In a sample of college women, it was predicted that body shame would mediate the relationship between body size and bulimic symptomatology. It was also predicted that negative urgency would exacerbate this mediation pathway, such that with increasing body shame and increasing negative urgency, the greater would be the bulimic symptomatology. Finally, it was expected that the predicted moderated-mediation relationships would occur over and above persistent levels of depression. All results were in line with predictions.
The significant moderated-mediation model reported in this study is, firstly, consistent with the contemporary sociocultural theory of women’s body image disturbance, whereby a woman’s negative thoughts and feelings about her body arise because she perceives that her body is discrepant from the cultural esthetic body standard . Secondly, it converges with research suggesting that body size may influence disordered eating indirectly through its effects on negative affect . Thirdly, the model is in line with research linking body shame to bulimic symptomatology [20, 22]. Fourthly, the moderating role of negative urgency is consistent with research not only suggesting negative urgency is the most predictive component of impulsivity for bulimia nervosa, but also with research and theory indicating that negative urgency influences bulimic symptomatology in the context of negative emotion [29, 30, 44]. Placing the significant moderated-mediation model within escape theory , our findings suggest that with increasing body size the young women in this sample felt more body shame at being too distant from the cultural esthetic standard and as a result engaged in more binging and purging to “escape” from such an aversive experience. Moreover, those women who were also higher in negative urgency, appear to be especially likely to engage in escape behaviors in the form of bulimic symptomatology when experiencing body shame specifically and not just when experiencing current depressive symptoms.
It is important to note here that the mean BMI of the sample was well within the normal range and suggests that many college women experience body shame even though they are not overweight. This supports contemporary sociocultural theory which purports that in modern Western society many women have internalized an unrealistic and unachievable thin ideal . Presumably, comparison with this internal body standard leads to many women may experience body shame despite falling within a normal body range . Such being the case, the findings of this study are also consistent with research indicating that women may experience bulimic symptomatology despite not being overweight .
Taken together, it would seem that women with both a higher body size and greater negative urgency may be particularly vulnerable to significant levels of bulimic symptomatology. Central to this vulnerability is that these women not only experience more body shame but unfortunately are also likely respond to this aversive emotional experience rashly in the form of behaviors symptomatic of bulimia nervosa. It could be, therefore, that focusing on the emotion of body shame rather than a general measure of body dissatisfaction may have greater potential clinical utility for health professionals. In this regard, such a focus would provide greater insight into the phenomenology of the body image experience and, furthermore, interventions can be targeted at developing specific adaptive emotional regulation strategies . However, it is important to recognize that the focus of this study was on body shame. Recent research on body dysmorphic phenomenology suggests that body shame and general shame differentially influence disordered eating, with the former influencing body-related thoughts and behaviors and the latter influencing wider psychosocial functioning [22, 47]. Accordingly, a potential avenue of future research should be to examine the independent roles of general shame and body shame in our predicted model.
Thus, for women higher in both body size and negative urgency, individual treatment should perhaps focus on addressing the recognition, intensity and tolerance of body shame experiences specifically. Such an intervention could involve dialectical behavior therapy which utilises mindfulness, distress tolerance and emotion regulation skills, and has been found to be effective in this regard [48, 49]. Indeed, research would suggest that a particular focus of the intervention would be to enhance emotion regulation in emotion-inducing situations. Within the body image domain, situations that involve body checking (behavior aimed at acquiring information about body size, shape and weight) tend to make salient a discrepancy from the thin ideal body standard and, by so doing, evoke negative emotions like body shame . Under such circumstances, therapeutic interventions could help women with greater body size and negative urgency cope more effectively with the consequences of body checking by enhancing their decentering abilities to attenuate body shame as well as reduce their attempts to control or avoid the body shame experience . Furthermore, given the role of fear of compassion in fueling body shame, an effective preventative and therapeutic intervention could also involve enhancing self-compassion in the context of being at variance from the cultural thin-ideal, as well as facilitate strategies to promote warm and supportive relationships with others [52, 53]. Finally, it is important to recognize that effective emotion regulation also involves focusing on actually preventing a negative emotional experience taking place . Given the relationship between body size and body shame in this study, an important antecedent-focused emotion regulation strategy focused on preventing the generation of body shame would appear to be a useful. This could involve challenging the sociocultural meanings that women attach to thinness and fatness, critically evaluating manifestations of the sociocultural esthetic standard (i.e., the so called thin-ideal), as well as promoting a broader conception of beauty focused on the functioning of the body rather than bodily appearance .
Our findings should not be interpreted without consideration of several limitations. Firstly, this study incorporated a cross-sectional design. Such designs may often produce biased estimates of mediation because of assumptions about stationarity, stability and the equilibrium of variables . In recognizing this limitation, the significant findings could still be said to have utility because they facilitate a preliminary understanding of how key predictor variables may interact to increase bulimic symptomatology . Nevertheless, our findings need to be replicated in a prospective design to produce truly prognostic results. Secondly, this study utilized a sample of college women. Although this sample can be considered to be taken from a population at risk for the development of bulimia nervosa , it is important to recognize that our college sample may differ from a clinical sample in terms of symptomatology, body shame and negative urgency. It is also worth noting that recent research suggests that levels of bulimic symptoms among college men are not insignificant , and thus there is a need to examine if our model is also relevant for male college students. Finally, we did not measure ethnicity; our sample was taken from a predominantly white northern European university. In this regard, some previous research , using a college sample, has reported a role for impulsivity in exacerbating the effects of body shame on women’s bulimic symptomatology in their black participants and not in their white participants. It is essential to recognize that Higgins et al’s  findings are valuable because they shed light on a relatively understudied racial group with regard to eating disorder pathology. However, while cultural and methodological differences could underpin our divergent findings, the results of Higgins and colleagues do suggest that among white college students, the influence of body shame on bulimic symptomatology is not benign. Clearly, future research is required to confirm whether such differences do indeed exist between differing ethnicities.
The significant findings of our study suggest other interesting directions for future research. For example, body size was also directly related to bulimic symptomatology suggesting the presence of the other mediating mechanism. It could be that other discrepancy-related body emotions, such as envy or guilt, also play a role in energizing and directing bulimic symptomatology. Given the potential role of emotion regulation in the development and maintenance of disordered eating , future researchers should perhaps also begin to examine the potential role of specific regulatory strategies in explaining the influence of body emotions on pathology. For example, researchers could examine the relative impact of such strategies as rumination suppression and distraction, in mediating relationship between negative body emotion and disordered eating.
In sum, body shame was found to mediate the relationship between body size and bulimic symptomatology. This suggests that many women attempt to “escape” this negative emotional experience by engaging in the binging and purging behaviors that are characteristic of bulimia. Furthermore, women who were also higher in negative urgency were particularly likely to engage in such “escape” behaviors when experiencing body shame. Finally, it appears that it is body shame specifically, over and above any current depressive symptoms, which underpins our results. For women higher in both body size and negative urgency therapeutic interventions should focus on emotion-regulatory strategies that prevent or attenuate the development of body shame.