Body Image Treatment for a Community Sample
of Obligatory and Nonobligatory Exercisers
Jane Ellen Smith,* Brenda L. Wolfe, and Denise E. Laframboise
Department of Psychology, University of New Mexico, Albuquerque, New Mexico
Accepted 2 July 2001
Abstract: Objective: Cognitive-behavioral therapy (CBT) was used to treat body dissatisfaction in obligatory and nonobligatory exercisers within a community sample of normal
weight women. Method: Ninety-four women (36% obligatory exercisers, 64% nonobligatory exercisers) were assigned randomly to CBT or the waiting-list (WL) control group.
Results: The hypotheses that obligatory exercisers would show poorer pretreatment body
image and greater compulsivity than nonobligatory exercisers were supported partially. The
prediction that obligatory exercisers would respond less favorably to treatment was not
supported. Overall, CBT participants evidenced signi®cantly better body image outcomes
than the WL at posttreatment, but many effects were lost by the follow-up. Discussion:
Treatment response is considered in light of the unique characteristics of this ethnically
diverse, older community sample when compared with the young students in earlier body
image intervention studies. The high rate of physical activity among even the nonobligatory
exercisers is highlighted for its mood-regulation properties and its treatment implications.
Ó 2001 by John Wiley & Sons, Inc. Int J Eat Disord 30: 375 388, 2001.
Key words: body image; obligatory; exercise; compulsive
INTRODUCTION
Body dissatisfaction has become exceedingly common among the general female
population (Rodin, Silberstein, & Striegel-Moore, 1984; Thompson, Heinberg, Altabe, &
Tantleff-Dunn, 1999). Importantly, poor body image has been linked to various types of
psychological distress (Adams, Katz, Beauchamp, Cohen, & Zavis, 1993; Cash & Pruzinsky, 1990; Elam & Kimbrell, 1995) and to eating pathology (Herzog, Hopkins, & Burns,
1993; Kiemble, Slade, & Dewey, 1987; Rosen, 1992). Six controlled body image treatment
studies have targeted body dissatisfaction in non-eating disordered normal weight
women. The efficacy of these cognitive-behavioral interventions generally has been
supported; most clearly when compared with a waiting-list (WL) condition (Butters
Presented at the 9th International Conference on Eating Disorders, New York City, May 7, 2000.
*Correspondence to: Jane Ellen Smith, Ph.D., Department of Psychology, University of New Mexico, Logan Hall,
Albuquerque, NM 87131. E-mail: janellen@unm.edu
Ó 2001 by John Wiley & Sons, Inc.
376
Smith et al.
& Cash, 1987) or with minimal treatment (Rosen, Saltzberg, & Srebnik, 1989). In two
studies, cognitive-behavioral therapy (CBT) was superior to a control condition, but was
only comparable to exercise therapy (Fisher & Thompson, 1994) and was less effective
than cognitive therapy (Dworkin & Kerr, 1987). When CBT was contrasted with a
modest-contact version of it (Grant & Cash, 1995) or one that added size perception
training (Rosen, Cado, Silberg, Srebnik, & Wendt, 1990), clinically relevant within-group
changes were found, but there were no between-group effects.
Although the use of CBT to treat body dissatisfaction in nonclinical samples appears
promising, there are questions still to be addressed. To begin with, it is difficult to draw
firm conclusions in several cases because CBT showed no advantage over the active
treatment comparison condition (Fisher & Thompson, 1994; Grant & Cash, 1995; Rosen
et al., 1990). Moreover, because each study utilized primarily young, Anglo college students, the treatments were never tested with older, heavier, ethnically diverse community participants. Also, the initial incentive for participating in each case was class
research credit, and so the generalizability of the results to natural treatment-seeking
samples was unknown. Additionally, two of the studies did not include follow-ups
(Dworkin & Kerr, 1987; Fisher & Thompson, 1994) and one did not have follow-up data
on the control group (Butters & Cash, 1987).
Another limitation of previous studies is that only one study monitored weight
throughout treatment (Grant & Cash, 1995), a necessary step because weight change can
serve as a confound in body image therapy (Cash, 1994a). Further, none of the studies
reported the amount of exercise in which participants engaged. This is regrettable because individuals with body dissatisfaction often attempt to alter their size or shape
through exercise (Davis, 1997; Eliot & Smith, 2001) and because changes in exercise habits
are suspected of contributing to changes in body satisfaction (McAuley, Bane, Rudolph,
& Lox, 1995; Tucker & Mortell, 1993). Also relevant is the literature that discovered both
positive and negative associations between exercise and body image (Loland, 1998;
Sonstroem, Harlow, & Josephs, 1994); equivocal results that were sometimes attributed to
the type of exercise or to the reasons motivating it (Brownell, Rodin, & Wilmore, 1992;
Davis, Fox, Cowles, Hastings, & Schwass, 1990; Imm & Pruitt, 1991). And yet, these
distinctions have not produced consistent findings (Davis, 1997; Eliot & Smith, 2001).
Arguably, the most important exercise factor linked with body image is the extent to
which it is excessive or compulsive. Terms like obligatory and compulsive exerciser have
been adopted to represent those individuals who exercise often and who seem unable to
control their need to exercise despite physical injury or social demands (Coen & Ogles,
1993; Pasman & Thompson, 1988; Steffen & Brehm, 1999). A number of conclusions have
been drawn about these compulsive exercisers that could be of consequence should they
participate in a body image intervention. First, several researchers detected higher levels
of disturbed eating in obligatory exercisers than in controls (Pasman & Thompson, 1988;
Slay, Hayaki, Napolitano, & Brownell, 1998). When obligatory exercisers were compared
with nonobligatory exercisers, they had lower weights (Slay et al., 1998), but greater
weight concerns (Davis et al., 1990; Yates, Shisslak, Allender, Crago, & Leehey, 1992), and
poorer body images (Davis, Shapiro, Elliott, & Dionne, 1993; Imm & Pruitt, 1991). As far
as personality characteristics, obligatory exercisers had elevated levels of trait anxiety,
perfectionism, and obsessive-compulsiveness (Coen & Ogles, 1993; Davis et al., 1995;
Goldfarb & Plante, 1984; Thompson & Sherman, 1999; Yates, 1991).
Given this profile, one might expect that obligatory exercisers who receive body image
therapy are at a disadvantage compared with nonobligatory exercisers and, therefore,
may require a more specialized or extended treatment. Conceivably, their presence to
Obligatory Exercise and Body Image
377
varying degrees in such programs could explain some of the variability in treatment
response (Grant & Cash, 1995). Nevertheless, this had not been tested. The current study
addressed this issue by recruiting normal weight women for a CBT program for body
dissatisfaction and by categorizing them as obligatory or nonobligatory exercisers on the
basis of their Obligatory Exercise Questionnaire (OEQ) scores. It was first predicted that
the obligatory exercisers would enter treatment with a significantly more disturbed body
image than the nonobligatory exercisers. Second, obligatory exercisers also were expected
to score significantly higher than nonobligatory exercisers on the Maudsley ObsessionalCompulsive Inventory (MOCI) at pretreatment. High-level exercisers had scored significantly higher than moderate exercisers on the Symptom Checklist-90 obsessive-compulsive scale (Davis et al., 1995), but this construct had not been tested with OEQ-defined
obligatory exercisers. Third, it was hypothesized that the nonobligatory exercisers would
have significantly better body image treatment outcomes than the obligatory exercisers.
Finally, it was predicted that the treated (CBT) participants overall in this diverse community sample would have significantly better outcomes than the WL control group.
METHOD
Participants
Individuals were recruited via flyers posted throughout Albuquerque, NM, announcing a free body image program for normal weight women who were dissatisfied
with their bodies. A total of 308 telephone screens were conducted, which resulted in
excluding individuals who either had an eating disorder within the last 5 years (n = 19),
were receiving psychotherapy (n = 11), were on psychotropic medication (n = 10), were
outside the normal weight range (‹20%) for their height (n = 23), or had unresolvable
schedule con¯icts (n = 12). Another 76 individuals were no longer interested upon
hearing that it was not a weight-loss program.
The Multidimensional Body-Self Relations Questionnaire (MBSRQ; Brown, Cash, &
Mikulka, 1990; Cash, 1994b) and the OEQ (Pasman & Thompson, 1988) were mailed to the
157 remaining potential participants. Six of them failed to return the questionnaires. The
31 women who scored above 23 on the MBSRQ Appearance Evaluation scale were excluded, as these scores are not considered indicative of negative body image (Cash, 1995a).
Excluded individuals were offered treatment at a later date. Respondents who scored
above 50 on the OEQ were classified as obligatory exercisers (Coen & Ogles, 1993; Pasman
& Thompson, 1988) and those scoring 50 or below were designated as nonobligatory
exercisers. Pretreatment assessments were scheduled with the 120 remaining individuals,
but 26 women did not attend. Among the 94 who did, 34 (36%) were obligatory and 60
(64%) were nonobligatory exercisers. Random assignment to treatment condition resulted
in 46 participants in the CBT group (18 obligatory exercisers, 28 nonobligatory exercisers)
and 48 in the WL (16 obligatory exercisers, 32 nonobligatory exercisers).
On average, participants were 36.66 years of age (SD = 12.08, range = 17 69) and had
0.85 children (SD = 1.23, range = 0 5). They had an average height of 64.02 in. (SD = 2.49,
range = 58 69) and a weight of 139.89 lb (SD = 18.97, range = 95 190). Their mean body
mass index (BMI: kg/m2) was 23.87 (SD = 2.74, range = 18.12 29.82). Regarding marital
status, 43% of the participants were single, 40% were married, and 17% were divorced,
separated, or widowed. The ethnic breakdown was 59% Anglo (n = 56), 28% Hispanic
(n = 26), and 13% ``Other'' (n = 12). The most common occupations by category (Hollingshead, 1965) were business manager/lesser professional (28%), administrative per-
378
Smith et al.
sonnel/minor professional (16%), and clerical/sales (13%). Another 24% were classi®ed
as students or unemployed.
Materials
In addition to its screening function, the Appearance Evaluation scale and the four
remaining scales of the MBSRQ were used as dependent measures of body satisfaction.
These scales included Appearance Orientation (efforts to maintain or improve appearance), Body Areas Satisfaction (satisfaction with specific body parts), Overweight Preoccupation (fat anxiety and weight vigilance), and Self-Classified Weight (weight
perception). This 69-item instrument has excellent psychometric properties (Brown et al.,
1990; Fisher & Thompson, 1994; Keeton, Cash, & Brown, 1990), including high internal
consistency (.75 .91) and test-retest reliability (.78 .94).
The Adjustable Light Beam Apparatus (ALBA; Thompson & Spana, 1988; Thompson
& Thompson, 1986) was used as a measure of body satisfaction for a specific area that is
viewed notoriously as problematic by women, that is, the hip and thigh region (Bailey,
Goldberg, Swap, Chomitz, & Houser, 1990). Participants adjusted the width of horizontal
beams of light projected onto a wall to indicate the width of these areas. Body dissatisfaction was measured by three scores: (1) Feel-Ideal = the discrepancy between how wide
participants felt they were and how wide they ideally wanted to be, (2) Feel-Think = the
discrepancy between how wide they felt they were and how wide they thought they
actually were, and (3) Think-Ideal = the discrepancy between how wide they thought
they were and how wide they ideally wanted to be. The ALBA has a test-retest reliability
of .75 and an internal consistency of .83 (Thompson & Spana, 1988).
The OEQ (Pasman & Thompson, 1988) was used to determine initial exercise status and
to track this attitude/behavior over time. This 20-item scale has an internal consistency
alpha value of .96, a test-retest reliability of .96, and has been shown to successfully
discriminate obligatory exercisers from controls (Coen & Ogles, 1993; Pasman &
Thompson, 1988). The Exercise Involvement Questionnaire was introduced (Eliot & Smith,
2001) as a means to record the frequency and duration of all types of physical activity, such
as gardening and dancing, as well as formal exercise. It was shown to have good test-retest
reliability (r = .65, p < .0001), convergent validity with the OEQ (r = .51, p < .0001), and
discriminant validity with the MOCI cleaning scale (p > .55). Finally, the MOCI (Hodgson
& Rachman, 1977), a general measure of obsessive-compulsive behaviors, was administered as well. This instrument is a 30-item true-false scale whose total score correlates
signi®cantly with other measures of obsessive-compulsiveness, and which has high testretest reliability (Hodgson & Rachman, 1977). Of particular interest was the MOCI's
checking scale, because obligatory exercisers were expected to share certain characteristics
with the nonclinical ``checkers'' who had been distinguished from controls on this scale
(Frost, Sher, & Green, 1986; Sher, Mann, & Frost, 1984). These characteristics included
exaggerated interpersonal fears and general anxiety (De Coverly Veale, 1987; Yates, 1991).
Procedure
Pretreatment Assessment
After signing the consent form, participants were given the ALBA. The order of their
estimates of how wide they judged their two body parts to be in terms of their actual
Obligatory Exercise and Body Image
379
perception (Think), their affective experience (Feel), and their ideal (Ideal) was counterbalanced. Next, the Exercise Involvement Questionnaire was administered, followed by
measurements of participants' height and weight, and their body part widths using a
caliper. The assessment was finished at an athletic field, where participants were timed
while walking a mile as quickly as possible per the Rockport Fitness Walking Test (Kline
et al., 1987).
Treatment
Participants were randomly assigned to the CBT or the WL group. Six CBT groups
were conducted at the university's clinic over the course of 2 years, with 6 10 members
per group. The 1 ‰hr sessions ran for 8 weeks. Two experienced, advanced clinical
psychology graduate students served as therapists. Their work was observed and supervised by the first author. Therapists were not informed about participants' exercise
status. The CBT program was modeled closely after Cash's program (Cash, 1995b), with
an emphasis on clarifying cognitive distortions and modifying habitual behaviors that
triggered negative body image experiences. Individuals assigned to WL had treatment
delayed until after the final assessment.
Posttreatment and Follow-Up Assessments
The posttreatment assessment was conducted when the 8-week therapy phase was
completed. The follow-up occurred 2 months later. Except for the MOCI, all instruments
were repeated at each assessment. Upon completing the follow-up, individuals who had
given a $20 deposit initially were returned their deposit.1
RESULTS
Pretreatment Characteristics
There were no significant pretreatment demographic differences between the CBT and
WL groups. As far as the dependent measures, separate 2 (CBT, WL) ´ 2 (obligatory
exercisers, nonobligatory exercisers) analyses of variance (ANOVAs) were used for the
MBSRQ scales, as they measure unique constructs (Brown et al., 1990; Smith, Thompson,
Raczynski, & Hilner, 1999). A 2 ´ 2 repeated measures ANOVA was used for the six
ALBA discrepancy scores, due to the similar nature of these variables. A significant
pretreatment difference was detected for the treatment factor on only one variable, the
MBSRQ Overweight Preoccupation scale. The CBT group was more weight preoccupied
than the WL, F (1, 90) = 4.31, p = .04. This was addressed later in the treatment outcome
analyses, as analyses of covariance (ANCOVAs) were used, with pretreatment values and
current BMI as covariates.
1
A deposit was not collected initially so as not to exclude participants for ®nancial reasons. A $20 deposit was
introduced for the ®nal 34 participants (36% of the total sample) because it became apparent that many participants were not attending follow-up assessments. A chi-square test showed that signi®cantly more participants completed both the posttreatment and follow-up assessments if they had been required to give the deposit
(85.3%) than if they had not (48.3%), v2 (df = 1) = 12.55, p < .001. Causality cannot be assumed because
participants were not randomly assigned to the deposit/no deposit condition. Importantly, when those who
paid the deposit were compared on demographics and pretreatment dependent variables with those who had
not paid, no signi®cant differences were found. Therefore, these groups were combined for all analyses. Later
tests demonstrated that there were no group differences in outcome.
380
Smith et al.
Table 1. Comparison of demographics and pretreatment characteristics by exercise status
Exercise Status
Variable
Age (years)
Children (number)
Height (in.)
Weight (lb)
Body mass index
Caliper: hips (cm)
Caliper: thighs (cm)
Marital status (%)
Married
Singlea
Ethnicity (%)
Anglo
Hispanic
Other
Occupation (%)b
Professional
Skilled
Unskilled
Student/unemployed
OEQ
Walk time (s)
MOCI
Checking
Total
Exercise hours (per week)
Exercise activities
(per week)
Obligatory
(N = 34)
M
35.61
0.85
64.06
134.71
22.96
34.52
30.20
(SD)
(11.70)
(1.20)
(2.50)
(15.71)
(2.22)
(2.84)
(3.17)
Nonobligatory
(N = 60)
M
(SD)
37.25
0.85
63.98
142.84
24.39
35.93
32.10
(12.35)
(1.26)
(2.50)
(20.12)
(2.88)
(2.88)
(3.14)
Value
Probability
0.43
0.00
0.04
3.97
6.33
4.85
7.74
0.20
ns
ns
ns
.05
.01
.03
.007
ns
0.34
ns
1.04
ns
35.29
64.71
40.00
60.00
55.88
29.41
14.71
61.67
26.67
11.67
50.00
14.71
8.82
26.47
56.67
855.75
(5.01)
(120.45)
45.00
21.67
11.67
21.67
41.47
919.51
(6.09)
(100.57)
147.05
6.79
.0001
.01
2.19
10.71
9.82
13.03
(2.30)
(5.72)
(5.30)
(6.84)
1.32
8.67
4.90
6.87
(1.58)
(4.42)
(4.00)
(4.72)
4.70
3.53
25.15
25.52
.03
.06
.0001
.0001
Note: OEQ = Obligatory Exercise Questionnaire; MOCI = Maudsley Obsessional-Compulsive Inventory.
a
Single includes never married, divorced, separated, and widowed.
b
Occupation is collapsed across Hollingshead (1965) categories: professional (categories 1 3), skilled (4 6),
unskilled (7 8), and student/unemployed (9).
As expected for the second factor, significant pretreatment differences between
obligatory and nonobligatory exercisers were found using 2 ´ 2 ANOVAs, beginning
with the obligatory group scoring higher than the nonobligatory group on the OEQ
screening instrument, p < .0001 (see Table 1 for all Ms, SDs). Additionally, obligatory
exercisers reported signi®cantly greater time devoted to physical activity weekly (M =
9.82 hr, SD = 5.30) than nonobligatory exercisers (M = 4.90 hr, SD = 4.00), as well as more
activities (ps < .0001). Obligatory exercisers also completed the 1-mile walk faster than did
the nonobligatory group (p = .01). For demographics, obligatory exercisers had lower
BMIs than the nonobligatory exercisers (p = .01) and smaller caliper measurements for
hips (p = .03) and thighs (p = .007). As predicted, obligatory exercisers also scored signi®cantly higher than the nonobligatory group on the MOCI checking scale (p = .03).
There was a trend for MOCI total score differences as well (p = .06).
Several predicted differences were found on the pretreatment body image variables
(Table 2). Obligatory exercisers showed more fat anxiety than nonobligatory exercisers on
the MBSRQ Overweight Preoccupation scale (p = .05) and more overall hip and thigh
dissatisfaction than the nonobligatory group on the repeated measures ANOVA for
ALBA discrepancy scores, F (1, 89) = 6.15, p < .02. Individual 2 ´ 2 ALBA ANOVAs
Obligatory Exercise and Body Image
381
Table 2. Pretreatment MBSRQ and ALBA means (SDs) by exercise status
Exercise Status
Variable
MBSRQ
Appearance Evaluationa
Appearance Orientation
Body Areas Satisfactiona
Overweight Preoccupation
Self-Classi®ed Weight
ALBA
Feel-Ideal: hips
Feel-Ideal: thighs
Feel-Think: hips
Feel-Think: thighs
Think-Ideal: hips
Think-Ideal: thighs
Obligatory
(N = 34)
M
(SD)
Nonobligatory
(N = 60)
M
(SD)
F Value
Probability
16.41
47.53
20.88
14.24
7.21
(4.24)
(8.50)
(4.77)
(3.21)
(0.73)
16.57
46.33
20.73
12.97
7.42
(3.72)
(7.41)
(4.30)
(2.58)
(1.08)
0.03
0.41
0.01
3.95
1.02
ns
ns
ns
.05
ns
14.33
15.36
2.90
3.21
12.14
12.15
(9.67)
(10.97)
(5.87)
(5.50)
(9.38)
(9.85)
10.51
10.44
1.71
0.75
8.81
9.69
(9.75)
(8.11)
(8.10)
(5.37)
(6.65)
(8.26)
3.53
6.14
0.62
4.49
4.04
1.64
.06
.02
ns
.04
.05
ns
Note: MBSRQ = Multidimensional Body-Self Relations Questionnaire; ALBA = Adjustable Light Beam Apparatus. The df for the MBSRQ and individual ALBA exercise status effects are 1,90. ALBA: Feel-Think = the
discrepancy between how large a participant feels and how large she thinks she is. Feel-Ideal = the discrepancy
between how large a participant feels and how large she ideally would like to be. Think-Ideal = the discrepancy
between how large a participant thinks she is and how large she ideally would like to be. Larger discrepancies
indicate greater body dissatisfaction.
a
For these two MBSRQ scales, higher values signify better body image. For the remaining three scales, lower
values represent better body image.
showed signi®cant differences on two measures for thighs (Feel-Ideal, p = .02, and FeelThink, p = .04) and on one for hips (Think-Ideal, p = .05).
Treatment Outcome Between Groups
Drop-outs and Assessment Rates
Treatment (CBT) drop-outs were defined as women who attended fewer than one half
of the eight sessions. Among these 46 treated participants, 9 dropped out (19.6%; 2
obligatory and 7 nonobligatory exercisers). This difference was not significant. Nor were
significant differences found when demographics and pretreatment values were contrasted between the drop-outs and the completers. Overall, an average of 5.67 (SD = 2.28)
sessions were attended. There was no difference in attendance between the exercise
conditions. Furthermore, there were no differences in drop-out rates, attendance, or
treatment outcome when the two therapists' participants were compared or when ethnicity was examined.
For the total sample, posttreatment and follow-up rates varied slightly by instrument,
due to some incomplete MBSRQ data. Posttreatment MBSRQ data were collected for 68%
of the original 94 participants (n = 64) and follow-ups were obtained for 61% (n = 57). For
the ALBA, 74% of the total sample completed the posttreatment (n = 70) and 66%
®nished the follow-up (n = 62). There were no differences in assessment completion rates
across treatment conditions or exercise status. In comparing pretreatment values on all
variables for the participants who had completed assessments with those who had not, a
signi®cant difference was found on one instrument, the MOCI. The women lost to attrition scored higher on both the MOCI total score, t(86) = 2.63, p < .02, and on the
checking scale, t(18.3) = 2.54, p < .03.
382
Smith et al.
Table 3. MBSRQ outcome means and SDs by treatment condition
Treatment
Variable
M
Control
(SD)
M
(SD)
F Value
Probability
a
Appearance Evaluation
Pre
Post
Follow-Up
Appearance Orientation
Pre
Post
Follow-Up
Body Areas Satisfactiona
Pre
Post
Follow-Up
Overweight Preoccupation
Pre
Post
Follow-Up
Self-Classi®ed Weight
Pre
Post
Follow-up
16.46
22.83
21.71
(3.64)
(4.05)
(4.42)
16.56
18.32
18.77
(4.15)
(5.05)
(4.59)
24.74
13.52
47.74
43.77
43.94
(7.27)
(7.45)
(7.63)
45.83
45.26
42.35
(8.24)
(8.34)
(8.23)
4.42
0.00
21.18
25.13
25.35
(4.27)
(4.32)
(3.67)
20.42
21.74
22.81
(4.62)
(5.10)
(3.89)
16.50
15.03
14.04
12.43
12.23
(3.03)
(3.06)
(3.00)
12.83
12.41
11.77
(2.62)
(3.21)
(2.80)
0.68
0.47
ns
ns
7.30
7.03
7.06
(0.92)
(1.13)
(0.93)
7.38
7.44
7.12
(1.02)
(0.99)
(0.91)
4.98
0.42
.03
ns
.0001
.001
.04
ns
.0001
.001
Note: MBSRQ = Multidimensional Body-Self Relations Questionnaire. Only the unadjusted means are presented. Samples sizes differ for pretreatment (n = 94), posttreatment (n = 64), and follow-up (n = 57). Pretreatment means (SDs) are included for comparison purposes. The df for the MBSRQ treatment effects are 1,58 at
posttreatment and 1,51 at follow-up.
a
For these two MBSRQ scales, higher values signify better body image. For the remaining three scales, lower
values represent better body image.
MBSRQ
Using separate 2 ´ 2 ANCOVAs, a main effect for treatment condition that favored CBT
over WL was found at posttreatment for four of the five scales (Table 3). The strongest
effects were for Appearance Evaluation and Body Areas Satisfaction (ps < .0001), which
measure the affective component of body image. These same scales were the only ones
for which signi®cant group differences were detected at follow-up (ps < .001). Posttreatment differences also were found for Appearance Orientation (p < .04), which
measures cognitive and behavioral investment in appearance, and for Self-Classi®ed
Weight (p < .03), which measures weight perception.2
There was neither a main effect of exercise status nor any significant interaction at
either posttreatment or follow-up. Planned comparisons tested specifically the prediction
that treated (CBT) nonobligatory exercisers would respond better than the treated
obligatory exercisers. The prediction was not supported.3
2
Intention-to-treat analyses were run using pretreatment values for missing data. Only the weakest signi®cant
®nding from the treated analyses was lost (Appearance Orientation).
3
Planned comparisons were then conducted between the obligatory exercisers in the CBT and WL conditions
to see if treatment appeared bene®cial for them as a subgroup. The obligatory CBT group showed signi®cantly
better body satisfaction than the obligatory WL at both posttreatment and follow-up on the two MBSRQ scales
that had shown the most robust effects overall: Appearance Evaluation (post), F (1, 58) = 8.26, p = .006; (followup), F (1, 51) = 5.76, p = .02; Body Areas Satisfaction (post), F (1, 58) = 6.06, p = .02; (follow-up), F (1,51) = 4.13, p =
.05. When similar planned comparisons were run for the ALBA measures, only trends were detected that
favored the obligatory CBT participants over the obligatory WL group.
Obligatory Exercise and Body Image
383
Table 4. ALBA outcome means and SDs by treatment condition
Treatment
Variable
Feel-Ideal: hips
Pre
Post
Follow-Up
Feel-Ideal: thighs
Pre
Post
Follow-Up
Feel-Think: hips
Pre
Post
Follow-Up
Feel-Think: thighs
Pre
Post
Follow-Up
Think-Ideal: hips
Pre
Post
Follow-UP
Think-Ideal: thighs
Pre
Post
Follow-Up
Control
M
(SD)
M
(SD)
F Value
Probability
10.40
6.55
5.51
(8.53)
(6.70)
(7.29)
13.24
11.88
10.61
(10.83)
(8.33)
(9.21)
6.79
.01
12.37
8.28
7.64
(9.77)
(7.85)
(7.66)
12.08
12.00
11.09
(9.32)
(10.04)
(12.16)
3.93
.05
1.27
0.84
)1.64
(7.30)
(5.10)
(7.48)
2.93
3.44
2.37
(7.44)
(5.52)
(8.37)
4.16
.05
1.58
1.15
0.25
(5.76)
(5.53)
(6.32)
1.70
2.23
2.50
(5.34)
(5.18)
(8.59)
0.91
ns
9.70
5.71
7.16
(7.92)
(5.77)
(10.33)
10.31
8.44
8.23
(7.89)
(5.72)
(5.82)
3.89
.05
10.79
7.13
7.39
(9.43)
(6.82)
(10.74)
10.38
9.77
8.59
(8.45)
(7.38)
(8.58)
2.56
ns
Note: ALBA = Adjustable Light Beam Apparatus. Only the unadjusted means are presented. Sample sizes
differ for pretreatment (n = 94), posttreatment (n = 70), and follow-up (n = 62). Pretreatment means (SDs) are
included for comparison purposes, as are follow-up means (SDs) despite there being no repeated measures
effect. The df for the individual ALBA treatment effects are 1, 64 at posttreatment. ALBA: Feel-Think = the
discrepancy between how large a participant feels and how large she thinks she is. Feel-Ideal = the discrepancy
between how large a participant feels and how large she ideally would like to be. Think-Ideal = the discrepancy
between how large a participant thinks she is and how large she ideally would like to be. Larger discrepancies
indicate greater body dissatisfaction.
ALBA
A 2 ´ 2 repeated measures ANCOVA detected a significant overall treatment factor
effect at posttreatment, F (1,64) = 5.83, p < .02, with the CBT group being more satis®ed
with their hips and thighs than the WL. The overall effect was not signi®cant at followup. Individual 2 ´ 2 ANCOVAs found a main effect for treatment condition on four of the
six ALBA variables at posttreatment (p values .01 .05). Three of the four differences were
for hip measures (Table 4). Speci®cally, the CBT group showed more satisfaction than the
WL for both hips and thighs on Feel-Ideal. This was indicated by less of a difference for
the CBT group than for the WL between how they felt they looked and how they ideally
wanted to look. Relatedly, the CBT condition showed less of a discrepancy than the WL
between how large their hips felt and how large they believed them to be (Feel-Think).
Also, the CBT group showed a smaller discrepancy than the WL for the Think-Ideal hip
measure, suggesting that the CBT participants' ideal hip size was closer to how they
thought their hips actually looked than it was for the WL.4
There was no overall exercise status effect or any interaction at either posttreatment or
follow-up on the 2 ´ 2 repeated measures ANCOVA. Planned comparisons found one
significant disadvantage for the obligatory exerciser group, which occurred at follow-up
4
The repeated measures ANCOVA remained signi®cant in the intention-to-treat analysis.
384
Smith et al.
for hips (Think-Ideal), F (1,56) = 6.46, p = .01. Obligatory exercisers receiving CBT had
more of a discrepancy between their ideal and perceived hip size (M = 12.50, SD = 14.64)
than did nonobligatory exercisers in CBT (M = 4.02, SD = 4.95).
Within-Group Changes
Given that few significant between-group differences were found for treatment condition at follow-up, matched pair t tests were used to investigate pretreatment to followup within-group improvement. For the MBSRQ, the CBT group showed signi®cant improvement on four of the ®ve scales: Appearance Evaluation, t(30) = 6.61, p < .0001,
Appearance Orientation, t(30) = )3.77, p = .001, Body Areas Satisfaction, t(30) = 6.28,
p < .0001, and Overweight Preoccupation, t(30) = )3.58, p = .001. The WL showed some
improvement, but it occurred for only two scales and was less robust: Appearance
Evaluation, t(25) = 2.66, p = .05, and Appearance Orientation, t(25) = )3.12, p = .01. In
terms of pretreatment to follow-up ALBA change, the CBT group showed one trend for
improvement: Feel-Ideal hips (p = .07). The WL demonstrated none.
In addition to evaluating within-group body image progress, OEQ change was also
tracked. The obligatory CBT group showed a significant pre to posttreatment reduction in
obligatory exercise characteristics, t(5.68) = )2.40, p = .04, whereas the obligatory WL
controls did not.
It was necessary to track changes in physical activity and BMI to determine whether
they contributed to the body image outcomes. None of the conditions showed any change
in the time devoted to physical activities. One group, the nonobligatory exercisers as a
whole, showed a significant increase in BMI from pretreatment to follow-up, t(40) = 2.03,
p = 0.5, that was driven primarily by CBT participants. The change was nonsigni®cant
from pretest to posttest.
Exploratory Analysis with New Exercise Status Variable
The high reported level of physical activity of the nonobligatory exercisers (M = 4.9 hr
per week) could have contributed to the lack of exercise status differences. This was
investigated by creating an exercise status independent variable that considered both the
pretreatment OEQ score and the amount of physical activity. Obligatory/high exercisers
were de®ned as scoring above 50 on the OEQ and above the median (>5.58 hr per week)
for physical activity (M = 11.38, SD = 4.75). Nonobligatory/low exercisers scored less than
or equal to 50 on the OEQ and fell below the median for physical activity (M = 2.58 hr, SD =
1.88). Neither a signi®cant exercise effect nor an interaction was found for any of the
MBSRQ scales, or for the repeated measures ANCOVA for the ALBA discrepancy scores,
at posttreatment or follow-up.
DISCUSSION
The prediction that obligatory exercisers would show more disturbed pretreatment
body image than nonobligatory exercisers was supported partially. This was most pronounced on the ALBA, where obligatory exercisers showed greater dissatisfaction for
their hips and thighs than the nonobligatory exercisers, despite these body areas being
Obligatory Exercise and Body Image
385
objectively smaller for them. The significant MBSRQ pretreatment difference (Overweight Preoccupation) was noteworthy because obligatory exercisers had lower BMIs
than nonobligatory exercisers, and because the "fat anxiety" represented by this scale was
in line with a general theme of more anxiety symptoms for the obligatory group. As
predicted, obligatory exercisers, scored significantly higher than the nonobligatory exercisers on the MOCI checking scale. Although they did not score at a level associated
with obsessive-compulsive disorder (Hodgson & Rachman, 1977), research has linked
elevated checking scores with social fears and symptoms of anxiety and depression (Frost
et al., 1986). This interpretation is compatible with the belief that obligatory exercisers
have high trait anxiety and avoid intimate relationships (Coen & Ogles, 1993; De Coverly
Veale, 1987, Yates, 1991). The suggestion of underlying mood issues also is reasonable
from the standpoint of exercise being empirically supported as an effective short-term
strategy for regulating negative mood (Yeung, 1996). Future studies should attempt to
replicate these tentative findings with other instruments and should test stringently for
symptoms of comorbid conditions.
Even though obligatory exercisers entered treatment at a disadvantage in terms of
relevant symptoms, this did not interfere with outcome. Although this implies that
obligatory exercisers respond to body image treatment just as well as nonobligatory
exercisers, other explanations should be considered. One might argue that there was too
much overlap between the exercise conditions in the study, given the high level of
activity in the nonobligatory group. But in the Coen and Ogles (1993) study that provided
the OEQ psychometrics, the nonobligatory exercisers averaged even more physical activity than our nonobligatory exercisers. Still, researchers now often require distinct
groups in terms of both obligatory status and amount of exercise when examining
compulsive exercisers (Davis, Kaptein, Kaplan, Olmsted, & Woodside, 1998). However,
when this practice was followed in the current study's exploratory analyses, our findings
did not change. Another possible explanation for the lack of exercise effects is that the
nonobligatory exercisers gained a significant amount of weight from pretreatment to
follow-up. This increase of approximately 2.6 lb over 4 months might have attenuated
their treatment response (Cash, 1994a), thereby minimizing group differences. Yet, the
weight gain was not substantial at posttreatment, and exercise status differences still
were not found.
In terms of overall treatment response, most predictions were supported at posttreatment, but many of the effects were lost at follow-up. The diminution in effect over
time did not appear to be related to treatment exposure or content because 71% of the
sessions were attended, and experienced therapists delivered an empirically supported
program. Instead, the issue probably was one of sample characteristics. These women
averaged 37 years of age; a minimum of 15 years older than most participants in the
earlier body image studies (Butters & Cash, 1987; Rosen et al., 1989, 1990). Age alone
would not explain the less robust findings, but associated features meriting attention
include the fact that many of these women had families and jobs, as opposed to being
primarily single students. It is also likely that the women in the current study were
heavier than those in other studies, despite all of them being normal weight. Unfortunately, this cannot be tested directly, given that BMIs were not reported for any of
the body image treatment studies. Still, if one uses the National Health and Nutrition
Examination Survey's findings that the weight of women ages 25 44 increases by 5.2%
over 10-year intervals (Williamson, Kahn, Remington, & Anda, 1990), then the current
study's 5 ft. 4 in. woman was nearly 12 lb heavier than the 19 24-year-olds in other
studies.
386
Smith et al.
The main limitation of the current study was the relatively low follow-up rate, which
raises questions about how representative the data are. In response to this, one must note
that there were no differences in assessment completion rates across treatment condition
or exercise status, and there was only one pretreatment difference (on the MOCI) for those
who finished the assessments and those who did not. Further, an intention-to-treat
analysis, which assumed that noncompleters did not improve, mirrored the major outcome results. Perspective also should be maintained because several earlier studies had
incomplete follow-up data or none (Butters & Cash, 1987; Dworkin & Kerr, 1987; Fisher
& Thompson, 1994) and others may have had higher rates because "captive" audiences
(i.e., students) were involved. More generally, attrition is routinely a problem in eating
disorder treatment research, with drop-out rates frequently being quite similar to the
current study's (Allison, Kreibich, Heshka, & Heymsfield, 1995; Steel et al., 2000). The
problem seems to be most pronounced in community samples (Cachelin et al., 1999).
This appears to be the first body image therapy study for older community women
who had families and jobs and who fell at the upper end of the normal weight range. It is
unique in that it included a large percentage of ethnic minority participants (41%) and
demonstrated no ethnic differences in treatment response. The results suggest that CBT is
a reasonable body image treatment for a community sample, but that refinement may be
needed to improve long-term outcomes for everyone, not just for obligatory exercisers.
There were two intriguing findings that require replication. First, obligatory exercisers
had somewhat elevated (albeit not pathological) compulsivity scores that may be linked
with anxiety and mood problems. Second, high levels of physical activity were the norm
for even the nonobligatory participants. Because exercise has mood regulation properties
(Yeung, 1996), both of these findings suggest indirectly that general anxiety and mood
symptoms may need to be addressed in standard body image programs. Also, because
high levels of exercise serve to further increase a negative body focus (Davis et al., 1990),
this study intimates that the majority of women in body image programs may benefit
from discussions of their physical activity.
The authors express their appreciation to the women of Albuquerque who graciously participated
in this study and to Thomas Cash, Ph.D., for his permission to adapt the treatment to ®t our format.
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