The relative importance of body change strategies, weight perception, perceived social support, and self-esteem on adolescent depressive symptoms: Longitudinal findings from a national sample

Abstract

Objective

This study aimed to evaluate the relative importance of body change strategies and weight perception in adolescent depression after accounting for established risk factors for depression, namely low social support across key adolescent contexts. The moderating effect of self-esteem was also examined.

Methods

Participants (N = 4587, 49% female) were selected from the National Longitudinal Study of Adolescent Health. Regression analyses were conducted on the association between well-known depression risk factors (lack of perceived support from parents, peers, and schools), body change strategies, weight perception, and adolescent depressive symptoms one year later.

Results

Each well-known risk factor significantly predicted depressive symptoms. Body change strategies related to losing weight and overweight perceptions predicted depressive symptoms above and beyond established risk factors. Self-esteem moderated the relationship between trying to lose weight and depressive symptoms.

Conclusion

Maladaptive weight loss strategies and overweight perceptions should be addressed in early identification depression programs.

Introduction

There is a critical need to broaden our understanding of depression across the lifespan, particularly since it is the third most disabling condition in the world [1]. Adolescence is a key developmental period in which to examine risk factors that contribute to the emergence and maintenance of depression, particularly since depression symptoms often first arise in adolescence [2] and are associated with various long-standing problems, such as substance abuse, suicidal behavior, and academic and psychosocial problems [3], [4], [5]. One set of burgeoning risk factors for adolescent depression is eating- and weight-related disturbances (EWRDs), which are defined as negative cognitions and behaviors related to eating and weight [6], [7]. Eating and weight cognitions include negative body, weight, and eating perceptions (e.g., perception of being overweight, drive for thin or muscular physiques), while unhealthy eating and weight behaviors include body change strategies, such as engagement in severe weight loss or weight gain behaviors and using substances to control one's weight (e.g., diet pills, cigarette smoking) [8]. EWRDs are conceptualized as less severe cognitions and behaviors compared to clinical symptoms of eating disorders (e.g., severe restriction of caloric intake and binging) [9]. Recent research suggests that among adolescent boys and girls prevalence estimates of maladaptive body change strategies are 11.6%, particularly prolonged fasting (8.3%) [10].

There is growing research supporting a prospective relationship between EWRDs and depressive symptoms among adolescents (for a review, see [7]). Stice and colleagues [11] conducted a longitudinal study using a large, ethnically diverse, school sample with adolescent girls and found that elevated body dissatisfaction, dietary restraint, and bulimic symptoms at baseline predicted the onset of subsequent depression. Additionally, a longitudinal study by Stice and Bearman [12] found that pressure to be thin, negative body perceptions, dieting, and bulimic symptoms predicted subsequent increases in depression. Given the prospective nature of this study, the results suggest that body dissatisfaction and other EWRDs are not simply concomitants or consequences of depression but rather predictive risk factors [12]. Further research is needed to explore the relation between EWRDS and depressive symptoms using large samples of both young men and women in order to strengthen the generalizability of this area of research [7]. Recent research using a longitudinal design (i.e., two year follow-up period) supports that body dissatisfaction is associated with depressive symptoms among adolescent boys and girls [13], and additional research would be beneficial in order to replicate and generalize this finding among national samples of adolescent boys and girls (e.g., see [14], for a related study on body dissatisfaction and suicidal ideation in a nationally representative sample). As well, the majority of studies in the EWRDs and depression literature focus on body dissatisfaction and body image variables (e.g., [13], [15], [16], [17]), and it would be useful to examine multiple measures of cognitive (e.g., weight perceptions) and behavioral (e.g., maladaptive body change strategies) EWRDs.

Recent research has demonstrated that adolescent boys dissatisfied with their body are at risk for substance misuse, negative mood, and muscle dysmorphia [18]. The gender additive model theorizes that although adolescent boys and girls possess certain shared risk factors for depression (e.g., low self-esteem, low social support, poor body image), other risk factors may be gender-specific (e.g., BMI; [12]). Further, Santos and colleagues [19] found that a model predicting depressive symptoms through body image factors was statistically supported for both boys and girls suggesting that risk factors once thought to be specific to girls (e.g., body dissatisfaction) may also be associated with depressive symptoms in boys. This finding, in combination with the growing interest in boys' unique experience of EWRDs [18], motivated the inclusion of adolescent boys in the current study.

Although there is growing evidence linking EWRDs and depressive symptoms in adolescence [11], [12], [20], [21], there have been few studies that have documented the importance of these risk factors after accounting for established predictors of depression in adolescence (e.g., lack of perceived social support, low self-esteem). Given that EWRDs are burgeoning risk-factors for depression, examining their relative importance to well-known risk factors for depression could strengthen the rationale for including EWRDs as key predictors in developmental theories of depression. Moreover, many studies examining the relation between EWRDs and depressive symptoms have used community-based samples consisting mainly of adolescent girls [11], [12], [21], and it would be valuable to replicate these findings using a population-based sample of both adolescent girls and boys. Thus, this study evaluated the importance of EWRDs in predicting depressive symptoms among adolescents after accounting for established risk factors for depression, namely lack of perceived social support across key adolescent contexts, as well as the moderating role of self-esteem on the relation between EWRDs and depressive symptoms. In doing so, this study also aimed to replicate findings from previous studies using a population-based sample.

A key predictor of child and adolescent health is the role of perceived social support [22]. Specifically, the relationship between the level of perceived social support and depressive symptoms has been studied extensively [23], [24], [25]. Much of this research is grounded in social developmental and cognitive vulnerability theories, which state that depressive symptoms are likely to occur when individuals experience negative life events and perceive a lack of support in key contextual domains, including by parents and peers and at school [26]. Many researchers have found both cross-sectional [27], [28], [29] and longitudinal support [30], [31] for the critical role of parental support on depressive symptoms, particularly among young women [32]. Problematic interpersonal relationships with peers or teachers also predict increases in depressive symptoms in children and adolescents [33], [34]. Further, perceived school support and school connectedness (i.e., the extent to which students feel support, accepted, and valued in the school) are strong predictors of depressive symptoms [35]. Overall, these findings underscore the established relation between lack of perceived social support and depressive symptoms among adolescents.

Research studies suggest that self-esteem is a key predictor of depressive symptoms among youth, although these findings are mixed. For example, a longitudinal study using a primary care sample of adolescents (e.g., follow-up of approximately 10 months) found that low self-esteem predicted higher levels of depressive symptoms and disordered eating behaviors [36]. Other smaller community-based cross-sectional samples have found that self-esteem, measured by the Rosenberg Self-Esteem Scale [37], was associated with depressive symptoms [38]. However, using a larger community-based cross-sectional sample and the Rosenberg Scale, Ferreiro and colleagues [33] found that self-esteem was not associated with depressive symptoms. Thus, it would be useful to examine self-esteem predicting depressive symptoms in population-based samples of adolescents to clarify the relationship between self-esteem and depressive symptoms, particularly among normative samples.

Within the EWRDs and depression literature, despite the strong relation between body dissatisfaction and self-esteem [39], few studies have assessed self-esteem alongside depression and EWRDs in adolescence (see [13], [16], [36] as exceptions). Previous research suggests that self-esteem is an important predictor and moderator of depressive symptoms among young adults [36], [38], [40], [41]. Using a single school sample, Allgood-Merten et al. [41] found that poor body image predicted depression symptoms at follow-up, although this relationship became lessened when including an adolescent's self-esteem. Thus, preliminary research generally supports the critical role of self-esteem alongside EWRDs and adolescent depression, although it is unclear if self-esteem may buffer or exacerbate depressive symptoms, particularly after accounting for putative risk factors of depression.

In sum, the Objectives of the present study were two-fold. First, this study aimed to identify the specific EWRD factors (i.e., weight perception, body change strategies) that longitudinally predicted depressive symptoms among adolescents after accounting for established predictors of depressive symptoms, namely lack of perceived social support by parents, peers, and schools. Second, this study aimed to examine the predictive role of self-esteem on depressive symptoms among adolescents, as well as to examine the moderating role of self-esteem on the relation between EWRDs and depressive symptoms in adolescence. To the author's knowledge, this is the first population-based study to longitudinally investigate the relative importance of this combination of factors, as well as the moderating role of self-esteem.