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The effect of food and weight-related cues on physiological stress measures in women with high versus… Sanghera, Mandeep 2010

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THE EFFECT OF FOOD AND WEIGHT-RELATED CUES ON PHYSIOLOGICAL STRESS MEASURES IN PREMENOPAUSAL WOMEN WITH HIGH VERSUS LOW LEVELS OF COGNITIVE DIETARY RESTRAINT by Mandeep Sanghera BA, Queen’s University, 2006 BScH, Queen’s University, 2007  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in The Faculty of Graduate Studies (Human Nutrition)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) May 2010 © Mandeep Sanghera, 2010  ii ABSTRACT Cognitive dietary restraint (CDR) reflects a perception of constantly monitoring or attempting to restrict food intake as a means to control body weight, rather than eating in response to physiological hunger cues. Higher salivary and urinary cortisol levels have been observed in women with high versus low CDR. This study assessed whether food and weight-related cues differentially activate the physiological stress response in 70 healthy women aged 19-35 with low (0-5; n = 35) or high (13-21; n = 35) scores on the Three Factor Eating Questionnaire Restraint subscale. Participants completed questionnaires on eating attitudes, stress, anxiety, depression and physical activity in the presence of food temptations. Concurrently, blood pressure, heart rate and salivary cortisol measures were obtained every 15 minutes over a 90 minute period. Results showed significant between-group differences in eating attitudes while anthropometric, general perceived stress, anxiety, depression and physical activity variables were similar. Although women with high CDR perceived the protocol as more stressful, physiological measures did not differ by CDR level. Participants also provided 4 saliva samples collected within 1 hour of awakening to assess the awakening cortisol response (ACR). ACR disturbances may be indicative of disrupted hypothalamicpituitary-adrenal axis functioning, which may be responsible for the higher cortisol levels observed in high restraint women. Morning sampling procedures showed no between-group differences in the ACR. In conclusion, women with high and low CDR had similar physiological stress responses after cue exposure; however, this may have been the result of a weak stressor.  iii TABLE OF CONTENTS Abstract.................................................................................................................................... ii Table of Contents ................................................................................................................... iii List of Tables ........................................................................................................................... v List of Figures......................................................................................................................... vi Acknowledgements ............................................................................................................... vii Chapter 1: Introduction ......................................................................................................... 1 Chapter 2: Literature Review ................................................................................................ 3 2.1 Introduction ........................................................................................................................ 3 2.2 What is cognitive dietary restraint? ................................................................................... 3 2.3 Assessment of CDR ........................................................................................................... 4 2.4 CDR and stress................................................................................................................... 5 2.5 Cortisol and stress .............................................................................................................. 7 2.6 Health concerns associated with high CDR ....................................................................... 8 2.7 Awakening cortisol response and CDR ........................................................................... 11 2.8 Effects of cue exposure .................................................................................................... 14 2.9 Research objectives.......................................................................................................... 16 2.10 Study hypotheses ........................................................................................................... 17 Chapter 3: Methods .............................................................................................................. 18 3.1 3.2 3.3 3.4  Research participants ....................................................................................................... 18 Inclusion criteria .............................................................................................................. 18 Exclusion criteria ............................................................................................................. 19 Research design ............................................................................................................... 19 3.4.1 Eligibility assessment............................................................................................ 20 3.4.2 Afternoon procedure ............................................................................................. 22 3.4.3 Morning sampling ................................................................................................. 24 3.4.4 Debriefing session................................................................................................. 25 3.5 Measurement .................................................................................................................... 26 3.5.1 Questionnaire package .......................................................................................... 26 3.5.2 Saliva collections .................................................................................................. 32 3.5.3 Blood pressure readings ........................................................................................ 32 3.5.4 Anthropometric measurements ............................................................................. 33 3.6 Statistical analysis ............................................................................................................ 33  iv Chapter 4: Results................................................................................................................. 36 4.1 4.2 4.3 4.4 4.5  Participant characteristics ................................................................................................ 36 Eating attitudes................................................................................................................. 39 Physical activity, depression, anxiety and stress ............................................................. 42 Appetite sensations and food choices .............................................................................. 44 Physiological measures .................................................................................................... 45 4.5.1 Cue exposure and physiological arousal ............................................................... 45 4.5.2 Cue exposure, physiological arousal and CDR..................................................... 48 4.6 Awakening cortisol response ........................................................................................... 53 4.6.1 ACR and dietary restraint ..................................................................................... 54 Chapter 5: Discussion and Conclusions .............................................................................. 57 5.1 5.2 5.3 5.4 5.5 5.6 5.7  Introduction ...................................................................................................................... 57 Anthropometric findings .................................................................................................. 57 Eating attitudes results ..................................................................................................... 58 Physical activity, depression, anxiety and stress findings ............................................... 61 Cue exposure, physiological arousal and CDR................................................................ 63 ACR and dietary restraint ................................................................................................ 67 Conclusions, study strengths, limitations and future directions ...................................... 69  Bibliography .......................................................................................................................... 73 Appendices ............................................................................................................................. 84 Appendix A: Recruitment poster ............................................................................................ 84 Appendix B: Recruitment e-mail ............................................................................................ 85 Appendix C: Screening questionnaire .................................................................................... 86 Appendix D: E-mail to ineligible participants ........................................................................ 89 Appendix E: Reminder e-mail ................................................................................................ 90 Appendix F: Consent form ..................................................................................................... 91 Appendix G: Questionnaire part one ...................................................................................... 95 Appendix H: Questionnaire part two .................................................................................... 115 Appendix I: Morning sampling instructions ......................................................................... 132 Appendix J: Debriefing form ................................................................................................ 135 Appendix K: UBC Behavioural Research Ethics Board’s certificate of approval ............... 136  v LIST OF TABLES Table 1: Food options ............................................................................................................. 23 Table 2: Mean age, body mass index (BMI) and waist-to-hip ratio ....................................... 37 Table 3: Occupation and ethnicity .......................................................................................... 38 Table 4: Participants’ thoughts regarding diet and weight status ........................................... 39 Table 5: Mean scores on eating attitude assessment tools ...................................................... 41 Table 6: Mean scores on physical activity, depression, anxiety and stress scales .................. 43 Table 7: Mean visual analogue scale scores for stress due to study participation .................. 44 Table 8: Mean scores for appetite sensations and food choices ............................................. 45 Table 9: Overall mean values for systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate and afternoon salivary cortisol measures in the lab setting .......... 47 Table 10: Group means for systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate and afternoon salivary cortisol measures in the lab setting .................... 50 Table 11: Group means for morning salivary cortisol ............................................................ 53 Table 12: Group means for mean increase (MnInc), area under the response curve (AURC) and area under the curve (AUC) values .................................................................. 56  vi LIST OF FIGURES Figure 1: Recruitment process ................................................................................................ 36 Figure 2: Distribution of final scores on the Three-Factor Eating Questionnaire Restraint subscale ................................................................................................................... 40 Figure 3: Mean values of systolic blood pressure (SBP) in the lab setting for women with low and high restraint scores.......................................................................................... 51 Figure 4: Mean values of diastolic blood pressure (DBP) in the lab setting for women with low and high restraint scores................................................................................... 51 Figure 5: Mean values of heart rate in the lab setting for women with low and high restraint scores....................................................................................................................... 52 Figure 6: Mean values of afternoon salivary cortisol levels for women with low and high restraint scores ........................................................................................................ 52 Figure 7: Mean salivary cortisol levels after awakening for women with low and high restraint scores ........................................................................................................ 55  vii ACKNOWLEDGEMENTS  A thesis haiku To say thanks for the support, Guidance, and the smiles. Firstly, Susan Barr Thanks for giving me a chance Your support, patience, Feedback, expertise Have helped me gain confidence As a researcher. I am so thankful For the opportunity To have worked with you. I have learned so much A mentor like no other, Truly inspiring. Jen Bedford, thank you For the initial pilot That brought me to Van. More for the support, Answering my silly Qs, And being a friend. Next, my committee Tim Green and Wolfgang Linden Thanks for making time To help with design, Offer a new perspective, ‘Til the very end.  viii  Of course, my family Mom, Dad, Kino and Sukhveer For endless support Even when I moved Quite far, travelled on a whim, And forgot to call. You’ve shaped who I am, Supported my decisions And that means the world. Thanks for being there And for learning not to ask “What’s taking so long?” Massi, Mamaji For the check-ins, reminders That I’m not alone. My amazing friends I’m grateful that some moment Brought us together. Nights out / in, skype dates, Concerts, e-mails, study dates. You added balance Whether just one night Or endless talks, it all made Such a difference. Through the good, bad, and Tragically hilarious Thanks for all the smiles. And last, but not least Baristas of Vancouver Thank you for caffeine.  1 CHAPTER 1: INTRODUCTION The increasing rate of obesity over the past several decades has led to increased pressure to lose weight and conform to societal ideals of a thin figure. Every day, individuals report having over 200 food-related thoughts and decisions1 and for some people, constant environmental food cues lead to difficulties in losing or maintaining body weight. Cognitive dietary restraint (CDR) is a term describing the thought process in which one continually monitors or attempts to restrict food intake as a means of weight control. However, despite these perceptual differences, the relative weights of healthy individuals with high versus low levels of CDR are generally similar. Most literature on CDR has focused on women, and among other findings, reports that those with higher levels of CDR have increased salivary and urinary levels of the stress hormone cortisol. Food and weight-related cues are hypothesized sources of perceived stress; however, it has yet to be determined whether cues cause direct activation of the stress response and if it can be captured in an experimental setting. The purpose of this study was to assess whether women with high versus low levels of dietary restraint differed in their blood pressure, heart rate and salivary cortisol levels after exposure to various food cues and diet-related questionnaires. Furthermore, the awakening cortisol response (ACR) was examined since an altered ACR is believed to be suggestive of disturbances in the hypothalamic-pituitary-adrenal axis. Chapter 2 is a review of the literature. This chapter discusses the definition of CDR, the hypothesized relationship between CDR and the stress response and the potential effects of food cue exposure on individuals with high CDR. Chapter 2 concludes with the research objectives and three hypotheses of interest in this study. Chapter 3 discusses the research methodology and statistical approaches associated with each hypothesis. Chapter 4 presents  2 the research results. Lastly, Chapter 5 discusses the findings, study strengths and limitations and provides suggestions for future work.  3 CHAPTER 2: LITERATURE REVIEW 2.1 Introduction In the following literature review, several topics related to cognitive dietary restraint (CDR) are discussed including (1) the definition and key features of high CDR, (2) methodology used to characterize levels of dietary restraint, (3) the association between CDR and the physiological stress response, (4) mechanism of action and role of cortisol in the body, (5) potential health concerns associated with high CDR, (6) the awakening cortisol response and (7) the effects of cue exposure on individuals exhibiting dietary restraint.  2.2 What is cognitive dietary restraint? Influences in media and popular culture have led many to value a thin and lean female figure. As a result, many women feel negatively about their body image, are conscious of their eating habits and struggle to lose or maintain weight. High levels of cognitive dietary restraint reflect a perception in which one is constantly monitoring or attempting to restrict food intake as a means to control body weight, rather than eating in response to physiological hunger cues2. This pattern of thinking is believed to be a relatively stable characteristic that persists throughout the lifespan. A past study on postmenopausal women found that those with high CDR reported similar patterns of dietary restraint throughout the majority of their adolescent and adult years3. The concept of dietary restraint applies to both men and women but literature tends to focus on female eating behaviours due to the increased societal pressures and higher reported rates of dieting and dietary restraint4. The “cognitive” nature of dietary restraint emphasizes the difference between restrained eating and dieting. Women with high levels of restraint do not always self-report  4 as being on a diet5. Furthermore, despite a heightened awareness of food intake, the diet of high restraint women does not appear to differ significantly from that of low restraint women in terms of caloric intake, macronutrient or micronutrient content6. Levels of restraint are not usually correlated with body mass index (BMI) values, thus providing further support for a similar caloric intake among the two restraint groups over an extended period of time7,8.  2.3 Assessment of CDR A number of assessment methods can be used to categorize an individual’s level of dietary restraint. Among the commonly used tools are the Three-Factor Eating Questionnaire Restraint subscale (TFEQ-R)9 and the Restraint Scale (RS)10. The assessment methods differ because the RS measures restrained eating and the effects of unsuccessful restraint, including disinhibition and weight fluctuation, while the TFEQ-R focuses exclusively on dietary restraint. Since dietary restraint is not recognized as a clinical condition, neither questionnaire serves to “diagnose” a high level of CDR and investigators must choose how they wish to define high restraint. When the TFEQ-R is used, total scores range from 0 to 21. Levels of restraint are categorized using either a continuous scale11,12, median split6,8,13,14, tertiles15 or quartiles of scores such that the first quartile is defined as “low restraint”, second and third as “medium restraint” and fourth as “high restraint”7,16-18. The lack of strict diagnostic criteria makes it difficult to determine an exact prevalence of high CDR. The subtle nature of this type of disordered eating also leads to difficulties in estimating true prevalence rates. However, dietary restraint is thought to be a common concern among women and past studies observe that many women report some features of CDR. In one recent study, all women over the age of 18 recruited from various  5 undergraduate classes were asked to complete a questionnaire package on eating attitudes, perceived stress and self-esteem7. The TFEQ-R scale was used to categorize levels of restraint. A total of 596 women completed the questionnaires and 32% of the sample was classified with low restraint (scores 0-5), 44% with medium restraint (scores 6-12) and 24% with high restraint (scores 13-21). Further characteristics of women with high levels of CDR compared to those with low CDR in this sample included higher exercise scores, increased desire to lose weight, a greater likelihood of reporting a history of eating disorders, higher perceived stress levels and lower self-esteem. The three restraint groups were similar in their age, height, weight and BMI. Thus, there appears to be a continuum in the level of restraint among female women, which is unrelated to one’s age or weight.  2.4 CDR and stress Although this is a fairly new and growing area of research, several studies suggest that a potential relationship may exist between CDR and the physiological stress response such that CDR may act as a subtle, yet chronic stressor. Times of stress lead to an increased release of the hormone cortisol19. Higher 24 hour urinary levels of this stress hormone have been observed in samples of both premenopausal17 and postmenopausal women3 with high CDR. An alternative approach to measuring urinary cortisol levels is to examine salivary cortisol release. Two studies have reported higher levels of salivary cortisol among premenopausal women scoring high in CDR11,12. In one study, 85 female university students provided a single saliva sample in the morning hours for subsequent cortisol analysis11. All participants completed the TFEQ-R and were categorized as restrained or non-restrained eaters based on a median split of scores. Restrained eaters had  6 a significantly higher level of salivary cortisol than unrestrained eaters (0.32 ± 0.50 μg/dl versus 0.15 ± 0.12 μg/dl, p = 0.04). Putterman and Linden replicated these findings in an additional study12. A total of 170 female participants provided one saliva sample 30 minutes after awakening to examine morning cortisol levels and another 6-8 hours later. The afternoon sample aimed to provide information on cortisol levels after exposure to daily food and weight-related cues. The TFRQ-R Rigid and Flexible Control subscales assessed restraint along with questions investigating women’s appearance beliefs, perceived stress and body dissatisfaction. Cortisol change scores from morning to afternoon levels showed a significant positive relationship between scores on the Flexible Control subscale (r = 0.17, p = 0.03), Rigid Control subscale (r = 0.16, p = 0.04) and Beliefs About Appearance scale (r = 0.19, p < 0.05). Although two studies have reported no association between CDR and cortisol measures, this may be explained by a smaller sample size (n = 31)6 or differences in research design20. Pirke and colleagues’ study, which failed to find a relationship between CDR and cortisol, involved a collection of overnight blood samples from a small sample of high (n = 9) and low restraint individuals (n = 13)20. If CDR is truly associated with the stress response, food cues and eating decisions throughout the day may be required to observe increases in cortisol and would not likely be captured in an overnight sampling procedure. In support of this hypothesis, Putterman and Linden found significant positive relationships between afternoon salivary cortisol and restraint scores (r = 0.15, p < 0.05), whereas morning samples were not correlated to scores on the TFEQ-R Flexible (r = 0.02, p > 0.05) or Rigid Control (r = 0.04, p > 0.05) subscale. They proposed that daytime cues might be necessary for differences in cortisol secretion to be evident since afternoon samples were collected after  7 usual daily cue exposure while morning samples were not12. Nickols-Richardson and colleagues also reported no significant correlations between the salivary cortisol levels and restraint scores in premenopausal women who provided a saliva sample within 1.5 hours of awakening (r = 0.04, p > 0.05, n = 63)21. These women were in fasted state and thus would not have experienced typical cues associated with breakfast. Overall, past research supports a positive relationship between levels of dietary restraint and cortisol release after exposure to daytime cues. These findings are of potential significance due to the role of cortisol as a stress hormone in the human body.  2.5 Cortisol and stress Cortisol is a glucocorticoid that has received significant research attention due to its association with the stress response. Both physical and psychological stressors activate the hypothalamic-pituitary-adrenal (HPA) axis, which consists of the hypothalamus, pituitary and adrenal glands. The origin of the HPA axis is the synthesis of corticotropin-releasing hormone (CRH) in the paraventricular nucleus of the hypothalamus. Stressors stimulate the release of CRH into the hypophyseal portal veins to act on the anterior pituitary glands22. Adrenocorticotropic hormone (ACTH) is subsequently released into the bloodstream from the anterior pituitary. This hormone targets the adrenal glands and stimulates the synthesis and release of cortisol and other glucocorticoids19. Cortisol is the end point of the HPA axis and also regulates the pathway through a negative feedback loop in which high levels of cortisol prevent the further release of CRH and ACTH23. Cortisol release is typically an adaptive response to stressful situations; however, an abnormally high level of cortisol is linked to many negative health conditions. Cushing’s  8 syndrome is characterized by excess cortisol release and illustrates the cardiovascular and metabolic consequences that result from elevated levels of cortisol. Some of the symptoms associated with this condition are insulin resistance, dyslipidemia, hypertension, hyperglycemia and central obesity24. A further implication of stress-induced cortisol release of particular relevance to this study is the role cortisol appears to have in menstrual irregularity and decreased bone mineral content. Cortisol directly and indirectly influences bone and menstrual health. Glucocorticoids alter osteoclast and osteoblast activity as well as calcium metabolism25. Furthermore, excess cortisol indirectly affects bone health due to the relationship between the HPA axis and the hypothalamic-pituitary-gonadal (HPG) axis. Activation of the HPA axis inhibits the HPG axis, resulting in decreased secretion of sex hormones and impaired reproductive function19. Reproductive hormones are essential for reaching peak bone mass and maintaining bone density in women26. The decrease in sex hormones consequently contributes to stress-induced losses in bone density. Thus, if a subtle but sustained activation of the HPA axis due to high CDR sufficiently increases cortisol levels, women’s reproductive and bone health may be compromised.  2.6 Health concerns associated with high CDR Several studies have attempted to discover whether elevated cortisol levels observed in those with high CDR are associated with women’s health concerns. Women rating high on the TFEQ-R have had measurable menstrual disturbances in comparison to low restraint women. One study comparing a group of low (n =13) and high CDR (n = 9) women first discovered that high restraint women were more likely to have decreased progesterone  9 concentrations and a shorter luteal phase of their ovarian cycle27. Findings of shorter luteal cycles have been replicated in subsequent studies collecting physiological data on menstrual cycles in healthy young women28,29. Furthermore, a large questionnaire-based study of premenopausal women found twice the rate of self-reported menstrual irregularity among females with high CDR (n = 145) compared to those with low (n = 189) or medium (n = 262) levels of restraint7. This finding is not universal as Waugh and colleagues could not detect an association between CDR and subclinical ovulatory disturbances in a group of 225 healthy premenopausal women15. However, methodological differences may have affected the research outcome. As in studies using temperature methods or self-report, a short luteal phase was defined as less than 10 days. Differences occurred because ovulatory assessment was conducted based on urine luteinizing hormone (LH) levels. Since the LH peak occurs prior to ovulation, whereas temperature changes occur afterwards, the definition of a short luteal phase should likely have been extended to 11-12 days. The stringent criteria could have underestimated the prevalence of ovulatory disturbances among women with high CDR. As previously discussed, a relationship between CDR and reproductive health may affect bone due to the altered secretion of reproductive hormones. Furthermore, elevated cortisol release directly causes negative effects on bone25. Past research examining CDR and its relationship to bone health has led to conflicting results. Vescovi’s research team compared premenopausal exercising women with high CDR (TFEQ-R score ≥ 9, n = 38) and low CDR (TFEQ-R score < 9, n = 46). They observed that the high CDR group had lower total body (1.140 ± 0.011 versus 1.179 ± 0.010 g/cm2; p = 0.015) and lumbar spine (1.114 ± 0.019 versus 1.223 ± 0.022 g/cm2, p = 0.001) bone mineral density (BMD)18. Menstrual status was assessed through self-reported regularity and it was noted that there was an  10 increased frequency of oligomenorrhea in the high CDR group over those with lower restraint scores (χ2 = 5.110, p = 0.024). In another study, lower bone mineral content (BMC; p = 0.033) was reported among 96 premenopausal women characterized with high CDR (TFEQ-R score ≥ 9) compared to 89 with low CDR13. The relationship was specific to BMC since no differences were observed between the BMD of high and low restraint women. Menstrual regularity was not examined so the relationship between bone and menstrual health is unknown for women in this study. Inconclusive findings were also reported by McLean and colleagues in a study of 62 healthy, regularly menstruating women30. In this sample, 29 women were categorized with low restraint (TFEQ-R between 0-5) and 33 with high restraint (TFEQ-R between 13-21). Total BMC was observed to be significantly lower in the high CDR group when weekly exercise hours, height and weight were considered as covariates (p = 0.041). Differences in spinal BMD, spinal BMC and total body BMD were non-significant but values tended to be lower in the high restraint group. Although these three studies found moderate negative relationships between level of restraint and bone health, two other studies failed to detect an association15,21. A 2 year prospective study involving 189 healthy premenopausal women observed no relationship between high CDR, menstrual regularity and bone health15. CDR categorization was based on tertiles of scores on the TFEQ-R subscale. There were no significant associations between CDR and the average initial value or change in lumbar spine BMD. Furthermore, no significant differences existed in the number of subclinical ovulatory disturbances between restraint groups. The contrasting findings may be related to differences in the study  11 population since women had a higher mean age, greater variation in BMI and as described earlier, the criterion for subclinical ovulatory disturbances was likely overly stringent. Nickols-Richardson and colleagues also reported null findings in their group of 65 healthy, normal weight premenopausal young women21. No significant relationships existed between CDR scores, total body, hip, forearm or lumbar spine BMD or BMC. However, CDR scores were inversely related to serum osteocalcin (r = −0.32, p < 0.01, n = 63) and urinary n-telopeptide concentrations (r = −0.25, p < 0.05, n = 63), which are markers of bone turnover. Reduced bone turnover may compromise bone health in high restraint women but further investigation is necessary before conclusions can be drawn. In summary, conflicting data describe the relationships among CDR, subclinical ovulatory disturbances and bone health. Research on the topic of CDR suggests that the potential implications for women’s health may be widespread and serious in nature due to the importance of menstrual regularity for reproductive function and bone mass for osteoporosis related risk. Due to the mixed findings of previous studies, the relationship between high levels of dietary restraint and cortisol release clearly needs further exploration.  2.7 Awakening cortisol response and CDR An additional method of examining cortisol release involves the study of the awakening cortisol response (ACR). There is a diurnal and circadian pattern of cortisol release following CRH and ACTH secretion. CRH and ACTH undergo pulsatile release with pulses of greater amplitude in the morning hours, which decrease in magnitude over the course of the day31. Accordingly, cortisol follows the same pattern where levels elevate after awakening and decrease until they are at their lowest in the evening22,32. The ACR is a  12 distinct part of the cortisol secretion profile. It describes the period of time roughly within the first thirty minutes of awakening when cortisol levels reach their daily maximum. The primary importance of the ACR is the stability of this response. Pruessner and colleagues were first to report that the increase in morning cortisol is consistent32 and subsequent studies have shown fairly high intraindividual stability over time (r = 0.63 for area under the curve measures over two days)33. This contrasts with the large intraindividual variation observed when taking single samples based on clock time, rather than awakening time34. Furthermore, the ACR is consistently shown in both sexes, can distinguish between subsets of healthy participants and is unaffected by factors including age, weight, smoking, sleep duration or quality, the time of awakening and alcohol consumption32. The precise role of the ACR is still unknown35; however, its reliable nature compared to other aspects of the cortisol secretion profile has led to exploration into the significance of this response. There appears to be an association between the ACR and dysregulation of the HPA axis36. Various psychosocial conditions believed to involve HPA dysregulation have become a target for ACR-related research including posttraumatic stress syndrome, burnout, general life stress and depression37. Of particular interest to the topic of dietary restraint is the association of the ACR with chronic stress and anxiety scores. Studies examining the relationship between chronic stress and the ACR have found that participants with higher reported stress levels have significantly higher increases in peak morning cortisol levels than nonstressed individuals38,39. A common hypothesis surrounding the role of the ACR is that it may function in activating memory representations that help prepare an individual for upcoming demands40,41. Support for this hypothesis rests in the observation that the cortisol response is  13 larger on weekdays over weekends, consistent with the increased workday demands placed on most individuals42,43. Increased cortisol release among those experiencing chronic stress and worrying also supports the idea that an increased ACR is likely for those with greater perceived daily demands39,42. Few studies have directly examined ACR as a marker for HPA axis dysregulation in restrained eaters. In a sample of 170 female undergraduates, the ACR was investigated with a single saliva sample collected thirty minutes after awakening12. There was no association between any of the restraint-related measures and morning peak cortisol levels, which led to the suggestion that food or weight-related cues may be necessary to activate the stress response. There are limitations to using a single cortisol measure because it does not capture the full ACR profile and may be subject to increased sampling error. A recent study conducted by Therrien and colleagues looked at the relationships between ACR and anxiety, depression, eating behaviours and body esteem44. Analysis on 78 men and women illustrated gender-dependent results where men were observed to have a negative correlation between ACR and the flexible control and strategic dieting behaviour measures of the restraint scale. On the other hand, women were observed to have negative associations between ACR and trait anxiety, disinhibition, hunger, binge eating, body esteem related to appearance, drive for thinness, body dissatisfaction, interoceptive awareness and the rigid control subscale of restraint. One additional study examined the relationship between HPA dysregulation and dietary restraint using methodology comparable to the ACR14. This study examined HPA axis functioning in 38 men and 38 women with use of the dexamethasone suppression test. This test is commonly used in studies looking for elevated levels of cortisol among  14 participants. No relationship was observed between cortisol levels and dietary restraint in men; however, increased cortisol concentrations were reported in women categorized with high CDR based on a median split of scores on the TFEQ-R. Overall, research on variables associated with HPA axis dysregulation and CDR are limited and inconsistent in nature, illustrating the need for further research on this topic.  2.8 Effects of cue exposure A key purpose of our study was to investigate whether differences exist between women with high and low CDR after exposure to various food and weight-related cues. Cephalic phase responses (CPRs) are commonly used to measure an individual’s response to food-related stimuli. CPRs occur following the sight, smell, taste or thought of eating45. The body reacts to food exposures with a variety of autonomic and endocrine responses such as changes in salivation and cardiac output. Physiological changes are believed to have a primary role in preparing the body for efficient utilization of incoming food46. Cephalic phase salivation is a measure of appetite that has received significant research attention. An increased salivary flow rate has been observed among individuals with high dietary restraint following food exposure than among unrestrained eaters; however, this finding is not universal47. Increased salivation in restrained individuals is hypothesized to occur as a result of an increased sensitivity to food cues in their surroundings48. Other measures of physiological arousal following food exposure have also been examined. In a study conducted by Vögele and colleagues, food exposure led to increased physiological arousal in both binge and nonbinge eaters including increased heart rate, blood pressure, electrodermal activity and respiratory rate. Furthermore, over the 20 minute exposure period,  15 the two groups differed among certain measures of physiological arousal; for example, binge eaters maintained an elevated systolic blood pressure throughout the trial and had altered electrodermal activity when compared to nonbinge eaters49. Similar findings were observed in a group of healthy female participants when CPRs following food exposure were examined45. In this study, significant changes were observed in salivation, temperature, heart rate, blood pressure and skin conductance following food exposure in all subjects, suggestive of the role of CPRs in preparation for incoming food. Of particular interest is the observation that systolic and diastolic blood pressure correlated significantly with restraint scores classified using the Restraint Scale (r = 0.66, p < 0.05 and r = 0.64, p < 0.05, respectively). These findings are not universal, as illustrated in a study conducted by Rutledge and Linden50. They recruited 77 healthy young women and categorized dietary restraint based on a median split of scores on the Restraint Scale. Heart rate, systolic and diastolic blood pressure were monitored while participants completed various cognitive tasks in the presence of sweet and salty food temptations. Comparisons between the high and low restraint group did not detect any significant difference in blood pressure or heart rate variables during the task completion or recovery phases. Likewise, differences were not observed in a smaller study comparing the physiological responses of skin conductance, heart rate, startle reflex and facial electromyography in a group of 11 restrained and 13 unrestrained eaters classified using the Restraint Scale51. In this study, women were asked to look at pictures of neutral foods, foods self-selected as preferred and “binge-provoking”, and pictures of their own body. This study did not report significant differences in cue reactivity although it was hypothesized that  16 restrained eaters would experience a greater physiological response to food and weightrelated cues. It is important to note that several difficulties arise when comparing across studies. The classification of restrained versus unrestrained eating varies with each study, a range of physiological measures have been examined and studies differ in the presentation of cues through the use of images, standardized food or only the individual’s favourite food. Studies also differ in how directly participants were asked to attend to the cues used. The strength of cue exposure may have a key role in subsequent physiological responses. Direct changes in salivary cortisol levels following food exposure have not been examined and present an alternative measure of physiological arousal. Furthermore, previous studies have exclusively used the Restraint Scale while the TFEQ-R can act as a different measure of dietary restraint.  2.9 Research objectives In previous studies, CDR and physiological stress were investigated through comparisons of the level of salivary or urinary cortisol in women with high CDR to the levels in women with low CDR. If CDR is a true physiological stressor, it may cause activation of the stress response after exposure to food or weight-related cues. Since past studies have not examined whether these types of stimuli can act as stressors that cause an immediate observable response, this study was designed to assess salivary cortisol, blood pressure and heart rate as indices of physiological stress experienced in an experimental setting. Both food and weight-related cues were presented to women to observe whether differing physiological responses are present between high and low CDR groups. The ACR was also  17 examined as it acts as an additional assessment measure of disturbances in the HPA axis and thus the stress response.  2.10 Study hypotheses We hypothesize that high levels of CDR act as a source of physiological stress among healthy premenopausal women such that: (1) A lab simulation involving exposure to everyday food and weight-related cues will lead to signs of physiological arousal, evident through changes in blood pressure, heart rate and salivary cortisol. (2) High levels of CDR will cause increased activation of the physiological stress response and greater elevations in blood pressure, heart rate and afternoon salivary cortisol than those observed in women with lower levels of restraint. (3) The awakening cortisol response will differ between women with high and low levels of CDR, providing evidence of HPA axis dysregulation.  18 CHAPTER 3: METHODS 3.1 Research participants Female participants were recruited from the University of British Columbia Vancouver campus using poster advertisements (Appendix A) and announcements in various undergraduate classes. Individuals interested in the study were asked to e-mail us and were directed to an online screening questionnaire (Appendix B and C). Blood pressure (BP) data was used to estimate the required sample size for our study. Based on previous research observing a significant increase of roughly 13.3 mmHg in systolic and 10.3 mmHg in diastolic BP among healthy premenopausal women who completed laboratory stress tests52, a significant difference between groups with 80% power and a two-sided 0.05 significance level required 21 participants per group. Our stressor was weaker in nature and comparable research studies examining differences among individuals scoring high and low in dietary restraint have recruited 60-80 individuals in total44,49. As a result, we had a total of 70 participants complete the study protocol, with equal numbers of high and low restraint women.  3.2 Inclusion criteria Eligibility was assessed through the use of an online screening questionnaire hosted on SurveyMonkey (Appendix C). Women eligible for full study participation met the following criteria: •  Non-smoker between the age of 19 and 35 years, inclusive.  19 •  Reported a BMI that was neither underweight (less than 18.5 kg/m2) nor obese (greater than 30 kg/m2) on the screening questionnaire. Height and weight measurements were confirmed during the lab visit.  •  Fell within the upper or lower range of restraint scores characterized by the TFEQ Restraint subscale. A low level of CDR was defined as a score of 0-5 whereas a score of 13-21 classified participants with high CDR.  •  Fluent in English to allow for proper completion of the questionnaire package and communication with the research team.  3.3 Exclusion criteria Women were ineligible for participation if they had TFEQ-R scores between 6 and 12, inclusive. Women were also ineligible if they self-reported use of corticosteroids, antihistamines or blood pressure medications. These medications affect cortisol or blood pressure and could have altered our research findings. Lastly, women were excluded if they self-reported previous diagnosis or treatment for an eating disorder, such as anorexia or bulimia, or were currently pregnant or lactating.  3.4 Research design This study involved four components that are described in detail below: (1) Eligibility assessment for all interested women. (2) Lab visit at UBC’s Human Nutrition facilities for completion of the questionnaire package and collection of anthropometric data, afternoon salivary cortisol, blood pressure and heart rate readings.  20 (3) Morning saliva collection for investigation of the ACR. (4) Debriefing session following return of the morning samples.  3.4.1 Eligibility assessment Recruitment materials provided interested individuals with an e-mail address to contact the student investigator. Those interested were informed via e-mail (Appendix B) that the study involved a two hour lab visit during which they would complete a questionnaire, provide saliva samples and have their blood pressure monitored. We also specified that they would be asked to provide four saliva samples within the first hour of awakening the morning following their lab visit. Individuals were directed to the online screening questionnaire (Appendix C) and asked to provide brief personal information. Volunteers were also asked to complete the TFEQ-R (described below). Responses to this 21 item questionnaire were coded, scored and those with either low (score of 0-5) or high (score of 13-21) levels of restraint were contacted via phone or e-mail to schedule a lab visit. Individuals who were ineligible due to any of the previously described criteria were contacted by e-mail (Appendix D) to thank them for their interest and to let them know that they did not meet the eligibility criteria. Eligible women were informed that the study purpose was to assess their physiological response to questionnaires on eating attitudes and body image. Participants were told that saliva samples would be collected during the lab visit to measure the hormone cortisol. They were also informed that they would be provided materials for the morning sampling procedure at the end of the visit and that a $20 gift certificate in recognition of their involvement would be provided after all morning cortisol samples were received.  21 Since cortisol release undergoes a diurnal variation32, all visits were scheduled between 1pm and 5pm. Visits were also scheduled during the follicular phase of the menstrual cycle (days 2-10) because the menstrual cycle can affect cortisol release patterns53. To ensure proper scheduling, each participant was asked to estimate when she would be within days 2-10 of her cycle to tentatively book her lab visit. All participants were e-mailed a study reminder (Appendix E) two days prior to the scheduled visit and asked to confirm day 1 of her menstrual cycle. Lab visits were rescheduled if the participant’s cycle began significantly earlier or later than expected to ensure that all visits fell within the correct time frame. All lab visits and morning saliva collections were completed on weekdays. This is believed to help minimize ACR differences between weekdays and weekends since there have been some reports of a greater cortisol response on weekdays mornings42,43. In the reminder e-mail, we also asked if participants were currently experiencing a significant degree of personal stress due to school or other reasons. One participant’s lab visit was rescheduled because it fell on the same day as an exam that was causing increased stress levels. Participants were asked to refrain from eating two hours prior to the lab visit such that they arrived neither very hungry nor overly full. This helped to minimize salivary cortisol elevations due to a recent meal since meal-induced elevations in salivary cortisol have been observed in previous studies54,55. Lastly, participants were asked to refrain from physical activity they perceived as “strenuous exercise” the morning of the lab visit. Strenuous exercise gradually increases cortisol levels over a prolonged period of time56 so this instruction minimized exercise-related effects on our outcome variable.  22 3.4.2 Afternoon procedure At their scheduled visit at the UBC Human Nutrition lab, participants met with the student investigator. The procedure was explained in detail while discussing the letter of consent (Appendix F), with the exception that women were not told that the snack foods placed in the room were a component of the study design. After reviewing the procedure, each participant was asked to provide written informed consent. The participant was then instructed on how to use the Salivette (the sampling protocol is discussed in detail below) and the first saliva sample was collected after the participant fully rinsed her mouth with water. We demonstrated how to set a timer for 15 minute intervals as a reminder of the appropriate sampling time. The 15 minute sampling interval was chosen in an attempt to capture responses at different rates specific to each individual since cortisol responses are not immediate and take a variable number of minutes to be observed among different people57. The ambulatory blood pressure (BP) monitor (described below) was fitted on the participant’s non-dominant arm. Baseline BP monitoring began at this point and readings were programmed to occur every 15 minutes while the participant was seated and completing the questionnaire package (Appendix G and H). Two saliva samples and BP measures were completed before providing the first part of the questionnaire package to the participant. Prior to leaving the room to allow the participant to complete the questionnaire package, the student investigator informed the participant that the basket of packaged snacks on the table were leftovers from a study that finished earlier that day. The snack options of rice chips, raisins, fruit bars, potato chips, almonds, chocolate chip cookies and chocolate covered granola bars were categorized as low-fat/low-sugar, low-fat/high-sugar, highfat/low-sugar or high-fat/high-sugar foods as shown in Table 1 below. The participant was  23 told that she was welcome to take as many snacks as she would like but she must refrain from eating until the end of the procedure since consumption would contaminate the saliva samples. The participant was also informed that the student investigator would return in 3035 minutes to provide part two of the questionnaire package. Participants were provided with women’s health and fitness magazines (Women’s Health, Shape, Fitness and Nutrition) and told that they could look through these magazines if questionnaires were completed prior to the student investigator’s return.  Table 1: Food options Snack category  Food item  Low-fat, low-sugar  Rice chips  Low-fat, high-sugar  Fruit bars, raisins  High-fat, low-sugar  Potato chips, almonds  High-fat, high-sugar  Chocolate chip cookies, chocolate granola bars  After roughly 30 minutes, the BP monitor was checked to make sure it was still properly attached. The participant was provided with the opportunity to ask any questions regarding part one of the questionnaire package. The volunteer was then given the second half of the questionnaire package and told that the student investigator would return in another 30-35 minutes. Once the participant completed the questionnaire package, the blood pressure equipment was removed and anthropometric data were collected (explained in detail below). Written instructions for morning saliva sampling were provided and verbally explained to the participant (Appendix I). After explaining the procedure and answering any questions, the  24 student investigator told the participant that she forgot the Salivettes in her office down the hall. The participant was asked to meet the student investigator in her office but to first read over the instruction sheet in case she had any questions. She was reminded once more that she was free to take snacks with her prior to leaving the lab. The student investigator then left the participant alone in the room so that she was free to take food without any feelings of self-consciousness. After leaving the lab, the participant was provided with Salivettes to use for morning cortisol collection, thanked for her assistance and reminded to return the sampling kit the following afternoon to receive compensation for participation. Lastly, the remaining food items were counted to determine the amount and type of food taken by the participant.  3.4.3 Morning sampling The ACR was examined using salivary cortisol collected on a weekday morning following the lab visit. Although most participants provided samples the next weekday after their lab visit, some sampling was completed within a few days to ensure that the sampling occurred on a usual morning. For example, sampling was not done on a morning where the participant had to wake up unusually early or went to bed unusually late. Participants were instructed to take the first saliva sample immediately after waking up (time 0) and 15, 30 and 45 minutes afterwards. Participants were instructed not to brush their teeth or consume breakfast prior to completing the sampling procedure, as this could cause sample contamination. A 45 minute sampling period aimed to capture the awakening cortisol response since it has been observed that the ACR profile of women tends to have a delayed peak in comparison to men with increases in salivary cortisol apparent past thirty minutes  25 after awakening32. A minimum of three saliva samples allowed accurate estimation of total cortisol secretory activity using area under the curve calculations58. The student investigator emphasized the importance of accurate sampling because the ACR is a time-sensitive response and noncompliant participants can significantly alter research results59. Compliance was strengthened by providing programmable timers in the morning sampling kit. The participant was asked to program the timer for 15 minute intervals after taking the first sample so that there would be a clear reminder of when to sample. The participant was also instructed to record the time of each sample on the sampling log that was later checked for accuracy. Lastly, participants were provided with the student investigator’s cell phone number and told that if a delay did occur, they should not hesitate to call and reschedule the morning procedure. It was emphasized that rescheduling the sampling procedure was highly preferred over inaccurate sampling.  3.4.4 Debriefing session All participants returned morning Salivettes on the same day as sampling. At that time, two questions were asked to gauge whether deception (related to provision of snack foods) was successful: (1) the participant was asked to describe the study in her own words and (2) she was asked if she felt there was anything unusual about the study procedures. Only 2 of the 70 participants guessed the true reasons behind the presence of snack foods. Finally, participants were debriefed (Appendix J), provided compensation in the form of a gift certificate and thanked for their participation.  26 3.5 Measurement 3.5.1 Questionnaire package (Appendix G and H) The questionnaire was completed in two parts with each portion balanced in terms of time needed for completion and content material. Participants were first asked to provide general information including their age, occupation, program of study, ethnicity, dietary habits and medication use. The following validated self-report questionnaires were included in the study package:  Three-Factor Eating Questionnaire (TFEQ)9: The TFEQ is a 51 item questionnaire that examines three different aspects of restrained eating: dietary restraint, disinhibition and feelings of perceived hunger. There is a strong internal consistency in this scale with Cronbach’s alpha scores of 0.92 for the restraint subscale, 0.91 for disinhibition and 0.85 for perceived hunger9. Past studies examining dietary restraint have typically used the Restraint Scale (RS10) or the TFEQ Restraint subscale (TFEQ-R). The TFEQ-R was chosen for this study because stronger correlations have been observed between high scores on the TFEQ-R and elevated salivary cortisol levels than with the RS11. The 21 item subscale looks at controlling behaviours focused on weight loss or weight maintenance with questions such as “while on a diet, if I eat food that is not allowed, I consciously eat less for a period of time to make up for it” and “I do not eat some foods because they make me fat.” The TFEQ-R was incorporated into the screening questionnaire with answers to each question coded as either 0 or 1 and summed to calculate a final score. We categorized scores ≤ 5 as “low restraint” and ≥ 13 as “high restraint.”  27 The TFEQ Cognitive Restraint Rigid and Flexible Control subscales were included in part one of the questionnaire package60. The 16 item Rigid Control and 12 item Flexible Control subscales were created based on the observation that individuals display dietary restraint in different ways. Those high in Rigid Control are believed to have an “all-or-none” approach to eating where certain foods are completely avoided and treated as “forbidden foods”. If consumed, the individual does not attempt to adjust their intake to compensate for the given food. On the other hand, Flexible Control describes an eating pattern in which the individual allows for sweets in their usual diet without feelings of guilt61. Internal consistency for the Rigid Control subscale is reflected by a Cronbach’s alpha coefficient of 0.79, while the Flexible Control subscale has an alpha of 0.77.  Body Shape Questionnaire (BSQ)62: The BSQ is a 34 item questionnaire that explores the concern one has over their body shape and feelings of fatness. Shortened forms of this questionnaire have been developed since the detailed nature of the 34 item tool is deemed unnecessary for studies where body dissatisfaction is not the primary concern63. The 8-item shortened version (BSQ-8C) was included in our questionnaire package63. A recent study examining differences between the 8-item, 14-item and 16-item versions found that the BSQ8C has a high internal consistency with Cronbach’s alpha of 0.91 and is the shortened version with a sensitivity to change that most closely resembles that of the full-length BSQ64. The shortened version provided a good assessment of the participant’s dissatisfaction due to body shape while ensuring the questionnaire was completed in a reasonable amount of time.  28 Beliefs About Appearance Scale (BAAS)65: The 20 items on this questionnaire assess the importance one believes appearance can have on relationships, achievement, self-view and emotions. A 5 point Likert scale is used to indicate how strongly one agrees with different statements ranging from 0 (“not at all”) to 4 (“extremely”). The BAAS exhibits high internal consistency with alpha scores ranging from 0.94 to 0.9665.  Eating Disorder Examination Questionnaire (EDE-Q)66: The EDE-Q is a self-report questionnaire based directly from the Eating Disorders Examination (EDE)67. The EDE is conducted in an interview format and is highly preferred for the assessment of eating disorders and disordered eating symptoms. However, the nature of the interview is that it is lengthy, intrusive and difficult to administer. The questionnaire version provides necessary information for a research setting and is well correlated with most aspects of the EDE, including measures of dietary restraint66. With a total of 28 items evaluating the frequency of various eating behaviours and attitudes over the past four weeks, the EDE-Q examines key behavioural aspects of eating disorders. Questions are categorized into the subscales of Restraint, Shape Concern, Weight Concern and Eating Concern. The Global subscale creates a final score based on the average of the 4 subscales. Strong test-retest reliability and internal consistency for the EDE-Q have been documented with a Cronbach’s alpha coefficient of 0.93 for the Global subscale68,69.  Baecke Questionnaire of Habitual Physical Activity70: This 16 item tool gathers information on an individual’s physical activity during work, sport and non-sport leisure activity. It is a short and user-friendly questionnaire that is frequently used by epidemiological studies  29 exploring various aspects of habitual physical activity. This tool has been validated with physical activity levels measured using doubly labelled water71. Intense physical activity is observed to induce cortisol secretion such that cortisol levels rise in a pattern related to the degree of physical stress56. Although participants were instructed to avoid strenuous physical activity the morning of the lab visit, this questionnaire was included to assess the participant’s usual physical activity.  Daily Stress Inventory (DSI)72: The DSI consists of 58 items that allow an individual to selfreport minor stressors that occurred within the previous 24 hours. The participant must read a list of events and indicate whether or not a given event occurred. For those events that did occur, a subsequent Likert scale is used to indicate the amount of stress associated with each event. The Likert scale ranges from a score of 1 (“occurred but was not stressful”) to 7 (“caused me to panic”). The DSI provides three scores for each participant: the total number of stressful events within the last 24 hours (Frequency), total impact rating of the events combined (Sum) and average stress rating of the events (Average Impact Rating). Convergent validity for the DSI as a tool assessing minor daily stresses has been illustrated through comparisons with biochemical measures of stress including daily urinary cortisol and vanillylmandelic acid, a metabolite of epinephrine and norepinephrine73. The role of the DSI in the questionnaire package was to assess the participant’s stress level in the time period preceding the laboratory visit. It has been shown that individuals with high levels of stress prior to an experiment participation show lower cortisol levels in the experimental setting57,74.  30 Depression Anxiety Stress Scales (DASS)75: The DASS consists of three 14 item subscales measuring depression, anxiety and stress. Overall, the 42 symptoms listed relate to negative emotions and ask the participant to rate the frequency with which they experienced a symptom in the last week from 0 (“did not apply to me at all”) to 3 (“applied to me very much, or most of the time”). The internal consistencies for each subscale are high with an alpha score of 0.91 for Depression, 0.84 for Anxiety and 0.90 for Stress76. Along with support for internal consistency, convergent and discriminant validity in nonclinical samples76,77, reliability and validity in clinical samples with conditions such as major depressive disorder, obsessive compulsive disorder and social phobia have also been demonstrated78,79. This questionnaire was included because depressed and control individuals differ in cortisol secretion following stress exposure80 and in their ACR81,82. The DASS was chosen over other depression and anxiety scales since it was developed largely from a pool of healthy, non-clinical participants76, which is representative of the participants in our study.  Perceived Stress Scale (PSS)83: This 14 item tool examines the degree to which events within the last month were deemed stressful by the individual. The scale provides a measure of stress that considers both chronic and minor stresses. It has been used in past CDR research, which will allow for comparisons between findings7,12. Internal consistency for the PSS ranges from a Cronbach’s alpha of 0.84 to 0.8683.  100 mm Visual Analogue Scale (VAS) for Stress: The questionnaire package included a 100 mm VAS asking participants to rate the level of stress they felt due to participation in  31 this study ranging from 0 (“not stressful at all”) to 100 (“extremely stressful). This question was asked at the end of part 1 and part 2 of the package and examined whether participants differed in their rating of stress associated with the lab procedure. The VAS acts as a quick assessment tool that has been used in past research53.  100 mm Visual Analogue Scale (VAS) for Appetite Sensations84: Since participants were allowed to take snacks with them following the completion of the questionnaire package, appetite sensations were considered as potential confounding variables for any differences in the quantity of food taken. Appetite sensations were examined through questions regarding one’s hunger, fullness and desire to eat. The VAS provided by Flint and colleagues84 consists of 8 questions such as “how hungry do you feel?” and “how much do you think you can eat?” The participant was asked to indicate their response by marking a point on a line anchored with the most positive and most negative rating. Although it is difficult to establish validity for appetite sensations due to their subjective nature, VAS scales for appetite sensations are commonly used tools with acceptable within-subject reliability and validity85.  In addition to these validated questionnaires, participants answered two open-ended questions in each part of the questionnaire package (Appendix G and H). We asked participants to read mock magazine articles describing women’s diet and fitness routines and discuss their thoughts and feelings. The open-ended questions served to provide additional food and weight-related cues in the form of visual images and anecdotes from healthconscious women. Furthermore, we included these questions in an attempt to avoid  32 questionnaire fatigue and give the participants a break from the multiple choice style answers in the remainder of the questionnaire package.  3.5.2 Saliva collections Salivary cortisol has become a commonly used measure of stress due to the ease and non-invasive nature of collection compared to blood samples86. There are strong correlations between salivary and serum cortisol values, r = 0.71-0.9623. Furthermore, saliva samples can be stored at room temperature and easily returned to the lab following the morning collection. In this study, the Salivette was used for saliva collection. The Salivette is a cotton roll held within a centrifugation tube. Women were asked to chew on the cotton roll for one minute and then place it within the tube. Participants were also instructed to rinse their mouth with water prior to the first sample collected during the lab visit and morning procedure. All samples were frozen until shipped to the University of Dresden in Germany where subsequent centrifugation and immunoassays were used to determine salivary cortisol levels87.  3.5.3 Blood pressure readings Stressors activate the HPA axis and sympathetic nervous system88, thus blood pressure (BP) and heart rate acted as additional measures of perceived stress to increase the strength of experimental findings. Ambulatory BP and heart rate were recorded in 15 minute intervals throughout the lab visit, including a baseline period prior to completion of the questionnaire package. The Spacelabs Burdick ambulatory blood pressure monitor (model #90207-80) was used. Validation studies have illustrated consistent performance for at least  33 a six year period with this model89,90. The monitor was fitted on the participant’s nondominant arm so that readings could be taken while the participant was seated and completing the questionnaire package.  3.5.4 Anthropometric measurements To determine each participant’s body mass index in kg/m2, height and weight information was collected at the end of the lab visit. With shoes taken off, height was measured to the nearest 0.1 cm. Weight was also recorded with shoes taken off and to the nearest 0.1 kg on a standard electronic scale. Two measurements were recorded for both height and weight to ensure minimal differences in measurement. If differences did occur, a third measure was taken and the average of the closest measures was recorded. Waist and hip circumferences were also measured to the nearest 0.1 cm in the same manner.  3.6 Statistical analysis Data from the screening questionnaire, lab protocol and morning sampling procedure were entered into SPSS Version 17.0 for analysis. Descriptive statistics, Student’s t-test and chi-square tests were used to describe the characteristics of the study population. When necessary, the Yates continuity correction was used for chi-square tests, Greenhouse-Geisser correction for analysis of variance (ANOVA) tests and Bonferroni adjustments for post-hoc tests. The following statistical approaches were used to examine our three research hypotheses:  Hypothesis #1: Exposure to food and weight-related cues will lead to signs of physiological arousal among participants.  34 •  To assess whether a physiological response was activated and captured in the laboratory setting, a one-way ANOVA for repeated measures was used to identify changes in blood pressure, heart rate and afternoon salivary cortisol.  Hypothesis #2: High levels of CDR will lead to a greater activation of the physiological stress response and cause higher elevations in BP, heart rate and afternoon salivary cortisol than those observed in women with lower levels of restraint. •  A mixed between-within subjects ANOVA (restraint X time) was used to analyze each variable of interest and examine whether differences existed between women with high and low levels of restraint. Restraint was expressed as a categorical variable (high or low).  Hypothesis #3: CDR is a subtle and chronic stressor that causes disturbances of the HPA axis and leads to measurable differences in the ACR of women who vary in their levels of dietary restraint. •  A mixed between-within subjects ANOVA was used to confirm that the ACR response occurred and investigated whether differences were apparent between restraint groups. Furthermore, 3 common methods used to investigate the ACR in past studies were used to explore differences between the two restraint groups37,91,92: 1. Mean increase (MnInc) calculates the mean rise in cortisol levels from awakening to 45 minutes post-awakening. o MnInc = (Awakening cortisol15min + AC30min + AC45min)/3 – AC0min 2. Area under the response curve (AURC) indicates the dynamic of the ACR by looking at the area under the curve with respect to the first sample collected.  35 o AURC = AC15min + AC30min − (2 x AC0min) + ((AC45min − AC15min)/2) 3. Area under the curve (AUC) examines the cortisol response with reference to zero to calculate the overall amount of cortisol produced in the first 45 minutes postawakening. o AUC = AC0min + AC15min + AC30min + ((AC45min − AC0min)/2)  36 CHAPTER 4: RESULTS 4.1 Participant characteristics A total of 341 women completed the online screening questionnaire for eligibility assessment. Figure 1 illustrates the screening process that led to the exclusion of 230 of these women. The remaining 111 women were eligible for study participation; however, 40 women did not reply to subsequent e-mails or were no longer interested in study participation (“lost to follow-up”). As a result, the full study protocol was completed by 71 participants. One participant’s results were excluded due to saliva sample contamination leaving an equal number of low restraint (LR) and high restraint (HR) women as desired.  Figure 1: Recruitment process  TFEQ-R = Three-Factor Eating Questionnaire Restraint subscale, BMI = body mass index, ED = eating disorder.  Oral contraceptives were used by 13 LR and 8 HR women and as discussed earlier, this is not believed to have an effect on physiological data. Questionnaire packages were  37 completed in their entirety and the few missing answers were replaced with the most common answer among other participants. As summarized in Table 2, the mean age of all participants was roughly 22 years, with no significant difference in age between the LR and HR group. Anthropometric measures also did not significantly differ between groups. Participants had a mean BMI of 22.0 and mean waist-to-hip ratio of 0.78.  Table 2: Mean age, body mass index (BMI) and waist-to-hip ratio Overall mean (n = 70)  LR group mean (n = 35)  HR group mean (n = 35)  t-test  p value  Age (years)  22.2 ± 3.4  22.8 ± 3.2  21.9 ± 3.6  0.531  0.597  BMI (kg/m2)  22.0 ± 2.3  22.2 ± 2.5  21.8 ± 2.1  0.777  0.440  Waist-to-hip ratio  0.78 ± 0.05  0.78 ± 0.05  0.78 ± 0.05  -0.409  0.684  Data are presented as mean ± SD, LR = low restraint, HR = high restraint, BMI = body mass index.  The participants’ occupation and ethnicity information is provided in Table 3. The majority of women were students, primarily at the undergraduate level. Program majors differed among the student group since we made a conscious effort to avoid recruitment from a particular discipline. The remaining participants were employed in research, administration or had recently graduated. To gather ethnicity data, the questionnaire asked participants to check off any of the following groups they felt described their background: Caucasian, Chinese, South Asian, Black, Arab/West Asian, Filipino, Southeast Asian, Latin American, Japanese, Korean or Other (asked to specify). We grouped the ethnicity results into two categories for simplicity: (1) Caucasian, which described individuals who self-identified as Caucasian or Latin American and (2) Asian, which included all other ethnic groups. Overall, a larger number of  38 participants were Asian than Caucasian. Of the 35 women in the LR group, 16 were Caucasian (45.7%) and 19 were Asian (54.3%). This was in contrast to the 9 Caucasian women (25.7%) and 26 Asian women (74.3%) in the HR group. However, a chi-square test for independence with Yates Continuity Correction showed no significant association between level of CDR and ethnicity, χ2(1, n = 70) = 2.24, p = 0.13. Table 3: Occupation and ethnicity n  %  Occupation Undergraduate student Graduate student Unclassified student Recently graduated or employed  51 10 2 7  72.9% 14.3% 2.9% 10.0%  Ethnicity Caucasian Asian  25 45  35.7% 64.3%  Table 4 presents data on participants’ weight loss efforts, weight perceptions and usual diet. Among the group as a whole, almost a third reported that they were currently trying to lose weight, with a majority of these women belonging to the HR group. Almost two-thirds of participants felt their current weight was “about right”, about one-third felt “slightly overweight” and very few reported feeling “very overweight” or “slightly underweight”. Weight perceptions differed between restraint groups, with HR women more likely to perceive themselves as “slightly overweight”. Lastly, when asked to describe their typical diet, the majority of LR and HR women reported consuming a mixed diet of meat, dairy products, eggs, fruits, vegetables and grains. Some participants reported dietary  39 restrictions such as excluding red meat, dairy or all animal products but this response did not differ between restraint groups.  Table 4: Participants’ thoughts regarding diet and weight status  Are you currently trying to lose weight? No Yes How do you feel about your current weight? Very or slightly overweight About right or slightly underweight  Overall n, (%)  LR group n, (%)  HR group n, (%)  χ2 test  p value  47 (67.1%) 23 (32.9%)  33 (94.3%) 2 (5.7%)  14 (40%) 21 (60%)  20.981*  < 0.001  25 (35.7%)  5 (14.3%)  20 (57.1%)  12.196*  < 0.001  45 (64.3%)  30 (85.7%)  15 (42.9%)  30 (85.7%) 5 (14.3%)  29 (82.9%) 6 (17.1%)  0.000*  1.000  How would you describe your usual diet? Mixed 59 (84.3%) Other (lacto-ovo, 11 (15.7%) pesco-pollo, vegan or specific food intolerances) LR = low restraint, HR = high restraint. *Yates continuity correction applied.  4.2 Eating attitudes For inclusion in the full study protocol, participants had scores ranging from 0-5 or 13-21 on the TFEQ-R component of the screening questionnaire. Upon visiting the lab, participants were asked to complete the full TFEQ so the TFEQ-R was completed again, as part of the questionnaire package. Although some participants’ scores on the TFEQ-R changed between visits and subsequently fell in the mid-range of scores (6-12), no participant changed restraint group category based on the second score. As expected, final TFEQ-R  40 scores were significantly different between groups. Figure 2 illustrates the distribution of final TFEQ-R scores.  Figure 2: Distribution of final scores on the Three-Factor Eating Questionnaire Restraint subscale 8  Low restraint High restraint  Number of participants  7 6 5 4 3 2 1 0 0  5  10  15  20  Score  Additional measures examining eating attitudes included the Disinhibition, Hunger, Rigid and Flexible Control subscales of the TFEQ, the shortened version of the Body Shape Questionnaire (BSQ-8C), the Beliefs About Appearance Scale (BAAS) and the Eating Disorders Examination Questionnaire (EDE-Q). Table 5 summarizes overall and group means on the different scales with scores on BSQ-8C multiplied by 4 to allow for easy comparison to the full 32 item BSQ63. With the exception of the hunger subscale of the TFEQ, the LR and HR group means were significantly different across all assessment tools.  41 Table 5: Mean scores on eating attitude assessment tools Questionnaire subscale  Possible range of scores  Overall mean (n = 70)  LR group mean (n = 35)  HR group mean (n = 35)  t-test  p value  TFEQ Restraint Disinhibition Hunger Rigid control Flexible control  0 – 21 0 – 14 0 – 16 0 – 16 0 – 12  9.2 ± 6.1 6.9 ± 3.4 6.1 ± 2.8 5.5 ± 3.9 5.6 ± 3.0  3.8 ± 2.3 5.9 ± 3.3 6.4 ± 2.7 2.3 ± 1.8 3.2 ± 1.6  14.5 ± 3.3 7.8 ± 3.4 5.8 ± 2.9 8.7 ± 2.6 7.9 ± 2.2  -15.665 -2.334 0.847 -11.936 -10.326  < 0.001 0.023 0.400 < 0.001 < 0.001  BSQ  34 - 204  88.1 ± 28.4  69.5 ± 20.7  106.6 ± 22.3  -7.127  < 0.001  BAAS*  0 – 76  25.4 ± 15.3  20.2 ± 15.1  30.5 ± 13.9  -2.990  0.004  EDE-Q Restraint Shape concern Weight concern Eating concern Global score  0–6 0–6 0–6 0–6 0–6  1.1 ± 1.2 1.9 ± 1.2 1.4 ± 1.2 0.7 ± 0.8 1.3 ± 1.0  0.3 ± 0.6 1.3 ± 1.0 0.6 ± 0.6 0.3 ± 0.4 0.6 ± 0.6  1.9 ± 1.2 2.6 ± 1.0 2.2 ± 1.1 1.2 ± 0.8 2.0 ± 0.9  -7.130 -5.640 -7.408 -5.965 -7.577  < 0.001 < 0.001 < 0.001 < 0.001 < 0.001  Data are presented as mean ± SD, LR = low restraint, HR = high restraint, TFEQ = Three Factor Eating Questionnaire, BSQ = Body Shape Questionnaire, BAAS = Beliefs About Appearance Scale, EDE-Q = Eating Disorders Examination Questionnaire. *One question from the 20-item BAAS was omitted in our questionnaire package, resulting in a maximum score of 76 rather than 80.  42 4.3 Physical activity, depression, anxiety and stress Participants completed the following questionnaires related to usual physical activity, depression, anxiety and stress: Baecke Questionnaire of Habitual Physical Activity, Daily Stress Inventory (DSI), Depression Anxiety Stress Scales (DASS) and the Perceived Stress Scale (PSS). Student’s t-tests were conducted to analyze differences in group means between the LR and HR groups. As summarized in Table 6, no significant between group differences were found among any of the subscales. Participants were also asked to rate how stressful they found study participation using a 100 mm visual analogue scale. This question was asked at the end of each part of the questionnaire package with results shown in Table 7. Women in the HR group reported significantly higher levels of stress than the LR group after completing each part of the questionnaire package.  43 Table 6: Mean scores on physical activity, depression, anxiety and stress scales Questionnaire subscale  Possible range of scores  Overall mean (n = 70)  LR group mean (n = 35)  HR group mean (n = 35)  t-test  p value  1–5 1–5 1–5  2.3 ± 0.6 2.6 ± 1.1 3.0 ± 0.7  2.3 ± 0.6 2.4 ± 1.0 3.0 ± 0.7  2.2 ± 0.7 2.7 ± 1.1 3.0 ± 0.6  0.942 -1.242 0.045  0.349 0.218 0.964  0 – 58 0 – 406 0–7  15.5 ± 7.5 51.3 ± 34.7 3.2 ± 0.9  14.5 ± 6.9 46.3 ± 33.5 3.0 ± 0.9  16.6 ± 8.0 56.3 ± 35.5 3.3 ± 0.9  -1.150 -1.211 -1.111  0.254 0.230 0.270  DASS Depression Anxiety Stress  0 – 42 0 – 42 0 – 42  7.7 ± 8.2 6.5 ± 5.9 12.9 ± 8.8  6.6 ± 8.3 5.3 ± 4.2 11.2 ± 9.0  8.8 ± 8.1 7.8 ± 7.1 14.6 ± 8.5  -1.139 -1.800 -1.644  0.259 0.076 0.105  PSS  0 – 56  24.7 ± 7.0  24.1 ± 7.9  25.3 ± 6.2  -0.712  0.479  Baecke Work index Sport index Leisure index DSI Frequency Sum Average impact rating  Data are presented as mean ± SD, LR = low restraint, HR = high restraint, Baecke = Baecke Questionnaire of Habitual Physical Activity, DSI = Daily Stress Inventory, DASS = Depression Anxiety Stress Scales, PSS = Perceived Stress Scale.  44 Table 7: Mean visual analogue scale scores for stress due to study participation* Overall (n = 70)  LR group (n = 35)  HR group (n = 35)  t-test  p value  Stress rating after part 1  13.9 ± 17.5  8.5 ± 8.1  19.3 ± 22.2  -2.722  0.009  Stress rating after part 2  17.0 ± 18.8  10.5 ± 10.0  23.4 ± 23.1  -3.040  0.004  *A 100 mm visual analog scale was used, with anchors of “not at all stressful” (0) and “extremely stressful” (100). Data are presented as mean (mm) ± SD, LR = low restraint, HR = high restraint.  4.4 Appetite sensations and food choices Since this study had food items present as a form of cue exposure, we examined whether differences in hunger between restraint groups acted as a confounding variable. Hunger and food preferences were assessed using 100 mm visual analogue scales for appetite sensations at the start of the study. Differences in the number and type of food items taken by LR and HR individuals were later examined. Results are presented in Table 8. Of key importance is that no significant differences existed between the feelings of hunger, satisfaction or fullness among LR and HR women at the start of the study. LR women had a significantly higher preference for salty, savoury or fatty foods than HR women but groups did not actually differ in the overall number of food items taken. HR women were observed to take more low-fat, low-sugar items on average but preference for all other food types did not significantly differ between the two groups.  45 Table 8: Mean scores for appetite sensations and food choices Overall (n = 70)  LR group (n = 35)  HR group (n = 35)  t-test  p value  32.4 ± 24.3 47.7 ± 19.0 40.1 ± 24.3 54.5 ± 24.7  37.7 ± 25.1 44.8 ± 17.1 35.1 ± 23.3 59.3 ± 24.8  27.0 ± 22.5 50.8 ± 20.8 45.1 ± 24.6 49.7 ± 24.0  1.876 -1.308 -1.750 1.645  0.065 0.195 0.085 0.105  Desire for specific food type* Sweet Salty Savoury Fatty  49.8 ± 29.8 47.2 ± 28.8 55.1 ± 27.2 31.1 ± 24.0  56.2 ± 28.3 56.5 ± 26.9 63.8 ± 24.4 38.1 ± 25.0  43.9 ± 30.4 37.9 ± 27.9 46.5 ± 27.4 24.1 ± 21.1  1.825 2.849 2.798 2.534  0.072 0.006 0.007 0.014  Food choices** Total items taken Low-fat, low-sugar Low-fat, high-sugar High-fat, low-sugar High-fat, high-sugar  4.9 ± 4.1 0.6 ± 0.8 1.5 ± 2.1 1.3 ± 1.6 1.5 ± 1.7  4.5 ± 3.8 0.3 ± 0.5 1.4 ± 2.2 1.2 ± 1.4 1.6 ± 1.7  5.4 ± 4.4 0.9 ± 1.0 1.6 ± 2.1 1.4 ± 1.8 1.5 ± 1.7  -0.875 -3.539 -0.280 -0.602 0.419  0.385 0.001 0.780 0.549 0.676  Appetite scores* Hunger Satisfaction Fullness Prospective food consumption  *A 100 mm visual analog scale was used, with anchors of two opposing statements such as “I am not hungry at all” (0) and “I have never been more hungry” (100) for the Hunger score. Data are presented as mean (mm) ± SD, LR = low restraint, HR = high restraint. **Food choices reflects the mean number of food items taken, with total items ranging from a minimum of 0 to a maximum of 55 items.  4.5 Physiological measures 4.5.1 Cue exposure and physiological arousal The first research hypothesis proposed that food and weight-related cues present in the lab setting would lead to signs of physiological arousal. Changes were predicted for the measures of systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate and afternoon salivary cortisol. For each physiological variable, a one-way repeated measures ANOVA was used with Greenhouse-Geisser corrections applied if necessary. Post hoc tests with Bonferroni  46 adjustments were completed after obtaining significant results. For SBP, DBP and heart rate, a complete set of 6 measures was recorded for all participants except 1 LR female. Mean values for the resulting sample size of 69 are provided in Table 9. The results indicate that SBP measures significantly changed over the 6 time points, F(5, 340) = 25.83, p < 0.001. Post hoc tests reveal that baseline measures were significantly higher from all other time points. Likewise, there was a significant change in DBP over the duration of the study protocol, F(5, 340) = 2.85, p < 0.05. Mauchly’s test indicated that assumption of sphericity had been violated for the effect of time on heart rate measures, χ2(14) = 217.21, p < 0.001. Therefore, the GreenhouseGeisser correction was applied, ɛ = 0.36. There was a significant change in heart rate measures over time, F(1.80, 122.60) = 16.24, p < 0.001. Pairwise comparisons shown in Table 9 illustrate that measures collected in the first and second half of the study significantly differed from each other. Lastly, mean values of afternoon salivary cortisol levels are provided in Table 9. Missing samples from 2 LR participants reduced the sample size to 68 women. Participants were asked to record the time each sample was collected in the lab setting to verify accuracy of sampling. Most samples were collected within a 15-16 minute interval. Out of 408 samples, only 1 was collected after 17 minutes and this represents the largest deviation from the requested 15 minute sampling interval. The Greenhouse-Geisser correction was applied (ɛ = 0.67) due to a violation of the assumption of sphericity for cortisol data, χ2(14) = 370.84, p < 0.001. Similar to other variables, afternoon cortisol levels significantly changed over time, F(1.51, 101.32) = 24.18, p < 0.001. Pairwise comparisons with Bonferroni corrections are provided in Table 9.  47 Table 9: Overall mean values for systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate and afternoon salivary cortisol measures in the lab setting Variable  0 minutes  15 minutes  Minutes elapsed 30 minutes 45 minutes  SBP (mmHg, n = 69)  110.2 ± 10.2a  107.9 ± 10.0a  105.5 ± 9.2bc  105.3 ± 9.0bc  104.1 ± 9.4bc  104.6 ± 10.1bc  DBP (mmHg, n = 69)  67.4 ± 7.9df  66.3 ± 7.9  65.3 ± 9.5b  66.0 ± 8.6  65.1 ± 9.4b  65.8 ± 9.1  Heart rate (bpm, n = 69)  73.3 ± 11.3efg  71.7 ± 9.8efg  70.5 ± 9.1efg  67.8 ± 7.8bcd  68.5 ± 8.2bcd  66.8 ± 8.4bcd  Salivary cortisol (nmol/L, n = 68)  7.0 ± 5.3fg  7.5 ± 4.7defg  6.6 ± 3.8cefg  5.8 ± 3.1cdfg  5.2 ± 2.7a  4.8 ± 2.5a  60 minutes  75 minutes  Data are presented as mean ± SD, SBP = systolic blood pressure, DBP = diastolic blood pressure. a = significantly different from all other time points (p < 0.05), b = significantly different from time point 1 (p < 0.05), c = significantly different from time point 2 (p < 0.05), d = significantly different from time point 3 (p < 0.05), e = significantly different from time point 4 (p < 0.05), f = significantly different from time point 5 (p < 0.05), g = significantly different from time point 6 (p < 0.05).  48 4.5.2 Cue exposure, physiological arousal and CDR A mixed between-within subjects ANOVA (restraint X time) was used to examine whether levels of restraint had an impact on physiological responses in the lab setting. Mean values across time points for each restraint group are presented in Table 10 and are illustrated in Figures 3-6. Changes in SBP and DBP over time are illustrated in Figures 3 and 4, respectively. There was no significant interaction between restraint and SBP or DBP values over time, F(5, 335) = 1.54, p = 0.18 and F(5, 335) = 0.77, p = 0.57, respectively. There was a significant main effect of time with both groups showing a decrease in SBP (F(5, 335) = 26.15, p < 0.001) and DBP (F(5, 335) = 2.87, p = 0.02) over time. In contrast to hypothesis two, the main effect for restraint was not significant. Levels of restraint did not appear to have an effect on SBP (F(1, 67) = 2.82, p = 0.10) or DBP measures (F(1, 67) = 2.47, p = 0.12) after cue exposure. Changes in heart rate are illustrated in Figure 5. Mauchly’s test indicated that the assumption of sphericity was violated with χ2(14) = 215.93, p < 0.001. The GreenhouseGeisser correction was applied to adjust degrees of freedom, ɛ = 0.36. There was no significant interaction between heart rate measures over time and restraint, F(1.79, 119.97) = 0.29, p = 0.72. A significant main effect of time was observed since both groups appeared to have a decrease in heart rate over time, F(1.79, 119.97) = 16.10, p < 0.001. However, restraint groups were not significantly different in their heart rate response over time, F(1, 67) = 1.23, p = 0.27. Lastly, Figure 6 illustrates changes in afternoon salivary cortisol levels. Mauchly’s test showed that the assumption of sphericity was violated for salivary cortisol measures,  49 χ2(14) = 366.84, p < 0.001 and the Greenhouse-Geisser correction was applied, ɛ = 0.30. There was no significant interaction between cortisol measures over time and levels of restraint, F(1.51, 99.67) = 0.82, p = 0.41. Both groups were observed to have a significant decrease in salivary cortisol over time, F(1.51, 99.67) = 23.90, p < 0.001. However, consistent with other findings in this study, high and low restraint women did not significantly differ in their cortisol response over time, F(1, 66) = 0.30, p = 0.59. In summary, the physiological response of high and low restraint women did not appear to differ from each other in the measures of SBP, DBP, heart rate and afternoon salivary cortisol.  50 Table 10: Group means for systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate and afternoon salivary cortisol measures in the lab setting Variable  Restraint group  0 minutes  15 minutes  Minutes elapsed 30 minutes 45 minutes  SBP (mmHg)  Low (n = 34)  113.1 ± 11.5  109.2 ± 11.2  107.1 ± 10.0  107.2 ± 10.7  105.8 ± 10.9  106.0 ± 11.6  High (n = 35)  107.4 ± 8.0  106.6 ± 8.6  103.9 ± 8.1  103.3 ± 6.6  102.5 ± 7.4  103.2 ± 8.3  Low (n = 34)  69.6 ± 9.7  67.8 ± 9.6  67.0 ± 11.6  67.2 ± 9.9  66.5 ± 11.5  66.8 ± 10.9  High (n = 35)  65.2 ± 4.7  64.8 ± 5.6  63.6 ± 6.8  64.8 ± 7.0  63.7 ± 6.6  64.9 ± 6.9  Low (n = 34)  75.9 ± 11.6  73.4 ± 9.7  71.2 ± 9.2  68.8 ± 7.5  69.8 ± 8.0  67.4 ± 8.0  High (n = 35)  73.3 ± 18.5  69.9 ± 9.7  69.6 ± 9.0  66.8 ± 8.1  67.2 ± 8.2  66.1 ± 8.7  Low (n = 33)  6.9 ± 5.0  7.8 ± 4.9  6.8 ± 4.1  6.0 ± 3.5  5.6 ± 3.2  5.2 ± 2.8  High (n = 33)  7.1 ± 5.7  7.3 ± 4.5  6.5 ± 3.5  5.6 ± 2.8  4.7 ± 2.2  4.4 ± 2.0  DBP (mmHg)  Heart rate (bpm)  Salivary cortisol (nmol/L)  Data are presented as mean ± SD, SBP = systolic blood pressure, DBP = diastolic blood pressure.  60 minutes  75 minutes  51 Figure 3: Mean values of systolic blood pressure (SBP) in the lab setting for women with low and high restraint scores 120 Low restraint  115  Mean SBP (mmHg)  High restraint 110  Error bars = 95% CI  105  100  95  90 0  15  30  45  60  75  Minutes elapsed  Figure 4: Mean values of diastolic blood pressure (DBP) in the lab setting for women with low and high restraint scores 80 Low restraint  75  Mean DBP (mmHg)  High restraint 70  Error bars = 95% CI  65  60  55  50 0  15  30  45  Minutes elapsed  60  75  52 Figure 5: Mean values of heart rate in the lab setting for women with low and high restraint scores 85 Low restraint  80  Mean heart rate (bpm)  High restraint 75  Error bars = 95% CI  70  65  60  55 0  15  30  45  60  75  Minutes elapsed  Figure 6: Mean values of afternoon salivary cortisol levels for women with low and high restraint scores 12 Low restraint  10  Mean cortisol (nmol/L)  High restraint 8  Error bars = 95% CI  6  4  2  0 0  15  30  45  Minutes elapsed  60  75  53 4.6 Awakening cortisol response The ACR was examined using 3 approaches common to most studies37: mean increase (MnInc), area under the curve with reference to sample one (AURC) and area under the curve with reference to zero (AUC). Please refer to Section 3.6 for the formulas used. Mean cortisol levels for samples collected 0, 15, 30 and 45 minutes after awakening are provided in Table 11. A complete set of 4 morning samples were provided by all participants; however, technical error led the loss of a 15 minute sample from a LR and HR female. Calculations for these participants were based on remaining values.  Table 11: Group means for morning salivary cortisol  Level of restraint  0 minutes  Cortisol levels (nmol/L) Time after awakening 15 minutes 30 minutes  Low (n = 34)  13.8 ± 6.7  23.3 ± 8.9  31.4 ± 12.1  31.8 ± 13.5  High (n = 34)  14.2 ± 6.8  22.8 ± 9.6  28.1 ± 10.7  27.5 ± 12.9  45 minutes  Data are presented as mean ± SD.  All participants were asked to record the time of sampling to verify compliance to the requested 15 minute sampling interval. The majority of the 280 samples were provided within a 15-16 minute interval. Two samples were collected 5 minutes earlier than desired and 1 was collected after 17 minutes. These small differences in sampling time are believed to have negligible effects on overall results59,93. Participants were asked if they had any difficulties with the morning sampling procedure prior to the debriefing session and the consensus was that there were no problems. Those who experienced unexpected issues the morning of the procedure (such as falling back asleep rather than taking the initial sample)  54 had contacted the student investigator to reschedule data collection. As a result, it is believed that all participants completed the morning sampling procedure as requested.  4.6.1 ACR and dietary restraint A mixed between-within subjects ANOVA (restraint X time) was used to confirm that morning cortisol levels increased as expected in the ACR response. Group means over the 4 time points are illustrated in Figure 7. Mauchly’s test indicated that the assumption of sphericity was violated for ACR measures, χ2(5) = 104.95, p < 0.001 and the GreenhouseGeisser correction was applied, ɛ = 0.51. There was no significant interaction between morning cortisol levels over time and restraint, F(1.52, 100.23) = 1.98, p = 0.15. There was a significant main effect of time with both groups showing the expected increase in cortisol levels after awakening, F(1.52, 100.23) = 86.34, p < 0.001. Furthermore, the responder rate was calculated to determine the number of participants who experienced a minimum 2.5 nmol/L increase in cortisol in comparison to baseline levels. This cut-off has been established as a strict method of identifying those who show a cortisol response upon awakening33. Cortisol levels increased by at least 2.5 nmol/L in 66 of 70 participants (94.3%). The ACR was thus observed in most participants but the main effect for restraint was not significant, F(1, 66) = 0.85, p = 0.36. This suggests that results were in contrast to hypothesis three such that there were no observed differences in the ACR profile of LR and HR women. Mean MnInc, AURC and AUC values for each restraint group are shown in Table 12 and further illustrate that ACR profiles did not differ between restraint groups. The mean increase in morning cortisol was determined by averaging post-awakening cortisol levels and  55 calculating the change from the sample collected immediately upon awakening. There was no significant difference between the mean MnInc value calculated for the LR and HR group. AURC reflects the increase in cortisol levels from baseline to 45 minutes postawakening. Student’s t-tests comparing mean AURC values between the LR and HR group showed that no significant between-group difference was found. Lastly, mean AUC values were calculated to gain an understanding of the amount of cortisol secreted after awakening. No significant differences were observed between the AUC of the LR and HR group.  Figure 7: Mean salivary cortisol levels after awakening for women with low and high restraint scores 40  Mean cortisol (nmol/L)  35  Low restraint High restraint  30  Error bars = 95% CI  25 20 15 10 5 0 0  15  30  Minutes elapsed  45  56 Table 12: Group means for mean increase (MnInc), area under the response curve (AURC) and area under the curve (AUC) values LR group mean (n = 35)  HR group mean (n = 35)  t-test  p value  MnInc (nmol/L)  15.8 ± 10.6  11.7 ± 8.6  1.782  0.079  AURC (nmol/L)  31.0 ± 20.5  23.9 ± 18.2  1.541  0.128  AUC (nmol/L)  78.2 ± 27.5  70.4 ± 27.1  1.198  0.235  Data are presented as mean ± SD, LR = low restraint, HR = high restraint, MnInc = mean increase, AURC = area under the response curve, AUC = area under the curve.  57 CHAPTER 5: DISCUSSION AND CONCLUSIONS 5.1 Introduction The purpose of this study was to examine the relationship between CDR and physiological stress in healthy young women. It was previously unknown if the food and weight-related cues believed to be more stressful to those with high CDR would activate the stress response in such a way that measurable differences could be observed in an experimental setting. We proposed that (1) food and weight-related cues would lead to signs of physiological arousal, (2) HR women would experience higher degrees of physiological stress and (3) the LR and HR group would differ in their awakening cortisol response. I will first discuss findings related to anthropometric and general participant characteristics. Differences in eating attitude measures will be explored, followed with a discussion of the physical activity, depression, anxiety and stress variables in the two groups. Next, there will be a discussion of the research results related to each of the three study hypotheses. Lastly, conclusions, study strengths and limitations and suggestions for future work will be presented.  5.2 Anthropometric findings The eligibility criteria for this study required that participants had a BMI that was neither underweight nor obese. Initial height and weight information was collected by selfreport on the screening questionnaire. Based on this information, less than 8% of potential participants were ineligible due to weight criteria. Anthropometric data were confirmed during the lab visit and the LR and HR group did not significantly differ in terms of BMI, with a mean of 22.0 ± 2.3 kg/m2. Mean waist-to-hip ratios were identical between the two  58 groups. In contrast to these similarities, HR women were more likely to report that they were currently “slightly overweight” and were trying to lose weight. These findings confirm existing literature supporting the idea that CDR differences are not usually correlated with differences in anthropometric data and caloric intake, despite the variability in food and weight-related concerns6,7,16.  5.3 Eating attitudes results Eating attitudes were examined using the full Three Factor Eating Questionnaire (TFEQ), which includes the Restraint, Disinhibition, Hunger, Rigid Control and Flexible Control subscales; Body Shape Questionnaire (BSQ); Beliefs About Appearance Scale (BAAS) and the Eating Disorder Examination Questionnaire (EDE-Q) which consists of the Restraint, Shape Concern (SC), Weight Concern (WC), Eating Concern (EC) and Global subscales. Significant differences were observed between the two restraint groups for all scales and subscales, excluding the Hunger subscale of the TFEQ. This finding was expected since we selectively recruited participants on extreme ends of the TFEQ-R. Past research on LR and HR women has also observed significant between-group differences in the TFEQ Restraint and Disinhibition subscales while Hunger scores remained the same30. This study confirms that HR women are more likely to report disordered eating habits, controlling behaviours and concerns regarding their weight and body shape. The BSQ focuses on body shape concerns and feelings of fatness in women62. In this study, the shortened BSQ-8C was used due to time limitations with mean scores multiplied by 4 for ease of comparison to the full scale. BSQ scores were significantly different between groups (LR mean = 69.5 ± 20.7, HR mean = 106.6 ± 22.3, t = -7.127, p < 0.001)  59 which indicates that HR women were more likely to report body dissatisfaction. A validation study of the BSQ reported that women who self-identified moderate or extreme weight concerns, shape concerns and fears of fatness had a mean BSQ score of 109.0 ± 21.2 compared to a score of 55.9 ± 14.4 among unconcerned women62. Since the HR group in our study had similar BSQ scores, they are believed to be at a higher risk of psychopathologies due to the widespread and stable nature of body dissatisfaction. To supplement the role of the BSQ in examining the frequency of shape and weight concerns, the BAAS was included to gain an understanding of the potential implications of these beliefs. The BAAS functions to assess the importance of appearance to an individual and the effects they believe physical appearance has on relationships, work, achievement, self-view and emotions65. BAAS scores were significantly higher among HR women with a group mean of 30.5 ± 15.9 compared to 20.2 ± 15.1 in the LR group, t = -2.990, p < 0.05. Past studies using the BAAS in a university sample reported means ranging from 23.3 ± 14.9 to 30.6 ± 18.094, similar to scores in this study. Negative appearance beliefs have been shown to predict eating disorder risk factors such as dietary restraint and body dissatisfaction94. Thus, there are clear relationships between CDR, body dissatisfaction and appearance beliefs. The HR group was observed to have a high number of weight and body shape concerns that are likely being perceived as having negative effects on their work, relationships and self-esteem. The EDE-Q was included as one final measure of eating attitudes. By gathering information on the subscales of Restraint, Eating Concern (EC), Weight Concern (WC) and Shape Concern (SC), this tool helped to identify further items of interest in our sample population. The LR and HR group significantly differed in all subscales, p < 0.001. Norms  60 for the EDE-Q have been established for a large group of American university-aged women (n = 723)95. Independent t-tests were used to compare overall mean EDE-Q scores in our study to Luce et al.’s sample population which had a mean Global score = 1.7 ± 1.3, mean Restraint = 1.6 ± 1.5, mean EC = 1.1 ± 1.1, mean SC = 2.3 ± 1.5 and mean WC = 2.0 ± 1.6. Our study population had significantly lower scores on the Global (t = 2.813, p < 0.05), Restraint (t = 2.585, p < 0.05), EC (t = 2.796, p < 0.05) and WC subscales (t = 3.125, p < 0.05), reflecting fewer diet and weight concerns on average than the American sample. Differences in our study compared to Luce et al.’s may be due to differences in ethnicity or age across the two groups. The study conducted by Luce and colleagues primarily recruited Caucasian participants (88% of total) who were of a significantly younger age than our study (mean age = 18.7 ± 1.2, t = 18.346, p < 0.001). Past studies using the EDE-Q in a sample of healthy Australian women aged 18-42 years observed that mean subscale scores decreased with age96. A further finding of interest from the EDE-Q is the proportion of women with extreme scores (≥ 4) on each of the subscales. Compared to Luce et al.’s finding of 19.4% of women with extreme scores in SC and 11.3% in WC95, the current study had a lower proportion with 11.5% of all women scoring extremely high in SC and 4.2% in WC. Extreme scores varied between restraint groups. None were observed in the Restraint, WC, EC or Global subscale for the LR group whereas 8.6% of HR women scored ≥ 4 in Restraint, 8.7% in WC, 2.9% in EC and 2.9% in the Global subscale. Shape concerns were evident in both groups with 5.8% of LR women and 17.1% of HR women reporting extreme scores. This finding confirms the high scores reported on the BSQ and BAAS, indicating that body shape is a central issue among our participants, especially those with high CDR.  61 5.4 Physical activity, depression, anxiety and stress findings The Baecke Physical Activity questionnaire assessed usual physical activity levels in the study population. Participants did not differ in terms of activity levels at work, which was expected since the majority of participants in both restraint groups were students. The LR and HR group were also similar in terms of sport and leisure time activity. This finding has been observed in the past28 but contrasts most studies examining the relationship between dietary restraint and exercise. A study by Beiseigel and colleagues compared women scoring high in restraint (TFEQ-R score ≥ 12; n = 21) to those with low levels (TFEQ-R score ≤ 6; n = 20) and found that the HR group dedicated 1.5 times more hours of physical activity each week6. Two additional research groups used the same criteria for restraint as our study and also observed higher hours of physical activity among HR women. In the first study, weekly hours of exercise were significantly higher in the HR group with 3.4 ± 1.7 (n = 33) versus 2.2 ± 1.8 (n = 29) hours reported, p < 0.0130. A second questionnaire-based study observed that LR women reported fewer weekly hours of exercise with a mean of 3.2 ± 3.5 (n = 180) compared to 4.6 ± 5.3 (n = 145), p < 0.057. Physical activity was not a key variable of interest in this study; however, it may have been helpful to have an additional question asking participants for their motivations behind exercise. This question could have been beneficial because although Baecke subscale scores did not significantly differ between groups, the motivations behind physical activity could provide further information. For instance, one might expect HR women to use physical activity for weight-related reasons rather than general health when compared to LR women. The self-report nature of the physical activity questionnaire also presents some difficulties  62 when comparing restraint groups. This method of estimating activity is subject to error since individuals can differ in how they rate exercise intensity and duration. HR women may be more likely to perceive an activity, such as walking, to be purposeful exercise due to their increased awareness of weight and fitness-related activities. Objective measures such as accelerometers may be useful to better understand whether physical activity levels differed by restraint. Depression, anxiety and stress scores assessed by the Daily Stress Inventory (DSI), Depression Anxiety Stress Scales (DASS) and Perceived Stress Scale (PSS) were comparable between the LR and HR groups. The DASS was primarily used to assess depression and anxiety in our study population. The overall means on the three subscales were 7.7 ± 8.2 for depression, 6.5 ± 5.9 for anxiety and 12.9 ± 8.8 for stress. Scores on the DASS were compared to established norms created from a nonclinical sample of 717 male and female undergraduate students with a mean age of 21.0 years76. “Normal” scores fall between the range of 0-9 on the depression subscale, 0-7 on the anxiety subscale and 0-14 on the stress subscale75. Based on this categorization, the mean scores for all participants fell within the normal range and we can conclude that the participants in this study had a similar frequency of depressive, anxiety and stress symptoms as their general age group. Previous studies examining restraint among healthy premenopausal women have not commonly assessed depression and anxiety but based on our results, the level of restraint did not affect depression and anxiety assessed by the DASS. On the other hand, perceived stress scores were regularly reported in past studies examining dietary restraint7,12. In a large questionnaire-based study, perceived stress scores were slightly (but significantly) higher among HR women than those categorized with low  63 levels of restraint7. It was hypothesized that higher levels of dietary restraint may heighten stress levels or alternatively, that higher levels of perceived stress may cause HR women to attend to negative food or weight-related thoughts more often. However, the findings of this study conflict with that hypothesis. Perceived stress scores also did not differ in a study of postmenopausal women with high and low levels of restraint, although urinary cortisol levels significantly differed between the two groups3. Since DSI scores also did not differ between restraint groups, it may be that stress experienced by HR women is primarily isolated to the domain of food and weight-related cognitions, which were not captured on stress scales.  5.5 Cue exposure, physiological arousal and CDR One of my primary research questions was whether women at opposite ends of the CDR spectrum differ in their physiological response to cue exposure. Before this could be examined, it was important to determine whether participants as a whole showed physiological changes after exposure to food and weight-related stimuli. By using repeated measures ANOVAs, it was observed that SBP, DBP, heart rate and afternoon salivary cortisol levels significantly changed over time and mean scores decreased from baseline to final measures. However, this study did not detect any significant between-group differences. The results are in accordance with the first hypothesis that a change in physiological measures would occur over the duration of the study. However, it was expected that cue exposure would lead to increases over time based on the belief that stimuli would activate the stress response similar to findings reported in past studies. In Vögele and colleagues’ study on the effects of cue exposure on binge and nonbinge eaters, the main effect of time was  64 significant for measures of SBP, DBP and heart rate with significant increases from baseline for all participants49. There were key methodological differences in comparison to our study. Participants in Vögele et al.’s study had 20 minutes of intense cue exposure in which their individually selected favourite foods were placed on a rotating plate close to their face. Data were collected each minute and although binge eaters had a sustained increase in SBP over the 20 minute trial, nonbinge eaters experienced decreases in SBP after 10 minutes of food exposure, which was thought to represent habituation to the stressor. Physiological arousal in response to cue exposure was also observed in a study involving 24 normal weight, non dieting women who were instructed to actively attend to their favourite foods by looking, smelling and licking food items45. Repeated measures ANOVAs involving 4 time points collected in 8 minute intervals showed significant increases in SBP, DBP and heart rate from the initial baseline measure. SBP and DBP remained significantly higher at the final measurement collected 24 minutes after the first, while heart rate decreased such that there was a nonsignificant change. A significant correlation was observed between restraint scores and SBP and DBP measures during cue exposure. The contrast between our study’s findings and past research may be due to differences in sampling and the nature of the stressor. Our sampling interval of 15 minutes was longer than both studies previously described. Physiological effects may not have been captured in our study since we collected samples over a longer duration, but with more time between samples. The stressors chosen for this study were also more subtle in nature. Food temptations and media images were selected to represent environmental cues commonly experienced by the general population. Care was taken to ensure the participant was aware  65 of food items next to her throughout the study; however, there were no instructions for direct visual attention as she completed the questionnaire package. Packaged foods were chosen due to budget and food safety reasons but the packaging may have decreased the impact of the visual stimulus. Packaging also prevented an olfactory stimulus from having an effect. Lastly, food items were chosen to represent a variety of food preferences from salty to sweet, unhealthy to healthy, but it is possible that the cues that would have provoked the most significant response for each participant were not selected. Other studies using subtle cues have had a tendency to report null findings as well. In a study on restrained (n = 11) and unrestrained women (n = 13) categorized using the Restraint Scale, physiological responses including heart rate measures were assessed immediately after exposure to pictures of neutral items, body shapes or participants’ favourite food items51. No significant between-group differences in cue reactivity were reported, nor were food slides shown to cause consistent physiological changes compared to neutral slides. Although the small sample size limits the power to detect minor differences, our study had a larger number of participants and confirms that subtle cues do not appear to differentially activate the stress response in HR versus LR women. An additional study observed no significant between-group differences in the stress reactivity of low (n = 38) and high restraint (n = 39) women assessed using Restraint Scale50. In this study, women completed stressful cognitive tests with food placed nearby on a table, with instructions that it could be eaten later. Participants had significant increases in SBP, DBP and heart rate from baseline to the end of the task period, which was expected due to the nature of the stressful cognitive tests.  66 A point of interest in our study is that HR women self-reported increased stress due to study participation in comparison to LR women, p < 0.05. CDR-related stress may not have been captured through afternoon salivary cortisol measures because cortisol levels could have decreased due to the natural circadian rhythms more than any stress-related increase over the 2 hour lab visit. Putterman and Linden reported similar findings when they collected afternoon saliva samples before and after questionnaire package completion in a subset of 48 of 170 women12. It was hypothesized that cortisol would be higher after completing restraint-related questionnaires but afternoon cortisol levels were actually lower in those who provided samples after completing the questionnaire (n = 48, t(165) = -2.4, p < 0.05). They proposed that the hour required to fill out the questionnaire may have had a sedating effect or that circadian rhythms were responsible for the decrease in cortisol. The seated period in our study was a half hour to a full hour longer than theirs so a potential sedating effect and the role of natural decreases due to circadian patterns could have had a larger effect. A further point of importance regarding afternoon salivary cortisol is that our sample population differs from past studies because we observed no afternoon differences in mean values between LR and HR women. Much of previous literature reported higher levels of afternoon salivary cortisol11,12 and 24 hour urinary cortisol17 in HR women. It is unknown why our findings contrast previous studies. Ethnicity was one between-group difference that was taken into consideration in post-hoc analysis. Overall, more Asian women participated in this study than Caucasian students, which is reflective of the UBC student demographic. Ethnicity had the potential to act as a confounding variable since differing cultural beliefs and physiological responses could have affected our research outcome. However, ethnicity  67 did not appear to have a significant effect on cortisol levels during the cue exposure period or morning sampling when we controlled for this variable during statistical analysis. The number of ACR responders also was not affected by reported ethnicity. Participants’ ethnic breakdown has often been described in past studies but usually not in relationship to restraint categories. Ethnicity also was not a primary research question in this study so a thorough investigation could not be accomplished. In conclusion, the cues used in this study may not have been ideal since the saliency of food cues appears to have a key role in predicting whether physiological changes are captured in an experimental setting. Strong visual and olfactory cues consistently cause physiological arousal. Subtle cues, as used in this study, do not appear to elicit increases in blood pressure, heart rate or afternoon salivary cortisol that can be measured in an experimental setting.  5.6 ACR and dietary restraint The awakening cortisol response was assessed the morning after the lab visit to investigate whether differences were apparent between LR and HR women. There were several strengths to this part of the procedure. It was emphasized that sampling should be completed in 15 minute intervals immediately upon awakening. This was completed correctly based on sampling logs. Furthermore, participants were instructed to call the student investigator if delays occurred, rather than sample inaccurately. A few participants did reschedule the procedure, which helped to minimize sampling error. Lastly, participants were asked if any problems arose when they returned the samples and no serious issues were reported.  68 A minimum 2.5 nmol/L increase in cortisol after awakening is required for a participant to be classified as a “responder” who shows an ACR33. In our study, 94.3% of participants met this criterion, providing confidence that the morning sampling procedure effectively captured the ACR. Although most women were observed to show an ACR, no between-group differences were observed between LR and HR women when analyzed using repeated measures ANOVA, change scores and area under the curve measures. Null findings have also been reported in a previous study where premenopausal women provided a single morning sample roughly 30 minutes after awakening12. Although this procedure does not fully capture the profile of the ACR and is more likely to be affected by inaccurate timing, no significant differences were observed between LR and HR women. The only study that has reported significant findings was completed by Therrien and colleagues44. The ACR of female participants was negatively correlated with certain eating attitude variables including disinhibition, hunger, drive for thinness, body dissatisfaction and interoceptive awareness. However, given the many variables that were assessed in this study, there is a possibility that the finding was due to chance. Alternatively, the conflicting findings may result from different participant characteristics in comparison to our study. Both studies involved premenopausal women; however, Therrien’s study recruited women who were older (mean age of 37.0 ± 1.4 years) and included obese and reduced obese women (mean BMI of 28.8 ± 1.2). Although CDR is believed to involve HPA axis dysregulation similarly to other psychosocial conditions correlated with ACR disturbances37, the failure to detect an association between CDR and the ACR suggests that differences exist between conditions. As a result of these differences, CDR may not exert clinical effects like other stressors. CDR  69 has not been recognized as a clinical condition due to its subtle, yet chronic nature. HR participants in this study did not show increased depression, anxiety or general perceived stress and while these factors have been related to ACR disturbances, CDR does not appear to have a causative role.  5.7 Conclusions, study strengths, limitations and future directions This study adds new findings to the field of literature on cognitive dietary restraint by examining the short-term effects of cue exposure and the awakening cortisol response in women experiencing very high or low levels of restraint. Overall, this study supports much of the past literature on CDR while presenting some conflicting findings. Women were chosen to be on opposite ends of the TFEQ-R scale and did not differ in age, occupation or anthropometric measures. Mean scores on eating attitude questionnaires were comparable to previous cohorts of young university aged women, with body shape being a central concern for HR women in our sample. As expected, the HR group had significantly higher scores on eating attitude subscales such as the BSQ, BAAS and EDE-Q. Depression, anxiety, stress and physical activity measures did not differ between groups, although self-reported stress due to study participation was significantly higher in the HR group. Despite this finding, the experimental setting did not lead to significant between-group differences in physiological arousal in the measures of blood pressure, heart rate or afternoon salivary cortisol. The stressor likely was not of sufficient magnitude to show large increases from baseline measures. Furthermore, the decrease in mean afternoon cortisol may have resulted from the natural fall in cortisol levels over time that was greater than any potential stress-related elevation. Lastly, the ACR did not differ between groups. While other psychosocial  70 conditions have caused ACR disturbances, CDR may not be a stressor of significant magnitude to show this type of physiological change. There were several strengths to the study design. We minimized confounding variables among participant groups by excluding those who used medications affecting blood pressure or cortisol release. Furthermore, all participants visited the lab during the days 2-10 of their menstrual cycle to avoid hormonal effects and between 1-5pm to lessen the effects of circadian rhythms on cortisol release. We emphasized the importance of accurate sampling to prevent non-compliance in the morning sampling procedure. Participants were comfortable sampling in 15 minute intervals having done so in the lab the day before. Furthermore, we encouraged that they call us to reschedule if problems arose rather than sampling inaccurately. Compliance was discussed prior to the debriefing session and analysis of the sampling logs showed that deviations were minimal. Lastly, only 2 of 70 participants guessed the true purpose of the study so deception was successful. Study limitations have been previously mentioned and are mostly focused on the nature of the stressor. Since our research question required a stressor that reflected everyday food and weight-related cues, a key component of the research design was choosing a stressor that would act as a cue, without being overly obvious to the participant. As a result, we did not tell the participant to directly attend to the experimental cues but this might have been necessary to evoke a strong physiological response. Cost and food safety concerns resulted in the use of packaged foods that the participant was encouraged to take with her; however, the packaging may have decreased the strength of the temptation item. There is also the possibility that the food items provided may not have reflected the participant’s most stress-provoking food, although we did choose a variety of food items to minimize this  71 concern. Morning sampling is believed to be completed as requested but the possibility remains that participants may not have been as careful as desired, especially when providing the first sample immediately upon awakening. Multiple days of sampling would have increased accuracy but this method was not chosen since it would have increased participant burden. Based on study results, there are several suggestions for future work. The impact of ethnicity presents an area of future exploration. In our study, we asked participants to selfidentify their ethnic group on a pre-selected list, with the option of “other” if needed. Data were collapsed into the categories of Caucasian and Asian for simplicity, resulting in the loss of some information and roughly two-thirds of participants classified as “Asian”. It could be of interest to identify whether the assessment scales used adequately reflected the concerns of all ethnic groups. Exploring ethnicity issues also requires consideration of the degree of acculturation among participants. Acculturation varied since some participants had lived in Canada all of their lives, while others were exchange students from various parts of the world. Since regional and cultural groups vary in their beliefs about food and weight-related issues, future studies could benefit from assessing the participant’s beliefs in relation to their ethnicity. Future work examining the stress-related effects of cue exposure would need to alter the stressor used. If possible, future studies may benefit from using cues that are more provoking through sight and smell such as baked goods rather than packaged foods. Prestudy questions that discretely ask the participant of their food preferences could also help to maximize the strength of the stressor by ensuring that the cues selected are most likely to provoke a response. Lastly, it could be of interest to see if and how the study influenced the  72 participant’s day after the lab visit. Since HR participants significantly differed from the LR group in the Disinhibition subscale, cue temptations may have had effects beyond the study procedure. Overall, this study added to the literature on cognitive dietary restraint and serves to illustrate that the relationship between CDR and physiological stress requires further research.  73 BIBLIOGRAPHY 1. Wansink B, Sobal J. Mindless eating: the 200 daily food decisions we overlook. Environ Behav. 2007;39(1):106-123. 2. Herman CP, Mack D. 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The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther. 1995;33(3):335-343. 77. Crawford JR, Henry JD. The Depression Anxiety Stress Scales (DASS): normative data and latent structure in a large non-clinical sample. Br J Clin Psychol. 2003;42(2):111131. 78. Antony M, Bieling P, Cox B, Enns M, Swinson R. Psychometric properties of the 42item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychol Assess. 1998;10(2):176-181. 79. Brown TA, Chorpita BF, Korotitsch W, Barlow DH. Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behav Res Ther. 1997;35(1):79-89. 80. Gotthardt U, Schweiger U, Fahrenberg J, Lauer CJ, Holsboer F, Heuser I. Cortisol, ACTH, and cardiovascular response to a cognitive challenge paradigm in aging and depression. Am J Physiol. 1995;268(4 pt 2):R865-873. 81. Stetler C, Miller GE. Blunted cortisol response to awakening in mild to moderate depression: regulatory influences of sleep patterns and social contacts. J Abnorm Psychol. 2005;114(4):697-705.  82 82. Pruessner M, Hellhammer DH, Pruessner JC, Lupien SJ. Self-reported depressive symptoms and stress levels in healthy young men: associations with the cortisol response to awakening. Psychosom Med. 2003;65(1):92-99. 83. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385-396. 84. Flint A, Raben A, Blundell JE, Astrup A. Reproducibility, power and validity of visual analogue scales in assessment of appetite sensations in single test meal studies. Int J Obes Relat Metab Disord. 2000;24(1):38-48. 85. Stubbs RJ, Hughes DA, Johnstone AM, et al. The use of visual analogue scales to assess motivation to eat in human subjects: a review of their reliability and validity with an evaluation of new hand-held computerized systems for temporal tracking of appetite ratings. Br J Nutr. 2000;84(4):405-415. 86. Kudielka BM, Kirschbaum C. Sex differences in HPA axis responses to stress: a review. Biol Psychol. 2005;69(1):113-132. 87. Kirschbaum C, Hellhammer DH. Salivary cortisol in psychobiological research: An overview. Neuropsychobiology. 1989;22(3):150-169. 88. Noble RE. Diagnosis of stress. Metabolism. 2002;51(6):37-39. 89. Amoore JN, Dewar D, Gough K, Padfield PL. Do SpaceLabs ambulatory non-invasive blood pressure recorders measure blood pressure consistently over several years use? Blood Press Monit. 2005;10(1):51-56. 90. O'Brien E, Atkins N, Mee F, O'Malley K. Comparative accuracy of six ambulatory devices according to blood pressure levels. J Hypertens. 1993;11(6):673-675.  83 91. Edwards S, Clow A, Evans P, Hucklebridge F. Exploration of the awakening cortisol response in relation to diurnal cortisol secretory activity. Life Sci, 2001;68(1):2093-2103. 92. Edwards S, Evans P, Hucklebridge F, Clow A. Association between time of awakening and diurnal cortisol secretory activity. Psychoneuroendocrinology. 2001;26(6):613-622. 93. DeSantis AS, Adam EK, Mendelsohn KA, Doane LD. Concordance between selfreported and objective wakeup times in ambulatory salivary cortisol research. Int J Behav Med. 2010;17(1):74-78. 94. Spangler DL. Testing the cognitive model of eating disorders: The role of dysfunctional beliefs about appearance. Behav Ther. 2002;33(1):87-105. 95. Luce KH, Crowther JH, Pole M. Eating Disorder Examination Questionnaire (EDE-Q): norms for undergraduate women. Int J Eat Disord. 2008;41(3):273-276. 96. Mond JM, Hay PJ, Rodgers B, Owen C. Eating Disorder Examination Questionnaire (EDE-Q): norms for young adult women. Behav Res Ther. 2006;44(1):53-62.  84 APPENDIX A: RECRUITMENT POSTER  The UBC Human Nutrition Lab is looking for female participants for a study on eating attitudes and stress Your participation will involve: 1. A 2 hour lab visit where you will complete a questionnaire package while we monitor your blood pressure and collect saliva samples. 2. Providing 4 saliva samples collected within the first hour of awakening the next morning (at your own home). You will receive a $20 gift certificate for your participation.  Eating Attitudes Study eatingattitude@gmail.com  Eating Attitudes Study eatingattitude@gmail.com  Eating Attitudes Study eatingattitude@gmail.com  Eating Attitudes Study eatingattitude@gmail.com  Eating Attitudes Study eatingattitude@gmail.com  Eating Attitudes Study eatingattitude@gmail.com  Eating Attitudes Study eatingattitude@gmail.com  Eating Attitudes Study eatingattitude@gmail.com  Eating Attitudes Study eatingattitude@gmail.com  If you are interested in participating or would like further information, please contact: eatingattitude@gmail.com  85 APPENDIX B: RECRUITMENT E-MAIL Dear ____________, Thank you for your interest in the Eating Attitudes and Stress study! This study involves a 2 hour lab visit in which you will be asked to complete a questionnaire package while we monitor your blood pressure and collect saliva samples. On the next day, you will be asked to provide 4 saliva samples collected within the first hour of awakening (this step will be done at your own home). After returning the samples to the lab, you will receive a $20 gift certificate (Starbucks, Safeway or UBC Food Services) for all of your help! To participate in this study, you must complete a short online screening questionnaire (less than 5 min) to determine whether you meet the eligibility criteria for our study. All participants must be between 19-35 years of age, non-smokers and fall within a range of scores on a screening questionnaire. You will be e-mailed if your score does not fall within the range required. If you are eligible, we will call you to schedule a lab visit at your convenience. The questionnaire can be accessed by going to the following website: https://www.surveymonkey.com/s.aspx?sm=PBtth8n_2fui1vc2roKgtyvA_3d_3d Thanks again for your interest and participation. Feel free to forward this message to any friends you think may be interested in being involved in our study. If you have any questions, please do not hesitate to ask. Mandeep Please note: Survey Monkey, a commercial online survey company, is being used to host the screening questionnaire (www.surveymonkey.com). This company was selected due to its high user ratings, no spam policy, and high degree of data security. Please be advised that any information provided to a US company is subject to the Patriot Act which allows authorities access to the records of internet service providers. The websurvey company servers record incoming IP addresses of the computer that you use to access the survey but no connection is made between your data and your computer's IP address. If you choose to participate in the survey, you understand that your responses to the survey questions will be stored and accessed in the USA. The security and privacy policy for Survey Monkey can be found at the following link: http://www.surveymonkey.com/HelpCenter/Answers.aspx?CatID=6.  86 APPENDIX C: SCREENING QUESTIONNAIRE The purpose of this questionnaire is to determine whether you meet the eligibility criteria for our study. Please answer the following questions as accurately as possible. All responses on this website are secure and encrypted. Your information will remain confidential and will only be used by the research team for screening assessment. You will be e-mailed if your score does not fall within the specified range required for this study. If you are eligible, we will call you to schedule a lab visit at your convenience. Thank you for your interest and participation. Please note: This screening questionnaire is hosted on Survey Monkey, a commercial online survey company based in the US (www.surveymonkey.com). This company was selected due to its high user ratings, no spam policy, and high degree of data security. Please be advised that any information provided to a US company is subject to the Patriot Act which allows authorities access to the records of internet service providers. This company servers record incoming IP addresses of the computer that you use to access the survey but no connection is made between your data and your computer’s IP address. If you choose to participate in the survey, you understand that your responses to the survey questions will be stored and accessed in the USA. The security and privacy policy for Survey Monkey can be found at the following link: http://www.surveymonkey.com/HelpCenter/Answers.aspx?CatID=6. 1. Name:_____________________________________ 2. Phone number: ______________________________ 3. E-mail address: ______________________________ 4. Birthday (month/date/year): ____________________ 5. What is your current weight in pounds (please provide best estimate)? ____________ lbs 6. What is your current height (please provide best estimate): _______feet _______inches 7. Do you regularly smoke cigarettes? Please choose one: Yes No 8. Have you had an eating disorder? Please choose one: Yes No 9. Are you currently pregnant or lactating? Please choose one: Yes No 10. Do you use oral contraceptives (ie: “the pill”)? Please choose one: Yes No 11. Do you take any blood pressure medications? Please choose one: Yes No 12. Do you take any corticosteroids? Please choose one: Yes No 13. Do you currently take any antihistamines? Please choose one: Yes No 14. Please list any other prescription medications you commonly take: __________________  87 Please read each statement and answer True (T) or False (F). Please answer each question as best as you can. True  False  T  F  T  F  T  F  T  F  19. While on a diet, if I eat food that is not allowed, I consciously eat less for a period of time to make up for it…………………………………...  T  F  20. I enjoy eating too much to spoil it by counting calories or watching my weight…………………………………………………………………...  T  F  21. I often stop eating when I am not really full as a conscious means of limiting the amount of food that I eat………………..…………………  T  F  T  F  T  F  T  F  T  F  T  F  15. When I have eaten my quota of calories, I am usually good about not eating any more………………………………………………………… 16. I deliberately take small helpings as a means of controlling my weight. 17. Life is too short to worry about dieting………………..……………….. 18. I have a pretty good idea of the number of calories in common foods…  22. I consciously hold back at meals in order to not gain weight………….. 23. I eat anything I want, anytime I want………………..…………………. 24. I count calories as a conscious means of controlling my weight………. 25. I do not eat some foods because they make me fat………………..…… 26. I pay a great deal of attention to changes in my figure…………………  Please answer the following questions by circling the number above the response that is most appropriate to you. Please answer the questions as best as you can. 27. How often are you dieting in a conscious effort to control your weight? 1 Rarely  2 Sometimes  3 Usually  4 Always  28. Would a weight fluctuation of 5 lbs (~2.3 kg) affect the way you live your life? 1 Not at all  2 Slightly  3 Moderately  4 Very much  88 29. Do your feelings of guilt about overeating help you to control your food intake? 1 Never  2 Rarely  3 Often  4 Always  30. How conscious are you of what you are eating? 1 Not at all  2 Slightly  3 Moderately  4 Extremely  31. How frequently do you avoid ‘stocking up’ on tempting foods? 1 Almost never  2 Seldom  3 Usually  4 Almost always  32. How likely are you to shop for low calorie foods? 1 Unlikely  2 Slightly likely  3 Moderately likely  4 Very likely  33. How likely are you to consciously eat slowly in order to cut down on how much you eat? 1 Unlikely  2 Slightly likely  3 Moderately likely  4 Very likely  34. How likely are you to consciously eat less than you want? 1 Unlikely  2 Slightly likely  3 Moderately likely  4 Very likely  35. On a scale of 0 to 5, where 0 means no restraint in eating (eating whatever you want, whenever you want it) and 5 means total restraint (constantly limiting food intake and never ‘giving in’), what would you number yourself? Please circle the number which best applies to you most of the time. 0 1 2 3 4 5  Eat whatever you want, whenever you want it. Usually eat whatever you want, whenever you want it Often eat whatever you want, whenever you want it. Often limit food intake, rarely ‘give in’. Usually limit food intake, rarely ‘give in’. Constantly limiting food intake, never ‘giving in’.  Thank you for completing this questionnaire. You will be contacted within the next few days and informed whether you are or are not eligible for participation.  89 APPENDIX D: E-MAIL TO INELIGIBLE PARTICIPANTS Dear ____________, Thank you for the time you took to complete the online screening questionnaire for the Eating Attitudes and Stress study. Unfortunately, your score on this questionnaire does not fit within the range of scores required for participation in the full study protocol. Confidentiality of the information you provided will be fully maintained. All information provided in your questionnaire has been deleted off of the secure, encrypted website. If you have any further questions, please do not hesitate to e-mail our research team at eatingattitude@gmail.com. Thank you, Mandeep  90 APPENDIX E: REMINDER E-MAIL Hi ____________, I hope you're doing well since we last spoke. I'm just sending a friendly reminder of your lab visit scheduled for ____________ from __________ pm. If any conflicts come up with this scheduled time, please contact me as soon as you can by e-mail or at (778) XXX-XXXX. Your lab visit is in Room 313 at the Food, Nutrition and Health Building (2205 East Mall). To get there, take the stairs to the third floor and turn right. There will be signs directing you to the room. Key information: •  • • •  •  As you may remember, your lab visit must occur between days 2-10 of your menstrual cycle. Please e-mail me back once you know the date your next cycle starts to ensure that ____________ falls within this time period. If your period starts significantly later than expected, I'll be in touch to discuss whether rescheduling is necessary. We would like to take 2 baseline samples at the beginning of your visit. Please review the attached letter of consent so that we may begin as soon as you arrive. A lightweight blood pressure monitor will be placed on your non-dominant arm. Please wear a loose fitting shirt, t-shirt or a cami/tank top under your shirt. Please do not eat within 2 hours of you lab visit or engage in strenuous exercise the morning of your lab visit. Have a snack/meal 2 hours prior to your visit to ensure that you are neither overly hungry nor overly full when you arrive. Lastly, if you are currently experiencing significant levels of stress, please contact me so we can discuss potentially rescheduling your lab visit.  If you have any questions, please do not hesitate to ask. I look forward to hearing back from you soon! Mandeep  91 APPENDIX F: CONSENT FORM  THE UNIVERSITY OF BRITISH COLUMBIA Food, Nutrition and Health Faculty of Land and Food Systems 2205 East Mall Vancouver, B.C. Canada V6T 1Z4 Phone: (604) 822-2502 Fax: (604) 822-5143 Title of Study: Eating Attitudes and Physiological Stress SUBJECT INFORMATION AND CONSENT FORM Principal Investigator: Susan Barr, PhD, RD Professor; Food, Nutrition and Health, University of British Columbia (UBC); (604) 822-6766 Co-Investigators: Mandeeep Sanghera, BScH, BA MSc Candidate Human Nutrition, UBC  Wolfgang Linden, PhD Professor Clinical Psychology, UBC (604) 822-4156  Tim Green, PhD Associate Professor Human Nutrition, UBC (604) 822-0421 Sponsor: Canadian Institutes of Health Research (CIHR) Invitation to Participate: You are being invited to participate in this study after indicating your interest and meeting eligibility requirements on our study website. Your Participation is Voluntary: It is important that before you make a decision to participate, you read the rest of this form. This consent form will tell you about the study, why the research is being done, what will happen during the study and the possible risks, benefits, and discomforts. Please read the following form carefully and ask questions if anything is not clear.  92 If you wish to participate, you will be asked to sign this form. If you do decide to take part in this study, you are still free to withdraw at any time and without giving any reasons for your decision. If you do not wish to participate, you do not have to provide any reason for your decision not to participate. Please take the time to read this document carefully. If you wish, you may discuss it with your family, friends and others before you decide. Purpose: The purpose of this study is to assess the physiological response of healthy young women completing questionnaires on eating attitudes and body image. Who Can Participate? You are eligible to participate in this study if you: (1) are a non-smoking female, (2) are between 19 and 35 years of age, (3) have a body mass index score that is neither underweight (less than 18.5 kg/m2) nor obese (greater than 30 kg/m2), (4) fall within a specified range of scores on a screening questionnaire regarding eating attitudes, and (5) are able to read and understand English. Who Should Not Participate? You are not able to participate in this study if you: (1) do not meet the inclusion criteria listed above, (2) use blood pressure medication, antihistamines or corticosteroids, (3) have been diagnosed with or treated for an eating disorder, or (4) are pregnant or lactating. What Does the Study Involve? If you are eligible for this study, your score on an eating attitudes questionnaire previously completed on our study website fell within a specified range. Furthermore, you met the eligibility criteria listed above (see Who Can Participate). If you choose to participate, you will visit UBC’s Human Nutrition facilities for a two-hour lab visit. In this lab visit, the study procedure will be outlined and your height, weight, waist and hip circumference will be measured. You will be asked to complete a questionnaire package consisting of various instruments designed to assess eating attitudes, body image concerns and anxiety. While completing the questionnaire package, a compact, lightweight blood pressure (BP) monitor will be fitted on your non-dominant arm to collect BP readings every 15 minutes. Upon visiting the lab and at 15 minute intervals throughout the study, you will be asked to provide saliva samples using a tool called a Salivette. Saliva samples are collected to measure cortisol, a stress hormone in the human body. At the completion of the lab visit, you will be provided with materials to collect saliva samples within your own home the next morning. You will be provided with Salivettes and general instructions, as well as a timer to remind you of when to take a sample. Saliva samples must be collected immediately upon awakening and 15, 30 and 45 minutes postawakening. You will not be allowed to eat during this period of time to prevent sample contamination. You will be asked to return these samples to UBC’s Human Nutrition facilities later that day, at which time you will receive a $20 gift certificate for your participation. Potential Risks: There are no known risks involved with participating in this research study.  93 Potential Benefits: There is no direct benefit to you for participating in this study. It is hoped that the information gained from this research study will provide insight into the relationship between physiological stress and eating attitudes among young women. A summary of the research results, once completed, will be provided to you, if you would like to receive it. Your Participant Rights & Responsibilities: Your participation in this study is entirely voluntary and you may refuse to participate or withdraw from the study at any time without penalty or repercussions. You may withdraw without providing any explanation of your reasons for doing so. If you choose to enter the study and then decide to withdraw at a later time, all data collected about you during your enrolment in the study will be retained for analysis. By law, this data cannot be destroyed. Your participation in this study is not associated with any known risks of injury or illness. However, you do not waive any of your legal rights by signing this consent form. We ask that you please inform the research team if you are no longer able or willing to participate in the study. Remuneration/Compensation: After returning saliva samples to the UBC Human Nutrition facilities, you will receive a $20 gift certificate in recognition of your participation. Confidentiality: All samples, test results, questionnaires and other documents will be labelled with code numbers only (your name will not be associated with these results or documents) and will be kept in a locked filing cabinet in the investigators’ office. After your saliva samples have been analyzed, they will be disposed of. Your study-related information will be used at UBC as part of the co-investigator’s graduate thesis. Your confidentiality will be respected and no information that discloses your identity will be released or published. If the results of this study are published or presented in public, information that identifies you will be removed. Contact Information: If you have any questions or desire further information about this study before or during participation, you can contact Mandeep Sanghera at (778) XXXXXXX or Dr. Susan Barr at (604) 822-6766. If you have any concerns about your rights as a research subject and/or your experiences while participating in this study, contact the Research Subject Information Line in the University of British Columbia Office of Research Services at (604) 822-8598.  94 Consent to Participate:  I have read and understood the subject information and consent form.  I have had the opportunity to ask questions and have had satisfactory responses to my questions.  I understand that all of the information collected will be kept confidential and that the result will only be used for scientific objectives.  I understand that my participation in this study is voluntary and that I am completely free to refuse to participate or to withdraw from this study at any time and without changing in any way the quality of care that I receive.  I understand that there is no guarantee that this study will provide any benefits to me.  I have read this form and I freely consent to participate in this study.  I have been told that I will receive a dated and signed copy of this form to keep for my records.  ________________________________________________________________________ Printed Name of Participant Signature Date  ________________________________________________________________________ Printed Name of Signature Date Principal Investigator or Designated Representative  95 APPENDIX G: QUESTIONNAIRE PART ONE  ID #_______  QUESTIONNAIRE PACKAGE – PART ONE –  INSTRUCTIONS •  This will take 30 minutes to complete.  •  Please answer the questions as best you can by choosing the most appropriate answer for each question. Ignore the columns marked “Office Use Only”.  •  Please use the provided pen. If you need to make any changes, please clearly indicate the desired answer with a note in the margin.  •  Your confidentiality will be respected and no information that discloses your identity will be released.  •  Please do not remove any pages and keep the booklet attached.  •  Do not hesitate to contact Mandeep at (778) XXX-XXXX if you have any questions. Thank you very much for accurately completing this questionnaire!  PLEASE TURN THE PAGE TO BEGIN.  96 1. What is your current age? __________________ years 2. Are you a student? ___ No ___ Yes  If yes: (a) Please check off to indicate whether you are: ___ An undergraduate student ___ A graduate student ___ An unclassified student (b) What is your major? ________________________________ 3. With what race/ethnic group do you identify? (Check all that apply) ___ Caucasian ___ Chinese ___ South Asian (Indian, Pakistani, Punjabi, Sri Lankan) ___ Black (African, Haitian, Jamaican, Somali) ___ First Nations ___ Arab/West Asian (Armenian, Egyptian, Iranian, Lebanese) ___ Filipino ___ South East Asian (Cambodian, Indonesian, Vietnamese) ___ Latin American ___ Japanese ___ Korean ___ Other (please specify): ________________________________  The following questions relate to lifestyle behaviours. Please answer the questions choosing the most appropriate answer for each statement. 4. How would you describe your typical diet? ____ Mixed: I eat meat, dairy products, eggs, fruits & vegetables, grains ____ Lacto-ovo vegetarian: I DO NOT eat meat, fish or poultry, but I DO eat dairy, eggs, fruits & vegetables, grains ____ Pesco-pollo vegetarian: I DO NOT eat red meat, but I DO eat chicken and/or fish, dairy, eggs, fruits & vegetables, grains ____ Vegan: I exclude ALL animal products ____ Other (please specify): ________________________________ 5. Are you currently trying to lose weight? ___ No ___ Yes  97 6. How do you feel about your weight right now? I think I am… ____ Very overweight ____ Slightly overweight ____ About right ____ Slightly underweight ____ Very underweight 7. Do you currently take any medications (including prescription, over-the-counter, homeopathic or naturopathic)? ___ No ___ Yes  If yes: please list the NAME of medication(s), what you are taking it for and the FREQUENCY you take them below (i.e. twice per day, daily, weekly, etc.): Example: Midol, Menstrual cramps, ~5 days per month ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ___ 8. Do you currently take any nutritional or herbal supplements? ___ No ___ Yes  If yes: please list the NAME, DOSE, and BRAND of the supplement(s) and the FREQUENCY you use them (i.e. twice per day, daily, weekly, etc.): Example: Echinacea (1000 mg), Jamieson, Daily ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ____________________________________________________________  Questions 9-16 relate to your current level of appetite and desire for food. Please answer by placing a vertical mark in the appropriate position on the line below: 9. How hungry do you feel?  | I am not hungry at all  | I have never been more hungry  98 10. How satisfied do you feel?  | I am completely empty  | I cannot eat another bite  11. How full do you feel?  |  |  Not at all full  Totally full  12. How much do you think you can eat?  | Nothing at all  | A lot  13. Would you like to eat something sweet?  | Yes, very much  | No, not at all  14. Would you like to eat something salty?  | Yes, very much  | No, not at all  15. Would you like to eat something savoury?  | Yes, very much  | No, not at all  16. Would you like to eat something fatty?  | Yes, very much  | No, not at all  99  The following questions relate to eating behaviours. Please read each statement and circle True (T) or False (F). Please answer each question as best you can. True  False  17. When I smell the aroma of my favourite food, I find it very difficult to keep from eating, even if I have just finished a meal…………………...  T  F  18. I usually eat too much at social occasions, like parties and picnics…….  T  F  19. I am usually so hungry that I eat more than three times a day………….  T  F  20. When I have eaten my quota of calories, I am usually good about not eating any more………………..………………..………………………  T  F  21. Dieting is so hard for me because I just get too hungry………………...  T  F  22. I deliberately take small helpings as a means of controlling my weight.  T  F  23. Sometimes things just taste so good that I keep on eating even when I am no longer hungry………………..…………………..…....................  T  F  24. Since I am often hungry, I sometimes wish that while I am eating, an expert would tell me that I have had enough or that I can have something more to eat……………………………………………..........  T  F  25. When I feel anxious, I find myself eating………………..……………..  T  F  26. Life is too short to worry about dieting………………..………………..  T  F  27. Since my weight goes up and down, I have gone on reducing diets more than once………………………………………………………….  T  F  28. I often feel so hungry that I just have to eat something………………...  T  F  29. When I am with someone who is overeating, I usually overeat too……  T  F  30. I have a pretty good idea of the number of calories in common foods…  T  F  31. Sometimes when I start eating, I just can’t seem to stop……………….  T  F  32. It is not difficult for me to leave something on my plate……………….  T  F  33. At certain times of the day, I get hungry because I have gotten used to eating then………………………………………………………………  T  F  34. While on a diet, if I eat food that is not allowed, I consciously eat less for a period of time to make up for it………………..………………….  T  F  35. Being with someone who is eating often makes me hungry enough to eat also…..................................................................................................  T  F  36. When I feel blue, I often overeat………………..………………………  T  F  37. I enjoy eating too much to spoil it by counting calories or watching my weight…………………………………………………………………...  T  F  38. When I see a real delicacy, I often get so hungry that I have to eat right away……………………………………………………………………  T  F  100  39. I often stop eating when I am not really full as a conscious means of limiting the amount of food that I eat………………..…………………  T  F  40. I get so hungry that my stomach often seems like a bottomless pit…….  T  F  41. My weight has hardly changed at all in the last two years……………...  T  F  42. I am always hungry so it is hard for me to stop eating before I finish the food on my plate………………..…………………………………...  T  F  43. When I feel lonely, I console myself by eating…………………………  T  F  44. I consciously hold back at meals in order to not gain weight…………..  T  F  45. I sometimes get very hungry late in the evening or at night……………  T  F  46. I eat anything I want, anytime I want………………..………………….  T  F  47. Without even thinking about it, I take a long time to eat……………….  T  F  48. I count calories as a conscious means of controlling my weight……….  T  F  49. I do not eat some foods because they make me fat………………..……  T  F  50. I am always hungry enough to eat at any time………………..………...  T  F  51. I pay a great deal of attention to changes in my figure…………………  T  F  52. While on a diet, if I eat a food that is not allowed, I often then splurge and eat other high calorie foods………………..……………………….  T  F  53. If I eat a little bit more on one day, I make up for it the next day……...  T  F  54. I pay attention to my figure, but I still enjoy a variety of foods………..  T  F  55. I prefer light foods that are not fattening………………..……………...  T  F  56. If I eat a little bit more during one meal, I make up for it at the next meal……………………………………………………………………..  T  F  57. I eat diet foods, even if they do not taste very good……………………  T  F  58. A diet would be too boring a way for me to lose weight……………….  T  F  59. I would rather skip a meal than stop eating in the middle of one………  T  F  60. I alternate between times when I diet strictly and times when I don’t pay much attention to what and how much I eat………………..………  T  F  61. Sometimes I skip meals to avoid gaining weight……………………….  T  F  62. I avoid some foods on principle even though I like them………………  T  F  63. I try to stick to a plan when I lose weight………………..……………..  T  F  64. Without a diet plan I wouldn’t know how to control my weight……….  T  F  65. Quick success is most important to me during a diet…………………...  T  F  101  Please answer the following questions by circling the number above the response that is most appropriate to you. Please answer the questions as best as you can. 66. How often are you dieting in a conscious effort to control your weight? 1 Rarely  2 Sometimes  3 Usually  4 Always  67. Would a weight fluctuation of 5 lbs (~2.3 kg) affect the way you live your life? 1 Not at all  2 Slightly  3 Moderately  4 Very much  3 Often between meals  4 Almost always  68. How often do you feel hungry? 1 Only at mealtimes  2 Sometimes between meals  69. Do your feelings of guilt about overeating help you to control your food intake? 1 Never  2 Rarely  3 Often  4 Always  70. How difficult would it be for you to stop eating halfway through dinner and not eat for the next four hours? 1 Easy  2 Slightly difficult  3 Moderately difficult  4 Very difficult  71. How conscious are you of what you are eating? 1 Not at all  2 Slightly  3 Moderately  4 Extremely  72. How frequently do you avoid ‘stocking up’ on tempting foods? 1 Almost never  2 Seldom  3 Usually  4 Almost always  73. How likely are you to shop for low calorie foods? 1 Unlikely  2 Slightly likely  3 Moderately likely  4 Very likely  74. Do you eat sensibly in front of others and splurge alone? 1 Never  2 Rarely  3 Often  4 Always  102 75. How likely are you to consciously eat slowly in order to cut down on how much you eat? 1 Unlikely  2 Slightly likely  3 Moderately likely  4 Very likely  76. How frequently do you skip dessert because you are no longer hungry? 1 Almost never  2 Seldom  3 At least once a week  4 Almost every day  77. How likely are you to consciously eat less than you want? 1 Unlikely  2 Slightly likely  3 Moderately likely  4 Very likely  78. Do you go on eating binges though you are not hungry? 1 Never  2 Rarely  3 Sometimes  4 At least once a week  79. Do you deliberately restrict your intake during meals even though you would like to eat more? 1 Never  2 Rarely  3 Often  4 Always  80. On a scale of 0 to 5, where 0 means no restraint in eating (eating whatever you want, whenever you want it) and 5 means total restraint (constantly limiting food intake and never ‘giving in’), what number would you give yourself? Please circle the number which best applies to you most of the time. 0 1 2 3 4 5  Eat whatever you want, whenever you want it. Usually eat whatever you want, whenever you want it Often eat whatever you want, whenever you want it. Often limit food intake, but often ‘give in’. Usually limit food intake, rarely ‘give in’. Constantly limiting food intake, never ‘giving in’.  81. To what extent does this statement describe your eating behaviour? ‘I start dieting in the morning, but because of any number of things that happen during the day, by evening I have given up and eat what I want, promising myself to start dieting again tomorrow’. 1 Not like me  2 Little like me  3 Pretty good description of me  4 Describes me perfectly  103  “I used to crave bad foods all the time. Now I value clean eating because I love the feeling of being in control of my diet, rather than have it control me.” Kate, 23, fitness model. Kate Richards Daily Calories: 1,600  To keep in shape, Kate includes a variety of foods in her six daily meals. She focuses on a diet that includes lean meats, whole grains and healthy fats from sources like olive oil. FAVOURITE CLEAN MEAL: pumpkin pancakes (½ cup oatmeal, ½ cup canned pumpkin and 3 egg whites, topped with Splenda) COULDN’T LIVE WITHOUT: “My food scale. It’s easy to overestimate portion sizes so I measure out my foods to keep track of calories and make sure I meet my goals.” ǀJ uly 2008 ǀ  What are your thoughts on Kate’s diet? Is this eating attitude similar to your own? Why or why not? Please continue on the back of this page if needed.  _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________  104  The questions in this scale relate to stress and ask you about your feelings and thoughts during the last month. In each case, you will be asked to indicate how often you felt or thought a certain way. Although some of the questions are similar, there are differences between them and you should treat each one as a separate question. The best approach is to answer each question fairly quickly. That is, don’t try to count up the number of times you felt a particular way, but rather indicate the alternative that seems like a reasonable estimate. 82. In the last month, how often have you been upset because of something that happened unexpectedly? 0 Never  1 Almost never  2 Sometimes  3 Fairly often  4 Very often  83. In the last month, how often have you felt that you were unable to control the important things in your life? 0 Never  1 Almost never  2 Sometimes  3 Fairly often  4 Very often  84. In the last month, how often have you felt nervous and “stressed”? 0 Never  1 Almost never  2 Sometimes  3 Fairly often  4 Very often  85. In the last month, how often have you dealt successfully with irritating life hassles? 0 Never  1 Almost never  2 Sometimes  3 Fairly often  4 Very often  86. In the last month, how often have you felt that you were effectively coping with important changes that were occurring in your life? 0 Never  1 Almost never  2 Sometimes  3 Fairly often  4 Very often  87. In the last month, how often have you felt confident about your ability to handle your personal problems? 0 Never  1 Almost never  2 Sometimes  3 Fairly often  4 Very often  88. In the last month, how often have you felt that things were going your way? 0 Never  1 Almost never  2 Sometimes  3 Fairly often  4 Very often  105 89. In the last month, how often have you found that you could not cope with all the things that you had to do? 0 Never  1 Almost never  2 Sometimes  3 Fairly often  4 Very often  90. In the last month, how often have you been able to control irritations in your life? 0 Never  1 Almost never  2 Sometimes  3 Fairly often  4 Very often  91. In the last month, how often have you felt that you were on top of things? 0 Never  1 Almost never  2 Sometimes  3 Fairly often  4 Very often  92. In the last month, how often have you been angered because of things that happened that were outside of your control? 0 Never  1 Almost never  2 Sometimes  3 Fairly often  4 Very often  93. In the last month, how often have you found yourself thinking about things that you have to accomplish? 0 Never  1 Almost never  2 Sometimes  3 Fairly often  4 Very often  94. In the last month, how often have you been able to control the way you spend your time? 0 Never  1 Almost never  2 Sometimes  3 Fairly often  4 Very often  95. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them? 0 Never  1 Almost never  2 Sometimes  3 Fairly often  4 Very often  106  “Food is fuel. Nothing more, nothing less.” Lindsay, 26, triathlete.  Jenny Kim  Daily Calories: 1,200 – 1,500  Jenny, a gymnast and fitness instructor, knows that carbs are a key source of energy. Her favourite sources are oatmeal and sweet potatoes.  Lindsay Marshall  #1 TEMPTATION: Fast-food. “I have a cheat meal once a week and that’s when I indulge with all the pizza and ice cream I can eat!”  Lindsay believes in clean eating every day and think cheat meals do more harm than good. She believes in intuitive eating rather than counting calories: “I try to eliminate all distractions during meals so I’m aware of my hunger signals and stop eating when full.” BIGGEST NUTRITIONAL CHALLENGE: “I have a HUGE sugar tooth!! I stay away from high calorie desserts by choosing low-fat, low-calorie foods.” Some of Lindsay’s favourites are protein brownies and sugar-free hot chocolate. ǀJ uly 2008ǀ 45 Do you identify more with Lindsay or Jenny’s diet strategy? Please explain and continue on the back of this page if necessary.  ______________________________________________ ______________________________________________ ______________________________________________  107  These questions are designed to assess emotional state. Please read each statement and circle a number 0, 1, 2 or 3 that indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. 96. I found myself getting upset by quite trivial things… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  97. I was aware of dryness of my mouth… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  98. I couldn’t seem to experience any positive feeling at all… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  99. I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion)… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  100. I just couldn’t seem to get going… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  108 101. I tended to over-react to situations… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  102. I had a feeling of shakiness (eg, legs going to give way)… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  103. I found it difficult to relax… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  104. I found myself in situations that made me so anxious I was most relieved when they ended… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  105. I felt that I had nothing to look forward to… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  106. I found myself getting upset rather easily… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  109 107. I felt that I was using a lot of nervous energy… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  108. I felt sad and depressed… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  109. I found myself getting impatient when I was delayed in any way (eg, elevators, traffic lights, being kept waiting)… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  110. I had a feeling of faintness… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  111. I felt that I had lost interest in just about everything… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  112. I felt I wasn’t worth much as a person… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  110 113. I felt that I was rather touchy… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  114. I perspired noticeably (eg, hands sweaty) in the absence of high temperatures or physical exertion… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  115. I felt scared without any good reason… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  116. I felt that life wasn't worthwhile… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  117. I found it hard to wind down… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  118. I had difficulty in swallowing… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  111 119. I couldn't seem to get any enjoyment out of the things I did… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  120. I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat)… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  121. I felt down-hearted and blue… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  122. I found that I was very irritable… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  123. I felt I was close to panic… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  124. I found it hard to calm down after something upset me… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  112 125. I feared that I would be "thrown" by some trivial but unfamiliar task… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  126. I was unable to become enthusiastic about anything… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  127. I found it difficult to tolerate interruptions to what I was doing… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  128. I was in a state of nervous tension… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  129. I felt I was pretty worthless… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  130. I was intolerant of anything that kept me from getting on with what I was doing… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  113 131. I felt terrified… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  132. I could see nothing in the future to be hopeful about… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  133. I felt that life was meaningless… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  134. I found myself getting agitated… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  135. I was worried about situations in which I might panic and make a fool of myself… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  136. I experienced trembling (eg, in the hands)… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  114 137. I found it difficult to work up the initiative to do things… 0 Did not apply to me at all  1 Applied to me to some degree, or some of the time  2 Applied to me a considerable degree, or a good part of the time  3 Applied to me very much, or most of the time  138. Please indicate, by placing a vertical mark in the appropriate position on the line below, how stressful your participation in this study has been so far:  | 0 Not at all stressful  | 100 Extremely stressful  **************************************************************** Thank you for completing this questionnaire! ****************************************************************  115 APPENDIX H: QUESTIONNAIRE PART TWO  ID #_______  QUESTIONNAIRE PACKAGE – PART TWO –  INSTRUCTIONS •  This will take 30 minutes to complete.  •  Please answer the questions as best you can by choosing the most appropriate answer for each question. Ignore the columns marked “Office Use Only”.  •  Please use the provided pen. If you need to make any changes, please clearly indicate the desired answer with a note in the margin.  •  Your confidentiality will be respected and no information that discloses your identity will be released.  •  Please do not remove any pages and keep the booklet attached.  •  Do not hesitate to contact Mandeep at (778) XXX-XXXX if you have any questions. Thank you very much for accurately completing this questionnaire!  PLEASE TURN THE PAGE TO BEGIN.  116  We would like to know how you have been feeling about your appearance over the past month. Please read each question and circle the appropriate number. Please answer the questions the best you can. 1. Have you been afraid that you might become fat (or fatter)? 1 Never  2 Rarely  3 Sometimes  4 Often  5 Very often  6 Always  2. Has feeling full (e.g., after eating a large meal) made you feel fat? 1 Never  2 Rarely  3 Sometimes  4 Often  5 Very often  6 Always  3. Has thinking about your shape interfered with your ability to concentrate (e.g., while watching television, reading, listening to conversations)? 1 Never  2 Rarely  3 Sometimes  4 Often  5 Very often  6 Always  4 Often  5 Very often  6 Always  4 Often  5 Very often  6 Always  4. Have you imagined cutting off fleshy areas of your body? 1 Never  2 Rarely  3 Sometimes  5. Have you felt excessively large and rounded? 1 Never  2 Rarely  3 Sometimes  6. Have you thought that you are the shape you are because you lack self-control? 1 Never  2 Rarely  3 Sometimes  4 Often  5 Very often  6 Always  7. Has seeing your reflection (e.g. in a mirror or shop window) made you feel bad about your shape? 1 Never  2 Rarely  3 Sometimes  4 Often  5 Very often  6 Always  8. Have you been particularly self-conscious about your shape when in the company of other people? 1 Never  2 Rarely  3 Sometimes  4 Often  5 Very often  6 Always  117  The following section is designed to assess attitudes, feelings and behaviours related to eating. These questions are concerned with the past four weeks only. 9. On how many of the past 28 days, have you been deliberately trying to limit the amount of food you eat to influence your shape or weight (whether or not you have succeeded)? 0 No days  1 1-5 days  2 6-12 days  3 13-15 days  4 16-22 days  5 23-27 days  6 Every day  10. On how many of the past 28 days, have you gone for long periods of time (8 waking hours or more) without eating anything at all in order to influence your shape or weight? 0 No days  1 1-5 days  2 6-12 days  3 13-15 days  4 16-22 days  5 23-27 days  6 Every day  11. On how many of the past 28 days, have you tried to exclude from your diet any foods that you like in order to influence your shape or weight (whether or not you have succeeded)? 0 No days  1 1-5 days  2 6-12 days  3 13-15 days  4 16-22 days  5 23-27 days  6 Every day  12. On how many of the past 28 days, have you tried to follow definite rules regarding your eating (for example, a calorie limit) in order to influence your shape or weight (whether or not you have succeeded)? 0 No days  1 1-5 days  2 6-12 days  3 13-15 days  4 16-22 days  5 23-27 days  6 Every day  13. On how many of the past 28 days, have you had a definite desire to have an empty stomach with the aim of influencing your shape or weight? 0 No days  1 1-5 days  2 6-12 days  3 13-15 days  4 16-22 days  5 23-27 days  6 Every day  14. On how many of the past 28 days, have you had a definite desire to have a totally flat stomach? 0 No days  1 1-5 days  2 6-12 days  3 13-15 days  4 16-22 days  5 23-27 days  6 Every day  118 15. On how many of the past 28 days, has thinking about food, eating or calories made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)? 0 No days  1 1-5 days  2 6-12 days  3 13-15 days  4 16-22 days  5 23-27 days  6 Every day  16. On how many of the past 28 days, has thinking about shape or weight made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)? 0 No days  1 1-5 days  2 6-12 days  3 13-15 days  4 16-22 days  5 23-27 days  6 Every day  17. On how many of the past 28 days, have you had a definite fear of losing control over eating? 0 No days  1 1-5 days  2 6-12 days  3 13-15 days  4 16-22 days  5 23-27 days  6 Every day  18. On how many of the past 28 days, have you had a definite fear that you might gain weight? 0 No days  1 1-5 days  2 6-12 days  3 13-15 days  4 16-22 days  5 23-27 days  6 Every day  4 16-22 days  5 23-27 days  6 Every day  19. On how many of the past 28 days, have you felt fat? 0 No days  1 1-5 days  2 6-12 days  3 13-15 days  20. On how many of the past 28 days, have you had a strong desire to lose weight? 0 No days  1 1-5 days  2 6-12 days  3 13-15 days  4 16-22 days  5 23-27 days  6 Every day  For questions 21-25, please fill in the appropriate number in the blank on the right. Please remember that the questions only refer to the past four weeks (28 days). 21. Over the past 28 days, how many times have you eaten what other people would regard as an unusually large amount of food (given the circumstances)?  _________  •  _________  On how many of these times did you have a sense of having lost control over your eating (at the time that you were eating)?  119  22. Over the past 28 days, on how many DAYS have such episodes of overeating occurred (i.e., you have eaten an unusually large amount of food and have had a sense of loss of control at the time)?  _________  23. Over the past 28 days, how many times have you made yourself sick (vomit) as a means of controlling your shape or weight?  _________  24. Over the past 28 days, how many times have you taken laxatives as a means of controlling your shape or weight?  _________  25. Over the past 28 days, how many times have you exercised in a “driven” or “compulsive” way as a means of controlling your weight, shape or amount of fat, or to burn off calories?  _________  For the following questions, please circle the appropriate number. Please note that for these questions the term “binge eating” means eating what others would regard as an unusually large amount of food for the circumstances, accompanied by a sense of having lost control over eating. 26. Over the past 28 days, on how many days have you eaten in secret (ie, furtively)? Do not count episodes of binge eating. 0 No days  1 1-5 days  2 6-12 days  3 13-15 days  4 16-22 days  5 23-27 days  6 Every day  27. Over the past 28 days, on what proportion of the times that you have eaten have you felt guilty (felt that you’ve done wrong) because of its effect on your shape or weight? Do not count episodes of binge eating. 0 No days  1 1-5 days  2 6-12 days  3 13-15 days  4 16-22 days  5 23-27 days  6 Every day  28. Over the past 28 days, how concerned have you been about other people seeing you eat? Do not count episodes of binge eating. Not at All 0  Slightly 1  2  Moderately 3  4  Markedly 5  6  29. Over the past 28 days, has your weight influenced how you think about (judge) yourself as a person? Not at All 0  Slightly 1  2  Moderately 3  4  Markedly 5  6  120 30. Over the past 28 days, has your shape influenced how you think about (judge) yourself as a person? Not at All 0  Slightly 1  2  Moderately 3  4  Markedly 5  6  31. Over the past 28 days, how much would it have upset you if you had been asked to weigh yourself once a week (no more, or less, often) for the next four weeks? Not at All 0  Slightly 1  2  Moderately 3  4  Markedly 5  6  32. Over the past 28 days, how dissatisfied have you been with your weight? Not at All 0  Slightly 1  2  Moderately 3  4  Markedly 5  6  33. Over the past 28 days, how dissatisfied have you been with your shape? Not at All 0  Slightly 1  2  Moderately 3  4  Markedly 5  6  34. Over the past 28 days, how uncomfortable have you felt seeing your body (for example, seeing your shape in the mirror, in a shop window reflection, while undressing or taking a bath or shower)? Not at All 0  Slightly 1  2  Moderately 3  4  Markedly 5  6  35. Over the past 28 days, how uncomfortable have you felt about others seeing your shape of figure (for example, in communal changing rooms, when swimming, or wearing tight clothes)? Not at All 0  Slightly 1  2  Moderately 3  4  Markedly 5  6  121  Carmen Marie Daily Calories: 2,000  When competing, Carmen’s staples are high-protein foods including chicken, salmon and canned tuna. “I don’t get bored with my diet by trying new ways of cooking and seasoning.” FAVOURITE CLEAN EATING TOOL: George Foreman grill COULDN’T LIVE WITHOUT: Chocolate whey protein powder  Alyson Porter  Daily Calories: 1,800 – 2,200  To power her intense workout regimen, Alyson eats every three hours. She packs clean meals and snacks when away from home. “I always have a stash of protein bars and trail mix at work, it keeps me away from the vending machines!” FAVOURITE CLEAN MEAL: grilled chicken with veggies  “Never skip meals! It becomes so much harder to resist cravings for junk food.” Alyson, 26, Fitness Pacific Champion 2008. ǀJ uly 2008 ǀ  After reading Carmen and Alyson’s profile, how would you describe your usual diet? What do you define as “clean eating”? Please continue on the back of this page if needed.  _________________________________________________ _________________________________________________ _________________________________________________  122  The following questions ask about usual physical activity. Please answer the questions choosing the most appropriate answer for each statement. 36. What is your main occupation? _____________________________________________. 37. At work I sit: 1 Never  2 Seldom  3 Sometimes  4 Often  5 Always  2 Seldom  3 Sometimes  4 Often  5 Always  2 Seldom  3 Sometimes  4 Often  5 Always  3 Sometimes  4 Often  5 Always  2 Seldom  3 Sometimes  4 Often  5 Always  2 Seldom  3 Sometimes  4 Often  5 Always  38. At work I stand: 1 Never 39. At work I walk: 1 Never  40. At work I lift heavy loads: 1 Never  2 Seldom  41. After working I am tired: 1 Never 42. At work I sweat: 1 Never  43. In comparison with others of my own age I think my work is physically: 1 Much lighter  2 Lighter  3 As heavy  4 Heavier  5 Much heavier  44. Do you play a sport (running & biking are considered sports)? ___ No ___ Yes  If yes: which sport do you play most frequently? ___________________ a. How many hours a week? ___ Less than 1 hour ___ 2 to 3 hours ___ More than 4 hours  ___ 1 to 2 hours ___ 3 to 4 hours  123 b. How many months a year? ___ Less than 1 month ___ 4 to 6 months ___ More than 9 months  ___ 1 to 3 months ___ 7 to 9 months  45. Do you play a second sport (running & biking are considered sports)? ___ No ___ Yes  If yes: Which sport is it? ______________________________________ a. How many hours a week? ___ Less than 1 hour ___ 2 to 3 hours ___ More than 4 hours  ___ 1 to 2 hours ___ 3 to 4 hours  b. How many months a year? ___ Less than 1 month ___ 4 to 6 months ___ More than 9 months  ___ 1 to 3 months ___ 7 to 9 months  46. In comparison with others of my own age I think my physical activity during leisure time is: 1 Much less  2 Less  3 The same  4 More  5 Much more  3 Sometimes  4 Often  5 Very often  3 Sometimes  4 Often  5 Very often  3 Sometimes  4 Often  5 Very often  3 Sometimes  4 Often  5 Very often  3 Sometimes  4 Often  5 Very often  47. During leisure time I sweat: 1 Never  2 Seldom  48. During leisure time I play sport: 1 Never  2 Seldom  49. During leisure time I watch television: 1 Never  2 Seldom  50. During leisure time I walk: 1 Never  2 Seldom  51. During leisure time I cycle: 1 Never  2 Seldom  124 52. How many minutes do you walk and/or cycle per day to and from work, school and shopping? ___ Less than 5 minutes ___ 5 to 15 minutes ___ 15 to 30 minutes ___ 30 to 45 minutes ___ More than 45 minutes  The following series of questions ask you to indicate the degree of agreement with the following statements about appearance. Please answer each question as best as you can by circling the appropriate number. 53. The opinion others have of me is based on my appearance… 1 Not at all  2 Somewhat  3 Moderately  4 A lot  5 Extremely  54. The amount of influence I have on other people depends upon how I look… 1 Not at all  2 Somewhat  3 Moderately  4 A lot  5 Extremely  4 A lot  5 Extremely  55. People would be more interested in me if I looked better… 1 Not at all  2 Somewhat  3 Moderately  56. My relationships would improve if I looked the way I wished… 1 Not at all  2 Somewhat  3 Moderately  4 A lot  5 Extremely  57. The amount of success I have in my future job or career depends largely upon how I look… 1 Not at all  2 Somewhat  3 Moderately  4 A lot  5 Extremely  4 A lot  5 Extremely  58. My appearance influences my ability to do things… 1 Not at all  2 Somewhat  3 Moderately  59. My performance in activities (e.g. school, work, hobbies) is influenced by how I look… 1 Not at all  2 Somewhat  3 Moderately  4 A lot  5 Extremely  125 60. The opportunities that are available to me depend upon how I look… 1 Not at all  2 Somewhat  3 Moderately  4 A lot  5 Extremely  61. My school and work performance or opportunities would improve if I looked the way I wished… 1 Not at all  2 Somewhat  3 Moderately  4 A lot  5 Extremely  4 A lot  5 Extremely  62. My value as a person depends upon how I look… 1 Not at all  2 Somewhat  3 Moderately  63. How I feel about myself is largely based on my appearance… 1 Not at all  2 Somewhat  3 Moderately  4 A lot  5 Extremely  64. I would think more highly of myself if I looked the way I wished… 1 Not at all  2 Somewhat  3 Moderately  4 A lot  5 Extremely  4 A lot  5 Extremely  65. How I look is a large part of who I am… 1 Not at all  2 Somewhat  3 Moderately  66. It is difficult to feel good about myself when I am not looking my best… 1 Not at all  2 Somewhat  3 Moderately  4 A lot  5 Extremely  4 A lot  5 Extremely  67. My ability to feel happy depends upon how I look… 1 Not at all  2 Somewhat  3 Moderately  68. Improving my appearance is one of the few activities that makes me feel good or like I am accomplishing something…  1 Not at all  2 Somewhat  3 Moderately  4 A lot  5 Extremely  69. My life will be more exciting or rewarding if I look good… 1 Not at all  2 Somewhat  3 Moderately  4 A lot  5 Extremely  126 70. My moods are influenced by how I look… 1 Not at all  2 Somewhat  3 Moderately  4 A lot  5 Extremely  4 A lot  5 Extremely  71. I would enjoy life more if I looked the way I wished… 1 Not at all  2 Somewhat  3 Moderately  127  “I eat protein at every meal and have a meal or snack every 3 hours to keep my metabolism going. My diet helps me feel healthy and fuels my day.” Sarah, 24, fitness instructor. After reading the article, do you agree with Sarah’s diet strategy? Why or why not? Please write on the back of this page if necessary.  __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ Sarah Miller  Daily Calories: 1,800 – 2,100  Sarah wakes up to her daily routine of a morning workout, followed with quick oats mixed with protein powder. Snacks include protein shakes with soy milk, fat-free cottage cheese or scrambled egg whites with veggies. ALWAYS IN HER KITCHEN: liquid egg whites, protein powder and quick oats. HER LAST MEAL WOULD BE: waffles with ice cream and chocolate sauce.  ǀJ uly 2008ǀ  48  128 72. Below are listed a variety of events that may be viewed as stressful or unpleasant. Read each item carefully and decide whether or not that event occurred within the PAST 24 HOURS. Indicate if the event did occur (Y) or did not occur (N) in the DID EVENT OCCUR? column. If the event DID occur, indicate the amount of stress that it caused on a scale of 1 to 7 by checking the appropriate column. Please answer honestly as you can so that we may obtain accurate information.  EVENT  Performed poorly at a task Performed poorly due to others Thought about unfinished work Hurried to meet a deadline Interrupted during a task/activity Someone spoiled your completed task Did something you are unskilled at Unable to complete a task Was unorganized Criticized or verbally attacked Ignored by others Spoke or performed in public Dealt with rude waiter/waitress/salesperson Interrupted while talking Was forced to socialize Someone broke a promise/appointment Competed with someone Was misunderstood  In the Past 24 Hours, Did Event Occur? (Y or N)  Amount of Stress Event Caused (only answer if the event occurred and you marked “Y” in the leftmost column): 1 Not stressful  2 Very Little Stress  3 A little stress  4 Some stress  5 Much stress  6 Very much stress  7 Caused me to panic  129  EVENT  Did not hear from someone you expected to hear from Was embarrassed Had your sleep disturbed Forgot something Feared illness/pregnancy Experienced illness/physical discomfort Had car trouble Your property was damaged Unable to complete all plans for today Thought about future Ran out of food/personal article Argued with spouse/boyfriend/girlfriend Argued with another person Waited longer than you wanted Interrupted while thinking/relaxing Someone ‘cut’ ahead of you in line Performed poorly at sport/game Had minor accident (broke something, tore clothing) Did something you did not want to do Someone borrowed something without your permission  In the Past 24 Hours, Did Event Occur? (Y or N)  Amount of Stress Event Caused (only answer if the event occurred and you marked “Y” in the leftmost column): 1 Not stressful  2 Very Little Stress  3 A little stress  4 Some stress  5 Much stress  6 Very much stress  7 Caused me to panic  130  EVENT  Was stared at Had difficulty in traffic Money problems Misplaced something Bad weather Unexpected expense (fines, ticket, etc.) Had confrontation with an authority figure Heard some bad news Concerned over personal appearance Exposed to feared situation/object Exposed to upsetting TV show/movie/book ‘Pet peeve’ violated Failed to understand something Worried about another’s problems Experienced narrow escape from danger Had problem with kid(s) Was late for work/appointment Stopped unwanted personal habit (smoking, nail biting) Other? _____________________ Other? _____________________  In the Past 24 Hours, Did Event Occur? (Y or N)  Amount of Stress Event Caused (only answer if the event occurred and you marked “Y” in the leftmost column): 1 Not stressful  2 Very Little Stress  3 A little stress  4 Some stress  5 Much stress  6 Very much stress  7 Caused me to panic  131 73. Please indicate, by placing a vertical mark in the appropriate position on the line below, how stressful your participation in this study has been so far:  | 0 Not at all Stressful  | 100 Extremely Stressful  **************************************************************** Thank you for completing the questionnaire! ****************************************************************  132 APPENDIX I: MORNING SAMPLING INSTRUCTIONS  Instructions for Morning Saliva Collection ID # ______________ We are asking for four saliva samples to be collected tomorrow morning to help measure your levels of the stress hormone cortisol. Please collect these samples immediately after awakening. Do not eat, drink, brush your teeth or engage in strenuous physical activity during the 45 minute sampling period. These activities will cause sample contamination. You may go about your usual routine (ex: showering, getting dressed, etc) but please remember to sample at the appropriate times since this is a highly time-sensitive procedure. Please read and carefully follow these instructions: (a) Preparing for morning sampling: 1. Tonight, place the following materials by your bed: • Salivette tubes • Timer • One glass of water • One empty glass • Sampling log (page 3 (b) Morning sampling procedure 1. Immediately after you wake up, rinse your mouth with water and spit the water into the empty glass. 2. Collect first saliva sample using the salivette labelled Morning Sample #1 using the same procedure as in your lab visit. As a reminder, the instructions are as follow: a. b. c.  d. e.  Take off the top of the tube and drop the cotton roll in your mouth. Avoid using your hands. Record the time you completed this step on your sampling log under the column “Time of sample: _____”. Keep the cotton roll in your mouth for one full minute. While the cotton roll is in your mouth, start the timer for sample #2. The timer will countdown as a reminder of when to take the next sample since samples must be taken in 15 minute intervals. Set the timer by pressing “Min” repeatedly until it reads 0:15. Press the “Start/Stop” button once this is done. After the roll has been in your mouth for roughly one minute, place it back in the tube without using your hands. Place the Salivette back in the Ziploc bag. You may go about your usual morning routine until it is time for the next sample.  133 3. 15 minutes later, repeat steps (a) through (e) using the tube labelled Morning Sample #2. The timer should beep to remind you when to sample but please pay attention to the time in case of technical problems. After the timer beeps, press “Start/Stop”. Place the cotton roll in your mouth and record the time you do this step in the log. Reset the timer for 15 minutes by pressing “Min” repeatedly until it reads 0:15. Start the countdown for the next sample by pressing “Start/Stop”. 4. Repeat steps (a) through (e) 30 minutes after Sample #1 was collected. 5. Repeat steps (a) through (e) 45 minutes after Sample #1 was collected. *If you forget to collect a sample, continue with the next sample as scheduled. For example, if you wake up and take your first sample at 8:15, the other samples should be collected at 8:30, 8:45 and 9:00. If you miss sample 2, continue with sample 3 at 8:45. *Record any difficulties that may arise during this procedure on your sampling log. If you have any questions, please do not hesitate to call Mandeep at (778) XXXXXXX. How to Use the Timer •  The timer has two useful settings marked “clock” and “timer” in the red panel next to the time. To switch settings, slide the red button up/down (located on the right side of the timer).  •  When recording the time, the timer must be in “clock” mode. For all other steps, make sure it is in “timer” mode.  •  To set the timer for 15 minutes, press “Min” repeatedly until the timer reads 0:15. Press “Start/Stop” to start the countdown.  (c) Returning your sampling kit •  Please return the kit containing the 5 Salivettes, timer, sampling log and this instruction sheet to the Food, Nutrition and Health Building.  •  If you cannot return the kit on the same day as sampling, store all materials in your freezer until you are ready to return the kit.  •  You will receive $20 for your participation after returning all of the study materials.  THANK YOU FOR YOUR CAREFUL COMPLETION OF THIS TASK!  134  Sampling Log ID # ______________  Sample Number  Time of Sample Please record the time you first place the cotton roll in your mouth  Sample #1 (collect immediately after you wake up) Sample #2 (collect roughly 15 minutes after sample #1) Sample #3 (collect roughly 15 minutes after sample #2) Sample #4 (collect roughly 15 minutes after sample #3)  When you are ready to return the samples to the lab, place all materials back in the Ziploc bag (5 Salivettes, timer, instruction sheet and sampling log). Thank you!  135 APPENDIX J: DEBRIEFING FORM  Eating Attitudes and Physiological Stress Study Cognitive dietary restraint (CDR) reflects the perception that one is constantly monitoring and attempting to restrict food intake as a means to control body weight, rather than eating in response to hunger cues. Recent research suggests that high CDR may act as a subtle and consistent stressor that activates the physiological stress response. This study aims to provide additional evidence to support this hypothesis by investigating differences in the stress response of high and low restraint women after exposure to food and weight-related cues. The awakening cortisol response of participants is also examined since differences can suggest increased levels of chronic stress. In this study, you completed an online screening questionnaire. The purpose of this questionnaire was to assess your level of dietary restraint. Women with either high or low levels of dietary restraint were invited to participate in the full procedure. During the lab visit, you were asked to complete a questionnaire package while blood pressure and saliva samples were collected. The experimenter also placed a tray of food options near you, explaining that the food was leftover from another study. However, the food was presented to simulate everyday foodrelated stress. We will examine the blood pressure and salivary cortisol levels before and after cue exposure to look for relationships among levels of CDR and physiological stress. We expect to find that women with high levels of CDR will have elevated levels of salivary cortisol and blood pressure after exposure to tempting food options. The awakening cortisol response is also hypothesized to differ among women with high and low levels of CDR. If you are interested in receiving a summary of the research findings, please let us know by contacting us at eatingattitude@gmail.com. If you have any further questions, please feel free to ask the experimenter or use the contact information provided below to contact a member of the research team at a later time. Contact Information about the Experiment This experiment is being conducted under the supervision of Dr. Susan Barr, the primary investigator, with Mandeep Sanghera as the co-investigator. Please call one of them if you have any further questions about this study. Mandeep Sanghera may be reached at (778) XXX-XXXX and Dr. Barr may be reached at (604) 8226766. You may also e-mail our research team at eatingattitude@gmail.com. Please do not share information outlined in this debriefing form because this could impact our research findings. Thank you for your participation!  136 APPENDIX K: UBC BEHAVIOURAL RESEARCH ETHICS BOARD’S CERTIFICATE OF APPROVAL The University of British Columbia Office of Research Services Behavioural Research Ethics Board Suite 102, 6190 Agronomy Road, Vancouver, B.C. V6T 1Z3  CERTIFICATE OF APPROVAL - FULL BOARD INSTITUTION / UBC BREB NUMBER: DEPARTMENT: UBC/Land and Food Susan I. Barr Systems/Human and Animal H08-01745 Nutrition INSTITUTION(S) WHERE RESEARCH WILL BE CARRIED OUT: PRINCIPAL INVESTIGATOR:  Institution  UBC  Site  Vancouver (excludes UBC Hospital)  Other locations where the research will be conducted:  Subject's home: the participant will be asked to provide four salivary cortisol samples collected the morning following her lab visit.  CO-INVESTIGATOR(S): Wolfgang Linden Mandeep Sanghera Tim John Green SPONSORING AGENCIES: Canadian Institutes of Health Research (CIHR) PROJECT TITLE: Eating Attitudes and Physiological Stress REB MEETING DATE: CERTIFICATE EXPIRY DATE: September 11, 2008 September 11, 2009 DOCUMENTS INCLUDED IN THIS APPROVAL: DATE APPROVED: December 10, 2008 Document Name  Protocol: Research Proposal Consent Forms: Consent form Advertisements: Recruitment poster Questionnaire, Questionnaire Cover Letter, Tests: Questionnaire (Part One) Questionnaire (Part Two) Other Documents: Debriefing form Screening questionnaire Proviso response E-mail drafts  Version  Date  N/A  November 1, 2008  N/A  November 1, 2008  N/A  November 1, 2008  N/A N/A  November 1, 2008 November 1, 2008  N/A N/A N/A N/A  November 1, 2008 December 1, 2008 November 1, 2008 December 1, 2008  137 Deception form N/A July 1, 2008 Other: The website for the screening questionnaire is still in development; however, the questionnaire is provided in part 9.8.A.  The application for ethical review and the document(s) listed above have been reviewed and the procedures were found to be acceptable on ethical grounds for research involving human subjects.  Approval is issued on behalf of the Behavioural Research Ethics Board and signed electronically by one of the following:  Dr. M. Judith Lynam, Chair Dr. Ken Craig, Chair Dr. Jim Rupert, Associate Chair Dr. Laurie Ford, Associate Chair Dr. Daniel Salhani, Associate Chair Dr. Anita Ho, Associate Chair  

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