Appetite 188 (2023) 106975

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Appetite
journal homepage: www.elsevier.com/locate/appet

Research report

The relationship between childhood trauma, eating behaviours, and the

mediating role of metacognitive beliefs
Sarah Martin, Esben Strodl *
School of Psychology and Counselling, Queensland University of Technology, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Disordered eating poses a significant risk to psychological and physical health. The experience of childhood
Childhood trauma trauma has been linked to the development of disordered eating behaviours, but the causal psychological
Disordered eating mechanisms remain unclear. The metacognitive model holds promise as a potential framework for understanding
Metacognitive beliefs
the mediating psychological processes that explain how childhood trauma may lead to disordered eating. The
Metacognitions
purpose of this study was to examine the role of metacognitive beliefs mediating the relationship between
Thoughts are uncontrollable and dangerous
childhood trauma and disordered eating behaviours. Adults from the Australian community (N = 461) completed
an online self-report survey measuring childhood maltreatment (Childhood Trauma Questionnaire – Short Form),
disordered eating behaviour (Three Factor Eating Questionnaire – Revised 21), and metacognitive beliefs
(Metacognitive Questionnaire 30). Hierarchical multiple regression analyses revealed no independent associa­
tions between any forms of childhood maltreatment and cognitive restraint, while childhood emotional abuse
was uniquely associated with uncontrolled eating and emotional eating. Through bootstrapping tests, the
mediating effect between childhood trauma and uncontrolled and emotional eating consistently involved the
metacognitive beliefs that thoughts are uncontrollable and dangerous. Future longitudinal research is required to
confirm causal relationships.

1. Introduction and detrimental impacts of disordered eating, there is surprisingly

Disordered eating is becoming increasingly recognised as a common
worldwide public health concern that has been linked to significant
impairments in physical and psychological functioning (Santomauro
et al., 2021; Sheehan & Herman, 2015). The prevalence of disordered
eating behaviours such as overconsumption, binge-eating, and rigid
dieting, have significantly increased in Western countries such as
Australia across the last two decades (da Luz et al., 2017). Many in­
dividuals do not seek help for these behaviours due to the social
acceptability of dieting/fasting, eating for emotional coping purposes,
and skipping meals (Neumark-Sztainer et al., 2011). However, disor­
dered eating behaviours have been associated with a plethora of co­
morbid physical and mental health conditions such as higher BMI lower
self-esteem and body dissatisfaction (Markey et al., 2022), poorer
self-rated health and psychological distress (Kärkkäinen et al., 2018)
and the presence of a greater number of metabolic cardiovascular dis­
ease risk factors (Lopez-Cepero et al., 2018).
Despite the growing body of literature that recognises the prevalence
limited understanding of the psychological mechanisms that precipitate
and perpetuate such eating behaviours. Experiences of childhood
trauma have been identified as one important predisposing factor to the
development of disordered eating behaviours (Emery et al., 2021; Kong
& Bernstein, 2009; Zelkowitz et al., 2021). While a range of possible
mediators of the association between experiences of childhood
maltreatment and disordered eating behaviours have been considered
(e.g. pathological dissociation, difficulty with emotion self-regulation,
body dissatisfaction, negative affect/depression, anxiety, general
distress, self-criticism, and alexithymia; Rabito-Alcón et al., 2021), un­
fortunately the psychological mechanisms linking childhood trauma to
disordered eating behaviours are still poorly understood.
Research by Strodl and Wylie (2020) explored the relation between
distinct forms of childhood trauma (emotional abuse, emotional neglect,
physical abuse, physical neglect and sexual abuse) and disordered eating
behaviours (cognitive restraint, uncontrolled eating and emotional
eating) and investigated whether the diminished ability to monitor and
describe emotional states (alexithymia) or beliefs about emotions

* Corresponding author. School of Psychology and Counselling, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, 4059, Queensland,
Australia.
E-mail address: e.strodl@qut.edu.au (E. Strodl).

https://doi.org/10.1016/j.appet.2023.106975
Received 19 December 2022; Received in revised form 4 July 2023; Accepted 10 July 2023
Available online 14 July 2023
0195-6663/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
S. Martin and E. Strodl
mediated these associations. While alexithymia did not mediate these
relationships, various indirect mediation effects were found for beliefs
about emotions. In particular, the beliefs that emotions are over­
whelming and uncontrollable, shameful, and irrational and damaging
were consistently implicated in the indirect associations. This finding
provided preliminary support for the metacognitive model mediating
the association between childhood maltreatment and disordered eating
but raised the question of whether different forms of metacognitive
knowledge are implicated in these associations.
The metacognitive model was first introduced to the cognitive
developmental literature by John Flavell (Flavell, 1979). Flavell con­
ceptualised metacognition in terms of metacognitive knowledge, meta­
cognitive experiences and metacognitive strategies. Metacognitive
knowledge refers to an individual’s knowledge/beliefs about one’s own
and others’ cognitive abilities, strengths, limitations, other internal and
external factors that may affect cognition, as well as knowledge about
strategies and goals of thinking (Flavell, 1979). Metacognitive experi­
ences refer to “any conscious cognitive or affective experiences that
accompany and pertain to any intellectual enterprise” (Flavell, 1979, p.
906). These include feelings, judgements/estimates, as well as aware­
ness of thoughts and ideas experienced during a task (Efklides, 2006).
Metacognitive knowledge and metacognitive experiences guide the se­
lection and implementation of metacognitive strategies aimed to control
cognition to achieve one’s goals.
In addition to beliefs about emotions, another common form of
metacognitive knowledge are beliefs about cognitions. The role of
metacognitive beliefs, or beliefs about emotions, in the development and
maintenance of psychopathology has been promoted particularly by
Adrian Wells (2002). Indeed, there is evidence that metacognitive be­
liefs are important in understanding the experiences of depression and
anxiety (Russell et al., 2021; Strodl et al., 2015), alcohol misuse (Spada
et al., 2013), post-traumatic stress disorder (Capobianco et al., 2020),
addictive behaviours (Hamonniere & Varescon, 2018) and eating dis­
orders (Vann et al., 2013).
Wells (2002) suggests a core construct in understanding psychopa­
thology is the activation of a dysfunctional thinking response referred to
as the cognitive-attentional syndrome (CAS). The CAS is characterised
by perseverative thinking patterns, attentional bias to threat, and the use
of ineffective coping strategies, such as thought avoidance and sup­
pression (Wells, 2002). The CAS is believed to be triggered, controlled,
and maintained by positive and negative beliefs about thinking (Wells,
2002). Positive metacognitive beliefs include beliefs that cognitive
strategies such as worry, rumination, and threat monitoring are helpful
in achieving one’s goals (Wells, 2002). Negative metacognitive beliefs
include the beliefs about the negative effects of thinking patterns or
strategies (e.g., ‘worrying is dangerous for me’; Wells, 2002). The Met­
acognitions Questionnaire (MCQ-30; Wells & Cartwright-Hatton, 2004)
measures five metacognitive beliefs and processes considered relevant
to the vulnerability and maintenance of psychopathology. This measure
assesses negative metacognitive beliefs (worry is uncontrollable and
dangerous), positive beliefs about worry (benefits of worry to prevent
distress and improve mood), belief in the need to control thoughts, lack
of cognitive confidence, and cognitive self-consciousness which char­
acterises the tendency to monitor thoughts. These beliefs perpetuate the
CAS (Wells, 2002) which is implicated in the development and main­
tenance of psychopathology and maladaptive coping strategies (Wells &
Carter, 2009).
Applied within the context of eating, the activation of the CAS may
be identified by repetitive thoughts about food/eating/body image,
focused attention on food/eating/body image, and maladaptive eating
behaviours (Vann et al., 2013, 2014). For example, negative evaluations
about one’s body shape/size might be perpetuated by positive meta­
cognitive beliefs such as “thinking about my weight will protect me from
putting on weight”. Attentional bias towards cues indicating weight gain
(e.g. the tightness of clothes) might be perpetuated by a metacognitive
belief that “identifying early signs of weight gain, through tight clothes,
2
Appetite 188 (2023) 106975
will protect me from putting on weight”. While the presence of these two
metacognitive beliefs may be deemed functional to the individual, in
terms of protecting the individual from gaining weight, they also in­
crease the probability of becoming distressed through increasing the
probability of true or false positive signals of weight gain and intensi­
fying the perseverative negative evaluations of body size. This distress
may then be strengthened by the activation of negative metacognitive
beliefs such as “my worry about my body shame/weight is over­
whelming and uncontrollable”. As distress increases, metacognitive
beliefs about appropriate coping strategies become activated. If such a
metacognitive belief includes “eating helps me to calm down”, then
emotional eating may follow.
The association between metacognitive beliefs and eating behav­
iours has been well supported in populations with eating disorder di­
agnoses (Cooper et al., 2004; Georgantopolous et al., 2020; Olstad et al.,
2015; Sapuppo et al., 2018; Spada et al., 2016; Vann et al., 2013, 2014).
Collectively, these studies highlight that metacognitive beliefs are
important psychological mechanisms in eating disorder pathology.
However, less is known about the association between disordered eating
and metacognitions, although emerging evidence suggests promising
associations within nonclinical samples. For example, a small (N = 44)
cross-sectional study by Quattropani et al. (2016) found significant as­
sociations between several eating disorder symptoms and metacognitive
beliefs. Building on this research, Laghi et al. (2018) reported a positive
correlation between metacognitive beliefs and the frequency of binge
eating. While this sample was larger (n = 804) it was limited to an
adolescent sample. Similarly, Limbers et al. (2021) reported higher
levels of emotional eating behaviours to be associated with negative
metacognitive beliefs in a nonclinical sample of adolescents. These
studies were conducted among adolescents making the results difficult
to generalise to adult populations.
The plausibility of metacognitive beliefs mediating the association
between childhood trauma and adult disordered eating is supported by a
study by Hosseini-Ramaghani et al. (2019) that found a direct correla­
tion between childhood trauma and the strength of maladaptive meta­
cognitive beliefs. Moreover, a review by Mansueto et al. (2019) found
that exposure to traumatic childhood experiences such as abuse or
neglect is related to the development of maladaptive metacognitive
beliefs in later adulthood. The authors also reported that metacognitive
beliefs mediated the relationship between childhood adversity and re­
petitive thinking/negative affect among both clinical and healthy adult
samples (Mansueto et al., 2019). Similarly, Østefjells et al. (2017)
showed that metacognitive beliefs about thoughts being uncontrollable
and dangerous mediated the experiences of childhood emotional abuse
and adult symptoms of depression and anxiety in individuals with psy­
chosis or bipolar disorder. While the sample limits the generalisability of
these findings to a nonclinical general population, the results are
consistent with metacognitive theory which should also be applicable to
non-clinical populations. To date, no study has examined whether
metacognition beliefs mediate the relationship between childhood
trauma and disordered eating in adults. Identifying such a mediating
relationship may guide the development of novel interventions for
disordered eating based upon a metacognitive model.
1.1. The present study
The above evidence suggests that childhood trauma is a risk factor
for the development of disordered eating behaviours with maladaptive
metacognitive beliefs being a potential psychological mechanism or
mediator linking the two. Thus, the present study will examine the as­
sociation of five forms of childhood trauma (emotional abuse, physical
abuse, sexual abuse, emotional neglect, and physical neglect) with three
disordered eating behaviours (cognitive restraint, uncontrolled eating,
and emotional eating). This study has two hypotheses.
S. Martin and E. Strodl Appetite 188 (2023) 106975

1. It is hypothesised that each form of childhood trauma (emotional 2.2. Measures

abuse, physical abuse, sexual abuse, emotional neglect, physical
neglect) will independently be associated with each type of disor­ 2.2.1. Demographic questions asked about age, gender, education,
dered eating (cognitive restraint, uncontrolled eating, emotional employment status, annual income, marital status, and whether they
eating), after controlling for covariates and other forms of childhood came from an English-speaking background.
trauma. 2.2.2. COVID-19 Questions. Data collection occurred in the context
2. It is hypothesised that the relationship between childhood trauma of the COVID-19 pandemic from July 2021 to September 2021. In
(emotional abuse, physical abuse, sexual abuse, emotional neglect, Australia, the pandemic disrupted aspects of daily life and restrictions
physical neglect) and each type of disordered eating (cognitive re­ were imposed such as physical distancing and lockdown measures,
straint, uncontrolled eating, and emotional eating) will be mediated which may have impacted an individual’s eating habits (O’Sullivan
by metacognitive beliefs (uncontrollable and dangerous, positive et al., 2020). Therefore, questions were included to gain insight into
beliefs, need to control thoughts, cognitive self-consciousness, whether the pandemic altered participants eating behaviours. Approx­
cognitive confidence). imately 65 percent (n = 298) of participants reported taking extra pre­
cautions to socially distance due to COVID-19 at the time of completing
2. Method the questionnaire. Individuals were asked if their eating behaviour
(cognitive restraint, uncontrolled eating, and emotional eating) was
2.1. Participants impacted by COVID-19, for frequency of behaviour and volume of food
(see Supplementary Table A).
The inclusion criteria for this study were being 18 years or older and 2.2.3. Childhood Trauma Questionnaire-Short Form (CTQ-SF). The
residing in Australia. The exclusion criteria involved self-reporting CTQ-SF is a widely used 28-item self-report measure of traumatic
having a current or previous eating disorder diagnosis (e.g. anorexia childhood experiences for adults (Bernstein et al., 2003). The scale is a
nervosa, bulimia nervosa or binge eating disorder), and self-selecting short-form version of the initial CTQ scale developed by Bernstein et al.
that they would become distressed thinking about their experience of (1994). Responses were measured on a five-point Likert scale ranging
childhood trauma, beliefs, or personal eating behaviour. Six hundred from never true (1) to very often true (5). Higher scores represent higher
and thirteen individuals began the study. Among those who commenced levels of childhood maltreatment (Bernstein & Fink, 1998). The scale
the questionnaire, 19 did not meet the inclusion criteria and 133 exited assesses emotional abuse (CEA) e.g., ‘I felt that someone in my family
before completion (the majority before completing demographics). Of hated me’; physical abuse (CPA) e.g., ‘I was punished with a belt, a
those remaining, 9 responses had over 10% missing data and were board, a cord, or some other hard object’; sexual abuse (CSA) e.g.,
subsequently excluded from the analyses. The final sample comprised of ‘Someone tried to touch me in a sexual way, or tried to make me touch
461 participants with 65.7 percent females (n = 303). Participants them’; emotional neglect (CEN); e.g., ‘My family was a source of
ranged from 18 to 82 years of age (M = 39.6; SD = 19.3). The sample strength and support’; and physical neglect (CPA) e.g., ‘I didn’t have
demographics are detailed in Table 1. enough to eat’. The CTQ-SF has indicated good to excellent internal
reliability across the five subscales among large samples (Hernandez
et al., 2013; Kongerslev et al., 2019; Mizuki & Fujiwara, 2020). The scale
has also demonstrated good construct validity and good retest reliability
(Kim et al., 2013; Spinhoven et al., 2014). Similarly, the internal reli­
Table 1 ability for the present study ranged from good to excellent for the three
Demographic characteristics of sample. eating behaviours (CEA α = 0.91, CPA α = .85, CSA α = 0.92, CEN α =
Characteristic n (%) 0.94, CPN α = .73).
Marital status 2.2.4. Three-Factor Eating Questionnaire (TFEQ-R21). The TFEQ-
Single 154 (33.4) R21 is a 21-item instrument that measures three types of disordered
Married 159 (34.5) eating behaviours: cognitive restraint (CR), uncontrolled eating (UE)
Divorced 29 (6.3)
and emotional eating (EE; Cappelleri et al., 2009). The TFEQ was orig­
Co-habiting 80 (17.4)
Other 39 (8.5)
inally developed by Stunkard and Messick (1985) and was later refined
Highest level of education by Karlsson et al., (2000) to reflect the TFEQ-R21. Items 1–20 were
High school 127 (27.5) measured on a four-point Likert scale ranging from definitely true (1) to
Certificate or diploma 109 (23.6) definitely false (4) and item 21 was measured on an eight-point numerical
Bachelor’s degree 138 (29.9)
scale. Higher scores represent higher levels of disordered eating. The
Post-graduate degree/masters/doctoral level 82 (17.8)
Other 5 (1.1) cognitive restraint subscale assesses individual control over food con­
Employment status sumption to influence body weight and body shape e.g., ‘I don’t eat some
Full-time 126 (27.3) foods because they make me fat’. The uncontrolled eating subscale as­
Part-time/casual 169 (36.7) sesses the likelihood to lose control overeating when feeling hungry or
Self-employed 34 (7.4)
Unemployed 88 (19.1)
exposed to external stimuli e.g., ‘Sometimes when I start eating, I just
Homemaker 27 (5.9) can’t seem to stop.’ The emotional eating subscale measures tendency to
Prefer not to answer 17 (3.7) overeat with reference to negative mood states e.g., ‘I start to eat when I
Annual income feel anxious’. The TFEQ-R21 supports measurement invariance across
$0 - $14,999 78 (16.9)
genders, has good internal consistency, and has previously demon­
$15,000 - $34,999 105 (22.8)
$35,000 - $49,000 63 (13.7) strated appropriate discriminative and convergent validity (de Medeiros
$50,000 - $64,999 51 (11.1) et al., 2017; Duarte et al., 2020). Lin et al. (2021) reported good to
$65,000 - $74,999 33 (7.2) excellent internal reliability. Similarly, the internal reliability for the
$75,000 - $99,999 48 (10.4) present study ranged from good to excellent for the three eating be­
$100,000 - $159,999 35 (7.6)
$160,000+ 17 (3.7)
haviours (CR α = 0.79, UE α = 0.88, EE α = 0.94).
Prefer not to answer 31 (6.7) 2.2.5. Metacognitions Questionnaire (MCQ-30). The MCQ-30 is a
English speaking background measure of individual differences in metacognitive beliefs, judgements,
Yes 407 (88.3) and monitoring tendencies across five distinct metacognitive factors
No 54 (11.7)
(Wells & Cartwright-Hatton, 2004). Responses to the 30-item,

3
S. Martin and E. Strodl
self-assessment questionnaire are measured on a four-point Likert scale
ranging from do not agree (1) to agree very much (4). The scale assesses
five thought patterns which are negative beliefs about uncontrollability
and danger (UD) e.g., ‘when I start worrying, I cannot stop’, positive be­
liefs about worry (PB) e.g., ‘worrying helps me cope’, negative beliefs
about the need to control thoughts (NCT) e.g. ‘It is bad to think certain
thoughts’, cognitive self-consciousness (CS) e.g., ‘I am constantly aware of
my thinking’, cognitive confidence (CC) e.g., ‘I have a poor memory’.
Higher subscale scores indicate a higher maladaptive metacognitive
style (Wells & Cartwright-Hatton, 2004). The MCQ-30 has previously
demonstrated good to excellent internal consistency and good test-retest
reliability (Spada et al., 2016; Wells & Cartwright-Hatton, 2004). The
internal reliability for the present study ranged from good to excellent
(UD α = 0.91, PB α = .91, NCT α = 0.80, CS α = 0.83, CC α = 0.90).
2.3. Procedure
The design was a cross-sectional survey. The project was approved by
the Queensland University Technology (QUT) Human Research Ethics
Committee (Approval Number: 2021100236). Participants were
recruited through an Australia-wide social media campaign conducted
by QUT social media department, the survey link was posted on the
associate researcher’s Facebook page and the flyer was uploaded to
various online community groups. A snowballing and convenience
sampling technique was employed by the associate researcher for
further dissemination (Emerson, 2015). Additionally, psychology stu­
dents at QUT were invited to join the study through university email lists
and first-year psychology students were able to participate through the
SONA course credit system. Community participants had the opportu­
nity enter the random prize draw to win one of two $50 vouchers while
QUT students were offered 0.5 course credit. The survey was adminis­
tered online using Qualtrics (2021) platform.
2.4. Statistical analyses
All analyses were conducted using IBM Statistical Package for the
Social Sciences (SPSS) version 27. Data was screened, responses with
over 10% missing data were excluded, items were reverse coded where
appropriate, and subscales were calculated using mean values. A missing
values analysis revealed less than 1% missing data per item and Little’s
(1988) MCAR test indicated that data was missing completely at random
(χ 2 (172) = 129.58, p = .99). Missing data was imputed using the
expectation maximisation procedure in SPSS. Normality statistics and
visual inspection of histograms revealed no departure from linearity and
normality. However, minor clustering was observed on all scatterplots
containing physical neglect and sexual abuse, suggesting potential
breaches to homoscedasticity. A transform (square root, log10) was
conducted, and transformations did not impact the overall significance
of the model, therefore the untransformed data was retained for sub­
sequent analyses. No influential outliers were present as Cook’s distance
scores were less than 1, indicating that the outliers would not impact the
overall solution. No breaches to multicollinearity or independence of
errors were present.
The independent variable was childhood trauma which consisted of
the scores for each of the five subscales in the CTQ-SF. The proposed
mediators were the five subscales of the MCQ-30. The dependent vari­
ables were the cognitive restraint, uncontrolled eating and emotional
eating subscales derived from the TFEQ-R21.
Bivariate correlations between the independent variables, the pro­
posed mediators and the three dependent variables were calculated to
assist the interpretation of the multivariate analyses. Cohen’s (1988)
standard was used to evaluate effect sizes with correlation coefficients of
0.10 classified as small, 0.30 as medium, and >0.50 as large. Three hi­
erarchical regression analyses were conducted to determine the effect of
the independent variables (all forms of childhood trauma) on each
dependent variable (cognitive restraint, uncontrolled eating, and
4
Appetite 188 (2023) 106975
emotional eating). Age, gender, level of education and income were
covariates and socioeconomic status was operationalised using annual
income and level of education. Gender was dummy coded into males
(reference category) and females (entered into the model). Alpha was
kept at p < .05 to allow easy comparison with our two previous similar
studies (e.g. Dawson et al., 2022; Strodl & Wylie, 2020).
For the mediation hypotheses, each form of childhood trauma was
independently assessed with the five metacognition variables, with one
eating behaviour, while controlling for covariates. To ensure a robust
interpretation, indirect effects were analyses in the present study
through Andrew Hayes PROCESS Macro in SPSS through bias-corrected
and accelerated (BCa) bootstrapped confidence intervals (based on 5000
samples). Historically, it is argued that a causal relationship between the
independent and dependent variable is necessary for mediation effects
to be investigated (Baron & Kenny, 1986). Contrary to traditional
methods, growing research has suggested that mediation can occur
despite a non-significant causal relationship as this method is often
associated with reduced power to detect significant effects (MacKinnon,
2008; Mackinnon et al., 2007; Rucker et al., 2011). Hayes (2018) sug­
gests that significant total effects are not a precondition for investigating
indirect effects. This methodology for testing mediation relationships
has been highlighted by similar studies examining the relationship be­
tween childhood trauma and disordered eating (e.g., Dawson et al.,
2022; Strodl & Wylie, 2020). Thus, in the present study, the indirect
effects were analysed irrespective of whether significant total effects
were detected in the hierarchical regression. Beta weights of .10 were
categorised as small, 0.30 was considered medium, and >0.50 classed as
large (Cohen, 1988).
3. Results
3.1. Bivariate analyses
A negative association was found between age and uncontrolled
eating (r = -0.29, p < .001) and emotional eating (r = − 0.15, p < .01). A
small positive association was found between gender and cognitive re­
straint (r = 0.14, p < .05) and emotional eating (r = 0.05, p < .05), with
females having larger scores on these variables than males. Income was
significantly negatively correlated with uncontrolled eating (r = − 0.12,
p < .05) and emotional eating (r = − 0.16, p < .001). No significant
associations were found between education and the three disordered
eating behaviours. Given many of the demographics had significant
associations with the dependent variables and have been known to ac­
count for influences on the investigated eating behaviour in previous
studies (e.g., Emery et al., 2021; Minnich et al., 2017; Strodl & Wylie,
2020), they were retained as covariates in the present study.
Table 2 illustrates the means and standard deviations as well as the
bivariate correlation matrix for the measured variables. Emotional
abuse, physical abuse, emotional neglect, and physical neglect displayed
significant, small to large associations with all MCQ-30 subscales. Sexual
abuse evidenced small significant associations with all subscales across
the MCQ-30 scales excluding cognitive self-consciousness.
Small to medium, positive, and significant correlations were found
between metacognition scales uncontrollability and danger, positive
beliefs, need to control thoughts, and cognitive self-consciousness and
all three eating behaviours. However, cognitive confidence yielded only
small, positive significant associations with uncontrolled and emotional
eating behaviours. Additionally small, positive, and significant associ­
ations were identified between emotional abuse, physical abuse and
physical neglect and uncontrolled eating. All forms of childhood trauma
produced significant bivariate correlations with the emotional eating
subscale with associations ranging from small to moderate.
S. Martin and E. Strodl Appetite 188 (2023) 106975

Table 2
Bivariate correlation matrix for psychometric research variables.
Measure 1 2 3 4 5 6 7 8 9 10 11 12 13

1. Emotional –
abuse
2. Physical .62*** –
abuse
3. Sexual abuse .31*** .29*** –
4. Emotional .72*** .48*** .27*** –
neglect
5. Physical .65*** .57*** .32*** .65*** –
neglect
6. MCQ (UD) .40*** .17** .16*** .21*** .21*** –
7. MCQ (PB) .18*** .11* .15** .10* .07** .45*** –
8. MCQ (NCT) .28*** .17*** .11* .15*** .14** .58*** .44*** –
9. MCQ (CS) .22*** .12* .05 .13** .13** .43*** .34*** .41*** –
10. MCQ (CC) .28*** .13** .14** .25*** .18*** .40*** .30*** .32*** .15*** –
11.TFEQ – CR .11* .03 .03 .04 .06 .16*** .15** .10* .15** .07 –
12 TFEQ – UE .24*** .14** .06 .09 .15** .35*** .23*** .30*** .15** .25*** .03 –
13. TFEQ – EE .31*** .15*** .10* .16*** .17*** .35*** .23*** .23*** .15** .22*** .07 .73*** –
Means (SD) 2.26 1.61 1.35 2.40 1.50 2.24 1.84 2.10 2.72 2.00 2.42 2.25 2.60
(1.10) (0.78) (0.73) (1.07) (0.59) (0.86) (0.70) (0.71) (0.67) (0.79) (0.62) (0.67) (0.95)

Note. N =461. MCQ = Metacognitions questionnaire. MCQ (UD) = uncontrollable and dangerous; MCQ (PB) = positive beliefs; MCQ (NCT) = need to control thoughts;
MCQ (CS) = cognitive self-consciousness; MCQ (CC) = cognitive confidence.
*p < .05, **p < .01, ***p < .001.

3.2. Main analyses
3.2.1. Hierarchical multiple regression
Table 3 summarises the hierarchical multiple regression analysis
conducted to explore the relationship between the five forms of child­
hood trauma and the three forms of disordered eating behaviour, after
controlling for age, gender, income, and level of education. In step one,
gender (female) was significantly related to Cognitive Restraint, age was
significantly and negatively related to Uncontrolled Eating, while age,
gender and income were significantly related to Emotional Eating.
The addition of the five childhood trauma subscales in step 2
significantly contributed to the model explaining Uncontrolled Eating,
ΔR2 = 0.06, ΔF(5, 451) = 6.18, p < .001, and Emotional Eating ΔR2 =
0.08, ΔF(5, 451) = 8.55, p < .001. However, the additive effect of these
subscales did not significantly contribute to the model predicting
Cognitive Restraint ΔR2 = 0.01, ΔF(5, 451) = 1.27, p = .227.
3.2.2. Test of indirect effects
3.2.2.1. Cognitive restraint. Supplementary Table B presents all tests of
indirect effects with Cognitive Restraint. No significant indirect effects
were evidenced for cognitive restraint.
3.2.2.2. Uncontrolled eating. Supplementary Table C presents all tests of
indirect effects with Uncontrolled Eating. Fig. 1 illustrates the signifi­
cant direct and indirect pathways. The total indirect effect of the com­
bination of mediator variables was positive and significant but small
from all five forms of childhood trauma to Uncontrolled Eating. Through
independent analysis of the mediator variables, a significant, positive
pathway through the negative belief that thoughts are uncontrollable
and dangerous to Uncontrolled Eating was evident from childhood
emotional abuse, physical abuse, sexual abuse, emotional neglect, and
physical neglect.
3.2.2.3. Supplementary Table D Illustrates tests of indirect effects tests with
the dependent variable as emotional eating. Fig. 2 displays the significant
pathways. The total indirect effect of the combination of mediator var­
iables was positive and significant yet small from all five forms of
childhood trauma to Emotional Eating. Independent analysis of the
mediator variables revealed a significant pathway through the negative
belief that thoughts are uncontrollable and dangerous to uncontrolled
eating was evident from childhood emotional abuse, physical abuse,
sexual abuse, emotional neglect, and physical neglect.

Table 3
Hierarchical multiple regression analysis of childhood trauma for cognitive restraint, uncontrolled eating and emotional eating.
Outcome

Cognitive restraint Uncontrolled eating Emotional eating

b [95% CI] β sr2 b [95% CI] β sr2 b [95% CI] β sr2

Step 1
Age − 0.00 [-0.01, 0.00] − .06 .00 − 0.01 [-0.01, –0.01] − .30*** .07 − 0.01 [-0.01, 0.00] − .11 .01
Female 0.20 [0.07, 0.32] .15* .02 − 0.07 [-0.20, 0.06] − .05 .00 0.20 [-0.09, 0.40] .10 .01
Income 0.02 [-0.01, 0.05] .08 .01 − 0.02 [-0.05, 0.01] − .07 .00 − 0.05 [-0.10, 0.00] − .12 .01
Education level 0.01 [-0.04, 0.07] .02 .00 0.02 [-0.04, 0.08] .04 .00 0.02 [-0.09, 0.13] .02 .00
R2 = .03* R2 = .09* R2 = .05*
Step 2
Emotional abuse 0.08 [-0.05, 0.17] .13 .01 0.16 [0.07, 0.25] .26*** .02 0.31[0.13, 0.48] .35* .04
Physical abuse − 0.02 [-0.12, 0.09] − .02 .00 0.01 [-0.10, 0.11] .01 .00 − 0.01 [-0.20, 0.18] − .01 .00
Sexual abuse − 0.00 [-0.09, 0.08] − .00 .00 0.02 [-0.07, 0.10] .02 .00 0.02 [-0.14, 0.18] .01 .00
Emotional neglect − 0.02 [-0.11, 0.06] − .04 .00 − 0.07 [-0.16, 0.01] − .12 .01 − 0.08 [-0.24, 0.08] − .09 .00
Physical neglect 0.04 [-0.10, 0.18] .036 .00 0.07 [-0.07, 0.25] .06 .00 0.01 [-0.27, 0.28] .00 .00
ΔR2 = .01 ΔR2 = .06* ΔR2 = .08*

Note. N =461. Gender reference category = Male. *p < .05; **p < .01; ***p < .001.

5
S. Martin and E. Strodl Appetite 188 (2023) 106975

Fig. 1. Significant Indirect Pathways from Childhood Trauma to Uncontrolled Eating.x

Note. Unstandardised coefficients reported. *p < .01, **p < .001.

6
S. Martin and E. Strodl Appetite 188 (2023) 106975

Fig. 2. Significant Indirect Pathways from Childhood Trauma to Emotional Eating.

Note. Unstandardised coefficients reported. *p < .01, **p < .001.

7
S. Martin and E. Strodl
4. Discussion
The present study aimed to characterise the association between
childhood trauma (i.e., childhood emotional abuse, physical abuse,
sexual abuse, emotional neglect, physical neglect) and three disordered
eating behaviours (cognitive restraint, uncontrolled eating, and
emotional eating). Additionally, it sought to examine the indirect role
that metacognitive beliefs (Uncontrollable and Dangerous, Positive Be­
liefs, Need to Control Thoughts, Cognitive Self-Consciousness, Cognitive
Confidence) play in the associations between the five measures of
childhood maltreatment and three measures of disordered eating.
4.1. Hypothesis 1
The results partially support the hypotheses that each form of
childhood trauma (emotional abuse, physical abuse, sexual abuse,
emotional neglect, physical neglect) would be independently associated
with each type of disordered eating (cognitive restraint, uncontrolled
eating, emotional eating), after controlling for covariates and other
forms of childhood trauma. Examination of total effects revealed that
only childhood emotional abuse significantly independently contributed
to uncontrolled eating and emotional eating behaviours. This study did
not find any support for direct and independent associations between
childhood trauma experiences and cognitive restraint.
The significant association detected between childhood emotional
abuse and uncontrolled and emotional eating aligns with existing
research. The literature suggests that this form of childhood abuse is the
most prevalent (Stoltenborgh et al., 2015) and may better predict
disordered eating in adulthood above and beyond that of childhood
physical or sexual abuse in non-clinical community samples (Burns
et al., 2012; Kent et al., 1999). Research examining childhood emotional
abuse and constructs similar to uncontrolled eating (i.e. binge eating and
overeating) have similarly reported significant associations in clinical
samples (Amianto et al., 2018; Caslini et al., 2016) and community
samples (Feinson & Hornik-Lurie, 2016). The findings in this study
support the results presented by Michopoulos et al. (2015) and Hymo­
witz et al. (2017) who found childhood emotional abuse to be the form
of abuse that was most associated with emotional eating behaviours in
non-clinical community samples. Furthermore, the association between
emotional abuse and emotional eating as a coping mechanism has also
been characterised in previous research with non-clinical community
samples (Burns et al., 2012; Kennedy et al., 2007).
While our findings are in line with other research, a couple of notable
differences were identified compared with the findings from similar
previous research. Strodl and Wylie (2020) and Dawson et al. (2022)
both identified an independent association between childhood sexual
abuse and emotional eating. This is puzzling given that the present study
adopted a similar methodology and questionnaires to that of Strodl and
Wylie (2020) and Dawson et al. (2022). This difference may be in part
due to the current sample consisting of a more even gender split, as
studies have reported gender differences in the association between
childhood trauma and disordered eating behaviours (Ackard et al.,
2008; Fuemmeler et al., 2009). Other studies have found childhood
sexual abuse in addition to emotional neglect, and physical neglect to be
associated with disordered eating behaviours (Demirci, 2018; Emery
et al., 2021). However, these samples consisted of adolescents and
young adults rather than adults with a broad age range and did not
control for sociodemographic factors as in the present study. Similarly,
while the findings of no direct independent associations between any of
the five forms of childhood trauma and cognitive restraint is similar to
the findings by Dawson et al. (2022), it differs from the finding by Strodl
and Wylie (2020) who found a direct association between childhood
emotional abuse and cognitive restraint. The inconsistencies in the
literature highlight that the relationship between different forms of
childhood trauma and disordered eating is complex and requires further
investigation to identify potential moderators.
8
Appetite 188 (2023) 106975
4.2. Hypothesis 2
The findings partially support the hypothesis that the relationship
between all forms of childhood trauma and each type of disordered
eating would be mediated by all forms of metacognitive beliefs. The
findings indicate that all forms of childhood trauma were related to
uncontrolled eating and emotional eating behaviours through one
metacognitive belief that thoughts are uncontrollable and dangerous.
These findings are in line with existing research that has found negative
metacognitive beliefs to play a role in the association between childhood
trauma and psychological disorders (Hosseini-Ramaghani et al., 2019;
Myers & Wells, 2015; Østefjells et al., 2017). The findings did not detect
any support for the other metacognitive beliefs. To the authors’
knowledge, no existing research has explored these three factors in a
mediation model so direct comparison with other studies is not possible.
The findings provide some level of support for the original cognitive
developmental metacognitive model (Flavell, 1979) and Well’s (2002)
metacognitive model of psychopathology within a disordered eating
context. That is, metacognitive knowledge, in the form of beliefs about
cognitions, appear to be important in guiding the selection of meta­
cognitive strategies, in the form of maladaptive coping strategies such as
uncontrolled and emotional eating behaviours. However, the findings
differ from Well’s (2002) metacognitive model, in that only negative
beliefs that thoughts are uncontrollable and dangerous, and not positive
beliefs about thinking strategies (such as worry or rumination), medi­
ated the association between childhood trauma and uncontrolled or
emotional eating. Comparatively, research examining the association
between metacognitive beliefs and disordered eating report both posi­
tive and negative metacognitive beliefs to predict various disordered
eating behaviours in both clinical (Aloi et al., 2021; Spada et al., 2016)
and non-clinical samples (Laghi et al., 2018; Limbers et al., 2021).
Further research is therefore needed to clarify whether positive beliefs
about thinking strategies is an important component of a metacognitive
model explaining the link between childhood trauma and disordered
eating. In addition, it is also important to highlight that the same met­
acognitive belief (thoughts are uncontrollable and dangerous) inde­
pendently mediated the associations between each of the five forms of
childhood trauma and two of the types of disordered eating behaviours
measured in this study. It therefore appears that the metacognitive
model identified in this study may be generic across different forms of
childhood abuse and different forms of reactive disordered eating be­
haviours. That is, any form of childhood trauma may facilitate the
development of a belief that thoughts are uncontrollable and dangerous
and that, in turn, this metacognitive belief facilitates the selection of
uncontrolled or emotional eating behaviours as maladaptive coping
strategies. This finding is consistent with a previous review of the
literature indicating that multiple forms of childhood adversity are risk
factors for the metacognitive belief that thoughts are uncontrollable and
dangerous (Mansueto et al., 2019). These authors propose that while
childhood positive metacognitive beliefs might initially activate the CAS
(according to Wells’ (2002) metacognitive model), continued poor
emotion regulation and heightened distress over time might result in the
strengthening of the metacognitive belief that thoughts are uncontrol­
lable and dangerous. This is a plausible explanation and in further
support of this explanation, there is also evidence that both positive and
negative metacognitive beliefs are present in children (Ellis & Hudson,
2010) and that parenting factors may be related to genesis and perpet­
uation (Chow & Lo, 2017; Gallagher & Cartwright-Hatton, 2008). As
such, further longitudinal research is required to clarify the mechanisms
linking childhood maltreatment with changes in positive metacognitive
beliefs and the strengthening of the belief that thoughts are uncontrol­
lable and dangerous over time.
4.3. Implications
These findings have important practical and theoretical implications.
S. Martin and E. Strodl
In terms of a practical implication, the study strengthens the literature
showing the role of childhood traumatic experiences in disordered
eating behaviours within a community sample. Such evidence empha­
sises the need to further develop effective preventative programs to
reduce the incidence of childhood traumatic experiences to reduce the
long-term detrimental consequences of such experiences. In terms of a
theoretical implication, the present study also adds to the existing body
of research by identifying an important metacognitive belief that ap­
pears to be an influential psychological mechanism in uncontrolled and
emotional eating. Conversely, the findings of this study indicate that
positive beliefs about thinking strategies, such as worry and rumination,
may not be relevant to a metacognitive model of reactive disordered
eating behaviours. It is important to note that the positive beliefs about
thinking subscale of the Metacognitions Questionnaire 30 was devel­
oped based upon a metacognitive model of depression and anxiety. As
such, it is possible that a questionnaire that measures more precisely
positive beliefs about perseverative thinking about body image, eating
behaviours or food may identify a mediating role of a metacognitive
beliefs about the positive role of thinking processes more relevant to
disordered eating. There is, therefore, a need to develop a questionnaire
that may more precisely, and more comprehensively, assess the meta­
cognitive model in relation to eating pathology.
The consistent finding within this study of the important role of the
belief that thoughts are uncontrollable and dangerous supports the need
to further test the potency of this metacognitive belief in longitudinal
studies. In addition, the causal role of the belief that thoughts are un­
controllable and dangerous in uncontrolled and emotional eating,
should be tested by interventional studies targeting this metacognitive
belief, particularly in those who have experienced childhood trauma.
Metacognitive therapy was developed by Wells (2002) to modify mal­
adaptive metacognitive beliefs and has been shown to be a successful
treatment measure among various psychological disorders (Normann &
Morina, 2018; Philipp et al., 2019; Wells & Colbear, 2012). Meta­
cognitive therapy has also been found to be a promising treatment for
individuals with binge eating disorder (Robertson & Strodl, 2020).
Future interventional studies may consider utilising metacognitive
therapy to challenge the belief that thoughts are uncontrollable and
dangerous community samples with experiencing high levels of un­
controlled and emotional eating and a history of childhood trauma. This
is particularly important to test given that the highest probability of poor
treatment outcomes with eating pathology has been observed in in­
dividuals who have experienced childhood trauma (Kong & Bernstein,
2009).
4.4. Limitations and future directions
Despite the contribution of the current study to the broader literature
and practice, various limitations may affect the accuracy of the findings
reported. Firstly, the CTQ-SF does not assess experiences of non-
interpersonal trauma (e.g., natural disasters, car accidents, bullying,
witnessing violence, sudden loss, crime, or related events). These ad­
versities have also been identified as risk factors for disordered eating
(Hecht & Hansen, 2001; Johnson et al., 2002). Thus, while the current
study is valuable in investigating the impacts of multiple domains of
trauma, it may not capture the influence of wider traumatic experiences,
including experiences beyond childhood. Reporting bias and social
desirability may be a limitation when interpreting the results of this
study. While the Childhood Trauma Questionnaire has shown good
temporal stability in adults (Goltermann et al., 2023), there is also ev­
idence of respondents commonly minimising their past history of
childhood maltreatment (MacDonald et al., 2016). Furthermore, there is
good evidence of a low level of agreement between prospective and
retrospective measures of childhood maltreatment (Baldwin et al.,
2019).
Additionally, the data collection occurred in the context of the
COVID-19 pandemic which may impact the generalisability of findings
9
Appetite 188 (2023) 106975
as the pandemic disrupted individuals’ daily life (Brown et al., 2021;
Simone et al., 2021). In response to uncertainty, individuals may be
more likely to engage in disordered eating behaviours as an effort to
cope with emotional states and/or gain control (Schlegl et al., 2020).
The results from this study found that most participants’ eating behav­
iours were approximately the same as prior to the pandemic, however, a
small proportion of individuals reported engaging in an increase or
decrease in the frequency and volume of eating behaviours (see Sup­
plementary Table A). The present study attempted to capture how
COVID-19 altered eating behaviours but did not include this assessment
in the analyses due to the absence of reliable measures. To examine this
further, it is suggested future research replicating the design of this study
are required at a time when social distancing and no stay-at-home
measures are imposed. In addition, given the exploratory nature of
this study, replication of the relationships found between independent
and dependent variables is required.
The present study utilised a community-based sample, thus findings
may not be applicable to individuals with diagnosed eating disorders.
Given the logistical challenges of screening the participants using a
structured clinical interview with such a large sample size, we were
reliant on the participants self-report to exclude participants with a
diagnosed eating disorder. This may have resulted in some misclassifi­
cation. In addition, given the nature of this sample, further research is
needed to investigate whether similar associations are found in a clinical
sample of adults diagnosed with an eating disorder. The over-
representation of female participants and the absence of gender
diverse participants in the current sample is another notable limitation.
While controlled for as a covariate, this sample resulted in an inability to
make gender-difference inferences. Therefore, the impact of gender on
the found effects remains unknown due to the non-representative sam­
ple. Future research should seek to recruit a more representative sample,
as it would be interesting to assess the gender effects. In addition, given
the presence of minor cross-country variations in correlates with
disordered eating behaviours such as restrained eating (Strodl et al.,
2020), there is a need to test cultural variations in the associations
identified in this study.
This study was also limited to measuring metacognitive constructs as
assessed by the MCQ-30. There is evidence that other important meta­
cognitive processes, such as attentional bias as proposed in Wells’
(2002) metacognitive model, are important in understanding the rela­
tionship between traits such as impulsivity and disordered eating be­
haviours (Hou et al., 2011). Future research should incorporate further
measures of metacognitive knowledge, metacognitive strategies and
metacognitive experiences to more fully test the applicability of the
metacognitive model to disordered eating. Similarly, the CTQ-SF was
limited in its measure of childhood maltreatment resulting in malnu­
trition as it is possible that there may be a unique link between this form
of childhood maltreatment and disordered eating. While the CTQ-SF did
include one item measuring this issue “Did not have enough to eat”, the
correlations with the three measures of adult disordered eating were
weak and statistically non-significant (see Supplementary Table E). It is
possible though that a more rigorous assessment of childhood malnu­
trition might be useful in future studies. Finally, the cross-sectional
design of this study precludes confident interpretations about the di­
rection of causality. Rather the findings of this study represent pre­
liminary evidence that may provide direction and confidence to
researchers to explore the direction of causality in more resource
demanding longitudinal studies.
5. Conclusion
Disordered eating is common in society and the consequences of
these behaviours threaten peoples physical and mental wellbeing. The
present study contributes to the limited literature exploring the role of
metacognitive beliefs in the association between childhood trauma and
disordered eating behaviours. It was found childhood emotional abuse
S. Martin and E. Strodl
was associated with uncontrolled eating and emotional eating behav­
iours. Secondly, it was found that the metacognitive belief that thoughts
are uncontrollable and dangerous mediated the association between all
domains of childhood trauma and uncontrolled and emotional eating
behaviours. None of the metacognitive beliefs measured in this study
mediated the association between childhood trauma and cognitive
restraint.
These findings provide preliminary support for the role of meta­
cognitions as an underlying mechanism in the relationship between
childhood trauma and uncontrolled eating and emotional eating, but not
cognitive restraint. Together, the results help to inform future treatment
planning protocols when working with both clinical and subclinical
disordered eating behaviours. The early identification and treatment of
these beliefs could also prevent the onset of more severe psychopa­
thology during adulthood among clients who have experienced child­
hood trauma or engage in disordered eating behaviours.
Author contributions
SM and ES designed the study. SM oversaw the data collection. SM
and ES performed the data analysis. SM was the primary author of the
manuscript with ES writing sections of the manuscript as well as revising
the manuscript. All authors have approved the final article.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Data code and availability
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
Ethical statement
This study involves human data and has been performed in accor­
dance with the Declaration of Helsinki. The project was approved by the
Queensland University Technology (QUT) Human Research Ethics
Committee (Approval Number: 2021100236).
Declaration of competing interest
The authors declare no competsing interests.
Data availability
Data will be made available on request.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.appet.2023.106975.
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