Journal of Contextual Behavioral Science ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Journal of Contextual Behavioral Science
journal homepage: www.elsevier.com/locate/jcbs
Empirical Research
Body image avoidance: An under-explored yet important factor in the
relationship between body image dissatisfaction and disordered eating
C. Alix Timko a,b,n, Adrienne S. Juarascio c, Lindsay M. Martin a,1,
Ashley Faherty a, Cynthia Kalodner a
a
Department of Psychology, Towson University, USA
Department of Behavioral and Social Sciences, University of the Sciences, 600 S. 43rd Street, Philadelphia, PA 19104, USA
c
Department of Psychology, Drexel University, USA
b
art ic l e i nf o
a b s t r a c t
Article history:
Received 17 April 2012
Received in revised form
19 December 2013
Accepted 27 January 2014
Body dissatisfaction is highly predictive of disordered eating cognitions and behavior, however many
more individuals experience body dissatisfaction than disordered eating. While several variables appear
to influence the relationship between body dissatisfaction and disordered eating, one potential understudied construct is experiential avoidance (EA) of body image. Individuals with high body image EA may
be more likely to engage in behaviors designed to reduce body dissatisfaction and its associated
cognitions and emotions, including disordered eating (i.e., restricting, purging, laxative use, etc.).
The Body Image-Acceptance and Action questionnaire (BIAAQ; Sandoz, Wilson, Merwin, & Kellum,
2013) was recently developed to assess EA of body image, however despite promising initial validation
data, it is still a relatively novel instrument and additional validation is warranted. The present study
includes a series of cross-sectional studies designed to accomplish three goals: (1) to provide additional
validation data for the BI-AAQ, (2) to assess the potential indirect effect of EA on the relationship
between body image dissatisfaction and disordered eating cognition and behavior, and (3) to compare
the BI-AAQ to an existing measure of body avoidance. Overall, results indicate that the BI-AAQ is a valid
measure of body image EA; it partially explains the relationship between body image dissatisfaction and
disordered eating. The measure also appears to have incremental validity over pre-existing measures.
Future research is needed to further clarify the role of body image EA and to examine whether
treatments targeting this construct can prevent or treat disordered eating.
& 2014 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
Keywords:
Body dissatisfaction
Experiential avoidance
Body image
Body acceptance
1. Introduction
Body image dissatisfaction is the negative subjective experience of one's weight and shape (Stice & Shaw, 2002), and often
leads to various forms of eating disorder symptomatology
(Brannan & Petrie, 2008; Corning, Krumm, & Smitham, 2006).
However, the fact that many individuals with body image dissatisfaction do not go on to develop disordered eating habits
suggests that body image dissatisfaction may be causally linked to
disordered eating through mediating variables. Several variables
have been found to influence the relationship between body image
dissatisfaction and disordered eating behavior and cognition,
including neuroticism, self-esteem, perfectionism, body surveillance, and having a family member with an eating disorder
n
Corresponding author at: Department of Behavioral and Social Sciences,
University of the Sciences, 600 S. 43rd Street, Philadelphia, PA 19104, USA.
E-mail address: a.timko@usciences.edu (C.A. Timko).
1
Now at: The Department of Psychology, Drexel University, USA.
(Brennan & Petrie, 2008; Twamley & Davis, 1999; Tylka, 2004).
One potential under-studied factor that may causally influence the
relationship between body image dissatisfaction and disordered
eating is experiential avoidance (EA).
EA consists of two phenomena: (1) the unwillingness to
experience negative internal events (i.e., thoughts, feelings, and
physiological experiences), and (2) actions directed at altering or
removing the stimuli that invoke these aversive experiences (Hayes,
Wilson, Gifford, Follette, & Strosahl, 1996; Orsillo, Roemer, Lerner, &
Tull, 2004). EA is an increasingly influential construct pertaining to
the etiology and maintenance of various forms of psychopathology
(Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Hayes, Masuda, Bissett,
Luoma, & Guerrero, 2004; Hayes, Strosahl & Wilson, 2012). Individuals high in EA are thought to have lower psychological flexibility
and greater difficulty engaging in value consistent behavior (Hayes
et al., 2004). While the relationship is still unclear, EA may function
similarly to other constructs that have a negative impact on psychological adjustment, including thought suppression and overt avoidance of distressing contexts (Chawla & Ostafin, 2007).
http://dx.doi.org/10.1016/j.jcbs.2014.01.002
2212-1447 & 2014 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
Please cite this article as: Timko, C. A., et al. Body image avoidance: An under-explored yet important factor in the relationship between
body image dissatisfaction and.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.01.002i
2
C.A. Timko et al. / Journal of Contextual Behavioral Science ∎ (∎∎∎∎) ∎∎∎–∎∎∎
In the context of body dissatisfaction, body image EA refers to
efforts to avoid, suppress, modify, or otherwise escape from
distressing negative thoughts, feelings, or sensations about the
body. These distressing psychological experiences might include
negative thoughts (e.g., “I’m so fat—I look disgusting”), negative
physical sensations (e.g., tight clothing), or negative feelings (e.g.,
shame, guilt, or embarrassment about the body). For persons with
high levels of body image EA, these experiences evoke escape
efforts. Various maladaptive behaviors such as extreme dieting,
restrictive eating, compulsive exercising, binge eating, and purging
may function to attempt to eliminate or reduce these distressing
psychological experiences (Merwin et al., 2011; Timko, Merwin,
Herbert, & Zucker, 2013). Conversely, individuals with low EA are
theorized to be more willing to experience negative body image
and are therefore less motivated to change this experience.
Consider the following example: one woman is distressed about
the size of her thighs, feels uncomfortable having this distress, and
in response, compulsively restricts her food intake in an effort to
neutralize her discomfort. Another woman also notices negative
thoughts about her thighs, is also distressed by the thoughts;
however, instead of engaging in behaviors aimed to minimize her
distress (i.e., restriction, excessive exercise, binging and/or purging) she is willing to experience the discomfort and continues to
engage in activities that are meaningful or highly valued. Notably,
both women experience distress, but only one actively engages in
EA as a means of reducing this distress. Thus, in the context of
body disturbance, EA refers not to whether or not an individual is
distressed by negative body image, but rather the degree to which
he or she is motivated to reduce that distress, even when doing so
is ineffective or results in negative consequences. The definition of
body image EA suggests that body image dissatisfaction itself does
not directly cause disordered eating pathology, but is instead
partially explained by the degree to which an individual actively
fights against or avoids their negative body image.
A growing body of research suggests that generalized EA is high
amongst eating disorder populations (Cockell, Geller, & Linden,
2002; Keyser et al., 2009; Merwin et al., 2011; Orsillo & Batten,
2002), further suggesting that disordered eating behaviors function as a way to help individuals avoid upsetting internal experiences, including body dissatisfaction (Hayes & Pankey, 2002;
Keyser et al., 2009; Paxton & Diggens, 1997). Given that EA is high
among patients with an eating disorder, and that disordered
eating may function as an avoidant coping mechanism for body
image experiences, both generalized and body image EA may
partially explain the relationship between body dissatisfaction and
disordered eating such that higher levels of EA will lead to higher
disordered eating behavior.
Generalized EA is typically assessed using the Acceptance and
Action Questionnaire (AAQ). Although the original AAQ was
developed in 2006 (Hayes et al., 2006), it was recently revised
into a seven-item version (AAQ-II) with superior psychometric
properties (Bond et al., 2011). The AAQ-II assesses one construct,
often referred to using various terms, including: acceptance,
experiential avoidance and psychological inflexibility. Although
results indicate that AAQ scores concurrently, longitudinally, and
incrementally predict a range of outcomes (Bond et al., 2011),
levels of EA across various behavioral presentations might differ.
In fact, conceptual concerns exist regarding the use of one general
measure of experiential avoidance, and experts posit that the
measure may have more clinical utility if applied in a more
context-specific way. For example, various highly context-specific
measures have been developed that are linked to positive outcomes in clinical populations, including social anxiety (MacKenzie
& Kocovski, 2010), diabetes management (Gregg, Callaghan, Hayes,
& Glenn-Lawson, 2007), weight-related issues (Lillis & Hayes,
2008), chronic pain (McCracken, Vowles, & Eccleston, 2004), food
cravings (Juarascio, Forman, Timko, Butryn, & Goodwin, 2011), and
hallucinations (Shawyer et al., 2007). Thus, a context-specific AAQ
measure that targets body image EA might be more predictive of
related behaviors such as disordered eating. No specific version of
the AAQ existed to measure body image EA until a newly
developed measure (Body Image-AAQ, described below) was
developed in 2013.
Before the Body Image AAQ was created, the questionnaire that
assessed a construct most similar to body image EA was the Body
Image Avoidance Questionnaire (BIAQ; Rosen, Srebnik, Saltzberg,
& Wendt, 1991), a well-validated 19-item measure designed to
assess how often a person avoids situations that trigger body
image thoughts or feelings. The self-report measure was primarily
designed to assess the overt behavioral avoidance tendencies that
occur alongside body dissatisfaction (e.g., avoiding tight fitting
clothes, physical intimacy, or social outings, restricting intake).
Although the BIAQ provides useful information regarding behavioral avoidance, it only captures some of the many ways an
individual might attempt to avoid distressing thoughts and feelings about his or her body. It is most distinct from the BI-AAQ in
that it was neither designed to nor does it measure avoidance of
internal experiences directly. For example, questions on the BIAQ
include, “I wear baggy clothes,” “I restrict the amount of food I
eat,” “I do not go out socially if the people I am with will discuss
weight,” and “I am inactive”.
Sandoz, Wilson, Merwin, & Kellum (2013) developed a measure
designed to assess a wider array of body image avoidance: the
Body Image Acceptance and Action Questionnaire (BI-AAQ).2
Compared to the BIAQ, this measure assesses cognitive and
emotional avoidance in addition to behavioral avoidance to
provide a more comprehensive assessment of the ways someone
might try to avoid distressing body image experiences. This is 12item measure is scored on a 7-point likert-type scale, and
generally has good internal reliability (Cronbach's alpha ranging
from 0.92 to 0.95; Ferreira, Pinto-Gouveia, & Duarte, 2011; Sandoz
et al., 2013; Timko, England, Herbert, & Forman, 2010). Questions
assess the degree to which individuals attempt to avoid distressing
thoughts or feelings about their body (i.e., Question 3: “I shut
down when I feel bad about my body shape or weight,” Question
4: “My thoughts and feelings about my body weight and shape
must change before I can take important steps in my life,” and
Question 11: “When I start thinking about the size and shape of
my body, it’s hard to do anything else.”). Note that items were
reverse scored and higher scores indicate greater acceptance
whereas lower scores indicate greater avoidance.
A growing number of published studies have investigated the
relationship between body image EA, body dissatisfaction, and
disordered eating (Ferreira et al., 2011; Hrabosky et al., 2009;
Pearson, Follette, & Hayes, 2012), yet the specific nature of this
relationship is still in question. A better understanding of the
specific relationship between these three constructs may help
explain why certain individuals are more likely to develop disordered eating and could inform treatment by providing specific
targets for change. Thus far, the BI-AAQ has been shown to be
predictive of disordered eating behavior, such that greater acceptance of thoughts and feelings about one’s body predicts fewer
disordered eating symptoms (Sandoz et al., 2013). Further evidence indicates that the BI-AAQ partially mediates the relationship
between disorder eating cognitions and overall disordered eating
pathology, after controlling for both gender and body mass index
2
It is important to note that the authors of the BI-AAQ have conceptualized it
as a measure of psychological acceptance and psychological flexibility. However, we
discusses the BI-AAQ in terms of experiential avoidance in order to be comparable
to the literature on body image avoidance—specifically the function and understanding of the of the Body Image Avoidance Questionnaire (Rosen et al., 1991).
Please cite this article as: Timko, C. A., et al. Body image avoidance: An under-explored yet important factor in the relationship between
body image dissatisfaction and.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.01.002i
C.A. Timko et al. / Journal of Contextual Behavioral Science ∎ (∎∎∎∎) ∎∎∎–∎∎∎
(Wendell, Masuda, & Le, 2012). Additionally, body dissatisfaction
and BI-AAQ scores have been shown to be uniquely predictive of
disordered eating, with lower experiential avoidance (or, greater
‘body image flexibility’) negatively associated with disordered
eating, but only in individuals with a low BMI of o20 (Hill,
Masuda, & Latzman, 2013). To date, no study has examined the
potential indirect effect of body image EA on the relationship
between body dissatisfaction and eating cognition and behavior.
Thus, the following series of cross-sectional studies aimed to:
(1) provide additional validation data for the BI-AAQ, (2) assess the
potential indirect effect of body image EA in the relationship
between body image dissatisfaction and disordered eating cognition and behavior, and (3) compare the BI-AAQ to an existing
measure of body avoidance.
2. Study 1
The purpose of Study 1 was to explore the relationship
between body image EA and various correlates of body dissatisfaction and to provide additional validation data by examining body
image EA in a population of female dieters and non-dieters. A large
percentage of normal weight women self-identify as dieting to
lose weight (Fayet, Petocz, & Samman, 2012; Schembre, Nigg, &
Albright, 2011; Timko & Perone, 2005; Timko, Perone, & Crossfield,
2006). Self-identified dieters tend to have greater body dissatisfaction (Massey & Hill, 2012), desire a lower body weight than their
current weight (Schembre et al., 2011), are more likely to engage
in extreme weight control behaviors (Timko et al., 2006), are more
likely to report cravings (Massey & Hill, 2012), and have a higher
body mass index (Massey & Hill, 2012; Timko & Perone, 2005;
Timko et al., 2006) than non-dieters. Frequent dieting is associated
with greater eating disorder symptomatology, low self-esteem,
poor emotion regulation, high body dissatisfaction, and depression
(Ackard, Croll, & Kearney-Cooke, 2002). Indeed, body dissatisfaction is a greater predictor of disordered eating in women who selfidentify as dieting to lose weight (Juarascio, Perone, & Timko,
2011) compared to those who are not dieting. Thus, participants
who self-identified as dieting to lose weight in this study were
compared to those who reported not dieting in order to establish
between groups validity for the BI-AAQ and to serve as an analog
for a clinical population.
2.1. Method
2.1.1. Participants
109 female students were recruited from the Psychology
Department's subject pool at a large public Northeastern university. College women were chosen because they represent a
population with high body dissatisfaction and disordered eating
(Fairburn, Cooper, Doll, Norman & O’Connor, 2000), thus making
the hypothesized relationships easier to assess. A total of 136
women consented to participate, however, only 109 completed all
measures in the packet and were included in this analysis.
Participants ranged in age from 18 to 25, (M ¼18.18, SD ¼ 0.78).
This sample was primarily Caucasian (76.1%), followed by African
American (9.2%), Asian (6.4%), Hispanic, (1.8%), Pacific Islander
(0.9%), and 4.6% who identified as “other.”
3
completion. All procedures were approved by the Human Subjects
Review Board.
2.3. Materials
2.3.1. Demographics questionnaire
Participants were asked to provide information about their age,
ethnicity, self-reported weight, height, and two questions regarding dieting status. The dieting questions were as follows: “Are you
currently on a diet to lose weight?” and “Are you currently on a
diet to maintain your weight?” These questions have been used in
the past by the authors (Lowe & Timko, 2004; Timko et al., 2006)
and are answered dichotomously (yes/no).
Sociocultural Attitudes Towards Appearance Questionnaire-3
(SATAQ-3; Thompson, van den Berg, Roehrig, Guarda & Heinberg,
2004) was used to measure participants' internalization of the
thin-ideal. This questionnaire consists of 30 items, and each is
rated on a Likert scale of 1–5 (completely disagree to completely
agree). It contains four subscales: internalization (internalization
related to generic media influences), information (internalization
related to media as an informational source), pressure (internalization reflecting media pressures), and athletic ideal (internalization of athletic and sports figures); the SATAQ can also be used as a
total score. Reliability in this sample was high, with a Cronbach's
alpha of 0.96 for the total scale and alphas ranging from 0.85 to
0.94 for the subscales.
Eating Disorder Inventory-3 (EDI; Garner, 2004) was used to
measure eating disorder symptoms, body dissatisfaction, and drive
for thinness. Multiple validated measures of body dissatisfaction
exist and the use of these measures among studies examining the
relationship between body dissatisfaction, body image EA, and
disordered eating is inconsistent. Subscales of the EDI were chosen
as adequate measures of body dissatisfaction and disordered
eating due to the excellent internal consistency, sensitivity, and
specificity of the individual subscale scores in both normal and
clinical populations (Clausen, Rosenvinge, Friborg, & Rokkedal,
2011).
The Body Dissatisfaction scale consists of 9 items that focus on
satisfaction with these female body parts: stomach, hips, thighs,
and buttocks. In this sample it had an internal reliability of 0.88.
The Drive for Thinness Scale consists of 7 questions that focus on
restricting, fear of weight gain, and wanting to lose weight;
reliability was 0.88. The Bulimia Scale consists of 9 questions that
focus on behaviors such as binging, purging, and other symptoms
of bulimia. Cronbach's alpha for the Bulimia scale in this sample
was 0.85. Items are rated on a Likert scale from 1 to 6 (always to
never).
Body Image Acceptance and Action Questionnaire (BI-AAQ;
Sandoz et al., 2013) was used to measure the level to which the
participants reported engaging in experiential avoidance regarding thoughts and feelings about their body. The BI-AAQ is a body
specific version of the Acceptance and Action Questionnaire (AAQ;
Bond et al., 2011) that assesses unwillingness to experience
negative thoughts, physical sensations, and emotions associated
with the body. This is a 12-item measure scored on a 7-point
likert-type scale, and generally has good internal reliability
(Sandoz et al., 2013). In this sample, Cronbach's alpha was 0.92.
2.4. Statistical analyses
2.2. Procedure
All participants were administered a series of questionnaires
(presented as a pen and pencil packet) in a standardized, fixed
order represented below. Participants met the researcher in small
groups (the size of which varied due to student schedules), were
consented, and provided with the questionnaire packets for
Differences in body image EA, body image dissatisfaction, BMI,
internalization of the thin ideal, and disordered eating between
dieting status groups were assessed using a series of one way
analyses of variance (ANOVA) with a bonferroni post-hoc comparison when appropriate. In order to determine the indirect effects
of body-related EA on disordered eating, the Preacher and Hayes
Please cite this article as: Timko, C. A., et al. Body image avoidance: An under-explored yet important factor in the relationship between
body image dissatisfaction and.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.01.002i
C.A. Timko et al. / Journal of Contextual Behavioral Science ∎ (∎∎∎∎) ∎∎∎–∎∎∎
4
macro for SPSS (Preacher & Hayes, 2004) was utilized. The macro
utilizes a bootstrapping procedure with a default of 1000 bootstrap samples requested. This is a non-parametric test of indirect
effects that is more robust with small sample sizes and can be used
with cross-sectional data (Hayes, 2013).
2.5. Results
Participants had an average Body Mass Index (BMI; weight in
kg/height in m2) of 22.51 (SD ¼3.80) with a range between 16.24
and 39.48. The majority of the sample was within the normal
weight range (75.2%), followed by overweight (15.6%) individuals.
A small percentage of the sample was either underweight (6.4%) or
obese (2.4%). Approximately one quarter of the sample selfidentified as dieting to lose weight (24.8%), and one third reported
dieting to maintain weight (35.8%). Fewer than half the sample
identified as not dieting (39.4%).
An ANOVA indicated that there was a significant difference in
body image EA based on dieting status [F(2, 106) ¼14.36, p o0.001,
η2p ¼ 0.21, observed power¼0.99]; women who self-identified as
dieting to lose weight had significantly lower scores on the BI-AAQ
(indicating more experiential avoidance) compared to women
who self-identified as dieting to maintain weight and women
not dieting. A similar pattern emerged across variables, with
women dieting to lose weight having significantly higher BMIs
[F(2, 106) ¼5.91, p o0.01, η2p ¼0.10, observed power¼ 0.87] than
those dieting to maintain weight or not dieting. Likewise, those
dieting to lose weight had higher body dissatisfaction [F(2, 106) ¼
19.32, po 0.01, η2p ¼0.27, observed power¼ 0.99], higher drive
for thinness [F(2, 106) ¼23.35, p o0.01, η2p ¼0.31, observed
power¼ 0.99], higher scores on the bulimia subscale of the EDI-3
[F(2, 106) ¼3.61, p ¼0.03, η2p ¼0.06, observed power¼ 0.66], and
greater overall internalization of the thin ideal [F(2, 106) ¼ 11.58,
p o0.01, η2p ¼0.18, observed power ¼0.99]. Means and standard
deviations are presented in Table 1. This replicates prior data
indicating that women who diet tend to be more dissatisfied with
their shape and weight and provides support for the use of self-
identified dieting to lose weight as an analog for disordered eating.
Overall, body image EA is higher in those with greater eating and
body image pathology. This contention was further supported by
the significant negative correlation between body image EA and all
other variables included in this study [BMI: r ¼ 0.31; SATAQInternalization: r ¼ 0.57; SATAQ-Pressure: r ¼ 0.54; SATAQInformation: r ¼ 0.45; SATAQ-Athletic ideal: r ¼ 0.24; and
SATAQ-total: r ¼ 0.57, all po 0.05].
Next, the indirect effect of body image EA in the relationship
between body dissatisfaction and disordered eating (as assessed by
the drive for thinness and bulimia subscales of the EDI-3) was
explored. The 99% confidence interval for the bootstrapping method
for drive for thinness (0.09–0.31) and bulimia (0.05–0.26) did not cross
zero, indicating the presence of an indirect effect of body image EA on
the relationship between body dissatisfaction and bulimic symptoms/
drive for thinness. In both models, the direct effect from body
dissatisfaction to bulimia and to drive for thinness remained significant, suggesting that body image EA partially mediated the relationship between body dissatisfaction and disordered eating. See Fig. 1 for
a graphic depiction.
2.6. Study 1 discussion
The purpose of this study was to both provide additional
validation data for the BI-AAQ and to investigate the relationship
between body image EA, body dissatisfaction, and disordered
eating cognitions. The inclusion of women who were dieting to
lose or maintain weight allowed for a comparison of body image
EA between groups with higher and lower degrees of food and
weight preoccupation. Overall, the results support Sandoz et al.
(2013) findings that their measure of body image EA, the BI-AAQ,
is valid. Scores on the BI-AAQ were negatively correlated with
all measures such that higher body weight, more internalization
of the thin ideal, less body satisfaction, and more disordered
eating cognitions were all associated with greater body image
EA. Furthermore, body image EA was higher in individuals who
self-identified as dieting to lose weight—a group who had more
Table 1
Means and standard deviations for all variables by dieting status from studies 1, 2, and 3.
Study 1
Dieting to lose (N¼ 27)
Dieting to maintain (N¼39)
Not dieting (N¼ 43)
Total sample
Measure
M
SD
M
SD
M
SD
M
SD
BI-AAQa
BMIa
SATAQ-Ib
SATAQ-Pb,c
SATAQ-Gb,c
SATAQ-A
SATAQ-Tb,c
EDI-BDIa,c
EDI-DTa,c
EDI-BULb
53.30
24.51
29.93
25.22
32.07
15.81
103.04
40.30
26.96
17.81
13.01
4.70
6.44
5.75
6.81
3.76
17.40
9.57
6.60
7.10
64.79
22.28
28.25
23.10
29.38
16.36
97.10
32.23
21.72
14.31
11.87
2.55
8.86
6.44
7.19
4.50
21.91
8.59
5.88
5.00
70.12
21.47
24.14
17.37
23.30
14.23
79.05
26.42
16.14
14.28
13.52
3.73
10.41
6.96
8.64
4.62
25.10
9.25
7.03
5.84
64.05
22.51
27.06
21.37
27.65
15.39
91.45
31.94
20.82
15.17
14.32
3.80
9.26
7.25
8.48
4.45
24.35
10.53
7.77
6.04
Study 2
Dieting to lose (N¼ 92)
BI-AAQa,c
BMIb,c
EDI-BDb,c
EDI-DTa,c
EDI-BULb,c
45.47
26.64
24.37
17.10
9.89
18.78
6.40
10.15
7.12
8.05
Dieting to maintain (N¼42)
Not dieting (N¼ 158)
Total sample
55.83
22.27
17.74
11.31
5.05
62.76
24.77
15.16
7.77
4.87
56.21
25.00
18.48
11.26
6.51
17.25
3.02
10.02
6.82
5.69
17.20
5.72
10.56
7.27
5.65
19.13
5.81
11.13
8.29
6.91
Note. BI-AAQ: Body Image Acceptance and Action Questionnaire, BMI: Body Mass Index, EDI-BD: Eating Disorder Inventory Body Dissatisfaction Subscale, EDI-DT: Eating
Disorder Inventory Drive for Thinness Subscale, EDI-BUL: Eating Disorder Inventory-Bulimia Subscale, SATAQ-I: Sociocultural Attitudes towards Appearance QuestionnaireInternalization Subscale; SATAQ-P: Sociocultural Attitudes towards Appearance Questionnaire-Pressure Subscale; SATAQ-G: Sociocultural Attitudes towards Appearance
Questionnaire-General Internalization Subscale; SATAQ-A: Sociocultural Attitudes towards Appearance Questionnaire-Athletic Subscale; and SATAQ-T: Sociocultural
Attitudes towards Appearance Questionnaire-Total.
a
b
c
Indicates a significant difference between current dieters and those maintaining or not dieting.
Indicates a significant difference between current dieters and those not dieting.
Indicates a significant difference between those not dieting and maintainers.
Please cite this article as: Timko, C. A., et al. Body image avoidance: An under-explored yet important factor in the relationship between
body image dissatisfaction and.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.01.002i
C.A. Timko et al. / Journal of Contextual Behavioral Science ∎ (∎∎∎∎) ∎∎∎–∎∎∎
5
Fig. 1. Graphical representation of indirect effects in study 1 and study 2. First, the direct effect of body dissatisfaction on disordered eating (bulimia or drive for thinness) is
presented. Below each of these models is a graphical representation of the indirect effects.
negative attitudes toward their bodies and were more likely to
engage in disordered eating; this between group difference
provides evidence for known groups validity of the BI-AAQ. Finally,
the bootstrap analysis indicated that body image EA plays a role in
the relationship between body dissatisfaction on disordered eating.
beyond other measures of distress (Gloster, Klotsche, Chaker,
Hummel, & Hoyer, 2011). In this sample it had a Cronbach's alpha
of.91. All methods were approved by the appropriate review board
at Towson University.
3.3. Results
3. Study 2
The purpose of Study 2 was to replicate the results of Study 1 in
a larger, community-based sample to ensure the reliability and
generalizability of the relationships observed.
3.1. Method
3.1.1. Participants
382 females were recruited from four national online research
websites (available upon request from the authors). A total of 54
participants were removed from the sample because they were
underage and 56 individuals were removed for failing to complete
all questionnaires. A total of 272 adult women completed the
study. Participants ranged in age from 18 to 57, (M ¼23.29,
SD ¼7.98). This sample was primarily Caucasian (71.2%), followed
by African American (10.4%), Asian (7.1%), Hispanic, (5.6%), Pacific
Islander (0.9%), and 4.7% who identified as “other.”
3.2. Materials and procedure
With the exception of the SATAQ, participants were given the
same series of questionnaires as in Study 1; questionnaires were
completed on-line and in a fixed order. In order to examine the
relationship between the BI-AAQ and the original AAQ, the AAQ
was administered as well (Bond et al., 2011). Data analysis
followed the same procedure as in Study 1.
Acceptance and Action Questionnaire-II (AAQ; Bond et al.,
2011) The AAQ is believed to assess psychological flexibility more
generally, and demonstrates incremental validity above and
The women had an average BMI of 24.25 (SD ¼5.66) with a
range between 14.77 and 48.23. The majority of the sample was
within the normal weight range (58%), followed by overweight
(15%) individuals. A moderate percentage of the sample was either
underweight (11.3%) or obese (15.7%). Approximately one third of
the sample self-identified as dieting to lose weight (31.5%), and
one fifth reported dieting to maintain weight (13.9%). Fewer than
half the sample identified as not dieting (45.4%).
Cronbach’s alpha score for the BI-AAQ was 0.91. A one-way
analysis of variance (ANOVA) again indicated that there was a
significant difference in body image EA based on dieting status
[F(2, 279) ¼31.82, po 0.001, η2p ¼ 0.16, observed power ¼0.99],
women who self-identified as dieting to lose weight had significantly more EA compared to women who self-identified as dieting
to maintain weight and women not dieting. A similar pattern
emerged across variables, with women dieting to lose weight
having significantly higher BMIs [F(2, 306) ¼11.94, p o0.001,
η2p ¼ 0.06, observed power¼ 0.97] than those dieting to maintain
weight or not dieting. Likewise, those dieting to lose weight had
higher body dissatisfaction [F(2, 278) ¼26.63, po 0.001, η2p ¼ 0.14,
observed power ¼0.99], higher drive for thinness [F(2, 278) ¼
54.68, p o0.001, η2p ¼ 0.25, observed power¼0.99], and higher
scores on the bulimia subscale of the EDI-3 [F(2, 278) ¼20.31,
po 0.001, η2p ¼0.11, observed power¼0.99]. Means and standard
deviations were similar to those observed in Study 1. These
findings further support the use of dieting status as an analog
for disordered eating and that body image EA is higher in those
with greater eating and body image pathology. The BI-AAQ was
negatively correlated with BMI (r ¼ 0.21, p o0.05) and positively
correlated with the AAQ (r ¼ 0.55, p o0.01).
Please cite this article as: Timko, C. A., et al. Body image avoidance: An under-explored yet important factor in the relationship between
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6
The indirect effect of body image EA was again assessed using
the Preacher & Hayes Macro as described in Study 1. Fig. 1 provides
a visual representation of the model. The 99% confidence interval
for bulimic symptoms (0.10–0.21) and drive for thinness (0.22–
0.34) did not cross zero, indicating the presence of an indirect
effect of body image EA on the relationship between body
dissatisfaction and bulimic symptoms/drive for thinness.
Finally, a hierarchical linear regression was conducted in order
to determine if the BI-AAQ was able to account for variance in
eating disorder symptomatology above and beyond body dissatisfaction and the AAQ. Two regressions were conducted: one with
drive for thinness scores as the dependent variable and one with
bulimia scores as the dependent variable. In each regression, BMI
was entered in the first step, body dissatisfaction in the second,
the AAQ in the third, and the BI-AAQ in the fourth. The final
models for both regressions were significant.
BMI was not a predictor of drive for thinness in any step of the
equation. Body dissatisfaction predicted drive for thinness in the
second step (B ¼0.59, β ¼0.80, t¼ 19.16, po 0.01). Body dissatisfaction continued to be a significant predictor in the third step;
however, the AAQ was not (B ¼ 0.05, β ¼ 0.07, t¼ 1.54,
p ¼0.12). The final model was significant [F(4, 226)¼ 142.45,
p o0.01, R2 ¼0.72, adjusted R2 ¼ 0.71; R2Δ ¼0.09, FΔ(1, 226) ¼72.12,
p o0.001] with only body dissatisfaction (B ¼0.36, β ¼ 0.45,
t¼8.16, p o0.01) and body image EA (B ¼ 0.23, β ¼ 0.48,
t¼ 8.19, po 0.01) significant predictors of drive for thinness.
Unlike with the first regression, BMI did significantly predict
bulimic symptoms in all steps of the equation, as did body
dissatisfaction. Adding the AAQ to the equation in the third step
significantly improved the predictive ability of the model
[R2Δ ¼0.02, FΔ(1, 227) ¼ 8.76, p ¼0.003, and the AAQ was a significant predictor (B ¼ 0.10, β ¼ 0.17, t ¼ 2.96, p¼ 0.003). The final
model was significant F(4, 226) ¼43.98, po 0.01, R2 ¼0.44,
adjusted R2 ¼ 0.43; R2Δ ¼0.05, FΔ(1, 226) ¼17.93, po 0.001] with
BMI (B ¼0.17, β ¼0.15, t¼2.93, p o0.01), body dissatisfaction
(B ¼0.16, β ¼0.27, t¼3.42, p o0.01), and body image EA
(B ¼ 0.13, β ¼ 0.34, t¼ 4.23, p o0.01) all significant predictors. General EA (AAQ) was not a significant predictor (B ¼ 0.26,
β ¼ 0.10, t¼ 1.66, po 0.10).
3.4. Study 2 discussion
The purpose of this study was to replicate the relationship
between body image EA, body dissatisfaction, and disordered eating
seen in Study 1 in a larger community sample. We also wished to
determine whether or not the BI-AAQ provided incremental validity
in the prediction of disordered eating above and beyond a measure
of general EA. Overall, the results showed the same strong relationships between the variables of interest, suggesting that the impact
of body dissatisfaction on disordered eating is, in part, an indirect
effect and that the relationship between body dissatisfaction and
disordered eating is carried at least in part through an indirect effect
of body image EA. The BI-AAQ provided more predictive power
of for both types of disordered eating symptoms than the AAQ
(a measure of general experiential avoidance), particularly in the
case of drive for thinness.
4. Study 3
Given the novelty of the BI-AAQ, comparisons to more standard
measures of closely related constructs were warranted. Study
3 attempted to compare the BI-AAQ and the BIAQ, the more
standard measure of behavioral avoidance of body dissatisfaction,
to ensure that the BI-AAQ had incremental validity above and
beyond the previously developed measure.
4.1. Method
4.1.1. Participants
259 females were recruited from the same websites as in Study
2. Thirty-three individuals were removed because they were under
18 years old. An additional 63 participants were removed from the
sample because they did not complete the study questionnaires.
A total of 163 participants were included in the following analyses.
Participants ranged in age from 18 to 53, (M ¼23.13, SD ¼7.17). This
sample was primarily Caucasian (72.2%), followed by African
American (12.8%), Asian (5.0%), Hispanic, (3.3%), Pacific Islander
(1.7%), and 5% who identified as “other.”
4.2. Materials and procedure
Participants were given the same series of questionnaires as in
Study 2; however, the Body Image Avoidance Questionnaire was
added to this study; again, questionnaires were completed on-line
and in a fixed order. All methods were approved by the appropriate review board at Towson University.
Body Image Avoidance Questionnaire (Rosen et al., 1991). The
BIAQ consists of 19 items (e.g. “I wear baggy clothes,” “I do not go
out socially if it involves eating”) that examine domains related to
both social activities and clothing; all 19 items are solely reflect
overt behavioral avoidance. Psychometric properties are sufficient,
with a test-retest reliability of 0.87; Cronbach's α of in the current
sample was 0.89. Higher scores on this measure indicate greater
body avoidance.
4.3. Results
The sample for this study was comparable to the samples of the
previous two studies. The average BMI was 23.90 (SD ¼5.59) with
a range between 12.87and 47.82. Again, the sample was primarily
normal weight range (59.3%), followed by overweight (14.4%)
individual; with a quarter of the sample either underweight
(12.0%) or obese (14.3%). Approximately one third of the sample
self-identified as dieting to lose weight (26.1%), and one fifth
reported dieting to maintain weight (12.8%). Slightly over half of
the sample identified as not dieting (51.1%).
The BIAQ and BI-AAQ were found to be highly correlated
(r ¼ 0.70, p o0.001), indicating that these measures assess similar constructs. Given the high correlation between BIAQ and BIAAQ
scores, two hierarchical regression analyses was conducted where
all three variables (body dissatisfaction, BIAAQ scores, and BIAQ
scores) were used to predict bulimic symptoms and drive for
thinness. BMI was controlled for by entering it into the first step.
Body dissatisfaction was entered in the second step, BIAQ scores in
the third step, and BIAAQ scores in the final step. For bulimic
symptoms, the model was significant at each step, and the
addition of each new variable significantly changed the fit of the
model. BMI was only a significant predictor of bulimic symptoms
in the first step (B ¼0.33, β ¼0.28, t ¼3.68, p o0.01), adding body
dissatisfaction (B ¼0.33, β ¼ 0.53, t¼ 7.12, p o0.01) in the second
step significantly improved the model fit [F(2, 162) ¼34.18,
po 0.01, R2 ¼ 0.32, adjusted R2 ¼ 0.31; R2Δ ¼0.22, FΔ(1, 162) ¼50.69,
po 0.001]. Likewise, adding body avoidance (BIAQ; B ¼0.20,
β ¼0.42, t¼ 5.19, p o0.01) in the third step improved the model
[F(3, 161) ¼35.40, p o0.01, R2 ¼ 0.40, adjusted R2 ¼0.39; R2Δ ¼0.10,
FΔ(1, 161) ¼26.91, p o0.001]. Body dissatisfaction remained
a significant predictor (B ¼0.16, β ¼0.26, t¼ 2.98, p¼ 0.003). However, in the fourth step, body dissatisfaction ceased to be a
significant predictor (B ¼ 0.10, β ¼ 0.16, t ¼1.71, p ¼0.09). In the
final model [F(4, 160) ¼29.75, p o0.01, R2 ¼0.43, adjusted
R2 ¼0.41; R2Δ ¼0.03, FΔ(1, 160) ¼8.12, p ¼ 0.005] only body avoidance as measured by the BIAQ (B ¼ 0.16, β ¼0.30, t¼3.35, p ¼0.001)
Please cite this article as: Timko, C. A., et al. Body image avoidance: An under-explored yet important factor in the relationship between
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and BI-AAQ (B ¼ 0.10, β ¼ 0.26, t¼ 2.85, p ¼0.005) were significant predictors of bulimic symptomatology. This analysis suggests that body dissatisfaction and body avoidance (as captured by
the two scales) each explained unique variance in bulimic scores
and that avoidance may be more important than body
dissatisfaction.
When drive for thinness was the dependent variable, the
overall pattern was slightly different. Unlike with bulimic symptomatology, BMI remained a significant predictor in all four steps;
however, as with the previous regression, adding variables in each
step significantly improved the model fit. In the first step, high
BMI predicted high drive for thinness [B ¼0.31, β ¼0.22, t ¼2.93,
p ¼0.004; F(1, 163) ¼8.57, p ¼0.004, R2 ¼0.05, adjusted R2 ¼ 0.04],
adding body dissatisfaction (B¼ 0.55, β ¼0.75, t ¼11.97, p o0.01) in
the second step significantly improved the model fit [F(2, 162) ¼
79.65, p o0.01, R2 ¼0.50, adjusted R2 ¼ 0.49; R2Δ ¼0.45, FΔ(1, 162) ¼
143.26, po 0.001]. Interestingly, the addition of body dissatisfaction altered the impact of BMI on drive for thinness such that low
BMI predicted greater drive for thinness (B ¼ 0.17, β ¼ 0.12,
t¼ 1.90, p ¼0.06). Although not technically a significant predictor
in step two, the predictive ability of BMI became apparent again in
step 3 (B ¼ 0.17, β ¼ 0.12, t¼ 2.00, p ¼0.047). Body dissatisfaction (B ¼0.42, β ¼0.56, t ¼7.50, p o0.01) remained a significant
predictor as was body avoidance [BIAQ: B ¼0.17, β ¼0.29, t ¼4.14,
p o0.01]. The addition of the BIAQ improved the fit of the model
[F(3, 161) ¼64.12, p o0.01, R2 ¼ 0.74, adjusted R2 ¼0.54; R2Δ ¼0.05,
FΔ(1, 161) ¼ 17.16, p o0.001]. In the final model [F(4, 160) ¼ 70.74,
p o0.01, R2 ¼0.64, adjusted R2 ¼ 0.63; R2Δ ¼0.09, FΔ(1, 160) ¼41.82,
p o0.001] only BMI (B¼ 0.16, β ¼ 0.11, t¼ 2.07, p ¼0.04), body
dissatisfaction (B¼ 0.28, β ¼0.38, t¼ 5.24, p o0.001), and body
avoidance as measured by the BI-AAQ (B ¼ 0.21, β ¼ 0.47,
t¼ 6.47, p o0.001) were significant predictors. Body avoidance
as measured by the BIAQ (B ¼0.04, β ¼0.07, t ¼1.07, p ¼0.29) no
longer significantly predicted drive for thinness. These results
suggest that BIAQ scores do not explain unique variance in drive
for thinness, suggesting that experiential avoidance of body image
more broadly may play a larger role in predicting drive for
thinness/fear of fatness.
4.4. Study 3 discussion
The purpose of this study was to compare two similar measures
of body avoidance to assess their unique explanatory power above
and beyond body dissatisfaction for disordered eating cognition.
Results suggested that the BIAQ and BI-AAQ were highly correlated;
when predicting bulimic symptoms, both constructs appeared to
contribute unique explanatory power, suggesting that they are not
redundant. However, when predicting drive for thinness, BIAQ
scores were not predictive when BI-AAQ scores were entered into
the regression, suggesting that BIAQ scores may be less strongly
related to drive for thinness.
5. Overall discussion
The current series of studies had three separate goals: to
provide additional validation data for a relatively new measure
of body image EA, to assess whether body image EA might
partially account for the relationship between body dissatisfaction
and disordered eating, and to determine if the BI-AAQ offers
insight into body image avoidance, above and beyond that of
the BIAQ.
Overall, the results of Study 1 and Study 2 suggest that the
BI-AAQ assesses an important variable that is related to theoretically consistent constructs, including body image, sociocultural
attitudes towards appearance, and disordered eating. More
7
specifically, high scores on the BI-AAQ are associated with lower
internalization of the thin ideal and lessened disordered eating
symptomatology (e.g., drive for thinness, body dissatisfaction, and
bulimia). Additionally, those who identified as dieters tended to be
less satisfied with their bodies and have more body avoidance,
providing known groups validity for the BI-AAQ.
The second aim of these studies was to assess the role that
experiential avoidance (as measured by the BI-AAQ) plays in
accounting for the relationship between body dissatisfaction and
disordered eating. Given that many women experience body
dissatisfaction, but only a small number develop disordered eating,
it is clear that other variables must play a role in this relationship.
Indeed, the results of our studies suggest that the relationship
between body dissatisfaction and disordered eating can be partially
explained through an indirect effect of body image EA. These results
suggest that individuals who engage in behaviors or cognitive
strategies designed to avoid uncomfortable thoughts, feelings, or
physical sensations related to their body image are more likely to
engage in disordered eating behaviors. Thus, disordered eating behavior may be one mechanism by which individuals can suppress
negative body image related thoughts or feelings.
These results support existing clinical trends towards
acceptance-based treatments that target EA, rather than body
dissatisfaction directly, and indicate that these newer acceptance
based treatments may be useful in reducing disordered eating.
Several new acceptance-based behavioral therapies focus heavily
on reducing EA in an effort to increase behaviors associated with
important values in an individual's life (Forman & Herbert, 2009).
In comparison to more traditional forms of CBT, acceptance-based
behavioral therapies encourage acceptance of negative internal
experiences, with an emphasis on changing how one interacts
with and responds to various distressing cognitions rather than
aiming to alter or modify the thoughts or feelings directly (Hayes
et al., 2004). Acceptance and Commitment Therapy (ACT) is an
acceptance-based behavioral therapy with perhaps the strongest
focus on reducing EA. Meta-analyses have indicated that ACT is
consistently better than control conditions (i.e., waiting lists,
psychological placebos, treatment as usual) and on par with
established treatments, further suggesting that reductions in EA
is an important part of treatment (Powers, Zum Vörde Sive
Vörding, & Emmelkamp, 2009). Recent treatments for disordered
eating behavior have begun to use mindfulness and acceptancebased therapeutic approaches (e.g., Baer, Fischer, & Huss, 2005;
Forman, Butryn, Hoffman, & Herbert, 2009; Heffner, Sperry, Eifert,
& Detweiler, 2002; Juarascio et al., 2013; Merwin, Zucker, & Timko,
2012; Telch, Agras, & Linehan, 2002; Timko, Hormes, Roth,
Limberakis, & Chekroun, 2008; Timko et al., 2013) to target
avoidance of thoughts, feelings, and sensations of one's body.
These strategies are designed to increase acceptance of distressing
body image experiences. Although the body of research is small
(see Wanden-Berghe, Sanz-Valero, & Wanden-Berghe, 2011, for a
review), results are promising: reductions in body image EA (or
conversely, increases in body image acceptance) might lead to
more adaptive eating patterns (Pearson et al., 2012). Body image
EA also explains the relationship between self-compassion and
intuitive eating, an adaptive eating style (Schoenefeld & Webb,
2013). Additional research is needed to continue assessing experiential avoidance and its effect outcome in treatment studies.
Given the specific nature of the BI-AAQ, its use may need to be
supplemented by a more general measure of EA (i.e., the AAQ) as
general EA may be related to other constructs hypothesized to
maintain disordered eating (e.g., perfectionism, mood intolerance,
interpersonal distress).
Finally, the results of these studies indicate that the BI-AAQ is
not redundant to a pre-existing measure of body image avoidance
(BIAQ), as the construct measured by these two assessments
Please cite this article as: Timko, C. A., et al. Body image avoidance: An under-explored yet important factor in the relationship between
body image dissatisfaction and.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.01.002i
8
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appears to contribute differently to disordered eating. Both the BIAAQ and the BIAQ predicted reported bulimic symptomatology;
however only the BI-AAQ predicted drive for thinness. Such results
are consistent with the BIAQ and BI-AAQ development and
validation studies. The BIAQ demonstrated sensitivity to one
primary variable—body dissatisfaction—and distinguishing between
individuals with bulimia nervosa and controls (Rosen et al., 1991).
The BI-AAQ is strongly correlated with multiple disordered eating
variables, including body dissatisfaction, food preoccupation, and
dieting (Sandoz et al., 2013). It is also related to drive for thinness,
whereas the BIAQ is not. Given its relationship with a wider variety
of variables associated with eating disorders, the BI-AAQ may be a
more appropriate measure to use in treatment studies and measurement of avoidance in clinical populations. The high rates of
diagnostic crossover and the high rates of incidence in the Eating
Disorder Not Otherwise Specified category (Machado, Machado,
Gonçalves & Hoek, 2007) also indicate that a flexible measure may
be more useful for measuring avoidance over time and across
populations.
The finding that body image EA is more predictive than both
general measures of EA and other measures of body image behavioral
avoidance suggest that there is incremental validity in assessing body
image EA. These results suggest that although measures of behavioral
avoidance of body dissatisfaction and measures of general EA both
partially explain the relationship between body image dissatisfaction
and disordered eating, they are not as directly related as a broader
measure of body image avoidance (that assesses both behavioral,
cognitive, and emotional strategies). Overall, the results from this
series of studies add additional support to the notion that body image
EA is a relevant construct that has not been adequately captured by
prior self-report tools.
While further validation studies are necessary, the results
suggest that the BI-AAQ is an appropriate process measure to
use in understanding the relationship between body image EA and
disordered eating behavior and cognition. Due to the fact that
acceptance and mindfulness-based therapies specifically target
psychological flexibility (of which EA is an essential element),
the BI-AAQ may be well suited for clinical or research purposes in
which one wishes to track change either specifically in body image
EA or in body image psychological flexibility more broadly.
Although additional research is needed to continue validating this
measure, data thus far are promising. Overall, the results of this
series of studies indicate that the BI-AAQ can be a useful measure
of experiential acceptance/psychological flexibility of body image
thoughts, feelings, and sensations. As acceptance-based treatments are better studied in this population, a greater understanding of how experiential avoidance affects the development
and maintenance of disordered eating and the role that it may play
in treatment will be crucial.
Despite the strengths of this study, several limitations exist.
First and foremost, disordered eating behavior and cognition was
measured in a non-clinical sample. While dieting status was used
as an analog for severity of disordered eating cognitions, the
findings cannot be generalized to a clinical population. Although
theory would suggest that body image EA could cause body
dissatisfaction to result in disordered eating, this claim is premature as temporal differences were not assessed in the current
study. Because the study was cross-sectional, indirect effects of
body dissatisfaction on disordered eating (via body image EA) can
be assessed, but true mediation and a deeper understanding of the
relationship between these variables can only be addressed in a
longitudinal study. Ideally, future research using a longitudinal
paradigm will clarify whether body image EA is causally linked to
increases in disordered eating. A few other limitations to note are,
(a) the questionnaires for all studies were completed in a fixed
order, and (b) the participant pool was somewhat homogenous
regarding racial/ethnic, regional, and socioeconomic status. Future
research would benefit from randomizing the order of questionnaires administered and recruiting a more diverse sample.
Although we included participants who completed all measures,
the variability in the amount of data provided by non-completers
precludes an exploration of any differences in demographic makeup between completers and non-completers. Lastly, prior research
has noted that a number of variables have been found to influence
the relationship between body dissatisfaction and disordered
eating. However, the current study did not include many of these
measures and therefore is unable to determine how body image
EA might be related to these other important constructs. Ideally,
future research will examine the relationship between body image
EA and established factors to determine whether EA is just one
important variable in the equation between body dissatisfaction
and disordered eating or if EA itself might explain some of the
other variables.
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Please cite this article as: Timko, C. A., et al. Body image avoidance: An under-explored yet important factor in the relationship between
body image dissatisfaction and.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.01.002i