Contextual and psychosocial factors

Grant Proposal

Academic Abstract - 216

This research programme aims to untangle the complex multi-factorial host of contextual and psychosocial factors to understand the phenomenon of body image and eating disorders in men. The nature of the contributions of stress, body image and habit in regulating behaviour will be assessed in three groups aged 18- 35 - a group of obese males (n=55), a group of males experiencing eating disorders (n=55) and a male control group with a BMI 19-24.5 kg/m2 experiencing no disordered eating symptoms (n=55). Participants will be recruited from weight loss groups, eating disorder clinics, and a university in England. Psychometrically validated and standardised self-report measures of body image, stress, habit and eating attitudes will be collected. It was hypothesised i) obese individuals will experience the same body dissatisfaction as those suffering from eating disturbances. ii) Higher stress/body image dissatisfaction scores will predict disturbed eating iii) Obese and disordered eating patients will experience more habitual behaviours than the control group. Results will be analysed using SPSS a one way ANOVA to analyse between group differences on measures of stress, body image, habit and eating disturbance while linear regression will analyse the predictive effects of body image, stress and habit on disturbed eating. The anticipated commonalities and differences in the processes associated with two very different aspects of problematic weight regulation will help to untangle this complex relationship. The research will be useful for health professionals in identifying causes of problematic weight regulation in men who are obese or underweight in identifying improvements to existing treatments specific to men.

Lay Abstract - 159

This research project aims to explore the complex phenomenon of eating disorders and body image disturbance in men. The same physical and psychological processes seem to operate in both conditions however, in different aspects of weight regulation - maintaining weight loss versus maintaining weight gain. We will look at the relationship between body image, stress and habits in a group of obese males (n = 55), males experiencing disordered eating (n = 55) and a group of males experiencing no eating disorder symptoms with a healthy weight (n = 55). Participants will complete questionnaires on measures of body image, stress, habit and eating attitudes. Results for each group will be compared in order to explore the relationship between each factor for each group. Results will have implications for both professionals in the area in terms of improving treatment for men with eating disorders and obesity and also the general population through raising awareness for what is considered a taboo subject.

Background - 1180

The eating disorder literature largely focuses on females. Limited research has examined the assessment and treatment of eating disorders in males. The recent rise in the prevalence of obesity is an important public health concern as it is associated with increased rates of mortality and morbidity (WHO, 2002). Similarly, we have seen an increase in the number of cases of disordered eating in men, which may include binge-eating, self-starvation and purging (Carlet et al., 2004). Latest figures from the NHS information centre show that around 700,000 men are registered with eating disorders ((NHS IC, 2007)). As will be argued, many of the same processes seem to operate in both these conditions (stress, body image disturbance, habits) albeit in relation to different aspects of weight regulation - maintaining weight loss versus maintaining weight gain. Eating disorders in men can take different forms to those in women, and often stem from a desire to change body shape. One route in for men is through exercise and body building, this often becomes accompanied by controlling calorie intake which can sometimes lead to clinically diagnosed eating disorders (Ingledew, 1998).

Body Image: Body image can be defined as how we perceive our physical appearance, as well as how we think that others perceive us. Historically, the literature addressing body image concerns has focused primarily on the female experience of this phenomenon (Grabe, Ward, & Hyde, 2008), with little if any focus on men. Many reasons exist for this disparity (e.g., prevalence rates of eating disorders, gender role theories, emphasis placed on female attractiveness in media); however the main reason involves the belief that males are at little or no risk of having problems related to their body image (Weltzin & Weisensel, 2005, Schooler; Ward, 2006). Researchers such as Cafri, and Thompson (2007) have since rejected this notion and are striving to define, measure, and develop theories that capture the male experience of body image and explain the recent increase in male body image and eating disturbances.

A large number of theories have been offered to explain the development and maintenance of body image disturbance in men and women. Perhaps the most empirically supported approach is a socio-cultural model. This model identifies the social endorsement of an ideal body shape, as the motivation behind an individual's need to conform to body shape standards (Fallon, 1990; Stormer & Thompson, 1996,). Exposure to media images of idealised hyper-mesomorphic, hyper-lean male physiques was a key predictor of body image and eating disturbances in boys aged 13-16 (Botta, 1996). Further to this older adolescents and young men are also at risk from body image and eating disturbances, with one study reporting a 20% prevalence of disturbed eating and eating disorders in a university sample (O'Dea & Abraham, 2002). Similarly obese men experience body image disturbance induced by media images, which for both biological and psychological reasons, lead to increased eating and further weight gain (Schwartz and Brownell 2003). A focus on body image, is often used to address the obesity issue as well as to sell commercial products (Jamile et al., 2008). These campaigns often depict thin people, or the ideal body-image, as popular and successful while also containing anti-obesity messages. This stigmatises overweight individuals as failures and can lead to further problems; such as, over eating and eating disorders (Annis et al., 2004).

A rise in body image disturbance in men has been explained as men internalise these ideals by setting them as personal goals which are unachievable, this has lead to problems in body size perception (Arbour & Ginis, 2006Morrison et al., 2003 T. Morrison, M. Morrison and C. Hopkins, Striving for bodily perfection? An exploration of the drive for muscularity in Canadian men, Psychology of Men and Masculinity 4 (2003), pp. 111-120. Abstract | Article | (61 K) | Full Text via CrossRef | View Record in Scopus )Cited By in Scopus (24)). Lorenzen (2004) found that when estimating body size in anorexic, bulimia nervosa, obese, and control participants that control participants were quite accurate, and all three clinical groups were significantly less accurate, overestimating body size. However Bell (1996) compared anorexic, obese, and normal weight control participants using a silhouette chart to assess accuracy in body size estimation. Anorexic patients overestimated, obese patients underestimated, and control participants were accurate in their estimation of current body size. Taken together this research suggests both under and overweight individuals experience problems with body image and body size perception.

Stress: Stress may be defined as "a real or interpreted threat to the physiological or psychological integrity of an individual that results in physiological and/or behavioural responses" (McCabe & McEwen 2007). Stress is an important proximal determinant for a range of psychological problems and illness behaviours including overeating and weight gain (Roberts et al., 2007) as well as the onset of anorexia nervosa (Schmidt et al., 1997).

Recent studies have suggested that stress may be a precipitating factor in the etiology of anorexia nervosa (Donohoe, 2005). Mechanisms involved in stress-induced anorexia lead to changes in the hypothalamic-pituitary-adrenal axis and serotonergic systems which may provide an explanation for the physiological and behavioural responses observed in anorexia nervosa (Willenbring 1999). Appetite regulation is also often effected by stress as psychosocial and endocrinological factors interact to provide the setting conditions for the syndrome. Laboratory studies have shown that patients with eating disorders often experience abnormal patterns of hunger and satiety over the course of a meal (Stone and Brownell 1994). Serotonin plays an important role in post-ingestive satiety, and appears to be important in regulation of mood and anxiety-related symptoms (jimerson, 2007).

However Roberts et al. (2006) followed weight change over a 12-week period in male students completing a training course leading up to an unseen written examination. An increase in cortisol (indicating an increase in stress from the beginning of the study to immediately before the exams) predicted weight gain but this effect was moderated by mastery (i.e. there was a very high correlation between stress and weight gain in those with low levels of mastery but a non-significant correlation in those high levels of mastery). Furthermore, this effect was perfectly mediated by a reduction in dietary restraint (a cognitive attempt to restrict food intake (Tuschl, R.J., 1990. From dietary restraint to binge eating: Some theoretical considerations. Appetite 14, pp. 105-109. Article | (493 K) | View Record in Scopus | Cited By in Scopus (61)Tuschl, 1990) such that the effect of stress and mastery on weight gain can be explained by a reduction in (a disinhibition of) dietary restraint. Further analyses have shown that the effect of this reduction in dietary restraint is that it leads to binge eating and an increase in the proportion of diet that is high in fat (Roberts, 2006). Similar changes in disinhibition also seem to account for weight regain in men who have successfully lost weight (McGuire et al., 1999).

Habit: Habit is more than simply the frequency with which behaviours are repeated. It refers to the mental construct of a lack of awareness, automaticity (difficulty in controlling) and mental efficiency (Verplanken, 2006). Using measures derived from this perspective, frequency of consuming unhealthy (fattening) snacks was predicted by habit independently of ratings of intention, perceptions of control over eating and the frequency of consuming unhealthy snacks in the past (Verplanken, 2006). Conversely, healthy eating was (negatively) predicted by unhealthy eating habits (i.e. snacking) (Verplanken & Faes, 2007). Other studies have shown that weight regain following successful weight loss is related to the perpetuation of bad habits such as ongoing restriction, eating higher levels of fat and leading a sedentary lifestyle (Weiss et al., 2008; McGuire et al., 1999).

Although habit has not been measured directly in this way in men with eating disorders, there is reason to suppose that it may help to maintain the disorder. Defining habit as a mental construct in which there is a lack of awareness, automaticity and mental efficiency (Verplanken, 2006) suggests a resemblance to the cognitive rigidity. Cognitive rigidity is a state associated with an inability to turn one's attention away from a dominant stimulus and an inability to change behaviour; it is identified in sufferers of anorexia nervosa which appears to persist even after recovery or weight restoration (Tchanturia et al., 2001, 2004).

Aims and Objectives

This research programme aims to untangle the complex multi-factorial host of contextual and psychosocial factors to understand the phenomenon of body image and eating disorders in men. The nature of the contributions of stress, body image and habit in regulating behaviour will be assessed in three groups - a group of obese males, a group of males experiencing eating disorders and a male control group with a BMI 19-24.5 kg/m2 experiencing no disordered eating symptoms.

Three main questions will be addressed: -

  1. Do obese individuals experience the same body dissatisfaction as those suffering from eating disturbances?
  2. Does habit, stress or body image predict disturbed eating?
  3. Do men with obesity and men with disordered eating experience more habitual behaviours than the control group?

The research will be useful in the medium term for health professionals in identifying causes of problematic weight regulation in men and in the longer term for identifying improvement to existing treatments or the development of new ones specific to men.

Methodology -956


A crossectional questionnaire design will be used. A pilot study will not be necessary as all the questionnaires and methods have been validated in previous studies.

Sampling and Recruitment

A purpositive sample of 165 males aged 18 - 35 will be recruited. A sample of 165 is deemed appropriate on the basis that, taking account of attrition it is anticipated 120 will be recruited, the sample size will be similar to that reported by Roberts et al. (2007). It is also feasible within the time-frame to collect data on this number. Participants will be excluded if they meet any of the following criteria: (a) age below 18 years, (b) have missing values for any diagnostic items (c) have a current psychotic disorder (d) failure to meet the criteria for the specific study.

Study 1. A sample of 55 men currently obese (BMI=30 kg/m2 World Health Organization, 1998 World Health Organization, Obesity preventing and managing the global epidemic, WHO/NUT/NCD/98.1, Geneva (1998).WHO, 2002) will be recruited through a number of sources including weight loss programs such as Weight Watchers, diet clinics, local media and the internet.

Study 2. The sample for this study will be recruited through previous studies and existing well established research collaborations with eating disorders clinics in the UK. We will also place adverts in appropriate media (internet sites/health centre notice boards) and practitioner newsletters. Fifty five patients with a current diagnosis of disordered eating will be recruited; type of disorder will be controlled for at analysis.

Study 3. It is anticipated the control group will be recruited through the university and local media. Fifty five participants will be recruited with a BMI 19-24.5 kg/m2 determined "normal range" (WHO, 2002) and a EAT inventory for eating disorders score < 20.


Body dissatisfaction

Body dissatisfaction will be assessed by the Body Areas Satisfaction Scale (BASS; Brown, Cash & Lewis, 1989). Participants will be asked to provide judgments of their face, upper torso (chest), mid torso (waist, stomach), lower torso (hips, legs), muscle tone, height, and weight. Responses are given on 5-point scales, ranging from "very satisfied" (1) to "very dissatisfied" (5). High scores indicate negative body image attitudes.

The Contour Drawing Rating Scale (CDRS; Thompson & Gray, 1995). The male version of the CDRS, will be used in this study, this consists of nine male drawings with detailed figures of precisely graduated sizes. Individuals are asked to choose the image that most accurately represents their current body size and the image that most accurately represents their ideal body size. The discrepancies between these two figures serve as an index of body image dissatisfaction. Greater discrepancies indicate greater body image dissatisfaction.


The Self-Report Habit Index, (SRHI; Verplanken & Orbell, 2003) will be used to assess habit; that is, a history of repetition, automaticity (lack of control and awareness, efficiency), and expressing identity. The SRHI correlates strongly with past behavioural frequency and the response frequency measure of habit. The index discriminates between behaviours varying in frequency, and also between daily vs. weekly habits on a 12 point scale. The SRHI will be useful in determining habit strength without measuring behavioural frequency.


The Perceived Stress Scale (PSS; Cohen et al., 1983) was used to assess the degree to which participants appraised their daily life as unpredictable, uncontrollable, and overwhelming. This stress appraisal scale includes 14 items (e.g., "In the last week, how often have you felt that you were unable to control the important things in your life?"); each item is scored on a 5-point scale, ranging from 0 (never) to 4 (very often).

Binge eating

To measure the severity of binge eating, the Binge Eating Scale (BES) will be used (Gormally & Block, 1982). The Binge Eating Scale has been proposed, with a threshold score of 17, as a rapid screening instrument for BED in obese patients, and it examines both behavioural signs (eating large amounts of food) and feeling or cognition during a binge episode (loss of control, guilt, fear of being unable to stop eating) through 16 items.

Eating Attitudes

The EAT-26 (Garner et al., 1982) consists of 26 items that measure eating attitudes and behaviors on a six-point Likert scale. Higher scores signify greater symptomatology. The EAT has been found to distinguish eating disorder groups from controls (Gross and Prather 1991).


The same measures will be used in the three samples for the purposes of direct comparison (e.g. stress, body image, habit and eating behaviours). Additional demographic and clinical information including age and race will also be collected. Participant's height (cm) will be measured without shoes to the nearest 0.5 cm using a stadiometer. Weight will be measured without shoes in light clothing using calibrated digital tanita scales to the nearest 0.01 kg. The body mass index (BMI) [weight (kg)/height (m2)] will be calculated. It is anticipated the battery of tests and physical measurement will take approximately an hour to complete.


0-3 months: Literature review; recruiting and baseline testing of the control group sample.

3-9 months: Ongoing data collection and analysis.

9-12 months: Data analysis and writing-up.


Multivariate analysis will be carried out with SPSS 16 for Windows. One-way analyses of variance (ANOVAs) will be conducted to examine group differences for the eating disorder, obese and control group on overall eating attitudes (BES, EAT), stress (PSS), habit (SRHI) and body image (BASS, CDRS) scores. This will assess whether obese individuals experience the same body dissatisfaction as those suffering from eating disturbances and whether men with obesity and men with disordered eating experience more habitual behaviours than the control group.

We will perform a regression analyses to assess which measure was the primary predictor for disordered eating in the obese and eating disorder group. We will regress all of the predictor variables (stress PSS), body image (BASS, CDRS) and habit (SRHI) on the dependant variables binge eating (BES) and eating attitudes (EAT) for each group separately, in order to assess whether habit, stress or body image predicts disturbed eating in each group.

Ethical Considerations

Ethical approval will be sought from both the University of Manchester and the NHS for the clinical sample. Our sample will only include adult males over the age of 18. Fully informed consent will be gained from all participants taking part. At the end of the study all participants will be given overall feedback on the study's results as well as generic advice on where to go for help with any weight/eating issues. This information will be given to all participants regardless of whether or not they have expressed signs of disordered eating or behaviour.

The clinical sample will have a diagnosed eating disorder and will currently be receiving treatment therefore the researcher will not be required to decide on a course of action for these individuals. Information from the study will be confidential for the control and obese sample but the clinical sample will be informed that confidentiality will include their allocated clinical practitioner e.g. clinical psychologist where relevant.


Difficulties maybe incurred when recruiting such high numbers of men with disordered eating as many men do not seek treatment and are therefore not diagnosed. How ever we will be recruiting on a national level through existing well established contacts from previous research collaborations with eating disorders clinics. Recruitment and data collection for this sample will take place over a period of 9 months therefore we should reach our target of 55. Recruiting obese and control group should not be a problem given the time frame.

Potential contribution to the research area

This research project will add to the small yet growing body of research into male eating and body image problems. This research will contribute to the understanding of the onset and maintenance of eating disturbances in men to try to improve treatment for obesity and disordered eating seen in men. The anticipated commonalities and differences in the processes associated with two very different aspects of problematic weight regulation will help to untangle this complex relationship. A vital task for the professional community is to normalise these conditions, stimulate discussion and encourage men to seek help in order to lift the taboo on discussing male eating disorders.

Dissemination Strategy - 218

The dissemination strategy is an inherent part of this research project which aimed at enhancing both the clinical and social understanding of eating disturbances in men. Disseminating results from the project also has a more practical objective: to contribute to the development of treatments aimed specifically at men experiencing obesity and eating disorders.

The dissemination of the project objectives, intermediary and final results will be organised to cover the project's duration and beyond on three levels:

  • International - predominantly westernised countries where such disorders are seen Europe, Australia and America;
  • National - within the UK;
  • Local - in the communities where participants may have been recruited.

The strategy has three broad target groups:

  • Specific service users/general population - men experiencing disordered eating whether overweight or underweight.
  • Professionals - particularly Doctors, Dieticians, Psychologists and Psychiatrists working with such patients.
  • Academic community - researchers, lecturers, experts and students.

The following channels for dissemination to our target audiences will be used:

  • Written articles in academic journals, medical journals and practitioners' newsletters.
  • Papers presented at a variety of international conferences, seminars and workshops for example - Beat (Beating Eating Disorders) international conference.
  • Media coverage through widely read newspapers, as well as major TV and radio stations and the internet through various websites utilised by professionals, patients and general population.

Costs Incurred

Measuring scales and computer software - 500

Placing adverts in various media - 1000

Printing and paper for questionnaires - 500

Battery of tests - 2000

Participants inconvenience (20 per participant for the 1 hour of their time) - 3000

It is hoped the majority of participants will be recruited through local media, however the clinical sample will be recruited nationwide therefore expenses will be incurred travelling to participants around the country with the possible need for overnight stays - 3000

Total cost = 10,000


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