EMPIRICAL ARTICLE

Longitudinal Predictors of Dieting and Disordered Eating

Among Young Adults in the U.S.
Janet M. Liechty, PhD, MSW1,2*
Meng-Jung Lee, MSW1

ABSTRACT
Objective: To assess longitudinal
associations between cognitive and
behavioral characteristics in adolescence and dieting and eating pathology in young adulthood.
Method: Data from the National Longitudinal Study of Adolescent Health and
multivariate logistic regressions were
used to examine the unique and cumulative effects of adolescent behavior and
cognition on four weight-related health
indicators in young adulthood: dieting,
extreme weight loss behaviors (EWLB),
binge eating, and eating disorder (ED)
diagnosis (N 5 14,322).
Results: Early dieting, depression, and
body image distortion (BID) prospectively
predicted dieting or EWLB at Wave 3. In
addition, early depression and dieting
were associated with binge eating in
young adulthood, and early BID was
associated with ED diagnosis. Gender differences were observed. In the prospective models, the effect of depression on
the onset of EWLB was stronger for
women than men; while association

Introduction
Adolescence and young adulthood are periods of
heightened risk for development of disordered eating, unsafe dieting, and eating disorder symptoms.1
Disordered eating and eating disorders (EDs) are
concerns because of their associations with depression, obesity, functional impairment, psychiatric
disorders, adverse health outcomes, and suicidality.2,3 The National Comorbidity Study (n 5 10,123
adolescents aged 1318) shows that among adolescents, the lifetime prevalence of all ED combined is
6%.2 Other research suggests that the prevalence of
Accepted 13 July 2013
*Correspondence to: Dr. Janet Liechty, the School of Social Work
and the College of Medicine at the University of Illinois, UrbanaChampaign, IL. E-mail: jliechty@illinois.edu
1
School of Social Work at the University of Illinois, UrbanaChampaign, Illinois
2
College of Medicine, the University of Illinois, Urbana-Champaign, Illinois
Published online 28 August 2013 in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/eat.22174
C 2013 Wiley Periodicals, Inc.
V

790

between early depression and ED diagnosis was significantly stronger for men
than women. Findings supported a
cumulative risk effect. Among women,
each additional correlate was associated
with greater odds of eating pathology in
young adulthood; among men, each
additional correlate was associated with
greater odds of ever reporting ED diagnosis. Overall prevalence of dieting and eating pathology among young adults was
higher among women than men and
increased over time for both sexes.
Discussion: Early weight control behavior and cognition affect long term eating
patterns and are salient for both young
adult men and women. Transition to
young adulthood is a critical period for
assessing and preventing weight and
C 2013
eating-related health problems. V
Wiley Periodicals, Inc.
Keywords: disordered eating; eating disorders;
longitudinal; risk factors; depression; young
adult; weight loss behaviors; dieting
(Int J Eat Disord 2013; 46:790800)

clinical EDs does not capture the extent of the public health problem of disordered eating. For example, in a population-based study of 2,287 youth,
researchers found that at middle adolescence the
prevalence of unhealthy weight loss behaviors was
61% among girls and 28% among boys.4 Even when
diagnostic criteria are unmet, subthreshold ED and
symptoms of disordered eating are themselves
associated with adverse social, emotional, and
health consequences.1,2,5,6
Binge eating behavior is a growing concern.7 The
National Comorbidity Study shows that binge eating disorder (BED) and subthreshold BED (SBED)
have the highest 12-month and lifetime prevalence
of any ED among both adolescents and adults.
Among adolescents, lifetime prevalence of BED
and SBED is 1.6% and 2.5%, respectively, as compared to 0.3% for anorexia nervosa (AN) and 0.9%
for bulimia nervosa (BN).2 In the adult population,
lifetime prevalence of BED and SBED is 2.8% and
1.2%, respectively, as compared to 0.6% for AN and
1.0% for BN.8 Clinical studies show that BED
International Journal of Eating Disorders 46:8 790800 2013

LONGITUDINAL PREDICTORS OF DISORDERED EATING

accounts for about 53% of persons diagnosed with

ED not otherwise specified,9 one of the reasons
the DSM-5 added BED as a distinct diagnostic
category.10
Prior research has established that EDs and disordered eating have robust associations with weightrelated health behaviors such as dieting, unhealthy
weight loss behaviors, and binge eating4,5,11; and
with psychosocial factors such as depression, body
image dissatisfaction, and teasing.1214 Many studies
of correlates have used cross-sectional and clinical
or convenience samples; although longitudinal
studies to identify trends and risk factors for disordered eating over time are increasing4,1517 and are
necessary to examine trends, risk factors, and pathways of risk.18,19 However, few nationally representative, longitudinal studies have been conducted to
examine how behavioral and cognitive characteristics in adolescence may serve as long-term correlates and risk factors for dieting and disordered
eating in young adulthood.
The transition to adulthood has been identified
as an important developmental period for exploring and establishing eating and weight-related
health habits and beliefs.20 Emerging adulthood
(ages 1825) is a stage of late adolescence found in
industrialized countries when individuals are gradually transitioning from the dependence of childhood to the full independence of adulthood.21
Because many body and weight-related cognitions
and behaviors established during adolescence persist across the lifespanregardless of changes in
objective weight22adolescence and young adulthood offer potent developmental windows for
assessing predictors and risk factors for eating
pathology. Longitudinal research is needed to
examine associations and risk factors for disordered eating using nationally representative data
with greater potential for generalizability than clinical or community samples.11 In addition, body
image concerns, disordered eating, and EDs are
increasingly recognized as a concern for adolescent
boys as well as girls,1,2 but less is known about the
extent to which these problems extend into emerging adulthood among young men.
There is some disagreement in the empirical literature about whether the rate of disordered eating
increases or decreases with time. A 20-year longitudinal study among college aged individuals at baseline
found that dieting and extreme dieting decreased
over the lifespan between young adulthood and midlife,23 but their sample did not include adolescents.
An 11-year population study tracked bulimic symptoms among Norwegian youth (grades 712; ages 12

International Journal of Eating Disorders 46:8 790800 2013

20 at baseline) over three time points into young

adulthood, and findings were mixed. Among females,
bulimic symptoms increased between ages 14 and
16, and then trended downward; among males
bulimic symptoms decreased between ages 14 and
16 and then trended upward.17 Using outcomes similar to the ones we used in this study, another 10-year
longitudinal study found that rates of dieting and disordered eating increased or remained the same during the transition between adolescence and young
adulthood across both genders.4 This study, based on
nationally representative data, may clarify whether
rates of dieting and EWLB increase or decrease during the transition from adolescence to young adulthood in the U.S.
The purpose of this study was to examine the
longitudinal impact of psychosocial and behavioral characteristics measured at W1 (depression,
body image distortion, dieting, and EWLB) on
dieting and three indicators of disordered eating
measured in young adulthood at W3 (EWLB,
binge eating, and ED diagnosis), after adjusting
for age, race/ethnicity, parent education, family
structure, and body mass index. First, we
hypothesized that early dieting, EWLB, depression, and body image distortion at W1 will be risk
factors for the onset of dieting and EWLB 7 years
later. Second, we hypothesized that early dieting,
EWLB, depression, and body image distortion will
be associated over time with binge eating and
with ever being diagnosed with an ED reported at
W3 after adjustments. Third, recognizing the differential impact of gender socialization and societal body objectification on women and men,24,25
we stratified analyses by sex. We also tested sex as
a moderator the associations between correlates
and outcomes (interaction effects) to determine if
associations significantly differed by sex. We
expected associations to be weaker among males
than females due to lower rates of weight loss
behaviors, depression, and body image problems
among males. Finally, we hypothesized that the
four correlates, conceptualized as an index from 0
to 4, will have a cumulative association over time
with later eating pathology in young adulthood,
consistent with a multiple stressor model.26 Specifically, in the prospective samples, we hypothesized that cumulative risk will predict onset of
dieting and onset of EWLB. In the full sample we
expected higher scores on the index of cumulative
risk to be associated over time with binge eating
in young adulthood and with ever being diagnosed with an ED.

791

LIECHTY ET AL.

Method

TABLE 1.

Sample characteristics at Wave 1 by sex (n 5 14,322)

All

Data and Participants

Data were drawn from the National Longitudinal Study
of Adolescent Health (Add Health), the largest national
study of adolescents ever undertaken in the U.S. Add Health
is based on a stratified random sample of 80 high schools
and 52 feeder middle schools and is representative of U.S.
schools with respect to region of country, urbanicity, school
size, school type, and ethnicity.27 The Add Health In-home
survey was first administered in 19941995 at Wave 1 (W1)
and again at each subsequent wave (1996, 20012002, and
20072008). We used data from the adolescent In-home
Survey and Parent Survey. The analytic sample for this study
consisted of participants completing the In-home Survey at
W1 (19941995, grades 712, n 5 20,745) and Wave 3 (W3)
(20012002; ages 1826; n 5 15,197) with valid sampling
weights to ensure representativeness, yielding an analytic
sample of N 5 14,322. This study was approved by the Institutional Review Board at the University of Illinois.
Measures
Demographics. Age was calculated from dates of birth
and interview. Race/ethnicity was based on self-report.
Parent education was assessed using the highest educational attainment of either parent reported in the Parent
Survey, and missing data were filled in from the adolescent In-home Survey. Family structure was assessed
using 26 items (13 items for each parent) on the In-home
Survey to determine number of parents in the household.
These were recoded into a binary variable: two-parent
households versus other than two-parent households.
Body Mass Index (BMI). Self-reported height and
weight from W1 were used to calculate BMI using the
standard formula (BMI 5 weight/height2). Subsequent
waves of Add Health assessed both measured and selfreported height and weight, and in W2 a strong correlation (r 5 0.92) was found between BMI based on measured and self-reported values.28 Missing data for BMI
were 2.6% due to missing height or weight, and deleted
listwise.
Weight Status, BMI Percentiles, and BMI Z-scores.
BMI-for-age growth charts and SAS program code provided by the centers for disease and control and prevention (CDC) were used to calculate BMI percentiles
(BMIpct) and z-scores (BMIz), and BMIpct was used to
assign each adolescent respondent a weight status.29,30
The CDC growth charts classify weight status according
to BMIpct scores as follows: underweight (BMI < 5th percentile for age and sex); healthy weight (BMI 5 5th
to < 85th percentile); overweight (BMI 5 85th to < 95th
percentile); and obese (BMI  95th percentile). Weight
status was used to calculate body image distortion and

792

Characteristics
Sex
Age
Race
NH White
Hispanic
NH Black
NH Asian
NH Am Indian
Other
Parent education
HS or less
Some college
College or more
Family structure
2-parent household
Others
BMI percentile
Weight status
Underweight
Healthy weight
Overweight
Obese
BID overestimation
CES-D index
CES-D 16

% or
M (SD)

Women
% or
M(SD)

Men
N

% or
M (SD)

100.0
15.9
(1.8)

14,322

50.9
15.9
(1.8)

7,555

49.1
16.0
(1.8)

6,767

65.5
11.8
16.0
3.9
2.0
0.8

7,482
2,319
3,066
1,072
263
110

66.1
11.6
16.3
3.7
1.8
0.6

3,961
1,169
1,772
513
131
52

64.9
12.2
15.7
4.1
2.2
0.9

3,521
1,150
1,344
559
132
58

45.8
20.7
33.6

6,120
2,846
5,011

45.8
21.6
32.6

3,254
1,543
2,560

45.7
19.6
34. 2

2,866
1,303
2,451

67.5
32.5
59.5
(28.8)

9,500
4,822

66.3
33.7
58.6
(29.1)

4,909
2,646

67.8
32.2
60.4
(28.4)

4,591
2,167

3.4
71.2
14.4
10.9
15.2
10.6
(7.6)
22.7

423
9,999
1,983
1,537
2,219

2.8
74.1
14.5
8.6
21.9
11.8
(8.4)
27.4

193
5,410
1,019
658
1,666

4.0
68.5
14.4
13.2
8.8
10.1
(6.6)
18.1

230
4,589
964
879
553

3508

2,201

1,307

Note: M, Mean; EWLB, extreme weight loss behaviors; ED, eating disorder; BID, body image distortion; BMI, body mass index; HS, high
school; CES-D, Center for Epidemiologic Studies Depression Scale (modified 19-item). The CES-D cut-point for mild depression is 16 (range 0
57). NH, non-Hispanic; Am, American. Binge eating and ED diagnosis are
not shown because they were not assessed at W1. Sample sizes are raw
numbers; percentages are weighted to the U.S. population. Please see
Table 2 for prevalence of dieting and EWLB at baseline.

to describe the sample in Table 1. BMIz scores at W1

were used as controls in the multivariate models.
Depression. Depressive symptoms were assessed by a
19-item scale adapted from the 20-item Center for Epidemiologic Studies Depression Scale (CES-D).31 Adolescents were asked to rate their agreement with statements
such as You felt you were too tired to do things. The
response scale ranged from 0 (never or rarely) to 3 (most
of the time or all of the time). Following standard scoring
instructions, items were summed as an index, where
higher scores indicated greater frequency of depressive
symptoms (range 057). In this sample, Chronbachs
alpha was 0.83. The cut-point for mild depression is CESD scores 16.32 Mean scores and depression prevalence
were calculated based on the index (057) for Table 1,
and mean participant scores (range 03) were used as a
continuous variable in the multivariate models for ease
of interpretation. Missing data on the CES-D scale were
0.1% and deleted listwise. This construct was assessed at
W1.
International Journal of Eating Disorders 46:8 790800 2013

LONGITUDINAL PREDICTORS OF DISORDERED EATING

TABLE 2.

Prevalence of outcomes measured at W1 and W3 by sex (N 5 14,322)

W1
All

W3

Women

Men

All

Women

Men

Characteristics

Dieting
EWLB
Binge eating*
ED diagnosis*

13.0
0.9

2000
156

20.7
1.5

1572
128

5.6
0.3

428
28

19.1
3.56
6.14
2.13

2795
559
906
293

27.3
5.79
7.22
3.83

2030
448
536
268

11.3
1.42
5.10
0.49

765
111
370
25

Note: EWLB, extreme weight loss behaviors; ED, eating disorder; BID, body image distortion. Sample sizes are raw numbers; percentages are
weighted to the U.S. population.
*Binge eating and ED diagnosis were not assessed at W1.

Body Image Distortion (BID). In keeping with prior Add

Health studies,33 a BID variable was constructed to indicate nonconcordance between perceived and actual
weight status. Participants were asked, How do you think
of yourself in terms of weight? [very underweight, slightly
underweight, about right, slightly overweight, very overweight]. BID was coded 1 if there was a discrepancy
between BMI-based weight status and perceived weight
status, and further binary coded for direction of distortion. Specifically, if a participant was underweight or
healthy weight according to BMI but perceived herself to
be slightly or very overweight, this was coded as BIDoverestimation. BID overestimation is a known risk factor
for disordered eating.34 BID-overestimation was compared to no overestimation. BID was assessed at W1.
Dieting. Two types of weight control behaviors were
assessed: dieting and extreme weight loss behaviors
(EWLB). Dieting to control weight was a binary measure.
In both waves, participants marked whether or not they
dieted in the past seven days to lose weight (coded 1),
all others were coded 0. Dieting was assessed at W1 as
a baseline variable, and at W3 as an outcome variable. In
the prospective model, dieters at W1 were excluded from
the sample to assess onset of new dieting behavior
between waves.
Extreme Weight Loss Behaviors. Three items measured
EWLB that participants reported using in order to lose
weight or stay the same weight (yes/no). EWLB included
any one or more of the following: diet pills, laxatives, or
vomiting within the past 7 days to lose weight, and the
items were included in both waves. EWLB was assessed
at W1 as a baseline variable, and at W3 as an outcome
variable. In the prospective model, individuals with
EWLB at W1 were excluded from the sample to assess
onset of new EWLB between waves.
Binge Eating Symptoms. We used one item from W3 to
assess a symptom of binge eating. The item reads: In the
past seven days, have you been afraid to start eating
because you thought you would not be able to stop or control your eating? This is a proxy item for out of control
eating, a common feature of clinical BED.10 Marked
International Journal of Eating Disorders 46:8 790800 2013

items were coded 1 and unmarked items were coded

0. (Binge eating was not assessed in W1.). Previous
studies have used this Add Health item to assess binge
eating.35
Eating Disorder Diagnosis. In W3 participants reported
whether they had Ever been told by a doctor that you
have an eating disorder, such as anorexia nervosa or bulimia. This was coded as a binary variable (yes/no).
Marked items were coded 1 and unmarked items were
coded 0. (Eating disorder diagnosis was not assessed in
Add Health W1). This item from Add Health has been
used in prior studies to indicate eating disorder
diagnosis.36
Cumulative Risk. We used binary recodes of each of
the four known correlates of eating pathology (depression, dieting, BID, and EWLB) to create and test a
cumulative risk index (range 04).37 Cumulative risk for
the four weight-related health outcomes in this study
was examined descriptively and in multivariate regression models.
Analytic Strategy
Descriptive characteristics were obtained using SPSS
version 19.0 and normalized weights were applied. Multivariate logistic regressions were conducted in STATA version 10.0 using survey commands to adjust for the
complex survey design of Add Health. When baseline
data were available (i.e., for outcomes EWLB and dieting), we used a prospective model and excluded cases
presenting with the outcome behavior at W1 from the
analysis in order to examine onset of the outcome. When
baseline data were not available to implement a prospective model, we assessed longitudinal associations
between characteristics at W1 and outcomes at W3. In
addition, we tested interactions between gender and
depression, dieting, EWLB, and BID in the multivariate
models, controlling for main effects. Unless otherwise
noted, we used listwise deletion of missing data, which
did not exceed 2.6% for any item in the final models, a
level considered acceptable.38

793

LIECHTY ET AL.
TABLE 3. Multivariate logistic regression predicting dieting, EWLB, binge eating symptoms, and ED diagnosis reported at Wave 3 from psychosocial
and background factors at Wave 1, stratified by sex
Prospective Models
Dieting W3 (n 5 12,322)
Predictors

OR (95% CI)

Age
Male
1.19 (1.11, 1.28)
Female
1.06 (1.00, 1.12)
Race/ethnicity
Hispanic
Male
1.17 (0.86, 1.61)
Female
1.07 (0.82, 1.38)
NH Black
Male
0.45 (0.29, 0.70)
Female
0.56 (0.43, 0.74)
NH Asian
Male
0.70 (0.43, 1.15)
Female
0.55 (0.35, 0.85)
Parent education
Some college
Male
0.98 (0.68, 1.14)
Female
1.27 (0.98, 1.64)
College or more
Male
1.31 (0.97, 1.76)
Female
1.15 (0.94, 1.42)
Two parent household
Male
1.62 (1.20, 2.27)
Female
1.14 (0.95, 1.36)
BMIz W1
Male
2.52 (2.20, 2.89)
Female
1.74 (1.58, 1.92)
CES-D W1
Male
1.01 (0.69, 1.48)
Female
1.11 (0.87, 1.42)
BID W1
Male
1.72 (1.13, 2.61)
Female
1.25 (1.02, 1.53)
Dieting W1
Male

Female

EWLB W1
Male
2.01 (0.48, 8.38)
Female
0.72 (0.36, 1.44)

Longitudinal Association Models

EWLB W3 (n 5 14,166)

Binge W3 (n 5 14,322)

ED diagnosis W3 (n 5 14,322)

p-value

OR (95% CI)

p-value

OR (95% CI)

p-value

OR (95% CI)

p-value

<0.001
0.04

0.99 (0.84, 1.17)

1.05 (0.97, 1.15)

0.93
0.19

1.00 (0.84, 1.21)

0.92 (0.83, 1.02)

0.92
0.13

1.13 (0.69, 1.86)

0.95 (0.86, 1.05)

0.62
0.30

0.32
0.62

2.10 (0.94, 4.69)

1.07 (0.72, 1.60)

0.07
0.72

0.73 (0.28, 1.94)

2.04 (1.17, 3.54)

0.53
0.01

2.35 (0.56, 9.81)

0.62 (0.34, 1.10)

0.24
0.09

<0.001
<0.001

0.40 (0.15, 1.04)

1.09 (0.78, 1.55)

0.06
0.60

1.02 (0.47, 2.24)

0.71 (0.37, 1.38)

0.97
0.31

0.93 (0.19, 4.37)

0.35 (0.19, 0.62)

0.93
<0.001

0.16
0.01

0.65 (0.13, 3.31)

1.01 (0.42, 2.41)

0.60
0.98

3.07 (1.41, 6.68)

1.72 (0.96, 3.07)

0.01
0.07

*
0.27 (0.09, 0.71)

0.01

0.93
0.07

1.75 (0.78, 3.86)

0.96 (0.66, 1.38)

0.17
0.81

1.23 (0.59, 2.59)

1.17 (0.73, 1.86)

0.58
0.52

0.68 (0.14, 3.31)

0.95 (0.58, 1.54)

0.63
0.82

0.76
0.18

1.75 (0.85, 3.59)

0.80 (0.54, 1.19)

0.13
0.27

1.06 (0.54, 2.11)

1.51 (1.03, 2.21)

0.85
0.04

1.14 (0.31, 6.52)

1.68 (1.17, 2.40)

0.66
0.01

0.002
0.15

0.82 (0.42, 1.61)

1.07 (0.79, 1.45)

0.56
0.65

0.86 (0.51, 1.42)

0.85 (0.57, 1.27)

0.55
0.43

0.22 (0.05, 0.83)

0.96 (0.66, 1.40)

0.03
0.85

<0.001
<0.001

2.52 (1.92, 3.31)

1.48 (1.28, 1.73)

<0.001
<0.001

1.20 (0.91, 1.59)

1.23 (0.99, 1.52)

0.19
0.07

0.87 (0.56, 1.35)

0.7 (0.59, 0.84)

0.54
<0.001

0.96
0.42

0.66 (0.27, 1.64)

1.42 (1.03, 1.95)

0.37
0.03

3.51 (1.91, 6.39)

2.43 (1.78, 3.31)

<0.001
<0.001

5.72 (1.92, 17.0)

2.01 (1.48, 2.76)

<0.001
<0.001

0.01
0.03

1.50 (0.67, 3.37)

1.04 (0.75, 1.45)

0.32
0.78

0.75 (0.33, 1.75)

0.95 (0.64, 1.43)

0.51
0.82

2.88 (1.04, 8.00)

1.07 (0.74, 1.55)

0.04
0.74

0.90 (0.29, 2.67)

1.63 (1.16, 2.29)

0.86
0.01

0.81 (0.27, 2.45)

1.82 (1.17, 2.83)

0.72
0.01

1.87 (0.34, 10.27)

1.43 (0.94, 2.15)

0.47
0.09

0.34
0.34

2.63 (0.24, 29.7)

2.02 (0.83, 4.89)

0.43
0.12

*
3.59 (1.83, 7.07)

<0.001

Note: EWLB, extreme weight loss behaviors; ED, eating disorder; OR, odds ratio; CI, confidence intervals; NH, non-Hispanic; BMIz, body mass index
standardized z-scores; CES-D, Center for Epidemiologic Studies Depression Scale (mean score, range 03); BID, body image distortion-overestimation. Reference categories were as follows: Race/ethnicity (White), Parent education (High School or less), and Family structure (other than 2-parent household).
*Too few cases to analyze.

Cases with baseline behaviors were excluded from the analyses in the prospective models.

Results
Prevalence of any disordered eating indicator
among young adults ranged from 2 to 6%, and
binge eating was the most prevalent type in the
total sample and in both sexes. In addition, 27% of
women and 11% of men reported dieting to lose
weight in young adulthood. In general, prevalence
of eating pathology was higher among women than
men and rates of dieting and EWLB increased over
time in this sample (see Table 2). The rate of EWLB
increased from less than 1% (0.9%) in W1 to 3.6%
in W3, and dieting increased from 13.0 to 19.1% by
W3 for the total sample (changes in binge eating
794

and ED diagnosis could not be reported because

measures were not available before W3).
Hypothesis 1 was partially supported. Logistic
regression results are shown in Table 3. In the prospective models, excluding cases in which dieting
or EWLB were present at baseline, we found that
BID was a risk factor for onset of dieting at W3,
according to an established definition and typology
of risk factors.18,19,39 Specifically, BID predicted
higher odds of dieting onset by W3 among both
men and women (OR 5 1.72, CI 5 1.132.61,
p < 0.05; OR 5 1.25, CI 5 1.021.53, p < 0.05, respectively). We also found that early dieting and
International Journal of Eating Disorders 46:8 790800 2013

LONGITUDINAL PREDICTORS OF DISORDERED EATING

FIGURE 1. Cumulative risk shown as prevalence of dieting and disordered eating at Wave 3 by number of psychosocial and behavioral risk characteristics reported at Wave 1 (range 04: depression, body image distortion, dieting, and extreme weight loss behavior).

depression were risk factors for onset of EWLB at

W3 among women. Specifically, dieting at W1 was
associated with a 1.6 increase in odds of onset of
EWLB at W3; and each unit on the mean depression scale (range 03) was associated with a 1.4
increase in odds of onset of EWLB at W3 (Table 3).
Contrary to hypothesis 1, not all characteristics were
found to be risk factors for the onset of dieting and
EWLB. For example, BID was not a risk factor for
onset of EWLB among either sex; and neither EWLB
nor depression were risk factors for onset of dieting
at W3. Although we treated BMIz as a control variable, it bears noting that higher BMIz was a potent
risk factor for onset of both dieting and EWLB
among both men and women (Table 3).
Hypothesis 2 was partially supported. In the full
sample, adjusting for demographics and BMIz at
W1 (Table 3), we examined associations over time
between early behaviors and cognitions and W3
binge eating symptoms and ED diagnosis (ever
diagnosed with an ED). Depression at W1 was
strongly associated with binge symptoms at W3
among both men and women (OR 5 3.51,
CI 5 1.916.39; p < 0.001; OR 5 2.43, CI 5 1.783.31,
p < 0.001, respectively), and with ED diagnosis
International Journal of Eating Disorders 46:8 790800 2013

among both men and women (OR 5 5.72,

CI 5 1.9217.0; p < 0.001; OR 5 2.01, CI 5 1.482.76,
p < 0.001, respectively). Thus, each unit on the
mean depression scale (range 03) at W1 was associated with a nearly 6-fold increase in the odds of
reported ED diagnosis among men and two times
the odds among women. Among women only, dieting at W1 was associated over time with binge eating at W3 (OR 5 1.82, CI 5 1.172.83; p < 0.05).
Among men only, early BID at W1 was associated
with increased odds of ever being diagnosed with
ED (OR 5 2.88, CI 5 1.048.00; p < 0.05). Among
women, EWLB at W1 was associated with more
than a threefold increase in the odds of ever reporting being diagnosed with ED by W3 (OR 5 3.59,
CI 5 1.837.07; p < 0.001). There were no associations between dieting at W1 and ever being diagnosed with ED, or between BID or EWLB at W1 and
binge eating in W3 (Table 3).
Hypothesis 3 was partially supported. In the
multivariate models controlling for main effects,
gender interacted only with depression (not with
dieting, EWLB, or BID), and only in predicting
EWLB and ED diagnosis (not shown in table). Specifically, compared to women with depression at
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LIECHTY ET AL.
TABLE 4. Multivariate logistic regression showing longitudinal associations between cumulative risk at Wave 1 and dieting, EWLB, binge eating,
and ED diagnosis reported at Wave 3 (n 5 14,322)
Dieting W3
OR (95% CI)
Cumulative risk
Male
1.25 (1.03, 1.52)
Female
1.28 (1.17, 1.39)

EWLB W3

Binge W3

ED diagnosis W3

p-value

OR (95% CI)

p-value

OR (95% CI)

p-value

OR (95% CI)

p-value

<0.001
<0.001

0.92 (0.56, 1.48)

1.30 (1.00, 1.54)

0.43
0.003

1.41 (0.96, 2.08)

1.67 (1.37, 2.04)

0.69
<0.001

3.21 (1.79, 5.78)

1.55 (1.35, 1.78)

<0.001
<0.001

Note: OR, odds ratio; CI, confidence interval; EWLB, extreme weight loss behaviors; ED, eating disorder. All models are adjusted for age, race/ethnicity, parent education, family structure, and body mass index z-scores at Wave 1, and stratified by sex. Cumulative risk index (range 04) included: Center
for Epidemiologic Studies-Depression scale 16 (cut-off for mild depression), body image distortion-overestimation, dieting, and EWLB at W1.

W1, men with depression at W1 had twice the odds

of EWLB onset by W3 (OR 5 2.25, CI 5 1.015.00;
p < 0.05) but a 75% decrease in odds of ever being
diagnosed with an ED by W3 (OR 5 0.25, CI 5 0.10
0.62; p < 0.01). Further, stratification revealed
gender-specific patterns of association (see Table 3).
In the prospective models, depression and dieting
were risk factors for the onset of EWLB among
women only. In the longitudinal association models,
BID was associated with ED diagnosis among men
only. Among women only, early EWLB was associated
with ED diagnosis and early dieting was associated
with later binge eating. Overall, the level of significance and strength of associations varied by gender.
The final hypothesis regarding a cumulative effect
of distress symptoms was supported. As shown in
Figure 1, rates of each of the weight-related outcomes increased incrementally by the number of
distress symptoms present at W1. For example, the
rate of EWLB was 2.5% among those with no identified W1 symptoms, 4.8% among those with one
symptom, 8.6% with two, 9.6% with three, and
22.7% among those with all four W1 distress symptoms. More than half (58%) of the sample had no
symptoms at W1 (n 5 8,354), and one-third (30%) of
the sample had one symptom at W1 (n 5 4,350).
Participants who reported two, three, and four W1
symptoms were 9% (n 5 1,345), 2% (n 5 251), and
0.2% (n 5 22), respectively. The cumulative risk
index ranged from 0 to 4. Depression was the most
frequently reported symptom to occur by itself (a
score of 1), followed by BID and dieting. In contrast, EWLB rarely occurred by itself. The most frequently occurring 2-symptom combinations were
depressiondiet (n 5 419), Depression-BID (n 5 486)
and BID-Diet (n 5 379); and the other 2-symptom
combinations were very infrequent (Ns 510, 15, and
26). By far the most frequent 3-symptom combination was depressiondietBID (n 5 203 out of 251
cases with an index score of 3), while the remaining 3-symptom potential combinations were very
infrequent (Ns 5 12, 14, and 22). Finally, only 22
cases reported all four symptoms at W1.
796

Results of multivariate logistic regression models

of cumulative risk, controlling for demographics
and BMIz and stratified by sex, are shown in Table
4. Among women, each additional W1 symptom
was associated with 1.31.7 times increase in odds
of each of the four outcomes (dieting, EWLB, binge
eating symptoms, and ever being diagnosed with
an ED). Among men, each additional symptom was
associated with 1.3 times the odds of dieting and
3.2 times the odds of ED diagnosis at W3 (Table 4).

Discussion
The purpose of this study was to prospectively
assess risk factors for dieting and EWLB, and to
assess longitudinal associations with binge eating
symptoms and ED diagnosis reported by W3
among young adults in the U.S. All hypotheses
were at least partly supported. Early dieting,
depression, body image distortion, and EWLB were
each associated with at least one indicator of disordered eating in young adulthood. We also found
support for a cumulative risk model. Findings are
discussed below.
Prevalence of Dieting and EWLB Over Time

The prevalence of both dieting and EWLB

increased between W1 and W3 among both men
and women (Table 2). Among females, the rate of
EWLB more than tripled in the 7 years between W1
and W3. This study, based on nationally representative data, suggests that adolescents continue to
engage in dieting and EWLB into young adulthood,
and the behaviors become more widespread over
time. As described in the Introduction section, there
are discrepant findings in the empirical literature
about whether the rate of disordered eating
increases or decreases with time, but the discrepancies may be in the details. One of the prior studies
that found a downward trend in eating pathology
began with college age students at baseline, so they
were assessing trends from early to later young
International Journal of Eating Disorders 46:8 790800 2013

LONGITUDINAL PREDICTORS OF DISORDERED EATING

adulthood,10 which we would expect to differ from

trends in adolescence. Indeed, a Norwegian population cohort study found that trends in bulimic
symptoms were not even linear during adolescence:
trajectories of bulimic symptoms changed course
from middle to late adolescence.17 Among females,
bulimic symptoms increased to age 16, and then
trended downward, but among males they
decreased to age 16 and then trended upward.17 It is
possible that our study might miss fluctuations in
symptoms during adolescence, but we can conclude
that there was at least a net increase in prevalence
of dieting and EWLB between adolescence and
young adulthood for both genders in the U.S. This
finding is consistent with other population level
research examining a similar developmental window and measuring similar constructs.4 Overall,
these findings point to the need to better understand the natural history of a range of eating behaviors from childhood through adolescence and into
young adulthood, in order to identify sensitive periods for symptom progression and effectively apply
prevention and intervention efforts to populations
at risk.
Prospective Findings: Risk Factors for Dieting
and EWLB

The prospective analyses in this nationally representative study revealed several risk factors19,39 for
specific weight-related health outcomes. According
to Kraemers typology, depression and dieting in
adolescence were variable risk factors for the onset
of EWLB among young adult women; and BID in
adolescence was a variable risk factor for onset of
dieting among both men and women. The next
step toward empirically driven prevention targets
would be to test if depression and/or dieting are
causal risk factors for EWLB, and BID for dieting, in
experimental designs that manipulate the risk factor and observe corresponding changes in the outcomes.19,39 In addition, several background
demographic variables shown in Table 3 can be
classified as fixed markers (e.g., race/ethnicity, family structure). The current study adds to the literature on risk factors for weight-related health
behaviors among men and women during the transition to young adulthood in the U.S.
Associations Over Time Between Adolescent
Characteristics and Young Adult Eating
Patterns

Dieting during adolescence was associated with

binge eating (and prospectively with EWLB, as
noted earlier) among young adult women in the
International Journal of Eating Disorders 46:8 790800 2013

U.S. This finding is consistent with prior research on

the role of dieting in binge eating etiology, whereby
calorie insufficiency from restrictive behavior may
trigger overeating and binge eating.40 In a previous
study, compared to nondieters, dieters were two to
three times more likely to develop binge eating 5
years later based on a longitudinal study among
adolescents in Minnesota (n 5 1,827).11 Another
study among adolescent girls found that the risk of
binge eating increased when dieting was comorbid
with depressive symptoms,40 consistent with the
cumulative risk model examined in this study. Our
results extend these findings to a nationally representative sample. However, because we did not have
data on baseline binge eating behavior, we cannot
determine temporal order, only that adolescent dieting is a correlate of binge symptoms 7 years later.
Consistent with prior studies, this study found
that depression was strongly associated with young
adult binge symptoms and with ED diagnosis for
both sexes. For example, in the national Growing
Up Today Study (n 5 4,798), depression predicted
binge eating among young adult women.13
Although most studies on the relation between
depression and eating pathology have been conducted among girls and women,12 this study and
others have found similar associations for both
genders in adolescence.11,41 Thus, depression prevention and intervention are important to address
among both sexes to improve weight-related
health. Reciprocal models also have empirical support and posit that depressive symptoms lead to
binge eating as a means of coping, and binge eating to depression via shame and distress.3 This
study and others showing strong associations
between depression and disordered eating over
time suggest that enhancing skills for coping with
negative emotion could be an effective adjunct to
prevention.
It was somewhat surprising that BID in adolescence was not a risk factor for EWLB or associated
with binge eating in young adulthood, since BID
was a strong risk factor for dieting and unsafe
weight control among adolescent girls in a shorter
term longitudinal study.34 Using just the first two
waves of the Add Health data, among a subsample
of girls of normal weight (n 5 5,137), BID increased
the odds of onset of EWLBs by 4.3 times and the
odds of onset of dieting by 2.3 times one year
later.34 The current study suggests that BID persisted as a risk factor for dieting but not for EWLB
after 7 years into young adulthood, and that association between early BID and this measure of young
adult binge eating were not significant at a population level. Thus, at least among females, some of
797

LIECHTY ET AL.

the risks associated with BID appear to be mitigated with time, raising new questions about factors that may foster resilience and recovery from
early body image problems. Among males only,
BID in adolescence was associated with ever having been diagnosed with an ED as reported in
young adulthood, confirming the salience of body
image issues among some males.42
Further study is needed to determine the course
and impact of BID: does BID self-correct among
women by young adulthood? Does BID persist but
lose its potency as a correlate? Do some women experience growth and improvement in overall body selfconcept? Factors that promote wellness and body
acceptance warrant further study, and studies with
larger samples of males with disordered eating could
further illuminate the impact of body image issues.
Gender Differences

Consistent with prior research, in this study the

prevalence of depression was lower among men
than women (Table 1) and yet it was a significant
predictor of eating pathology for both sexes.17
Somewhat surprisingly, our study found that
depression at W1 had a stronger adverse effect on
ED diagnosis among men than women (Table 3) in
both stratified and interaction analyses. Why? Interestingly, both depression and ED are gendered phenomena in our society, and a sociocultural model
points to gender socialization as one of the many
contributing factors to the development of both
EDs43 and depression.44 Do depression and other
internalizing problems confer a stronger penalty for
men than women, perhaps due to gender noncomformity? If so, we would expect that depression
would have a stronger effect on the other eating
behaviors among men than women; however, this
was not the case. Although the odds ratio for predicting binge eating from depression was higher for
men than women, they did not differ significantly.
Further, the strength of depression as a risk factor
for onset of EWLB differed by sex but the effect was
significantly higher among females than males. Further research is needed to understand and test
causal factors in gendered pathways of risk toward
disordered eating and weight-related health.
Stratified analyses showed that patterns of significant relationships between putative risk factors and
outcomes differed by gender for all predictors except
depression (when depression effect sizes were significant or nonsignificant, they were so for both genders). For example, EWLB at W1 was associated with
ED diagnosis among women only, and BID with ED
diagnosis among men only. Further, dieting during
798

adolescence was not associated with any of the outcomes assessed in young adulthood among men, yet
dieting was a risk factor for EWLB and associated
with binge eating among women. While this may be
due in part to the lower prevalence of dieting among
boys and men than among girls and women,4 a possible explanation for observed sex differences is that
socioculturally, weight control may have a different
meaning and salience for women than men, given
differences in weight and shape ideals. Girls and
adolescent women are more likely to internalize the
thin ideal and seek slimness, while boys and adolescent males seek muscularity and bulk45 and males
are less likely to engage in body checking about their
weight or shape.24 Consistent with social cognitive
theory, self-perceptions of eating behavior may also
be gendered, be shaped by sociocultural influences,
and affect dieting motivation and self-efficacy.46 In a
large community sample (n 5 5,522; ages 1835),
men were more likely to report overeating than
women, while women were more likely to report loss
of control eating than men, despite weak differences
in effect sizes in binge eating frequency by sex.24
Thus while sex differences in disordered eating
behavior may be negligible, the salience of weight
control, frequency of body checking, selfperceptions about eating, and psychosocial impact
of eating behavior over time appear to differ by sex,
and may contribute to gender differences in pathways of risk for disordered eating.1

Cumulative Risk

The accumulation of symptomatic cognitions

and behaviors at W1 (depression, BID, dieting, and
EWLB) was significantly associated with dieting,
EWLB, binge eating, and ED diagnosis among
women; and with dieting and ED diagnosis among
men in adjusted models.
Cumulatively, characteristics at W1 were associated with higher prevalence of dieting and eating
pathology at W3, especially among women. Cumulative effects models highlight the association
between multiple stressors and adverse outcomes.26 Such models are useful for understanding
multidetermined adverse outcomes such as disordered eating, where the additive impact of low or
medium-level risk factors and correlates may be as
important as isolating single extreme risk factors;
however, few studies have examined cumulative
effects for disordered eating. An exception is a
community sample study (N 5 543) that examined
the combined effect of dieting and depression. This
study found that the combined risks of depression
and dieting predicted binge eating at three waves
International Journal of Eating Disorders 46:8 790800 2013

LONGITUDINAL PREDICTORS OF DISORDERED EATING

(age 10, 12, and 14).40 A prior state-level population

study examined multiple risk factors for binge eating and EWLBs separately but not cumulatively.41
Our study builds on prior research by examining
the effect of multiple distress symptoms on eating
patterns. For example, when examined separately,
BID was only associated with onset of dieting by
W3 among women; however, when examined
cumulatively, each additional early psychosocial
and behavioral factor, including BID, was associated with about 1.5 times the odds of EWLB, binge
eating, and ED diagnosis among women.
Findings suggest that screening tools for disordered eating may be improved by inclusion of psychosocial and behavioral characteristics, including
depression and body image distortion for both
sexes, and dieting and EWLB for females. The correlates and characteristics examined here had
lower cumulative effect on outcomes for men than
women after 7 years, but it is possible that additional risk factors would have more salience for
men, a question that warrants further study. For
example, our findings suggest that psychosocial
correlates (e.g., depression, BID) may be more
salient than behavioral risk factors (e.g., dieting,
EWLB) for men with regards to the weight-related
outcomes examined here.

Conclusion
Overall, this study shows partial support for both
long-term and cumulative impact of early cognitive
and behavioral correlates and risk factors for eating
patterns and pathology in young adulthood, and
sex differences are evident. Further research is
needed to examine temporal order of risk and protective factors and potential reciprocal effects in
the interplay between psychosocial risk factors and
eating pathology, and to better understand the relative potency of various combinations of cumulative
risk. This study highlights the importance of understanding the impact of early psychosocial correlates and risk factors among young adults of both
sexes in order to improve prevention, risk assessment, and referral for treatment of disordered eating and EDs.
This research uses data from Add Health, a program
project directed by Kathleen Mullan Harris and designed
by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the University of North Carolina at Chapel
Hill. Special acknowledgment is due Ronald R. Rindfuss
and Barbara Entwisle for assistance in the original
design. Information on how to obtain the Add Health
data files is available on the Add Health website (http://
www.cpc.unc.edu/addhealth). No direct support was
received from grant P01-HD31921 for this analysis.

Limitations

Several limitations of this study bear noting.

Measures of ED and binge eating were only available in W3 and thus did not allow us to predict the
onset of these conditions, as we did for onset of
dieting and EWLB. Therefore, we could only examine correlates over time for ED diagnosis and binge
eating. Measurements of disordered eating outcomes in the Add Health survey are a limitation.
The single item indicators for ED diagnosis and
binge eating in the Add Health survey are selfreported and specific diagnostic criteria for BED
were not available. The ED diagnosis item was not
time specific and so permits only correlational
analysis. Although Add Health draws upon a large
sample, the cell size for ED diagnosis at W3 among
men was still too small to analyze in multivariate
models (Table 3). Finally, we examined characteristics from W1 for this study; however more proximal
correlates and risk factors may yield different
results. Particular strengths of the study are its longitudinal design, nonclinical nationally representative sample, and the examination of early
characteristics on young adult outcomes for both
sexes.

International Journal of Eating Disorders 46:8 790800 2013

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