Body dissatisfaction and disordered eating are prevalent problems among U.S. young people from diverse socioeconomic backgrounds: Findings from the EAT 2010–2018 study
Introduction
Body dissatisfaction and disordered eating (including thinness-oriented dieting, unhealthy and extreme weight control behaviors, and binge eating) are highly prevalent among U.S. young people and are associated with several adverse consequences (Arcan et al., 2014; Chin et al., 2018; Hart et al., 2020; Kärkkäinen et al., 2018; Nagata et al., 2018a; Nagata et al., 2018b; Neumark-Sztainer, Wall, Larson, et al., 2012; Neumark-Sztainer et al., 2018; Patton et al., 1999). Experiencing body dissatisfaction is linked to greater risk for poor psychosocial health, inadequate physical activity, and engaging in disordered eating (Brechan & Lundin Kvalem, 2015; Johnson et al., 2013; McLean & Paxton, 2019; Neumark-Sztainer et al., 2004; Neumark-Sztainer, Paxton, Hannan, et al., 2006; Stice & Shaw, 2002). Young people who engage in dieting and other forms of disordered eating are at increased risk for poor dietary intake, excess weight gain, alcohol and tobacco use, eating disorders, and serious medical problems (Field et al., 2007; Killen et al., 1996; Larson et al., 2009; Neumark-Sztainer, Wall, Gou, et al., 2006b; Piran & Robinson, 2011; Puccio et al., 2016). Disordered eating behaviors are of public health concern for both adolescent and emerging adult populations, and tend to track within individuals over time (Lewinsohn et al., 2000; Neumark-Sztainer et al., 2011). For example, population-based data from the Project EAT study indicate that more than 50% of adolescent girls and nearly 40% of adolescent boys use inherently unhealthy weight control behaviors (UWCBs such as taking diet pills, fasting) (Neumark-Sztainer et al., 2011; Neumark-Sztainer, Wall, Larson, et al., 2012). The prevalence of using UWCBs is constant in emerging adulthood (18–24 years) and young women and men have a higher relative risk of engaging in UWCBs during this life stage if they previously used these practices in early adolescence (Neumark-Sztainer et al., 2011).
As research addressing the treatment of body dissatisfaction and disordered eating has largely focused on populations of middle and upper socioeconomic status (SES), an important question is whether the prevalence of these problems is socioeconomically patterned (Mitchison et al., 2014; Mitchison & Hay, 2014; Sonneville & Lipson, 2018). The extant literature includes few studies addressing SES patterns in these outcomes and additional research addressing this gap in the literature is imperative to inform efforts to ensure the equitable distribution of resources for prevention and design of health services (e.g., screening tools, referrals for treatment) (DeLeel et al., 2009; Lipson & Sonneville, 2017; Marcus et al., 2007; Mitchison et al., 2014; Mitchison & Hay, 2014; Mulders-Jones et al., 2017; Nagata et al., 2018a; Pope et al., 1987; Rogers et al., 1997; Swanson et al., 2011). There is a need to comprehensively examine SES patterns in body dissatisfaction, disordered eating behaviors, and the use of other approaches to weight management because limited access to nutrient-dense foods and opportunities for engaging in physical activity may lead individuals to use UWCBs. Few studies have comprehensively investigated disordered eating and weight management behaviors among young people, and particularly few studies have accounted for the potential roles of body mass index (BMI) and ethnicity/race in observed patterns (DeLeel et al., 2009; Mulders-Jones et al., 2017; Sonneville & Lipson, 2018). There is also a lack of studies with designs that allow for comparing prevalence patterns across the life stages of adolescence and emerging adulthood within the same population.
Adolescence and emerging adulthood are nutritionally vulnerable stages of development. Having poor dietary intake, engaging in thinness-oriented dieting or disordered eating, and engaging in inadequate or excessive physical activity as a result of body dissatisfaction during these vulnerable periods can have long-term consequences for multiple aspects of health (Kärkkäinen et al., 2018; VanKim et al., 2012; Neumark-Sztainer, Wall, Story, et al., 2012). It is therefore critical that the timely recognition of body dissatisfaction and disordered eating be improved, and disparities in prevention and treatment are eliminated. There is much evidence that socioeconomic disparities in mental health, dietary intake, and physical activity are major public health problems that are driven by multiple social and environmental factors (Aneshensel, 2009; Larson, 2020; Larson & Story, 2015; Meyer et al., 2014; Reiss, 2013). Building on this evidence to describe the socioeconomic patterning of body dissatisfaction, disordered eating, and lifestyle weight management behaviors (e.g., regularly eating more fruits and vegetables) could help to better inform research with regard to potential explanatory mechanisms (e.g., disparities in exposure to adverse experiences, access to health care, opportunities for physical activity, food insecurity, and access to nutrient-dense food and beverages) along with approaches to addressing the disparities across the spectrum of diet and health outcomes. If it is established that body dissatisfaction and disordered eating are prevalent concerns among populations of lower SES, then future research and service provision needs to better address the needs of young people with limited household resources. For example, health care professionals need to be informed regarding the importance of screening and providing referrals for body dissatisfaction and disordered eating in a manner that does not exacerbate disparities in access to appropriate treatment services, adequate nutrient intake, and engaging in physical activity that meets recommendations for preventing chronic disease (U.S. Department of Agriculture & U.S. Department of Health and Human Services, 2020; U.S. Department of Health and Human Services, 2018).
The current study will make use of data from a population-based cohort of young people that is more socioeconomically and ethnically/racially diverse than the study sample for earlier Project EAT studies (Neumark-Sztainer et al., 2011) and will extend the evidence base by examining whether body dissatisfaction, disordered eating, and lifestyle weight management behaviors (hereafter referred to as lifestyle behaviors) are socioeconomically patterned. SES patterning among this young cohort is examined with a focus on household-level markers of access to resources (i.e., parent educational attainment, parental employment, and receipt of public assistance). The first aim is to describe the distribution of body dissatisfaction, disordered eating, and lifestyle behaviors across SES groups. Secondly, the study aims to examine whether the SES patterning of these variables might be explained by differences in the distribution of ethnic/racial identities and BMI across SES. In addressing each aim, the study will examine potential differences between the stages of adolescence and emerging adulthood, and separately examine patterns by gender. It is hypothesized that body dissatisfaction, disordered eating, and the use of lifestyle behaviors will be similarly prevalent or more prevalent among low SES populations as compared to middle and upper SES population groups.
Section snippets
Study design and population
EAT 2010–2018 (Eating and Activity over Time) is a population-based cohort study of eating, activity, and weight-related behaviors and associated factors in young people. Participants enrolled in the EAT 2010 study as adolescents during the 2009–2010 academic year (mean age = 14.4 ± 2.0 years) and completed a follow-up EAT 2018 survey as emerging adults in 2017–2018 (mean age = 22.0 ± 2.0 years). For EAT 2010, middle and senior high school students at 20 urban public schools in Minneapolis-St.
Female adolescents and emerging adults
For females, unadjusted models of past year prevalence showed SES disparities in body dissatisfaction, UWCBs, and lifestyle behaviors (p ≤ .010, Table 2). High body dissatisfaction and use of UWCBs were more prevalent and regular use of any lifestyle behaviors was less prevalent among the low SES group as compared to the middle and/or upper SES groups. Prevalence data showed a consistent pattern for multiple forms of lifestyle behaviors, including limited intake of high-fat foods, limited
Discussion
This study extends the literature on socioeconomic patterns in the prevalence of body dissatisfaction, disordered eating, and regular use of lifestyle behaviors by reporting on a large, ethnically and racially diverse cohort. The results include unadjusted prevalences to inform the design of services and interventions, and adjusted models to build understanding of why there are prevalence differences across SES. Results of this study provide information on the critical life stages of
Conclusions
In summary, the results of this study indicate that young people of low SES experience an equal or excess burden of body dissatisfaction and disordered eating compared to young people of upper SES. Future studies are needed to examine explanatory mechanisms to build understanding of observed SES patterns in the prevalence of body dissatisfaction, disordered eating, and regular use of lifestyle behaviors. In particular, there is a need for research to identify reasons why SES patterns in the
CRediT authorship contribution statement
Nicole Larson: Conceptualization, formal analysis, writing – original draft, project administration.
Katie Loth: Methodology, writing – review and editing.
Marla Eisenberg: Methodology, writing – review and editing.
Vivienne Hazzard: Methodology, writing – review and editing.
Dianne Neumark-Sztainer: Supervision, methodology, writing – review and editing, funding acquisition,
Declaration of competing interest
The authors declare that they have no conflicts of interest.
Acknowledgements
None.
Funding
This study was supported by Grant Numbers R01HL127077 and R35HL139853 from the National Heart, Lung, and Blood Institute (PI: Dianne Neumark-Sztainer). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health. The effort of author Vivienne Hazzard was supported by Grant Number T32MH082761 from the National Institute of Mental Health (PI: Scott Crow).
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