Mediators linking insecure attachment to eating symptoms: A systematic review and meta-analysis

Abstract

In the last two decades, the number of studies focused on the mediators connecting insecure attachment with Eating Disorders (EDs), at both clinical and sub-clinical level, has considerably increased. However, there has not been a systematic synthesis of this literature to date. To fill this gap, the current meta-analytic review aimed at identifying and quantifying the extent to which mediators contribute to the explanation of this relationship. The present study was registered with PROSPERO (CRD42017076807). A comprehensive search process in seven different electronic databases retrieved 24 studies that examined how insecure attachment leads to ED symptoms through mediation analysis. Standardized regression coefficients of the indirect and total paths of 21 mediation models were pooled. Studies were coded and ranked for quality. We found evidence to show that maladaptive emotion regulation and depressive symptoms had the highest effect size for mediation (mediation ratio [PM] = 0.71). Further, body dissatisfaction, neuroticism, perfectionism, mindfulness and social comparison had significant, but moderate to low mediating effects (PM = 0.21-0.58). The methodological quality of these studies was mostly low to moderate and potential areas for development were highlighted. Our findings support the direct targeting of these psychological constructs in prevention programs and treatment of EDs. Future investigations addressing the time sequence between the variables will provide valuable clues to untangle the prospective contribution of each variable on the development and maintenance of eating pathology.

Fig 1. Flowchart for search strategy.

Fig 1 represents the flow information through the different four phases of the systematic review. Following PRISMA guidelines, a total of 24 studies were eligible to be included in the systematic review and 21 model were included to be meta-analyzed.

Fig 2. Funnel plots of correlations versus variance of correlations for total effect (path c) and indirect effect (path a*b).

Left hand side: Funnel plot for the total effect (path c). Right hand side: Funnel plot for the indirect effect (path a*b). In both charts, Egger’s test p-value shows no publication bias (p > .05).