Moderators of the Relationship Between Body Dissatisfaction and Eating Pathology in Preadolescent Girls

Abstract

Body dissatisfaction (BD) is a common experience among preadolescent girls and a robust risk factor and precursor to eating pathology (EP). Although the relationship between BD and EP has been well documented, there is less research exploring the factors that may make this relationship more or less pronounced. In the current study, we investigated several factors that may moderate the relationship between BD and EP. Preadolescent girls (n = 169) aged between 10 and 12 years completed questionnaires measuring EP, BD, negative affect, perfectionism, self-esteem, teasing, and perceived pressure from others and the media. Moderator analyses indicated that self-oriented and socially prescribed perfectionism, media pressure, and self-esteem each moderated the relationship between BD and EP. These factors may potentially make a preadolescent girl more susceptible to developing EP and may be useful to address in targeted prevention efforts among girls dissatisfied with their bodies.

Keywords

eating pathology body dissatisfaction moderators

Although most research on established risk factors for eating disorders (EDs) has focused on women and adolescent girls, an increasing number of studies have shown that pathological eating attitudes and behaviors occur in preadolescence. Pathological eating behaviors are particularly dangerous for preadolescents who need to receive adequate nutrition for growth and normal physical and pubertal development. Moreover, the literature clearly suggests that early eating pathology (EP) is predictive of EP later in life (Evans et al., 2017). Although clinical EDs are rare in this younger population, evidence suggests that children are aware of the societal value of thinness and the connection between eating, weight, and dieting behaviors, with dieting behaviors being observed in girls as young as 5 (Damiano, Paxton, Wertheim, McLean, & Gregg, 2015; Flannery-Schroeder & Chrisler, 1996; Oliver & Thelen, 1996; Ricciardelli & McCabe, 2001; Vander Wal & Thelen, 2000; Wood, Becker, & Thompson, 1996). Clinical presentations and risk factors for EP may not be the same for preadolescents as for adolescents, and understanding these factors is important to improve treatments. Although there are divergent opinions about how adolescence is best defined, in this article, preadolescence is defined as a period of early adolescence demarcated at age 13 years, and adolescence a time, often called middle to late adolescence, from ages 13 to 18 (Breinbauer & Maddaleno, 2005). This definition is based on much of the literature reviewed as well as the start of secondary school in New Zealand (age 13) often seen as heralding the start of adolescence.

As well as EP, body dissatisfaction (BD) can also begin before adolescence. A recent study by Dion and colleagues (2016) of 1,515 preadolescents reported that 50.5% of girls wanted a thinner shape, compared with 35.9% of boys. Similarly, using a computer-based figure rating scale, Evans, Tovee, Boothroyd, and Drewett (2013) found that 65% of preadolescent girls chose a smaller ideal body shape than their current perceived body shape. A large study of 10,526 nine- to 12-year olds reported that 30% wanted a smaller body size and 9.3% wanted a larger body size. Those preadolescents who were dissatisfied had a higher risk of having disordered eating symptoms, compared with preadolescents satisfied with their body. This relationship was more pronounced for the preadolescent girls in the study (Figueiredo, Simola-Ström, Isomaa, & Weiderpass, 2019). These prevalence rates illustrate that BD in preadolescence may also be a common, if not normative, experience (Phares, Steinberg, & Thompson, 2004) and highlight the importance of better understanding the nature and impact of BD before it increases in intensity.

Given that BD is a robust and consistent risk factor for EP, research exploring the factors that may moderate the association between BD and EP is warranted. Stice, South, and Shaw (2012) described the need for studies to explore how various established risk factors may interact together. A better understanding of these factors could potentially protect preadolescents before their BD symptoms increase in severity and lead to EP. Given the dearth of literature on these factors among preadolescent girls, and how they might moderate the BD to EP pathway, we now review the adult and older adolescent research that explores these risk factors.

Moderator studies have provided insight into what factors may affect the relationship between BD and EP, primarily with adults. Vohs, Bardone, Joiner, Abramson, and Heatherton (1999) found a three-way interaction effect between perfectionism, BD, and self-esteem for adult women, suggesting that those who were highly perfectionistic, dissatisfied with their bodies, and had low self-esteem engaged in more pathological eating behaviors. Among adolescents, Shaw, Stice, and Springer (2004) did not find this moderating effect. Individually, perfectionism is associated with greater EP (Bento et al., 2010) and has been found to moderate the link between BD and shape and weight concerns and drive for thinness among adolescent girls (Boone, Soenens, & Luyten, 2014); however, the moderating role of perfectionism needs to be further refined and explored in a younger population. Despite perfectionism being a common and characteristic antecedent of EP (see Bardone-Cone et al., 2007), studies examining perfectionism and EP in preadolescents are scarce. Saling, Ricciardelli, and McCabe (2005) found that high levels of perfectionism were associated with higher reported levels of dieting and food and muscle preoccupation among boys and not girls; however, this was a study of even younger children aged 8 to 10 years and therefore may not be as relevant to preadolescents. Moreover, Machado, Gonçalves, Martins, Hoek, and Machado (2014) reported that adults with anorexia nervosa, an ED characterized by a restriction of energy intake, weight loss, fear of weight gain, and extreme shape and weight importance (American Psychiatric Association, 2013), had higher levels of childhood perfectionism than a psychiatric comparison group.

The tripartite influence model, well supported in the adolescent literature, posits that parents, peers, and media are primary sources that contribute to the development of body image and eating disturbance via processes of internalization and comparison (Keery, van den Berg, & Thompson, 2004; Shroff & Thompson, 2006). Perceived pressure from others, particularly parents, has been associated with increased EP among preadolescents (Allen, Gibson, McLean, Davis, & Byrne, 2014; Field et al., 2001; Hill & Pallin, 1998). Longitudinally, both maternal concern with child’s weight, significantly predicted later in child’s ED symptoms (between 8 and 13 years at baseline; Allen et al., 2014), and paternal concern over thinness have been associated with constant dieting (Field et al., 2001). However, other studies have not found a direct relationship between parental and peer pressure from others and EP, instead suggesting that pressure is more closely related to weight concerns (Saling et al., 2005; Thøgersen-Ntoumani et al., 2016), which in turn leads to EP, perhaps via social comparison as the tripartite model suggests.

Similarly, studies have examined weight-related teasing and its relationship with EP among preadolescents (e.g., Gardner, Stark, Friedman, & Jackson, 2000; Jendrzyca & Warschburger, 2016; Madowitz, Knatz, Maginot, Crow, & Boutelle, 2012). Gardner and colleagues (2000) found that, among participants aged 9 to 14 years of age, teasing was a significant predictor of EP at ages 12 and 14, yet nonsignificant from ages 7 to 11. These results suggest that teasing and peer influences may be less salient in preadolescence. Conversely, in their study of girls and boys aged 6 to 11 years, Jendrzyca and Warschburger (2016) found a relationship between experiences of weight stigma and restrained eating, with BD mediating this relationship. The inconsistency in these findings may be due to the sociocultural shifts seen recently with the advent of social media and increase in weight-related teasing via this medium. Indeed, media pressure and exposure have also been directly related to EP (Damiano et al., 2015; Field et al., 1999; Harrison & Hefner, 2006), with both television (Harrison & Hefner, 2006) and magazines (Field et al., 1999) leading to increased dieting among preadolescent girls. In a cross-sectional study of adolescent girls, social media use was related to increased EP (Latzer, Spivak-Lavi, & Katz, 2015). However, Ferguson (2013) suggested the relationship between media and EP is often inconsistent with small effects and mainly seen among those with preexisting BD. While perceived pressure from others and the media seem closely related to BD rather than to EP directly, further research is needed to better understand the impact of this pressure among preadolescents who experience BD.

Among adolescent girls, low self-esteem is related to greater BD and EP (Button, Sonuga-Barke, Davies, & Thompson, 1996; Cervera et al., 2003; Hoare & Cosgrove, 1998); however, the research with preadolescents is less clear. In a prospective study, Button and colleagues (1996) found that girls with low self-esteem at ages 11 to 12 were at significantly greater risk of developing EP. However, McCabe and Ricciardelli (2003a) found that low self-esteem was associated with BD rather than EP per se. Indeed, Mendelson, White, and Mendelson (1996) found that children (aged between 8 and 10 years) with high self-esteem tended to have positive attitudes toward their shape and weight. It is possible that the contribution of low self-esteem to EP during preadolescence (if any) is clouded by its theoretical overlap with body-esteem. Shavelson, Hubner, and Stanton (1976) suggested that self-esteem and body-esteem might be interdependent parts of a broader construct of self-concept. For example, among children, BD is closely associated with lower global self-worth and dissatisfaction with other areas of their life (Tiggemann, 2005).

Although negative affect has been associated with increased dieting and disordered eating among pre- and early adolescent girls (Evans et al., 2013; Holt & Ricciardelli, 2002; Rodgers, Paxton, & McLean, 2014), this finding is inconsistent (Ricciardelli, McCabe, Holt, & Finemore, 2003; Saling et al., 2005). In their study, Saling and colleagues (2005) found negative affect only predicted girls’ muscle preoccupation. Again, negative affect may be more consistently related to the importance placed on weight and their intentions to lose weight (McCabe & Ricciardelli, 2003a) rather than EP in this age group. Further research is needed to clarify this relationship.

Although the literature on adolescence may be clearer, studies have not consistently found the above-mentioned factors to be directly related to increased EP in preadolescence and questions remain whether these factors may moderate the well-established link between BD and EP. In light of their developmental differences, it should not be assumed that the factors that moderate the BD-EP link in adulthood and adolescence are the same for younger girls. For example, preadolescents may have more controls put on their media exposure/usage than adolescents, ameliorating this mode of social pressure, or may be less likely to experience negative affect as these difficulties tend to increase in adolescence (see Thapar, Collishaw, Pine, & Thapar, 2012). Similarly, self-esteem tends to be more robust until adolescence, with changes in self-esteem commonly occurring because of the physical and social changes that happen during adolescence. Conversely, the rapid increase in social media and access to the Internet may mean that there are fewer age-related differences. Testing for moderator effects could provide a deeper understanding about if and how these factors influence BD in leading to EP in this particular age group.

The aim of this study was to identify the effect of negative affect, perfectionism, self-esteem, teasing, and sociocultural pressure on the relationship between BD and EP among preadolescent girls. It was expected that the moderation analyses would reveal significant effects for perfectionism, teasing, and perceived pressure from others to lose weight. This hypothesis was put forward because perfectionism is a strong predictor of EP and likely to drive an individual who is dissatisfied with her shape and weight to lose weight and not be satisfied until her expectations are met. Furthermore, given their age, preadolescent girls may be less independent and more exposed or susceptible to pressure, expectations, and teasing from others to lose weight. This perceived pressure may encourage them to strive to lose weight in order to gain acceptance.

Method

Participants

Participants were 169 preadolescent girls aged between 10 and 12 years recruited from schools in Christchurch, New Zealand. Effort was made to recruit participants from both private and public schools from a range of socioeconomic areas. Thirteen schools were invited to participate, and seven local primary schools agreed to participate: one private all girls’ school and six state schools.¹ The decile ratings (a government measure of socioeconomic status [SES] of students) of the participating schools ranged from 5 to 10, indicating that, on average, the children were from moderate to high socioeconomic communities (Ministry of Education, 2018).

Procedure

Parents and guardians of all 10- to 12-year-old girls from participating schools received an information sheet and a consent form prior to data collection. On the day of data collection, participants with parental consent received an information sheet and assent form to sign, which was also read to them aloud. Participants were instructed to answer the questionnaires honestly and were informed that there were no right or wrong answers. They were encouraged to ask questions at any time and if they felt uncomfortable doing this activity they could stop. Confidentiality was assured, defined for them using age-appropriate language. All participants gave written assent. Questionnaires were group administered during class time and lasted approximately 1 hour. After the questionnaires were completed, each participant was discretely measured for weight and height. Participants were then debriefed in a way that allowed the research topic to be embedded into an educational and healthy context. Ethics approval was obtained from the University of Canterbury Human Ethics Committee before this study was carried out.

Measures

Demographic questionnaire

A questionnaire assessed age, ethnicity, and mother and father/guardian occupations.

SES

The New Zealand Socioeconomic Index (NZSEI; Davis, McLeod, Ransom, & Ongley, 1997) is a widely used occupationally based measure of SES. Participants completed details about their parent’s/guardian’s occupation to yield an SES score, which was then categorized into a 6-point rating system, ranging from high to low.

EP

The Children’s version of the Eating Attitudes Test (ChEAT; Maloney, McGuire, & Daniels, 1988) is a 26-item measure of children’s eating and dieting behavior. The ChEAT is a simplified version of the EAT-26 with language suitable for individuals aged between 8 and 15 years. Participants endorse items on a 6-point scale ranging from 1 (always) to 6 (never) (e.g., “I like my stomach to be empty”). Maloney and colleagues (1988) recommended that a cutoff score of 20 on the ChEAT is indicative of severe EP that warrants further clinical assessment. Good internal consistencies have been reported for children between the ages of 8 and 13 (Maloney et al., 1988; Smolak & Levine, 1994). In the current study, Cronbach’s alpha for this scale was .80.

BD

The Collin’s Body Figure Perceptions (Collins, 1991) is a pictorial instrument aimed at assessing body perceptions in preadolescent children. Participants are presented with seven silhouettes from very thin to obese and asked to choose their perceived current size and their ideal size. A discrepancy score is obtained by subtracting ideal body size from perceived current size. Moderate test-retest reliability data have been reported for this scale (Collins, 1991; Wood et al., 1996).

The Eating Disorders Inventory–BD (EDI-BD; Garner, Olmstead, & Polivy, 1983) is a 9-item measure of BD used to rate dissatisfaction one’s body (e.g., “I think my stomach is too big”) on a 6-point scale ranging from always to never. Total scores range from 0 to a possible score of 27; the three most symptomatic responses are given a score of 3, 2, and 1 and the three least symptomatic responses are given a score of 0. This subscale has been validated on children from ages 8 to 18 and scores have showed good test-retest reliability and internal consistency (Cusumano & Thompson, 2001; Shore & Porter, 1990; Wood et al., 1996). In the current study, Cronbach’s alpha was .92.

Perfectionism

The Child-Adolescent Perfectionism Scale (CAPS; Flett, Hewitt, Boucher, Davidson, & Munro, 2000) is a 22-item multidimensional perfectionism scale used to assess socially prescribed (SP) perfectionism (e.g., “People expect more from me than I am able to give”) and self-oriented (SO) perfectionism (e.g., “When I do something, it has to be perfect”) in children and adolescents. Participants respond on a 5-point scale and higher scores on the scale indicate higher levels of perfectionism. In a study of 10- to 15-year olds, Hewitt et al. (2002) reported good internal consistency of .86 for SO and .85 SP perfectionism. Other researchers have studied the CAPS and found a three-factor model (McCreary, Joiner, Schmidt, & Ialongo, 2004; O’Connor, Dixon, & Rasmussen, 2009) or four-factor model (Yang, Hong, Tao, & Zhu, 2015) to be a better fit for the data. However, we used the CAPS as originally developed, given we found good score reliability for the factor scores. For this sample, the Cronbach’s alphas for the SP perfectionism and SO perfectionism subscales were .85 and .83, respectively.

Self-esteem

The Rosenberg Self-Esteem Scale (RSE; Rosenberg, 1965) is a widely used 10-item measure of general self-esteem in nonclinical populations. Example items include “I feel I do not have much to be proud of” and “At times I think I am no good at all.” Participants respond using a 4-point scale, ranging from strongly agree to strongly disagree. Scores range from 10 to 40, with high scores indicating low self-esteem. Among children aged 11 years, good internal consistency has been reported (Bannink, Pearce, & Hope, 2016). In the current study, Cronbach’s alpha was .84.

Negative affect

The Positive and Negative Affect Scale for Children (PANAS-C; Laurent et al., 1999) provides a separate measure of positive and negative affect for children. Participants rate the degree to which they have experienced the emotion (e.g., “interested” or “scared”) the past few weeks, on a scale ranging from 1 (very slightly or not at all) to 5 (extremely). This scale has been adapted from the adult version of the PANAS (Watson, Clark, & Tellegen, 1988) and uses words that are more understandable to children, for example, “sad” as opposed to “distressed.” Joiner, Catanzaro, and Laurent (1996) reported good internal consistency of .80. Cronbach’s alpha was .87 for the current study.

Perceived pressure to lose weight

The Sociocultural Influences and Body Change Questionnaire (McCabe & Ricciardelli, 2001) assesses perceived pressure from others (father, mother, best female friend, and best male friend) and the media to lose weight. Participants are required to rate each item on a 5-point scale ranging from never to always; items include “Does your best friend encourage you to lose weight” and “Does the TV give you the idea you should eat less to lose weight.” Higher scores are indicative of higher perceived pressure to lose weight. Among girls aged 8 to 11 years, good internal consistency has been found (McCabe & Ricciardelli, 2003b). In this sample, Cronbach’s alphas were .79 and .88 for the perceived pressure and media pressure scales, respectively.

Weight-related teasing

The Perception of Teasing Scale (POTS; Thompson, Cattarin, Fowler, & Fisher, 1995) is an 11-item measure of teasing and its effect. This measure has two subscales: general weight teasing and competency teasing; however, we only analyzed the weight-based teasing subscale in this study. Participants rate teasing frequency on a 5-point scale of never to very often, for example, “People made jokes about you being heavy.” High scores on this subscale are indicative of a greater frequency of weight-related teasing. Score reliability in the original study was .94 for general weight teasing. In the current study, Cronbach’s alpha was .94.

Statistical Analyses

Data analyses were performed using SPSS Version 25 and ModGraph-I (Jose, 2013). In terms of missing data, we used the expectation-maximization (EM) method of data imputation (see Graham, 2009). There were two variables for which this strategy was not employed (due to those variables, the ChEAT and PANAS-C Scale, not passing preliminary Little’s Missing Completely at Random [MCAR] tests). Therefore, the majority of analyses were conducted with 146 participants (as most included the ChEAT), except the analyses including the PANAS-C, which were conducted with 133 participants. Descriptive statistics were calculated to determine the sample composition. A subsequent series of hierarchical multiple regressions was computed to test for moderator effects, with EP as the dependent variable. Each centered independent variable, each centered moderator variable, and the product of the centered independent and centered moderator variable were entered into these regression analyses. For tests of three-way interactions, all three two-way interactions were also included in the model. Interaction terms were centered before being entered into the regression equation in order to generate meaningful interpretations and to reduce the potential of multicollinearity between the interaction terms and their constituent parts (Aiken & West, 1991). The nature of each statistically significant interaction was examined using ModGraph-I, with high, medium, and low representing the effects at 1 SD above the mean, the mean, and 1 SD below the mean, respectively (Jose, 2013).

Results

Descriptive Analyses

Body mass index (BMI) percentiles and z scores for age and sex were computed using the U.S. Centers for Disease Control BMI-for-age growth charts (www.cdc.gov/growthcharts) as a similar index has not been developed for New Zealand children. In terms of weight, no participants were underweight (<5th percentile), 73.5% were in the normal weight range (5th percentile to <85th percentile), 16.0% were at risk for overweight (85th to <95th percentile), and 10.1% were overweight (95th percentile or greater) (Barlow & Dietz, 1998). The participants had a mean BMI of 19.7 kg/m² (SD = 3.51), indicating a healthy average height to weight ratio. However, it is important to note that deviation from expected body weight, through looking at age- and gender-adjusted BMI percentiles, is more appropriate than BMI for this age group, given that they are still growing (Le Grange et al., 2012). The ethnic composition of the sample was 84.0% New Zealand European, 11% New Zealand Māori, 6% Asian, 2% Pacific Island, and 1% Other. In addition, mean SES was 3.30, close to the median of the scale. Participants’ households were represented in each of the six SES groups and at rates comparable with those found in the New Zealand population (Davis et al., 1997).

Table 1 presents the participants’ means and standard deviations for each of the measures. Mean scores on all the measures were similar to the norms that have been reported for the respective tests in nonclinical preadolescent samples (Donovan, Spence, & Sheffield, 2006; Hayden-Wade et al., 2005; Joiner et al., 1996; Maloney et al., 1988; Martin & Huebner, 2007; McVey, Pepler, Davis, Flett, & Abdolell, 2002; Smolak & Levine, 1994; Wood et al., 1996). Although individuals generally reported low levels of EP $(\bar{X} = 10.03)$ , 28 participants (12.3%) had scores exceeding the criterion of 20 on the ChEAT, indicative of EP (Maloney, McGuire, Daniels, & Specker, 1989; Maloney et al., 1988). In the ChEAT development study, Maloney and colleagues (1988) found 9.5% of 11-year-old girls exceeded this cutoff score.

Table 1.

Intercorrelations, Cronbach’s Alpha, Means and Standard Deviations for Each Measure.

	1	2	3	4	5	6	7	8	9	10
1. Eating pathology	.80	.43**	.64**	−.47**	.34**	.35**	.29**	.48**	.45**	.40**
2. Figure Drawings		N/A	.69**	−.33**	.05	.15*	.20**	.47**	.55**	.53**
3. Body dissatisfaction			.92	−.50**	.22	.23*	.39**	.70**	.62**	.63**
4. Self-esteem				.84	−.33**	−.08	−.41**	−.39**	−.34**	−.37**
5. Perfectionism-SP					.85	.44**	.32**	.22**	.23**	.29**
6. Perfectionism-SO						.83	.07	.18*	.30**	.12
7. Negative affect							.87	.34**	.26**	.32**
8. Weight teasing								.94	.49**	.68**
9. Media pressure									.88	.55**
10. Perceived pressure										.79
M	10.03	0.73	6.92	30.22	23.85	34.40	26.69	8.26	7.95	14.07
SD	7.95	1.08	6.78	4.92	7.77	8.29	8.72	4.40	3.93	5.32
Range	0-78	0-89	0-27	10-40	10-50	12-60	15-75	6-30	3-18	9-54

Note. The alphas for each measure are listed on the diagonal. Perfectionism-SP = socially prescribed perfectionism; perfectionism-SO = self-oriented perfectionism; perceived pressure = pressure to lose weight from significant others, including mother, father, best female friend, and best male friend.

p < .05. **p < .01.

Composite BD

Following the recommendations of Thompson (2004), we created a composite score for BD (using the Collins Figure Drawings and EDI-BD) to act as a cautionary measure to reduce multicollinearity of the regression analysis and because these two variables were essentially measuring two aspects of the same construct. This composite score was calculated by entering the EDI-BD items and the Figure Drawings discrepancy score into a principal component analysis (PCA). The Kaiser-Meyer-Olkin was .92, demonstrating that these data were suitable for factor analysis (Kaiser, 1974). As expected, in the PCA, there was one component with an eigenvalue of greater than 1.00 (eigenvalue = 6.25), which we retained, and this accounted for 62.46% of the variance. We calculated this composite variable by using the regression method and this was used in the remainder of the analyses.

Interactions Between Potential Moderator Variables and BD

Three-way analysis with perfectionism, self-esteem, and BD

Regression results for each moderation analysis are depicted in Table 2. A three-way interaction between BD, perfectionism (SO and SP but tested separately), and self-esteem was tested, using EP as the dependent variable. When SO perfectionism was entered, the three-way interaction was also not statistically significant, β = .01, t(138) = .06, p = .96. When SP perfectionism was entered, the interaction effect was not statistically significant, β = −.14, t(138) = −.62, p = .54.

Table 2.

Summary of Moderator Effects on Eating Pathology From Regression Analyses.

Predictor	ΔR²	B	SE B	β
Body dissatisfaction	.34	4.91	.57	.58**
SO perfectionism	.06	1.92	.52	.24**
Self-esteem	.05	−2.14	.60	−.26**
Body dissatisfaction × SO perfectionism	.03	1.14	.42	.17**
Body dissatisfaction × Self-esteem	.01	−0.98	.55	−.12
Self-esteem × SO perfectionism	<.01	0.08	.45	.01
SO perfectionism × Body dissatisfaction × Self-esteem	<.01	0.03	.48	.01
Body dissatisfaction	.34	4.91	.57	.58**
SP perfectionism	.08	2.25	.52	.28**
Self-esteem	.02	−1.27	.63	−.16*
Body dissatisfaction × SP perfectionism	.03	1.58	.55	.18**
Body dissatisfaction × Self-esteem	.02	−1.29	.55	−.16*
Self-esteem × SP perfectionism	<.01	−0.19	.51	−.03
SP perfectionism × Body dissatisfaction × Self-esteem	<.01	−0.88	.54	−.14
Body dissatisfaction	.34	4.91	.57	.58**
SO perfectionism	.06	1.92	.52	.24**
SO perfectionism × Body dissatisfaction	.03	1.12	.44	.17**
Body dissatisfaction	.34	4.91	.57	.58**
SP perfectionism	.08	2.25	.52	.28**
SP perfectionism × Body dissatisfaction	.03	1.52	.55	.17**
Body dissatisfaction	.34	4.91	.57	.58**
Media pressure	.02	1.29	.68	.16
Media pressure × Body dissatisfaction	.03	1.42	.53	.20**
Body dissatisfaction	.34	4.91	.57	.58**
Self-esteem	.04	−1.91	.63	−.23**
Self-esteem × Body dissatisfaction	.02	−1.30	.58	−.16*
Body dissatisfaction	.35	4.98	.60	.59**
Negative affect	.01	0.81	.58	.10
Negative affect × Body dissatisfaction	.01	−0.98	.58	−.13
Body dissatisfaction	.34	4.91	.57	.58**
Perceived pressure	<.01	0.50	.71	.06
Perceived pressure × Body dissatisfaction	<.01	−0.05	.40	−.01
Body dissatisfaction	.34	4.91	.57	.58**
Weight teasing	.02	1.69	.73	.20*
Weight teasing × Body dissatisfaction	.01	−0.59	.51	−.13

Note. Tests reported are based on sequential sums of squares. The moderator analysis using negative affect has a smaller sample size, hence different regression coefficients for BD. SO = self-oriented; SP = socially prescribed; BD = body dissatisfaction.

p < .05. **p < .01.

Two-way analysis with perfectionism and BD

The interaction between SO perfectionism and BD was statistically significant, β = .17, t(142) = 2.58, p = .01. As can be seen in Figure 1, at high levels of SO perfectionism, there was a greater effect of BD on EP. The interaction between SP perfectionism and BD was also statistically significant, β = .17, t(142) = 2.76, p = .01. As can be seen in Figure 2, when an individual had high SP perfectionism, the relationship between BD and EP was greater.

Figure 1.

Moderator effect of SO perfectionism in predicting eating pathology from BD.

Figure 2.

Moderator effect of SP perfectionism in predicting eating pathology from BD.

Two-way analysis with media pressure and BD

The interaction between BD and perceived pressure from the media to lose weight was statistically significant, β = .20, t(141) = 2.69, p = .01. Figure 3 depicts this interaction effect and suggests that the relationship between BD and EP was more pronounced for those who reported having experienced high levels of media pressure.

Figure 3.

Moderator effect of media pressure in predicting eating pathology from BD.

Two-way analysis with self-esteem and BD

Self-esteem also moderated the relationship between BD and EP at a statistically significant level, β = −.16, t(142) = −2.25, p = .03. Figure 4 depicts this interaction and suggests that the effect of BD on EP. EP was greater for those with low self-esteem.

Figure 4.

Moderator effect of self-esteem in predicting eating pathology from BD.

There were no statistically significant interactions for the effect of negative affect, β = −.13, t(130) = −1.69, p = .09; perceived pressure from others, β = −.01, t(143) = −1.18, p = .91; or teasing, β = −.13, t(142) = −1.15, p = .25, upon the relationship between BD and EP relationship (see Table 2).

Discussion

In the current study, we found that perfectionism (both SO and SP), self-esteem, and media pressure each moderated the association between BD and EP among preadolescent girls. Consistent with the research with adolescents (Shaw et al., 2004), we did not find statistically significant three-way interactions involving perfectionism, self-esteem, and BD. However, we used EP rather than bulimic pathology as the criterion variable, so the tests were not identical. Although we did not predict that there would be a three-way moderator effect, and despite this relationship not being replicated with adolescents, it is prudent to examine this relationship, given that BD, self-esteem, and perfectionism are independently related to increased EP in preadolescents.

At high levels of SP and SO perfectionism, BD had a greater effect on EP than at lower levels of perfectionism. This is similar to the findings of Boone and colleagues (2014) who reported that, with adolescents, perfectionism moderated the relationship between BD and shape and weight concerns and drive for thinness. Preadolescent girls who have low levels of perfectionism may be protected from EP, as although dissatisfied with their bodies, they may dismiss their dissatisfaction more easily and not engage in the unrelenting pursuit of unhealthy or extreme weight loss behaviors. Moreover, their standards may be more malleable than those who are more perfectionistic. Although the role of perfectionism in increasing the likelihood of EP is well established (Wade, O’Shea, & Shafran, 2016), given these data were cross-sectional, it could be possible that EP increases perfectionism, especially if an individual is underweight. Further longitudinal research is needed to clarify the relationship between perfectionism and EP and the potential importance of addressing perfectionism as a target of prevention in preadolescents. As mentioned, other researchers have studied the factor structure of the CAPS and found different structures (e.g., three- or four-factor models). However, we used the scale as originally developed, given we found good score reliability and these studies had participants of varying ages and ethnicity, which may not be directly comparable with the current sample (O’Connor et al., 2009).

Self-esteem also moderated the BD to EP pathway. This finding extends that of Button and colleagues (1996), where preadolescent girls with low self-esteem were at significantly greater risk of developing EP. It is possible that body-dissatisfied girls with low self-esteem may cease to acknowledge their other positive attributes and may instead believe that engaging in pathological eating behaviors to lose weight will enhance their self-worth. In other words, if a girl is specifically dissatisfied with her body, self-esteem may play an important role in influencing the outcome of EP. However, these findings may be limited by a theoretical overlap between the constructs of self-esteem and body image in children (Shavelson et al., 1976). Furthermore, given these results are cross-sectional, it is possible that preadolescent girls with high levels of EP could be less confident or self-conscious due to their eating problems and its impact on their interpersonal and emotional functioning.

Surprisingly, high levels of perceived pressure to lose weight from the media, but not other sources, also moderated the pathway between BD and EP. This finding highlights the potential exposure to the media in younger girls and, perhaps, the impact of social media, which might make these messages more quickly transmitted and readily accessed. This moderating effect extends our current understanding of the impact of the media on preadolescent girls (Field et al., 1999; Harrison & Hefner, 2006). Among girls who perceive this pressure, the media may not only encourage girls to change their shape and weight, but may also teach and model strategies for doing so, including unhealthy weight control practices and unhelpful social media connections. Indeed, the effect of the increasing anti-obesity message in the media that is reinforcing the importance of weight control in young people is not completely known (Striegel-Moore & Bulik, 2007). It may also be possible that preadolescent girls who endorse high levels of BD seek out distorted media images and thus have greater exposure to media (Polivy & Herman, 2002; Stice, Schupak-Neuberg, Shaw, & Stein, 1994). Low levels of perceived media pressure may buffer preadolescent girls from developing EP because, although dissatisfied, they may be protected from the same societal pressure to lose weight and have a greater ability to discriminate unhelpful and unrealistic media messages. Effective dissonance-based prevention programs have helped girls develop and hone this ability, resulting in reduced EP (Stice, Rohde, Shaw, & Gau, 2011). Given the cross-sectional nature of these data, it could be possible that girls who engage in pathological eating attitudes and behaviors may seek out these media messages or be more sensitive to media pressure.

Weight-related teasing and perceived pressure from others did not statistically moderate the relationship between BD and EP. Although we expected weight-related teasing or pressure from others to strengthen the relationship between BD and EP, these factors may be more important in the development of BD rather than interacting with BD to increase the likelihood of EP. It may also be possible that using a collapsed variable for perceived pressure containing items measuring pressure from father, mother, and friends, could explain why a significant effect was not found. As expected, negative affect was not associated with a significantly increased effect of BD upon EP. That negative affect was not predictive of EP among preadolescent girls is consistent with other research (Saling et al., 2005). One possible reason for this finding may be that negative affect is only related to negative body and eating attitudes as opposed to EP (Evans et al., 2013; McCabe & Ricciardelli, 2003a). Moreover, children may not yet perceive unhealthy weight control behaviors or weight loss as a means of offsetting a negative mood (Saling et al., 2005) or may have alternative ways of managing their mood states.

The current study indicated that rates of EP in this sample of New Zealand preadolescent girls were similar to those found in Australia, North America, and the United Kingdom. This similarity was expected, given the pervasiveness, and conjectured influence, of sociocultural norms and the mass media in New Zealand. This study was the first to examine EP among New Zealand preadolescent girls and the frequency of known risk factors for EP among New Zealand preadolescent girls.

There were some limitations to this study. The cross-sectional design limits the causal inferences that can be made from this research as causal links are best established through longitudinal analysis or experimental research. Moreover, there may be unmeasured variables that explain the relationships found in this study. Another limitation of this study was the reliance on self-report data. Although the questionnaires were valid and age appropriate, some children may not have responded openly or paid attention to the questionnaires. To reduce this likelihood, participants were informed of confidentiality throughout this study and reminded to read every question carefully. This study did not employ random selection of schools because it required principals’ consent. Although effort was given to recruit children from a wide range of socioeconomic areas, consenting schools were from moderate to high socioeconomic areas. Moreover, because of the age of the sample, some girls may have undergone pubertal onset and some may have not. Considering pubertal onset is important because during this high-risk time girls are more likely to experience negative body image and BD due to the physical changes in their body (Brooks-Gunn, 1987; Cotrufo, Cella, Cremato, & Labella, 2007; Fairburn, Cooper, Doll, & Welch, 1999).

Despite these limitations, these findings contribute some useful research leads regarding factors that could be targeted among preadolescent girls at risk of developing EP. The age group studied is a formative time for a girl, with both BD and EP increasing in incidence, and in light of early EP often being a predictor of later EP. Researchers have recommended that prevention programs are most effective when they are focused on reducing established risk factors, targeting those with higher EP, and when implemented at a younger age (McVey & Davis, 2002; Stice & Shaw, 2004). If corroborated by longitudinal research, targeting perfectionism, self-esteem, and media pressure, among those with high BD, could be an important intervention strategy. Providing girls at high risk of EP the opportunity to engage in prevention programs that specifically address these factors could help interrupt the chain of events that may lead to EP. Given that girls as young as 5 years are aware of the societal standard of thinness and the acceptance of dieting as a weight control strategy (Lowes & Tiggemann, 2003), research should further examine the current risk factors and other potential moderating factors in even younger children.

Footnotes

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by a University of Canterbury Doctoral Scholarship to the first author.

ORCID iD

Juliet K. Rosewall

Notes

Author Biographies

Juliet K. Rosewall, PhD, is a senior clinical psychologist at the Child and Adolescent Eating Disorder Service, South London and Maudsley NHS Foundation Trust. She received her PhD from the University of Canterbury, New Zealand. Her research interests are in eating disorders and body image.

David H. Gleaves, PhD, is a professor of psychology (Clinical) in the School of Psychology, Social Work, and Social Policy at the University of South Australia. His research interests are in the areas of eating disorders, body image, and dissociation.

Janet D. Latner, PhD, is a professor of psychology at the University of Hawaii at Manoa. Her research interests are in eating disorders, obesity, and weight stigma.

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