Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2025 Apr 1.
Published in final edited form as: Health Psychol. 2023 Dec 7;43(4):289–297. doi: 10.1037/hea0001336

Longitudinal associations between adolescent skin color satisfaction and adult health outcomes in Black women

Asociaciones longitudinales entre la satisfacción del color de la piel de los adolescentes y los resultados de salud de los adultos en Mujeres Negras

Jordan E Parker 1, Craig K Enders 1, Stephanie L Fitzpatrick 2, Mujahid Mahasin S 3, Barbara A Laraia 4, Elissa S Epel 5, A Janet Tomiyama 1
PMCID: PMC10939857  NIHMSID: NIHMS1948057  PMID: 38059930

Abstract

Objective:

Although emerging studies examine the inverse relationship between body satisfaction and disordered eating for Black women, it has not been established how racially-salient aspects of body satisfaction may have implications for eating behaviors and longitudinal health outcomes.

Methods:

In a longitudinal sample of 455 Black women, we examined whether skin color satisfaction across ages 10–15 was directly related to adult health outcomes at age 40 (e.g., disordered eating, self-esteem, self-reported health, depressive symptoms, and cardiovascular risk). We also investigated the indirect impact of skin color satisfaction on adult health, mediated by body satisfaction and binge eating.

Results:

No significant direct or indirect effects of adolescent skin color satisfaction were observed for depressive symptoms or cardiovascular health outcomes. At ages 10 and 12, skin color satisfaction had negative and positive direct effects, respectively, on self-esteem. At age 15, greater skin color satisfaction was directly associated with greater self-reported health. Post-hoc analyses revealed that when additionally accounting for adolescent body satisfaction, greater skin color satisfaction was indirectly associated with greater self-esteem and self-reported health, alongside lower cardiovascular risk.

Conclusions:

Although previous research suggests that in adolescence, Black girls’ skin color satisfaction affects both body satisfaction and disordered eating behaviors, this association does not hold into midlife. Rather, post-hoc analyses suggest that the lasting effects of adolescent skin color satisfaction are mediated by the longitudinal stability of body satisfaction, which in turn, is associated with adult health outcomes.

Keywords: Skin color satisfaction, body satisfaction, binge eating, Black women, health

Decades of studies have established that low body satisfaction is a robust upstream predictor of disordered eating in both community and clinical samples (Stice et al., 2011). Numerous theoretical models have hypothesized potential pathways through which body satisfaction is negatively influenced and results in changes in eating behaviors, and empirical studies have replicated these effects (Ata et al., 2015). However, prior studies disproportionately focus on White women, who constitute approximately 70% of research samples (Egbert et al., 2022). Accordingly, most measures of body satisfaction are normed on White women’s sense of embodiment and may not capture how women from other racial/ethnic groups experience embodiment (Schaefer et al., 2018). Both disordered eating and body satisfaction are influenced by the sociocultural context in which they occur, including cultural and racial influences on eating behaviors, beauty norms, and idealized body shape and size (Watson et al., 2019). For Black women in particular, the relationship between body satisfaction and disordered eating remains understudied, precluding the examination of how racially-salient aspects of body image may contribute to disordered eating.

Black women idealize fuller and curvier figures in comparison to White women, who often idealize thinness (Overstreet et al., 2010). Studies have also identified specific features—like skin color, lips, and hair—that influence body satisfaction among Black women; however, these features are often omitted from traditional measures of body satisfaction, limiting the degree to which studies can examine how they may relate to disordered eating behaviors (Capodilupo & Kim, 2014). For example, several studies report skin color as a body image concern unique to Black women, finding that low skin color satisfaction contributes to negative self-image, accounts for a significant amount of the variance in appearance evaluation, and is exacerbated when media portrayals idealize lighter skinned Black women (Capodilupo, 2015; Falconer & Neville, 2000). Skin color also holds unique sociohistorical influence among Black women, having served as a means to devalue Black women in relation to their White counterparts and to stratify definitions of beauty within the Black community (Capodilupo, 2015). To date, only one study has linked skin color to disordered eating (Parker, Enders, et al., 2022): in longitudinal analyses in Black girls across adolescence (age 10–19), skin color satisfaction was positively associated with body satisfaction and indirectly associated with reduced binge eating, mediated through body satisfaction. These findings lend insight to how patterns of disordered eating for Black women may be preceded by racially-salient aspects of body satisfaction that are not captured by traditional metrics.

In addition to representing a core feature of Black women’s body satisfaction, skin color may also be central to their racial identity, offering another pathway through which evaluations of one’s skin color may be linked to disordered eating. Indeed, private regard, a dimension of racial identity representing positive feelings toward one’s own racial group, has been associated with skin color satisfaction (Maxwell et al., 2015) and higher body satisfaction (Oney et al., 2011). Several studies have also found that stronger ethnic identity is inversely associated with disordered eating (Rakhkovskaya & Warren, 2014; Wood & Petrie, 2010). Moreover, high levels of acculturative stress, in which one perceives their ethnic identity as at odds with dominant culture, are associated with both lower body satisfaction and disordered eating symptoms in Black women (Gordon et al., 2010). Thus, in both the body image and racial identity literatures, there is evidence to suggest that skin color contributes to Black women’s self-view, influencing how they feel about their bodies and their eating behaviors.

Examining the relationship between skin color, body satisfaction, and disordered eating is not only important in the effort to diversify these bodies of research, but is also particularly important given the potential relationship of these constructs to adverse health outcomes, which Black women disproportionately experience (Chinn et al., 2021). Studies suggest that decreased skin color and body satisfaction may damage self-esteem, be associated with depression and anxiety, and drive disordered eating which is associated with poor cardiometabolic health outcomes (Bucchianeri & Neumark-Sztainer, 2014; Cash & Pruzinsky, 2002; Mucherah & Frazier, 2013; Sardar et al., 2015). Body dissatisfaction has also been labelled an overlooked public health concern and is associated with reduced psychological and health-related quality of life (Baceviciene et al., 2020; Mond et al., 2013). Studying the effects of skin color and body satisfaction in the domain of binge eating disorder is imperative, given that Black women present with relatively high rates of this disorder and experience greater associated mental and functional impairments than White women (Coffino et al., 2019; Taylor et al., 2013). While there is no extant theoretical model that accounts for our specific posited associations between skin color satisfaction, body satisfaction, disordered eating, and health outcomes, the biopsychosocialcultural model—and how it explains discrimination and health—has utility for contextualizing these associations (Revenson & Gurung, 2019). In addition to the assertion that biological, psychological, and social factors together predict health outcomes, this model posits that health is a reciprocal relationship between people and the contexts in which they live. Thus, racism is not only part of the fabric of American culture, but is also a specific intervening variable to be understood in the context of health outcomes. For example, decreased skin color satisfaction may arise when individuals perceive this aspect of their racial identity as the source of discriminatory experiences. Low skin color satisfaction could subsequently predict decreased body satisfaction and disordered eating behaviors may arise as a coping mechanism, ultimately begetting adverse psychological and physical health outcomes. The role of culture is also underscored by the Tripartite Influence Model, which holds that one’s self-view is influenced by societal norms and influences, leading to decreased body satisfaction and other processes of self-comparison. These sources of self-criticism are theorized to lead to disordered eating behaviors and adverse psychological outcomes, again predicting poor health outcomes (Keery et al., 2004).

Although there is a burgeoning area of research examining the inverse relationship between body satisfaction and disordered eating for Black women, it has not yet been established how unique, racially-salient aspects of body satisfaction may have implications for pathological eating behaviors and longitudinal health outcomes. Our previous work demonstrates that skin color satisfaction is associated with body satisfaction in adolescence (Parker et al., 2022); however, the extent to which this association has a lasting impact on adult health outcomes is unknown. In the present study, we sought to address this gap in the literature and determine whether skin color satisfaction in adolescence is related to body satisfaction and eating disturbances for Black women in midlife. Further, we investigated whether skin color satisfaction would be directly related to adult health outcomes or, if its effect on adult health would occur indirectly, through the pathway involving body satisfaction and disordered eating. We hypothesized that greater skin color satisfaction in adolescence would be related to body satisfaction and predict reduced binge eating behaviors at age 40. Moreover, we predicted that this relationship would have direct and indirect implications for Black women’s adult health outcomes in the domains of self-esteem, depressive symptoms, cardiovascular disease risk, and self-reported health.

Methods

Study design

Data for the present study were collected as part of the National Heart Lung and Blood Institute’s Growth and Health Study (NGHS), a longitudinal cohort study spanning childhood/adolescence and adulthood/midlife in an approximately equal sample of Black and White women (N = 2379). Data were collected annually across ages 10–19, with an additional follow-up visit at approximately age 40. At baseline, participants were recruited from three U.S. cities—Richmond, California, Washington, D.C., and Cincinnati, Ohio. For the age 40 follow-up, the Richmond participants were re-consented into the study. Additional details about the study participants, measures, and procedures have been described elsewhere (NHLBI Growth and Health Study & Research Group, 1992). The present secondary data analyses did not meet the definition of human subjects research and were granted an IRB Exemption (IRB #13–000876).

Participants

From 1987 – 1989, the original NGHS investigators enrolled a sample of 1213 Black and 1166 White girls. To be eligible for inclusion, participants had to be female and no more than 2 weeks older or younger than 9 or 10 years old, respectively. Additional inclusion criteria were a self-reported race of White or Black and living with a parent/guardian who was racially-concordant with the enrollee, willing to consent on behalf of the child (participant) under their supervision, and provide the study team with sociodemographic information about the child’s household and family. Data were primarily collected via in-home visit by trained study staff at annual timepoints across ages 10 – 19.

A subset of the original study participants from the Richmond site were re-enrolled into the study at approximately age 40, from 2016 – 2019. Participants were eligible for re-enrollment based on the following inclusion criteria: (1) not currently pregnant, (2) no pregnancy, miscarriage, or abortion within the last three months, (3) not currently living abroad, and (4) not currently incarcerated or institutionalized. Using these inclusion criteria, over 73% of the original Richmond participants (N = 624 out of 883) were re-enrolled. Participants completed a mailed survey, after which a study staff member scheduled an in-home visit for collection of biosample and anthropometric data.

The present analyses focus only on the sample of Black women from the Richmond cohort who were eligible for both the adolescent and adult time points (N = 455).

Transparency and Openness

All analyses were pre-registered at https://osf.io/w2dn6. Data associated with adolescence (ages 10–19) are available at https://biolincc.nhlbi.nih.gov/studies/nghs/ in accordance with NIH guidelines. Data and scripts specific to the present analyses are available on the OSF page for this project.

Measures

Skin color satisfaction

The focal predictor was skin color satisfaction, measured on a 4-point Likert scale and collected only at ages 10, 11, 12, 13, 14, and 15. Participants were asked: “How happy or unhappy are you with your skin color?” with the scale: 1 = Very happy, 2 = Happy, 3 = Unhappy, 4 = Very unhappy. The scale was reverse scored such that a higher score indicates higher satisfaction.

Body satisfaction

Body satisfaction was measured using the Eating Disorders Inventory-body dissatisfaction subscale (EDI-3; (Garner, 2004), at age 40. The body dissatisfaction subscale contains ten items that represent preoccupation with one’s own shape and size. Each of the ten items was rated on a six-point scale: “Always,” “usually,” “often,” and “sometimes,” received respective scores of 4, 3, 2 and 1 while both “rarely” and “never” received scores of 0. The total sum score ranges from 0 – 40. Cronbach’s alpha in our sample was 0.83. The score was reverse-coded such that higher scores indicate higher satisfaction.

Binge eating

Binge eating was measured at age 40 using the EDI-3 bulimia subscale (Garner, 2004) excluding the singular question about purging (Question 23, Cronbach’s alpha = 0.81). The scale contained seven items scored on the same six-point Likert scale as the body dissatisfaction subscale, indexing tendency for uncontrollable eating (bingeing) and associated emotional responses. Responses are summed and the resulting total scores range from 0 – 28.

Self-esteem

Self-esteem was assessed via self-report, using the Rosenberg self-esteem scale at age 40 (Rosenberg, 1965). The scale contains ten questions rated on a 4 point-Likert scale corresponding to “Strongly agree”, “Agree”, “Disagree” and “Strongly Disagree,” which receive scores of 3, 2, 1, and 0, respectively. Items are summed with higher scores indexing higher self-esteem. Cronbach’s alpha in our sample was 0.86.

Self-reported health

At age 40, participants also completed a single item measure of their self-reported health (CDC, 2014). The question read “Would you say that in general your health is” with response choices of “Excellent,” “Very good,” “Good,” “Fair,” and “Poor.” Responses are coded 1, 2, 3, 4 and 5, respectively, such that higher scores represent poorer health.

Depressive symptoms

Depressive symptoms were measured using the 20-item Center for Epidemiological Studies Depression Scale (CES-D; (Radloff, 1977) collected at age 40. The CES-D assesses depressive symptoms experienced by the individual in the past week using a 4-point Likert scale from 0 = Rarely or None of the Time to 3 = Most or Almost All the Time. Sum scores range from 0 to 60 with higher scores indicating more depressive symptoms (Cronbach’s alpha = 0.91).

Cardiovascular disease risk

Risk for atherosclerotic cardiovascular disease (ASCVD) was assessed according to the guidelines set by the American College of Cardiology and American Heart Association (Arnett et al., 2019). The pooled cohort equations (PCE) that calculate sex- and race-specific risk for ASCVD also account for the influence of self-reported age, smoking status, and use of diabetic or hypertension medications as well as objective measures of total cholesterol, HDL-cholesterol, and systolic blood pressure. Present analyses use the ASCVD sum score as the outcome of interest, in which higher scores correspond to greater cardiovascular risk. The raw sum score can also be transformed into an estimate of an individual’s 10-year estimated risk of an ASCVD event. Further details on this measure and its transformation are in Supplementary Materials.

Socioeconomic status

Parental income and education at baseline (age 10) were included as covariates in all models. Parental income was measured on a four-point categorical scale defined as: (1) less than $5,000, (2) $5,000– $20,000, (3) $20,000–$40,000, and (4) $40,000 or more. Parental education was defined as the highest level of education obtained by the participant’s primary caregiver on a three-point categorical scale: (1) high school or less, (2) 1–3 years post-high school, and (3) 4–year college degree or more. Although socioeconomic measures were re-assessed at age 40, we chose the covariate wherein its exposure could plausibly influence both the predictor and the outcome variables, consistent with the definition of a confounding variable.

Analytic Plan

To test our hypotheses, we fit a total of four (one for each health outcome) first-stage, serial, moderated mediation models (Figure 1). In each model, the focal predictor was skin color satisfaction, the first and second serial mediators were body satisfaction and binge eating, and the outcome variables were one of the four possible health outcomes. Age was included as a moderator to account for multiple observations of skin color satisfaction. Parental income and education were included as covariates in all models.

Figure 1.

Figure 1.

Open in a new tab

Conceptual diagram for proposed serial moderated mediation model.

Data handling procedures

All variables other than age and race were incomplete and required sophisticated analytic methods to address missingness (range = 6.70 to 34.95%). A fully Bayesian procedure was used to fit the mediation models in Blimp (Keller & Enders, 2021). Outlier detection was performed on the imputed data, in accordance with our pre-registration. Further details of our approach are available in Supplementary Materials.

Hypotheses

First, we predicted that greater skin color satisfaction across ages 10 – 15 will predict reduced binge eating symptoms at age 40 indirectly, through its positive effect on body satisfaction at age 40 (Hypothesis 1). Next, we hypothesized a direct effect of skin color satisfaction on health outcomes at age 40, such that greater skin color satisfaction will predict higher self-esteem, lower depressive symptoms, greater self-reported health, and improved cardiovascular health, controlling for body satisfaction and binge eating (Hypothesis 2). We additionally hypothesized an indirect effect of skin color satisfaction on health, such that greater skin color satisfaction will predict higher self-esteem, lower depressive symptoms, greater self-reported health, and improved cardiovascular health, through the mechanism in which skin color satisfaction is associated with higher body satisfaction and reduced binge eating (Hypothesis 3).

Results

Descriptive statistics for the sample are presented in Table 1, stratified by age. Results presented are robust to the inclusion of adolescent binge eating (Parker, Enders, et al., 2022) as a covariate in each model.

Table 1.

Descriptive statistics for participants, stratified by age, across all time points

Age 10 Age 11 Age 12 Age 13 Age 14 Age 15 Age 40
Parental Education (%)
≤ High school 26.23%
1–3 years post-high school 53.74%
≥ 4-year college degree 20.03%
Parental income (%)
< $5,000 33.41%
$5,000 – $20,000 23.07%
$20,000 – $40,000 26.43%
≥ $40,000 17.09%
Skin color satisfaction 3.64 (0.68) 3.60 (0.67) 3.60 (0.63) 3.53 (0.62) 3.52 (0.62) 3.52 (0.62)
Body satisfaction 20.82 (8.54)
Binge eating 1.92 (3.51)
Self-esteem 23.75 (5.28)
Self-reported health 2.97 (1.06)
Depression 14.95 (11.61)
ASCVD risk sum 84.45 (1.48)
ASCVD risk (%)
Low risk 92.79%
Borderline risk 2.38%
Intermediate risk 3.69%
High risk 1.14%
Open in a new tab

Values presented in the table for parental income and education are the percentage of the sample of Black women represented in that category. Values presented for all other variables are means and (standard deviations).

Hypothesis 1

Table 2 presents the age-specific indirect effects of skin color satisfaction in adolescence on binge eating at age 40, through body satisfaction at age 40. At all time-points, this effect was non-significant.

Table 2.

Age-specific indirect effect of skin color satisfaction on binge eating at age 40.

MDN SD LCL UCL
Age 10 0.04 0.07 −0.09 0.17
Age 11 −0.03 0.07 −0.16 0.11
Age 12 0.04 0.07 −0.10 0.19
Age 13 −0.03 0.08 −0.18 0.12
Age 14 −0.08 0.08 −0.24 0.07
Age 15 −0.13 0.08 −0.30 0.02
Open in a new tab

Note. Point estimates presented in the table represent the median of the Bayesian posterior distribution, its standard deviation, and the 95% credible interval around the point estimate. LCL and UCL correspond to the lower and upper credible limits, respectively.

Hypothesis 2

Table 3 presents the age-specific direct effects of skin color satisfaction on the four adult health outcomes at age 40. Results indicated partial support for Hypothesis 2, with significant age-specific effects for the models with self-esteem and self-reported health as the outcome. At ages 10 and 12, we observed a significant direct effect of skin color satisfaction on self-esteem at age 40, controlling for body satisfaction at age 40, binge eating at age 40, and parental income/education. Opposite our hypotheses, at age 10, greater skin color satisfaction predicted lower self-esteem. At age 12, however, the significant effect was in the opposite direction, such that greater skin color satisfaction was associated with greater self-esteem, supporting our hypotheses. The age-specific indirect effects at ages 11, 13, 14 and 15 were non-significant. For self-reported health, only at age 15 did we observe support for our hypotheses—a significant direct effect such that greater skin color satisfaction at age 15 was associated with greater self-reported health at age 40, controlling for body satisfaction at age 40, binge eating at age 40, and parental income/education. No significant direct effects were observed for the models predicting depressive symptoms or ASCVD risk.

Table 3.

Age-specific direct effect of skin color satisfaction on adult health outcomes at age 40.

MDN SD LCL UCL
Self-esteem
Age 10 −0.89* 0.41 −1.70 −0.07
Age 11 0.26 0.43 −0.57 1.09
Age 12 1.02* 0.45 0.15 1.91
Age 13 0.83 0.46 −0.10 1.71
Age 14 0.05 0.48 −0.89 1.00
Age 15 0.77 0.49 −0.20 1.73
Self-reported health
Age 10 0.13 0.08 −0.04 0.29
Age 11 −0.11 0.09 −0.19 0.15
Age 12 −0.16 0.09 −0.35 0.02
Age 13 −0.17 0.10 −0.36 0.02
Age 14 −0.06 0.10 −0.25 0.14
Age 15 −0.28* 0.10 −0.47 −0.07
Depressive symptoms
Age 10 1.45 0.95 −0.38 3.30
Age 11 −0.82 0.98 −2.71 1.15
Age 12 −1.74 1.06 −3.81 0.34
Age 13 −1.31 1.07 −3.38 0.79
Age 14 −1.04 1.12 −3.27 1.14
Age 15 −1.49 1.19 −3.79 0.85
ASCVD risk
Age 10 −0.02 0.13 −0.27 0.23
Age 11 −0.05 0.14 −0.31 0.23
Age 12 −0.06 0.15 −0.34 0.23
Age 13 0.06 0.15 −0.25 0.36
Age 14 −0.13 0.15 −0.43 0.17
Age 15 −0.20 0.15 −0.50 0.10
Open in a new tab

Note.

*

indicates a significant 95% credible interval. Point estimates presented in the table represent the median of the Bayesian posterior distribution, its standard deviation, and the 95% credible interval around the point estimate. LCL and UCL correspond to the lower and upper credible limits, respectively.

Hypothesis 3

We did not observe significant indirect effects of skin color satisfaction on health outcomes at age 40, through body satisfaction and binge eating at age 40 (Table 4).

Table 4.

Age-specific indirect effect of skin color satisfaction on adult health outcomes at age 40.

MDN SD LCL UCL
Self-esteem
Age 10 −0.01 0.02 −0.06 0.03
Age 11 0.01 0.02 −0.04 0.06
Age 12 −0.01 0.03 −0.07 0.03
Age 13 0.01 0.03 −0.04 0.06
Age 14 0.03 0.03 −0.02 0.08
Age 15 0.04 0.03 −0.01 0.11
Self-reported health
Age 10 0.001 0.002 −0.002 0.004
Age 11 −0.001 0.002 −0.004 0.003
Age 12 0.001 0.002 −0.002 0.01
Age 13 −0.001 0.002 −0.01 0.003
Age 14 −0.002 0.002 −0.01 0.002
Age 15 −0.003 0.002 −0.01 0.001
Depressive symptoms
Age 10 0.02 0.04 −0.05 0.09
Age 11 −0.02 0.04 −0.09 0.05
Age 12 0.02 0.04 −0.06 0.10
Age 13 −0.02 0.04 −0.10 0.06
Age 14 −0.04 0.04 −0.13 0.03
Age 15 −0.07 0.04 −0.16 0.01
ASCVD risk
Age 10 0.00 0.001 −0.002 0.002
Age 11 0.00 0.001 −0.002 0.002
Age 12 0.00 0.001 −0.003 0.002
Age 13 −0.00 0.001 −0.002 0.002
Age 14 −0.00 0.001 −0.002 0.003
Age 15 −0.00 0.002 −0.003 0.004
Open in a new tab

Note. Point estimates presented in the table represent the median of the Bayesian posterior distribution, its standard deviation, and the 95% credible interval around the point estimate. LCL and UCL correspond to the lower and upper credible limits, respectively.

Post-hoc analyses

Closer inspection of model parameters revealed that across all four health outcomes and at all timepoints in adolescence, skin color satisfaction did not predict body satisfaction at age 40. Given our previous findings—namely that skin color satisfaction in adolescence was associated with body satisfaction in adolescence (Parker, Enders, et al., 2022) and that lower body satisfaction in adolescence predicts low body satisfaction in adulthood (Parker, Levinson, et al., 2022)—we additionally explored whether the inclusion of adolescent body satisfaction in the model would improve overall model fit. Specifically, we modeled body satisfaction at age 19 (Brown et al., 1995) as the first mediator, body satisfaction at age 40 as the second mediator, while the remaining variables stayed the same as the original analyses. See Figure S2 for a visual representation of this post-hoc model.

Table S3 presents a summary of the original and post-hoc model fit parameters. Inclusion of adolescent body satisfaction in the model significantly improved model fit. The f2 effect sizes ranged from 0.02 to 0.07, constituting moderate to large effects (Cohen, 1988).

Hypothesis 1

Table S4 presents the age specific-indirect effects of skin color satisfaction across ages 10 to 15 on body satisfaction at age 40, mediated by body satisfaction at age 19. Supporting our hypotheses, at ages 12 and 15, skin color satisfaction had a significant indirect effect on age 40 body satisfaction wherein greater skin color satisfaction was associated with greater adulthood body satisfaction.

Hypothesis 2

No significant direct effects of skin color satisfaction were observed for the ASCVD or depression outcomes at any time point (Table S5 and S6, respectively). Opposite our hypotheses, at age 10, skin color satisfaction had a direct effect on self-esteem, such that higher skin color satisfaction was associated with lower self-esteem at age 40 (Table S7). No other age-specific time points were significant for self-esteem. For self-reported health, our hypotheses were supported only at age 15: skin color satisfaction was directly associated with higher self-reported health at age 40 (Table S8).

Hypothesis 3

Significant indirect effects of skin color satisfaction on adult health outcomes were observed for the models predicting ASCVD risk, self-esteem, and self-reported health (Tables S9–11, respectively). Consistent with our hypotheses, at ages 12 and 15, skin color satisfaction had indirect effects on age 40 health outcomes such that greater skin color satisfaction was associated with lower ASCVD risk, higher self-esteem, and better self-reported health. For depressive symptoms, there were no significant indirect effects at any time point (Table S12).

Discussion

In previous work, we established that skin color satisfaction predicted reduced binge eating symptoms through influencing Black girl’s body satisfaction in adolescence. In the present study, we aimed to examine whether these associations would hold across the lifespan, or the extent to which skin color satisfaction in adolescence may be related to body satisfaction disordered eating, and health outcomes in adulthood. Interestingly, the mediating role of body satisfaction between skin color satisfaction and binge eating did not remain significant when examined across adolescence and midlife. Moreover, across a number of health outcomes, skin color satisfaction did not prove to have a direct or indirect association with adult health. Post-hoc analyses suggested an alternate pathway through which skin color satisfaction may influence longitudinal health outcomes. Analyses that included adolescent and adulthood body satisfaction as mediators significantly improved model fit. Body satisfaction at age 19 mediated the relationship between adolescent skin color satisfaction and adulthood body satisfaction. Moreover, skin color satisfaction had direct and indirect effects on self-esteem, self-reported health, and cardiovascular risk as mediated by longitudinal body satisfaction.

Two of the three significant direct effects were observed with self-esteem as the outcome of interest. We found that at age 10, greater skin color satisfaction was directly associated with lower self-esteem; however, at age 12, the direction of the association was reversed such that greater skin color satisfaction was associated with higher self-esteem. Though the latter result is consistent with our hypotheses, the observed negative effect of skin color satisfaction at age 10 merits further exploration. Qualitative studies, for example, may provide insight into the mechanisms by which skin color satisfaction arises, the factors that predict its variability, and the nature of its stability across adolescence and into adulthood.

In our main analyses, we found no significant effects of skin color satisfaction on adulthood binge eating mediated by adulthood body satisfaction; however, in previous studies, we did find positive associations between skin color satisfaction and body satisfaction in adolescence (Parker, Enders, et al., 2022), in addition to positive associations between adolescent and adulthood body satisfaction (Parker, Levinson, et al., 2022). Thus in post-hoc analyses, we examined whether the effects of skin color satisfaction on adult health may instead be mediated by body satisfaction in adolescence and adulthood. Results from these analyses replicated the direct effects of skin color satisfaction at age 10 on self-esteem at age 40, and the direct effect of skin color satisfaction at age 15 on self-reported health at age 40. Moreover, analyses revealed a series of significant indirect effects. Specifically, we found that greater skin color satisfaction predicted greater self-esteem, greater self-reported health, and lower cardiovascular risk, mediated by body satisfaction in adolescence and adulthood. Although these results must be replicated, the pattern of significant direct and indirect effects observed in our post-hoc model may suggest that the effect of skin color satisfaction is on health is more likely mediated through body satisfaction across the lifespan, rather than through adult body satisfaction and binge eating.

We also acknowledge that there may be other pathways through which skin color satisfaction influences adult health. For example, perhaps with age and experience in the social world, one’s conceptualization of skin color moves beyond being a body image construct and instead constitutes more of a sociocultural identity, whose effects on health could be exerted through other pathways that were not measured in the present analyses. For example, one study among Black youth found that more positive feelings toward one’s racial group, specifically the extent to which one believes their racial group is valued by others, was associated with better health outcomes (Zapolski et al., 2019). Thus, the effect of skin color satisfaction on self-reported health may occur due to a positive association between skin color satisfaction and positive collective racial identity—that is, perhaps feeling good about one’s own skin color is related to the belief that one’s own racial group is valued, which both appear to be good for Black youth’s health outcomes (Parker, Enders, et al., 2022; Zapolski et al., 2019). To fully contextualize the association between skin color satisfaction and health outcomes, future research should aim to characterize the longitudinal stability of skin color satisfaction, leveraging qualitative studies to provide richer understanding of the complex interplay between skin color satisfaction, racial identity, and adult health. Comparing profiles of individual-level variation in skin color satisfaction and establishing how these profiles relate to longitudinal health outcomes may also be of interest.

Limitations

The use of the EDI-3 to assess binge eating is novel. Since there was not a validated measure of binge eating captured in this sample, we approximated bingeing behaviors using the EDI-3 but acknowledge this may be an imperfect measure of our target construct. These data also did not contain any assessment of threshold-level psychopathology, limiting our ability to comment on the clinical significance of our findings; however, using the EDI-3, we were able to calculate the Eating Disorder Risk Composite (EDRC) score at age 40 to index participant’s global concerns about eating (Table S2). Approximately 30% of participants had typical or elevated risk for Anorexia Nervosa, while all participants had low clinical risk for Bulimia Nervosa. However, even in the absence of clinical diagnoses, disordered eating symptoms remain an outcome of interest given their independent relationship to adverse health outcomes, such as hypertension, chronic pain, and psychiatric disorders (Johnson et al., 2002).

An additional measurement concern is the lack of data between age 19 and age 40. We are unable to assess how the relationships between our constructs of interest may change in this developmental window and are thus unable to characterize the pattern of our association across more discrete intervals of time. This also raises potential temporal concerns related to the use of mediation analyses. In the main analyses, the mediators and health outcomes were collected simultaneously and in the post-hoc model, only the second mediator and health outcomes were concurrently collected. Thus, we did not fully satisfy the requirements for temporal and causal ordering and caution should be taken in extrapolating the present results given their preliminary nature.

Finally, we acknowledge limitations related to our use of a single item predictor to measure skin color satisfaction. Due to the nature of these secondary analyses, we were not able to use a measure of skin color satisfaction that has been previously validated in the literature, such as the Skin Color Satisfaction Scale (SCSS; Falconer & Neville, 2000) or the Skin Color Questionnaire (SCQ; Bond & Cash, 1992). However, the skin color satisfaction measure used in this study does overlap with both the SCSS and SCQ in that the first item in both scales index satisfaction with one’s skin color. The SCSS and SCQ then go on to measure satisfaction with one’s skin color in relation to one’s family, in relation to other African Americans, and the desire to have a lighter skin tone. Thus, though we acknowledge the limitations in our use of a single item measure, we note that this operationalization does directly reflect our intended construct, as we did not aim to measure skin color satisfaction in relation to others or the desire for light skin. Finally, we note that the original investigators did not capture a measure of skin color satisfaction at age 40, so we are unable to assess its stability over time. In future work, we hope to conduct prospective studies with more comprehensive measures of skin color satisfaction and binge eating, in addition to exploring additional objective and subjective indices of health. The use of a single item measure of self-reported health, although widely used, is also noted as a limitation; however, the present measure of subjective health has been shown to be a stronger predictor of mortality than objective clinical measures (Kaplan et al., 2017).

Constraints on generality

The present sample of Black girls is not a nationally representative sample given that all participants were from the same geographic enrollment site in Richmond, California. Moreover, this study’s findings would be further substantiated by replicating the observed effects using more comprehensive measures of skin color satisfaction and validated measures of binge eating, which were not collected in the present sample.

Conclusion

Skin color satisfaction in adolescence was associated with measures of self-esteem, self-reported health, and cardiovascular risk in adulthood. We hypothesized these associations would be mediated by body satisfaction and binge eating behaviors; however, our results did not support this. Instead, the effects of skin color satisfaction on self-esteem and self-reported health appeared to be mediated by body satisfaction in adulthood and adolescence. Taken together with previous findings, our results suggest that while in adolescence, Black girls may consider skin color to be a component of their body satisfaction that can influence proximate measures of disordered eating, this association does not hold into midlife. Indeed, there appear to be lasting impacts of skin color satisfaction in adolescence, mediated by body satisfaction, but not necessarily disordered eating behaviors. Future studies should continue to explore factors that influence Black girls’ body satisfaction across the lifespan, as they may have direct and indirect implications for adult health outcomes.

Supplementary Material

Supplemental Material

Public significance statement.

We examined whether skin color satisfaction in adolescence would have long-term impacts on Black women’s body satisfaction, eating behaviors, and health outcomes. Results suggested that skin color satisfaction—at key periods in the adolescent developmental process—may be related to Black women’s subjective, psychological, and physical health.

Acknowledgements

We would like to thank the NGHS research team for their support and guidance on this project and the participants who graciously gave their time to this study over so many years.

We have no known conflict of interest to disclose. This work was supported by a UCLA Graduate Research Mentorship Fellowship and the Ford Foundation Predoctoral Fellowship to JEP, National Institutes of Health Institute of Child Health and Human Development R01HD073568 to BAL and ESE, and National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases R01DK128575 to AJT. Data used in the preparation of this manuscript was obtained from the National Heart Lung and Blood Institute’s Growth and Health Study and does not necessarily reflect the opinions or views of those entities or individuals.

Footnotes

All analyses were pre-registered at https://osf.io/w2dn6. Data and scripts specific to the present analyses are available on the corresponding OSF page for this project: https://osf.io/e65yg/.

References

  1. Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC, Virani SS, Williams KA, Yeboah J, & Ziaeian B (2019). 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 140(11), e596–e646. 10.1161/CIR.0000000000000678 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Ata RN, Schaefer LM, & Thompson JK (2015). Sociocultural Theories of Eating Disorders. In Smolak L & Levine MP (Eds.), The Wiley Handbook of Eating Disorders (pp. 269–282). John Wiley & Sons, Ltd. 10.1002/9781118574089.ch21 [DOI] [Google Scholar]
  3. Baceviciene M, Jankauskiene R, & Balciuniene V (2020). The Role of Body Image, Disordered Eating and Lifestyle on the Quality of Life in Lithuanian University Students. International Journal of Environmental Research and Public Health, 17(5), 1593. 10.3390/ijerph17051593 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Bond S, & Cash TF (1992). Black Beauty: Skin Color and Body Images among African-American College Women1. Journal of Applied Social Psychology, 22(11), 874–888. 10.1111/j.1559-1816.1992.tb00930.x [DOI] [Google Scholar]
  5. Brown KM, Schreiber GB, McMahon RP, Crawford P, & Ghee KL (1995). Maternal influences on body satisfaction in Black and White girls aged 9 and 10: The NHLBI Growth and Health Study (NGHS)1. Annals of Behavioral Medicine, 17(3), 213–220. 10.1007/BF02903915 [DOI] [PubMed] [Google Scholar]
  6. Bucchianeri MM, & Neumark-Sztainer D (2014). Body dissatisfaction: An overlooked public health concern. Journal of Public Mental Health, 13(2), 64–69. 10.1108/JPMH-11-2013-0071 [DOI] [Google Scholar]
  7. Capodilupo CM (2015). One size does not fit all: Using variables other than the thin ideal to understand Black women’s body image. Cultural Diversity and Ethnic Minority Psychology, 21(2), 268–278. 10.1037/a0037649 [DOI] [PubMed] [Google Scholar]
  8. Capodilupo CM, & Kim S (2014). Gender and race matter: The importance of considering intersections in Black women’s body image. Journal of Counseling Psychology, 61(1), 37–49. 10.1037/a0034597 [DOI] [PubMed] [Google Scholar]
  9. Cash TF, & Pruzinsky T (2002). Body image and social relations. In Body image: A handbook of theory, research, and clinical practice (pp. 277–286). Guilford Press. [Google Scholar]
  10. CDC. (2014). Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System (CDC BRFSS).
  11. Chinn JJ, Martin IK, & Redmond N (2021). Health Equity Among Black Women in the United States. Journal of Women’s Health, 30(2), 212–219. 10.1089/jwh.2020.8868 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Coffino JA, Udo T, & Grilo CM (2019). Rates of Help-Seeking in US Adults With Lifetime DSM-5 Eating Disorders: Prevalence Across Diagnoses and Differences by Sex and Ethnicity/Race. Mayo Clinic Proceedings, 94(8), 1415–1426. 10.1016/j.mayocp.2019.02.030 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Cohen J (1988). Statistical Power Analysis for the Behavioral Sciences (2nd ed.). Routledge. 10.4324/9780203771587 [DOI] [Google Scholar]
  14. Egbert AH, Hunt RA, Williams KL, Burke NL, & Mathis KJ (2022). Reporting racial and ethnic diversity in eating disorder research over the past 20 years. The International Journal of Eating Disorders. 10.1002/eat.23666 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Falconer JW, & Neville HA (2000). African American College Women’s Body Image: An Examination of Body Mass, African Self-Consciousness, and Skin Color Satisfaction: Psychology of Women Quarterly, 24(3), 236–243. [Google Scholar]
  16. Garner DM (2004). Eating Disorder Inventory 3 | EDI-3 https://www.parinc.com/Products/Pkey/103
  17. Gordon KH, Castro Y, Sitnikov L, & Holm-Denoma JM (2010). Cultural body shape ideals and eating disorder symptoms among White, Latina, and Black college women. Cultural Diversity & Ethnic Minority Psychology, 16(2), 135–143. 10.1037/a0018671 [DOI] [PubMed] [Google Scholar]
  18. Johnson JG, Cohen P, Kasen S, & Brook JS (2002). Eating Disorders During Adolescence and the Risk for Physical and Mental Disorders During Early Adulthood. Archives of General Psychiatry, 59(6), 545–552. 10.1001/archpsyc.59.6.545 [DOI] [PubMed] [Google Scholar]
  19. Kaplan RM, Howard VJ, Manly JJ, & Howard G (2017). Comparison of simple efficient clinical and self-reported predictors of mortality in a National United States Cohort. Journal of Epidemiological Research, 3(2), 23. 10.5430/jer.v3n2p23 [DOI] [Google Scholar]
  20. Keery H, van den Berg P, & Thompson JK (2004). An evaluation of the Tripartite Influence Model of body dissatisfaction and eating disturbance with adolescent girls. Body Image, 1(3), 237–251. 10.1016/j.bodyim.2004.03.001 [DOI] [PubMed] [Google Scholar]
  21. Keller BT, & Enders CK (2021). Blimp User’s Guide (Version 3) [Computer software].
  22. Maxwell M, Brevard J, Abrams J, & Belgrave F (2015). What’s Color Got To Do With It? Skin Color, Skin Color Satisfaction, Racial Identity, and Internalized Racism Among African American College Students. Journal of Black Psychology, 41(5), 438–461. 10.1177/0095798414542299 [DOI] [Google Scholar]
  23. Mond J, Mitchison D, Latner J, Hay P, Owen C, & Rodgers B (2013). Quality of life impairment associated with body dissatisfaction in a general population sample of women. BMC Public Health, 13, 920. 10.1186/1471-2458-13-920 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Mucherah W, & Frazier AD (2013). How deep is skin-deep? The relationship between skin color satisfaction, estimation of body image, and self-esteem among women of African descent. Journal of Applied Social Psychology, 43(6), 1177–1184. 10.1111/jasp.12081 [DOI] [Google Scholar]
  25. NHLBI Growth and Health Study & Research Group. (1992). Obesity and cardiovascular disease risk factors in black and white girls: The NHLBI Growth and Health Study. American Journal of Public Health, 82(12), 1613–1620. 10.2105/ajph.82.12.1613 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Oney CN, Cole ER, & Sellers RM (2011). Racial Identity and Gender as Moderators of the Relationship Between Body Image and Self-esteem for African Americans. Sex Roles, 65(7), 619. 10.1007/s11199-011-9962-z [DOI] [Google Scholar]
  27. Overstreet NM, Quinn DM, & Agocha VB (2010). Beyond Thinness: The Influence of a Curvaceous Body Ideal on Body Dissatisfaction in Black and White Women. Sex Roles, 63(1–2), 91–103. 10.1007/s11199-010-9792-4 [DOI] [Google Scholar]
  28. Parker JE, Enders CK, Mujahid MS, Laraia BA, Epel ES, & Tomiyama AJ (2022). Prospective relationships between skin color satisfaction, body satisfaction, and binge eating in Black girls. Body Image, 41, 342–353. 10.1016/j.bodyim.2022.04.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Parker JE, Levinson JA, Hunger JM, Enders CK, Laraia BA, Epel ES, & Tomiyama AJ (2022). Longitudinal stability of disordered eating symptoms from age 12 to 40 in Black and white women. Clinical Psychological Science. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Radloff LS (1977). The CES-D Scale: A Self-Report Depression Scale for Research in the General Population. Applied Psychological Measurement, 1(3), 385–401. 10.1177/014662167700100306 [DOI] [Google Scholar]
  31. Rakhkovskaya LM, & Warren CS (2014). Ethnic identity, thin-ideal internalization, and eating pathology in ethnically diverse college women. Body Image, 11(4), 438–445. 10.1016/j.bodyim.2014.07.003 [DOI] [PubMed] [Google Scholar]
  32. Rosenberg M (1965). Society and the adolescent self-image. University Press. [Google Scholar]
  33. Sardar MR, Greway A, DeAngelis M, Tysko EO, Lehmann S, Wohlstetter M, & Patel R (2015). Cardiovascular Impact of Eating Disorders in Adults: A Single Center Experience and Literature Review. Heart Views : The Official Journal of the Gulf Heart Association, 16(3), 88–92. 10.4103/1995-705X.164463 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Schaefer LM, Burke NL, Calogero RM, Menzel JE, Krawczyk R, & Thompson JK (2018). Self-objectification, body shame, and disordered eating: Testing a core mediational model of objectification theory among White, Black, and Hispanic women. Body Image, 24, 5–12. 10.1016/j.bodyim.2017.10.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Stice E, Marti CN, & Durant S (2011). Risk factors for onset of eating disorders: Evidence of multiple risk pathways from an 8-year prospective study. Behaviour Research and Therapy, 49(10), 622–627. 10.1016/j.brat.2011.06.009 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Taylor JY, Caldwell CH, Baser RE, Matusko N, Faison N, & Jackson JS (2013). Classification and Correlates of Eating Disorders among Blacks: Findings from the National Survey of American Life. Journal of Health Care for the Poor and Underserved, 24(1), 289–310. 10.1353/hpu.2013.0027 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Watson LB, Lewis JA, & Moody AT (2019). A sociocultural examination of body image among Black women. Body Image, 31, 280–287. 10.1016/j.bodyim.2019.03.008 [DOI] [PubMed] [Google Scholar]
  38. Wood NAR, & Petrie TA (2010). Body dissatisfaction, ethnic identity, and disordered eating among African American women. Journal of Counseling Psychology, 57(2), 141–153. 10.1037/a0018922 [DOI] [PubMed] [Google Scholar]
  39. Zapolski TCB, Beutlich MR, Fisher S, & Barnes-Najor J (2019). Collective ethnic-racial identity and health outcomes among African American youth: Examination of promotive and protective effects. Cultural Diversity & Ethnic Minority Psychology, 25(3), 388–396. 10.1037/cdp0000258 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Material
NIHMS1948057-supplement-Supplemental_Material.pdf (590.7KB, pdf)

RESOURCES