Intuitive Eating in Relation to Other Eating Patterns
and Psychosocial Correlates
by
Lauren Jade Bruce
Bachelor of Arts, Graduate Diploma in Psychology
Submitted in partial fulfilment of the requirements for the degree of
Doctor of Psychology (Health)
Deakin University
August, 2017
Acknowledgements
I would like to express my deepest gratitude to my supervisor, Professor Lina
Ricciardelli. Your continuous support and guidance have been invaluable in
completing this thesis. I have appreciated your wisdom, your encouragement, and
your patience throughout the last five years. I would also like to thank my associate
supervisor, Associate Professor Matthew Fuller-Tyszkiewicz. Your practical support
and advice in conducting my empirical study is very much appreciated. To Professor
Helen Skouteris, thank you for your support and understanding as I balanced
working on your projects with my doctoral studies. To my fellow colleagues and
students, thank you for being a significant source of motivation and for keeping me
focused. A heartfelt thank you to my family and friends who have supported me
throughout this journey. To my parents, I will be forever grateful for your support
during my academic pursuits. Your love and care have enabled me to reach this
milestone. Mum, I am certain I could not have achieved this without you. To my
dearest friends EJ and Rachel, without your support, the process of writing this thesis
would have been much more of a challenge. EJ, you walked this journey with me.
Thank you for holding me up in times I felt overwhelmed, for making me laugh, and
for celebrating those little milestones with me along the way. Rachel, thank you for
your encouragement and your thoughtfulness. Our coffee dates and spending time
with your girls were a welcome distraction, particularly in the final few months. To
Patrick and Ruby, you have been a much-needed source of comfort and humour.
Finally, I would like to dedicate this thesis to the memory of my Pop, Victor Barson.
Pop, you were my mentor. I am so grateful for the time I shared with you. Your
actions and your words inspired me to live a more meaningful and courageous life.
Abstract
Intuitive eating has been proposed as an eating style that fosters a positive
attitude towards food, the body, and physical activity. In contrast with disordered
eating, which encourages eating based on external cues for what, when, and how
much to eat, intuitive eating places emphasis on physical cues for hunger and satiety
to guide food intake. As assessed by the Intuitive Eating Scale (IES; Tylka, 2006),
intuitive eating comprises three components: unconditional permission to eat, eating
for physical rather than emotional reasons, and reliance on hunger and satiety cues.
However, the extent to which these aspects of intuitive eating overlap with
disordered eating and other eating patterns has yet to be fully established. The overall
aim of the thesis was to examine intuitive eating in relation to other eating patterns
and psychosocial correlates.
Firstly, a systematic review of intuitive eating literature was conducted to
summarise psychosocial factors that correlate with intuitive eating in adult women.
Twenty-four cross-sectional studies were included for review based on the following
eligibility criteria: examined females aged 18 years and older; used a measure of
intuitive eating; and assessed a psychosocial correlate of intuitive eating. The review
showed that higher levels of intuitive eating were associated with less dieting and
other aspects of disordered eating, greater emotional functioning, and a more positive
body image. Additional psychosocial factors that are components of the acceptance
model of intuitive eating (e.g., body acceptance by others), and the dual pathway
model of disordered eating (e.g., pressure for thinness, and internalisation of the thin-
ideal) were also related to intuitive eating. Another important finding of the review is
that the strength of association between intuitive eating and psychosocial factors
differed for each aspect of intuitive eating. In comparison to eating for physical
rather than emotional reasons and reliance on hunger/satiety cues, unconditional
permission to eat was more strongly correlated with disordered eating, body
dissatisfaction, societal pressure for thinness, and internalisation of the thin-ideal.
The review suggested that unconditional permission to eat may not be a distinct
pattern of eating, and instead may be assessing low levels of disordered eating.
Following the systematic review, an empirical study was conducted to: (1)
examine the factor structure of the IES in a community sample of adult women; (2)
to examine each of the three aspects of intuitive eating in relation to other eating
behaviours; and (3) to examine and compare the psychosocial correlates of the three
aspects of intuitive eating with other patterns of eating. These included: dieting,
restrained eating, bulimia/food preoccupation, emotional eating and external eating.
Psychosocial factors examined were those from the acceptance model of intuitive
eating (i.e., perceived social support, body acceptance by others, body function, and
body appreciation) and the dual pathway model of disordered eating (i.e., pressure
for thinness, internalisation of the thin-ideal, body dissatisfaction, and negative
affect). Participants were a community sample of 457 women aged 18 years and
older, who were English-speaking and lived in Australia.
The three-factor structure of the IES was supported in the community sample
of women. However, due to low factor loadings, five items across the three subscales
were removed. All three revised subscales demonstrated high levels of internal
consistency. Principal axis factoring was conducted to determine if the three aspects
of intuitive eating are distinct from the following eating behaviours: dieting,
restrained eating, bulimia/food preoccupation, emotional eating and external eating.
Unconditional permission to eat loaded onto the first factor with dieting, restrained
eating, and bulimia/food preoccupation. This eating factor was labelled ‘disordered
eating’. Eating for physical rather than emotional reasons loaded onto a second
eating factor with emotional eating and external eating. This eating factor was
labelled ‘eating for non-emotional/non-external reasons’. Reliance on hunger/satiety
cues did not load onto either eating factor, suggesting that it is more distinct from the
other eating behaviours.
A comparison of the psychosocial correlates of disordered eating, eating for
non-emotional/non-external reasons, and the reliance on hunger/satiety cues subscale
was conducted by examining bivariate correlations, the acceptance model of intuitive
eating, and a modified dual pathway model of disordered eating. As indicated by the
bivariate correlations and across both the acceptance model and dual pathway model,
body dissatisfaction/body satisfaction was the strongest direct predictor of each of
the three eating patterns.
All other psychosocial factors in the acceptance model and the modified dual
pathway model correlated significantly at the bivariate level with the three eating
patterns. However, when specifically testing the acceptance model, body function
was found to predict disordered eating and eating for non-emotional/non-external
reasons but it did not predict reliance on hunger/satiety cues. In addition, when
testing the modified dual pathway model, negative affect predicted disordered eating
and eating for non-emotional/non-external reasons but not reliance on hunger/satiety
cues. Societal pressure for thinness was directly associated with eating for non-
emotional/non-external reasons but not disordered eating; and internalisation of the
thin-ideal was directly associated with disordered eating but not eating for non-
emotional/non-external reasons.
Overall, findings from the systematic review and the empirical study of this
thesis demonstrated that only the reliance on hunger/satiety cues subscale of the IES,
is conceptually distinct from other eating patterns. Reliance on hunger/satiety cues
involves an awareness and trust in physical cues to guide food intake, instead of
emotional and external cues.
Longitudinal research is now needed to examine whether reliance on
hunger/satiety cues leads to more positive health outcomes than disordered eating,
emotional eating, and external eating. In addition, research is needed to examine how
the additional component of the revised IES, body-food choice congruence, which
was not examined in this thesis, is related to these other eating patterns.
Furthermore, other aspects of intuitive eating, such as body acceptance and respect,
and a positive attitude towards physical activity, which are not assessed by either the
original or the revised IES, also need to be considered in future research. Lastly,
additional psychosocial factors need to be examined and longitudinal research is
needed to evaluate whether these psychosocial factors are antecedents or
consequences of intuitive eating.
I
Table of Contents
CHAPTER ONE........................................................................................ 1
Thesis Overview ........................................................................................ 1
Overview of Thesis and Chapters ................................................................ 1
Chapter Two: An Introduction to Intuitive Eating ........................................ 2
Chapter Three: A Systematic Review of the Psychosocial Correlates
of Intuitive Eating among Adult Women ..................................................... 2
Chapter Four: Empirical Study: Introduction and Method............................ 3
Chapter Five: Empirical Study: Results and Discussion Part One ................ 3
Chapter Six: Empirical Study: Results and Discussion Part Two ................. 4
Chapter Seven: General Discussion ............................................................. 5
CHAPTER TWO ...................................................................................... 6
An Introduction to Intuitive Eating .......................................................... 6
Principles of Intuitive Eating ....................................................................... 6
Psychometric Scales Designed to Measure Intuitive Eating ....................... 13
CHAPTER THREE ................................................................................ 22
A Systematic Review of the Psychosocial Correlates of Intuitive
Eating among Adult Women................................................................... 22
Introduction ............................................................................................... 22
Methods .................................................................................................... 24
Search Strategy .............................................................................. 25
Eligibility Criteria ......................................................................... 25
Selection Process ........................................................................... 25
II
Data Extraction ............................................................................. 26
Assessment of Study Quality ........................................................... 26
Results ...................................................................................................... 27
Methodological Quality of Studies ................................................. 28
Summary of Included Studies ......................................................... 29
Eating Attitudes and Behaviours .................................................... 68
Body Image .................................................................................... 70
Emotional Functioning .................................................................. 72
Other Psychosocial Correlates ...................................................... 73
Discussion ................................................................................................. 76
Limitations and Recommendations for Future Research ................ 81
CHAPTER FOUR ................................................................................... 83
Empirical Study: Introduction and Method .......................................... 83
Factor Structure of IES .............................................................................. 84
The Association between Intuitive Eating and
Other Eating Behaviours ........................................................................... 85
Psychosocial Correlates of Intuitive Eating and
Other Patterns of Eating ............................................................................ 91
Method ...................................................................................................... 95
Participants ................................................................................... 95
Measures ....................................................................................... 98
Background Information .................................................... 98
Weight Status ..................................................................... 98
III
Intuitive eating ................................................................... 98
Dieting ............................................................................... 99
Bulimia and Food Preoccupation ..................................... 100
Restrained Eating ............................................................. 100
Emotional Eating ............................................................. 101
External Eating ................................................................ 101
Perceived Social Support ................................................. 102
Body Acceptance by Others .............................................. 102
Body Function .................................................................. 103
Body Appreciation ............................................................ 104
Pressure for Thinness ....................................................... 104
Thin-ideal Internalisation ................................................. 105
Appearance Evaluation .................................................... 105
Body Area Satisfaction ..................................................... 106
Negative Affect ................................................................. 107
Procedure .................................................................................... 107
Data Analyses .............................................................................. 108
CHAPTER FIVE ................................................................................... 110
Empirical Study: Results and Discussion Part One ............................. 110
Factor Structure of the IES ...................................................................... 110
Correlations between Eating Behaviours ................................................. 116
Exploratory Factor Analysis of Intuitive Eating and
Other Eating Behaviours ......................................................................... 118
IV
Discussion ............................................................................................... 120
CHAPTER SIX ..................................................................................... 127
Empirical Study: Results and Discussion Part Two............................. 127
Age, Education, and BMI ........................................................................ 128
Bivariate Correlations between Eating Patterns
and Psychosocial Variables ..................................................................... 129
Psychosocial Predictors of Disordered eating,
Eating for Non-emotional/Non-external Reasons, and
Reliance on Hunger/satiety Cues ............................................................. 132
Model Based on the Acceptance Model of Intuitive Eating ...................... 134
Model Based on the Dual Pathway Model of Disordered Eating .............. 146
Discussion ............................................................................................... 156
CHAPTER SEVEN ............................................................................... 162
General Discussion ................................................................................ 162
Summary of Aims and Main Findings ..................................................... 162
Assessing Principles of Intuitive Eating ................................................... 165
Other Psychosocial Factors...................................................................... 169
Intuitive Eating and Positive Health Outcomes ........................................ 171
Examining Intuitive Eating in Other Populations ..................................... 173
Study Limitations .................................................................................... 179
Conclusion .............................................................................................. 179
REFERENCES ...................................................................................... 181
APPENDICES ....................................................................................... 221
V
Appendix A ............................................................................................. 221
Ethics Approval Documentation ................................................... 221
Appendix B ............................................................................................. 223
Plain Language Statement and Consent Form ............................. 223
Appendix C ............................................................................................. 227
Principal Axis Factoring for Three Body Image Variables ........... 227
Appendix D ............................................................................................. 228
Authorship Statement ................................................................... 228
Licensing Agreement for Reproduction of Published Article......... 230
VI
List of Figures
Chapter Three Page
Figure 3.1 Search terms and search strategy ............................. 26
Figure 3.2 Flow diagram of included studies............................ 28
Chapter Five
Figure 5.1 Proposed first order model of the IES ................... 111
Figure 5.2 Re-specified model of the IES .............................. 114
Chapter Six
Figure 6.1 Model I – Modified acceptance model for the
three eating patterns: disordered eating, eating for
non-emotional and external reasons and reliance
on hunger/satiety cues ........................................... 132
Figure 6.2 Model II - Modified dual pathway model
for the three eating patterns: disordered eating,
eating for non-emotional and external reasons
and reliance on hunger/satiety cues ....................... 133
Figure 6.3 Re-specified Model I – Modified acceptance
model with disordered eating as the outcome ........ 136
Figure 6.4 Re-specified Model I - Modified acceptance
model with non-emotional/external reasons
as the outcome ...................................................... 140
Figure 6.5 Re-specified Model I - Modified acceptance
model with reliance on hunger/satiety cues
VII
as the outcome ...................................................... 144
Figure 6.6 Re-specified Model II – Modified dual pathway
model with disordered eating as the outcome ........ 148
Figure 6.7 Re-specified Model II – Modified dual pathway
model with eating for non-emotional/non-external
reasons as the outcome ......................................... 151
Figure 6.8 Re-specified Model II – Modified dual pathway
model with reliance on hunger/satiety cues
as the outcome ...................................................... 155
VIII
List of Tables
Chapter Three Page
Table 3.1 Summary of Cross-sectional Studies Examining
Psychosocial Correlates of Intuitive Eating ............. 31
Chapter Four
Table 4.1 Sample Characteristics ............................................ 96
Chapter Five
Table 5.1 Factor Loadings for Proposed First-order
Model of the IES .................................................. 113
Table 5.2 Covariances and Correlations between Factors
in the Proposed First-order Model of the IES ........ 114
Table 5.3 Estimates, Standard Error of Estimates
and p-values for Re-Specified Model .................... 115
Table 5.4 Covariances and Correlations between Factors
In the Re-Specified Model .................................... 116
Table 5.5 Mean (SD), Range, Internal Reliability for
Eating-related Scales ............................................ 117
Table 5.6 Correlations between Intuitive Eating
and Other Eating Patterns ..................................... 118
Table 5.7 Pattern Matrix with Rotated Factor Loadings ........ 120
Chapter Six
Table 6.1 Correlations between Eating Patterns, Age,
Education, and BMI .............................................. 128
IX
Table 6.2 Mean, Standard Deviation, and Bivariate
Correlations for Psychosocial Factors and
Eating Patterns ...................................................... 131
Table 6.3 Initial Estimates for Model I – Modified
Acceptance Model with Disordered Eating as
the Outcome ......................................................... 135
Table 6.4 Final Estimates for Model I – Modified
Acceptance Model with Disordered Eating as
the Outcome ......................................................... 137
Table 6.5 Initial Estimates for Model I – Modified
Acceptance Model with Eating for
Non-emotional/external Reasons
as the Outcome ..................................................... 139
Table 6.6 Final Estimates for Model I – Modified
Acceptance Model with Eating for
Non-emotional/external Reasons
as the Outcome ..................................................... 141
Table 6.7 Initial Estimates for Model I – Modified
Acceptance Model with Reliance on
Hunger/satiety Cues as the Outcome ..................... 143
Table 6.8 Final Estimates for Model I – Modified
Acceptance Model with Reliance on
Hunger/satiety cues as the Outcome ...................... 145
X
Table 6.9 Initial Estimates for Model II – Modified
Dual Pathway Model with Disordered Eating
as the Outcome ..................................................... 147
Table 6.10 Final Estimates for Model II - Modified Dual
Pathway Model with Disordered Eating
as the Outcome ..................................................... 149
Table 6.11 Initial Estimates for Model II – Modified Dual
Pathway Model with Eating for
Non-emotional/external Reasons
as the Outcome ..................................................... 150
Table 6.12 Final Estimates for Model II - Modified Dual
Pathway Model with Eating for
Non-emotional/external Reasons
as the Outcome ..................................................... 152
Table 6.13 Initial Estimates for Model II – Modified Dual
Pathway Model with Reliance on
Hunger/satiety Cues as the Outcome ..................... 154
Table 6.14 Final Estimates for Model II – Modified Dual
Pathway Model with Reliance on Hunger/satiety
Cues as the Outcome ............................................ 156
1
CHAPTER ONE
Thesis Overview
Overview of the Thesis
Intuitive eating is an eating style proposed to foster a positive relationship
with food by encouraging a focus on physical hunger and satiety cues to guide food
intake. The eating approach is proposed to target disordered eating patterns by
removing the focus on emotional and external cues for eating, promoting body
acceptance rather than modifying weight and shape, and promoting a positive
relationship with exercise (Tribole & Resch, 1995, 2012). Intuitive eating has had an
increasing presence in the literature over the past decade, with the first study of
intuitive eating, as proposed by Tribole and Resch (1995), being published by Tylka
(2006). However, the relationship between intuitive eating and other patterns of
eating, and its association with psychosocial factors, as both predictors and/or
outcomes of intuitive eating is yet to be fully established.
This doctoral thesis investigated intuitive eating in relation to other eating
patterns and its psychosocial correlates in adult women. Intuitive eating research has
largely focused on adult women, particularly female university students. Firstly, a
systematic review of existing literature on the psychosocial correlates of intuitive
eating in adult women was conducted. An empirical study was then conducted to
examine the three aspects of intuitive eating in relation to other patterns of eating and
their psychosocial correlates in a community sample of adult women. This included
an examination of the three-factor structure of the Intuitive Eating Scale (IES; Tylka,
2006); an examination of the three IES subscales (unconditional permission to eat,
eating for physical rather than emotional reasons, reliance on hunger/satiety cues) in
relation to dieting, restrained eating, bulimia/food preoccupation, emotional eating
2
and external eating; and an examination and comparison of the psychosocial
correlates of the different eating patterns.
Chapter Two: An Introduction to Intuitive Eating
The second chapter provides an introduction to the intuitive eating approach,
as proposed by Tribole and Resch (1995, 2012). This includes an overview of the
principles of intuitive eating and the psychometric scales that have been developed to
assess intuitive eating.
Chapter Three: A Systematic Review of the Psychosocial Correlates of Intuitive
Eating among Adult Women
Chapter Three presents the systematic review that has been published in
Appetite1. The review was conducted to examine the psychosocial correlates that
have found to be associated with intuitive eating in adult women. This review set out
to provide a summary of findings and determine gaps in the literature. No systematic
reviews of intuitive eating had been published at the time the review had
commenced. Moreover, there had been no review of studies that had investigated the
association between intuitive eating and disordered eating patterns.
The systematic review demonstrated that a majority of intuitive eating studies
have investigated female university students living in the United States. The three
main correlates that have been examined are: eating attitudes and behaviours; body
image; and emotional functioning. Firstly, the review showed that intuitive eating
was negatively associated with aspects of disordered eating, including dieting, and
there were differences between IES subscales (i.e., unconditional permission to eat,
1 Bruce, L. J., & Ricciardelli, L. A. (2016). A systematic review of the psychosocial correlates of
intuitive eating among adult women. Appetite, 96, 454-472.
3
eating for physical rather than emotional reasons, reliance on hunger/satiety cues) in
the strength of their relationship with disordered eating. More specifically, the review
suggested that unconditional permission to eat may be less conceptually distinct from
disordered eating. Secondly, the review demonstrated that intuitive eating was
associated with a more positive body image, better emotional functioning, and other
psychosocial correlates such as body acceptance by others, perceived social support,
societal pressure for thinness, and internalisation of the thin-ideal.
Chapter Four: Empirical Study: Introduction and Method
Chapter Four provides an introduction to the empirical study of the thesis,
and details the aims and method. The introduction provides an overview of the
association between intuitive eating and other eating patterns, and the psychosocial
factors that have found to be related to intuitive eating. This is then followed with an
overview of two psychosocial models of eating: the acceptance model of intuitive
eating and the dual pathway model of disordered eating. The method section of this
chapter provides a description of the sample, the measures used to assess study
variables, and the procedure used to conduct the study.
Chapter Five: Empirical Study: Results and Discussion Part One
The fifth chapter provides a report of the findings for the first part of the
empirical study and is divided into two sections. The first section examined the
three-factor structure of the IES (Tylka, 2006). A confirmatory factor analysis
demonstrated that sixteen items loaded onto three factors of intuitive eating:
unconditional permission to eat (7 items); eating for physical rather than emotional
reasons (5 items); and reliance on hunger/satiety cues (4 items). Five items were
removed from the scale due to low factor loadings.
4
Following the examination of the IES (Tylka, 2006), the empirical study
examined the association between each of the IES subscales (unconditional
permission to eat, eating for physical rather than emotional reasons, and reliance on
hunger/satiety cues) and the following eating behaviours: dieting, restrained eating,
bulimia/food preoccupation, emotional eating and external eating. Principal axis
factoring was used to examine the overlap between the three intuitive eating factors
and these eating behaviours. Two eating factors emerged from the analyses.
Unconditional permission to eat loaded onto the first factor with dieting, restrained
eating, and bulimia/food preoccupation. This factor was labelled ‘disordered eating’.
Eating for physical rather than emotional reasons loaded onto the second factor with
emotional eating and external eating. This factor was labelled ‘eating for non-
emotional/non-external reasons’. Reliance on hunger/satiety cues did not load onto
either of the two factors. Findings suggest unconditional permission to eat is not a
distinct eating pattern and overlaps with aspects of disordered eating. Moreover,
eating for physical rather than emotional reasons is not a unique eating pattern and
overlaps with emotional eating and external eating. Finally, the third aspect of
intuitive eating, reliance on hunger/satiety cues, is a distinct pattern of eating,
separate from aspects of disordered eating, emotional eating and external eating.
Chapter Six: Empirical Study: Results and Discussion Part Two
Chapter Six provides a summary of the second part of the empirical study.
The second part of the study examined the psychosocial correlates of the three eating
patterns (disordered eating, eating for non-emotional/non-external reasons, reliance
on hunger/satiety cues), assessed by bivariate correlations and two psychosocial
models of eating: the acceptance model of intuitive eating and a modified version of
the dual pathway model of disordered eating. Two of the three eating patterns,
5
disordered eating and eating for non-emotional/non-external reasons, were eating
factors identified in Chapter Five. The third eating pattern was assessed using the
modified reliance on hunger/satiety cues subscale of the IES (Tylka, 2006).
Psychosocial factors included were those from the acceptance model of intuitive
eating (i.e., perceived social support, body acceptance by others, body function, and
body appreciation) and the modified dual pathway model of disordered eating (i.e.,
societal pressure for thinness, internalisation of the thin-ideal, body area satisfaction,
appearance evaluation, and negative affect). Overall, findings of the study
demonstrated there were more similarities than differences in the psychosocial
factors that predict each eating pattern. However, the differences found in the study
highlighted that reliance on hunger/satiety cues is more distinct from disordered
eating and eating for non-emotional/non-external reasons.
Chapter Seven: General Discussion
A summary of the main aims and findings of the thesis are provided.
Secondly, the chapter discusses reliance on hunger/satiety cues and other factors not
examined in this thesis that have been found to be related to this eating behaviour.
Thirdly, the chapter discusses the implications of findings of the empirical study for
the Intuitive Eating Scale (Tylka, 2006). Following this, limitations and
recommendations for future research are discussed, including the need for studies to
examine the positive health outcomes associated with reliance on physical hunger
and satiety cues for eating, and extending research to examine other populations,
including adult men, adolescents, and clinical populations.
6
CHAPTER TWO
An Introduction to Intuitive Eating
Intuitive eating is an eating approach that promotes a positive relationship
with food and eating. Coined by Tribole and Resch (1995), intuitive eating describes
eating based on physical hunger and satiety cues, eating that ignores emotional and
external cues. Overall, intuitive eating is an approach that promotes a positive
attitude towards food, the body, and physical activity (Tribole & Resch, 2012). This
introductory chapter first provides an overview of the principles of intuitive eating,
as proposed by Tribole and Resch (2012). Secondly, a review of the main
psychometric scales that have been developed to measure intuitive eating is
provided.
Principles of Intuitive Eating
Intuitive eating is described using a set of ten principles proposed by Tribole
and Resch (1995, 2012). While these principles have not been tested in empirical
studies, they were the basis for developing Tylka’s (2006) widely used psychometric
scale of intuitive eating. The first principle is focused on a rejection of the ‘dieting
mentality’. Dieting is considered to be maladaptive and ineffective in modifying
body weight and shape (Tribole & Resch, 2012), yet it is a common strategy used to
lose weight or prevent weight gain (National Task Force on the Prevention and
Treatment of Obesity, 2000; Ouwehand & Papies, 2010; Timmerman & Gregg,
2003). Research shows that dieting is ineffective for controlling weight in the longer-
term (Field, Austin, Taylor, Malspeis, Rosner, Rockett et al., 2003; Mann,
Tomiyama, Westling, Lew, Samuels, & Chatman, 2007; Neumark-Sztainer, Wall,
Story, & Standish, 2012; Sarlio-Lahteenkorva, Rosanne, & Kaprio, 2000). There is
also research to suggest that dieting is associated with a higher Body Mass Index
7
(BMI) (e.g., Enriquez, Duncan, & Schur, 2013; Van Strien, Herman, & Verheijden,
2014), and dieting interventions for weight loss have been found to be associated
with weight regain (Langeveld & DeVries, 2015; Lowe, Doshi, Katterman, & Freig,
2013; Mann et al., 2007; Pietiläinen, Saarni, Kaprio, & Rissanen, 2012; Ulen,
Huizinga, Beech, & Elasy, 2008). Two systematic reviews of weight loss
interventions that incorporated dieting and/or physical activity components have
found that almost 50% of weight lost during the intervention was regained one year
later (Barte, Ter Bogt, Bogers, Teixeira, Blissmer, Mori, & Bemelmans, 2010;
Curioni & Lourenco, 2005). In addition, dieting, which is often considered part of
disordered eating, has been associated with food preoccupation (Timmermen &
Gregg, 2003) and perceived food deprivation (Markowitz, Butryn, & Lowe, 2008;
Timmerman & Gregg, 2003), and is a risk factor for the development of other
disordered eating behaviours (Haines & Neumark-Sztainer, 2006; Neumark-Sztainer,
Wall, Guo, Story, Haines, & Eisenberg, 2006). Attending to physical cues for hunger
and fullness when eating is thought to reduce the likelihood of engaging in
overeating or binge eating; two eating practices that have been found to be related to
dieting (e.g., Andrés & Saldaña, 2014; Rideout & Barr, 2009; Zunker, Peterson,
Crosby, Cao, Engel, Mitchell et al., 2011).
The second principle of intuitive eating is attending to physical cues for
hunger. This involves identifying cues that signal physical hunger and responding to
these cues. Such cues might include: stomach gurgling or growling, low energy or
lethargy, light-headedness, poor concentration, irritability, headaches, and persistent
thoughts about food (Bacon & Matz, 2010; Tribole & Resch, 2012). Eating patterns
that ignore hunger are discouraged. This includes attending to external cues, such as
confining food intake to set meal times, dieting rules that specify an amount of food,
or only eating in the presence of other people who are eating. Ignoring physical cues
8
for hunger can lead to inadequate food intake, and eating in the absence of hunger
can result in overeating. These both have implications for managing a healthy
weight. Research to date suggests that intuitive eating is associated with being in a
healthier weight range (Van Dyke & Drinkwater, 2014) whereas eating for reasons
other than physical hunger has been associated with weight gain (Enriquez et al.,
2013; Hays, Bathalon, McCrory, Roubenoff, Lipman, & Roberts, 2002; Koenders &
Van Strien, 2011; Van Strien et al., 2014).
The third principle of intuitive eating is an unconditional permission to eat.
This principle involves not categorising foods according to acceptability (i.e., ‘good’
and ‘bad’ foods; ‘healthy’ versus ‘junk’ foods), which is often encouraged by dieting
practices. By removing such rules and having the freedom to choose whatever food
is desired, unconditional eating is believed to address feelings of deprivation,
cravings associated with restrictive eating, and food-related guilt (Tribole & Resch,
1995, 2012). An unconditional permission to eat is also thought to prevent periods of
overeating in response to perceived food deprivation. Research shows that more
flexible eating practices are associated with less disinhibited eating (Timko &
Perone, 2005; Westenhoefer, Stunkard, & Pudel, 1999). Moreover, difficulties in
regulating eating have been associated with a discrepancy between the desire to
enjoy palatable foods and a desire to control body weight (Stroebe, Mensink, Aarts,
Schut & Kruglanski, 2008).
The fourth principle of intuitive eating relates to managing self-critical
thoughts and distorted thinking in relation to food and eating (Tribole & Resch,
1995, 2012). The approach promotes a non-judgemental attitude towards eating, and
encourages individuals to manage negative or unhelpful thoughts. This includes
dichotomous thoughts in relation to food (e.g., categorising foods as either ‘good’ or
9
‘bad’), which have been found to be associated with eating, weight and shape
concerns (Byrne, Allen, Dove, Watt, & Nathan, 2008), and is a maintaining factor for
disordered eating (Fairburn, Cooper, & Shafran, 2003). Moreover, self-criticism has
been found to predict disordered eating in those diagnosed with an eating disorder
(Fennig, Hadas, Itzhaky, Roe, Apter, & Shahar, 2014), and increases in self-
compassion have been shown to reduce negative feelings and alleviate disordered
eating in highly restrictive eaters (Adams & Leary, 2007) and in those diagnosed
with an eating disorder (Kelly, Carter, & Borairi, 2014).
The fifth principle focuses on an awareness of internal cues of satiety and
eating to a comfortable degree of fullness. Eating mindfully to recognise feelings of
fullness and the absence of hunger is an aspect of this principle. This principle
includes resisting the ‘clean your plate’ mentality (i.e., eating to completion), eating
without distraction, and being prepared to respond in situations likely to involve
obligatory eating (Tribole & Resch, 2012). Tuning into bodily cues for satiety is said
to help prevent overeating, including emotional eating and binge eating.
Mindfulness-based eating interventions have been demonstrated to reduce emotional
eating, external eating, and binge eating (Alberts, Thewissen, & Raes, 2012;
Katterman, Kleinman, Hood, Nackers, & Corsica, 2014; Kristeller, Wolever, &
Sheets, 2014).
The sixth principle is focused on satisfaction during eating, and is closely
connected to the principles described above, particularly the second, third, and fifth
principles. Eating satisfaction is heightened by an unconditional permission to eat,
and eating when hungry and until comfortably full. The pleasure of eating has been
identified as an important factor in the effect dieting has psychological well-being.
Dieting and restrained eating have been associated with poorer psychological well-
10
being in individuals who experience more pleasure in eating (Appleton & McGown,
2006; Remick, Pliner, & McLean, 2009). Moreover, it has been argued that dieters
are unable to maintain their control over eating due to a conflict between their desire
to enjoy palatable food and their desire to control their body weight (Stroebe,
Mensink, Aarts, Schut, & Kruglanski, 2008).
The seventh principle of intuitive eating addresses emotional eating.
Emotional eating involves eating in response to negative emotions (Van Strien,
Frijters, Bergers, & Defares, 1986) and has been associated with emotional
difficulties, such as anxiety and depression (Evers, Stok, & de Ridder, 2010;
Konttinen, Männistö, Sarlio-Lähteenkorva, Silventoinen, & Haukkala, 2010;
Schneider, Appelhans, Whited, Oleski, & Pagoto, 2010; Schulz & Laessle, 2010).
Engaging in emotional eating behaviours has been associated with a loss of control
over eating (Goossens, Braet, Van Vlierberghe, & Mels, 2009; Groesz, McCoy, Carl,
Saslow, Stewart, Adler et al., 2012) and binge eating behaviours (Ricca, Castellini,
Sauro, Ravaldi, Lapi, Mannucci et al., 2009; Zeeck, Stelzer, Linster, Joos, &
Hartmann, 2011). To prevent periods of emotional eating, intuitive eating promotes
an awareness of emotions, identification of the role that food plays in relation to
emotions (e.g., comfort, distraction), and situations that trigger emotional eating
(e.g., boredom, procrastination, stress). In addition, intuitive eating encourages
alternative strategies to manage emotions that do not involve using food, including:
engaging in activities such as spending time with friends or pets and engaging in
hobbies that provide nurturance and a distraction from feelings; and managing
feelings through activities such as journaling, meditation, and talking to friends or a
therapist (Tribole & Resch, 2012).
11
The eighth principle of intuitive eating addresses body image. Respecting
body size and shape, and discouraging unrealistic expectations or being critical of
weight and shape, are the primary focus of this principle (Tribole & Resch, 1995;
2012). Engaging in intuitive eating to modify weight or shape is not the aim of the
eating style (Tribole and Resch, 1995; 2012). Respect and appreciation of the body,
regardless of size and shape, is promoted. Body appreciation has been studied in
samples of women of different ages (Tiggemann & McCourt, 2013), male and
female university students (Avalos, Tylka, & Wood-Barcalow, 2005; Tylka, 2013;
Tylka & Wood-Barcalow, 2015) and in women from non-western countries (Ng,
Barron, & Swami, 2015; Swami & Jaafar, 2012). Body appreciation is viewed as
being distinct from body satisfaction and appearance evaluation (Tylka, & Wood-
Barcalow, 2015), and has been found to be associated with lower levels of disordered
eating and higher levels of psychological well-being (Avalos et al., 2005; Tylka, &
Wood-Barcalow, 2015).
In addition to addressing body image, intuitive eating encourages a healthy
attitude towards physical activity. The ninth principle of intuitive eating promotes
exercise as a healthy and enjoyable activity, rather than an activity carried out for
weight control by expending calories (Tribole & Resch, 1995, 2012). An awareness
of how the body feels and responds to physical activity is part of this principle.
Research suggests that enjoyment received while engaging in physical activity is
associated with higher levels of participation (e.g., Hagberg, Lindahl, Nyberg, &
Hellénius, 2009), and exercising for intrinsic reasons (such as enjoyment, or for the
challenge) rather than extrinsic reasons (such as for weight and appearance-related
reasons) is associated with greater exercise adherence in the longer-term (Ryan,
Christina, Deborah, Rubio, & Kennan, 1997; Kilpatrick, Hebert, & Bartholomew,
2005). Two studies have examined intuitive eating in relation to exercise motivation
12
(Gast, Campbell Nielson, Hunt, & Leiker, 2015; Tylka & Homan, 2015). In the study
conducted by Gast and colleagues (2015), female university students who identified
as eating more intuitively reported greater intrinsic motivation (i.e., pleasure) for
regular physical activity, compared with students who did not eat as intuitively (Gast
et al., 2015). Moreover, lower levels of intuitive eating were associated with physical
activity motivation that was based on external pressures, or a sense of guilt or shame
(Gast et al., 2015). Tylka and Homan (2015) investigated intuitive eating in relation
to exercise motivation based on appearance (including weight control) or health and
enjoyment. Male and female university students reported that appearance-based
motivation for exercise (including weight control) was negatively associated with
intuitive eating (Tylka & Homan, 2015).
The tenth principle of intuitive eating emphasises making food choices that
contribute to body functioning and are nourishing, but are also satisfying in terms of
taste (Tylka & Wilcox, 2006). This includes a focus on body’s response to food and
eating, and using this to guide food choices. Another aspect of this principle is eating
for nutrition, including: eating a variety of foods; eating in moderation; and
considering the taste, quality and quantity of foods in making food choices. There is
some empirical support for the relationship between intuitive eating and increased
pleasure associated with food and eating, a greater diversity of diet, and less of a
focus on food in terms of its properties, such as calories and amount of fat (Smith &
Hawks, 2006). Moreover, some aspects of intuitive eating have been associated with
lower energy intake, less sweet and fatty foods, less dairy, meat and fish products,
and more grain foods (Camilleri, Mejean, Bellisle, Andreeva, Kesse-Guyot,
Hercberg et al., 2017), though the unconditional permission to eat has been
associated with increased energy intake and less fruit and vegetable intake (Camilleri
et al., 2017).
13
Taken as a whole, these ten principles describe the intuitive eating approach.
While these principles are yet to be individually empirically tested, two psychometric
scales (Hawks, Merril, & Madanat, 2004; Tylka, 2006) used to assess aspects of
intuitive eating were developed in part according to these principles.
Psychometric Scales Designed to Measure Intuitive Eating
In order to assess intuitive eating behaviours in adults, two psychometric
scales were initially developed using samples of university students living in the
United States. The first scale published was the 27-item Intuitive Eating Scale
developed by Hawks and colleagues (2004). This was followed by the 21-item IES
developed by Tylka (2006). Of the two scales, Tylka’s (2006) scale is a more widely
used measure, with more than 30 studies having used the scale to assess intuitive
eating (e.g., Augustus-Horvath & Tylka, 2011; Brown, Parman, Rudat, & Craighead,
2012; Herbert, Blechert, Hautzinger, Matthias, & Herbert, 2013; Homan &
Cavanaugh, 2013; Iannantuono & Tylka, 2012; Järvelä-Reijonen, Karhunen,
Sairanen, Rantala, Laitinen, Puttonen, 2016; Madden, Leong, Gray, & Horwath,
2012; Mensinger, Calogero, & Tylka, 2016; Oh, Wiseman, Hendrickson, Phillips, &
Hayden, 2012; Schoenefeld & Webb, 2013; Shouse & Nilsson, 2011; Tylka &
Homan, 2015; Wheeler, Lawrence, Chae, Paterson, Gray, Healey et al., 2016). These
studies have provided support for the scale’s reliability and validity. The systematic
review conducted as part of this thesis demonstrated that a majority of studies that
examined the psychosocial correlates of intuitive eating, including disordered eating,
used Tylka’s (2006) scale. For these reasons, the empirical study conducted as part of
the thesis used Tylka’s (2006) IES to examine intuitive eating in relation to other
eating behaviours and psychosocial correlates. An overview of the two main intuitive
eating scales is provided below, and given that it has been frequently used, more
14
emphasis is placed on the Tylka’s (2006) scale and its revised versions (Camilleri,
Méjean, Bellisle, Andreeva, Sautron, Hercberg et al., 2015; Carbonneau,
Carbonneau, Lamarche, Provencher, Bégin, Bradette-Laplante et al., 2016;
Dockendorff, Petrie, Greenleaf & Martin, 2012; Tylka & Kroon Van Diest, 2013;
van Dyck, Herbert, Happ, Kleveman, & Vogele, 2016).
The 27-item scale developed by Hawks et al. (2004) is comprised of four
subscales: intrinsic eating (four items), extrinsic eating (six items), anti-dieting (13
items) and self-care (four items). The intrinsic eating subscale assesses eating in
response to physical cues for hunger and satiety (e.g. “I seldom eat unless I notice I
am physically hungry”), in comparison to the extrinsic eating subscale, which
assesses external influences on the decision to eat (e.g. “I often turn to food when I
feel sad, anxious, lonely, or stressed out”). The anti-dieting subscale assesses the
level of disagreement with dieting practices (e.g. “I generally count calories before
deciding if something is OK to eat”) while the self-care subscale assesses the
preference for health and fitness over attractiveness (e.g. “The health and strength of
my body is more important to me than how much I weigh”).
The scale was validated using a sample of 391 male and female university
students in the United States. This involved an examination of the scale’s internal
consistency, test-retest reliability, and an examination of the scale’s construct
validity. A principal components analysis demonstrated that 27 items loaded onto
four factors: intrinsic eating, extrinsic eating, anti-dieting, and self-care (Hawks et
al., 2004). Poor internal consistency for the intrinsic subscale (α=.42) and the self-
care subscale (α=.59) was reported (Hawks et al., 2004). This has been replicated in
subsequent studies that have used this scale (Gast, Madanat, Nielson, 2012; Gast et
al., 2015; Wilson, 2014), though internal consistency for the scale overall (i.e., all 27
15
items) has been demonstrated to be satisfactory (e.g., Gast et al., 2012; Smith &
Hawks, 2006). Test-retest reliability for the scale was determined over a four-week
period and was found to be high (r=.85, p<.0001) (Hawks et al. 2004). Construct
validity was assessed by comparing the scale to a measure of current dieting for
weight loss (Martz, Sturgis & Gustafdon, 1996). Intrinsic eating was strongly and
negatively associated with current dieting (r=-.84, p<.0001). Extrinsic eating (r=-.42,
p<.0001), and anti-dieting (r=-.48, p<.0001) were moderately and negatively
associated with current dieting. However, self-care was not related to current dieting
(r=-.02, p<.66) (Hawks et al., 2004), which suggests that individuals with more of a
preference for health and fitness were less likely to be currently dieting.
The IES (Tylka, 2006) was developed using the principles of intuitive eating
proposed by Tribole and Resch (1995). The scale is comprised of three subscales:
unconditional permission to eat (nine items, e.g. “If I am craving a certain food, I
allow myself to have it”), eating for physical rather than emotional reasons (six
items, e.g. “I find myself eating when I am bored, even when I’m not physically
hungry”), and a reliance on hunger and satiety cues (six items, e.g. “I trust my body
to tell me when to eat”) (Tylka, 2006).
The scale was validated in four studies of 1260 female university students
aged 17 to 61, who lived in the United States. Exploratory and confirmatory factor
analyses were conducted and the scale’s internal consistency, test-retest reliability,
and construct validity was assessed. In the first study, an exploratory factor analysis
demonstrated that 25 items loaded onto three factors: unconditional permission to
eat, eating for physical rather than emotional reasons, and reliance on hunger/satiety
cues (Tylka, 2006). A confirmatory factor analysis conducted in the second study
verified the three-factor structure, however, four items were deleted due to low factor
16
loadings. The 21-item scale demonstrated high levels of internal consistency for the
total scale (α=.85) and each of the three subscales (unconditional permission to eat,
α=.87; eating for physical rather than emotional reasons, α=.85; reliance on
hunger/satiety cues, α=.78) (Tylka, 2006). Subsequent studies have supported the
internal consistency of the total IES and its subscales (e.g., Augustus-Horvath &
Tylka, 2011; Kroon Van Diest & Tylka, 2010; Tylka & Homan, 2015). Test-retest
reliability for the total scale was established over a three-week period and found to
be very high (r= .90, p<.001) (Tylka, 2006). Construct validity of the IES was
evaluated against measures of disordered eating (Garner, Olmsted, Bohr & Garfinkel,
1982), body dissatisfaction (Garner, 1991), interoceptive awareness (Garner, 1991),
pressure for thinness (Stice, Ziemba, Margolis & Flick, 1996), and thin-ideal
internalisation (Heinberg, Thompson, & Stormer, 1995). Intuitive eating was
moderately and negatively correlated with disordered eating, body dissatisfaction,
pressure for thinness and thin-ideal internalisation (Tylka, 2006). At the subscale
level, a strong correlation was demonstrated between unconditional permission to eat
and disordered eating symptoms (r= -.72, p<.001). All other correlations between
intuitive eating subscales and these measures were moderate in strength, ranging
from -.23 to -.44 (p<.001).
Since the IES was published, it has been adapted for use with adolescents
(Dockendorff et al., 2012), and a 23-item revised version of the IES has been
published (Tylka & Kroon Van Diest, 2013). Moreover, the revised scale has been
translated for use in French (Camilleri et al., 2015), French-Canadian (Carbonneau et
al., 2016), and German populations (van Dyck et al., 2016).
The adolescent version of the scale (Dockendorff et al., 2012) was developed
using items included in the original version of the scale, and was validated in a
17
sample of male and female adolescents aged 11 to 15 years. Six of the 21 items were
modified to be more appropriate for adolescents (e.g., “I don’t keep certain foods in
my house/apartment because I think I may lose control and eat them” was reworded
to “In my house, my family does not keep certain foods because they think that I may
lose control and eat them”). The scale was validated using factor analyses in two
samples of adolescents. Internal consistency and concurrent validity of the scale were
also assessed. Exploratory and confirmatory factor analyses resulted in the deletion
of four items from the scale. Seventeen items were retained and four factors were
extracted: unconditional permission to eat; eating for physical rather than emotional
reasons; trust in hunger/satiety cues; and awareness of hunger/satiety cues. However,
the confirmatory factor analysis did not support intuitive eating as a higher order
factor, therefore only subscale scores were calculated, not a total intuitive eating
score.
Internal consistency of the subscales across the two samples of adolescents
used in the study were satisfactory for the unconditional permission to eat (α=.78 to
.81), eating for physical rather than emotional reasons (α=.83 to .85), and trust in
hunger/satiety cues (α=.75 to .79). Internal consistency was poorer for the awareness
of hunger/satiety cues subscale across both samples (α=.60 to .65). More recent
studies have reported satisfactory levels of internal consistency for the total scale
(Andrew, Tiggemann, & Clark, 2015; Andrew, Tiggemann, & Clark, 2016). An
assessment of concurrent validity for the scale with adolescents demonstrated that
three of four intuitive eating subscales (unconditional permission to eat, eating for
physical rather than emotional reasons, trust in hunger/satiety cues) correlated
positively with body satisfaction and aspects of positive affect (e.g., happiness,
confidence), and correlated negatively with pressure for thinness, internalisation of
the thin-ideal, and aspects of negative affect (e.g., feeling sad/depressed, shameful,
18
guilty, worthless, anxious) (Dockendorff et al., 2012. However, the awareness of
hunger/satiety cues did not correlate with any of these constructs.
Following the modification of the IES for adolescents, the original IES was
revised to incorporate the tenth principle of intuitive eating (Tribole & Resch, 2003).
This principle describes honouring health and engaging in ‘gentle nutrition’, which
involves making food choices that not only contribute to body functioning, but are
satisfying to the taste buds and for health. The revised version of the scale, the
Intuitive Eating Scale-2 (IES-2), included a fourth subscale to capture this principle
of intuitive eating, and was labelled ‘body-food choice congruence’ (e.g., “I mostly
eat foods that give my body energy and stamina”). In addition, 16 positively-worded
items were included in the scale, compared to eight items in the original IES (Tylka,
2006). This was to focus on assessing the presence of rather than the absence of
intuitive eating behaviours. Exploratory and confirmatory factor analyses were
conducted with two samples of male and female university students. Internal
consistency, convergent validity and test-retest reliability were assessed. Eleven
items from the original scale were retained and 12 new items were included. The
internal consistency of the total scale and each of the four subscales were satisfactory
for both men and women (α ranging from .81 to .93). Convergent validity was
assessed by examining the correlation of scores on the IES-2 with scores on the
original IES (Tylka, 2006). Strong correlations were reported between the two
versions of the scale, for total scores and subscale scores in both men and women (r
ranging from .86 and .95). Test-retest reliability was assessed over a period of three
weeks. Total scores and subscale scores were found to be stable across the three-
week period, with correlations ranging from .75 to .92 (Tylka & Kroon Van Diest,
2013).
19
Following the publication of the IES-2 (Tylka & Kroon Van Diest, 2013), the
scale was adapted and translated into the French language and validated in a French
sample of adult men and women (Camilleri et al., 2015). Factor analyses resulted in a
total of 18 items loading onto three factors, as with the original IES (Tylka, 2006):
unconditional permission to eat, eating for physical rather than emotional reasons,
and a reliance on hunger/satiety cues. The fourth factor of the IES-2 (Tylka & Kroon
Van Diest, 2013), body-food choice congruence, was not retained in the French
translated version. Internal consistency, concurrent validity and test-retest reliability
were assessed. Internal consistency for the total scale and the three subscales were
adequate (α ranging from .70 to .92). Total intuitive eating scores correlated
negatively with cognitive restraint, emotional eating, uncontrolled eating, and
depressive symptoms. The total scale and two of three subscales (unconditional
permission to eat, eating for physical rather than emotional reasons) demonstrated
good test-retest reliability (r ranging from .71 to .81). The reliance on hunger/satiety
cues subscale demonstrated moderate test-retest reliability (r= .66) (Camilleri et al.,
2015).
In addition to the French adapted version of the IES-2, a study conducted by
Carbonneau and colleagues (2016) adapted the scale to assess intuitive eating in a
sample of French-Canadian women. This study tested the factor structure and content
validity of the translated scale and, unlike the study conducted by Camilleri et al.
(2015), the four factors of the original IES-2 were retained. The French-Canadian
scale reported good internal consistency for the total scale (α= .90) and all four
subscales (α= .74 to .92), and scores were stable over a four to seven-week period in
both women and men (r=.73 to .78), except for the body-food choice congruence
subscale (r=.68). Total scores correlated strongly and negatively with measures of
bulimia symptoms and body dissatisfaction (Carbonneau et al., 2016).
20
More recently, a German version of the IES-2 was validated in a sample of
primarily female university students living in Germany, and included adults who had
received an eating disorder diagnosis (van Dyck et al., 2016). A confirmatory factor
analysis was conducted with the four factors of the IES-2 (Tylka & Kroon Van Diest,
2013) that loaded onto a higher order factor (i.e., intuitive eating). The four-factor
structure and all items of the scale were retained, and good internal consistency was
reported for all four subscales (α ranging from .72 to .91). Total scores were strongly
and negatively correlated with disordered eating, body dissatisfaction, drive for
thinness and emotional eating, supporting the construct validity of the scale.
While Tylka’s (2006) and Hawks and colleagues’ (2004) intuitive eating
measures have coexisted in the literature, there has been no comparison of the scale
developed by Hawks et al. (2004) with the scale developed by Tylka (2006), or its
revised versions. However, examining the subscales’ content, there does appear to be
some overlap. Both scales include a subscale that captures eating in response to
physical cues of hunger and satiety (the intrinsic eating subscale of Hawks et al.,
2004; the reliance on hunger/satiety subscale of Tylka (2006) and revised versions).
These subscales relate to the second and fifth principles of intuitive eating (i.e.,
eating based on physical hunger cues, an awareness of satiety cues and eating to a
comfortable degree of fullness) (Tribole & Resch, 2012). In addition, both scales
include an assessment of eating in response to external or emotional cues (the
extrinsic eating subscale of the Hawks et al., 2004; the eating for physical rather than
emotional reasons subscale of Tylka, 2006). These subscales relate to the second and
seventh principles (i.e., eating based on physical hunger cues and ignoring external
cues, and avoiding the use of food to manage emotions). The anti-dieting subscale of
Hawks et al. (2004) and the unconditional permission to eat subscale of Tylka (2006)
are similar in so far as they assess eating patterns and cognitions associated with
21
dieting or restrained eating. These subscales include items that relate to the first,
third, and fourth principles of intuitive eating (i.e., rejecting the dieting mentality,
unconditional permission to eat, non-judgemental attitudes towards eating) (Tribole
& Resch, 2012). One notable difference between the two intuitive eating scales is
that the Hawks et al. (2004) scale includes items that make reference to weight
control, appearance, and physical fitness. The items are part of the self-care subscale,
and are related to the eighth and ninth principles of intuitive eating (i.e., body
appreciation/respect, and a positive attitude towards physical activity) (Tribole &
Resch, 2012). The IES (Tylka, 2006) and its revised versions only make reference to
elements associated with food and eating.
Research to date shows that for the IES (Tylka, 2006) and its revised
versions, the factor structure is the same with regards to the first three subscales:
unconditional permission to eat, eating for physical rather than emotional reasons,
and reliance on hunger/satiety cues. However, the fourth subscale of the revised IES,
body-food choice congruence, was retained in two of the three translated versions of
the scale (Carbonneau et al., 2016; van Dyck et al., 2016). The body-food choice
congruence subscale was not retained in a community sample of French adults
(Camilleri et al., 2015). This suggests that this aspect of intuitive eating may not be
valid in all adult populations. Additional research is needed to validate the four-
factor structure of the English version of the IES-2 (Tylka & Kroon Van Diest, 2013)
and its translated versions in other populations, including community samples of
adults, adolescents and clinical eating disorder populations.
22
CHAPTER THREE
A Systematic Review of the Psychosocial Correlates of Intuitive Eating Among
Adult Women2
Introduction
Extensive research shows that weight loss strategies that promote the
restriction of food intake are largely ineffective for long term weight loss and weight
maintenance (Field et al., 2003; Mann et al., 2007; Neumark-Sztainer et al., 2012).
Moreover, restrictive eating practices have been associated with a higher body mass
index (BMI) (Enriquez et al., 2013; Quick & Byrd-Bredbenner, 2012; Rideout &
Barr, 2009; Van Strien et al., 2014); weight gain (Field et al., 2003; Mann et al.,
2007; Pietiläinen et al., 2012; Ulen et al., 2008); an increased risk of disordered
eating (Appleton & McGowan, 2006; Goldschmidt, Wall, Loth, Le Grange, &
Neumark-Sztainer, 2012; Holmes, Fuller-Tyszkiewicz, Skouteris, & Broadbent,
2014; Kenardy, Brown, & Vogt, 2001; Neumark-Sztainer et al., 2006); and
psychological problems such as emotional difficulties, body image concerns and
reduced cognitive functioning (Appleton & McGowan, 2006; Hawks, Madanat, &
Christly, 2008; Kenardy et al., 2001).
Intuitive eating has been proposed as an eating style that encourages a
positive relationship with food, the body, and physical activity (Tribole & Resch,
2012). The principles of intuitive eating include: focusing on physical cues for
hunger and satiety; permitting an unconditional permission to eat; making food
2 The systematic review has been published in its complete form, as presented in this chapter. Bruce,
L. J., & Ricciardelli, L. A. (2016). A systematic review of the psychosocial correlates of intuitive
eating among adult women. Appetite, 96, 454-472.
23
choices for both health and eating satisfaction; not using food to cope with emotions;
respecting the body regardless of weight and shape; and being physically active for
the enjoyment and health rather than calorie-burning for weight loss (Tribole &
Resch, 2012). This approach discourages a focus on weight control, though the
emergence and maintenance of an individual’s natural weight and shape is
acknowledged as a potential outcome (Tribole & Resch, 2012). The Intuitive Eating
Scale (IES-T)3 is one scale, developed by Tylka (2006), to assess the principles
proposed by Tribole and Resch (2012). The scale assesses three key features: (1)
relying on internal hunger and satiety cues to guide food intake; (2) permitting
oneself to eat unconditionally; and (3) eating for physical rather than emotional
reasons. Tylka and Kroon Van Diest (2013) developed a revised version of the scale
and identified a fourth feature: making food choices to enhance body functioning. An
alternative measure is the Intuitive Eating Scale (IES-H; Hawks et al., 2004) which
also assesses four features: intrinsic eating (i.e., motivation to eat based on internal
cues of hunger); extrinsic eating (i.e., lack of eating based on external cues);
antidieting (i.e., disagreement with dieting behaviours); and self-care (i.e., focus on
health/fitness rather than appearance).
A review of the literature conducted by Van Dyke and Drinkwater (2014)
has shown that intuitive eating (defined as any eating approach based on hunger and
satiety that does not restrict food type, unless for medical reasons) is associated with
a lower BMI; weight maintenance but not weight loss; and factors such as body
image, self-esteem, affect, optimism, and life satisfaction. The relationship between
intuitive eating and health behaviours such as physical activity and dietary intake
3 In the published version of the systematic review, abbreviations of the two intuitive eating scales
were distinguished by the first author to avoid any confusion when referring to each scale. Tylka’s
(2006) Intuitive Eating Scale was abbreviated using ‘IES-T’. The Hawks et al. (2004) Intuitive Eating
Scale was abbreviated using ‘IES-H’.
24
was less clear (Van Dyke & Drinkwater, 2014). A major limitation of this previous
review is that it was not a systematic review and it did not examine intuitive eating in
relation to other eating attitudes and behaviours, such as disordered eating, dieting,
and other weight loss practices.
The aim of this study was to conduct a systematic review of the literature
with a focus on intuitive eating in adult women, in relation to other eating attitudes
and behaviours, body image, and emotional functioning. These are three of the main
domains that address the principles underlying the intuitive eating approach (Tribole
& Resch, 2012). In order to make a significant contribution to the field, the review
also systematically examined all other psychosocial correlates that have been studied
in relation to intuitive eating. This includes factors such as self-esteem, messages
received by women relating to eating and body size and shape, and motivation for
engaging in physical activity. Women were the focus of this review as a majority of
intuitive eating studies have been conducted with women. Women are also more
likely than men to engage in restrictive and disordered eating practices for the
purpose of managing their weight (Enriquez et al., 2013; Forrester-Knauss & Zemp
Stutz, 2012; French, Jeffery, & Wing, 1994) and are at greater risk of developing an
eating disorder (e.g., Elgin & Pritchard, 2006).
Method
The review of quantitative studies was conducted according to the guidelines
specified by the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) statement (Moher, Liberati, Tetzlaff, & Altman, 2010).
25
Search Strategy
A search was conducted between September, 2014 and September, 2015 of
the following bibliographic databases: Academic Search Complete, Cumulative
Index to Nursing and Allied Health Literature Complete (CINAHL Complete),
Health Source (Nursing and Academic Edition), Medline Complete, PsycINFO,
PsycARTICLES, Psychology and Behavioral Sciences Collection, PubMed and
Scopus. All databases were accessed using EbscoHost with the exception of the
PubMed and Scopus databases. Papers were limited to quantitative studies published
in peer-reviewed journals in the English language up until September 2015. An
example of the search strategy and search terms used is provided in Figure 3.1.
Eligibility Criteria
Eligible studies were those that included: (1) females aged 18 years and
older; (2) a measure of intuitive eating; and (3) assessed a psychosocial correlate of
intuitive eating. Studies were excluded for the following reasons: (1) sampled from
females under the age of 18 years; (2) sampled only from males; (3) sampled from
both males and females but findings were not analysed by gender; (4) examined the
effect of an intuitive eating intervention but did not include a measure of intuitive
eating; or (5) did not assess a psychosocial correlate of intuitive eating.
Selection Process
The first author independently screened the titles and abstracts of identified
citations for potential eligibility. If eligibility criteria could not be determined then
papers were read in their entirety. Both authors then examined the full texts of
potential papers for eligibility criteria. Figure 3.2 shows a flow diagram of the
processing of the initial literature review.
26
"Intuitive Eating" OR "intuitive eater" OR "eating intuitively" OR "Intuitive Eating
Scale"
Combined with each of the following:
psych* OR soci* OR emotions OR affect OR depression OR anxiety OR stress OR
body image OR body acceptance OR body satisfaction OR eating disorders OR
disordered eating OR eating behavior
correlat* OR predict* OR factor OR associat* OR determin*
Limiters: peer reviewed, English language, adult 18 years and older, female
349 articles found
Figure 3.1. Search terms and strategy.
Data Extraction
Data extracted from each study included: authors, date of publication, and
country; study design, sample size and participant characteristics; measure used to
assess intuitive eating; psychosocial correlates and measure used; and study findings.
These data were extracted to allow for comparison across studies. Where studies
reported multiple summary statistics, data extracted were limited to bivariate
analyses that were evaluated against Cohen’s criteria for strength of association
(Rosenthal, 1996).
Assessment of Study Quality
The Standard Quality Assessment Criteria for Evaluating Primary Research
Papers from a Variety of Fields (Kmet, Lee, & Cook, 2004) was used to assess the
quality of eligible studies. It is a widely used tool for assessing the quality of study
designs (e.g., Bukowska-Durawa & Luszczynska, 2014; Fiszer, Dolbeault, Sultan, &
Brédart, 2014; Satherley, Howard, & Higgs, 2015). Each study was scored according
to a set of criteria using 14 items. Items assessed criteria such as the inclusion of
27
study objectives, study design and method of subject selection, description of
analyses, and adequate reporting of results. Scores for each item were indicative of
the degree to which each paper met specific criteria (‘yes’ = 2, ‘partial’ = 1, ‘no’ = 0,
or ‘N/A’ = not applicable). Three criteria were not applicable for all 24 studies as
they related to randomised designs. A summary score was calculated for each study
by dividing the sum of each relevant item score by the total possible score.
Results
The initial search produced 349 records. After the removal of duplicates, 237
potential papers were identified, and of these, 200 abstracts did not meet eligibility
criteria. Authors then examined the full texts of 37 potential papers to determine
eligibility for inclusion in the review. A further 16 papers did not meet eligibility
criteria. Further information on reasons for exclusion is provided in Figure 3.2. This
resulted in 21 eligible papers published between 2006 and 2015, six of which
reported multiple studies (Avalos & Tylka, 2006; Dittmann & Freedman, 2009;
Kroon Van Diest & Tylka, 2010; Tylka, 2006; Tylka & Kroon Van Diest, 2013;
Tylka & Wilcox, 2006). All studies reported in each of the six papers met eligibility
criteria except two studies in Tylka (2006), two studies in Tylka and Kroon Van
Diest (2013), and one study each in Kroon Van Diest and Tylka (2010) and Dittmann
and Freedman (2009). Each study in the six papers mentioned previously was
assessed separately, resulting in a total of 24 studies that met eligibility criteria4.
4 Eleven eligible studies published between 2010 and 2015 were not examined in the review by Van
Dyke and Drinkwater (2014) (Brown et al., 2012; Carbonneau et al., 2015; Dittmann & Freedman,
2009; Galloway et al., 2010; Gast et al., 2015; Herbert et al., 2013; Homan & Cavanaugh, 2013;
Schoenefeld & Webb, 2013; Shouse & Nilsson, 2011; Tylka et al., 2015; Tylka & Homan, 2015).
Five cross-sectional studies reviewed by Van Dyke and Drinkwater (2014) were not eligible for
inclusion in this review due to the following reasons: (1) two studies included males in their sample
but findings were not analysed by gender (Hawks, Merrill, & Madanat, 2004; Hawks et al., 2004); (2)
two studies were not published in a peer-reviewed publication (Banks, 2008; Nielson, 2009); and (3)
one study assessed mindful eating, not intuitive eating (Framson et al., 2009).
28
Figure 3.2. Flow diagram of included studies.
Methodological Quality of Studies
Quality assessment criteria were applied to each of the 24 studies. Authors
used the cut-off recommended by Kmet et al. (2004) for article inclusion. Studies
meeting at least 75 percent of criteria were included for review. All 24 studies met
the recommended cut-off. The summary score for each study according to relevant
criteria is presented in Table 3.1. While the summary score was useful in assessing
the eligibility of studies based on methodological quality, authors also reported the
strengths and weaknesses according to the relevant criteria that were common across
29
studies. Methodological strengths of studies included: describing study objectives
and participant characteristics; describing analyses and results in sufficient detail;
and appropriate conclusions that are drawn from the results. All 24 studies gained
full scores for these criteria. Methodological weaknesses that were common across
studies included: method of subject selection and possible measurement bias in the
use of self-report measures. A majority of studies used convenience sampling
methods, such as recruiting university students who were part of an existing research
pool (e.g., Brown et al., 2012), or undergraduate psychology students who received
class credit for their participation in the study (e.g., Avalos & Tylka, 2006; Kroon
Van Diest & Tylka, 2010; Tylka & Wilcox, 2006). One exception was Madden et al.
(2012), who randomly selected the sample from electoral rolls in New Zealand. All
studies used self-report measures to assess intuitive eating and psychosocial
correlates, including the use of individual items (e.g., Denny, Neumark-Sztainer,
Loth, & Eisenberg, 2013; Dittmann & Freedman, 2009; Madden et al., 2012).
Additionally, a proportion of studies did not consider confounding factors in their
study, such as participant characteristics. Seventeen of 24 studies considered at least
one participant characteristic in their analyses, including: age, ethnicity, gender, body
mass index, socioeconomic status, relationship status and level of education. Overall,
studies had more methodological strengths than weaknesses.
Summary of Included Studies
Table 3.1 provides a summary of each of the 24 cross-sectional studies that
assessed at least one psychosocial correlate of intuitive eating. The most frequently
used measure of intuitive eating was the 21-item IES-T (Tylka, 2006): nineteen of
the 24 studies assessed intuitive eating using this measure (Augustus-Horvath &
Tylka, 2011; Avalos & Tylka, 2006; Brown et al., 2012; Dittmann & Freedman,
30
2009; Galloway, Farrow, & Martz, 2010; Herbert, Blechert, Hautzinger, Matthias, &
Herbert, 2013; Homan & Cavanaugh, 2013; Iannantuono & Tylka, 2012; Kroon Van
Diest & Tylka, 2010; Madden et al., 2012; Oh et al., 2012; Schoenefeld & Webb,
2013; Shouse & Nilsson, 2011; Tylka, 2006; Tylka & Homan, 2015; Tylka &
Wilcox, 2006). The remaining five studies used either the revised 23-item IES-2
(Carbonneau, Carbonneau, Cantin, & Gagnon-Girouard, 2015; Tylka, Calogero, &
Danielsdottir, 2015; Tylka & Kroon Van Diest, 2013); the 27-item IES-H developed
by Hawks et al. (2004) (Gast et al., 2015); or two individual items from the Tylka’s
(2006) IES-T (Denny et al., 2013).
The majority of studies included predominantly university students (n=17).
Other studies included: university athletes (Oh et al., 2012); members of an online
community (Tylka et al., 2015); women involved in a heterosexual relationship
(Carbonneau et al., 2015); women aged 40 to 50 years (Madden et al., 2012); women
in their mid-twenties (Denny et al., 2013); three groups of women aged between 18
and 25, 26 and 39, and 40 and 65 years (Augustus-Horvath & Tylka, 2011); and
women who regularly practice yoga (Dittmann & Freedman, 2009). All studies
except for three were conducted in the United States. One of the exceptions was
conducted in New Zealand (Madden et al., 2012), one in Canada (Carbonneau et al.,
2015), and the other in Germany (Herbert et al., 2013). Nine of 21 papers (12 of 24
studies) included Tylka as an author.
31
Table 3.1
Summary of Cross-sectional Studies Examining Psychosocial Correlates of Intuitive Eating
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Augustus-
Horvath &
Tylka (2011)
United States
Participants:
emerging, early and
middle adult females
Mean age: emerging:
19.47 years (SD
1.90); early: 32.63
years (SD 4.06);
middle: 51.38 years
(SD 7.07)
Age range: 18-65
years
Ethnicity: Caucasian
82.4%, African
American 6.2%,
Other 11.4%
IES-T
(Tylka,
2006)
Body acceptance
by others
Body appreciation
Resistance in
adopting the
observer
perspective of the
body
Perceived social
support
Body Acceptance
by Others Scale
(Avalos & Tylka,
2006)
Body Appreciation
Scale (Avalos et al.,
2005)
Body Surveillance
subscale,
Objectified Body
Consciousness
Scale (McKinley &
Hyde, 1996)
IE positively associated with body
acceptance by others in emerging
(r=.43, p<.001), early (r=.50,
p<.001), and middle adulthood
(r=.45, p<.05).
IE positively related to body
appreciation in emerging (r=.60,
p<.001), early (r=.56, p<.001) and
middle adulthood (r=.60, p<.05).
IE positively associated with
resisting an observer perspective of
the body (r=.52, p<.001), early
(r=.53, p<.001, and middle
adulthood (r=.52, p<.05).
90.91
32
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Mean BMI:
emerging, 23.95
kg/m2; early, 25.55
kg/m2; middle, 28.86
kg/m2
Sample size: 801
(emerging, 318;
early, 238; middle,
245)
Study design: cross-
sectional
Social Provisions
Scale (Cutrona &
Russell, 1987)
IE positively related to perceived
social support for emerging (r=.24,
p<.001), early (r=.35, p<.001), and
middle (r=.23, p<.05) adulthood.
Avalos &
Tylka (2006)
United States
Study One:
Participants: female
university students
Mean age: 20.24
years (SD 5.17)
IES-T
(Tylka,
2006)
Body acceptance
by others
Body function
Body appreciation
Body Acceptance
by Others Scale
(Avalos & Tylka,
2006)
Body Surveillance
Subscale,
Objectified Body
Study One:
IE positively associated with body
acceptance by others (r=.45,
p<.001), body function, (r=.43,
p<.001) and body appreciation
(r=.58, p<.001), but not perceived
Study One:
90.00
33
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Age range: 17-55
years
Ethnicity: Caucasian
82.2%, African
American 5%, Other
12.8%
Sample size: 181
Study design/method:
cross-sectional
Study Two:
Participants: female
university students
Mean age: 19.92
years (SD 4.60)
Perceived
unconditional
acceptance from
others
Consciousness
Scale (McKinley &
Hyde, 1996)
Body Appreciation
Scale (Avalos et al.,
2005)
Barrett-Lennard
Relationship
Inventory (Claiborn
et al., 1983)
general unconditional acceptance
from others (r= .07, ns).
Study Two:
IE positively related to perceived
unconditional acceptance from
others (r=.19, p<.01), body
acceptance by others (r=.38,
p<.001), body function (r=.50,
<.001), and body appreciation
(r=.64, p<.001).
Study Two:
90.00
34
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Age range: 17-50
years
Ethnicity: Caucasian
American 77.6%,
African American
9.1%, Other 13.3%
Sample size: 416
Study design: cross-
sectional
Brown et al.
(2012)
United States
Participants: female
university students
Mean age: 19.2
years (SD 2.5)
Age range: 18-35
years
IES-T
(Tylka,
2006)
Self-oriented
perfectionism
Multidimensional
Perfectionism Scale
(Hewitt & Flett,
1991)
IE inversely associated with self-
oriented perfectionism (β =-.40,
p<.01)
85.00
35
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Ethnicity: Caucasian
66.7%, African
American 4.2%,
Asian 18.8%, Other
10.3%
Sample size: 48
Study design: cross-
sectional
Carbonneau
et al. (2015)
Participants: French-
Canadian women in
a heterosexual
relationship
Mean age: 29.86
years (SD 6.57)
Age range: 20-45
years
IES-2
(Tylka &
Kroon
Van
Diest,
2013)
Mother’s
interpersonal style
(autonomy-
supported,
controlling)
Partner’s
interpersonal style
(autonomy-
Perceived Parental
Autonomy Support
Scale (Mageau et
al., 2015)
The 6-item
autonomy support
subscale (Koestner
et al., 2012)
IE positively correlated with the
autonomy-supportive interpersonal
style of the mother (r=.23, p<.001)
but not the partner (r=.09, ns), and
negatively correlated with the
controlling interpersonal style of
the mother (r=-.27, p<.001) but not
the partner (r=-.09, ns).
UPE subscale positively correlated
with the autonomy-supportive
90.00
36
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Ethnicity: Caucasian
94.9%, Other 5.2%
Sample size: 272
Study design: cross-
sectional
supported,
controlling)
Eating regulation
(autonomous,
controlled)
Adapted version of
two scales to assess
partner’s
controlling
interpersonal style
(Bartholomew et
al., 2010; Moreau
& Mageau, 2012)
Regulation of
Eating Behaviors
Scale (Pelletier et
al., 2004).
interpersonal style of the mother
(r=.17, p<.01) but not the partner
(r=.12, ns), and negatively
correlated with the controlling
interpersonal style of the mother
(r=-.20, p<.01) but not the partner
(r=-.07, ns).
EPR Subscale positively correlated
with the autonomy-supportive
interpersonal style of the mother
(r=.16, p<.01) but not the partner
(r=.05, ns), and negatively
correlated with the controlling
interpersonal style of the mother
(r=-.23, p<.01) but not the partner
(r=-.06, ns).
RHSC subscale positively
correlated with the autonomy-
supportive interpersonal style of
37
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
the mother (r=.19, p<.01) but not
the partner (r=.00, ns), and
negatively correlated with the
controlling interpersonal style of
the mother (r=-.20, p<.01) but not
the partner (r=-.09, ns).
B-FCC subscale positively
correlated with the autonomy-
supportive interpersonal style of
the mother (r=.17, p<.01) and the
partner (r=.19, p<.01), but did not
correlate with the controlling
interpersonal style of the mother
(r=-.07, ns) or the partner (r=-.03,
ns).
IE positively correlated with
autonomous eating regulation
(r=.29, p<.001) and negatively
38
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
associated with controlled eating
regulation (r=-.47, p<.001).
UPE subscale negatively correlated
with both autonomous eating
regulation (r=-.15, p<.05) and
controlled eating regulation (r =-
.29, p<.001).
EPR subscale positively correlated
with autonomous eating regulation
(r =.20, p<.01) and negatively
associated with controlled eating
regulation (r =-.40, p<.001).
RHSC subscale positively
correlated with autonomous eating
regulation (r =.33, p<.001) and
negatively associated with
controlled eating regulation (r =-
.36, p<.001).
39
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
B-FCC subscale positively
correlated with autonomous eating
regulation (r =.58, p<.001) and
negatively associated with
controlled eating regulation (r =-
.24, p<.001).
Denny et al.
(2013)
United States
.
Participants: young
adult males and
females
Mean age (males and
females): 25.3 years
(SD 1.7)
Age range: not
reported
Ethnicity(females):
Caucasian 45.6%,
African American
Two
items
from IES-
T (Tylka,
2006)
Chronic dieting
Unhealthy weight
control practices
(fasting, starvation,
food supplement,
skipping meals,
smoking)
Extreme weight
control practices
(diet pills,
laxatives, diuretics)
One item each
assessing chronic
dieting, unhealthy
weight control, and
extreme weight
control practices
Two items
assessing binge
eating
Women who reported trusting their
body to tell them how much to eat
reported lower odds of chronic
dieting (OR = .58, 95% CI = [.38,
0.87], p<.05), unhealthy (OR= .55,
CI = [.41, .72], p<.05) and extreme
(OR = .62, CI = [.45, .85], p<.05)
weight control practices, and binge
eating (OR= .45, [.31, .65] , p<.05)
than women who did not trust their
body to tell them how much to eat
(controlled for ethnicity, socio-
economic status and BMI).
86.36
40
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
21.2%, Asian 18.8%,
Other 14.4%
Mean BMI: not
reported. Females
classified as normal
weight (n=630),
overweight (n=297),
obese (n=305)
Sample size: 2287
(females, n=1257)
Study design: cross-
sectional
Binge eating Women who reported that they
stopped eating when full reported
lower odds of chronic dieting (OR=
.62, CI = [.41, .95], p<.05) and
binge eating (OR = .34, CI = [.23,
.48], p<.05), but not unhealthy (OR
= .75, CI= [.55, 1.02], ns) or
extreme weight control practices
(OR = .81, CI= [.58, 1.14], ns)
(controlled for ethnicity, socio-
economic status and BMI).
Dittmann &
Freedman
(2009)
United States
Participants: females
who regularly
practice yoga
IES-T
(Tylka,
2006)
Body satisfaction
Body awareness
Body
responsiveness
Single item
assessing body
satisfaction
Observe subscale,
Five Facet
IE positively associated with body
satisfaction (r=.47, p<.01), body
awareness (r=.22, p<.01) and body
responsiveness (r=.415, p<.01), but
not spiritual readiness (r=.036, ns).
86.36
41
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Mean age: 47.4
years (SD 11.19)
Age range: 22-72
years
Ethnicity: majority
Caucasian
(proportion not
reported)
Mean BMI: 22.2
kg/m2
Sample size: 157
Study design: cross-
sectional
Spiritual readiness Mindfulness
Questionnaire (Baer
et al., 2006)
7-item scale
assessing body
responsiveness
(Daubenmier,
2005)
17-item scale
assessing spiritual
readiness
Galloway et
al. (2010)
Participants: male
and female
university students
IES-T
(Tylka,
2006)
Caregiver eating
messages (parent-
reported)
Child Feeding
Questionnaire for
Children (Carper et
UPE subscale not associated with
pressure to eat (r= -.08, ns),
restriction (r= -.05, ns), or
90.91
42
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
United States
Mean age(females):
18.5 years (SD .95)
Age range (males
and females): 17-23
years
Ethnicity (males and
females): Caucasian
96%, African
American 3%, Asian
American 1%
Sample size: 93
(females, n=71)
Study design: cross-
sectional
al., 2000), adapted
version completed
by parents.
monitoring (r= -.19, ns) caregiver
eating messages.
RHSC subscale were not
associated with pressure to eat (r=
.07, ns), restriction (r= -.03, ns), or
monitoring (r= -.17, ns) caregiver
eating messages.
EPR subscale inversely associated
with caregiver eating messages of
restriction (r= -.33, p<.01) and
monitoring (r=-.40, p<.01) but not
pressure to eat caregiver eating
messages (r=-.13, ns).
43
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Gast et al.
(2015)
United States
Participants: female
university students
Mean age: 19.58 (SD
2.42)
Age range: not
reported
Ethnicity: Caucasian
90%, Hispanic 4%,
Asian 3%, Other 4%
Mean BMI: 23.23
kg/m2
Underweight 6.5%,
Normal weight 69%,
Overweight 17.5%,
Obese 7%
Sample size: 200
IES-H
(Hawks et
al., 2004)
Motivation for
physical activity
(external pressure,
guilt or shame,
values physical
activity, feels
pleasure in physical
activity)
Behavioral
Regulation in
Exercise
Questionnaire
(Mullan et al.,
1997)
Total IES-H scores inversely
associated with external regulation
(β= -.008, p<.05) and introjected
regulation (β= -.04, p<.05), and
positively associated with intrinsic
regulation (β = .005, p<.05), but
not identified regulation (β =
.0001, ns).
Extrinsic subscale negatively
correlated with introjected
regulation (r= -.482, p<.0001) but
not external (r=-.141, ns),
identified (r=-.103, ns) or intrinsic
(r=.088, ns) regulation.
Antidieting subscale inversely
associated with external (r=-.348,
p<.0001) and introjected (r=-.563,
p<.0001) regulation, and positively
associated with intrinsic regulation
90.91
44
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Study design: cross-
sectional
(r=.206, p<.05) but did not
correlate with identified regulation
(r=-.07, ns).
Intrinsic subscale did not correlate
with any of the four regulation
types (p>.0003).
Self-care subscale correlated
negatively with introjected
regulation (r=-.227, p<.001) and
positively with identified
regulation (r=.291, p<.0001) and
intrinsic regulation (r=.433,
p<.0001), but not external
regulation (r=-.151, ns).
*Bonferroni adjustments applied to
correlations with IES subscales
(alpha level of .0003).
45
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Herbert et al.
(2013)
Germany
Participants: female
university students
Mean age: 25.4
years (SD 4.8)
Age range: not
reported
Ethnicity: not
reported
Mean BMI: 22.21
kg/m2
Sample size:111
Study design: cross-
sectional
IES-T
(Tylka,
2006)
State anxiety
Trait anxiety
State–Trait-Anxiety
Inventory
(Spielberger et al.,
1983)
IE total scores were not associated
with state anxiety (r= -.02, ns) or
trait anxiety (r= -.05, ns). IES-T
subscale scores were not associated
with state anxiety or trait anxiety
(p>.05).
90.00
46
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Homan &
Cavanaugh
(2013)
United States
Participants: female
undergraduate
students from a
Christian liberal arts
college.
Mean age: 20 (SD
0.88)
Age range: 18-22
years
Ethnicity: Caucasian
95.2%; Other 4.8%
Sample size: 104
Study design: cross-
sectional
IES-T
(Tylka,
2006)
Parent attachment
Anxious and
avoidant
attachment to God
Anxiety and
Avoidance
subscales,
Attachment to God
Inventory (Beck &
McDonald, 2004).
Parent Trust
subscale, Inventory
of Parent and Peer
Attachment
(Armsden &
Greenberg, 1987).
Intuitive eating negatively
associated with an anxious
attachment to God (r=-.30, p<.01).
After controlling for religious
service attendance, the relationship
remained significant (β= -.29,
p=.006).
Intuitive eating did not correlate
with an avoidant attachment to God
(r=-.07, ns) and was not
significantly associated with parent
attachment (r=.18, ns).
90.00
47
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Iannantuono
& Tylka
(2012)
United States
Participants: female
university students
Mean age: 19.1
years (SD 1.7)
Age range: 18-28
years
Ethnicity: Caucasian
86.3%, African
American 4.8%,
Other 8.9%
Mean BMI: 23.1
kg/m2
Sample size: 249
Study design: cross-
sectional
IES-T
(Tylka,
2006)
Body appreciation
Caregiver eating
messages
Adult attachment
Perfectionism
Depressive
symptomatology
Body Appreciation
Scale (Avalos et al.,
2005)
Caregiver Eating
Messages Scale
(Kroon Van Diest
& Tylka, 2010)
Experiences in
Close Relationships
Scale (Brennan et
al., 1998)
Almost Perfect
Scale-Revised
(Slaney et al., 2001)
IE positively related to body
appreciation (r=.58, p<.001) and
negatively associated with
depressive symptomatology (r=-
.35, p<.001), discrepancy
perfectionism (r=-.45, p<.001),
avoidant (r=-.22, p<.001) an
anxious attachment (r=-.43,
p<.001), and restrictive/critical
caregiver eating messages (r=-.40,
p<.001).
IE not associated with pressure to
eat caregiver eating messages (r=-
.11, ns), high standards
perfectionism (r=.03, ns) or order
perfectionism (r=.07, ns).
90.00
48
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Beck Depression
Inventory-II (Beck
et al., 1996)
Kroon Van
Diest &
Tylka (2010)
United States
Participants: male
and female
university students
Mean age (males and
females): 20.87 years
(SD 3.92)
Age range: 18-35
years
Ethnicity (males and
females): Caucasian
91.6%, African
American 2.5%,
Asian 2.5%, Other
3.4%
IES-T
(Tylka,
2006)
Caregiver eating
messages
Perceived body
acceptance by
family
Body appreciation
Caregiver Eating
Messages Scale
(Kroon Van Diest
& Tylka, 2010)
Body Acceptance
by Others Scale
(Avalos & Tylka,
2006)
Body Appreciation
Scale (Avalos et al.,
2005)
IE had a positive relationship with
perceived body acceptance by
family (r=.49, p<.05) and body
appreciation (r=.53, p<.05), and a
negative relationship with
restrictive/critical caregiver eating
messages (r=-.42, p<.05) in
females. IE did not correlate with
pressure to eat caregiver eating
messages (r=.01, ns).
90.91
49
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Mean BMI (females):
24.80 kg/m2
Sample size: 238
(females, n = 160)
Study design: cross-
sectional
Madden et al.
(2012)
New Zealand
Participants: mid-
age females
Mean age: 45.5
years (SD 3.2)
Age range: 40-50
years
Ethnicity: Caucasian
80.3%, Māori 11.4%,
Asian 5.3%, Pacific
3.0%
IES-T
(Tylka,
2006)
Binge eating One item assessing
frequency of binge
eating in the past
year
A one unit increase in IE was
associated with a 1.62% (CI 1.79,
1.46; p<.001) decrease in binge
eating frequency.
95.00
50
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Mean BMI: 25.8
kg/m2
Sample size: 1441
Study design: cross-
sectional
Oh et al.
(2012)
United States
Participants: Female
college athletes
Mean age:19.88
years (SD 1.91)
Age range: 18-23
years
Ethnicity: Caucasian
88.8%, African
American 4.4%,
Other 6.8%
IES-T
(Tylka,
2006)
Perceived
unconditional
acceptance from
significant others
Body acceptance
by others
Body function
Body appreciation
Barrett-Lennard
Relationship
Inventory (Barrett-
Lennard, 1962)
Body Acceptance
by Others Scale
(Avalos & Tylka,
2006)
Body Surveillance
subscale,
Objectified Body
Consciousness
After controlling for BMI, IE
positively associated with body
acceptance by others (r=.40,
p<.001), body function (r=.57,
p<.001) and body appreciation
(r=.48, p<.001), but not perceived
unconditional acceptance by others
(r=.12, ns).
90.00
51
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Sample size: 160
Study design: cross-
sectional
Scale (McKinley &
Hyde, 1996)
Body Appreciation
Scale (Avalos et al.,
2005)
Schoenefeld
& Webb
(2013)
United States
Participants: female
university students
Mean age: 19.48
years (SD 1.46)
Age range: 18-24
years
Ethnicity: Caucasian
67.4%, African
American 21.1%,
Other 11.5%
IES-T
(Tylka,
2006)
Self-compassion
Distress tolerance
Body image
flexibility
Self-esteem
Self-compassion
Scale (Neff, 2003)
Distress Tolerance
Scale (Simons &
Gaher, 2005)
Body Image-
Acceptance and
Action
Questionnaire
(Hayes et al., 1999)
IE correlated positively with self-
compassion (r=.39, p<.01), distress
tolerance (r=.21, p<.01), body
image flexibility (r=.69, p<.01),
and self-esteem (r=.40, p<01).
90.00
52
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Mean BMI 23.55
kg/m2
Sample size: 322
Study design: cross-
sectional
Rosenberg Self-
Esteem Scale
(Rosenberg, 1965)
Shouse &
Nilsson
(2011)
United States
Participants: female
university students
Mean age: 20.8
years (SD 1.9)
Age range: 18-24
years
Ethnicity: Caucasian
52%, African
American 36%,
Asian 4%, Other 8%
Sample size: 140
IES-T
(Tylka,
2006)
Self-silencing
Disordered eating
Emotional
awareness
Silencing the Self
Scale (Jack & Dill,
1996)
Eating Attitudes
Test-26 (Garner et
al, 1982)
Clarity of Feeling
subscale, Trait
Meta-Mood Scale
(Salovey et al.,
1995)
IE correlated negatively with self-
silencing (r=-.28, p<.01) and
disordered eating (r=-.58, p<.01),
and correlated positively with
emotional awareness (r=.19,
p<.05).
90.91
53
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Study design:
cross-sectional
Tylka (2006)
United States
Study One:
Participants: female
university students
Mean age: 20.85
years (SD 6.21)
Age range: 17-61
years
Ethnicity: Caucasian
87.7%, Asian 3.8%,
African American
3.1%, Other 5.4%
Sample size: 391
IES-T
(Tylka,
2006)
Study One:
Disordered eating
Body
dissatisfaction
Interoceptive
awareness
Pressure for
thinness from
significant others
Internalisation of
the thin-ideal
Study Two:
Eating Attitudes
Test-26 (Garner et
al., 1982)
Body
Dissatisfaction and
Interoceptive
Awareness
subscales, Eating
Disorder Iventory-2
(Garner, 1991)
Perceived
Sociocultural
Pressures Scale
(Stice, 1996)
Internalization
subscale,
Study One:
IE was negatively related to
disordered eating (r=-.66, p<.001),
body dissatisfaction (r=-.53,
p<.001), poor interoceptive
awareness (r=-.46, p<.001),
pressure for thinness (r=-.52,
p<.001) and internalisation of the
thin-ideal (r=-.47, p<.001).
UPE subscale negatively associated
with disordered eating (r= -.72,
p<.001), body dissatisfaction (r= -
.44, p<.001), poor interoceptive
awareness (r= -.31, p<.001),
pressure for thinness (r= -.41,
Study One:
90.00
54
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Study design: cross-
sectional
Study Two:
Participants: female
university students
Mean age: 19.70
years (SD 4.50)
Age range: 17-50
years
Ethnicity: Caucasian
86.2%, Asian 5.3%,
African American
3.9%, Other 4.5%
Sample size: 476
Self-esteem
Optimism
Proactive coping
Global life
satisfaction
Sociocultural
Attitudes Toward
Appearance
Questionnaire
(Heinberg et al.,
1995)
Rosenberg Self-
Esteem Scale
(Rosenberg, 1965)
Life Orientation
Test—Revised
(Scheier et al.,
1994)
Proactive Coping
subscale, Proactive
Coping Inventory
(Greenglass et al.,
1999)
p<.001), and internalisation of the
thin-ideal (r= -.41, p<.001).
EPR subscale negatively associated
with disordered eating (r=-.23,
p<.001), body dissatisfaction (r= -
.31, p<.001), poor interoceptive
awareness (r= -.41, p<.001),
pressure for thinness (r= -.37,
p<.001), and internalisation of the
thin-ideal (r= -.29, p<.001).
RHSC subscale negatively
associated with disordered eating
(r=-.27, p<.001), body
dissatisfaction (r= -.35, p<.001),
poor interoceptive awareness (r= -
.28, p<.001), pressure for thinness
(r= -.28, p<.001), and
55
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Study design: cross-
sectional
Satisfaction with
Life Scale (Diener
et al., 1985)
internalisation of the thin-ideal (r=
-.23, p<.001).
Study Two:
IE positively correlated with self-
esteem (r=.44, p<.001), optimism
(r=.29, p<.001), proactive coping
(r=.29, p<.001), and life
satisfaction (r=.41, p<.001).
EPR subscale positively related to
self-esteem (r= .28, p<.001),
optimism (r= .14, p<.01), and life
satisfaction (r=.26, p<.001) but not
proactive coping (r=.10, ns)
UPE positively related to self-
esteem (r= .36, p<.001), optimism
(r= .24, p<.001), proactive coping
Study Two:
90.00
56
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
(r=.27, p<.001) and life satisfaction
(r=.26, p<.001).
RHSC subscale positively related
to self-esteem (r= .35, p<.001),
optimism (r= .31, p<.001),
proactive coping (r=.34, p<.001)
and life satisfaction (r=.38,
p<.001).
Tylka et al.
(2015)
Participants: male
and female online
community
participants
Mean age (females):
35.01 years (SD
12.45)
Age range: 18-
63years
IES-2
(Tylka &
Kroon
Van
Diest,
2013)
Flexible control of
eating
Rigid control of
eating
Life satisfaction
Positive affect
Negative affect
Flexible Control
and Rigid Control
subscales,
Cognitive
Restraint Scale
(Westenhoefer et
al., 1999)
IE was negatively associated with
rigid control (r=-.51, p <.001) and
flexible control (r=-.27, p <.001) of
eating, negative affect (r=-.30, p
<.001), poor interoceptive
awareness (r=-.60, p <.001), binge
eating (r=-.68, p <.001), and food
preoccupation (r=-.65, p <.001).
IE was positively associated with
life satisfaction (r= .35, p<.001),
90.00
57
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Ethnicity (males and
females): Caucasian
71.9%, African
American 8.4%,
Asian 9.2%, Other
10.4%
Mean BMI (females):
26.82 kg/m2
Sample size: 382
(females, n = 192)
Study design: cross-
sectional
Body appreciation
Interoceptive
awareness
Binge eating
Food preoccupation
Satisfaction with
Life Scale (Diener
et al., 1985)
Positive and
Negative Affect
Schedule-Expanded
(Watson et al.,
1988)
Body Appreciation
Scale-2 (Tylka &
Wood- Barcalow,
2015)
Interoceptive
Awareness
subscale, Eating
Disorder Inventory-
2 (Garner, 1991)
positive affect (r= .29, p<.001),
and body appreciation (r= .64,
p<.001).
58
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Binge Eating Scale
(Gormally et al.,
1982)
Frequency
subscale, Food
Preoccupation
Questionnaire
(Tapper & Pothos,
2010)
Tylka &
Homan
(2015)
Participants: male
and female
undergraduate
university students
Mean age (females):
19.62 years (SD
2.87)
IES-T
(Tylka,
2006)
Body acceptance
by others
Internal body
orientation
Exercise motives
(functional,
appearance)
Body Acceptance
by Others Scale
(Avalos & Tylka,
2006)
Body Surveillance
subscale,
Objectified Body
Consciousness
IE correlated positively with body
acceptance by others (r= .28,
p<.001), internal body orientation
(r= .46, p<.001) and body
appreciation (r= .48, p<.001).
IE correlated negatively with
appearance exercise motives (r=-
.61, p <.001) but did not correlated
90.00
59
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Age range: 18-
47years
Ethnicity (males and
females): Caucasian
88.5%, African
American 5.2%,
Asian 2.0%, Other
4.2%
Mean BMI: females,
22.59 kg/m2
Sample size: 406
(females, n = 258)
Study design: cross-
sectional
Body appreciation
Scale (McKinley &
Hyde,1996)
The Function of
Exercise Scale
(DiBartolo et al.,
2007)
Body Appreciation
Scale (Avalos et al.,
2005)
with functional exercise motives
(r=.10, ns).
60
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Tylka &
Kroon Van
Diest (2013)
United States
Participants: male
and female
university students
Mean age (males and
females): 20.45 years
(SD 5.06)
Age range (males
and females): 18-53
years
Ethnicity: Caucasian
81.7%, African
American 5.5%,
Asian 3.5%, Other
9.3%
Mean BMI
(females):24.02
kg/m2
IES-2
(Tylka &
Kroon
Van
Diest,
2013)
Disordered eating
Interoceptive
awareness
Body appreciation
Body surveillance
Body shame
Internalisation of
thin media ideal
Self-esteem
Positive and
Negative affect
Global life
satisfaction
Eating Attitudes
Test–26 (Garner et
al., 1982)
Interoceptive
Awareness
subscale, Eating
Disorder Inventory-
2 (Garner, 1991)
Body Appreciation
Scale (Avalos et al.,
2005)
Body Surveillance
and Body Shame
subscales,
Objectified Body
Consciousness
IE negatively associated with
disordered eating (r=-.50, p<.001),
body surveillance (r=-.36, p<.001),
body shame (r=-.56, p<.001),
internalisation (r=-.37, p<.001),
poor interoceptive awareness (r=-
.35, p<.001), and negative affect
(r=-.36, p<.001).
EPR subscale negatively related to
disordered eating (r=-.20, p<.001),
body surveillance (r=-.25, p<.001),
body shame (r=-.35, p<.001),
internalisation (r=-.30, p<.001),
poor interoceptive awareness (r=-
.28, p<.001), and negative affect
(r=-.31, p<.001).
UPE subscale negatively related to
disordered eating (r=-.68, p<.001),
body surveillance (r=-.26, p<.001),
90.91
61
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Sample size: 1200
(females, n=680)
Study design: cross-
sectional
Scale (McKinley &
Hyde, 1996)
Internalization
subscale,
Sociocultural
Attitudes Toward
Appearance
Questionnaire–
Revised (Heinberg
et al., 1995)
Rosenberg Self-
Esteem Scale
(Rosenberg, 1965)
Positive and
Negative Affect
Schedule–
Expanded (Watson
et al., 1988)
body shame (r=-.52, p<.001),
internalisation (r=-.30, p<.001),
poor interoceptive awareness (r=-
.17, p<.001), and negative affect
(r=-.15, p<.001).
RHSC subscale negatively related
to disordered eating (r=-.37,
p<.001), body surveillance (r=-.24,
p<.001), body shame (r=-.39,
p<.001), internalisation (r=-.22,
p<.001), poor interoceptive
awareness (r=-.24, p<.001), and
negative affect (r=-.21, p<.001).
B-FCC subscale negatively related
to body surveillance (r=-.19,
p<.001), internalisation (r= -.13,
p<.001), poor interoceptive
awareness (r=-.13, p<.001), and
negative affect (r=-.19, p<.001) but
62
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Satisfaction with
Life Scale (Diener
et al., 1985)
not disordered eating (r=.05, ns) or
body shame (r=-.08, ns).
IE positively associated with body
appreciation (r=.52, p<.001), self-
esteem (r=.41, p<.001), positive
affect (r=.26, p<.001), and life
satisfaction (r=.33, p<.001).
EPR subscale positively associated
with body appreciation (r=.32,
p<.001), self-esteem (r=.26,
p<.001), positive affect (r=.18,
p<.001), and life satisfaction
(r=.28, p<.001).
UPE subscale positively associated
with body appreciation (r=.33,
p<.001), self-esteem (r=.27,
p<.001), but not positive affect
63
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
(r=.00, ns), or life satisfaction
(r=.12, ns).
RHSC subscale positively
associated with body appreciation
(r=.40, p<.001), self-esteem (r=.30,
p<.001), positive affect (r=.22,
p<.001), and life satisfaction
(r=.21, p<.001).
B-FCC subscale positively
associated with body appreciation
(r=.29, p<.001), self-esteem (r=.22,
p<.001), positive affect (r=.37,
p<.001), and life satisfaction
(r=.18, p<.001)
64
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Tylka &
Wilcox
(2006)
United States
Study One:
Participants:
female university
students
Mean age: 18.44
years (SD 1.02)
Age range: 17-30
years
Ethnicity: Caucasian
85.9%, Asian 5.0%,
African American
5.3%, Other 3.8%
Sample size: 388
Study design: cross-
sectional
IES-T
(Tylka,
2006)
Study One:
Disordered eating
(dieting,
bulimia/food
preoccupation)
Positive affect
Self-esteem
Proactive coping
Study Two:
Unconditional self-
regard
Psychological
hardiness
Study One:
Dieting and
Bulimia/food
preoccupation
subscales, Eating
Attitudes Test–26
(Garner et al.,
1982)
Positive Affect
subscale of Positive
and Negative
Affect Schedule-
Expanded (Watson
et al., 1988)
Rosenberg Self-
Esteem Scale
(Rosenberg, 1965)
Study One:
UPE negatively associated with
dieting (r=-.67, p<.001) and
bulimia/food preoccupation (r= -
40, p<.001).
EPR negatively associated with
dieting (r=-.13, p<.05) and
bulimia/food preoccupation (r=-
.26, p<.001).
RHSC negatively associated with
dieting (r= -.35, p<.001) and
bulimia/food preoccupation (r=-
.36, p<.001).
UPE positively associated with
self-esteem (r=.23, p<.001) and
proactive coping (r=.11, p<.05) but
not positive affect (r=.03, ns).
Study One:
90.00
65
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Study Two:
Participants: female
university students
Mean age: 18.72
years (SD 2.44)
Age range: 17-55
years
Ethnicity: Caucasian
81.6%, African
American 8.3%,
Asian 4.3%, Other
5.8%
Sample size: 396
Study design: cross-
sectional
Social problem-
solving
Proactive Coping
subscale of the
Proactive Coping
Inventory
(Greenglass et al.,
1999)
Study Two:
Life Orientation
Test-Revised
(Scheier et al.,
1994)
Unconditional Self-
Regard Scale (Betz
et al., 1995)
Psychological
Hardiness Scale-
EPR positively related to positive
affect (r=.25, p<.001), self-esteem
(r=.30, p<.001) and proactive
coping (r=.26, p<.001).
RHSC positively related to positive
affect (r=.33, p<.001), self-esteem
(r=.34, p<.001) and proactive
coping (r=.33, p<.001).
Study Two:
UPE negatively associated with
dieting (r=-.73, p<.001) and
bulimia/food preoccupation (r=-
.36, p<.001).
EPR negatively associated with
dieting (r=-.21, p<.001) and
bulimia/food preoccupation (r=-
.37, p<.001).
Study Two:
90.00
66
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
Short Form (Betz &
Campbell, 2003)
Social Problem
Solving Inventory-
Revised (D’Zurilla
et al., 1997)
RHSC negatively associated with
dieting (r=-.26, p<.001) and
bulimia/food preoccupation (r=-
.30, p<.001).
UPE positively related to optimism
(r=.10, p<.05), unconditional self-
regard (r=.24, p<.001), and
psychological hardiness (r=.11,
p<.05), but not social problem
solving (r=-.01, ns).
EPR positively associated with
optimism (r=.25, p<.001),
unconditional self-regard (r=.28,
p<.001), psychological hardiness
(r=.34, p<.001), and social problem
solving (r=.30, p<.001).
RHSC subscale had a positive
relationship with optimism (r=.24,
67
Reference
Country
Participant
characteristics
Study design
Measure
of
intuitive
eating
Psychosocial
correlate(s)
Measure(s) of
psychosocial
correlate(s)
Main findings Quality
Assessment
Sore (%)
p<.001), unconditional self-regard
(r=.32, p<.001), psychological
hardiness (r=.25, p<.001) and
social problem solving (r=.23,
p<.001).
Note. IE = intuitive eating; IES-T = Intuitive Eating Scale (Tylka, 2006); IES-H = Intuitive Eating Scale (Hawks et al., 2004); IES-2 = Intuitive Eating
Scale-2 (Tylka & Kroon Van Diest, 2013); EPR = Eating for Physical Reasons; UPE = Unconditional Permission to Eat; RHSC = Reliance on
Hunger/Satiety Cues; B-FCC = Body–Food Choice Congruence; BMI = Body Mass Index; ns = non-significant correlation.
68
The correlates of intuitive eating in each of the 24 studies were categorised as
follows: eating attitudes and behaviours; body image; emotional functioning; and
other psychosocial correlates.
Eating Attitudes and Behaviours
Eight of the 24 studies examined intuitive eating in relation to other eating
attitudes and behaviours (Denny et al., 2013; Madden et al., 2012; Shouse & Nilsson,
2011; Tylka, 2006; Tylka & Kroon Van Diest, 2013; Tylka & Wilcox, 2006). This
included disordered eating symptomatology, restrained eating and dieting, eating
regulation, and other weight loss practices. Three studies (Shouse & Nilsson, 2011;
Tylka, 2006; Tylka & Kroon Van Diest, 2013) used all three subscales of the Eating
Attitudes Test-26 (EAT-26; Garner et al., 1982); two studies used two subscales of
the EAT-26 (Tylka & Wilcox, 2006); one study (Tylka et al., 2015) assessed binge
eating and food preoccupation using The Binge Eating Scale (Gormally, Black,
Daston, & Rardin,1982) and a subscale from the Food Preoccupation Questionnaire
(Tapper & Pothos, 2010); and one study (Carbonneau et al., 2015) used the
Regulation of Eating Behaviors Scale (Pelletier, Dion, Slovinec-D’Angelo, & Reid,
2004) to assess regulation of eating. The remaining two studies used one or two
individual items to assess binge eating (Denny et al., 2013; Madden et al., 2012),
dieting, and unhealthy or extreme weight loss practices (Denny et al., 2013).
Studies demonstrated that intuitive eating was inversely associated with
disordered eating symptomatology, according to total scores on the EAT-26 (Shouse
& Nilsson, 2011; Tylka, 2006, Tylka & Kroon Van Diest, 2013), and correlated
negatively with bulimia and food preoccupation (Tylka et al., 2015; Tylka & Wilcox,
2006), binge eating behaviours (Denny et al., 2013; Madden et al., 2012; Tylka et al.,
2015), and dieting (Denny et al., 2013; Tylka & Wilcox, 2006). Additionally,
69
intuitive eating was negatively associated with two forms of restrained eating: rigid
control (an “all-or-nothing” approach to eating) and flexible control (a more balanced
approach to managing food intake) (Tylka et al., 2015). Correlations between
intuitive eating and disordered eating, including restrained eating and dieting, ranged
from -.50 to -.68 in size.
Studies examining individual subscales of the IES-T (Tylka, 2006; Tylka &
Kroon Van Diest, 2013; Tylka & Wilcox, 2006) demonstrated relationships
consistent with the overall scale for disordered eating and dieting (Tylka, 2006;
Tylka & Wilcox, 2006). An exception was Tylka and Kroon Van Diest (2013), who
found no association between the Body-Food Choice Congruence subscale of the
revised IES-T (assesses the extent to which individuals match food choice with the
body’s needs) and disordered eating among university students. In addition, Denny
and colleagues (2013) showed that women who trusted their body to tell them how
much to eat reported that they were less likely to engage in unhealthy weight loss
practices (i.e. fasting, starvation, food supplementation, skipping meals, smoking)
and extreme weight loss practices (i.e., diet pills, laxatives and diuretics). However,
there was no difference in the likelihood of engaging in these behaviours between
women who did or did not stop eating when experiencing fullness. Correlations
between intuitive eating subscales and disordered eating, including dieting, ranged
from -.13 to -.73. Correlations between the Unconditional Permission to Eat subscale
and disordered eating ranged from -.36 to -.73. Lower correlations were found
between the Eating for Physical Reasons subscale and disordered eating (ranged
from -.13 to -.37), and between the Reliance on Hunger/Satiety Cues subscale and
disordered eating (ranged from -.23 to -.37).
70
Carbonneau and colleagues (2015) investigated intuitive eating and its
association with two forms of regulated eating: autonomous (self-determined or
feeling empowered towards eating choices) and controlled (feeling pressured or
controlled in eating choices). Examples of items were “…because I take pleasure in
fixing healthy meals” (autonomous regulation) and “…because I would feel ashamed
of myself if I was not eating healthy” (controlled regulation) (Carbonneau et al.,
2015). Intuitive eating was positively associated with autonomous regulation and
negatively associated with controlled regulation. Further examination of the
subscales of the revised IES-T showed that three of the four subscales reported
correlations consistent with the overall scale. The exception was Unconditional
Permission to Eat subscale, which was inversely associated with both forms of eating
regulation.
Body Image
Eleven studies examined the relationship between intuitive eating and body
image. Body appreciation, the extent to which one has a favourable attitude and
treatment of one’s body, regardless of perceived appearance-related flaws, was
examined in eight studies (Augustus-Horvath & Tylka, 2011; Avalos & Tylka, 2006;
Iannantuono & Tylka, 2012; Kroon Van Diest & Tylka, 2010; Oh et al., 2012; Tylka
et al., 2015; Tylka & Homan, 2015; Tylka & Kroon Van Diest, 2013). All studies
used the 13-item Body Appreciation Scale (Avalos et al., 2005) or the revised 10-
item scale (Tylka & Wood-Barcalow, 2015). Intuitive eating correlated with body
appreciation in a positive direction in all eight studies, and was consistent for total
scores and subscale scores of intuitive eating (Tylka & Kroon Van Diest, 2013),
across three different age groups (Augustus-Horvath & Tylka, 2011), and after
controlling for BMI (Oh et al., 2012).
71
Body satisfaction or dissatisfaction (the overall evaluation of one’s body size,
shape or appearance) was examined in two studies (Dittmann & Freedman, 2009;
Tylka, 2006). Dittmann and Freedman (2009) used a single item to assess body
satisfaction, while Tylka (2006) assessed body dissatisfaction using a subscale of the
Eating Disorder Inventory (EDI-2; Garner, 1991). Both studies demonstrated that
eating more intuitively was associated with greater body satisfaction (Dittmann &
Freedman, 2009; Tylka, 2006). Tylka (2006) also demonstrated that this relationship
was consistent when examining subscales of the IES-T.
Body surveillance (adopting an observer perspective of the body, or
habitually monitoring appearance), body function or an internal body orientation (a
focus on how the body functions and feels rather than appearance) were examined in
five studies (Augustus-Horvath & Tylka, 2011; Avalos & Tylka, 2006; Oh et al.,
2012; Tylka & Homan, 2015; Tylka & Kroon Van Diest, 2013) using the Body
Surveillance subscale of the Objectified Body Consciousness Scale (McKinley &
Hyde, 1996). Higher levels of intuitive eating correlated with greater resistance in
adopting an observer’s perspective of the body, according to total (Augustus-Horvath
& Tylka, 2011, Tylka & Kroon Van Diest, 2013) and subscale intuitive eating scores
(Tylka & Kroon Van Diest, 2013). In addition, intuitive eating correlated with a
greater focus on body function and feeling rather than appearance (Avalos & Tylka,
2006; Oh et al., 2012; Tylka & Homan, 2015). Body image flexibility, described as
the degree to which one accepts thoughts and feelings about the body, was examined
by Schoenefeld and Webb (2013). Intuitive eating correlated with body image
flexibility in a positive direction. Overall, correlations between total scores of
intuitive eating and positive aspects of body image ranged from .43 to .69.
Correlations for negative aspects of body image ranged between -.36 to -.56.
Correlations between subscales of the IES-T and negative aspects of body image
72
ranged from -.26 to -.52 for the Unconditional Permission to Eat subscale, -.25 to -
.35 for the Eating for Physical Reasons subscale, and -.24 to -.39 for the Reliance on
Hunger/Satiety Cues subscale. Correlations between IES-T subscales and positive
aspects of body image ranged from .29 to .40, with the Reliance on Hunger/Satiety
Cues reporting the largest correlation.
Emotional Functioning
Seven studies examined aspects of emotional functioning (Herbert et al.,
2013; Iannantuono & Tylka, 2012; Schoenefeld & Webb, 2013; Shouse & Nilsson,
2011; Tylka et al., 2015; Tylka & Kroon Van Diest, 2013; Tylka & Wilcox, 2006),
including affect, mood and the management of emotions. Intuitive eating was
inversely associated with negative affect, for both total and subscale scores of the
revised IES-T (Tylka et al., 2015; Tylka & Kroon Van Diest, 2013), and depressive
symptomatology (Iannantuono & Tylka, 2012). However, intuitive eating did not
correlate with levels of state and trait anxiety, according to both total and subscale
scores of the IES-T, among German university students (Herbert et al., 2013).
Positive affect was examined in three studies (Tylka et al., 2015; Tylka & Kroon Van
Diest, 2013; Tylka & Wilcox, 2006), each of which demonstrated a positive
association between intuitive eating and positive affect. Subscale scores for intuitive
eating were also assessed in two of three studies. Positive affect correlated with
higher scores on all subscales, except the Unconditional Permission to Eat subscale
(Tylka & Kroon Van Diest, 2013; Tylka & Wilcox, 2006).
In addition to aspects of affect and mood, two studies examined the
management of emotions in university students (Schoenefeld & Webb, 2013; Shouse
& Nilsson, 2011). Shouse and Nilsson (2011) demonstrated that higher levels of
intuitive eating were associated with greater emotional awareness and less self-
73
silencing of emotions. Schoenefeld and Webb (2013) found a positive association
between intuitive eating and distress tolerance. Correlations between total intuitive
eating scores and positive emotional functioning ranged from .21 to .29 in size.
Correlations between total intuitive eating scores and negative emotional functioning
ranged from -.28 to -.36 in size. Correlations between each subscale of the IES-T and
emotional functioning were similar, except for the Unconditional Permission to Eat
subscale, which did not correlate with positive affect. Correlations for the two
remaining subscales of the IES-T ranged from -.15 to -.31 for negative emotional
functioning and .18 to .33 for positive emotional functioning.
Other Psychosocial Correlates
Twenty studies examined the association between intuitive eating and one or
more psychosocial correlates that could not be categorised into eating attitudes and
behaviours, body image or emotional functioning. Five studies (Augustus-Horvath &
Tylka, 2011; Avalos & Tylka, 2006; Kroon Van Diest & Tylka, 2010; Oh et al.,
2012; Tylka & Homan, 2015) assessed the perceived acceptance of weight and shape
by others using the 10-item Body Acceptance by Others Scale (Avalos & Tylka,
2006). Intuitive eating was associated with greater body acceptance by others among
women aged 18 to 65 years (Augustus-Horvath & Tylka, 2011), female university
athletes (Oh et al., 2012) and physically active university students (Tylka & Homan,
2015), and undergraduate psychology students (Avalos & Tylka, 2006; Kroon Van
Diest & Tylka, 2010).
Three studies examined women’s (Iannantuono & Tylka, 2012; Kroon Van
Diest & Tylka, 2010) or their parent’s (Galloway et al., 2010) retrospective reports of
eating messages delivered by caregivers. Findings were dependent on the type of
eating message. Two studies showed intuitive eating was negatively associated with
74
restrictive or critical messages (Iannantuono & Tylka, 2012; Kroon Van Diest &
Tylka, 2010). Galloway and colleagues (2010) reported an inverse correlation
between the Eating for Physical Reasons subscale of Tylka’s IES-T (2006) and
messages relating to the restriction and monitoring of food intake, however, no
association was found for remaining IES-T subscales with caregiver messages of
restriction or monitoring of food intake. No association was found for intuitive eating
and pressure to eat messages from caregivers in both studies which examined this
type of message (Galloway et al., 2010; Iannantuono & Tylka, 2012).
Other factors shown to correlate with higher levels of intuitive eating
included self-esteem (Schoenefeld & Webb, 2013; Tylka, 2006; Tylka & Kroon Van
Diest, 2013; Tylka & Wilcox, 2006), self-compassion (Schoenefeld & Webb, 2013),
unconditional self-regard (Tylka & Wilcox, 2006), responsiveness to internal bodily
sensations (Dittmann & Freedman, 2009), greater life satisfaction (Tylka, 2006;
Tylka et al., 2015; Tylka & Kroon Van Diest, 2013), optimism (Tylka, 2006; Tylka
& Wilcox, 2006), an autonomy-supportive interpersonal style of a woman’s mother
with regards to eating behaviours (Carbonneau et al., 2015) and perceived social
support (Augustus-Horvath & Tylka, 2011). Studies have also shown that intuitive
eating correlates positively with proactive coping (Tylka, 2006; Tylka & Wilcox,
2006), psychological hardiness, and social problem solving (Tylka & Wilcox, 2006).
The three studies that assessed individual subscales of the original and revised IES-T
demonstrated relationships consistent with the total scale, except the Unconditional
Permission to Eat subscale did not correlate with the life satisfaction (Tylka & Kroon
Van Diest, 2013), proactive coping (Tylka, 2006), or social problem solving (Tylka
& Wilcox, 2006).
75
In addition, studies demonstrated that total and subscale scores of intuitive
eating correlated negatively with internalisation of the thin ideal (Tylka, 2006; Tylka
& Kroon Van Diest, 2013), pressure for thinness from others (Tylka, 2006), and poor
interoceptive awareness (Tylka, 2006; Tylka et al., 2015; Tylka & Kroon Van Diest,
2013). Eating intuitively also correlated negatively with a controlling interpersonal
style of a woman’s mother, in terms of eating behaviour (Carbonneau et al., 2015),
and attachment style and perfectionistic traits, including: an anxious or avoidant
attachment style (Iannantuono & Tylka, 2012), an anxious or insecure attachment to
God (Homan et al., 2013), self-oriented perfectionism (applying unrealistic standards
and scrutiny to one’s self) (Brown et al., 2012) and discrepancy perfectionism
(perceiving a discrepancy between self-imposed standards and performance)
(Iannantuono & Tylka, 2012).
Two studies examined intuitive eating in relation to motivation for physical
activity. Gast and colleagues (2015) examined four types of motivation using the
IES-H (Hawks et al., 2004). Total intuitive eating scores correlated negatively with
motivation based on external pressures and feelings of guilt or shame, and correlated
in a positive direction with motivation based on feelings of pleasure. Findings varied
when subscales of the IES-H were examined. Only one of four IES-H subscales
correlated negatively with motivation for physical activity based on external
pressures (Antidieting subscale); three of four subscales correlated negatively with
motivation based on feelings of guilt or shame (Extrinsic eating, Antidieting and
Self-care subscales); and only two of four subscales (Antidieting, Self-care
subscales) positively correlated with motivation based on feelings of pleasure. Tylka
and Homan (2015) used the IES-T to examine intuitive eating in relation to exercise
motivation in physically active university students. Total intuitive eating scores were
76
inversely associated with motivation to exercise based on appearance-related
reasons.
Factors that did not correlate with intuitive eating included: high standards
perfectionism (setting goals that are realistic, motivating and encouraging), order
perfectionism (a focus on organisation and order) (Iannantuono & Tylka, 2012),
spiritual readiness (Dittmann & Freedman, 2009), an avoidant attachment to God and
trust in parental relationships (Homan et al., 2013), and the interpersonal style of a
woman’s partner with regards to eating behaviour (autonomous-supportive or a
controlling interpersonal style) (Carbonneau et al., 2015). In addition, total scores of
intuitive eating did not correlate with physical activity motivation based on the value
placed on physical activity (Gast et al., 2015) or for functional reasons (Tylka &
Homan, 2015), and did not correlate with unconditional acceptance by others in
university athletes (Oh et al., 2012) or in one of the two student samples examined by
Avalos and Tylka (2006).
Discussion
The aim of this paper was to systematically review the literature on intuitive
eating and its relationship with other eating attitudes and behaviours, body image and
emotional functioning, in adult women. In addition, this review systematically
examined other psychosocial correlates that have been examined in relation to
intuitive eating. This review has furthered our understanding of intuitive eating and
highlighted areas that require additional research.
Intuitive eating is viewed as promoting a healthy relationship with food by
discouraging restrictive eating, emotional eating, and eating in response to external
cues (Tribole & Resch, 2012). More specifically, intuitive eating is viewed as
promoting eating in response to bodily cues for hunger and satiety and permits
77
women to eat unconditionally, thus removing rules for what, when and how much to
eat. On the whole, the findings of this review showed that intuitive eating, when
assessed with total scores, was inversely related to disordered eating and dieting,
with moderate to high correlations. However, it is also important to consider the
intuitive eating subscales. This review showed that in all three studies that examined
the IES-T subscales, the Unconditional Permission to Eat subscale demonstrated the
highest correlation with disordered eating (Tylka, 2006; Tylka & Kroon Van Diest,
2013; Tylka & Wilcox, 2006), thus suggesting that this feature of intuitive eating is
less conceptually distinct from disordered eating (Tylka & Kroon Van Diest, 2013;
Tylka & Wilcox, 2006). The Eating for Physical Reasons subscale and the Reliance
on Hunger/Satiety Cues subscale demonstrated small to medium correlations with
disordered eating, while the Body-Food Choice Congruence subscale was unrelated
with disordered eating, thus suggesting that these three aspects of intuitive eating are
more conceptually distinct from disordered eating. Studies which examine the factor
structure of the IES-T in relation to measures of disordered eating are now needed to
more fully address this question.
Research is also emerging that supports intuitive eating as an effective
intervention for reducing dieting attitudes and behaviours. For example, a 15-week
classroom-based program that encouraged hunger-based eating led to a decrease in
dieting in college females (Hawks, Madanat, Smith & De La Cruz, 2008); and a 10-
week group-based program that promoted the ten principles of intuitive eating (as
proposed by Tribole & Resch, 1995) reduced dieting attitudes in female military
spouses (Cole & Horacek, 2010). A review by Schaefer and Magnuson (2014) has
shown interventions that have implemented intuitive eating principles reduced
disordered eating practices such as dieting, disinhibited eating and binge eating.
78
There is limited research on intuitive eating and its association with other
eating patterns in adult women, such as emotional eating and external eating.
Emotional eating describes eating in response to negative emotions and external
eating describes eating in response to food-related cues (Van Strien et al., 1986).
None of the 24 studies examined in this systematic review investigated these eating
patterns. One study that was ineligible for inclusion in this review, due to the
inclusion of males in the sample and not analysing findings by gender, examined
intuitive eating in relation to emotional eating and uncontrolled eating (i.e. loss of
control over food intake that results in overeating) in a sample of French adults
(Camilleri et al., 2015). Total intuitive eating scores were moderately to strongly and
inversely correlated with both the emotional eating and uncontrolled eating subscales
of the revised Three Factor Eating Questionnaire (Tholin, Rasmussen, Tynelius, &
Karlsson, 2005). However, findings varied when examining the intuitive eating
subscales, thus again highlighting the importance of using the subscales and not
relying exclusively on the total scores. The Unconditional Permission to Eat subscale
did not correlate with uncontrolled eating and showed a weak correlation with
emotional eating; the Reliance on Hunger/Satiety Cues subscale was weakly
correlated with both emotional and uncontrolled eating; but the Eating for Physical
Reasons subscale correlated strongly with both emotional and uncontrolled eating
(Camilleri et al. 2015). Further studies, using the subscales of the IES-T, are needed
to investigate these relationships, given intuitive eating is hypothesised to discourage
eating based on non-physiological cues and eating to regulate emotions.
This review further showed that intuitive eating correlated with aspects of
positive body image such as body appreciation and body satisfaction; and other
psychosocial factors associated with body image in women, such as self-esteem,
perceived acceptance of weight and shape by others, pressure for thinness, and
79
internalisation of the thin-ideal (e.g., Green & Pritchard, 2003; Lewis & Cachelin,
2001; Lowery et al., 2005; Tylka & Hill, 2004; Webster & Tiggemann, 2003). This
contrasts with research that shows that disordered eating practices, which are often
employed for the purpose of modifying weight and shape to improve appearance
(O’Brien et al., 2007; Putterman & Linden, 2004), are associated with greater weight
and shape concerns in women (Quick & Byrd-Bredbenner, 2012) and greater body
dissatisfaction (Putterman & Linden, 2004). Intuitive eating is viewed as promoting
respect and care of the body, realistic expectations of body size, and discourages
women from making body comparisons and engaging in negative self-talk about
body size and shape (Tribole & Resch, 2012).
Non-dieting approaches (Clifford et al., 2015) and interventions that promote
principles of intuitive eating (i.e., eating based on internal cues of hunger and satiety)
(Schaefer & Magnuson, 2014) have demonstrated improvements in body image,
including: reduced weight concerns and increased perceived sexual attractiveness
(Hawks et al., 2008), and improvements in body image avoidance and body
dissatisfaction (Bacon et al., 2002; Bacon et al., 2005; Jackson, 2008). In addition,
these interventions have also reduced the drive for thinness and internalisation of the
thin-ideal (Schaefer & Magnuson, 2014).
This review also showed that intuitive eating correlated with positive
emotional functioning in women. This is consistent with not using food to cope with
emotions, another principle of intuitive eating (Tribole & Resch, 2012). This
contrasts with research demonstrating that restrictive and disordered eating practices
are associated with depressive symptomatology and poor emotional regulation
(Ackard, Croll & Kearney-Cooke, 2002; Gillen, Markey & Markey, 2012). In
intuitive eating, emphasis is placed on being able to distinguish between biological
80
and emotional hunger and regulate emotions with alternative strategies. In our view,
it is also possible that the relationship between intuitive eating and emotional
functioning may be bidirectional, that is, women may eat more intuitively in the
absence of negative emotions but they may also experience more positive emotions
as a consequence of intuitive eating. Studies are now needed to test this hypothesis.
Other psychosocial correlates of intuitive eating that were found in this
review included the awareness and responsiveness of women towards bodily states
(e.g., sensations, emotions, hunger and satiety) and motivation to engage in physical
activity. Greater awareness and responsiveness to bodily states is related to the
feature of intuitive eating that focuses on eating based on internal cues for
hunger/satiety (Tribole & Resch, 2012). In addition, intuitive eating encourages an
attitude towards physical activity that is not focused on calorie-burning for weight
control. Instead, the approach is focused on the body’s response to exercise and the
enjoyment of being physically active (Tribole & Resch, 2012). In line with this
principle, studies showed that intuitive eating correlated with greater motivation to
engage in physical activity when focused on feelings of pleasure (Gast et al., 2015),
and less motivation when focused on feelings of pressure or guilt (Gast et al., 2015)
or appearance (Tylka & Homan, 2015).
Limitations and Recommendations for Future Research
A limitation of the reviewed studies is that all studies used a cross-sectional
design. Thus, no conclusion about the cause-effect relationship between intuitive
eating and psychosocial correlates is possible. Prospective studies with a range of
follow up intervals are needed to verify these cross-sectional findings. This would
allow an examination of intuitive eating and these correlates over time to assess if
intuitive eating is an approach that may improve women’s psychological health and
81
well-being. Studies that have examined other eating behaviours, such as disordered
eating, have included follow up intervals as short as five and a half months (Lowe et
al., 2013) to nine months (Stice, 2002), and longer term intervals from two to 10
years (e.g., Goldschmidt et al., 2012; Skinner, Haines, Austin, & Field, 2012;
Sonneville et al., 2013)
Studies were also limited with regards to sample characteristics. This review
showed that intuitive eating has been examined primarily among female university
students, who reported their ethnicity as Caucasian and lived in the United States.
The sample size of some studies was also small. For example, Brown et al.’s (2012)
study included 48 female university students and Galloway et al.’s (2010) study
included 71 female university students. It is recommended that future studies
examine more diverse samples of adult women with a focus on different age and
ethnic groups, level of education, and socioeconomic status. It also needs to be noted
that 12 of 24 studies of studies included Tylka as an author. However, a comparison
of findings between Tylka’s studies and the remaining 12 reviewed studies showed
similar findings.
Only one of 24 studies (Gast et al., 2015) used the intuitive eating measure
developed by Hawks et al. (2004). There have been no studies directly comparing the
two different measures of intuitive eating (the IES-T and IES-H). However, the IES-
H has demonstrated lower internal consistency than Tylka’s IES-T (2006). Also,
some subscales of the IES-H (Hawks et al., 2004) have been found to demonstrate
inadequate or low Cronbach’s coefficient alphas (e.g., .22 to .43 for Intrinsic Eating
and .49 to .68 for Self-care) (e.g., Gast et al., 2015; Hawks et al., 2004; Hawks,
Merrill, Madanat, & Miyagawa, Suwanteerangkul, Guarin et al., 2004), and poorer
test-retest reliability in comparison to subscales of Tylka’s IES-T (e.g., Hawks et al.,
82
2004). Several of the psychosocial correlates have also not been examined as
extensively as disordered eating, body image and emotional functioning. Moreover,
the assessment of intuitive eating and psychosocial correlates across all reviewed
studies was conducted using self-reports. Experimental and prospective cohort
studies are now needed to verify findings.
Traditional methods of weight control encourage restrictive eating practices.
However, research suggests these methods are largely ineffective for weight loss and
maintenance in the longer term, they increase the risk of disordered eating, and have
been associated with poor psychological health and well-being (Appleton &
McGowan, 2006; Goldschmidt et al., 2012; Hawks, Madanat, & Christly, 2008;
Mann et al., 2007). Intuitive eating has been proposed as a non-dieting approach that
aims to address unhealthy attitudes towards food, the body and physical activity.
This systematic review showed that intuitive eating is associated with lower levels of
disordered eating, a more positive body image, and positive emotional functioning.
However, further studies are needed to build on the cross-sectional findings of
current research. Future research in this area will help establish if intuitive eating is
an approach that could prevent and/or reduce disordered eating practices, body image
concerns, and negative emotional functioning.
83
CHAPTER FOUR
Empirical study: Introduction and Method
This chapter provides the background, aims and method for the empirical
study that was conducted for this thesis. The first aim was to test the factor structure
of the IES (Tylka, 2006) in a community sample of adult women. The second aim
was to examine the three intuitive eating factors (i.e., unconditional permission to
eat, eating for physical rather than emotional reasons, reliance on hunger/satiety
cues) in relation to the following eating behaviours: dieting, restrained eating,
bulimia/food preoccupation, emotional eating, and external eating. The third aim of
the empirical study was to examine and compare the psychosocial correlates of these
eating patterns. These psychosocial factors were found to be associated with intuitive
eating in the systematic review conducted for this thesis. In addition, these were
psychosocial correlates that are specific to the acceptance model of intuitive eating
(Augustus-Horvath & Tylka, 2011; Avalos & Tylka, 2006) or the dual pathway
model of disordered eating (Stice, 2001; Stice & Agras, 1998). Psychosocial
correlates derived from the acceptance model included: perceived social support,
body acceptance by others, body function, and body appreciation (Augustus-Horvath
& Tylka, 2011). Psychosocial correlates derived from the dual pathway model
included: pressure for thinness, internalisation of the thin-ideal, body dissatisfaction,
and negative affect (Stice, 2001).
Previous intuitive eating studies have focused on young adult women,
perhaps due to the typical onset of disordered eating during adolescence and early
adulthood (Favaro, Caregaro, Tenconi, Bosello, & Santonastaso, 2009). However,
research shows that for women, disordered eating and body image concerns are
experienced across the lifespan (Fulton, 2016; Lewis & Cachelin, 2001; Mangweth-
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Matzek, Hoek, Rupp, Lackner-Seifert, Frey, Whitworth et al., 2014; Slevec &
Tiggemann, 2011). Therefore, the empirical study set out to address this limitation in
previous research by examining intuitive eating in relation to other eating patterns
and psychosocial correlates in a community sample of adult women. At the time the
empirical study commenced, the IES (Tylka, 2006) had not been used with adult
men, and there were limited studies that had examined intuitive eating in the adult
male population.
Factor Structure of IES
In the initial study that developed and validated the IES using a female
university student sample, the three-factor structure of the scale was demonstrated
(Tylka, 2006). Nine items loaded onto the unconditional permission to eat factor, six
items loaded onto the eating for physical rather than emotional reasons factor, and
six items loaded onto the reliance on hunger/satiety cues factor. Since the initial
study by Tylka (2006), there has been no further examination of the factor structure
of the scale, yet studies have used the scale in samples that have varied according to
age (e.g., Augustus-Horvath & Tylka, 2011) and gender (e.g., Galloway Farrow, &
Martz, 2010; Tylka & Homan, 2015), and the scale has been used in non-student
samples (e.g., Madden et al., 2012). Given that the factor structure of the original IES
(Tylka, 2006) has only been tested in a student sample, it is important to examine the
scale’s properties in other samples of women. Thus, the first aim of the empirical
study was to test the factor structure of the original IES (Tylka, 2006) in a
community sample of women ranging in age, education, and BMI.
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The Association between Intuitive Eating and Other Eating Behaviours
The second aim of the empirical study was to examine the three intuitive
eating factors in relation to other eating behaviours. Distinguishing intuitive eating
from other eating patterns, particularly disordered eating, is an important step in
establishing if intuitive eating is a style of eating that could be promoted to prevent
or treat disordered eating. Components of intuitive eating that overlap with aspects of
disordered eating might be incorporated into interventions designed to prevent or
treat disordered eating, whereas more distinct aspects of intuitive eating might be
used to promote a positive relationship with food and eating more generally.
Disordered eating can incorporate a range of eating practices including: dieting or
restrained eating, and binge eating (Eating Disorders Victoria, 2015; National Eating
Disorders Collaboration, 2015; Pereira & Alvarenga, 2007). Dieting or restrained
eating, which are often used interchangeably, is a restrictive eating practice used for
controlling body weight, and this eating pattern occurs in both normal weight and
overweight populations (e.g., Fayet, Petocz, & Samman, 2012; Kenardy et al., 2001).
Some researchers argue that dieting is a temporary state of calorie restriction to
encourage weight loss (Allen, Byrne, & McLean, 2012; Tomiyama, Ahlstrom, &
Mann, 2013; Williamson, Martin, York-Crowe, Anton, Redman, Han et al., 2007)
whereas restrained eating involves an intention to restrict or monitor food intake to
avoid weight gain (Lowe & Levine, 2005; Williamson et al., 2007) but does not
necessarily lead to reduced calorie intake (Lowe et al., 2013; Stice, Sysko, Roberto &
Allison, 2010). Both dieting and restrained eating are viewed as ineffective for long-
term weight loss (Mann et al., 2007; Sarlio-Lahteenkorva et al., 2000; Field et al.,
2003; Neumark-Sztainer et al., 2012) and are negatively associated with
psychological well-being (Abrantes, Strong, Ramsey, Lewinsohn, & Brown 2006).
Intuitive eating was proposed as an alternative eating style that removes the focus on
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weight control and targets factors associated with restrictive and other disordered
eating practices, including: a focus on eating for satisfaction and nourishment of the
body instead of for weight control; engaging in physical activity for the enjoyment
rather than for modifying/maintaining weight and shape; and encouraging body
acceptance rather than focusing on achieving an ideal body weight and shape
(Tribole & Resch, 2012).
As highlighted in the systematic review conducted for this thesis, intuitive
eating has been investigated in adult women in relation to disordered eating. The
systematic review demonstrated that the unconditional permission to eat component
of intuitive eating was less conceptually distinct from disordered eating
symptomatology, including dieting and bulimia/food preoccupation, whereas the
eating for physical rather than emotional reasons and reliance on hunger/satiety cues
components were found to be more conceptually distinct from aspects of disordered
eating.
Two of the reviewed studies examined the distinctiveness of intuitive eating
from disordered eating using the original IES (Tylka & Wilcox, 2006) and the
revised IES-2 (Tylka & Kroon Van Diest, 2013). Tylka and Wilcox (2006) examined
the distinctiveness of intuitive eating from disordered eating symptomatology (i.e.,
dieting, bulimia/food preoccupation) in a sample of female psychology
undergraduate students, aged 17 to 30 years (Tylka & Wilcox, 2006). The study
assessed the unique contribution of the three intuitive eating components for
indicators of psychological well-being, by controlling for the contribution of
disordered eating as assessed by dieting and bulimia/food preoccupation subscales
from the EAT-26 (Garner et al., 1982). The eating for physical rather than emotional
reasons and reliance on hunger/satiety cues aspects of intuitive eating both
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contributed uniquely to positive affect, optimism, psychological hardiness, self-
esteem, unconditional self-regard, proactive coping, social problem solving.
Unconditional permission to eat did not contribute uniquely to any of these indicators
of psychological well-being, above that of dieting and bulimia/food preoccupation.
Thus, in contrast to unconditional permission to eat, the two other subscales of the
IES (eating for physical rather than emotional reasons and reliance on hunger/satiety
cues) were more distinct from disordered eating.
In the second study, Tylka and Kroon Van Diest (2013) used the same
approach as Tylka and Wilcox (2006) in examining the distinctiveness of the
components of intuitive eating from disordered eating symptomatology, in a sample
of male and female university students aged 18 to 53 years. However, the study also
examined the body-food choice congruence subscale that is included in the IES-2
(Tylka & Kroon Van Diest, 2013). The unique contribution of the four intuitive
eating components to indicators of psychological well-being was assessed after
controlling for the contribution of disordered eating. Overall disordered eating
symptomatology was assessed using total scores on the EAT-26 (Garner et al., 1982).
For women in the sample, eating for physical rather than emotional reasons
contributed uniquely to self-esteem, negative affect, and life satisfaction; reliance on
hunger/satiety cues uniquely predicted self-esteem and positive affect; and body-food
choice congruence contributed uniquely to self-esteem, positive affect, and negative
affect. Unconditional permission to eat did not uniquely predict any indicators of
psychological well-being above that of disordered eating, which is in line with
findings of Tylka and Wilcox (2006), demonstrating that unconditional permission to
eat overlapped with disordered eating. The findings of both studies suggest that
unconditional permission to eat may be assessing eating behaviours that are already
covered by disordered eating, although given the wording of the items and how the
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scale is scored, higher scores on unconditional permission to eat represent lower
levels of disordered eating.
Three studies published since the systematic review was conducted have also
examined how each of the IES subscales relates to other eating behaviours
(Anderson, Reilly, Schaumberg, Dmochowski, & Anderson, 2016; Camilleri et al.,
2015; van Dyck et al., 2016). Anderson and colleagues (2016) examined restrained
eating, an overall measure of disordered eating, and mindful eating (i.e., non-
judgmental awareness of physical and emotional sensations associated with eating)
using the restraint subscale of the Three Factor Eating Questionnaire (Stunkard &
Messick, 1985), the Eating Disorder Diagnostic Scale (Stice, Telch, & Rizvi, 2000),
and the Mindful Eating Questionnaire (Framson, Kristal, Schenk, Littman, Zeliadt, &
Benitez, 2009). Camilleri and colleagues (2015) examined restrained eating,
emotional eating and uncontrolled eating (i.e., loss of control over food intake that
results in overeating) using a French version of the Three Factor Eating
Questionnaire (de Lauzon, Romon, Deschamps, Lafay, Borys, Karlsson et al., 2004).
Van Dyck and colleagues examined restrained eating, emotional eating, and external
eating using the German version of the Dutch Eating Behaviour Questionnaire
(Grunert, 1989), and symptoms of bulimia using the German version of the Eating
Disorder Inventory-2 (Paul & Thiel, 2005).
Similar to Tylka and Wilcox (2006), the unconditional permission to eat
subscale was found to overlap with disordered eating in that it was moderately to
strongly associated with restrained eating (Anderson et al., 2016; Camilleri et al.,
2015; van Dyck et al., 2016) and moderately to strongly associated with disordered
eating symptomatology (Anderson et al., 2016; van Dyck et al., 2016). However,
unconditional permission to eat was only weakly associated with emotional eating
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(Camilleri et al., 2015; van Dyck et al., 2016) and external eating (van Dyck et al.,
2016), and it was not associated with uncontrolled eating in French adults (Camilleri
et al., 2015) or mindful eating in female university students (Anderson et al., 2016).
Overall, the eating for physical rather than emotional reasons subscale was
found to overlap substantially with emotional eating, uncontrolled eating, and
symptoms of bulimia. Eating for physical rather than emotional reasons was strongly
associated with emotional eating (Camilleri et al., 2015; van Dyck et al., 2016),
uncontrolled eating (Camilleri et al., 2015), and symptoms of bulimia (van Dyck et
al., 2016), and moderately associated with overall disordered eating symptoms
(Anderson et al., 2016). In addition, the subscale was moderately related to external
eating (van Dyck et al., 2016) and mindful eating (Anderson et al., 2016). For
restrained eating, eating for physical rather than emotional reasons was weakly
associated with restrained eating in two studies (Camilleri et al., 2015; van Dyck et
a., 2016), however, it was not related to restrained eating in a third study of female
university students (Anderson et al., 2016).
The relationship between the reliance on hunger/satiety cues subscale and
aspects of disordered eating was consistent with relationships reported in previous
studies included in the systematic review (Tylka, 2006; Tylka & Kroon Van Diest,
2013; Tylka & Wilcox, 2006). Reliance on hunger/satiety cues was moderately
associated with overall disordered eating symptoms in female university students
(Anderson et al., 2016). In addition, reliance on hunger/satiety cues was only weakly
associated with restrained eating in French adults (Camilleri et al., 2015), and was
not associated with restrained eating in female university students (Anderson et al.,
2016). However, an exception was one study (van Dyck et al., 2016) whose findings
were not consistent with previous studies. In a sample of mostly German adult
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women, reliance on hunger/satiety cues overlapped with aspects of disordered eating
(van Dyck et al., 2016), with reliance on hunger/satiety cues being strongly
associated with restrained eating and symptoms of bulimia (van Dyck et al., 2016).
Other eating patterns not assessed in the systematic review demonstrated less overlap
with reliance on hunger/satiety cues in these three studies. This subscale of the IES
was only weak to moderately associated with emotional eating (Camilleri et al.,
2015; van Dyck et al., 2016), only weakly associated with uncontrolled eating
(Camilleri et al., 2015) and external eating (van Dyck et al., 2016), and was not
associated with mindful eating (Anderson et al., 2016). This suggests that there is
less overlap between the reliance on hunger/satiety cues subscale and other eating
patterns.
The empirical study for this thesis was specially designed to further examine
the three IES subscales in relation to other eating patterns. These included dieting,
restrained eating, bulimia and food preoccupation, emotional eating and external
eating. At the time the empirical study commenced, only one study (Tylka & Wilcox,
2006) had examined the IES subscales in relation to disordered eating. Subsequent
studies used revised versions of the IES and used student samples, with the exception
of Camilleri et al. (2015). Based on the previous studies, it was expected that
unconditional permission to eat would correlate moderately to strongly but
negatively with dieting, restrained eating, and bulimia/food preoccupation. In
addition, it was expected that eating for physical rather than emotional reasons would
correlate moderately to strongly but negatively with emotional eating, external
eating, and bulimia/food preoccupation. Lastly, it was expected that reliance on
hunger/satiety cues would correlate weakly to moderately but negatively with all
other eating patterns.
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Psychosocial Correlates of Intuitive Eating and Other Patterns of Eating
The last aim of the empirical study conducted for this thesis was to compare
the psychosocial correlates of intuitive eating with those of other eating patterns. To
date, no studies have directly compared the psychosocial correlates of the three IES
subscales with other eating patterns, including disordered eating. Understanding the
psychosocial factors that predict an intuitive eating style is an important step in
determining how intuitive eating may develop and is maintained. Moreover,
establishing what factors predict intuitive eating and how these may be different
and/or similar to disordered eating will inform interventions designed to prevent or
reduce disordered eating and other eating patterns not based on internal cues, and
promote more positive eating patterns.
The systematic review of the psychosocial correlates of intuitive eating
conducted as part of this thesis demonstrated that several psychosocial factors are
associated with intuitive eating in adult women. These included body image,
emotional functioning, body acceptance by others, societal pressure for thinness,
internalisation of the thin-ideal, and perceived social support. Several of these factors
have also been shown to be associated with disordered eating. These include: societal
pressure for thinness, internalisation of the thin-ideal, body image (e.g., body
dissatisfaction), and negative affect (Pennesi & Wade, 2016; Stice, 2002). However,
a direct comparison of the psychosocial correlates of intuitive eating to those of
disordered eating has yet to be conducted. Thus, this empirical study was designed to
also examine the bivariate associations between each of the above psychosocial
correlates with the three components of intuitive eating, and each of the psychosocial
correlates with the other included eating patterns.
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In addition to examining bivariate relationships, the acceptance model of
intuitive eating and a modified version of the dual pathway model of disordered
eating5 were also examined. Given that these models have been developed from
different theoretical viewpoints, it was expected that these would further assist in
better understanding both the similarities and differences between intuitive eating
and disordered eating.
The acceptance model of intuitive eating describes the sociocultural and
psychological factors that influence patterns of intuitive eating among women
(Avalos & Tylka, 2006). However, unlike models of disordered eating, the focus is
on a set of positively-framed psychosocial factors (Augustus-Horvath & Tylka,
2011). These factors include: unconditional acceptance by others; body acceptance
by others; resisting an observer perspective of the body (or a focus on body
function); and body appreciation (Augustus-Horvath & Tylka, 2011). Unconditional
acceptance is proposed to predict body acceptance by others, which predicts a focus
on body function and body appreciation; and body function and body appreciation
are proposed to predict intuitive eating (Augustus-Horvath & Tylka, 2011).
Avalos and Tylka (2006) first tested the acceptance model in a sample of 181
female psychology students. A path analysis was conducted to test the relationship
between each of the four psychosocial factors and intuitive eating. The path analysis
demonstrated a non-significant relationship between general unconditional
acceptance by others and body function; hence the model was revised and retested. It
was shown that body function and body appreciation mediated the relationship
5 The dual pathway model was modified as a result of principal axis factoring conducted in the first
part of the empirical study (Chapter five). Dieting and bulimia/food preoccupation loaded onto the
first eating factor labelled ‘disordered eating’. Due to this eating factor being examined as an outcome
of the dual pathway model, dieting was not included as a separate variable in the model. Instead of a
path from body dissatisfaction to dieting and disordered eating, the modified dual pathway model
incorporated a path directly from body dissatisfaction to disordered eating.
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between body acceptance by others and intuitive eating. Approximately 42.5% of the
variance in intuitive eating was contributed by body appreciation and body function.
Overall, the study provided preliminary support for the acceptance model of intuitive
eating.
In a subsequent study, Augustus-Horvath and Tylka (2011) examined the
acceptance model among 801 women aged 18 to 65 years, who were mostly
university students. Women were categorised by age into three groups: emerging (18
to 25 years), early (26 to 39 years) and middle (40 to 65 years) adulthood. Perceived
social support was examined in place of unconditional acceptance by others. The
model fit the data for all three age groups of women. Higher levels of intuitive eating
were predicted by greater body appreciation and a focus on body function. Perceived
social support predicted body acceptance by others, and body acceptance by others
predicted body function. Overall, the model accounted for 40% to 50.8% of variance
in intuitive eating among emerging, early and middle adult women.
In another study, Oh and colleagues (2012) tested the acceptance model in a
sample of 160 female university athletes aged 18 to 23 years. They examined
unconditional acceptance by others as in the original study by Avalos and Tylka
(2006). As with the previous study (Avalos & Tylka, 2006), general unconditional
acceptance from others did not predict body function. Body appreciation and body
function predicted intuitive eating, body acceptance by others predicted body
function and body appreciation, and unconditional acceptance from others predicted
body acceptance by others. The findings of this study demonstrated that the
acceptance model extends to female athletes.
The extent to which the positively framed psychosocial correlates from the
acceptance model may also predict lower levels of disordered eating has yet to be
94
investigated. However, several of the factors that have been shown to predict
disordered eating have been found to be associated with lower levels of intuitive
eating. These include the main components of the dual pathway model: societal
pressure for thinness, internalisation of the thin-ideal, body dissatisfaction, dieting,
and negative affect (Stice, 2001; Stice & Agras, 1998).
The dual pathway model is a prominent theoretical model in the literature
(Pennesi & Wade, 2016). The model posits that body dissatisfaction leads to
disordered eating through two pathways: either through dieting practices or negative
affect. Body dissatisfaction is proposed to occur as a consequence of experiencing
societal pressure for thinness and internalisation of the thin-ideal (Stice, 2001). The
dual pathway model has been examined in young women and adolescents (e.g.,
Allen, Byrne, & McLean, 2012; Dakanalis, Timko, Carrà, Clerici, Zanetti, Riva, et
al., 2014; Stice, Nemeroff, & Shaw, 1996; Urvelyte & Permnias, 2015) and has
received support in both normative and clinical samples of women (e.g., Stice et al.,
2011; Van Strien, Engels, Van Leeuwe, & Snoek, 2005). As highlighted in the
systematic review, each of the individual components of the model have been found
to be associated with lower levels of intuitive eating, according to the total IES and
each subscale (Tylka, 2006; Tylka et al., 2015; Tylka & Kroon Van Diest, 2013),
however, the full model with the IES subscales as outcome variables has yet to be
examined.
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Method
Participants
The participants were 457 Australian women aged between 18 and 87 years,
with a mean age of 38.15 (SD 15.40). The majority of women identified with an
Australian and/or British/European background (89.3%), were married or in a de
facto relationship (61%), had gained tertiary qualifications (62.1%), and were
engaged in full-time or part-time work (62.2%). The sample had a mean BMI of
26.11 kg/m2 (SD 6.85). According to BMI classification, 51.3 % of women were of a
normal weight and 43.8% were classified as overweight or obese. A large portion of
the sample (n=145) reported a health condition that may affect their food intake
(31.7%). This included gastrointestinal issues or food allergies, diabetes (Type I and
II), physical conditions such as hypertension, high cholesterol, a current/historical
cancer diagnosis, and current/historical psychological difficulties such as depressive
symptomatology or an eating disorder diagnosis. Given the proportion of women
who identified themselves as having a health condition that may affect their food
intake, these women were not excluded from the study in order for the sample to be
more representative of the wider population. Sample characteristics are summarised
in Table 4.1.
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Table 4.1
Sample Characteristics
N %
Age
18-24 100 21.9
25-44 219 47.9
45-64 108 23.6
65+ 30 6.6
Relationship status
Married 176 38.5
Divorced 22 4.8
De facto 103 22.5
Separated 13 2.8
Widowed 9 2.0
Single 134 29.3
Ethnic/cultural background
Australian 262 57.3
British/Irish 84 18.4
European 54 11.9
Asian 27 5.9
Indigenous Australian 8 1.8
Other 22 4.7
Education level
Secondary education 86 18.8
Certificate/advanced diploma 80 17.6
Bachelor/graduate certificate 155 33.9
Postgraduate degree 129 28.2
Other 7 1.5
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N %
Work status
Full time 159 34.8
Part time 125 27.4
Casual 68 14.9
Unemployed 18 3.9
Student 78 17.1
Retired 31 6.8
Other 27 5.9
BMI
Underweight 18 3.9
Normal weight 239 52.3
Overweight 95 20.8
Obese 105 23.0
Health condition
Gastrointestinal issues/food
allergies
Modified diet with no medical
basis
Diabetes (Type I or II)
Other physical condition
Psychological condition
Pregnancy/breastfeeding
Eating Disorder
Other
72
17
12
17
9
8
6
4
15.8
3.7
2.6
3.7
2.0
1.8
1.3
1.6
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Measures
Background information. Participants were asked to report their age (in years
and months), their ethnic/cultural background, relationship status, level of education,
and their current work status. In addition, participants were asked to describe any
health conditions or factors that may influence their food intake (i.e., “Please indicate
if there are any health conditions or other factors that influence your eating attitudes
or behaviours.”).
Weight status. Weight status was assessed using BMI. BMI is a weight-for-
height index calculated by dividing weight (kg) by the square of height (metres)
(World Health Organisation, 2016). BMI was calculated using self-report measures
of height (cm) and weight (kg). Participants were categorised according to BMI
classification: underweight (<18.00 kg/m2), normal weight (18.00-24.99 kg/m2),
overweight (25.00-29.99 kg/m2), and obese (>30.00 kg/m2).
Intuitive eating. Intuitive eating was measured by the IES (Tylka, 2006). The
scale contains 21 items rated along a five-point scale, from one (strongly disagree) to
five (strongly agree). Thirteen items were reverse scored. Examples of items
included: “If I am craving a certain food, I allow myself to have it”, “I use food to
help me soothe my negative emotions” and “When I’m eating, I can tell when I am
getting full”. The three-factor solution was supported for this scale in female
university students (Tylka, 2006), representing three aspects of intuitive eating: (1)
unconditional permission to eat (nine items); (2) eating for physical rather than
emotional reasons (six items); and (3) reliance on hunger/satiety cues (six items).
Subscale scores for each of the three subscales were calculated by summing each
applicable item and obtaining an average score. For the purpose of this study, only
subscale scores were used. The IES has been shown to demonstrate good internal
99
consistency, with Cronbach alphas ranging from .85 to .89 for the total scale
(Augustus-Horvath & Tylka, 2011; Avalos & Tylka, 2006; Kroon Van Diest &
Tylka, 2010; Tylka, 2006), and .72 to .87 for the three subscales (Tylka, 2006).
Construct validity of the scale has been established using measures of disordered
eating, body dissatisfaction, interoceptive awareness, and thin-ideal internalisation
(Tylka, 2006). Three-week test-retest reliability has also been found to be good for
the scale (Tylka, 2006).
Dieting. Dieting was assessed using the 13-item dieting subscale of the Eating
Attitudes Test (EAT-26; Garner et al., 1982). The EAT-26 is used as a screening tool
to assess eating disorder symptomology and the risk of developing an eating
disorder. Items in the dieting scale were rated on a six-point scale from 1 (never) to 6
(always). Examples of items include: “Aware of the calorie content of foods that I
eat”, “Feel uncomfortable after eating sweets”, and “I am terrified about being
overweight”. In the original version of the scale, items are recoded along a four-point
scale, however, the original version was normed in a clinical population with a non-
clinical comparison group (Garner et al., 1982). It has been suggested that scoring
with this method may affect skewness in a non-clinical population (Maïano, Morin,
Lanfranchi, & Therme, 2013). For the current study scores were calculated using the
items rated on a six-point scale. Tylka (2006) also used the six-point scale in
assessing disordered eating symptomatology, as have other researchers (e.g., Kroon
Van Diest & Tylka, 2010; Tylka & Kroon Van Diest, 2013). Item scores were
summed and averaged to provide a mean score for dieting, where higher scores were
indicative of a higher level of dieting. The EAT-26 was validated in a clinical sample
of 160 young adult females diagnosed with Anorexia Nervosa, and a comparison
group of 140 female university students (Garner et al., 1982). More recent research
has demonstrated criterion validity of the scale in clinical and non-clinical samples
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(e.g., Mintz & O’Halloran, 2000). Construct validity of the EAT-26 has been
evaluated against other measures of disordered eating in a clinical sample (Berland,
Thompson, & Linton, 1986). Strong correlations have been reported for the scale
with the EAT-40 (Garner & Garfinkel, 1979) and the Eating Inventory (Stunkard,
1981). High test-retest reliability has been demonstrated for the scale over a four to
five-week period (e.g., Banasiak, Wertheim, Koerner, & Voudouris, 2001), and the
dieting subscale has demonstrated acceptable internal consistency across studies
(e.g., Gleaves, Pearson, Ambwani, & Morey, 2014).
Bulimia and food preoccupation. Symptoms of bulimia and food
preoccupation were measured using the six-item bulimia and food preoccupation
subscale of the EAT-26 (Garner et al., 1982). Examples of items include: “Find
myself preoccupied with food” and “Have the impulse to vomit after meals”. Items
were rated on a six-point scale and the subscale score calculated according to
procedures followed for the dieting subscale of the EAT-26. Higher scores were
indicative of a greater degree of bulimic symptomatology and food preoccupation.
The bulimia and food preoccupation subscale has demonstrated acceptable internal
consistency (e.g., Gleaves, Pearson, Ambwani, & Morey, 2014).
Restrained eating. The restraint subscale of the Dutch Eating Behaviour
Questionnaire (DEBQ; Van Strien et al., 1986) was used to assess restrained eating.
The subscale includes 10 items rated along a five-point scale from 1 (seldom) to 5
(very often). In addition, items had a “non-relevant” response option. Examples of
items include: “Do you take into account your weight with what you eat?” and
“How often do you refuse food or drink offered because you are concerned about
your weight?”. Item scores were summed and averaged to provide a mean score.
Higher scores were indicative of higher levels of restrained eating. The restraint
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subscale has shown good internal consistency across studies (e.g., Dakanalis, Zanetti,
Clerici, Madeddu, Riva, & Caccialanza, 2013; Van Strien et al., 1986). The DEBQ
was validated in a community sample of normal weight and overweight adults (Van
Strien et al., 1986) and the three-factor structure (i.e., restrained eating, emotional
eating, external eating) has been validated in normative samples of adults,
overweight adults, and in adults diagnosed with Anorexia Nervosa and Bulimia
Nervosa (e.g., Wardle, 1987). High test-retest reliability has been demonstrated to be
high over a four to five-week period (Banasiak et al., 2001).
Emotional eating. The emotional eating subscale of the DEBQ (Van Strien et
al., 1986) was used to assess emotional eating. Thirteen items are rated along a five-
point scale from 1 (seldom) to 5 (very often), in addition to a “non-relevant” response
option. Examples of items include: “Do you have the desire to eat when you are
feeling lonely?” and “Do you have a desire to eat when you are bored or restless?”.
Item scores were summed and averaged to provide a mean score. Higher scores were
indicative of higher levels of emotional eating. The emotional eating subscale has
demonstrated good internal consistency across studies (e.g., Dakanalis et al., 2013;
Van Strien et al., 1986).
External eating. The external eating subscale of the DEBQ (Van Strien et al.,
1986) was used to assess external eating. The subscale contains 10 items rated along
a five-point scale from 1 (seldom) to 5 (very often). Items also had a “non-relevant”
response option. One item was reverse scored (“Can you resist eating delicious
foods?”). Examples of items include: “If you see others eating, do you also have the
desire to eat?” and “If food smells and looks good, do you eat more than usual?”.
Item scores were summed and averaged to provide a mean score. Higher scores were
indicative of higher levels of emotional eating. The external eating subscale has
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demonstrated adequate internal consistency across studies (e.g., Dakanalis et al.,
2013; Van Strien et al., 1986).
Perceived social support. The degree of social support, perceived by women,
was assessed using the 24-item Social Provisions Scale (SPS; Cutrona & Russell,
1987). The scale assesses aspects of social support including: attachment,
opportunity for nurturance, social integration, reliable alliance, guidance, and
reassurance of worth. Items are rated on a scale from 0 (strongly disagree) to 3
(strongly agree). Twelve items were reverse scored. Examples of items include:
“There are people I can depend on to help me if I really need it” and “There is
someone I could talk to about important decisions in my life”. Item scores were
summed to provide a total score. Higher scores represented greater perceived social
support. The SPS was validated using samples of university students, older adults,
new mothers, teachers, and nurses (Cutrona & Russell, 1987) and has demonstrated
good internal consistency (Cutrona & Russell, 1987; Mattanah, Ayers, Brand,
Brooks, Quimby, & McNary, 2010). Scores have been found to be positively
correlated with other measures of social support (Cutrona & Russell, 1987), and the
scale has reported good test-retest reliability (Cutrona, Russell, & Rose, 1984).
Body acceptance by others. The perceived acceptance by others of weight and
shape was assessed using the Body Acceptance by Others Scale (Avalos & Tylka,
2006). Ten items were rated along a 5-point scale ranging from 1 (never) to 5
(always) and assess body acceptance from sources including: family, friends,
partners, society and the media. Examples of items include: “I've felt acceptance
from my friends regarding my body shape and/or weight” and “I've felt acceptance
from the media (e.g., TV, magazines) regarding my body shape and/or weight”. Item
scores were summed and averaged to provide a mean score. Higher scores were
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indicative of greater perceived acceptance of weight and shape by others. The scale
was developed using a modified version of the Perceived Sociocultural Pressures
Scale (Stice et al., 1996) and examined in a sample of female university students.
Subsequent studies have examined the scale in samples of female university students
(Avalos & Tylka, 2006; Tylka & Homan, 2015) and women aged 18 to 65 years
(Augustus-Horvath & Tylka, 2011). The scale has demonstrated good internal
consistency (e.g., Augustus-Horvath & Tylka, 2011; Tylka & Homan, 2015) and has
been found to correlate negatively with pressure for thinness and positively with
body appreciation (Avalos & Tylka, 2006; Tylka & Homan, 2015). Good test-retest
reliability for the scale has been demonstrated for the scale over a three-week period
(Avalos & Tylka, 2006).
Body function. The surveillance subscale of the Objectified Body
Consciousness Scale (OBS; McKinley & Hyde, 1996) was used to assess the degree
to which women focus on how their body feels and functions rather than their
appearance. In the original subscale, eight items are rated on a 6-point scale from 1
(strongly agree) to 7 (strongly disagree), and two items are reverse scored. Examples
include: “I think more about how my body feels than how my body looks” and “I am
more concerned with what my body can do than how it looks”. Higher scores on the
Surveillance subscale indicate more of a focus on appearance. To obtain an
assessment of the degree to which women focus on how their body functions, rather
than their appearance, items were reverse scored, summed and averaged to provide a
mean score. Higher scores were indicative of a greater focus on how the body feels
and functions, rather than appearance. The OBS was validated using samples of
female university students and middle-aged women (McKinley & Hyde, 1996). The
surveillance subscale has been associated with body shame and disordered eating
symptomatology, and negatively associated with body esteem (McKinley & Hyde,
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1996). The modified version of the subscale (i.e., reverse-scored to represent body
function) has been examined in studies of female university students and women
aged 18 to 65 (Augustus-Horvath & Tylka, 2011; Homan & Tylka, 2014). The
modified subscale has demonstrated good internal consistency (e.g., Augustus-
Horvath & Tylka, 2011; Avalos & Tylka, 2006; Tylka & Homan, 2015). Test-retest
reliability of the OBS has been demonstrated over a two-week period (McKinley &
Hyde, 1996).
Body appreciation. Body appreciation was assessed using the Body
Appreciation Scale (Avalos et al., 2005). Thirteen items are rated along a five-point
scale from 1 (never) to 5 (always). Examples of items include: “Despite its flaws, I
accept my body for what it is” and “I take a positive attitude toward my body”. Item
scores were summed and averaged to provide a mean score for body appreciation.
Higher scores were indicative of more positive attitudes and treatment of the body,
regardless of perceived appearance-related flaws. The scale was validated in 1109
female university students (Avalos et al., 2005). Good internal consistency has been
reported the for scale (Avalos et al., 2005; Iannantuono & Tylka, 2012; Tylka &
Kroon Van Diest, 2013) and test-retest reliability has been established for the scale
over a three-week period (Avalos et al., 2005). Higher scores have been associated
with lower levels of body dissatisfaction, body preoccupation, weight concern, and
disordered eating (Avalos et al., 2005).
Perceived pressure for thinness. Pressure for thinness from family, friends,
and partners, as perceived by women, was assessed using the Perceived Sociocultural
Pressure Scale (Stice et al., 1996). 10 items are rated along a scale from 1 (disagree)
to 5 (strongly agree). Example items: “I've felt pressure from my friends to lose
weight” and “I've felt pressure from the media (e.g., TV, magazines) to lose weight”.
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Item scores were summed to provide a total score. Higher scores indicate greater
perceived pressure to be thin. The scale was originally validated using a sample of
female university students (Stice et al., 1996). The scale has been found to show
good internal consistency (e.g., Reina, Shomaker, Mooreville, Courville, Brady,
Olsen et al., 2013; Stice et al., 1996) and test-retest reliability over a two-week
period (Stice et al., 1996). Scores have been found to be correlate with thin-ideal
internalisation, body dissatisfaction and disordered eating (e.g., Tylka & Subich,
2004).
Thin-ideal internalisation. The degree to which women adopt the thin-ideal
stereotype was measured using the 9-item internalisation-general subscale of the
Sociocultural Attitudes Toward Appearance Questionnaire-3 (Thompson, van den
Berg, Roehrig, Guarda, & Heinberg, 2004). Items are rated along a scale from 1
(completely disagree) to 5 (completely agree). Three items were reverse scored. Item
scores were then summed to form a total score. Examples of items include: “I
compare my body to the bodies of people who are on TV” and “I compare my
appearance to the appearance of people in magazines.” Higher scores indicate
greater internalisation of the thin-ideal stereotype. The scale was validated using a
sample of female university students (Thompson et al., 2004) and has subsequently
been examined in clinical (e.g., Calogero, Davis, & Thompson, 2004; Forman &
Davis, 2005) and non-clinical populations (e.g., Swami, Steadman, & Tovée, 2009).
The subscale has demonstrated good internal consistency (e.g., Swami, 2009;
Thompson et al., 2004), and has been associated with the drive for thinness, body
dissatisfaction and disordered eating (Calogero et al., 2004; Thompson et al., 2004).
Appearance evaluation. Appearance evaluation was assessed using the
appearance evaluation subscale of the Multidimensional Body-Self Relations
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Questionnaire (MBSRQ) (Brown, Cash, & Mikulka, 1990; Cash, 2000). Seven items
are rated on a 5-point scale from 1 (definitely disagree) to 5 (definitely agree).
Examples of items include: “I like my looks just the way they are” and “I like the way
I look without my clothes on”. Item scores were summed and averaged to provide a
mean score. Higher scores are indicative of women being more positive and satisfied
with their appearance. The MBSRQ has been validated in normative (Brown et al.,
1990; Cash & Henry, 1995) and clinical populations (Hrabosky, Cash, Veale,
Neziroglu, Soll, Garner, et al., 2009). The appearance evaluation subscale has
demonstrated good internal consistency (Cash, 2000) and test-retest reliability over a
one-month period (Banasiak et al., 2001; Cash, 2000). Scores correlate negatively
with body shame, body surveillance, and disordered eating (Kinsaul, Curtin, Bazzini,
& Martz, 2014; Kelly, Mitchell, Gow, Trace, Lydecker, Bair et al., 2012).
Body area satisfaction . Body area satisfaction was assessed using the body
area satisfaction subscale of the Multidimensional Body-Self Relations
Questionnaire (MBSRQ) (Brown et al., 1990; Cash, 2000). Nine items are rated on a
5-point scale from 1 (very dissatisfied) to 5 (very satisfied). Items relate to specific
body areas including: face, hair, lower/mid/upper torso, muscle tone, weight, height,
and overall appearance. Item scores were summed and averaged to provide a mean
score. Higher scores indicate greater level of satisfaction with most areas of the body.
The body area satisfaction subscale has demonstrated adequate internal consistency
and good test-retest reliability for a one-month period (Cash, 2000). Scores have
been found to correlate negatively with measures of disordered eating (Giovannelli,
Cash, Henson, & Engle, 2008; Kinsaul et al., 2014), and negative body image (Cash,
Fleming, Alindogan, Steadman, & Whitehead, 2002; Giovannelli et al., 2008).
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Negative affect. Negative affect was assessed using the 10-item negative
affect subscale of the Positive and Negative Affect Schedule (Watson, Clark, &
Tellegen, 1988). Each item was rated on a scale from 1 (very slightly or not at all) to
5 (extremely) according to the degree to which women have felt a specific feeling or
emotion over the past week. Examples of feelings and emotions assessed included:
distressed, nervous, guilty and hostile. Item scores were summed to provide a total
score for negative affect. Higher scores indicate a greater degree of negative affect
over the past week. The scale was validated using student and non-student samples
(Watson et al., 1988) and has subsequently been used with community samples of
adults (e.g., Crawford & Henry, 2004). Good levels of internal consistency have been
found for the scale (e.g., Watson & Clark, 1994; Watson et al., 1988), and scores
correlate positively with measures of depression and anxiety (e.g., Crawford &
henry, 2004), disordered eating, and body dissatisfaction (Lavender & Anderson,
2010).
Procedure
The study was approved by the Human Ethics Advisory Group, Faculty of
Health at Deakin University in January, 2013 (see Appendix A). Recruitment
commenced in March, 2013, and was completed in May, 2014. A flyer promoting the
study was advertised in several organisations providing health and community
services to women living in Australia. Recruitment sites included women’s fitness
centres, women’s personal training groups, women’s health centres and medical
clinics, community/neighbourhood centres, weight loss support groups, day spas,
physiotherapy clinics, private psychology practices, and women’s online health
forums. The study was also promoted within Deakin University, on social media
sites, and by personal invitation. A majority of organisations were located in the state
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of Victoria, however, the study was advertised in a number of organisations in New
South Wales, South Australia, Western Australia, Tasmania, and the Australian
Capital Territory (ACT). Prospective participants were informed that the purpose of
the study was to investigate the relationship between eating patterns, health and well-
being among Australian women.
All women were provided with a Plain Language Statement and the
opportunity to contact the research team with questions or concerns. Consent to
participate in the study was inferred from completion of the survey. The Plain
Language Statement and Consent Form is provided in Appendix B. The survey took
approximately 30 minutes to complete and was made available online or as a
hardcopy with a postage paid envelope. The online survey was hosted online by
Deakin University for a period of 14 months, from March 2013 until May 2014.
Hardcopy surveys (n=140) were mailed to organisations to be made available to
women who preferred to complete a paper-based version, or who had limited access
to computer and internet facilities. Of those hardcopy surveys provided to
organisations during the recruitment period, 49.3% of hardcopy surveys (n=69) were
returned with complete responses. The participant survey is provided in Appendix B.
Women who completed the study were provided with the opportunity to enter a prize
draw to win one of six $30 gift vouchers.
Data Analyses
Missing data and assumptions of normality and linearity were assessed using
IBM SPSS Statistics, version 22. Minimal data were missing across items (ranging
from 0.2% to 2.8%). Little’s MCAR test was used to assess patterns of missing data.
Data were identified to be missing at random (χ2 = 459.912, df = 344, p>.05),
therefore, expectation maximisation was used to impute missing data (Tabachnick &
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Fidell, 2007). Variables were assessed for normality using histograms and by
examining skewness and kurtosis. Data did not violate assumptions of normality
(Kline, 2011), therefore, no transformation of variables were needed.
To address the first aim of the study, a confirmatory factor analysis was
performed on the IES (Tylka, 2006) using maximum likelihood estimation, to
examine the factor structure of the scale. To address the second aim of the study,
bivariate correlations and principal axis factoring were used to examine the
relationship between the three IES subscales and measures of disordered eating. To
address the third aim of the study, bivariate correlations and path analyses using the
Maximum Likelihood method of estimation were conducted, to examine and
compare the psychosocial correlates of the intuitive eating components and aspects
of disordered eating. More detailed information on data analyses is presented in
Chapters Five and Six.
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CHAPTER FIVE
Empirical Study: Results and Discussion Part One
Factor Structure of the IES
To address the first aim of the study, a confirmatory factor analysis was
performed on the 21-item IES using maximum likelihood estimation, in SPSS Amos
Graphics version 22. As the focus of the empirical study was on the three subscales
of intuitive eating, a first order model was examined, with unconditional permission
to eat, eating for physical rather than emotional reasons, and reliance on
hunger/satiety cues as first order factors. The size of the sample exceeded the
recommended number of cases required to estimate parameters (Tabachnick &
Fidell, 2007). In addition to the Chi Square Goodness of Fit Test (χ2), a further four
model fit indices were used: the Comparative Fit Index (CFI), the Tucker-Lewis
Index (TLI), the Standardised Root Mean-square Residual (SRMR), and the Root-
Mean-Square Error of Approximation (RMSEA). CFI and TLI values above 0.90
indicate acceptable fit, and values above 0.95 indicate good fit. RMSEA and SRMR
values approaching zero are desired, with values below 0.08 for RMSEA and below
0.06 for SRMR indicating good fit (Hu & Bentler, 1999; Kline, 2011). The proposed
model is presented in Figure 5.1.
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Figure 5.1. Proposed first order model of the IES.
The proposed model did not provide a good fit to the data, χ2 (186, N=457) =
907.42, p<.001, CFI = .82, TLI = .79, RMSEA = .09, SRMR = 0.09. Model estimates
are presented in Table 5.1. Correlations between each intuitive eating factor are
presented in Table 5.2. To develop a better-fitting model, items with factor loadings
below .45 on their respective first order factor were removed from the model.
Comrey and Lee (1992) suggest that this is a fair cut-off for factor loadings, and
Tylka (2006) also used .45 as the cut-off for items in developing the original scale.
This resulted in five items being discarded: Item 1 (“I try to avoid certain foods high
in fat, carbohydrates, or calories”) and Item 4 (“If I am craving a certain food, I allow
112
myself to have it”) from the unconditional permission to eat factor; Item 2 (“I stop
eating when I feel full (not overstuffed)”) from the eating for physical rather than
emotional reasons factor; and Item 7 (“I can tell when I’m slightly full”) and Item 8
(“I can tell when I’m slightly hungry”) from the reliance on hunger/satiety cues
factor. The re-specified model is presented in Figure 5.2. The re-specified model
provided a better and more acceptable fit to the data, χ2 (101, N=457) = 367.956,
p<.001, CFI = .92, TLI = .90, RMSEA = .08, SRMR = 0.06. A Chi Square
Difference Test was carried out to determine if the re-specified model provided a
significantly better fit than the hypothesised model. Compared to the hypothesised
model, the re-specified model provided a significantly better fit to the data, χ2diff =
539.464, df = 85, p<.05. Item descriptives and model estimates are summarised in
Table 5.3.
Each of the retained items loaded significantly on their respective factors. The
loadings for seven items on the unconditional permission to eat factor ranged from
.46 to .85. The loadings for five items on the eating for physical rather than
emotional reasons factor ranged from .67 to .88, and loadings for four items on the
reliance on hunger/satiety cues factor ranged from .40 to .80. The three intuitive
eating factors were moderately and positively correlated as shown in Table 5.4.
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Table 5.1
Factor Loadings for Proposed First-order Model of the IES
Item Range Mean (SD) Unstandardised
estimate
Standard
error
Standardised
estimate
UPE
Item 1 1-5 2.41 (1.05) .59 .07 .44**
Item 4 1-5 3.61 (.91) .23 .06 .19**
Item 5 1-5 3.58 (1.18) .74 .09 .48**
Item 9 1-5 2.82 (1.22) 1.34 .11 .84**
Item 14 1-5 3.43 (1.21) .82 .09 .52**
Item 18 1-5 2.72 (1.23) 1.37 .11 .85**
Item 19 1-5 2.25 (1.06) .75 .08 .54**
Item 20 1-5 3.26 (1.23) 1.03 .10 .64**
Item 21 1-5 3.07 (1.33) 1.0 - .58**
EPR
Item 2 1-5 3.47 (1.03) .38 .05 .39**
Item 3 1-5 2.47 (1.18) .99 .04 .87**
Item 6 1-5 2.55 (1.06) .70 .04 .69**
Item 10 1-5 3.01 (1.19) .76 .05 .67**
Item 16 1-5 2.92 (1.71) .98 .04 .87**
Item 17 1-5 2.85 (1.24) 1.0 - .84**
RHSC
Item 7 1-5 3.78 (.79) 1.01 .15 .42**
Item 8 1-5 3.86 (.74) .66 .13 .29**
Item 11 1-5 3.42 (.96) 2.09 .24 .71**
Item 12 1-5 2.96 (1.06) 2.14 .25 .66**
Item 13 1-5 3.15 (1.04) 2.50 .28 .79**
Item 15 2-5 3.84 (.70) 1.0 - .47**
Note. N=457, ** = p<.001. UPE = unconditional permission to eat; EPR = eating for
physical rather than emotional reasons; RHSC = reliance on hunger/satiety cues.
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Figure 5.2. Re-specified model of the IES
Table 5.2
Covariances and Correlations between Factors in the Proposed First-order Model of
the IES
1 2 3
1 UPE - .39** .12**
2 EPR .49** - .12**
3 RHSC .46** .37** -
Note. ** = p<.001; Covariances are presented in the top half of the matrix,
correlations are presented in the bottom half of the matrix. UPE = unconditional
permission to eat; EPR = eating for physical rather than emotional reasons; RHSC =
reliance on hunger/satiety cues.
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Table 5.3
Estimates, Standard Error of Estimates and p-values for Re-Specified Model
Unstandardised
estimate
Standard error Standardised
estimate
UPE
Item 5 .71 .09 .46**
Item 9 1.35 .11 .85**
Item 14 .79 .09 .50**
Item 18 1.36 .11 .85**
Item 19 .73 .08 .53**
Item 20 1.06 .10 .66**
Item 21 1 - .58**
Mean (SD) 3.02 (.85)
EPR
Item 3 .99 .04 .88**
Item 6 .69 .04 .68**
Item 10 .76 .05 .67**
Item 16 .98 .04 .87**
Item 17 1 - .84**
Mean (SD) 2.76 (.98)
RHSC
Item 11 2.48 .33 .72**
Item 12 2.57 .35 .68**
Item 13 2.96 .39 .80**
Item 15 1 - .40**
Mean (SD) 3.34 (.71)
Note. N=457, ** = p<.001. UPE = unconditional permission to eat; EPR = eating for
physical rather than emotional reasons; RHSC = reliance on hunger/satiety cues.
Cronbach alpha for modified UPE subscale = .83, EPR subscale = .89, RHSC
subscale = .74.
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Table 5.4
Covariances and Correlations between Factors in the Re-Specified Model
1 2 3
1 UPE - .41** .10**
2 EPR .51** - .10**
3 RHSC .49** .35** -
Note. ** = p<.001; Covariances are presented in the top half of the matrix,
correlations are presented in the bottom half of the matrix. UPE = unconditional
permission to eat; EPR = eating for physical rather than emotional reasons; RHSC =
reliance on hunger/satiety cues.
Correlations between Eating Behaviours
Descriptive statistics, including mean scores and the Cronbach alpha for each
subscale are presented in Table 5.5. All scales showed good to high levels of internal
consistency. Bivariate correlations were conducted between the three components of
intuitive eating and each of the other eating behaviours: dieting, restrained eating,
bulimia/food preoccupation, emotional eating and external eating. The modified
subscales of the IES resulting from the confirmatory factor analysis were used. Total
IES scores were not calculated for the purpose of this study. Cohen’s criteria for
strength of association was used to interpret all correlations. Cohen suggests a
correlation of .10 is small/weak, .30 is medium/moderate, and .50 is a large/strong
association (Cohen, 1988). These findings are summarised in Table 5.6.
Unconditional permission to eat correlated strongly and negatively with
dieting, restrained eating, and bulimia/food preoccupation. Unconditional permission
to eat was also moderately and negatively associated with emotional eating and
external eating. Eating for physical rather than emotional reasons correlated strongly
and negatively with emotional eating, bulimia/food preoccupation, and external
eating, was moderately and negatively correlated with dieting, and was weakly and
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negatively correlated with restrained eating. Reliance on hunger/satiety cues
correlated moderately and negatively with dieting, restrained eating, bulimia/food
preoccupation and emotional eating, and was weakly and negatively associated with
external eating.
Table 5.5
Mean (SD), Range, Internal Reliability for Eating-related Scales
Scale Mean (SD) Range α
Unconditional permission to eat
3.02 (.85)
1.0-5.0
.83
Eating for physical rather than emotional
reasons
2.76 (.99) 1.0-5.0 .87
Reliance on hunger/satiety cues 3.34 (.71) 1.25-5.0 .75
Dieting 2.89 (.90) 1.0-5.62 .87
Restrained eating 2.79 (.84) 0.90-5.0 .85
Bulimia/food preoccupation 2.14 (.90) 1.0-5.83 .91
Emotional eating 2.48 (1.0) 0.92-5.0 .96
External eating 3.12 (.62) 1.20-4.7 .84
Note. α = Cronbach alpha
Correlations among dieting, restrained eating, bulimia/food preoccupation
were strong and positive, as was the correlation between emotional eating and
external eating. Dieting was moderately and positively associated with emotional
eating, and weakly and positively associated with external eating. Restrained eating
was moderately associated with emotional eating, and weakly associated with
external eating. Bulimia/food preoccupation correlated strongly and positively with
emotional eating and was moderately and positively associated with external eating.
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Table 5.6
Correlations between Intuitive Eating and Other Eating Patterns
1 2 3 4 5 6 7
1 Unconditional
permission to eat
-
2 Eating for physical
rather than
emotional reasons
.44** -
3 Reliance on
hunger/satiety cues
.39** .30** -
4 Dieting -.78** -.37** -.38** -
5 Bulimia/food
preoccupation
-.62** -.53** -.40** .73** -
6 Restrained eating -.70** -.27** -.32** .80** .53** -
7 Emotional eating -.43** -.84** -.33** .42** .57** .34** -
8 External eating -.28** -.51** -.19** .21** .39** .14** .56**
Note. ** p<.001
Exploratory Factor Analysis of Intuitive Eating and Other Eating Behaviours
To address the second aim of the study, principal axis factoring was
conducted using the modified subscales of the IES; the dieting and bulimia/food
preoccupation subscales of the EAT-26 (Garner et al., 1982); and the restrained
rating, emotional eating and external eating scales of the DEBQ (Van Strien et al.,
1986). The Kaiser-Meyer-Olkin measure of sampling adequacy for all variables was
adequate (.81) according to cut-offs recommended by Hutcheson and Sofroniou
(1999). Measures of sampling adequacy for individual scales demonstrated that three
of the eight scales reported good sampling adequacy: eating for physical rather than
emotional reasons (.74), emotional eating (.75), and dieting (.76). All other scales
reported great sampling adequacy (ranging from .81 to .96). Bartlett’s test of
sphericity, χ2 (457) = 2335.60, p<.001, indicated that correlations between items
119
were sufficient in size to conduct principal axis factoring. Direct oblimin rotation
(oblique) was applied as the factors were expected to be correlated (Tabachnick &
Fidell, 2007) and eigenvalues were assessed.
Two factors had eigenvalues over Kaiser’s criterion of 1 (Kaiser, 1960) and
these factors explained 64.56% of the variance. The scree plot (Cattell, 1966) also
suggested the presence of two factors. A criterion of .45 (20% overlap between
variable and factor) was used for defining significant loadings (Comrey & Lee,
1992). Factor loadings after rotation are summarised in Table 5.7.
The first factor had high positive loadings on restrained eating, dieting,
bulimia/food preoccupation and a high negative loading on unconditional permission
and was labelled “disordered eating”. The disordered eating factor explained 49.84%
of the variance in these eating patterns. The second factor had a high positive loading
on eating for physical rather than emotional reasons and high negative loadings on
emotional eating and external eating. This factor was labelled “eating for non-
emotional/non-external reasons”. The eating for non-emotional/non-external reasons
factor explained 14.72% of the variance in these eating patterns. Reliance on
hunger/satiety cues did not load on either factor. Factor scores were computed using
the regression method.
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Table 5.7
Pattern Matrix with Rotated Factor Loadings
Disordered
eating
Eating for non-
emotional/non-
external reasons
Communality
IES
Unconditional permission
to eat
-.79 .08 .69
Eating for physical rather
than emotional reasons
-.02 .87 .78
Reliance on
hunger/satiety cues
-.35 .18 .21
EAT-26
Dieting 1.01 .09 .94
Bulimia/food
preoccupation
.58 -.32 .63
DEBQ
Restrained eating .88 .13 .68
Emotional eating .04 -.91 .88
External eating -.02 -.61 .36
Eigenvalue 3.99 1.18
Factor correlation -.49
Variance (%) 49.84 14.72
Total variance 64.56
Discussion
Part one of the empirical study had two aims. The first aim of the study was
to examine the factor structure of the IES (Tylka, 2006) in a community sample of
adult women. This was conducted using confirmatory factor analysis. The second
121
aim of the study was to examine the three aspects of intuitive eating (i.e.,
unconditional permission to eat, eating for physical rather than emotional reasons,
and reliance on hunger/satiety cues) in relation to the following eating patterns:
dieting, restrained eating, bulimia/food preoccupation, emotional eating, and external
eating. These relationships were examined using principal axis factoring.
The confirmatory factor analysis demonstrated that the three-factor structure
of the IES (unconditional permission to eat, eating for physical rather than emotional
reasons, and reliance on hunger/satiety cues) was upheld for a community sample of
adult women which was more diverse with regards to age and weight status, in
comparison to the student samples used in the initial validation of the scale (Tylka,
2006).However, the scale was modified, with the removal of five items included in
the original version of the scale.
Two items were removed from the unconditional permission to eat subscale.
The content of Item 1 (“I try to avoid certain foods high in fat, carbohydrates, or
calories”) overlapped with Item 18 (“I feel guilty if I eat a certain food that is high in
calories, fat, or carbohydrates”); and Item 4 (“If I am craving a certain food, I allow
myself to have it”) overlapped with Item 14 (“I have forbidden foods that I don’t
allow myself to eat”). Thus, these items may not have been contributing any new
information.
One item, Item 2 (“I stop eating when I feel full (not overstuffed)”), was
removed from the eating for physical rather than emotional reasons subscale. The
focus of this item was on physical feelings of fullness whereas all the retained items
were focused on emotions associated with eating (e.g., “I find myself eating when I
am stressed out, even when I’m not physically hungry”). It was also the only item in
the subscale that was not reverse-scored (i.e., was positively framed).
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Two items were removed from the reliance on hunger/satiety cues subscale:
Item 7 (“I can tell when I’m slightly full”) and Item 8 (“I can tell when I’m slightly
hungry”). In both of these items, the focus was on assessing hunger and/or satiety,
however, the emphasis was on an awareness of being “slightly” hungry or “slightly”
full. Therefore, these items may not have been sufficiently sensitive to assess the
intended construct and discriminate between degrees of reliance on hunger/satiety.
Each of the retained items were more explicitly worded (e.g., “When I’m eating, I
can tell when I’m getting full”, “I trust my body when to eat”).
This was the first study to examine the factor structure of the original IES
since its development and validation in a sample of female university students
(Tylka, 2006). The original scale was validated in a sample of undergraduate
psychology students with a mean age of 20 years, who were primarily White, were of
a higher socioeconomic status, and lived in the United States. The community
sample used in this study were women with a mean age of 38.15 years, who
identified as Australian and/or British/European, and were mostly tertiary educated,
engaged in paid employment, and were married or in a de facto relationship.
Therefore, it is possible that the deleted items may not be as relevant for a
community sample. It is important to highlight that, with the exception of the two
items that were removed from the unconditional permission to eat subscale (i.e., “I
try to avoid certain foods high in fat, carbohydrates, or calories” and “If I am craving
a certain food, I allow myself to have it”), the items deleted in this study have not
been included in the revised IES-2 (Tylka & Kroon Van Diest, 2013). Additional
studies are needed to examine the factor structure of the original scale (Tylka, 2006)
in other community samples of adult women, to further examine whether the same
items need to be deleted. In addition, the factor structure needs to also be examined
123
more fully with samples that differ according to age, level of education, cultural
background and socioeconomic status.
Extending this research using the IES-2 (Tylka & Kroon Van Diest, 2013) is
also needed6. The scale was intentionally revised to incorporate a greater proportion
of items that are worded positively to capture the presence of intuitive eating,
compared to the original IES, which includes a majority of items that are negatively
worded to capture the absence of intuitive eating. Moreover, the IES-2 includes
additional items that were not part of the original IES, and includes is a fourth
subscale that assesses food choices that benefit health - body-food choice congruence
(e.g., “I mostly eat foods that give my body energy and stamina”). The IES-2 was
developed and validated in a sample of 2600 primarily male and female university
students, and a four-factor structure was obtained. Three subsequent studies have
examined the factor structure of three separate versions of the IES-2 translated into
French (Camilleri et al., 2015; Carbonneau et al., 2016) and German (van Dyck et
al., 2016). Camilleri and colleagues (2015) did not replicate the factor structure in a
community sample of 632 French women and men, with a mean age of 48.5 years
(Camilleri et al., 2015), whereas two later studies did replicate the four-factor
structure, in a sample of 409 French-Canadian women and men (Carbonneau et al.,
2016) and in a German sample of 1134 primarily female university students (van
Dyck et al., 2016). However, since the study conducted by Tylka and Kroon Van
Diest (2013), there has been no further examination of the factor structure of the
original English version of the IES-2.
6 The IES-2 (Tylka & Kroon Van Diest, 2013) was not available at the commencement of the
empirical study, therefore, the original IES (Tylka, 2006) was used to assess intuitive eating.
124
To address the second aim of the study, principal axis factoring was
conducted to examine the three subscales of the IES (i.e., unconditional permission
to eat, eating for physical rather than emotional reasons, and reliance on
hunger/satiety cues) in relation to the other eating behaviours. Principal axis
factoring demonstrated that two of the three subscales overlap with other eating
patterns. Unconditional permission to eat was not found to be conceptually distinct
from the following aspects of disordered eating: dieting, restrained eating, and
bulimia/food preoccupation. Specifically, the factor analysis showed that
unconditional permission to eat loaded highly on the first factor with dieting,
restrained eating and bulimia/food preoccupation, and was labelled ‘disordered
eating’. This in line with previous studies that have demonstrated substantial overlap
between the unconditional permission to eat subscale and aspects of disordered
eating, including dieting and bulimia/food preoccupation (Anderson et al., 2016;
Tylka & Wilcox, 2006; Tylka & Kroon Van Diest, 2013; van Dyck et al., 2016).
Therefore, this study and other studies suggest that the unconditional permission to
eat subscale is also assessing disordered eating.
The second subscale of the IES, eating for physical rather than emotional
reasons, was not found to be distinct from emotional eating and external eating.
Eating for physical rather than emotional reasons, emotional eating and external
eating all loaded onto the second factor. This factor was labelled ‘eating for non-
emotional/non-external reasons’. Two other studies have examined this subscale with
emotional and external eating (Camilleri et al., 2015; van Dyck et al., 2016). In both
studies, eating for physical rather than emotional reasons was most strongly
associated with emotional eating. The study conducted by van Dyck et al. (2016) also
found that the eating for physical rather than emotional reasons subscale was
moderately related to external eating, whereas unconditional permission to eat and
125
reliance on hunger/satiety cues were weakly related to external eating. Overall, this
study and other studies suggest that the eating for physical rather than emotional
reasons subscale is also assessing emotional eating and external eating.
The third aspect of intuitive eating, reliance on hunger/satiety cues, did not
load onto either the disordered eating or eating for non-emotional/non-external eating
factors. This suggests that reliance on hunger/satiety cues is a more distinct pattern of
eating from other eating behaviours. These findings are consistent with Tylka and
Wilcox (2006), and Tylka and Kroon Van Diest (2013), who demonstrated that
reliance on hunger/satiety cues was distinct from aspects of disordered eating,
including dieting and bulimia/food preoccupation. Other more recent studies have
demonstrated that this aspect of intuitive eating is weakly to moderately associated
with aspects of disordered eating, including restrained eating, and overall disordered
eating symptoms (Anderson et al., 2016; Camilleri et al., 2015). One exception is the
study conducted by van Dyck et al. (2016), which found a strong relationship in
German women for the reliance on hunger/satiety cues subscale with restrained
eating and symptoms of bulimia.
Further studies are needed to examine the relationship between aspects of
intuitive eating and other patterns of eating. This should include an examination of
the subscales of the IES-2 (Tylka & Kroon Van Diest, 2013). The revised scale
includes a greater proportion of positively-worded items that capture the presence of
intuitive eating, whereas a majority of items in the original IES assess the absence of
intuitive eating. Moreover, the IES-2 contains a fourth subscale labelled body-food
choice congruence. Body-food choice congruence has been examined in three
studies. One study found this aspect of intuitive eating was moderately and
negatively associated with symptoms of bulimia (Carbonneau et al., 2016), while two
126
studies have demonstrated that body-food choice congruence was not related to
restrained eating, emotional eating, external eating, symptoms of bulimia (van Dyck
et al., 2016), or overall symptoms of disordered eating (Tylka & Kroon Van Diest,
2013). Further studies are needed to examine which subscales of the IES-2 may
differentiate intuitive eating behaviours from disordered eating behaviours more than
the IES (Tylka, 2006).
127
CHAPTER SIX
Empirical Study: Results and Discussion Part Two
This chapter presents results and a discussion of findings from the second
part of the empirical study. The second part set out to examine the psychosocial
correlates of intuitive eating and disordered eating, with a focus on the similarities
and differences in these psychosocial correlates. Initially, the study sought to
compare the psychosocial correlates of the three intuitive eating factors (i.e.,
unconditional permission to eat, eating for physical rather than emotional reasons,
and reliance on hunger/satiety cues) with disordered eating and other eating patterns
(i.e., dieting, restrained eating, bulimia/food preoccupation, emotional eating, and
external eating). However, the factor analysis conducted in Chapter Five
demonstrated that two of three intuitive eating subscales overlapped with the other
eating patterns. Unconditional permission to eat loaded onto the disordered eating
factor, along with dieting, restrained eating and bulimia/food preoccupation. Eating
for physical rather than emotional reasons loaded onto the eating for non-
emotional/non-external reasons factor, along with emotional eating and external
eating. Only reliance on hunger/satiety cues was found to load on neither factor.
Therefore, the aims were modified to incorporate the outcomes of the factor analysis.
Instead, the study investigated the psychosocial correlates of the two factors:
disordered eating, eating for non-emotional/non-external reasons, and the subscale
from the modified IES, reliance on hunger/satiety cues.
The psychosocial variables outlined in Chapter Four were selected from the
main variables that have been shown to be related to intuitive eating (see Chapter
Three) and disordered eating (e.g., Pennesi & Wade, 2016; Stice, 2002). The
variables included: perceived social support, body acceptance by others, body
128
function, body appreciation, pressure for thinness, internalisation of the thin-ideal,
body area satisfaction, appearance evaluation, and negative affect. In addition to
examining bivariate correlations between psychosocial factors and the three eating
patterns, the psychosocial factors were incorporated into two models of eating based
on the acceptance model (Avalos & Tylka, 2006; Augustus-Horvath & Tylka, 2011)
and the modified dual pathway model (Stice, 2001; Stice & Agras, 1998). Before
examining these relationships, the association between each of the three eating
patterns with demographic variables, age, education level, and BMI, were assessed.
Age, Education, and BMI
Bivariate correlations were conducted for each of the three eating patterns
with age, level of education, and BMI. Correlations are summarised in Table 6.1.
Age and BMI did not correlate significantly with disordered eating, eating for non-
emotional/non-external reasons, or a reliance on hunger/satiety cues. Level of
education did not correlate with disordered eating or a reliance on hunger/satiety
cues, but was weakly and negatively associated with eating for non-emotional/non-
external reasons.
Table 6.1
Correlations between Eating Patterns, Age, Education, and BMI
1 2 3
1 Disordered eating
2 Eating for non-emotional/non-
external reasons
-.51**
3 Reliance on hunger/satiety cues -.44** .36**
4 BMI .02 -.08 -.04
5 Age -.03 .05 -.06
6 Education level .04 -.11* -.02
Note. ** p<.01; * p<.05
129
Bivariate Correlations between Eating Patterns and Psychosocial Variables
Bivariate correlations were examined between the three eating patterns and
each of the following psychosocial variables: perceived social support, body
acceptance by others, body function, body appreciation, pressure for thinness,
internalisation of the thin-ideal, body area satisfaction, appearance evaluation, and
negative affect. Means, standard deviations and correlations are summarised in Table
6.2.
Disordered eating was strongly and negatively correlated with appearance
evaluation, body appreciation, and body function; moderately and negatively
correlated with body area satisfaction and body acceptance by others; and weakly
and negatively associated with perceived social support. Higher levels of disordered
eating were moderately associated with greater pressure for thinness and
internalisation of the thin ideal, and higher levels of negative affect.
Eating for non-emotional/non-external reasons was moderately and positively
associated with appearance evaluation, body area satisfaction, body appreciation,
body function, and body acceptance by others. Eating for non-emotional/non-
external reasons were moderately and negatively correlated with pressure for
thinness, internalisation of the thin-ideal, and negative affect. Additionally, eating for
non-emotional/non-external reasons correlated weakly and positively with perceived
social support.
Reliance on hunger/satiety cues correlated moderately and positively with
appearance evaluation, body area satisfaction, body appreciation, and body
acceptance by others. In addition, a greater reliance on hunger/satiety cues was
weakly associated with greater body function and higher levels of perceived social
130
support, less pressure for thinness, lower levels of internalisation of the thin-ideal,
and lower levels of negative affect.
As shown in Table 6.2, the three body image variables were strongly
interrelated: appearance evaluation, body area satisfaction, and body appreciation
(ranging from r= .80 to .87). An exploratory factor analysis was conducted to
determine if these three variables might be better represented as a single body image
factor. Principal axis factoring was conducted to test the factor structure of the three
body image variables (see Appendix C). All three variables loaded onto a single
factor which accounted for 83% of the variance. This factor was labelled “body
satisfaction”. Factor scores were computed using the regression method, for use in
the model that was based on the acceptance model. Higher scores were indicative of
a more positive body image. Factor scores were also reversed to create a “body
dissatisfaction” factor, for use in the model that was based on the dual pathway
model.
131
Table 6.2
Mean, Standard Deviation (SD), and Bivariate Correlations for Psychosocial Factors and Eating Patterns
1 2 3 4 5 6 7 8 9 10 11
1 Disordered eating -
2 Eating for non-emotional/non-external reasons -.51 -
3 Reliance on hunger/satiety cues -.44 .36 -
4 Perceived social support -.29 .19 .21 -
5 Body acceptance by others -.39 .31 .36 .45 -
6 Body function -.53 .32 .22 .18 .23 -
7 Body appreciation -.61 .46 .45 .43 .62 .50 -
8 Pressure for thinness .45 -.45 -.23 -.25 -.51 -.38 -.52 -
9 Internalisation of thin-ideal .46 -.32 -.14 -.19 -.15 -.55 -.45 .38 -
10 Appearance evaluation -.51 .41 .44 .43 .64 .39 .82 -.50 -.32 -
11 Body area satisfaction -.48 .39 .42 .44 .63 .39 .80 -.51 -.31 .87 -
12 Negative affect .41 -.37 -.19 -.38 -.24 -.33 -.42 .37 .35 -.32 -.34
Mean
SD
0
.98
0
.96
3.34
.71
81.26
10.71
3.41
.83
3.56
1.17
44.00
10.87
1.23
.85
2.74
.90
3.1
.93
3.19
.75
Note. All correlations significant, p<.001
132
Psychosocial Predictors of Disordered Eating, Eating for Non-emotional/Non-
external Reasons, and Reliance on Hunger/Satiety cues
Following the calculation of bivariate correlations between psychosocial
factors and the three eating patterns, the psychosocial model based on the acceptance
model of intuitive eating7 (Model I), and another model based on the dual pathway
model of disordered eating (Model II), were tested with each of the three eating
patterns as outcome variables. Models I is presented in Figure 6.1. Model II is
presented in Figure 6.2.
Figure 6.1. Model I – Modified acceptance model for the three eating patterns:
disordered eating, eating for non-emotional and external reasons and reliance on
hunger/satiety cues.
7 The acceptance model was modified due to the overlap between the body appreciation, body area
satisfaction, and appearance evaluation variables. These three variables loaded onto a common factor
labelled ‘body satisfaction’. This factor was incorporated into the model, replacing the body
appreciation variable in the original acceptance model (Augustus-Horvath & Tylka, 2011; Avalos &
Tylka, 2006).
133
Figure 6.2. Model II - Modified dual pathway model for the three eating patterns:
disordered eating, eating for non-emotional and external reasons and reliance on
hunger/satiety cues.
For Model I, the following paths were hypothesised: perceived social support
was hypothesised to predict greater body acceptance by others and a greater focus on
body function; body acceptance by others was expected to predict a greater focus on
body function; and body function was expected to predict greater body satisfaction.
A focus on body function and greater body satisfaction were hypothesised to predict
less disordered eating, higher levels of eating for non-emotional/non-external
reasons, and greater reliance on hunger/satiety cues.
For Model II, the following paths were included: pressure for thinness was
hypothesised to predict greater internalisation of the thin-ideal and body
dissatisfaction; greater internalisation was expected to predict greater body
dissatisfaction; and greater body dissatisfaction was expected to predict higher levels
of negative affect. Body dissatisfaction and negative affect were hypothesised to
134
predict higher levels of disordered eating, less eating for non-emotional/non-external
reasons and less reliance on hunger/satiety cues.
Six path analyses (three for Model 1 and three for Model II) were conducted
using the Maximum Likelihood method of estimation in SPSS Amos version 22. The
size of the sample exceeded the recommended number of cases required to estimate
parameters for each of the six models (Tabachnick & Fidell, 2007). Path models
were assessed using the Model Chi Square test (χ2) (p>.05) in addition to the
following model fit indices: CFI, TLI, SRMR, and RMSEA. Re-specification of
models was conducted by using modification indices.
Model Based on the Acceptance Model of Intuitive Eating
Model I, based on the acceptance model of intuitive eating, was examined
with disordered eating as the outcome variable. The model did not provide a good fit
to the data, χ2 (4, N=457) = 273.44, p<.001, CFI = .63, TLI = .08, RMSEA = .38,
SRMR = 0.20. In addition, the path from perceived social support to body function
was not significant (p=.06). Initial estimates of the model are presented in Table 6.3.
Modification indices indicated that the addition of paths from perceived social
support to body satisfaction, and from body acceptance by others to body satisfaction
would improve model fit. The two paths were added and the re-specified model
tested.
135
Table 6.3
Initial Estimates for Model I – Modified Acceptance Model with Disordered Eating
as the Outcome
Parameter
estimate
Unstandardised
estimate
Standard
error
Standardised
estimate
p
Body
acceptance by
others
Perceived
social
support
.04 .00 .45 <.001
Body function
Perceived
social
support
.01 .01 .10 .056
Body
acceptance
by others
.27 .07 .19 <.001
Body
satisfaction
Body
function
.36 .04 .44 <.001
Disordered
eating
Body
satisfaction
-.40 .04 -.39 <.001
Body
function
-.30 .03 -.36 <.001
The re-specified model provided a good fit to the data, χ2 (2, N=457) = 3.71,
p=.16, CFI = 1.0, TLI = .99, RMSEA = .04, SRMR = 0.02. Compared to the initial
model, the re-specified model provided a significantly better fit to the data, χ2diff =
269.73, df = 2, p<.05. However, the path from perceived social support to body
function remained non-significant (p=.06). This path was removed and the re-
specified model tested. The model with the path removed provided a good fit to the
136
data, χ2 (3, N=457) = 7.35, p=.06, CFI = .99, TLI = .98, RMSEA = .06, SRMR =
0.03. A chi square difference test was conducted on the two re-specified models (i.e.,
models with and without the path from perceived social support to body function).
There was not a significant difference in fit between the two re-specified models,
χ2diff = 3.64, df = 1, p>.05. Therefore, the model with the path removed from
perceived social support to body function was retained as a more parsimonious
model. Overall, the model accounted for 41% of the variance in disordered eating.
The final model is presented in Figure 6.3 and final estimates are presented in Table
6.4.
Figure 6.3. Re-specified Model I – Modified acceptance model with disordered
eating as the outcome.
137
As shown in Figure 6.3 and Table 6.4, higher levels of perceived social
support predicted greater body acceptance by others, and greater body acceptance by
others predicted a greater focus on body function. Higher levels of perceived social
support, body acceptance by others, and more of a focus on body function predicted
greater body satisfaction. Greater body satisfaction and a focus on body function
predicted lower levels of disordered eating. Women who reported being more
satisfied with their body or focused more on how their body functions rather than
appearance, reported engaging in less disordered eating.
Table 6.4
Final Estimates for Model I - Modified Acceptance Model with Disordered Eating as
the Outcome
Parameter
estimate
Unstandardised
estimate
Standard
error
Standardised
estimate
p
Body
acceptance by
others
Perceived
social
support
.04 .00 .45 <.001
Body function
Body
acceptance
by others
.33 .07 .23 <.001
Body
satisfaction
Body
function
.23 .03 .28 <.001
Perceived
social
support
.02 .00 .17 <.001
Body
acceptance
by others
.62 .04 .53 <.001
138
Parameter
estimate
Unstandardised
estimate
Standard
error
Standardised
estimate
p
Disordered
eating
Body
satisfaction
-.40 .04 -.39 <.001
Body
function
-.30 .03 -.36 <.001
Model I was examined with eating for non-emotional/non-external reasons as
the outcome variable. The model did not provide a good fit to the data, χ2 (4, N=457)
= 270.47, p<.001, CFI = .56, TLI = -.14, RMSEA = .38, SRMR = 0.19. The path
from perceived social support to body function was non-significant (p=.06). Initial
estimates of the model are presented in Table 6.5. Modification indices indicated that
the inclusion of a path from body acceptance by others to body satisfaction, and from
perceived social support to body satisfaction would improve model fit. These paths
were added and the re-specified model was tested. The re-specified model provided
an acceptable fit to the data, χ2 (2, N=457) = 0.73, p=.69, CFI = 1.0, TLI = 1.01,
RMSEA = .00, SRMR = 0.01. A chi square difference test showed that compared to
the initial model, the re-specified model provided a significantly better fit to the data,
χ2diff = 269.74, df = 2, p<.05. However, the path from perceived social support to
body function remained non-significant (p=.06). This path was removed and the re-
specified model tested. This model provided a good fit to the data, χ2 (3, N=457) =
4.37, p=.22, CFI = 1.0, TLI = .99, RMSEA = .03, SRMR = 0.02. A chi square
difference test reported that there was not a significant difference in fit between the
two re-specified models, χ2diff = 3.64, df = 1, p>.05. The re-specified model with the
path removed from perceived social support to body function was retained as the
more parsimonious model. Overall, the model accounted for 21% of the variance in
139
eating for non-emotional/non-external reasons. The final model with eating for non-
emotional/non-external reasons is presented in Figure 6.4 and final estimates are
presented in Table 6.6.
Table 6.5
Initial Estimates for Model I - Modified Acceptance Model with Eating for Non-
emotional/Non-external reasons as the Outcome
Parameter
estimate
Unstandardised
estimate
Standard
error
Standardised
estimate
p
Body acceptance
by others
Perceived
social support
.04 .00 .45 <.001
Body function
Perceived
social support
.01 .01 .10 .056
Body
acceptance by
others
.27 .07 .19 <.001
Body satisfaction
Body function .36 .04 .44 <.001
Eating for non-
emotional/non-
external reasons
Body
satisfaction
.37 .05 .37 <.001
Body function .13 .04 .16 <.001
140
Figure 6.4. Re-specified Model I - Modified acceptance model with non-
emotional/non-external reasons as the outcome.
As demonstrated in Figure 6.4 and Table 6.6, greater perceived social support
predicted greater body acceptance by others; greater body acceptance by others
predicted a greater focus on body function; and higher levels of perceived social
support, body acceptance by others, and a focus on body function predicted greater
body satisfaction. A greater focus on body function and greater body satisfaction
predicted higher levels of eating for non-emotional/non-external reasons. Women
were more likely to eat for non-emotional/non-external reasons if they focused more
on body function over appearance, or were more satisfied with their bodies.
141
Table 6.6
Final Estimates for Model I - Modified Acceptance Model with Eating for Non-
emotional/Non-external Reasons as the Outcome
Parameter
estimate
Unstandardised
estimate
Standard
error
Standardised
estimate
p
Body acceptance
by others
Perceived
social support
.04 .00 .45 <.001
Body function
Body
acceptance by
others
.33 .07 .23 <.001
Body satisfaction
Body function .23 .03 .28 <.001
Perceived
social support
.02 00 .17 <.001
Body
acceptance by
others
.62 .04 .53 <.001
Eating for non-
emotional/non-
external reasons
Body
satisfaction
.37 .05 .37 <.001
Body function .13 .04 .16 <.001
Model I was examined with reliance on hunger/satiety cues as the outcome
variable. The initial model did not provide a good fit to the data, χ2 (4, N=457) =
272.39, p<.001, CFI = .55, TLI = -.12, RMSEA = .38, SRMR = 0.20. The paths from
perceived social support to body function (p=.06), and from body function to reliance
on hunger/satiety cues (p=.53) were non-significant. Initial estimates of the model
are presented in Table 6.7. Modification indices indicated that the inclusion of a path
142
from body acceptance by others to body satisfaction, and from perceived social
support to body satisfaction would improve model fit. These paths were added and
the re-specified model was tested. The re-specified model provided a good fit to the
data, χ2 (2, N=457) = 2.65, p=.27, CFI = 1.0, TLI = 1.0, RMSEA = .03, SRMR =
0.01. The chi square difference test indicated that the re-specified model provided a
significantly better fit to the data, χ2diff = 269.74, df = 2, p<.05. However, the paths
from perceived social support to body function, and from body function to reliance
on hunger/satiety cues remained non-significant. These two paths were deleted and
the re-specified model was tested. The model provided a good fit to the data, χ2 (4,
N=457) = 6.69, p=.15, CFI = 1.0, TLI = .99, RMSEA = .04, SRMR = 0.03, however,
the two re-specified models were not significantly different in their fit to the data,
χ2diff = 4.04, df = 2, p>.05. The re-specified model with the two removed paths from
perceived social support to body function, and from body function to reliance on
hunger/satiety cues was retained as the more parsimonious model. Overall, the model
explained 21% of the variance in reliance on hunger/satiety cues. The final model is
presented in Figure 6.5 and final estimates are provided in Table 6.8.
143
Table 6.7
Initial Estimates for Model I - Modified Acceptance Model with Reliance on
Hunger/Satiety cues as the Outcome
Parameter
estimate
Unstandardised
estimate
Standard
error
Standardised
estimate
p
Body
acceptance by
others
Perceived
social
support
.04 .00 .45 <.001
Body function
Perceived
social
support
.01 .01 .10 .056
Body
acceptance
by others
.27 .07 .19 <.001
Body
satisfaction
Body
function
.36 .04 .44 <.001
Reliance on
hunger/satiety
cues
Body
satisfaction
.33 .03 .45 <.001
Body
function
.02 .03 .03 .53
144
Figure 6.5. Re-specified Model I - Modified acceptance model with reliance on
hunger/satiety cues as the outcome.
Figure 6.5 and Table 6.8 summarise findings for the modified acceptance
model with reliance on hunger/satiety cues subscale as the outcome. Higher levels of
perceived social support predicted greater body acceptance by others; body
acceptance by others predicted a greater focus on body function; and higher levels of
perceived social support, body acceptance by others, and a focus on body function
predicted greater body satisfaction. Greater body satisfaction predicted a greater
reliance on hunger/satiety cues. Women were more likely to rely on hunger/satiety
cues for eating if they reported greater satisfaction with their bodies.
145
Table 6.8
Final Estimates for Model I - Modified Acceptance Model with Reliance on
Hunger/Satiety Cues as the Outcome
Parameter
estimate
Unstandardised
estimate
Standard
error
Standardised
estimate
p
Body
acceptance by
others
Perceived
social
support
.04 .00 .45 <.001
Body function
Body
acceptance
by others
.33 .07 .23 <.001
Body
satisfaction
Body
function
.23 .03 .28 <.001
Perceived
social
support
.02 00 .17 <.001
Body
acceptance
by others
.62 .04 .53 <.001
Reliance on
hunger/satiety
cues
Body
satisfaction
.34 .03 .46 <.001
146
Model Based on the Dual Pathway Model of Disordered Eating
Model II with disordered eating as an outcome variable was tested. The
hypothesised model did not provide a good fit to the data, χ2 (4, N=457) = 91.25,
p<.001, CFI = .85, TLI = .63, RMSEA = .22, SRMR = 0.11. Initial estimates for the
model are presented in Table 6.9. Modification indices indicated the inclusion of a
path from pressure for thinness to negative affect, from internalisation of the thin-
ideal to negative affect, and from internalisation of the thin-ideal to disordered eating
would improve model fit. These paths were added to the re-specified model. The re-
specified model provided a better fit to the data, χ2 (1, N=457) = 6.26, p<.001, CFI =
.99, TLI = .91, RMSEA = .11, SRMR = 0.02. A chi square difference test also
showed that the final model was a significantly better fitting model than the initial
one, χ2diff = 84.99, df = 3, p<.05. Overall, the model explained 41% of the variance in
disordered eating. The final model is presented in Figure 6.6 and final estimates are
summarised in Table 6.10.
147
Table 6.9
Initial Estimates for Model II – Modified Dual Pathway Model with Disordered
Eating as the Outcome
Parameter
estimate
Unstandardised
estimate
Standard
error
Standardised
estimate
p
Thin-ideal
internalisation
Pressure for
thinness
.40 .05 .38 <.001
Negative affect
Body
dissatisfaction
2.83 .34 .36 <.001
Body
dissatisfaction
Pressure for
thinness
.53 .05 .47 <.001
Thin-ideal
internalisation
.20 .05 .18 <.001
Disordered
eating
Body
dissatisfaction
.47 .04 .47 <.001
Negative
affect
.03 .01 .24 <.001
148
Figure 6.6. Re-specified Model II – Modified dual pathway model with
disordered eating as the outcome.
As shown in Figure 6.6 and Table 6.10, greater pressure for thinness
predicted greater internalisation of the thin-ideal, greater body dissatisfaction, and
higher levels of negative affect. In addition, thin-ideal internalisation moderately
predicted greater body dissatisfaction and negative affect; and body dissatisfaction
predicted higher levels of negative affect. Greater internalisation of the thin-ideal,
body dissatisfaction, and negative affect predicted higher levels of disordered eating.
Women were more likely to engage in disordered eating if they were dissatisfied
with their bodies, internalised the thin-ideal, or experienced negative affect.
149
Table 6.10
Final Estimates for Model II - Modified Dual Pathway Model with Disordered
Eating as the Outcome
Parameter
estimate
Unstandardised
estimate
Standard
error
Standardised
estimate
p
Thin-ideal
internalisation
Pressure for
thinness
.40 .05 .38 <.001
Negative affect
Body
dissatisfaction
1.42 .39 .18 <.001
Pressure for
thinness
1.73 .39 .20 <.001
Thin-ideal
internalisation
1.75 .45 .21 <.001
Body
dissatisfaction
Pressure for
thinness
.53 .05 .47 <.001
Thin-ideal
internalisation
.20 .05 .18 <.001
Disordered
eating
Body
dissatisfaction
.40 .04 .40 <.001
Negative
affect
.02 .01 .17 <.001
Thin-ideal
internalisation
.28 .04 .26 <.001
The next model tested was Model II with eating for non-emotional/non-
external reasons as the outcome. The model did not provide a good fit to the data, χ2
(4, N=457) = 76.64, p<.001, CFI = .86, TLI = .64, RMSEA = .20, SRMR = 0.10.
Initial model estimates are presented in Table 6.11. Modification indices indicated
150
the inclusion of a path from pressure for thinness to negative affect and to eating for
non-emotional/non-external reasons, and from internalisation of the thin-ideal to
negative affect would improve model fit. The re-specified model is presented in
Figure 6.7. The final model provided a better fit to the data, χ2 (1, N=457) = 4.27,
p=.039, CFI = .99, TLI = .94, RMSEA = .09, SRMR = 0.10. A chi square difference
test was conducted between the initial and re-specified models to assess the fit.
Compared to the initial model, the final model provided a significantly better fit to
the data, χ2diff = 72.37, df = 3, p<.05. Overall, the model explained 29% of the
variance in eating for non-emotional/non-external reasons.
Table 6.11
Initial Estimates for Model II – Modified Dual Pathway Model with Eating for Non-
emotional/Non-external Reasons as the Outcome
Parameter
estimate
Unstandardised
estimate
Standard
error
Standardised
estimate
p
Thin-ideal
internalisation
Pressure for
thinness
.40 .05 .38 <.001
Negative affect
Body
dissatisfaction
2.83 .34 .36 <.001
Body
dissatisfaction
Pressure for
thinness
.53 .05 .47 <.001
Thin-ideal
internalisation
.20 .05 .18 <.001
Eating for non-
emotional/non-
external reasons
Body
dissatisfaction
-.35 .04 -.35 <.001
Negative affect -.03 .01 -.25 <.001
151
As shown in Figure 6.7 and Table 6.12., pressure for thinness predicted
higher levels of thin-ideal internalisation; pressure for thinness and thin-ideal
internalisation predicted greater body dissatisfaction; and pressure for thinness, thin-
ideal internalisation and body dissatisfaction predicted higher levels of negative
affect. Higher levels of body dissatisfaction, negative affect, and greater pressure for
thinness were associated with less eating for non-emotional/non-external reasons.
Women were less likely to engage in eating for non-emotional/non-external reasons
if they were dissatisfied with their bodies, felt the pressure to be thin, or experienced
negative affect.
Figure 6.7. Re-specified Model II – Modified dual pathway model with eating for
non-emotional/non-external reasons as the outcome.
152
Table 6.12
Final Estimates for Model II - Modified Dual Pathway Model with Eating for Non-
emotional/Non-external Reasons as the Outcome
Parameter
estimate
Unstandardised
estimate
Standard
error
Standardised
estimate
p
Thin-ideal
internalisation
Pressure for
thinness
.40 .05 .38 <.001
Negative affect
Body
dissatisfaction
1.42 .39 .18 <.001
Pressure for
thinness
1.74 .45 .20 <.001
Thin-ideal
internalisation
1.75 .39 .21 <.001
Body
dissatisfaction
Pressure for
thinness
.53 .05 .47 <.001
Thin-ideal
internalisation
.20 .05 .18 <.001
Eating for non-
emotional/non-
external reasons
Body
dissatisfaction
-.23 .05 -.23 <.001
Negative affect -.02 .01 -.19 <.001
Pressure for
thinness
-.29 .05 -.26 <.001
Model II was tested with reliance on hunger/satiety cues as an outcome
variable. The model did not provide an acceptable fit to the data, χ2 (4, N=457) =
45.30, p<.001, CFI = .91, TLI = .77, RMSEA = .15, SRMR = 0.07. Initial estimates
are presented in Table 6.13. The path from negative affect to intuitive eating was
153
non-significant (p=.59). Modification indices indicated the inclusion of a path from
internalisation of the thin-ideal to negative affect would improve model fit. This path
was added and the re-specified model tested. The re-specified model provided an
acceptable fit to the data, χ2 (3, N=457) = 15.50, p=.001, CFI = .97, TLI = .91,
RMSEA = .10, SRMR = 0.03. Compared to the initial model, the re-specified model
provided a significantly better fit to the data, χ2diff = 29.80, df = 1, p<.05. However,
the path from negative affect to reliance on hunger/satiety cues remained non-
significant (p=.59). This path was deleted and the re-specified model tested. This
model provided a good fit to the data, χ2 (4, N=457) = 15.79, p=.003, CFI = .97, TLI
= .94, RMSEA = .08, SRMR = 0.04 and was not significantly different in fit to the
first re-specified model, χ2diff = 0.29, df = 1 p>.05. Therefore, the re-specified model
with the path between removed between negative affect and reliance on
hunger/satiety cues was retained as the more parsimonious model. Overall, the model
accounted for 21% of the variance in reliance on hunger/satiety cues. The final
model is presented in Figure 6.8 and final estimates are presented in Table 6.14.
154
Table 6.13
Initial Estimates for Model II – Modified Dual Pathway Model with Reliance on
Hunger/Satiety Cues as the Outcome
Parameter
estimate
Unstandardised
estimate
Standard
error
Standardised
estimate
p
Thin-ideal
internalisation
Pressure for
thinness
.40 .05 .38 <.001
Negative affect
Body
dissatisfaction
2.83 .34 .36 <.001
Body
dissatisfaction
Pressure for
thinness
.53 .08 .47 <.001
Thin-ideal
internalisation
.20 .05 .18 <.001
Reliance on
hunger/satiety
cues
Body
dissatisfaction
-.33 .03 -.45 <.001
Negative
affect
-.00 -.00 -.02 .591
155
Figure 6.8. Re-specified Model II – Modified dual pathway model with reliance
on hunger/satiety cues as the outcome.
As shown in Figure 6.8 and Table 6.14, pressure for thinness predicted higher
levels of thin-ideal internalisation and body dissatisfaction; thin-ideal internalisation
predicted greater body dissatisfaction; and body dissatisfaction and thin-ideal
internalisation predicted higher levels of negative affect. Body dissatisfaction
predicted less reliance on hunger/satiety cues.
156
Table 6.14
Final Estimates for Model II – Modified Dual Pathway Model with Reliance on
Hunger/Satiety Cues as the Outcome
Parameter
estimate
Unstandardised
estimate
Standard
error
Standardised
estimate
p
Thin-ideal
internalisation
Pressure for
thinness
.40 .05 .38 <.001
Negative affect
Body
dissatisfaction
2.12 .35 .27 <.001
Thin-ideal
internalisation
2.11 .38 .25 <.001
Body
dissatisfaction
Pressure for
thinness
.53 .08 .47 <.001
Thin-ideal
internalisation
.20 .05 .18 <.001
Reliance on
hunger/satiety
cues
Body
dissatisfaction
-.34 .03 -.46 <.001
Discussion
The aim of the second part of the empirical study was to examine the
similarities and differences in the psychosocial factors that are associated with
disordered eating, eating for non-emotional/non-external reasons, and reliance on
hunger/satiety cues. This was examined using bivariate correlations and two
psychosocial models of eating: the acceptance model of intuitive eating and a
modified version of the dual pathway model of disordered eating.
157
More similarities than differences were found. As indicated by the bivariate
correlations with each of the body image variables, body appreciation, appearance
evaluation, and body area satisfaction were moderately to strongly associated with
lower levels of disordered eating, and moderately associated with higher levels of
eating for non-emotional/non-external reasons and greater reliance on hunger/satiety
cues. In addition, given that the three body image variables were highly interrelated,
an overall body dissatisfaction/satisfaction factor was computed using principal axis
factoring and was included in the models. This is in contrast with previous research
that has shown body appreciation to be distinct from body satisfaction and
appearance evaluation (Tylka, & Wood-Barcalow, 2015).
In line with the hypothesised models and previous research, body
dissatisfaction/body satisfaction was found to be the main direct predictor of each of
the examined eating outcomes. In the acceptance model, greater body satisfaction
predicted lower levels of disordered eating, and higher levels of eating for non-
emotional/non-external reasons and reliance on hunger/satiety cues. In the modified
dual pathway model, greater body dissatisfaction predicted higher levels of
disordered eating, and lower levels of eating for non-emotional/non-external reasons
and reliance on hunger/satiety cues. Body dissatisfaction has consistently been found
to predict disordered eating (e.g., Andrés & Saldaña, 2014; Dakanalis, Timko,
Serino, Riva, Clerici, & Carrà, 2016; Johnson & Wardle, 2005; Mailloux, Bergeron,
Meilleur, D’Antono, & Dubé, 2014; Stice, Ng, & Shaw, 2010) and is often the target
of interventions that aim to prevent or reduce disordered eating (Ciao, Loth, &
Neumark-Sztainer, 2014). In addition, previous studies have shown that greater body
dissatisfaction is associated with higher levels of emotional eating (e.g., Annesi,
Mareno, & McEwen, 2016; Anschutz, Engels, & Van Strien, 2008; Johnson &
Wardle, 2005). Body dissatisfaction is associated with a desire to modify body
158
weight or shape to achieve the thin-ideal body type, which promotes the use of
disordered eating practices, including dieting (Stice, 2002; Stice & Shaw, 2002).
Body dissatisfaction may also lead to the experience of emotional distress (Stice,
2002), which in turn may promote emotional eating as a way of coping.
These findings are also in line with other studies that have examined the
reliance on hunger/satiety cues subscale in relation to body dissatisfaction or body
appreciation (Carbonneau et al., 2016; van Dyck et al., 2016). Greater body
dissatisfaction has also been found to be moderately to strongly related to less
reliance on hunger/satiety cues (Carbonneau et al., 2016; van Dyck et al., 2016).
Moreover, greater body appreciation has been found to be moderately to strongly
associated with greater reliance on hunger/satiety cues in adult women (Oswald,
Chapman, & Wilson, 2017; Tylka & Kroon Van Diest, 2013). Overall, the findings
suggest that women who are less dissatisfied with their body weight and shape, or are
more appreciative of their body, regardless of weight/shape, are more likely to eat
based on physical cues for hunger and satiety. Appreciating or being satisfied with
the body may be a prerequisite for eating based on physical hunger and satiety cues.
The other psychosocial factors that form part of the acceptance model of
intuitive eating are perceived social support, body acceptance by others, and body
function, with the focus being on the positively-framed psychosocial factors
(Augustus-Horvath & Tylka, 2011). Both perceived social support and body
acceptance by others were found to be associated with the three eating patterns in the
same way. At the bivariate level, perceived social support was found to be weakly
correlated while body acceptance by others was found to be moderately correlated
with each of the eating patterns. Only body function was found to relate differently to
the three eating outcomes. Body function was highly correlated with disordered
159
eating, moderately correlated with eating for non-emotional/non-external reasons,
and weakly correlated with reliance on hunger/satiety cues.
In addition to the bivariate relationships, overall support for the acceptance
model of intuitive eating was found for each of the examined outcomes. In line with
previous research which has examined the total IES as the outcome variable,
perceived social support predicted body acceptance by others, body acceptance by
others predicted body function and body satisfaction, body function predicted body
satisfaction, and body satisfaction predicted each eating pattern (Avalos & Tylka,
2006; Tylka & Kroon Van Diest, 2011; Oh et al., 2012). The only exception was that
body function was not found to predict reliance on hunger/satiety cues. However, all
previous studies have examined the acceptance model using the total IES as the
outcome variable. This is the first study to examine the acceptance model with the
reliance on hunger/satiety subscale. Given that no previous study has examined the
model with the separate IES subscales, this finding pertaining to the reliance on
hunger/satiety cues needs to be verified. It may be that the relationship between body
function and the total IES is attributable to unconditional permission to eat and eating
for physical rather than emotional reasons, which overlap with disordered eating,
emotional eating and external eating.
The remaining psychosocial factors that were examined in the study, pressure
for thinness, internalisation of the thin-ideal, and negative affect, are components of
the dual pathway model. At the bivariate level, all three of these factors were
moderately related with disordered eating and eating for non-emotional/non-external
reasons but they were only weakly related to reliance on hunger/satiety cues. In
addition, and in line with the dual pathway model (Stice, 2001; Stice & Agras, 1998),
pressure for thinness and thin-ideal internalisation predicted body dissatisfaction, and
160
body dissatisfaction predicted negative affect and each eating pattern. Negative affect
was found to predict both disordered eating and eating for non-emotional/non-
external reasons, however, it did not predict reliance on hunger/satiety cues. The
findings support previous research that has shown negative affect predicts disordered
eating in women (Dakanalis et al., 2016; Stice et al., 2010), as have other aspects of
emotional functioning, such as depressive symptomatology (e.g., Skinner et al.,
2012). Moreover, studies that have examined intuitive eating in relation to negative
affect have found that lower levels of negative affect are moderately correlated with
higher scores on the total IES (Tylka et al., 2015). However, when examining each of
the three subscales of intuitive eating, negative affect was moderately correlated with
unconditional permission to eat and eating for physical rather than emotional
reasons, but only weakly correlated with reliance on hunger/satiety cues (Tylka &
Kroon Van Diest, 2013).
In addition to the relationships proposed in the dual pathway model (Stice,
2001), a direct relationship was demonstrated between: pressure for thinness and
eating for non-emotional/non-external reasons; thin-ideal internalisation and
disordered eating; and both pressure for thinness and thin-ideal internalisation with
negative affect. These findings suggest that these two factors may directly influence
these eating behaviours and negative affect, in addition to their indirect effect
through body dissatisfaction. The dual pathway model proposes that societal
messages received by women promote the thin-ideal stereotype. These messages are
internalised and this can result in women experiencing dissatisfaction with their
weight/shape. Consequently, women engage in disordered eating practices, in an
attempt to attain this thin-ideal body type (Stice, 2001).
161
Overall, the empirical study provided support for the acceptance model and
the modified dual pathway model for all three eating patterns. The similarities
demonstrated for each model with each eating outcome suggests that there are
psychosocial factors that predict the three distinct eating patterns in a similar way.
The differences demonstrated in the psychosocial factors that were related to each
eating outcome highlights that reliance on hunger/satiety cues is more conceptually
distinct from disordered eating and eating for non-emotional/non-external reasons.
Additional studies are needed to validate these findings. This includes examining the
two models in other groups of adult women and in other populations such as adult
men, adolescents, and in clinical populations.
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CHAPTER SEVEN
General Discussion
Summary of Aims and Main Findings
The overall aim of this thesis was to examine intuitive eating in relation to
other eating patterns and psychosocial correlates in adult women. Firstly, a
systematic review of existing literature was conducted that examined the
psychosocial correlates of intuitive eating in adult women. An empirical study was
then conducted to examine the factor structure of the IES (Tylka, 2006) in a
community sample of adult women. The study also examined the three IES subscales
in relation to other eating patterns. Finally, the study compared the psychosocial
correlates of the three IES subscales and these other eating patterns.
The systematic review showed that intuitive eating was associated with a
number of psychosocial factors in adult women, including other eating patterns,
aspects of body image, and emotional functioning. This included psychosocial
factors that have been incorporated in the acceptance model of intuitive eating (i.e.,
perceived social support, body acceptance by others, a focus on body function, and
body appreciation), and the dual pathway model of disordered eating (i.e., societal
pressure for thinness, internalisation of the thin-ideal, body dissatisfaction, and
negative affect). For studies that examined the subscales of the IES, unconditional
permission to eat was found to be moderate to strongly related to aspects of
disordered eating. The eating for physical rather than emotional reasons and reliance
on hunger/satiety cues subscales were weakly to moderately associated with
disordered eating. The review showed that the three subscales of the IES
163
(unconditional permission to eat, eating for physical rather than emotional reasons,
reliance on hunger/satiety cues) (Tylka, 2006) related differently to aspects of
disordered eating. Moreover, the review highlighted the importance of examining the
subscales of intuitive eating in assessing psychosocial correlates, and the need for
studies to examine the factor structure of the IES in relation to disordered eating. In
addition, none of the reviewed studies had examined other eating patterns, such as
emotional eating and external eating, in relation to the total IES or its subscales.
Studies were also limited by the use of primarily female university student samples
from the United States. The empirical study set out to build on existing studies of
adult women and address some of these limitations.
The empirical study provided support for the three-factor structure of the
original version of the IES (Tylka, 2006). Although the original scale was validated
only among female university students, this study showed that the three subscales
were clearly distinguishable among an Australian community sample of adult
women. In addition, the empirical study showed that two of the IES subscales,
unconditional permission to eat and eating for physical rather than emotional
reasons, overlapped with other examined eating behaviours, including aspects of
disordered eating, emotional eating, and external eating. Only the third subscale,
reliance on hunger/satiety cues, was found to be distinct from other examined eating
patterns. This was demonstrated through a factor analysis of the three IES subscales,
dieting, restrained eating, bulimia/food preoccupation, emotional eating, and external
eating. This resulted in two eating factors: disordered eating and eating for non-
emotional/non-external reasons. Unconditional permission to eat loaded onto the
disordered eating factor along with dieting, restrained eating, and bulimia/food
preoccupation. Eating for physical rather than emotional reasons loaded onto the
eating for non-emotional/non-external reasons factor with emotional eating and
164
external eating. Reliance on hunger/satiety cues was the only IES subscale that did
not load onto either factor.
Lastly, an examination of bivariate relationships and two psychosocial
models of eating, the acceptance model and a modified version of the dual pathway
model, demonstrated that there were both similarities and differences in the
psychosocial factors that were associated with the three eating outcomes (disordered
eating, eating for non-emotional/non-external reasons, and reliance on hunger/satiety
cues). At the bivariate level, psychosocial factors that were part of the acceptance
model (i.e., perceived social support, body acceptance by others, body satisfaction)
were related to each eating pattern in the same way. The main difference was for
body function, which was strongly related to disordered eating, moderately related to
eating for non-emotional/non-external reasons, and weakly related to reliance on
hunger/satiety cues. For psychosocial factors that were part of the modified dual
pathway model (i.e., societal pressure for thinness, internalisation of the thin-ideal,
body dissatisfaction, negative affect), each of these factors were also related to the
three eating patterns in a similar way. The main differences were for pressure for
thinness, thin-ideal internalisation, and negative affect, which were moderately
related to disordered eating and eating for non-emotional/non-external reasons, but
only weakly related to reliance on hunger/satiety cues.
The empirical study provided support for both the acceptance model and the
modified dual pathway model for the each of the three eating outcomes. More
similarities than differences were found in how the psychosocial factors in each
model were related to each eating pattern. Differences in the psychosocial factors
that were related to each eating pattern highlighted the distinctiveness of reliance on
hunger/satiety cues.
165
Assessing Principles of Intuitive Eating
The IES subscale that has been found to be substantially distinct from other
eating behaviours is reliance on hunger/satiety cues. This subscale assesses the
degree to which individuals rely on physical cues for hunger and satiety to guide
eating behaviours. The subscale relates to the second and fifth intuitive eating
principles proposed by Tribole and Resch (2012). The first principle promotes eating
based on physical hunger cues, and the second principle promotes an awareness of
satiety cues and eating to a comfortable degree of fullness. These aspects of intuitive
eating involve an awareness and trust in these physical cues, and the ignorance of
external and emotional cues that can influence food intake. Similar to the reliance on
hunger/satiety cues subscale, the intrinsic and extrinsic subscales of the Hawks et al.
(2004) IES also assesse eating based on physical hunger and satiety cues (e.g., “I
seldom eat unless I notice that I am physically hungry”, and “After eating, I often
realise that I am fuller than I would like to be”) and avoidance of external cues for
eating (e.g., “It’s hard to resist eating something good if it is around me, even if I’m
not very hungry”)
The other two subscales from the IES (Tylka, 2006), unconditional
permission to eat and eating for physical rather than emotional reasons, were found
to show substantial overlap with measures of disordered eating (including dieting,
restrained eating, and bulimia/food preoccupation), and/or emotional eating and
external eating. Although not specifically noted in Tylka (2006), the unconditional
permission to eat subscale of the IES includes items that capture the first, third, and
fourth principles of intuitive eating, including rejection of the dieting mentality, an
unconditional permission to eat, and non-judgmental attitudes towards eating. The
eating for physical rather than emotional reasons subscale includes items that capture
166
the seventh principle, avoiding the use of food to manage emotions. The Hawks et
al. (2004) scale also captures these four principles in the anti-dieting and extrinsic
eating subscales, using reverse-scored items. The anti-dieting subscale assesses the
rejection of the dieting mentality (e.g., “I generally count calories before deciding if
something is OK to eat”), unconditional permission to eat (e.g., “There are certain
foods that I really like, but I try to avoid them so that I won’t gain weight”), and non-
judgmental attitudes towards eating (e.g., “I usually feel like a failure when I eat
more than I should”). Moreover, the extrinsic subscale also captures the principle
relating to emotional eating (e.g., “I often turn to food when I feel sad, anxious,
lonely, or stressed out”).
Given that unconditional permission to eat and eating for physical rather than
emotional reasons showed substantial overlap with other eating behaviours, this
raises the question as to whether these two subscales should be labelled as intuitive
eating, or whether they should be labelled to reflect lower levels of disordered eating
and lower levels of emotional/external eating. Alternatively, more sensitive measures
that more fully address the specific principles of intuitive eating underlying these
constructs are needed. It might be that these two aspects of intuitive eating exist on a
spectrum with other eating patterns, such that unconditional permission to eat and
disordered eating exist on one spectrum, and eating for physical rather than
emotional reasons and emotional/external eating exist on another. A more in-depth
examination of these specific intuitive eating principles and how they relate to eating
behaviours, by conducting individual interviews with women, is now needed.
A limitation of this thesis is that the revised IES-2 (Tylka & Kroon Van
Diest, 2013) was not assessed, due to the scale not being available when the
empirical study was commenced in 2013. A fourth subscale, body-food choice
167
congruence, was included in the revised scale to incorporate the tenth principle of
intuitive eating, which refers to making food choices that are nourishing and
contribute to body functioning, but also consider taste satisfaction. The body-food
choice congruence subscale includes three items (e.g., “Most of the time, I desire to
eat nutritious foods”) and assesses the degree to which food choices are aligned with
the body’s needs. This principle assessed by this subscale encourages food choices
for body functioning and nourishment, but also for taste satisfaction (Tribole &
Resch, 2012).
Findings of studies that have examined the body-food choice congruence
subscale suggest that this subscale may be more conceptually distinct from other
eating patterns. Body-food choice congruence has been found to be weakly related to
restrained eating, emotional eating and symptoms of bulimia in German adult women
(van Dyck et al., 2016), and was not related with disordered eating in female
American university students (Tylka & Kroon Van Diest, 2013). One exception is
that body-food choice congruence was found to be moderately related to symptoms
of bulimia in French-Canadian adults (Carbonneau et al., 2016). In addition, Tylka
and Kroon Van Diest (2013) found that, after controlling for the contribution of
disordered eating, body-food choice congruence contributed uniquely to self-esteem,
positive affect, and negative affect. This suggests that body-food choice congruence
is more distinct from disordered eating. In comparison with the other three IES
subscales, some research has shown that body-food choice congruence is weakly
related to psychosocial factors such as body dissatisfaction (van Dyck et al., 2016),
body shame, and anxiety (Tylka & Kroon Van Diest, 2013), while the other three
IES subscales are moderately to strongly related to these factors. Additional studies
are needed that examine this subscale of the IES in relation to other patterns of eating
and psychosocial correlates.
168
In addition to the body-food choice congruence, there are three principles of
intuitive eating, proposed by Tribole and Resch (2012), that have not been included
in the IES (Tylka, 2006) or the revised IES (Tylka & Kroon Van Diest, 2013). These
principles focus on eating satisfaction, body appreciation/respect, and a positive
relationship with physical activity (Tribole & Resch, 2012). Two of these principles
do not address eating behaviours. This may explain why they were not incorporated
when the IES was developed (Tylka, 2006). Two of these aspects have been assessed
in studies using independent scales. For example, body appreciation has been
assessed using the BAS (Avalos et al., 2005), and a recent study conducted by Tylka
and Homan (2015) examined exercise motivation in university students (i.e.,
appearance-related, or for health and enjoyment) using the Function of Exercise
Scale (DiBartolo, Lin, Montoya, Neal, & Shaffer, 2007). Moreover, while the
Intuitive Eating Scale developed by Hawks et al. (2004) has not been widely used, in
comparison to the IES (Tylka, 2006), it includes a subscale labelled ‘self-care’,
which overall assesses the degree to which individuals focus on health and fitness
rather than appearance. This subscale captures these two principles (i.e., body
appreciation/respect, and a positive relationship with physical activity) by assessing
the degree to which an individual is focused on health and fitness rather than weight
(e.g., “The health and strength of my body is more important to me than how much I
weigh”), and attitudes towards physical activity (e.g., “I mostly exercise because of
how good it makes me feel physically”). The third principle, relating to eating
satisfaction or the pleasure associated with food and eating, has been assessed using
an independent measure in one study (Smith & Hawks, 2006), however, this study
used the Hawks et al. (2004) scale to assess intuitive eating, not the IES (Tylka,
2006) or the revised version (Tylka & Kroon Van Diest, 2013).
169
Other Psychosocial Factors
There are various environmental, biological, situational and other psychological
factors not examined in this study that may be related to intuitive eating and more
specially to the reliance on hunger and satiety cues subscale. Given the focus on
hunger and/or satiety, other factors may be those that heighten, reduce or interrupt
the awareness and/or response to these biological signals. For example, distractions
in the immediate eating environment (e.g., television, meal time conversation, eating
while working), food availability (e.g., not having food on-hand when hungry, social
situations that are centred on food), or family-related factors (e.g., child-feeding
practices; food attitudes held by significant others) (French, Story, & Jeffery, 2001;
Tribole & Resch, 2012; Scaglioni, Salvioni, & Galimbert, 2008; Story, Neumark-
Sztainer, & French, 2002; Wansink, 2004). None of these factors have to be directly
examined in relation to this subscale of the IES.
There is some research that has found reliance on hunger/satiety cues to be
related to interoceptive awareness (Oswald et al., 2017; Tylka, 2006; Tylka & Kroon
Van Diest, 2013; van Dyck et al., 2016), and autonomous eating regulation
(Carbonneau et al., 2015). Interoceptive awareness describes the ability to recognise
and identify signals of hunger/satiety and emotions (Garner, Olmstead, & Polivy,
1983). Reliance on hunger/satiety cues was weakly and negatively related to poor
interoceptive awareness in two samples of university students living in the United
States (Tylka, 2006; Tylka & Kroon Van Diest, 2013), moderately related to greater
interoceptive awareness in Australian female university students (Oswald et al.,
2017), and strongly and negatively correlated with poor interoceptive awareness of
appetite in a sample of German women (van Dyck et al., 2016). These studies
suggest that the degree to which women can recognise and identify internal signals of
hunger/satiety could impact on whether or not these signals are responded to when
170
eating. Not being able to adequately recognise feelings of hunger and fullness is
likely to impact on how much they eat, either not eating enough or overeating.
Autonomous eating regulation is described as eating that is self-determined,
rather than being determined by external factors (Mask & Blanchard, 2011).
Carbonneau and colleagues (2015) found that greater reliance on hunger/satiety cues
was moderately associated with higher levels of autonomous eating regulation in a
sample of French-Canadian women. This suggests that women who were more self-
determined in their eating and were less influenced by external factors were more
likely to rely on internal cues for eating. Alternatively, women who rely more on
internal hunger/satiety cues were more likely to be self-determined in their eating,
and less likely to be influenced by external factors when eating. Autonomously
regulated eating has been found to be strongly and positively related to healthy eating
behaviours (e.g., consumption of healthy foods and eating other foods in moderation,
such as chips, chocolate and candy), as assessed by the Healthy Eating Behavior
Scale (Pelletier, Dion, Slovinec-D’Angelo, & Reid, 2004). Further research is needed
to examine these eating-related factors in relation to the reliance on hunger/satiety
cues subscale.
There are also other psychosocial factors that have been examined in relation the
IES subscales as shown in the systematic review but were not examined in the
empirical study for this thesis. Reliance on hunger/satiety cues was found to be
moderately and positively associated with self-esteem (Tylka & Kroon Van Diest,
2013; Tylka & Wilcox, 2006), unconditional self-regard (Tylka & Wilcox, 2006),
and proactive coping (Tylka, 2006; Tylka & Wilcox, 2006) in female university
students. In addition, this subscale was found to be only weak to moderately
associated with optimism (Tylka, 2006; Tylka & Wilcox, 2006), positive affect
(Tylka & Kroon Van Diest, 2013; Tylka & Wilcox, 2006), and life satisfaction
171
(Tylka, 2006; Tylka & Kroon Van Diest, 2013), and only weakly associated with
psychological hardiness and social problem solving (Tylka & Wilcox, 2006). Studies
have found that reliance on hunger/satiety cues relates more strongly to some of
these psychosocial factors (e.g., optimism, life satisfaction, proactive coping,
unconditional self-regard, and positive affect), compared to unconditional permission
to eat and eating for physical rather than emotional reasons, in samples of university
students (Tylka, 2006; Tylka & Kroon Van Diest, 2013; Tylka & Wilcox, 2006).
Research is now needed to examine whether these psychosocial factors can
differentiate between aspects of intuitive eating and other eating patterns in
community samples. This will lead to a better understanding of how intuitive eating
is different from disordered eating, emotional eating, and external eating.
Intuitive Eating and Positive Health Outcomes
Prospective studies are needed to determine if intuitive eating is associated
with positive health outcomes, including a healthy weight. While intuitive eating is
not proposed as an eating approach for weight control, weight changes have been
identified as a potential outcome of adopting an intuitive eating style (Tribole &
Resch, 2012). Cross-sectional studies that have examined the association between the
reliance on hunger/satiety cues subscale of intuitive eating and weight status, as
assessed by BMI, have shown that greater reliance on hunger/satiety cues is
associated with a lower BMI in samples of both women and men (Camilleri, Méjean,
Bellisle, Andreeva, Kesse-Guyot, Hercberg et al., 2016; Madden et al., 2012), and
university students (Herbert et al., 2013; Tylka, 2006; Tylka & Kroon Van Diest,
2013; van Dyck et al., 2016). In addition, adults within a normal weight range have
reported greater reliance on hunger/satiety cues, compared to overweight adults
(Camilleri et al., 2015; Cole, Clark, Heileson, DeMay, & Smith, 2016). In contrast,
172
Anderson and colleagues (2016) found no relationship between this aspect of
intuitive eating and BMI, however, a majority of the sample were within a healthy
weight range. Findings of the empirical study, in relation to reliance on
hunger/satiety cues and weight status, were in line with Anderson et al. (2016). The
correlation between reliance on hunger/satiety cues and BMI was non-significant.
Interventions that have incorporated principles of intuitive eating, including
the promotion of eating based on physical cues, have demonstrated effectiveness in
modifying disordered eating behaviours and improving aspects of physical and
psychological health. A systematic review conducted by Schaefer and Magnuson
(2014) showed that interventions which promote eating based on internal cues were
effective in reducing aspects of disordered eating, led to an increase in positive body
image, improvements in aspects of psychological well-being (i.e., depression,
anxiety, self-esteem), better diet quality and engagement in physical activity, and
improvements in health indicators such as blood pressure and cholesterol levels. The
review also found support for the effectiveness of these interventions in reducing or
maintaining body weight (Schaefer & Magnuson, 2014). A more recent systematic
review examined outcomes of interventions that adopted a non-dieting approach to
eating (Clifford, Ozier, Bundros, Moore, Kreiser, & Morris, 2015). Findings were in
line with the Schaefer and Magnuson (2014), demonstrating that interventions were
effective in reducing disordered eating behaviours and improving body image,
emotional functioning, and self-esteem (Clifford et al., 2015). Subsequent studies
have found that non-dieting interventions have been able to increase intuitive eating
behaviours, as assessed by the total IES (Young, 2010) or its subscales (Bush, Rossy,
Mintz, & Schopp, 2014; Healy, Joram, Matvienko, Woolf, & Knesting, 2015;
Humphrey, Clifford, & Neyman Morris, 2015), the Hawks et al. (2004) scale
173
(Wilson, 2014), or a scale to assess a rejection of the dieting mentality (Cole &
Horacek, 2010).
In addition to increasing intuitive eating, these interventions reduced dieting,
and improved body image in female university students (Humphrey et al., 2015;
Wilson, 2014; Young, 2010), high school students (Healy et al., 2015), women with
partners in the military (Cole & Horacek, 2010), and adult women working in a
university setting (Bush et al., 2014). Future research should include a greater focus
on the IES subscales in examining the effect of interventions on intuitive eating
outcomes, but also the impact of increasing intuitive eating on physical and
psychological health outcomes.
Examining Intuitive Eating in Other Populations
A strength of the empirical study is the use of a community sample of adult
women. As shown in the systematic review, the majority of studies that have
examined intuitive eating used samples of primarily female university students who
lived in the United States. This study used a community sample of adult women that
was representative of the Australian population with regards to age, cultural
background and weight status (Australian Bureau of Statistics, 2016). Women were
aged 18 to 87 years, were primarily of an Australian and/or British/European
background, were tertiary educated, in a relationship, and engaged in paid
employment. In addition, more than forty percent of the sample were classified as
overweight or obese, and over one third of women experienced a gastrointestinal
condition, food allergies or another other health condition, such as diabetes. In the
Australian adult population more broadly, over a third of Australian adults meet
criteria for a functional gastrointestinal disorder (Koloski, Talley, & Boyce, 2002),
approximately six percent of the population are diagnosed with diabetes (Australian
174
Bureau of Statistics, 2015), and two percent of adults are diagnosed with a food
allergy (Australasian Society of Clinical Immunology & Allergy, 2016). While the
empirical study did not make comparisons based on these characteristics, the
findings suggest that intuitive eating and the relationships examined may be
applicable to the wider population of adult women, including those who are
overweight or who experience a health conditions that may influence their eating
patterns. Further studies are needed to validate the findings of this thesis in other
community samples of adult women, and in other populations, including adult men,
adolescents, and in clinical populations.
Several studies have examined intuitive eating among males using the
original IES and the revised IES scale (Cole, Clark, Heileson, DeMay, & Smith,
2016; Ellis, Galloway, Webb, Martz, & Farrow, 2016; Tylka & Homan, 2015; Tylka
& Kroon Van Diest, 2013). Other studies have examined adult men using the Hawks
et al. (2004) IES scale (e.g., Gast et al., 2012; Hawks et al., 2004). Some research has
shown that men reported higher levels of intuitive eating than women, according to
the total IES and subscales (Tylka & Kroon Van Diest, 2013; van Dyck et al., 2016),
except the body-food choice congruence subscale (Tylka & Kroon Van Diest, 2013).
Two studies to date have specifically examined the factor structure of the
IES-2 in adult men (Tylka & Kroon Van Diest, 2013; van Dyck et al., 2016). The
four-factor structure of the IES-2 was retained for a sample of 391 men included in
the initial validation of the scale (Tylka & Kroon Van Diest, 2013), and the four-
factor structure was also retained in a sample of 212 men for the German translated
version of the IES-2 (van Dyck et al., 2016). The four-factor structure of the IES-2 in
adult men was the same as for adult women.
175
To date, only two studies have included adult men in examining intuitive
eating subscales in relation to other eating patterns and psychosocial correlates (e.g.,
Tylka & Kroon Van Diest, 2013; van Dyck et al., 2016). The findings of these
studies of men are in line with the findings on adult women, with regards to the
relationship between the IES subscales and other eating patterns. Unconditional
permission to eat has been found to be strongly related to overall disordered eating
(Tylka & Kroon Van Diest, 2013) and restrained eating (van Dyck et al., 2016), and
eating for physical rather than emotional reasons has been found to be strongly
related to emotional eating (van Dyck et al., 2016). However, some findings are
inconsistent with the empirical study, showing that unconditional permission to eat
was only weakly related to symptoms of bulimia, and eating for physical rather than
emotional reasons was only weakly related to external eating in German men (van
Dyck et al., 2016).
Two studies have examined the IES subscales in relation to some of the
psychosocial correlates included in this empirical study. Body dissatisfaction was
negatively associated with each of the four IES subscales in a sample of German men
(van Dyck et al., 2016). Tylka and Kroon Van Diest (2013) examined body
appreciation, body shame, body surveillance, internalisation of the thin-ideal, and
negative affect. Body shame was strongly and negatively related to unconditional
permission to eat, moderately and negatively related to eating for physical rather than
emotional reasons and reliance on hunger/satiety cues, and was not related to body-
food choice congruence. Body appreciation was moderately and positively related to
all IES subscales except body-food choice congruence; body surveillance was
weakly and negatively related to all subscales except body-food choice congruence;
thin-ideal internalisation was moderately and negatively related to eating for physical
rather than emotional reasons, weakly and negatively related to unconditional
176
permission to eat and reliance on hunger/satiety cues, and was not associated with
body-food choice congruence. Finally, negative affect was moderately and
negatively related to eating for rather than emotional physical reasons, weakly and
negatively related to reliance on hunger/satiety cues and body-food choice
congruence, but was not associated with unconditional permission to eat. This study
suggests that the body-food choice congruence subscale may be a more distinct
pattern of eating in adult men. It is not clear if the reliance on hunger/satiety cues can
be differentiated from the other IES subscales. Research is now needed to more
thoroughly examine the IES subscales in relation to the other eating patterns and
psychosocial correlates in adult men. This should include an examination of the
acceptance model of intuitive eating with IES subscales, as one study has examined
the acceptance model in men but used the total IES (Tylka & Homan, 2015).
There are a growing number of studies that have examined intuitive eating in
adolescents (e.g., Andrew, Tiggemann, & Clark, 2016; Andrew et al., 2015;
Dockendorff et al., 2012; Moy, Petrie, Dockendorff, Greenleaf, & Martin, 2013).
One study examined the factor structure of the adolescent version of the IES in a
sample of adolescent boys and girls. Unlike the three-factor structure of original IES
(Tylka, 2006), which was validated in an adult sample, four factors were identified:
unconditional permission to eat, eating for physical rather than emotional reasons,
trust in internal hunger/satiety cues, and awareness of internal hunger/satiety cues
(Dockendorff et al., 2012). However, the two factors relating to hunger and satiety
cues are similar to the reliance on hunger/satiety cues for the IES (Tylka, 2006), with
the subscales of the adolescent version including some of the same items as the
subscale in the IES (e.g., “I can tell when I’m slightly full” and “I trust my body to
tell me when to eat”). The factor-structure of the adolescent version of the scale is
similar to that of the original IES for adult women (Tylka, 2006).
177
To date, only one study has examined the subscales of the adolescent version
of the IES in relation to other eating patterns (Moy, Petrie, Dockendorff, Greenleaf,
& Martin, 2013), and one study has examined the IES subscales and psychosocial
correlates (Dockendorff et al., 2012). In the study conducted by Moy et al. (2013),
adolescents who were not currently dieting reported higher levels of unconditional
permission to eat and eating for physical rather than emotional reasons, whereas
adolescents who were currently dieting reported lower levels of unconditional
permission to eat and eating for physical rather than emotional reasons. Interestingly,
dieters and non-dieters did not differ for reliance on hunger/satiety cues subscale. It
is not clear if the reliance on hunger/satiety cues subscale is more distinct from other
eating patterns in adolescent males and females.
The psychosocial correlates of the IES subscales were examined in
Dockendorff et al. (2012). Body satisfaction was related to unconditional permission
to eat, eating for physical rather than emotional reasons, and trust in internal
hunger/satiety cues in a similar way, but was not related to the fourth subscale,
awareness of internal hunger/satiety cues. Thin-ideal internalisation was weakly
related to the first three subscales but not awareness of internal hunger/satiety cues.
Pressure to have a thin body was moderately related to unconditional permission to
eat and weakly related to eating for physical rather than emotional reasons and trust
in internal hunger/satiety cues, but was not associated with awareness of internal
hunger/satiety cues. Based on these limited findings, the awareness of internal
hunger/satiety cues subscale appears to be more distinct from other subscales.
Further research using adolescents will help establish if the findings of the empirical
study can be extended to younger populations, particularly as adolescence is a
significant developmental stage, and to establish if there are age differences and/or
similarities in psychosocial factors that predict the IES subscales and other eating
178
patterns. The acceptance model has only been examined using total IES score in
adolescents (Andrew et al., 2015), therefore, studies are needed to examine the
model in relation to the IES subscales.
Only one study to date has examined intuitive eating in relation to type of
eating disorder (van Dyck et al., 2016). The study examined the relationship between
the subscales of the German version of the IES-2 and type of eating disorder
diagnosis in a sub-sample of 87 women who reported a current diagnosis of either
Anorexia Nervosa (AN), Bulimia Nervosa (BN), or Binge Eating Disorder (BED)
(van Dyck et al., 2016). Research is yet to be conducted that examines the factor
structure of the IES, and the IES subscales in relation to psychosocial correlates in
the clinical population. Extending findings of this study to the clinical population,
and comparing clinical and community samples of adult women, will increase our
understanding of how intuitive eating relates to clinical levels of disordered eating,
and if there are similarities and/or differences in the psychosocial factors that predict
intuitive eating and disordered eating patterns in this population.
Study Limitations
In addition to the limitations already highlighted in this chapter, there are
further limitations that need to be considered in relation to study findings. Firstly, the
empirical study used a cross-sectional design in addressing each aim of the study.
Therefore, the cause-effect relationships between intuitive eating, other eating
patterns, and their psychosocial correlates cannot be established. Prospective studies
are now needed to examine these relationships. Secondly, the sampling methods used
in the study included recruiting from organisations that were associated with
women’s health (e.g., women’s health centres, fitness centres, physiotherapy clinics,
and weight loss groups). It is possible that women who participated in the study
179
placed importance on their health and well-being, and may also have had an interest
in eating behaviours, particularly considering the proportion of the sample who
reported a health condition that may affect their food intake. Future studies should
consider using sampling methods that ensure their sample is representative of the
population in which they are examining, and to minimise potential sampling bias.
Conclusion
The findings of this thesis contribute to a greater understanding of how
aspects of intuitive eating relate to other eating patterns, and the similarities and
differences in their psychosocial correlates. The empirical study was novel in that it
was the first study to examine the factor structure of the IES (Tylka, 2006) using a
community sample; no previous studies had examined the subscales of the IES
(Tylka, 2006) in relation to other eating patterns in a community sample; it was the
first study to directly compare the psychosocial correlates of intuitive eating to those
of disordered eating; and it was also the first study to examine both the acceptance
model of intuitive eating and the dual pathway model of disordered eating in relation
to the three IES subscales.
Findings of this thesis suggest that unconditional permission to eat and eating
for physical rather than emotional reasons are aspects of intuitive eating that overlap
with other patterns of eating. The unconditional permission to eat subscale
overlapped with aspects of disordered eating, and the eating for physical rather than
emotional reasons subscale overlapped with emotional eating and external eating.
The third subscale of the IES (Tylka, 2006), reliance on hunger/satiety cues, was
found to be assessing a distinct pattern of eating. The empirical study provided
support for the acceptance model and the dual pathway model with disordered eating,
eating for non-emotional/non-external reasons, and reliance on hunger/satiety cues as
180
outcomes. Moreover, the psychosocial factors that were found to relate differently to
reliance on hunger/satiety cues provided additional support for the distinctiveness of
this eating pattern from disordered eating and non-emotional/non-external eating.
The findings of this thesis have potential implications for the prevention and
treatment of eating concerns. The overlap between components of intuitive eating
with aspects of disordered eating, emotional eating, and external eating, suggests that
the intuitive eating could be used to target a range of eating behaviours. Firstly,
strategies that encourage unconditional permission to eat could be used to prevent
and/or reduce aspects of disordered eating, including dieting, restrained eating, and
bulimia/food preoccupation. In addition, strategies that focus on eating for physical
rather than emotional reasons could be used to target emotional eating and external
eating. Finally, the findings of this thesis suggest that targeting body dissatisfaction
and promoting positive body image, such as body appreciation, may be the primary
target for increase eating based on internal cues of hunger/satiety and reducing
disordered eating patterns. Research is now needed to extend the findings of this
thesis to other populations, including adult men, adolescents, and clinical
populations. In addition, establishing the psychosocial factors that predict an increase
in reliance on hunger/satiety cues through prospective studies may inform the
development of interventions designed to prevent or reduce disordered eating, and
improve physical and psychological health outcomes such as body weight, nutritional
intake, body image, and emotional well-being.
181
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221
APPENDIX A
Ethics Approval Documentation
223
APPENDIX B
Plain Language Statement and Consent Form
PLAIN LANGUAGE STATEMENT AND CONSENT FORM TO: Prospective Participants
Plain Language Statement
Project Title: Eating Patterns, Health and Wellbeing among Australian Women
Principal Researcher: Associate Professor Lina Ricciardelli, School of Psychology, Deakin University, Melbourne
Student Researcher: Lauren Jade Bruce, School of Psychology, Deakin University, Melbourne
Associate Researcher(s): Dr Matthew Fuller-Tyszkiewicz, School of Psychology, Deakin University, Melbourne
1. Introduction
You are invited to take part in a research project being conducted by the School of
Psychology, Deakin University. The research project aims to examine the relationship
between eating patterns and health and wellbeing among Australian women aged 18
years and older.
This Plain Language Statement provides you with information about the research
project. It explains what is involved to help you decide if you want to take part. Please
read this information carefully. Ask questions about anything that you don’t
understand or want to know more about.
224
2. What is the purpose of this research project?
The aim of the project is to examine the relationship between eating patterns, health
and wellbeing among adult women. More specifically, the project aims to examine
the relationship between eating attitudes and behaviours, weight management and
psychosocial wellbeing.
Some research suggests that dieting or restrained eating patterns are associated with
decreased health and wellbeing, while eating patterns which are based on biological
feelings of hunger and fullness are associated with increased health and wellbeing.
Researchers aim to recruit at least 300 women into the research project. The project
is being conducted by researchers at Deakin University and will form part of a Doctor
of Psychology research thesis.
3. What does participation in this research project involve?
If you agree to participate, you will be asked to provide information in the form of a
survey. The survey will take no more than 30 minutes to complete. Survey items will
include information about your background (e.g., age, education), your height and
weight, your eating attitudes and behaviours, mood, body satisfaction and social
support.
Examples of questions that will be asked include the extent to which you agree with
the following statements: “"If I am craving a certain food, I allow myself to have it",
“"Despite its flaws, I accept my body for what it is"” and "There are people I can
depend on to help me if I really need it".
You will not be paid for your participation in this project. However, if you complete
the survey you will have the chance to win one of six $30 Coles-Myer gift vouchers.
4. What are the possible benefits?
There are no direct benefits from your participation in this project. However,
participating in this research may contribute to knowledge about the relationship
between eating patterns, health and wellbeing of Australian women.
5. What are the possible risks?
There are no anticipated risks of participating in this project. However, given that the
questionnaires will include questions regarding issues such as mood and body image,
there is a possibility that you may experience some concern about your responses.
Thus, you are invited to examine the questionnaire material before agreeing to
participate. If you find yourself feeling sad or distressed at any point, you are
encouraged to contact your GP and/or other health care professional. In addition,
you can also contact Associate Professor Lina Ricciardelli on (03) 9244 6866. You will
225
have the opportunity to discuss your concerns in a confidential manner and
appropriate follow-up will be suggested if necessary.
Additionally, you may call one of the following services for further information, to
discuss your concerns, or to obtain a referral for treatment if necessary:
Lifeline: 13 11 14
Eating Disorder Foundation of Victoria Helpline: 1300 550 236
Body Image Eating Disorders Treatment and Recovery Service: (03) 9854 1700
6. Do I have to take part in this research project?
Participation in any research project is voluntary. If you do not wish to take part you
are not obliged to. Due to the completely anonymous nature of this study, no
identifying information will be placed on your completed survey. As such, it will not
be possible to withdraw your survey from the study once it has been returned or
submitted. Please read through this information sheet and look through the
questionnaire prior to deciding whether you would like to participate. Your decision
whether to take part or not to take part, or to take part and then withdraw, will not
affect your relationship with Deakin University in any way.
7. How will I be informed of the final results of this research project?
A summary of the findings will be provided to the School of Psychology, Deakin
University and will be available for any interested participants to read at the
completion of the study. Please contact Lauren Bruce at [email protected] if you
would like to receive a copy of this report.
8. What will happen to information about me?
Any information obtained in connection with this research project that can identify
you will remain confidential and will only be used for the purpose of this research
project. It will only be disclosed with your permission, except as required by law. You
can be assured that you will not be identified by name in any way in the reporting of
our results in the research thesis, publications and conference presentations. Any
information we collect from you that can identify you will be identified with a
participant code and will remain confidential. Information will be stored in a locked
cabinet within the School of Psychology at Deakin University for a minimum of 6 years
from the date of publication, after which time it will be securely disposed of.
9. Can I access research information kept about me?
In accordance with relevant Australian and/or Victorian privacy and other relevant
laws, you have the right to access the information collected and stored by the
226
researchers about you. Please contact one of the researchers named at the end of
this document if you would like to access your information.
10. Is this research project approved?
The ethical aspects of this research project have been approved by the Human Ethics
Advisory Group, Faculty of Health, Deakin University.
This project will be carried out according to the National Statement on Ethical
Conduct in Human Research (2007) produced by the National Health and Medical
Research Council of Australia. This statement has been developed to protect the
interests of people who agree to participate in human research studies.
11. Who can I contact?
For further information concerning this project, or if you have any problems which
may be related to your involvement in the project (for example, feelings of distress),
you can contact the principal researcher Associate Professor Lina Ricciardelli in the
School of Psychology, Deakin University, 221 Burwood Highway, Burwood, Victoria,
3125, on 9244 6866 or email: [email protected]
Complaints
If you have any complaints about any aspect of the research,
the way it is being conducted or any questions about your
rights as a participant then you may contact:
Secretary HEAG- H, Dean's Office, Faculty of Health, Medicine,
Nursing and Behavioural Sciences, 221 Burwood Hwy,
Burwood, VIC 3125, Telephone: (03) 9251 7174, Email
Please quote project number HEAG-H 02_ 2013
227
APPENDIX C
Principal Axis Factoring for Three Body Image Variables
Principal axis factoring was used to conducted in SPSS version 22.0 using the
following three scales: the Body Appreciation Scale (Avalos et al., 2005), and the
Appearance Evaluation and Body Area Satisfaction subscales of the
Multidimensional Body-Self Relations Questionnaire (Brown et al., 1990; Cash,
2000). The Kaiser-Meyer-Olkin measure of sampling adequacy for all variables was
adequate (.76), according to cut-offs recommended by Hutcheson and Sofroniou
(1999). Bartlett’s test of sphericity, χ2 (457) = 1181.50, p<.001, indicated that
correlations between items were sufficient in size to conduct principal axis factoring.
One factor had an eigenvalue over Kaiser’s criterion of 1 (Kaiser, 1960) and this
factor explained 83.0% of the variance. The scree plot (Cattell, 1966) also suggested
the presence of one factor. This factor was labelled “Body dissatisfaction”. Factor
scores were calculated using the regression method.
Table A
Factor Matrix with Factor Loadings
Body
satisfaction
Communality
Body appreciation .87 .76
Appearance evaluation .94 .88
Body area satisfaction .92 .85
Eigenvalue 2.49
Variance (%) 83.0
230
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Appetite
Licensed Content Title A systematic review of the psychosocial correlates of
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Licensed Content Author Lauren J. Bruce, Lina A. Ricciardelli
Licensed Content Date Jan 1, 2016
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Intuitive Eating in Relation to Other Eating Patterns and
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231
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• Charging fees for document delivery or access
• Article aggregation
• Systematic distribution via e-mail lists or share buttons
Posting or linking by commercial companies for use by customers of those
companies.
20. Other Conditions:
v1.9