Received: 7 October 2019 Revised: 15 February 2020 Accepted: 17 February 2020

DOI: 10.1002/eat.23254

BRIEF REPORT

Avoidance coping during mealtimes predicts higher eating

disorder symptoms

Irina A. Vanzhula MS1 Margarita Sala MA2

| Caroline Christian BS1 |
|
Rowan A. Hunt BA1 | Ani C. Keshishian BA1 | Valerie Z. Wong3 |
Sarah Ernst BS1 | Samantha P. Spoor BS1 | Cheri A. Levinson PhD1

1
Department of Psychological and Brain
Sciences, University of Louisville, Louisville,
Kentucky
2
Southern Methodist University, Dallas, Texas
3
Department of Psychology, Yale University,
New Haven, Connecticut
Correspondence
Irina A. Vanzhula, Department of Psychological
and Brain Sciences, University of Louisville,
Louisville, KY.
Email: irina.vanzhula@louisville.edu
Action Editor: Ruth Weissman
Abstract
Objective: Eating disorders (EDs) are characterized by significant anxiety during meal-
time that contributes to food avoidance and weight loss. Individuals with EDs commonly
use avoidance coping (e.g., distraction) to tolerate meals and comply with meal plans.
Although this strategy may be effective short term, a large body of anxiety literature sug-
gests that avoidance can lead to worsening of psychological symptoms long term.
Method: The current study (N = 66 individuals diagnosed with ED) used ecological
momentary assessment (EMA) to examine the short-term and long-term associations
of avoidance coping on ED symptoms.
Results: Distraction during meals predicted a reduction in anxiety in the short term,
and both distraction and avoidance of emotions predicted increases in excessive
exercise in the short term. Distraction and avoidance of emotions predicted increases
in bulimic symptoms 1 month after completion of EMA.
Discussion: These results are consistent with prior literature on avoidance and sug-
gest that avoidance coping during meals may contribute to the increase of ED behav-
iors in the long term. Coping strategies that encourage approach and tolerance of
difficult thoughts and emotions (e.g., acceptance-based strategies) rather that avoid-
ance coping may promote longer-term symptom reduction.

KEYWORDS

anxiety, avoidance, eating disorders

1 | I N T RO DU CT I O N Avoidance coping (i.e., the use of avoidance of thoughts,

Individuals with eating disorders (EDs) experience heightened anxiety
and fear during mealtimes, which can foster avoidance of eating and
reduced food intake (Levinson & Byrne, 2015; Steinglass et al., 2010).
Low caloric intake during meals contributes to weight loss and poor
treatment outcomes (Gianini et al., 2015; Treasure, Cardi, & Kan, 2012).
Factors contributing to mealtime anxiety (e.g., worry about weight gain
and perfectionistic cognitions) predict a future increase in ED behaviors
(Levinson et al., 2018). Coping with mealtime anxiety presents an
important area for research and a possible intervention target.
avoidance or denial of emotions; Christiano & Mizes, 1997) during
mealtimes is common in individuals with EDs (Cowdrey, Stewart, Rob-
erts, & Park, 2013). Avoidance coping strategies employed during
mealtimes include avoiding distressing foods, eating alone, food rituals
(e.g., eating foods in a specific order; tearing food), and distraction
(i.e., redirecting attention to less distressing stimuli; Ulian et al., 2013;
Long, Meyer, Leung, & Wallis, 2011). Avoidance coping has been
widely studied in the anxiety literature (Berman, Wheaton, Mcgrath, &
Abramowitz, 2010), showing that avoidance reduces anxiety in the
short term, but maintains anxiety in the long term, creating a

Int J Eat Disord. 2020;1–6. wileyonlinelibrary.com/journal/eat © 2020 Wiley Periodicals, Inc. 1

2 VANZHULA ET AL.

reinforcing cycle of anxiety-avoidance (Beesdo-Baum et al., 2012;
Wheaton, Gershkovich, Gallagher, Foa, & Simpson, 2018).
Individuals with EDs may avoid eating a meal out of fear of
weight gain, which prevents learning that eating does not lead to
immediate or substantial weight gain. This experience “teaches” the
individuals that it was avoidance of eating that prevented weight gain
and fosters further avoidance to prevent a feared catastrophe. Con-
tinued efforts to avoid such anxiety may increase ED behaviors in the
short term, such as restricting, excessive exercising, and purging,
which help individuals escape anxiety and distress (Kleifield, Wag-
ner, & Halmi, 1996). However, after the temporary relief from anxiety,
anxiety usually returns at higher levels, which may then drive the con-
tinual reliance on food avoidance and ED behaviors, thereby rein-
forcing ED symptoms over the long term (Levinson et al., 2018).
Although research shows that avoidance coping (specifically emotion-
focused coping and distraction) is positively associated with maladap-
tive eating behaviors (MacNeil, Esposito-Smythers, Mehlenbeck, &
Weismoore, 2012; Spoor, Bekker, Van Strien, & van Heck, 2007), no
study to date has examined avoidance coping in individuals with EDs
during mealtimes and its longitudinal effects on ED symptoms.
The current study used ecological momentary assessment (EMA) to
examine the possible role of avoidance coping during meals on the main-
tenance of ED cognitions and behaviors. We aimed to test both the
short-term impact of avoidance coping on anxiety and ED behaviors, as
well as the longer-term impact of avoidance coping on ED symptoms.
We hypothesized that emotional avoidance and distraction during meal-
time would predict (a) a reduction of anxiety in the short term, but predict
an increase of ED behaviors (e.g., purging and excessive exercise) short
term and (b) higher overall ED symptoms in the long term.
attributes typically associated EDs. It has demonstrated good internal
consistency, as well as good convergent and discriminant validity
(Garner & Garfinkel, 1982). Three subscales of the EDI-2 were
included: Drive for Thinness, Bulimic Symptoms, and Body Dissatis-
faction. In the current sample, internal consistency for each subscale
was excellent (α = .99 for all subscales).
2.4 | EMA measures
Daily Life Daily Habits Questionnaire (Levinson et al., 2018) assesses
cognitions, behaviors, and emotions around mealtimes (Levinson
et al., 2018). Intraclass correlation coefficient was computed for each
item (see Table 1); values above 0.75 indicate excelled reliability
(Koo & Li, 2016). Avoidance coping was measured using two items
(“I tried to avoid my emotions during the meal” and “I tried to distract
myself during the meal or snack”). Anxiety was measured with one
item (“How anxious are you currently feeling about your last meal or
snack?”). Additionally, participants were asked how much they had
used the following behaviors in the time since their last meal or snack:
(a) restriction, (b) excessive exercise, (c) body-checking, (d) weighing,
(e) binge eating, and (f) compensatory behaviors. Items were mea-
sured on a 6-point Likert-type scale (1 = not at all, 6 = extremely).
2.5 | Data analysis
Data were analyzed with SPSS using multilevel modeling. We used
within-subject cross-lag panel analyses (Hamaker, Kuiper, & Grasman,
2015). In these analyses, we disaggregated time varying predictors

2 | METHODS TABLE 1 Descriptive statistics

Baseline 1-month follow-up

2.1 | Procedure ED symptoms M (SD) M (SD)
Drive for thinness 4.60 (.90) 4.67 (.89)
This study is a secondary data analysis as described in Levinson et al.
Bulimic symptoms 2.18 (.96) 2.12 (.91)
(2018). Please see Levinson et al., 2018 for recruitment and data col-
Body dissatisfaction 4.71 (.94) 4.84 (.78)
lection procedures. All procedures were approved by the Washington
EMA items ICC M (SD)
University Institutional Review Board.
Emotional avoidance (“I tried to .34 2.83 (1.43)
avoid my emotions during the meal”)

2.2 | Participants Distraction (“I tried to distract myself .55 2.89 (1.43)
during the meal or snack”)
Anxiety (“How anxious are you currently .56 2.62 (1.63)
Participants were 66 individuals diagnosed with an ED. Diagnoses
feeling about your last meal or snack?”)
were assessed prior to beginning the EMA protocol using the ED
Restriction .23 2.46 (1.71)
Diagnostic Scale (Stice, Telch, & Rizvi, 2000). Please see Supplemental
Binge eating .03 1.28 (1.00)
Table 1 for demographic and diagnostic information.
Compensatory behaviors −.21 1.31 (.97)
Excessive exercise −.38 1.63 (1.30)

2.3 | Self-report measures Weighing .41 1.59 (1.45)

Body checking .08 3.02 (1.87)
Eating Disorder Inventory-2 (EDI-2; Garner, Olmstead, & Polivy, 1983). Abbreviations: ED, eating disorder; EMA, ecological momentary
The EDI-2 is a self-report questionnaire measuring psychological assessment; ICC, intraclass correlation coefficient.
VANZHULA ET AL. 3

(TVPs) into the participants' average across all assessments (TVPmean;
the between-person component) and the participants' deviation from
their own mean (TVP TVPdev the within-person component;
TVPdev = TVPraw − TVPmean) (Hamaker et al., 2015).
We tested lagged relationships, such that we tested whether the
time varying predictors (at time t) predicted subsequent changes in
the dependent variables (at time t + 1) controlling for the dependent
variable at time t. The intercept was included as a random effect, and
we used an AR1 covariance structure. In addition, we tested whether
mean levels of distraction and emotion avoidance predicted ED symp-
toms in the long term (at time 2), while controlling for baseline ED
symptoms (at time 1). Our model can be described as:
In the results outlined below, we only report TVPdev effects, as
these effects represent quasi-casual effects of the predictor on the
outcome (i.e., allowing us to understand how changes in the predictor
variable influence changes in the outcome variable; Hamaker et al.,
2015; Curran & Bauer, 2011). However, we included both TVPmean
and TVPdev effects in our analyses, as including both is necessary to
assess TVPdev effects (Hamaker et al., 2015).
3 | RE SU LT S
3.1 | Descriptive statistics

Outcomeðt + 1Þi = b0i + b1i*TVPmeani + b1i*TVPdevit + b2i*outcometi + εit :
Outcome(t + 1)i is the outcome (e.g., ED behaviors and meal anxi-
ety) for individual i time point at t + 1. TVPmeani is the participants'
mean across all 28 assessments for the predictor variable
(e.g., distraction and emotion avoidance). TVPdevit is the participant's
deviation from the mean at each assessment for the predictor vari-
able. Outcometi is the outcome variable for individual i at time point t.
See Table 1 for means and SDs for all variables. EMA compliance aver-
aged 74% (range = 14–100%).
3.2 | Distraction
Higher distraction significantly predicted lower subsequent meal anxi-
ety and higher subsequent excessive exercise but did not other ED

T A B L E 2 Emotional avoidance and

Distraction
distraction predicting meal anxiety and
eating disorder behaviors Over 4 hr (EMA) b SE p d
Anxiety −.08 .03 .027 −.20
Restriction .00 .03 .914 .01
Binge eating −.02 .02 .316 −.01
Compensatory behaviors −.01 .02 .603 −.03
Excessive exercise .04 .02 .042 .14
Weighing .00 .02 .960 .00
Body-checking −.04 .03 .184 −.10
1-month follow-up β SE p Part r F Df p R2
Drive for thinness .09 .39 .300 .08 55.80 2,48 <.001 .69
Bulimic symptoms .13 .26 .031 .13 125.19 2,50 <.001 .83
Body dissatisfaction −.02 .38 .786 −.02 78.38 2,50 <.001 .75

Emotional avoidance

Over 4 hr (EMA) b SE p d
Anxiety −.06 .03 .075 −.17
Restriction −.01 .03 .753 −.02
Binge eating −.02 .02 .398 −.07
Compensatory behaviors −.01 .02 .621 −.03
Excessive exercise .04 .02 .039 .14
Weighing .00 .02 .924 .00
Body-checking −.04 .03 .238 −.09
1-month follow-up β SE p Part r F Df p R2
Drive for thinness .12 .38 .168 .11 57.20 2,48 <.001 .69
Bulimic symptoms .13 .26 .029 .13 125.54 2,50 <.001 .83
Body dissatisfaction .01 .37 .934 .01 78.24 2,50 <.001 .75

Note: EMA, ecological momentary assessment.

Bold indicates statistically significant findings at p < .05.
4 VANZHULA ET AL.
behaviors (see Table 2). Higher mean levels of distraction also
predicted higher bulimic symptoms at 1-month follow-up, but not
drive for thinness or body dissatisfaction.
3.3 | Emotion avoidance
Higher emotion avoidance significantly predicted higher subsequent
excessive exercise, but not other ED behaviors or meal anxiety (see
Table 2). Higher mean levels of emotion avoidance also predicted
higher bulimic symptoms at 1-month follow-up, but not drive for thin-
ness or body dissatisfaction.
Additionally, when we analyzed the data without male participants
and only with AN participants and age as a covariate, the pattern of results
did not change, with distraction and avoidance continuing to be significant
predictors of excessive exercise and bulimic symptoms (ps < .02).
4 | DISCUSSION
This study found initial support for the anxiety-avoidance coping
model in EDs (Krypotos, Effting, Kindt, & Beckers, 2015). Consistent
with our hypotheses, distraction avoidance coping during meals
predicted lower meal anxiety in the short term and predicted higher
excessive exercise in the short term and bulimic symptoms in the long
term. These results are consistent with prior literature on avoidance
coping in psychopathology (Beesdo-Baum et al., 2012; Wheaton
et al., 2018) and indicate that avoidance coping may contribute to the
maintenance of EDs.
Distraction, but not emotional avoidance, predicted lower meal
anxiety several hours later. Despite a reduction in anxiety, avoidance
coping (both distraction and emotional avoidance) predicted higher
excessive exercise several hours after a meal. Contrary to our expecta-
tions, avoidance coping did not predict any other ED behaviors in the
short term. A possible explanation is that most ED behaviors (i.e., body
checking and purging) are habitual (Walsh, 2013) and may occur after
meals regardless of avoidance coping because of the habitual nature.
Excessive exercise is slightly different than other habitual ED behav-
iors, such that it is a common compensatory behavior in EDs, but is con-
ceptualized as a compulsion in response to obsessive cognitions about
weight or shape, similar to compulsions in obsessive–compulsive disor-
der (OCD; Davis & Kaptein, 2006; Holland, Brown, & Keel, 2014). In
OCD, avoidance is related to an increased urge to perform a compul-
sion, which in our sample may explain why higher excessive exercise
the primary behavior individuals engage in after avoidance coping
(Gillan et al., 2014). Additionally, excessive exercise was more common
in our primarily AN sample than other types of compensatory behaviors
such as purging, and therefore we had more variability and power to
detect effects for exercise. Further exercise is a more goal-directed
action than other types of compensatory behaviors such as restriction,
body checking, and weighing as it requires more time and effort and is
less likely to occur habitually “on the fly.” Future replication studies
should assess for habitual nature of ED behaviors (Verplanken, 2003)
and should control for duration of illness.
As hypothesized, we found that both emotional avoidance and
distraction during meals predicted higher bulimic symptoms 1 month
later. These results are consistent with prior findings suggesting that
avoidance coping predicts worsening symptoms in depression and
anxiety disorders (Grant et al., 2013). Interestingly, avoidance coping
did not predict changes in drive for thinness or body dissatisfaction.
These findings suggest that ED behaviors, but not cognitions may
increase in response to avoidance coping as a function to relieve anxi-
ety. These results are consistent with theories that posit that ED
behaviors are a maladaptive coping strategy (Blackburn, Johnston,
Blampied, Popp, & Kallen, 2006; Merwin, 2011). For example, emo-
tional avoidance and distraction may prevent individuals with EDs
from testing feared predictions (i.e., gaining weight after a meal),
which may then strengthen the fear, reinforce reliance on avoidance
coping, and increase the need to rely on ED behaviors (as a form of
avoidance coping) to prevent the feared catastrophe (i.e., future
weight gain). However, it is entirely possible that over a longer than
1-month time period avoidance coping might also impact cognitions.
Further research is needed to test this theory.
These findings have implications for both meal therapy in treat-
ment centers and meal planning outside of treatment. Instead of
encouraging distraction and emotional avoidance during meal therapy,
clinicians may teach approach strategies during meals, while providing
education on the consequences of avoidance coping. If our results
replicate in meal therapy settings, approach strategies may lead to
increased food intake and reduced ED behaviors in the long term.
Interventions that are focused on approach and tolerating emotions
during meals (i.e., exposure and response prevention [ERP]; mindful
acceptance) may lead to improved long-term outcomes. For example,
ERP has been found to reduce fear of foods and food avoidance
behaviors, is associated with increased caloric intake (Steinglass et al.,
2012), and is feasible to implement during meal therapy in an inpa-
tient setting (Farrell et al., 2019). Acceptance-based strategies may be
beneficial as they both reduce anxiety in the short term (Helbig-Lang,
Rusch, Rief, & Lincoln, 2015), but, unlike distraction, also improve
long-term outcomes in ED symptoms (Espel, Goldstein, Manasse, &
Juarascio, 2016). Future research should continue investigating long-
term effects of approach-based meal therapy interventions.
This study has several limitations. Our sample size, although large
for a clinical EMA sample, is relatively small, and our analyses may be
underpowered. The symptoms were assessed using single items
designed for this EMA study and the reliability and validity of the mea-
sures are unknown, though we attempted to adhere to standardized
measures. Although surveys were sent at semi-randomized intervals
scheduled around typical mealtimes, we were not always able to assess
cognitions immediately following meals. Further, our measures are retro-
spective and limited by self-report biases. Additionally, we did not assess
other coping styles. Finally, we did not account for how types of emotion
regulation strategies may differ across age groups and varied ED diagno-
ses (Anderson et al., 2018; Danner, Sternheim, & Evers, 2014).
VANZHULA ET AL.
To our knowledge this is the first longitudinal investigation of the
role of avoidance coping in maintaining ED symptoms. This study rep-
resents a first step in understanding how avoidance functions during
meals finding that distraction and emotional avoidance are associated
with increased ED behaviors in the long term. Future research should
seek to replicate these findings in a larger sample and examine a wider
range of coping strategies.
DATA AVAI LAB ILITY S TATEMENT
The data that support the findings of this study are available on
request from the corresponding author. The data are not publicly
available due to privacy or ethical restrictions.
ORCID
Irina A. Vanzhula https://orcid.org/0000-0001-8323-1290
Margarita Sala https://orcid.org/0000-0002-6775-9607
Rowan A. Hunt https://orcid.org/0000-0002-7626-7049
Cheri A. Levinson https://orcid.org/0000-0002-8098-6943
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