Journal of Contextual Behavioral Science 2 (2013) 39–48

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Journal of Contextual Behavioral Science

journal homepage: www.elsevier.com/locate/jcbs

Research—Basic Empirical Research

Assessment of body image flexibility: The Body Image-Acceptance

and Action Questionnaire
Emily K. Sandoz a,n, Kelly G. Wilson b, Rhonda M. Merwin c, Karen Kate Kellum b
a
University of Louisiana at Lafayette, Psychology Department, Girard 202-A, P.O. Box 43131, Lafayette, LA 70504, USA
b
University of Mississippi, USA
c
Duke University Medical Center, USA

art ic l e i nf o a b s t r a c t

Article history: Acceptance and mindfulness components are increasingly incorporated into treatment for eating
Received 1 August 2012 disorders with promising results. The development of measures of proposed change processes would
Received in revised form facilitate ongoing scientific progress. The current series of studies evaluated one such instrument, the
8 February 2013
Body Image-Acceptance and Action Questionnaire (BI-AAQ), which was designed to measure body image
Accepted 17 March 2013
flexibility. Study one focused on the generation and reduction of items for the BI-AAQ and a
demonstration of construct validity. Body image flexibility was associated with increased psychological
Keywords: flexibility, decreased body image dissatisfaction, and less disordered eating. Study two demonstrated
Body image adequate internal consistency and test–retest reliability of BI-AAQ. Study three extended findings related
Psychological flexibility
to structural and construct validity, and demonstrated an indirect effect of body image dissatisfaction on
Acceptance
disordered eating via body image flexibility. Research and clinical utility of the BI-AAQ are discussed. The
Mindfulness
Eating BI-AAQ is proposed as a measure of body image flexibility, a potential change process in acceptance-
Assessment oriented treatments of eating disorders.
& 2013 Published by Elsevier Inc. on behalf of Association for Contextual Behavioral Science.

1. Introduction Quillian-Wolever, and Baer (2006) for reviews), with recent

A number of cognitive behavior therapies (CBTs) focus on
teaching clients to behave effectively in the presence of disturbing
thoughts and feelings (Hayes, 2004). This is particularly well
suited for clinical populations which tend to be cognitively rigid
(and therefore have thoughts that are difficult to change) or for
whom cognitions are consistent with a preferred self-image
(despite being harmful), such as in eating disorders like anorexia
nervosa. Acceptance and Commitment Therapy (ACT; Sandoz,
Wilson, & DuFrene, 2011), Dialectical Behavior Therapy (DBT; e.
g., Safer, Telch, & Chen, 2009), Mindfulness Based Cognitive
Therapy (MBCT; e.g., Baer, Fischer, & Huss, 2005b), and Mind-
fulness Based Stress Reduction (MBSR; e.g., Kristeller & Hallet,
1999) have all been adapted for treatment of disordered eating.
Common to each of these approaches is an emphasis on building
awareness and openness toward experience (for example, cues for
hunger and satiation and dissatisfaction with the body) while
replacing automatic or reactive eating behavior with more inten-
tional, committed behaviors.
This emphasis seems to be particularly well suited for treating
disordered eating (see Baer, Fischer, and Huss (2005a), Kristeller,
n
Corresponding author. Tel.: +1 3373715440.
E-mail address: emilysandoz@louisiana.edu (E.K. Sandoz).
evidence that symptoms are maintained, at least in part, by non-
acceptance or experiential avoidance. ACT has recently gathered
preliminary support in the treatment of eating disorders. A
randomized controlled trial comparing ACT to traditional cognitive
therapy (CT) for treatment of comorbid eating pathology found
that ACT produced larger reductions in eating pathology than CT
(Juarascio, Forman, & Herbert, 2010). A small case series investi-
gating ACT as a treatment for unremitting anorexia nervosa
showed clinically significant improvement in disordered eating
in all three clients (Berman, Boutelle, & Crow, 2009). A randomized
controlled trial investigating ACT as a treatment for obesity and
obesity-related stigma showed significantly greater improvements
in obesity stigma, quality of life, psychological distress, and body
mass (Lillis, Hayes, Bunting, & Masuda, 2009).
2. Psychological flexibility and disordered eating
In ACT, this combination of openness to experience with
constructive behavior is called psychological flexibility. Psycholo-
gical flexibility is the ability to fully experience the present
moment while engaging in behavior that is consistent with one's
chosen values even when the present moment includes difficult
emotions, thoughts, memories or body sensations (Hayes, Luoma,
Bond, Masuda, & Lillis, 2006). From this perspective, healthy

2212-1447/$ - see front matter & 2013 Published by Elsevier Inc. on behalf of Association for Contextual Behavioral Science.
http://dx.doi.org/10.1016/j.jcbs.2013.03.002
40 E.K. Sandoz et al. / Journal of Contextual Behavioral Science 2 (2013) 39–48
psychological functioning involves psychological flexibility (Hayes
et al., 2006). A growing body of evidence supports psychological
flexibility as central to psychological health (Kashdan &
Rottenberg, 2010), and psychological inflexibility as central to
psychological vulnerability (Kashdan, Barrios, Forsyth, & Steger,
2006). Psychological flexibility seems to be important in under-
standing the role of disordered eating-related cognitions in poor
psychological health (Masuda, Price, Anderson, & Wendell, 2010;
Merwin et al., 2011). Inflexibility with distressing thoughts and
feelings has been associated with binge-eating (Barnes & Tantleff-
Dunn, 2010), anorectic (Merwin, Zucker, Lacy, & Elliott, 2010) and
bulimic symptoms (Lavender, Jardin, & Anderson, 2009).
Among the thoughts and feelings most strongly associated with
disordered eating is body image dissatisfaction (e.g., Polivy &
Herman, 2002). Conceptualizations of eating disorders have long
pointed to body image dissatisfaction (also called “weight con-
cerns)” as a common precursor to disordered eating (e.g., Polivy &
Herman, 2002; Rosen, 1992; Shisslak & Crago, 2001; Slade, 1982;
Stice, 2002; Thompson, 1992). Meta-analytic reviews support
these theories, demonstrating the important role of body image
dissatisfaction in both the development and maintenance of
disordered eating (Jacobi, Hayward, de Zwaan, Kraemer & Agras,
2004; Stice & Shaw, 2002). Body image dissatisfaction seems
necessary to the development of disordered eating but does not
explain how some can remain dissatisfied without it impacting
their eating behavior (e.g., Polivy & Herman, 2002).
3. Psychological flexibility and body image dissatisfaction
Body dissatisfaction is so pervasive that it has been described
as “normative discontent” (Rodin, Silberstein, & Streigel-Moore,
1985, p. 267). Thus, it cannot only be the presence of the
disturbing thoughts and feelings about the body that is of issue.
Rather, the key skill may be the individual's ability to have a
disturbing thought/feeling about the body and not let it impact
health and well being (Masuda et al., 2010). For example, a woman
may, upon regarding her reflection, be filled with disgust and
think, “I've gained so much weight. I look awful.” If she is low in
psychological flexibility, it is likely that she will engage in some
behaviors to manage her thoughts and feelings about her body
such as canceling social plans, changing her clothes, having a
drink, binge eating, or skipping a meal, even if these are contrary
to how she would like to live her life. If she is high in psychological
flexibility, however, she is more likely to notice her thoughts and
the disgust she feels without making choices that are inconsistent
with her personal values. If her relationships are important to her,
it is likely she will keep her social plans, even on the days when it
makes her feel worse about her body to be around people.
The emerging acceptance and mindfulness-based treatments
for disordered eating are targeting precisely this kind of flexibility
with promising results (see Baer et al. (2005), Kristeller et al.
(2006) for reviews). Continued progress in the development of
these treatments of eating disorders will require the demonstra-
tion of both positive outcomes (e.g., improvements to quality of
life and eating behavior) and the processes by which these
outcomes occur. Although processes of change have not been
demonstrated with respect to traditional cognitive-interventions
for body image disturbance, the assessments exist that would
allow for such research (e.g., Appearance Schemas Inventory—
Revised; Cash, Melnyk, & Hrabosky, 2004; Assessment of Body-
Image Cognitive Distortions; Jakatdar, Cash, & Engle, 2006). Body
image inflexibility could not be assessed using existing measures
of body image as it is functionally defined while these measures
focus on formal properties of behavior. Body image inflexibility is
not characterized by the contents of thoughts (e.g., “What I look
like is an important part of who I am;” Cash et al., 2004) or
topography of behaviors (e.g., “I wear baggy clothes;” Rosen,
Srebnik, Saltzberg, & Wendt, 1991), but on how body image is
impacting life (e.g., “When I start thinking about the size and
shape of my body, it's hard to do anything else;” Sandoz & Wilson,
2006).
4. Assessing body image flexibility
Psychological flexibility has typically been assessed using a
brief self-report measure, the Acceptance and Action Question-
naire (AAQ; Hayes et al., 2004; Bond et al., 2011) or one of its
variations. Mediation of treatment outcomes may be better
assessed by measures of psychological flexibility that target
specific areas of difficulty. Domain-specific measures have been
found to be sensitive to changes in psychological flexibility with
smoking urges (Gifford et al., 2004), diabetes-related thoughts and
feelings (Gregg, Callaghan, Hayes, & Glenn-Lawson, 2007), obesity
stigma (Lillis & Hayes, 2008), auditory hallucinations (Shawyer
et al., 2007), and pain-related thoughts and feelings (McCracken,
Vowles, & Eccleston, 2004). In some cases, the domain-specific
measures mediated treatment outcomes where the general AAQ
did not (e.g., Gifford et al., 2004; Gregg et al., 2007).
To date, two studies in this area have assessed body image
flexibility as a proposed process of change (Berman et al., 2009;
Lillis et al., 2009). Berman et al., 2009 conducted a small case
series investigating ACT with previously treated, unremitted
anorexia nervosa, and demonstrated improvement in body image
flexibility in all three participants. The design did not, however,
allow for a formal mediation analysis, and used an unpublished
version of a measure the authors developed (Sandoz & Wilson,
2006). Lillis et al., 2009 demonstrated weight-specific psychologi-
cal flexibility as a mediator of weight control and quality of life
following an ACT-based workshop. Their measure, the Acceptance
and Action Questionnaire for Weight-Related Difficulties (AAQ-W;
Lillis & Hayes, 2008), may not be sensitive to body image inflex-
ibility in the form of controlled eating (e.g., avoidant restriction).
Although an item like, “I am in control of my eating behavior”
might indicate greater flexibility for an individual struggling with
binge eating, it would likely indicate inflexibility in an individual
engaging in harmful dietary restriction.
Further investigation of the role of body image flexibility in the
prevention or treatment of disordered eating depends on the
development of a brief measure of body image flexibility that is
psychometrically sound, easy to administer, and appropriate for
individuals with a range of weight concerns and a variety of
disordered eating behaviors. For example, disordered eating and
eating-related behaviors (e.g., purging and excessive exercise) are
exhibited by both male (e.g., Drummond, 2002; Lavender, De
Young, & Anderson, 2010; O'Dea & Abraham, 2002; Petrie,
Greenleaf, Reel, & Carter, 2008) and female (e.g., Berg, Frazier, &
Sherr, 2009; Napolitano & Himes, 2011; Reinking & Alexander,
2005) college students. In many cases, subclinical levels of dis-
ordered eating can be just as disruptive to functioning as eating
patterns meeting diagnostic criteria (Fairburn & Bohn, 2005).
However, measures developed in clinical populations may not be
appropriate for these populations, as they might be insensitive to
variations in the subclinical range.
5. The Body Image-Acceptance and Action Questionnaire
The current series of studies present an attempt to develop a
measure of body image flexibility that could allow for research
that examines the role of body image flexibility in preventing or
 E.K. Sandoz et al. / Journal of Contextual Behavioral Science 2 (2013) 39–48
reducing disordered eating in a nonclinical population. The Body
Image-Acceptance and Action Questionnaire (BI-AAQ) was
adapted from existing measures of psychological flexibility to
specifically assess flexible responding to body-related thoughts
and feelings. Three studies were conducted in a college student
sample so as to include individuals with varying degrees of
disordered eating. Pilot data suggested significant disordered
eating in around ten to fifteen percent of this particular
population.
Study one focused on the generation and selection of items for
the BI-AAQ, and an initial evaluation of its validity. Concurrent
validity was examined in terms of the relationship between body
image flexibility and overall psychological flexibility, body image
dissatisfaction, and disordered eating. Study two focused on an
evaluation of the reliability of the BI-AAQ. Study three focused on
replicating the results of study one.
6. Study one: initial validation
6.1. Participants
One hundred eighty-two (182) undergraduates were recruited for
participation in return for extra credit in their psychology classes.
Participants had an average age of 19.65 with 92% being between the
ages of 18 and 22. The sample was 70% female. They were 68.2%
Caucasian and 15.3% African American. Only one individual in the
sample reported having been diagnosed with an eating disorder at
one time. Sixty-five percent of the sample had a calculated body
mass index (BMI) (from self-reported weight and height) within
normal range (18.5 kg/m2 oBMIo25 kg/m2), with 4.9% classified as
“underweight,” 18% classified as “overweight,” and 10.4% classified as
“obese” (WHO, 1995).
6.2. Measures
6.2.1. Body Image-Acceptance and Action Questionnaire
The BI-AAQ (see Appendix) was designed to measure body
image flexibility. Body image flexibility is defined as the capacity
to experience the ongoing perceptions, sensations, feelings,
thoughts, and beliefs associated with one's body fully and inten-
tionally while pursuing chosen values. The original BI-AAQ item
pool included 46 items adapted from (1) the three published
versions of the Acceptance and Action Questionnaire (Hayes et al.,
2004; Bond & Bunce, 2003; Bond et al., 2011) and (2) the item
pools from which the published AAQ items were selected. The
authors rewrote these items to focus specifically on body-related
content as opposed to psychological experiences in general. Items
worded in the direction of inflexibility are reverse scored such that
higher summed scores are indicative of greater body image
flexibility.
6.2.2. Acceptance and Action Questionnaire-II (AAQ-II; Bond et al.,
2011)
Psychological flexibility involves both the ability to accept
difficult thoughts and feelings and to engage in valued activity in
their presence. This study employed the 10-item version of the
AAQ-II (Bond et al., 2011), an improved version of the earlier AAQ
(Hayes et al., 2004). Although the 7-item version has been recom-
mended by the authors (Bond et al., 2011), the 10-item version was
what was available and in common use at the time that the study
was conducted. Higher scores are indicative of greater psychological
flexibility. Scores on the AAQ-II have been shown to have good
reliability and construct validity (Bond et al., 2011). The internal
consistency of the AAQ-II in this sample was good, with a Cron-
bach's alpha of 0.84.
41
6.2.3. Body Shape Questionnaire (BSQ; Cooper, Taylor, Cooper,
& Fairburn, 1986)
Body image dissatisfaction was assessed using the BSQ (Cooper
et al., 1986), a commonly used 34-item measure. Participants
respond on a five-point scale from never to always, and responses
are scored such that higher scores indicated higher body image
dissatisfaction. The BSQ has demonstrated good test–retest relia-
bility, discriminant validity, concurrent validity, and criterion-
related validity (Cooper et al., 1986; Rosen, Jones, Ramirez, &
Waxman, 1996). The internal consistency of the BSQ in this sample
was excellent, with a Cronbach's alpha of 0.97.
6.2.4. Eating Attitudes Test-26 (EAT-26; Garner, Olmsted, Bohr,
& Garfinkel, 1982)
Disordered eating behavior was assessed using the EAT-26
(Garner et al., 1982). Participants respond to 26 items on a six-
point scale from never to always. Responses were recorded such
that “Always,” “Usually,” or “Often,” are scored as 3, 2, or 1,
respectively. All other responses (i.e., “Sometimes,” “Rarely,” or
“Never”) were scored as 0. Responses result in scores on three
subscales: Dieting, Food Preoccupation, and Oral Control. The
Dieting subscale includes items that describe the extent to which
individuals restrict intake, obsess about thinness, and experience
eating related discomfort. The Food Preoccupation subscale
includes items that describe the extent to which individuals feel
controlled by food and food-related thoughts and engage in
bulimic behavior. The Oral Control subscale includes items that
describe the extent to which individuals exert highly-controlled
eating behavior and feel pressure to gain weight or eat more. On
all three subscales, higher scores indicate more disordered eating
behavior.
The EAT-26 has been shown to have good criterion-related,
discriminant, concurrent validity (Garner et al., 1982; Mintz &
O'Halloran, 2000; Koslowsky et al., 1992), internal consistency
(Garner et al., 1982; Mazzeo, 1999), and test–retest reliability
(Mazzeo, 1999). It has also been adapted as a valid measure
disordered eating behavior in a number of populations (see
Garfinkel & Newman, 2001 for a thorough review of the EAT).
Internal consistency of the EAT-26 in this sample was good, with a
Cronbach's alpha of 0.86.
6.3. Procedures
After consenting to participation, participants completed the
battery of measures including the BI-AAQ item pool, the AAQ, the
EAT-26, the BSQ, and a demographics questionnaire, in that order.
Participants received a debriefing form upon completion, provid-
ing more detailed information regarding the study's hypotheses
and references for supplementary information and mental health
services.
6.4. Study one results
6.4.1. Factor analysis
Body image flexibility was defined to be actively contacting
perceptions, thoughts, beliefs, and feelings about the body without
attempts to change their intensity, frequency, or form. It was
expected to demonstrate a unidimensional structure. Seventeen
items were omitted based on low or negative item-total correla-
tions ( o0.30). Omission followed an iterative procedure. All items
with negative item-total correlations were omitted. Then the item
with the lowest item-total correlation was omitted, and the
remaining item-total correlations examined. This was repeated
until all items had item-total correlations over 0.30. Internal
42 E.K. Sandoz et al. / Journal of Contextual Behavioral Science 2 (2013) 39–48

consistency of the remaining 29 items was good, with a Cronbach's produce a measure of shorter length. Twelve items with factor
alpha of 0.93. loadings above 0.60 were retained for further analyses.
The remaining data were then examined to further determine
factorability. First, the Kaiser–Meyer–Olkin (KMO) Measure of Sam-
6.4.2. Calculation and descriptive statistics
pling Adequacy was 0.91, above the recommended 0.6 (Kaiser, 1970;
Body image flexibility scores were calculated by reverse-
Kaiser & Rice, 1974) and indicating enough common variability
scoring and summing responses on the 12-item BI-AAQ (see
amongst items to indicate factorability. Second, Bartlett's test of
Appendix). The distribution of scores was examined for central
Sphericity was significant (χ2 (406)¼2596.45, po0.001), meaning
tendency and spread. BI-AAQ scores ranged from 14 to 84, with a
that the correlation matrix diverged significantly from an identity
mean of 66.56 and a standard deviation of 15.11. Thus, the
matrix in which the items would be uncorrelated. Third, the
distribution was slightly negatively skewed, indicating a trend
diagonals of the anti-image correlation matrix (KMO for individual
toward body image flexibility.
items) were all over 0.8, supporting the inclusion of all 29 items in
the factor analysis based on partial correlations other items. Fourth,
the initial communalities ranged from 0.33 to 0.72, suggesting a 6.4.3. Internal consistency
satisfactory amount of shared variance for each item with other The twelve-item version of the BI-AAQ was examined for
items. Taken together, these indices suggested that despite the internal consistency. All item-total correlations were over 0.57.
moderate sample size, factor analysis was appropriate for these data Cronbach's alpha was 0.92, and decreased if any one item was
(MacCallum, Widaman, Zhang, & Hong, 1999). deleted.
Principal factor analysis was conducted to determine the latent
structure of the data with the intention of determining which items
6.4.4. Covariates
best measure body image flexibility. Direct oblimin rotation (with a
Correlational analyses were conducted to examine the relation-
delta of 0) was employed so that multiple factors, if found, would be
ships between body image flexibility and theoretically relevant
allowed to correlate. Parallel analysis (Horn, 1965), a Monte Carlo test
criterion variables. The relationship between BMI and body image
for retention of factors based on size of eigenvalues, was conducted
flexibility approached significance, such that higher body mass
to determine the number of factors corresponding to eigenvalues
index (BMI) was associated with lower body image flexibility
significantly greater than parallel random eigenvalues (i.e., eigenva-
(r (176) ¼−0.15, p ¼ 0.054). This suggests that it may be important
lues generated from completely independent items). One hundred
to control for BMI when examining the relationship between body
sets of eigenvalues reflecting sampling were generated based on
image flexibility and disordered eating.
random data matrices representing 29 variables and 175 cases to
Significant gender differences were also noted with the dis-
represent the effects of sampling error. Because of the tendency of
tribution of scores being significantly less variable for males
parallel analysis to overfactor, the 95th percentiles of the random
(p ¼0.034) and males reporting significantly higher body image
eigenvalues were used, instead of the means (Glorfeld, 1995;
flexibility than females (p o0.001). Examination of correlation
Harshman & Reddon, 1983). As seen in Fig. 1, a comparison of the
matrices of body image flexibility with other covariates and
actual eigenvalues obtained to those calculated from the random
dependent variables revealed that this difference did not extend
data, suggested retention of two factors would be appropriate. The
to the multivariate level, meaning that the pattern of relationships
first factor accounted for 34.6% of the variance and the second factor
between body image flexibility and other variables of interest was
accounted for an additional 7.4% of the variance.
similar enough between genders to allow for subsequent analyses
Examination of the rotated factor loadings revealed that all 29
to be conducted on males and females as one group.
items loaded above 0.30 on one factor. Eleven of these items also
The pattern of correlations was wholly similar with one notable
loaded above 0.30 on both factors. Additionally, all of the items
exception. The correlation between body image flexibility and BMI,
loading on the second factor were those that were worded in the
although nonsignificant in the female sample and in the sample as
direction of flexibility, suggesting that this factor may be an
a whole, was significant and of moderate size in the male sample,
artifact of item wording. There were no other cross loadings.
(r (53) ¼−0.366, p ¼0.007). For this reason, BMI was controlled for
Finally, the two factors were correlated 0.45. For these reasons,
in subsequent analyses.
the analysis was repeated and one factor extracted, as would be
theoretically consistent.
The single extracted factor accounted for 34.4% of the variance. 6.5. Construct validity
Twenty-six items had factor loadings above 0.40, suggesting a
more conservative criterion for retention could be used in order to 6.5.1. Concurrent validity
Body image flexibility would be expected to relate negatively to
body dissatisfaction and disordered eating. As seen in Table 1,
partial correlational analysis supported these relationships.
BI-AAQ scores were highly negatively related to body image
dissatisfaction as assessed by the BSQ and disordered eating as
assessed by the EAT-26 and the BULIT-R. The sole exception were
responses on the Oral Control subscale, which were unrelated to
BI-AAQ scores, suggesting that body image flexibility does not
predict oral control when BMI is controlled for. Body image
flexibility was low when body image dissatisfaction and disor-
dered eating were high.
If the BI-AAQ measures psychological flexibility specific to the
body, BI-AAQ scores would be expected to have a moderately
positive correlation with measures of overall psychological flex-
ibility. As seen in Table 1, partial correlation coefficients provided
initial support for the hypothesized relationship. BI-AAQ scores
Fig. 1. Actual vs. randomly generated eigenvalues in study 1. were moderately positively related to psychological flexibility.
 E.K. Sandoz et al. / Journal of Contextual Behavioral Science 2 (2013) 39–48 43

6.5.2. Incremental validity behavior over existing measures of general flexibility. Hierarchical
If body image flexibility is important in predicting disordered regression analyses were conducted predicting disordered eating
eating, then body image flexibility would be expected to (a) improve behavior from BSQ, AAQ, and BI-AAQ scores after controlling for
prediction of disordered eating behavior above and beyond body BMI and with BI-AAQ scores entered last. The BI-AAQ remained a
shape dissatisfaction and (b) moderate the predictive value of body significant predictor of EAT-26 scores even after controlling for
image dissatisfaction for disordered eating. Hierarchical regression BMI, body shape dissatisfaction, and general flexibility (p o0.001).
analyses were conducted predicting disordered eating behavior from Even when general flexibility was a significant predictor of
BSQ and BI-AAQ scores after controlling for BMI, and with BI-AAQ disordered eating behavior, BI-AAQ scores still contributed
entered last. As indicated in Table 2, BI-AAQ scores remained a significantly to the overall predictive power of the model.
significant predictor of EAT-26 scores even after controlling for body
dissatisfaction and actual body size (BMI). In addition, the model
including both BSQ and BI-AAQ accounted for over half of the
7. Study two: test–retest reliability
variance in disordered eating behavior scores.
Next, hierarchical regression analyses were repeated, including
7.1. Participants
the BSQ  BI-AAQ interaction term to test for moderation effects of
body image flexibility on the relationship between body shape
Two hundred thirty-four (234) undergraduates were recruited
dissatisfaction and disordered eating behavior. The interaction
for participation in return for extra credit in their psychology
between body shape dissatisfaction and body image flexibility
classes. Participants were unique to this study (i.e., potential
was a significant predictor of disordered eating behavior, indicat-
participants were restricted from participation if they had parti-
ing that body image flexibility moderated the relationship
cipated in study one). Participants had an average age of 19.42
between body image dissatisfaction and disordered eating.
years with 97% being between the ages of 18 and 22. The sample
(p o0.001). As indicated in Fig. 2, the slope of the regression line
was 68.4% female. The sample was 84.2% Caucasian and 12.8%
for predicted disordered eating at different levels of body image
African American.
dissatisfaction was significantly greater when body image flex-
ibility was low (p o0.001). This suggests that body image dis-
satisfaction had a decreased impact on disordered eating when
body image flexibility was high.
Additionally, if body image flexibility is to be a useful construct,
it would be expected to improve prediction of disordered eating

Table 1
Correlations between body image flexibility, psychological flexibility, and eating-
related difficulties.

Body image flexibility

Study 1 Study 3
rpartial r

Psychological flexibility (AAQ) 0.48nnn 0.30nnn

Body image dissatisfaction (BSQ) −0.73nnn −0.80nnn
Bulimic symptoms (BULIT-R) −0.70nnn
Dieting (EAT-26) −0.69nnn −0.70nnn
Food preoccupation (EAT-26) −0.60nnn −0.61nnn
Oral control (EAT-26) −0.09 −0.27nnn

Note: Study 1 correlations were calculated after controlling for Body Mass Index. Fig. 2. Predicated disordered eating from body image dissatisfaction by body image
n
p o0.05, nnp o0.01, nnnp o 0.001.. flexibility.

Table 2
Hierarchical regression model predicting disordered eating (EAT-26 total) from body shape dissatisfaction and body image flexibility after controlling for BMI.

Std. beta t R2 ΔR2

BMI −0.030 −0.391 (0.149) 0.001 0.001

BMI −0.184 −3.571 (0.102) 0.556 0.555nnnn

Body image dissatisfaction 0.761 14.750 (0.015)nnnn

BMI −0.184 −3.743 (0.097)nnnn 0.601 0.045nnnn

Body image dissatisfaction 0.537 7.633 (0.020)nnnn
Body image flexibility −0.309 −4.437 (0.041)nnnn

BMI −0.172 −3.591 (0.094)nnnn 0.626 0.025nnn

Body image dissatisfaction 1.121 5.996 (0.054)nnnn
Body image flexibility 0.107 0.758 (0.083)
Body image dissatisfaction  body image flexibility −0.434 −3.357 (0.001)nnn

Note: Values in parentheses are standard errors.

n
p o0.05, nnp o0.01, nnnp o 0.005, nnnnp o 0.001.
44 E.K. Sandoz et al. / Journal of Contextual Behavioral Science 2 (2013) 39–48
Table 3
Hierarchical regression equation predicting disordered eating (EAT-26 scores) from body image dissatisfaction and body image flexibility.
Body image dissatisfaction
Body image dissatisfaction
Body image flexibility
Body image dissatisfaction
Body image flexibility
Body image dissatisfaction  body image flexibility
Note: Values in parentheses are standard errors.
n nnn
p o 0.05, p o0.001.
7.2. Measures
In study two, the Demographic Questionnaire and the twelve-
item BI-AAQ developed in study one were included in a packet of
measures of psychological flexibility and related constructs (e.g.,
mindfulness). None of the other measures are of interest to the
reliability of the BI-AAQ and will not be described further.
7.3. Procedure
After consenting to participation, participants completed the
battery of 12 brief questionnaires including the Demographic
Questionnaire and 12-item BI-AAQ. This took participants no
longer than 60 mins. Participants returned between two and three
weeks later and completed a shorter battery of three question-
naires including the BI-AAQ. This took participants no longer than
20 min. Participants received a debriefing form upon completion,
providing more detailed information regarding the study's hypoth-
eses and references for supplementary information and mental
health services.
7.4. Study two results
7.4.1. Calculation and descriptive statistics
The distributions of scores were examined for central tendency
and spread. For the first administration, BI-AAQ scores ranged
from 15 to 84, with a mean of 59.9 and a standard deviation of
17.4. For the second administration, BI-AAQ scores ranged from 22
to 84, with a mean of 63.3 and a standard deviation of 16.1.
Consistent with study one, both distributions were negatively
skewed, indicating a trend toward body image flexibility.
7.5. Reliability
7.5.1. Internal consistency
The 12-item version of the BI-AAQ was examined for internal
consistency in both administrations. For the first administration,
all item-total correlations were over 0.54. Cronbach's alpha was
0.92, and decreased if any one item was deleted. For the second
administration, most item-total correlations were over 0.62, with
one item (“If I start to feel fat, I try to think of something else”)
correlating with the total 0.39. Cronbach's alpha was 0.93. Cron-
bach's alpha decreased if any item except this item was deleted, in
which case it stayed the same.
7.2.2. Test–retest reliability
The Pearson product–moment correlation between the two
administrations of the BI-AAQ was 0.80 (p o0.01). Correlations
between administrations for individual items ranged from 0.30 for
one item (“I will have better control over my life if I can control
Std. beta t R2 ΔR2
0.712 16.834 (0.013)nnn 0.507 0.507nnn
nnn
0.392 5.972 (0.021) 0.565 0.059nnn
−0.401 −6.104 (0.046)nnn
1.417 7.910 (0.057)nnn 0.617 0.052nnn
0.320 2.399 (0.094)n
−0.667 −6.093 (0.001)nnn
negative thoughts about my body”) and 0.68 for another item
(“I care too much about my body weight and shape”), but all were
significant at 0.01 level.
8. Study three: validation, replication and extension
8.1. Participants
Two hundred eighty-eight (288) undergraduates were
recruited for participation in return for extra credit in their
psychology classes. Participants were unique to this study (i.e.,
potential participants were restricted from participation if they
had participated in study one or two). Participants had an average
age of 19.5 years with 95.2% being between the ages of 18 and 22.
The sample was 59.9% female. The sample was 77.4% Caucasian
and 17.5% African American.
8.2. Measures
In study three, the AAQ-2, the EAT-26, BSQ and the BI-AAQ
described above were included in a packet of measures of depres-
sion, anxiety, and education-related difficulties. Other measures
were not of interest to the validity of the BI-AAQ and will not be
described further.
8.3. Procedure
After consenting to participation, participants completed the
battery of 16 brief questionnaires. This took participants no longer
than 60 min. Participants received a debriefing form upon com-
pletion, providing more detailed information regarding the study's
hypotheses and references for supplementary information and
mental health services.
8.4. Study three results
8.4.1. Calculation and descriptive statistics
The distribution of scores was examined for central tendency
and spread. BI-AAQ scores ranged from 15 to 84, with a mean of
66.2 and a standard deviation of 15.8. Consistent with studies one
and two, the distribution was negatively skewed, indicating a
trend toward body image flexibility.
7.4.2. Internal consistency and structural validity
The 12-item version of the BI-AAQ was examined for internal
consistency. The scale was found to have good internal consis-
tency. All item-total correlations were over 0.52. Cronbach's alpha
was 0.93, and decreased or stayed the same if any one item was
deleted. The principal factor analysis and the parallel analysis
conducted in study one were replicated, providing additional
 E.K. Sandoz et al. / Journal of Contextual Behavioral Science 2 (2013) 39–48 45

Table 4
Logistic regression equation predicting eating disorder risk (EAT-26≥11) from body image flexibility and body shape dissatisfaction.

Predictor Std. beta SE Wald's χ2 Odds ratio

Constant −0.672 0.127 28.066 N/A

Constant 5.483 0.775 50.057 N/A

Body image flexibility −0.096 0.012 64.125nnn 0.908

Constant −2.021 1.565 1.668 N/A

Body image flexibility −0.036 0.016 5.384nn 0.964
Body image dissatisfaction 0.040 0.008 25.158nnn 1.041

Constant 3.087 3.199 0.931 N/A

Body image flexibility −0.113 0.046 6.018nn 0.893
Body image dissatisfaction −0.007 0.026 0.069 0.993
Body image flexibility  body image dissatisfaction 0.001 0.000 3.307n 1.001

Evaluation of final model 128.254nnnn

Likelihood ratio test 131.179nnnn

Hosmer–Lemeshow goodness-of-fit test 6.392

n
p o 0.10.
nn
p o 0.05.
nnn
po 0.01.
nnnn
p o 0.001.

support for the stability of the unidimensional model. This single
factor accounted for 54% of the variance in responses.
8.4.3. Concurrent validity
Body image flexibility was related to overall psychological
flexibility and disordered eating in study one. As seen in Table 1,
these relationships were replicated in the current study. BI-AAQ
scores were positively related to psychological flexibility. They
were also negatively related to body shape dissatisfaction and
disordered eating.
8.4.4. Incremental validity
In study one, body image flexibility improved prediction of
disordered eating behavior above and beyond body shape dis-
satisfaction and moderated the predictive value of body image
dissatisfaction for disordered eating. As seen in Table 3, hierarch-
ical regression analyses replicated this finding. Notably, a full 61%
of the variance in disordered eating was predictable from body
image dissatisfaction, body image flexibility, and the interaction
term. As in study 1, body image dissatisfaction had less of an
impact on disordered eating when body image flexibility was high.
8.4.5. Criterion-related validity
Ninety-six participants (33.3%) were classified as at-risk for
eating disorders using the recommended cutoff for nonclinical
samples of 11 on the EAT-26 (Orbitello et al., 2006). If body image
flexibility is important in predicting disordered eating, BI-AAQ
scores should discriminate those at-risk for eating disorders from
the rest of the sample. Logistic regression was performed to
explore the extent to which increases body image flexibility
correspond to an increase in the likelihood of eating disorder risk.
Body image dissatisfaction and the interaction term were included
as predictors in Blocks 2 and 3, respectively.
As seen in Table 4, all three models were significant. Body
image flexibility improved prediction over the null model, χ2(1)¼
99.204, p o0.001. Body image flexibility alone correctly classified
91.5% of those with eating disorder risk, and 54.3% without. Body
image dissatisfaction improved prediction when included along
with body image flexibility, χ2(2)¼ 128.254, p o0.001. Body image
flexibility and body image dissatisfaction correctly classified 92.6%
of those with eating disorder risk, and 63.6% without. The final
model, including the body image flexibility  body image dissa-
tisfaction interaction, was also significant, χ2(2)¼ 128.254,
po 0.001. The full factorial model correctly classified 92.6% of
those with eating disorder risk and 63.6% without, for a total of
72.7% correct classification. Interestingly, body image dissatisfac-
tion was not a significant predictor once the interaction term was
included.
9. Discussion
The current series of studies attempted to develop and provide
initial psychometric support for a brief self-report measure of
body image flexibility, the Body Image-Acceptance and Action
Questionnaire (BI-AAQ). To be useful, such an instrument would
need to demonstrate both that it does, indeed, measure body
image flexibility (validity), and that it does so consistently
(reliability).
9.1. Reliability
The twelve-item BIAAQ was found to assess body image
flexibility with good reliability between items and administra-
tions. Internal consistency was high (0.92–0.93) in all four admin-
istrations across three different samples. Temporal stability was
good (0.80) for overall BI-AAQ scores.
8.2. Validity
Body image flexibility was defined as the capacity to experience
the perceptions, sensations, feelings, thoughts, and beliefs about the
body fully and intentionally while pursuing effective action in other
life domains. Although conceptually, body image flexibility could be
distinguished into different capacities (e.g., capacity to experience
body image vs. capacity to pursue effective action), each item was
generated to refer to both acceptance and action. In other words,
the BI-AAQ was intended to measure body image flexibility as a
unidimensional construct. Results of principal factor analysis in the
first study supported the retention of 12 items that loaded on a
single factor with a conservative retention criterion. Studies 2 and
3 replicated a single, highly homogenous factor. Since data were
first collected for these studies, the item selection and
46 E.K. Sandoz et al. / Journal of Contextual Behavioral Science 2 (2013) 39–48
unidimensional structure of the BI-AAQ has been replicated using
confirmatory factor analysis in a large sample with more diverse
body sizes (Ferreira, Pinto-Gouveia, & Duarte, in press). Together,
these findings suggest that the unidimensional structure is stable.
Body image flexibility was the focus of these studies because of
its relationship with disordered eating, and purported role as a
process of change in prevention and treatment of disordered
eating. Study one and study three both supported a strong
negative relationship between body image flexibility and a range
of self-reported disordered eating behaviors. Dieting, bulimic
symptoms, and preoccupation with food were all strongly asso-
ciated with inflexibility with body image after controlling for BMI.
Oral control, however, was only associated with body image
flexibility when BMI was not controlled for. Consistent with the
extant literature, this may reflect more variability in the functions
of oral control than with other facets of disordered eating
(Masuda, Price, & Latzman, 2012). For some individuals, control-
ling dietary intake may actually reflect increased flexibility. This
also may be an artifact of the homogenous samples common in
this literature.
Body image flexibility also proved important in correct identi-
fication of individuals at risk for eating disorders. Nearly 73% of
participants' risk status was accurately predicted by body image
flexibility alone, and body image dissatisfaction did not contribute
significantly to the predictive model once the interaction term was
added. Body image flexibility seems to be more important than
body image dissatisfaction when it comes to predicting who is at
risk for development of eating disorders.
Construct validity depends, however, not only on relationships
with the outcome of interest, but also on relationships with other
predictors. Body image flexibility was positively related to overall
psychological flexibility. Body image flexibility improved predic-
tion of disordered eating, however, above and beyond overall
psychological flexibility even after controlling for body image
dissatisfaction and BMI. This suggests that the AAQ might be less
sensitive to differences in the kind of psychological inflexibility
important in eating disorders. This also provides additional sup-
port for the continued development of measures of psychological
flexibility that are domain specific.
Body image flexibility was strongly negatively related to body
image dissatisfaction. This was not surprising, as many items on
the final BI-AAQ included specific reference to how people relate
to aversive experiences with the body (e.g., “feeling fat,” or
“negative thoughts about the body”). Notably, these items were
empirically selected. In study one, the items in the pool that did
not refer specifically to dissatisfaction (e.g., “When I think about
my body…”) did not meet the criterion for retention. This suggests
that body image flexibility may be more important when people
feel badly about their bodies than when they feel good or neutral.
Despite the strong relationship between body image flexibility
and body image dissatisfaction, body image flexibility predicted
disordered eating above and beyond body image dissatisfaction.
Consistent with the theoretical model (e.g., Sandoz, Wilson, &
Kellum, 2009) and with extant literature (see Hayes et al., 2006),
body image flexibility moderated the relationship between body
image dissatisfaction and disordered eating. Body image dissatis-
faction had less of an impact on disordered eating when body
image flexibility was high. This was consistent in linear and
categorical models (i.e., when predicting EAT-26 scores and when
predicting risk status).
These data complement previous research indicating that
mindfulness moderates the relationship between disordered eat-
ing cognitions and disordered eating behaviors (Masuda et al.,
2012). Masuda et al. (2012) have posited that overall psychological
flexibility is not as important to predicting disordered eating as it
is general psychological health. Flexibility specific to body image,
however, seems to make a considerable contribution. It is likely
that the moderation effect of body image flexibility extends to the
relationship between disordered eating cognitions (of which
body image dissatisfaction is an aspect) and disordered eating
behaviors.
9.3. Methodological limitations
There were methodological issues that limit the conclusions
that can be drawn from this series of studies. For one, all three
samples were drawn from the same population of undergraduate
students. The participants were mostly Caucasian females around
nineteen years of age. The homogenous samples limited range, and
thus, statistical power in such a way as to prevent meaningful
analyses examining individual differences in body image, disor-
dered eating, or the relationships between body image and
disordered eating. Generalizability of these findings will depend
on the BI-AAQ's validation with diverse genders, ethnicities, age
groups, cultures and clinical groups. This work is already under-
way, and with promising initial findings (e.g., Ferrerira et al., in
press; Merwin, France, & Zucker, 2009; Rabitti, Manduchi, Miselli,
Presti, & Moderato, 2010).
In addition, the order of administration of the questionnaires
was not randomized between subjects. This means that responses
on the BI-AAQ could be affected by the participants' experience of
having just completed other questionnaires. Order effects seem
unlikely, however, as the BI-AAQ was administered following
different questionnaires in all three studies with similar univariate
and multivariate results.
Finally, all data were collected via concurrent self-report.
Anonymity reduces the likelihood of dishonesty. It does not
ensure, however, that the participants understood the questions
and successfully discriminated the correct answers. The validity of
these findings also rests on the assumption that these relation-
ships do not tend to vary significantly without intervention. These
conclusions would be strengthened if BI-AAQ scores were found to
predict performance on behavioral tasks or trends in behavior
over time.
9.4. Future directions
In addition to replications of this work in various samples and
with suggested methodological improvements, future work should
focus on further specification of body image flexibility as a
construct. For example, efforts should be made to examine how
body image flexibility might contribute to the overall multidimen-
sional construct of body image. Traditional cognitive behavioral
approaches have focused on body image as including three
dimensions: perceptions, attitudes, and overt behavior (Cash &
Pruzinsky, 2002). The current studies addressed only the relation-
ship between body image flexibility and body image dissatisfac-
tion, and in a limited way. Future research might integrate current
findings with existing research by examining how body image
flexibility relates to traditional conceptualizations of body image.
Of particular interest might be longitudinal studies that examine
body image flexibility and other body image variables over time,
along with associated difficulties. It may be that body image
flexibility changes an individual's susceptibility to body image
disturbances in perception, attitudes, and overt behavior.
Future research might also focus on outcomes of body image
flexibility interventions on different components of body image.
Interventions that target body image flexibility may effect some
improvement of body image distortion, body image dissatisfaction,
body image investment and body image avoidance. For example,
cognitive interventions have traditionally focused not only on
body image dissatisfaction but also on body image investment
 E.K. Sandoz et al. / Journal of Contextual Behavioral Science 2 (2013) 39–48
(e.g., Cash, 1997; Rosen, 1997). This is an important area of
development as body image investment predicts treatment
response, treatment outcome, and long-term remission (e.g.,
Fairburn, Cooper, & Shafran, 2003; Fairburn, Peveler, Jones, Hope,
& Doll, 1993; Masheb & Grilo, 2008; McFarlane, Olmsted, &
Trottier, 2008; Spoor, Stice, Burton, & Bohon, 2007). There has
been some evidence, however, that targeting flexibility with
thoughts can produce bigger reductions in believability of
thoughts than direct cognitive disputation (e.g., Zettle & Hayes,
1986; Bach & Hayes, 2002). It could be that body image dissatis-
faction and investment may be better targeted through interven-
tions on body image flexibility.
Finally, the current studies provided support for body image
flexibility as a moderator of the relationship between body image
dissatisfaction and disordered eating. Body image dissatisfaction
seems to have less of an impact on disordered eating if body image
flexibility is high than when it is low. Other approaches have
supported body image flexibility as a mediator of the relationship
between disordered eating cognitions, such as body image dis-
satisfaction, and disordered eating behavior (Wendell, Masuda, &
Le, 2012). This slightly different model suggests that body image
flexibility may account for the association between body image
dissatisfaction and disordered eating. This does not, however,
speak specifically to the role of body image flexibility as a potential
mediator of changes to disordered eating or risk of disordered
eating following mindfulness-based prevention or treatment
efforts. Now that the BI-AAQ has demonstrated reliability and
validity, future research should include direct examination of
validity and utility in the context of response to interventions
over time in both clinical and nonclinical samples.
The BI-AAQ was developed with the ultimate goal of facilitating
continued prevention and treatment development in the area of
disordered eating. Mindfulness-based treatments of eating disor-
ders are quickly gaining support for their effectiveness (see Baer
et al. (2005), Kristeller et al. (2006) for reviews). To date, however,
there has been no way to demonstrate that they are effective by
changing the processes they target. The findings of these studies
provide not only psychometric support for a measure that could be
used in precisely this way but also provide further support for the
importance of including body image flexibility in the conceptua-
lization and treatment of disordered eating. The current findings
suggest that interventions targeting body image flexibility may
prevent or reduce disordered eating, and offers the BI-AAQ as an
assessment of purported mechanisms of change in such
interventions.
Appendix. BI-AAQ
Directions: Below you will find a list of statements. Please rate the
truth of each statement as it applies to you. Use the following rating
scale to make your choices. For instance, if you believe a statement is
‘Always True,’ you would write a 7 next to that statement.
Never Very Seldom Sometimes Frequently Almost Always
true seldom true true true always true
true true
1 2 3 4 5 6 7 871–878.
1. Worrying about my weight makes it difficult for me to live a
life that I value.
2. I care too much about my weight and body shape.
3. I shut down when I feel bad about my body shape or weight.
4. My thoughts and feelings about my body weight and shape
must change before I can take important steps in my life.
47
5. Worrying about my body takes up too much of my time.
6. If I start to feel fat, I try to think about something else.
7. Before I can make any serious plans, I have to feel better about
my body.
8. I will have better control over my life if I can control my
negative thoughts about my body.
9. To control my life, I need to control my weight.
10. Feeling fat causes problems in my life.
11. When I start thinking about the size and shape of my body, it's
hard to do anything else.
12. My relationships would be better if my body weight and/or
shape did not bother me.
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