by Jose Nicolas Murgueitio
Nicolas Murgueitio is a 2022 UNC CEED Summer Research Fellow and a graduate student in the Department of Psychology and Neuroscience at UNC Chapel Hill. (En español, haga clic aqui)
As a developmental psychology graduate student, I spent my summer thinking about eating disorders from a developmental/child perspective. This means not only thinking what developmental factors (e.g., behaviors, environment) might contribute to the development these disorders, but also how as a developmental scientist I can contribute to the field. In developmental psychology, we do not typically study disorders, but precursors or risk factors (e.g., temperament, fear, emotion regulation, social connection, biomarkers) of psychopathology. That is why I decided to write about risk factors that put children at risk of developing an eating disorder or disordered eating.
Eating disorders, such as anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), and avoidant restrictive food intake disorder (ARFID), are disorders characterized by disturbance of eating behaviors, which in turn, can lead to poor outcomes in both health and social well-being (American Psychiatric Association, 2022). Parents and other primary caregivers often wonder what the risk factors are for developing eating disorders, and if anything can be done to avoid them. The short answer is that we still have much to learn. The longer answer is the topic of this blog.
Let’s start by defining “risk factor.” A risk factor is something that increases the probability (likelihood) of developing certain trait (e.g., disordered eating) or disease (e.g., eating disorders). If we say, for example, that childhood anxiety increases the chances of developing an eating disorder later in life, we are not saying that all children with anxiety will develop an eating disorder. Nor are we saying that everyone with an eating disorder had a childhood anxiety disorder. What we are saying is that those with childhood anxiety have greater chances of developing an eating disorder than those who do not. Next, we examine the evidence for some of the several risk factors that have been studied in relation to eating disorders. Bullying or teasing—related and unrelated to one’s appearance—appears to be related to the development of eating disorders (Lee & Vailancourt, 2018; Lie et al., 2019). One interesting study found that weight-related bullying in children and adolescents was associated with disordered eating behaviors such as emotional eating, and that youth with negative affect were more likely to show disordered eating behaviors (Rubin et al., 2021). Another study reported that people with BN and BED experienced more digital, verbal, and indirect bullying during their formative years than those without eating disorders (Lie et al., 2021). Interestingly it is not only those children who are bullied that are more likely to develop an eating disorder, but also their bullies. One study found, specifically, that the bullies were more at risk of developing symptoms related to BN and preoccupation with eating. This study also looked at those who were both bullies and victims of bullying and found that they were at risk of developing AN (Copeland et al., 2015). Several studies have now implicated bullying as a risk-factor for eating disorders, not only for the victims of bullying but also for the bullies.
Several studies have focused on “internalizing symptoms” as risk factors for eating disorders. This is a fairly broad term that covers negative internal experiences, such as sadness, fear, loneliness, which are often related to so-called internalizing disorders such as anxiety and depression (Levesque, 2011). Several studies report that internalizing symptoms relate to disordered eating and eating pathology across wide age range of 8 to 17 (Aime et al., 2008; Lee & Vailancourt, 2019; Schaumberg et al., 2018). For example, one study looking at 9–11-year-old children found that anxiety symptoms, but not depressive symptoms, were related to disordered eating (Thomas et al., 2020). New work related to COVID-19, reported an increase of both internalizing symptoms (i.e., being anxious and depressed) and eating disorder prevalence in 14–15-year-old adolescents (Cerniglia & Cimino, 2022). Childhood internalizing symptoms have also been associated with severity of AN, with individuals with greater fear or anxiety during childhood having lower BMIs (Dellava et al., 2010). As a developmental scientist, these and related findings underscore the importance of following children with internalizing symptoms closely for the development of not only anxiety and depression but eating disorders as well.
Physical symptoms such as symptoms of gastrointestinal symptoms in childhood may also be risk factors for eating disorders (Kerr et al., 2021). In fact, it has been suggested that early GI pain and discomfort may increase vulnerability to AN via aversive visceral conditioning
(Zucker & Bulik, 2020). Supporting this, people who experienced physical manifestations of anxiety during childhood were more likely to present with an eating disorder during adolescence, specifically BN (Schaumberg et al., 2018). Another study of women with BN reported that those with a history of childhood GI complaints had a younger onset BN and more severe binge-eating symptoms (Gendall et al., 2005). A twin study in Sweden reported that prolonged constipation and diarrhea during childhood and adolescence was associated with later disordered eating (Wiklund et al., 2019). Developmentally, this body of work suggests that we need to carefully monitor both physical and mental health to develop accurate risk models for eating disorders.
Many other risk factors have been studied in relation to eating disorders, but these three are particularly important to those of us who work with childhood development. Identifying ways to interrupt risk pathways from childhood bullying, internalizing symptoms, and physical symptoms to eating disorders may hold promise as tailored prevention strategies. Understanding individual risk profiles may also aid in personalizing treatment and potentially interrupting some of the personal pathways that maintain eating disorders.
Aimé, A., Craig, W. M., Pepler, D., Jiang, D., & Connolly, J. (2008). Developmental pathways of eating problems in adolescents. International Journal of Eating Disorders, 41(8), 686–696. https://doi.org/10.1002/eat.20561
American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787
Cerniglia, L., & Cimino, S. (2022). Eating Disorders and Internalizing/Externalizing Symptoms in Adolescents before and during the COVID-19 Pandemic. Journal of the American Nutrition Association, 1–7. https://doi.org/10.1080/07315724.2022.2063206
Copeland, W. E., Bulik, C. M., Zucker, N., Wolke, D., Lereya, S. T., & Costello, E. J. (2015). Does childhood bullying predict eating disorder symptoms? A prospective, longitudinal analysis: Eating Disorders and Bullying. International Journal of Eating Disorders, 48(8), 1141–1149. https://doi.org/10.1002/eat.22459
Dellava, J. E., Thornton, L. M., Hamer, R. M., Strober, M., Plotnicov, K., Klump, K. L., Brandt, H., Crawford, S., Fichter, M. M., Halmi, K. A., Jones, I., Johnson, C., Kaplan, A. S., LaVia, M., Mitchell, J., Rotondo, A., Treasure, J., Woodside, D. B., Berrettini, W. H., … Bulik, C. M. (2010). Childhood anxiety associated with low BMI in women with Anorexia Nervosa. Behaviour Research and Therapy, 48(1), 60–67. https://doi.org/10.1016/j.brat.2009.09.009
Gendall, K. A., Joyce, P. R., Carter, F. A., McIntosh, V. V., & Bulik, C. M. (2005). Childhood gastrointestinal complaints in women with bulimia nervosa. International Journal of Eating Disorders, 37(3), 256–260. https://doi.org/10.1002/eat.20088
Kerr, K. L., Ralph‐Nearman, C., Colaizzi, J. M., DeVille, D. C., Breslin, F. J., Aupperle, R. L., Paulus, M. P., & Morris, A. S. (2021). Gastric symptoms and low perceived maternal warmth are associated with eating disorder symptoms in young adolescent girls. International Journal of Eating Disorders, 54(6), 1009–1018. https://doi.org/10.1002/eat.23516
Lee, K. S., & Vaillancourt, T. (2018). Longitudinal Associations Among Bullying by Peers, Disordered Eating Behavior, and Symptoms of Depression During Adolescence. JAMA Psychiatry, 75(6), 605. https://doi.org/10.1001/jamapsychiatry.2018.0284
Lee, K. S., & Vaillancourt, T. (2019). A Four-Year Prospective Study of Bullying, Anxiety, and Disordered Eating Behavior Across Early Adolescence. Child Psychiatry & Human Development, 50(5), 815–825. https://doi.org/10.1007/s10578-019-00884-7
Levesque, R. (2011). Externalizing and internalizing symptoms. In R. Levesque (Ed.), Encyclopedia of Adolescence (pp. 903–905).
Lie, S. Ø., Bulik, C. M., Andreassen, O. A., Rø, Ø., & Bang, L. (2021). The association between bullying and eating disorders: A case–control study. International Journal of Eating Disorders, 54(8), 1405–1414. https://doi.org/10.1002/eat.23522
Lie, S. Ø., Rø, Ø., & Bang, L. (2019). Is bullying and teasing associated with eating disorders? A systematic review and meta‐analysis. International Journal of Eating Disorders, 52(5), 497–514. https://doi.org/10.1002/eat.23035
Micali, N., Horton, N. J., Crosby, R. D., Swanson, S. A., Sonneville, K. R., Solmi, F., Calzo, J. P., Eddy, K. T., & Field, A. E. (2017). Eating disorder behaviours amongst adolescents: Investigating classification, persistence and prospective associations with adverse outcomes using latent class models. European Child & Adolescent Psychiatry, 26(2), 231–240. https://doi.org/10.1007/s00787-016-0877-7
Rubin, A. G., Schvey, N. A., Shank, L. M., Altman, D. R., Swanson, T. N., Ramirez, E., Moore, N. A., Jaramillo, M., Ramirez, S., Davis, E. K., Broadney, M. M., LeMay-Russell, S., Byrne, M. E., Parker, M. K., Brady, S. M., Kelly, N. R., Tanofsky-Kraff, M., & Yanovski, J. A. (2021). Associations between weight-based teasing and disordered eating behaviors among youth. Eating Behaviors, 41, 101504. https://doi.org/10.1016/j.eatbeh.2021.101504
Schaumberg, K., Zerwas, S., Goodman, E., Yilmaz, Z., Bulik, C. M., & Micali, N. (2019). Anxiety disorder symptoms at age 10 predict eating disorder symptoms and diagnoses in adolescence. Journal of Child Psychology and Psychiatry, 60(6), 686–696. https://doi.org/10.1111/jcpp.12984
Thomas, K. S., Williams, M. O., & Vanderwert, R. E. (2021). Disordered eating and internalizing symptoms in preadolescence. Brain and Behavior, 11(1). https://doi.org/10.1002/brb3.1904
Udo, T., & Grilo, C. M. (2019). Psychiatric and medical correlates of DSM-5 eating disorders in a nationally representative sample of adults in the United States. International Journal of Eating Disorders, 52(1), 42–50. https://doi.org/10.1002/eat.23004
Wiklund, C. A., Kuja-Halkola, R., Thornton, L. M., Hübel, C., Leppä, V., & Bulik, C. M. (2019). Prolonged constipation and diarrhea in childhood and disordered eating in adolescence. Journal of Psychosomatic Research, 126, 109797. https://doi.org/10.1016/j.jpsychores.2019.109797
Zucker, N. L., & Bulik, C. M. (2020). On bells, saliva, and abdominal pain or discomfort: Early aversive visceral conditioning and vulnerability for anorexia nervosa. International Journal of Eating Disorders, 53(4), 508–512. https://doi.org/10.1002/eat.23255