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. Author manuscript; available in PMC: 2025 Apr 1.
Published in final edited form as: Eat Behav. 2024 Mar 23;53:101873. doi: 10.1016/j.eatbeh.2024.101873

Eating disorder-related functional impairment predicts greater depressive symptoms across one semester of college

Anna Gabrielle G Patarinski 1, Gregory T Smith 2, Heather A Davis 1
PMCID: PMC11144091  NIHMSID: NIHMS1983752  PMID: 38579503

Abstract

Eating disorder (ED) behaviors and depression are associated with numerous negative outcomes, including lower quality of life and functional impairment. College women are at elevated risk for both. Prior research indicates ED behaviors, including binge eating, self-induced vomiting, and fasting, predict increases in future depressive symptoms. However, symptom heterogeneity in EDs is common, and all disordered eating, or its associated distress, cannot be captured by the endorsement of behaviors. Impairment that results from ED behaviors may be a comparable, or stronger, predictor of depressive symptoms. We sought to characterize the longitudinal relationship between ED-related functional impairment, ED behaviors, and depressive symptoms. College-aged women [N = 304; 72% white, mean (SD) age = 18.45 (0.88)] completed an online survey in August (baseline), and then three months later in November (follow-up). Baseline ED-related functional impairment, but not baseline ED behaviors, significantly predicted depressive symptoms at follow-up, controlling for baseline depressive symptoms, negative affect, and body mass index. Findings indicate ED-related functional impairment is a risk factor for increases in depressive symptoms across one semester of college, irrespective of ED behavior engagement, weight status, and dispositional negative affect. Intervening upon ED-related functional impairment may reduce or prevent future depressive symptoms among college-aged women.

Keywords: eating disorders, disordered eating, functional impairment, depression

1. Introduction

Although eating disorder (ED) behaviors frequently co-occur with a variety of other mental health problems, the most frequently-overlapping syndrome is depression (Udo & Grilo, 2019). When disordered eating and depression co-occur, symptoms of both (e.g., eating and weight concerns, low self-esteem, suicidality) are more severe (Aspen et al., 2014; Hughes et al., 2013; Sander et al., 2021). Given the prevalence and impairment associated with eating pathology and depression, especially among college-aged women (Amaltinga & Mbinta, 2020; Galmiche et al., 2019; Udo & Grilo, 2019), further examination of the development of their overlap merits attention. It is particularly important to identify aspects of eating pathology that elevate risk for depressive symptoms. Eating pathology broadly appears to predict future depressive symptoms (Micali et al., 2015; Puccio et al., 2016). However, given emerging work suggesting comparable distress related to ED behaviors regardless of frequency (Aspen et al., 2014), it is also possible that functional impairment associated with disordered eating, regardless of the presence or frequency of behavior(s), is a similar or stronger predictor of depressive symptoms. The current study examined ED behavior frequency and ED-related functional impairment as predictors of depressive symptoms across three months among college women.

1.1. ED-Related functional impairment

ED-related functional impairment is defined as the severity of distress and psychosocial impairment that occurs as a direct result of one’s eating habits, feelings about shape or weight, or exercise behaviors (Vannucci et al., 2012). EDs are associated with physical (e.g., sleep problems), emotional (e.g., emotion dysregulation), cognitive (e.g., attentional biases), and interpersonal (e.g., social difficulties) problems across samples (Cardi et al., 2018; Cinosi et al., 2011; Siep et al., 2011). Although prior work has focused on ED behavior frequency as an indicator of distress, emerging research suggests that significant distress and impairment associated with ED behaviors occurs both within and outside of clinical thresholds of symptomatic behaviors. At the subthreshold level, ED behaviors (e.g., binge eating, diet pill use) are associated with comparable health complications and interpersonal problems as clinical threshold EDs (Aspen et al., 2014; Cardi et al., 2018; Fichter & Quadflieg, 2016). As such, examining the distress and impairment that results from ED behaviors, regardless of their frequency or duration, may increase understanding of the downstream effects of EDs.

1.2. Depressive Symptoms

Depressive symptoms are common in ED clinical (Godart et al., 2015) and population samples (Garcia et al., 2020). A large literature demonstrates elevated severity of overlapping disordered eating and depressive symptoms (Aspen et al., 2014; Hughes et al., 2013; Sander et al., 2021). Across samples, individuals with comorbid depression and ED diagnoses reported greater ED behavior severity (e.g., binge eating, dietary restraint) than individuals with only one diagnosis (Elran-Barak & Goldschmidt, 2021; Hughes et al., 2013; Sander et al., 2021), suggesting that the presence of depression exacerbates disordered eating. Considering the distress related to disordered eating behaviors (Amaltinga & Mbinta, 2020; Galmiche et al., 2019), it may be that the experience of ED-related functional impairment promotes the development of future depressive symptoms such as hopelessness, sadness, and helplessness. Given the distress and dysfunction associated with overlap between disordered eating and depression, understanding the development or exacerbation of depressive symptoms within the context of ED behaviors is important.

1.3. Longitudinal Relations Between ED and Depressive Symptoms

More longitudinal research is necessary to clarify which aspect of disordered eating is the most precise predictor of future depressive symptoms. Recent meta-analytic and empirical findings indicate that the presence of a clinical-threshold ED (e.g., bulimia nervosa) prospectively predicts depressive symptoms, especially among adolescents (Micali et al., 2015; Puccio et al., 2016). However, ED behaviors are associated with distress and impairment both within and outside of clinical thresholds (Galmiche et al., 2019; Maine et al., 2015; Peebles et al., 2010; Withnell et al., 2022). Because clinical threshold-EDs are significantly less common than subthreshold EDs (Fairweather-Schmidt & Wade, 2014; Stice et al., 2013), examining the influence of only clinical threshold EDs on depressive symptoms limits our understanding of how ED behaviors across the clinical spectrum predict depressive symptoms.

Although some studies demonstrate significant longitudinal associations between ED behaviors and depressive symptoms (Kenny et al., 2022; Lee & Vaillancourt, 2018; Sharpe et al., 2018; Solmi et al., 2015; Stice, Hayward, et al., 2000; Tanofsky-Kraff et al., 2011), others report no significant associations (Ferreiro et al., 2014; Puccio et al., 2017). Despite these inconsistencies, there are notable patterns. Binge eating, the consumption of large amounts of food over short periods of time, consistently predicts depressive symptoms (Davis et al., 2019; Tanofsky-Kraff et al., 2011). Dietary restraint prospectively predicted depressive symptoms in one study (Stice, Hayward, et al., 2000), but not in a more recent investigation (Kenny et al., 2022). In one study, self-induced vomiting prospectively predicted depressive symptoms (Solmi et al., 2015). In another study, college students with moderate levels of depressive symptoms reported greater engagement in laxative misuse than college students with no or low levels of depressive symptoms (Eck & Byrd-Bredbenner, 2021). Other studies used measures that collapsed across several ED behaviors, including self-induced vomiting and laxative misuse (Lee & Vaillancourt, 2018; Stice, Hayward, et al., 2000), so it is unclear if any particular symptom was a unique predictor of depressive symptoms.

Research examining ED symptoms’ prediction of depressive symptoms has primarily focused on youth. Only one study has examined longitudinal associations between ED symptoms and depressive symptoms among college students. Boujut and Gana (2014) found that greater levels of cognitive and behavioral ED symptoms (measured with a composite score) predicted greater depressive symptoms one year later among college women. However, this study did not examine specific ED behaviors as predictors of depressive symptoms or whether ED-related functional impairment was a predictor of future depressive symptoms. Further study of ED behaviors and ED-related functional impairment in the prediction of depressive symptoms may clarify potential prevention targets in vulnerable college student populations.

1.4. ED-Related Functional Impairment and Depressive Symptoms Among College Women

The prodromal phase of EDs ranges from early adolescence to the mid-twenties (Favaro et al., 2019). Accordingly, ED-related functional impairment may be elevated during the college years, relative to adolescent years when behavior engagement first begins (Lipson & Sonneville, 2017; Maillet & Grouzet, 2023). Further, college women appear to be at high risk for EDs and ED-related functional impairment, compared to college men (Fitzsimmons-Craft et al., 2019). Among college women, the presence of ED behaviors is associated with academic difficulties, depression, and anxiety (Eisenberg et al., 2009).

Similarly, depressive symptoms increase during the college years (Liu et al., 2019). Given the high prevalence of ED symptoms among college women (Eisenberg et al., 2011; Lipson & Sonneville, 2017) and their associated distress (Byrne et al., 2016), it is possible that ED-related functional impairment is a more precise predictor of depressive symptom risk than frequency of symptoms. Further, recent qualitative work suggests that ED-related distress contributes to low mood and isolation (McCombie et al., 2020), which may reflect and/or promote increases in depressive symptoms. In summary, the experience of ED-related distress and ED behaviors can result in significant impairment for college students, including academically, interpersonally, emotionally, and physically. The dysfunction related to ED distress and behaviors may predict future depressive symptoms.

1.5. Current Study

No study to date has examined the differential prediction of depressive symptoms from ED behaviors and ED-related functional impairment. We examined the longitudinal relationship among ED behaviors, ED-related functional impairment, and depressive symptoms among college women across three months (a fall semester). Given evidence that depressive symptoms increase across the fall semester in college, particularly among women (Arigo & Cavanaugh, 2016; Barker et al., 2018), we considered it important to examine whether ED behaviors and ED-related functional impairment may contribute to increases in depression across this timeframe. ED behaviors examined included binge eating and self-induced vomiting, as these behaviors longitudinally predict depressive symptoms in prior studies (Kenny et al., 2022; Lee & Vaillancourt, 2018; Solmi et al., 2015; Stice, Hayward, et al., 2000; Tanofsky-Kraff et al., 2011). We included fasting as a proxy for dietary restraint, which similarly predicts depressive symptoms (Stice, Hayward, et al., 2000). We also included laxative misuse because prior work indicates purging behavior in general, and laxative use in particular, is cross-sectionally associated with depressive symptoms (Eck & Byrd-Bredbenner, 2021). Given evidence that ED behaviors, regardless of frequency or duration, are associated with impairment and distress (Aspen et al., 2014; Cardi et al., 2018; Fichter & Quadflieg, 2016), we hypothesized that higher levels of baseline ED-related functional impairment would be associated with greater depressive symptoms at three-month follow-up, beyond prediction from ED behaviors frequency and baseline depressive symptoms.

We controlled for two potentially confounding variables in analyses. First, we included baseline dispositional negative affect as a covariate, given evidence for its correlation and prospective associations with depression and ED behaviors (Kitsantas et al., 2003; Stice, Akutagawa, et al., 2000; Stice et al., 2008). We also included body mass index (BMI) as a covariate, to control for its potential overlap with ED behaviors and ED-related functional impairment (Davis et al., 2022; Kelly-Weeder et al., 2014; Lipson & Sonneville, 2017) and variation in body size that may contribute to depression risk (Pereira-Miranda et al., 2017).

2. Methods

2.1. Participants

Data came from a larger study examining antecedents and consequences of ED behaviors across one semester of college (Davis et al., 2022). Participants were 302 college-aged women [mean (SD) age = 18.45 (0.88) years, 72.0% White, 15.8% Black, 4.9% Biracial, 3.6% Hispanic, 2.0% Asian, and 0.3% Native American] assessed at two time points (baseline, follow-up) across three months. Retention at follow-up (N = 260) was 86.1%.

2.2. Procedure

Participants were recruited from a public university using SONA Systems, an undergraduate research participation pool. Participants received one hour of research course credit at each time point. Informed consent was obtained prior to participation in the online survey. All study procedures were approved by the university’s Institutional Review Board.

2.3. Measures

2.3.1. Clinical Impairment Assessment (CIA; Bohn et al., 2008)

The CIA is a 16-item scale that assesses ED-related functional impairment within three domains (personal, cognitive, and social; Bohn et al., 2008) using a 4-point ordered rating scale anchored at 0 (“Not at all”) and 3 (“A lot”). Scores are summed to obtain a global score; higher scores indicate greater impairment and a cut-off of 16 indicates ED case status (Bohn et al., 2008). The CIA converges with eating pathology measures among clinical and nonclinical samples (Jenkins, 2013; Reas et al., 2010) and demonstrates high test-retest reliability and internal consistency (Reas et al., 2010). In the current study, internal consistency was high (α = .94).

2.3.2. Eating Disorder Examination Questionnaire, 6th edition (EDE-Q; Fairhurn & Beglin, 1994)

The EDE-Q is a self-report questionnaire adapted from the Eating Disorder Examination. We used the behavioral items to assess binge eating, self-induced vomiting, and fasting over the past 28 days. EDE-Q behavioral items demonstrate high reliability and validity across studies (Berg et al., 2012; Luce & Crowther, 1999).

Binge eating was assessed using two questions: First, “Have there been times where you have eaten what most people would regard as an unusually large amount of food?” If yes, participants answered the question, “During how many of these episodes of overeating did you have a sense of having lost control over your eating (at the time that you were eating)?” “No” responses were coded 0. “Yes” responses were coded the number of reported episodes.

Self-induced vomiting was assessed using the question “Over the past 28 days, how many times have you made yourself sick (vomit) as a means of controlling your shape or weight?” The number of reported episodes was coded.

Fasting was measured by the question, “Have you gone for long periods of time (8 waking hours or more) without eating anything at all in order to influence your shape or weight?” Responses included No days, 1-5 days, 6-12 days, 13-15 days, 16-22 days, 23-27 days, and Every day. This single-item measure of fasting has been used in previous studies as a predictor of psychopathology (Forrest et al., 2016; Wang et al., 2020).

Laxative misuse was measured by the question, “Over the past 28 days, how many times have you taken laxatives as a means of controlling your shape or weight?” The number of reported episodes was coded.

2.3.3. Center for Epidemiologic Studies Depression scale (CES-D; Radloff 1977)

The CES-D is a 20-item self-report scale used to assess the presence and frequency of depressive symptoms over the last week. Participants indicate their responses to items using a 4-point ordered rating scale anchored at (1) “rarely or none of the time/less than 1 day” and (4) “most or all of the time/5-7 days.” Higher scores indicate greater depressive symptoms (Radloff, 1977). A cut-off of 16 indicates clinically meaningful depression in young people (Santor et al., 1995). The CES-D demonstrates discriminant validity with other self-report measures of depression and high test-retest reliability in clinical and general populations (Radloff, 1977). The CES-D is accurate in detecting major depression in primary care and community populations (Vilagut et al., 2016) and demonstrates high internal consistency in both populations (Carleton et al., 2013). In the current study, measures of internal consistency were high (baseline α = .92, follow-up α = .91).

2.3.4. Positive and Negative Affect Schedule (PANAS; Watson et al., 1988)

The PANAS is a 20-item self-report instrument that assesses positive and negative affect using a 5-point ordered rating scale anchored at (1) “very slightly or not at all” and (5) “extremely” (Watson et al., 1988). We used only the Negative Affect subscale. The PANAS has demonstrated measurement invariance, construct validity, high internal consistency, and convergent validity with other measures of mood (Crawford & Henry, 2004; Merz et al., 2013; Watson et al., 1988). In the current study, internal consistency of the PANAS was high (α = .87).

2.3.5. Body Mass Index (BMI)

BMI was calculated by dividing self-reported weight in kilograms by height in meters squared. Participant self-reported height and weight is strongly correlated with objectively measured height and weight across studies (Davies et al., 2020; Kuczmarski et al., 2001; Olfert et al., 2018).

2.4. Data Analyses

Descriptive statistics for study variables and bivariate correlations between variables were calculated. At baseline and follow-up, participants with missing data did not differ on any study variables, so data were inferred to be missing at random. We used the expectation maximization procedure to impute missing values, a procedure shown to more accurately approximate population data than alternative methods (e.g., case deletion, mean substitution; Enders, 2006; Little & Rubin, 1989). Thus, we were able to use the entire sample of N = 302.

A hierarchical linear regression model was used to assess the influence of ED behaviors and ED-related functional impairment on depressive symptoms three months later, controlling for baseline levels of depressive symptoms, BMI, and negative affect. Depressive symptoms at follow-up were specified as the outcome variable. At Step 1, baseline depressive symptoms, BMI, and negative affect were entered as predictor variables. At Step 2, baseline binge eating, self-induced vomiting, and fasting were entered as predictor variables. At Step 3, baseline ED-related functional impairment was entered.

2.4.1. Post Hoc Data Analyses

As reported below, the proportion of participants who reported clinically significant depressive symptoms decreased from baseline to follow-up. We conducted a repeated measures analysis of variance (ANOVA) to explore whether that change was significant. We also conducted a frequency analysis to examine the proportion of participants with baseline clinically significant ED-related functional impairment (i.e., CIA scores ≥16) that reported an increase in depressive symptoms at follow-up.

3. Results

3.1. Preliminary Analyses

Means and standard deviations of ED-related functional impairment, depressive symptoms, negative affect, and BMI at each time point are presented in Table 1. At baseline, 21.2% of participants reported clinically significant ED impairment (CIA score of ≥16) and 40.1% reported clinically significant depressive symptoms (CES-D score of ≥16). At follow-up, 33.8% reported clinically significant depressive symptoms. Correlations among study variables are presented in Table 2. A repeated measures ANOVA indicated that the decline in depressive symptoms from baseline to follow-up was significant (F = 7.87, p = .005).

Table 1.

Descriptive Statistics for All Study Variables

Study Variable Baseline
Mean (SD)
N = 302		 Follow-Up
Mean (SD)
N = 260
PANAS-Negative Affect 20.89 (7.15) 19.54 (7.76)
Body Mass Index 23.66 (4.51) 23.84 (4.53)
Clinical Impairment Assessment 9.17 (9.22) 8.54 (9.95)
CES-D 15.09 (10.92) 13.48 (10.42)
Eating Disorder Behavior Frequency of Behavior
Baseline
n (%)		 Over the Past 28 Days
Follow-up
n (%)
Fasting
1 – 5 times 59 (19.53) 49 (18.85)
6 – 12 times 9 (2.98) 14 (5.38)
13 – 15 times 12 (3.97) 5 (1.92)
16 – 22 times 5 (1.66) 1 (0.38)
23 – 27 times 2 (0.66) 1 (0.38)
28+ times 6 (1.99) 3 (1.15)
Binge eating
1 – 5 times 59 (19.54) 54 (20.77)
6 – 12 times 22 (7.28) 8 (3.08)
13 – 15 times 4 (1.32) 2 (0.77)
16 – 22 times 4 (1.32) 0 (0)
23 – 27 times 1 (0.33) 1 (0.38)
28+ times 3 (1) 3 (1.15)
Self-induced vomiting
1 – 5 times 12 (3.97) 18 (6.92)
6 – 12 times 3 (0.99) 2 (0.77)
13 – 15 times 0 (0) 0 (0)
16 – 22 times 0 (0) 1 (0.38)
23 – 27 times 0 (0) 0 (0)
28+ times 0 (0) 1 (0.38)
Laxative misuse
1 – 5 times 9 (2.98) 10 (3.85)
6 – 12 times 3 (0.99) 0 (0)
13 – 15 times 1 (0.33) 1 (0.38)
16 – 22 times 2 (0.66) 0 (0)
23 – 27 times 0 (0) 0 (0)
28+ times 0 (0) 1 (0.38)
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Note. PANAS-NA = Positive and Negative Affect Schedule, Negative Affect subscale, CES-D = Center for Epidemiologic Studies Depression scale.

Table 2.

Correlations Between Study Variables

Baseline
BMI		 Baseline
PANAS-NA		 Baseline
CIA		 Baseline
Binge
Eating		 Baseline Self-
Induced
Vomiting		 Baseline
Fasting		 Baseline
Laxative
Misuse		 Baseline
CES-D
Baseline PANAS-NA .03 -- -- -- -- -- -- --
Baseline CIA .17** .55*** -- -- -- -- -- --
Baseline Binge Eating .08 .25*** .24*** -- -- -- -- --
Baseline Self-Induced Vomiting .00 .20*** .19*** .19*** -- -- -- --
Baseline Fasting .14* .33*** .50*** .10 .21*** -- -- --
Baseline Laxative Misuse .06 .10 .12* .15* .19*** .08 -- --
Baseline CES-D −.00 .72*** .57*** .12* .20*** .33*** .13* --
Follow-up CES-D .11 .49*** .47*** .12* .09 .29*** .08 .61***
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Note. N = 302. BMI = body mass index; PANAS-NA = Positive and Negative Affect Schedule, Negative Affect subscale; CIA = Clinical Impairment Assessment; CES-D = Center for Epidemiologic Studies Depression scale; *p < .05, **p < .01, ***p < .001

3.2. Hypothesis Test

Given observed correlations among study variables, we checked collinearity in the regression model by measuring variance inflation factor (VIF) values. All VIF values were under 10, indicating no problems with collinearity (Fox, 2019). Results of the hierarchical linear regression predicting depressive symptoms at follow-up are presented in Table 3. At Step 1, the overall model was significant, F{3, 298) = 62.19, p < .001, R2 = .38. Baseline CES-D and BMI significantly predicted follow-up CES-D score. Baseline negative affect did not predict follow-up CES-D score. At Step 2, the overall model was significant [F(6, 294) = 27.18, p < .001, R2 = .38], but the addition of binge eating, self-induced vomiting, fasting, and laxative misuse did not significantly improve the model over the prior step. At Step 3, the overall model was significant [F(7, 293) = 24.63, p < .001, R2 = .39]. The inclusion of CIA score significantly improved the model over the prior step, Fchange (1, 293) = 4.52, p = .03, R2change = .01.

Table 3.

Hierarchical Linear Regression Predicting Depression Symptoms at Follow-up

Step Predictor Variablea B (SE) β t p 95% CI for B
1 CES-D .51 (.06) .54 8.20 <.001 .39 - .63
PANAS-NA .14 (.09) .10 1.51 .13 −.04 - .33
BMI .24 (.10) .11 2.35 .02 .04 - .45
2 CES-D .50 (.06) .53 7.93 <.001 .38 - .63
PANAS-NA .12 (.10) .08 1.20 .23 −.08 - .31
BMI .22 (.11) .09 2.04 .04 .01 - .42
Binge Eating .07 (.10) .03 0.69 .50 −.13 - .28
Self-Induced Vomiting −.53 (.45) −.06 −1.18 .23 −1.40 - .35
Fasting .67 (.42) .08 1.59 .11 −.16 - 1.49
Laxative misuse −.03 (.26) −.01 −0.12 .90 −.55 - .48
3 CES-D .46 (.07) .49 7.05 <.001 .33 - .59
PANAS-NA .08 (.10) .06 0.82 .41 −.11 - .27
BMI .18 (.11) .08 1.70 .09 −.03 - .39
Binge Eating .04 (.10) .02 0.38 .70 −.16 - .25
Self-Induced Vomiting −.53 (.44) −.06 −1.24 .23 −1.40 - .34
Fasting .33 (.45) .04 0.74 .46 −.55 - 1.20
Laxative misuse −.04 (.26) −.01 −0.16 .88 −.55 - .47
CIA .15 (.07) .13 2.13 .03 .01 - .29
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Note. aAll predictors were assessed at baseline. N = 302. BMI = body mass index; PANAS-NA = Positive and Negative Affect Schedule, Negative Affect subscale; CIA = Clinical Impairment Assessment; CES-D = Center for Epidemiologic Studies Depression scale.

Greater ED-related functional impairment at baseline predicted greater depressive symptoms at follow-up. When baseline ED-related functional impairment was added to the model, baseline BMI was no longer a significant predictor of depressive symptoms at follow-up. Because the overall frequency of clinically significant depressive symptoms decreased from baseline to follow-up, we examined the frequency of participants with baseline CIA scores ≥16 who endorsed an increase in depressive symptoms at follow-up. Of the 64 participants with CIA scores ≥ 16, n = 17 (26.6%) reported higher depression scores at follow-up.

4. Discussion

Hypotheses were supported: ED-related functional impairment prospectively predicted depressive symptoms, even when controlling for baseline ED behaviors, depressive symptoms, negative affect, and BMI. Binge eating, self-induced vomiting, fasting behavior, and laxative misuse frequency did not significantly predict depressive symptoms across three months.

Although prior work indicates that ED diagnoses or symptom frequency predict depressive symptoms longitudinally in college students (Boujut & Gana, 2014) and youth (Lee & Vaillancourt, 2018; Micall et al., 2015; Solmi et al., 2015; Stice, Hayward, et al., 2000; Tanofsky-Kraff et al., 2011), impairment or distress related to behavior engagement was not investigated in these studies. We found that frequency of binge eating, self-induced vomiting, fasting behavior, and laxative misuse did not predict future depressive symptoms, with or without ED-related functional impairment in the predictive model. Although this finding diverges from previous research, it is not surprising considering existing literature.

First, the only previous study of the longitudinal relationship between ED behaviors and depressive symptoms that included college women used a composite ED measure as a predictor of future depressive symptoms (Boujut & Gana, 2014). As a result, symptom endorsement and distress were subsumed in one measure, which did not allow for interpretation of whether ED behaviors or ED-related distress uniquely predicted future depressive symptoms. In the current study, we examined individual ED behavior frequency and ED-related functional impairment as unique predictors of depressive symptoms, and only ED-related functional impairment emerged as significant. It is possible that the difference in measurement of ED behaviors between our study and Boujut & Gana (2014) contributed to our disparate findings. Second, Boujut & Gana (2014) measured effects over a one-year time frame; in the current study, we examined effects across three months. Although ED-related functional impairment predicted depressive symptoms across this relatively short time period, three months may not have been long enough to detect the effects of individual ED behavior frequency on future depressive symptoms. Future studies should attempt to replicate our findings across longer follow-up periods to examine this possibility. Third, ED-related functional impairment represents the negative impact of disordered eating on one’s quality of life, which is lower in individuals with ED behaviors (Doll et al., 2005; Sanftner, 2011) and is consistently associated with depression (Berlim & Fleck, 2007; Özabacı, 2010). It may be that disordered eating, regardless of behavior frequency, contributes to functional impairment that leads to unhappiness and dissatisfaction, which ultimately increases vulnerability to depressive symptoms like sadness and hopelessness.

Future studies should clarify the longitudinal relationship observed in this study by investigating potential mechanisms underlying the prospective association between ED-related functional impairment and depressive symptoms. A starting point may be investigating shared correlates as mechanisms. For example, given evidence for loneliness as a correlate of disordered eating (Southward et al., 2014) and a predictor of depression (Erzen & Çikrikci, 2018), the experience of having disordered eating may result in social withdrawal, contributing to isolation and later depression. Future longitudinal studies with multiple time points and longer follow-up periods may be used to test this and other potential mechanisms (e.g., low self-esteem, perfectionism, shame) underlying previously observed longitudinal relationships.

Findings indicate that college women experiencing functional impairment related to disordered eating are at increased risk of depressive symptoms three months later, even considering prior depression level. Notably, our sample experienced an overall decline in depressive symptoms at follow-up. Despite this, ED-related functional impairment still predicted new or more frequent depressive symptoms at follow-up for 26.6% of women with clinically significant ED-related functional impairment. ED-related functional impairment appeared to mitigate follow-up reductions in depressive symptoms for the remaining women. Because depression and disordered eating are associated with numerous negative downstream effects (Cardi et al., 2018; Solmi et al., 2015), it is important for future research to investigate the potential ongoing nature of this risk process. For example, do depressive symptom levels predicted by ED-related functional impairment in turn predict more ED-related functional impairment? Given the significant overlap between suicidality and EDs (Smith et al., 2018; Udo & Grilo, 2019), future research should investigate whether depressive symptoms resulting from ED-related functional impairment predict greater suicidality in particular.

Results suggest ED-related functional impairment is a prospective predictor of depressive symptoms among college women regardless of baseline dispositional negative affect, a shared risk factor for disordered eating and depressive symptoms (Kitsantas et al., 2003; Stice, Akutagawa, et al., 2000; Stice et al., 2008). Researchers studying college mental health, including depression, may consider including eating pathology in their risk models. Given extant literature showing significant negative consequences of both depression and disordered eating (Cardi et al., 2018; Solmi et al., 2015), clinicians and researchers alike should continue their efforts to treat and understand these pernicious problems. Consideration of functional impairment and distress, rather than a focus on behavior frequency, may be important in efforts to reduce the public health burden of both disordered eating and depression.

Notably, baseline BMI was not a significant predictor of greater depressive symptoms at follow-up when ED-related functional impairment was included in the model. This suggests that body size is not a significant contributor to future depressive symptoms when ED-related functional impairment is considered. This diverges from prior work demonstrating associations between high BMI and depression (Pereira-Miranda et al., 2017). It may be that distress related to eating, which overlaps with BMI, is a stronger predictor of depressive symptoms. Future work should attempt to clarify relationships between BMI, disordered eating, and depressive symptoms.

Regarding clinical implications of these findings, there are several to note. First, our results indicate that healthcare providers of young adults, particularly those on college campuses, should screen their patients for disordered eating. In particular, providers should ensure that ED screening includes assessing ED-related functional impairment in addition to ED behaviors, especially among women. It is well-known that early detection of and intervention upon distress related to ED behaviors helps to mitigate their duration and resulting impairment (Davidsen et al., 2017), but it also may help prevent ED comorbidity with depression. Follow-up monitoring of students who report ED-related functional impairment is also warranted to help prevent or reduce later depressive symptoms. In light of these results and prior findings, clinicians could also consider integrating interventions designed to reduce depressive symptoms (e.g., behavioral activation, mindfulness; Ma et al., 2019; Reyes Para et al., 2019) within ED treatment to help prevent the development or exacerbation of depressive symptoms. Finally, the implementation of psychoeducation programs describing the link between depression and EDs on college campuses may promote help-seeking for these symptoms. Ideally, such programs would include connecting students with resources if/when needed.

4.1. Future Directions

Strengths of the current study include the longitudinal design, which allowed us to examine ED-related functional impairment as a prospective predictor of depressive symptoms. We included potentially confounding variables as controls in our model, which allowed us to understand the relationship irrespective of baseline levels of negative affect and BMI. We also had good retention between baseline and follow-up, which provided us sufficient power to detect effects of our model.

Limitations of the study include the inability to draw causal conclusions based on these data, but the longitudinal findings are consistent with a causal model indicating ED-related functional impairment results in greater depressive symptoms over time among college women. The follow-up period of the study was relatively short (one semester). Studies with longer follow-up periods are needed to understand the potential long-term consequences of the effects reported. The sample included only cisgender college women, the majority identifying as white, limiting generalizability. Future studies should test this model in larger samples with greater age, racial, ethnic, and gender diversity to determine for whom this effect is relevant. For example, it would be particularly important to investigate this effect among college men, given the historical underrepresentation of men in ED research (Brown & Keel, 2023). Further, we did not include cognitive ED symptoms (e.g., body dissatisfaction, overvaluation of weight/shape) as predictors in our model, so we cannot know if ED-related functional impairment predicts future depressive symptoms above and beyond cognitive ED symptoms as well as behavioral symptoms; future studies should examine this possibility. We also did not assess loss of control eating outside of objectively large eating episodes in the parent study from which these data were drawn, so we could not include that behavior as a predictor in our model. Future research should investigate the possibility that loss of control eating, whether it is objectively large or not, predicts future depressive symptoms above and beyond ED-related functional impairment. Finally, the data were self-reported. Though the measures used in this study have demonstrated strong psychometric properties across samples, findings could differ if clinical interviews were used to assess key variables.

4.2. Conclusion

This study offers a new perspective on the longitudinal relationship between EDs and depression by investigating ED-related functional impairment as a predictor of depressive symptoms. Findings contribute to an accumulating literature describing the aspects of disordered eating that predict greater depressive symptoms over time and may help inform the development of interventions to decrease depressive symptoms through the treatment of eating-related distress. Future research is needed to elucidate therapeutic mechanisms and potential treatment targets underlying the observed relationship.

Highlights.

ED-related impairment in college women predicted depressive symptoms over 3 months

BMI and ED symptom frequency did not predict depressive symptoms over 3 months

ED interventions addressing impairment over symptoms may reduce/prevent depression

Funding:

This work was supported by the National Institute of Mental Health under grant F31-MH114551.

Footnotes

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Disclosure Statement: All authors have no conflicts of interest to report.

Declaration of Interest Statement: All authors have no interests to declare.

Data Availability Statement:

Data are available upon reasonable request.

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Data are available upon reasonable request.

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