (Carper et

UPE subscale not associated with

pressure to eat (r= -.08, ns),

restriction (r= -.05, ns), or

90.91

42

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

United States

Mean age(females):

18.5 years (SD .95)

Age range (males

and females): 17-23

years

Ethnicity (males and

females): Caucasian

96%, African

American 3%, Asian

American 1%

Sample size: 93

(females, n=71)


sectional

al., 2000), adapted

version completed

by parents.

monitoring (r= -.19, ns) caregiver

eating messages.

RHSC subscale were not

associated with pressure to eat (r=

.07, ns), restriction (r= -.03, ns), or

monitoring (r= -.17, ns) caregiver

eating messages.

EPR subscale inversely associated

with caregiver eating messages of

restriction (r= -.33, p<.01) and

monitoring (r=-.40, p<.01) but not

pressure to eat caregiver eating

messages (r=-.13, ns).

43

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Gast et al.

(2015)

United States


university students

Mean age: 19.58 (SD

2.42)

Age range: not

reported


90%, Hispanic 4%,

Asian 3%, Other 4%

Mean BMI: 23.23

kg/m2

Underweight 6.5%,

Normal weight 69%,

Overweight 17.5%,

Obese 7%

Sample size: 200

IES-H

(Hawks et

al., 2004)

Motivation for

physical activity

(external pressure,

guilt or shame,

values physical

activity, feels

pleasure in physical

activity)

Behavioral

Regulation in

Exercise

Questionnaire

(Mullan et al.,

1997)

Total IES-H scores inversely

associated with external regulation

(β= -.008, p<.05) and introjected

regulation (β= -.04, p<.05), and

positively associated with intrinsic

regulation (β = .005, p<.05), but

not identified regulation (β =

.0001, ns).

Extrinsic subscale negatively

correlated with introjected

regulation (r= -.482, p<.0001) but

not external (r=-.141, ns),

identified (r=-.103, ns) or intrinsic

(r=.088, ns) regulation.

Antidieting subscale inversely

associated with external (r=-.348,

p<.0001) and introjected (r=-.563,

p<.0001) regulation, and positively

associated with intrinsic regulation

90.91

44

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)


sectional

(r=.206, p<.05) but did not

correlate with identified regulation

(r=-.07, ns).

Intrinsic subscale did not correlate

with any of the four regulation

types (p>.0003).

Self-care subscale correlated

negatively with introjected

regulation (r=-.227, p<.001) and

positively with identified

regulation (r=.291, p<.0001) and

intrinsic regulation (r=.433,

p<.0001), but not external

regulation (r=-.151, ns).

*Bonferroni adjustments applied to

correlations with IES subscales

(alpha level of .0003).

45

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Herbert et al.

(2013)

Germany


university students

Mean age: 25.4

years (SD 4.8)

Age range: not

reported

Ethnicity: not

reported

Mean BMI: 22.21

kg/m2

Sample size:111


sectional

IES-T

(Tylka,

2006)

State anxiety

Trait anxiety

State–Trait-Anxiety

Inventory

(Spielberger et al.,

1983)

IE total scores were not associated

with state anxiety (r= -.02, ns) or

trait anxiety (r= -.05, ns). IES-T

subscale scores were not associated

with state anxiety or trait anxiety

(p>.05).

90.00

46

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Homan &

Cavanaugh

(2013)

United States


undergraduate

students from a

Christian liberal arts

college.

Mean age: 20 (SD

0.88)

Age range: 18-22

years


95.2%; Other 4.8%

Sample size: 104


sectional

IES-T

(Tylka,

2006)

Parent attachment

Anxious and

avoidant

attachment to God

Anxiety and

Avoidance

subscales,

Attachment to God

Inventory (Beck &

McDonald, 2004).

Parent Trust

subscale, Inventory

of Parent and Peer

Attachment

(Armsden &

Greenberg, 1987).

Intuitive eating negatively

associated with an anxious

attachment to God (r=-.30, p<.01).

After controlling for religious

service attendance, the relationship

remained significant (β= -.29,

p=.006).

Intuitive eating did not correlate

with an avoidant attachment to God

(r=-.07, ns) and was not

significantly associated with parent

attachment (r=.18, ns).

90.00

47

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Iannantuono

& Tylka

(2012)

United States


university students

Mean age: 19.1

years (SD 1.7)

Age range: 18-28

years


86.3%, African

American 4.8%,

Other 8.9%

Mean BMI: 23.1

kg/m2

Sample size: 249


sectional

IES-T

(Tylka,

2006)

Body appreciation

Caregiver eating

messages

Adult attachment

Perfectionism

Depressive

symptomatology

Body Appreciation


2005)

Caregiver Eating

Messages Scale

(Kroon Van Diest

& Tylka, 2010)

Experiences in

Close Relationships

Scale (Brennan et

al., 1998)

Almost Perfect

Scale-Revised

(Slaney et al., 2001)

IE positively related to body

appreciation (r=.58, p<.001) and


depressive symptomatology (r=-

.35, p<.001), discrepancy

perfectionism (r=-.45, p<.001),

avoidant (r=-.22, p<.001) an

anxious attachment (r=-.43,

p<.001), and restrictive/critical

caregiver eating messages (r=-.40,

p<.001).

IE not associated with pressure to

eat caregiver eating messages (r=-

.11, ns), high standards

perfectionism (r=.03, ns) or order

perfectionism (r=.07, ns).

90.00

48

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Beck Depression

Inventory-II (Beck

et al., 1996)

Kroon Van

Diest &

Tylka (2010)

United States

Participants: male

and female

university students

Mean age (males and


(SD 3.92)

Age range: 18-35

years


females): Caucasian

91.6%, African

American 2.5%,

Asian 2.5%, Other

3.4%

IES-T

(Tylka,

2006)

Caregiver eating

messages

Perceived body

acceptance by

family

Body appreciation

Caregiver Eating

Messages Scale

(Kroon Van Diest

& Tylka, 2010)

Body Acceptance

by Others Scale

(Avalos & Tylka,

2006)

Body Appreciation


2005)

IE had a positive relationship with

perceived body acceptance by

family (r=.49, p<.05) and body

appreciation (r=.53, p<.05), and a

negative relationship with

restrictive/critical caregiver eating

messages (r=-.42, p<.05) in

females. IE did not correlate with

pressure to eat caregiver eating

messages (r=.01, ns).

90.91

49

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Mean BMI (females):

24.80 kg/m2

Sample size: 238

(females, n = 160)


sectional

Madden et al.

(2012)

New Zealand

Participants: mid-

age females

Mean age: 45.5

years (SD 3.2)

Age range: 40-50

years


80.3%, Māori 11.4%,

Asian 5.3%, Pacific

3.0%

IES-T

(Tylka,

2006)

Binge eating One item assessing

frequency of binge

eating in the past

year

A one unit increase in IE was

associated with a 1.62% (CI 1.79,

1.46; p<.001) decrease in binge

eating frequency.

95.00

50

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Mean BMI: 25.8

kg/m2

Sample size: 1441


sectional

Oh et al.

(2012)

United States

Participants: Female

college athletes

Mean age:19.88

years (SD 1.91)

Age range: 18-23

years


88.8%, African

American 4.4%,

Other 6.8%

IES-T

(Tylka,

2006)

Perceived

unconditional

acceptance from

significant others

Body acceptance

by others

Body function

Body appreciation

Barrett-Lennard

Relationship

Inventory (Barrett-

Lennard, 1962)

Body Acceptance

by Others Scale

(Avalos & Tylka,

2006)

Body Surveillance

subscale,

Objectified Body

Consciousness

After controlling for BMI, IE

positively associated with body


p<.001), body function (r=.57,

p<.001) and body appreciation

(r=.48, p<.001), but not perceived

unconditional acceptance by others

(r=.12, ns).

90.00

51

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Sample size: 160


sectional

Scale (McKinley &

Hyde, 1996)

Body Appreciation


2005)

Schoenefeld

& Webb

(2013)

United States


university students

Mean age: 19.48

years (SD 1.46)

Age range: 18-24

years


67.4%, African

American 21.1%,

Other 11.5%

IES-T

(Tylka,

2006)

Self-compassion

Distress tolerance

Body image

flexibility

Self-esteem

Self-compassion

Scale (Neff, 2003)

Distress Tolerance

Scale (Simons &

Gaher, 2005)

Body Image-

Acceptance and

Action

Questionnaire

(Hayes et al., 1999)

IE correlated positively with self-

compassion (r=.39, p<.01), distress

tolerance (r=.21, p<.01), body

image flexibility (r=.69, p<.01),

and self-esteem (r=.40, p<01).

90.00

52

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Mean BMI 23.55

kg/m2

Sample size: 322


sectional

Rosenberg Self-

Esteem Scale

(Rosenberg, 1965)

Shouse &

Nilsson

(2011)

United States


university students

Mean age: 20.8

years (SD 1.9)

Age range: 18-24

years


52%, African

American 36%,

Asian 4%, Other 8%

Sample size: 140

IES-T

(Tylka,

2006)

Self-silencing

Disordered eating

Emotional

awareness

Silencing the Self

Scale (Jack & Dill,

1996)

Eating Attitudes

Test-26 (Garner et

al, 1982)

Clarity of Feeling

subscale, Trait

Meta-Mood Scale

(Salovey et al.,

1995)

IE correlated negatively with self-

silencing (r=-.28, p<.01) and

disordered eating (r=-.58, p<.01),

and correlated positively with

emotional awareness (r=.19,

p<.05).

90.91

53

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Study design:

cross-sectional

Tylka (2006)

United States

Study One:


university students

Mean age: 20.85

years (SD 6.21)

Age range: 17-61

years


87.7%, Asian 3.8%,

African American

3.1%, Other 5.4%

Sample size: 391

IES-T

(Tylka,

2006)

Study One:

Disordered eating

Body

dissatisfaction

Interoceptive

awareness

Pressure for

thinness from

significant others

Internalisation of

the thin-ideal

Study Two:

Eating Attitudes

Test-26 (Garner et

al., 1982)

Body

Dissatisfaction and

Interoceptive

Awareness

subscales, Eating

Disorder Iventory-2

(Garner, 1991)

Perceived

Sociocultural

Pressures Scale

(Stice, 1996)

Internalization

subscale,

Study One:

IE was negatively related to


body dissatisfaction (r=-.53,

p<.001), poor interoceptive

awareness (r=-.46, p<.001),

pressure for thinness (r=-.52,

p<.001) and internalisation of the

thin-ideal (r=-.47, p<.001).

UPE subscale negatively associated

with disordered eating (r= -.72,

p<.001), body dissatisfaction (r= -

.44, p<.001), poor interoceptive

awareness (r= -.31, p<.001),

pressure for thinness (r= -.41,

Study One:

90.00

54

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)


sectional

Study Two:


university students

Mean age: 19.70

years (SD 4.50)

Age range: 17-50

years


86.2%, Asian 5.3%,

African American

3.9%, Other 4.5%

Sample size: 476

Self-esteem

Optimism

Proactive coping

Global life

satisfaction

Sociocultural

Attitudes Toward

Appearance

Questionnaire

(Heinberg et al.,

1995)

Rosenberg Self-

Esteem Scale

(Rosenberg, 1965)

Life Orientation

Test—Revised

(Scheier et al.,

1994)

Proactive Coping

subscale, Proactive

Coping Inventory

(Greenglass et al.,

1999)

p<.001), and internalisation of the

thin-ideal (r= -.41, p<.001).

EPR subscale negatively associated

with disordered eating (r=-.23,

p<.001), body dissatisfaction (r= -

.31, p<.001), poor interoceptive

awareness (r= -.41, p<.001),

pressure for thinness (r= -.37,

p<.001), and internalisation of the

thin-ideal (r= -.29, p<.001).

RHSC subscale negatively

associated with disordered eating

(r=-.27, p<.001), body

dissatisfaction (r= -.35, p<.001),

poor interoceptive awareness (r= -

.28, p<.001), pressure for thinness

(r= -.28, p<.001), and

55

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)


sectional

Satisfaction with

Life Scale (Diener

et al., 1985)

internalisation of the thin-ideal (r=

-.23, p<.001).

Study Two:

IE positively correlated with self-

esteem (r=.44, p<.001), optimism

(r=.29, p<.001), proactive coping

(r=.29, p<.001), and life

satisfaction (r=.41, p<.001).

EPR subscale positively related to

self-esteem (r= .28, p<.001),

optimism (r= .14, p<.01), and life

satisfaction (r=.26, p<.001) but not

proactive coping (r=.10, ns)

UPE positively related to self-

esteem (r= .36, p<.001), optimism

(r= .24, p<.001), proactive coping

Study Two:

90.00

56

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

(r=.27, p<.001) and life satisfaction

(r=.26, p<.001).

RHSC subscale positively related

to self-esteem (r= .35, p<.001),

optimism (r= .31, p<.001),

proactive coping (r=.34, p<.001)

and life satisfaction (r=.38,

p<.001).

Tylka et al.

(2015)

Participants: male

and female online

community

participants

Mean age (females):

35.01 years (SD

12.45)

Age range: 18-

63years

IES-2

(Tylka &

Kroon

Van

Diest,

2013)

Flexible control of

eating

Rigid control of

eating

Life satisfaction

Positive affect

Negative affect

Flexible Control

and Rigid Control

subscales,

Cognitive

Restraint Scale

(Westenhoefer et

al., 1999)

IE was negatively associated with

rigid control (r=-.51, p <.001) and

flexible control (r=-.27, p <.001) of

eating, negative affect (r=-.30, p

<.001), poor interoceptive

awareness (r=-.60, p <.001), binge

eating (r=-.68, p <.001), and food

preoccupation (r=-.65, p <.001).

IE was positively associated with

life satisfaction (r= .35, p<.001),

90.00

57

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)


females): Caucasian

71.9%, African

American 8.4%,

Asian 9.2%, Other

10.4%

Mean BMI (females):

26.82 kg/m2

Sample size: 382

(females, n = 192)


sectional

Body appreciation

Interoceptive

awareness

Binge eating

Food preoccupation

Satisfaction with

Life Scale (Diener

et al., 1985)

Positive and

Negative Affect

Schedule-Expanded

(Watson et al.,

1988)

Body Appreciation

Scale-2 (Tylka &

Wood- Barcalow,

2015)

Interoceptive

Awareness

subscale, Eating

Disorder Inventory-

2 (Garner, 1991)

positive affect (r= .29, p<.001),

and body appreciation (r= .64,

p<.001).

58

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Binge Eating Scale

(Gormally et al.,

1982)

Frequency

subscale, Food

Preoccupation

Questionnaire

(Tapper & Pothos,

2010)

Tylka &

Homan

(2015)

Participants: male

and female

undergraduate

university students

Mean age (females):

19.62 years (SD

2.87)

IES-T

(Tylka,

2006)

Body acceptance

by others

Internal body

orientation

Exercise motives

(functional,

appearance)

Body Acceptance

by Others Scale

(Avalos & Tylka,

2006)

Body Surveillance

subscale,

Objectified Body

Consciousness

IE correlated positively with body

acceptance by others (r= .28,

p<.001), internal body orientation

(r= .46, p<.001) and body

appreciation (r= .48, p<.001).

IE correlated negatively with

appearance exercise motives (r=-

.61, p <.001) but did not correlated

90.00

59

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Age range: 18-

47years


females): Caucasian

88.5%, African

American 5.2%,

Asian 2.0%, Other

4.2%

Mean BMI: females,

22.59 kg/m2

Sample size: 406

(females, n = 258)


sectional

Body appreciation

Scale (McKinley &

Hyde,1996)

The Function of

Exercise Scale

(DiBartolo et al.,

2007)

Body Appreciation


2005)

with functional exercise motives

(r=.10, ns).

60

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Tylka &

Kroon Van

Diest (2013)

United States

Participants: male

and female

university students

Mean age (males and


(SD 5.06)

Age range (males

and females): 18-53

years


81.7%, African

American 5.5%,

Asian 3.5%, Other

9.3%

Mean BMI

(females):24.02

kg/m2

IES-2

(Tylka &

Kroon

Van

Diest,

2013)

Disordered eating

Interoceptive

awareness

Body appreciation

Body surveillance

Body shame

Internalisation of

thin media ideal

Self-esteem

Positive and

Negative affect

Global life

satisfaction

Eating Attitudes

Test–26 (Garner et

al., 1982)

Interoceptive

Awareness

subscale, Eating

Disorder Inventory-

2 (Garner, 1991)

Body Appreciation


2005)

Body Surveillance

and Body Shame

subscales,

Objectified Body

Consciousness

IE negatively associated with


body surveillance (r=-.36, p<.001),

body shame (r=-.56, p<.001),

internalisation (r=-.37, p<.001),

poor interoceptive awareness (r=-

.35, p<.001), and negative affect

(r=-.36, p<.001).

EPR subscale negatively related to



body shame (r=-.35, p<.001),




(r=-.31, p<.001).

UPE subscale negatively related to



90.91

61

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Sample size: 1200

(females, n=680)


sectional

Scale (McKinley &

Hyde, 1996)

Internalization

subscale,

Sociocultural

Attitudes Toward

Appearance

Questionnaire–

Revised (Heinberg

et al., 1995)

Rosenberg Self-

Esteem Scale

(Rosenberg, 1965)

Positive and

Negative Affect

Schedule–

Expanded (Watson

et al., 1988)

body shame (r=-.52, p<.001),




(r=-.15, p<.001).

RHSC subscale negatively related

to disordered eating (r=-.37,

p<.001), body surveillance (r=-.24,

p<.001), body shame (r=-.39,

p<.001), internalisation (r=-.22,


awareness (r=-.24, p<.001), and

negative affect (r=-.21, p<.001).

B-FCC subscale negatively related

to body surveillance (r=-.19,

p<.001), internalisation (r= -.13,


awareness (r=-.13, p<.001), and

negative affect (r=-.19, p<.001) but

62

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Satisfaction with

Life Scale (Diener

et al., 1985)

not disordered eating (r=.05, ns) or

body shame (r=-.08, ns).


appreciation (r=.52, p<.001), self-

esteem (r=.41, p<.001), positive

affect (r=.26, p<.001), and life

satisfaction (r=.33, p<.001).

EPR subscale positively associated

with body appreciation (r=.32,

p<.001), self-esteem (r=.26,

p<.001), positive affect (r=.18,

p<.001), and life satisfaction

(r=.28, p<.001).

UPE subscale positively associated

with body appreciation (r=.33,

p<.001), self-esteem (r=.27,

p<.001), but not positive affect

63

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

(r=.00, ns), or life satisfaction

(r=.12, ns).


associated with body appreciation

(r=.40, p<.001), self-esteem (r=.30,



(r=.21, p<.001).


associated with body appreciation

(r=.29, p<.001), self-esteem (r=.22,



(r=.18, p<.001)

64

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Tylka &

Wilcox

(2006)

United States

Study One:

Participants:

female university

students

Mean age: 18.44

years (SD 1.02)

Age range: 17-30

years


85.9%, Asian 5.0%,

African American

5.3%, Other 3.8%

Sample size: 388


sectional

IES-T

(Tylka,

2006)

Study One:

Disordered eating

(dieting,

bulimia/food

preoccupation)

Positive affect

Self-esteem

Proactive coping

Study Two:

Unconditional self-

regard

Psychological

hardiness

Study One:

Dieting and

Bulimia/food

preoccupation

subscales, Eating

Attitudes Test–26

(Garner et al.,

1982)

Positive Affect

subscale of Positive

and Negative

Affect Schedule-

Expanded (Watson

et al., 1988)

Rosenberg Self-

Esteem Scale

(Rosenberg, 1965)

Study One:

UPE negatively associated with

dieting (r=-.67, p<.001) and

bulimia/food preoccupation (r= -

40, p<.001).

EPR negatively associated with


bulimia/food preoccupation (r=-

.26, p<.001).

RHSC negatively associated with

dieting (r= -.35, p<.001) and


.36, p<.001).

UPE positively associated with

self-esteem (r=.23, p<.001) and

proactive coping (r=.11, p<.05) but

not positive affect (r=.03, ns).

Study One:

90.00

65

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Study Two:


university students

Mean age: 18.72

years (SD 2.44)

Age range: 17-55

years


81.6%, African

American 8.3%,

Asian 4.3%, Other

5.8%

Sample size: 396


sectional

Social problem-

solving

Proactive Coping

subscale of the

Proactive Coping

Inventory

(Greenglass et al.,

1999)

Study Two:

Life Orientation

Test-Revised

(Scheier et al.,

1994)

Unconditional Self-

Regard Scale (Betz

et al., 1995)

Psychological

Hardiness Scale-

EPR positively related to positive

affect (r=.25, p<.001), self-esteem

(r=.30, p<.001) and proactive

coping (r=.26, p<.001).

RHSC positively related to positive

affect (r=.33, p<.001), self-esteem

(r=.34, p<.001) and proactive

coping (r=.33, p<.001).

Study Two:

UPE negatively associated with



.36, p<.001).

EPR negatively associated with



.37, p<.001).

Study Two:

90.00

66

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

Short Form (Betz &

Campbell, 2003)

Social Problem

Solving Inventory-

Revised (D’Zurilla

et al., 1997)

RHSC negatively associated with



.30, p<.001).

UPE positively related to optimism

(r=.10, p<.05), unconditional self-

regard (r=.24, p<.001), and

psychological hardiness (r=.11,

p<.05), but not social problem

solving (r=-.01, ns).

EPR positively associated with

optimism (r=.25, p<.001),

unconditional self-regard (r=.28,

p<.001), psychological hardiness

(r=.34, p<.001), and social problem

solving (r=.30, p<.001).

RHSC subscale had a positive

relationship with optimism (r=.24,

67

Reference

Country

Participant

characteristics

Study design

Measure

of

intuitive

eating

Psychosocial

correlate(s)

Measure(s) of

psychosocial

correlate(s)


Assessment

Sore (%)

p<.001), unconditional self-regard

(r=.32, p<.001), psychological

hardiness (r=.25, p<.001) and

social problem solving (r=.23,

p<.001).

Note. IE = intuitive eating; IES-T = Intuitive Eating Scale (Tylka, 2006); IES-H = Intuitive Eating Scale (Hawks et al., 2004); IES-2 = Intuitive Eating

Scale-2 (Tylka & Kroon Van Diest, 2013); EPR = Eating for Physical Reasons; UPE = Unconditional Permission to Eat; RHSC = Reliance on

Hunger/Satiety Cues; B-FCC = Body–Food Choice Congruence; BMI = Body Mass Index; ns = non-significant correlation.

68

The correlates of intuitive eating in each of the 24 studies were categorised as

follows: eating attitudes and behaviours; body image; emotional functioning; and

other psychosocial correlates.

Eating Attitudes and Behaviours

Eight of the 24 studies examined intuitive eating in relation to other eating

attitudes and behaviours (Denny et al., 2013; Madden et al., 2012; Shouse & Nilsson,

2011; Tylka, 2006; Tylka & Kroon Van Diest, 2013; Tylka & Wilcox, 2006). This

included disordered eating symptomatology, restrained eating and dieting, eating

regulation, and other weight loss practices. Three studies (Shouse & Nilsson, 2011;

Tylka, 2006; Tylka & Kroon Van Diest, 2013) used all three subscales of the Eating

Attitudes Test-26 (EAT-26; Garner et al., 1982); two studies used two subscales of

the EAT-26 (Tylka & Wilcox, 2006); one study (Tylka et al., 2015) assessed binge

eating and food preoccupation using The Binge Eating Scale (Gormally, Black,

Daston, & Rardin,1982) and a subscale from the Food Preoccupation Questionnaire

(Tapper & Pothos, 2010); and one study (Carbonneau et al., 2015) used the

Regulation of Eating Behaviors Scale (Pelletier, Dion, Slovinec-D’Angelo, & Reid,

2004) to assess regulation of eating. The remaining two studies used one or two

individual items to assess binge eating (Denny et al., 2013; Madden et al., 2012),

dieting, and unhealthy or extreme weight loss practices (Denny et al., 2013).

Studies demonstrated that intuitive eating was inversely associated with

disordered eating symptomatology, according to total scores on the EAT-26 (Shouse

& Nilsson, 2011; Tylka, 2006, Tylka & Kroon Van Diest, 2013), and correlated

negatively with bulimia and food preoccupation (Tylka et al., 2015; Tylka & Wilcox,

2006), binge eating behaviours (Denny et al., 2013; Madden et al., 2012; Tylka et al.,

2015), and dieting (Denny et al., 2013; Tylka & Wilcox, 2006). Additionally,

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intuitive eating was negatively associated with two forms of restrained eating: rigid

control (an “all-or-nothing” approach to eating) and flexible control (a more balanced

approach to managing food intake) (Tylka et al., 2015). Correlations between

intuitive eating and disordered eating, including restrained eating and dieting, ranged

from -.50 to -.68 in size.

Studies examining individual subscales of the IES-T (Tylka, 2006; Tylka &

Kroon Van Diest, 2013; Tylka & Wilcox, 2006) demonstrated relationships

consistent with the overall scale for disordered eating and dieting (Tylka, 2006;

Tylka & Wilcox, 2006). An exception was Tylka and Kroon Van Diest (2013), who

found no association between the Body-Food Choice Congruence subscale of the

revised IES-T (assesses the extent to which individuals match food choice with the

body’s needs) and disordered eating among university students. In addition, Denny

and colleagues (2013) showed that women who trusted their body to tell them how

much to eat reported that they were less likely to engage in unhealthy weight loss

practices (i.e. fasting, starvation, food supplementation, skipping meals, smoking)

and extreme weight loss practices (i.e., diet pills, laxatives and diuretics). However,

there was no difference in the likelihood of engaging in these behaviours between

women who did or did not stop eating when experiencing fullness. Correlations

between intuitive eating subscales and disordered eating, including dieting, ranged

from -.13 to -.73. Correlations between the Unconditional Permission to Eat subscale

and disordered eating ranged from -.36 to -.73. Lower correlations were found

between the Eating for Physical Reasons subscale and disordered eating (ranged

from -.13 to -.37), and between the Reliance on Hunger/Satiety Cues subscale and

disordered eating (ranged from -.23 to -.37).

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Carbonneau and colleagues (2015) investigated intuitive eating and its

association with two forms of regulated eating: autonomous (self-determined or

feeling empowered towards eating choices) and controlled (feeling pressured or

controlled in eating choices). Examples of items were “…because I take pleasure in

fixing healthy meals” (autonomous regulation) and “…because I would feel ashamed

of myself if I was not eating healthy” (controlled regulation) (Carbonneau et al.,

2015). Intuitive eating was positively associated with autonomous regulation and

negatively associated with controlled regulation. Further examination of the

subscales of the revised IES-T showed that three of the four subscales reported

correlations consistent with the overall scale. The exception was Unconditional

Permission to Eat subscale, which was inversely associated with both forms of eating

regulation.

Body Image

Eleven studies examined the relationship between intuitive eating and body

image. Body appreciation, the extent to which one has a favourable attitude and

treatment of one’s body, regardless of perceived appearance-related flaws, was

examined in eight studies (Augustus-Horvath & Tylka, 2011; Avalos & Tylka, 2006;

Iannantuono & Tylka, 2012; Kroon Van Diest & Tylka, 2010; Oh et al., 2012; Tylka

et al., 2015; Tylka & Homan, 2015; Tylka & Kroon Van Diest, 2013). All studies

used the 13-item Body Appreciation Scale (Avalos et al., 2005) or the revised 10-

item scale (Tylka & Wood-Barcalow, 2015). Intuitive eating correlated with body

appreciation in a positive direction in all eight studies, and was consistent for total

scores and subscale scores of intuitive eating (Tylka & Kroon Van Diest, 2013),

across three different age groups (Augustus-Horvath & Tylka, 2011), and after

controlling for BMI (Oh et al., 2012).

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Body satisfaction or dissatisfaction (the overall evaluation of one’s body size,

shape or appearance) was examined in two studies (Dittmann & Freedman, 2009;

Tylka, 2006). Dittmann and Freedman (2009) used a single item to assess body

satisfaction, while Tylka (2006) assessed body dissatisfaction using a subscale of the

Eating Disorder Inventory (EDI-2; Garner, 1991). Both studies demonstrated that

eating more intuitively was associated with greater body satisfaction (Dittmann &

Freedman, 2009; Tylka, 2006). Tylka (2006) also demonstrated that this relationship

was consistent when examining subscales of the IES-T.

Body surveillance (adopting an observer perspective of the body, or

habitually monitoring appearance), body function or an internal body orientation (a

focus on how the body functions and feels rather than appearance) were examined in

five studies (Augustus-Horvath & Tylka, 2011; Avalos & Tylka, 2006; Oh et al.,

2012; Tylka & Homan, 2015; Tylka & Kroon Van Diest, 2013) using the Body

Surveillance subscale of the Objectified Body Consciousness Scale (McKinley &

Hyde, 1996). Higher levels of intuitive eating correlated with greater resistance in

adopting an observer’s perspective of the body, according to total (Augustus-Horvath

& Tylka, 2011, Tylka & Kroon Van Diest, 2013) and subscale intuitive eating scores

(Tylka & Kroon Van Diest, 2013). In addition, intuitive eating correlated with a

greater focus on body function and feeling rather than appearance (Avalos & Tylka,

2006; Oh et al., 2012; Tylka & Homan, 2015). Body image flexibility, described as

the degree to which one accepts thoughts and feelings about the body, was examined

by Schoenefeld and Webb (2013). Intuitive eating correlated with body image

flexibility in a positive direction. Overall, correlations between total scores of

intuitive eating and positive aspects of body image ranged from .43 to .69.

Correlations for negative aspects of body image ranged between -.36 to -.56.

Correlations between subscales of the IES-T and negative aspects of body image

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ranged from -.26 to -.52 for the Unconditional Permission to Eat subscale, -.25 to -

.35 for the Eating for Physical Reasons subscale, and -.24 to -.39 for the Reliance on

Hunger/Satiety Cues subscale. Correlations between IES-T subscales and positive

aspects of body image ranged from .29 to .40, with the Reliance on Hunger/Satiety

Cues reporting the largest correlation.

Emotional Functioning

Seven studies examined aspects of emotional functioning (Herbert et al.,

2013; Iannantuono & Tylka, 2012; Schoenefeld & Webb, 2013; Shouse & Nilsson,

2011; Tylka et al., 2015; Tylka & Kroon Van Diest, 2013; Tylka & Wilcox, 2006),

including affect, mood and the management of emotions. Intuitive eating was

inversely associated with negative affect, for both total and subscale scores of the

revised IES-T (Tylka et al., 2015; Tylka & Kroon Van Diest, 2013), and depressive

symptomatology (Iannantuono & Tylka, 2012). However, intuitive eating did not

correlate with levels of state and trait anxiety, according to both total and subscale

scores of the IES-T, among German university students (Herbert et al., 2013).

Positive affect was examined in three studies (Tylka et al., 2015; Tylka & Kroon Van

Diest, 2013; Tylka & Wilcox, 2006), each of which demonstrated a positive

association between intuitive eating and positive affect. Subscale scores for intuitive

eating were also assessed in two of three studies. Positive affect correlated with

higher scores on all subscales, except the Unconditional Permission to Eat subscale

(Tylka & Kroon Van Diest, 2013; Tylka & Wilcox, 2006).

In addition to aspects of affect and mood, two studies examined the

management of emotions in university students (Schoenefeld & Webb, 2013; Shouse

& Nilsson, 2011). Shouse and Nilsson (2011) demonstrated that higher levels of

intuitive eating were associated with greater emotional awareness and less self-

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silencing of emotions. Schoenefeld and Webb (2013) found a positive association

between intuitive eating and distress tolerance. Correlations between total intuitive

eating scores and positive emotional functioning ranged from .21 to .29 in size.

Correlations between total intuitive eating scores and negative emotional functioning

ranged from -.28 to -.36 in size. Correlations between each subscale of the IES-T and

emotional functioning were similar, except for the Unconditional Permission to Eat

subscale, which did not correlate with positive affect. Correlations for the two

remaining subscales of the IES-T ranged from -.15 to -.31 for negative emotional

functioning and .18 to .33 for positive emotional functioning.

Other Psychosocial Correlates

Twenty studies examined the association between intuitive eating and one or

more psychosocial correlates that could not be categorised into eating attitudes and

behaviours, body image or emotional functioning. Five studies (Augustus-Horvath &

Tylka, 2011; Avalos & Tylka, 2006; Kroon Van Diest & Tylka, 2010; Oh et al.,

2012; Tylka & Homan, 2015) assessed the perceived acceptance of weight and shape

by others using the 10-item Body Acceptance by Others Scale (Avalos & Tylka,

2006). Intuitive eating was associated with greater body acceptance by others among

women aged 18 to 65 years (Augustus-Horvath & Tylka, 2011), female university

athletes (Oh et al., 2012) and physically active university students (Tylka & Homan,

2015), and undergraduate psychology students (Avalos & Tylka, 2006; Kroon Van

Diest & Tylka, 2010).

Three studies examined women’s (Iannantuono & Tylka, 2012; Kroon Van

Diest & Tylka, 2010) or their parent’s (Galloway et al., 2010) retrospective reports of

eating messages delivered by caregivers. Findings were dependent on the type of

eating message. Two studies showed intuitive eating was negatively associated with

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restrictive or critical messages (Iannantuono & Tylka, 2012; Kroon Van Diest &

Tylka, 2010). Galloway and colleagues (2010) reported an inverse correlation

between the Eating for Physical Reasons subscale of Tylka’s IES-T (2006) and

messages relating to the restriction and monitoring of food intake, however, no

association was found for remaining IES-T subscales with caregiver messages of

restriction or monitoring of food intake. No association was found for intuitive eating

and pressure to eat messages from caregivers in both studies which examined this

type of message (Galloway et al., 2010; Iannantuono & Tylka, 2012).

Other factors shown to correlate with higher levels of intuitive eating

included self-esteem (Schoenefeld & Webb, 2013; Tylka, 2006; Tylka & Kroon Van

Diest, 2013; Tylka & Wilcox, 2006), self-compassion (Schoenefeld & Webb, 2013),

unconditional self-regard (Tylka & Wilcox, 2006), responsiveness to internal bodily

sensations (Dittmann & Freedman, 2009), greater life satisfaction (Tylka, 2006;

Tylka et al., 2015; Tylka & Kroon Van Diest, 2013), optimism (Tylka, 2006; Tylka

& Wilcox, 2006), an autonomy-supportive interpersonal style of a woman’s mother

with regards to eating behaviours (Carbonneau et al., 2015) and perceived social

support (Augustus-Horvath & Tylka, 2011). Studies have also shown that intuitive

eating correlates positively with proactive coping (Tylka, 2006; Tylka & Wilcox,

2006), psychological hardiness, and social problem solving (Tylka & Wilcox, 2006).

The three studies that assessed individual subscales of the original and revised IES-T

demonstrated relationships consistent with the total scale, except the Unconditional

Permission to Eat subscale did not correlate with the life satisfaction (Tylka & Kroon

Van Diest, 2013), proactive coping (Tylka, 2006), or social problem solving (Tylka

& Wilcox, 2006).

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In addition, studies demonstrated that total and subscale scores of intuitive

eating correlated negatively with internalisation of the thin ideal (Tylka, 2006; Tylka

& Kroon Van Diest, 2013), pressure for thinness from others (Tylka, 2006), and poor

interoceptive awareness (Tylka, 2006; Tylka et al., 2015; Tylka & Kroon Van Diest,

2013). Eating intuitively also correlated negatively with a controlling interpersonal

style of a woman’s mother, in terms of eating behaviour (Carbonneau et al., 2015),

and attachment style and perfectionistic traits, including: an anxious or avoidant

attachment style (Iannantuono & Tylka, 2012), an anxious or insecure attachment to

God (Homan et al., 2013), self-oriented perfectionism (applying unrealistic standards

and scrutiny to one’s self) (Brown et al., 2012) and discrepancy perfectionism

(perceiving a discrepancy between self-imposed standards and performance)

(Iannantuono & Tylka, 2012).

Two studies examined intuitive eating in relation to motivation for physical

activity. Gast and colleagues (2015) examined four types of motivation using the

IES-H (Hawks et al., 2004). Total intuitive eating scores correlated negatively with

motivation based on external pressures and feelings of guilt or shame, and correlated

in a positive direction with motivation based on feelings of pleasure. Findings varied

when subscales of the IES-H were examined. Only one of four IES-H subscales

correlated negatively with motivation for physical activity based on external

pressures (Antidieting subscale); three of four subscales correlated negatively with

motivation based on feelings of guilt or shame (Extrinsic eating, Antidieting and

Self-care subscales); and only two of four subscales (Antidieting, Self-care

subscales) positively correlated with motivation based on feelings of pleasure. Tylka

and Homan (2015) used the IES-T to examine intuitive eating in relation to exercise

motivation in physically active university students. Total intuitive eating scores were

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inversely associated with motivation to exercise based on appearance-related

reasons.

Factors that did not correlate with intuitive eating included: high standards

perfectionism (setting goals that are realistic, motivating and encouraging), order

perfectionism (a focus on organisation and order) (Iannantuono & Tylka, 2012),

spiritual readiness (Dittmann & Freedman, 2009), an avoidant attachment to God and

trust in parental relationships (Homan et al., 2013), and the interpersonal style of a

woman’s partner with regards to eating behaviour (autonomous-supportive or a

controlling interpersonal style) (Carbonneau et al., 2015). In addition, total scores of

intuitive eating did not correlate with physical activity motivation based on the value

placed on physical activity (Gast et al., 2015) or for functional reasons (Tylka &

Homan, 2015), and did not correlate with unconditional acceptance by others in

university athletes (Oh et al., 2012) or in one of the two student samples examined by

Avalos and Tylka (2006).

Discussion

The aim of this paper was to systematically review the literature on intuitive

eating and its relationship with other eating attitudes and behaviours, body image and

emotional functioning, in adult women. In addition, this review systematically

examined other psychosocial correlates that have been examined in relation to

intuitive eating. This review has furthered our understanding of intuitive eating and

highlighted areas that require additional research.

Intuitive eating is viewed as promoting a healthy relationship with food by

discouraging restrictive eating, emotional eating, and eating in response to external

cues (Tribole & Resch, 2012). More specifically, intuitive eating is viewed as

promoting eating in response to bodily cues for hunger and satiety and permits

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women to eat unconditionally, thus removing rules for what, when and how much to

eat. On the whole, the findings of this review showed that intuitive eating, when

assessed with total scores, was inversely related to disordered eating and dieting,

with moderate to high correlations. However, it is also important to consider the

intuitive eating subscales. This review showed that in all three studies that examined

the IES-T subscales, the Unconditional Permission to Eat subscale demonstrated the

highest correlation with disordered eating (Tylka, 2006; Tylka & Kroon Van Diest,

2013; Tylka & Wilcox, 2006), thus suggesting that this feature of intuitive eating is

less conceptually distinct from disordered eating (Tylka & Kroon Van Diest, 2013;

Tylka & Wilcox, 2006). The Eating for Physical Reasons subscale and the Reliance

on Hunger/Satiety Cues subscale demonstrated small to medium correlations with

disordered eating, while the Body-Food Choice Congruence subscale was unrelated

with disordered eating, thus suggesting that these three aspects of intuitive eating are

more conceptually distinct from disordered eating. Studies which examine the factor

structure of the IES-T in relation to measures of disordered eating are now needed to

more fully address this question.

Research is also emerging that supports intuitive eating as an effective

intervention for reducing dieting attitudes and behaviours. For example, a 15-week

classroom-based program that encouraged hunger-based eating led to a decrease in

dieting in college females (Hawks, Madanat, Smith & De La Cruz, 2008); and a 10-

week group-based program that promoted the ten principles of intuitive eating (as

proposed by Tribole & Resch, 1995) reduced dieting attitudes in female military

spouses (Cole & Horacek, 2010). A review by Schaefer and Magnuson (2014) has

shown interventions that have implemented intuitive eating principles reduced

disordered eating practices such as dieting, disinhibited eating and binge eating.

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There is limited research on intuitive eating and its association with other

eating patterns in adult women, such as emotional eating and external eating.

Emotional eating describes eating in response to negative emotions and external

eating describes eating in response to food-related cues (Van Strien et al., 1986).

None of the 24 studies examined in this systematic review investigated these eating

patterns. One study that was ineligible for inclusion in this review, due to the

inclusion of males in the sample and not analysing findings by gender, examined

intuitive eating in relation to emotional eating and uncontrolled eating (i.e. loss of

control over food intake that results in overeating) in a sample of French adults

(Camilleri et al., 2015). Total intuitive eating scores were moderately to strongly and

inversely correlated with both the emotional eating and uncontrolled eating subscales

of the revised Three Factor Eating Questionnaire (Tholin, Rasmussen, Tynelius, &

Karlsson, 2005). However, findings varied when examining the intuitive eating

subscales, thus again highlighting the importance of using the subscales and not

relying exclusively on the total scores. The Unconditional Permission to Eat subscale

did not correlate with uncontrolled eating and showed a weak correlation with

emotional eating; the Reliance on Hunger/Satiety Cues subscale was weakly

correlated with both emotional and uncontrolled eating; but the Eating for Physical

Reasons subscale correlated strongly with both emotional and uncontrolled eating

(Camilleri et al. 2015). Further studies, using the subscales of the IES-T, are needed

to investigate these relationships, given intuitive eating is hypothesised to discourage

eating based on non-physiological cues and eating to regulate emotions.

This review further showed that intuitive eating correlated with aspects of

positive body image such as body appreciation and body satisfaction; and other

psychosocial factors associated with body image in women, such as self-esteem,

perceived acceptance of weight and shape by others, pressure for thinness, and

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internalisation of the thin-ideal (e.g., Green & Pritchard, 2003; Lewis & Cachelin,

2001; Lowery et al., 2005; Tylka & Hill, 2004; Webster & Tiggemann, 2003). This

contrasts with research that shows that disordered eating practices, which are often

employed for the purpose of modifying weight and shape to improve appearance

(O’Brien et al., 2007; Putterman & Linden, 2004), are associated with greater weight

and shape concerns in women (Quick & Byrd-Bredbenner, 2012) and greater body

dissatisfaction (Putterman & Linden, 2004). Intuitive eating is viewed as promoting

respect and care of the body, realistic expectations of body size, and discourages

women from making body comparisons and engaging in negative self-talk about

body size and shape (Tribole & Resch, 2012).

Non-dieting approaches (Clifford et al., 2015) and interventions that promote

principles of intuitive eating (i.e., eating based on internal cues of hunger and satiety)

(Schaefer & Magnuson, 2014) have demonstrated improvements in body image,

including: reduced weight concerns and increased perceived sexual attractiveness

(Hawks et al., 2008), and improvements in body image avoidance and body

dissatisfaction (Bacon et al., 2002; Bacon et al., 2005; Jackson, 2008). In addition,

these interventions have also reduced the drive for thinness and internalisation of the

thin-ideal (Schaefer & Magnuson, 2014).

This review also showed that intuitive eating correlated with positive

emotional functioning in women. This is consistent with not using food to cope with

emotions, another principle of intuitive eating (Tribole & Resch, 2012). This

contrasts with research demonstrating that restrictive and disordered eating practices

are associated with depressive symptomatology and poor emotional regulation

(Ackard, Croll & Kearney-Cooke, 2002; Gillen, Markey & Markey, 2012). In

intuitive eating, emphasis is placed on being able to distinguish between biological

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and emotional hunger and regulate emotions with alternative strategies. In our view,

it is also possible that the relationship between intuitive eating and emotional

functioning may be bidirectional, that is, women may eat more intuitively in the

absence of negative emotions but they may also experience more positive emotions

as a consequence of intuitive eating. Studies are now needed to test this hypothesis.

Other psychosocial correlates of intuitive eating that were found in this

review included the awareness and responsiveness of women towards bodily states

(e.g., sensations, emotions, hunger and satiety) and motivation to engage in physical

activity. Greater awareness and responsiveness to bodily states is related to the

feature of intuitive eating that focuses on eating based on internal cues for

hunger/satiety (Tribole & Resch, 2012). In addition, intuitive eating encourages an

attitude towards physical activity that is not focused on calorie-burning for weight

control. Instead, the approach is focused on the body’s response to exercise and the

enjoyment of being physically active (Tribole & Resch, 2012). In line with this

principle, studies showed that intuitive eating correlated with greater motivation to

engage in physical activity when focused on feelings of pleasure (Gast et al., 2015),

and less motivation when focused on feelings of pressure or guilt (Gast et al., 2015)

or appearance (Tylka & Homan, 2015).

Limitations and Recommendations for Future Research

A limitation of the reviewed studies is that all studies used a cross-sectional

design. Thus, no conclusion about the cause-effect relationship between intuitive

eating and psychosocial correlates is possible. Prospective studies with a range of

follow up intervals are needed to verify these cross-sectional findings. This would

allow an examination of intuitive eating and these correlates over time to assess if

intuitive eating is an approach that may improve women’s psychological health and

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well-being. Studies that have examined other eating behaviours, such as disordered

eating, have included follow up intervals as short as five and a half months (Lowe et

al., 2013) to nine months (Stice, 2002), and longer term intervals from two to 10

years (e.g., Goldschmidt et al., 2012; Skinner, Haines, Austin, & Field, 2012;

Sonneville et al., 2013)

Studies were also limited with regards to sample characteristics. This review

showed that intuitive eating has been examined primarily among female university

students, who reported their ethnicity as Caucasian and lived in the United States.

The sample size of some studies was also small. For example, Brown et al.’s (2012)

study included 48 female university students and Galloway et al.’s (2010) study

included 71 female university students. It is recommended that future studies

examine more diverse samples of adult women with a focus on different age and

ethnic groups, level of education, and socioeconomic status. It also needs to be noted

that 12 of 24 studies of studies included Tylka as an author. However, a comparison

of findings between Tylka’s studies and the remaining 12 reviewed studies showed

similar findings.

Only one of 24 studies (Gast et al., 2015) used the intuitive eating measure

developed by Hawks et al. (2004). There have been no studies directly comparing the

two different measures of intuitive eating (the IES-T and IES-H). However, the IES-

H has demonstrated lower internal consistency than Tylka’s IES-T (2006). Also,

some subscales of the IES-H (Hawks et al., 2004) have been found to demonstrate

inadequate or low Cronbach’s coefficient alphas (e.g., .22 to .43 for Intrinsic Eating

and .49 to .68 for Self-care) (e.g., Gast et al., 2015; Hawks et al., 2004; Hawks,

Merrill, Madanat, & Miyagawa, Suwanteerangkul, Guarin et al., 2004), and poorer

test-retest reliability in comparison to subscales of Tylka’s IES-T (e.g., Hawks et al.,

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2004). Several of the psychosocial correlates have also not been examined as

extensively as disordered eating, body image and emotional functioning. Moreover,

the assessment of intuitive eating and psychosocial correlates across all reviewed

studies was conducted using self-reports. Experimental and prospective cohort

studies are now needed to verify findings.

Traditional methods of weight control encourage restrictive eating practices.

However, research suggests these methods are largely ineffective for weight loss and

maintenance in the longer term, they increase the risk of disordered eating, and have

been associated with poor psychological health and well-being (Appleton &

McGowan, 2006; Goldschmidt et al., 2012; Hawks, Madanat, & Christly, 2008;

Mann et al., 2007). Intuitive eating has been proposed as a non-dieting approach that

aims to address unhealthy attitudes towards food, the body and physical activity.

This systematic review showed that intuitive eating is associated with lower levels of

disordered eating, a more positive body image, and positive emotional functioning.

However, further studies are needed to build on the cross-sectional findings of

current research. Future research in this area will help establish if intuitive eating is

an approach that could prevent and/or reduce disordered eating practices, body image

concerns, and negative emotional functioning.

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CHAPTER FOUR

Empirical study: Introduction and Method

This chapter provides the background, aims and method for the empirical

study that was conducted for this thesis. The first aim was to test the factor structure

of the IES (Tylka, 2006) in a community sample of adult women. The second aim

was to examine the three intuitive eating factors (i.e., unconditional permission to

eat, eating for physical rather than emotional reasons, reliance on hunger/satiety

cues) in relation to the following eating behaviours: dieting, restrained eating,

bulimia/food preoccupation, emotional eating, and external eating. The third aim of

the empirical study was to examine and compare the psychosocial correlates of these

eating patterns. These psychosocial factors were found to be associated with intuitive

eating in the systematic review conducted for this thesis. In addition, these were

psychosocial correlates that are specific to the acceptance model of intuitive eating

(Augustus-Horvath & Tylka, 2011; Avalos & Tylka, 2006) or the dual pathway

model of disordered eating (Stice, 2001; Stice & Agras, 1998). Psychosocial

correlates derived from the acceptance model included: perceived social support,

body acceptance by others, body function, and body appreciation (Augustus-Horvath

& Tylka, 2011). Psychosocial correlates derived from the dual pathway model

included: pressure for thinness, internalisation of the thin-ideal, body dissatisfaction,

and negative affect (Stice, 2001).

Previous intuitive eating studies have focused on young adult women,

perhaps due to the typical onset of disordered eating during adolescence and early

adulthood (Favaro, Caregaro, Tenconi, Bosello, & Santonastaso, 2009). However,

research shows that for women, disordered eating and body image concerns are

experienced across the lifespan (Fulton, 2016; Lewis & Cachelin, 2001; Mangweth-

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Matzek, Hoek, Rupp, Lackner-Seifert, Frey, Whitworth et al., 2014; Slevec &

Tiggemann, 2011). Therefore, the empirical study set out to address this limitation in

previous research by examining intuitive eating in relation to other eating patterns

and psychosocial correlates in a community sample of adult women. At the time the

empirical study commenced, the IES (Tylka, 2006) had not been used with adult

men, and there were limited studies that had examined intuitive eating in the adult

male population.

Factor Structure of IES

In the initial study that developed and validated the IES using a female

university student sample, the three-factor structure of the scale was demonstrated

(Tylka, 2006). Nine items loaded onto the unconditional permission to eat factor, six

items loaded onto the eating for physical rather than emotional reasons factor, and

six items loaded onto the reliance on hunger/satiety cues factor. Since the initial

study by Tylka (2006), there has been no further examination of the factor structure

of the scale, yet studies have used the scale in samples that have varied according to

age (e.g., Augustus-Horvath & Tylka, 2011) and gender (e.g., Galloway Farrow, &

Martz, 2010; Tylka & Homan, 2015), and the scale has been used in non-student

samples (e.g., Madden et al., 2012). Given that the factor structure of the original IES

(Tylka, 2006) has only been tested in a student sample, it is important to examine the

scale’s properties in other samples of women. Thus, the first aim of the empirical

study was to test the factor structure of the original IES (Tylka, 2006) in a

community sample of women ranging in age, education, and BMI.

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The Association between Intuitive Eating and Other Eating Behaviours

The second aim of the empirical study was to examine the three intuitive

eating factors in relation to other eating behaviours. Distinguishing intuitive eating

from other eating patterns, particularly disordered eating, is an important step in

establishing if intuitive eating is a style of eating that could be promoted to prevent

or treat disordered eating. Components of intuitive eating that overlap with aspects of

disordered eating might be incorporated into interventions designed to prevent or

treat disordered eating, whereas more distinct aspects of intuitive eating might be

used to promote a positive relationship with food and eating more generally.

Disordered eating can incorporate a range of eating practices including: dieting or

restrained eating, and binge eating (Eating Disorders Victoria, 2015; National Eating

Disorders Collaboration, 2015; Pereira & Alvarenga, 2007). Dieting or restrained

eating, which are often used interchangeably, is a restrictive eating practice used for

controlling body weight, and this eating pattern occurs in both normal weight and

overweight populations (e.g., Fayet, Petocz, & Samman, 2012; Kenardy et al., 2001).

Some researchers argue that dieting is a temporary state of calorie restriction to

encourage weight loss (Allen, Byrne, & McLean, 2012; Tomiyama, Ahlstrom, &

Mann, 2013; Williamson, Martin, York-Crowe, Anton, Redman, Han et al., 2007)

whereas restrained eating involves an intention to restrict or monitor food intake to

avoid weight gain (Lowe & Levine, 2005; Williamson et al., 2007) but does not

necessarily lead to reduced calorie intake (Lowe et al., 2013; Stice, Sysko, Roberto &

Allison, 2010). Both dieting and restrained eating are viewed as ineffective for long-

term weight loss (Mann et al., 2007; Sarlio-Lahteenkorva et al., 2000; Field et al.,

2003; Neumark-Sztainer et al., 2012) and are negatively associated with

psychological well-being (Abrantes, Strong, Ramsey, Lewinsohn, & Brown 2006).

Intuitive eating was proposed as an alternative eating style that removes the focus on

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weight control and targets factors associated with restrictive and other disordered

eating practices, including: a focus on eating for satisfaction and nourishment of the

body instead of for weight control; engaging in physical activity for the enjoyment

rather than for modifying/maintaining weight and shape; and encouraging body

acceptance rather than focusing on achieving an ideal body weight and shape

(Tribole & Resch, 2012).

As highlighted in the systematic review conducted for this thesis, intuitive

eating has been investigated in adult women in relation to disordered eating. The

systematic review demonstrated that the unconditional permission to eat component

of intuitive eating was less conceptually distinct from disordered eating

symptomatology, including dieting and bulimia/food preoccupation, whereas the

eating for physical rather than emotional reasons and reliance on hunger/satiety cues

components were found to be more conceptually distinct from aspects of disordered

eating.

Two of the reviewed studies examined the distinctiveness of intuitive eating

from disordered eating using the original IES (Tylka & Wilcox, 2006) and the

revised IES-2 (Tylka & Kroon Van Diest, 2013). Tylka and Wilcox (2006) examined

the distinctiveness of intuitive eating from disordered eating symptomatology (i.e.,

dieting, bulimia/food preoccupation) in a sample of female psychology

undergraduate students, aged 17 to 30 years (Tylka & Wilcox, 2006). The study

assessed the unique contribution of the three intuitive eating components for

indicators of psychological well-being, by controlling for the contribution of

disordered eating as assessed by dieting and bulimia/food preoccupation subscales

from the EAT-26 (Garner et al., 1982). The eating for physical rather than emotional

reasons and reliance on hunger/satiety cues aspects of intuitive eating both

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contributed uniquely to positive affect, optimism, psychological hardiness, self-

esteem, unconditional self-regard, proactive coping, social problem solving.

Unconditional permission to eat did not contribute uniquely to any of these indicators

of psychological well-being, above that of dieting and bulimia/food preoccupation.

Thus, in contrast to unconditional permission to eat, the two other subscales of the

IES (eating for physical rather than emotional reasons and reliance on hunger/satiety

cues) were more distinct from disordered eating.

In the second study, Tylka and Kroon Van Diest (2013) used the same

approach as Tylka and Wilcox (2006) in examining the distinctiveness of the

components of intuitive eating from disordered eating symptomatology, in a sample

of male and female university students aged 18 to 53 years. However, the study also

examined the body-food choice congruence subscale that is included in the IES-2

(Tylka & Kroon Van Diest, 2013). The unique contribution of the four intuitive

eating components to indicators of psychological well-being was assessed after

controlling for the contribution of disordered eating. Overall disordered eating

symptomatology was assessed using total scores on the EAT-26 (Garner et al., 1982).

For women in the sample, eating for physical rather than emotional reasons

contributed uniquely to self-esteem, negative affect, and life satisfaction; reliance on

hunger/satiety cues uniquely predicted self-esteem and positive affect; and body-food

choice congruence contributed uniquely to self-esteem, positive affect, and negative

affect. Unconditional permission to eat did not uniquely predict any indicators of

psychological well-being above that of disordered eating, which is in line with

findings of Tylka and Wilcox (2006), demonstrating that unconditional permission to

eat overlapped with disordered eating. The findings of both studies suggest that

unconditional permission to eat may be assessing eating behaviours that are already

covered by disordered eating, although given the wording of the items and how the

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scale is scored, higher scores on unconditional permission to eat represent lower

levels of disordered eating.

Three studies published since the systematic review was conducted have also

examined how each of the IES subscales relates to other eating behaviours

(Anderson, Reilly, Schaumberg, Dmochowski, & Anderson, 2016; Camilleri et al.,

2015; van Dyck et al., 2016). Anderson and colleagues (2016) examined restrained

eating, an overall measure of disordered eating, and mindful eating (i.e., non-

judgmental awareness of physical and emotional sensations associated with eating)

using the restraint subscale of the Three Factor Eating Questionnaire (Stunkard &

Messick, 1985), the Eating Disorder Diagnostic Scale (Stice, Telch, & Rizvi, 2000),

and the Mindful Eating Questionnaire (Framson, Kristal, Schenk, Littman, Zeliadt, &

Benitez, 2009). Camilleri and colleagues (2015) examined restrained eating,

emotional eating and uncontrolled eating (i.e., loss of control over food intake that

results in overeating) using a French version of the Three Factor Eating

Questionnaire (de Lauzon, Romon, Deschamps, Lafay, Borys, Karlsson et al., 2004).

Van Dyck and colleagues examined restrained eating, emotional eating, and external

eating using the German version of the Dutch Eating Behaviour Questionnaire

(Grunert, 1989), and symptoms of bulimia using the German version of the Eating

Disorder Inventory-2 (Paul & Thiel, 2005).

Similar to Tylka and Wilcox (2006), the unconditional permission to eat

subscale was found to overlap with disordered eating in that it was moderately to

strongly associated with restrained eating (Anderson et al., 2016; Camilleri et al.,

2015; van Dyck et al., 2016) and moderately to strongly associated with disordered

eating symptomatology (Anderson et al., 2016; van Dyck et al., 2016). However,

unconditional permission to eat was only weakly associated with emotional eating

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(Camilleri et al., 2015; van Dyck et al., 2016) and external eating (van Dyck et al.,

2016), and it was not associated with uncontrolled eating in French adults (Camilleri

et al., 2015) or mindful eating in female university students (Anderson et al., 2016).

Overall, the eating for physical rather than emotional reasons subscale was

found to overlap substantially with emotional eating, uncontrolled eating, and

symptoms of bulimia. Eating for physical rather than emotional reasons was strongly

associated with emotional eating (Camilleri et al., 2015; van Dyck et al., 2016),

uncontrolled eating (Camilleri et al., 2015), and symptoms of bulimia (van Dyck et

al., 2016), and moderately associated with overall disordered eating symptoms

(Anderson et al., 2016). In addition, the subscale was moderately related to external

eating (van Dyck et al., 2016) and mindful eating (Anderson et al., 2016). For

restrained eating, eating for physical rather than emotional reasons was weakly

associated with restrained eating in two studies (Camilleri et al., 2015; van Dyck et

a., 2016), however, it was not related to restrained eating in a third study of female

university students (Anderson et al., 2016).

The relationship between the reliance on hunger/satiety cues subscale and

aspects of disordered eating was consistent with relationships reported in previous

studies included in the systematic review (Tylka, 2006; Tylka & Kroon Van Diest,

2013; Tylka & Wilcox, 2006). Reliance on hunger/satiety cues was moderately

associated with overall disordered eating symptoms in female university students

(Anderson et al., 2016). In addition, reliance on hunger/satiety cues was only weakly

associated with restrained eating in French adults (Camilleri et al., 2015), and was

not associated with restrained eating in female university students (Anderson et al.,

2016). However, an exception was one study (van Dyck et al., 2016) whose findings

were not consistent with previous studies. In a sample of mostly German adult

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women, reliance on hunger/satiety cues overlapped with aspects of disordered eating

(van Dyck et al., 2016), with reliance on hunger/satiety cues being strongly

associated with restrained eating and symptoms of bulimia (van Dyck et al., 2016).

Other eating patterns not assessed in the systematic review demonstrated less overlap

with reliance on hunger/satiety cues in these three studies. This subscale of the IES

was only weak to moderately associated with emotional eating (Camilleri et al.,

2015; van Dyck et al., 2016), only weakly associated with uncontrolled eating

(Camilleri et al., 2015) and external eating (van Dyck et al., 2016), and was not

associated with mindful eating (Anderson et al., 2016). This suggests that there is

less overlap between the reliance on hunger/satiety cues subscale and other eating

patterns.

The empirical study for this thesis was specially designed to further examine

the three IES subscales in relation to other eating patterns. These included dieting,

restrained eating, bulimia and food preoccupation, emotional eating and external

eating. At the time the empirical study commenced, only one study (Tylka & Wilcox,

2006) had examined the IES subscales in relation to disordered eating. Subsequent

studies used revised versions of the IES and used student samples, with the exception

of Camilleri et al. (2015). Based on the previous studies, it was expected that

unconditional permission to eat would correlate moderately to strongly but

negatively with dieting, restrained eating, and bulimia/food preoccupation. In

addition, it was expected that eating for physical rather than emotional reasons would

correlate moderately to strongly but negatively with emotional eating, external

eating, and bulimia/food preoccupation. Lastly, it was expected that reliance on

hunger/satiety cues would correlate weakly to moderately but negatively with all

other eating patterns.

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Psychosocial Correlates of Intuitive Eating and Other Patterns of Eating

The last aim of the empirical study conducted for this thesis was to compare

the psychosocial correlates of intuitive eating with those of other eating patterns. To

date, no studies have directly compared the psychosocial correlates of the three IES

subscales with other eating patterns, including disordered eating. Understanding the

psychosocial factors that predict an intuitive eating style is an important step in

determining how intuitive eating may develop and is maintained. Moreover,

establishing what factors predict intuitive eating and how these may be different

and/or similar to disordered eating will inform interventions designed to prevent or

reduce disordered eating and other eating patterns not based on internal cues, and

promote more positive eating patterns.

The systematic review of the psychosocial correlates of intuitive eating

conducted as part of this thesis demonstrated that several psychosocial factors are

associated with intuitive eating in adult women. These included body image,

emotional functioning, body acceptance by others, societal pressure for thinness,

internalisation of the thin-ideal, and perceived social support. Several of these factors

have also been shown to be associated with disordered eating. These include: societal

pressure for thinness, internalisation of the thin-ideal, body image (e.g., body

dissatisfaction), and negative affect (Pennesi & Wade, 2016; Stice, 2002). However,

a direct comparison of the psychosocial correlates of intuitive eating to those of

disordered eating has yet to be conducted. Thus, this empirical study was designed to

also examine the bivariate associations between each of the above psychosocial

correlates with the three components of intuitive eating, and each of the psychosocial

correlates with the other included eating patterns.

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In addition to examining bivariate relationships, the acceptance model of

intuitive eating and a modified version of the dual pathway model of disordered

eating5 were also examined. Given that these models have been developed from

different theoretical viewpoints, it was expected that these would further assist in

better understanding both the similarities and differences between intuitive eating

and disordered eating.

The acceptance model of intuitive eating describes the sociocultural and

psychological factors that influence patterns of intuitive eating among women

(Avalos & Tylka, 2006). However, unlike models of disordered eating, the focus is

on a set of positively-framed psychosocial factors (Augustus-Horvath & Tylka,

2011). These factors include: unconditional acceptance by others; body acceptance

by others; resisting an observer perspective of the body (or a focus on body

function); and body appreciation (Augustus-Horvath & Tylka, 2011). Unconditional

acceptance is proposed to predict body acceptance by others, which predicts a focus

on body function and body appreciation; and body function and body appreciation

are proposed to predict intuitive eating (Augustus-Horvath & Tylka, 2011).

Avalos and Tylka (2006) first tested the acceptance model in a sample of 181

female psychology students. A path analysis was conducted to test the relationship

between each of the four psychosocial factors and intuitive eating. The path analysis

demonstrated a non-significant relationship between general unconditional

acceptance by others and body function; hence the model was revised and retested. It

was shown that body function and body appreciation mediated the relationship

5 The dual pathway model was modified as a result of principal axis factoring conducted in the first

part of the empirical study (Chapter five). Dieting and bulimia/food preoccupation loaded onto the

first eating factor labelled ‘disordered eating’. Due to this eating factor being examined as an outcome

of the dual pathway model, dieting was not included as a separate variable in the model. Instead of a

path from body dissatisfaction to dieting and disordered eating, the modified dual pathway model

incorporated a path directly from body dissatisfaction to disordered eating.

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between body acceptance by others and intuitive eating. Approximately 42.5% of the

variance in intuitive eating was contributed by body appreciation and body function.

Overall, the study provided preliminary support for the acceptance model of intuitive

eating.

In a subsequent study, Augustus-Horvath and Tylka (2011) examined the

acceptance model among 801 women aged 18 to 65 years, who were mostly

university students. Women were categorised by age into three groups: emerging (18

to 25 years), early (26 to 39 years) and middle (40 to 65 years) adulthood. Perceived

social support was examined in place of unconditional acceptance by others. The

model fit the data for all three age groups of women. Higher levels of intuitive eating

were predicted by greater body appreciation and a focus on body function. Perceived

social support predicted body acceptance by others, and body acceptance by others

predicted body function. Overall, the model accounted for 40% to 50.8% of variance

in intuitive eating among emerging, early and middle adult women.

In another study, Oh and colleagues (2012) tested the acceptance model in a

sample of 160 female university athletes aged 18 to 23 years. They examined

unconditional acceptance by others as in the original study by Avalos and Tylka

(2006). As with the previous study (Avalos & Tylka, 2006), general unconditional

acceptance from others did not predict body function. Body appreciation and body

function predicted intuitive eating, body acceptance by others predicted body

function and body appreciation, and unconditional acceptance from others predicted

body acceptance by others. The findings of this study demonstrated that the

acceptance model extends to female athletes.

The extent to which the positively framed psychosocial correlates from the

acceptance model may also predict lower levels of disordered eating has yet to be

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investigated. However, several of the factors that have been shown to predict

disordered eating have been found to be associated with lower levels of intuitive

eating. These include the main components of the dual pathway model: societal

pressure for thinness, internalisation of the thin-ideal, body dissatisfaction, dieting,

and negative affect (Stice, 2001; Stice & Agras, 1998).

The dual pathway model is a prominent theoretical model in the literature

(Pennesi & Wade, 2016). The model posits that body dissatisfaction leads to

disordered eating through two pathways: either through dieting practices or negative

affect. Body dissatisfaction is proposed to occur as a consequence of experiencing

societal pressure for thinness and internalisation of the thin-ideal (Stice, 2001). The

dual pathway model has been examined in young women and adolescents (e.g.,

Allen, Byrne, & McLean, 2012; Dakanalis, Timko, Carrà, Clerici, Zanetti, Riva, et

al., 2014; Stice, Nemeroff, & Shaw, 1996; Urvelyte & Permnias, 2015) and has

received support in both normative and clinical samples of women (e.g., Stice et al.,

2011; Van Strien, Engels, Van Leeuwe, & Snoek, 2005). As highlighted in the

systematic review, each of the individual components of the model have been found

to be associated with lower levels of intuitive eating, according to the total IES and

each subscale (Tylka, 2006; Tylka et al., 2015; Tylka & Kroon Van Diest, 2013),

however, the full model with the IES subscales as outcome variables has yet to be

examined.

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Method

Participants

The participants were 457 Australian women aged between 18 and 87 years,

with a mean age of 38.15 (SD 15.40). The majority of women identified with an

Australian and/or British/European background (89.3%), were married or in a de

facto relationship (61%), had gained tertiary qualifications (62.1%), and were

engaged in full-time or part-time work (62.2%). The sample had a mean BMI of

26.11 kg/m2 (SD 6.85). According to BMI classification, 51.3 % of women were of a

normal weight and 43.8% were classified as overweight or obese. A large portion of

the sample (n=145) reported a health condition that may affect their food intake

(31.7%). This included gastrointestinal issues or food allergies, diabetes (Type I and

II), physical conditions such as hypertension, high cholesterol, a current/historical

cancer diagnosis, and current/historical psychological difficulties such as depressive

symptomatology or an eating disorder diagnosis. Given the proportion of women

who identified themselves as having a health condition that may affect their food

intake, these women were not excluded from the study in order for the sample to be

more representative of the wider population. Sample characteristics are summarised

in Table 4.1.

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Table 4.1

Sample Characteristics

N %

Age

18-24 100 21.9

25-44 219 47.9

45-64 108 23.6

65+ 30 6.6

Relationship status

Married 176 38.5

Divorced 22 4.8

De facto 103 22.5

Separated 13 2.8

Widowed 9 2.0

Single 134 29.3

Ethnic/cultural background

Australian 262 57.3

British/Irish 84 18.4

European 54 11.9

Asian 27 5.9

Indigenous Australian 8 1.8

Other 22 4.7

Education level

Secondary education 86 18.8

Certificate/advanced diploma 80 17.6

Bachelor/graduate certificate 155 33.9

Postgraduate degree 129 28.2

Other 7 1.5

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N %

Work status

Full time 159 34.8

Part time 125 27.4

Casual 68 14.9

Unemployed 18 3.9

Student 78 17.1

Retired 31 6.8

Other 27 5.9

BMI

Underweight 18 3.9

Normal weight 239 52.3

Overweight 95 20.8

Obese 105 23.0

Health condition

Gastrointestinal issues/food

allergies

Modified diet with no medical

basis

Diabetes (Type I or II)

Other physical condition

Psychological condition

Pregnancy/breastfeeding

Eating Disorder

Other

72

17

12

17

9

8

6

4

15.8

3.7

2.6

3.7

2.0

1.8

1.3

1.6

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Measures

Background information. Participants were asked to report their age (in years

and months), their ethnic/cultural background, relationship status, level of education,

and their current work status. In addition, participants were asked to describe any

health conditions or factors that may influence their food intake (i.e., “Please indicate

if there are any health conditions or other factors that influence your eating attitudes

or behaviours.”).

Weight status. Weight status was assessed using BMI. BMI is a weight-for-

height index calculated by dividing weight (kg) by the square of height (metres)

(World Health Organisation, 2016). BMI was calculated using self-report measures

of height (cm) and weight (kg). Participants were categorised according to BMI

classification: underweight (<18.00 kg/m2), normal weight (18.00-24.99 kg/m2),

overweight (25.00-29.99 kg/m2), and obese (>30.00 kg/m2).

Intuitive eating. Intuitive eating was measured by the IES (Tylka, 2006). The

scale contains 21 items rated along a five-point scale, from one (strongly disagree) to

five (strongly agree). Thirteen items were reverse scored. Examples of items

included: “If I am craving a certain food, I allow myself to have it”, “I use food to

help me soothe my negative emotions” and “When I’m eating, I can tell when I am

getting full”. The three-factor solution was supported for this scale in female

university students (Tylka, 2006), representing three aspects of intuitive eating: (1)

unconditional permission to eat (nine items); (2) eating for physical rather than

emotional reasons (six items); and (3) reliance on hunger/satiety cues (six items).

Subscale scores for each of the three subscales were calculated by summing each

applicable item and obtaining an average score. For the purpose of this study, only

subscale scores were used. The IES has been shown to demonstrate good internal

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consistency, with Cronbach alphas ranging from .85 to .89 for the total scale

(Augustus-Horvath & Tylka, 2011; Avalos & Tylka, 2006; Kroon Van Diest &

Tylka, 2010; Tylka, 2006), and .72 to .87 for the three subscales (Tylka, 2006).

Construct validity of the scale has been established using measures of disordered

eating, body dissatisfaction, interoceptive awareness, and thin-ideal internalisation

(Tylka, 2006). Three-week test-retest reliability has also been found to be good for

the scale (Tylka, 2006).

Dieting. Dieting was assessed using the 13-item dieting subscale of the Eating

Attitudes Test (EAT-26; Garner et al., 1982). The EAT-26 is used as a screening tool

to assess eating disorder symptomology and the risk of developing an eating

disorder. Items in the dieting scale were rated on a six-point scale from 1 (never) to 6

(always). Examples of items include: “Aware of the calorie content of foods that I

eat”, “Feel uncomfortable after eating sweets”, and “I am terrified about being

overweight”. In the original version of the scale, items are recoded along a four-point

scale, however, the original version was normed in a clinical population with a non-

clinical comparison group (Garner et al., 1982). It has been suggested that scoring

with this method may affect skewness in a non-clinical population (Maïano, Morin,

Lanfranchi, & Therme, 2013). For the current study scores were calculated using the

items rated on a six-point scale. Tylka (2006) also used the six-point scale in

assessing disordered eating symptomatology, as have other researchers (e.g., Kroon

Van Diest & Tylka, 2010; Tylka & Kroon Van Diest, 2013). Item scores were

summed and averaged to provide a mean score for dieting, where higher scores were

indicative of a higher level of dieting. The EAT-26 was validated in a clinical sample

of 160 young adult females diagnosed with Anorexia Nervosa, and a comparison

group of 140 female university students (Garner et al., 1982). More recent research

has demonstrated criterion validity of the scale in clinical and non-clinical samples

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(e.g., Mintz & O’Halloran, 2000). Construct validity of the EAT-26 has been

evaluated against other measures of disordered eating in a clinical sample (Berland,

Thompson, & Linton, 1986). Strong correlations have been reported for the scale

with the EAT-40 (Garner & Garfinkel, 1979) and the Eating Inventory (Stunkard,

1981). High test-retest reliability has been demonstrated for the scale over a four to

five-week period (e.g., Banasiak, Wertheim, Koerner, & Voudouris, 2001), and the

dieting subscale has demonstrated acceptable internal consistency across studies

(e.g., Gleaves, Pearson, Ambwani, & Morey, 2014).

Bulimia and food preoccupation. Symptoms of bulimia and food

preoccupation were measured using the six-item bulimia and food preoccupation

subscale of the EAT-26 (Garner et al., 1982). Examples of items include: “Find

myself preoccupied with food” and “Have the impulse to vomit after meals”. Items

were rated on a six-point scale and the subscale score calculated according to

procedures followed for the dieting subscale of the EAT-26. Higher scores were

indicative of a greater degree of bulimic symptomatology and food preoccupation.

The bulimia and food preoccupation subscale has demonstrated acceptable internal

consistency (e.g., Gleaves, Pearson, Ambwani, & Morey, 2014).

Restrained eating. The restraint subscale of the Dutch Eating Behaviour

Questionnaire (DEBQ; Van Strien et al., 1986) was used to assess restrained eating.

The subscale includes 10 items rated along a five-point scale from 1 (seldom) to 5

(very often). In addition, items had a “non-relevant” response option. Examples of

items include: “Do you take into account your weight with what you eat?” and

“How often do you refuse food or drink offered because you are concerned about

your weight?”. Item scores were summed and averaged to provide a mean score.

Higher scores were indicative of higher levels of restrained eating. The restraint

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subscale has shown good internal consistency across studies (e.g., Dakanalis, Zanetti,

Clerici, Madeddu, Riva, & Caccialanza, 2013; Van Strien et al., 1986). The DEBQ

was validated in a community sample of normal weight and overweight adults (Van

Strien et al., 1986) and the three-factor structure (i.e., restrained eating, emotional

eating, external eating) has been validated in normative samples of adults,

overweight adults, and in adults diagnosed with Anorexia Nervosa and Bulimia

Nervosa (e.g., Wardle, 1987). High test-retest reliability has been demonstrated to be

high over a four to five-week period (Banasiak et al., 2001).

Emotional eating. The emotional eating subscale of the DEBQ (Van Strien et

al., 1986) was used to assess emotional eating. Thirteen items are rated along a five-

point scale from 1 (seldom) to 5 (very often), in addition to a “non-relevant” response

option. Examples of items include: “Do you have the desire to eat when you are

feeling lonely?” and “Do you have a desire to eat when you are bored or restless?”.

Item scores were summed and averaged to provide a mean score. Higher scores were

indicative of higher levels of emotional eating. The emotional eating subscale has

demonstrated good internal consistency across studies (e.g., Dakanalis et al., 2013;

Van Strien et al., 1986).

External eating. The external eating subscale of the DEBQ (Van Strien et al.,

1986) was used to assess external eating. The subscale contains 10 items rated along

a five-point scale from 1 (seldom) to 5 (very often). Items also had a “non-relevant”

response option. One item was reverse scored (“Can you resist eating delicious

foods?”). Examples of items include: “If you see others eating, do you also have the

desire to eat?” and “If food smells and looks good, do you eat more than usual?”.

Item scores were summed and averaged to provide a mean score. Higher scores were

indicative of higher levels of emotional eating. The external eating subscale has

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demonstrated adequate internal consistency across studies (e.g., Dakanalis et al.,

2013; Van Strien et al., 1986).

Perceived social support. The degree of social support, perceived by women,

was assessed using the 24-item Social Provisions Scale (SPS; Cutrona & Russell,

1987). The scale assesses aspects of social support including: attachment,

opportunity for nurturance, social integration, reliable alliance, guidance, and

reassurance of worth. Items are rated on a scale from 0 (strongly disagree) to 3

(strongly agree). Twelve items were reverse scored. Examples of items include:

“There are people I can depend on to help me if I really need it” and “There is

someone I could talk to about important decisions in my life”. Item scores were

summed to provide a total score. Higher scores represented greater perceived social

support. The SPS was validated using samples of university students, older adults,

new mothers, teachers, and nurses (Cutrona & Russell, 1987) and has demonstrated

good internal consistency (Cutrona & Russell, 1987; Mattanah, Ayers, Brand,

Brooks, Quimby, & McNary, 2010). Scores have been found to be positively

correlated with other measures of social support (Cutrona & Russell, 1987), and the

scale has reported good test-retest reliability (Cutrona, Russell, & Rose, 1984).

Body acceptance by others. The perceived acceptance by others of weight and

shape was assessed using the Body Acceptance by Others Scale (Avalos & Tylka,

2006). Ten items were rated along a 5-point scale ranging from 1 (never) to 5

(always) and assess body acceptance from sources including: family, friends,

partners, society and the media. Examples of items include: “I've felt acceptance

from my friends regarding my body shape and/or weight” and “I've felt acceptance

from the media (e.g., TV, magazines) regarding my body shape and/or weight”. Item

scores were summed and averaged to provide a mean score. Higher scores were

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indicative of greater perceived acceptance of weight and shape by others. The scale

was developed using a modified version of the Perceived Sociocultural Pressures

Scale (Stice et al., 1996) and examined in a sample of female university students.

Subsequent studies have examined the scale in samples of female university students

(Avalos & Tylka, 2006; Tylka & Homan, 2015) and women aged 18 to 65 years

(Augustus-Horvath & Tylka, 2011). The scale has demonstrated good internal

consistency (e.g., Augustus-Horvath & Tylka, 2011; Tylka & Homan, 2015) and has

been found to correlate negatively with pressure for thinness and positively with

body appreciation (Avalos & Tylka, 2006; Tylka & Homan, 2015). Good test-retest

reliability for the scale has been demonstrated for the scale over a three-week period

(Avalos & Tylka, 2006).

Body function. The surveillance subscale of the Objectified Body

Consciousness Scale (OBS; McKinley & Hyde, 1996) was used to assess the degree

to which women focus on how their body feels and functions rather than their

appearance. In the original subscale, eight items are rated on a 6-point scale from 1

(strongly agree) to 7 (strongly disagree), and two items are reverse scored. Examples

include: “I think more about how my body feels than how my body looks” and “I am

more concerned with what my body can do than how it looks”. Higher scores on the

Surveillance subscale indicate more of a focus on appearance. To obtain an

assessment of the degree to which women focus on how their body functions, rather

than their appearance, items were reverse scored, summed and averaged to provide a

mean score. Higher scores were indicative of a greater focus on how the body feels

and functions, rather than appearance. The OBS was validated using samples of

female university students and middle-aged women (McKinley & Hyde, 1996). The

surveillance subscale has been associated with body shame and disordered eating

symptomatology, and negatively associated with body esteem (McKinley & Hyde,

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1996). The modified version of the subscale (i.e., reverse-scored to represent body

function) has been examined in studies of female university students and women

aged 18 to 65 (Augustus-Horvath & Tylka, 2011; Homan & Tylka, 2014). The

modified subscale has demonstrated good internal consistency (e.g., Augustus-

Horvath & Tylka, 2011; Avalos & Tylka, 2006; Tylka & Homan, 2015). Test-retest

reliability of the OBS has been demonstrated over a two-week period (McKinley &

Hyde, 1996).

Body appreciation. Body appreciation was assessed using the Body

Appreciation Scale (Avalos et al., 2005). Thirteen items are rated along a five-point

scale from 1 (never) to 5 (always). Examples of items include: “Despite its flaws, I

accept my body for what it is” and “I take a positive attitude toward my body”. Item

scores were summed and averaged to provide a mean score for body appreciation.

Higher scores were indicative of more positive attitudes and treatment of the body,

regardless of perceived appearance-related flaws. The scale was validated in 1109

female university students (Avalos et al., 2005). Good internal consistency has been

reported the for scale (Avalos et al., 2005; Iannantuono & Tylka, 2012; Tylka &

Kroon Van Diest, 2013) and test-retest reliability has been established for the scale

over a three-week period (Avalos et al., 2005). Higher scores have been associated

with lower levels of body dissatisfaction, body preoccupation, weight concern, and

disordered eating (Avalos et al., 2005).

Perceived pressure for thinness. Pressure for thinness from family, friends,

and partners, as perceived by women, was assessed using the Perceived Sociocultural

Pressure Scale (Stice et al., 1996). 10 items are rated along a scale from 1 (disagree)

to 5 (strongly agree). Example items: “I've felt pressure from my friends to lose

weight” and “I've felt pressure from the media (e.g., TV, magazines) to lose weight”.

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Item scores were summed to provide a total score. Higher scores indicate greater

perceived pressure to be thin. The scale was originally validated using a sample of

female university students (Stice et al., 1996). The scale has been found to show

good internal consistency (e.g., Reina, Shomaker, Mooreville, Courville, Brady,

Olsen et al., 2013; Stice et al., 1996) and test-retest reliability over a two-week

period (Stice et al., 1996). Scores have been found to be correlate with thin-ideal

internalisation, body dissatisfaction and disordered eating (e.g., Tylka & Subich,

2004).

Thin-ideal internalisation. The degree to which women adopt the thin-ideal

stereotype was measured using the 9-item internalisation-general subscale of the

Sociocultural Attitudes Toward Appearance Questionnaire-3 (Thompson, van den

Berg, Roehrig, Guarda, & Heinberg, 2004). Items are rated along a scale from 1

(completely disagree) to 5 (completely agree). Three items were reverse scored. Item

scores were then summed to form a total score. Examples of items include: “I

compare my body to the bodies of people who are on TV” and “I compare my

appearance to the appearance of people in magazines.” Higher scores indicate

greater internalisation of the thin-ideal stereotype. The scale was validated using a

sample of female university students (Thompson et al., 2004) and has subsequently

been examined in clinical (e.g., Calogero, Davis, & Thompson, 2004; Forman &

Davis, 2005) and non-clinical populations (e.g., Swami, Steadman, & Tovée, 2009).

The subscale has demonstrated good internal consistency (e.g., Swami, 2009;

Thompson et al., 2004), and has been associated with the drive for thinness, body

dissatisfaction and disordered eating (Calogero et al., 2004; Thompson et al., 2004).

Appearance evaluation. Appearance evaluation was assessed using the

appearance evaluation subscale of the Multidimensional Body-Self Relations

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Questionnaire (MBSRQ) (Brown, Cash, & Mikulka, 1990; Cash, 2000). Seven items

are rated on a 5-point scale from 1 (definitely disagree) to 5 (definitely agree).

Examples of items include: “I like my looks just the way they are” and “I like the way

I look without my clothes on”. Item scores were summed and averaged to provide a

mean score. Higher scores are indicative of women being more positive and satisfied

with their appearance. The MBSRQ has been validated in normative (Brown et al.,

1990; Cash & Henry, 1995) and clinical populations (Hrabosky, Cash, Veale,

Neziroglu, Soll, Garner, et al., 2009). The appearance evaluation subscale has

demonstrated good internal consistency (Cash, 2000) and test-retest reliability over a

one-month period (Banasiak et al., 2001; Cash, 2000). Scores correlate negatively

with body shame, body surveillance, and disordered eating (Kinsaul, Curtin, Bazzini,

& Martz, 2014; Kelly, Mitchell, Gow, Trace, Lydecker, Bair et al., 2012).

Body area satisfaction . Body area satisfaction was assessed using the body

area satisfaction subscale of the Multidimensional Body-Self Relations

Questionnaire (MBSRQ) (Brown et al., 1990; Cash, 2000). Nine items are rated on a

5-point scale from 1 (very dissatisfied) to 5 (very satisfied). Items relate to specific

body areas including: face, hair, lower/mid/upper torso, muscle tone, weight, height,

and overall appearance. Item scores were summed and averaged to provide a mean

score. Higher scores indicate greater level of satisfaction with most areas of the body.

The body area satisfaction subscale has demonstrated adequate internal consistency

and good test-retest reliability for a one-month period (Cash, 2000). Scores have

been found to correlate negatively with measures of disordered eating (Giovannelli,

Cash, Henson, & Engle, 2008; Kinsaul et al., 2014), and negative body image (Cash,

Fleming, Alindogan, Steadman, & Whitehead, 2002; Giovannelli et al., 2008).

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Negative affect. Negative affect was assessed using the 10-item negative

affect subscale of the Positive and Negative Affect Schedule (Watson, Clark, &

Tellegen, 1988). Each item was rated on a scale from 1 (very slightly or not at all) to

5 (extremely) according to the degree to which women have felt a specific feeling or

emotion over the past week. Examples of feelings and emotions assessed included:

distressed, nervous, guilty and hostile. Item scores were summed to provide a total

score for negative affect. Higher scores indicate a greater degree of negative affect

over the past week. The scale was validated using student and non-student samples

(Watson et al., 1988) and has subsequently been used with community samples of

adults (e.g., Crawford & Henry, 2004). Good levels of internal consistency have been

found for the scale (e.g., Watson & Clark, 1994; Watson et al., 1988), and scores

correlate positively with measures of depression and anxiety (e.g., Crawford &

henry, 2004), disordered eating, and body dissatisfaction (Lavender & Anderson,

2010).

Procedure

The study was approved by the Human Ethics Advisory Group, Faculty of

Health at Deakin University in January, 2013 (see Appendix A). Recruitment

commenced in March, 2013, and was completed in May, 2014. A flyer promoting the

study was advertised in several organisations providing health and community

services to women living in Australia. Recruitment sites included women’s fitness

centres, women’s personal training groups, women’s health centres and medical

clinics, community/neighbourhood centres, weight loss support groups, day spas,

physiotherapy clinics, private psychology practices, and women’s online health

forums. The study was also promoted within Deakin University, on social media

sites, and by personal invitation. A majority of organisations were located in the state

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of Victoria, however, the study was advertised in a number of organisations in New

South Wales, South Australia, Western Australia, Tasmania, and the Australian

Capital Territory (ACT). Prospective participants were informed that the purpose of

the study was to investigate the relationship between eating patterns, health and well-

being among Australian women.

All women were provided with a Plain Language Statement and the

opportunity to contact the research team with questions or concerns. Consent to

participate in the study was inferred from completion of the survey. The Plain

Language Statement and Consent Form is provided in Appendix B. The survey took

approximately 30 minutes to complete and was made available online or as a

hardcopy with a postage paid envelope. The online survey was hosted online by

Deakin University for a period of 14 months, from March 2013 until May 2014.

Hardcopy surveys (n=140) were mailed to organisations to be made available to

women who preferred to complete a paper-based version, or who had limited access

to computer and internet facilities. Of those hardcopy surveys provided to

organisations during the recruitment period, 49.3% of hardcopy surveys (n=69) were

returned with complete responses. The participant survey is provided in Appendix B.

Women who completed the study were provided with the opportunity to enter a prize

draw to win one of six $30 gift vouchers.

Data Analyses

Missing data and assumptions of normality and linearity were assessed using

IBM SPSS Statistics, version 22. Minimal data were missing across items (ranging

from 0.2% to 2.8%). Little’s MCAR test was used to assess patterns of missing data.

Data were identified to be missing at random (χ2 = 459.912, df = 344, p>.05),

therefore, expectation maximisation was used to impute missing data (Tabachnick &

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Fidell, 2007). Variables were assessed for normality using histograms and by

examining skewness and kurtosis. Data did not violate assumptions of normality

(Kline, 2011), therefore, no transformation of variables were needed.

To address the first aim of the study, a confirmatory factor analysis was

performed on the IES (Tylka, 2006) using maximum likelihood estimation, to

examine the factor structure of the scale. To address the second aim of the study,

bivariate correlations and principal axis factoring were used to examine the

relationship between the three IES subscales and measures of disordered eating. To

address the third aim of the study, bivariate correlations and path analyses using the

Maximum Likelihood method of estimation were conducted, to examine and

compare the psychosocial correlates of the intuitive eating components and aspects

of disordered eating. More detailed information on data analyses is presented in

Chapters Five and Six.

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CHAPTER FIVE

Empirical Study: Results and Discussion Part One

Factor Structure of the IES

To address the first aim of the study, a confirmatory factor analysis was

performed on the 21-item IES using maximum likelihood estimation, in SPSS Amos

Graphics version 22. As the focus of the empirical study was on the three subscales

of intuitive eating, a first order model was examined, with unconditional permission

to eat, eating for physical rather than emotional reasons, and reliance on

hunger/satiety cues as first order factors. The size of the sample exceeded the

recommended number of cases required to estimate parameters (Tabachnick &

Fidell, 2007). In addition to the Chi Square Goodness of Fit Test (χ2), a further four

model fit indices were used: the Comparative Fit Index (CFI), the Tucker-Lewis

Index (TLI), the Standardised Root Mean-square Residual (SRMR), and the Root-

Mean-Square Error of Approximation (RMSEA). CFI and TLI values above 0.90

indicate acceptable fit, and values above 0.95 indicate good fit. RMSEA and SRMR

values approaching zero are desired, with values below 0.08 for RMSEA and below

0.06 for SRMR indicating good fit (Hu & Bentler, 1999; Kline, 2011). The proposed

model is presented in Figure 5.1.

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Figure 5.1. Proposed first order model of the IES.

The proposed model did not provide a good fit to the data, χ2 (186, N=457) =

907.42, p<.001, CFI = .82, TLI = .79, RMSEA = .09, SRMR = 0.09. Model estimates

are presented in Table 5.1. Correlations between each intuitive eating factor are

presented in Table 5.2. To develop a better-fitting model, items with factor loadings

below .45 on their respective first order factor were removed from the model.

Comrey and Lee (1992) suggest that this is a fair cut-off for factor loadings, and

Tylka (2006) also used .45 as the cut-off for items in developing the original scale.

This resulted in five items being discarded: Item 1 (“I try to avoid certain foods high

in fat, carbohydrates, or calories”) and Item 4 (“If I am craving a certain food, I allow

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myself to have it”) from the unconditional permission to eat factor; Item 2 (“I stop

eating when I feel full (not overstuffed)”) from the eating for physical rather than

emotional reasons factor; and Item 7 (“I can tell when I’m slightly full”) and Item 8

(“I can tell when I’m slightly hungry”) from the reliance on hunger/satiety cues

factor. The re-specified model is presented in Figure 5.2. The re-specified model

provided a better and more acceptable fit to the data, χ2 (101, N=457) = 367.956,

p<.001, CFI = .92, TLI = .90, RMSEA = .08, SRMR = 0.06. A Chi Square

Difference Test was carried out to determine if the re-specified model provided a

significantly better fit than the hypothesised model. Compared to the hypothesised

model, the re-specified model provided a significantly better fit to the data, χ2diff =

539.464, df = 85, p<.05. Item descriptives and model estimates are summarised in

Table 5.3.

Each of the retained items loaded significantly on their respective factors. The

loadings for seven items on the unconditional permission to eat factor ranged from

.46 to .85. The loadings for five items on the eating for physical rather than

emotional reasons factor ranged from .67 to .88, and loadings for four items on the

reliance on hunger/satiety cues factor ranged from .40 to .80. The three intuitive

eating factors were moderately and positively correlated as shown in Table 5.4.

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Table 5.1

Factor Loadings for Proposed First-order Model of the IES

Item Range Mean (SD) Unstandardised

estimate

Standard

error

Standardised

estimate

UPE

Item 1 1-5 2.41 (1.05) .59 .07 .44**

Item 4 1-5 3.61 (.91) .23 .06 .19**

Item 5 1-5 3.58 (1.18) .74 .09 .48**

Item 9 1-5 2.82 (1.22) 1.34 .11 .84**

Item 14 1-5 3.43 (1.21) .82 .09 .52**

Item 18 1-5 2.72 (1.23) 1.37 .11 .85**

Item 19 1-5 2.25 (1.06) .75 .08 .54**

Item 20 1-5 3.26 (1.23) 1.03 .10 .64**

Item 21 1-5 3.07 (1.33) 1.0 - .58**

EPR

Item 2 1-5 3.47 (1.03) .38 .05 .39**

Item 3 1-5 2.47 (1.18) .99 .04 .87**

Item 6 1-5 2.55 (1.06) .70 .04 .69**

Item 10 1-5 3.01 (1.19) .76 .05 .67**

Item 16 1-5 2.92 (1.71) .98 .04 .87**

Item 17 1-5 2.85 (1.24) 1.0 - .84**

RHSC

Item 7 1-5 3.78 (.79) 1.01 .15 .42**

Item 8 1-5 3.86 (.74) .66 .13 .29**

Item 11 1-5 3.42 (.96) 2.09 .24 .71**

Item 12 1-5 2.96 (1.06) 2.14 .25 .66**

Item 13 1-5 3.15 (1.04) 2.50 .28 .79**

Item 15 2-5 3.84 (.70) 1.0 - .47**

Note. N=457, ** = p<.001. UPE = unconditional permission to eat; EPR = eating for

physical rather than emotional reasons; RHSC = reliance on hunger/satiety cues.

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Figure 5.2. Re-specified model of the IES

Table 5.2

Covariances and Correlations between Factors in the Proposed First-order Model of

the IES

1 2 3

1 UPE - .39** .12**

2 EPR .49** - .12**

3 RHSC .46** .37** -

Note. ** = p<.001; Covariances are presented in the top half of the matrix,

correlations are presented in the bottom half of the matrix. UPE = unconditional

permission to eat; EPR = eating for physical rather than emotional reasons; RHSC =

reliance on hunger/satiety cues.

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Table 5.3

Estimates, Standard Error of Estimates and p-values for Re-Specified Model

Unstandardised

estimate

Standard error Standardised

estimate

UPE

Item 5 .71 .09 .46**

Item 9 1.35 .11 .85**

Item 14 .79 .09 .50**

Item 18 1.36 .11 .85**

Item 19 .73 .08 .53**

Item 20 1.06 .10 .66**

Item 21 1 - .58**

Mean (SD) 3.02 (.85)

EPR

Item 3 .99 .04 .88**

Item 6 .69 .04 .68**

Item 10 .76 .05 .67**

Item 16 .98 .04 .87**

Item 17 1 - .84**

Mean (SD) 2.76 (.98)

RHSC

Item 11 2.48 .33 .72**

Item 12 2.57 .35 .68**

Item 13 2.96 .39 .80**

Item 15 1 - .40**

Mean (SD) 3.34 (.71)

Note. N=457, ** = p<.001. UPE = unconditional permission to eat; EPR = eating for

physical rather than emotional reasons; RHSC = reliance on hunger/satiety cues.

Cronbach alpha for modified UPE subscale = .83, EPR subscale = .89, RHSC

subscale = .74.

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Table 5.4

Covariances and Correlations between Factors in the Re-Specified Model

1 2 3

1 UPE - .41** .10**

2 EPR .51** - .10**

3 RHSC .49** .35** -

Note. ** = p<.001; Covariances are presented in the top half of the matrix,

correlations are presented in the bottom half of the matrix. UPE = unconditional

permission to eat; EPR = eating for physical rather than emotional reasons; RHSC =

reliance on hunger/satiety cues.

Correlations between Eating Behaviours

Descriptive statistics, including mean scores and the Cronbach alpha for each

subscale are presented in Table 5.5. All scales showed good to high levels of internal

consistency. Bivariate correlations were conducted between the three components of

intuitive eating and each of the other eating behaviours: dieting, restrained eating,

bulimia/food preoccupation, emotional eating and external eating. The modified

subscales of the IES resulting from the confirmatory factor analysis were used. Total

IES scores were not calculated for the purpose of this study. Cohen’s criteria for

strength of association was used to interpret all correlations. Cohen suggests a

correlation of .10 is small/weak, .30 is medium/moderate, and .50 is a large/strong

association (Cohen, 1988). These findings are summarised in Table 5.6.

Unconditional permission to eat correlated strongly and negatively with

dieting, restrained eating, and bulimia/food preoccupation. Unconditional permission

to eat was also moderately and negatively associated with emotional eating and

external eating. Eating for physical rather than emotional reasons correlated strongly

and negatively with emotional eating, bulimia/food preoccupation, and external

eating, was moderately and negatively correlated with dieting, and was weakly and

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negatively correlated with restrained eating. Reliance on hunger/satiety cues

correlated moderately and negatively with dieting, restrained eating, bulimia/food

preoccupation and emotional eating, and was weakly and negatively associated with

external eating.

Table 5.5

Mean (SD), Range, Internal Reliability for Eating-related Scales

Scale Mean (SD) Range α

Unconditional permission to eat

3.02 (.85)

1.0-5.0

.83

Eating for physical rather than emotional

reasons

2.76 (.99) 1.0-5.0 .87

Reliance on hunger/satiety cues 3.34 (.71) 1.25-5.0 .75

Dieting 2.89 (.90) 1.0-5.62 .87

Restrained eating 2.79 (.84) 0.90-5.0 .85

Bulimia/food preoccupation 2.14 (.90) 1.0-5.83 .91

Emotional eating 2.48 (1.0) 0.92-5.0 .96

External eating 3.12 (.62) 1.20-4.7 .84

Note. α = Cronbach alpha

Correlations among dieting, restrained eating, bulimia/food preoccupation

were strong and positive, as was the correlation between emotional eating and

external eating. Dieting was moderately and positively associated with emotional

eating, and weakly and positively associated with external eating. Restrained eating

was moderately associated with emotional eating, and weakly associated with

external eating. Bulimia/food preoccupation correlated strongly and positively with

emotional eating and was moderately and positively associated with external eating.

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Table 5.6

Correlations between Intuitive Eating and Other Eating Patterns

1 2 3 4 5 6 7

1 Unconditional

permission to eat

-

2 Eating for physical

rather than

emotional reasons

.44** -

3 Reliance on

hunger/satiety cues

.39** .30** -

4 Dieting -.78** -.37** -.38** -

5 Bulimia/food

preoccupation

-.62** -.53** -.40** .73** -

6 Restrained eating -.70** -.27** -.32** .80** .53** -

7 Emotional eating -.43** -.84** -.33** .42** .57** .34** -

8 External eating -.28** -.51** -.19** .21** .39** .14** .56**

Note. ** p<.001

Exploratory Factor Analysis of Intuitive Eating and Other Eating Behaviours

To address the second aim of the study, principal axis factoring was

conducted using the modified subscales of the IES; the dieting and bulimia/food

preoccupation subscales of the EAT-26 (Garner et al., 1982); and the restrained

rating, emotional eating and external eating scales of the DEBQ (Van Strien et al.,

1986). The Kaiser-Meyer-Olkin measure of sampling adequacy for all variables was

adequate (.81) according to cut-offs recommended by Hutcheson and Sofroniou

(1999). Measures of sampling adequacy for individual scales demonstrated that three

of the eight scales reported good sampling adequacy: eating for physical rather than

emotional reasons (.74), emotional eating (.75), and dieting (.76). All other scales

reported great sampling adequacy (ranging from .81 to .96). Bartlett’s test of

sphericity, χ2 (457) = 2335.60, p<.001, indicated that correlations between items

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were sufficient in size to conduct principal axis factoring. Direct oblimin rotation

(oblique) was applied as the factors were expected to be correlated (Tabachnick &

Fidell, 2007) and eigenvalues were assessed.

Two factors had eigenvalues over Kaiser’s criterion of 1 (Kaiser, 1960) and

these factors explained 64.56% of the variance. The scree plot (Cattell, 1966) also

suggested the presence of two factors. A criterion of .45 (20% overlap between

variable and factor) was used for defining significant loadings (Comrey & Lee,

1992). Factor loadings after rotation are summarised in Table 5.7.

The first factor had high positive loadings on restrained eating, dieting,

bulimia/food preoccupation and a high negative loading on unconditional permission

and was labelled “disordered eating”. The disordered eating factor explained 49.84%

of the variance in these eating patterns. The second factor had a high positive loading

on eating for physical rather than emotional reasons and high negative loadings on

emotional eating and external eating. This factor was labelled “eating for non-

emotional/non-external reasons”. The eating for non-emotional/non-external reasons

factor explained 14.72% of the variance in these eating patterns. Reliance on

hunger/satiety cues did not load on either factor. Factor scores were computed using

the regression method.

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Table 5.7

Pattern Matrix with Rotated Factor Loadings

Disordered

eating

Eating for non-

emotional/non-

external reasons

Communality

IES

Unconditional permission

to eat

-.79 .08 .69

Eating for physical rather

than emotional reasons

-.02 .87 .78

Reliance on

hunger/satiety cues

-.35 .18 .21

EAT-26

Dieting 1.01 .09 .94

Bulimia/food

preoccupation

.58 -.32 .63

DEBQ

Restrained eating .88 .13 .68

Emotional eating .04 -.91 .88

External eating -.02 -.61 .36

Eigenvalue 3.99 1.18

Factor correlation -.49

Variance (%) 49.84 14.72

Total variance 64.56

Discussion

Part one of the empirical study had two aims. The first aim of the study was

to examine the factor structure of the IES (Tylka, 2006) in a community sample of

adult women. This was conducted using confirmatory factor analysis. The second

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aim of the study was to examine the three aspects of intuitive eating (i.e.,


and reliance on hunger/satiety cues) in relation to the following eating patterns:

dieting, restrained eating, bulimia/food preoccupation, emotional eating, and external

eating. These relationships were examined using principal axis factoring.

The confirmatory factor analysis demonstrated that the three-factor structure

of the IES (unconditional permission to eat, eating for physical rather than emotional

reasons, and reliance on hunger/satiety cues) was upheld for a community sample of

adult women which was more diverse with regards to age and weight status, in

comparison to the student samples used in the initial validation of the scale (Tylka,

2006).However, the scale was modified, with the removal of five items included in

the original version of the scale.

Two items were removed from the unconditional permission to eat subscale.

The content of Item 1 (“I try to avoid certain foods high in fat, carbohydrates, or

calories”) overlapped with Item 18 (“I feel guilty if I eat a certain food that is high in

calories, fat, or carbohydrates”); and Item 4 (“If I am craving a certain food, I allow

myself to have it”) overlapped with Item 14 (“I have forbidden foods that I don’t

allow myself to eat”). Thus, these items may not have been contributing any new

information.

One item, Item 2 (“I stop eating when I feel full (not overstuffed)”), was

removed from the eating for physical rather than emotional reasons subscale. The

focus of this item was on physical feelings of fullness whereas all the retained items

were focused on emotions associated with eating (e.g., “I find myself eating when I

am stressed out, even when I’m not physically hungry”). It was also the only item in

the subscale that was not reverse-scored (i.e., was positively framed).

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Two items were removed from the reliance on hunger/satiety cues subscale:

Item 7 (“I can tell when I’m slightly full”) and Item 8 (“I can tell when I’m slightly

hungry”). In both of these items, the focus was on assessing hunger and/or satiety,

however, the emphasis was on an awareness of being “slightly” hungry or “slightly”

full. Therefore, these items may not have been sufficiently sensitive to assess the

intended construct and discriminate between degrees of reliance on hunger/satiety.

Each of the retained items were more explicitly worded (e.g., “When I’m eating, I

can tell when I’m getting full”, “I trust my body when to eat”).

This was the first study to examine the factor structure of the original IES

since its development and validation in a sample of female university students

(Tylka, 2006). The original scale was validated in a sample of undergraduate

psychology students with a mean age of 20 years, who were primarily White, were of

a higher socioeconomic status, and lived in the United States. The community

sample used in this study were women with a mean age of 38.15 years, who

identified as Australian and/or British/European, and were mostly tertiary educated,

engaged in paid employment, and were married or in a de facto relationship.

Therefore, it is possible that the deleted items may not be as relevant for a

community sample. It is important to highlight that, with the exception of the two

items that were removed from the unconditional permission to eat subscale (i.e., “I

try to avoid certain foods high in fat, carbohydrates, or calories” and “If I am craving

a certain food, I allow myself to have it”), the items deleted in this study have not

been included in the revised IES-2 (Tylka & Kroon Van Diest, 2013). Additional

studies are needed to examine the factor structure of the original scale (Tylka, 2006)

in other community samples of adult women, to further examine whether the same

items need to be deleted. In addition, the factor structure needs to also be examined

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more fully with samples that differ according to age, level of education, cultural

background and socioeconomic status.

Extending this research using the IES-2 (Tylka & Kroon Van Diest, 2013) is

also needed6. The scale was intentionally revised to incorporate a greater proportion

of items that are worded positively to capture the presence of intuitive eating,

compared to the original IES, which includes a majority of items that are negatively

worded to capture the absence of intuitive eating. Moreover, the IES-2 includes

additional items that were not part of the original IES, and includes is a fourth

subscale that assesses food choices that benefit health - body-food choice congruence

(e.g., “I mostly eat foods that give my body energy and stamina”). The IES-2 was

developed and validated in a sample of 2600 primarily male and female university

students, and a four-factor structure was obtained. Three subsequent studies have

examined the factor structure of three separate versions of the IES-2 translated into

French (Camilleri et al., 2015; Carbonneau et al., 2016) and German (van Dyck et

al., 2016). Camilleri and colleagues (2015) did not replicate the factor structure in a

community sample of 632 French women and men, with a mean age of 48.5 years

(Camilleri et al., 2015), whereas two later studies did replicate the four-factor

structure, in a sample of 409 French-Canadian women and men (Carbonneau et al.,

2016) and in a German sample of 1134 primarily female university students (van

Dyck et al., 2016). However, since the study conducted by Tylka and Kroon Van

Diest (2013), there has been no further examination of the factor structure of the

original English version of the IES-2.

6 The IES-2 (Tylka & Kroon Van Diest, 2013) was not available at the commencement of the

empirical study, therefore, the original IES (Tylka, 2006) was used to assess intuitive eating.

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To address the second aim of the study, principal axis factoring was

conducted to examine the three subscales of the IES (i.e., unconditional permission

to eat, eating for physical rather than emotional reasons, and reliance on

hunger/satiety cues) in relation to the other eating behaviours. Principal axis

factoring demonstrated that two of the three subscales overlap with other eating

patterns. Unconditional permission to eat was not found to be conceptually distinct

from the following aspects of disordered eating: dieting, restrained eating, and

bulimia/food preoccupation. Specifically, the factor analysis showed that

unconditional permission to eat loaded highly on the first factor with dieting,

restrained eating and bulimia/food preoccupation, and was labelled ‘disordered

eating’. This in line with previous studies that have demonstrated substantial overlap

between the unconditional permission to eat subscale and aspects of disordered

eating, including dieting and bulimia/food preoccupation (Anderson et al., 2016;

Tylka & Wilcox, 2006; Tylka & Kroon Van Diest, 2013; van Dyck et al., 2016).

Therefore, this study and other studies suggest that the unconditional permission to

eat subscale is also assessing disordered eating.

The second subscale of the IES, eating for physical rather than emotional

reasons, was not found to be distinct from emotional eating and external eating.

Eating for physical rather than emotional reasons, emotional eating and external

eating all loaded onto the second factor. This factor was labelled ‘eating for non-

emotional/non-external reasons’. Two other studies have examined this subscale with

emotional and external eating (Camilleri et al., 2015; van Dyck et al., 2016). In both

studies, eating for physical rather than emotional reasons was most strongly

associated with emotional eating. The study conducted by van Dyck et al. (2016) also

found that the eating for physical rather than emotional reasons subscale was

moderately related to external eating, whereas unconditional permission to eat and

125

reliance on hunger/satiety cues were weakly related to external eating. Overall, this

study and other studies suggest that the eating for physical rather than emotional

reasons subscale is also assessing emotional eating and external eating.

The third aspect of intuitive eating, reliance on hunger/satiety cues, did not

load onto either the disordered eating or eating for non-emotional/non-external eating

factors. This suggests that reliance on hunger/satiety cues is a more distinct pattern of

eating from other eating behaviours. These findings are consistent with Tylka and

Wilcox (2006), and Tylka and Kroon Van Diest (2013), who demonstrated that

reliance on hunger/satiety cues was distinct from aspects of disordered eating,

including dieting and bulimia/food preoccupation. Other more recent studies have

demonstrated that this aspect of intuitive eating is weakly to moderately associated

with aspects of disordered eating, including restrained eating, and overall disordered

eating symptoms (Anderson et al., 2016; Camilleri et al., 2015). One exception is the

study conducted by van Dyck et al. (2016), which found a strong relationship in

German women for the reliance on hunger/satiety cues subscale with restrained

eating and symptoms of bulimia.

Further studies are needed to examine the relationship between aspects of

intuitive eating and other patterns of eating. This should include an examination of

the subscales of the IES-2 (Tylka & Kroon Van Diest, 2013). The revised scale

includes a greater proportion of positively-worded items that capture the presence of

intuitive eating, whereas a majority of items in the original IES assess the absence of

intuitive eating. Moreover, the IES-2 contains a fourth subscale labelled body-food

choice congruence. Body-food choice congruence has been examined in three

studies. One study found this aspect of intuitive eating was moderately and

negatively associated with symptoms of bulimia (Carbonneau et al., 2016), while two

126

studies have demonstrated that body-food choice congruence was not related to

restrained eating, emotional eating, external eating, symptoms of bulimia (van Dyck

et al., 2016), or overall symptoms of disordered eating (Tylka & Kroon Van Diest,

2013). Further studies are needed to examine which subscales of the IES-2 may

differentiate intuitive eating behaviours from disordered eating behaviours more than

the IES (Tylka, 2006).

127

CHAPTER SIX

Empirical Study: Results and Discussion Part Two

This chapter presents results and a discussion of findings from the second

part of the empirical study. The second part set out to examine the psychosocial

correlates of intuitive eating and disordered eating, with a focus on the similarities

and differences in these psychosocial correlates. Initially, the study sought to

compare the psychosocial correlates of the three intuitive eating factors (i.e.,


and reliance on hunger/satiety cues) with disordered eating and other eating patterns

(i.e., dieting, restrained eating, bulimia/food preoccupation, emotional eating, and

external eating). However, the factor analysis conducted in Chapter Five

demonstrated that two of three intuitive eating subscales overlapped with the other

eating patterns. Unconditional permission to eat loaded onto the disordered eating

factor, along with dieting, restrained eating and bulimia/food preoccupation. Eating

for physical rather than emotional reasons loaded onto the eating for non-

emotional/non-external reasons factor, along with emotional eating and external

eating. Only reliance on hunger/satiety cues was found to load on neither factor.

Therefore, the aims were modified to incorporate the outcomes of the factor analysis.

Instead, the study investigated the psychosocial correlates of the two factors:

disordered eating, eating for non-emotional/non-external reasons, and the subscale

from the modified IES, reliance on hunger/satiety cues.

The psychosocial variables outlined in Chapter Four were selected from the

main variables that have been shown to be related to intuitive eating (see Chapter

Three) and disordered eating (e.g., Pennesi & Wade, 2016; Stice, 2002). The

variables included: perceived social support, body acceptance by others, body

128

function, body appreciation, pressure for thinness, internalisation of the thin-ideal,

body area satisfaction, appearance evaluation, and negative affect. In addition to

examining bivariate correlations between psychosocial factors and the three eating

patterns, the psychosocial factors were incorporated into two models of eating based

on the acceptance model (Avalos & Tylka, 2006; Augustus-Horvath & Tylka, 2011)

and the modified dual pathway model (Stice, 2001; Stice & Agras, 1998). Before

examining these relationships, the association between each of the three eating

patterns with demographic variables, age, education level, and BMI, were assessed.

Age, Education, and BMI

Bivariate correlations were conducted for each of the three eating patterns

with age, level of education, and BMI. Correlations are summarised in Table 6.1.

Age and BMI did not correlate significantly with disordered eating, eating for non-

emotional/non-external reasons, or a reliance on hunger/satiety cues. Level of

education did not correlate with disordered eating or a reliance on hunger/satiety

cues, but was weakly and negatively associated with eating for non-emotional/non-

external reasons.

Table 6.1

Correlations between Eating Patterns, Age, Education, and BMI

1 2 3

1 Disordered eating

2 Eating for non-emotional/non-

external reasons

-.51**

3 Reliance on hunger/satiety cues -.44** .36**

4 BMI .02 -.08 -.04

5 Age -.03 .05 -.06

6 Education level .04 -.11* -.02

Note. ** p<.01; * p<.05

129

Bivariate Correlations between Eating Patterns and Psychosocial Variables

Bivariate correlations were examined between the three eating patterns and

each of the following psychosocial variables: perceived social support, body

acceptance by others, body function, body appreciation, pressure for thinness,

internalisation of the thin-ideal, body area satisfaction, appearance evaluation, and

negative affect. Means, standard deviations and correlations are summarised in Table

6.2.

Disordered eating was strongly and negatively correlated with appearance

evaluation, body appreciation, and body function; moderately and negatively

correlated with body area satisfaction and body acceptance by others; and weakly

and negatively associated with perceived social support. Higher levels of disordered

eating were moderately associated with greater pressure for thinness and

internalisation of the thin ideal, and higher levels of negative affect.

Eating for non-emotional/non-external reasons was moderately and positively

associated with appearance evaluation, body area satisfaction, body appreciation,

body function, and body acceptance by others. Eating for non-emotional/non-

external reasons were moderately and negatively correlated with pressure for

thinness, internalisation of the thin-ideal, and negative affect. Additionally, eating for

non-emotional/non-external reasons correlated weakly and positively with perceived

social support.

Reliance on hunger/satiety cues correlated moderately and positively with

appearance evaluation, body area satisfaction, body appreciation, and body

acceptance by others. In addition, a greater reliance on hunger/satiety cues was

weakly associated with greater body function and higher levels of perceived social

130

support, less pressure for thinness, lower levels of internalisation of the thin-ideal,

and lower levels of negative affect.

As shown in Table 6.2, the three body image variables were strongly

interrelated: appearance evaluation, body area satisfaction, and body appreciation

(ranging from r= .80 to .87). An exploratory factor analysis was conducted to

determine if these three variables might be better represented as a single body image

factor. Principal axis factoring was conducted to test the factor structure of the three

body image variables (see Appendix C). All three variables loaded onto a single

factor which accounted for 83% of the variance. This factor was labelled “body

satisfaction”. Factor scores were computed using the regression method, for use in

the model that was based on the acceptance model. Higher scores were indicative of

a more positive body image. Factor scores were also reversed to create a “body

dissatisfaction” factor, for use in the model that was based on the dual pathway

model.

131

Table 6.2

Mean, Standard Deviation (SD), and Bivariate Correlations for Psychosocial Factors and Eating Patterns

1 2 3 4 5 6 7 8 9 10 11

1 Disordered eating -

2 Eating for non-emotional/non-external reasons -.51 -

3 Reliance on hunger/satiety cues -.44 .36 -

4 Perceived social support -.29 .19 .21 -

5 Body acceptance by others -.39 .31 .36 .45 -

6 Body function -.53 .32 .22 .18 .23 -

7 Body appreciation -.61 .46 .45 .43 .62 .50 -

8 Pressure for thinness .45 -.45 -.23 -.25 -.51 -.38 -.52 -

9 Internalisation of thin-ideal .46 -.32 -.14 -.19 -.15 -.55 -.45 .38 -

10 Appearance evaluation -.51 .41 .44 .43 .64 .39 .82 -.50 -.32 -

11 Body area satisfaction -.48 .39 .42 .44 .63 .39 .80 -.51 -.31 .87 -

12 Negative affect .41 -.37 -.19 -.38 -.24 -.33 -.42 .37 .35 -.32 -.34

Mean

SD

0

.98

0

.96

3.34

.71

81.26

10.71

3.41

.83

3.56

1.17

44.00

10.87

1.23

.85

2.74

.90

3.1

.93

3.19

.75

Note. All correlations significant, p<.001

132

Psychosocial Predictors of Disordered Eating, Eating for Non-emotional/Non-

external Reasons, and Reliance on Hunger/Satiety cues

Following the calculation of bivariate correlations between psychosocial

factors and the three eating patterns, the psychosocial model based on the acceptance

model of intuitive eating7 (Model I), and another model based on the dual pathway

model of disordered eating (Model II), were tested with each of the three eating

patterns as outcome variables. Models I is presented in Figure 6.1. Model II is

presented in Figure 6.2.

Figure 6.1. Model I – Modified acceptance model for the three eating patterns:

disordered eating, eating for non-emotional and external reasons and reliance on

hunger/satiety cues.

7 The acceptance model was modified due to the overlap between the body appreciation, body area

satisfaction, and appearance evaluation variables. These three variables loaded onto a common factor

labelled ‘body satisfaction’. This factor was incorporated into the model, replacing the body

appreciation variable in the original acceptance model (Augustus-Horvath & Tylka, 2011; Avalos &

Tylka, 2006).

133

Figure 6.2. Model II - Modified dual pathway model for the three eating patterns:

disordered eating, eating for non-emotional and external reasons and reliance on


For Model I, the following paths were hypothesised: perceived social support

was hypothesised to predict greater body acceptance by others and a greater focus on

body function; body acceptance by others was expected to predict a greater focus on

body function; and body function was expected to predict greater body satisfaction.

A focus on body function and greater body satisfaction were hypothesised to predict

less disordered eating, higher levels of eating for non-emotional/non-external

reasons, and greater reliance on hunger/satiety cues.

For Model II, the following paths were included: pressure for thinness was

hypothesised to predict greater internalisation of the thin-ideal and body

dissatisfaction; greater internalisation was expected to predict greater body

dissatisfaction; and greater body dissatisfaction was expected to predict higher levels

of negative affect. Body dissatisfaction and negative affect were hypothesised to

134

predict higher levels of disordered eating, less eating for non-emotional/non-external

reasons and less reliance on hunger/satiety cues.

Six path analyses (three for Model 1 and three for Model II) were conducted

using the Maximum Likelihood method of estimation in SPSS Amos version 22. The

size of the sample exceeded the recommended number of cases required to estimate

parameters for each of the six models (Tabachnick & Fidell, 2007). Path models

were assessed using the Model Chi Square test (χ2) (p>.05) in addition to the

following model fit indices: CFI, TLI, SRMR, and RMSEA. Re-specification of

models was conducted by using modification indices.

Model Based on the Acceptance Model of Intuitive Eating

Model I, based on the acceptance model of intuitive eating, was examined

with disordered eating as the outcome variable. The model did not provide a good fit

to the data, χ2 (4, N=457) = 273.44, p<.001, CFI = .63, TLI = .08, RMSEA = .38,

SRMR = 0.20. In addition, the path from perceived social support to body function

was not significant (p=.06). Initial estimates of the model are presented in Table 6.3.

Modification indices indicated that the addition of paths from perceived social

support to body satisfaction, and from body acceptance by others to body satisfaction

would improve model fit. The two paths were added and the re-specified model

tested.

135

Table 6.3

Initial Estimates for Model I – Modified Acceptance Model with Disordered Eating

as the Outcome

Parameter

estimate

Unstandardised

estimate

Standard

error

Standardised

estimate

p

Body

acceptance by

others

Perceived

social

support

.04 .00 .45 <.001

Body function

Perceived

social

support

.01 .01 .10 .056

Body

acceptance

by others

.27 .07 .19 <.001

Body

satisfaction

Body

function

.36 .04 .44 <.001

Disordered

eating

Body

satisfaction

-.40 .04 -.39 <.001

Body

function

-.30 .03 -.36 <.001

The re-specified model provided a good fit to the data, χ2 (2, N=457) = 3.71,

p=.16, CFI = 1.0, TLI = .99, RMSEA = .04, SRMR = 0.02. Compared to the initial

model, the re-specified model provided a significantly better fit to the data, χ2diff =

269.73, df = 2, p<.05. However, the path from perceived social support to body

function remained non-significant (p=.06). This path was removed and the re-

specified model tested. The model with the path removed provided a good fit to the

136

data, χ2 (3, N=457) = 7.35, p=.06, CFI = .99, TLI = .98, RMSEA = .06, SRMR =

0.03. A chi square difference test was conducted on the two re-specified models (i.e.,

models with and without the path from perceived social support to body function).

There was not a significant difference in fit between the two re-specified models,

χ2diff = 3.64, df = 1, p>.05. Therefore, the model with the path removed from

perceived social support to body function was retained as a more parsimonious

model. Overall, the model accounted for 41% of the variance in disordered eating.

The final model is presented in Figure 6.3 and final estimates are presented in Table

6.4.

Figure 6.3. Re-specified Model I – Modified acceptance model with disordered

eating as the outcome.

137

As shown in Figure 6.3 and Table 6.4, higher levels of perceived social

support predicted greater body acceptance by others, and greater body acceptance by

others predicted a greater focus on body function. Higher levels of perceived social

support, body acceptance by others, and more of a focus on body function predicted

greater body satisfaction. Greater body satisfaction and a focus on body function

predicted lower levels of disordered eating. Women who reported being more

satisfied with their body or focused more on how their body functions rather than

appearance, reported engaging in less disordered eating.

Table 6.4

Final Estimates for Model I - Modified Acceptance Model with Disordered Eating as

the Outcome

Parameter

estimate

Unstandardised

estimate

Standard

error

Standardised

estimate

p

Body

acceptance by

others

Perceived

social

support

.04 .00 .45 <.001

Body function

Body

acceptance

by others

.33 .07 .23 <.001

Body

satisfaction

Body

function

.23 .03 .28 <.001

Perceived

social

support

.02 .00 .17 <.001

Body

acceptance

by others

.62 .04 .53 <.001

138

Parameter

estimate

Unstandardised

estimate

Standard

error

Standardised

estimate

p

Disordered

eating

Body

satisfaction

-.40 .04 -.39 <.001

Body

function

-.30 .03 -.36 <.001

Model I was examined with eating for non-emotional/non-external reasons as

the outcome variable. The model did not provide a good fit to the data, χ2 (4, N=457)

= 270.47, p<.001, CFI = .56, TLI = -.14, RMSEA = .38, SRMR = 0.19. The path

from perceived social support to body function was non-significant (p=.06). Initial

estimates of the model are presented in Table 6.5. Modification indices indicated that

the inclusion of a path from body acceptance by others to body satisfaction, and from

perceived social support to body satisfaction would improve model fit. These paths

were added and the re-specified model was tested. The re-specified model provided

an acceptable fit to the data, χ2 (2, N=457) = 0.73, p=.69, CFI = 1.0, TLI = 1.01,

RMSEA = .00, SRMR = 0.01. A chi square difference test showed that compared to

the initial model, the re-specified model provided a significantly better fit to the data,

χ2diff = 269.74, df = 2, p<.05. However, the path from perceived social support to

body function remained non-significant (p=.06). This path was removed and the re-

specified model tested. This model provided a good fit to the data, χ2 (3, N=457) =

4.37, p=.22, CFI = 1.0, TLI = .99, RMSEA = .03, SRMR = 0.02. A chi square

difference test reported that there was not a significant difference in fit between the

two re-specified models, χ2diff = 3.64, df = 1, p>.05. The re-specified model with the

path removed from perceived social support to body function was retained as the

more parsimonious model. Overall, the model accounted for 21% of the variance in

139

eating for non-emotional/non-external reasons. The final model with eating for non-

emotional/non-external reasons is presented in Figure 6.4 and final estimates are

presented in Table 6.6.

Table 6.5

Initial Estimates for Model I - Modified Acceptance Model with Eating for Non-

emotional/Non-external reasons as the Outcome

Parameter

estimate

Unstandardised

estimate

Standard

error

Standardised

estimate

p

Body acceptance

by others

Perceived

social support

.04 .00 .45 <.001

Body function

Perceived

social support

.01 .01 .10 .056

Body

acceptance by

others

.27 .07 .19 <.001

Body satisfaction

Body function .36 .04 .44 <.001

Eating for non-

emotional/non-

external reasons

Body

satisfaction

.37 .05 .37 <.001

Body function .13 .04 .16 <.001

140

Figure 6.4. Re-specified Model I - Modified acceptance model with non-

emotional/non-external reasons as the outcome.

As demonstrated in Figure 6.4 and Table 6.6, greater perceived social support

predicted greater body acceptance by others; greater body acceptance by others

predicted a greater focus on body function; and higher levels of perceived social

support, body acceptance by others, and a focus on body function predicted greater

body satisfaction. A greater focus on body function and greater body satisfaction

predicted higher levels of eating for non-emotional/non-external reasons. Women

were more likely to eat for non-emotional/non-external reasons if they focused more

on body function over appearance, or were more satisfied with their bodies.

141

Table 6.6

Final Estimates for Model I - Modified Acceptance Model with Eating for Non-

emotional/Non-external Reasons as the Outcome

Parameter

estimate

Unstandardised

estimate

Standard

error

Standardised

estimate

p

Body acceptance

by others

Perceived

social support

.04 .00 .45 <.001

Body function

Body

acceptance by

others

.33 .07 .23 <.001

Body satisfaction

Body function .23 .03 .28 <.001

Perceived

social support

.02 00 .17 <.001

Body

acceptance by

others

.62 .04 .53 <.001

Eating for non-

emotional/non-

external reasons

Body

satisfaction

.37 .05 .37 <.001

Body function .13 .04 .16 <.001

Model I was examined with reliance on hunger/satiety cues as the outcome

variable. The initial model did not provide a good fit to the data, χ2 (4, N=457) =

272.39, p<.001, CFI = .55, TLI = -.12, RMSEA = .38, SRMR = 0.20. The paths from

perceived social support to body function (p=.06), and from body function to reliance

on hunger/satiety cues (p=.53) were non-significant. Initial estimates of the model

are presented in Table 6.7. Modification indices indicated that the inclusion of a path

142

from body acceptance by others to body satisfaction, and from perceived social

support to body satisfaction would improve model fit. These paths were added and

the re-specified model was tested. The re-specified model provided a good fit to the

data, χ2 (2, N=457) = 2.65, p=.27, CFI = 1.0, TLI = 1.0, RMSEA = .03, SRMR =

0.01. The chi square difference test indicated that the re-specified model provided a

significantly better fit to the data, χ2diff = 269.74, df = 2, p<.05. However, the paths

from perceived social support to body function, and from body function to reliance

on hunger/satiety cues remained non-significant. These two paths were deleted and

the re-specified model was tested. The model provided a good fit to the data, χ2 (4,

N=457) = 6.69, p=.15, CFI = 1.0, TLI = .99, RMSEA = .04, SRMR = 0.03, however,

the two re-specified models were not significantly different in their fit to the data,

χ2diff = 4.04, df = 2, p>.05. The re-specified model with the two removed paths from

perceived social support to body function, and from body function to reliance on

hunger/satiety cues was retained as the more parsimonious model. Overall, the model

explained 21% of the variance in reliance on hunger/satiety cues. The final model is

presented in Figure 6.5 and final estimates are provided in Table 6.8.

143

Table 6.7

Initial Estimates for Model I - Modified Acceptance Model with Reliance on

Hunger/Satiety cues as the Outcome

Parameter

estimate

Unstandardised

estimate

Standard

error

Standardised

estimate

p

Body

acceptance by

others

Perceived

social

support

.04 .00 .45 <.001

Body function

Perceived

social

support

.01 .01 .10 .056

Body

acceptance

by others

.27 .07 .19 <.001

Body

satisfaction

Body

function

.36 .04 .44 <.001

Reliance on

hunger/satiety

cues

Body

satisfaction

.33 .03 .45 <.001

Body

function

.02 .03 .03 .53

144

Figure 6.5. Re-specified Model I - Modified acceptance model with reliance on

hunger/satiety cues as the outcome.

Figure 6.5 and Table 6.8 summarise findings for the modified acceptance

model with reliance on hunger/satiety cues subscale as the outcome. Higher levels of

perceived social support predicted greater body acceptance by others; body

acceptance by others predicted a greater focus on body function; and higher levels of

perceived social support, body acceptance by others, and a focus on body function

predicted greater body satisfaction. Greater body satisfaction predicted a greater

reliance on hunger/satiety cues. Women were more likely to rely on hunger/satiety

cues for eating if they reported greater satisfaction with their bodies.

145

Table 6.8

Final Estimates for Model I - Modified Acceptance Model with Reliance on

Hunger/Satiety Cues as the Outcome

Parameter

estimate

Unstandardised

estimate

Standard

error

Standardised

estimate

p

Body

acceptance by

others

Perceived

social

support

.04 .00 .45 <.001

Body function

Body

acceptance

by others

.33 .07 .23 <.001

Body

satisfaction

Body

function

.23 .03 .28 <.001

Perceived

social

support

.02 00 .17 <.001

Body

acceptance

by others

.62 .04 .53 <.001

Reliance on

hunger/satiety

cues

Body

satisfaction

.34 .03 .46 <.001

146

Model Based on the Dual Pathway Model of Disordered Eating

Model II with disordered eating as an outcome variable was tested. The

hypothesised model did not provide a good fit to the data, χ2 (4, N=457) = 91.25,

p<.001, CFI = .85, TLI = .63, RMSEA = .22, SRMR = 0.11. Initial estimates for the

model are presented in Table 6.9. Modification indices indicated the inclusion of a

path from pressure for thinness to negative affect, from internalisation of the thin-

ideal to negative affect, and from internalisation of the thin-ideal to disordered eating

would improve model fit. These paths were added to the re-specified model. The re-

specified model provided a better fit to the data, χ2 (1, N=457) = 6.26, p<.001, CFI =

.99, TLI = .91, RMSEA = .11, SRMR = 0.02. A chi square difference test also

showed that the final model was a significantly better fitting model than the initial

one, χ2diff = 84.99, df = 3, p<.05. Overall, the model explained 41% of the variance in

disordered eating. The final model is presented in Figure 6.6 and final estimates are

summarised in Table 6.10.

147

Table 6.9

Initial Estimates for Model II – Modified Dual Pathway Model with Disordered

Eating as the Outcome

Parameter

estimate

Unstandardised

estimate

Standard

error

Standardised

estimate

p

Thin-ideal

internalisation

Pressure for

thinness

.40 .05 .38 <.001

Negative affect

Body

dissatisfaction

2.83 .34 .36 <.001

Body

dissatisfaction

Pressure for

thinness

.53 .05 .47 <.001

Thin-ideal

internalisation

.20 .05 .18 <.001

Disordered

eating

Body

dissatisfaction

.47 .04 .47 <.001

Negative

affect

.03 .01 .24 <.001

148

Figure 6.6. Re-specified Model II – Modified dual pathway model with

disordered eating as the outcome.

As shown in Figure 6.6 and Table 6.10, greater pressure for thinness

predicted greater internalisation of the thin-ideal, greater body dissatisfaction, and

higher levels of negative affect. In addition, thin-ideal internalisation moderately

predicted greater body dissatisfaction and negative affect; and body dissatisfaction

predicted higher levels of negative affect. Greater internalisation of the thin-ideal,

body dissatisfaction, and negative affect predicted higher levels of disordered eating.

Women were more likely to engage in disordered eating if they were dissatisfied

with their bodies, internalised the thin-ideal, or experienced negative affect.

149

Table 6.10

Final Estimates for Model II - Modified Dual Pathway Model with Disordered

Eating as the Outcome

Parameter

estimate

Unstandardised

estimate

Standard

error

Standardised

estimate

p

Thin-ideal

internalisation

Pressure for

thinness

.40 .05 .38 <.001

Negative affect

Body

dissatisfaction

1.42 .39 .18 <.001

Pressure for

thinness

1.73 .39 .20 <.001

Thin-ideal

internalisation

1.75 .45 .21 <.001

Body

dissatisfaction

Pressure for

thinness

.53 .05 .47 <.001

Thin-ideal

internalisation

.20 .05 .18 <.001

Disordered

eating

Body

dissatisfaction

.40 .04 .40 <.001

Negative

affect

.02 .01 .17 <.001

Thin-ideal

internalisation

.28 .04 .26 <.001

The next model tested was Model II with eating for non-emotional/non-

external reasons as the outcome. The model did not provide a good fit to the data, χ2

(4, N=457) = 76.64, p<.001, CFI = .86, TLI = .64, RMSEA = .20, SRMR = 0.10.

Initial model estimates are presented in Table 6.11. Modification indices indicated

150

the inclusion of a path from pressure for thinness to negative affect and to eating for

non-emotional/non-external reasons, and from internalisation of the thin-ideal to

negative affect would improve model fit. The re-specified model is presented in

Figure 6.7. The final model provided a better fit to the data, χ2 (1, N=457) = 4.27,

p=.039, CFI = .99, TLI = .94, RMSEA = .09, SRMR = 0.10. A chi square difference

test was conducted between the initial and re-specified models to assess the fit.

Compared to the initial model, the final model provided a significantly better fit to

the data, χ2diff = 72.37, df = 3, p<.05. Overall, the model explained 29% of the

variance in eating for non-emotional/non-external reasons.

Table 6.11

Initial Estimates for Model II – Modified Dual Pathway Model with Eating for Non-


Parameter

estimate

Unstandardised

estimate

Standard

error

Standardised

estimate

p

Thin-ideal

internalisation

Pressure for

thinness

.40 .05 .38 <.001

Negative affect

Body

dissatisfaction

2.83 .34 .36 <.001

Body

dissatisfaction

Pressure for

thinness

.53 .05 .47 <.001

Thin-ideal

internalisation

.20 .05 .18 <.001

Eating for non-

emotional/non-

external reasons

Body

dissatisfaction

-.35 .04 -.35 <.001

Negative affect -.03 .01 -.25 <.001

151

As shown in Figure 6.7 and Table 6.12., pressure for thinness predicted

higher levels of thin-ideal internalisation; pressure for thinness and thin-ideal

internalisation predicted greater body dissatisfaction; and pressure for thinness, thin-

ideal internalisation and body dissatisfaction predicted higher levels of negative

affect. Higher levels of body dissatisfaction, negative affect, and greater pressure for

thinness were associated with less eating for non-emotional/non-external reasons.

Women were less likely to engage in eating for non-emotional/non-external reasons

if they were dissatisfied with their bodies, felt the pressure to be thin, or experienced

negative affect.

Figure 6.7. Re-specified Model II – Modified dual pathway model with eating for

non-emotional/non-external reasons as the outcome.

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Table 6.12

Final Estimates for Model II - Modified Dual Pathway Model with Eating for Non-


Parameter

estimate

Unstandardised

estimate

Standard

error

Standardised

estimate

p

Thin-ideal

internalisation

Pressure for

thinness

.40 .05 .38 <.001

Negative affect

Body

dissatisfaction

1.42 .39 .18 <.001

Pressure for

thinness

1.74 .45 .20 <.001

Thin-ideal

internalisation

1.75 .39 .21 <.001

Body

dissatisfaction

Pressure for

thinness

.53 .05 .47 <.001

Thin-ideal

internalisation

.20 .05 .18 <.001

Eating for non-

emotional/non-

external reasons

Body

dissatisfaction

-.23 .05 -.23 <.001

Negative affect -.02 .01 -.19 <.001

Pressure for

thinness

-.29 .05 -.26 <.001

Model II was tested with reliance on hunger/satiety cues as an outcome

variable. The model did not provide an acceptable fit to the data, χ2 (4, N=457) =

45.30, p<.001, CFI = .91, TLI = .77, RMSEA = .15, SRMR = 0.07. Initial estimates

are presented in Table 6.13. The path from negative affect to intuitive eating was

153

non-significant (p=.59). Modification indices indicated the inclusion of a path from

internalisation of the thin-ideal to negative affect would improve model fit. This path

was added and the re-specified model tested. The re-specified model provided an

acceptable fit to the data, χ2 (3, N=457) = 15.50, p=.001, CFI = .97, TLI = .91,

RMSEA = .10, SRMR = 0.03. Compared to the initial model, the re-specified model

provided a significantly better fit to the data, χ2diff = 29.80, df = 1, p<.05. However,

the path from negative affect to reliance on hunger/satiety cues remained non-

significant (p=.59). This path was deleted and the re-specified model tested. This

model provided a good fit to the data, χ2 (4, N=457) = 15.79, p=.003, CFI = .97, TLI

= .94, RMSEA = .08, SRMR = 0.04 and was not significantly different in fit to the

first re-specified model, χ2diff = 0.29, df = 1 p>.05. Therefore, the re-specified model

with the path between removed between negative affect and reliance on

hunger/satiety cues was retained as the more parsimonious model. Overall, the model

accounted for 21% of the variance in reliance on hunger/satiety cues. The final

model is presented in Figure 6.8 and final estimates are presented in Table 6.14.

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Table 6.13

Initial Estimates for Model II – Modified Dual Pathway Model with Reliance on


Parameter

estimate

Unstandardised

estimate

Standard

error

Standardised

estimate

p

Thin-ideal

internalisation

Pressure for

thinness

.40 .05 .38 <.001

Negative affect

Body

dissatisfaction

2.83 .34 .36 <.001

Body

dissatisfaction

Pressure for

thinness

.53 .08 .47 <.001

Thin-ideal

internalisation

.20 .05 .18 <.001

Reliance on

hunger/satiety

cues

Body

dissatisfaction

-.33 .03 -.45 <.001

Negative

affect

-.00 -.00 -.02 .591

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Figure 6.8. Re-specified Model II – Modified dual pathway model with reliance

on hunger/satiety cues as the outcome.

As shown in Figure 6.8 and Table 6.14, pressure for thinness predicted higher

levels of thin-ideal internalisation and body dissatisfaction; thin-ideal internalisation

predicted greater body dissatisfaction; and body dissatisfaction and thin-ideal

internalisation predicted higher levels of negative affect. Body dissatisfaction

predicted less reliance on hunger/satiety cues.

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Table 6.14

Final Estimates for Model II – Modified Dual Pathway Model with Reliance on


Parameter

estimate

Unstandardised

estimate

Standard

error

Standardised

estimate

p

Thin-ideal

internalisation

Pressure for

thinness

.40 .05 .38 <.001

Negative affect

Body

dissatisfaction

2.12 .35 .27 <.001

Thin-ideal

internalisation

2.11 .38 .25 <.001

Body

dissatisfaction

Pressure for

thinness

.53 .08 .47 <.001

Thin-ideal

internalisation

.20 .05 .18 <.001

Reliance on

hunger/satiety

cues

Body

dissatisfaction

-.34 .03 -.46 <.001

Discussion

The aim of the second part of the empirical study was to examine the

similarities and differences in the psychosocial factors that are associated with

disordered eating, eating for non-emotional/non-external reasons, and reliance on

hunger/satiety cues. This was examined using bivariate correlations and two

psychosocial models of eating: the acceptance model of intuitive eating and a

modified version of the dual pathway model of disordered eating.

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More similarities than differences were found. As indicated by the bivariate

correlations with each of the body image variables, body appreciation, appearance

evaluation, and body area satisfaction were moderately to strongly associated with

lower levels of disordered eating, and moderately associated with higher levels of

eating for non-emotional/non-external reasons and greater reliance on hunger/satiety

cues. In addition, given that the three body image variables were highly interrelated,

an overall body dissatisfaction/satisfaction factor was computed using principal axis

factoring and was included in the models. This is in contrast with previous research

that has shown body appreciation to be distinct from body satisfaction and

appearance evaluation (Tylka, & Wood-Barcalow, 2015).

In line with the hypothesised models and previous research, body

dissatisfaction/body satisfaction was found to be the main direct predictor of each of

the examined eating outcomes. In the acceptance model, greater body satisfaction

predicted lower levels of disordered eating, and higher levels of eating for non-

emotional/non-external reasons and reliance on hunger/satiety cues. In the modified

dual pathway model, greater body dissatisfaction predicted higher levels of

disordered eating, and lower levels of eating for non-emotional/non-external reasons

and reliance on hunger/satiety cues. Body dissatisfaction has consistently been found

to predict disordered eating (e.g., Andrés & Saldaña, 2014; Dakanalis, Timko,

Serino, Riva, Clerici, & Carrà, 2016; Johnson & Wardle, 2005; Mailloux, Bergeron,

Meilleur, D’Antono, & Dubé, 2014; Stice, Ng, & Shaw, 2010) and is often the target

of interventions that aim to prevent or reduce disordered eating (Ciao, Loth, &

Neumark-Sztainer, 2014). In addition, previous studies have shown that greater body

dissatisfaction is associated with higher levels of emotional eating (e.g., Annesi,

Mareno, & McEwen, 2016; Anschutz, Engels, & Van Strien, 2008; Johnson &

Wardle, 2005). Body dissatisfaction is associated with a desire to modify body

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weight or shape to achieve the thin-ideal body type, which promotes the use of

disordered eating practices, including dieting (Stice, 2002; Stice & Shaw, 2002).

Body dissatisfaction may also lead to the experience of emotional distress (Stice,

2002), which in turn may promote emotional eating as a way of coping.

These findings are also in line with other studies that have examined the

reliance on hunger/satiety cues subscale in relation to body dissatisfaction or body

appreciation (Carbonneau et al., 2016; van Dyck et al., 2016). Greater body

dissatisfaction has also been found to be moderately to strongly related to less

reliance on hunger/satiety cues (Carbonneau et al., 2016; van Dyck et al., 2016).

Moreover, greater body appreciation has been found to be moderately to strongly

associated with greater reliance on hunger/satiety cues in adult women (Oswald,

Chapman, & Wilson, 2017; Tylka & Kroon Van Diest, 2013). Overall, the findings

suggest that women who are less dissatisfied with their body weight and shape, or are

more appreciative of their body, regardless of weight/shape, are more likely to eat

based on physical cues for hunger and satiety. Appreciating or being satisfied with

the body may be a prerequisite for eating based on physical hunger and satiety cues.

The other psychosocial factors that form part of the acceptance model of

intuitive eating are perceived social support, body acceptance by others, and body

function, with the focus being on the positively-framed psychosocial factors

(Augustus-Horvath & Tylka, 2011). Both perceived social support and body

acceptance by others were found to be associated with the three eating patterns in the

same way. At the bivariate level, perceived social support was found to be weakly

correlated while body acceptance by others was found to be moderately correlated

with each of the eating patterns. Only body function was found to relate differently to

the three eating outcomes. Body function was highly correlated with disordered

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eating, moderately correlated with eating for non-emotional/non-external reasons,

and weakly correlated with reliance on hunger/satiety cues.

In addition to the bivariate relationships, overall support for the acceptance

model of intuitive eating was found for each of the examined outcomes. In line with

previous research which has examined the total IES as the outcome variable,

perceived social support predicted body acceptance by others, body acceptance by

others predicted body function and body satisfaction, body function predicted body

satisfaction, and body satisfaction predicted each eating pattern (Avalos & Tylka,

2006; Tylka & Kroon Van Diest, 2011; Oh et al., 2012). The only exception was that

body function was not found to predict reliance on hunger/satiety cues. However, all

previous studies have examined the acceptance model using the total IES as the

outcome variable. This is the first study to examine the acceptance model with the

reliance on hunger/satiety subscale. Given that no previous study has examined the

model with the separate IES subscales, this finding pertaining to the reliance on

hunger/satiety cues needs to be verified. It may be that the relationship between body

function and the total IES is attributable to unconditional permission to eat and eating

for physical rather than emotional reasons, which overlap with disordered eating,

emotional eating and external eating.

The remaining psychosocial factors that were examined in the study, pressure

for thinness, internalisation of the thin-ideal, and negative affect, are components of

the dual pathway model. At the bivariate level, all three of these factors were

moderately related with disordered eating and eating for non-emotional/non-external

reasons but they were only weakly related to reliance on hunger/satiety cues. In

addition, and in line with the dual pathway model (Stice, 2001; Stice & Agras, 1998),

pressure for thinness and thin-ideal internalisation predicted body dissatisfaction, and

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body dissatisfaction predicted negative affect and each eating pattern. Negative affect

was found to predict both disordered eating and eating for non-emotional/non-

external reasons, however, it did not predict reliance on hunger/satiety cues. The

findings support previous research that has shown negative affect predicts disordered

eating in women (Dakanalis et al., 2016; Stice et al., 2010), as have other aspects of

emotional functioning, such as depressive symptomatology (e.g., Skinner et al.,

2012). Moreover, studies that have examined intuitive eating in relation to negative

affect have found that lower levels of negative affect are moderately correlated with

higher scores on the total IES (Tylka et al., 2015). However, when examining each of

the three subscales of intuitive eating, negative affect was moderately correlated with

unconditional permission to eat and eating for physical rather than emotional

reasons, but only weakly correlated with reliance on hunger/satiety cues (Tylka &

Kroon Van Diest, 2013).

In addition to the relationships proposed in the dual pathway model (Stice,

2001), a direct relationship was demonstrated between: pressure for thinness and

eating for non-emotional/non-external reasons; thin-ideal internalisation and

disordered eating; and both pressure for thinness and thin-ideal internalisation with

negative affect. These findings suggest that these two factors may directly influence

these eating behaviours and negative affect, in addition to their indirect effect

through body dissatisfaction. The dual pathway model proposes that societal

messages received by women promote the thin-ideal stereotype. These messages are

internalised and this can result in women experiencing dissatisfaction with their

weight/shape. Consequently, women engage in disordered eating practices, in an

attempt to attain this thin-ideal body type (Stice, 2001).

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Overall, the empirical study provided support for the acceptance model and

the modified dual pathway model for all three eating patterns. The similarities

demonstrated for each model with each eating outcome suggests that there are

psychosocial factors that predict the three distinct eating patterns in a similar way.

The differences demonstrated in the psychosocial factors that were related to each

eating outcome highlights that reliance on hunger/satiety cues is more conceptually

distinct from disordered eating and eating for non-emotional/non-external reasons.

Additional studies are needed to validate these findings. This includes examining the

two models in other groups of adult women and in other populations such as adult

men, adolescents, and in clinical populations.

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CHAPTER SEVEN

General Discussion

Summary of Aims and Main Findings

The overall aim of this thesis was to examine intuitive eating in relation to

other eating patterns and psychosocial correlates in adult women. Firstly, a

systematic review of existing literature was conducted that examined the

psychosocial correlates of intuitive eating in adult women. An empirical study was

then conducted to examine the factor structure of the IES (Tylka, 2006) in a

community sample of adult women. The study also examined the three IES subscales

in relation to other eating patterns. Finally, the study compared the psychosocial

correlates of the three IES subscales and these other eating patterns.

The systematic review showed that intuitive eating was associated with a

number of psychosocial factors in adult women, including other eating patterns,

aspects of body image, and emotional functioning. This included psychosocial

factors that have been incorporated in the acceptance model of intuitive eating (i.e.,

perceived social support, body acceptance by others, a focus on body function, and

body appreciation), and the dual pathway model of disordered eating (i.e., societal

pressure for thinness, internalisation of the thin-ideal, body dissatisfaction, and

negative affect). For studies that examined the subscales of the IES, unconditional

permission to eat was found to be moderate to strongly related to aspects of

disordered eating. The eating for physical rather than emotional reasons and reliance

on hunger/satiety cues subscales were weakly to moderately associated with

disordered eating. The review showed that the three subscales of the IES

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(unconditional permission to eat, eating for physical rather than emotional reasons,

reliance on hunger/satiety cues) (Tylka, 2006) related differently to aspects of

disordered eating. Moreover, the review highlighted the importance of examining the

subscales of intuitive eating in assessing psychosocial correlates, and the need for

studies to examine the factor structure of the IES in relation to disordered eating. In

addition, none of the reviewed studies had examined other eating patterns, such as

emotional eating and external eating, in relation to the total IES or its subscales.

Studies were also limited by the use of primarily female university student samples

from the United States. The empirical study set out to build on existing studies of

adult women and address some of these limitations.

The empirical study provided support for the three-factor structure of the

original version of the IES (Tylka, 2006). Although the original scale was validated

only among female university students, this study showed that the three subscales

were clearly distinguishable among an Australian community sample of adult

women. In addition, the empirical study showed that two of the IES subscales,

unconditional permission to eat and eating for physical rather than emotional

reasons, overlapped with other examined eating behaviours, including aspects of

disordered eating, emotional eating, and external eating. Only the third subscale,

reliance on hunger/satiety cues, was found to be distinct from other examined eating

patterns. This was demonstrated through a factor analysis of the three IES subscales,

dieting, restrained eating, bulimia/food preoccupation, emotional eating, and external

eating. This resulted in two eating factors: disordered eating and eating for non-

emotional/non-external reasons. Unconditional permission to eat loaded onto the

disordered eating factor along with dieting, restrained eating, and bulimia/food

preoccupation. Eating for physical rather than emotional reasons loaded onto the

eating for non-emotional/non-external reasons factor with emotional eating and

164

external eating. Reliance on hunger/satiety cues was the only IES subscale that did

not load onto either factor.

Lastly, an examination of bivariate relationships and two psychosocial

models of eating, the acceptance model and a modified version of the dual pathway

model, demonstrated that there were both similarities and differences in the

psychosocial factors that were associated with the three eating outcomes (disordered

eating, eating for non-emotional/non-external reasons, and reliance on hunger/satiety

cues). At the bivariate level, psychosocial factors that were part of the acceptance

model (i.e., perceived social support, body acceptance by others, body satisfaction)

were related to each eating pattern in the same way. The main difference was for

body function, which was strongly related to disordered eating, moderately related to

eating for non-emotional/non-external reasons, and weakly related to reliance on

hunger/satiety cues. For psychosocial factors that were part of the modified dual

pathway model (i.e., societal pressure for thinness, internalisation of the thin-ideal,

body dissatisfaction, negative affect), each of these factors were also related to the

three eating patterns in a similar way. The main differences were for pressure for

thinness, thin-ideal internalisation, and negative affect, which were moderately

related to disordered eating and eating for non-emotional/non-external reasons, but

only weakly related to reliance on hunger/satiety cues.

The empirical study provided support for both the acceptance model and the

modified dual pathway model for the each of the three eating outcomes. More

similarities than differences were found in how the psychosocial factors in each

model were related to each eating pattern. Differences in the psychosocial factors

that were related to each eating pattern highlighted the distinctiveness of reliance on


165

Assessing Principles of Intuitive Eating

The IES subscale that has been found to be substantially distinct from other

eating behaviours is reliance on hunger/satiety cues. This subscale assesses the

degree to which individuals rely on physical cues for hunger and satiety to guide

eating behaviours. The subscale relates to the second and fifth intuitive eating

principles proposed by Tribole and Resch (2012). The first principle promotes eating

based on physical hunger cues, and the second principle promotes an awareness of

satiety cues and eating to a comfortable degree of fullness. These aspects of intuitive

eating involve an awareness and trust in these physical cues, and the ignorance of

external and emotional cues that can influence food intake. Similar to the reliance on

hunger/satiety cues subscale, the intrinsic and extrinsic subscales of the Hawks et al.

(2004) IES also assesse eating based on physical hunger and satiety cues (e.g., “I

seldom eat unless I notice that I am physically hungry”, and “After eating, I often

realise that I am fuller than I would like to be”) and avoidance of external cues for

eating (e.g., “It’s hard to resist eating something good if it is around me, even if I’m

not very hungry”)

The other two subscales from the IES (Tylka, 2006), unconditional

permission to eat and eating for physical rather than emotional reasons, were found

to show substantial overlap with measures of disordered eating (including dieting,

restrained eating, and bulimia/food preoccupation), and/or emotional eating and

external eating. Although not specifically noted in Tylka (2006), the unconditional

permission to eat subscale of the IES includes items that capture the first, third, and

fourth principles of intuitive eating, including rejection of the dieting mentality, an

unconditional permission to eat, and non-judgmental attitudes towards eating. The

eating for physical rather than emotional reasons subscale includes items that capture

166

the seventh principle, avoiding the use of food to manage emotions. The Hawks et

al. (2004) scale also captures these four principles in the anti-dieting and extrinsic

eating subscales, using reverse-scored items. The anti-dieting subscale assesses the

rejection of the dieting mentality (e.g., “I generally count calories before deciding if

something is OK to eat”), unconditional permission to eat (e.g., “There are certain

foods that I really like, but I try to avoid them so that I won’t gain weight”), and non-

judgmental attitudes towards eating (e.g., “I usually feel like a failure when I eat

more than I should”). Moreover, the extrinsic subscale also captures the principle

relating to emotional eating (e.g., “I often turn to food when I feel sad, anxious,

lonely, or stressed out”).

Given that unconditional permission to eat and eating for physical rather than

emotional reasons showed substantial overlap with other eating behaviours, this

raises the question as to whether these two subscales should be labelled as intuitive

eating, or whether they should be labelled to reflect lower levels of disordered eating

and lower levels of emotional/external eating. Alternatively, more sensitive measures

that more fully address the specific principles of intuitive eating underlying these

constructs are needed. It might be that these two aspects of intuitive eating exist on a

spectrum with other eating patterns, such that unconditional permission to eat and

disordered eating exist on one spectrum, and eating for physical rather than

emotional reasons and emotional/external eating exist on another. A more in-depth

examination of these specific intuitive eating principles and how they relate to eating

behaviours, by conducting individual interviews with women, is now needed.

A limitation of this thesis is that the revised IES-2 (Tylka & Kroon Van

Diest, 2013) was not assessed, due to the scale not being available when the

empirical study was commenced in 2013. A fourth subscale, body-food choice

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congruence, was included in the revised scale to incorporate the tenth principle of

intuitive eating, which refers to making food choices that are nourishing and

contribute to body functioning, but also consider taste satisfaction. The body-food

choice congruence subscale includes three items (e.g., “Most of the time, I desire to

eat nutritious foods”) and assesses the degree to which food choices are aligned with

the body’s needs. This principle assessed by this subscale encourages food choices

for body functioning and nourishment, but also for taste satisfaction (Tribole &

Resch, 2012).

Findings of studies that have examined the body-food choice congruence

subscale suggest that this subscale may be more conceptually distinct from other

eating patterns. Body-food choice congruence has been found to be weakly related to

restrained eating, emotional eating and symptoms of bulimia in German adult women

(van Dyck et al., 2016), and was not related with disordered eating in female

American university students (Tylka & Kroon Van Diest, 2013). One exception is

that body-food choice congruence was found to be moderately related to symptoms

of bulimia in French-Canadian adults (Carbonneau et al., 2016). In addition, Tylka

and Kroon Van Diest (2013) found that, after controlling for the contribution of

disordered eating, body-food choice congruence contributed uniquely to self-esteem,

positive affect, and negative affect. This suggests that body-food choice congruence

is more distinct from disordered eating. In comparison with the other three IES

subscales, some research has shown that body-food choice congruence is weakly

related to psychosocial factors such as body dissatisfaction (van Dyck et al., 2016),

body shame, and anxiety (Tylka & Kroon Van Diest, 2013), while the other three

IES subscales are moderately to strongly related to these factors. Additional studies

are needed that examine this subscale of the IES in relation to other patterns of eating

and psychosocial correlates.

168

In addition to the body-food choice congruence, there are three principles of

intuitive eating, proposed by Tribole and Resch (2012), that have not been included

in the IES (Tylka, 2006) or the revised IES (Tylka & Kroon Van Diest, 2013). These

principles focus on eating satisfaction, body appreciation/respect, and a positive

relationship with physical activity (Tribole & Resch, 2012). Two of these principles

do not address eating behaviours. This may explain why they were not incorporated

when the IES was developed (Tylka, 2006). Two of these aspects have been assessed

in studies using independent scales. For example, body appreciation has been

assessed using the BAS (Avalos et al., 2005), and a recent study conducted by Tylka

and Homan (2015) examined exercise motivation in university students (i.e.,

appearance-related, or for health and enjoyment) using the Function of Exercise

Scale (DiBartolo, Lin, Montoya, Neal, & Shaffer, 2007). Moreover, while the

Intuitive Eating Scale developed by Hawks et al. (2004) has not been widely used, in

comparison to the IES (Tylka, 2006), it includes a subscale labelled ‘self-care’,

which overall assesses the degree to which individuals focus on health and fitness

rather than appearance. This subscale captures these two principles (i.e., body

appreciation/respect, and a positive relationship with physical activity) by assessing

the degree to which an individual is focused on health and fitness rather than weight

(e.g., “The health and strength of my body is more important to me than how much I

weigh”), and attitudes towards physical activity (e.g., “I mostly exercise because of

how good it makes me feel physically”). The third principle, relating to eating

satisfaction or the pleasure associated with food and eating, has been assessed using

an independent measure in one study (Smith & Hawks, 2006), however, this study

used the Hawks et al. (2004) scale to assess intuitive eating, not the IES (Tylka,

2006) or the revised version (Tylka & Kroon Van Diest, 2013).

169

Other Psychosocial Factors

There are various environmental, biological, situational and other psychological

factors not examined in this study that may be related to intuitive eating and more

specially to the reliance on hunger and satiety cues subscale. Given the focus on

hunger and/or satiety, other factors may be those that heighten, reduce or interrupt

the awareness and/or response to these biological signals. For example, distractions

in the immediate eating environment (e.g., television, meal time conversation, eating

while working), food availability (e.g., not having food on-hand when hungry, social

situations that are centred on food), or family-related factors (e.g., child-feeding

practices; food attitudes held by significant others) (French, Story, & Jeffery, 2001;

Tribole & Resch, 2012; Scaglioni, Salvioni, & Galimbert, 2008; Story, Neumark-

Sztainer, & French, 2002; Wansink, 2004). None of these factors have to be directly

examined in relation to this subscale of the IES.

There is some research that has found reliance on hunger/satiety cues to be

related to interoceptive awareness (Oswald et al., 2017; Tylka, 2006; Tylka & Kroon

Van Diest, 2013; van Dyck et al., 2016), and autonomous eating regulation

(Carbonneau et al., 2015). Interoceptive awareness describes the ability to recognise

and identify signals of hunger/satiety and emotions (Garner, Olmstead, & Polivy,

1983). Reliance on hunger/satiety cues was weakly and negatively related to poor

interoceptive awareness in two samples of university students living in the United

States (Tylka, 2006; Tylka & Kroon Van Diest, 2013), moderately related to greater

interoceptive awareness in Australian female university students (Oswald et al.,

2017), and strongly and negatively correlated with poor interoceptive awareness of

appetite in a sample of German women (van Dyck et al., 2016). These studies

suggest that the degree to which women can recognise and identify internal signals of

hunger/satiety could impact on whether or not these signals are responded to when

170

eating. Not being able to adequately recognise feelings of hunger and fullness is

likely to impact on how much they eat, either not eating enough or overeating.

Autonomous eating regulation is described as eating that is self-determined,

rather than being determined by external factors (Mask & Blanchard, 2011).

Carbonneau and colleagues (2015) found that greater reliance on hunger/satiety cues

was moderately associated with higher levels of autonomous eating regulation in a

sample of French-Canadian women. This suggests that women who were more self-

determined in their eating and were less influenced by external factors were more

likely to rely on internal cues for eating. Alternatively, women who rely more on

internal hunger/satiety cues were more likely to be self-determined in their eating,

and less likely to be influenced by external factors when eating. Autonomously

regulated eating has been found to be strongly and positively related to healthy eating

behaviours (e.g., consumption of healthy foods and eating other foods in moderation,

such as chips, chocolate and candy), as assessed by the Healthy Eating Behavior

Scale (Pelletier, Dion, Slovinec-D’Angelo, & Reid, 2004). Further research is needed

to examine these eating-related factors in relation to the reliance on hunger/satiety

cues subscale.

There are also other psychosocial factors that have been examined in relation the

IES subscales as shown in the systematic review but were not examined in the

empirical study for this thesis. Reliance on hunger/satiety cues was found to be

moderately and positively associated with self-esteem (Tylka & Kroon Van Diest,

2013; Tylka & Wilcox, 2006), unconditional self-regard (Tylka & Wilcox, 2006),

and proactive coping (Tylka, 2006; Tylka & Wilcox, 2006) in female university

students. In addition, this subscale was found to be only weak to moderately

associated with optimism (Tylka, 2006; Tylka & Wilcox, 2006), positive affect

(Tylka & Kroon Van Diest, 2013; Tylka & Wilcox, 2006), and life satisfaction

171

(Tylka, 2006; Tylka & Kroon Van Diest, 2013), and only weakly associated with

psychological hardiness and social problem solving (Tylka & Wilcox, 2006). Studies

have found that reliance on hunger/satiety cues relates more strongly to some of

these psychosocial factors (e.g., optimism, life satisfaction, proactive coping,

unconditional self-regard, and positive affect), compared to unconditional permission

to eat and eating for physical rather than emotional reasons, in samples of university

students (Tylka, 2006; Tylka & Kroon Van Diest, 2013; Tylka & Wilcox, 2006).

Research is now needed to examine whether these psychosocial factors can

differentiate between aspects of intuitive eating and other eating patterns in

community samples. This will lead to a better understanding of how intuitive eating

is different from disordered eating, emotional eating, and external eating.

Intuitive Eating and Positive Health Outcomes

Prospective studies are needed to determine if intuitive eating is associated

with positive health outcomes, including a healthy weight. While intuitive eating is

not proposed as an eating approach for weight control, weight changes have been

identified as a potential outcome of adopting an intuitive eating style (Tribole &

Resch, 2012). Cross-sectional studies that have examined the association between the

reliance on hunger/satiety cues subscale of intuitive eating and weight status, as

assessed by BMI, have shown that greater reliance on hunger/satiety cues is

associated with a lower BMI in samples of both women and men (Camilleri, Méjean,

Bellisle, Andreeva, Kesse-Guyot, Hercberg et al., 2016; Madden et al., 2012), and

university students (Herbert et al., 2013; Tylka, 2006; Tylka & Kroon Van Diest,

2013; van Dyck et al., 2016). In addition, adults within a normal weight range have

reported greater reliance on hunger/satiety cues, compared to overweight adults

(Camilleri et al., 2015; Cole, Clark, Heileson, DeMay, & Smith, 2016). In contrast,

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Anderson and colleagues (2016) found no relationship between this aspect of

intuitive eating and BMI, however, a majority of the sample were within a healthy

weight range. Findings of the empirical study, in relation to reliance on

hunger/satiety cues and weight status, were in line with Anderson et al. (2016). The

correlation between reliance on hunger/satiety cues and BMI was non-significant.

Interventions that have incorporated principles of intuitive eating, including

the promotion of eating based on physical cues, have demonstrated effectiveness in

modifying disordered eating behaviours and improving aspects of physical and

psychological health. A systematic review conducted by Schaefer and Magnuson

(2014) showed that interventions which promote eating based on internal cues were

effective in reducing aspects of disordered eating, led to an increase in positive body

image, improvements in aspects of psychological well-being (i.e., depression,

anxiety, self-esteem), better diet quality and engagement in physical activity, and

improvements in health indicators such as blood pressure and cholesterol levels. The

review also found support for the effectiveness of these interventions in reducing or

maintaining body weight (Schaefer & Magnuson, 2014). A more recent systematic

review examined outcomes of interventions that adopted a non-dieting approach to

eating (Clifford, Ozier, Bundros, Moore, Kreiser, & Morris, 2015). Findings were in

line with the Schaefer and Magnuson (2014), demonstrating that interventions were

effective in reducing disordered eating behaviours and improving body image,

emotional functioning, and self-esteem (Clifford et al., 2015). Subsequent studies

have found that non-dieting interventions have been able to increase intuitive eating

behaviours, as assessed by the total IES (Young, 2010) or its subscales (Bush, Rossy,

Mintz, & Schopp, 2014; Healy, Joram, Matvienko, Woolf, & Knesting, 2015;

Humphrey, Clifford, & Neyman Morris, 2015), the Hawks et al. (2004) scale

173

(Wilson, 2014), or a scale to assess a rejection of the dieting mentality (Cole &

Horacek, 2010).

In addition to increasing intuitive eating, these interventions reduced dieting,

and improved body image in female university students (Humphrey et al., 2015;

Wilson, 2014; Young, 2010), high school students (Healy et al., 2015), women with

partners in the military (Cole & Horacek, 2010), and adult women working in a

university setting (Bush et al., 2014). Future research should include a greater focus

on the IES subscales in examining the effect of interventions on intuitive eating

outcomes, but also the impact of increasing intuitive eating on physical and

psychological health outcomes.

Examining Intuitive Eating in Other Populations

A strength of the empirical study is the use of a community sample of adult

women. As shown in the systematic review, the majority of studies that have

examined intuitive eating used samples of primarily female university students who

lived in the United States. This study used a community sample of adult women that

was representative of the Australian population with regards to age, cultural

background and weight status (Australian Bureau of Statistics, 2016). Women were

aged 18 to 87 years, were primarily of an Australian and/or British/European

background, were tertiary educated, in a relationship, and engaged in paid

employment. In addition, more than forty percent of the sample were classified as

overweight or obese, and over one third of women experienced a gastrointestinal

condition, food allergies or another other health condition, such as diabetes. In the

Australian adult population more broadly, over a third of Australian adults meet

criteria for a functional gastrointestinal disorder (Koloski, Talley, & Boyce, 2002),

approximately six percent of the population are diagnosed with diabetes (Australian

174

Bureau of Statistics, 2015), and two percent of adults are diagnosed with a food

allergy (Australasian Society of Clinical Immunology & Allergy, 2016). While the

empirical study did not make comparisons based on these characteristics, the

findings suggest that intuitive eating and the relationships examined may be

applicable to the wider population of adult women, including those who are

overweight or who experience a health conditions that may influence their eating

patterns. Further studies are needed to validate the findings of this thesis in other

community samples of adult women, and in other populations, including adult men,

adolescents, and in clinical populations.

Several studies have examined intuitive eating among males using the

original IES and the revised IES scale (Cole, Clark, Heileson, DeMay, & Smith,

2016; Ellis, Galloway, Webb, Martz, & Farrow, 2016; Tylka & Homan, 2015; Tylka

& Kroon Van Diest, 2013). Other studies have examined adult men using the Hawks

et al. (2004) IES scale (e.g., Gast et al., 2012; Hawks et al., 2004). Some research has

shown that men reported higher levels of intuitive eating than women, according to

the total IES and subscales (Tylka & Kroon Van Diest, 2013; van Dyck et al., 2016),

except the body-food choice congruence subscale (Tylka & Kroon Van Diest, 2013).

Two studies to date have specifically examined the factor structure of the

IES-2 in adult men (Tylka & Kroon Van Diest, 2013; van Dyck et al., 2016). The

four-factor structure of the IES-2 was retained for a sample of 391 men included in

the initial validation of the scale (Tylka & Kroon Van Diest, 2013), and the four-

factor structure was also retained in a sample of 212 men for the German translated

version of the IES-2 (van Dyck et al., 2016). The four-factor structure of the IES-2 in

adult men was the same as for adult women.

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To date, only two studies have included adult men in examining intuitive

eating subscales in relation to other eating patterns and psychosocial correlates (e.g.,

Tylka & Kroon Van Diest, 2013; van Dyck et al., 2016). The findings of these

studies of men are in line with the findings on adult women, with regards to the

relationship between the IES subscales and other eating patterns. Unconditional

permission to eat has been found to be strongly related to overall disordered eating

(Tylka & Kroon Van Diest, 2013) and restrained eating (van Dyck et al., 2016), and

eating for physical rather than emotional reasons has been found to be strongly

related to emotional eating (van Dyck et al., 2016). However, some findings are

inconsistent with the empirical study, showing that unconditional permission to eat

was only weakly related to symptoms of bulimia, and eating for physical rather than

emotional reasons was only weakly related to external eating in German men (van

Dyck et al., 2016).

Two studies have examined the IES subscales in relation to some of the

psychosocial correlates included in this empirical study. Body dissatisfaction was

negatively associated with each of the four IES subscales in a sample of German men

(van Dyck et al., 2016). Tylka and Kroon Van Diest (2013) examined body

appreciation, body shame, body surveillance, internalisation of the thin-ideal, and

negative affect. Body shame was strongly and negatively related to unconditional

permission to eat, moderately and negatively related to eating for physical rather than

emotional reasons and reliance on hunger/satiety cues, and was not related to body-

food choice congruence. Body appreciation was moderately and positively related to

all IES subscales except body-food choice congruence; body surveillance was

weakly and negatively related to all subscales except body-food choice congruence;

thin-ideal internalisation was moderately and negatively related to eating for physical

rather than emotional reasons, weakly and negatively related to unconditional

176

permission to eat and reliance on hunger/satiety cues, and was not associated with

body-food choice congruence. Finally, negative affect was moderately and

negatively related to eating for rather than emotional physical reasons, weakly and

negatively related to reliance on hunger/satiety cues and body-food choice

congruence, but was not associated with unconditional permission to eat. This study

suggests that the body-food choice congruence subscale may be a more distinct

pattern of eating in adult men. It is not clear if the reliance on hunger/satiety cues can

be differentiated from the other IES subscales. Research is now needed to more

thoroughly examine the IES subscales in relation to the other eating patterns and

psychosocial correlates in adult men. This should include an examination of the

acceptance model of intuitive eating with IES subscales, as one study has examined

the acceptance model in men but used the total IES (Tylka & Homan, 2015).

There are a growing number of studies that have examined intuitive eating in

adolescents (e.g., Andrew, Tiggemann, & Clark, 2016; Andrew et al., 2015;

Dockendorff et al., 2012; Moy, Petrie, Dockendorff, Greenleaf, & Martin, 2013).

One study examined the factor structure of the adolescent version of the IES in a

sample of adolescent boys and girls. Unlike the three-factor structure of original IES

(Tylka, 2006), which was validated in an adult sample, four factors were identified:


trust in internal hunger/satiety cues, and awareness of internal hunger/satiety cues

(Dockendorff et al., 2012). However, the two factors relating to hunger and satiety

cues are similar to the reliance on hunger/satiety cues for the IES (Tylka, 2006), with

the subscales of the adolescent version including some of the same items as the

subscale in the IES (e.g., “I can tell when I’m slightly full” and “I trust my body to

tell me when to eat”). The factor-structure of the adolescent version of the scale is

similar to that of the original IES for adult women (Tylka, 2006).

177

To date, only one study has examined the subscales of the adolescent version

of the IES in relation to other eating patterns (Moy, Petrie, Dockendorff, Greenleaf,

& Martin, 2013), and one study has examined the IES subscales and psychosocial

correlates (Dockendorff et al., 2012). In the study conducted by Moy et al. (2013),

adolescents who were not currently dieting reported higher levels of unconditional

permission to eat and eating for physical rather than emotional reasons, whereas

adolescents who were currently dieting reported lower levels of unconditional

permission to eat and eating for physical rather than emotional reasons. Interestingly,

dieters and non-dieters did not differ for reliance on hunger/satiety cues subscale. It

is not clear if the reliance on hunger/satiety cues subscale is more distinct from other

eating patterns in adolescent males and females.

The psychosocial correlates of the IES subscales were examined in

Dockendorff et al. (2012). Body satisfaction was related to unconditional permission

to eat, eating for physical rather than emotional reasons, and trust in internal

hunger/satiety cues in a similar way, but was not related to the fourth subscale,

awareness of internal hunger/satiety cues. Thin-ideal internalisation was weakly

related to the first three subscales but not awareness of internal hunger/satiety cues.

Pressure to have a thin body was moderately related to unconditional permission to

eat and weakly related to eating for physical rather than emotional reasons and trust

in internal hunger/satiety cues, but was not associated with awareness of internal

hunger/satiety cues. Based on these limited findings, the awareness of internal

hunger/satiety cues subscale appears to be more distinct from other subscales.

Further research using adolescents will help establish if the findings of the empirical

study can be extended to younger populations, particularly as adolescence is a

significant developmental stage, and to establish if there are age differences and/or

similarities in psychosocial factors that predict the IES subscales and other eating

178

patterns. The acceptance model has only been examined using total IES score in

adolescents (Andrew et al., 2015), therefore, studies are needed to examine the

model in relation to the IES subscales.

Only one study to date has examined intuitive eating in relation to type of

eating disorder (van Dyck et al., 2016). The study examined the relationship between

the subscales of the German version of the IES-2 and type of eating disorder

diagnosis in a sub-sample of 87 women who reported a current diagnosis of either

Anorexia Nervosa (AN), Bulimia Nervosa (BN), or Binge Eating Disorder (BED)

(van Dyck et al., 2016). Research is yet to be conducted that examines the factor

structure of the IES, and the IES subscales in relation to psychosocial correlates in

the clinical population. Extending findings of this study to the clinical population,

and comparing clinical and community samples of adult women, will increase our

understanding of how intuitive eating relates to clinical levels of disordered eating,

and if there are similarities and/or differences in the psychosocial factors that predict

intuitive eating and disordered eating patterns in this population.

Study Limitations

In addition to the limitations already highlighted in this chapter, there are

further limitations that need to be considered in relation to study findings. Firstly, the

empirical study used a cross-sectional design in addressing each aim of the study.

Therefore, the cause-effect relationships between intuitive eating, other eating

patterns, and their psychosocial correlates cannot be established. Prospective studies

are now needed to examine these relationships. Secondly, the sampling methods used

in the study included recruiting from organisations that were associated with

women’s health (e.g., women’s health centres, fitness centres, physiotherapy clinics,

and weight loss groups). It is possible that women who participated in the study

179

placed importance on their health and well-being, and may also have had an interest

in eating behaviours, particularly considering the proportion of the sample who

reported a health condition that may affect their food intake. Future studies should

consider using sampling methods that ensure their sample is representative of the

population in which they are examining, and to minimise potential sampling bias.

Conclusion

The findings of this thesis contribute to a greater understanding of how

aspects of intuitive eating relate to other eating patterns, and the similarities and

differences in their psychosocial correlates. The empirical study was novel in that it

was the first study to examine the factor structure of the IES (Tylka, 2006) using a

community sample; no previous studies had examined the subscales of the IES

(Tylka, 2006) in relation to other eating patterns in a community sample; it was the

first study to directly compare the psychosocial correlates of intuitive eating to those

of disordered eating; and it was also the first study to examine both the acceptance

model of intuitive eating and the dual pathway model of disordered eating in relation

to the three IES subscales.

Findings of this thesis suggest that unconditional permission to eat and eating

for physical rather than emotional reasons are aspects of intuitive eating that overlap

with other patterns of eating. The unconditional permission to eat subscale

overlapped with aspects of disordered eating, and the eating for physical rather than

emotional reasons subscale overlapped with emotional eating and external eating.

The third subscale of the IES (Tylka, 2006), reliance on hunger/satiety cues, was

found to be assessing a distinct pattern of eating. The empirical study provided

support for the acceptance model and the dual pathway model with disordered eating,

eating for non-emotional/non-external reasons, and reliance on hunger/satiety cues as

180

outcomes. Moreover, the psychosocial factors that were found to relate differently to

reliance on hunger/satiety cues provided additional support for the distinctiveness of

this eating pattern from disordered eating and non-emotional/non-external eating.

The findings of this thesis have potential implications for the prevention and

treatment of eating concerns. The overlap between components of intuitive eating

with aspects of disordered eating, emotional eating, and external eating, suggests that

the intuitive eating could be used to target a range of eating behaviours. Firstly,

strategies that encourage unconditional permission to eat could be used to prevent

and/or reduce aspects of disordered eating, including dieting, restrained eating, and

bulimia/food preoccupation. In addition, strategies that focus on eating for physical

rather than emotional reasons could be used to target emotional eating and external

eating. Finally, the findings of this thesis suggest that targeting body dissatisfaction

and promoting positive body image, such as body appreciation, may be the primary

target for increase eating based on internal cues of hunger/satiety and reducing

disordered eating patterns. Research is now needed to extend the findings of this

thesis to other populations, including adult men, adolescents, and clinical

populations. In addition, establishing the psychosocial factors that predict an increase

in reliance on hunger/satiety cues through prospective studies may inform the

development of interventions designed to prevent or reduce disordered eating, and

improve physical and psychological health outcomes such as body weight, nutritional

intake, body image, and emotional well-being.

181

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brief measures of positive and negative affect: The PANAS scales. Journal of

Personality & Social Psychology, 54(6), 1063. doi:10.1037/0022-

3514.54.6.1063

Webster, J. & Tiggemann, M. (2003). The relationship between women's body

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The Journal of Genetic Psychology: Research & Theory on Human

Development, 164, 241-252. doi:10.1080/00221320309597980.

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Westenhoefer, J., Stunkard, A. J., & Pudel, V. (1999). Validation of the flexible and

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Disorders, 26(1), 53-64. doi:0.1002/(SICI)1098-

108X(199907)26:1<53::AID-EAT7>3.0.CO;2-N

Wheeler, B. J., Lawrence, J., Chae, M., Paterson, H., Gray, A. R., Healey, D., . . .

Taylor, B. J. (2016). Intuitive eating is associated with glycaemic control in

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Williamson, D. A., Martin, C. K., York-Crowe, E., Anton, S. D., Redman, L. M.,

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Wilson, R. E. (2014). A brief non-dieting intervention increases intuitive eating and

reduces dieting intention, body image dissatisfaction, and anti-fat attitudes: A

randomized controlled trial. (Doctoral dissertation). Retrieved from

http://hdl.handle.net/10125/100284.

World Health Organisation. (2016). BMI classification. Retrieved from

http://apps.who.int/bmi/index.jsp?introPage=intro_3.html.

Young, S. K. (2010). Promoting healthy eating among college women: Effectiveness

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http://lib.dr.iastate.edu/etd/11308.

Zeeck, A., Stelzer, N., Linster, H. W., Joos, A., & Hartmann, A. (2011). Emotion and

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APPENDIX A

Ethics Approval Documentation

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APPENDIX B

Plain Language Statement and Consent Form

PLAIN LANGUAGE STATEMENT AND CONSENT FORM TO: Prospective Participants

Plain Language Statement

Project Title: Eating Patterns, Health and Wellbeing among Australian Women

Principal Researcher: Associate Professor Lina Ricciardelli, School of Psychology, Deakin University, Melbourne

Student Researcher: Lauren Jade Bruce, School of Psychology, Deakin University, Melbourne

Associate Researcher(s): Dr Matthew Fuller-Tyszkiewicz, School of Psychology, Deakin University, Melbourne

1. Introduction

You are invited to take part in a research project being conducted by the School of

Psychology, Deakin University. The research project aims to examine the relationship

between eating patterns and health and wellbeing among Australian women aged 18

years and older.

This Plain Language Statement provides you with information about the research

project. It explains what is involved to help you decide if you want to take part. Please

read this information carefully. Ask questions about anything that you don’t

understand or want to know more about.

224

2. What is the purpose of this research project?

The aim of the project is to examine the relationship between eating patterns, health

and wellbeing among adult women. More specifically, the project aims to examine

the relationship between eating attitudes and behaviours, weight management and

psychosocial wellbeing.

Some research suggests that dieting or restrained eating patterns are associated with

decreased health and wellbeing, while eating patterns which are based on biological

feelings of hunger and fullness are associated with increased health and wellbeing.

Researchers aim to recruit at least 300 women into the research project. The project

is being conducted by researchers at Deakin University and will form part of a Doctor

of Psychology research thesis.

3. What does participation in this research project involve?

If you agree to participate, you will be asked to provide information in the form of a

survey. The survey will take no more than 30 minutes to complete. Survey items will

include information about your background (e.g., age, education), your height and

weight, your eating attitudes and behaviours, mood, body satisfaction and social

support.

Examples of questions that will be asked include the extent to which you agree with

the following statements: “"If I am craving a certain food, I allow myself to have it",

“"Despite its flaws, I accept my body for what it is"” and "There are people I can

depend on to help me if I really need it".

You will not be paid for your participation in this project. However, if you complete

the survey you will have the chance to win one of six $30 Coles-Myer gift vouchers.

4. What are the possible benefits?

There are no direct benefits from your participation in this project. However,

participating in this research may contribute to knowledge about the relationship

between eating patterns, health and wellbeing of Australian women.

5. What are the possible risks?

There are no anticipated risks of participating in this project. However, given that the

questionnaires will include questions regarding issues such as mood and body image,

there is a possibility that you may experience some concern about your responses.

Thus, you are invited to examine the questionnaire material before agreeing to

participate. If you find yourself feeling sad or distressed at any point, you are

encouraged to contact your GP and/or other health care professional. In addition,

you can also contact Associate Professor Lina Ricciardelli on (03) 9244 6866. You will

225

have the opportunity to discuss your concerns in a confidential manner and

appropriate follow-up will be suggested if necessary.

Additionally, you may call one of the following services for further information, to

discuss your concerns, or to obtain a referral for treatment if necessary:

Lifeline: 13 11 14

Eating Disorder Foundation of Victoria Helpline: 1300 550 236

Body Image Eating Disorders Treatment and Recovery Service: (03) 9854 1700

6. Do I have to take part in this research project?

Participation in any research project is voluntary. If you do not wish to take part you

are not obliged to. Due to the completely anonymous nature of this study, no

identifying information will be placed on your completed survey. As such, it will not

be possible to withdraw your survey from the study once it has been returned or

submitted. Please read through this information sheet and look through the

questionnaire prior to deciding whether you would like to participate. Your decision

whether to take part or not to take part, or to take part and then withdraw, will not

affect your relationship with Deakin University in any way.

7. How will I be informed of the final results of this research project?

A summary of the findings will be provided to the School of Psychology, Deakin

University and will be available for any interested participants to read at the

completion of the study. Please contact Lauren Bruce at [email protected] if you

would like to receive a copy of this report.

8. What will happen to information about me?

Any information obtained in connection with this research project that can identify

you will remain confidential and will only be used for the purpose of this research

project. It will only be disclosed with your permission, except as required by law. You

can be assured that you will not be identified by name in any way in the reporting of

our results in the research thesis, publications and conference presentations. Any

information we collect from you that can identify you will be identified with a

participant code and will remain confidential. Information will be stored in a locked

cabinet within the School of Psychology at Deakin University for a minimum of 6 years

from the date of publication, after which time it will be securely disposed of.

9. Can I access research information kept about me?

In accordance with relevant Australian and/or Victorian privacy and other relevant

laws, you have the right to access the information collected and stored by the

226

researchers about you. Please contact one of the researchers named at the end of

this document if you would like to access your information.

10. Is this research project approved?

The ethical aspects of this research project have been approved by the Human Ethics

Advisory Group, Faculty of Health, Deakin University.

This project will be carried out according to the National Statement on Ethical

Conduct in Human Research (2007) produced by the National Health and Medical

Research Council of Australia. This statement has been developed to protect the

interests of people who agree to participate in human research studies.

11. Who can I contact?

For further information concerning this project, or if you have any problems which

may be related to your involvement in the project (for example, feelings of distress),

you can contact the principal researcher Associate Professor Lina Ricciardelli in the

School of Psychology, Deakin University, 221 Burwood Highway, Burwood, Victoria,

3125, on 9244 6866 or email: [email protected]

Complaints

If you have any complaints about any aspect of the research,

the way it is being conducted or any questions about your

rights as a participant then you may contact:

Secretary HEAG- H, Dean's Office, Faculty of Health, Medicine,

Nursing and Behavioural Sciences, 221 Burwood Hwy,

Burwood, VIC 3125, Telephone: (03) 9251 7174, Email

[email protected].

Please quote project number HEAG-H 02_ 2013

227

APPENDIX C

Principal Axis Factoring for Three Body Image Variables

Principal axis factoring was used to conducted in SPSS version 22.0 using the

following three scales: the Body Appreciation Scale (Avalos et al., 2005), and the

Appearance Evaluation and Body Area Satisfaction subscales of the

Multidimensional Body-Self Relations Questionnaire (Brown et al., 1990; Cash,

2000). The Kaiser-Meyer-Olkin measure of sampling adequacy for all variables was

adequate (.76), according to cut-offs recommended by Hutcheson and Sofroniou

(1999). Bartlett’s test of sphericity, χ2 (457) = 1181.50, p<.001, indicated that

correlations between items were sufficient in size to conduct principal axis factoring.

One factor had an eigenvalue over Kaiser’s criterion of 1 (Kaiser, 1960) and this

factor explained 83.0% of the variance. The scree plot (Cattell, 1966) also suggested

the presence of one factor. This factor was labelled “Body dissatisfaction”. Factor

scores were calculated using the regression method.

Table A

Factor Matrix with Factor Loadings

Body

satisfaction

Communality

Body appreciation .87 .76

Appearance evaluation .94 .88

Body area satisfaction .92 .85

Eigenvalue 2.49

Variance (%) 83.0

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230

Licensing Agreement for Reproduction of Published Article

ELSEVIER LICENSE

TERMS AND CONDITIONS

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License Number 4161221279428

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Appetite

Licensed Content Title A systematic review of the psychosocial correlates of

intuitive eating among adult women

Licensed Content Author Lauren J. Bruce, Lina A. Ricciardelli

Licensed Content Date Jan 1, 2016

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Intuitive Eating in Relation to Other Eating Patterns and

Psychosocial Correlates

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231

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Documents

Intuitive Eating in Relation to Other Eating Patterns …dro.deakin.edu.au/.../bruce-intuitiveeating-2017.pdfAbstract Intuitive eating has been proposed as an eating style that fosters