longitudinal predictors of restrictive eating and bulimic tendencies in three different age groups...

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Journal of Youth and Adolescence [jya] PP055-294581 January 27, 2001 12:34 Style file version Nov. 19th, 1999

Journal of Youth and Adolescence, Vol. 30, No. 1, 2001

Longitudinal Predictors of Restrictive Eating andBulimic Tendencies in Three Different Age Groupsof Adolescent Girls

Eleanor H. Wertheim,1 Jody Koerner,2 and Susan J. Paxton3

Received January 27, 1999; accepted July 31, 2000

This study examined longitudinal predictors of future eating problems in 435 femaleadolescents in Grades 7, 8, and 10, who were tested at two time points 8 monthsapart. Restrictive eating and bulimic tendencies were found to be relatively stablefrom Time 1 to Time 2, particularly in older grade levels. Partial correlationspredicting Time 2 restrictive eating and bulimic tendencies indicated a role of bodydissatisfaction, depression, and weight-related teasing, with findings being mostclear in Grade 7. Path analyses indicated that the relationships among predictorswere more complex and that some of the relationships were mediated by othervariables.

INTRODUCTION

A substantial body of research has confirmed the high prevalence of bodyconcerns, restrictive eating, and disordered eating behaviors such as binge eatingin adolescent girls (Grigget al., 1996; Huon, 1994; Wertheimet al., 1992). Thesebehaviors are of concern because of their association with eating disorders, and

This project was supported by a grant from the Australian Research Council. The authors thank JennyAnderson, Tracey Holt, and Fiona McDonald for helping with data collection and preparation andSimone Blaney for providing background material on the research literature.

1Associate Professor, School of Psychological Science, La Trobe University, Melbourne, Australia.Received her Ph.D. in clinical psychology from University of Connecticut. Major research interestsare the etiology and prevention of disordered eating behaviors and body concerns. To whom corre-spondence should be addressed at School of Psychological Science, La Trobe University, Bundoora,Melbourne, Victoria, Australia 3083; e-mail: [email protected].

2Psychologist, received M.Psych (Health Psychology) from the School of Psychological Science, LaTrobe University, Australia. Major research interests related to eating disturbances in adolescents.

3Associate Professor, Department of Psychology, University of Melbourne, Parkville, Australia. Re-ceived her Ph.D. in psychology from University of Tasmania. Major research interests are the etiology,prevention, and treatment of disordered eating behaviors and eating disorders.

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0047-2891/01/0200-0069$19.50/0C© 2001 Plenum Publishing Corporation

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70 Wertheim, Koerner, and Paxton

because even at subclinical levels they can be detrimental to health and well-being(Brownell and Rodin, 1994; O’Dea, 1995; Pattonet al., 1990).

To understand the predictors, risk factors, and natural development of eatingproblems in adolescent girls, longitudinal methodology is required. In additionto identifying mechanisms that predict problem eating behaviors, longitudinal de-signs can help to identify variables involved in the development of eating problemsbeforethere are confounding effects of the disorder itself (Leonet al., 1995), canidentify variables that could serve as potential targets for prevention (Fairburn andBeglin, 1990; Killenet al., 1994), and can assess the stability of problem eatingover time that is important in ascertaining whether early intervention efforts arewarranted.

A review of prospective research suggests that dieting, binge eating, andother weight control behaviors have consistently been found to predict futureeating behaviors (e.g., Attie and Brooks-Gunn, 1989; Keelet al., 1997; Leonet al., 1995). Thus eating behaviors appear to be relatively stable over time. Mostother possible risk factors have, however, yielded more inconsistent results inlongitudinal research.

The hypothesis that body size predicts future eating patterns has been sup-ported inconsistently (Attie and Brooks-Gunn, 1989; Keelet al., 1997). There havealso been conflicting findings related to the role of body image, with it reachingsignificance as a predictor of later eating behaviors in some studies (Attie andBrooks-Gunn, 1989; Cattarin and Thompson, 1994; Graberet al., 1994; Stice andAgras, 1998) but not in others (Killenet al., 1994, 1996; Leonet al., 1995; Keelet al., 1997).

Recently, the influence of weight related teasing on body image dissatisfac-tion and future eating problems has been examined (Cattarin and Thompson, 1994;Thompsonet al., 1995). These studies suggest that Time 1 teasing by others pre-dicted future body dissatisfaction in a sample of adolescent girls but did not addto prediction of drive for thinness above body dissatisfaction at Time 1 or Time 2.

Several longitudinal studies have also examined the prediction of problemeating from psychological functioning variables such as self-esteem (Buttonet al.,1996), feelings of ineffectiveness (Graberet al., 1994; Leonet al., 1995; Killenet al., 1994, 1996; Striegel-Mooreet al., 1989), and depressive symptoms (Graberet al., 1994; Leonet al., 1995, Stice, 1998; Stice and Agras, 1998). These studieshave also yielded inconsistent findings that are in contrast to the concurrent researchin which eating problems are often found to correlate with greater levels of distress,depression, and anxiety (Rosenet al., 1987; Wertheimet al., 1992; Wertheim andWeiss, 1989).

In summary, some longitudinal evidence suggests that body size, teasing, bodyimage dissatisfaction, restrictive eating, binge eating (or bulimic symptoms), andpsychological dysfunction contribute to future patterns of problem eating. How-ever, the nature, strength, and salience of these risk factors are not yet fully clear.

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Longitudinal Predictors of Restrictive Eating and Bulimic Tendencies 71

One possible reason for the conflicting findings across studies is that theimportance of particular risk factors may vary depending on the age of the groupstudied. To date, researchers have generally included one age group only or groupedvarious ages together without examining whether certain risk factors are partic-ularly important at specific developmental stages. This grouping in longitudinalstudies has occurred despite evidence from concurrent research that predictorsmay vary depending on developmental level (Gralenet al., 1990). Therefore, thispaper takes a developmental perspective, in that risk factors were examined inthree different age groups (Grades 7, 8, and 10) with the aim of observing theextent to which the salience of those risk variables differs with age.

A first aim of this study was to examine stability of bulimic and restric-tive eating behavior over time in adolescent girls. A second aim was to examinelongitudinal predictors controlling for Time 1 eating behaviors. First, individualpredictors were examined. Then, a path model of the relationships among thesevariables was tested (see Figs. 1–3 for variables and general direction of paths)based on the theoretical model proposed and tested by Thompson and colleagues(1995). In addition to examining the roles of body size, weight related teasing, andbody dissatisfaction, the role of psychological functioning was examined, specif-ically whether depression and self-esteem predict restrictive eating and bulimictendencies concurrently and longitudinally. To examine whether risk factors varyfor different age groups, the path analyses were conducted on three separate gradelevels of adolescent girls.

Fig. 1. Path model for Grade 7 predicting Time 2 Drive for Thinness and Bulimia from Time 1variables (∗indicatesp < .01,∗∗indicatesp < .001,∗∗∗indicatesp < .000).

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Fig. 2. Path model for Grade 8 predicting Time 2 Drive for Thinness and Bulimia from Time 1variables (∗∗indicatesp < .001,∗∗∗indicatesp < .000).

METHOD

Participants

Participants were female adolescents from six state secondary high schools inthe Melbourne metropolitan area (Australia) from a range of socioeconomic statusareas. At Time 1 all girls enrolled in Grades 7, 8, and 10 were invited to participatein the study (N = 748). Seventy-four percent of these girls participated in the firstwave of testing. Eight months later these girls were encouraged to participate again(Time 2). Eighty-two percent (N = 437) of the Time 1 sample participated at Time2. Two girls were later eliminated from this sample because of bivariate outliers intheir data, resulting in 435 girls who participated at both time points; 130 Grade 7girls (Mean age= 12.82 ), 174 Grade 8 girls (Mean age= 13.71 ), 131 Grade 10girls (Mean age= 15.75). A series of independentt-tests comparing participants

Fig. 3. Path model for Grade 10 predicting Time 2 Drive for Thinness and Bulimia from Time 1variables (∗indicatesp < .01,∗∗indicatesp < .001,∗∗∗indicatesp < .000).

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who dropped out at Time 2 to those who participated at both time points indicatedthat the two groups did not differ significantly (p < .05) on any of the variablesincluded in the study.

Measures

Eating Disorder Inventory

The three subscales of the well-validated Eating Disorder Inventory (EDI;Garner, 1991; Garneret al., 1983) that assess core symptoms of eating disorderswere used: Drive for Thinness (Drive), Body Dissatisfaction (BodyDis), Bulimia(Bulimia). Scale scores were derived by summing the untransformed 6-point items,as is appropriate for normative samples (Schoemakeret al., 1994).

Self-Esteem and Depression

The Rosenberg Self-Esteem Scale (Self-Esteem; Rosenberg, 1965) mea-sures general self-esteem and was developed for adolescents (Demo, 1985; Wylie,1989). The 13-item short form of the Beck Depression Inventory (BDI; Beck andBeck, 1972; Beck, 1972; Becket al., 1974; Reynolds and Gould, 1981) assesseddepression.

Teasing

The Weight Teasing frequency subscale (Teasing) of the Perception of TeasingScale (POTS; Thompsonet al., 1995) measures the frequency of being teased aboutweight and size in childhood. In this sample, the Time 1 Weight Teasing frequencysubscale had a Cronbach’s alpha of .96.

Dutch Eating Behaviour Questionnaire

The Restrictive Eating subscale of the Dutch Eating Behaviour Questionnaire(DEBQ-R; Allisonet al., 1992; Banasiaket al., in press; Laessleet al., 1989; VanStrienet al., 1986; Van Strienet al., 1986) measures the intention and degree ofrestriction of food intake for weight reasons.

Body Mass Index (BMI)

BMI was calculated (kilograms/meters2) based on measured weight andheight (Keyset al., 1972).

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Procedure

Information sheets and informed consent forms were given by teachers tostudents to take home for parents and students to sign. Consent forms indicatedthat participation was voluntary, that consent could be withdrawn at any time,and that answers would be code numbered for confidentiality. Only students whoreturned signed forms from parent and self took part in the study. Participantswere assessed at two time points (each time preceded by signing consent forms).At Time 1 they were in Grades 7, 8, or 10, and at Time 2, 8 months later in the nextgrade (the change to a different grade accounted for much of the attrition in samplesize at Time 2). On each occasion, testing was completed in large classrooms ateach school in a 90-min session. One researcher guided the class in completingthe test package, whereas another measured weight and height (without shoes) ina separate room, to ensure privacy.

RESULTS

Given the large number of analyses undertaken, alpha was set generally at.01 to have reasonable control over Type 1 error. All significance levels were alsotwo-tailed for a further conservative test. To overcome skewness in data, a squareroot transformation was used for Drive, and logarithmic transforms were used forBulimia, BDI, BMI, and Weight Teasing in correlation and regression analyses.

Correlations Among Variables

Correlations among all of the variables for the entire sample, as well as meansand standard deviations are displayed in Table I. All Time 1 variables were signif-icantly correlated with each other and also significantly correlated with Bulimia-2, Drive 2, and DEBQ-R2. Because of the high correlations between Drive andDEBQ-R at Time 1 (r = .82) and Time 2 (r = .84), only the findings from Drivewill be reported (unless findings differed) and Drive for Thinness was referred toas restrictive eating to reflect its strong association with the DEBQ-R.

Stability Findings

Changes in group means over time were examined first, using pairedt-tests.Results for the entire sample indicated that there was no significant differencebetween Time 1 and 2 Drive scores (t(435)= 1.52, p = .13) or between Time 1and Time 2 Bulimia scores (t(435)= 1.62, p = .10). When grades were examinedseparately, there were no significant differences between time points (allps< .05)for Grades 7 or 8, whereas for Grade 10 the means became somewhat lower at

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Tabl

eI.

Cor

rela

tions

,Mea

ns,a

ndS

tand

ard

Dev

iatio

nsof

All

the

Varia

bles

12

34

56

78

910

1112

1.A

ge—

.10

.05

.12

.06

.13∗

.22∗

.09

.13∗

.17∗

.10

−.06

2.B

ulim

ia1

—.6

5∗.5

3∗.4

5∗.5

2∗.5

0∗.5

7∗.3

0∗.4

3∗.3

8∗−.

41∗

3.B

ulim

ia2

—.4

4∗.6

3∗.4

7∗.4

1∗.5

1∗.2

0∗.3

7∗.5

6∗−.

38∗

4.D

rive

1—

.73*

.44*

.75*

.49*

.48*

.82*

.67*

−.44

*5.

Driv

e2

—.4

2∗.6

3∗.4

4∗.4

0∗.6

5∗.8

4∗−.

39∗

6.D

epre

ssio

n1

—.4

5∗.3

6∗.1

8∗.4

2∗.3

8∗−.

61∗

7.B

ody

Dis

1—

.47∗

.53∗

.66∗

.56∗

−.53∗

8.Te

asin

g1

—.4

0∗.4

0∗.4

0∗−.

35∗

9.B

ody

mas

s1

—.4

0∗.3

6∗−.

14∗

10.

DE

BQ

1—

.71∗

−.40∗

11.

DE

BQ

2—

−.37∗

12.

Est

eem

1—

Mea

n14

.07

14.0

813

.75

19.4

219

.83

5.27

32.8

119

.18

21.3

122

.80

23.0

628

.23

SD

1.24

5.70

5.95

8.35

8.13

5.64

11.4

77.

183.

909.

7710

.05

4.66

No

te.1

:T

ime

1,2:

Tim

e2,

Bul

imia

:E

atin

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Inve

ntor

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Driv

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Driv

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ED

IB

ody

Dis

satis

fact

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Dep

ress

ion:

Bec

kD

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vent

ory,

Teas

ing:

PO

TS

Wei

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requ

ency

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Inde

x,D

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utch

Eat

ing

Beh

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uest

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aire

Res

trai

ned

Eat

ing,

Est

eem

:Ros

enbe

rgS

elf-

Est

eem

.∗ p<.0

1.

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Time 2, a difference which approached significance, Bulimiat(132)= 2.56, p =.01, Drive t(132)= 2.60, p = .01.

To examine stability of eating behaviors, correlations between Drive 1 andDrive 2 and between Bulimia-1 and Bulimia-2 were performed for each year level.Although all grades showed high stability, Grade 7 girls’ Drive for Thinness scoresover time were the least stable (r = .67), with Grade 8 (r = .80) and Grade 10(r = .78) being very stable. The Bulimia subscale scores were similar for Grade 7(r = .66) and Grade 8 (r = .65), with Grade 10 girls having the most stable bulimicbehavior (r = .73).

Partial Correlations Controlling for Time 1 Eating Behaviors

To examine longitudinal predictors controlling for Time 1 eating behaviors,partial correlations were conducted for each grade level. First, Drive 2 was pre-dicted while partialling out Drive 1. For Grade 7, significant partialrs were foundfor Time 1 BodyDis,r = .38, p = .000, and Weight Teasing,r = .24, p = .006,with Self-Esteem,r = −.11, p = .023, and BDI,r = .21, p = .018, tending to-ward significance. For Grade 7, partialrs controlling for Time 1 Bulimia indi-cated that Time 2 Bulimia was predicted by Time 1 BodyDis,r = .24, p = .007,BDI, r = .29, p = .001, Self-Esteem,r = −.22, p = .01, and Weight Teasing,r = .29, p = .001. Analyses for Grade 8 indicated that only Drive 1 predictedTime 2 Bulimia,r = .25, p = .001 (DEBQ-R1r = .19, p = .01), with BDI tend-ing toward significant predictiveness,r = .17, p = .023. In Grade 10, only WeightTeasing predicted Time 2 Bulimia,r = .26, p = .003.

Path Models Predicting Time 1 and 2 Restrictive Eating and BulimicSymptoms for the Three Grade Levels

For each grade level (7, 8, and 10), a series of regression analyses were run todetermine path models of the concurrent and longitudinal predictors of restrictiveeating and bulimic symptoms. The variables were entered in the following order:BMI, Teasing, BodyDis, Self-Esteem, BDI, Drive 1, Bulimia-1, Drive 2, Bulimia-2, with previous variables being entered as predictors of subsequent variables.

Figures 1 through 3 show the path models for Grades 7 through 10 respec-tively. The first part of each model depicts concurrent relationships at Time 1. Forall three grade levels Time 1 Bulimia was predicted concurrently by Teasing andDepression and Time 1 Drive for Thinness was predicted by Body Dissatisfaction.The role of other variables varied according to grade level (see figures).

Regarding longitudinal predictors of Time 2 eating behaviors, Fig. 1 showsthe significant pathways for Grade 7 girls. Time 2 restrictive eating (Drive) waspredicted by Time 1 Drive for Thinness and Body Dissatisfaction. Time 2 bulimic

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tendencies (Bulimia) were predicted by Time 2 Drive and also Time 1 BMI, Teas-ing, Drive, and Bulimia. As also seen in Fig. 1, Bulimia-2 was negatively predictedby Drive 1. Because the bivariate correlation between these two variables is posi-tively significant (r = .36, p = .000) this negative pathway indicates the presenceof a suppressor variable (Tabachnick and Fidell, 1996). To identify the meaningof the paths from Drive 1, Bulimia-1 and Drive 2 to Bulimia-2, extremez-scoreswere inserted into the regression equation. These indicated that the order from low-est to highest scores was: (1) former restrictive eaters with low Bulimia-1 scores(who had lowest Time 2 bulimia scores), (2) continual nonrestrictive eaters withlow Bulimia-1 scores, (3) continual restrictive eaters with low Bulimia-1 scores,(4) improved restrictive eaters with high Bulimia-1 scores, (5) increased restrictiveeaters who had low Bulimia-1 scores, (6) continual nonrestrictive eaters who hadhigh Bulimia-1 scores, (7) continual restrictive eaters who had high Bulimia-1scores, and (8) increased restrictive eaters with high Bulimia-1 scores (who hadhighest Time 2 bulimia scores). The significant finding related to a negative pathfrom BMI to future bulimic tendencies also suggested it was a suppressor variable,however, further regression analyses failed to find a consistent pattern to explainits meaning.

Figure 2 shows the significant pathways in the predictive model for girls inGrade 8. The only predictor of Drive 2 was Drive 1. Bulimia-2 was significantlypredicted by Drive 2 and also Drive 1 and Bulimia-1. Again the pathway withDrive 1 was negative and similar patterns of eating emerged whenz-scores wereentered into the regression equation as for the Grade 7 sample.

Figure 3 shows the significant paths in the model for Grade 10. Drive 2 waspredicted by Drive 1 and Bulimia-2 was again predicted by Drive 2 and Bulimia-1.

DISCUSSION

The first aim of this study was to determine the stability of eating problemsin adolescent girls. Second, predictors of restrictive eating and bulimic tendencieswere examined for girls in three different grade levels to observe any differencesin salient risk variables due to age.

Both drive for thinness, and bulimic tendencies were found to be highlystable over an 8-month period from one grade level to the next. This stabilitywas reflected in high correlations between Time 1 and Time 2 eating variablesof the same type and no significant differences (for Grades 7 and 8) or minimaldecreases (for Grade 10) in group means at the two time points. When grade levelswere examined separately, correlations between Times 1 and 2 were somewhat lesshigh for Grade 7 girls (r = .67) than for Grade 8 (.80) and Grade 10 (.78) on Drivefor Thinness, and correlations between Times 1 and 2 were highest for Grade 10girls on Bulimia scores. The high stability across an 8-month period is consistentwith previous research (Attie and Brooks-Gunn, 1989; Pattonet al., 1990), and

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suggests that rather than being transient experimental attitudes or behaviors, eatingbehaviors in adolescents already tend to be relatively entrenched, particularly byGrade 8.

When three grade levels were examined separately in path models, significantrisk factors (aside from the eating behaviors themselves) were primarily identifiedin the Grade 7 girls, although in partial correlations only, weight related teasingpredicted future bulimic behaviors in Grade 10 girls and drive for thinness predictedbulimic behaviors in Grade 8 girls. For the Grade 7 girls, in both path models andpartial rs, body dissatisfaction predicted later increases in restrictive eating andhaving been teased about weight predicted later increases in bulimic behaviorssuch as binge eating.

The greater number of predictive variables found for Grade 7 girls may partlyreflect the fact that there was generally less stability in Grade 7 girls’ eating be-haviors, so more variance was left to explain. That body dissatisfaction was onlya significant longitudinal predictor of restrictive eating in Grade 7 girls may alsobe because early adolescence is a formative time in one’s life, when many devel-opmental changes are occurring related to one’s body shape and size. It is at thistime when girls often begin to experiment with weight loss behaviors.

The role of weight related teasing in the development of eating problems(Cattarin and Thompson, 1994; Thompsonet al., 1995) was partially supportedin this study. Reports of having been teased about weight or shape predicted laterincreases in bulimic tendencies in two age groups, and also later drive for thinnessin Grade 7.

The findings did not suggest as strong a role of psychological distress (lowself-esteem and depression) in predicting future drive for thinness although on aconcurrent basis they were moderately correlated. On a prospective level, psycho-logical distress, particularly depression, did predict increases in bulimic tendenciesin Grade 7 univariate analyses; however, in the path model they did not add uniquevariance to predicting bulimia scores, suggesting that their influence may be me-diated by other variables.

The present study is the first to examine and compare longitudinal predictorsof eating behavior in independent grade levels. Consistent with the concurrentresearch of Gralen and colleagues (1990), predictors varied depending on age level.The findings reported here suggest that Grade 7 girls experience the largest amountof individual change in eating behavior, and thus have more longitudinal predictors(particularly weight related teasing, body dissatisfaction, restrictive eating, andbulimic tendencies), than older girls have.

Among the older girls, the main predictor of dietary restriction was priorlevels of dietary restriction. There was little evidence that dietary restraint led tolater bulimic tendencies in a linear manner except in a Grade 8 partial correla-tion in which drive for thinness at Time 1 predicted increased bulimic tendencies8 months later. Thus Grade 8 may be a threshold time for the development of

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binge eating as a result of dieting experiences, although this possibility needsreplicating. Nonetheless, once girls reach about Grade 8 their eating patternsappear relatively stable. This is a matter of concern because if an individualstarts on a disordered eating path, then the patterns of behavior appear likely tocontinue.

To prevent these disordered eating patterns from being established it is nec-essary to accurately determine the period of onset of these attitudes and behaviors.Most longitudinal research has focused on postpubescent girls (Pattonet al., 1990;Rosenet al., 1993; Santonastasoet al., 1995; Stice, 1998) because this is the pe-riod when dieting and other weight control behaviors become prevalent. However,from the findings here and elsewhere (Keelet al., 1997; Marchi and Cohen, 1990),it is likely that girls younger than Grade 7 have attitudes and behaviors that putthem at risk for the development of future eating disturbances. Thus, future lon-gitudinal research needs to begin with prepubescent girls. The findings also haveimplications for primary prevention and early intervention, which may be mostappropriate in early adolescence or prior to that age; however, this possibility needsto be examined empirically.

The present study had some limitations that should be noted. First, the pathmodels assumed that the paths were unidirectional; however, in reality the re-lationships between predictor variables are probably somewhat more complex(e.g., circular). Second, it is likely that other variables, not included in the currentstudy (e.g., maturational timing) may further explain changes in eating behaviors.Third, the measures, aside from body size, were all self-report. However, given thewell-established nature of the measures used, it is likely the results are relativelyaccurate. Finally, the present study used a nonclinical sample, and thus the resultscannot be generalized to clinical samples. Results need to be replicated in bothpopulations.

In summary, in this longitudinal study, overall restrictive eating and bulimictendencies were relatively stable over an 8-month period. In examining predictorsof change over time, several risk factors were identified, although these wereprimarily applicable to Grade 7 girls. The results from the present study suggestthat by the time girls reach Grade 8 their eating behavior is relatively stable.Thus, if an individual has problem eating patterns at this time, they are likely tocontinue. This finding has implications for the timing for implementing preventionprograms, which may be most appropriate in early adolescence or even younger agegroups.

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longitudinal predictors of restrictive eating and bulimic tendencies in three different age groups...

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