Assessing positive body image (PDF)

Body Image 14 (2015) 130–145 Contents lists available at ScienceDirect Body Image journal homepage: www.elsevier.com/locate/bodyimage Assessing positive body image: Contemporary approaches and future directions Jennifer B. Webb a,∗, Nichole L. Wood-Barcalow b, Tracy L. Tylka c a Department of Psychology, University of North Carolina at Charlotte, Charlotte, NC, United States b The Center for Balanced Living, Columbus, OH, United States c Department of Psychology, The Ohio State University, Columbus and Marion Campuses, OH, United States a r t i c l e i n f o Article history: Received 1 February 2015 Received in revised form 22 March 2015 Accepted 25 March 2015 Keywords: Positive body image Assessment Formal assessment Psychotherapy Applied research Qualitative research a b s t r a c t Empirical and clinical interest in positive body image has burgeoned in recent years. This focused atten- tion is generating various measures and methods for researchers and psychotherapists to assess an array of positive body image constructs in populations of interest. No resource to date has integrated the available measures and methods for easy accessibility and comparison. Therefore, this article reviews contemporary scales for the following positive body image constructs: body appreciation, positive ratio- nal acceptance, body image flexibility, body functionality, attunement (body responsiveness, mindful self-care), positive/self-accepting body talk, body pride, body sanctification, broad conceptualization of beauty, and self-perceived body acceptance by others. Guidelines for the qualitative assessment of positive body image and recommendations for integrating positive body image assessment within psy- chotherapy and applied research settings are also offered. The article concludes with articulating broad future directions for positive body image assessment, including ideas for expanding its available meas- ures, methods, and dynamic expressions. © 2015 Elsevier Ltd. All rights reserved. Introduction A research team conducting a randomized controlled trial of a yoga-based intervention for binge eating disorder seeks to ascertain whether change in negative body image or change in positive body image is a more robust contributor to reductions in dysfunctional eating patterns among participants. A physical therapy clinic is interested in adopting a more strengths-based understanding of the positive body image changes that occur in their patients during treatment. A clinical health psychologist working in a fertility clinic feels constrained by only monitoring components of negative body image (e.g., body shame) in clients undergoing assisted repro- ductive technology procedures. Scenarios reflecting the need for positive body image assess- ment, such as the ones presented above, are plentiful. Thankfully, ∗ Corresponding author at: Department of Psychology, University of North Car- olina at Charlotte, 9201 University City Boulevard, Charlotte, NC 28223, United States. Tel.: +1 704 687 1320; fax: +1 704 687 1317. E-mail address: [email protected] (J.B. Webb). recent advances in the conceptualization and measurement of pos- itive body image now offer researchers and clinicians opportunities to assess an array of positive body image constructs. These advances were in response to calls from scholars who realized the utility of measuring positive body image to complement the measurement of negative body image (Avalos, Tylka, & Wood-Barcalow, 2005; Cash, Jakatdar, & Williams, 2004). Specifically, measuring positive body image provides a more holistic understanding of body image, which then holds the potential to uncover unique and underutilized resources for optimizing health and well-being for clients, schools, and the community (Cook-Cottone, Tribole, & Tylka, 2013). The initial approach to operationalizing positive body image was rather narrowly centered on satisfaction-based instrumentation such as the Body Esteem Scale (Franzoi & Shields, 1984), the Body Esteem Scale for Adolescents and Adults (Mendelson, Mendelson, & White, 2001), and the Appearance Evaluation subscale of the Mul- tidimensional Body-Self Relations Questionnaire (Brown, Cash, & Mikulka, 1990; Cash, 2000). Such measures position positive and negative body image as opposite ends of one body image contin- uum, with positive body image representing body satisfaction and negative body image representing body dissatisfaction. Such meas- ures contributed to our early understanding and measurement of what may constitute positive body image. Yet, a more contem- porary perspective has been established, which is informed by http://dx.doi.org/10.1016/j.bodyim.2015.03.010 1740-1445/© 2015 Elsevier Ltd. All rights reserved.  J.B. Webb et al. / Body Image 14 (2015) 130–145 131 findings from mixed methods and qualitative research on positive body image. This perspective frames positive body image as a com- plex, multifaceted construct distinct from low levels of negative body image and extending beyond body satisfaction or appearance evaluation (see Tylka & Wood-Barcalow, 2015b, this issue), and thus would entail the adequate understanding and measurement of positive body image’s multiple facets. This article reflects this contemporary perspective. First, we review the available formal measures that provide the best assess- ment to date of positive body image’s various facets. For each measure reviewed, we present its psychometric properties (i.e., statistical estimates that support its reliability and validity) and discuss its strengths and limitations when relevant. Second, we include guidelines for positive body image assessment in mixed methods or qualitative research. Third, we discuss the incre- mental value of incorporating formal and informal positive body image assessment within the context of psychotherapy. Fourth, we explore how positive body image assessment can be inte- grated within applied research contexts, such as eating disorder prevention programs and interventions, and medical, surgical, and rehabilitation settings. Last, we conclude the article by iden- tifying broad areas in need of attention within positive body image assessment. Recognizing the dynamic and evolving status of contemporary positive body image assessment, the present arti- cle represents a formative or exploratory rather than conclusive or exhaustive approach to summarizing and critiquing existing research. Formal Assessment of Positive Body Image Body Appreciation As originally defined by Avalos et al. (2005), body apprecia- tion is exemplified by an intentional choice to: (a) accept one’s body regardless of its size or bodily imperfections, (b) respect and take care of one’s body by attending to its needs through engag- ing in health-promoting behaviors, and (c) protect one’s body by resisting the internalization of unrealistically narrow standards of beauty promulgated in the media. To arrive at this definition, Avalos et al. reviewed educational sources focused on promot- ing body acceptance (Cash, 1997; Freedman, 2002; Maine, 2000; Tribole & Resch, 2003) and prevention efforts designed to pro- tect body image from sociocultural influences (Levine & Smolak, 2001). From this definition, Avalos et al. (2005) developed the Body Appreciation Scale (BAS) and conducted four studies examining its psychometric properties with U.S. college women. While 16 items were originally developed, 13 were retained. These 13 items, which loaded on one factor, had the highest factor loadings via exploratory and confirmatory factor analysis and, together, comprehensively assessed the three aspects of body appreciation contained within the construct definition (i.e., body acceptance, body respect, and body protection by resisting media appearance influences). Exam- ples of retained items include, “Despite its imperfections, I still like my body,” “I respect my body,” and “My self-worth is indepen- dent of my body shape or weight.” Participants rate their level of agreement on a 5-point scale ranging from 1 (Never) to 5 (Always). Avalos et al. accrued solid support for the BAS’s psychometric prop- erties. Estimates supported scores’ internal consistency reliability (˛s = .91–.94) and stability over a 3-week period (r = .90). Evidence for the BAS’s convergent validity was garnered via its positive rela- tionships with body esteem and appearance evaluation, and its inverse relationships with body preoccupation, body dissatisfac- tion, disordered eating, body surveillance, and body shame. The BAS was not related to social desirability, upholding its discriminant validity. The BAS was associated uniquely with several aspects of well-being (i.e., self-esteem, optimism, and proactive coping) after extracting shared variance with appearance evaluation, body preoccupation, and body dissatisfaction. This latter finding solidi- fied body appreciation as distinct from high levels of appearance satisfaction and low levels of body preoccupation and body dissat- isfaction. The BAS was originally evaluated with women and thus con- tained a gender-specific item (i.e., “I do not allow unrealistically thin images of women presented in the media to affect my atti- tudes toward my body”). A gender-specific item for men (i.e., “I do not allow unrealistically muscular images of men presented in the media to affect my attitudes toward my body”) was offered; however, it was never examined in the original validation study (Avalos et al., 2005). Later, Tylka (2013) compared this modified male BAS with the female BAS in a mixed-gender sample of U.S. college women and men and found both versions’ scores to be inter- nally consistent (male BAS ˛ = .92, female BAS ˛ = .94). Construct validity evidence was finally obtained for the male version, as it was inversely related to men’s dissatisfaction with their muscularity, body fat, and height. Furthermore, invariance analyses indicated that, for women and men, items loaded on the same factor (config- ural invariance), the magnitudes of factor loadings were the same (factor loading invariance), and regression intercepts relating each item to the factor were similar (intercept invariance). These analy- ses confirmed that the BAS measures the same construct equally for women and men. That said, men reported significantly higher BAS scores than women in U.S., Spanish, and German samples (Kroon Van Diest & Tylka, 2010; Lobera & Ríos, 2011; Swami, Stieger, Haubner, & Voracek, 2008; Tylka, 2013), but not in a U.K. sample (Swami, Hadji-Michael, & Furnham, 2008). Further internal consistency and construct validity evidence has been accrued for the BAS’s scores, primarily for women and men in Western countries such as the U.S., U.K., Canada, and Australia. Scores on the BAS have been found to be internally consistent, with Cronbach’s alpha coefficients at or above .90 within these samples. In terms of validity evidence, BAS scores were positively related to positive affect, life satisfaction, and self-compassion (Swami, Stieger, et al., 2008; Tylka & Kroon Van Diest, 2013; Wasylkiw, MacKinnon, & MacLellan, 2012). Behaviorally, BAS scores were positively linked to intuitive eating (i.e., eating according to phys- iological hunger and satiety cues; Andrew, Tiggemann, & Clark, 2014b; Avalos & Tylka, 2006; Hahn Oh, Wiseman, Hendrickson, Phillips, & Hayden, 2012; Tylka & Kroon Van Diest, 2013), women’s sexual arousal and satisfaction (Satinsky, Reece, Dennis, Sanders, & Bardzell, 2012), and enjoyment-based physical activity (Homan & Tylka, 2014). Moreover, BAS sores were inversely correlated with social physique anxiety, body image avoidance, body checking behaviors, self-comparison, internalization of societal appearance ideals, and maladaptive perfectionism (Andrew et al., 2014b; Iannantuono & Tylka, 2012; Swami et al., 2012; Tylka & Kroon Van Diest, 2013). Scores on the BAS are inversely related to body mass index (BMI) for women and men from most Western and non- Western countries examined (Lobera & Ríos, 2011; Ng, Barron, & Swami, 2015; Satinsky et al., 2012; Swami & Chamorro-Premuzic, 2008; Swami & Jaafar, 2012; Tylka & Kroon Van Diest, 2013; Tylka & Wood-Barcalow, 2015a; Webb, Butler-Ajibade, & Robinson, 2014). However, BAS scores were unrelated to BMI among women from Zimbabwe (Swami, Mada, & Tovée, 2012). The BAS’s unidimensional factor structure has been upheld in samples of college and community women and men from the U.S., U.K., and Germany (Swami, Hadji-Michael, & Furnham, 2008; Swami, Stieger, et al., 2008), and adolescent girls and boys from Spain (Lobera & Ríos, 2011). In many non-Western samples, how- ever, several of its items do not load on its primary factor, as evidenced for Indonesian women and men (Swami & Jaafar, 2012),  132 J.B. Webb et al. / Body Image 14 (2015) 130–145 Malaysian and Chinese women (Swami & Chamorro-Premuzic, 2008), Brazilian women and men (Swami et al., 2011), Zimbab- wean women (Swami, Mada, & Tovée, 2012), women and men from Hong Kong (Ng et al., 2015), and South Korean college women and men (Swami, Hwang, & Jung, 2012). In these samples, more gen- eral body appreciation items seemed to form a distinct factor from adaptive body investment items, suggesting that the constitution of body appreciation may not be exactly the same across cultures (Ng et al., 2015). These results suggest some caution in using all 13 BAS items to calculate an overall score across different cultures. We suggest that it is also possible that the BAS does not translate equally among cross-cultural samples, as the translation process is subject to the expertise of those converting the items into a new language. Regardless, researchers assessing body appreciation via the BAS in non-Western cultures may want to trim the adaptive investment items prior to calculating a total score. When Swami and colleagues’ trimmed items that did not load on the main body appreciation factor, they consistently found expected positive rela- tionships between body appreciation and well-being and inverse relationships between body appreciation and distress, indicating that body appreciation has some utility across a range of cultural contexts. Since its development in 2005, much theoretical and empirical literature has advanced our understanding of positive body image. Tylka and Wood-Barcalow (2015a) examined the BAS’s individual items for convergence with this literature, and revised several items as a result. For instance, the item “Despite its imperfections, I still like my body” was revised to “I appreciate the different and unique characteristics of my body,” because the original item assumes that individuals view their bodies as imperfect. The one gender- specific item was revised to “I feel like I am beautiful even if I am different from media images of attractive people, e.g., mod- els, actresses/actors,” which no longer necessitated gender-specific forms. Items that consistently exhibited item-factor loadings <.50, both in Western and non-Western cultures were deleted and other items that emerged in qualitative studies of positive body image were added, such as “I feel love for my body,” “I am comfortable in my body,” and “My behavior reveals my positive attitude toward my body; for example, I hold my head high and smile.” Like the orig- inal BAS, participants rate their level of agreement on a 5-point scale ranging from 1 (Never) to 5 (Always). This updated version, titled the BAS-2, resulted in 10 items, which included five original BAS items (e.g., “I respect my body”) and five newly developed or revised items (e.g., “I appreciate the different and unique characteristics of my body”). The psychometric properties of the BAS-2 were upheld among college and community samples of U.S. women and men (Tylka & Wood-Barcalow, 2015a). Specifically, the BAS-2 conformed to a unidimensional factor structure, and estimates supported its scores’ internal consistency reliability (˛s = .93–.96) and stabil- ity over a 3-week period (r = .90). The BAS-2 was positively related to appearance evaluation, self-esteem, and proactive coping and inversely associated with body dissatisfaction, internaliza- tion of societal appearance ideals, and body surveillance, therefore upholding construct validity. Moreover, its incremental validity was supported, as the BAS-2 accounted for unique variance in intuitive eating (for women and men) and disordered eating (for women only) after extracting shared variance from appearance evaluation and body dissatisfaction. The BAS-2 was negligibly related to impression management, a form of social desirabil- ity responding, demonstrating discriminant validity. Measurement invariance analyses indicated that the structure of the BAS-2 was similar between college men and women, community women and men, college and community men, and college and community women. Although these preliminary results are promising for the BAS-2, researchers need to examine its psychometric properties with various ethnicities, cultures, geographic regions, and age groups. Over the last decade, the rapidly accruing investigations of body appreciation have catapulted the BAS to the center stage of posi- tive body image assessment (Menzel & Levine, 2011). Nonetheless, there remains a need to further broaden the scope and depth of the qualities that characterize the multifaceted experience of pos- itive body image (Tylka, 2011; Webb et al., 2014). Thus, scholars are now recognizing and assessing a broader spectrum of features that comprise our current understandings of positive body image in order to better reflect its widening theoretical conceptualization (see Tylka & Wood-Barcalow, 2015b, this issue). Positive Rational Acceptance Coping In his cognitive-behavioral process model of body image, Cash (2002) outlined the dynamic transactions operating among dis- tal socio-developmental predisposing factors and more proximal cognitive-emotional mediating variables that give rise to one’s cur- rent experience of body image. Drawing from this model, Cash, Santos, and Williams (2005) underscored the value of articulating the connection between regular exposure to body image-related threats or challenges (distal factors), cognitive and behavioral cop- ing response styles that emerge from these threats (proximal mediating variables), and body image. Body image-related threats and challenges, for example, include being teased about weight or pressured to alter body size, viewing advertisements including thin female or muscular male models, comparing one’s appearance to an attractive peer, and experiencing weight changes in a non-desired direction (Webb et al., 2014). Cash et al. (2005) identified three body image coping response styles to manage body image-related threats/challenges. Two are less adaptive: avoidant (attempting to avert or escape body image-related threats) and appearance fixing (engaging in efforts to alter appearance by covering, camouflaging, or correcting the perceived flaw); and one is more adaptive and thus relevant to positive body image inquiry: positive rational accep- tance (accepting the distressing event and engaging in self-care and rational self-talk). Cash et al. (2005) developed the Body Image Coping Strate- gies Inventory (BICSI) to assess these three coping styles. For this article, we limit discussion to the Positive Rational Acceptance sub- scale. This subscale consists of 11 items in which respondents use a 4-point rating scale ranging from 0 (definitely not like me) to 3 (definitely like me) to indicate the extent to which they use pos- itive rational acceptance when coping with body image-related threats. Examples of items include, “I remind myself of my good qualities,” and “I remind myself that I will feel better after awhile.” Cash et al. (2005) upheld the psychometric properties of this sub- scale with U.S. undergraduate students. Findings suggested that this subscale yielded internally consistent scores for men (˛ = .85) and women (˛ = .80). Principal components analysis confirmed high item-factor loadings for this subscale. Women reported higher lev- els of positive rational acceptance coping than men, and White and African American women reported comparable levels. Whereas positive rational acceptance was unrelated to BMI among men, it was slightly associated with BMI for women in an inverse direction. Support for positive rational acceptance’s discriminant validity (i.e., distinctiveness from low levels of negative body image) among women was evidenced by its negligible inverse relationships with indices of negative body image, such as discrepancies between ide- alized and actual physical qualities (as well as the importance of these idealized qualities) and negative body image emotions in various situational contexts. For men, however, positive rational acceptance was positively related to negative body image indices, such as dysfunctional investment in appearance and negative body image emotions in various situational contexts. Support for this  J.B. Webb et al. / Body Image 14 (2015) 130–145 133 subscale’s convergent validity was demonstrated for women in that it was positively linked to higher body image quality of life, self-esteem, and perceived social support. Yet, for men, positive rational acceptance was only linked to perceived social support in an adaptive direction. This outcome may relate to the different gen- der socialization processes associated with rerouting distress from body image-related threats. Additional studies have explored positive rational acceptance’s connection to well-being. Choma, Shove, Busseri, Sadava, and Hosker (2009) found that positive rational acceptance was related to higher subjective well-being and inversely associated with trait self-objectification among their sample of Canadian college women. Hughes and Gullone (2011) observed that higher posi- tive rational acceptance corresponded to higher levels of adaptive internal and external emotion regulation strategies and lower endorsement of maladaptive modes of regulating affect, primarily among girls in their large community-based sample of Australian adolescents. Positive rational acceptance buffered the relationship between body image concerns and depression symptoms for the full sample. Corresponding moderator effects were not detected when drive for thinness, reported bulimic symptoms, or anxiety symptoms were examined as the criterion variables. Hrabosky et al. (2009) found that women with eating disorders, especially those with bulimia nervosa, were less apt to utilize positive rational acceptance relative to a female control group. Given its content integrity and connections to various indices of well-being, the Positive Rational Acceptance subscale deserves recognition as a measure of positive body image. Preliminary work indicates that positive rational acceptance holds the poten- tial to dampen the adverse effects of body image-related threats on well-being (Hughes & Gullone, 2011), and this line of research is important to continue. Given the abundance of body image- related threats that many individuals frequently experience (Buote, Wilson, Strahan, Gazzola, & Papps, 2011), findings that positive rational acceptance buffers distress in the face of these threats holds great clinical value for this construct (i.e., cognitive behavioral interventions could be developed and implemented to facilitate positive rational acceptance in therapy settings). Body Image Flexibility Body image flexibility represents a compassionate response to embrace rather than avoid, escape, or otherwise alter the content or form of aversive body-related thoughts and feelings (Sandoz, Wilson, Merwin, & Kellum, 2013). It is a dialectical approach to assessing embodiment grounded in psychological flexibility, which is exemplified by utilizing mindfulness and acceptance skills to fully engage in life and pursue valued action. Psychological flex- ibility serves as the cornerstone of Acceptance and Commitment Therapy (ACT), which bridges Western contextual behavioral sci- ence with Buddhism’s contemplative wisdom (Hayes, Strosahl, & Wilson, 1999) to promote human flourishing (Ciarrochi, Kashdan, & Harris, 2013). Sandoz et al. (2013) designed the Body Image-Acceptance and Action Questionnaire (BI-AAQ) to measure body image flexibility. Forty-six preliminary items were generated by modifying exist- ing items on scales of psychological flexibility to be specific to body image. Participants rate their level of agreement with how true each statement is for them on a 7-point scale ranging from 1 (Never true) to 7 (Always true). In a sample of U.S. college stu- dents, Sandoz et al. preserved the items with the highest factor loadings (i.e., >.60) on one factor. This practice resulted in reducing the content drastically, with the retention of 12 items that are all negatively worded (e.g., “My thoughts and feelings about my body weight must change before I take important steps in my life,” “I shut down when I feel bad about my body shape or weight”). It is important to note that the sole use of negatively worded items calls into question the BI-AAQ’s content and face validity in relation to the body image flexibility construct specifically as well as positive body image measures more generally (see Tylka & Wood-Barcalow, 2015b, this issue). As it stands, the BI-AAQ measures the degree of negative body-related thoughts, behaviors, and affect that stifle growth rather than the presence of mindful acceptance, flexibility, and compassion that promote growth when experiencing aver- sive body-related thoughts and feelings. Indeed, Timko, Juarascio, Martin, Faherty, and Kalodner (2014) referred to the BI-AAQ as assessing “body image experiential avoidance” (i.e., the unwilling- ness to experience negative thoughts, feelings, and physiological experiences and attempts to alter or remove the stimuli that invoke these adverse internal events), and therefore chose to not reverse score its items. Clearly, refining BI-AAQ item content to be con- sistent with the body image flexibility construct is imperative to improve assessment of this facet of positive body image. Until such a measure is developed, researchers may want to use the BI-AAQ as a preliminary gauge of body image flexibility. How- ever, we strongly recommend that researchers who choose to use the BI-AAQ in this manner note its inherent content limitations as a measure of this construct. Therefore, we review the BI-AAQ’s psychometric properties under the assumption that its construct limitations will be acknowledged. In Sandoz et al.’s (2013) validation study, the BI-AAQ scores demonstrated internal consistency reliability (˛ = .92) and stabil- ity over a 2–3 week period (r = .80) among U.S. college students. When its items were reverse-scored, the BI-AAQ was related to lower body dissatisfaction, dysfunctional eating attitudes, bulimic symptoms, and food preoccupation, along with higher psycholog- ical flexibility, supporting its convergent validity. BI-AAQ scores explained unique variance in disordered eating after controlling for BMI, body dissatisfaction, and general psychological flexibility, upholding its incremental validity. Further, individual variability in BI-AAQ scores was able to classify accurately 91.5% of partic- ipants at risk for an eating disorder and over half of students designated as not meeting this vulnerability threshold, reinforcing its criterion-related validity. Other studies also have provided psychometric support for BI-AAQ scores. When its items were reverse-scored, higher BI-AAQ scores corresponded with greater self-compassion, self-esteem, distress tolerance, body apprecia- tion, and intuitive eating (Ferreira, Pinto-Gouveia, & Duarte, 2011; Kelly, Vimalakanthan, & Miller, 2014; Schoenefeld & Webb, 2013; Webb et al., 2014) and lower internalization of media appearance ideals, dietary restraint, weight concern, psychological distress, and disordered eating among U.S., Canadian, and Portuguese samples (Ferreira et al., 2011; Kelly et al., 2014; Timko et al., 2014; Webb et al., 2014; Wendell, Masuda, & Le, 2012). Furthermore, BI-AAQ scores attenuated the association between body dissatisfaction and dysfunctional eating attitudes among Portuguese community adults (Ferreira et al., 2011) and U.S. college students (Sandoz et al., 2013). Scores on the BI-AAQ have been found to be higher among men compared to women in samples of U.S. college students (Sandoz et al., 2013) and Portuguese adults (Ferreira et al., 2011). This gen- der difference may be a result of 9 of its 12 items containing “body fat,” “weight,” or “shape,” suggesting that it may be more relevant for the body-related concerns of women than men. Most studies that have explored the link between body image flexibility and BMI have revealed an inverse association for men and women (Ferreira et al., 2011; Hill, Masuda, & Latzman, 2013; Kelly et al., 2014; Timko et al., 2014; Webb et al., 2014). Furthermore, body image flexibility appears to be associated positively with age (Ferreira et al., 2011). Once a more content representative measure of body image flexibility is created, body image flexibility could refine our aware- ness and understanding of what may be “positive” about positive  134 J.B. Webb et al. / Body Image 14 (2015) 130–145 body image. Body image flexibility does not adopt an exclusive focus on experiencing the body in wholly positive terms. Rather, body image flexibility encourages mindful contact with negative emotions that may emerge when body image is threatened, and this mindful contact helps facilitate body acceptance and commit- ted positive behavioral change via self-care. Additionally, clarifying the shared and distinct properties of instruments used to assess the conceptually-similar constructs of body image flexibility and positive rational acceptance coping are also deserving of further exploration in subsequent research. Body Functionality Recognizing and appreciating the various functions that the body provides is gaining momentum as a viable resource for enhancing positive body image, especially for girls and women (Alleva, Martijn, Jansen, & Nederkoorn, 2014; Avalos & Tylka, 2006; Clark, Skouteris, Wertheim, Paxton, & Milgrom, 2009; Rubin & Steinberg, 2011). Indeed, cultivating body functionality has been framed as a proactive resistance to the passive and externally ori- ented experience of body surveillance (McKinley & Hyde, 1996), which prioritizes preoccupation with managing one’s outward appearance (Augustus-Horvath & Tylka, 2011; Avalos & Tylka, 2006). It is important to refrain from conceptualizing body func- tionality as solely physical ability; this perspective would position body functionality as a discriminatory construct applicable to only able-bodied people. Three quantitative measures have been used to assess body functionality. First, the Surveillance subscale of the 8-item Objectified Body Consciousness Scale (McKinley & Hyde, 1996) has served to evalu- ate individual variability in body functionality as a more centralized “internal body orientation” (Homan & Tylka, 2014, p. 103). Respon- dents use a 7-point scale ranging from 1 (strongly disagree) to 7 (strongly agree) to rate their level of agreement on items such as “I think more about how my body feels than how my body looks” and “I am more concerned with what my body can do than how it looks.” As originally designed by McKinley and Hyde (1996) to cap- ture the degree to which an individual has adopted an “external body orientation” via constant appearance monitoring (i.e., body surveillance), the six items suggestive of an internal body orienta- tion are reverse scored. To use this subscale as a measure of internal body orientation, the two items that are suggestive of an exter- nal body orientation are instead reverse scored (Augustus-Horvath & Tylka, 2011; Avalos & Tylka, 2006; Homan & Cavanaugh, 2013; Homan & Tylka, 2014). Internal and external body orientation are thus measured as polar opposites that exist on the same contin- uum. As such, high scores on internal body orientation correspond with low scores on external body orientation (i.e., body surveil- lance) and vice versa: using the 1–7 rating scale, an average score of 4.8 on internal body orientation would correspond to a 3.2 score on external body orientation. In the original psychometric study with U.S. college and community women, this subscale’s scores were internally consistent (˛s = .86–.89) and stable over a 2-week period (r = .79; McKinley & Hyde, 1996). When scored in the direc- tion of internal body orientation, it has been found to be positively related to body appreciation, satisfaction with the body’s function- ality, body acceptance by others, and intuitive eating but unrelated to BMI, upholding its convergent and discriminant validity, respec- tively, among U.S. adult women (Augustus-Horvath & Tylka, 2011; Avalos & Tylka, 2006; Homan & Tylka, 2014). Yet, given that pos- itive and negative body image do not appear to be opposite ends of the same continuum (see Tylka & Wood-Barcalow, 2015b, this issue), additional inquiry is needed to determine whether inter- nal and external body orientation are an exception. If not, distinct measures of both constructs are needed. Second, affective, behavioral, and cognitive dimensions of body functionality are assessed via three subscales of the Embodied Image Scale (EIS; Abbott & Barber, 2010): Functional Satisfaction (three items, ˛ = .89; e.g., “I feel really good about what I can do physically”), Functional Investment (three items, ˛ = .80; e.g., “I par- ticipate in physical activities whenever I can [e.g., sports, hiking, exercise]”), and Functional Values (three items, ˛ = .72; e.g., “One of the most important reasons why people should take care of their bodies is so they can be physically active”). Participants use a 5- point scale ranging from 1 (not at all true for me) to 5 (very true for me) when endorsing items, and items are averaged. In their validation study, Abbott and Barber (2010) found that its 3-factor structure was upheld in Australian male and female adolescents (ages 12–17). Upholding construct validity, Functional Satisfaction and Functional Investment were positively related to self-esteem and appearance satisfaction and inversely related to depression. Functional Values was positively related to self-esteem and appear- ance satisfaction but unrelated to depression. Homan and Tylka (2014) further provided support for Functional Satisfaction’s con- vergent validity via its strong positive links with body appreciation and internal body orientation among U.S. college women (func- tional values and investment were not assessed). Abbott and Barber (2010) further observed specific gender, age, BMI, and pubertal timing differences in the EIS functionality sub- scales in their adolescent sample. Girls reported lower values on all three subscales. Younger girls reported higher scores on all three subscales relative to their older female peers. Boys in the average BMI category and girls in the average or underweight BMI category reported higher Functional Satisfaction in comparison to the other BMI groups. While earlier physical maturation relative to same- gender peers was linked to lower Functional Satisfaction among girls, it conversely was related to higher Functional Satisfaction among boys. Third, Rubin and Steinberg (2011) constructed a measure of body functionality during pregnancy. The authors reasoned that for some women the experience of pregnancy could hone a more refined awareness of the range of changes in bodily sensations that occur throughout the prenatal period. Their measure con- tained the awareness and appreciation conceptualizations of body functionality, with item content derived mainly from thematic analysis of qualitative interviews with U.S. women during their first pregnancy. Respondents use a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree) to indicate the degree to which they endorse awareness of and appreciation for their body’s functionality during pregnancy. Inspection of confirmatory factor analytic model fit parameters retained two subscales: Func- tional Awareness (six items, ˛ = .83, e.g., “I have paid attention to the changing sensations of my body”) and Functional Apprecia- tion (five items, ˛ = .82, e.g., “I have been grateful for what my body has allowed me to do”). In a sample of mainly White, edu- cated pregnant women living in the U.S., Rubin and Steinberg (2011) found that participants reported higher levels of functional awareness than functional appreciation, providing evidence that higher awareness of functionality does not equate to higher appre- ciation for this functionality during pregnancy. Both functional awareness and functional appreciation were inversely associated with depressive symptoms and engaging in less health-promoting behaviors during the pre-partum period, upholding the construct validity of these subscales. However, only functional appreciation was related to lower body surveillance. Both subscales were unre- lated to BMI, upholding their discriminant validity. Moreover, the authors found a protective effect for functional appreciation: the relationship between body surveillance and more frequent reports of unhealthy prenatal behaviors was stronger at lower levels of functional appreciation. Functional awareness, however, did not moderate this association. Rubin and Steinberg asserted that girls  J.B. Webb et al. / Body Image 14 (2015) 130–145 135 and women may counter some of the negative consequences of self- objectification by developing an appreciative view of their body’s functionality, and pregnancy may be an opportune time for such an intervention. These three measures offer intriguing possibilities for expand- ing body functionality’s scope and application within positive body image assessment. Interestingly, Alleva et al. (2014) found that experimentally augmenting body functionality awareness may be an intervention modality for improving functional body satisfac- tion. Examinations of these body functionality measures within more diverse samples are needed. Subsequent mixed methods designs may uncover unique insights into how body functionality is experienced adaptively amidst a wider range of individuals who have limited functionality in the internal or external workings of the body (e.g., acquired or congenital deformities or disfigurement, amputation, paralysis, sexual dysfunction, infertility, etc.). Attunement According to Cook-Cottone (2006), attunement is the ability to appropriately sense and respect the body by regularly engaging in adaptive behaviors to attend to its needs. To date, attunement can be estimated via measures of two constructs: body responsiveness and mindful self-care. Body responsiveness is a sense of being fully attuned to the body’s needs and using that embodied information to guide behavior; this construct can be measured via Daubenmier’s (2005) Body Responsiveness Scale (BRS). For this measure, respon- dents rate the level of how true they believe seven statements (e.g., “I am confident that my body will let me know what is good for me,” “I listen to my body to advise me about what to do”) are for them on a 7-point scale ranging from 1 (not at all true about me) to 7 (very true about me). In Daubenmier’s (2005) original psychometric article, estimates for the internal consistency reliability of its scores were upheld among a primarily White female sample of predom- inantly yoga practitioners and aerobics exercisers (˛ = .83) living on the West Coast of the U.S.; however, estimates were lower for U.S. college women (˛ = .70). Furthermore, the BRS was inversely related to body surveillance and disordered eating and positively associated with body awareness and body satisfaction, upholding its construct validity. Scores on the BRS were higher for yoga prac- titioners relative to women engaging in regular aerobic activity and women engaging in neither yoga nor aerobic exercise in the past two years, upholding its criterion-related validity. Addition- ally, BRS scores were uniquely associated with disordered eating above and beyond the variance contributed by self-objectification, upholding its incremental validity. Dittmann and Freedman (2009) subsequently observed that higher levels of body responsiveness corresponded with greater engagement in intuitive eating among predominantly White female yoga practitioners also living on the West Coast of the U.S. Mindful self-care is the daily practice of being aware of basic physiological and emotional needs and structuring one’s envi- ronment, relationships, and daily routine to meet these needs (Cook-Cottone, 2015b), which provides a foundation for embodied self-regulation (Linehan, 1993). While the Mindful Self-Care Scale (MSCS; Cook-Cottone, 2015b) was first developed for use within a yoga-based eating disorder prevention program (Cook-Cottone, Kane, Keddie, & Haugli, 2013), its psychometric properties are in the process of being evaluated with U.S. community adults. Of note, the MSCS is not a measure of positive body image measure per se, but rather it represents behavioral strategies that have been found to facilitate and maintain positive body image (Wood-Barcalow, Tylka, & Augustus-Horvath, 2010). As such, it has the potential for practical value within psychotherapy settings focused on improv- ing positive body image. Because the MSCS is in the process of psychometric evaluation, discussion of its items and structure is brief. The original item pool contains 84 items that help individuals identify areas of strength and weakness in self-care within nutrition/exercise, self-soothing, self-awareness/mindfulness, rest, relationships, physical/medical, environment, self-compassion, spiritual practice, and general self- care. Item examples are “I exercised at least 30 to 60 minutes,” “I used deep breathing to relax,” and “I made time for people who sustain and support me.” Respondents indicate how often, within the last week, they engaged in such behaviors along a 5-point scale: never (0 days, scored as 0), rarely (1 day, scored as 1), sometimes (2 to 3 days, scored as 2), often (4 to 5 days, scored as 3), and regularly (6 to 7 days, scored as 4). The MSCS was designed to be clinically ori- ented, whereby low item averages suggest areas of self-care that can be targeted for improvement, and items are prescriptive. For instance, the item “I exercised at least 30 to 60 minutes” can be translated into the goal: “I will exercise at least 30 to 60 minutes most days of the week.” For a full list of the items and scale updates, see Cook-Cottone (2015b) or visit http://gse.buffalo.edu/ about/directory/faculty/cook-cottone. After its psychometric eval- uation, future research could explore the connections between implementing mindful self-care and corresponding increments in positive body image and physical and psychological well-being. Body Pride Body pride is a strong, positive, self-conscious emotion towards the body that results from engaging in valued behaviors or pre- senting with positive characteristics (Castonguay, Gilchrist, Mack, & Sabiston, 2013). Context is important for determining whether body pride could align with the definition of positive body image as described by Tylka and Wood-Barcalow (2015b, this issue). If an individual strongly prides her or his body’s appearance for being consistent with sociocultural ideals and/or “better than” others’ appearances, as well as prides her or his investment in achieving and maintaining that desired appearance, then body pride rep- resents a more narcissistic preoccupation with appearance and is inconsistent with the definition provided by Tylka and Wood- Barcalow. In contrast, if an individual prides her or his body for what it can do for them and what their bodies represent in terms of their connectivity with others, then body pride is more con- sistent with Tylka and Wood-Barcalow’s definition. For example, body pride may be particularly adaptive for members of culturally- diverse groups whose positive representations of the body tend to be marginalized, derogated, or wholly absent within Western mainstream media (McHugh, Coppola, & Sabiston, 2014). Some ethnic minority individuals may be socialized to be proud of their bodies and bodily features representative of their ethnic heritage; this body pride may help inoculate them against internalizing Euro- centric beauty ideals (e.g., McHugh et al., 2014; Schooler & Daniels, 2014). When young Latina American adolescents were presented with sexualized media images portraying the Eurocentric thin ideal they tended to describe aspects of their physical appearance and body image more favorably if their ethnic identity was salient (Schooler & Daniels, 2014). Aboriginal adolescent females living in Canada reported that their body pride facilitated their comfort and love for their bodies and believed their body pride to be a result of their gratitude for their cultural roots and spirituality (McHugh et al., 2014). Indeed, higher body pride was found to be the strongest protective factor of Native American adolescent girls’ and boys’ emotional and physical health (Cummins, Ireland, Resnick, & Blum, 1999). Thus, when assessing body pride, we recommend that researchers acknowledge that body pride may have differing mean- ings as a result of individuals’ social identities. The experience of positive body image likely differs for appearance-related pride (e.g.,  136 J.B. Webb et al. / Body Image 14 (2015) 130–145 “I am proud of my body for being good looking”) and functionality- related pride (e.g., “When I think of what my body is able to do, such as grow and carry a child to term, I am proud”). Thus, when choosing a measure to assess body pride, researchers need to be confident that it reflects the construct that they wish to assess in their particular sample. If a measure does not exist, we encourage researchers to develop one. Unfortunately, available measures of body pride do not coincide well with the construct definition of positive body image outlined by Tylka and Wood-Barcalow (2015b, this issue) because these measures assess pride related to looking superior to others and pride related to achieving appearance-related goals. Nevertheless, we acknowledge the Body and Appearance Self-Conscious Emo- tions Scale (BASES; Castonguay, Sabiston, Crocker, & Mack, 2014) as a measure of appearance-related pride. The BASES used the pro- cess model of self-conscious emotions (see Tracy & Robins, 2004) as its base to develop four subscales, two of which reflect body pride. The hubristic pride subscale reflects body pride as a result of an individual believing that positive appearance outcomes are a result of his or her ability, reflecting a more self-aggrandizing or egotistical attribution style (six items, e.g., “Proud that I am more attractive than others,” “Proud of my great looks”). Hubristic pride has been found to be related to narcissistic self-aggrandizement (Tracy & Robins, 2007); the connection between hubristic body- related pride and narcissism, however, has not yet been examined to our knowledge. The authentic pride subscale reflects body pride as a sense of personal appearance-related achievement (six items, e.g., “Proud that I maintain my desired appearance,” “Proud of the effort I place on maintaining my appearance”). For the BASES, participants use a 5-point scale ranging from 1 (never) to 5 (always) to rate the frequency with which they expe- rience body pride. Data drawn from an initial validation sample of Canadian undergraduates supported the factor structure of the BASES, and body pride items loaded highly on their respective factors (Castonguay et al., 2014). Estimates supported the inter- nal consistency reliability of each pride subscale’s scores (hubristic pride: ˛ = .91; authentic pride: ˛ = .88) and the 2-week stabil- ity of their scores (hubristic pride r = .78; authentic pride r = .85). Higher scores on both subscales were associated with (a) lower body shame, body guilt, depressive symptoms, negative affect, neu- roticism, and social physique anxiety and (b) higher self-esteem, positive affect, and positive body fat self-perceptions, upholding construct validity. Meanley, Hickok, Johns, Pingel, and Bauermeister (2014) devel- oped a 4-item body pride measure (e.g., “I think I have a good body,” “I’m looking as nice as I’d like to”), which corresponds more closely to authentic pride. This measure is rated on a scale ranging from Never (scored as 0) to Always (scored as 4), and Meanley et al. exam- ined it within a U.S. sample of young adult men who have sex with men. This measure’s scores yielded evidence of internal consistency reliability (˛ = .88) and convergent validity via its positive links to appearance evaluation and inverse links to body dissatisfaction. Neither body pride measure assesses functional body pride, nor do they assess body pride related to the rejection of soci- ety’s negative portrayals of groups one identifies with. A fruitful area for research is to develop a measure of functional body pride and exp...