Journal of Abnormal Psychology © 2016 American Psychological Association

2016, Vol. 125, No. 3, 369 –380 0021-843X/16/$12.00 http://dx.doi.org/10.1037/abn0000146

Characterizing and Predicting Trajectories of Disordered Eating

Over Adolescence
A. Kate Fairweather-Schmidt and Tracey D. Wade
Flinders University

This study sought to identify distinct trajectory classes of growth of disordered eating (DE), and their
respective correlates and risk factors. Females ages 12–19 years (Australian Twin Registry) were
interviewed by telephone with the Eating Disorder Examination on 3 occasions (Wave 1: N ⫽ 699; Wave
2: N ⫽ 669; Wave 3: N ⫽ 499). Each participant also completed self-report measures across all waves,
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and their parents at Waves 1 and 2. Growth mixture modeling determined the optimal classes represent-
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ing DE growth trajectories over 3 data-points. The best fit was a 3-class solution constituting: (a) no
growth in DE over time (90%; low-static) where 10% reported a lifetime eating disorder (ED); (b) a high
intercept but decreasing over time (7%; 53% had a lifetime ED; attenuating); (c) an increasing level of
DE (3%; 80% experiencing a lifetime ED; escalating). The majority (64%) of EDs in the attenuating
group were diagnosed at Wave 1, whereas 84% of EDs in the escalating group were diagnosed at
subsequent waves. The low-static group had fewest significant correlates/risk factors for DE. A multi-
variable GEE identified that over adolescence, internalization of the thin ideal was 2.5 times more likely
characterize an escalating rather than low-static DE symptom trajectory. These findings underscore the
fundamental importance of concentrating efforts on reducing the potency of the thin ideal message, and
strategies directed toward resolving life stressors by effective management of emotion and problem
resolution, in order to prevent the development of DE.

General Scientific Summary

This study was able to identify and characterize longitudinal changes in disordered eating symptom
trajectories of subpopulations of female adolescent twins. Internalization of the thin ideal was found
to distinguish a group with low-stable symptoms from a group whose symptoms escalated over
adolescence.

Keywords: disordered eating, adolescents, trajectory, longitudinal, internalization of the thin ideal

Supplemental materials: http://dx.doi.org/10.1037/abn0000146.supp

It is well known that risk for expression of disordered eating
increases over adolescence for girls, with new sources of genetic and
environmental risk for disordered eating emerging at puberty (Klump,
Burt, McGue, & Iacono, 2007) and during late adolescence
(Fairweather-Schmidt & Wade, 2015). Lifetime prevalence of eating
This article was published Online First February 4, 2016.
A. Kate Fairweather-Schmidt and Tracey D. Wade, School of Psychol-
ogy, Flinders University.
The authors report no declarations of financial or conflicts of interest.
National Health and Medical Research Council (NHMRC) Grants 324715
and 480420 to Tracey D. Wade supported this work. Administrative
support for data collection was received from the Australian Twin Registry,
which is supported by an NHMRC Enabling Grant (ID 310667) adminis-
tered by the University of Melbourne. We thank the twins and their
families for their participation in this research, and Ms. Judith Slater for
coordinating the data collection.
Correspondence concerning this article should be addressed to Tracey D.
Wade, School of Psychology, Flinders University, GPO Box 2100, Ade-
laide, South Australia 5001, Australia. E-mail: tracey.wade@flinders
.edu.au
369
disorders by late adolescence is around 13% to 15% (Allen, Byrne,
Oddy, & Crosby, 2013; Stice, Marti, Shaw, & Jaconis, 2009; Wade &
O’Shea, 2015), and by early adulthood almost one in four women
report recent disordered eating, which is then associated with signif-
icantly poorer physical and psychological quality of life over a 9-year
follow-up period compared with women without disordered eating
(Wade, Wilksch, & Lee, 2012).
However, a number of studies have identified that disordered
eating does not increase uniformly for all adolescent girls, as
shown in Table 1. This is consistent with the substantial influence
of both genetic and environmental sources on disordered eating,
with an estimated median genetic variance of 52% (Culbert,
Racine, & Klump, 2015), which suggests that trajectory of growth
differs between groups who are differentially genetically suscep-
tible to exposure to the different levels of various risk factors
present in the environment. It is also consistent with the findings
of studies using sample means of disordered eating, which show no
coherent common trajectory across adolescence (Abebe, Lien, &
von Soest, 2012; Allen et al., 2013; Fairweather-Schmidt & Wade,
2015; Klump et al., 2007; Kotler, Cohen, Davies, Pine, & Walsh,
2001; Neumark-Sztainer, Wall, Larson, Eisenberg, & Loth, 2011).
 370 FAIRWEATHER-SCHMIDT AND WADE

Table 1
Studies Examining Trajectory of Disordered Eating (DE) Over Adolescence in Unselected Female Samples

N females Age at N waves of N disordered eating

Study baseline: M (SD) data collection DE measure trajectories: type (%)

Smith, Simmons, Flory, 394 3 Bulimia Test-Revised 4 binge eating: absence (77),
Annus, & Hill, 2007 (Thelen, Farmer, stable moderate (12),
Wonderlich, & Smith, increasing (7), decreasing
1991) from high to moderate (4)
12.84 (no SD 4 purging: absence (82),
reported) stable moderate (9),
increasing (8), decreasing
from high to moderate (1)
Aimé, Craig, Pepler, Jiang, & 426 4 Eating Attitudes Test 5: None (43), stable low
Connolly, 2008 (Garner & Garfinkel, level (29), high and
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1979) declining (16), chronic

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high (8), increasing (4)

15.2 (.92)
Fay & Lerner, 2013 714 3 2 subscales of the Eating 6 drive for thinness: low
Disorder Inventory stable (32), decreasing
(Garner et al., 1983): (24), increasing/decreasing
drive for thinness and (17), increasing (12), high
body dissatisfaction stable (7.5), very low
stable (7.5)
14.90 (1.00) 5 body dissatisfaction: low
stable (34), very low
stable (32), moderate
stable (27), high stable
(6), none stable (1)
Pearson & Smith, 2015 938 8 3 items from the Eating 4 binge eating: none (55),
Disorder Examination- decreasing (23), increasing
Questionnaire (12), high steady (10)
(Fairburn & Beglin,
1994)
11 years (no M or SD 3 purging: none (74), dabble
reported) (19), increasing (7)

Across the four studies that have examined the longitudinal
trajectories of disordered eating phenotypes in adolescent girls,
three to six trajectories have been identified (Aimé, Craig, Pepler,
Jiang, & Connolly, 2008; Fay & Lerner, 2013; Pearson & Smith,
2015; Smith, Simmons, Flory, Annus, & Hill, 2007), which sug-
gest that a “one size fits all” trajectory approach disregards differ-
ent growth curves. Consistent across different age groups and
phenotypes are trajectories that include absent or low levels of
disordered eating at all time points, decreasing levels of disordered
eating from a high level of symptoms, and an increasing level of
disordered eating. Also present can be moderate to high levels of
disordered eating across all time points. Across these studies the
largest group is represented by the “low stable” trajectory, ranging
from 32% to 82% of the sample. The group experiencing decreas-
ing symptoms ranges from 1% to 23%, and the most consistently
smallest group is represented by those experiencing an increase in
disordered eating over time (4%–12%).
These studies have shown a variety of variables to predict those
girls who experience increasing levels of disordered eating, par-
ticularly symptoms relating to binge eating and purging, which are
more common in older adolescence (Hudson, Hiripi, Pope, &
Kessler, 2007; Lewinsohn, Striegel-Moore, & Seeley, 2000). Aimé
et al. (2008) found that externalizing and internalizing behavior
problems predicted increased disordered eating. Fay and Lerner
(2013) found depressive symptoms predicted increased drive for
thinness, which was moderated by involvement in sports (i.e., a
longer duration of sport decreased the impact of depressive symp-
toms on drive for thinness). Smith et al. (2007) and Pearson and
Smith (2015) have examined predictors of increasing trajectories
of binge eating and purging in adolescent girls. Expectations that
eating and thinness would provide overgeneralized life improve-
ment (reinforcement expectancies) and a tendency to act rashly
when distressed (negative urgency) predicted increases in both
binge eating and purging. Additionally, increased risk of binge
eating behavior was predicted by higher levels of subjective dis-
tress. To date, however, theoretical justification of risk variables
investigated in this context has been sparse with some exceptions
(Pearson & Smith, 2015; Smith et al., 2007).
A number of theories suggest that many other variables may be
implicated as risk factors for increasing trajectories of disordered
eating. However, although numerous models of the development
of disordered eating have been posited in the literature, only 10
exist that have resulted in evaluated interventions, the efficacy of
which have provided validation of the informing model (Pennesi
& Wade, 2016). Across these 10 models (Augustus-Horvath &
Tylka, 2011; Cooper, Wells, & Todd, 2004; Fairburn, Cooper,
& Shafran, 2003; Lyon et al., 1997; Neumark-Sztainer, Wall,
Story, & Perry, 2003; Stice, 2001; Treasure & Schmidt, 2013;
Wildes, Ringham, & Marcus, 2010; Wilfley, Mackenzie, Welch,
Ayres, & Weissman, 2000; Yamamiya, Shroff, & Thompson,
2008) the types of variables most commonly included are preoc-
cupation with weight and shape, self-esteem deficits, emotional
 GROWTH MIXTURE MODELING OF EDE GLOBAL 371

regulation difficulties, and problems with interpersonal function- least a low stable trajectory in addition to both an increasing and
ing. Preoccupation with weight and shape includes constructs such decreasing trajectory. We also hypothesized that of all our theo-
as weight and shape concern, which refers to both body dissatis- retically justified risk factors, baseline internalization of the thin
faction and importance of control over weight, shape and eating, ideal, external pressure to be thin, and perfectionism would predict
the latter somewhat similar to the idea of reinforcement expectan- membership of the increasing trajectory.
cies. Self-esteem deficits includes low self-esteem, ineffectiveness
and low self-efficacy. Emotion regulation difficulties include
Method
mood intolerance, emotional distress, emotional dysregulation,
emotional avoidance, and negative urgency, which can lead to
emotional eating. Problems with interpersonal functioning include Participants and Procedure
both peer and family relationships.
The current study came from three waves of data from adoles-
The two most robust models identified in the literature (Pennesi
cent female–female twin pairs depicted in Figure 1, described
& Wade, 2016), as determined by their role in the development of
previously (Wade, Byrne, & Bryant-Waugh, 2008; Wade et al.,
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both efficacious and effective interventions, are the Dual Pathway

2013; Wilksch & Wade, 2009, 2010). At Wave 1, twin pairs who
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model (Stice, 2001) and the Transdiagnostic model (Fairburn et al.,

were between 12 and 15 years of age registered with the Australian
2003). These models further highlight the importance of internal-
Twin Registry (ATR) were approached, along with their parents,
ization of the media-presented body ideal as one’s own personal
to participate in the present study by the ATR. Seven hundred and
ideal (e.g., “I would like my body to look like people who are on
19 families were contacted and invited to participate, and of these
TV”), external pressure to be thin, and perfectionism. When inter-
411 (57.2%) agreed, 237 (32.9%) declined, and 71 (9.9%) did not
nalization is applied to females, the focus is on internalization of
reply. Researchers approached those agreeing to take part and sent
the thin ideal associated with Western culture, and the degree to
self-report questionnaires to both parents, including those families
which it is accepted and viewed as an appropriate standard for
where the parents did not live together. After parents returned the
one’s own appearance (Heinberg, Thompson, & Stormer, 1995),
questionnaires, the EDE (Fairburn & Cooper, 1993) was con-
despite the fact that for the vast majority of females this body
ducted by telephone, such that 699 twins were interviewed at
composition is very difficult to achieve (Thompson, van den Berg,
separate times with a different interviewer for each child in the
Roehrig, Guarda, & Heinberg, 2004). The Dual Pathway model
family. The sample was Caucasian and the socioeconomic indexes
informs a prevention approach named “The Body Project” for
for areas—a standardized measure of socioeconomic status with a
young women who experience body dissatisfaction, and change in
mean of 100 (SD ⫽ 15), using an amalgam of parental occupation,
internalization of the thin ideal has been shown to fully mediate the
education (years of school), and income from 2006 census data
effects of the program on change in body dissatisfaction, and to
related to the postcode of primary residence (Farish, 2004)—was
partially mediate changes in bulimic symptoms (Stice, Marti,
101.14 (SD ⫽ 11.36). The Flinders University Clinical Ethics
Rohde, & Shaw, 2011). The Transdiagnostic model, where per-
Committee approved the data collection process; parents gave
fectionism and low self-esteem are considered important pathways
written informed consent and twins gave written assent. All twins
to the development of disordered eating, has informed the devel-
were contacted again at Wave 2 and Wave 3 (including nonre-
opment of enhanced cognitive behavior therapy, considered the
sponders); the mean duration of time between Waves 1 and 2, and
treatment of choice for eating disorders where the body mass index
Waves 1 and 3, respectively, was 1.15 years (SD ⫽ 0.17), and 2.96
is greater than 17.5 (Fairburn et al., 2015; Poulsen et al., 2014).
years (SD ⫽ 0.27).
Therefore, the main purpose of the current study was to examine
the range of theoretically justified variables described above that
could be expected to predict growth of disordered eating in ado- Measures
lescent girls. Our disordered eating variable was derived from a
Disordered eating. The twin interview consisted of two parts
gold standard interview, namely the global score of the Eating
for Waves 1 and 2; the EDE (Fairburn & Cooper, 1993) and
Disorder Examination (EDE; Fairburn & Cooper, 1993). This
questions from self-report questionnaires assessing a range of
global score has been used as the primary indicator of outcome in
variables including weight-related peer teasing and life events
treatment trials of eating disorders, both anorexia nervosa and
(Wilksch & Wade, 2009, 2010). Parents also completed self-report
bulimia nervosa, in children and adults (Fairburn et al., 2009; le
questionnaires at Waves 1 and 2, including twin weight and height.
Grange, Crosby, Rathouz, & Leventhal, 2007; Lock et al., 2010;
The interview at Wave 3 comprised only the EDE interview.
Wade, Treasure, & Schmidt, 2011). It incorporates both cognitive
Sixteen postgraduate clinical psychology trainees competent in the
and behavioral indicators of disordered eating, but not the behav-
use of the EDE conducted all interviews.
iors included in the diagnostic criteria for eating disorders. As
The EDE interview generates a global measure of disordered
such, this represents the first study of trajectories of disordered
eating over the previous 28 days (22 items) that includes four
eating over adolescence that utilizes an interview rather than
subscales weight concern, shape concern, eating concern and di-
self-report. The EDE was used over three waves of data collection
etary restraint. The items related to importance of weight and
to assess disordered eating in adolescent female twins, and differ-
shape were adapted for the younger age of the sample simply by
ent trajectories over time were identified using growth mixture
encouraging participants to verbalize the list related to the follow-
modeling (GMM), which constitutes a “person-centered” approach
ing question:
while integrating variable-centered methodology (Muthén &
Muthén, 2000), known as cluster or latent class modeling. In line Imagine the things that influence how you feel about (judge, think,
with previous studies we hypothesized that we would identify at evaluate) yourself as a person—such as how you are doing at school,
 372 FAIRWEATHER-SCHMIDT AND WADE
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Figure 1. Flow diagram illustrating the data collection process over the three waves and their respective rates
of participation.

what sort of friend you are, how you get along with other people—and
put these things in order of importance, where does your weight/shape
fit in?”
The EDE is generally considered the “preeminent” eating dis-
order interview assessment tool with sound validity and reliability
(Berg, Peterson, Frazier, & Crow, 2011, 2012; Berg, Peterson, et
al., 2012). With the present data, the global EDE (Fairburn &
Cooper, 1993) has previously been found to possess construct and
convergent validly, in addition to factorial invariance, medium-
large cross-wave correlations and high internal reliability
(Fairweather-Schmidt & Wade, 2015). Additionally, the EDE also
contains behavioral diagnostic items, which were assessed over the
lifetime. Over the time frame that behaviors met Diagnostic and
Statistical Manual of Mental Disorders (5th ed.; American Psy-
chiatric Association, 2013) diagnostic criteria, the relevant cogni-
tive criteria at that time were also assessed. This information was
used to obtain diagnoses for threshold eating disorders using a
methodology that has been previously described, with interrater
diagnostic kappas ranging from 0.67 for bulimia nervosa to 1.00
(Fairweather-Schmidt & Wade, 2014).
Body mass index (BMI) centile. As data relating to parental
report of the twins’ weight and height were highly correlated, the
mothers’ report was used, aside from instances where these data were
missing, when the fathers’ report was used. At Wave 3, twins reported
their own weight and height. As recommended by the Center for
Disease Control we use BMI centile for this adolescent sample.
Measures of theoretical correlates and risk. These measures
were derived from Wave 1 self-report questionnaires completed in
 GROWTH MIXTURE MODELING OF EDE GLOBAL
an interview format, as comprehensively described previously
(Wilksch & Wade, 2010). We offer a brief description below along
with internal reliability from the current sample.
Preoccupation with weight and shape and self-esteem. Body
dissatisfaction (␣ ⫽ .91) and Ineffectiveness (␣ ⫽ .88) were measured
using the Eating Disorder Inventory (EDI; Garner, Olmstead, &
Polivy, 1983). The former subscale has been used reliability with
populations as young as 11 years (Meltzer et al., 2001) and shows
high test–retest reliability over a 3-week interval (r ⫽ .97; Wear &
Pratz, 1987). The total EDI has been shown to significantly discrim-
inate individuals diagnosed with anorexia nervosa from a sample
without anorexia nervosa (Garner et al., 1983).
Emotional regulation. Sensitivity to punishment (␣ ⫽ .74)
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and sensitivity to reward (␣ ⫽ .64) subscales, which tap into
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anxiety and impulsivity respectively, were drawn from the Sensi-
tivity to Punishment and Sensitivity to Reward Questionnaire
(Torrubia, Avila, Molto, & Caseras, 2001), which has been found
to have acceptable internal and test–retest reliability, as well as
construct validity (Torrubia et al., 2001). The first subscale has
been found to correlate positively with Eysenck Personality Ques-
tionnaire (EPQ: Eysenck & Eysenck, 1978) dimension of neurot-
icism (r ⫽ .69 in males and r ⫽ .47 in females). The second
subscale is positively associated with the EPQ impulsiveness scale,
with a correlation of 0.43.
Interpersonal function. The conflict subscale of the Family
Environment Scale (Moos & Moos, 1986) was used to measure
parental conflict (␣ ⫽ .81), and has shown good factorial validity
between two different samples of adolescents (Robertson & Hyde,
1982). Parental care (␣ ⫽ .91) was assessed with the parental care
subscale of the Parental Bonding Inventory (Parker, Tupling, &
Brown, 1979), which has good test–retest reliability, and strong
factorial structure in adolescent populations (Parker, 1990). Given
a high correlation between maternal and paternal scores (r ⫽ .77),
only the former were examined in the analyses.
Internalization of the thin ideal. Internalization of the thin
ideal (␣ ⫽ .89) was measured using a subscale from the Multidi-
mensional Media Influence Scale (Cusumano & Thompson, 2001),
which has been demonstrated to correlate significantly and posi-
tively with body dissatisfaction among girls ages 8 –11 years.
External pressure to be thin. The Perceived Sociocultural
Pressure Scale (␣ ⫽ .80) assessed levels of perceived pressure to
be thin from friends, family, media and dating partners (Stice,
Ziemba, Margolis, & Flick, 1996) and significantly correlates with
recollection of pressure to lose weight in childhood (r ⫽ .51; Stice
et al., 1996). Weight-related peer teasing (␣ ⫽ .87) was measured
using the McKnight Risk Factor Survey (The McKnight Investi-
gators, 2003) and has shown good predictive ability in children for
detecting development of eating disorders (Field et al., 2008).
Perfectionism. Concern over mistakes (␣ ⫽ .87), parental ex-
pectations (␣ ⫽ .72) and parental criticism (␣ ⫽ .78) were measured
using the Multidimensional Perfectionism Scale (FMPS; Frost, Mar-
ten, Lahart, & Rosenblate, 1990). The FMPS possesses robust psy-
chometrics, and is used widely in eating disorder research. Conver-
gent validity has been demonstrated with the Perfectionism subscales
of the EDI within a sample with anorexia nervosa (r ⫽ .59; Garner et
al., 1983). The “just right” subscale (␣ ⫽ .85) from the Vancouver
Obsessional Compulsive Inventory has good convergent and discrim-
inant validity (Thordarson et al., 2004).
373
Statistical Analysis
Patterns of missing data. An outcome variable was formulated
for those who completed all three waves of data collection (71% of
the sample) versus those who completed less than 3. Generalized
estimating equation (GEE) models were undertaken specifying a
binomial model with a logit link function in order to examine if any
baseline variables differentiated between these two groups. To ac-
count for the nonindependence of these data, twins were clustered by
family (Hanley, Negassa, Edwardes, & Forrester, 2003).
Derivation of latent classes. Initially, two linear mixed mod-
els (LMM; unconditional means model, and unconditional growth
model) were used to determine whether significant variance in the
EDE global score could be related time. LMM is able to accom-
modate correlated observations and statistical nonindependence
(required due to the correlated nature of twin data) and is asymp-
totically efficient with unbalanced data. Using means and standard
deviations of existing data points, LMM employs restricted max-
imum likelihood approach (Nich & Carroll, 1997) to estimation of
missing at random data (Han & Guo, 2014), and is considered a
more accurate way of dealing with missing data such as
expectation-maximization algorithm (von Hippel, 2007).
The EDE global score over the three waves of data collection
was investigated using GMM, which provides a structure for post
hoc derivation and description of group differences over time
(Ram & Grimm, 2009), and constitutes an approach adopted by the
majority of the studies pertinent to this investigation (e.g., Fay &
Lerner, 2013; Pearson & Smith, 2015; Smith et al., 2007). Broadly,
theory, extant research findings, clinical knowledge and statistical
fit indices are all necessary tenets in the decision making process
to determine number of classes.
The determination of the optimal number of classes is informed
by fit statistics, usually constituting Akaike information criteria
(AIC), Bayesian information criteria (BIC), and sample-size ad-
justed BIC (ABIC). Better fitting models generally produce lower
absolute values (Muthén, 2003; Nylund, Asparouhov, & Muthén,
2007). Subsequently, models can also be evaluated by classifica-
tion precision or entropy, where higher values (where 1 denotes
perfect classification, high entropy values ⬎0.8) are indicative of
greater precision, and identify the preferred model in the event that
relative fit indices are essentially equivalent (Muthén, 2004). Fi-
nally, likelihood ratio tests, such as Vuong–Lo–Mendell–Rubin
likelihood ratio test (VLMR-LRT) and adjusted Lo–Mendell–
Rubin likelihood ratio test (Adjusted LRT), compare a model with
C classes with an analogous model with one fewer classes (i.e.,
C-1). All models adjusted for age at Wave 1, and accommodated
correlated observations and statistical nonindependence by clus-
tering within families. Analyses were undertaken with Mplus
version 7.11 (for Mac; Muthén & Muthén, 1999 –2010).
Characteristics of latent classes. First, across the identified
latent classes; participants were described in relation to the (a) pres-
ence of lifetime eating disorder, and (b) timing of first eating disorder
diagnosis. Comparisons were initially undertaken with the crosstab
function. To investigate the relative likelihoods of a lifetime eating
disorder across trajectory classes, GEE models were used. To account
for the nonindependence of these data, twins were clustered by family
(Hanley et al., 2003). Second, using LMM, our theoretical correlates
and risk factors were compared across the trajectory classes for
 374 FAIRWEATHER-SCHMIDT AND WADE

variables available at Waves 1 and 2. Models incorporated Bonferroni
adjustment for multiple comparisons.
Risk factors. GEE modeling was used to identify Wave 1
variables distinguishing the different trajectory classes. Signifi-
cance was adjusted using Bonferroni-corrected levels appropriate
for the multiple and post hoc testing required when undertaking a
number of comparisons. Initially, GEE were univariate, and vari-
ables with p values ⬍0.1 were subsequently simultaneously en-
tered into a multivariate model to determine the predictors inde-
pendently discriminating between a low-static and escalating class.
Analyses incorporated Bonferroni adjustment for multiple com-
parisons and were undertaken with SPSS version 22.
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model with an analogous model with one fewer class, and
indicated that in all instances (models for C2–C5) the C-1
model could not be rejected in favor of the C model.
Current recommendations (e.g., Ram & Grimm, 2009) encour-
age model selection to be driven by all available fit indices in
partnership with domain specific theory and existing research
findings. Although the four-class model had slightly better fit in
terms of AIC/BIC (but very similar entropy), it had very small
numbers in one of the four classes (only 2% of the sample), and
split the increasing trajectory into two inclines. Further, the 3-class
model was more consistent with previous pertinent trajectory
studies (e.g., Pearson & Smith, 2015), in which the increasing
classes were amalgamated. Therefore, we decided that the three-

Results class model was most appropriate for these data based on extant
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theory and empirical findings (e.g., Hudson Hiripi et al., 2007;

Patterns of Missing Data Pearson & Smith, 2015; Stice, Killen, Hayward, & Taylor, 1998).
Analysis of baseline predictors of participation across all three Figure 2 depicts these three classes as unique trajectories: Class 1
waves compared with participation in less than three waves indi- was low and horizontal, termed low-static, showing no change
cate no difference between key study variables (Table 2). There- over time; Class 2 was characterized by a decreasing EDE global
fore data was interpreted as being missing at random. score over time, termed attenuating; Class 3 increased, and was
termed escalating.
Identification of Trajectories of Growth of
Disordered Eating
Characteristics of the Latent Classes
Unconditional means model showed significant variance in
the EDE global, F(1, 353.93) ⫽ 283.28, p ⬍ .001, which the Table 4 presents the numbers and respective proportions of
unconditional growth model indicated was unrelated to time, eating disorders associated with each latent class. In low-static,
F(1, 1592.10) ⫽ 0.46, p ⫽ 0.50. Six models (specifying 1 about one third of eating disorders were diagnosed at each of the
through to 6 latent classes) were run with the EDE global score three waves. In contrast, the vast majority of eating disorders in
across the three waves of data. In order to identify the most attenuating were diagnosed at the first wave, whereas 84.2% of the
robust model for these observed data, three indicators of model eating disorders in escalating were diagnosed subsequent to Wave
fit were consulted. The first, the information criteria (AIC, BIC 1. Further GEE analyses identified that, relative to low-static, odds
and ABIC), are reported in Table 3. Each of AIC, BIC and of having any lifetime eating disorder were significantly elevated
ABIC criteria incrementally decreased with increasing numbers for attenuating (odds ratio [OR] ⫽ 10.36, 95% confidence interval
of latent classes specified. Second, increasing the number of [CI] [5.52, 19.45]), and escalating (OR ⫽ 34.63, 95% CI [12.49,
classes resulted in deteriorating accuracy of group membership 95.98]).
classification (entropy), where classification confidence was Table 5 presents comparisons of age-adjusted means (standard
lowest for the 6-class model. Third, likelihood ratio tests errors) and effect sizes for eating disorder risk factors for each of
(VLMR-LRT and adjusted LRT) were used to compare each
the three latent classes. At Wave 1, the majority of variables
showed attenuating to be significantly higher than low-static on the
Table 2 majority of risk factors, consistent with the finding that most of
Baseline Predictors of Participation at All Three Waves Versus those reporting a lifetime eating disorder in this group experienced
Less Than 3 Waves this earlier in adolescence. Despite the fact that most of the eating
disorders in the escalating trajectory group did not emerge until
Variable Wald ␹2(p) Exp B (95% CI) Waves 2 and 3, four key risk variables (ineffectiveness, internal-
Peer teasing 0.16 (.68) 0.98 [0.86, 1.10] ization of the thin ideal, body dissatisfaction, pressure to be thin)
Internalization of thin ideal 0.01 (.93) 1.00 [0.93, 1.08] were already significantly higher at Wave 1 compared with low-
Ineffectiveness 0.16 (.69) 0.98 [0.89, 1.08] static. However, mean scores on the aforementioned variables
Body dissatisfaction 1.43 (.23) 0.97 [0.93, 1.02]
were still notably lower in the escalating group compared with the
Concern over mistakes 1.43 (.23) 0.93 [0.83, 1.05]
Sensitivity to punishment 0.00 (.99) 1.00 [0.90, 1.11] attenuating group.
Sensitivity to reward 0.42 (.52) 0.97 [0.89, 1.06] Although the BMI centile were relatively comparable among the
Just right 0.09 (.76) 0.99 [0.95, 1.04] three classes at Wave 2, the EDE global score significantly dis-
Pressure to be thin 1.34 (.25) 0.92 [0.79, 1.06]
BMI centile 0.07 (.80) 1.00 [0.999, 1.002] criminated between low-static and the other two classes. However,
Global EDE 0.52 (.47) 0.96 [0.85, 1.08] there was little to distinguish attenuating and escalating trajectories
Age 0.15 (.70) 1.04 [0.85, 1.28] at this assessment point. Contrastingly, at Wave 3 the EDE global
Note. Exp ⫽ exponent; CI ⫽ confidence interval; BMI ⫽ body mass was now clearly highest in the escalating group, whereas low-static
index; EDE ⫽ Eating Disorder Examination. had the lowest (significantly) EDE global score.
 GROWTH MIXTURE MODELING OF EDE GLOBAL 375

Table 3
Information Criteria for Growth Mixture Modeling With 1– 6 Classes

Fit statistics
No. of free
Classes parameters AIC BIC ABIC Entropy LRTb p

Nc ⫽ 1 10 3,432.19 3,477.67 3,445.92

Nc ⫽ 2 14 3,017.81 3,081.48 3,037.03 .972 .072/.077
Nc ⫽ 3 18 2,789.71 2,871.58 2,814.42 .967 .256/.266
Nc ⫽ 4 22 2,622.64 2,722.71 2,652.85 .949 .062/.066
Nc ⫽ 5 26 2,521.46 2,639.71 2,557.15 .947 .707/.697
Nc ⫽ 6 30 2,459.04a 2,595.48 2,500.23 .944 a

Note. AIC ⫽ Akaike information criteria; BIC ⫽ Bayesian information criteria; ABIC ⫽ sample size adjusted BIC; LRT ⫽ likelihood ratio tests; N ⫽
number; c ⫽ classes.
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a
Starting value run(s) did not converge. b LRT (e.g., Vuong–Lo–Mendell–Rubin likelihood ratio tests; Lo–Mendell–Rubin adjusted LRT test) quantify
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specific comparisons between the model of interest and a model with one fewer class, C-1.

Baseline Factors Distinguishing Escalating From
Flat-Static Groups
Correlations between the global EDE and Wave 1 risk factors is
provided in the online supplement table, and ranged from 0.105
(parental expectations) to 0.686 (body dissatisfaction). After ad-
justing for age, BMI centile and zygosity, univariate GEE analyses
identified 5 of 13 theoretically important variables significantly
differentiated escalating from those in low-static as shown in Table
6. These five variables (p ⬍ .05) were simultaneously entered into
a multivariable model, which revealed that internalization of the
thin ideal (OR ⫽ 2.47, 95% CI [1.36, 4.49]) was the only factor to
uniquely discriminate the escalating from low-static trajectory.
Discussion
Consistent with some previous studies (Allen et al., 2013;
Fairweather-Schmidt & Wade, 2015) our analyses showed no
evidence of mean levels of EDE global scores increasing among
adolescent females over time, although significant variance in
these scores existed across adolescence. In line with our first
hypothesis, we were able to identify three different trajectories of
Figure 2. Trajectories of three latent classes of mean Eating Disorder
Examination (EDE) global scores identified by growth mixture model-
ing analyses across three data points. These trajectories represent raw
mean EDE global scores for Waves 1–3 (edew1– edew3). Class 1 ⫽
low-static, n ⫽ 627; Class 2 ⫽ attenuating, n ⫽ 47; and, Class 3 ⫽
escalating, n ⫽ 24.
disordered eating, based on model fit and extant empirical findings
(Aimé et al., 2008; Fay & Lerner, 2013; Pearson & Smith, 2015;
Smith et al., 2007), namely low-static, attenuating, and escalating
over time. In other words, this supports the suggestion that the
reason we do not observe sample-wide mean increases in EDE
global with age is that different youth proceed along different
trajectories, with some scores going down, others going up, and
others staying the same.
We were able to identify a number of correlates for each
class—with the exception to the low-static trajectory that was
characterized by a lack of EDE score growth over adolescence, and
little variation in the proportion of those first diagnosed with an
eating disorder at each time point. Further, the low-static trajectory
had a relatively low prevalence (9.9%) of lifetime eating disorders,
and a reasonably stable BMI centile over time (around 50th per-
centile). The second identifiable trajectory, attenuating, was pri-
marily distinguishable by decreasing growth and a noticeably
elevated baseline BMI centile. Accordingly, although approxi-
mately half of these adolescents had a lifetime eating disorder
diagnosis, two thirds of the eating disorder diagnoses were present
at the first wave. In view of the early onset of the attenuating
trajectory, it is unsurprising 12 of the 13 theoretical risk factors
were elevated, and significantly distinguishable from the low-static
trajectory. The third trajectory was discernible from the other
classes by elevated growth over adolescence. Although the vast
majority of first time diagnoses in this escalating group were made
later in adolescence, significant differences from the low-static
trajectory were already observable at Wave 1— especially BMI
centile, ineffectiveness, internalization of the thin ideal, body
dissatisfaction, perceived pressure to be thin, and weight related
peer teasing.
The global EDE score was also found to robustly indicate
probability of future clinical diagnoses, as 84% of those in the
escalating trajectory group reported subsequent lifetime eating
disorders in mid to late adolescence. Thus, there appears to be
significant utility in use of EDE global information, the benefit of
which may reside in the detection of a preventive window inferred
by an early elevation in EDE global scores. Further, relative to the
low-static trajectory, the escalating trajectory was much more
likely to have a lifetime eating disorder diagnosis, suggesting that
the identification of key discriminating variables for these groups
may provide opportunities to arrest DE development.
 376 FAIRWEATHER-SCHMIDT AND WADE

Table 4
Proportions by Latent Class Detailing Time of First Eating Disorder Diagnosis and Presence of
Lifetime Eating Disorders

Class 1 low-static, Class 2 attenuating, Class 3 escalating,

Variable N ⫽ 627, N (%) N ⫽ 47, N (%) N ⫽ 24, N (%)

Lifetime eating disorder 62 (9.89) 25 (53.19) 19 (79.17)

First diagnosed with eating disorder
Wave 1 18 (29.03) 16 (64.00) 3 (15.78)
Wave 2 20 (32.26) 8 (32.00) 8 (42.11)
Wave 3 24 (38.71) 1 (4.00) 8 (42.11)

In addressing our main aim, we undertook univariate and mul- Braet, 2011; Cafri, Yamamiya, Brannick, & Thompson, 2005).
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

tivariate analyses to identify whether theoretically derived risk There is considerable evidence supporting this proposition, includ-
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factors were able to differentiate between the low-static and esca-
lating trajectories. Univariate analyses identified a number of
predictors, including anxiety, ineffectiveness, body dissatisfaction,
internalization of the thin ideal and pressure to be thin. Partially
consistent with our second hypothesis, only one variable, internal-
ization of the thin ideal, significantly discriminated these two
populations in the multivariate analysis, where a subpopulation
characterized by an escalating trajectory of disordered eating
across adolescence was associated with higher baseline internal-
ization of the thin ideal.
There are two components related to internalization of the thin
ideal. The first is exposure to the unrealistic degree of thinness
valued by the Western beauty ideal, which does predict disordered
eating, including clinical eating disorders (Boone, Soenens, &
ing studies of cultural change as their exposure to Western culture
increases (Becker, Gilman, & Burwell, 2005; Hoek et al., 2005;
Pavlova, Uher, Dragomirecka, & Papezova, 2010).
However, although psychosocial/cultural influences have gen-
erally been considered responsible for the promotion of thin ideal
(Polivy & Herman, 2002), the broad exposure of society to ideal-
ized media images of slimness begs the question as to why a
smaller proportion of women progress to developing eating disor-
ders in Westernized societies, whereas the majority do not (Polivy
& Herman, 2004). This points to the second component of inter-
nalization of the thin ideal, which is the adoption of this ideal for
oneself, and an aspiration to work toward this ideal. Contemporary
work suggests that expectancies that thinness would provide over-
generalized life improvement including intra- and interpersonal

Table 5
Age-Adjusted Characteristics of the Latent Classes

Class 1 low-static Class 2 attenuating Class 3 escalating

Variable (N ⫽ 627) M (SE) (N ⫽ 47) M (SE) (N ⫽ 24) M (SE) F(df), ES

BMI centile Wave 1 50.33 (1.20)a 68.98 (4.41)b 60.14 (4.16)b 9.22 (694)ⴱ, 0.23
EDE global Wave 1 0.26 (0.02)a 2.34 (0.06)b 0.91 (0.08)c 694.81 (694)ⴱ, 2.00
BMI centile Wave 2 54.67 (1.78) 61.57 (5.33) 55.53 (12.46) .75 (328), .10
EDE global Wave 2 0.25 (0.02)a 1.07 (0.09)b 1.12 (0.08)c 163.96 (663)ⴱ, .99
BMI centile Wave 3 50.68 (1.64) 64.10 (6.40) 61.36 (8.24) 2.73 (331), .18
EDE global Wave 3 0.28 (0.02)a 0.89 (0.07)b 2.81 (0.11)c 302.92 (494)ⴱ, 1.56
Preoccupation with weight and shape and self-esteem
Body dissatisfaction 2.26 (0.04)a 4.30 (0.14)b 3.00 (0.20)c 101.21 (693)ⴱ, .76
Ineffectiveness 1.78 (0.03)a 3.10 (0.10)b 2.31 (0.14)c 47.94 (693)ⴱ, .71
Emotional regulation
Sensitivity to reward 2.17 (0.01)a 2.36 (0.05)b 2.28 (0.07) 4.66 (694)ⴱ, .22
Sensitivity to punishment 2.24 (0.02)a 2.82 (0.08)b 2.48 (0.11)a 28.65 (694)ⴱ, .41
Interpersonal function
Parental conflict 1.87 (0.02)a 2.01 (0.06)b 2.02 (0.08) 4.67 (674)ⴱ, .17
Mother’s care 2.39 (0.02)a 2.06 (0.06)b 2.29 (0.08) 14.28 (692)ⴱ, .29
Internalization of the thin ideal
Internalization of the thin ideal 1.51 (0.03)a 2.74 (.10)b 2.15 (0.13)c 93.65 (694)ⴱ, .73
External pressure to be thin
Perceived pressure to be thin 1.28 (0.02)a 2.13 (0.06)b 1.52 (0.08)c 96.12 (692)ⴱ, .75
Peer teasing 1.35 (0.02)a 2.40 (0.07)b 1.52 (0.10)a 96.65 (694)ⴱ, .75
Perfectionism
Parental expectations 2.31 (0.02) 2.41 (0.07) 2.44 (0.10) 1.44 (693), .09
Parental criticism 1.74 (0.02)a 2.05 (0.07)b 1.78 (0.06) 10.55 (693)ⴱ, .25
Concern over mistakes 1.65 (0.02)a 2.03 (0.06)b 1.78 (0.09) 17.80 (694)ⴱ, .32
Just right 0.60 (0.02)a 1.13 (0.08)b 0.70 (0.11)a 20.49 (693)ⴱ, .34
Note. Post hoc comparisons Bonferroni-adjusted and use alphabetical superscripts to indicate where significant differences between groups exist. BMI ⫽
body mass index; EDE ⫽ Eating Disorder Examination.
ⴱ
p ⬍ .05.
 GROWTH MIXTURE MODELING OF EDE GLOBAL 377

Table 6 predicated on the statistical and theoretical decisions during

Risk Factors Distinguishing Low-Static From Escalating Classes model specification. Although the number and various trajec-
tories of the classes identified in the present investigation make
Univariatea OR Multivariatea sense, further research with alternative data is needed to support
Wave 1 variable (95% CI) OR (95% CI)
these extant findings. Second, baseline response rate was 49%,
Concern about mistakes 2.08 [0.77, 5.61] but this equates with other large longitudinal epidemiological
Just right 1.37 [0.75, 2.49] studies of twins and singletons (Anstey et al., 2012; Wade,
Sensitivity to punishment 2.64 [1.21, 5.74] 1.33 [0.58, 3.05]
Bergin, Tiggemann, Bulik, & Fairburn, 2006). Third, it is
Sensitivity to reward 2.97 [0.60, 14.64]
Ineffectiveness 2.42 [1.52, 3.87] 1.53 [0.87, 2.69] possible that the use of the father’ report when the mother’s
Body dissatisfaction 1.99 [1.33, 2.98] 1.25 [0.76, 2.06] report was unavailable may have introduced greater variability,
Peer teasing 1.57 [0.82, 3.02] and potentially error, in the estimates of BMI centile. Addi-
Perceived pressure to be thin 2.84 [1.37, 5.89] 0.73 [0.25, 2.13] tional error may also have been introduced by transitioning
Internalization of the thin ideal 3.19 [1.89, 5.39] 2.47 [1.36, 4.49]
Mother’s care 0.57 [0.19, 1.73] from parental reporting of weight at Wave 1 and 2, to self-
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Parental conflict 1.40 [0.64, 3.03] reported weight by twins at Wave 3. Finally, participants re-
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Parental expectations 1.56 [0.70, 3.49]
Parental criticism 2.05 [0.74, 5.69]
Note. Bolded univariate predictors met significance of p ⬍ .05, and were
carried into the multivariate model. OR ⫽ odds ratio; CI ⫽ confidence
interval.
a
Model adjusted for Wave 1 age, Wave 1 body mass index centile, and
zygosity.
life functioning (Simmons, Smith, & Hill, 2002) increases risk for
the development of bingeing and purging in girls ages 11–15 years
(Pearson & Smith, 2015). Similarly, importance of control over
weight and shape, which forms part of the diagnostic criteria for
both anorexia nervosa and bulimia nervosa, and has been described
as the “core psychopathology” of eating disorders (Fairburn &
Cooper, 1993), has been found to predict the growth of disordered
eating behaviors in young adolescent girls (Wilksch & Wade,
2010). This construct is defined in the EDE as the degree to which
weight or shape influence how you feel about (judge, think,
evaluate) yourself as a person. Variation in expectancies for over-
generalized life improvement from thinness and in attaching im-
portance to control over weight and shape may lead to variation in
internalization of the thin ideal.
The belief that control over eating and weight will make life better
is also captured in qualitative research with anorexia nervosa (Serpell,
Treasure, Teasdale, & Sullivan, 1999; Sternheim et al., 2012), sug-
gesting that the pursuit of low weight addresses a sense of ineffec-
tiveness, makes the person feel safe, helps communicate distress
related to possible rejection and abandonment, and moderates the
experience of negative emotions. Heritability plays a significant role
in relation to internalization of the thin ideal (Suisman et al., 2012),
potentially explaining why some individuals more readily internalize
sociocultural messages compared with others. Similarly, importance
of weight and shape has also been found to be influenced significantly
by heritability, with a variance of 48% and 95% CIs ranging from
40 –56 (Wade, Zhu, & Martin, 2011).
Strengths, Limitations and Implications
This study was able to identify and characterize longitudinal
changes in EDE global trajectories of subpopulations of female
adolescent twins. However, there are important limitations that
inform interpretation of our results. First, GMM is best de-
scribed as a post hoc “constrained exploratory technique” (au-
thors’ emphasis, Ram & Grimm, 2009, p. 575) that has the
capacity to reveal latent patterns of change. However, these are
porting disordered eating at Wave 1 were offered referrals,
which may have influenced subsequent levels of disordered
eating at Waves 2 and 3.
By employing GMM methodology to describe latent subpopu-
lations within EDE global data, this investigation has been able to
pursue an approach more sympathetic to dimensional psychiatric
nosology, recently receiving further attention and support (e.g.,
Wildes & Marcus, 2013). Using the EDE global as a screening tool
at early adolescence may offer vital intervention opportunities that
could curtail development of eating disorders typically emerging
later in early adulthood. Future research could address which of the
EDE global items are most discriminatory for the purpose of
identifying future risk, in order to formulate a shorter measure that
is more likely to be used in population settings.
Given the significant link between internalization and disordered
eating, two important implications arise. The first is of the fundamen-
tal importance of efforts that concentrate on reducing the potency of
the thin ideal message. It is noteworthy that prevention approaches
that focus on equipping young people with skills to stand up to this
ideal are among the most successful for decreasing risk for disorder
eating, including the use of media literacy in universal prevention
(Wilksch et al., 2015) and cognitive dissonance in selective preven-
tion (Stice, Presnell, Gau, & Shaw, 2007). Second, strategies to
strengthen emotional regulation and problem solving such that an
escape to control over weight, shape and appearance is not substituted
for facing, and dealing with, life stressors and challenges continues to
be a priority. The connection between such strategies and the preven-
tion of disordered eating has shown some promise in older female
adolescents (Atkinson & Wade, 2015).
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Received September 22, 2015
Revision received December 21, 2015
Accepted December 25, 2015 䡲