Self-Esteem and Symptoms of Eating-Disordered Behavior Among Female Adolescents

Abstract

Background

Compared to males, female adolescents show greater concerns about their appearance, concerns related to their self-esteem. We explored the associations between self-esteem, body image and BMI as proxies for appearance, and eating-disordered behavior among adolescent females.

Methods

A total of 263 females (mean age:15.78 years) took part in this study. They completed questionnaires covering anthropometric characteristics, self-esteem, eating-disordered behavior, subjective physical activity levels, and body image.

Results

Higher scores for self-esteem were associated with higher scores for eating-disordered behavior, indices of physical activity, and slimmer body image. Body image was not associated with eating-disordered behavior. Multiple regression analyses showed that self-esteem, but not physical activity, or body image predicted eating-disordered behavior.

Conclusions

Among a non-clinical sample of female adolescents, self-esteem and eating-disordered behavior were positively associated. Body image was associated in a complex and contradictory fashion. It is possible that cognitive-emotional mastering of the vital impulse to eat may enhance self-esteem.

Keywords

self-esteem eating-disordered behavior BMI physical activity adolescents

Introduction

Compared to childhood, adolescence brings increased responsibility for the self and social interactions with peers. In addition, relative to both children and adults, adolescents are highly focused on evaluation by their peers. Accordingly, social acceptance and peer feedback are important factors in adolescents’ socio-emotional well-being. Van der Schuur et al. (2018) showed that female adolescents in particular experience stress around social media as a proxy for peer acceptance and peer feedback. Likewise, Guyer et al. (2014) showed that female but not male adolescents were concerned about peer evaluation and peer acceptance. Thus, girls with a strong desire to be liked by their peers felt better after being accepted versus rejected relative to those with less concern about being liked by peers. This pattern of results is consistent with Hyde et al.’s (2008) argument for the emergence and maintenance of depressive symptoms among females: relative to their male counterparts, females tend to build their self-esteem as a function of the social feedback they receive. Such findings fit well with the general observation of an association between continuous social rejection and psychiatric issues (Ding et al., 2018). But again, and compared to males, it appears that internalizing problems have increased in females over the last three decades (Bor et al., 2014). In a similar vein, studies of evoked potentials have shown that, compared to male adolescents, female adolescents elaborated negative social stimuli faster while positive social stimuli are poorly elaborated (Yang et al., 2017).

To conclude, social acceptance and peer evaluation are major concerns in the life of adolescents, and this holds particularly true for females for whom these evaluations appear to be highly associated with self-esteem. Here, self-esteem is understood as the feeling of one’s personal self-worth; self-esteem is thus a cognitive-emotional process of self-evaluation in which the evaluation is linked to affect (Liu et al., 2015). Liu et al. (2015) concluded that low levels of self-esteem in children and adolescents were associated with poorer psychological health, suicidal ideation, criminal behavior, and limited economic prospects during adulthood. Furthermore, Zamani Sani et al. (2016) showed that among young adults higher self-esteem scores were associated with increased physical activity levels and body image scores aligned with a more athletic body shape.

Next, higher self-esteem and a positive body image appear to be associated. Kostanski and Gullone (1998) assessed a non-clinical sample of 516 adolescents (mean age: M = 14.7 years; 51.9% females). The authors observed that a poor body image (that is to say, high body image dissatisfaction) was associated with a higher body mass index, more marked symptoms of depression and anxiety, and lower self-esteem. Espinoza et al. (2019) assessed 303 adolescents (age range: 12-15 years; 53.8% males) longitudinally and found a bidirectional association between self-esteem and eating-disordered behavior. Furthermore, a stronger internalization of beauty ideals predicted disordered eating behavior and lower self-esteem scores. Ozmen et al. (2007) assessed a non-clinical sample of 2101 adolescents (mean age: 16.6 years; 50% females) and showed that a) compared to males, females reported higher body dissatisfaction (that is: a negative body image), b) higher body dissatisfaction was associated with lower self-esteem, c) lower self-esteem was associated with a subjective perception of being overweight, while d) actual weight was unrelated to self-esteem. Zhang et al. (2018) assessed 2023 female students (age range: 18-30 years) and showed that a problematic thin-ideal as a proxy for a biased body image was associated with a lower BMI, more unpleasant peer feedback and lower self-esteem. Alipour et al. (2015) assessed 184 young adult Iranian females (mean age: 22.16 years) and found that a biased body image was reported in 41.7 to 67.9% of participants. In two different studies, Woodward et al. (2019) assessed female student and community samples. In the first study (N = 403; mean age = 23.94 years) lowself-esteem and high internalized shame were associated with higher scores for eating disorders, with body shame as a mediating factor. In the second study (N = 548; mean age = 22.94), internalized shame was associated both directly with disordered eating behavior and indirectly via higher body shame and symptoms of depression. These authors concluded that low self-esteem and internalized body shame were associated both directly and indirectly with eating disorder and depression. Last, Shoraka et al. (2019) reported in their review that issues with body image also appear to be a health issue among teenagers and young people in Iran. Given this, the first aim of the present study was to replicate previous results, and to examine the association between self-esteem and body image in a sample of females aged 13 to 18 years.

Next, while a large body of research shows that body image, physical activity and calorie-intake control are associated, this evidence comes from clinical samples such as individuals who are overweight or obese and with eating-disorders. In contrast, there remains limited evidence from non-clinical samples. To counter this, in the present study we assessed a non-clinical sample of female adolescents.

A slimmer body shape can be achieved either by increasing calorie expenditure via physical activity, or by reducing calorie intake. Militello et al. (2018) summarized reviews of work on this topic. Four of the 12 reviews examined were of high quality and indicated that treatment to reduce BMI was more successful than a wait list or control condition. That is to say, increased supervised physical exercise combined with a dietary and/or behavior support intervention led to a reduction in BMI among individuals who were seriously overweight or obese. Al-Khudairy et al. (2017) carried out a Cochrane systematic review to assess the effects of diet, physical activity and behavioral interventions in the treatment of overweight and obese adolescents aged 12 to 17 years. The authors concluded that the quality of interventions which involved a combination of diet, physical activity and behavioral components to reduce BMI was low. When compared to no treatment or a waiting list, however, interventions were more successful.

To conclude, compared to no intervention, both calorie-intake restriction and higher levels of physical activity appeared to be the most promising options for reducing BMI as a proxy for a slimmer body shape. One limitation of the studies reported in both reviews (Al-Khudairy et al., 2017; Militello et al., 2018) was that they focused exclusively on adolescents with severe weight problems (overweight and obese adolescents). However, keeping a slim body shape as a proxy for a desired slim body image and reducing BMI are not exclusively issues for overweight adolescents, but it appears that there is limited evidence on this topic based on non-clinical samples. Alipour et al. (2015) reported that, among 184 young adult Iranian females, those with an undistorted body image were also those with higher physical activity indices, more restoring sleep, normal weight, and low intake of food high in fat and calories. To counter this scarcity of knowledge, the second aim of the present study was to explore the associations between body image, physical activity and calorie intake control in a sample of female adolescents with no apparent weight problems.

As regards the association between self-esteem and restricted calorie intake understood as eating-disordered behavior, findings are conflicting. Pelletier Brochu et al. (2018) assessed 186 adolescent females aged 12 to 18 years and diagnosed with Anorexia Nervosa (AN). They observed that subjectively perceived detachment from peers and parents was associated with higher eating disorder severity scores, though this was indirectly mediated by mood and self-esteem. Collin et al. (2016) made a longitudinal assessment of 60 females diagnosed with AN (mean age: 25.6 years) and found that treatment improvements over time (reduction in eating disorders) were associated with gains in both self-esteem and weight. However, improvements were small and domain-specific. Global self-esteem was not predictive of treatment outcome; only self-esteem scores on the dimensions of Lovability and Moral Self-Control predicted changes in shape and weight concerns (as proxies for eating psychopathology), while changes in Self-Control and Lovability were predictive of changes in dietary restraint, and shape concern (again, as proxies for eating psychopathology). Collin et al. (2016) concluded that the relationship between self-esteem and eating disorder is neither linear nor straightforward. Similarly, Smink et al. (2018) explored the causal associations between self-esteem (self-perception; self-esteem; social acceptance; physical appearance), peer-perceived social status in early adolescence, and eating disorders in early adulthood. To this end, Smink et al. (2018) tested 732 participants at the age of 11 and followed them up at 13 and 22 years. Results showed that physical attractiveness at 11 years and peer popularity at 13 years predicted lower odds of eating disorders at 22 years, while self-esteem at either 11 or 13 years was not a predictor of eating disorders in early adulthood. In contrast, higher scores for likeability or the desire and need to be liked by one’s peer group at 13 predicted higher scores for eating disorders in early adulthood. Smink et al. (2018) concluded that it is not self-esteem per sé, but physical attractiveness as a specific dimension of self-esteem, along with peer-perceived status that predicts a lower risk of developing eating-disordered behavior in early adulthood.

Stice (2016), in his interactive and mediational etiologic model of eating disorder onset, argued that there is broad evidence for both the importance and lack of importance of self-esteem in explaining the onset of eating-disordered behavior.

Cornelius and Blanton (2016) tested the so-called Anorexia-Pride hypothesis that disordered eating might lead to higher self-esteem through pro-anorectic identification. The Anorexia-Pride hypothesis represents a change in paradigm in the theoretical etiology of eating-disordered behavior from a deficit focus to a self-esteem enhancing focus. However, in two separate samples of participants of online-platforms dedicated to peer-groups supporting anorexia-oriented behavior, Cornelius and Blanton (2016) were unable to confirm the Anorexia-Pride hypothesis.

Last, Goss and Allan (2009) reviewed the concept of pride as a factor triggering and maintaining eating-disordered behavior. They noted first that restrictions of both food and other desires and impulses are often culturally encouraged and associated with positive self-esteem and pride in the self. For example, fasting is often associated with religious practices involving control over impulses of food intake. Furthermore, as also reported in Cornelius and Blanton (2016), statements such as “Giving in to food shows weakness. Be strong and you will be better than everyone else” indicate that the ability to control food intake via disordered eating behavior, along with control of size, shape, and affect, are central features of eating disorders. In this context, Macleod (1981) made the anecdotal observation that anorexic habits gave her energy and interpersonal power. Likewise, Vitousek (1996) described how food intake restriction and control can improve self-esteem.

To summarize, there is no clear-cut or linear association between self-esteem and eating-disordered behavior. Rather there are indications of a possible association between more disordered eating behavior and high self-esteem. We also note that the relevant studies have been carried out almost entirely with participants who have eating disorders (Collin et al., 2016; Cornelius & Blanton, 2016; Macleod, 1981; Pelletier Brochu et al., 2018; Stice, 2016; Vitousek, 1996; for exception see Smink et al., 2018). As a result, to the best of our knowledge and with the exception of Smink et al. (2018), there is a lack of research on healthy young adolescents. Accordingly, the third aim of the present study was to explore the association between levels of self-esteem and eating-disordered behavior in a sample of young female adolescents drawn from the non-clinical population.

Based on the foregoing literature review, the following two hypotheses and two research questions were formulated. First, following others (Espinoza et al., 2019; Kostanski & Gullone, 1998; Ozmen et al., 2007; Woodward et al., 2019; Zamani Sani et al., 2016; Zhang et al., 2018), we expected that higher scores for self-esteem would be associated with a more positive and undistorted body image. Our second hypothesis followed others (Alipour et al. 2015; Espinoza et al., 2019; Woodward et al., 2019) in anticipating that higher body satisfaction, which is to say an undistorted body image, would be associated with higher indices for physical activity and less eating-disordered behavior. One of two research questions considered whether eating-disordered behavior is associated either with higher or with lower self-esteem. The second question explored the dimensions that might predict self-esteem, eating-disordered behavior, BMI, physical activity, and body image.

To these ends we recruited a sample of adolescent females who completed questionnaires covering anthropometric data, and dimensions of self-esteem, eating-disordered behavior, subjective physical activity levels, and body image. We believe that the present results have the potential to shed more light on the associations among body shape, self-esteem, physical activity and eating-disordered behavior in female adolescents, and to clarify whether and if so to what extent self-esteem and eating-disordered behavior are associated.

Method

Procedure

Between January 2017 and September 2017, girls attending a secondary school in Tabriz (Nord-west of Iran) were approached and asked to participate in the present study. All eligible participants were informed about the aims of the study and the anonymous and confidential data handling. Participants signed a written informed consent, and experts conducted a brief medical and psychiatric interview. Thereafter, participants completed a questionnaire booklet covering sociodemographic and anthropometric details, and including measures of self-esteem, subjective physical activity, eating-disordered behavior, and body image. The booklet was completed within 30 to 40 minutes during class. Once the booklet was completed, it was put in a sealed envelope. The local ethics committee of the University of Tabriz (Tabriz, Iran) approved the study, which was performed in accordance with the rules laid down in the seventh and current form of the Declaration of Helsinki (World Medical Association, 2013).

Sample

The sample consisted of 263 female adolescents (mean age: 15.78 years; age range: 13 to 18 years). Inclusion criteria were: 1. age between 13 and 18 years; 2. female; 3. willing and able to complete the booklet of questionnaires; 4. signed written informed consent. Exclusion criteria were: 1. signs of medical and psychological issues as assessed via a brief medical and psychiatric interview (Sheehan et al., 1998).

Tools

Sociodemographic and anthropometric information

Questions on sociodemographic and anthropometric characteristics covered age, weight, and height. BMI was calculated using the following formula: weight (kg)/height (in m)². Participants were instructed to measure their height and weight lightly dressed early in the morning at home. The university provided scales for those who did not have them at home.

Self-esteem

Self-esteem was measured with the ten-item Self-Esteem Scale (Rosenberg, 1965), which assesses global self-esteem. Shapurian et al. (1987) have provided a psychometric validation of the Farsi version. Answers are given on 4-point Likert scales ranging from 0 (= not at all true) to 3 (= completely true), with higher sum scores reflecting higher self-esteem (Cronbach’s alpha = .88).

Body image

As in a previous study (Zamani Sani et al., 2016), we employed a Figure Rating Scale (Stunkard et al., 1983). The scale comprises a set of nine figures (female figures for our respondents) depicting individuals ranging in body shape from very thin (1) to very obese (9). Respondents were asked to indicate which figure they believed looked most like their own body. Prior studies have shown that the scale is a valid and reliable measure of body image (Cardinal et al., 2006; Cronbach’s alpha = .85).

Self-reported physical activity

Participants completed the Physical Activity Questionnaire for Adolescent (PAQ-A), which is a 7-day recall questionnaire assessing level of general physical activity (Crocker et al., 1997). The Farsi version has been psychometrically validated (Faghihimani et al., 2010). The questionnaire consists of nine items. Typical items are: “Over the last seven days, how much have you been physically active in the mornings?”, “Over the last seven days, how much have you been physically active in the evenings?”, “Over the last seven days, how much sports (team sports, exercising, jogging, etc.) did you do in the afternoons?”. Answers are given on five-point Likert scales ranging from 0 (= not at all) to 4 (a lot/most often), with higher mean scores reflecting a higher level of physical activity (Cronbach’s alpha = .81).

Eating attitude

To assess eating attitude, participants completed the Eating Attitude Test-26 (Garfinkel & Newman, 2001; Garner & Garfinkel, 1979). The Farsi version has been psychometrically validated (Ahmadi et al., 2014). It consists of 26 items, loading on the following factors: dieting, bulimia and oral control. Answers are given on 6-point Likert scales ranging from 0 (= never) to 5 (= always), and with higher sum scores reflecting more disordered eating behavior. A total score of 20 points and higher is considered an indicator of eating-disordered behavior (Cronbach’s alpha = .89).

Statistical analysis

Pearson’s correlations were computed for the associations among age, self-esteem, BMI, physical activity, body image, and eating-disordered behavior. Five independent multiple regressions were performed to predict self-esteem, BMI, physical activity, body image, and eating-disordered behavior, with for each variable the others serving as predictors. Durbin-Watson coefficients are reported to indicate whether residuals were independent. In addition, R and R² are reported to indicate whether multiple regression models sufficiently explained the dependent variables. Predictors were excluded from the equation if they did not reach statistical significance. The nominal level of significance was set at alpha $\leq$ .05. All statistical computations were performed with SPSS® 25.0 (IBM Corporation, Armonk NY, USA) for Apple® Mac®.

Results

Sample characteristics

Table 1 reports the sample characteristics. Mean age of the 263 females was 15.78 (SD = 1.70) years, and the mean BMI was 22.32 (SD = 4.06).

Table 1.

Descriptive overview of demographic and anthropometric information.

Dimensions
N = 263	Mean (SD)
Age (years)	15.78 (1.70)
Height (meters)	1.64 (0.80)
Weight (kilogram)	59.90 (12.28)
Body mass index	22.23 (4.06)

Associations between age, BMI, self-esteem, physical activity, body image, and eating-disordered behavior

Table 2 gives the correlation coefficients, along with the descriptive statistical indices, for age, BMI, self-esteem, physical activity, body image, and eating-disordered behavior.

Table 2.

Descriptive statistics and Pearson’s correlation coefficients of variables.

	Age	BMI	Physical Activity	Self-esteem	Eating-disordered behavior	Dieting	Bulimia	Oral Control	Body image
	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)
	15.78 (1.70)	22.23 (4.07)	66.38 (13.67)	14.41 (3.38)	30.49 (16.24)	16.20 (9.63)	7.11 (5.02)	6.82 (4.16)	3.25 (1.81)
Age	–	.27**	−.40**	−.53**	−.43**	−.40**	−.44**	−.23**	.19**
BMI	–	–	−.20**	−.28**	−.14*	−.10	−.20**	−.10	.64**
Physical Activity	–	–	–	.34**	.26**	.26**	.30**	.11	−.15*
Self-esteem	–	–	–	–	.59**	.58**	.63**	.33**	−.13*
Eating-disordered behavior	–	–	–	–	–	.95**	.89**	.75**	−.06
Dieting	–	–	–	–	–	–	.80**	.58**	−.05
Bulimia	–	–	–	–	–	–	–	.54**	−.08
Oral Control	–	–	–	–	–	–	–	–	−.02

Notes: ** = p ≤ 0.01; * = p ≤ 0.05.

Greater age was significantly associated with higher BMI, lower physical activity, lower self-esteem, lower eating-disordered behavior (including lower scores for dieting, bulimia, and oral control), and a body image towards overweight.

A higher BMI was significantly associated with lower physical activity, lower self-esteem, and descriptively with lower eating-disordered behavior, and a body image towards overweight.

Higher physical activity levels were significantly associated with higher self-esteem, with higher scores for eating-disordered behavior, and with a body image towards a slimmer body shape and a distorted body image.

Higher scores for self-esteem were significantly associated with higher scores for eating-disordered behavior, including dieting, bulimia, and oral control, and with a body image towards a slimmer body shape and distorted body image.

The overall score for eating-disordered behavior was highly associated with its sub-components, but it was not associated with body image. Likewise, no sub-component was associated with the body image.

Predicting self-esteem, BMI, physical activity, body image, and eating-disordered behavior

Tables 3 to 7 report the statistical indices of five multiple regression analyses with self-esteem, BMI, eating-disordered behavior, physical activity, and body image respectively treated as the dependent variable. First, Durbin-Watson coefficients to indicate independence of residuals were satisfactory. Second, multiple regression models sufficiently explained (R and R²) the dependent variables.

Table 3.

Multiple linear regression with self-esteem as dependent variable, and eating disorders, body mass index, body image and physical activity as predictors.

Dimension	Variables	Coefficient	Standard error	Coefficient β	t	P	R	R²	Durbin-Watson coefficient
Self-esteem	Intercept	10.65	0.36	–	29.67	0.000*
	Eating-disordered behavior	0.12	0.01	0.59	11.85	0.000*	0.59	0.35	1.52
Excluded variables	Body Mass Index	–	–	0.02	0.66	0.51	–	–	–
	Physical Activity	–	–	0.07	1.32	0.19	–	–	–
	Body image	–	–	0.03	0.46	0.65	–	–	–

Notes: * = p ≤ 0.05; dependent variable = self-esteem.

Table 4.

Multiple linear regression with body mass index as dependent variable, and body image, eating disorders, physical activity and self-esteem as predictors.

Dimension	Variables	Coefficient	Standard error	Coefficient β	t	P	R	R²	Durbin-Watson coefficient
Body Mass Index	Intercept	17.57	0.40	–	44.134	0.000
	Body image	1.43	0.11	0.64	13.39	0.000	0.64	0.41	1.80
Excluded variables	Eating-disordered behavior	–	–	0.03	0.67	0.50	–	–	–
	Physical activity	–	–	−0.03	−0.59	0.56	–	–	–
	Self-esteem	–	–	0.05	1.07	0.29	–	–	–

Notes: dependent variable = Body Mass Index.

Table 5.

Multiple linear regression with eating disorders as dependent variable, and self-esteem, physical activity, body image and body mass index as predictors.

Dimension	Variables	Coefficient	Standard error	Coefficient β	t	P	R	R²	Durbin-Watson coefficient
Eating-disordered behavior	Intercept	−10.42	3.55	–	−2.94	0.004**
	Self-esteem	2.84	0.24	0.59	11.85	0.000	0.59	0.35	0.52
Excluded variables	Physical activity	–	–	0.07	1.32	0.187	–	–	–
	Body image	–	–	0.02	0.46	0.647	–	–	–
	Body Mass Index	–	–	0.03	0.66	0.513	–	–	–

Notes: ** = p ≤ 0.01; dependent variable = eating disorders.

Table 6.

Multiple linear regression with physical activity as dependent variable, self-esteem, eating disorder, and body image and as predictors.

Dimension	Variables	Coefficient	Standard error	Coefficient β	t	p	R	R²	Durbin-Watson coefficient
Physical Activity	Intercept	46.77	3.49	–	13.41	0.000
	Self-esteem	1.36	0.24	0.34	5.78	0.000	0.34	0.11	2.01
Excluded variables	Eating-disordered behavior	–	–	0.10	1.324	0.187	–	–	–
	Body image	–	–	−0.11	−1.87	0.063	–	–	–
	Body Mass Index	–	–	−0.11	−1.79	0.075	–	–	–

Notes: dependent variable = physical activity.

Table 7.

Multiple linear regression with body image as dependent variable, body mass index, self-esteem, eating disorder, and physical activity and as predictors.

Dimension	Variables	Coefficient	Standard error	Coefficient β	t	p	R	R²	Durbin-Watson coefficient
Body image	Intercept	−3.06	0.48	–	−6.38	0.000
	Body Mass Index	0.28	0.02	0.64	13.37	0.000	0.64	0.41	1.90
Excluded variables	Eating-disordered behavior	–	–	0.03	0.67	0.285	–	–	–
	Physical activity	–	–	−0.03	−0.59	0.504	–	–	–
	Self-esteem	–	–	−0.05	1.07	0.555	–	–	–

Note: dependent variable = body image.

Higher self-esteem was predicted by higher eating-disordered behavior, while BMI, physical activity, and body image were excluded from the equation as they did not reach statistical significance.

A higher BMI was predicted by a body image towards overweight, while eating-disordered behavior, physical activity, and self-esteem did not reach statistical significance and were excluded from the equation.

Higher eating-disordered behavior was predicted by higher scores for self-esteem, while BMI and body image were excluded from the equation as they did not reach statistical significance .

Higher physical activity scores were predicted by higher scores for self-esteem, while eating-disordered behavior, BMI, and body image were excluded from the equation as they did not reach statistical significance.

A body image towards overweight was predicted by higher BMI scores, while eating-disordered behavior, physical activity, and self-esteem were excluded from the equation as they did not reach statistical significance.

Discussion

The key findings of the present study of a non-clinical sample of female adolescents were that higher self-esteem were not only associated with higher physical activity and a more distorted body image, but also with more disordered eating behavior. The present results add to the current literature in that we confirmed a positive association between self-esteem and higher eating-disordered behavior, at least among a sample of psychologically healthy young female adolescents.

Two hypotheses and two research questions were formulated, and each of these is considered in turn

Our first hypothesis was that high self-esteem would be associated with a more positive and undistorted body image. This hypothesis was not supported; on the contrary we found the opposite. Higher self-esteem indices were associated with a slimmer and distorted body image. It follows that the present pattern of results is at odds with previous findings indicating higher self-esteem to be associated with a more positive body image (Espinoza et al., 2019; Kostanski & Gullone, 1998; Ozmen et al., 2007; Woodward et al., 2019; Zamani Sani et al., 2016; Zhang et al., 2018). The unexpected pattern of results demands a more thorough discussion, to which we will return below.

Our second hypothesis followed others (Alipour et al., 2015; Espinoza et al., 2019; Woodward et al. 2019) in anticipating that a better body image, which is to say an undistorted body image more reflective of actual body shape, would be associated with higher levels of physical activity and less disordered eating behavior, but again this hypothesis was not supported. While higher physical activity indices were negatively associated with a positive body image, the body image index was not associated with eating disordered behavior.

One source of uncertainty here might be the tool used to assess body image. The Figure Rating Scale (Stunkard et al., 1983) does not provide clear cut-off scores; instead the continuous scale from a very overweight to a very slim to anorectic body shape allows some degree of interpretation. Our results did, however, show that higher self-esteem scores were associated with a distorted or a more athletic to thin body shape, which would be in accord with previous results (Militello et al., 2018).

Our first research question concerned the direction of association in any relation between eating-disordered behavior and self-esteem. In our sample higher self-esteem scores were associated with more disordered eating behavior. This does not match the findings of studies which have reported a negative association between self-esteem scores and eating-disordered behavior (Collin et al., 2016; Cornelius & Blanton, 2016; Pelletier Brochu et al., 2018), though it is consistent with some other work (Goss & Allan, 2009; Macleod, 1981; Vitousek, 1996). Furthermore, Collin et al. (2016) and Smink et al. (2018) have commented that domain-specific dimensions of higher self-esteem might be associated with less disordered eating behavior, while Stice (2016) concluded from an overview of studies that there were no grounds for a conclusive answer as to the nature of the association.

Although the evidence available from the study is insufficient to shed any direct light on the psychological mechanisms the association we observed between higher self-esteem scores and higher eating-disordered behavior, we advance the following explanations. First, the current pattern of results is novel but the study is not strictly comparable to previous work which has been based on samples with serious eating disorders (Collin et al., 2016; Cornelius & Blanton, 2016; Goss & Allan, 2009; Macleod, 1981; Pelletier Brochu et al., 2018); we sampled adolescent females adolescents without evident psychopathologies. However, the characteristics of anon-clinical sample per se are not sufficient to explain the current findings, as Espinoza et al. (2019) also studied a non-clinical sample, in their case 303 female and male adolescents aged 12 to 15 years. Likewise, Woodward et al. (2019) reported results of a study of female students and one of a community sample. It should be pointed out nonetheless that in the student and community samples described in Woodward et al. (2019), low self-esteem and higher body shame were each directly and indirectly associated with both higher eating disorders and more marked symptoms of depression. Or to put it another way, symptoms of depression as clear indicators of psychopathology were important in explaining the association found between lower self-esteem and higher eating disorders. In Espinoza et al. (2019), 53.8% of the non-clinical sample were males. As mentioned in the Introduction section, compared to males, females display higher stress in relation to social media as proxies for peer acceptance and peer feedback (Guyer et al. 2014); they tend to build their self-esteem on social feedback (Hyde et al. 2008), and they score more highly on internalizing problems such as anxiety and depression (Bor et al. 2014). Given these gender differences, this might explain why our findings differ from those of Espinoza et al. (2019).

Second, it is also the case that sampling female adolescents and young adults with eating disorders (Collin et al., 2016; Cornelius & Blanton, 2016; Macleod, 1981; Pelletier Brochu et al., 2018) carries a risk of including those with additional psychiatric and somatic issues. Indeed, there is a considerable overlap between eating disorders and perfectionism (Johnston et al., 2018), complex multiple physical symptoms and comorbid psychiatric disorders (Cooney et al., 2018; Marucci et al., 2018), body image disturbances (Lewer et al., 2017), obesity (He et al., 2017), cystic fibrosis (Linkson et al., 2018), and Type I Diabetes (Toni et al., 2017). It is therefore quite possible that latent confounders biased the results of the studies referred to above.

Third, as shown in Table 2, the associations between self-esteem, eating-disordered behavior, and physical activity were high. In other words, those participants who were more physically active were also those with higher self-esteem and more disordered eating behavior. While the cross-sectional design of the present study does not allow any conclusions about the causal direction of influence, one of a bi-directional nature is quite possible, with higher self-esteem impacting on higher physical activity levels, calorie-intake control, slimmer body shape and a lower BMI, while successful calorie-intake control, higher physical activity levels, a slimmer body shape and a lower BMI all reinforce self-esteem.

Our second research question asked about possible predictors of self-esteem, eating-disordered behavior, physical activity, body imagine, and BMI (see Tables 3 to 7). It emerged that self-esteem and eating-disordered behavior exclusively predicted each other, while the other dimensions studied – physical activity, BMI, body shape – were not significant predictors of either. Accordingly, though it is speculative, it remains possible that self-esteem and eating-disordered behavior mutually influenced one another.

Again, the evidence we have from the study does not allow a deeper understanding of the underlying psychological mechanisms, and one might question why it should be so important to maintain a lean body shape and low BMI, and why achieving these aims should be associated with higher self-esteem. First, as noted by Goss and Allan (2009), controlling vital impulses such as calorie-intake requires will-power, effort and continual control over basic body needs. Sustained and successful management of such impulses may engender feelings of pride (Goss & Allan, 2009) and thus higher self-esteem. On these lines, we believe that the bolstering effect on self-esteem might be fueled by psychological mechanisms of self-efficacy (Bandura, 1977), or by cognitive-emotional processes in which success at achieving aims are attributed to one’s own efforts. Second, research from evolutionary psychology shows that females with lean body shapes are more attractive as a lean body shape is associated with a higher mate value, youth, health, virginity, and the prospect of greater fertility (Brüne, 2015; Buss, 2019). More specifically, Singh (1993, 2002) showed that a lower waist-to-hip ratio was associated with a higher mate value, higher odds of fertility and female attractiveness. In contrast, higher waist-to-hip ratios were associated with an increased risk of diabetes, stroke, low fertility and abortion. Importantly, Singh (1993, 2002) showed that the association between waist-to-hip ratio and female attractiveness was not culture-specific and not inculcated by modern Western fashion dictates or media. In our view, the kinds of mechanisms outlined above appear to be consistent with (female) adolescents’ needs for a positive appearance, physical attractiveness, and peer-accorded social status (Smink et al., 2018).

Despite the novelty of the results, several limitations should warn against overgeneration of the findings. First, the cross-sectional nature of the study precludes any clear conclusions about causal relationships between self-esteem, eating-disordered behavior, BMI, physical activity, and body shape. Although we performed a series of multiple regression analyses which by nature define variables as ‘dependent’ or ‘predictor’, the cross-sectional study design supports only correlational conclusions. Second, only adolescent females took part in the study; accordingly, the findings do not generalize to male adolescents. Third, additional unassessed and latent factors might have biased two or more dimensions in the same or opposite directions. In particular, sleep (Lang et al., 2013; Richardson et al., 2017; Skarupke et al., 2017), family functioning (Boe et al., 2012, 2014, 2018; Sivertsen et al., 2017), substance use (Fournier & Levy, 2006; Skarupke et al., 2017; Truong et al., 2017), symptoms of mood and anxiety (Bor et al., 2014), and parents’ attitudes towards physical activity (Madsen et al., 2009) were not assessed and could have biased the present pattern of results. Fourth, we relied entirely on self-reports; objective measurements of physical activity levels might have provided data of higher quality. Thus, while all participants were screened for somatic and in particular psychiatric issues, a thorough psychiatric interview performed by trained and experienced psychiatrists and clinical psychologists might have uncovered other psychiatric issues (e.g., anxiety disorders, major depressive disorders, traumatic events, substance use disorders); the presence of such issues could have biased the present pattern of results. Fifth and similarly, ratings provided by parents, siblings, peers or teachers would have allowed a more comprehensive assessment of individuals’ degree of peer acceptance and likability. In this view, the so-called ‘one-with-many’ procedure as extensively described in Holtzman and Strube (2013) would have allowed comparison of self-perceptions of behavior with the perceptions of peers and would have reduced the rating bias inherent in any single source of data. Sixth and last, the theoretical background and rationale was limited by our reliance on findings from clinical samples such as adolescents who were overweight or obese or suffering from eating disorders. There remains very little literature on the relations among self-esteem, eating behavior and physical activity in the non-clinical adolescent female population on which we could draw to construct a theoretical foundation for the present study.

Conclusions

Among a non-clinical sample of female adolescents, higher self-esteem scores were associated with higher levels of physical activity, and a negative body image, along with more disordered eating behavior. This last association might explain why the treatment of adolescents with eating disorders is particularly challenging.

Supplemental Material

sj-pdf-1-prx-10.1177_0033294120948226 - Supplemental material for Self-Esteem and Symptoms of Eating-Disordered Behavior Among Female Adolescents

Supplemental material, sj-pdf-1-prx-10.1177_0033294120948226 for Self-Esteem and Symptoms of Eating-Disordered Behavior Among Female Adolescents by Seyed Hojjat Zamani Sani, Zahra Fathirezaie, Markus Gerber, Uwe Pühse, Dena Sadeghi Bahmani, Mahdi Bashiri, Mohammad Pourali and Serge Brand in Psychological Reports

Supplemental Material

sj-pdf-2-prx-10.1177_0033294120948226 - Supplemental material for Self-Esteem and Symptoms of Eating-Disordered Behavior Among Female Adolescents

Supplemental material, sj-pdf-2-prx-10.1177_0033294120948226 for Self-Esteem and Symptoms of Eating-Disordered Behavior Among Female Adolescents by Seyed Hojjat Zamani Sani, Zahra Fathirezaie, Markus Gerber, Uwe Pühse, Dena Sadeghi Bahmani, Mahdi Bashiri, Mohammad Pourali and Serge Brand in Psychological Reports

Supplemental Material

sj-pdf-3-prx-10.1177_0033294120948226 - Supplemental material for Self-Esteem and Symptoms of Eating-Disordered Behavior Among Female Adolescents

Supplemental material, sj-pdf-3-prx-10.1177_0033294120948226 for Self-Esteem and Symptoms of Eating-Disordered Behavior Among Female Adolescents by Seyed Hojjat Zamani Sani, Zahra Fathirezaie, Markus Gerber, Uwe Pühse, Dena Sadeghi Bahmani, Mahdi Bashiri, Mohammad Pourali and Serge Brand in Psychological Reports

Footnotes

Author’s note

Mohammad Pourali is now affiliated with Department of Motor Behavior, Faculty of Physical Education and Sport Science, University of Tabriz, Tabriz, Iran.

Acknowledgements

We thank Nick Emler (University of Surrey, Surrey UK) for proofreading the manuscript.

Author Biographies

Seyed Hojjat Zamani Sani: He received the PhD degree in motor behavior in 2014 from Shahid Beheshti University, Tehran, Iran. At that time, he attended his academic sabbatical both at the Psychiatric Clinic of the University of Basel, Basel, Switzerland, and at the Department of Sport and Health Science, Division of Sport Science, University of Basel, Basel, Switzerland. He subsequently joined University of Tabriz, where he is currently an assistant professor in the Department of Motor Behavior.

Zahra Fathirezaie: She received the PhD degree in motor behavior in 2015 from Shahid Beheshti University, Tehran, Iran. At that time, she attended her academic sabbatical both at the Psychiatric Clinic of the University of Basel, Basel, Switzerland, and at the Department of Sport and Health Science, Division of Sport Science, University of Basel, Basel, Switzerland. She subsequently joined University of Tabriz, where she is currently an assistant professor and head of the Department of Motor Behavior.

Markus Gerber: PhD, is working as a full professor in the Department of Sport, Exercise and Health; he is the Head of the Division of Sport Science and Psychosocial Health of the Faculty of Medicine, University of Basel, Basel, Switzerland.

Uwe Pühse: PhD, is working as a full professor; he is Head of the Department of Sport, Exercise and Health of the Faculty of Medicine, University of Basel, Basel, Switzerland.

Dena Sadeghi Bahmani: PhD, is working as postdoctoral fellow at the University of Basel, Psychiatric Clinics (UPK), Basel, Switzerland, and as postdoctoral fellow at the Exercise Neuroscience Research Laboratory (ENRL), The University of Alabama at Birmingham (AL, USA).

Mahdi Bashiri: He received the Ph.D. degree in sport management in 2014 from University of Tehran, Tehran, Iran. He subsequently joined Azarbaijan Shahid Madani University, where he is currently an assistant professor in the Department of Sport Science Group, Faculty of Education and Psychology and head of the physical education section at the Azarbaijan Shahid Madani University. Dr Bashiri research interests is human resource psychology at sport and exercise management.

Mohammad Pourali: He received the MSc degree in motor learning and control from university of Tabriz. He coaches fitness and bodybuilding in sports. He is working on psychology of sport and exercise.

Serge Brand: PhD, is working as a research psychologist and adjunct professor at the University of Basel, Psychiatric Clinics (UPK), at the Department of Sport, Exercise and Health, Division of Sport and Psychosocial Health, and at the Faculty of Medicine, University of Basel, Basel, Switzerland. He is also visiting professor at the Kermanshah University of Medical Sciences (KUMS), Kermanshah, Iran, and at the Tehran University of Medical Sciences, School of Medicine (TUMS; Tehran, Iran).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Serge Brand

References

Ahmadi

Moloodi

Zarbaksh

M. R.

Ghaderi

(2014). Psychometric properties of the Eating Attitude Test-26 for female Iranian students. Eating and Weight Disorders, 19(2), 183–189. https://doi.org/10.1007/s40519-014-0106-7

Alipour

Abbasalizad Farhangi

Dehghan

Alipour

(2015). Body image perception and its association with body mass index and nutrient intakes among female college students aged 18-35 years from Tabriz, Iran. Eating and Weight Disorders, 20(4), 465–471. https://doi.org/10.1007/s40519-015-0184-1

Al-Khudairy

Loveman

Colquitt

J. L.

Mead

Johnson

R. E.

Fraser

H.,

Olajide, J., Murphy, M., Velho, R. M., O'Malley, C., Azevedo, L. B., Ells, L. J., Metzendorf, M. I., & Rees

(2017). Diet, physical activity and behavioural interventions for the treatment of overweight or obese adolescents aged 12 to 17 years. Cochrane Database of Systematic Review, 6, Cd012691. https://doi.org/10.1002/14651858.Cd012691

Bandura

(1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191–215. http://www.ncbi.nlm.nih.gov/pubmed/847061

Boe

Hysing

Stormark

K. M.

Lundervold

A. J.

Sivertsen

(2012). Sleep problems as a mediator of the association between parental education levels, perceived family economy and poor mental health in children. Journal of Psychosomatic Research, 73(6), 430–436. https://doi.org/10.1016/j.jpsychores.2012.09.008

Boe

Serlachius

A. S.

Sivertsen

Petrie

K. J.

Hysing

(2018). Cumulative effects of negative life events and family stress on children’s mental health: The Bergen Child Study. Social Psychiatry and Psychiatric Epidemiology, 53, 1–9. https://doi.org/10.1007/s00127-017-1451-4

Boe

Sivertsen

Heiervang

Goodman

Lundervold

A. J.

Hysing

(2014). Socioeconomic status and child mental health: The role of parental emotional well-being and parenting practices. Journal of Abnormal Child Psychology, 42(5), 705–715. https://doi.org/10.1007/s10802-013-9818-9

Bor

Dean

A. J.

Najman

Hayatbakhsh

(2014). Are child and adolescent mental health problems increasing in the 21st century? A systematic review. Australian and New Zealand Journal of Psychiatry, 48(7), 606–616. https://doi.org/10.1177/0004867414533834

Brüne

(2015). Textbook of evolutionary psychiatry and psychosomatic medicine. The origins of psychopathology. Oxford University Press.

10.

Buss

D. M.

(2019). Evolutionary psychology. The new science of the mind (6th ed.). Taylor & Francis.

11.

Cardinal

T. M.

Kaciroti

Lumeng

J. C.

(2006). The figure rating scale as an index of weight status of women on videotape. Obesity (Silver Spring), 14(12), 2132–2135. https://doi.org/10.1038/oby.2006.249

12.

Collin

Karatzias

Power

Howard

Grierson

Yellowlees

(2016). Multi-dimensional self-esteem and magnitude of change in the treatment of anorexia nervosa. Psychiatry Research, 237, 175–181. https://doi.org/10.1016/j.psychres.2016.01.046

13.

Cooney

Lieberman

Guimond

Katzman

D. K.

(2018). Clinical and psychological features of children and adolescents diagnosed with avoidant/restrictive food intake disorder in a pediatric tertiary care eating disorder program: A descriptive study. Journal of Eat Disorders, 6, 7. https://doi.org/10.1186/s40337-018-0193-3

14.

Cornelius

Blanton

(2016). The limits to pride: A test of the pro-anorexia hypothesis. Eating Disorders, 24(2), 138–147. https://doi.org/10.1080/10640266.2014.1000102

15.

Crocker

P. R.

Bailey

D. A.

Faulkner

R. A.

Kowalski

K. C.

McGrath

(1997). Measuring general levels of physical activity: Preliminary evidence for the Physical Activity Questionnaire for Older Children. Medicine & Science in Sports & Exercise, 29(10), 1344–1349.

16.

Ding

Zhang

Yang

(2018). A pathway to psychological difficulty: Perceived chronic social adversity and its symptomatic reactions. Frontiers in Psychology, 9, 615. https://doi.org/10.3389/fpsyg.2018.00615

17.

Espinoza

Penelo

Mora

Francisco

González

M. L.

Raich

R. M.

(2019). Bidirectional relations between disordered eating, internalization of beauty ideals, and self-esteem: A longitudinal study with adolescents. The Journal of Early Adolescence, 39(9), 1244–1260.

18.

Faghihimani

Nourian

Nikkar

A. H.

Farajzadegan

Khavariyan

Ghatrehsamani

Poursafa

Kelishadi

(2010). Validation of the child and adolescent international physical activity questionnaire in Iranian children and adolescents. Arya Atherosclerosis, 5(4), 1–3.

19.

Fournier

M. E.

Levy

(2006). Recent trends in adolescent substance use, primary care screening, and updates in treatment options. Current Opinion in Pediatrics, 18(4), 352–358. https://doi.org/10.1097/01.mop.0000236381.33907.9d

20.

Garfinkel

P. E.

Newman

(2001). The eating attitudes test: Twenty-five years later. Eating and Weight Disorders, 6(1), 1–24.

21.

Garner

D. M.

Garfinkel

P. E.

(1979). The Eating Attitudes Test: An index of the symptoms of anorexia nervosa. Psychological Medicine, 9(2), 273–279.

22.

Goss

Allan

(2009). Shame, pride and eating disorders. Clinical Psychology & Psychotherapy, 16(4), 303–316. https://doi.org/10.1002/cpp.627

23.

Guyer

A. E.

Caouette

J. D.

Lee

C. C.

Ruiz

S. K.

(2014). Will they like me? Adolescents’ emotional responses to peer evaluation. International Journal of Behavioral Development, 38(2), 155–163. https://doi.org/10.1177/0165025413515627

24.

Cai

Fan

(2017). Prevalence of binge and loss of control eating among children and adolescents with overweight and obesity: An exploratory meta-analysis. International Journal of Eating Disorders, 50(2), 91–103. https://doi.org/10.1002/eat.22661

25.

Holtzman

N. S.

Strube

M. J.

(2013). Above and beyond short-term mating, long-term mating is uniquely tied to human personality. Evolutionary Psychology, 11(5), 1101–1129.

26.

Hyde

J. S.

Mezulis

A. H.

Abramson

L. Y.

(2008). The ABCs of depression: Integrating affective, biological, and cognitive models to explain the emergence of the gender difference in depression. Psychological Review, 115(2), 291–313. https://doi.org/10.1037/0033-295X.115.2.291

27.

Johnston

Shu

C. Y.

Hoiles

K. J.

Clarke

P. J. F.

Watson

H. J.

Dunlop

P. D.

Egan

S. J.

(2018). Perfectionism is associated with higher eating disorder symptoms and lower remission in children and adolescents diagnosed with eating disorders. Eating Behaviors, 30, 55–60. https://doi.org/10.1016/j.eatbeh.2018.05.008

28.

Kostanski

Gullone

(1998). Adolescent body image dissatisfaction: Relationships with self-esteem, anxiety, and depression controlling for body mass. Journal of Child Psychology and Psychiatry, 39(2), 255–262.

29.

Lang

Brand

Feldmeth

A. K.

Holsboer-Trachsler

Puhse

Gerber

(2013). Increased self-reported and objectively assessed physical activity predict sleep quality among adolescents. Physiology & Behavior, 120, 46–53. https://doi.org/10.1016/j.physbeh.2013.07.001

30.

Lewer

Bauer

Hartmann

A. S.

Vocks

(2017). Different facets of body image disturbance in binge eating disorder: A review. Nutrients, 9(12), 1294. https://doi.org/10.3390/nu9121294

31.

Linkson

Macedo

Perrin

F. M. R.

Elston

C. M.

(2018). Anorexia nervosa in cystic fibrosis. Paediatric Respiratory Reviews, 26, 24–26. https://doi.org/10.1016/j.prrv.2017.03.002

32.

Liu

Ming

(2015). How does physical activity intervention improve self-esteem and self-concept in children and adolescents? Evidence from a meta-analysis. PLoS One, 10(8), e0134804.https://doi.org/10.1371/journal.pone.0134804

33.

Macleod

(1981). The art of starvation. Virago.

34.

Madsen

K. A.

McCulloch

C. E.

Crawford

P. B.

(2009). Parent modeling: Perceptions of parents' physical activity predict girls’ activity throughout adolescence. Journal of Pediatrics, 154(2), 278–283. https://doi.org/10.1016/j.jpeds.2008.07.044

35.

Marucci

Ragione

L. D.

De Iaco

Mococci

Vicini

Guastamacchia

Triggiani

(2018). Anorexia nervosa and comorbid psychopathology. Endocrine, Metabolic, Immune Disorders— Drug Targets, 18(4), 316–324. https://doi.org/10.2174/1871530318666180213111637

36.

Militello

L. K.

Kelly

Melynk

B. M.

Smith

Petosa

(2018). A review of systematic reviews targeting the prevention and treatment of overweight and obesity in adolescent populations. Journal of Adolescent Health, 63, 675–687. https://doi.org/10.1016/j.jadohealth.2018.07.013

37.

Ozmen

Ergin

Cetinkaya

A. C.

Sen

Dundar

P. E.

Taskin

E. O.

(2007). The association of self-esteem, depression and body satisfaction with obesity among Turkish adolescents. BMC Public Health, 7, 80. https://doi.org/10.1186/1471-2458-7-80

38.

Pelletier Brochu

Meilleur

DiMeglio

Taddeo

Lavoie

Erdstein

, Pause, R., Pesant, C., Thibault, I., & Frappier

J. Y.

(2018). Adolescents’ perceptions of the quality of interpersonal relationships and eating disorder symptom severity: The mediating role of low self-esteem and negative mood. Eat Disorders, 26(4), 388–406. https://doi.org/10.1080/10640266.2018.1454806

39.

Richardson

C. E.

Gradisar

Short

M. A.

Lang

(2017). Can exercise regulate the circadian system of adolescents? Novel implications for the treatment of delayed sleep-wake phase disorder. Sleep Medicine Reviews, 34, 122–129. https://doi.org/10.1016/j.smrv.2016.06.010

40.

Rosenberg

(1965). Society and the adolescent self-image. Princeton University Press.

41.

Shapurian

Hojat

Nayerahmadi

(1987). Psychometric characteristics and dimensionality of a Persian version of Rosenberg Self-esteem Scale. Perceptual and Motor Skills, 65(1), 27–34. https://doi.org/10.2466/pms.1987.65.1.27

42.

Sheehan

D. V.

Lecrubier

Sheehan

K. H.

Amorim

Janavs

Weiller

, Hergueta, T., Baker, R., & Dunbar

G. C.

(1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl 20), 22–33;quiz 34–57. http://www.ncbi.nlm.nih.gov/pubmed/9881538

43.

Shoraka

Amirkafi

Garrusi

(2019). Review of body image and some of contributing factors in Iranian population. International Journal of Preventive Medicine, 10, 19. https://doi.org/10.4103/ijpvm.IJPVM_293_18

44.

Singh

(1993). Adaptive significance of female physical attractiveness: Role of waist-to-hip ratio. Journal of Personality and Social Psychology, 65(2), 293–307.

45.

Singh

(2002). Female mate value at a glance: Relationship of waist-to-hip ratio to health, fecundity and attractiveness. Neuroendocrinology Letters, 23(Suppl 4), 81–91.

46.

Sivertsen

Boe

Skogen

J. C.

Petrie

K. J.

Hysing

(2017). Moving into poverty during childhood is associated with later sleep problems. Sleep Medicine, 37, 54–59. https://doi.org/10.1016/j.sleep.2017.06.005

47.

Skarupke

Schlack

Lange

Goerke

Dueck

Thome

, Szagun, B., & Cohrs

(2017). Insomnia complaints and substance use in German adolescents: Did we underestimate the role of coffee consumption? Results of the KiGGS study. Journal of Neural Transmission (Vienna), 124(Suppl 1), 69–78. https://doi.org/10.1007/s00702-015-1448-7

48.

Smink

F. R. E.

van Hoeken

Dijkstra

J. K.

Deen

Oldehinkel

A. J.

Hoek

H. W.

(2018). Self-esteem and peer-perceived social status in early adolescence and prediction of eating pathology in young adulthood. International Journal of Eating Disorders, 51(8), 852–862. https://doi.org/10.1002/eat.22875

49.

Stice

(2016). Interactive and mediational etiologic models of eating disorder onset: Evidence from prospective studies. Annual Review of Clinical Psychology, 12, 359–381. https://doi.org/10.1146/annurev-clinpsy-021815-093317

50.

Stunkard

A. J.

Sorensen

Schulsinger

(1983). Use of the Danish Adoption Register for the study of obesity and thinness. Research Publication—Association for Research in Nervous and Mental Disease, 60, 115–120.

51.

Toni

Berioli

M. G.

Cerquiglini

Ceccarini

Grohmann

Principi

Esposito

(2017). Eating disorders and disordered eating symptoms in adolescents with type 1 diabetes. Nutrients, 9(8), 906. https://doi.org/10.3390/nu9080906

52.

Truong

Moukaddam

Toledo

Onigu-Otite

(2017). Addictive disorders in adolescents. Psychiatrics Clinics of North America, 40(3), 475–486. https://doi.org/10.1016/j.psc.2017.05.012

53.

van der Schuur

W. A.

Baumgartner

S. E.

Sumter

S. R.

(2018). Social media use, social media stress, and sleep: Examining cross-sectional and longitudinal relationships in adolescents. Health Communication, 34, 552–559. https://doi.org/10.1080/10410236.2017.1422101

54.

Vitousek

K. M.

(1996). The current status of cognitive–behavioral models of anorexia nervosa and bulimia nervosa. In Salkovskis

P. M.

; (Ed.), Frontiers of cognitive therapy (pp. 383–418). Guilford.

55.

Woodward

McIlwain

Mond

(2019). Feelings about the self and body in eating disturbances: The role of internalized shame, self-esteem, externalized self-perceptions, and body shame. Self and Identity, 18(2), 159–182.

56.

World Medical Association. (2013). World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. Journal of American Medical Association, 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053

57.

Yang

Zhang

Lou

Long

Liang

Xie

Yuan

(2017). The increased sex differences in susceptibility to emotional stimuli during adolescence: An event-related potential study. Frontiers in Human Neuroscience, 11, 660. https://doi.org/10.3389/fnhum.2017.00660

58.

Zamani Sani

S. H.

Fathirezaie

Brand

Puhse

Holsboer-Trachsler

Gerber

Talepasand

(2016). Physical activity and self-esteem: Testing direct and indirect relationships associated with psychological and physical mechanisms. Neuropsychiatric Disease and Treatment, 12, 2617–2625. https://doi.org/10.2147/ndt.s116811

59.

Zhang

Qian

(2018). To be thin but not healthy—The body-image dilemma may affect health among female university students in China. PLoS One, 13(10), e0205282. https://doi.org/10.1371/journal.pone.0205282

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.01 MB

0.09 MB

0.19 MB