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Prospective changes in disordered eating and body dissatisfaction across women's first year of college: The relative contributions of sociocultural and college adjustment risk factors
Eating Behaviors 36 (2020) 101357
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Eating Behaviors journal homepage: www.elsevier.com/locate/eatbeh
Prospective changes in disordered eating and body dissatisfaction across women's first year of college: The relative contributions of sociocultural and college adjustment risk factors Lindsay M. Howarda, Kelly A. Romanoa, Kristin E. Herona,b, a b
T
⁎
The Virginia Consortium Program in Clinical Psychology, 555 Park Avenue, Norfolk, VA 23504, USA Old Dominion University, 250 Mills Godwin Building, Norfolk, VA 23529, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Eating behavior Risk factors Body image women's health Female undergraduates
Sociocultural models have consistently been used to explain the etiology of disordered eating (DE) and body dissatisfaction (BD) among female college students, but less is known about how college adjustment factors, such as missing friends from home and stress about academic performance, relate to the progression of female students' DE and BD during the transition into college. The present study examined changes in DE thoughts and BD during the first year of college by merging the college adjustment and DE fields to evaluate the comparative impact of the two areas of research. Female undergraduates (N = 119) reported on DE risk factors, college adjustment factors, DE thoughts, and BD during their first (Time 1) and second (Time 2) semesters of college. Hierarchical regressions controlling for Time 1 outcome variables found that perceived stress at Time 1 enhanced the prediction of increases in DE severity beyond DE risk factors alone, suggesting that efforts targeted at making the transition to college easier may assist in decreasing DE severity for young women.
Disordered eating (DE) attitudes (e.g., thoughts about binge eating, dietary restriction) and body dissatisfaction (BD; i.e., unhappiness with body shape or size) are common among female college students and commonly persist across the postsecondary years (Berg, Frazier, & Sherr, 2009; Dakanalis et al., 2017; Duarte, Ferreira, Trindade, & PintoGouveia, 2015). Recent multi-institute data suggest that 17% of female college students have elevated DE-risk and 31–49% binge eat or use compensatory behaviors (Lipson & Sonneville, 2017). Further, BD affects nearly 80% of college women and serves as a well-established risk factor of DE pathology (Mond et al., 2013; Stice, Marti, & Durant, 2011). Of note, the transition into college is an at-risk period wherein DE and BD may worsen due, in part, to traditional college students falling within the median age of eating disorder onset (Hudson, Hiripi, Pope, & Kessler, 2007). Yet, how factors specific to transitioning into college and established DE and BD risk factors converge to, or differentially, influence the progression of DE and BD across the first year of college has not been duly assessed. Sociocultural models have consistently been used to explain the etiology of DE and BD among female college students (FitzsimmonsCraft, 2011). For example, the Tripartite Influence Model posits that DE and BD-risk is conferred from family, peer, and media pressures to attain, and individuals' internalization of, culturally sanctioned
⁎
appearance ideals. The internalization of pressures to conform to these ideals increases BD and, subsequently, DE (Fitzsimmons-Craft, 2011). These sociocultural tenets (i.e., external pressures to attain appearance ideals, appearance ideal internalization, BD) are supported as risk factors in cross-sectional and experimental studies (Ata, Schaefer, & Thompson, 2015; Johnson, Edwards, & Gidycz, 2015) and, to a lesser degree, prospective studies (Berg et al., 2009; Dakanalis et al., 2017). For example, females at an Italian university were assessed for DE severity during their first year, and at nine-month and four-year followups. Baseline levels of DE risk factors—including heightened thin-ideal internalization—predicted increases in DE at both follow-ups (Dakanalis et al., 2017). Although this and previous research supports the role of sociocultural risk factors in the etiology of DE and BD across females' college years, it is unknown whether college adjustment factors confer added risk. As a formative developmental period, the transition into college is stressful, given the novel demands placed upon students that warrant psychosocial adjustment. Significant changes in an individual's environment during the college years, including living away from home and increased social comparisons with peers, may result in students engaging in risky behaviors (e.g., substance abuse, high risk sexual behaviors) and experiencing psychological distress (e.g., anxiety,
Corresponding author at: Old Dominion University, 250 Mills Godwin Building, Norfolk, VA 23529, USA. E-mail address: [email protected] (K.E. Heron).
https://doi.org/10.1016/j.eatbeh.2019.101357 Received 2 March 2019; Received in revised form 19 November 2019; Accepted 20 November 2019 Available online 21 November 2019 1471-0153/ © 2019 Elsevier Ltd. All rights reserved.
Eating Behaviors 36 (2020) 101357
L.M. Howard, et al.
dietary restraint (possible range: 0–6; observed range: 0–4.7). Items are endorsed on a 7-point response scale (0 = no days, 6 = every day). Cronbach's α for the current sample for the global score was 0.89 at T1 and 0.90 at T2.
depression; Ebert et al., 2018). Little is known, however, about how general college adjustment factors, such as missing friends from home and stress about academic performance, relate to the progression of female students' DE and BD during the transition into college. In one of the few studies on this topic, college females (53% freshmen) were assessed twice, two months apart. The authors found that an increase in BD was associated with increased DE behaviors, but a change in academic stress (a college adjustment factor) was not related to this change (Berg et al., 2009). Also, although not measured prospectively, other college adjustment factors, such as general stress (James et al., 2016) and social support (Barker & Galambos, 2007; Howard, Haislip, Heron, & Hu, 2019; Wonderlich-Tierney & Vander Wal, 2010), have been associated with college students' DE attitudes and BD. Heightened stress has been linked to binge eating severity among female college students and has been shown to induce body image concerns (Naumann, Svaldi, Wyschka, Heinrichs, & von Dawans, 2018; Sulkowski, Dempsey, & Dempsey, 2011). In addition to stress, other general college adjustmentrelated factors such as living away from home, poorer perceived social adjustment to college, and lower social support have been associated with DE and BD (Barker & Galambos, 2007; Howard et al., 2019; Wonderlich-Tierney & Vander Wal, 2010). To extend this research, the current study merges the college adjustment and DE fields to evaluate the comparative impact of sociocultural risk factors and college adjustment factors on prospective changes in female college students' DE and BD severity.
1.2.2. Body Shape Questionnaire (BSQ-16; Evans & Dolan, 1993) The BSQ-16 is a 16-item measure of body dissatisfaction that uses a 6-point response scale (1 = never, 6 = always). Total scores range from 16 to 96, with the full range being observed in this sample. Cronbach's α for the current sample was 0.97 at both time points. 1.2.3. Sociocultural Attitudes Towards Appearance Questionnaire (SATAQ4; Schaefer et al., 2015) The SATAQ-4 is a 22-item measure of societal and interpersonal norms, and appearance-related pressures. Items are rated on a 5-point response scale (1 = definitely disagree, 5 = definitely agree). This scale contains 5 subscales: thin-ideal internalization, muscular-ideal internalization, family pressure, media pressure, and peer pressure. The present study used the thin-ideal internalization (possible range: 5–25; observed range: 5–25) and the peer pressure subscales (possible range: 4–20; observed range: 4–20). The decision to use these two subscales were made for the following reasons: (1) In the United States, the most commonly sanctioned standard of attractiveness has historically been the thin-ideal (Thompson & Stice, 2001); (2) It is hypothesized that the role of social pressures is greater during this time period due to heightened peer influence, particularly because college marks a transition to adulthood wherein peers become more important sources of influence (Duarte et al., 2015); and (3) Given constraints due to sample size, we wanted to limit the number of predictors and present the most parsimonious model. Cronbach's α for the current sample was 0.87 for internalization and 0.94 for peer pressures at T1.
1. Method 1.1. Procedure and participants Following Institutional Review Board approval, first semester female students aged 18 and older attending a university in the MidAtlantic US were recruited from undergraduate psychology courses over the course of two academic years. After providing informed consent, 444 women completed an online survey in the fall of their first year (Time 1; T1) for course credit through a web-based research system. Of these 444 respondents, 360 provided email addresses and were contacted in the spring of the same year (Time 2; T2), and, 199 completed the follow-up survey. In order to match participants' responses at T1 and T2, they were asked to create a unique personal identification number that was used to link their assessments at both time points. Although participants were provided with an example of how to create their identification numbers that consisted of phone number and birth year (e.g., if Jane Smith's phone number is 757-5550667 and she was born in 1998, her Personal ID would be 06671998), many had difficulty doing so and did not provide matching identification numbers, and thus, we were unable to use their data. In total, we had T1 and T2 data for 119 women. There were no significant differences (ps > 0.05) among T1 demographic and predictor variables between individuals who completed both T1 and T2 measures and those who only completed T1. Respondents who completed the spring survey (T2) received $10 gift cards. The 119 first year female students who comprise the analytic sample were, on average, 19.46 years old (SD = 1.06). Similar numbers of participants identified as White (52.2%) and Black (40.3%), with the remaining respondents endorsing Asian (5%) and “other” (2.5%) racial identities. The average body mass index was 23.41 (SD = 5.72) at T1 and 23.72 (SD = 6.10) at T2.
1.2.4. Perceived Stress Scale (PSS-10; Cohen, Kamarck, & Mermelstein, 1983) The PSS-10 assesses the degree to which individuals appraise situations in their lives as stressful. Items are scored on a 5-point response scale (0 = never, 4 = very often). The PSS-10 includes a total score that ranges from 0 to 40, the observed range for this sample was 2 to 37. Cronbach's α for the current sample was 0.79 at T1. 1.2.5. College Adjustment Test (CAT; Pennebaker, Colder, & Sharp, 1990) The CAT is a 19-item measure of coping in relation to first year college adjustment. Items are scored on a 7-point response scale (1 = not at all, 7 = a great deal). Higher total scores reflect better adjustment (possible range: 19 to 123; observed range: 35 to 123). Cronbach's α for the current sample was 0.78 at T1. 1.2.6. Social Support Appraisals Scale (SS-A; Vaux et al., 1986) The SS-A is a 23-item measure of individuals' appraisals of perceived social support. Items are scored on a 5-point response scale (1 = strongly disagree, 4 = strongly agree), with higher scores suggesting higher appraisals of social support (possible range: 23–115; observed range: 38 to 95). Cronbach's α for the current sample was 0.93 at T1. 1.3. Data analyses Expectation maximization was used to handle missing data (< 5% across the variables of interest). After ensuring that all assumptions were met, two hierarchical regression analyses were conducted with T2 DE severity and BD as outcomes in separate models. T1 DE risk factors (thin-ideal internalization, peer pressure to conform to appearance ideals) and T1 college transition factors (overall college adjustment, perceived stress, social support) were sequentially entered in two steps, while baseline (T1) levels of the respective outcomes were controlled for in Step 1 (e.g., T1 DE severity in the model predicting T2 DE severity), allowing the researchers to examine whether T1 variables
1.2. Measures 1.2.1. Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994) The EDE-Q assesses the severity of DE thoughts and behaviors, and contains a global (total) score as well as subscale scores capturing individuals' weight concerns, shape concerns, eating concerns, and 2
Eating Behaviors 36 (2020) 101357
L.M. Howard, et al.
Table 1 Means, standard deviations, and zero-order correlations among study variables. Variable
M
SD
1
2
3
4
5
6
7
8
9
1. 2. 3. 4. 5. 6. 7. 8. 9.
1.51 1.54 38.29 37.40 14.82 6.45 19.09 74.69 71.72
1.19 1.21 19.89 20.90 13.81 3.83 5.94 15.80 10.41
1 0.77⁎⁎⁎ 0.84⁎⁎⁎ 0.74⁎⁎⁎ 0.58⁎⁎⁎ 0.50⁎⁎⁎ 0.34⁎⁎⁎ −0.47⁎⁎⁎ −0.41⁎⁎⁎
1 0.77⁎⁎⁎ 0.89⁎⁎⁎ 0.56⁎⁎⁎ 0.58⁎⁎⁎ 0.38⁎⁎⁎ −0.39⁎⁎⁎ −0.29⁎⁎
1 0.87⁎⁎⁎ 0.58⁎⁎⁎ 0.64⁎⁎⁎ 0.33⁎⁎⁎ −0.48⁎⁎⁎ −0.31⁎⁎
1 0.52⁎⁎⁎ 0.64⁎⁎⁎ 0.36⁎⁎⁎ −0.44⁎⁎⁎ −0.36⁎⁎⁎
1 0.42⁎⁎⁎ 0.17 0.29⁎⁎ −0.13
1 0.26⁎⁎ −0.27⁎⁎ −0.21⁎
1 −0.61⁎⁎⁎ −0.33⁎⁎
1 0.35⁎⁎⁎
1
EDE-Q T1 EDE-Q T2 BSQ-16 T1 BSQ-16 T2 Thin Intern. T1 Peer Pressure T1 PSS T1 CAT T1 SS-A T1
Note. EDE-Q = Eating Disorder Examination Questionnaire; BSQ-16 = Body Shape Questionnaire; Thin Intern. = Thin ideal internalization (SATAQ-4 subscale); Peer Pressure = Pressure from peers to conform to appearance ideal (SATAQ-4 subscale); PSS = Perceived Stress Scale; CAT = College Adjustment Test; SSA = Social Support Appraisals Scale. ⁎ p < .05. ⁎⁎ p < .01. ⁎⁎⁎ p < .001.
3. Discussion
predicted T2 outcomes. The variance inflation factor (VIF) was < 5 across the models, suggesting that multicollinearity was not an issue (Ringle, Wende, & Becker, 2015). Results of a post-hoc power analysis determined that 96 participants would be needed to detect medium effects with five predictors in a within-person hierarchical regression analysis.
Although a growing literature has evaluated prospective associations between sociocultural DE risk factors and changes in female college students' DE thoughts and BD (Berg et al., 2009; Dakanalis et al., 2017), little is known about whether factors associated with the college transition confer added explanatory power in predicting DE and BD change across students' first year. In the present study, peer pressure to attain the appearance ideal (i.e., a sociocultural DE risk factor) and elevated stress (i.e., a college adjustment factor) experienced during females' first semesters of college were both associated with elevated DE severity during their second semesters. Peer pressure to attain the appearance ideal was the only significant predictor in the BD model. These preliminary results suggest that it may be useful for health professionals to design and test the efficacy of prevention efforts that concomitantly target conventional DE risk factors and those associated with the college transition to mitigate worsening DE. As described previously, sociocultural DE models suggest that pressures to attain, and subsequent internalization of, culturally sanctioned appearance ideals are associated with elevated body dissatisfaction and, in turn, DE risk (Fitzsimmons-Craft, 2011). The present results suggest that peer pressure to attain the appearance ideal early in college predicts more severe DE symptoms and BD over females' first year of college. Thus, it may be beneficial for health professionals
2. Results Descriptive statistics and correlations between study variables are reported in Table 1. As shown in Table 2, sociocultural DE risk factors (Step 2) accounted for 6% (p < .001) and 2% (p = .03) of the variance in DE and BD at T2, respectively, after controlling for DE and BD at T1. Adjustment factors accounted for an additional 2% of the variance in DE change (p = .05) and 1% of the variance in BD change (p > .05; Step 3). Specifically, higher levels of T1 peer pressure to attain the appearance ideal and higher levels of T1 perceived stress were associated with more severe in DE at T2. Elevated T1 peer pressure to attain the appearance ideal was the only significant predictor of higher T2 BD. No other individual sociocultural or college adjustment factors were associated with DE or BD changes over this time period.
Table 2 Hierarchical regression analysis of predictors of Time 2 disordered eating and body dissatisfaction. Disordered eating
Step 1: Baseline Disordered Eating Time 1 Body Dissatisfaction Time 1 Step 2: ED-Specific Risk Factors Disordered Eating Time 1 Body Dissatisfaction Time 1 Thin Internalization Time 1 Peer Pressure Time 1 Step 3: College Adjustment Factors Disordered Eating Time 1 Body Dissatisfaction Time 1 Thin Internalization Time 1 Peer Pressure Time 1 Perceived Stress Time 1 College Adjustment Time 1 Social Support Time 1
Body dissatisfaction
B
SE B
β
0.79 –
0.06 –
0.77⁎⁎⁎ –
R2 Adj
ΔR2
0.59
–
– 0.64
0.07 – 0.02 0.02
0.58 – 0.12 0.24⁎⁎⁎
0.59 – 0.03 0.07 0.03 0.01 0.01
0.08 – 0.02 0.02 0.01 0.01 0.01
0.58⁎⁎⁎ – 0.12 0.22⁎⁎ 0.16⁎ 0.06 0.04
–
0.65 –
⁎
p < .05. p < .01. ⁎⁎⁎ p < .001. ⁎⁎
3
SE B
β
– 0.91
– 0.05
– 0.87⁎⁎⁎
– 0.80 0.07 0.84
– 0.07 0.22 0.32
– 0.76⁎⁎⁎ 0.02 0.15⁎
– 0.76 0.11 0.78 0.25 0.05 −0.19
– 0.07 0.21 0.32 0.20 0.08 0.10
– 0.72⁎⁎⁎ 0.03 0.14⁎ 0.07 0.04 −0.10
0.06⁎⁎⁎
⁎⁎⁎
0.59 – 0.03 0.08
B
0.02
R2 Adj
ΔR2
0.75 –
–
0.77 –
0.02⁎
0.78 –
0.01
Eating Behaviors 36 (2020) 101357
L.M. Howard, et al.
Acknowledgement
working with female college students to incorporate empirically supported dissonance-based interventions into existing preventative mental health services. For example, interventions such as the Body Project have been shown to decrease BD and related DE risk factors among college females by encouraging participants to challenge the appearance ideal (Becker & Stice, 2017). Although the Body Project has demonstrated efficacy, its reach is still in its infancy, making it important to increase efforts to engage undergraduate women during this at-risk period. Further, the present study extends previous work by demonstrating that elevated perceived stress at the beginning of females' transition into college was prospectively associated with elevated DE severity later in their first year, beyond the influence of established sociocultural DE risk factors. Of note, it is possible that students who experience difficulties transitioning into college may engage in DE as a way of coping with stress. This is consistent with prevailing theories that suggest DE behaviors provide an emotion regulation function, wherein DE behaviors help distract from or mitigate negative affect in the shortterm (Lavender et al., 2015). Interventions designed to reduce stress and provide college students with adaptive coping skills (e.g., relaxation training) may reduce DE severity on college campuses.
This study was funded in part by a grant from the Old Dominion University Office of Research awarded to Kristin E. Heron. References Ata, R. N., Schaefer, L. M., & Thompson, J. K. (2015). Sociocultural theories of eating disorders. In L. Smolak, & M. P. Levine (Eds.). The Wiley handbook of eating disorders (pp. 269–282). Hoboken, NJ: John Wiley & Sons. Barker, E. T., & Galambos, N. L. (2007). Body dissatisfaction, living away from parents, and poor social adjustment predict binge eating symptoms in young women making the transition to university. Journal of Youth and Adolescence, 36, 904–911. https:// doi.org/10.1007/s10964-006-9134-6. Becker, C. B., & Stice, E. (2017). From efficacy to effectiveness to broad implementation: Evolution of the body project. Journal of Consulting and Clinical Psychology, 85, 767–782. https://doi.org/10.1037/ccp0000204. Berg, K. C., Frazier, P., & Sherr, L. (2009). 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3.1. Limitations Although strengths of this preliminary study include its prospective design and the use of a racially diverse sample of female students, some limitations are noted. Perhaps most notably, there was high attrition for participants providing data at both T1 and T2, with 27% of women completing T1 also completing T2. However, participants who did not complete the T2 assessment did not differ on any of the assessed T1 variables from those who did, suggesting that data were missing at random. The all-female sample also limits generalizability. Future research using a gender-diverse sample is needed to gain a better understanding of associations between sociocultural DE risk factors and college adjustment factors, relative to changes in DE and BD.
3.2. Conclusions The present research suggests that stress associated with the college transition may enhance the prediction of changes in DE but not BD across female college students' first year, beyond the influence of sociocultural DE risk factors. Sociocultural DE risk factors should continue to be central treatment targets in prevailing DE and BD prevention programs (Menzel et al., 2010). By extending the present results, future research may identify additional treatment targets, such as factors that assist in smoothing the college transition, for DE programs, which can subsequently be tested within the context of existing or new DE prevention models.
CRediT authorship contribution statement Lindsay M. Howard: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Visualization, Writing - original draft, Writing - review & editing. Kelly A. Romano: Writing - original draft, Writing - review & editing, Formal analysis. Kristin E. Heron: Conceptualization, Methodology, Resources, Writing - original draft, Writing - review & editing, Supervision, Funding acquisition.
Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. 4
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Vaux, A., Phillips, J., Holly, L., Thomson, B., Williams, D., & Stewart, D. (1986). The social support appraisal scale: Studies of reliability and validity. American Journal of Community Psychology, 14, 195–218. Wonderlich-Tierney, A. L., & Vander Wal, J. S. (2010). The effects of social support and coping on the relationship between social anxiety and eating disorders. Eating Behaviors, 11, 85–91. https://doi.org/10.1016/j.eatbeh.2009.10.002.
Sulkowski, M. L., Dempsey, J., & Dempsey, A. G. (2011). Effects of stress and coping on binge eating in female college students. Eating Behaviors, 12, 188–191. https://doi. org/10.1016/j.eatbeh.2011.04.006. Thompson, K. J., & Stice, E. (2001). Thin-ideal internalization: Mounting evidence for a new risk factor for body-image disturbance and eating pathology. Current Directions in Psychological Science, 10, 181–183. https://doi.org/10.1111/1467-8721.00144.
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Contents lists available at ScienceDirect
Eating Behaviors journal homepage: www.elsevier.com/locate/eatbeh
Prospective changes in disordered eating and body dissatisfaction across women's first year of college: The relative contributions of sociocultural and college adjustment risk factors Lindsay M. Howarda, Kelly A. Romanoa, Kristin E. Herona,b, a b
T
⁎
The Virginia Consortium Program in Clinical Psychology, 555 Park Avenue, Norfolk, VA 23504, USA Old Dominion University, 250 Mills Godwin Building, Norfolk, VA 23529, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Eating behavior Risk factors Body image women's health Female undergraduates
Sociocultural models have consistently been used to explain the etiology of disordered eating (DE) and body dissatisfaction (BD) among female college students, but less is known about how college adjustment factors, such as missing friends from home and stress about academic performance, relate to the progression of female students' DE and BD during the transition into college. The present study examined changes in DE thoughts and BD during the first year of college by merging the college adjustment and DE fields to evaluate the comparative impact of the two areas of research. Female undergraduates (N = 119) reported on DE risk factors, college adjustment factors, DE thoughts, and BD during their first (Time 1) and second (Time 2) semesters of college. Hierarchical regressions controlling for Time 1 outcome variables found that perceived stress at Time 1 enhanced the prediction of increases in DE severity beyond DE risk factors alone, suggesting that efforts targeted at making the transition to college easier may assist in decreasing DE severity for young women.
Disordered eating (DE) attitudes (e.g., thoughts about binge eating, dietary restriction) and body dissatisfaction (BD; i.e., unhappiness with body shape or size) are common among female college students and commonly persist across the postsecondary years (Berg, Frazier, & Sherr, 2009; Dakanalis et al., 2017; Duarte, Ferreira, Trindade, & PintoGouveia, 2015). Recent multi-institute data suggest that 17% of female college students have elevated DE-risk and 31–49% binge eat or use compensatory behaviors (Lipson & Sonneville, 2017). Further, BD affects nearly 80% of college women and serves as a well-established risk factor of DE pathology (Mond et al., 2013; Stice, Marti, & Durant, 2011). Of note, the transition into college is an at-risk period wherein DE and BD may worsen due, in part, to traditional college students falling within the median age of eating disorder onset (Hudson, Hiripi, Pope, & Kessler, 2007). Yet, how factors specific to transitioning into college and established DE and BD risk factors converge to, or differentially, influence the progression of DE and BD across the first year of college has not been duly assessed. Sociocultural models have consistently been used to explain the etiology of DE and BD among female college students (FitzsimmonsCraft, 2011). For example, the Tripartite Influence Model posits that DE and BD-risk is conferred from family, peer, and media pressures to attain, and individuals' internalization of, culturally sanctioned
⁎
appearance ideals. The internalization of pressures to conform to these ideals increases BD and, subsequently, DE (Fitzsimmons-Craft, 2011). These sociocultural tenets (i.e., external pressures to attain appearance ideals, appearance ideal internalization, BD) are supported as risk factors in cross-sectional and experimental studies (Ata, Schaefer, & Thompson, 2015; Johnson, Edwards, & Gidycz, 2015) and, to a lesser degree, prospective studies (Berg et al., 2009; Dakanalis et al., 2017). For example, females at an Italian university were assessed for DE severity during their first year, and at nine-month and four-year followups. Baseline levels of DE risk factors—including heightened thin-ideal internalization—predicted increases in DE at both follow-ups (Dakanalis et al., 2017). Although this and previous research supports the role of sociocultural risk factors in the etiology of DE and BD across females' college years, it is unknown whether college adjustment factors confer added risk. As a formative developmental period, the transition into college is stressful, given the novel demands placed upon students that warrant psychosocial adjustment. Significant changes in an individual's environment during the college years, including living away from home and increased social comparisons with peers, may result in students engaging in risky behaviors (e.g., substance abuse, high risk sexual behaviors) and experiencing psychological distress (e.g., anxiety,
Corresponding author at: Old Dominion University, 250 Mills Godwin Building, Norfolk, VA 23529, USA. E-mail address: [email protected] (K.E. Heron).
https://doi.org/10.1016/j.eatbeh.2019.101357 Received 2 March 2019; Received in revised form 19 November 2019; Accepted 20 November 2019 Available online 21 November 2019 1471-0153/ © 2019 Elsevier Ltd. All rights reserved.
Eating Behaviors 36 (2020) 101357
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dietary restraint (possible range: 0–6; observed range: 0–4.7). Items are endorsed on a 7-point response scale (0 = no days, 6 = every day). Cronbach's α for the current sample for the global score was 0.89 at T1 and 0.90 at T2.
depression; Ebert et al., 2018). Little is known, however, about how general college adjustment factors, such as missing friends from home and stress about academic performance, relate to the progression of female students' DE and BD during the transition into college. In one of the few studies on this topic, college females (53% freshmen) were assessed twice, two months apart. The authors found that an increase in BD was associated with increased DE behaviors, but a change in academic stress (a college adjustment factor) was not related to this change (Berg et al., 2009). Also, although not measured prospectively, other college adjustment factors, such as general stress (James et al., 2016) and social support (Barker & Galambos, 2007; Howard, Haislip, Heron, & Hu, 2019; Wonderlich-Tierney & Vander Wal, 2010), have been associated with college students' DE attitudes and BD. Heightened stress has been linked to binge eating severity among female college students and has been shown to induce body image concerns (Naumann, Svaldi, Wyschka, Heinrichs, & von Dawans, 2018; Sulkowski, Dempsey, & Dempsey, 2011). In addition to stress, other general college adjustmentrelated factors such as living away from home, poorer perceived social adjustment to college, and lower social support have been associated with DE and BD (Barker & Galambos, 2007; Howard et al., 2019; Wonderlich-Tierney & Vander Wal, 2010). To extend this research, the current study merges the college adjustment and DE fields to evaluate the comparative impact of sociocultural risk factors and college adjustment factors on prospective changes in female college students' DE and BD severity.
1.2.2. Body Shape Questionnaire (BSQ-16; Evans & Dolan, 1993) The BSQ-16 is a 16-item measure of body dissatisfaction that uses a 6-point response scale (1 = never, 6 = always). Total scores range from 16 to 96, with the full range being observed in this sample. Cronbach's α for the current sample was 0.97 at both time points. 1.2.3. Sociocultural Attitudes Towards Appearance Questionnaire (SATAQ4; Schaefer et al., 2015) The SATAQ-4 is a 22-item measure of societal and interpersonal norms, and appearance-related pressures. Items are rated on a 5-point response scale (1 = definitely disagree, 5 = definitely agree). This scale contains 5 subscales: thin-ideal internalization, muscular-ideal internalization, family pressure, media pressure, and peer pressure. The present study used the thin-ideal internalization (possible range: 5–25; observed range: 5–25) and the peer pressure subscales (possible range: 4–20; observed range: 4–20). The decision to use these two subscales were made for the following reasons: (1) In the United States, the most commonly sanctioned standard of attractiveness has historically been the thin-ideal (Thompson & Stice, 2001); (2) It is hypothesized that the role of social pressures is greater during this time period due to heightened peer influence, particularly because college marks a transition to adulthood wherein peers become more important sources of influence (Duarte et al., 2015); and (3) Given constraints due to sample size, we wanted to limit the number of predictors and present the most parsimonious model. Cronbach's α for the current sample was 0.87 for internalization and 0.94 for peer pressures at T1.
1. Method 1.1. Procedure and participants Following Institutional Review Board approval, first semester female students aged 18 and older attending a university in the MidAtlantic US were recruited from undergraduate psychology courses over the course of two academic years. After providing informed consent, 444 women completed an online survey in the fall of their first year (Time 1; T1) for course credit through a web-based research system. Of these 444 respondents, 360 provided email addresses and were contacted in the spring of the same year (Time 2; T2), and, 199 completed the follow-up survey. In order to match participants' responses at T1 and T2, they were asked to create a unique personal identification number that was used to link their assessments at both time points. Although participants were provided with an example of how to create their identification numbers that consisted of phone number and birth year (e.g., if Jane Smith's phone number is 757-5550667 and she was born in 1998, her Personal ID would be 06671998), many had difficulty doing so and did not provide matching identification numbers, and thus, we were unable to use their data. In total, we had T1 and T2 data for 119 women. There were no significant differences (ps > 0.05) among T1 demographic and predictor variables between individuals who completed both T1 and T2 measures and those who only completed T1. Respondents who completed the spring survey (T2) received $10 gift cards. The 119 first year female students who comprise the analytic sample were, on average, 19.46 years old (SD = 1.06). Similar numbers of participants identified as White (52.2%) and Black (40.3%), with the remaining respondents endorsing Asian (5%) and “other” (2.5%) racial identities. The average body mass index was 23.41 (SD = 5.72) at T1 and 23.72 (SD = 6.10) at T2.
1.2.4. Perceived Stress Scale (PSS-10; Cohen, Kamarck, & Mermelstein, 1983) The PSS-10 assesses the degree to which individuals appraise situations in their lives as stressful. Items are scored on a 5-point response scale (0 = never, 4 = very often). The PSS-10 includes a total score that ranges from 0 to 40, the observed range for this sample was 2 to 37. Cronbach's α for the current sample was 0.79 at T1. 1.2.5. College Adjustment Test (CAT; Pennebaker, Colder, & Sharp, 1990) The CAT is a 19-item measure of coping in relation to first year college adjustment. Items are scored on a 7-point response scale (1 = not at all, 7 = a great deal). Higher total scores reflect better adjustment (possible range: 19 to 123; observed range: 35 to 123). Cronbach's α for the current sample was 0.78 at T1. 1.2.6. Social Support Appraisals Scale (SS-A; Vaux et al., 1986) The SS-A is a 23-item measure of individuals' appraisals of perceived social support. Items are scored on a 5-point response scale (1 = strongly disagree, 4 = strongly agree), with higher scores suggesting higher appraisals of social support (possible range: 23–115; observed range: 38 to 95). Cronbach's α for the current sample was 0.93 at T1. 1.3. Data analyses Expectation maximization was used to handle missing data (< 5% across the variables of interest). After ensuring that all assumptions were met, two hierarchical regression analyses were conducted with T2 DE severity and BD as outcomes in separate models. T1 DE risk factors (thin-ideal internalization, peer pressure to conform to appearance ideals) and T1 college transition factors (overall college adjustment, perceived stress, social support) were sequentially entered in two steps, while baseline (T1) levels of the respective outcomes were controlled for in Step 1 (e.g., T1 DE severity in the model predicting T2 DE severity), allowing the researchers to examine whether T1 variables
1.2. Measures 1.2.1. Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994) The EDE-Q assesses the severity of DE thoughts and behaviors, and contains a global (total) score as well as subscale scores capturing individuals' weight concerns, shape concerns, eating concerns, and 2
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Table 1 Means, standard deviations, and zero-order correlations among study variables. Variable
M
SD
1
2
3
4
5
6
7
8
9
1. 2. 3. 4. 5. 6. 7. 8. 9.
1.51 1.54 38.29 37.40 14.82 6.45 19.09 74.69 71.72
1.19 1.21 19.89 20.90 13.81 3.83 5.94 15.80 10.41
1 0.77⁎⁎⁎ 0.84⁎⁎⁎ 0.74⁎⁎⁎ 0.58⁎⁎⁎ 0.50⁎⁎⁎ 0.34⁎⁎⁎ −0.47⁎⁎⁎ −0.41⁎⁎⁎
1 0.77⁎⁎⁎ 0.89⁎⁎⁎ 0.56⁎⁎⁎ 0.58⁎⁎⁎ 0.38⁎⁎⁎ −0.39⁎⁎⁎ −0.29⁎⁎
1 0.87⁎⁎⁎ 0.58⁎⁎⁎ 0.64⁎⁎⁎ 0.33⁎⁎⁎ −0.48⁎⁎⁎ −0.31⁎⁎
1 0.52⁎⁎⁎ 0.64⁎⁎⁎ 0.36⁎⁎⁎ −0.44⁎⁎⁎ −0.36⁎⁎⁎
1 0.42⁎⁎⁎ 0.17 0.29⁎⁎ −0.13
1 0.26⁎⁎ −0.27⁎⁎ −0.21⁎
1 −0.61⁎⁎⁎ −0.33⁎⁎
1 0.35⁎⁎⁎
1
EDE-Q T1 EDE-Q T2 BSQ-16 T1 BSQ-16 T2 Thin Intern. T1 Peer Pressure T1 PSS T1 CAT T1 SS-A T1
Note. EDE-Q = Eating Disorder Examination Questionnaire; BSQ-16 = Body Shape Questionnaire; Thin Intern. = Thin ideal internalization (SATAQ-4 subscale); Peer Pressure = Pressure from peers to conform to appearance ideal (SATAQ-4 subscale); PSS = Perceived Stress Scale; CAT = College Adjustment Test; SSA = Social Support Appraisals Scale. ⁎ p < .05. ⁎⁎ p < .01. ⁎⁎⁎ p < .001.
3. Discussion
predicted T2 outcomes. The variance inflation factor (VIF) was < 5 across the models, suggesting that multicollinearity was not an issue (Ringle, Wende, & Becker, 2015). Results of a post-hoc power analysis determined that 96 participants would be needed to detect medium effects with five predictors in a within-person hierarchical regression analysis.
Although a growing literature has evaluated prospective associations between sociocultural DE risk factors and changes in female college students' DE thoughts and BD (Berg et al., 2009; Dakanalis et al., 2017), little is known about whether factors associated with the college transition confer added explanatory power in predicting DE and BD change across students' first year. In the present study, peer pressure to attain the appearance ideal (i.e., a sociocultural DE risk factor) and elevated stress (i.e., a college adjustment factor) experienced during females' first semesters of college were both associated with elevated DE severity during their second semesters. Peer pressure to attain the appearance ideal was the only significant predictor in the BD model. These preliminary results suggest that it may be useful for health professionals to design and test the efficacy of prevention efforts that concomitantly target conventional DE risk factors and those associated with the college transition to mitigate worsening DE. As described previously, sociocultural DE models suggest that pressures to attain, and subsequent internalization of, culturally sanctioned appearance ideals are associated with elevated body dissatisfaction and, in turn, DE risk (Fitzsimmons-Craft, 2011). The present results suggest that peer pressure to attain the appearance ideal early in college predicts more severe DE symptoms and BD over females' first year of college. Thus, it may be beneficial for health professionals
2. Results Descriptive statistics and correlations between study variables are reported in Table 1. As shown in Table 2, sociocultural DE risk factors (Step 2) accounted for 6% (p < .001) and 2% (p = .03) of the variance in DE and BD at T2, respectively, after controlling for DE and BD at T1. Adjustment factors accounted for an additional 2% of the variance in DE change (p = .05) and 1% of the variance in BD change (p > .05; Step 3). Specifically, higher levels of T1 peer pressure to attain the appearance ideal and higher levels of T1 perceived stress were associated with more severe in DE at T2. Elevated T1 peer pressure to attain the appearance ideal was the only significant predictor of higher T2 BD. No other individual sociocultural or college adjustment factors were associated with DE or BD changes over this time period.
Table 2 Hierarchical regression analysis of predictors of Time 2 disordered eating and body dissatisfaction. Disordered eating
Step 1: Baseline Disordered Eating Time 1 Body Dissatisfaction Time 1 Step 2: ED-Specific Risk Factors Disordered Eating Time 1 Body Dissatisfaction Time 1 Thin Internalization Time 1 Peer Pressure Time 1 Step 3: College Adjustment Factors Disordered Eating Time 1 Body Dissatisfaction Time 1 Thin Internalization Time 1 Peer Pressure Time 1 Perceived Stress Time 1 College Adjustment Time 1 Social Support Time 1
Body dissatisfaction
B
SE B
β
0.79 –
0.06 –
0.77⁎⁎⁎ –
R2 Adj
ΔR2
0.59
–
– 0.64
0.07 – 0.02 0.02
0.58 – 0.12 0.24⁎⁎⁎
0.59 – 0.03 0.07 0.03 0.01 0.01
0.08 – 0.02 0.02 0.01 0.01 0.01
0.58⁎⁎⁎ – 0.12 0.22⁎⁎ 0.16⁎ 0.06 0.04
–
0.65 –
⁎
p < .05. p < .01. ⁎⁎⁎ p < .001. ⁎⁎
3
SE B
β
– 0.91
– 0.05
– 0.87⁎⁎⁎
– 0.80 0.07 0.84
– 0.07 0.22 0.32
– 0.76⁎⁎⁎ 0.02 0.15⁎
– 0.76 0.11 0.78 0.25 0.05 −0.19
– 0.07 0.21 0.32 0.20 0.08 0.10
– 0.72⁎⁎⁎ 0.03 0.14⁎ 0.07 0.04 −0.10
0.06⁎⁎⁎
⁎⁎⁎
0.59 – 0.03 0.08
B
0.02
R2 Adj
ΔR2
0.75 –
–
0.77 –
0.02⁎
0.78 –
0.01
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Acknowledgement
working with female college students to incorporate empirically supported dissonance-based interventions into existing preventative mental health services. For example, interventions such as the Body Project have been shown to decrease BD and related DE risk factors among college females by encouraging participants to challenge the appearance ideal (Becker & Stice, 2017). Although the Body Project has demonstrated efficacy, its reach is still in its infancy, making it important to increase efforts to engage undergraduate women during this at-risk period. Further, the present study extends previous work by demonstrating that elevated perceived stress at the beginning of females' transition into college was prospectively associated with elevated DE severity later in their first year, beyond the influence of established sociocultural DE risk factors. Of note, it is possible that students who experience difficulties transitioning into college may engage in DE as a way of coping with stress. This is consistent with prevailing theories that suggest DE behaviors provide an emotion regulation function, wherein DE behaviors help distract from or mitigate negative affect in the shortterm (Lavender et al., 2015). Interventions designed to reduce stress and provide college students with adaptive coping skills (e.g., relaxation training) may reduce DE severity on college campuses.
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3.1. Limitations Although strengths of this preliminary study include its prospective design and the use of a racially diverse sample of female students, some limitations are noted. Perhaps most notably, there was high attrition for participants providing data at both T1 and T2, with 27% of women completing T1 also completing T2. However, participants who did not complete the T2 assessment did not differ on any of the assessed T1 variables from those who did, suggesting that data were missing at random. The all-female sample also limits generalizability. Future research using a gender-diverse sample is needed to gain a better understanding of associations between sociocultural DE risk factors and college adjustment factors, relative to changes in DE and BD.
3.2. Conclusions The present research suggests that stress associated with the college transition may enhance the prediction of changes in DE but not BD across female college students' first year, beyond the influence of sociocultural DE risk factors. Sociocultural DE risk factors should continue to be central treatment targets in prevailing DE and BD prevention programs (Menzel et al., 2010). By extending the present results, future research may identify additional treatment targets, such as factors that assist in smoothing the college transition, for DE programs, which can subsequently be tested within the context of existing or new DE prevention models.
CRediT authorship contribution statement Lindsay M. Howard: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Visualization, Writing - original draft, Writing - review & editing. Kelly A. Romano: Writing - original draft, Writing - review & editing, Formal analysis. Kristin E. Heron: Conceptualization, Methodology, Resources, Writing - original draft, Writing - review & editing, Supervision, Funding acquisition.
Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. 4
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Vaux, A., Phillips, J., Holly, L., Thomson, B., Williams, D., & Stewart, D. (1986). The social support appraisal scale: Studies of reliability and validity. American Journal of Community Psychology, 14, 195–218. Wonderlich-Tierney, A. L., & Vander Wal, J. S. (2010). The effects of social support and coping on the relationship between social anxiety and eating disorders. Eating Behaviors, 11, 85–91. https://doi.org/10.1016/j.eatbeh.2009.10.002.
Sulkowski, M. L., Dempsey, J., & Dempsey, A. G. (2011). Effects of stress and coping on binge eating in female college students. Eating Behaviors, 12, 188–191. https://doi. org/10.1016/j.eatbeh.2011.04.006. Thompson, K. J., & Stice, E. (2001). Thin-ideal internalization: Mounting evidence for a new risk factor for body-image disturbance and eating pathology. Current Directions in Psychological Science, 10, 181–183. https://doi.org/10.1111/1467-8721.00144.
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