Body Image 8 (2011) 349–356

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Body Image
journal homepage: www.elsevier.com/locate/bodyimage

The impact of exposure to images of ideally thin models in TV commercials on

eating behavior: An experimental study with women diagnosed with bulimia
nervosa
Ilka Rühl a , Tanja Legenbauer a,b,∗ , Wolfgang Hiller a
a
Department of Clinical Psychology and Psychotherapy, Johannes Gutenberg University, Wallstr. 3, 55099 Mainz, Germany
b
Ruhr-University Bochum, LWL University Hospital Hamm for Child and Adolescent Psychiatry, Heithofer Allee 64, 59071 Hamm, Germany

a r t i c l e i n f o a b s t r a c t

Article history: This study investigates whether eating behavior in women with diagnosed bulimia nervosa is influenced
Received 13 January 2011 by prior exposure to images of ideally thin models. Twenty-six participants diagnosed with bulimia
Received in revised form 29 June 2011 nervosa (BN) and 30 normal controls (NC) were exposed to body-related and neutral TV commercials;
Accepted 8 July 2011
then food that typically triggers binge eating was provided, and the amount of food eaten was measured.
No significant difference for food intake between NC and BN could be found, but food intake for BN was
Keywords:
predicted by the degree of thoughts related to eating behaviors during exposure to the thin ideal. No
Bulimia nervosa
impact of general body image or eating pathology on food intake could be found. The results emphasize
Mass media
Commercials
the importance of action-relevance of dysfunctional cognitions for the maintenance of eating-disordered
Thin ideal behaviors in women with bulimia nervosa, when exposed to eating-disorder-specific triggers.
Body image © 2011 Elsevier Ltd. All rights reserved.

Introduction body dissatisfaction, the tendency to compare oneself with oth-

Over the last decade, the role of mass media, in particular tele-
vision, in daily life has increased (Hagenah & Meulemann, 2006).
Today, 99% of the German as well as the British and US population
owns a TV set (British Medical Association, 2000; Meyen, 2004;
Tiggemann, 2002) and TV is reported as being the most frequently
domestic activity (British Medical Association, 2000), with an aver-
age viewing time of 3–4 h daily (Tiggemann, 2002). Interestingly,
only one out of five viewers switches the channel when TV com-
mercials are on the air (Meyen, 2004), resulting in a total of 35,000
TV commercials on average being watched over the period of one
year (Levine & Smolak, 1996).
Research in the field of eating disorders has shown that atti-
tudes toward the body, in particular, are negatively influenced by
the mass media, due to the omnipresent representation of ideally
thin women (Groesz, Levine, & Murnen, 2002; Harrison & Cantor,
1997; Legenbauer, Rühl, & Vocks, 2008; Tiggemann, 2002). In par-
ticular, exposure to images on TV featuring the thin body ideal
negatively impacts one’s body image directly (Tiggemann, 2003).
As a possible mediating mechanism linking media exposure and
∗ Corresponding author at: Ruhr-University Bochum, LWL University Hospital
Hamm for Child and Adolescent Psychiatry, Heithofer Allee 64, 59071 Hamm,
Germany. Tel.: +49 2381 893 5053; fax: +49 2381 893 202.
E-mail address: tanja.legenbauer@rub.de (T. Legenbauer).
ers has been further investigated, showing that especially among
women with bulimia nervosa, upward social comparison was more
prevalent and associated with a decrease in body dissatisfaction
(Blechert, Nickert, Caffier, & Tuschen-Caffier, 2009). Tiggemann and
Slater (2004) pointed out that exposure to the media, in particular
music videos featuring thin women, led to increased social compar-
ison and body dissatisfaction. The influence of the media exposure
was also mediated by the level of comparison processing.
The influence of mass media on body image is of interest,
because cognitive-behavioral models for the development and
maintenance of eating disorders consider a negative body image
to be of crucial importance for both development and mainte-
nance of the disorder (Williamson, Stewart, White, & York-Crowe,
2002). For example, studies have shown that, although a per-
son’s internalized preferred or ideal body shape may be stable,
feelings and attitudes toward his or her own body do vary, depend-
ing on situational contexts (e.g., Williamson et al., 2002). It is
thought that certain cues that are present in a situation act as
stimuli and can trigger body-related schemas leading to a negative
body image (Williamson, 1996). The association between body-
related schemas and the negative body image is thought to be
due to a cognitive bias—that is, a tendency to interpret informa-
tion in a schema-conforming way. For example, women with an
eating disorder are reported to interpret cues in such a way that
their pre-existing belief about their weight and shape is confirmed
(attitudinal bias). They also remember cues of food, weight, and

1740-1445/$ – see front matter © 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.bodyim.2011.07.002
350 I. Rühl et al. / Body Image 8 (2011) 349–356
shape better than women without an eating disorder, or encode
information related to weight and shape from memory more eas-
ily in comparison to other information (selective memory bias;
Williamson et al., 2002; Williamson, White, York-Crowe, & Stewart,
2004). The described difficulties in information processing then
trigger dysfunctional cognitions about weight, shape and eating, as
well as more general negative beliefs and self-statements. There is
some empirical evidence showing exactly the assumed association:
Cooper and Fairburn (1992) report that exposure to body-related
items triggers rumination about one’s own shape, weight, and
eating behavior. Other authors have pointed out that exposure
to commercials with appearance-relevant information triggered
thoughts about going on a diet in women with a diagnosed eating
disorder (Legenbauer et al., 2008). It is possible that the cognitive
bias and the associated dysfunctional cognitions hence lead to an
increase in negative emotions (Williamson et al., 2002) and, as a
consequence, can lead to compensatory behaviors such as dieting,
to reduce the negative body image (Thompson, 1992). The compen-
satory behaviors then establish a vicious circle, maintaining both
the eating disorder symptomatology and the disturbed body image
(Williamson et al., 2004).
Studies have shown, for example, that there is an association
between negative self-evaluation and a cognitively controlled eat-
ing style, mostly labeled as restraint eating (Turner & Cooper, 2002).
However, empirical evidence is scarce to support the assumed
action-relevance of cognitions in relation to eating behavior in
specific situational contexts. For example, one study indicated
that women with a restraint eating style showed disinhibited eat-
ing behavior after being exposed to ads representing the thin
ideal, whereas no disinhibited eating behavior was exhibited after
looking at ads showing larger women (Mills, Polivy, Herman, &
Tiggemann, 2002). Similarly, Seddon and Berry (1996) showed
such disinhibited eating behavior in women with a restraint eat-
ing style after exposure to TV commercials featuring the thin ideal.
Warren, Strauss, Taska, and Sullivan (2005) report that women with
a restraint eating style ate more snacks being offered after watching
ads for diet products that displayed ideally thin women, whereas
no such effect was found when TV commercials not relating to
appearance-relevant information were presented. It is still unclear,
whether exposure to TV images featuring ideally thin women influ-
ences eating behavior following the exposure, in women with a
diagnosed eating disorder. In particular, the diagnosis of bulimia
nervosa needs more attention, as research has shown that bulimic
behaviors are especially triggered by body dissatisfaction, social
comparison, and media influences (Thompson, Heinberg, Altabe, &
Tantleff-Dunn, 1999).
Taken all together, previous research points out that TV com-
mercials featuring ideally thin women directly impact body image
in women with eating disturbances, with the level of comparison
processing possibly linking body dissatisfaction and media expo-
sure. Further evidence supports the idea that exposure to the thin
ideal also affects eating behavior following the exposure (e.g., Mills
et al., 2002; Seddon & Berry, 1996; Warren et al., 2005). There-
fore, the specific content of automatic thoughts relating to eating
and diet rules appears to be a contributing factor. However, fur-
ther investigations are needed in order to shed light on the exact
association between disturbed eating behaviors and the cognitive
processes that are influenced by exposure to images of ideally thin
women, also considering possible moderating variables, so that the
assumptions of theoretical models of eating disorders and body
image disturbances can be confirmed (Fairburn, Cooper, & Shafran,
2003; Farrell, Shafran, & Lee, 2006; Thompson et al., 1999).
Therefore, the aim of the present study is to test whether (a)
women with diagnosed bulimia nervosa eat more after exposure to
TV commercials featuring ideally thin women, compared to women
without a history of an eating disorder; and (b) the amount of food
eaten is influenced by dysfunctional cognitions relating to eating
behavior and diet rules.
Method
Participants
Sixty women were admitted to the study, but only 56 were
able to be included (mean age: 24.3 years; SD = 4.5 range: 17–40
years), due to missing data. Four participants received an improper
test battery, because the reverse side of several questionnaires
had not been copied. With more than 10% of the items missing,
no scales could be calculated, and therefore the participants were
excluded from data analyses. All participants were assessed using
the Structured Clinical Interview for DSM Axis I Disorders (SCID I;
First, Spitzer, Gibbon, & Williams, 1996; German version: Wittchen,
Zaudig, & Fydrich, 1997), according to the fourth edition of the
Diagnostic and Statistical Manual of Mental Disorders (American
Psychiatric Association, 1994). Twenty-six women were diagnosed
with bulimia nervosa (BN). Of these, 10 women had bulimia of the
purging type and 16 had bulimia of the non-purging type. Fourteen
of the women diagnosed with bulimia nervosa showed comorbid-
ity with between one and three comorbid psychiatric disorders
each. Comorbid diagnoses included: affective disorders (major
depression n = 10; dysthymia n = 2; manic syndrome n = 1), anxi-
ety disorders (social phobia n = 1; agoraphobia n = 1; specific phobia
n = 1; generalized anxiety disorder n = 2), and post-traumatic stress
disorder (n = 2). Of the 26 women diagnosed with bulimia nervosa,
22 were students, two were employed, and one was unemployed.
The comparison group included 30 women for whom the
German version of the SCID revealed no form of an eating dis-
order or any other psychiatric disorder (NC). Of the 30 healthy
women, 28 were undergraduate students in Psychology and two
were employed. A 2 test revealed no significant differences in
occupation between the control and experimental groups, 2 (3,
N = 56) = 2.45, p = .49.
Measures
In order to assess general eating disorder pathology, the Eat-
ing Disorder Questionnaire (EDE-Q; Fairburn & Beglin, 1994;
German version, Hilbert, Tuschen-Caffier, Karwautz, Niederhofer,
& Munsch, 2007) was used, in addition to a structured clini-
cal interview (SCID). In addition, questionnaires assessing body
dissatisfaction and social comparison were administered. As exper-
imental stimuli, participants were exposed to TV commercials
featuring the thin ideal as well as neutral items.
Assessment of general eating disorder pathology and body
image. In order to measure disturbances in eating behavior and
body image, the German version of the EDE-Q (Hilbert et al.,
2007) was administered. The EDE-Q assesses relevant symptoms
of eating disorders that have occurred in the previous 28 days.
It includes 14 single items and four subscales: “restraint eating,”
“eating concerns,” “weight concerns,” and “shape concerns.” The
German version provides good internal consistencies for the sub-
scales, with between ˛ = .84 and ˛ = .93. Good internal consistencies
were also revealed for the current sample, with subscales ranging
between ˛ = .85 and ˛ = .94. The retest reliability for the subscales
(r = .68 to r = .74), based on a retest interval of three months, was
also considered to be good.
Assessment of social comparison. The Physical Appearance
Comparison Scale (PACS, Thompson, Heinberg, & Tantleff, 1991)
measures the overall tendency to compare one’s own body with
the bodies of others. It consists of five items, the scores of which are
added together to make a total score. The psychometric properties
 I. Rühl et al. / Body Image 8 (2011) 349–356
of the German translation (standardized back-translation proce-
dure) demonstrated a good internal consistency (˛ = .82) for the
current sample. High scores on the English version of this scale have
been shown to be strongly related to body image dissatisfaction and
eating disturbance (Thompson et al., 1991).
Assessment of cognitions. The German “Eating Disorder Cog-
nition Questionnaire” [Fragebogen zur Erfassung essstörungsspez-
ifischer dysfunktionaler Kognitionen] (EDCQ) was used to inves-
tigate specific eating-disorder-related cognitions. The original
version consists of three subscales (Legenbauer, Vocks, & Schütt-
Strömel, 2007): “body and self-esteem,” “dietary restraint,” and
“eating and loss of control.” Because in this study only thoughts
related to dietary restraint and loss of control were of interest, only
these subscales are described: the subscale “dietary restraint,” with
nine items (range 0–27), includes thoughts referring to restriction
of food and weight loss (e.g., “Tomorrow I will fast,” “I have to resist
and may eat nothing”), and therefore is used in order to assess the
action-relevance of thoughts relating to restraint eating behavior.
The subscale “eating and loss of control” is used to assess cognitions
that are associated with binge-eating behaviors. The eight items
of this subscale (range 0–24) describe negative thoughts regard-
ing eating, craving, and loss of control (e.g., “I will lose control
immediately and have a binge,” “I feel a craving to eat”). The items
of all subscales are answered on a four-point Likert scale (0 = not
at all, 3 = always). Normally the items evaluate the frequency of
cognitions during the previous month. In this study, we asked par-
ticipants to indicate the frequency in the past 5 min, while giving
the questionnaire after each of the five sections. The subscales are
of good internal consistency (Cronbach’s alpha “dietary restraint” as
well as “eating and loss of control” = .87). Evidence for good validity
is given by a fairly high degree of correspondence between “dietary
restraint” and EDI-2-subscale “strive for slimness” (r = .75) and by
good correlation between “dietary restraint” and EDE-Q-subscale
“restraint” (r = .57). Furthermore, “eating and loss of control” corre-
lates with frequency of binge-eating attacks in the last three to six
months (r = .48–.54) and with EDI-2-subscale “bulimia” (r = .79).
Assessment of state body dissatisfaction. The Contour Draw-
ing Rating Scale (CDRS, Thompson & Gray, 1995) is an instrument
to assess perceptions of women’s bodies. It consists of nine line-
drawings of women’s bodies arranged and numbered from 1
(smallest) to 9 (largest). The smallest figure is very underweight
and the largest very overweight. Women were asked to select the
line-drawing that (a) they thought most closely approximated their
current body; (b) represents what they feel they currently look like;
and (c) represents what they would like to look like. The results of
questions (b) and (c) can be used to calculate the body satisfaction
score by computing the difference between the felt and the ideal
(desired) appearance. A score of 0 indicates satisfaction, a negative
score indicates a desire to be heavier, and a positive score indicates
a desire to be thinner. The scale is well validated, which means that
the degree of correspondence between an individual’s reported
weight and current self-ratings is fairly high (r = .71) (Thompson &
Gray, 1995). Furthermore, the body differences between the figures
are consistently discernable, and self-ratings are highly correlated
with Body Mass Index (r = .59). The scale also demonstrated a good
test–retest reliability of current body size among college under-
graduate men and women (r = .78).
Experimental stimuli. Participants were presented with tele-
vision commercials which contained body-related versus neutral
contents. For the production of the experimental stimuli, com-
mercials from two German television channels were recorded.
The body-related commercials focus on slender and attractive
women and advertise products such as body lotions, shower gel,
or clothing. The women in these commercials were considered
to represent societal standards of attractiveness. For validation of
the experimental stimuli, we used a sample of 20 women who
351
were undergraduate students of psychology taking a basic course
in experimental psychology. None reported any clinically relevant
form of an eating disorder. They were asked to rate the content
of the commercials on two dimensions: “content referring to soci-
etal standards of attractiveness,” and “neutral content.” Based on
the results of the ratings, 16 body-related and 12 neutral television
commercials were chosen. These were then cut and put together
into a body-related and a neutral commercial sequence. Each com-
mercial sequence took 5 min of viewing time. The validity of the
stimulus material had been shown in a previous pilot study in
which body-related TV commercials triggered body dissatisfaction,
negative affect, and eating-disorder-specific cognitive contents, in
individuals with eating disorders (Legenbauer et al., 2008).
In contrast, the neutral television commercials advertise prod-
ucts such as cars or insurance policies. In these commercials, there
are mostly no people and no food-related cues. If people were
included, they were mostly males or children who did not meet the
criteria for body-related stimuli, according to the pre-test ratings.
Assessment of eating behavior. The presented food (gummy
bears, chocolate, and potato chips) was chosen due to the fact
that the preferred binge food of women with binge attacks con-
sists mostly of high-calorie fat or sweet food (Legenbauer, Vögele,
& Rüddel, 2004). In order to ascertain that the food items to be
presented were among the preferred binge foods of the women
included in the study, all participating women were asked during
the phone screening to describe their binge attacks. At least one of
the snacks had to trigger their attacks in order for the person to
be included in the study. The food items were weighed before and
after the experimental session. The difference between pre and post
weight for each food item indicated the amount of food eaten dur-
ing the experiment. The total amount of food eaten was calculated
by summing up the single difference scores. We also computed the
amount of kilocalories eaten for each item and the total amount of
food eaten.
Assessment of TV consumption. The weekly TV consumption
of participants was assessed using a semi-structured interview that
included two questions. First, participants were asked how often
they watched TV per week, on average. The answers were sum-
marized within three categories: less than once a week, twice to
four times per week, and at least five times per week. In reference
to the days on which TV viewing takes place, the second question
referred to the average duration of TV viewing per day. Categories of
answers included: less than 1 h, 1–2 h, 3–4 h, 5–6 h, 6–7 h, or more
than 7 h. None of the participants reported TV viewing of longer
than 4 h daily.
Design and Procedure
The study employed a between-subject design, distinguish-
ing between women diagnosed with bulimia nervosa (BN) versus
women with no history of an eating disorder (NC). Participants
with BN volunteered in reply to advertisements seeking individ-
uals experiencing regular binge-eating episodes, restrictive eating,
and who consider slimness to be an important factor for self-
esteem. They also had to be interested in taking part in a study
involving TV commercials. Twenty-five Euros was offered as com-
pensation. We applied three recruitment strategies in order to gain
the intended sample size: first, advertisements were placed in local
newspapers as well as the campus magazine, and fliers were dis-
tributed on the campus of the Johannes Gutenberg University in
Mainz (Germany). In the second step, additional bulletins were
posted at several stations of the university’s hospital and outpatient
treatment center, which includes an eating disorder unit. Third,
fliers and bulletins were posted in various public places in Mainz,
such as supermarkets, train stations, fitness centers, and medical
practices. Fifty women identifying themselves as suffering from an
352 I. Rühl et al. / Body Image 8 (2011) 349–356
eating disorder underwent an initial telephone screening. Partic-
ipants who answered affirmatively to the screening questions of
the SCID-I eating disorder section were then invited to a diagnostic
interview session. At this appointment, the German version of the
SCID (Wittchen et al., 1997) was conducted by a clinical psycholo-
gist who is well trained in this method of assessment. Women who
met the diagnosis of a current bulimia nervosa were included in
the study. Between the diagnostic interview and the experimental
session, participants received a series of questionnaires and were
asked to complete them prior to the next appointment. If partic-
ipants met the criteria for bulimia nervosa and had a BMI below
27 kg/m2 , they were accepted for the experimental group. A maxi-
mum weight was chosen because it has been pointed out that the
extent of body dissatisfaction is influenced by BMI (Allen, Byrne,
McLean, & Davis, 2008; Wade, Zhu, & Martin, 2011), in particular
that being of a larger girth leads to a higher discrepancy between
ideal and current size (Bulik, Wade, Heath, Martin, Stunkard, &
Eaves, 2001). By limiting the BMI range, we sought to minimize
variability in body dissatisfaction due to differences in BMI.
For the control group, inclusion criteria consisted of the
exclusion of any eating disorder or other psychiatric disorder.
Advertisements for this group were spread across the university
campus, requesting female individuals who were interested in
taking part in an experiment related to TV commercials. The adver-
tisement stated that anyone who was interested must not have an
eating disorder or a history of any mental disorder. Participants
were included consecutively, in order to stratify both groups for
age and BMI. They were mostly undergraduate students in psy-
chology. For taking part in the experiment, they were either given
partial credit toward their module in experimental psychology or
received 10 Euros in compensation. All accepted participants were
invited to attend the next stage: the experimental session.
The experimental session contained five sections, each lasting
5 min. The first, third, and fifth sections were recovery periods,
for relaxation only. The remaining two blocks were the actual
experimental sections. One of these included the presentation
of the sequence of body-related TV commercials. Participants
were instructed to watch the video sequence attentively. Dur-
ing the other experimental advertisement block, participants were
asked to watch a sequence of neutral TV commercials attentively.
Body-related TV commercials and neutral TV commercials were
presented in separate blocks. For all sections, the experimenter
left the room and only re-entered to signal the start of the next
section and to start the video, if necessary. At the end of the
experimental session, a semi-structured interview was conducted
which included questions regarding TV viewing. In order to avoid
sequence effects within each experimental session, half of the par-
ticipants watched the body-related commercials before the neutral
commercials, whereas the other half of the participants were pre-
sented with the commercials in reverse order. After viewing the
second block of TV commercials, the participants were presented
with 100 g of three different food items: gummy bears, potato chips,
and a very popular kind of chocolate. The snacks were arranged
within reach in the experimental room while the participants were
answering the questionnaires. As the snacks were presented, the
subjects were told, in passing, that the experiment was nearly fin-
ished and therefore they could eat as much as they would like
while filling out the last questionnaires. But they were not informed
that evaluation of their snack consumption was part of the study.
The end of the entire experiment consisted of a semi-structured
interview. When the participant had left, the remaining food was
weighed, and the consumed food was calculated, registered, and
evaluated.
The study was approved by the ethical committee of the medi-
cal council of Rhineland Palatinate, Germany. All participants gave
informed consent.
Results
Participant Characteristics
Using t-tests and 2 tests, we checked whether there were dif-
ferences between the groups for sample characteristics as well as
degree of eating and body-image pathology. Due to multiple t-
tests, the Bonferroni–Holm procedure to reduce Type I errors was
applied. The t-tests for independent samples did not find any signif-
icant differences between NC and BN for age or BMI. We ascertained
differences in eating behaviors and body image between NC and
BN by using the subscales of the EDE-Q, and differences in the
tendency to compare oneself with others (PACS). From t-tests, sta-
tistically significant differences were found between NC and BN
for body image and eating pathology. This suggests that BN show
higher levels of restraint eating, weight, shape concerns, and eat-
ing concerns, as well as tendencies to compare themselves with
others, in comparison to NC. All test statistics are summarized in
Table 1.
Group differences in TV consumption were analyzed by per-
forming 2 tests. They showed no significant differences in
distribution between NC and BN for the average weekly frequency
and daily duration of TV consumption.
Dysfunctional Cognitions and State Body Dissatisfaction
During Baseline
t-Tests were performed in order to control for differences
between the groups regarding baseline level of dysfunctional cog-
nitions and state body dissatisfaction. Again, due to multiple
testing, ˛ was adjusted using the Bonferroni–Holm procedure.
We found significant discrepancies for the degree of dysfunc-
tional cognitions during baseline for thoughts related to dietary
restraint and thoughts related to eating/loss of control, as
well as for state body dissatisfaction. Details are displayed in
Table 2.
Dysfunctional Cognitions and State Body Dissatisfaction
During Exposure to Appearance- and
Non-appearance-related TV Commercials
We performed an ANOVA in order to control for differences
between the groups, depending on the type of commercial. Pretest
degree of dysfunctional cognitions and state body dissatisfaction
was entered as covariate into the analyses when groups differed
significantly in their level prior to the exposure. We found signifi-
cant discrepancies for the degree of dysfunctional cognitions during
exposure to appearance- as well as non-appearance-related TV
commercials for thoughts related to dietary restraint and thoughts
related to eating/loss of control, as well as for state body dissatis-
faction. Mean values for exposure trials as well as test statistics for
group comparisons for each trial are also displayed in Table 2.
Moreover, we found a significant interaction for dysfunctional
cognitions related to dietary restraint, F(1, 53) = 9.04, p < .004,
eta = .15, indicating that the degree of cognitions differed between
participants and commercial condition: BN displayed a higher
degree of cognitions relating to dietary restraint compared to NC
during exposure to the thin ideal. Post hoc analyses revealed that
there is only a change in the degree of cognitions referring to dietary
restraint in the BN group (p < .001). We also found a significant
interaction effect, F(1, 53) = 6.47, p = .014, eta = .11, between group
and type of commercial for thoughts related to eating/loss of con-
trol, indicating a decrease in the BN group and an increase in the
NC group. In relation to body dissatisfaction, no significant inter-
action effect between group and type of commercial was found
when baseline scores for state body dissatisfaction were entered as
 I. Rühl et al. / Body Image 8 (2011) 349–356 353

Table 1
Participant characteristics.

NC (n = 30) BN (n = 26) t(df = 54) p d

M (SD) M (SD)

Age (years) 24.7 (5.4) 23.9 (3.5) 0.69 .49 –

BMI (kg/m2 ) 21.0 (2.3) 21.9 (2.3) −1.46 .15 –
EDE-Q
Restraint eating 0.6 (1.0) 3.3 (1.1) −9.57 <.001 2.6
Weight concerns 0.9 (1.0) 3.7 (1.3) −9.21 <.001 2.4
Shape concerns 1.2 (1.1) 4.2 (1.2) −9.86 <.001 2.6
Eating concerns 0.2 (0.4) 2.8 (1.2) −10.59a <.001 2.9
PACS 12.2 (3.6) 16.9 (4.0) −4.61 <.001 1.2
TV consumption
Less than once a week 8 4
2–4 times a week 17 20 2.59b .27
More than 5 times a week 5 2
TV hours watched
Less than 1 h 6 4
1–2 h 20 15 1.66b .44
3–4 h 4 7

Note. EDE-Q = Eating Disorder Examination-Questionnaire; PACS = Physical Appearance Comparison Scale; NC = normal controls; BN = participants diagnosed with bulimia
nervosa.
a
Due to heterogeneous variances, the degrees of freedom were reduced to df = 44.
b
2 -test with N = 56 and degrees of freedom = 2.

covariate into the analysis. However, post hoc tests showed that
within the BN group, body dissatisfaction changed significantly
from exposure to the thin ideal to exposure to non-appearance-
related TV commercials (p < .001), whereas this was not the case
for the NC group (p = .083).
Amount of Food Eaten After Exposure
To test whether the groups differed in food intake, we performed
t-tests with the dependent variable food intake in grams as well as
in kilocalories. We summed up the weight of the single food items
in grams to a total score, and calculated food intake in kilocalories.
We found no significant differences between the groups in regard
to the amount of food eaten, either for single food items or the
total amount of food in gram (NC: M = 17.89 (SD = 22.5) versus BN:
M = 16.7 (SD = 17.0)) or kilocalories (NC: M = 86.7 (SD = 118.5) versus
BN: M = 73.3 (SD = 79.1)) consumed.
Influence of Eating-disorder-relevant Variables on Eating
Behavior
First, Pearson’s correlations were calculated among food intake,
dysfunctional cognitions, state body image, TV consumption, and
general eating disorder characteristics (PACS, EDE-Q). Because we
assumed the postulated associations would especially be in the
BN group, we performed correlational analyses separately for BN
and NC. Within the NC group, no association between the vari-
ables tested and food intake could be identified, except a moderate
correlation with general TV consumption, whereas within the BN
group, we found mild to high associations between eating behav-
ior and dysfunctional cognitions in relation to dietary restraint and
eating and loss of control as well as the general degree of shape
concern assessed with the EDE-Q. For further details please see
Table 3.
Variables with significant associations to food intake then were
entered into a linear regression analysis, in order to identify pos-
sible predictors for eating behaviors after media exposure. Food
intake was the dependent variable. All relevant independent vari-
ables were entered at one time. For the NC group no statistical
significant model was found, whereas the model for the BN group
was of statistical significance, F(4, 25) = 5.73, p = .003 and explained
about 43.1% of variance for food intake within the BN group. Within
the variables entered, only the degree of thoughts relating to eating
and loss of control during exposure to the thin ideal was of sta-
tistical significance. This indicates that a high degree of thoughts
relating to eating and loss of control positively predicts food intake
(in grams). Statistics for this regression model are displayed in
Table 4.

Table 2
Dysfunctional cognitions and state body dissatisfaction during baseline and exposure.

NC (n = 30) BN (n = 26) t(df = 54)a p d

EDCQ (sum values)

Dietary restraint, mean (SD)
Baseline 10.2 (.5) 16.2 (7.6) −4.0 <.001 1.1
Exposure ARC 10.0 (.2) 16.0 (6.5) −6.0 <.001 1.3
Exposure Non-ARC 10.0 (.2) 13.6 (6.2) −3.6 .007 0.8
Eating and loss of control, mean (SD)
Baseline 8.7 (1.2) 13.1 (5.5) −3.9 <.001 1.1
Exposure ARC 8.4 (.9) 12.7 (4.0) −4.3 <.001 1.5
Exposure Non-ARC 8.7 (1.6) 12.2 (5.7) −3.5 .004 0.8
CDRS (sum value), mean (SD)
Baseline 0.9 (1.1) 3.0 (1.4) −6.3 <.001 1.7
Exposure ARC 0.9 (1.2) 3.3 (1.6) −2.4 <.001 1.7
Exposure Non-ARC 0.8 (1.2) 2.7 (1.3) −1.9 <.001 1.5

Note. Mean values for sum scores of EDCQ = Eating Disorder Cognition Questionnaire and CDRS = discrepancy score between ideal and felt body image of the Contour Drawing
Rating Scale separated for groups: NC = normal controls; BN = participants diagnosed with bulimia nervosa during baseline and exposure to appearance-related commercials
(ARC) and non-appearance-related commercials (Non-ARC).
a
Due to heterogeneous variance, the degrees of freedom was reduced to 26 for both subscales of the EDCQ.
354 I. Rühl et al. / Body Image 8 (2011) 349–356

Table 3 to TV commercials representing ideally thin women (Seddon &

Correlations between food consumed after exposure and dysfunctional cognitions
Berry, 1996; Strauss, Doyle, & Kreipe, 1994; Warren et al., 2005).
as well as eating disorder pathology.
Despite the fact that women with a restraint eating style can
Food consumed (g) be considered as a high-risk group for developing an eating dis-
NC (n = 30) BN (n = 26) order (Neumark-Sztainer, Wall, Guo, Story, Haines, & Eisenberg,
2006; Stice, 2001; Stice, Killen, Hayward, & Taylor, 1998), the
EDCQ
Dietary restraint, ARC, r .08 .40* results cannot be easily applied to women with bulimia nervosa.
Dietary restraint, NON-ARC, r .16 .36 For example, clinical evidence shows that most women hide their
Eating and loss of control, ARC, r .09 .63** disturbed eating behavior and control their eating behavior when
Eating and loss of control, NON-ARC, r .01 .56** under supervision, because they are ashamed of losing control in
EDE-Q
Restraint eating, r −.12 .03
front of others. This might explain why we did not find differences
Weight concern, r .11 −.24 between the groups, as women of the BN group monitored their
Shape concern, r −.02 −.42* eating behavior and thus prevented themselves from losing con-
Eating concern, r .08 −.18 trol over the amount of food they ate. An indicator for the exertion
CDRS
of control is that the BN participants who had an increased food
ARC, r −.08 .01
Non-ARC, r −.09 .05 intake ate more of the gummy bears than anything else; this might
PACS be a food item which is considered as not as dangerous as chocolate
Total score, r .04 .36 or chips.
TV Another explanation might be that we provided only small
Consumption, r −.45* .18
amounts of three food items (100 g each). From research in the
Hours watched, r .08 .09
field of food intake—and especially with regard to Binge-Eating
Note. Associations between food consumed in grams (g) and dysfunctional
Disorder—there is evidence that the bigger the portion size, the
cognitions and state body image during exposure to appearance-related com-
mercials (ARC) and non-appearance-related commercials (Non-ARC), as well as higher the food intake (DiLiberti, Bordi, Conklin, Roe, & Rolls, 2004;
general eating disorder pathology and TV consumption; EDCQ = Eating Disor- Gosnell, Mitchell, Lancaster, Burgard, Wonderlich, & Crosby, 2001;
der Cognition Questionnaire; EDE-Q = Eating Disorder Examination-Questionnaire; Wansink, Painter, & North, 2005). Hence, by providing only 100 g
PACS = Physical Appearance Comparison; separated by group: NC = normal controls; of each food item, it is possible that we made it easier to resist and
BN = participants diagnosed with bulimia nervosa.
* control food intake for the BN group. It also may be that due to the
p < .05.
**
p < .01. small amount, participants felt that food intake would catch the
investigator’s eye to a greater extent than had bigger portion sizes
been presented. Consequently, anxiety about embarrassing oneself
might have prevented disinhibition of food intake in patients with
Discussion
diagnosed bulimia nervosa in the experimental session.
Another possible explanation is offered by Fishbach, Friedman,
The aim of the study was to investigate whether exposure to
and Kruglanski (2003), who postulate that food cues that are pre-
images of ideally thin women in TV commercials influences eat-
sented in an incidental way led to self-control processes by the
ing behavior in women with bulimia nervosa more than in women
subject’s remembering the negative consequences of food intake,
without history/presence of eating disorders, and to identify cogni-
whereas concentrating one’s whole attention on the food triggers
tive predictors of food intake. The results revealed that there were
disinhibited eating (Coelho, Polivy, Herman, & Pliner, 2009). In our
no differences for the amount of food eaten between NC and BN;
study, we presented the snacks in such an incidental way, so this
but in contrast to NC, in BN patients the eating behavior was pre-
also might be the reason for the reserved eating behavior of the BN
dicted by the degree of thoughts related to eating behaviors that
participants.
were triggered during the exposure to the thin ideal. No impact of
However, there are also two studies focusing on women with
general body image or eating pathology (e.g., tendency to compare
a restraint eating style that also found no disinhibition effect
oneself with others) could be found. As expected, during expo-
(Anschutz, Engels, Becker, & Van Strien, 2009; Anschutz, Van Strien,
sure to the thin ideal, dysfunctional thoughts related to dietary
& Engels, 2008). The authors assumed that the impact of TV com-
restraint and eating and loss of control were triggered only in BN
mercials was weakened by the fact that the commercials were
patients.
shown during a movie as a commercial break (Anschutz et al., 2009,
There are several things that have to be discussed in relation
2008). Thus, attention may have been distracted and the impact not
to these results. To our knowledge, there is no prior study investi-
as strong as in previous studies, where women were able to focus
gating food intake after exposure to media images in a sample of
on the commercials featuring ideally thin women (Seddon & Berry,
women with a diagnosed eating disorder. Most studies that have
1996; Strauss et al., 1994; Warren et al., 2005).
been conducted assessed eating behavior after exposure in samples
In the present study, women were asked to watch the commer-
of college women with a restraint eating style. These studies mostly
cials attentively, as they would be questioned about their content
show that there is disinhibited eating behavior following exposure

Table 4
Summary of variables that predict food intake in women with bulimia nervosa after exposure to TV commercials.

Variables in the regression model B S.E. b t p

Absolute term 3.35 14.38 0.233 .82

EDE-Q
Shape concern −4.45 2.55 −.31 −1.75 .10
EDCQ
Dietary restraint, ARC −0.26 0.72 −.10 −0.36 .72
Eating and loss of control, ARC 2.65 1.2 .62 2.28 .03
Eating and loss of control, Non-ARC 0.22 0.77 .07 0.28 .78

Note. EDE-Q = Eating Disorder Examination Questionnaire; EDCQ = Eating Disorder Cognition Questionnaire; ARC = exposure to appearance-related TV commercials; Non-
ARC = exposure to TV commercials that do not feature appearance-related contents; B = beta coefficient; S.E. = standard error for B; b = beta; p = level of probability.
 I. Rühl et al. / Body Image 8 (2011) 349–356
afterwards for a memory test (see also Legenbauer, Maul, Rühl,
Kleinstäuber, & Hiller, 2010). It may be that due to this instruction,
the mass of images featuring the thin ideal poses a threat for BN and,
as postulated by Heatherton and Baumeister (1991), in the subjects’
escape from a negative self-awareness model, the disinhibited eat-
ing (in terms of thoughts about eating) occurs in order to reduce
the negative emotional state. Correlational and regression analy-
ses support this by showing that subjects reporting higher levels of
eating-related thoughts also eat more. It may be that women with
bulimia nervosa who show lower levels are either not as strongly
affected by the appearance-related commercials or were otherwise
distracted, as suggested by Warren et al. (2005).
However, these results also emphasize the impact of the action-
relevance of cognitions. Consistent with previous research, higher
levels of eating-related thoughts led to greater food intake. Powell
and Thelen (1996) found that when patients with diagnosed
bulimia nervosa reported stronger cognitions regarding feeling
heavy and believed that they could not maintain a diet, these
thoughts served to break their dietary restraint. Moreover, there is
evidence that in general, changes in rumination significantly pre-
dict changes in binge-eating behaviors, even after controlling for
changes in emotions (Selby, Anestis, & Joiner, 2008).
Finally, it has to be considered that there might be different sub-
types of BN patients: for example, a subtype that is more driven by
craving and food-related thoughts than others who are better char-
acterized by concerns about their bodies. Some studies ascertained
that there is a subgroup of bulimics who show multi-impulsive
behaviors such as suicide attempts, drug or alcohol abuse, sex-
ual promiscuity, or severe auto-aggression (Fichter, Quadflieg, &
Rief, 1994; Matsunaga et al., 2000). Maybe this subtype of bulimic
patients is more likely than the subgroup without this behavior to
fail to control their eating behavior in a supervised environment
such as an experimental session. As we did not assess the presence
of this behavior or impulsivity scores, further research is needed to
test these assumptions.
Besides the points already discussed, further limitations to this
study need to be mentioned. First, the study is based on a small
sample, which might restrict the generalizability of the results. Sec-
ond, the control group consists exclusively of a student population,
which limits the extent to which the effects found in this group
could be applied to the general population. Third, no individualized
binge food was offered, which might affect food intake by allow-
ing better control over less attractive food items. Fourth, the food
was presented incidentally, which might have led to greater control
over food intake. Fifth, we did not assess the amount of food eaten
by the participants before the experiment, and therefore, different
levels of hunger and satiety may have affected food intake during
the experiment.
To conclude, we found evidence for the action-relevance of
eating-related cognitions triggered by images of the thin ideal in the
group of participants with diagnosed bulimia nervosa. No relation-
ships between the exposure to pictures of ideally thin women and
eating-related thoughts or eating behavior were found in women
without an eating disorder. Further research is needed to investi-
gate possible moderators between thoughts related to eating and
food intake, in order to enhance understanding of the underlying
mechanisms of the maintenance of eating disorders and to optimize
treatment strategies.
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