Body Image 32 (2020) 155–166

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

Acceptance and commitment therapy to reduce eating disorder

symptoms and body image problems in patients with residual eating
disorder symptoms: A randomized controlled trial
Maria Fogelkvist a,∗ , Sanna Aila Gustafsson a , Lars Kjellin a , Thomas Parling b
a
University Health Care Research Center, Faculty of Medicine and Health, Örebro University, SE 701 82 Örebro, Sweden
b
Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Stockholm County Council,
The Centre for Psychotherapy, Education & Research, Liljeholmstorget 7, SE-117 63 Stockholm, Sweden

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

Article history: Body image problems are central aspects of eating disorders (ED), and risk factors both for the devel-
Received 29 March 2019 opment of and relapse into an ED. Acceptance and commitment therapy (ACT) aims at helping patients
Received in revised form 9 January 2020 accept uncomfortable internal experiences while committing to behaviors in accordance with life values.
Accepted 14 January 2020
The aim of the present study was to compare the effectiveness of a group intervention, consisting of 12
sessions, based on ACT to treatment as usual (TAU) for patients with residual ED symptoms and body
Keywords:
image problems. The study was a randomized controlled superiority trial. Patients with residual ED symp-
Acceptance and commitment therapy
toms and body image problems were recruited from a specialized ED clinic in Sweden. The final sample
Eating disorder
Body image
consisted of 99 women, randomized to ACT or TAU. At the two-year follow-up, patients who received
Body dissatisfaction ACT showed a significant greater reduction in ED symptoms and body image problems and received less
Randomized controlled trial specialized ED care than patients in TAU. In conclusion, ACT was superior in reducing ED symptoms and
Psychotherapy body image problems.
© 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Body image problems are risk factors for the development of an
eating disorder (ED; Stice, 2002), and are central traits in individu-
als with an ED (American Psychiatric Association, 2013). Behaviors
associated with EDs include food restriction, binge eating, purging,
compulsive exercise, and various avoidance or checking behaviors
regarding the physical appearance of the body (Fairburn, Cooper,
& Shafran, 2003). According to the transdiagnostic theory of ED,
these behaviors associated with EDs are driven by patients’ pre-
occupation with eating, weight and shape, and their control. This
preoccupation is part of a dysfunctional scheme for evaluating self-
worth. Self-esteem has been shown to be low for patients with ED
in comparison to healthy controls and other psychiatric disorders
(Silverstone & Salsali, 2003). EDs are difficult to treat, where many
treatment trials have shown low response rates (Halmi, 2013),
∗ Corresponding author at: University Health Care Research Center, Faculty of
Medicine and Health, Örebro University, S-huset, vån 2, Box 1613, 701 16 Örebro,
Sweden.
E-mail addresses: maria.fogelkvist@regionorebrolan.se (M. Fogelkvist),
sanna.aila-gustafsson@regionorebrolan.se (S.A. Gustafsson),
lars.kjellin@regionorebrolan.se (L. Kjellin), thomas.parling@ki.se (T. Parling).
high levels of dropout (Swift & Greenberg, 2014), and low rates
of remission (Keel & Brown, 2010). As noted by Wonderlich et al.
(2012), when patients do not remit after receiving evidence-based
care, treatment is often continued with less scientific guidance, and
there is a risk for repeated treatment failures and even chronicity
of symptoms. Many patients who do remit from an ED continue to
have difficulties with their body image, which has shown to be asso-
ciated with relapse (Keel, Dorer, Franko, Jackson, & Herzog, 2005)
and poor quality of life (Latner, Mond, Vallance, Gleaves, & Buckett,
2013). Further, evaluations of health care utilization and costs sug-
gest that patients with an ED, in comparison to healthy controls,
have elevated rates of hospitalization, outpatient care, and emer-
gency department visits, although many of them do not receive care
for their ED (Agh et al., 2016).
Since body image preoccupation is a central symptom in individ-
uals with an ED, treatments have been developed to target different
aspects of body image. It has previously been identified that there
is an underrepresentation in research of evaluations of specific
body image treatment in the context of ED (Farrell, Shafran, & Lee,
2006). This is in part due to such interventions often being part
of other ED treatment (e.g. Fairburn, 2008; Tuschen-Caffier, Pook,
& Frank, 2001), which complicates methods of assessment. How-
ever, in recent years there has been an increased activity in the

https://doi.org/10.1016/j.bodyim.2020.01.002
1740-1445/© 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.
0/).
156 M. Fogelkvist et al. / Body Image 32 (2020) 155–166
development and evaluation of body image treatment in the con-
text of ED (Mountford et al., 2015). In a meta-analytic review of
43 randomized control trials (RCT) on stand-alone interventions
targeting body image in participants with or without an ED, the
authors concluded that the interventions only had a small effect
on body image, thus highlighting the need for further interven-
tions (Alleva, Sheeran, Webb, Martijn, & Miles, 2015). The study
also highlighted the need for longer-term follow-up, since none of
the included studies had any follow-up beyond three months.
Acceptance and commitment therapy (ACT; Hayes, Strosahl,
& Wilson, 2012) is one of the so-called third wave of cogni-
tive behavioral therapies (Hayes, Luoma, Bond, Masuda, & Lillis,
2006). ACT conceptualizes mental disorders as stemming from
inflexible responses (thoughts, behaviors, emotions) to aversive
internal experiences. Avoiding internal experiences, even if this
creates harm in the long run, is called experiential avoidance. A
consequence of experiential avoidance is a narrowed behavioral
repertoire. ACT aims at broadening one’s psychological flexibility.
Psychological flexibility is the capacity to participate in situations
fully aware, in contact with all thoughts and feelings, even uncom-
fortable ones, and to commit to behaviors that are in line with
one’s values. ACT might be hypothesized, at a theoretical level, to
be helpful for individuals with an ED since their behaviors often
aim at avoiding (Juarascio, Shaw, Forman et al., 2013) or control-
ling (Tiggemann & Raven, 1998) inner experiences. Restrictions
of food intake and the onset of a binge-eating episode have both
been described as methods for controlling unwanted and intru-
sive thoughts and feelings (Hayaki, 2009; Heffner, Sperry, Eifert, &
Detweiler, 2002). Further, patients are often fused with a descrip-
tion of themselves that is strongly dependent on their body image.
In ACT, cognitive fusion is the propensity to adhere to thoughts
as literal truths that directly guides behavior. The overvaluation of
shape and weight and their control might lead to other areas in life
becoming less prioritized while the ED takes over control. In ACT,
patients are prompted to clarify their values. This aims at increas-
ing vitality and motivation to behavioral change (Katz, Catane, &
Yovel, 2016; Plumb, Stewart, Dahl, & Lundgren, 2009). Working
with mindfulness, acceptance, and willingness for inner experi-
ences helps the individual to change behaviors aimed at avoiding
or controlling painful inner states (Espel, Goldstein, Manasse, &
Juarascio, 2016; Hayes et al., 2006). Patients also work with defu-
sion, i.e., seeing the difference between a thought or a feeling and
the impulse toward behaviors elicited by this thought or feeling
and, while noticing all of these inner states, being able to flexibly
choose behaviors. Thus, ACT does not aim at altering the individ-
ual’s inner states, but instead helps the individual to be able to
experience them and choose behaviors in accordance with their
values.
ACT has shown promising outcomes for a range of different men-
tal disorders, from depression and anxiety to psychosis (Ruiz, 2012).
However, to date there are only a few studies published that exam-
ine ACT for patients with an ED, of which none targets body image
specifically. For patients with anorexia nervosa (AN) or bulimia
nervosa (BN) spectrum disorders, ACT seems to show outcomes
comparable to treatment as usual (TAU; Berman, Boutelle, & Crow,
2009; Juarascio, Kerrigan et al., 2013; Juarascio, Shaw et al., 2013;
Juarascio, Shaw, Forman et al., 2013; Parling, Cernvall, Ramklint,
Holmgren, & Ghaderi, 2016). One study indicated that patients with
more severe ED symptoms showed a greater reduction in eating
pathology when receiving ACT than when receiving TAU (Juarascio,
Kerrigan et al., 2013). For adolescents with AN or subthreshold AN,
a family-based approach based on ACT has shown to reduce ED
pathology (Merwin, Zucker, & Timko, 2013; Timko, Zucker, Herbert,
Rodriguez, & Merwin, 2015).
In the present study, we wanted to investigate the effect of
an ACT group intervention specifically targeting body image prob-
lems in adult patients in treatment at a specialized ED clinic. The
intervention targeted a transdiagnostic sample, where body image
problems was the common factor hypothesized to hinder further
changes in ED symptoms, such as patterns in eating. Thus, our
hypothesis was that by adding an intervention that aims at accept-
ing unwanted thoughts and feelings regarding body image would
lead to less inclination for avoidance and behavioral control strate-
gies, thus reducing symptoms of eating disorder and enhancing
self-esteem. Since this is the first trial of a specific intervention,
we wanted to investigate the effect based on symptom reduction
as well as amount of care consumed.
The aim of the study was to compare the effectiveness of a group
intervention, based on ACT, with TAU for patients with residual ED
symptoms and body image problems.
We hypothesized that:
1 ACT would lead to greater reduction in ED pathology in compar-
ison with TAU.
2 ACT would show a greater improvement than TAU on patients’
ratings of body image, self-esteem, and mindful attention.
3 Patients in ACT would consume more specialized ED outpatient
care during the intervention phase, but that they would have
consumed less specialized ED outpatient care at the two-year
follow-up.
2. Method
2.1. Trial design
The study was a superiority trial, with a randomized controlled
trial (RCT) design, consisting of two research arms. According
to a power calculation, where the effect size of (d = 0.50) was
derived from a clinical perspective, at a power of .85 and the
alpha level of .05, a total of 120 patients needed to be included,
60 in each arm. The time frame of recruitment was extended, but
we ended recruitment prior to the desired sample size had been
obtained.
The intervention phase was approximately 16 weeks. Note that
the ACT intervention consisted of 12 weekly sessions, but time for
assessment was 16 weeks as there were also one individual session
before and after the intervention. Data were collected before (T1)
and after (T2) treatment, and at one (T3) and two years (T4) after
initiation of treatment. The study was approved by the Regional
Ethical Review Board of Uppsala (Dnr 2009/294/1, 2012-06-05) and
registered at Clinical Trials (clinicaltrials.gov, ID: NCT02058121).
2.2. Participants
Participants were recruited from a specialized outpatient ED
clinic in Sweden from 2010 until 2014, with last follow-ups col-
lected in 2016. A total of 260 patients were deemed to be eligible
and received an information letter (5 men and 255 women). One
hundred and two of those, all women, expressed a desire to par-
ticipate. Three patients were excluded due to severe psychiatric
complicating factors. The final sample consisted of 99 participants
randomized to either a group intervention based on ACT (n = 52),
or to continue TAU (n = 47). A flowchart, following CONSORT (Con-
solidated Standards of Reporting Trials) guidelines, is included as
Fig. 1.
At intake at the specialized ED clinic, a structural clinical
assessment is mandatory for all patients, and a diagnosis of ED
is determined by integrating the M.I.N.I. diagnostic interview
(Sheehan et al., 1998) with self-assessments through the Swedish
quality assurance database, Stepwise (Birgegard, Bjorck, & Clinton,
2010). The included patients had received ED treatment prior to
 M. Fogelkvist et al. / Body Image 32 (2020) 155–166 157

Fig. 1. Flow chart of participants.

study participation and had improved regarding ED pathology.
However, they had residual symptoms and continued to report
body image problems. Prior treatment was of varying length (cur-
rent treatment episode 0–63 months), and for 62 patients it was
their first ED treatment episode. Inclusion criteria were patients in
the age range of 16–50 who were currently in specialized ED treat-
ment and had attained a somewhat regular eating pattern (e.g.,
eating at least three meals per day although still restrictive). Since
the ACT intervention did not include any work on patterns in eating,
this criterion was intended to ascertain that participants were able
to pause all other treatments at the clinic, during the intervention
phase (16 weeks). Patients were excluded if they had a physical or
158 M. Fogelkvist et al. / Body Image 32 (2020) 155–166
psychiatric complicating factor of such severity that these condi-
tions needed to be addressed during the treatment period.
2.3. Procedure
Twice a year, the head investigator (SAG) asked each clinician
at the treatment unit to report all patients that met the inclusion
criteria. Eligible patients received an information letter about the
trial and were instructed to notify their therapist if they wanted to
participate. This procedure was repeated twice a year, and all eli-
gible patients received the information letter. Patients who did not
actively accept the invitation to the trial continued to be viewed as
eligible, and thus could receive the information letter several times.
Each patient who wished to participate was invited to an individual
information and assessment meeting with the head investigator
at the clinic. During the assessment, the head investigator made
sure that patients understood the information and what each study
group might comprise. The head investigator did not reevaluate the
diagnosis or criteria for eligibility. Consent to participate, both ver-
bally and in writing, was collected during the assessment meeting.
After that, the self-assessment questionnaires were administered.
Participants then received a sealed and opaque envelope with the
randomization outcome and opened it during the meeting. The
randomization sequence was generated in R (R Core Team, 2009)
and was provided from an independent statistician in blocks. For
each consecutive participant, an administrator put the current ran-
domization in an envelope and gave it to the head investigator.
Neither patients, therapists nor researchers were blind to study
allocation. If randomized to TAU, treatment continued as planned.
If randomized to the intervention, other treatment interventions
were paused during the intervention phase, with the exception of
some planned appointments, such as to a physician or dietician.
After the intervention, all participants were contacted by their prior
therapist for decision on further treatment. For those who wished
to terminate the group treatment, or deteriorated during the inter-
vention period, further treatment was agreed upon in consultation
with the patient and was given in accordance to the clinic’s standard
procedures.
Follow-up assessments were distributed either at the end of
the intervention or sent by mail at predetermined time intervals.
The assessments could be filled in at home and sent back to the
treatment center, and some patients filled it in at the treatment cen-
ter. ED care consumption was assessed at both follow-ups through
entries in each patient’s case records.
2.4. ACT intervention
The ACT intervention was held in a group setting with 5–8 par-
ticipants. It consisted of 12 weekly two-hour sessions and two
Table 1
Steps of the intervention in the book, and content of sessions.
Step
1. Values – what is important in your life?
2. Rediscover your body – beyond your inner dialogue
3. The relation between body image and self-esteem
4. Delineate your inner dialogue – understand, take a stand, change and
accept
5. Willingness and acceptance – the art of living
6. Take care of your body and be mindful
7. Sustain changes and prevent relapse – keep it up
individual sessions, one before and one after the intervention.
The intervention was a manualized application of a self-help book
based on ACT, Lev med din kropp [Live with your body] (Ghaderi &
Parling, 2009) for people with body image problems. Each partic-
ipant received a copy of the book. Participants were encouraged
to read chapters of the book in preparation for each session, and
complete exercises between sessions. The six core processes of ACT
were addressed in the intervention: values, committed action, self
as context, defusion, acceptance, and mindfulness. The self-help
book was not written for patients with an ED, but rather uses gen-
eral ACT principles adapted to target body image problems. The
adaptations are manifested in that descriptions and examples given
are closely linked to common problems regarding body image. The
treatment progressed through seven stages, following the seven
chapters of the book, where one chapter was addressed in either
one or two sessions. Please see Table 1 for an outline of the interven-
tion. A detailed description of the intervention has been published
previously (Fogelkvist, Parling, Kjellin, & Gustafsson, 2016).
Those participants who were randomized to ACT but who did
not start the group treatment because the time did not suit them,
or who dropped out from the treatment group, were offered the
option to continue TAU.
2.5. TAU
Participants randomized to TAU were instructed to continue
their treatment in collaboration with their therapist in the same
way as if they were not in the study. This could mean that par-
ticipants chose to end current treatment. In contrast to those
randomized to ACT, there was no specific intervention given
between assessments at T1 and T2. Treatments included indi-
vidualized psychotherapy, other group interventions, physician
appointments, physiotherapy, meal support, daycare, family ses-
sions, supportive interventions, seeing a dietician, and occupational
therapy.
2.6. Therapists
Each ACT intervention was given by two group leaders, and there
were four group leaders in total. The first four groups were held by
the same pair of leaders, and one of them was the head investi-
gator who had also created the manual, in collaboration with the
authors of the book. The following four groups were held by a dif-
ferent pair of leaders, under supervision of the head investigator.
The ninth group was held by one of the original group leaders and
one from the second pair of group leaders. All four leaders received
ACT training by one of the authors of the book before starting the
intervention. Three of the group leaders had CBT, mindfulness, and
ACT training, and one was a physiotherapist with many years of
Session Content
1–2 Investigation and clarification of participants values in different areas
of life.
3–4 Investigation of control and avoidance strategies, creative
hopelessness, implications of language acquisition on well-being,
defusion
5–6 Further investigation of avoidance and control, committed action and
behavioral change strategies
7–8 Further work on defusion from thoughts regarding body image.
Committed action
9 Further work on willingness and acceptance of all inner experiences,
even if uncomfortable
10–11 Practicing ways of relating to the body with respect and appreciation.
12 Participants outline an individual plan to commit to behaviors in line
with values
 M. Fogelkvist et al. / Body Image 32 (2020) 155–166
training in mindfulness and body image problems. All therapists
were skilled and experienced ED therapists who had worked at the
clinic for several years.
2.7. Assessment
2.7.1. Self-report instruments
The primary outcome measure of this study was ED symp-
toms, as measured by a self-assessment questionnaire. Secondary
outcome measures included other self-assessment questionnaires
aimed at assessing self-esteem, changes in mindful awareness, and
body image problems at both cognitive and behavioral levels.
2.7.1.1. Eating disorder symptoms. The Eating Disorder Examina-
tion Questionnaire (EDE-Q) version 6.0 was used to assess ED
symptoms (Fairburn & Beglin, 1994). The EDE-Q is a 28-item
questionnaire that assesses cognitive and behavioral aspects of
eating-disordered pathology over the past 28 days. A global score
can be calculated based on 22 items, ranging from 0 to 6, where
higher ratings indicate more severe pathology. The global score
can be divided into four subscales: restraint, eating concern, shape
concern and weight concern. The EDE-Q has shown different lev-
els of test-retest reliability on the subscales depending on length
to follow-up, ranging from .66 to .94. Internal consistency has
been shown to range from .70 to .93 (Berg, Peterson, Frazier, &
Crow, 2012). Research furthermore supports the validity of the
EDE-Q in differentiating between cases and non-cases. We used
a Swedish version that has been validated for patients with ED
(Welch, Birgegard, Parling, & Ghaderi, 2011). In this study, Cron-
bach’s ␣ values for the EDE-Q global score, restraint, eating concern,
shape concern and weight concern were .85, .83, .82, .82, and .86,
respectively.
2.7.1.2. Body dissatisfaction. The Body Shape Questionnaire (BSQ)
was used to assess body dissatisfaction (Cooper, Taylor, Cooper, &
Fairburn, 1987). The BSQ measures concerns with body shape and
fear of fatness and is sensitive to change over time. The original
form consists of 34 items on a 6-point scale ranging from never to
always. It has been widely used and translated into several differ-
ent languages. It has shown good psychometric properties, with
high reliability and validity (Rosen, Jones, Ramirez, & Waxman,
1996). We used a shortened Swedish version consisting of eight
items that has also been validated for the ED population (Welch,
Lagerstrom, & Ghaderi, 2012). A total score was calculated, ranging
from 8 to 48, where higher scores indicate more pronounced body
dissatisfaction. Cronbach’s ␣ for the BSQ in this study was .86.
2.7.1.3. Body checking behaviors. The Body Checking Questionnaire
(BCQ) was used to assess the frequency of body checking behaviors
(Reas, Whisenhunt, Netemeyer, & Williamson, 2002). The BCQ con-
sists of 23 items on a 5-point scale ranging from 1 (never) to 5 (very
often). It generates a global score, ranging from 23 to 115, which
can be divided into three subscales that assess checking behaviors
related to overall appearance, specific body parts, and idiosyncratic
checking. Higher scores indicate more frequent behavioral mani-
festations of body dissatisfaction. Scores on the BCQ have shown
good internal consistency, and has high correlations with other
measurements of negative body image and EDs (Reas et al., 2002).
We used a Swedish version that has not been assessed for psycho-
metric properties. In this study, we focused on the global score.
Cronbach’s ␣ for the global score was .89.
2.7.1.4. Self-esteem. The Self-Concept Questionnaire (SCQ) was
used to assess self-esteem (Robson, 1989). The SCQ consists of 30
items on an 8-point scale, ranging from completely disagree to com-
pletely agree (e.g., “I’m easy to like,” “I’m glad I am who I am,”
159
“It’s pretty tough to be me”). Higher scores indicate higher self-
esteem. It has shown good reliability and high validity (Robson,
1989). A Swedish version has been assessed (Ghaderi, 2005), which
showed high test-retest reliability and was also highly correlated
with another widely used self-esteem measure, the Rosenberg scale
of self-esteem (Rosenberg, 1965), suggesting high validity. In this
study, Cronbach’s ␣ was .86.
2.7.1.5. Mindful attention. The Mindful Attention Awareness Scale
(MAAS) was used to assess changes in mindful attention in daily
living (Brown & Ryan, 2003). The MAAS consists of 15 items on a
6-point scale ranging from almost always to almost never. Higher
scores indicate more mindful awareness. The items are formulated
so as to be the opposite of mindfulness, such as “I find myself
doing things without paying attention.” A Swedish version with
high internal consistency and support for reliability and validity
(Hansen, Lundh, Homman, & Wangby-Lundh, 2009) was used, and
results were similar to the English version. In this study, Cronbach’s
␣ was .80.
2.7.1.6. Eating disorder care consumption. To assess ED care con-
sumption at the 24-month follow-up, participants were asked if
they had received any further care for their ED, and if so where
this treatment had taken place. Information on type and frequency
of treatment was then retrieved from the patients’ records. If they
received care from another unit, this information was requested
from that unit. Each outpatient session was counted as one session,
while each day in daycare was counted as two sessions. Each day
in inpatient care was counted as four sessions.
2.8. Statistical analysis
For between-group differences at baseline, analyses of vari-
ance (ANOVAs) were used for continuous variables and chi-square
tests for categorical variables. Statistical analyses were first per-
formed in an intent-to-treat principle, where each patient was
analyzed according to randomization. We then analyzed the data
per-protocol, where those who received ACT were only included
in the analysis if they received a minimum of six sessions of ACT.
We decided on six sessions as a cut-off because participants should
have been introduced to the core ACT processes by then. We used
a mixed-model repeated measures analysis (MMRM), which is
suitable for RCT studies with repeated measures (Hesser, 2015).
A MMRM differs from the general linear model (GLM) in that it
models both fixed and random effects. Each individual’s score was
used to model a regression estimate and comparing individual rat-
ings with group mean suggested which model best fit the data.
The restricted maximum likelihood was used. We included two
between levels (ACT and TAU), four within assessments (time was
coded 0, 16, 52 and 104 modeling the weeks of assessment). The
following covariates were investigated; quadratic and cubic time
(in case of non-linear change on the dependent variable) as well as
care consumption between pre- and post-measure. We also calcu-
lated effect sizes, between the groups at the last assessment (i.e.,
at 2 years follow-up), based on the estimated means, using Cohen’s
d where 0.20 is considered a small effect, 0.50 a medium effect,
and 0.80 a large effect (Cohen, 1988). ED care consumption was
measured by calculating the mean level of sessions received for
each group at T2 and T4. We also used a reliable change index (RCI;
Wise, 2004) to compare the groups. Using Ekeroth and Birgegard
(2014) calculations for standard error of difference (Sdiff = .74) of
a Swedish adult ED population, an RCI of 1.45 at an alpha level of
.05 was suggested. We calculated how many sessions, on average,
would be needed to reach the RCI, and odds ratio for reaching the
RCI between the groups.
160 M. Fogelkvist et al. / Body Image 32 (2020) 155–166

Table 2
Demographics and distribution of diagnoses at admission by treatment allocation and total according to DSM-5.

ACT n(%) TAU n(%) Total n(%) Test statistic p value

AN 2(3.8) 3(6.4) 5(5.1) ␹2 (1, N = 99)=0.33 .57

Atypical AN 7(13.5) 6(12.8) 13(13.1) ␹2 (1, N = 99)=0.01 .92
AN in partial remission 9(17.3) 9(19.1) 18(18.2) ␹2 (1, N = 99)=0.06 .81
BN 8(15.4) 4(8.5) 12(12.1) ␹2 (1, N = 99)=1.10 .30
BN of low frequency and/or limited duration 4(7.7) 3(6.4) 7(7.1) ␹2 (1, N = 99)=0.06 .80
BN in partial remission 6(11.5) 2(4.3) 8(8.1) ␹2 (1, N = 99)=1.76 .18
BED 8(15.4) 2(4.3) 10(10.1) ␹2 (1, N = 99)=3.37 .07
BED in partial remission 0(0) 3(6.4) 3(3) ␹2 (1, N = 99)=3.42 .06
Purging 5(9.6) 11(23.4) 16(16.2) ␹2 (1, N = 99)=3.46 .06
UFED 3(5.8) 4(8.5) 7(7.1) ␹2 (1, N = 99)=0.28 .60
Total 52(100) 47(100) 99(100)

M (SD) M (SD) M (SD)

Age at inclusion 27.08(7.81) 26.72(7.22) 26.91(7.50) F(1, 97) = 0.05 .82
Age at first admission 16.88(5.06) 16.28(4.38) 16.60(4.74) F(1, 97) = 0.40 .53
BMI 23.93(6.16) 23.07(5.66) 23.53(5.92) F(1, 96) = 0.51 .48
Length of current treatment (months) 10.83(9.54) 12.40(12.35) 11.58(10.93) F(1, 97) = 0.51 .48

Note. Test statistics: Chi-square for categorical variables and analysis of variance for dimensional variables. p values are for two-tailed tests. ACT = Acceptance and commitment
therapy, TAU = Treatment as usual, AN = anorexia nervosa; BN = bulimia nervosa; BED = binge eating disorder; UFED = unspecified feeding or eating disorder, BMI = Body mass
index.

Data were analyzed using SPSS, version 25 (IBM Corp, 2017).
Missing data in self-report questionnaires were handled by imput-
ing values when only a few items on a questionnaire were missing.
No more than a quarter of the items on a questionnaire were
allowed to be missing to use this method. Imputation was made by
using the individual’s mean on the available items on each specific
measure. In the MAAS questionnaire, there was an administrative
error resulting in between 6 and 13 participants at each assessment
receiving a questionnaire in which 4 of the 15 items were missing.
We excluded these questionnaires from the analysis. Not all par-
ticipants filled in the questionnaires at all of the assessment times,
which means that the data for each assessment have a different n
amount. Using a mixed-model analysis enabled the inclusion of all
available data since the analysis makes predictions based on the
data available, regardless of data missing at different time points.
3. Results
3.1. Sample characteristics
The study sample consisted of 99 women, in the age range of
16–47. BMI ranged from 16.33–48.55. Ratings of ED symptoms
according to EDE-Q ranged from 0.62 to 5.60, where 32 partici-
pants rated severity below a suggested clinical cut-off, based on
norms from a Swedish population, at 2.67 (Ekeroth & Birgegard,
2014). Characteristics of the participants at initial assessment can
be found in Table 2. There were no significant differences between
the groups in distribution of eating disorder diagnoses, age at inclu-
sion, age at first admission, BMI, or length of current treatment
episode.
Of the 52 participants randomized to ACT, 5 (10 %) never began
treatment, and 5 (10 %) dropped out of the intervention (please
see Fig. 1 for more details on reasons). A comparison of baseline
characteristics for completers and dropouts revealed no signifi-
cant differences between groups on none of the self-assessment
questionnaires, BMI, age at inclusion, or age at onset. Of the 52 par-
ticipants, 42 were considered treatment completers. Due to clinical
and ethical reasons, one participant received ACT contrary to ran-
domization to TAU, but was analyzed as TAU in ITT analyses, and
removed from completer analysis.
Distribution of diagnoses at admission was as follows: 36 (36.4
%) had a diagnosis of AN, atypical AN, or AN in partial remission.
In addition, 27 (27.3 %) had a diagnosis of BN, BN of low frequency
and/or limited duration, or BN in partial remission; 13 (13.1 %) had
a diagnosis of BED or BED in remission; 16 (16.2 %) had a purging
disorder; and 7 (7.1 %) had an unspecified feeding or eating disorder
(UFED).
3.2. Outcome analyses
3.2.1. Intent to treat (ITT) analysis
Mean levels, estimated from the mixed-model analysis, for each
outcome measure are described in Table 3. Overall, there were
significant interaction effects (group × time), and main effects for
time, but no main effects for group regarding EDE-Q global and
subscales (see Table 4). The interaction effects were due to signif-
icantly larger reductions in scores on the EDE-Q global and on the
eating, shape, and weight concerns subscales over time for patients
in ACT in comparison with those in TAU, with medium effect sizes
(d = 0.57–0.64). The main effects for time were due to reductions
on the EDE-Q global score and all subscales for both groups. For
the restraint subscale, there was a significant main effect for time
but no significant main effect for group and interaction effect. Both
quadratic and cubic time effects were significant on the global EDE-
Q, eating- and shape concern subscales (Table 4). From pre to post
both groups reported reductions in ED symptoms. From post to
two-year follow-up both groups reported a decrement in symp-
tom reduction in relation to the pre to post change. However, the
ACT group continued reporting symptom reduction while the TAU
group reported even less reduction or a stagnated symptom devel-
opment (see Table 3).
For the secondary outcome measures, the MAAS, BSQ and BCQ,
there were significant interaction effects (group × time), and main
effects for time, but no main effects for group. The interaction
effects were due to significantly larger increases on MAAS (more
mindfully aware), and larger reductions in BSQ (less shape con-
cerns) and BCQ (less body checking) for participants in ACT in
comparison with those in TAU, with small to medium effect sizes
(d = 0.43–0.64). For the SCQ, there was a significant main effect
for time but no significant main effect for group and no interac-
tion effect. The significant main effect for time was due to increase
in self-esteem ratings for both groups. There were significant
quadratic and cubic time effects for the BSQ and the BCQ (Table 4).
From pre to post, both groups reported less body shape concerns
and body checking but from post to two year follow up only the
ACT group reported continued reductions (see Table 3).
 M. Fogelkvist et al. / Body Image 32 (2020) 155–166 161

Table 3
Estimated mean scores and SD at each time point, by group according to ITT.

T1 T2 T3 T4

ACTM(SD) TAUM(SD) ACTM(SD) TAUM(SD) ACTM(SD) TAUM(SD) ACTM(SD) TAUM(SD)

n = 52 n = 47 n = 52 n = 47 n = 52 n = 47 n = 52 n = 47

EDE-Q Global 3.22 3.26 2.64 2.78 2.28 2.68 1.84 2.59
(0.86) (0.88) (0.88) (0.90) (0.98) (0.98) (1.17) (1.16)
Restraint 2.19 2.37 2.06 2.33 1.76 2.24 1.34 2.10
(0.96) (1.07) (0.97) (1.10) (1.02) (1.20) (1.14) (1.38)
Eating concern 2.65 2.56 2.06 2.10 1.70 2.01 1.31 2.03
(0.82) (0.91) (0.84) (0.92) (0.94) (0.97) (1.13) (1.08)
Shape concern 4.60 4.60 3.71 3.83 3.31 3.71 2.74 3.56
(0.89) (0.87) (0.93) (0.90) (1.07) (1.02) (1.33) (1.25)
Weight concern 3.20 3.24 2.99 3.14 2.52 2.90 1.83 2.55
(1.08) (1.13) (1.10) (1.14) (1.15) (1.18) (1.26) (1.27)
MAAS 51.77 54.33 53.00 54.42 55.76 54.65 59.74 54.97
(7.10) (9.75) (7.12) (9.76) (7.15) (9.79) (7.20) (9.83)
SCQ 112.30 108.03 115.16 109.50 121.60 112.81 130.90 117.60
(20.39) (19.95) (20.82) (20.13) (21.96) (20.67) (23.94) (21.78)
BSQ 33.37 33.20 28.70 29.35 26.62 29.12 24.19 29.37
(6.13) (6.41) (6.26) (6.57) (6.76) (7.15) (7.90) (8.41)
BCQ 64.76 60.79 56.16 53.77 52.28 53.46 47.26 53.60
(12.80) (14.86) (12.89) (15.02) (13.15) (15.42) (13.65) (16.07)

Note. ITT = Intent to treat; EDE-Q = Eating Disorder Examination-Questionnaire; MAAS = Mindful Attention Awareness Scale; SCQ = Self-Concept Questionnaire; BSQ = Body
Shape Questionnaire; BCQ = Body Checking Questionnaire, ACT = acceptance and commitment therapy, TAU = treatment as usual.

Table 4
Time, interaction, quadratic and cubic time effect from the MMRM analyses according to ITT and Cohen’s d between groups at two-year follow-up.

Time Groupa x Time Time2 Time3 Cohen’s

F(df) F(df) F(df) F(df) d

EDEQ global 15.0(193.1)*** 5.9(106.2)* 6.8(188.9)** 5.2(189.2)* 0.64

Restraint 10.7(110.7)** 2.9(110.7) n.s. 0.60
Eating concerns 12.1(185.5)** 6.9(110.4) * 5.4(181.9)* 3.9(182.2)* 0.65
Shape concerns 22.3(205.7)*** 4.9(109.9) * 11.3(202.2)** 8.9(202.5)** 0.63
Weight concerns 43.4(104.6)*** 4.6(104.6)* 0.57
MAAS 9.6(114.6)** 7.0(114.6)** 0.56
SCQb 26.2(105.4)*** 2.7(105.4) n.s. 0.58
BSQ 22.9(184.6)*** 7.0(102.0)** 11.8(180.3)** 9.1(180.6)** 0.64
BCQ 17.5(192.9)*** 9.0(101.0)** 9.1(190.0)** 7.1(190.2)** 0.43

Note: MMRM = Mixed model repeated measure; ITT = Intent to treat; EDE-Q = Eating Disorder Examination Questionnaire; MAAS = Mindful Attention Awareness Scale;
SCQ = Self-Concept Questionnaire; BSQ = Body Shape Questionnaire; BCQ = Body Checking Questionnaire.
*p < .05, **p < .01, ***p < .001.
a
Group effects for all models were non-significant, Fs < 1.65, ps > .20.
b
Care consumption was a significant predictor for SCQ, F(95.7) = 4.8, p = .031.

Table 5
Estimated mean scores and SD at each time point, by group for treatment completers.

T1 T2 T3 T4

ACTM(SD) TAUM(SD) ACTM(SD) TAUM(SD) ACTM(SD) TAUM(SD) ACTM(SD) TAUM(SD)

n = 42 n = 46 n = 42 n = 46 n = 42 n = 46 n = 42 n = 46

EDE-Q Global 3.10 3.19 2.71 2.93 2.07 2.57 1.72 2.64
(0.85) (0.90) (0.87) (0.92) (0.94) (0.99) (1.09) (1.15)
Restraint 2.28 2.52 1.99 2.32 1.52 2.07 1.33 2.20
(0.98) (1.08) (1.00) (1.11) (1.05) (1.21) (1.17) (1.40)
Eating concern 2.44 2.47 2.08 2.26 1.48 1.98 1.13 2.10
(0.76) (0.91) (0.78) (0.92) (0.82) (0.95) (0.92) (1.01)
Shape concern 4.59 4.58 3.72 3.87 3.14 3.63 2.61 3.60
(0.91) (0.90) (0.96) (0.94) (1.08) (1.05) (1.30) (1.26)
Weight concern 3.09 3.21 2.88 3.11 2.39 2.88 1.68 2.54
(1.05) (1.14) (1.06) (1.15) (1.10) (1.19) (1.17) (1.27)
MAAS 52.11 54.23 53.34 54.38 56.11 54.71 60.10 55.19
(7.26) (9.92) (7.26) (9.93) (7.28) (9.95) (7.31) (9.98)
SCQ 111.60 106.22 117.18 110.23 126.33 115.85 131.26 115.66
(20.66) (20.41) (21.03) (20.57) (21.97) (21.04) (23.61) (22.00)
BSQ 32.96 33.08 28.41 29.38 25.87 28.75 23.86 29.51
(6.13) (6.54) (6.24) (6.69) (6.73) (7.30) (7.88) (8.66)
BCQ 63.86 61.34 55.61 54.69 50.81 53.51 46.53 54.45
(12.64) (14.89) (12.76) (15.07) (13.11) (15.51) (13.76) (16.25)

Note. EDE-Q = Eating Disorder Examination-Questionnaire; MAAS = Mindful Attention Awareness Scale; SCQ = Self-Concept Questionnaire; BSQ = Body Shape Questionnaire;
BCQ = Body Checking Questionnaire, ACT = acceptance and commitment therapy, TAU = treatment as usual.
162 M. Fogelkvist et al. / Body Image 32 (2020) 155–166
Table 6
Time, interaction, quadratic and cubic time effect from the MMRM analyses according to treatment completers and Cohen’s d between groups at two-year follow-up.
Time F(df) Groupa x TimeF(df)
EDEQ global 26.9(202.9)*** 7.7(94.3)**
Restraint 9.7(200.7)** 3.1(96.4) n.s.
Eating concern 17.6(190.9)*** 10.1(102.8)**
Shape concern 18.2(185.3)*** 7.3(95.8)**
Weight concern 44.1(94.2)*** 5.4(94.2)*
MAAS 8.9(101.6)** 5.5(101.6)*
SCQb 13.0(199.7)*** 3.3(93.6) n.s.
BSQ 20.3(166.1)*** 6.9(89.6)**
BCQ 16.4(173.1)*** 9.4(87.1)**
Note: MMRM = Mixed model repeated measure; EDE-Q = Eating Disorder Examination Questionnaire; MAAS = Mindful Attention Awareness Scale; SCQ = Self-Concept Ques-
tionnaire; BSQ = Body Shape Questionnaire; BCQ = Body Checking Questionnaire.
*p < .05, **p < .01, ***p < .001.
a
Group effects for all models were non-significant, Fs < 3.0, ps > .088.
b
Care consumption was a significant predictor for SCQ, F(84.9) = 6.4, p = .014.
3.2.2. Completer analyses
Estimated means from the mixed-model analysis, for each
outcome measure are presented in Table 5. Overall, there were sig-
nificant main effects for time and interaction effects (except on the
restraint subscale) on the EDE-Q, but no significant main effects
for group (see Table 6). The interaction effects were due to signif-
icantly larger reductions in scores on the EDE-Q global and on the
eating, shape, and weight concerns subscales for the ACT group in
comparison with those in TAU, with medium to large effect sizes
(d = 0.77–1.00). The main effects for time was due to reductions in
eating disorder symptoms in both groups from pre to last assess-
ment. There were significant non-linear time effects on all subscales
(except weight concerns) that follows the differentiated develop-
ment described above regarding eating disorder symptoms (see
Tables 5 and 6).
For the secondary outcome measures (the MAAS, SCQ, BSQ, and
BCQ) main and interaction effects follow those presented in the ITT
results (see Table 6). The significant non-linear effects follow those
described earlier with continued improvements for participants in
ACT in comparison with those in TAU who report a more stagnated
improvement in the outcome from post to two-year follow-up.
There were medium effect sizes between the groups at the two
year follow up on the secondary outcome measures.
3.2.3. Specialized ED care consumption
The type and amount of specialized ED care received by each
group can be found in Table 7, and summarized in Table 8. During
the intervention phase, participants randomized to ACT attended a
mean of 8.12 (SD = 3.64) ACT group sessions and 1.75 (SD = 0.68)
individual ACT sessions. Some attended additional appointments
such as follow-up sessions with the physician, unplanned sessions
due to medical or psychological deterioration or need for social
support. Altogether, the ACT group received a mean of 11.77 (SD
= 3.86) treatment sessions during the intervention phase, and a
mean of 21.08 (SD = 15.02) treatment sessions throughout the study
period.
Participants in TAU received a mean of 8.60 (SD = 9.41) treat-
ment sessions during the intervention phase, and a total of 26.43(SD
= 32.67) sessions throughout the study period. One participant in
TAU received 11 days of specialized inpatient ED treatment dur-
ing the intervention phase, and two participants in TAU received
a combined total of 192 days of specialized inpatient ED treat-
ment during follow-up. Adding inpatient care changed the mean of
treatment sessions received during the entire study period to 43.60
(SD = 122.10). No participant in the ACT group received inpatient
treatment.
Participants in the ACT intervention consumed more care than
participants in TAU during the intervention phase. Care consump-
tion (during the intervention period) was a significant covariate
Time2 F(df) Time3 F(df) Cohen’sd
10.5(178.2)** 0.82
4.5(178.4)* 0.67
6.9(171.9)** 1.00
7.4(182.1)** 5.2(182.3)* 0.77
0.70
0.56
4.8(180.5)* 0.69
9.3(161.7)** 6.6(162.0)** 0.68
7.5(170.2)** 5.4(170.4)* 0.52
only in modeling the SCQ outcome (see Tables 4 and 6). During the
follow-up phase, the TAU group consumed more care than partici-
pants in ACT (Table 8).
In total, patients who received ACT reduced their ratings
of eating disorder pathology by 1.43 points according to EDE-
Q global. The corresponding amount for patients in TAU was
0.68. On average, to reliably change an individual’s ratings
on EDE-Q by 1.45 points, a patient in the ACT intervention
would have to attend 21.37 sessions. For a patient receiv-
ing TAU, the corresponding amount of sessions would be
56.36.
The odds ratio for reaching the RCI for patients randomized to
ACT in comparison with those randomized to TAU was OR = 2.85
(95 % CI: 1.15–7.05). Corresponding odds for treatment completers
was OR = 3.94 (95 % CI: 1.50–10.36).
4. Discussion
The results of this study show that an ACT group interven-
tion focusing on body image was effective in reducing residual
ED symptoms and body image problems in an ED sample. The
patients randomized to ACT showed significant larger symptom
reduction on all outcome measures except restraint and nega-
tive self-evaluation in comparison with those randomized to TAU,
while consuming less health care. Results were confirmed in the
completer analysis. With the exception of greater increase in self-
esteem, all three hypotheses were confirmed.
In the restraint subscale of the EDE-Q, we did not find a sig-
nificant difference between groups over time, which could be an
example of a floor effect. The patients included in this study had
received prior ED treatment, and represent a group of women
who had already reduced their ED pathology through other ED
treatments. They therefore had, on average, quite low ratings
on self-reported ED symptoms at initial assessment (Mond, Hay,
Rodgers, Owen, & Beumont, 2004). These low ratings should make
it more difficult to achieve further reductions, especially at a level
that could show differences between two treatment groups. The
medium effect size between groups on most outcome measures
must be interpreted in light of the fact that patients had only resid-
ual ED symptoms at initial assessment.
The ACT group did consume more health care during the
intervention phase in comparison with the TAU group. This was
expected, since the study sample consisted of patients that had
received prior treatment, and many only displayed residual symp-
toms. From a clinical point of view, it may be difficult to prioritize
continuing treatment in this phase, and this is consequently a
phase in which treatment is usually phased out. Thus, patients
who were randomized to TAU might be said to represent usual
care consumption at this phase in treatment. For patients random-
 M. Fogelkvist et al. / Body Image 32 (2020) 155–166 163

Table 7
Amount of specialized ED care consumed during intervention and follow up phase, divided by groups.

Intervention phase Follow up phase

ACT TAU ACT TAU

Partici-pants Sessions Partici-pants Sessions Partici-pants Sessions Partici-pants Sessions

n(%) N n(%) N n(%) N n(%) N

LWYB group & individual 48(92.3) 527 1(2.1) 13 0 0 0 0

CBT group or individual 12(23.1) 30 24(51.1) 149 26(50.0) 214 22(46.8) 306
Other psycho-therapy 1(1.9) 3 8(17.0) 77 8(15.4) 130 9(19.1) 147
Physician appointments 15(28.8) 26 11(23.4) 18 14(26.9) 35 16(34.0) 64
Physiotherapy 1(1.9) 3 12(25.5) 39 0 0 0 0
Meal support 1(1.9) 6 7(14.9) 61 3(5.8) 14 5(10.6) 96
Day care 0 0 1(2.1) 5 0 0 2(4.3) 15
Family sessions 3(5.8) 5 2(4.3) 4 0 0 0 0
Supportive 7(13.5) 24 5(10.6) 32 9(17.3) 55 6(12.8) 82
Dietitian 2(3.8) 2 2(4.3) 2 3(5.8) 4 1(2.1) 1
Occupational therapy 0 0 0 0 0 0 1(2.1) 13
Total amount of sessions 626 400 452 724

Note: LWYB = Live with your body, ACT = Acceptance and commitment therapy, TAU = Treatment as usual, CBT = Cognitive behavior therapy.

Table 8
Mean levels and SD, median, interquartile range, and min-max of amount of specialized ED care consumed, divided by groups.

Intervention phase (T1-T2) Follow up phase (T2-T4) Total amount of care (T1-T4)

Participation in Outpatient care Total amount Outpatient care Total amount Outpatient care Total amount
ACT Md (IQR, of care Md (IQR, of care Md (IQR, of care
(group + individual min-max) Md (IQR, min-max)) Md (IQR, min-max) Md (IQR,
session) min-max) min-max) min-max)
M(SD)

ACT ITT (n = 52) 8.12(3.64) 13.00 13.00 3.50 3.50 (12.25, 18.00 (11.25, 18.00 (11.25,
+1.75(0.68) (4.00, 1–18) (4.00, 1–18) (12.25, 0–94) 0–94) 2–98) 2–98)
TAU ITT (n = 47) 0.23(1.61) + 6.00 6.00 6.00 6.00 (24.00, 12.00 (39.00, 12.00 (39.00,
0.04(0.29)1 (9.00, 0–40) (9.00, 0–84) (24.00, 0–115) 0–742) 0–141) 0–826)
ACT completer (n = 42) 9.69(1.60) + 13.00 13.00 4.00 4.00 (11.00, 18.00 (10.50, 18.00 (10.50,
2.02(0.35) (2.25, 8–18) (2.25, 8–18) (11.00, 0–37) 0–37) 8–54) 8–54)
TAU completer (n = 46) 0(.00)+ 6.00 6.00 6.00 6.00 (25.00, 12.00 (39.25, 12.00 (39.25,
0(.00) (8.25, 0–40) (8.25, 0–84) (25.00, 0–115) 0–742) 0–141) 0–826)

Note. ACT = Acceptance and commitment therapy, TAU = Treatment as usual, ITT = Intent to treat, 1 = one patient received ACT, although randomized to TAU.

ized to ACT, treatment was instead intensified by weekly sessions
during the intervention phase of 12 weeks. Although we did not
conduct a health economic analysis, it is interesting to note that
patients in ACT showed a reduction in EDE-Q global ratings that
was twice that of participants in the TAU group, at the same time
as the TAU group had twice the amount of health care consump-
tion over a two-year follow-up period. This does seem to suggest
that offering an intervention to improve psychological wellbeing
and improving residual ED symptoms may pay off in the long
run.
The findings of this study are very promising. To our knowledge,
this is the first study to report long-term positive results for a body
image intervention for patients with ED. Usually shorter follow-
ups are associated with better outcomes, but for ACT, the opposite
might be hypothesized since ACT does not aim at short-term symp-
tom reduction, but rather at creating “creative hopelessness” in the
short term in order to enhance psychological flexibility in the long
term. Thus, the effect for ACT might be better at long-term follow-
up. A recent meta-analysis on body image treatments showed only
small effect sizes, and with a shorter follow-up period (Alleva et al.,
2015). Prior studies might have missed differences between groups
since they had shorter follow-up durations (e.g. Juarascio, Kerrigan
et al., 2013; Juarascio, Shaw et al., 2013; Juarascio, Shaw, Forman
et al., 2013; Timko et al., 2015).
The randomization sample was heterogeneous since patients
differed in their ED diagnosis and pathology. The transdiagnostic
view on ED suggests that many individuals with an ED move from
one diagnosis to another over time (Fairburn et al., 2003). There
are thus advantages in finding treatments that are suitable for a
transdiagnostic sample, which might also correspond to a clinical
setting. It should be noted that two participants in TAU were in need
of inpatient care during the study period, and two participants in
ACT discontinued the intervention due to severe psychiatric com-
plicating factors, which is not uncommon in clinical settings. The
ACT intervention might have contributed to the worsening of the
participants’ symptoms. All psychological treatments are demand-
ing, and the ACT intervention starts out by addressing how much
the patient has been struggling and how that struggling and effort
to alleviate painful inner experiences has been working for them.
It is often painful to discover that behavioral control strategies are
actually part of what maintains the inner experiences that the indi-
vidual wants, and struggles hard, to get rid of. This is in ACT called
creative hopelessness – aiming at letting go of control strategies
and opening up for other ways of responding to painful inner expe-
riences. This could perhaps have led to a worsening of symptoms.
The participants decided to withdraw from the intervention in col-
laboration with their group leaders, who were attentive to any
worsening of symptoms, which is important in any treatment.
As previously stated, ACT aims at accepting unwanted thoughts
and feelings, while committing to behaviors that are in line with life
values. In this intervention, patients were guided in stating their life
values, defusing from unhelpful thoughts and accepting thoughts
and feelings, while still remaining in anxiety-provoking situations
with the goal of enhancing flexibility in thought, feeling and behav-
ior. Treatment does thus not aim at immediate symptom reduction.
In the present study, 24 of the participants in TAU received treat-
ment based on CBT. It is common in CBT to set treatment goals
that aim at reducing discomfort through exposure exercises. The
164 M. Fogelkvist et al. / Body Image 32 (2020) 155–166
actual behaviors targeted for change might be the same in both
ACT and CBT; however, they differ in their theory of change, goals,
and coping strategies. A recent meta-analysis on the empirical
status of third-wave CBT for ED (Linardon, Fairburn, Fitzsimmons-
Craft, Wilfley, & Brennan, 2017) showed that interventions led to
improvements, and that more studies are needed to show efficacy
in comparison with other interventions. ACT and CBT might be very
similar treatments, and this study did not aim at comparing them.
However, CBT is the treatment of choice for ED, and half of the
patients in TAU received CBT in this study. Even so, patients in ACT
did reduce their symptoms to a greater extent than did patients in
TAU.
Since the planning and commencement of the present study,
there has been a growing interest in ACT that has led, for instance, to
developments in tools for assessment. In the field of ACT for EDs, the
Body Image Acceptance and Action Questionnaire (BI-AAQ; Sandoz,
Wilson, Merwin, & Kellum, 2013) has been developed and assessed
for validity and reliability in the measurement of psychological flex-
ibility in the context of body image (see Rogers, Webb, & Jafari,
2018). Using this assessment tool, it has been shown that ED treat-
ments that enhance this concept have advantages in ED outcomes,
such as ED risk, quality of life and general mental health (Lee, Ong,
Twohig, Lensegrav-Benson, & Quakenbush-Roberts, 2018; Moore,
Masuda, Hill, & Goodnight, 2014). In a study by Timko, Juarascio,
Martin, Faherty, and Kalodner (2014), the authors suggest that the
BI-AAQ is a valid measurement of body image experiential avoid-
ance, and that it partially explains the relationship between body
dissatisfaction and disordered eating. In light of this knowledge,
the ACT intervention in the present study might have enhanced the
participants’ psychological flexibility in the context of body image,
which also led to reductions in ED pathology.
It has been suggested that focusing on reducing negative body
image, without fostering a positive body image, might at best help
the individual to tolerate their body. It is suggested that a focus on a
positive body image might further assist the individual by helping
them appreciate, respect, celebrate and honor their bodies, which
would then lead to more lasting treatment gains (Tylka & Wood-
Barcalow, 2015). Moreover, the concept of a positive body image
differs from that of a negative body image. In the ACT intervention,
the focus was not on fostering a positive body image, but rather
on accepting the body and all internal experiences the body elicits.
However, one chapter is dedicated to listening to the needs of the
body and treating it with respect. These interventions might help
the individual to develop more than just a tolerance of their bodies;
it might also help them to listen to their bodies, to engage with more
positive situations with their bodies, and to foster a more positive
attitude towards their bodies that is more broadly defined than just
absence of dissatisfaction. This is in line with the attunement and
mindful self-care needed to foster a positive body image suggested
by Cook-Cottone (2015). In a prior study, we found that partici-
pants described a change in their relationships with their bodies
after participation in the ACT intervention (Fogelkvist et al., 2016),
which suggests they changed more than just the evaluation of their
bodies. Furthermore, they pronounced that they did not evaluate
themselves as much after the intervention, and that the interven-
tion had helped them to participate in areas of their lives they felt
were highly valued.
In all, ACT seems to be a promising intervention to address resid-
ual ED symptoms, such as body image problems. It seems to be able
to further improve psychological well-being, even in a sample with
only “medium” symptom severity and a rather small intervention
that can be applied to a transdiagnostic sample. Further, the sample
in the present study was heterogeneous both in symptom display
and severity, as well as in age and BMI. Thus, this intervention seems
cost-efficient and easy to adapt in a clinical setting, even at a smaller
clinic. The need for economy evaluations of third-wave CBT inter-
ventions has been called for (Feliu-Soler et al., 2018). This study
did not evaluate cost-effectiveness, but given the fact that relapse
is common in ED, and that remaining body image problems is a
factor associated with relapse (Keel et al., 2005), further research
is needed to evaluate if ACT can be a cost-effective intervention to
improve treatment outcome and prevent relapse in ED patients.
4.1. Strengths and limitations
The present study was a naturalistic intervention at an ED clinic
in Sweden. Thus, the intervention should be well-tolerated and eas-
ily applicable to a clinical setting. The number of dropouts was low,
and results indicate how beneficial this intervention is for a gen-
eral ED population with residual symptoms, consisting of women
with a diversity of eating-related difficulties and diagnoses. It is
a large sample, with an active control, and on a group level both
ACT and TAU were beneficial. Still, results indicate that patients in
ACT fare better than patients in TAU. It is interesting to note that
an intervention targeting body image leads to greater reductions
in ED pathology than TAU. This is in a clinical setting, at a special-
ized ED clinic, where TAU does produce reductions in ED pathology.
And yet the ACT intervention could produce medium to large effect
sizes, showing its superiority to TAU.
One limitation of the present study is that neither patients nor
therapist or researchers were blind to the treatment condition.
Patients could be reporting more positive results because they were
randomized to try this new intervention in which they might have
gotten more attention from therapists. They were also participat-
ing in a group with other patients with an ED where they discussed
aspects of ED and body image and were able to give and receive sup-
port from each other. We did not control for such factors, thus we
cannot reject the possibility of the group setting contributing to dif-
ferent outcomes between groups. We did not assess fidelity to the
method; however, the treatment manual was referring to sections
of the book, and all patients had homework that entailed reading
those sections, which to some extent ensures fidelity to the method.
Further, both research and therapist allegiance effects have shown
to bias trial outcomes (Gaffan, Tsaousis, & Kemp-Wheeler, 1995).
In the present study, one of the authors co-created the book that
the intervention was based on, and therapists chosen for the trial
might have had an interest in the intervention. Thus, allegiance
effects might also have contributed to outcome, which we did not
control for. Thus, replication of these findings from an independent
research group is needed to clarify such effects. Since the study
sample was transdiagnostic, results cannot be generalized to spe-
cific ED subtypes. Further, at initial and follow-up assessments, we
did not screen for ED diagnosis or other psychiatric disorders. We
only included the self-report version of the EDE, showing severity of
self-rated symptoms rather than diagnostic criteria for specific ED.
The comorbidity with other psychiatric disorders for patients with
an ED is high and has shown to have important clinical implica-
tions even for long-term outcomes (Franko et al., 2018). ACT can be
thought of as a transdiagnostic intervention that is likely to affect
more areas in life than only scorings of ED symptoms and body
image. Thus, another limitation is that we did not add any screen-
ings for general psychiatric symptoms or quality of life. However,
one has to consider the load of combined assessments for par-
ticipants, and judge whether this would deter participants from
providing assessments or even from participating in the study.
4.2. Conclusions
The current study adds to the body of research supporting ACT as
a valid treatment intervention for patients with residual ED pathol-
ogy and body image problems. It shows that ACT was superior in
reducing ED symptoms and body image problems among patients
 M. Fogelkvist et al. / Body Image 32 (2020) 155–166
with different EDs who had received prior interventions targeting
eating behaviors.
CRediT authorship contribution statement
Maria Fogelkvist: Writing - original draft, Writing - review
& editing, Formal analysis, Data curation, Visualization. Sanna
Aila Gustafsson: Conceptualization, Methodology, Investigation,
Supervision, Writing - review & editing, Funding acquisition. Lars
Kjellin: Supervision, Writing - review & editing. Thomas Parling:
Formal analysis, Supervision, Writing - review & editing, Software,
Validation.
Declaration of Competing Interest
Parling T, is the co-author of the self-help book “Lev med din
kropp” upon which the treatment in this study is based on. The
head of investigation Gustafsson, S.A., developed the manual in
collaboration with the authors of the self-help book.
Acknowledgments
Funding: This work was supported by Uppsala-Örebro
Regional Research Council [grant numbers RFR71381, RFR213931,
RFR138611], awarded to Sanna Aila Gustafsson.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in
the online version, at doi:https://doi.org/10.1016/j.bodyim.2020.
01.002.
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