An examination of risk factors that moderate the body dissatisfaction-eating pathology relationship among New Zealand adolescent girls

Abstract

Background
Eating disorders (EDs) and their subclinical variants are important health concerns for adolescent girls, and body dissatisfaction is a more common yet often debilitating experience that typically precedes the development of an ED. Despite this fact, little is known about what makes girls who are dissatisfied with their bodies more likely to engage in pathological eating behaviors. The present study explored eating pathology among a sample of adolescent girls from New Zealand and examined a variety of established risk factors that may moderate the relationship between body dissatisfaction (BD) and eating pathology.

Methods
Adolescent girls aged between 14 and 18 (N = 231) completed questionnaires assessing eating pathology, BD, negative affect, perfectionism, self-esteem, teasing and sociocultural pressure. Regression analyses tested for moderator effects to examine which variables moderated the relationship between BD and eating pathology.

Results
The analyses indicated that high levels of socially prescribed and self-oriented perfectionism, negative affect, perceived pressure from the media, and low levels of self-esteem all strengthened the relationship between BD and eating pathology.

Conclusions
The results highlight potential factors that may make adolescent girls who are dissatisfied with their bodies more susceptible to eating pathology.

Full text

R E S E A R C H A R T I C L E Open Access
An examination of risk factors that
moderate the body dissatisfaction-eating
pathology relationship among New
Zealand adolescent girls
Juliet K. Rosewall
1,2*
, David H. Gleaves
3
and Janet D. Latner
4
Abstract
Background: Eating disorders (EDs) and their subclinical variants are important health concerns for adolescent girls,
and body dissatisfaction is a more common yet often debilitating experience that typically precedes the
development of an ED. Despite this fact, little is known about what makes girls who are dissatisfied with
their bodies more likely to engage in pathological eating behaviors. The present study explored eating
pathology among a sample of adolescent girls from New Zealand and examined a variety of established
risk factors that may moderate the relationship between body dissatisfaction (BD) and eating pathology.
Methods: Adolescent girls aged between 14 and 18 (N= 231) completed questionnaires assessing eating
pathology, BD, negative affect, perfectionism, self-esteem, teasing and sociocultural pressure. Regression
analyses tested for moderator effects to examine which variables moderated the relationship between BD
and eating pathology.
Results: The analyses indicated that high levels of socially prescribed and self-oriented perfectionism,
negative affect, perceived pressure from the media, and low levels of self-esteem all strengthened the
relationship between BD and eating pathology.
Conclusions: The results highlight potential factors that may make adolescent girls who are dissatisfied
with their bodies more susceptible to eating pathology.
Keywords: Adolescent eating pathology, Body dissatisfaction, Moderators, Risk factors
Plain English summary
Many adolescent girls report being dissatisfied with their
shape and weight. Body dissatisfaction can lead to nega-
tive outcomes, including eating pathology or unhealthy
attitudes and behaviors towards food and eating. Eating
pathology can be dangerous for adolescent girls given
both the psychological and physical effects on a growing
young person. However, not all adolescents who are dis-
satisfied with their bodies have unhealthy attitudes and
behaviors towards food. This study looked at different
factors that may increase the relationship between body
dissatisfaction and eating pathology, or make it stronger.
In other words, we wanted to find out what factors made
someone who was dissatisfied more likely to also have
unhealthy eating attitudes and behaviors. We gave 231
adolescent girls questionnaires measuring eating path-
ology, body dissatisfaction, mood, perfectionism,
self-esteem, teasing and pressure to lose weight from the
media and from others. We found that adolescent girls
who were dissatisfied with their bodies, and who re-
ported high levels of perfectionism, low mood, felt pres-
sured by the media to lose weight or had low self-esteem
reported greater levels of eating pathology. This is im-
portant to know as potentially working to reduce these
factors among adolescents could protect those who are
* Correspondence: juliet.rosewall@slam.nhs.uk
1
Department of Psychology, University of Canterbury, Christchurch, New
Zealand
2
Child and Adolescent Eating Disorder Service, South London and Maudsley
NHS Foundation Trust, London, UK
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Rosewall et al. Journal of Eating Disorders (2018) 6:38
https://doi.org/10.1186/s40337-018-0225-z
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

dissatisfied with their bodies from developing eating
pathology.
Background
Eating disorders (EDs) are important health concerns
among young people due to their longstanding psycho-
logical and physical effects [1]. EDs are typically pre-
ceded by significant body dissatisfaction and the use of
weight control strategies, such as restrictive dieting,
which increase in severity and frequency over time [2].
Indeed, subclinical variants of EDs are also detrimental
to health and wellbeing, affect a greater number of indi-
viduals, and could develop into a diagnosable ED [3]. Be-
cause of the complexities involved in treating an ED,
particularly anorexia nervosa (AN), research focusing on
risk factors that contribute to the development of patho-
logical eating attitudes and behaviors is essential. Pre-
vention efforts may be most effective when they focus
on reducing established risk factors of ED development
among adolescents; however, these are limited by our
lack of understanding of these risk factors [4].
The sociocultural model of eating pathology purports
that body dissatisfaction, and subsequent eating path-
ology, is/are associated with the pressure to be thin from
one’s social environment [5] by reinforcing the message
that thinness leads to social rewards such as acceptance
and happiness [6]. According to this model, those who
internalize the media-espoused thin ideal may be more
likely to perceive a discrepancy between their appear-
ance and the thin ideal. This internalization leads to
body dissatisfaction and efforts to lose weight in order
to decrease the discrepancy and attain the thin ideal.
Evidence for the sociocultural model has been demon-
strated in adolescent populations [7].
Among adolescents, body dissatisfaction (BD) is a
common occurrence and, as the sociocultural model
suggests, one of the most robust predictors of eating
pathology [6,8–12]. In a New Zealand study, Fear, Bulik
and Sullivan [13] reported that 71% of adolescent girls
experienced significant BD. Similarly, a New Zealand na-
tional wellness survey conducted by Wood and col-
leagues [14], found that 39% of adolescent girls were
happy with their body, suggesting that the remaining
61% were not. Longitudinally, Neumark-Sztainer, Paxton,
Hannan, Haines, and Story [15] found a strong and con-
sistent relationship between BD and unhealthy weight
control behaviors over a five-year period, even after con-
trolling for BMI. Similarly, in their prospective study of
adolescent girls, Rohde, Stice and Marti [16] reported
that, of all the predictors they measured, BD was the
most consistent predictor of future eating pathology,
was significant at the four adolescent timepoints they
measured (ages 13, 14, 15 and 16) and increased the
likelihood of developing an eating disorder by 68%.
Given its “normative”nature [17], BD does not always
result in an ED. Indeed, a study comparing adolescent
girls with either AN, bulimia nervosa (BN), subthreshold
AN, subthreshold BN or no ED found that BD was a
common concern for each of these groups [18]. Al-
though BD is common, EDs are relatively rare, and risk
factors are likely to interact with each other [19]. Re-
searchers have tried to explore the factors that may
interact with BD in predicting eating pathology.
Using solely adult samples, moderator studies have ex-
amined various factors that affect the relationship be-
tween BD and eating pathology. In their longitudinal
study, Vohs, Bardone, Joiner, Abramson, and Heatherton
[20] found a three-way interaction effect between perfec-
tionism, BD and self-esteem among 18 to 20 year old
women. Perfectionistic women with high self-esteem
tended to engage in adaptive weight control behaviors,
whereas perfectionistic women with low self-esteem
tended to engage in more maladaptive behaviors to con-
trol their weight. However, subsequent research has not
always found support for this model [21]. In their study
of adolescent girls followed prospectively over 1 year,
Shaw, Stice, and Springer [22]also did not find this
interaction effect to be statistically significant. Looking
at perfectionism alone, in their study of college women,
Downey and Chang [23] found that socially prescribed
perfectionism, characterized by perceived high expecta-
tions from others, fear of negative evaluation and avoid-
ance of the disapproval of others [24], moderated the
pathway between BD and bulimic behaviors, and dieting.
Brannan and Petrie [25] found similar results in their
college sample with socially prescribed perfectionism
moderating the effects of BD on bulimic symptoms, and
self-oriented perfectionism, characterized by the setting
of high personal standards and the scrupulous evalu-
ation of one’s own behavior [26], serving as a moderator
for anorexic symptoms only. In their longitudinal study
of adolescent girls, Tyrka and colleagues [27] found that
perfectionism at adolescence was a significant predictor
of the onset of AN in young adulthood. The authors
posited that girls with perfectionistic standards might
shy away from the demands of adolescence, a time when
flexibility is necessary, and devote their efforts to con-
trolling their weight. In a subsequent longitudinal study
with adolescents, Boone, Soenens, and Luyten [28]
found that BD moderated the link between perfection-
ism and drive for thinness and overvaluation of shape
and weight, but not bulimic symptoms. However, that
study used the Frost Multidimensional Perfectionism
Scale [29], an adult measure, which does not specifically
measure self-oriented or socially prescribed perfection-
ism. These studies identified the moderating effect of
perfectionism on the BD to eating pathology pathway,
potentially due to having unrealistic expectations of
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shape and weight and increased inclination to strive for
the thin ideal through extreme and pathological eating
behaviors.
Other risk factors have also been shown to interact with
BD to increase the likelihood of eating pathology among
adults. Depression and anxiety have been found to moder-
ate the pathway between BD and eating pathology among
adult women [30]. Using an adolescent sample, Rodgers,
Paxton, and Chabrol [31] found that depression moder-
ated the impact of sociocultural influences on eating con-
cerns cross-sectionally; however, the researchers did not
specifically study the relationship between BD and eating
pathology. Leon and colleagues [32] found that, of the fac-
tors they studied, negative affect was the only significant
predictor of disordered eating over a 3 to 4-year period
during adolescence. This finding was further replicated in
an independent sample of girls. It is possible that an ado-
lescent girl could engage in pathological eating behaviors
to help reduce negative mood states related to body
dissatisfaction.
A longitudinal study by Button and colleagues [33]
found that low self-esteem at an early age was predictive
of later eating pathology in adolescent girls. Not only has
low self-esteem been postulated as a risk factor, the Vohs
et al. [20] study suggests that low self-esteem is a key
moderating factor in the development of bulimic symp-
tomatology. Moreover, Twamley and Davis [34] found that
high self-esteem weakened the relationship between BD
and eating pathology in women, meaning that these
women were less likely to engage in unhealthy behaviors
despite being dissatisfied. It is therefore plausible that ado-
lescent girls with low levels of self-esteem may also be less
likely to identify and focus on other personal strengths,
making them more susceptible to the effects of BD [34].
Although we are not aware of any studies of moder-
ator effects that have tested the interaction between BD
and weight-related teasing, weight -related teasing has
been found to predict eating pathology. In a large pro-
spective study, Haines and colleagues [35] reported that
adolescent girls who were teased were more likely than
their peers to become dieters. The effects of teasing
upon eating pathology have been shown to occur well
into adulthood [36]. Another longitudinal study of gen-
eral teasing in adolescence found that victims of teasing
were at increased risk for symptoms of AN and BN [37].
These relationships occurred after controlling for prior
ED symptoms, psychiatric status and family difficulties;
however, in this study, the relationships did not extend
into young adulthood. Similarly, perceived pressure to
lose weight from others (particularly, family members
and friends) is related to increased levels of eating path-
ology in adolescent girls. In a cross-sectional study of
adolescent girls’experiences of parental pressure, both
talking about weight at home and maternal dieting was
associated with increased eating pathology [38]. In
addition to parental pressure, Paxton and colleagues [39]
described how adolescent girls in the same friendship
group share similar levels of dietary restraint, weight
concerns, and extreme weight control practices. Pressure
from peers, or peer competition, has been shown to pre-
dict eating pathology, both concurrently and prospect-
ively, over and above that of social media and television
influences [40]. Although weight-related teasing and
pressure to lose weight are directly related to eating
pathology, moderator analyses could reveal whether
these factors increase eating pathology among those
already dissatisfied with their bodies.
Research with adolescents that explores these factors
is needed to determine why some young people who are
dissatisfied develop eating pathology, why some do not
develop eating pathology, and what factors may lessen
risk.Such research may guide prevention efforts that
aim to mitigate the effects of BD on eating pathology.
Prevention is especially important during adolescence
given that EDs tend to develop during this time, individ-
uals who develop eating pathology during adolescence
are at higher risk for eating pathology 10 years later [41]
and once an eating pathology has developed into a
full-blown ED, treatment can be challenging [42].
Guided by the sociocultural model of eating pathology,
the current study explored the impact of the above-men-
tioned factors in an adolescent sample, focusing on the
well-established relationship between BD and eating
pathology. Given that weight-related teasing and social
pressure to be thin are both prevalent in adolescence and
related to increased BD and eating pathology [35,43], we
tested whether these factors could also act as moderators.
Although the sociocultural model posits that these factors
precede BD, higher levels of these factors might still
strengthen the BD to eating pathology pathway. For ex-
ample, among girls who are dissatisfied with their bodies,
the media or others may erroneously instruct them on
how to achieve the thin ideal, through restrictive dieting
and overexercising [44], or such girls may model the
pathological eating behaviors they see in the media or
among friends. We predicted that high perfectionism,
negative affect, teasing, perceived pressure to be thin, and
low self-esteem would each strengthen the relationship
between BD and eating pathology.
Methods
Participants and procedures
Participants were 231 adolescent girls aged between 14 and
18 years, recruited from three state high schools through-
out Christchurch, New Zealand. The schools’decile ratings,
a government-issued score on a 10-point scale indicating
socio-economic level [45], ranged from 2 to 9, suggesting
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that both high and low socio-economic communities were
represented in the sample.
Eight secondary schools were invited to take part in
this study, and three agreed to participate. Once a school
agreed to participate, letters were sent home to recruit
female participants. Informed consent was obtained
from each participant and their parent or guardian.
Questionnaires were group-administered and completed
during class time. One school did not consent to their
students being measured for height and weight; there-
fore, these measurements were based on participant
self-report. For the remainder of the participants, a re-
search assistant conducted height and weight measure-
ments in a separate room.
Measures
Demographic information
A questionnaire assessed age, ethnicity, and mother and
father/guardian occupation.
Socio-economic status
The New Zealand Socio-Economic Index (NZSEI) [46]is
a widely used occupationally- based measure of socio-eco-
nomic status (SES) used in this study. Participants com-
pleted details about their parent/ guardian’soccupationin
order to derive a socio-economic index score.
Eating pathology
We used the Eating Attitudes Test −26 (EAT-26) [47]to
measure eating pathology. The EAT-26 is a widely used
26-item self-report questionnaire that measures eating
disturbances, originally designed to measure the symp-
toms of AN. An example item is “I feel terrified about
being overweight”. The EAT-26 is a shortened version
based on the factor analysis of the EAT-40 and corre-
lates highly with the original measure (r= .98). The
measure uses a 6-point scale ranging from “always”to
“never”and the most symptomatic response is given a
score of three, the second most symptomatic response is
assigned a score of two and the third, one. The other
three less symptomatic responses are given a score of
zero. Thus, scores range from 0 to 78. Although the
EAT-26 does not yield a specific diagnosis of an ED, it
can be an efficient screening tool in which a score at or
above a cut-off score of 20 is indicative of eating path-
ology [48]. The EAT-26 has demonstrated good score re-
liability with adolescents [40]. In the current study,
Cronbach’s alpha was .90.
Body dissatisfaction
The Stunkard Body Figure Drawings [49] is a measure of
body image perception and assesses BD in adolescents
and adults. Participants were presented with nine figures
ranging in size from very thin to obese, and were
required to identify the figure that represents their per-
ceived current body size and the figure that represents
their ideal body size. A discrepancy score is obtained by
subtracting ideal body size from perceived current size.
Fair to very good test-retest reliability has been reported
for scores on this measure [50].
The Eating Disorders Inventory-Body Dissatisfaction
subscale (EDI-BD) [51] is a nine-item measure of BD
that asks participants to rate statements about dissatis-
faction with parts of their body (e.g. “I think my thighs
are too large”) on 6-point scale ranging from “always”to
“never”. Total scores range from zero to a possible score
of 27. The most symptomatic response is given a score
of three, and the second and third most symptomatic re-
sponses are assigned scores of two and one, respectively.
The other three least symptomatic responses are given a
score of zero. This subscale has demonstrated good
score reliability and validity in adolescent populations
[52,53]. In the current study, Cronbach’s alpha was .83.
Perfectionism
The Child and Adolescent Perfectionism Scale (CAPS)
[54] is a 22-item multidimensional perfectionism scale
used to assess socially prescribed (SP) perfectionism (e.g.
“My family expects me to be perfect”) and self-oriented
(SO) perfectionism (e.g. “I get mad at myself when I
make a mistake”) in children and adolescents. The CAPS
consists of 5-point Likert scales and higher scores on the
scale indicate greater degrees of perfectionism. SO per-
fectionism scores range from 12 to 60 and SP perfec-
tionism score range from 10 to 50. The CAPS has
demonstrated good score reliability [55]. In the current
study, the Cronbach’s alpha for the SP perfectionism
scale was .82, and for SO perfectionism was .75.
Self-esteem
The Rosenberg Self-esteem Scale (RSES) [56] is a widely
used 10-item measure of general self-esteem. An ex-
ample item is “I feel I do not have much to be proud of”.
The RSES consists of a four-point Likert scale, ranging
from “strongly agree”to “strongly disagree”. Scores
range from 10 to 40, with high scores indicating low
self-esteem and low scores, high self-esteem. The RSES
has demonstrated good reliability in previous research
[57]. In the current study, Cronbach’s alpha was .86.
Perceived pressure to lose weight
The Perceived Pressure to Lose Weight subscale of the
Sociocultural Influences on Body Image and Body
Change Questionnaire [58] is an 18-item measure asses-
sing (1) perceived pressure from others (father, mother,
best female friend and best male friend) and (2) per-
ceived pressure from the media to lose weight. Example
items are e.g., “Does your best female friend diet to lose
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weight?”and “Do the media give you the idea that you
should eat less to lose weight?”This self-report measure
requires the participants to rate each item on a 5-point
scale ranging from “never”to “always”. Higher scores are
indicative of higher perceived pressure to lose weight. In
the current study, Cronbach’s alpha was .73 for pressure
to lose weight from others and .82 from the media,
respectively.
Negative affect
The Positive and Negative Affect Scale (PANAS) [59]is
a measure of positive and negative affect. We only used
the 10-item negative affect scale in this study. Partici-
pants were required to rate the degree to which different
words (e.g., “scared”) describe how they have felt during
the past few weeks, on a scale of 1 (very slightly or not
at all) to 5 (extremely). PANAS scores range from 10 to
50. Good reliability and validity data for young people
have been reported for the PANAS [60–62]. Cronbach’s
alpha in this study was .87.
Weight-related teasing
The Perception of Teasing Scale (POTS) [63]isan
11-item measure of teasing and its effect. This study
only examined the weight-related teasing subscale. An
example item is “People made fun of you because you
were heavy”. Participants were required to rate teasing
frequency on a Likert scale of “never”to “very often”.
High scores on this scale are indicative of a greater fre-
quency of negative verbal commentary. Potential scores
range from 6 to 30. The POTS has reliably assessed teas-
ing in adolescents and children [64]. In the current
study, Cronbach’s alpha was .88.
Statistical analyses
Data analyses were performed using SPSS version 24
with PROCESS for SPSS 2.16.3 [65]. Descriptive statis-
tics were calculated to determine the sample compos-
ition. Regression analyses tested for moderator effects to
examine which variables moderated the relationship be-
tween BD and eating pathology. Other than when we
tested three-way interactions, the two-way interactions
were tested one at a time. A composite BD score of the
EDI-BD and Stunkard Figure Drawings was computed
using principal components analysis and was subse-
quently used in the regression model. This served as a
cautionary measure to reduce multicollinearity and be-
cause these two variables were measuring two aspects of
BD [66,67]. A subsequent series of hierarchical multiple
regressions was computed to test for moderator effects,
with eating pathology as the dependent variable. Within
PROCESS, predictor and moderator variables were cen-
tered prior to testing interaction effects. All lower-order
effects were included in the models. Thus, for tests of
three-way interactions, all 3 two-way interactions were
also included in the model. BMI and age were also in-
cluded as covariates. To observe the nature of each sta-
tistically significant interaction, conditional effects at
high, medium and low values of the moderator variables
were tested. High, medium and low were tests of effects
at one SD above the mean, the mean, and one SD below
the mean respectively [68].
Results
Sample characteristics
The mean age of the sample was 15.5 years (SD = 1.05).
The percentages of the girls who reported being 14, 15,
16, 17, or 18 were 16.5%, 37.2%, 27.3%, 15.6% and 3.5%,
respectively. The mean body mass index (BMI; kg/m
2
)
was 21.9 (SD = 3.87); 67% of the girls had a BMI in the
normal range (5th to <85th percentile), 16% fell in the
underweight range (< 5th percentile), 12% in at risk for
overweight range (85th to 95th percentile), and 5% in
the overweight range (95th percentile and above) [69].
The ethnic composition of the sample was 73.7% New
Zealand European, 10.3% New Zealand Māori, 5.6%
Asian, 2.6% Pacific Island and 3% Other. Ethnic distribu-
tion was similar to the population statistics of children
and youth in Christchurch city [70]. The mean SES
score was 3.8, which falls in the middle-SES range [46].
In terms of missing data, a small number of participants
left all items of the POTS and media pressure scale blank
(15 and 5, respectively) and were excluded from the ana-
lyses. Of the remaining participants, 62 participants were
missing at least one item on any measure with the major-
ity missing only one item. To deal with remaining missing
data, we used the expectation-maximization (EM) method
of data imputation (see [71]). Due to incomplete data, the
majority of analyses were conducted with 207 participants
except the analyses including the POTS, which were con-
ducted with 195.
Mean scores and intercorrelations are shown in
Table 1. Although individuals generally reported low
levels of eating pathology on the EAT-26, a total of 28
participants (12.1%) scored above the recommended
cut-off of 20 on the EAT-26, indicative of eating path-
ology [24]. Thirty-seven participants (15.9%) reported
having engaged in compensatory behavior, such as
vomiting or laxatives, during the past 6 months.
Moderator analyses
Regression coefficients for each moderation analysis are
depicted in Table 2and their level of significance and
conditional effects are presented in Table 3.
The interactions between both SP perfectionism and
BD, and SO perfectionism and BD, as predictors of eat-
ing pathology, were statistically significant. As seen in
the conditional effect values, among adolescent girls
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who scored high (or one SD above the mean) on SP per-
fectionism, the relationship between BD and eating path-
ology was greater than for those at the mean or one SD
below the mean. Similarly, conditional effect values dem-
onstrated that for those scoring higher on SO perfec-
tionism, the relationship between BD and eating
pathology was also greater. The three-way interactions
between BD, self-esteem and both SP and SO perfection-
ism, in predicting eating pathology, were not statistically
significant.
The interaction between BD and self-esteem, as a pre-
dictor of eating pathology, was statistically significant.
Conditional effect values showed the relationship be-
tween BD and eating pathology increased at lower levels
of self-esteem.
The interaction between BD and negative affect, in pre-
dicting eating pathology, was also statistically significant.
High levels of negative affect strengthened the effect of
BD on eating pathology. Tests of conditional effects indi-
cated that the relationship between BD and eating path-
ology was strongest at higher levels of negative affect.
The interaction between BD and pressure from the media
to lose weight, in predicting eating pathology, was statisti-
cally significant. As can be seen in the conditional effects,
as media pressure becomes greater, the relationship be-
tween BD and eating pathology becomes stronger. There
was no significant interaction found between BD and
Table 1 Descriptive Statistics, Zero-order Correlations Between Variables of Interest and Cronbach’s Alphas for each Measure
α1234 5 6 78 9 1011
1 Eating pathology .90 .24** .50** .50** −.36** .36** .32** .45** .23** −.09 .30**
2 BMI N/A .55** .50** −.25** .13 .07 .19** .49** −.05 .28**
3 Figure drawings N/A .70** −.31** .24** .16* .31** .37** −.06 .31**
4 Body dissatisfaction .83 −.51** .24** .15* .33** .35** −.03 .35**
5 Self esteem .86 −.30** −.07 −.41** −.35** −.02 −.15*
6 SP perfectionism .82 .60** .34** .10 −.15* .24**
7 SO perfectionism .75 .23** .10 −.04 .16
8 Negative affect .87 .15* −.03 .20**
9 Weight teasing .88 −.01 .34**
10 Media pressure −.82 −.04
11 Perceived pressure .73
M9.76 21.97 1.16 10.88 28.74 28.49 35.33 21.67 8.29 9.96 16.32
SD 11.19 3.59 1.31 7.64 5.02 7.39 6.73 6.82 4.09 3.06 4.08
n= 195 (using listwise deletion); *p< .05. **p< .01; SD standard deviation, SP perfectionism socially prescribed perfectionism, SO perfectionism
self-oriented perfectionism
Table 2 Summary from Regression Analysis of Individual
Moderator Effects on the BD to Eating Pathology Pathway
Predictor B SE B ΔR
2
tp
SO perfectionism x BD .41 .09 .08** 4.69 <.001
SP perfectionism x BD .37 .70 .06** 3.78 <.001
Self esteem x BD −.33 .16 .02** −2.03 .05
Perceived pressure x BD .32 .26 .01 1.21 .22
Negative affect x BD .33 .12 .05** 2.71 <.01
Media pressure x BD .79 .28 .05** 2.79 <.01
Weight teasing x BD .18 .17 .01 1.03 .30
SO perfectionism x self esteem x BD .01 .03 .00 .27 .79
SP perfectionism x self esteem x BD −.01 .02 .00 −.29 .77
*p< .05. **p< .01; BMI and age were added as covariates in each model and
had no significant effect on interaction effects, n= 207, with the exception of
the analysis using the POTS (weight-related teasing) where n= 195
Table 3 Conditional Effects of BD on Eating Pathology at High,
Medium and Low Levels of each Moderator
Moderator Level Effect se tp
SO perfectionism High 8.22 1.17 7.06 <.001
Med 5.87 1.13 5.21 <.001
Low 3.51 1.37 2.59 .01
SP perfectionism High 7.05 1.21 5.85 <.001
Med 4.34 0.90 4.80 <.001
Low 1.62 1.10 1.47 .14
Self esteem High 3.49 1.83 1.90 .06
Med 5.12 1.55 3.30 <.01
Low 6.76 1.66 4.08 <.001
Negative affect High 7.01 1.50 4.68 <.001
Med 4.79 1.16 4.12 <.001
Low 2.58 1.34 1.92 .06
Media pressure High 8.23 1.49 5.53 <.001
Med 5.78 1.13 5.13 <.001
Low 3.34 1.37 2.44 .02
High, medium and low values are one SD above the mean, the mean and one
SD below the mean, respectively
Rosewall et al. Journal of Eating Disorders (2018) 6:38 Page 6 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

weight-related teasing or perceived pressure from others, in
predicting eating pathology.
Discussion
The current study revealed that SP and SO perfectionism,
self-esteem, negative affect and perceived pressure from the
media each moderated the relationship between BD and
eating pathology. Similar to adult samples [30], among ado-
lescents who are dissatisfied with their bodies, high levels of
negative affect may increase the effects on eating pathology.
Although causation cannot be inferred, negative affect may
exacerbate the challenges of adolescence, such as the
sometimes-unwanted physical changes associated with pu-
berty. Pathological eating behaviors may be a means of pro-
viding relief from negative mood states, particularly when
they are related to one’sBD[72]. However, as these data
are not longitudinal, it is also possible that eating pathology
leads to negative affect via feelings of shame and guilt [73]
or that some unmeasured variable is responsible for the ef-
fects that we found. Consistent with adult samples, high
levels of both SP and SO perfectionism increased the im-
pact of BD on eating pathology. This finding suggests that
girls who are dissatisfied with their bodies may be more
likely to engage in pathological eating behaviors if they are
highly perfectionistic, whereas girls who are low in perfec-
tionism may be less likely to act on their BD. Theoretically,
low perfectionism could decrease the likelihood adolescent
girls engage in eating pathology because personal standards
maybemorerealisticandthedrivetoachievethethin
body ideal may be less intense. Similarly, high levels of per-
fectionism may perpetuate a drive for thinness [28]andan
inability to lose weight may be met with more extreme and
unrealistic weight loss strategies to achieve the thin ideal.
Similar to the findings of Shaw and colleagues [22], the
three-way interaction between perfectionism, self-esteem
and BD found by Vohs et al. [20] was not replicated. Again,
given the cross-sectional nature of these findings it could
be possible that eating pathology increases perfectionism
via weight loss and the consequent exacerbation of weight
loss efforts.
Consistent with Twamley and Davis [34], low self-esteem
increased the relationship between BD and eating path-
ology. Low self-esteem might increase risk through prevent-
ing high-BD girls from viewing themselves in a more
positive light, or by diminishing other strengths [34]mak-
ing them more focussed on or affected by their BD. In a
similar vein, media pressure real or perceived, might ex-
acerbate her established view about her body and encour-
age an adolescent girl to pursue weight loss. Dissatisfied
girls might also seek out weight-related media messages, or
might be even more sensitive to them. However, as direc-
tionality cannot be assumed, it could also be possible that
eating pathology leads to an increase in media pressure to
lose weight, or a sensitivity to these messages. Interestingly,
teasing and perceived pressure did not significantly moder-
ate the BD-eating pathology pathway. In light of previous
research, weight-related teasing and pressure might be dir-
ectly associated with increased BD as opposed to moderat-
ing the BD-eating pathology relationship [12,74].
To our knowledge, this was the first study in the past
20 years to have examined adolescent eating pathology
in New Zealand and the first to examine established risk
factors for eating pathology among New Zealand adoles-
cent girls. Rates of eating pathology in this study were
similar to those found internationally (as measured by
exceeding the EAT-26 cutoff) [75,76]; however, given
that the sample was not randomly selected, we cannot
be certain that our sample was representative and thus
directly comparable to other overseas estimates.
A number of methodological limitations of this study
need to be considered. The cross-sectional nature of the
data makes it unclear what direction of causality (if any)
exists among the variables. Although we can be guided
by theoretical understanding, longitudinal research
would identify risk factors over time and partially clarify
causal relationships. Moreover, as the multiple modera-
tors were not entered into one analysis, we cannot be
sure which moderators were statistically significant
above and beyond the effects of other potential modera-
tors. Testing all of the interactions at once would have
created multicollinearity concerns that would have made
the estimates unstable, and may have made tests of mod-
eration problematically underpowered and increased the
chance of type-2 errors. As mentioned, the sample was
not randomly selected. Although effort was made to re-
cruit participants from schools that covered a wide range
of socioeconomic areas, not all schools consented to
participate. Moreover, data on enrolment or participa-
tion rates were not collected which again affects the rep-
resentation of the sample. Questionnaire data were
collected by self-report. Despite being reassured confi-
dentiality, participants may not have been completely
open and honest or, in the instance of the NZSEI, may
not have known. Including a clinical interview or paren-
tal report may have improved accuracy, but would have
been difficult with a large, non-clinical sample. Although
BD and eating pathology occurs in males, this study only
recruited female participants. Exploring these same po-
tential moderator relationships in adolescent boys is
greatly needed. Moreover, perceived pressure to lose
weight was a collapsed variable containing items meas-
uring pressure from father, mother and friends; there-
fore, individual sources of pressure were not identified.
Conclusions
Despite these limitations, the current study increases
our understanding of the relationships between BD and
the established risk factors that may potentially make
Rosewall et al. Journal of Eating Disorders (2018) 6:38 Page 7 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

adolescent girls more susceptible to eating pathology.
Without intervention, pathological eating could develop
into a diagnosable ED. Prevention strategies that seek to
reduce BD might be more effective if they address ways
to curtail the effects of these moderating factors also.
For example, rather than just addressing BD, targeted
prevention strategies for those with high levels of BD
could focus on reducing perfectionism (both SP and SO)
through addressing maladaptive perfectionist beliefs
about shape, weight and one’s control over their eating.
In addition, such interventions could possibly benefit
from an emotion regulation component to address nega-
tive affect. Negative affect may be alleviated by teaching
skills that allow an adolescent to manage unwanted
mood states in an adaptive fashion [32]. Similarly,
self-esteem could be targeted by encouraging and mod-
elling self-worth based on other areas of an individual,
such as inner qualities, values, and meaningful social re-
lationships. Prevention efforts that have targeted
self-esteem have shown good results at reducing BD and
eating pathology among adolescent girls [3]. Finally,
media messages that convey beauty and thinness leading
to success and happiness could also be challenged as can
the accuracy of images in the media. Prevention pro-
grammes often address these unhelpful media messages,
and have indeed demonstrated promising outcomes with
adolescents [77]. If corroborated by longitudinal and/or
experimental research, accentuating these moderating
factors could help improve our prevention strategies
and, ultimately, interrupt the chain of events that lead to
eating pathology.
Abbreviations
AN: Anorexia nervosa; BD: Body dissatisfaction; BMI: Body mass index;
BN: Bulimia nervosa; CAPS: Child and Adolescent Perfectionism Scale; EAT-
26: Eating Attitudes Test-26; EDI-BD: Eating Disorders Inventory- Body
Dissatisfaction; EDs: Eating disorders; NZSEI: New Zealand Socio-Economic
Index; PANAS: Positive Affect and Negative Affect Scale; POTS: Perception of
Teasing Scale; RSES: Rosenberg Self Esteem; SES: Socio-economic status;
SO: Self-Oriented; SP: Socially Prescribed
Acknowledgements
The authors gratefully acknowledge Daniela Melamed for her assistance in
the preparation of this manuscript.
Funding
The research was funded by a University of Canterbury Doctoral Scholarship
to the first author.
Availability of data and materials
The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.
Authors’contributions
JKR contributed to the conceptualization of the study, performed the
statistical analyses, interpretation of the data and drafted the manuscript;
DHG contributed to the conceptualization of the study, performed some of
the statistical analyses, interpretation of the data, and drafting of the
manuscript; JDL contributed to the conceptualization of the study and
drafting of the manuscript. All authors read and approved the final
manuscript.
Ethics approval and consent to participate
Informed consent was obtained from all individual participants included in
the study and their parent/guardian. All study procedures were approved by
the University of Canterbury Human Ethics Committee, Christchurch, New
Zealand.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department of Psychology, University of Canterbury, Christchurch, New
Zealand.
2
Child and Adolescent Eating Disorder Service, South London and
Maudsley NHS Foundation Trust, London, UK.
3
School of Psychology Social
Work and Social Policy, University of South Australia, Adelaide, Australia.
4
Department of Psychology, University of Hawaii, Honolulu, HI, USA.
Received: 23 April 2018 Accepted: 19 October 2018
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