Body Dissatisfaction Prospectively Predicts Depressive Mood and Low Self-Esteem in Adolescent Girls and Boys

Journal of Clinical Child and Adolescent Psychology ISSN: 1537-4416 (Print) 1537-4424 (Online) Journal homepage: http://www.tandfonline.com/loi/hcap20 Body Dissatisfaction Prospectively Predicts Depressive Mood and Low Self-Esteem in Adolescent Girls and Boys Susan J. Paxton, Dianne Neumark-Sztainer, Peter J. Hannan & Marla E. Eisenberg To cite this article: Susan J. Paxton, Dianne Neumark-Sztainer, Peter J. Hannan & Marla E. Eisenberg (2006) Body Dissatisfaction Prospectively Predicts Depressive Mood and Low Self- Esteem in Adolescent Girls and Boys, Journal of Clinical Child and Adolescent Psychology, 35:4, 539-549, DOI: 10.1207/s15374424jccp3504_5 To link to this article: https://doi.org/10.1207/s15374424jccp3504_5 Published online: 07 Jun 2010. Submit your article to this journal Article views: 6406 View related articles Citing articles: 205 View citing articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalinformation?journalcode=hcap20

Journal of Clinical Child and Adolescent Psychology 2006, Vol. 35, No. 4, 539 549 Copyright 2006 by Lawrence Erlbaum Associates, Inc. Body Dissatisfaction Prospectively Predicts Depressive Mood and Low Self-Esteem in Adolescent Girls and Boys Susan J. Paxton School of Psychological Science, La Trobe University, Melbourne Dianne Neumark-Sztainer, Peter J. Hannan, and Marla E. Eisenberg School of Public Health, University of Minnesota This research examined whether body dissatisfaction prospectively predicted depressive mood and low self-esteem in adolescent girls and boys 5 years later. Participants were early-adolescent girls (n = 440, Time 1 M age = 12.7 years) and boys (n = 366, Time 1 M age = 12.8 years) and midadolescent girls (n = 946, Time 1 M age = 15.8 years) and boys (n = 764, Time 1 M age = 15.9 years). After controlling for Time 1 of the relevant dependent variable, ethnicity, socioeconomic status, and body mass index, Time 1 body dissatisfaction was a unique predictor of Time 2 depressive mood and low self-esteem in early-adolescent girls (depressive mood: F = 4.80, p <.05; self-esteem: F = 9.64, p <.01) and midadolescent boys (depressive mood: F = 12.27, p <.001; self-esteem: F = 9.38, p <.01) but not in early-adolescent boys or midadolescent girls. These findings are consistent with the hypothesis that body dissatisfaction is a risk factor for depressive mood and low self-esteem in both girls and boys but in different phases of adolescence. Correspondence should be addressed to Susan Paxton, La Trobe University, School of Psychological Science, Bundoora, Melbourne, VIC 3086, Australia. E-mail: susan.paxton@latrobe.edu.au Body dissatisfaction is widespread among adolescents in Western cultures (Neumark-Sztainer, Story, Hannan, Perry, & Irving, 2002; Ricciardelli & McCabe, 2001). The negative impact of body dissatisfaction in adolescent girls and boys has been gauged in terms of the immediate distress, low self-esteem, and depressive mood with which it is consistently associated (Allgood-Merten, Lewinsohn, & Hops, 1990; Cash, 2002; Keery, van den Berg, & Thompson, 2004; Wertheim, Koerner, & Paxton, 2001; Wichstrom, 1999). In addition, the negative impact of body dissatisfaction has been demonstrated in longitudinal studies in which it has been identified as a reliable predictor of the increases in use of dieting and disordered eating symptoms and clinical eating disorders (e.g., Killen et al., 1996; Stice, 2001, 2002). However, less research attention has been directed toward the role of body dissatisfaction as a prospective predictor of other significant psychological problems, most notably depressive mood and low self-esteem. A theoretical rationale for a role for body dissatisfaction in predicting an increase in depression in girls has been articulated by Stice and Bearman (2001). They proposed that puberty moves girls away from the current thin beauty ideal and this change precipitates body dissatisfaction. As appearance is a critical evaluative dimension for girls in Western culture, body dissatisfaction directly contributes to increase in depressive mood. Although this rationale was specifically directed toward a relation between body dissatisfaction and depressive mood in girls, boys are under increasing pressure to meet an unrealistic, lean, muscular body ideal (Cafri et al., 2005; Cohane & Pope, 2001). It has been argued that this pressure could have similar consequences in adolescent boys (Holsen, Kraft, & Roysamb, 2001). In adolescent girls, a number of structural equation modeling studies that used cross-sectional data have strongly implicated body dissatisfaction as a predictor of low self-esteem and depression (e.g., Keery et al., 2004; van den Berg, Wertheim, Thompson, & Paxton, 2002; Wichstrom, 1999). Providing firmer support for body dissatisfaction preceding depression and self-esteem, a number of studies of adolescent girls have reported that body dissatisfaction prospectively predicts depressive mood (Holsen et al., 2001; Johnson & Wardle, 2005; Rierdan, Koff, & Stubbs, 1989; Stice & Bearman, 2001), and one study observed that body dissatisfaction predicts an increase in low self-esteem (Johnson & Wardle, 2005). Holsen and colleagues observed that body dissatisfaction predicted depressive mood within a single sample of girls 13 to 15 years old but not in girls 15 to 18 years old They did not report whether body dissatisfaction at first assessment (13 years) predicted depression at final assessment (18 years). Holsen and colleagues proposed that early ado- 539

PAXTON, NEUMARK-SZTAINER, HANNAN, EISENBERG lescence is the most challenging period for girls, as it is associated with entry into puberty, change in body shape, and greater capacity for self-reflection. Stice and Bearman observed that body dissatisfaction was directly related to increases in depressive mood and also indirectly related, with the effect mediated by dieting and bulimic symptoms. The research in girls to date is indicative of a risk factor role of body dissatisfaction for depressive mood and low self-esteem over a relatively short time period (1 to 2 years). However, it is unclear whether the effect of body dissatisfaction is over 1 to 2 years or whether it predicts depression or self-esteem over a longer time period (5 years). In addition, the observation of greater impact of body dissatisfaction on depression in early rather than midadolescence made by Holsen and colleagues (2001) has yet to be confirmed in an independent investigation. Although attention has focused on girls in the examination of the relation between body dissatisfaction and depressive mood, Holsen et al. (2001) also examined the nature of the relation in teenage boys. They found body dissatisfaction did not predict depressive mood in a single sample of boys ages 13 to 15 years but did predict depressed mood from age 15 to 18 years. They suggested that the underlying psychological processes behind the body image depressed mood relation may be similar in boys and girls but that the age difference may reflect typically later timing of puberty and appearance-related pressures. Holsen et al. did not examine whether body dissatisfaction prospectively predicted depressive mood over an extended follow-up period in the boys and did not examine whether body dissatisfaction assessed in boys in middle adolescence predicted an increase in depression in the early adult years. As far as we are aware, such prospective predictors of self-esteem in boys have yet to be explored. It would be valuable to understand whether body dissatisfaction in boys predicts depressive mood and low self-esteem at this later stage as the consequences of body dissatisfaction are often ignored in boys and this information could help guide early intervention for these possible outcomes. This study aimed to extend existing research examining the relation between body dissatisfaction and psychological outcomes in a number of ways. We explored whether body dissatisfaction is a prospective risk factor for boys and girls psychological outcomes over a relatively long (5-year) follow-up period. We aimed to extend Holsen et al. s (2001) exploration of developmental differences in outcomes of body dissatisfaction by exploring two longer developmental phases (12 to 17 years and 15 to 21 years) and using both self-esteem and depressive mood as outcome variables. We explored these questions in two cohorts of girls and boys involved in the Eating Among Teens Project (Project EAT). The first cohort was initially assessed in early adolescence, whereas the second cohort was initially assessed in midadolescence (Time 1). Both were reassessed 5 years later (Time 2). It was hypothesized that body dissatisfaction at Time 1 would prospectively predict depressive mood and self-esteem at Time 2, after controlling for baseline levels of the relevant variable, body mass index (BMI), and demographic variables in early-adolescent girls and midadolescent boys but in not early-adolescent boys or midadolescent girls. Method Participants Project EAT I is a large epidemiological study of socioenvironmental, personal, and behavioral determinants of dietary intake and weight status among adolescent girls and boys from diverse ethnic and socioeconomic backgrounds (Neumark-Sztainer, Story, Hannan, & Croll, 2002). In-class surveys and height and weight measurements were completed by students from junior and senior high school in 31 Minnesota schools (N = 4,746). Project EAT II aimed to resurvey as many of the original participants as could be contacted 5 years later (2003 2004). Surveys were mailed to the address provided by participants during EAT I. If the survey was not returned, a reminder postcard, then a survey, then a second reminder postcard, and then a final survey were sent by a commercial mail carrier to encourage response. If mail was returned due to an incorrect address, Internet tracking services were used to identify a current address where possible, and the mailing procedure recommenced. The University s Institutional Review Board Human Subjects Committee approved all protocols. At Time 1, letters were sent home to parents in advance of survey administration, describing the study and requesting active or passive consent, in accordance with requirements of each school. On the day of survey administration, project staff described study procedures, the confidentiality of the data, and the voluntary nature of participation. They also responded to questions as needed to obtain assent from those students with parental consent. At Time 2, initial letters were sent to all participants in the older cohort and parents of all participants in the younger cohort, explaining the study and inviting them and their children to participate in EAT II. If no refusal was received after a delay of 3 weeks, survey materials, including detailed consent and assent forms, were sent. Completion and return of surveys implied consent to participate in the study. In this manner, 3,672 of the original participants were contacted by mail and 2,516 completed surveys, representing 52.0% of the original cohort and 68.4% of participants who were contactable for EAT II. The fi- 540

BODY DISSATISFACTION PREDICTS DEPRESSION AND LOW SELF-ESTEEM nal sample who completed valid surveys in both EAT I (Time 1) and EAT II (Time 2) consisted of 440 girls in the early-adolescent cohort (Time 1 M age = 12.7 years, SD =.74; Time 2 M age = 17.2 years, SD =.62); 366 boys in the younger cohort (Time 1 M age = 12.8 years, SD =.76; Time 2 M age = 17.2 years, SD =.78); 946 girls in the older cohort (Time 1 M age = 15.8 years, SD =.81; Time 2 M age = 20.4 years, SD =.82); and 764 boys in the older cohort (Time 1 M age = 15.9 years, SD =.78; Time 2 M age = 20.5 years, SD =.82). The ethnic and racial background of the sample was 61.9% White, 11.1% African American, 4.5% Hispanic, 17.8% Asian, 1.9% Native American, and 2.7% of mixed or other ethnicity. There was also diversity in socioeconomic status (SES): 13% low, 17% middle-low, 25% middle, 28% middle-high, and 17% high. Measures Body dissatisfaction and BMI. Body dissatisfaction was assessed with a modification of the Body Shape Satisfaction Scale (Pingitore, Spring, & Garfield, 1997). Each respondent rated his or her satisfaction with 10 aspects of his or her body shape and parts (e.g., height, weight, body shape, waist, body build, and shoulders). The original scale included features of the body that could potentially be influenced by weight change. The modified scale used in this study also included items that could not be readily changed (e.g., height and body build) as these could also be sources of dissatisfaction and were likely to be relevant for boys. Items were rated on a 5-point Likert scale from 1 (very satisfied) to5(very dissatisfied) and item responses were summed (higher scores reflecting higher dissatisfaction). Principal components analyses, conducted separately by gender, confirmed the unitary structure of the body dissatisfaction construct for both girls and boys. The items were approximately equally weighted, making the sum a suitable summary. The single factor explained 59% and 61% of the variance in girls and boys, respectively; all other eigenvalues were less than 1. Cronbach s alpha was.92 and.91 in the early- and midadolescent girls, respectively, and.93 in both cohorts of boys. At Time 1, weight and height were measured using standardized equipment and procedures, and BMI was calculated (kg/m 2 ). Demographic variables. Gender, age, ethnicity, and SES were based on Time 1 youth self-report. Ethnicity was categorized as White, African American, Asian American, Hispanic, Native American, or mixed. SES was categorized as low, low-middle, middle, upper-middle, or upper SES. The prime determinant of SES category was parental education level, defined by the highest level of educational attainment of either parent. However, other variables were taken into account, including family eligibility for public assistance, eligibility for free or reduced-cost school meals, and parental employment status (Neumark-Sztainer, Story, Hannan, & Croll, 2002). Depressive mood. Depressive mood was assessed with the six-item Depressive Mood Scale developed by Kandel and Davies (1982). Items such as During the past 12 months, how often have you been bothered or troubled by feeling unhappy, sad, or depressed were rated on a 3-point scale from 1 (not at all) to 3(very much), and item responses were summed. Higher scores indicated higher depressed mood. Kandel and Davies validated the Depressive Mood Scale in adolescents who presented at two psychiatric clinics. They observed a significant correlation between the Depressive Mood Scale and the depressive mood subscale of the Symptom Check List 90 (Derogatis, 1977) and higher scores on the Depressive Mood Scale in adolescents diagnosed with major depressive illness compared to those who were not. Supporting the validity of Kandel and Davies measure, in this study at Time 2 strong significant correlations existed between scores on the Depressive Mood Scale and suicidal ideation, assessed on a 3-point scale of 1 (yes, during the last year),2(yes, more than a year ago), and 3 (never): early-adolescent girls r =.46, p <.001; early-adolescent boys r =.26, p <.001; midadolescent girls r =.35, p <.001; and midadolescent boys r =.38, p <.001. In our research, internal reliability of the Depressive Mood Scale was supported by Cronbach s alpha of.78 in both cohorts of girls and.78 and.80 in early and midadolescent boys, respectively. Self-esteem. Self-esteem was assessed with a shortened version of the Rosenberg Self-Esteem Inventory (Rosenberg, 1965). The original scale has 10 items, such as On the whole, I am quite satisfied with myself, rated on 4-point scale from 1 (strongly disagree) to4 (strongly agree). Item scores are summed, and higher scores are indicative of higher self-esteem. Validity of the scale is supported by a significant positive correlation with peer ratings of self-esteem (Demo, 1985), and, in a review of the convergent and discriminant validity of the Rosenberg Self-Esteem Inventory, Byrne (1983) concluded that this measure was one of the most valid measures of global self-esteem. Wylie (1989) reported a satisfactory 7-month test retest correlation of r =.73 in high school students and a 2-week test retest reliability of r =.85 in college students. Internal reliability is supported by high Cronbach s alpha of.80 (Paxton, Norris, Wertheim, Durkin, & Anderson, 2005). The original 10-item scale was shortened to 6 items to minimize the length of the survey instrument by omitting two positive and two negative items. The internal consistency of the scale remained satisfactory, with a Cronbach s alpha of:.75 and.79 for early- and midadolescent girls, respec- 541

PAXTON, NEUMARK-SZTAINER, HANNAN, EISENBERG tively, and.74 and.79 for early- and midadolescent boys, respectively. Data Analysis Distributions of the scores for depressive mood and self-esteem were confirmed to be symmetric and approximately normal, and thus the assumptions of multiple regression analysis of independence, constant variance and linearity, were met. There was a very small amount of missing item data (accounting for minor differences in sample sizes in analyses), but this was of such a minor scale as to introduce negligible bias. To examine whether body dissatisfaction prospectively predicted depressive mood after controlling for initial depressive mood, demographic variables and BMI, multiple regression analyses were conducted for each gender and cohort group separately in which Time 2 depressive mood was the dependent variable. The independent variables (Time 1 depressive mood, SES category, ethnic category, Time 1 BMI, and Time 1 body dissatisfaction) were entered into the regression simultaneously. To ensure that any failure to observe a predictive effect of body dissatisfaction was not due merely to shared variance with BMI, multiple regression analyses were conducted in which Time 2 depressive mood was the dependent variable and Time 1 depressive mood, SES category and ethnic category, but not Time 1 BMI, were entered simultaneously as independent variables. A similar strategy was used to examine whether body dissatisfaction at Time 1 prospectively predicted low self-esteem 5 years later. To test the differences postulated a priori between the genders and the cohorts for each of the outcomes, an analysis of covariance using all data and including the interactions of gender and cohort with body dissatisfaction was conducted (Jaccard, Turrisi, & Wan, 1990). Each analysis yielded a single degree-of-freedom F test of any differences in slopes of body dissatisfaction on the outcome, and targeted contrasts were examined between the gender and cohort groups. Comparisons of demographic characteristics of Project EAT I participants who did and did not respond to Project EAT II indicated several small but significant differences. Consequently, in all analyses, data were weighted to adjust for differential response rates using the response propensity method (Little, 1986) in which the inverse of the estimated probability that an individual responded at Time 2 was used as the weight. Thus, all Time 2 estimates are generalizable to the population represented by the original Project EAT I sample. The weighted ethnic and SES proportions of the study population were 48.3% White, 18.9% African American, 5.8% Hispanic, 19.6% Asian, 3.6% Native American, and 3.8% mixed or other race; and 17.8% low, 18.9% middle-low, 26.7% middle, 23.3% middle-high, and 13.3% high SES. Analyses were conducted with SAS 8.2, using propensity weights to account for nonresponse bias. Results Characteristics of Sample and Univariate Correlates of Time 2 Body Dissatisfaction Table 1 shows mean scores for Time 1 and Time 2 depressive mood and self-esteem and mean scores for Time 1 body dissatisfaction and BMI for each cohort of girls and boys. Univariate correlations between Time 1 and Time 2, body dissatisfaction, depressive mood, and self-esteem are shown in Table 2. Notably, Time 1 body dissatisfaction was positively correlated with Time 2 depressive mood and inversely correlated with Time 2 self-esteem in early- and midadolescent girls and midadolescent boys. However, these correlations were not observed in early-adolescent boys. Time 1 BMI was positively correlated with Time 2 depressive mood and inversely correlated with Time 2 self-esteem in early- and midadolescent girls. Time 1 BMI was also positively associated with Time 2 depressive mood in the early-adolescent boys but not midadolescent boys. Table 1. Means and Standard Deviations of Time 1 and Time 2 Depressive Mood, Self-Esteem, and Body Dissatisfaction and Time 1 Body Mass Index Early Adolescence Midadolescence Scale Range Girls a Boys b Girls c Boys d M SD M SD M SD M SD Time 1 Depressive Mood 6 18 10.5 2.7 9.4 2.6 11.3 2.7 9.8 2.7 Time 2 Depressive Mood 6 18 11.6 3.0 10.3 2.9 11.7 2.9 10.3 2.9 Time 1 Self-Esteem 6 24 17.6 3.4 18.4 3.6 17.2 3.4 18.8 3.4 Time 2 Self-Esteem 6 24 17.5 3.6 18.8 3.5 17.9 3.4 19.1 3.3 Time 1 Body Dissatisfaction 10 50 26.9 9.9 23.0 9.4 28.9 9.3 23.1 8.4 Time 2 Body Dissatisfaction 10 50 28.5 9.9 24.9 9.7 28.8 9.1 23.5 8.6 Time 1 Body Mass Index 21.7 4.4 21.3 5.2 22.6 4.5 23.0 4.2 Note: Within each group, the sample size for each analysis differs to a small degree due to differences in missing data. a n = 394 437. b n = 337 358. c n = 887 937. d n = 735 751. 542

BODY DISSATISFACTION PREDICTS DEPRESSION AND LOW SELF-ESTEEM Table 2. Pearson s Correlations Between Time 2 Depressive Mood and Self-Esteem and Time 1 Depressive Mood, Self-Esteem, Body Dissatisfaction, Body Mass Index, and SES Girls Boys BD 1 BD 2 Dep 1 Dep 2 SE 1 SE 2 BD 1 BD 2 Dep 1 Dep 2 SE 1 SE 2 Early Adolescence a BD 2.35.23 Dep 1.33.23.14.11 Dep 2.22.31.32.09 ns.28.32 SE 1.47.32.52.25.45.21.37.18 SE 2.32.57.31.52.37.10 ns.43.30.55.26 BMI 1.32.26.02 ns.12.08 ns.18.42.17.15.11.26.07 ns SES.13.11.23.09 ns.21.05 ns.13.22.11.10 ns.21.10 ns Mid-Adolescence b BD 2.48.42 Dep 1.31.15.33.21 Dep 2.18.34.39.24.39.40 SE 1.52.29.50.28.42.22.47.25 SE 2.28.52.27.55.47.27.45.30.58.39 BMI 1.33.32.02 ns.12.12.11.31.30.07 ns.07 ns.09.06 ns SES.12.15.01 ns.03 ns.06 ns.05 ns.11.12.05 ns.01 ns.13.04 ns Note: With 300 observations correlations of 0.11, 0.15, and 0.19 are statistically significant at p <.05,.01, and.001 levels, and with 700 observations the corresponding critical correlations are 0.073, 0.10, and 0.13. BD 1 = Time 1 body dissatisfaction; BD 2 = Time 2 body dissatisfaction; Dep1=Time1depressive mood; Dep2=Time2depressive mood; SE 1 = Time 1 self-esteem; SE 2 = Time 2 self-esteem; BMI 1 = Time 1 body mass index; SES = socioeconomic status; ns = not significant at p <.05. a Girls: n = 376 435; boys: n = 324 354. b Girls: n = 857 929; boys: n = 717 747. Table 3. Summary of Multiple Regression Analyses Predicting Time 2 Depressive Mood and Time 2 Self-Esteem in Early Adolescent Girls df Estimate SE F p Time 2 Depressive Mood a Ethnicity 5 0.42.832 SES 4 0.06.993 Time 1 Depressive Mood 1.32.06 24.66 <.001 Time 1 Body Mass Index 1.05.04 2.13.146 Time 1 Body Dissatisfaction 1.04.02 5.32.022 Time 2 Self-Esteem b Ethnicity 5 0.44.822 SES 4 0.26.906 Time1 Self-Esteem 1.28.06 23.79 <.001 Time 1 Body Mass Index 1.07.04 2.7.102 Time 1 Body Dissatisfaction 1.07.02 9.64.002 Note: Sample sizes differ slightly due to differences in missing data. SES = socioeconomic status. a n = 356, R 2 =.14. b n = 350, R 2 =.21. The Relation Between Time 1 Body Dissatisfaction and Time 2 Depressive Mood and Self-Esteem Early-adolescent girls. Table 3 presents summary statistics for multiple regression analyses in which we examined whether Time 1 body dissatisfaction predicted Time 2 depressive mood and low self-esteem in early-adolescent girls. As hypothesized, after controlling for Time 1 depressive mood, demographic variables, and BMI, Time 1 body dissatisfaction was a unique predictor of depressive mood 5 years later. Similarly, Time 1 body dissatisfaction was a unique inverse predictor of Time 2 self-esteem. Whereas Time 1 BMI was a significant univariate correlate of Time 2 depressive mood and self-esteem, when entered into the regression with body dissatisfaction, it did not make a unique contribution to variance in Time 2 depressive mood or self-esteem. When the regression analyses were conducted without controlling for BMI, the effect of Time 1 body dissatisfaction was similar as when BMI was controlled (depressive mood: estimate =.05, SE =.02, F = 7.06, p <.008; self-esteem: estimate =.08, SE =.02, F = 16.64, p <.0001). Early adolescent boys. Table 4 presents summary statistics for multiple regression analyses in which 543

PAXTON, NEUMARK-SZTAINER, HANNAN, EISENBERG Table 4. Summary of Multiple Regression Analyses Predicting Time 2 Depressive Mood and Time 2 Self-Esteem in Early Adolescent Boys df Estimate SE F p Time 2 Depressive Mood a Ethnicity 5 2.36 b.041 SES 4 0.56.690 Time 1 Depressive Mood 1.33.06 31.12 <.001 Time 1 Body Mass Index 1.01.03 0.04.838 Time 1 Body Dissatisfaction 1.02.02 0.75.386 Time 2 Self-Esteem c Ethnicity 5 3.19 d.008 SES 4 1.68.155 Time 1 Self-Esteem 1.27.06 20.95 <.001 Time 1 Body Mass Index 1.01.04 0.11.745 Time 1 Body Dissatisfaction 1.00.02 0.00.979 Note: Sample sizes differ slightly due to differences in missing data. a n = 297, R 2 =.18. b Hispanic ethnicity predicted higher depressive mood; estimate = 1.36, SE = 0.66. c n = 291, R 2 =.17. d African American ethnicity predicted higher self-esteem; estimate = 1.46, SE = 0.54. Table 5. Summary of Multiple Regression Analyses Predicting Time 2 Depressive Mood and Time 2 Self-Esteem in Midadolescent Girls df Estimate SE F p Time 2 Depressive Mood a Ethnicity 5 0.50.775 SES 4 0.73.574 Time 1 Depressive Mood 1.39.04 113.62 <.001 Time 1 Body Mass Index 1.06.02 5.99.015 Time 1 Body Dissatisfaction 1.01.01 0.27.602 Time 2 Self-Esteem b Ethnicity 5 0.94.455 SES 4 0.36.834 Time 1 Self-Esteem 1.44.04 147.98 <.001 Time 1 Body Mass Index 1.07.03 6.76.009 Time 1 Body Dissatisfaction 1.00.01 0.10.754 Note: Sample sizes differ due to differences in missing data. a n = 843, R 2 =.15. b n = 815, R 2 =.23. we examined whether Time 1 body dissatisfaction predicted Time 2 depressive mood and low self-esteem in early-adolescent boys. When controlling for BMI, as hypothesized and as one might expect from the absence of a univariate association, Time 1 body dissatisfaction was not a unique predictor of Time 2 depressive mood or self-esteem at 5-year follow-up. Similarly, when BMI was not controlled, body dissatisfaction did not significantly contribute to the variance in Time 2 depressive mood or self-esteem (depressive mood: estimate =.01, SE =.02, F = 0.50, p <.48; self-esteem: estimate =.01, SE =.02, F =.27, p <.60). Midadolescent girls. Table 5 presents summary statistics for multiple regression analyses in which we examined whether Time 1 body dissatisfaction predicted Time 2 depressive mood and low self-esteem in midadolescent girls. Although Time 1 body dissatisfaction was a univariate correlate of Time 2 depressive mood and self-esteem, in the multiple regression analyses, after controlling for Time 1 of the dependent variable, demographic variables, and BMI, Time 1 body dissatisfaction did not uniquely contribute to the prediction of the outcome variables. It was of interest that Time 1 BMI did significantly contribute to the prediction of Time 2 depressive mood and self-esteem. However, the failure of Time 1 body dissatisfaction to predict the Time 2 variables was not a result of shared variance with Time 1 BMI because, when the multiple regression analyses that did not control for BMI were examined, Time 1 body dissatisfaction still was not a significant predictor of depressive mood or self-esteem 5 years later (depressive mood: estimate =.01, SE =.01, F = 1.92, p <.17; self-esteem:estimate=.02,se=.01,f=1.36,p<.24). Midadolescent boys. Finally, Table 6 presents summary statistics for multiple regression analyses in which we examined whether Time 1 body dissatisfaction predicted Time 2 depressive mood and low self-esteem in midadolescent boys. As hypothesized, after entering control variables, Time 1 body dissatisfaction made significant unique contributions to the prediction 544

BODY DISSATISFACTION PREDICTS DEPRESSION AND LOW SELF-ESTEEM Table 6. Summary of Multiple Regression Analyses Predicting Time 2 Depressive Mood and Time 2 Self-Esteem in Midadolescent Boys df Estimate SE F p Time 2 Depressive Mood a Ethnicity 5 4.93 b <.001 SES 4 0.43.788 Time 1 Depressive Mood 1.36.04 82.46 <.001 Time 1 Body Mass Index 1.01.02 0.08.773 Time 1 Body Dissatisfaction 1.05.01 12.45 <.001 Time 2 Self-Esteem c Ethnicity 5 3.78 d.002 SES 4 1.87.115 Time 1 Self-Esteem 1.33.04 74.69 <.001 Time 1 Body Mass Index 1.01.03 0.08.784 Time 1 Body Dissatisfaction 1.05.02 9.38.002 Note: Sample sizes differ due to differences in missing data. a n = 705, R 2 =.19. b African American ethnicity predicted lower depression; estimate = 1.24, SE = 0.32. c n = 695, R 2 =.20. d African American ethnicity predicted higher self-esteem; estimate = 1.43, SE = 0.37. Table 7. Slopes of Depressive Mood and of Self-Esteem at Time 2 Regressed on Body Dissatisfaction at Time 1 in Analyses of Covariance Examining the Three-Way Interaction Between Gender, Cohort, and Body Dissatisfaction Estimate SE t p Depressive Mood.045 Early Adolescent Girls.037.015 2.44.015 Midadolescent Girls.009.010 0.89.372 Early Adolescent Boys.015.018 0.83.404 Midadolescent Boys.042.012 3.40.001 Self-Esteem.002 Early Adolescent Girls.055.017 3.18.001 Midadolescent Girls.017.012 1.35.176 Early Adolescent Boys.018.021 0.86.389 Midadolescent Boys.043.014 3.02.003 of Time 2 depressive mood and self-esteem (Table 6). Similar findings were observed when BMI was not controlled (depressive mood: estimate =.05, SE =.01, F = 14.95, p <.0001; self-esteem: estimate =.05, SE =.01, F = 12.36, p <.0005). Comparison of Gender and Cohort Effects Confirming the hypothesis that Time 1 body dissatisfaction would predict Time 2 depressive mood and self-esteem in early- but not midadolescent girls and mid- but not early-adolescent boys, in the analyses of covariance the 1 degree-of-freedom F tests of interaction were significant for the differences in slopes of body dissatisfaction on Time 2 depressive mood, F(1, 2181) = 4.05, p =.044, and self-esteem, F(1, 2181) = 10.6, p =.001. Tables 3 through 6 show the stratum specific effects of differences in body dissatisfaction on depressive mood and self-esteem measured 5 years later, controlling for ethnicity, SES, Time 1 BMI, and Time 1 depressive mood or self-esteem, respectively. Table 7 shows the effect of the interaction of body dissatisfaction with gender and cohort, confirming the stratification analyses by showing significant effects in the expected direction for each outcome only in earlyadolescent girls and midadolescent boys. Figure 1 presents the stratified results graphically, showing the maximum predicted difference on the Depressive Mood scale at Time 2 between 2 participants who differed at Time 1 by the maximum on the body dissatisfaction scale (50 compared to 10). Smaller differences in body dissatisfaction would lead to proportionally smaller differences on the Depressive Mood at Time 2. Figure 2 can be interpreted similarly but for effects on self-esteem. Note in Figure 1 and 2 the similarity of slopes in early-adolescent girls and midadolescent boys and the essentially null slopes in the other two gender and cohort groups. Discussion This study found body dissatisfaction to be a prospective risk factor for depressive mood and low selfesteem over a sustained period of time (5 years) in both 545

PAXTON, NEUMARK-SZTAINER, HANNAN, EISENBERG Figure 1. Differences in depressive mood (Time 2) for different levels of Time 1 depressive mood in early- and midadolescent girls and boys, adjusted for Time 1 depressive mood, BMI, ethnicity, and SES in gender and cohort stratified analyses. Figure 2. Differences in self-esteem (Time 2) for different levels of Time 1 body dissatisfaction in early- and midadolescent girls and boys, adjusted for Time 1 self-esteem, BMI, ethnicity, and SES in gender and cohort stratified analyses. girls and boys. However, the findings demonstrated that body dissatisfaction predicted depressive mood and low self-esteem in early- but not midadolescent girls and mid- but not early-adolescent boys. Although several interpretations are possible, our prospective research is consistent with the proposal that body dissatisfaction is a risk factor for increases in depressive mood and low self-esteem. Given the high value placed on achieving the current body ideal (Stice & Bearman, 2001), perceived failure to live up to these standards is likely to increase negative self-evaluation. In addition, in Western societies, which tend to view characteristics such as body weight, muscularity, and leanness as under individual control, an adolescent who is dissatisfied with his or her body is likely to perceive this to be the result of personal inadequacy. Such negative beliefs are likely to have the long-term effect of increasing depressive mood and low self-esteem. Body dissatisfaction and depressive mood and low self-esteem may also have a spiral relation. Recent research suggests self-esteem is a prospective risk factor for body dissatisfaction in girls across adolescence (Paxton, Eisenberg, & Neumark-Sztainer, in press) and depressive mood is a risk factor for body dissatisfaction in mid- to late-adolescent boys (Paxton et al., in press; Presnell, Bearman, & Stice, 2004). Body dissatisfaction may contribute to depressive mood and low self-esteem, which may in turn increase body dissatisfaction. Possibly, in some adolescents the nature of the relation between body dissatisfaction and negative affect is in one direction, whereas in others it is in the opposite. Body dissatisfaction predicted depressive mood and low self-esteem at different developmental stages in girls compared to boys, consistent with the study over a shorter time period by Holsen and colleagues (2001). It is a time of physical changes in girls that frequently move them away from the thin social ideal. As illustrated in Table 1, this was a period of increase in body dissatisfaction in our sample. In addition, it is a developmental stage in which there are strong pressures to 546

BODY DISSATISFACTION PREDICTS DEPRESSION AND LOW SELF-ESTEEM conform and be accepted by friends and peers (Berndt & Hestenes, 1996). Under these conditions, poor body image during this period could lead to feelings of unattractiveness and uncertainty about acceptability, contributing to increases in depressive mood and low self-esteem. In late-adolescent girls, body dissatisfaction was not a unique predictor of increases in psychological symptoms. Notably, there was little mean change in body dissatisfaction during this period. Girls who are vulnerable to a negative psychological impact of body dissatisfaction may already have been affected earlier in teenage years and during the latter period remain stable but high on body dissatisfaction and depressive mood and low on self-esteem. During this period, other factors may become more pertinent triggers to increased depression and low self-esteem, such as failed dieting attempts and related self-criticism or relationship problems. It has been suggested that boys become aware of external social pressures to conform to an appearance ideal laterthangirls(holsenetal.,2001).however,ifthiswas the explanation of the differences between cohorts, one would expect a substantial increase in body dissatisfaction in the later developmental phase in boys, which is not the case. Rather, there was an increase in body dissatisfaction across the assessment period in the early-adolescent boys. Although body dissatisfaction itself may not intensify, the importance attached to physical appearance may become greater during this developmental period compared to the earlier phase, and the interaction between these factors may contribute to increases in depressive mood and low self-esteem. Except in the case of the midadolescent girls, BMI was not a unique predictor of negative outcomes, consistent with previous research over a shorter time period (Needham & Crosnoe, 2005; Stice & Bearman, 2001). In our research, the pattern was somewhat different in girls from midadolescence to young adulthood. In this group, Time 1 BMI but not body dissatisfaction was a unique predictor of negative affect. It is notable, however, that Time 1 body dissatisfaction was correlated with Time 2 depressive mood and low selfesteem. Our results suggest that body dissatisfaction and BMI are closely related in midadolescent girls and share a substantial amount of variance in the prediction of depressive mood and low self-esteem. It is unlikely that the observed relations with depressive mood and low self-esteem were due to BMI per se. It is more likely that these relations were mediated by negative consequence of failed dieting experiences (Stice & Bearman, 2001) or the negative evaluation, weight teasing, and social discrimination frequently experienced by larger young women (e.g., Crandall, 1994; Rothblum, Brand, Miller, & Oetjen, 1989; Wertheim et al., 2001). Although differences in the pattern of prospective risk factors are suggested by our study, our design limits conclusions that can be drawn regarding timing of the relation between Time 1 body dissatisfaction and Time 2 depressive mood and low self-esteem. As participants were only assessed at 5-year intervals, it is possible that body dissatisfaction did prospectively predict psychological outcomes at some point during the time period but not precisely when assessed. For example, in girls, body dissatisfaction at 15.5 years may predict low self-esteem at 17.5 years but not at 20.5 years. In addition, our focus in this research was on the potential role of body dissatisfaction as a predictor of psychological outcomes. It also should be noted that the overall variance accounted for by the regression analyses was not very high (early-adolescent girls: depressive mood R 2 =.14, self-esteem R 2 =.21; earlyadolescent boys: depressive mood R 2 =.18, self-esteem R 2 =.17; midadolescent girls: depressive mood R 2 =.15, self-esteem R 2 =.23; early-adolescent boys: depressive mood R 2 =.19, self-esteem R 2 =.20). A wide range of other variables is also likely to contribute to the prediction of increases in depressive mood and low self-esteem in adolescents over this time period, such as family functioning, peer interactions, and stressful life events. The impact of these variables may also vary according to developmental stage. This study has a number of strengths that include the large and diverse sample of boys and girls, assessed at two developmental stages; the 5-year follow-up period that facilitated examination of body dissatisfaction as a long-term risk factor for mental health outcomes; assessment instruments that were sound for both girls and boys; and measured height and weight. This study also hasanumberoflimitations.attritionfromthefirsttothe follow-up assessment was substantial (47%). To overcome potential bias resulting from this, a weighting procedure was used to make findings more generalizable to the population represented in the EAT I sample. It is also not clear the extent to which the results from this research are generalizable to other populations. The consistency of our findings with those of Holsen and colleagues (2001), who conducted their research in Norway, provides support for the generalizability of the findings, but further research is required in other populations to confirm it. An additional limitation is that in research of this kind it is possible that the observed relations may be the result of a variable not assessed that influenced both body dissatisfaction and depressive mood and low self-esteem. For example, sexual or physical abusepriortotime1measurementoccasionmayleadto both Time 1 body dissatisfaction and, especially if continuing, to Time 2 depressive mood and self-esteem and thus be the common underlying basis for the association we found between Time 1 body dissatisfaction and Time 2 outcomes. Thus, further research is required to confirm causal relations indicated by this research. In addition, having only two time points in longitudinal research limits interpretations that can be drawn. Having 547

PAXTON, NEUMARK-SZTAINER, HANNAN, EISENBERG more frequent assessments would assist in elucidating mechanisms of action and mediators of the relations observed. A number of areas for future research emerge from this study. Although body dissatisfaction has been identified as a prospective risk factor for depressive mood and self esteem, this study did not explore whether particular patterns of persistence of body dissatisfaction were more strongly associated with the development of depressive mood and self-esteem. It would be valuable to examine whether relations between Time 1 body dissatisfaction and psychological mood are stronger when body dissatisfaction is stable throughout the follow-up period rather than present at first assessment but diminished over time. In this research it was also noted that ethnic background predicted depressive mood and self-esteem in boys but not girls, a finding that requires further exploration. In particular, being African American was psychologically protective in boys in the sample, consistent with previous research (e.g., Gray-Little & Hafdahl, 2000). Recent research, however, indicates that depression in African American teens is higher if they live among non-hispanic White Americans than African Americans (Wight, Aneshensel, Botticello, & Sepulveda, 2005). Thus, it will be important to consider the generalizability of this observation in other social environments. References Allgood-Merten, B., Lewinsohn, P. M., & Hops, H. (1990). Sex differences and adolescent depression. Journal of Abnormal Psychology, 99, 55 63. Berndt, T. J., & Hestenes, S. L. (1996). The developmental course of social support: Family and peers. In L. Smolak, M. P. Levine, & R. Striegel-Moore (Eds.), The developmental psychopathology of eating disorders: Implications for research, prevention and treatment (pp. 77 106). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. Byrne, B. M. (1983). Investigating measures of self-concept. Measurement and Evaluation in Guidance, 16, 115 126. Cafri, G., Thompson, J. K., Ricciardelli, L., McCabe, M., Smolak, L., & Yesalis, C. E. (2005). Pursuit of the muscular ideal: Physical and psychological consequences and putative risk factors. Clinical Psychology Review, 25, 215 239. Cash, T. F. (2002). Cognitive behavioral perspectives on body image. In T. F. Cash & T. Pruzinski (Eds.), Body image: A handbook of theory, research and clinical practice (pp. 38 46). New York: Guilford. Cohane, G. H., & Pope, H. G., Jr. (2001). Body image in boys: A review of the literature. International Journal of Eating Disorders, 29, 373 379. Crandall, C. S. (1994). Prejudice against fat people: Ideology and self-interest. Journal of Personality & Social Psychology, 66, 882 894. Demo, D. H. (1985). The measurement of self-esteem: Refining our methods. Journal of Personality & Social Psychology, 48, 1450 1502. Derogatis, L. R. (1977). SCL 90 administration, scoring and procedures manual 1. Baltimore: Johns Hopkins University School of Medicine. Gray-Little, B., & Hafdahl, A. R. (2000). Factors influencing racial comparisons of self-esteem: A quantitative review. Psychological Bulletin, 126, 26 54. Holsen, I., Kraft, P., & Roysamb, E. (2001). The relationship between body image and depressed mood in adolescence: A 5-year longitudinal panel study. Journal of Health Psychology, 6, 613 627. Jaccard, J., Turrisi, R., & Wan, C. K. (1990). Interaction effects in multiple regression. Newbury Park, CA: Sage. Johnson, F., & Wardle, J. (2005). Dietary restraint, body dissatisfaction and psychological distress: A prospect analysis. Journal of Abnormal Psychology, 114, 119 125. Kandel, D. B., & Davies, M. (1982). Epidemiology of depressive mood in adolescents: An empirical study. Archives of General Psychiatry, 39, 1205 1212. Keery, H., van den Berg, P., & Thompson, J. K. (2004). An evaluation of the Tripartite Influence Model of body dissatisfaction and eating disturbance with adolescent girls. Body Image, 1, 237 251. Killen, J. D., Taylor, C. B., Hayward, C., Haydel, K. F., Wilson, D. M., Hammer, L., et al. (1996). Weight concerns influence the development of eating disorders: A 4-year prospective study. Journal of Consulting & Clinical Psychology, 64, 936 940. Little, R. J. A. (1986). Survey nonresponse adjustments for estimates of means. International Statistical Review, 54, 137 139. Needham, B. L., & Crosnoe, R. (2005). Overweight status and depressive symptoms during adolescence. Journal of Adolescent Health, 36, 48 55. Neumark-Sztainer, D., Story, M., Hannan, P. J., & Croll, J. (2002). Overweight status and eating patterns among adolescents: Where do youth stand in comparison to the Healthy People 2010 Objectives? American Journal of Public Health, 92, 844 851. Neumark-Sztainer, D., Story, M., Hannan, P. J., Perry, C., & Irving, L. M. (2002). Weight-related concerns and behaviors among overweight and non-overweight adolescents: Implications for preventing weight-related disorders. Archives of Pediatrics and Adolescent Medicine, 156, 171 178. Paxton, S. J., Eisenberg, M. E., & Neumark-Sztainer, D. (in press). Prospective predictors of body dissatisfaction in adolescent girls and boys: A five-year longitudinal study. Developmental Psychology. Paxton, S. J., Norris, M., Wertheim, E. H., Durkin, S. J., & Anderson, J. (2005). Body dissatisfaction, dating, and importance of thinness to attractiveness in adolescent girls. Sex Roles: A Journal of Research, 53, 663 675. Pingitore, R., Spring, B., & Garfield, D. (1997). Gender differences in body satisfaction. Obesity Research, 5, 402 409. Presnell, K., Bearman, S. K., & Stice, E. (2004). Risk factors for body dissatisfaction in adolescent boys and girls: A prospective study. International Journal of Eating Disorders, 36, 389 401. Ricciardelli, L. A., & McCabe, M. P. (2001). Dietary restraint and negative affect as mediators of body dissatisfaction and bulimic behavior in adolescent girls and boys. Behaviour Research & Therapy, 39, 1317 1328. Rierdan, J., Koff, E., & Stubbs, M. L. (1989). A longitudinal analysis of body image as a predictor of the onset and persistence of adolescent girls depression. Journal of Early Adolescence, 9, 454 466. Rosenberg, M. (1965). Society and adolescent self-image. Princeton, NJ: Princeton University Press. Rothblum, E. D., Brand, P., Miller, C., & Oetjen, H. (1989). Results of the NAAFA survey on employment discrimination: Part II. NAAFA Newsletter, 17, 4 6. Stice, E. (2001). A prospective test of the dual pathway model of bulimic pathology: Mediating effects of dieting and negative affect. Journal of Abnormal Psychology, 110, 124 135. 548

BODY DISSATISFACTION PREDICTS DEPRESSION AND LOW SELF-ESTEEM Stice, E. (2002). Risk and maintenance factors for eating pathology: A meta-analytic review. Psychological Bulletin, 128, 825 848. Stice, E., & Bearman, S. K. (2001). Body image and eating disturbances prospectively predict increases in depressive symptoms in adolescent girls: A growth curve analysis. Developmental Psychology, 37, 597 607. van den Berg, P., Wertheim E. H., Thompson, J. K., & Paxton, S. J. (2002). Development of body image, eating disturbance, and general psychological functioning in adolescent females: A replication using covariance structure modeling in an Australian sample. International Journal of Eating Disorders, 31, 46 51. Wertheim, E. H., Koerner, J., & Paxton, S. J. (2001). Longitudinal predictors restrictive eating and bulimic behavior in adolescent girls. Journal of Youth and Adolescence, 30, 69 81. Wichstrom, L. (1999). The emergence of gender difference in depressed mood during adolescence: The role of intensified gender socialization. Developmental Psychology, 35, 232 245. Wight, R. G., Aneshensel, C. S., Botticello, A. L., & Sepulveda, J. E. (2005). A multilevel analysis of ethnic variation in depressive symptoms among adolescents in the United States. Social Science & Medicine, 60, 2073 2084. Wylie, R. C. (1989). Measures of self-concept. Lincoln: University of Nebraska Press. Received June 27, 2005 Accepted April 13, 2006 549