Development and testing of a model for risk and protective factors for eating disorders and higher weight among emerging adults: A study protocol
Introduction
Research has consistently revealed that eating disorders (ED) and higher weight have lifetime co-occurrence (Villarejo et al., 2012). These outcomes have been shown to share sociocultural, psychological, and behavioral risk and protective factors in adolescent populations (Haines, Kleinman, Rifas-Shiman, Field, & Austin, 2010). Body image, particularly body dissatisfaction, has been shown to play a strong direct and mediating role in predicting both ED and higher weight. These findings have prompted the suggestion that ED and higher weight may be best considered within a common etiological model (e.g., Wilson, 2010). Given that ED and higher weight have high levels of co-occurrence and cause distress across genders throughout the lifespan (Grogan, 2016), it is important to better understand the shared risk and protective factors for both outcomes. However, there is limited knowledge about the nature and extent to which they share risk and protective factors. Reviews that have investigated shared risk and protective factors have highlighted similarities across separate studies regarding factors identified as related to both higher weight and ED. Notably, body dissatisfaction appears to be an important risk factor for both outcomes, and also appears to be related to a range of psychological, biological, sociocultural, and behavioral risk and protective factors for higher weight and ED. Thus, this research is grounded in a framework that positions body image as a central variable responsible for the co-occurrence of the two conditions. However, given the diffuse network of proposed risk and protective factors, and the lack of a supporting coherent framework tying the together, a stronger articulation of how these many putative risk and protective factors interact is needed to drive empirical work. The first aim of this research is therefore to propose such a conceptual model that will be useful in guiding the development of testable models of the development of ED and higher weight.
This research will also explore the role of other possible risk and protective factors – both in relation to body image and in terms of incremental predictive value beyond body image – for ED and higher weight. Other risk and protective factors that have been found to be common to ED and higher weight across studies include dieting (Stice, Presnell, Shaw, & Rohde, 2005; Stice, Gau, Rohde, & Shaw, 2017), media influence (Dennison & Edmunds, 2008; Field et al., 2008), teasing (Copeland et al., 2015; Haines, Neumark-Sztainer, Eisenberg, & Hannan, 2006), parental behaviors (Johnson, Cohen, Kasen, & Brook, 2002; Neumark-Sztainer et al., 2010), and depression (Stice, Presnell, & Spangler, 2002, 2005). In line with the above findings, several reviews have argued for prevention programs that target both ED and higher weight (Golden, Schneider, & Wood, 2016; Haines & Neumark-Sztainer, 2006; Rancourt & McCullough, 2015), and Neumark-Sztainer and colleagues (2005, Neumark-Sztainer, 2003, 2009; Neumark-Sztainer, Wall, Story, & Sherwood, 2009) have repeatedly discussed the ways in which approaches to prevention of both ED and higher weight may be integrated. However, before the successful integration of prevention approaches can be achieved, it is important to establish a thorough understanding of the most significant risk and protective factors that are common to both ED and higher weight. This protocol paper is designed to present (a) the background for and articulation of the conceptual model underpinning the research, and (b) the methodology adopted to determine the role of body image and other risk and protective factors in the development of ED and higher weight. Reporting study protocols in advance allows the scientific community to evaluate whether the eventual analysis and results are consistent with the investigators’ original intent. Showing that the study has a specific design in advance based on a theoretical rationale also contributes to greater transparency. Making study protocols publicly available has the benefit of disseminating the most contemporary ideas with respect to study design and data analysis, and helps to avoid duplication and to better coordinate research efforts.
The conceptual model and empirical research outlined in this paper focuses on the period of emerging adulthood. This period occurs between the ages of 18 and 30 years, and is a particularly important stage of development for both ED and higher weight (Arnett, Žukauskienė, & Sugimura, 2014). During this stage of development, emerging adults are engaged in identity formation, experience high levels of anxiety and depression, experience instability in terms of their relationships and unemployment, express a high level of self-focus, and feel “in-between” adolescence and adulthood (Arnett et al., 2014). There is evidence that increasing weight gain during emerging adulthood is associated with higher mortality rates in later life compared with men and women who gain weight in later adulthood (Adams et al., 2013). This association is concerning given that emerging adulthood is generally a time of rapid increase in weight (Ng et al., 2014). Similarly, the prevalence rates of ED are significantly higher in emerging adults than older adults (Preti et al., 2009). As such, this study will particularly focus on developing a model of ED and higher weight in young adults aged 18 years to 30 years.
The findings from the above literature which was designed to identify shared risk and protective factors for ED and higher weight are limited in several ways. Comparisons of identified risk and protective factors across studies are impeded by differences in populations, outcome variables, methodologies, time-frames, and analytic approaches (Haines et al., 2010). As suggested by Neumark-Sztainer et al. (2007), these difficulties can be overcome by a comprehensive examination of risk and protective factors for ED and higher weight within a single study. Neumark-Sztainer et al. (2007) and Haines et al. (2010) examined the prevalence and co-occurrence of higher weight, binge eating, and extreme weight-control behaviors in adolescents, as well as a comprehensive range of factors that had the potential to increase or decrease participants’ risk of weight-related and behavioral outcomes. Both Neumark-Sztainer et al. (2007) and Haines et al. (2010) identified shared socioenvironmental, personal, psychological, and behavioral risk and protective factors for these three outcomes. A limitation of these studies, however, is that they did not examine how these factors may vary across gender, and there is no evidence regarding whether the models apply in different countries. One of the important advantages of including participants from a range of different countries is establishing the usefulness of the model beyond the handful of countries where studies of body image have tended to be focused, hence ensuring broader generalizability than has been possible in previous work. Further, the focus has been on the development of ED and higher weight among adolescents. Recently, developmental researchers have demonstrated historical trends towards a longer period of adolescence than previously defined (up to 24 years), characterized by later onset of developmental milestones in both adolescence and adulthood, longer duration of developmental uncertainty and latent risk periods extending into early adulthood (Sawyer, Azzopardi, Wickremarathne, & Patton, 2018). Thus, although the focus in risk and development research in ED and higher weight has focused on a more narrowly defined developmental window, this emerging work suggests the need to consider beyond the age of 18 as a continued – though underexplored – risk window. To date, no research has examined a model for shared factors for ED and higher weight among adults.
The aim of the current research project is to develop a conceptual model representing shared risk and protective factors for ED and higher weight in young adults and empirically examining this model in large samples of women and men from different cultures. The development of the current model was primarily based on the previous work of Neumark-Sztainer, Haines et al. (2007) and Haines et al. (2010) (see Fig. 1). These studies, as well as other studies reviewed above, informed the central variables included as well as the direction of the relationships between these variables. This conceptual model is now open to evaluation through the methodology described in this paper.
This project addresses three key research questions:
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What are the unique and common risk and protective factors that contribute to ED as well as higher weight in emerging adults?
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What are the unique and common risk and protective factors for men and women?
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What are the unique and common risk and protective factors across countries?
Section snippets
Design
There are tensions in the literature regarding the social construction of obesity and the concept of an ideal weight, as evidenced by a review conducted by Gotovac, LaMarre, and Lafreniere (2018). Further, a focus on obesity in healthcare has been shown to promote weight stigma (Alberga, McLaren, Russell-Mayhew, & von Ranson, 2018), where overweight males and females are discriminated against due to their weight. This alienation can present problems with patient engagement with health
Discussion
This paper provides a description of a proposal to evaluate the predictors of both ED and higher weight among young adult men and women in nine different countries. The variables included in this conceptual model have been identified in the literature as being consistent predictors of ED and higher weight among men and/or women. The way in which these variables relate to ED and higher weight will be determined. For example, although body dissatisfaction has been shown to be related to both ED
Funding sources
No funding was sought or obtained for the study.
Declaration of Competing Interest
None.
Acknowledgements
The authors would like to acknowledge the central role that Author 28 played in the conceptualization of this study and to the broader field of body image.
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Testing of a model for risk factors for eating disorders and higher weight among emerging adults: Baseline evaluation
2022, Body ImageCitation Excerpt :The aims of this study were therefore twofold. The first aim was to test and refine among emerging adults an integrated cross-sectional theoretical model of disordered eating and appearance change behaviors, including predictor variables grouped as biological, sociocultural, behavioral, and psychological factors, in particular body image (Fig. 1) (McCabe et al., 2019). Emerging adults are an important group to consider in terms of these behaviors because it is recognized as a period of elevated risk for a variety of mental health conditions (Arnett, Zukauskiene, & Sugimura, 2014), weight gain that has lifelong consequences (Adams et al., 2013, Ng et al., 2014), and emergence and worsening of eating disorder pathology (Preti et al., 2009).
Assessing positive body image, body satisfaction, weight bias, and appearance comparison in emerging adults: A cross-validation study across eight countries
2020, Body ImageCitation Excerpt :When the measures were not available in one of the non-English languages (i.e., either in Chinese, Dutch, French, Italian, Japanese, or Spanish), an iterative process of independent forward- and back-translation was undertaken. A detailed description of the translation process and procedure can be found elsewhere (see McCabe et al., 2019). Ethics approval for the project and data management were obtained (approval number: 2017-259E).
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Deceased.