Eur Child Adolesc Psychiatry
DOI 10.1007/s00787-014-0610-3
ORIGINAL CONTRIBUTION
Eating disorder symptoms do not just disappear: the implications
of adolescent eating-disordered behaviour for body weight
and mental health in young adulthood
Beate Herpertz-Dahlmann • Astrid Dempfle •
Kerstin Konrad • Fionna Klasen • Ulrike Ravens-Sieberer
The BELLA study group
Received: 30 April 2014 / Accepted: 22 August 2014
Ó Springer-Verlag Berlin Heidelberg 2014
Abstract This study reports the outcomes of childhood
and adolescent eating-disordered behaviour on the devel-
opment of body mass index (BMI) and psychological
functioning in young adulthood in a population-based
sample in Germany (the BELLA study). Information at
baseline and follow-up was obtained through a telephone
interview and mailed self-report questionnaires. At both
measurement points, BMI, eating disorder symptoms
(SCOFF questionnaire), and symptoms of depression and
anxiety were assessed in the same cohort of 771 partici-
pants (n = 420 females, n = 351 males). The age range at
baseline was 11–17 years, and the age range at follow-up
Members of the BELLA study group are: Ulrike Ravens-Sieberer and
Fionna Klasen, Hamburg (Principal Investigators), Claus Barkmann,
Hamburg; Monika Bullinger, Hamburg; Manfred Döpfner, Köln;
Beate Herpertz-Dahlmann, Aachen; Heike Hölling, Berlin; Franz
Resch, Heidelberg; Aribert Rothenberger, Göttingen; Sylvia
Schneider, Bochum; Michael Schulte-Markwort, Hamburg; Robert
Schlack, Berlin; Frank Verhulst, Rotterdam; Hans-Ulrich Wittchen,
Dresden.
Electronic supplementary material The online version of this
article (doi:10.1007/s00787-014-0610-3) contains supplementary
material, which is available to authorized users.
B. Herpertz-Dahlmann (&)
K. Konrad
Department of Child and Adolescent Psychiatry, Psychosomatics
and Psychotherapy, University Clinics, RWTH Aachen,
Neuenhofer Weg 21, 52074 Aachen, Germany
e-mail: bherpertz-dahlmann@ukaachen.de
A. Dempfle
Institute of Medical Biometry and Epidemiology,
Philipps-University Marburg, Marburg, Germany
F. Klasen
U. Ravens-Sieberer
Department of Child and Adolescent Psychiatry, Psychotherapy,
and Psychosomatics, University Medical Center Hamburg-
Eppendorf, Hamburg, Germany
•
was 17–23 years. High scores for eating-disordered
behaviour in childhood or adolescence significantly pre-
dicted eating-disordered behaviour in young adulthood
(multiplicative effect estimate: 1.31; 95 % CI: 1.2–1.42,
p \ 0.0001), although there was a decline in prevalence
(from 19.3 to 13.8 %, p = 0.002) and severity (mean
decrease in SCOFF 0.07, 95 % CI: -0.01–0.14, p = 0.06).
After accounting for potentially confounding variables at
baseline (SES, probands’ BMI, parental BMI, depressive
symptoms), participants with more eating disorder symp-
toms at baseline had a higher risk of developing overweight
(odds ratio (OR): 1.58; 95 % CI: 1.19–2.09, p = 0.001),
obesity (OR = 1.67; 95 % CI: 1.03–2.66, p = 0.03), and
depressive symptoms at follow-up (additive effect esti-
mate: 0.45; 95 %CI: 0.19–0.7, p = 0.0006). Early symp-
toms of depression showed a significant relationship with
extreme underweight in young adulthood (OR = 1.13;
95 %CI: 1.01–1.25, p = 0.02). The high stability of eating
disorder symptoms and the significant association with
overweight and worse mental health in adulthood under-
score the need for early detection and intervention during
childhood and adolescence. Youth with depression should
be monitored for the development of restrictive eating
disorders.
Keywords Eating disorders
Adolescence
Young
adulthood
BELLA study
Overweight
Depression

Anorexia nervosa
Introduction
Obesity and eating disorders (ED) are listed amongst the
three most common chronic illnesses amongst youth [1].
Recent epidemiological studies on ED according to DSM-
123

IV have reported prevalence rates in the US and Europe of
approximately 3–6 % in the adolescent population [2, 3]
and 10 % in the general adult population [4], with only a
minority seeking treatment [4]. During the last decade,
there has been a substantial increase in the incidence of ED
in 15- to 19-year-olds [5], especially unspecified ED [6].
The prevalence of eating-disordered behaviour (without
fulfilling all classification criteria) is even higher. In our
previous study, approximately one-third of girls and 15 %
of boys reported disordered eating attitudes and behaviour
(the BELLA study, Germany [7]). In the German ‘‘Health
Behaviour in School-aged Children’’ (HBSC) study,
approximately one-half of girls and one-third of boys in the
11- to 15-year-old sample complained of being too fat; at
the time of the investigation, approximately 20 % of the
girls practised dieting (data from HBSC Germany
2009/2010, [8]). Longitudinal studies investigating the
course of disordered eating from adolescence to young
adulthood in the community are limited in number and
have yielded heterogeneous results, most likely due to
relatively small sample sizes, different study designs or
selection of patients. Whilst several recent studies have
demonstrated that ED and eating-disordered behaviour are
stable from early adolescence to young adulthood [9–11],
other previous studies did not find evidence of continuity of
this behaviour in the majority of subjects [12, 13]. In the
majority of studies, continued eating-disordered behaviour
was accompanied by a wide range of psychopathology and
the development of obesity [11, 12, 14]. In a recent pro-
spective study of males and females followed from 14 to
20 years of age by Allen et al. [15], all ED diagnoses at all
time points were associated with depressive symptoms and
poor mental health quality of life. Key factors identified as
predictive for persistent disordered eating include weight
concerns, body dissatisfaction, weight importance,
unhealthy weight control behaviours and dieting, depres-
sive symptoms [9, 16], food-related parental practises [17],
and disturbed family cohesion [12], as well as higher
exposure to media influences [18].
Internalising mental disorders, such as depression, early
in youth may also be a risk factor for the development of
obesity [19]. However, there is little research on whether
symptoms of depression or anxiety might also promote the
development of eating-disordered behaviour.
The present investigation is based on a previous survey
of eating-disordered behaviour and attitudes, BMI, and
mental health problems in a large representative sample of
11- to 17-year-olds in Germany (the BELLA study) [7],
which was followed up 6–7 years later. The aim of the
current follow-up study was to investigate the stability of
eating-disordered behaviour, its effect on the development
of over- and underweight, and its contribution to adverse
outcomes in mental health, especially depressive states in
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Eur Child Adolesc Psychiatry
young adulthood. In addition, the reciprocal relationship
between early symptoms of depression and anxiety with
later disordered eating and extreme weight was examined.
Methods
Baseline data of the mental health module of the German
Health Interview and Examination Survey for Children and
Adolescents (KiGGS), conducted by the Robert Koch
Institute (the BELLA study), were collected between 2003
and 2006. Additional measurements were from 2004 to
2007 and from 2005 to 2008. The 6-year follow-up was
performed between 2009 and 2012 (for more detailed
information, see Ravens-Sieberer et al. this issue [20]).
Specially trained interviewers conducted a computer-
assisted interview with the children and adolescents and
one of their parents. In addition, participants completed a
questionnaire that was sent and returned by mail. Approval
for the BELLA study was obtained from the ethics com-
mittee of the University Hospital Charité in Berlin and the
Federal Commissioner for Data Protection in Germany.
As we were interested in the long-term course of eating-
disordered behaviour, and a disorder status in adolescence
is typically the strongest diagnostic predictor of having the
same disorder in adulthood [21], we analysed only the
6-year follow-up data.
Participants
Of the 2,863 probands participating in the BELLA study at
baseline, 1,734 (60.6 %) were in the age range
(11–18 years) to be interviewed and appropriate for the
SCOFF (see below) and depression and anxiety question-
naires (see below). Of all the BELLA baseline participants,
1,429 (49.9 %) took part in the 6-year follow-up; of those
775 (44.7 %) had been in the baseline age range of
11–18 years. Amongst these, sufficient baseline data
regarding BMI, ED behaviour and internalising disorders
(symptoms of depressive and anxiety disorders), and fol-
low-up reports were available for 771 children and ado-
lescents. Similar to the whole sample (see [20]), dropout at
the 6-year follow-up was significantly related to lower
socioeconomic status at baseline (p \ 0.0001); addition-
ally, the dropout group included more males (p = 0.001,
53 vs. 47 %) and slightly younger participants (p = 0.007,
mean difference = 3 months). Importantly, those with
6-year follow-up data did not differ significantly from
dropouts in symptoms of depression (p = 0.1) or anxiety
(p = 0.3) at baseline and reported only slightly more eat-
ing-disordered behaviour at baseline (p = 0.01). Demo-
graphic data are presented in Table 1. The mean age at
baseline and follow-up was 14 and 21 years, respectively.
Eur Child Adolesc Psychiatry

Table 1 Descriptive data on the sample high, the positive predictive value is low; that is, the
n %
SCOFF has a tendency towards overinclusion (for more
detailed information, see Herpertz-Dahlmann et al. [7,
Male sex 351 45.5 23]).
Female sex 420 54.5 In this study as well as in others [27], the SCOFF was
Socioeconomic status (baseline) used to investigate eating-disordered behaviour and atti-
Low 139 18.1 tudes. Associations between single positive and the number
Medium 379 49.2 of positive SCOFF items and mental health outcome
High 252 32.7 variables and over- and underweight were assessed.
Mean SD Min Max
Symptoms of depressive and anxiety disorders at baseline
Age (baseline) years 14.3 2.0 11.0 18.0 and follow-up
Age (follow-up) years 21.0 2.2 17.1 27.0
BMI (baseline) kg/m2 20.6 3.9 13.5 42.6 The self-report version of the Centre for Epidemiological
BMI (follow-up) kg/m2 22.7 3.7 15.3 46.2 Studies Depression Scale for children (CES-DC) was
administered at baseline.
BMI body mass index; socioeconomic status according to the Winkler
Index [32] This scale consists of 20 items covering mood, cogni-
tive, behavioural, somatic, and affective symptoms of
depression and has been validated for children and ado-
Instruments lescents between 11 and 18 years of age.
Because the majority of probands in our study had
Eating-disordered behaviour reached young adulthood at the time of the 6-year follow-
up, we used the depression module of the Patient Health
At baseline and follow-up, eating-disordered behaviour Questionnaire (PHQ). The module for the assessment of
was assessed by the SCOFF questionnaire, an instrument depression includes 8 items covering depressive mood,
originally designed by Morgan and colleagues [22] to be vital signs of depression, suicidal ideation, anhedonia, and
used routinely as a screening tool for eating disorders. The cognitive symptoms (PHQ-8, www.phqscreeners.com
abbreviation SCOFF is derived from the first letter of the [28]).
focus word in each of the five questions assessing different The Screen for Child Anxiety-Related Emotional Dis-
aspects of eating disorders. orders questionnaire (SCARED, [29]) was used to assess
symptoms of anxiety disorders at baseline, (but not at
1. Do you make yourself sick because you feel uncom-
follow-up because the questionnaire has only been vali-
fortably full? (deliberate vomiting)
dated for younger children). This questionnaire comprises
2. Do you worry you have lost control over how much
41 items that can be assigned to five subscales according to
you eat? (loss of control over eating)
the factor structure of the instrument: panic/somatic, gen-
3. Have you recently lost more than one stone in a three-
eralised anxiety, separation anxiety, social phobia, and
month period? (weight loss)
school phobia. Higher scores indicate higher
4. Do you believe yourself to be fat even when others say
symptomatology.
you are too thin? (body image distortion)
Data on psychological measures at baseline and the
5. Would you say that food dominates your life? (high
6-year follow-up are presented in Table 2.
impact of food on life)
As the weight unit ‘‘stone’’ is not used in Germany, the Body weight
item ‘‘weight loss’’ was reformulated and defined as weight
loss of more than 6 kg in 3 months. In the first wave of the KiGGS survey, body weight and
The SCOFF has been validated in several studies in height were measured in person at the examination centre
different settings and with different populations of ado- by trained assistants with the participants in underwear.
lescents and young adults [23, 24], including a sample of Body weight and height of the parents were self-reported.
807 adolescents in Germany [25], and showed good At the 6-year follow-up, the height and weight of the
sensitivity and specificity. As suggested in other studies, probands were obtained in the telephone interview
a positive screening status was defined as C2 positive (Table 1).
answers [26, 27]. Although the negative predictive value At follow-up, we concentrated on the extremes in the
(the proportion of those with negative screening results, BMI distribution, because only over- or underweight, not
who did not actually have an eating disorder) is very the large spectrum of normal weight variation, contributes

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Table 2 Questionnaire data for disordered eating and for symptoms of depression and anxiety at baseline and follow-up
Male (n = 351) Female (n = 420) All
Mean SD Mean SD Mean SD Min Max

Mean SCOFF (baseline) 0.54 0.87 0.89 1.03 0.73 1.0 0 5

Mean SCOFF (follow-up) 0.58 0.70 0.73 0.89 0.67 0.8 0 4
CES-DC (baseline) 8.1 5.5 10.8 7.4 9.6 6.7 0 44
SCARED (baseline) 13.5 7.4 17.2 9.5 15.5 8.8 0 47
PHQ depression (follow-up) 3.8 2.5 4.5 3.3 4.2 3.0 0 21
SCOFF screening questionnaire for disordered eating, CES-DC The Centre for Epidemiological Studies Depression Scale for Children, SCARED
Screen for Anxiety-Related Emotional Disorders questionnaire, PHQ Patient Health Questionnaire, depression module

to worse health outcomes and could be expected to be
related to disturbed eating symptoms.
According to the definition by the WHO [30], over-
weight was defined as a body mass index (BMI) C25 kg/
m2 in adults and a BMI C90th age- and sex-adjusted per-
centile in adolescents based on the broad population-based
data set by Kromeyer-Hauschild et al. [31]. Obesity was
defined as a BMI C30 kg/m2 in adults and C97th age- and
sex-adjusted percentile in adolescents.
Underweight was defined as a BMI B18.5 kg/m2 in
adults and a BMI B10th age- and sex-adjusted percentile in
adolescents. Extreme underweight was defined as a BMI
B17.5 kg/m2 in adults and a BMI B3rd age- and sex-
adjusted percentile in adolescents.
Socioeconomic status (SES)
Information on parents’ income, occupational status and
education at baseline was categorised by the Winkler Index
and subdivided into low, medium, and high [32] (Table 1).
with 95 % confidence intervals (CIs). To illustrate the
relationship between the baseline and follow-up SCOFF
scores, the predicted SCOFF values at follow-up (together
with 95 % prediction intervals) from this Poisson models
are presented separately for male and female probands
using the sex-specific mean age at follow-up and mean
baseline BMI of our sample (Fig. 1).
Similarly, the association between the baseline variables
(SCOFF, CES-DC, SCARED) and the dichotomous out-
comes overweight, obesity, underweight, and extreme
underweight at follow-up was investigated using logistic
regression, again adjusted for sex, age at follow-up, base-
line BMI, parental BMI at baseline and baseline socio-
economic status (for overweight and obesity only). We
controlled for parental BMI, because BMI has a high her-
itability, and parental BMI is a strong risk factor for obesity
of the child. Socioeconomic status and prior BMI are also
important predictive factors for later body weight [33].
Adjusted odds ratios (OR) from these models are given

Statistical analysis

The difference in prevalence of disordered eating (SCOFF

score C2) between baseline and follow-up was compared
using McNemar’s Chi square test for paired samples, and
the difference in mean SCOFF (severity) was compared
using a paired t test. The statistical association between
baseline variables (SCOFF, CES-DC, SCARED) and the
SCOFF at the 6-year follow-up was investigated using
Poisson regression models adjusted for sex, age at follow-
up and baseline BMI. In the case of the CES-DC and
SCARED, we investigated the models with and without the
baseline SCOFF as an additional covariate to assess whe-
ther observed longitudinal associations could be accounted
for by the baseline association between the SCOFF and Fig. 1 Relationship between SCOFF at baseline and at 6-year follow-
up; Poisson regression model (Table 4) adjusted for sex, current age,
CES-DC/SCARED. Effect estimates (exponentiated
and baseline BMI. The relationship is shown separately for males and
regression coefficients) from these models represent mul- females using sex-specific mean values of current age and baseline
tiplicative effects on the count scale and are given together BMI

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Table 3 Stability of disordered SCOFF C2 SCOFF \2 Total at p value

eating between baseline and (follow-up) (follow-up) baseline (McNemar
follow-up test)
n n n (%)

All participants 0.002

SCOFF C2 (baseline) 39 104 143 (19.3 %)
SCOFF \2 (baseline) 63 535 598 (80.7 %)
Total at follow-up 102 (13.8 %) 639 (86.2 %)
Female 0.002
SCOFF C2 (baseline) 31 74 105 (26.0 %)
SCOFF \2 (baseline) 40 259 299 (74.0 %)
Total at follow-up 71 (17.6 %) 333 (82.4 %)
Male 0.41
SCOFF C2 (baseline) 8 30 38 (11.3 %)
SCOFF \2 (baseline) 23 276 299 (88.7 %)
Total at follow-up 31 (9.2 %) 306 (90.8 %)

together with 95 % CIs. Finally, the association between
the baseline SCOFF and the PHQ depression score at fol-
low-up was investigated using a multiple linear regression
model, again adjusted for sex, age at follow-up and base-
line BMI. To account for baseline depressive symptoms,
we investigated models with and without the baseline CES-
DC score as an additional covariate.
Results
Stability of ED behaviour and attitudes (SCOFF)
From baseline to the 6-year follow-up, there was a decline
in prevalence of disturbed eating (i.e. SCOFF C2) from
19.3 to 13.8 % (p = 0.002, McNemar test, Table 3) and
severity of disturbed eating (i.e. mean SCOFF score) from
0.73 to 0.67 (p = 0.06, Table 2). This decrease was more
pronounced in those with a higher BMI (p \ 0.0001) and
in females compared to males (p = 0.01 for the difference
between males and females, linear model for difference in
SCOFF from baseline to follow-up). In fact, the SCOFF
score remained almost stable in males during the transition
from adolescence to adulthood (Table 2).
Whereas there was a significant age effect on the mean
SCOFF score in the child and adolescent sample at baseline
(11–18 years, p = 0.03, Poisson regression model, adjus-
ted for sex and BMI), there was no longer a significant age
effect (p = 0.69) in the young adult sample at follow-up
(17–27 years of age) (details not shown). Similarly, the
effect of sex was higher in the younger age group com-
pared to the older age group in the follow-up sample;
adolescent females scored 53 % higher on average
(p \ 0.0001, effect adjusted for age and BMI in a Poisson
regression model) versus 27 % in the adult sample
(p = 0.01, effect adjusted for age and BMI) on the SCOFF
than males (Table 2). The associations between BMI and
SCOFF scores were significant at both time points
(p \ 0.0001 at baseline and p = 0.0004 at follow-up, data
not shown).
Between the baseline scores of the SCOFF and those at
the 6-year follow-up, there was a highly significant asso-
ciation: participants with eating-disordered behaviour at
the beginning of the study had a higher risk of showing
disturbed eating behaviour 6 years later (Poisson regres-
sion model after adjusting for sex, age, and baseline BMI,
Table 4, Fig. 1) than adolescents without the respective
behaviour at baseline.
Association between eating-disordered behaviour
(SCOFF score) at baseline and BMI at follow-up
There was also a strong association between the SCOFF
scores at baseline and overweight and obesity at follow-up,
even after adjustment for baseline and parental BMI
(Table 4). In other words, participants with disordered
eating at the beginning of the observation period were
highly likely to become overweight or obese 6 years later,
independent of their baseline BMI or the BMI of their
parents.
By contrast, after adjusting for baseline and parental
BMI, there was no association between high SCOFF values
at baseline and underweight (Table 4, Supplementary
Appendix).
Associations between symptom patterns (single SCOFF
items) at baseline and later eating-disordered behaviour
All individual SCOFF items at baseline were significantly
associated with the overall SCOFF at follow-up (Table 5).

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Table 4 Relationships between disordered eating behaviour at baseline and follow-up and internalising symptoms
Baseline variable Outcome variable (at 6-year follow-up) Effect estimatea (95 % CI) p value

SCOFF SCOFF 1.31 (1.20–1.42) \0.0001

CES-DC SCOFF 1.01 (0.99–1.02) 0.37
SCARED SCOFF 1.00 (0.99–1.01) 0.62
SCOFF Overweight 1.58 (1.19–2.09) 0.001
CES-DC Overweight 1.01 (0.97–1.06) 0.55
SCARED Overweight 1.00 (0.97–1.03) 0.93
SCOFF Obesity 1.67 (1.03–2.66) 0.03
CES-DC Obesity 1.05 (0.97–1.13) 0.21
SCARED Obesity 1.07 (1.01–1.14) 0.03
SCOFF Underweight 1.27 (0.82–1.88) 0.26
CES-DC Underweight 1.02 (0.96–1.08) 0.45
SCARED Underweight 1.03 (0.99–1.08) 0.13
SCOFF Extreme underweight 1.19 (0.41–2.65) 0.70
CES-DC Extreme underweight 1.13 (1.01–1.25) 0.02
SCARED Extreme underweight 1.06 (0.98–1.15) 0.15
SCOFF PHQ depression score 0.45 (0.19–0.70) 0.0006
All models adjusted for current age, sex, baseline BMI, and baseline value of the outcome variable (i.e. baseline SCOFF, baseline CES-DC (for
PHQ depression score); these baseline values were all highly significant with all p \ 0.0001); models for all weight outcomes also adjusted for
baseline parental BMI; models for overweight and obesity additionally adjusted for baseline socioeconomic status (continuous scale)
SCOFF screening questionnaire for disordered eating, CES-DC The Centre for Epidemiological Studies Depression Scale for Children, SCARED
Screen for Anxiety-Related Emotional Disorders questionnaire, PHQ Patient Health Questionnaire, depression module
a
The effect estimates for the outcome SCOFF are from Poisson regression models and represent multiplicative effects on the count scale; the
effect estimates for the weight outcomes are odds ratios from logistic regression models; the effect estimates for the PHQ depression scale are
regression coefficients from linear regression models

Answering ‘‘yes’’ to any one additional SCOFF question at
baseline increased the overall SCOFF score at follow-up by
40–71 %. All SCOFF items were also associated with
overweight; these associations were weaker, but still sig-
nificant for the SCOFF items, ‘‘deliberate vomiting’’, ‘‘loss
of control over eating’’, and ‘‘body image distortion’’, when
controlling for BMI and parental BMI at baseline.
There was also a statistical association between the item
‘‘deliberate vomiting’’ and underweight (Table 5).
Eating-disordered behaviour at baseline (SCOFF score)
and depression at follow-up (PHQ-8)
Higher SCOFF scores at baseline were associated with
significantly increased PHQ depression scores at follow-up
(Table 4). Each additional ‘‘yes’’ to one of the SCOFF
questions at baseline increased the PHQ depression score at
follow-up by an average of 0.5 points (Table 4). As
expected, this relationship was stronger when it was not
adjusted for baseline depression symptoms (p \ 0.0001 for
baseline SCOFF, data not shown). Baseline BMI had no
additional effect on PHQ depression scores in a model with
baseline SCOFF and baseline CES-DC scores, nor did age
or sex (all p [ 0.3, Supplementary Appendix). Although
current BMI was significantly associated with PHQ
depression scores (p = 0.004 in a model adjusted only for
age and sex), this relationship disappeared when adjusting
for baseline or current eating-disordered behaviour (p val-
ues for current BMI 0.25 and 0.08). In particular, deliberate
vomiting and loss of control over eating at baseline
increased the risk of depressive symptoms 6 years later
(Table 5). Effects were comparable between boys and
girls.
Relationship between internalising symptoms
at baseline and ED symptoms
Both higher CES-DC scores and higher SCARED scores at
baseline were associated with increased eating-disordered
behaviour at follow-up (p = 0.004 for baseline CES-DC
and 0.02 for baseline SCARED in models not adjusted for
the baseline SCOFF). However, this relationship was
almost entirely explained by the strong association of eat-
ing-disordered behaviour and internalising symptoms at
baseline and, thus, disappeared when adjusting for baseline
SCOFF scores (Table 4).

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Table 5 Frequencies of probands responding with ‘‘yes’’ to individual questions of the SCOFF at baseline and their association with different
outcomes 6 years later
Number of probands % SCOFF at
responding with ‘‘yes’’ follow-up
at baseline
Deliberate vomiting 34 4.5 0.06
Loss of control over eating 176 23.3 \0.0001
Weight loss 36 4.8 0.05
Body image distortion 146 19.3 \0.0001
Food dominates life 159 21.1 0.0004
Model 1 for overweight at follow-up is only adjusted for current age and sex. All other p values are from models adjusted for current age, sex,
and baseline BMI; overweight (model 2) additionally adjusted for baseline socioeconomic status and baseline parental BMI, underweight
adjusted for baseline parental BMI, and PHQ depression score adjusted for baseline CES-DC score
PHQ Patient Health Questionnaire, depression module
Relationship between internalising symptoms
at baseline and later BMI
There was a significant association between symptoms of
anxiety at baseline (SCARED) and obesity 6 years later
even when controlling for baseline and parental BMI.
Similarly, the risk of extreme underweight (below the 3rd
percentile) was significantly increased by higher levels of
depressive symptoms at baseline (CES-DC), even when
controlling for baseline and parental BMI (Table 4).
Discussion
Most studies on the course and outcome of EDs and eating-
disordered behaviour have been conducted with clinical
samples, and population-based data, especially for adoles-
cents, are rare. This large prospective population-based
study on the course of eating-disordered behaviour between
adolescence and young adulthood revealed several impor-
tant results. First, disturbed eating showed high stability
over this life period, although the prevalence and severity
of eating-disordered behaviour decreased with advancing
age. Each positive answer to one of the SCOFF items
increased the probability of higher SCOFF scores at the
investigation 6–7 years later. Unhealthy weight control
practises, loss of control over eating, body dissatisfaction,
and a high impact of food on life could each be identified
as risk factors and confirmed the findings of previous
studies (e.g. [9, 16]). Second, we found a significant
association between disordered eating in adolescence and
overweight and obesity at the 6-year follow-up indepen-
dent of baseline and parental BMI. Third, we demonstrated
an important association between disturbed eating at
baseline and depression in young adulthood. Fourth, higher
depression scores in adolescence were significantly related
to later extreme underweight, whilst higher anxiety scores
were related to later obesity.
Overweight at Overweight at Underweight PHQ depression
follow-up follow-up at follow-up score at follow-up
(model 1) (model 2)
0.05 0.05 0.02 0.003
\0.0001 0.03 0.42 0.0006
\0.0001 0.11 0.28 0.48
0.0005 0.02 0.40 0.31
0.0001 0.22 0.07 0.25
Most studies have been based on ED diagnoses (i.e.
categorical measures), and dimensional evaluations are
lacking. The advantage of dimensional assessment is the
inclusion of less severe cases; several studies demonstrate
that the presence of mere ED symptoms might predict
adverse psychosocial and mental health outcomes [34, 35].
Our findings reveal the high stability of disturbed eating
behaviour during the transition from adolescence into
young adulthood and thus confirm the results of recent
studies. Explaining even a small percentage of the variance
in later eating problems is of great importance, especially
in a nonclinical population where base rates of eating
problems are relatively low.
In a previous five-year follow-up study based on ED
classification according to DSM-IV (as well as some
broader categories) in a population-based sample of male
and female adolescents in the US [11], all male partici-
pants and more than 80 % of female participants
remained symptomatic 5 years later, although diagnostic
classifications were unstable over time. In another longi-
tudinal study using data from the US National Longitu-
dinal Study of Adolescent Health, early dieting and body
image distortion at approximately age 16 predicted diet-
ing or weight loss behaviour at 18–26 years old [36]. In a
large Australian study, a DSM-IV eating disorder at age
14 significantly predicted a disorder at ages 17 and 20 in
females [15].
Several studies report the highest incidence and point
prevalence of disordered eating in adolescence compared
to other life periods [5, 6]. In our investigation, 19.3 % of
the 11- to 18-year-olds screened positively for an eating
disorder at baseline, in comparison to 13.8 % in young
adulthood at follow-up. The prevalence rates in our study
were very similar to another European population-based
study that used the SCOFF questionnaire [27]. It is known
that puberty and adolescence are critical risk periods for the
development of eating disorders mediated by psychosocial
pressure and hormonal changes [37]. In line with our
123

results, a lower prevalence of eating disorder symptoms
was found in older age groups compared to the youngest
age group in the cross-sectional study mentioned above
[27], as well as in other longitudinal studies [38].
In the present study, this decline was more pronounced
in females than in males, indicating an important impact of
pubertal status and timing on the incidence and mainte-
nance of eating disorders. This factor seems to play a much
larger role in girls than in boys (for a review, see Klump
et al. [37]).
Our results reveal an important association between
disturbed eating behaviour in adolescence and the preva-
lence of overweight and obesity in young adulthood inde-
pendent of baseline and parental BMI. This finding
underlines the importance of this relationship independent
of prior body weight. Our findings mirror those of Quick
et al. [39], who assessed behavioural and other factors
hypothesised to be relevant for later obesity in 15-year-old
non-overweight adolescents. Unhealthy weight control
practices, such as dieting and purging, binge eating, weight
concerns, and higher levels of body dissatisfaction, toge-
ther with parental weight-related concerns, predicted the
incidence of overweight 10 years later. In a study by Micali
et al. [40] with a much shorter observation period than our
study, eating disorder symptoms at age 13 (with the
exception of food restriction) were prognostic indicators of
higher BMI 2 years later, even when adjusting for the
original BMI.
To our knowledge, this is the first study to demonstrate
that disordered eating in adolescence implies a high risk for
future depression. In accordance with previous studies, we
also found a relationship between specific phenomena such
as loss of control of eating, purging behaviour, and body
distortion, in youth with later depression [41, 42], inde-
pendent of prior body weight and baseline depressive
symptoms. Eating-disordered behaviour likely reflects high
dissatisfaction with oneself and ‘‘the undue influence of
body weight or shape on self-esteem’’ (DSM-5, [43]), both
of which may contribute to the development of depression.
With respect to the relationship between internalising
symptoms at baseline and weight development, some pre-
vious studies demonstrated that depressive symptoms in
youth might be a risk factor for later obesity [19]. This
finding could not be confirmed in the present study inde-
pendently of baseline and parental BMI and former
depression scores, although we found an association with
earlier anxiety symptoms. Nevertheless, the results are
equivocal, and several studies did not control for original
BMI or original depressive states (for a review, see Blaine
[44]).
By contrast, we found a significant relationship between
early depression and later extreme underweight after
adjustment for baseline and parental BMI and
123
Eur Child Adolesc Psychiatry
psychological scores. It is likely that probands with
extreme underweight (below the 3rd percentile) represent
subjects with anorexia nervosa-like symptoms. It is well
known from retrospective studies that individuals with
anorexia nervosa often suffer from depression in childhood
[45].
Finally, some limitations should be noted. First, BMI at
follow-up was not assessed objectively by personal weight
assessment. Second, we could only assess dimensional
psychological parameters, not diagnostic categories of
mental disorder. The latter could have provided more
comprehensive knowledge about prevalence rates of eating
and other mental disorders, which is central for the pro-
vision of health care in the community. Third, we had a
rather high attrition rate, which is not too unusual in epi-
demiological studies. The differences between those
available for the assessment and dropouts were of minor
importance, although the higher rate of females in com-
parison to the original sample might have led to an over-
estimation of eating-disordered behaviour. However, the
dropouts were not restricted to our group of participants,
and our sample can be considered representative of the full
BELLA follow-up sample for this age group.
Notwithstanding these limitations, some important
conclusions can be drawn from this study. Eating-disor-
dered behaviour in adolescence is a highly relevant risk
factor for poor mental and physical health in young
adulthood with reference to the persistence of ED symp-
toms, overweight or obesity and depression. Adolescents
with depression should be monitored for the emergence of
severe underweight (e.g. anorexia nervosa spectrum dis-
orders). Given the novelty of the latter finding, replication
of this result is needed. Future research should also address
mediating factors that could help explain the mechanisms
by which these associations evolve. Our findings underline
the need for prevention, early detection, and intervention
for individuals with disturbed eating or internalising
symptoms, not only for overweight or obese adolescents.
Given the high stability of mental health states over time,
adolescence is not too late to intervene to reduce the risk of
the development of a full-blown eating disorder, obesity or
depressive illness in adulthood.
Key points
There is a high prevalence and increasing incidence of
eating-disordered behaviour in youth.
Previous studies reported poor physical and mental
health quality of life in individuals with eating-disordered
behaviour both cross-sectionally and longitudinally.
This large epidemiological study demonstrated a high
stability of disordered eating behaviour from adolescence
Eur Child Adolesc Psychiatry
to young adulthood. Moreover, a significant association
between disordered eating in adolescence and overweight/
obesity and depression in adulthood, independent of ado-
lescent body weight, was found. In addition, higher
depression scores in adolescence were significantly related
to later extreme underweight.
There is an urgent need for early detection and inter-
ventions targeting disordered eating behaviour in
adolescence.
Conflict of interest On behalf of all authors, the corresponding
author states that there is no conflict of interest.
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