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. Author manuscript; available in PMC: 2022 Aug 1.
Published in final edited form as: Appetite. 2021 Mar 23;163:105224. doi: 10.1016/j.appet.2021.105224

Childhood maltreatment and disordered eating attitudes and behaviors in adult men and women: Findings from Project EAT

Rebecca L Emery a, Cynthia Yoon a, Susan M Mason a, Dianne Neumark-Sztainer a
PMCID: PMC8137658  NIHMSID: NIHMS1686456  PMID: 33766616

Abstract

This study examined gender differences in the association between childhood maltreatment and disordered eating attitudes and behaviors in adulthood. Data were derived from 1,647 adults (ages 27-33) participating in a population-based, longitudinal study (Project EAT-IV: Eating Among Teens and Young Adults, 1998-2016). Childhood maltreatment (sexual abuse, physical abuse, emotional abuse, emotional neglect) and disordered eating attitudes and behaviors (overeating, binge eating, extreme weight control behaviors, unhealthy weight control behaviors, chronic dieting, weight and shape concerns) were assessed. Relative risk regression models were used to examine whether childhood maltreatment was related to individual disordered eating attitudes and behaviors. Gender differences in these associations were explored. A history of any childhood maltreatment was associated with more than 60% greater risk for chronic dieting and overeating, with additional associations found for binge eating, weight and shape concerns, and unhealthy weight control behaviors. All types of abuse and neglect were associated with at least one type of disordered eating outcome. Examination of the point estimates indicated that emotional neglect was most consistently related to higher risk for disordered eating attitudes and behaviors. Although there were no statistically significant gender differences in the association between childhood maltreatment and disordered eating attitudes and behaviors, the patterning of these effects highlighted unique qualitative similarities and differences in these relationships between men and women. Taken together, these findings implicate childhood maltreatment, particularly emotional neglect, as a meaningful risk factor for problematic eating outcomes in both men and women during adulthood.

Keywords: Abuse, neglect, childhood maltreatment, disordered eating attitudes, disordered, eating behaviors

1.1. Introduction

Exposure to childhood maltreatment, including abuse or neglect, is highly prevalent in the United States (Merrick et al., 2018) and has lasting effects on adult morbidity and mortality (Merrick et al., 2019). Previous research indicates that individuals with a history of childhood maltreatment are vulnerable to experiencing eating disturbances in adulthood, ranging from subclinical disordered eating attitudes and behaviors (Fischer et al., 2010) to clinically significant eating disorders (Brown et al., 2014; Caslini et al., 2016; Molendijk et al., 2017). These disordered eating outcomes are thought to partly arise as a consequence of poor emotion regulation abilities stemming from childhood maltreatment (Burns et al., 2012; Moulton et al., 2015; Racine & Wildes, 2015). Adults with eating disturbances who report a history of childhood maltreatment further display greater psychological distress (Hund & Espelage, 2005; Molendijk et al., 2017) and more psychiatric comorbidities (Armour et al., 2016; Guillaume et al., 2016) when compared to those who do not report such a history. Accordingly, understanding the relationship between childhood maltreatment and eating disturbances among adults, in particular what types of disordered eating attitudes and behaviors may be most affected and among which adults, has important implications for interventions aimed at the prevention and treatment of eating-related complications.

Disordered eating attitudes and behaviors encompass an array of factors, including concerns about weight and shape, overeating, binge eating, purging, and dieting, that vary in frequency and severity and can increase risk for negative health outcomes, such as more severe eating disorder pathology (Emery et al., 2013; Espinoza et al., 2010), higher weight status (Neumark-Sztainer et al., 2006; Yoon et al., 2020), and cardiometabolic impairment (Nagata et al., 2018a). Given that subclinical disordered eating attitudes and behaviors occur more frequently than clinical eating disorders (Nagata et al., 2018a), are relatively common in community samples of adults (Lavender et al., 2010; Reba-Harrelson et al., 2009), and are associated with numerous outcomes of public health concern as outlined above (Emery et al., 2013; Espinoza et al., 2010; Nagata et al., 2018a; Neumark-Sztainer et al., 2006; Yoon et al., 2020), a growing body of research has focused on how childhood maltreatment relates to such outcomes in adulthood (Burns et al., 2012; Dworkin et al., 2014; Fuemmeler et al., 2009; Kent & Waller, 2000; Mason et al., 2013; Miskinyte et al., 2006; Smolak & Murnen, 2002; Smyth et al., 2008). For example, Miskinyte and colleagues (2006) found that undergraduate women with a history of childhood physical and psychological abuse were more likely to report dieting and other disordered eating behaviors characteristic of anorexia nervosa when compared to those without such histories. Meanwhile, Burns and colleagues (2012) found that a history of childhood emotional abuse among undergraduate women was more predictive of eating disorder symptoms than was childhood physical or sexual abuse and was specifically related to a greater frequency of binge eating episodes and higher scores on a measure of disordered eating attitudes and behaviors.

Importantly, the majority of previous work has focused on a narrow scope of childhood maltreatment in relation to a limited number of disordered eating attitudes and behaviors and has further relied on convenience samples of undergraduate students, predominantly comprised of women. These limitations restrict our understanding of how childhood maltreatment relates to a range of disordered eating attitudes and behaviors throughout adulthood and whether these associations differ as a function of gender. Although a number of studies have looked at how gender modifies the effect of childhood maltreatment on disordered eating attitudes and behaviors in adolescence (Ackard et al., 2008; Ackard & Neumark-Sztainer, 2003; Ackard et al., 2001), the limited research extending these findings to adulthood has been inconclusive, with some studies reporting no gender differences in the association between childhood maltreatment and disordered eating attitudes and behaviors in adults (Abajobir et al., 2017; Dworkin et al., 2014; Smyth et al., 2008) and others only documenting a link between these factors in adult women and not in adult men (Fuemmeler et al., 2009).

Given that early adulthood is an important time for intervention, as it is before the onset of many chronic diseases and long-term morbidities that can arise from disordered eating, there remains a need for population-based studies that comprehensively examine the associations between multiple types of childhood maltreatment and a broad range of disordered eating attitudes and behaviors in early adult men and women. The present study aimed to address this gap by examining gender differences in the association between several types of childhood maltreatment (sexual abuse perpetrated by a family and/or non-family member and physical abuse, emotional abuse, and emotional neglect perpetrated by a family member) and disordered eating attitudes and behaviors (overeating, binge eating, extreme weight control behaviors, unhealthy weight control behaviors, chronic dieting, and weight and shape concerns) using a population-based sample of early adults. The specific aims were to 1) examine whether any history of childhood maltreatment relates to individual disordered eating attitudes and behaviors, 2) identify which types of childhood maltreatment are most strongly related to each disordered eating attitude and behavior, and 3) explore gender differences in these associations.

2.1. Methods

2.1.1. Participants and procedures

Data for this analysis were drawn from the population-based, Project EAT (Eating and Activity in Teens and Young Adults) longitudinal study of weight-related health among young people. The original EAT-I assessment, involving surveys and anthropometric measures, was designed as a cross-sectional study of students enrolled at middle schools and senior high schools in the Minneapolis-St. Paul metropolitan area of Minnesota in 1998-1999 (Neumark-Sztainer et al., 2002). Given growing research interest in the eating and weight-related health of young people, a decision was made to follow up at five-year intervals with participants from the original sample who had provided sufficient contact information at EAT-I (N=3,672 of 4,746). Follow-up mailed and online assessments were conducted in 2003-2004 (EAT-II) and 2008-2009 (EAT-III) to examine changes in the weight-related attitudes and behaviors of the original participants as they progressed through adolescence and emerging adulthood (Larson et al., 2011; Neumark-Sztainer et al., 2011). In 2015-2016, participants who previously responded to either EAT-II or EAT-III were contacted for additional follow-up (EAT-IV) in adulthood (ages 27-33). Follow-up surveys for EAT-IV were collected online, by mail, or by phone from 1,830 of the 2,270 participants that could be contacted (Larson et al., 2018; Neumark-Sztainer et al., 2018). The Institutional Review Board Human Subjects Committee at the University of Minnesota approved all protocols used in Project EAT at each time point and all participants provided informed consent before taking part in study procedures.

The current analysis used retrospective data of childhood maltreatment and current data on disordered eating attitudes and behaviors collected from participants who completed the EAT-IV survey (N=1,830). Participants with missing information on childhood maltreatment («=24), disordered eating attitudes and behaviors (n=15), and covariates (n=144) were further excluded, resulting in an analytic sample of 1,647 participants.

2.1.2. Survey Development

The EAT-IV survey was pre-tested as part of two focus groups with adults. Feedback from the 35 adult participants was used to guide refinements to the survey (e.g., rewording or eliminating on problematic survey measures) before fielding. Scale psychometric properties and the test-retest reliability of the survey, reported below, were determined in a subgroup of 103 participants who completed the EAT-IV survey twice within a period of one to four weeks.

2.1.3. Measurements

2.1.3.1. Childhood maltreatment.

Childhood maltreatment that occurred before age 18 was retrospectively assessed at EAT-IV. Childhood abuse and neglect items were adapted from the Minnesota Student Survey, one of the longest-running youth surveys in the nation administered by the Minnesota Department of Education (Adelman et al., 1998), and the Childhood Trauma Questionnaire, a valid and widely used measure of self-reported childhood maltreatment (Bernstein et al., 1994). Because the vast majority of childhood maltreatment is perpetrated by family members (Frewen et al., 2015; U.S. Department of Health & Human Services, 2018), measures of childhood maltreatment largely focus on abuse and neglect instigated by family members (Felitti et al., 1998). The exception to this pattern is childhood sexual abuse, which is perpetrated by family and non-family members at relatively high rates (Frewen et al., 2015). Consistent with previous literature, the present study thus assessed childhood sexual abuse perpetrated by family and/or non-family members and childhood physical abuse, emotional abuse, and emotional neglect perpetrated by family members. Following the cut-points provided in the Childhood Trauma Questionnaire scoring manual (Bernstein & Fink, 1998), responses were dichotomized into a “yes” or “no” variable for each type of childhood maltreatment assessed. As recommended by Bernstein & Fink (1998), varied cut-points were chosen to maximize the item’s sensitivity and specificity. An overall childhood maltreatment score was then calculated by summing the total number of childhood maltreatment experiences, and participants were dichotomized according to whether they reported experiencing “no” (0) versus “any” (≥1) type of childhood maltreatment.

2.1.3.1.1. Sexual abuse.

Participants responded to two items: “Did someone in your family touch you in a sexual way against your wishes or force you to touch them in a sexual way?” and “Did someone not in your family touch you in a sexual way against your wishes or force you to touch them in a sexual way?” Response options were “no,” “once,” or “more than once.” Sexual abuse was coded positively when participants indicated having one or more experiences of unwanted sexual touching by someone in or outside the family. Test-retest agreement=98%.

2.1.3.1.2. Physical Abuse.

Participants reported the frequency that “an adult in my family hit me so hard it left bruises or marks” using a 5-point scale, with response options being “never,” “rarely,” “sometimes,” “often,” and “very often.” Physical abuse was coded positively when participants indicated having been hit by a family member so hard that it left bruises or marks “rarely” or more. Test-retest agreement=90%.

2.1.3.1.3. Emotional Abuse.

Participants reported the frequency that “an adult in my family said hurtful or insulting things to me” using a 5-point scale, with response options being “never,” “rarely,” “sometimes,” “often,” and “very often.” Emotional abuse was coded positively when participants indicated that an adult in their family said hurtful or insulting things “often” or “very often.” Test-retest agreement=93%.

2.1.3.1.4. Emotional neglect.

Participants reported the frequency that “my family was a source of strength and support” and “someone in my family made me feel that I was important or special” using a 5-point scale, with response options being “never,” “rarely,” “sometimes,” “often,” and “very often.” The two items were averaged, and scores <3 were coded positively for familial emotional neglect (i.e., familial emotional neglect was coded positively among participants who indicated that someone in their family made them feel important or special “never” or “rarely” and that their family was a source of strength and support “never” or “rarely”). Test-retest agreement=85%.

2.1.3.2. Disordered Eating Attitudes and Behaviors.

Disordered eating attitudes and behaviors were assessed at EAT-IV.

2.1.3.2.1. Overeating.

Participants reported if, in the past year, they had “ever eaten so much food in a short period of time that you would be embarrassed if others saw you?” Response options were “yes” or “no.” Responses of “yes” were coded positively for overeating (Neumark-Sztainer et al., 2004; Yanovski, 1993). Test-retest agreement=90%.

2.1.3.2.2. Binge eating.

Participants who endorsed overeating were subsequently asked, “During the times when you ate this way, did you feel you couldn’t stop eating or control what or how much you were eating?” Response options were “yes” or “no.” Responses of “yes” were coded positively for binge eating (Neumark-Sztainer et al., 2004; Yanovski, 1993). Test-retest agreement=94%.

2.1.3.2.3. Extreme and unhealthy weight control behaviors.

Participants were asked if they had “done any of the following things in order to lose weight or keep from gaining weight during the past year?” Response options were “fasted,” “ate very little food,” “took diet pills,” “made myself vomit (throw up),” “used laxatives,” “used diuretics (water pills),” “used food substitutes (powder/special drink),” “skipped meals,” and “smoked more cigarettes.” Responses of “took diet pills,” “made myself vomit (throw up),” “used laxatives,” or “used diuretics (water pills)” were coded positively for extreme weight control behaviors. Responses of “fasted,” “ate very little food,” “used food substitutes (powder/special drink),” “skipped meals,” or “smoked more cigarettes” were coded positively for unhealthy weight control behaviors (Jeffery & French, 1999; Neumark-Sztainer et al., 2002; Neumark-Sztainer, Wall, Perry, et al., 2003; Sherwood et al., 2000). Test-retest agreement was 96% for extreme weight control behaviors and 86% for unhealthy weight control behaviors.

2.1.3.2.4. Chronic dieting.

Participants reported “how often have you gone on a diet during the last year? By ‘diet’ we mean changing the way you eat so you can lose weight” using a 5-point scale, with response options being “never,” “1-4 times,” “5-10 times,” “more than 10 times,” and “I am always dieting.” Responses of “5-10 times” or more were coded positively for chronic dieting (Blum et al., 1989; Jeffery & French, 1999; Neumark-Sztainer et al., 2002; Sherwood et al., 2000). Test-retest agreement=95%.

2.1.3.2.5. Weight and shape concerns.

Weight and shape concerns were assessed using an item adapted from the Questionnaire on Eating and Weight Patterns-Revised (Neumark-Sztainer, Wall, Story, et al., 2003; Spitzer, et al., 1993). Participants were asked: “During the past six months, how important has your weight or shape been in how you feel about yourself?” Response options were “Weight and shape were not very important,” “Weight and shape played a part in how I felt about myself,” “Weight and shape were among the main things that affected how I felt about myself,” and “Weight and shape were the most important things that affected how I felt about myself.” Responses of “Weight and shape were among the main things that affected how I felt about myself” or “Weight and shape were the most important things that affected how I felt about myself” were coded positively for weight and shape concerns. Test-retest r=0.71.

2.1.3.3. Covariates.

Age, gender (male versus female), race (white versus non-white), and socioeconomic status (SES) were self-reported at the EAT-I assessment and used as covariates. SES was based on parents’ education, defined as the highest level of education of either parent, with missing or implausible values imputed or corrected using information on eligibility for public assistance, free or reduced-cost school meals, and parental employment status (Sherwood et al., 2009). Body mass index (BMI) at EAT-I was also included in adjusted models and was calculated using the standard formula (weight in kilograms divided by height in meters squared) using self-reported height and weight obtained at EAT-I. In a substudy of 125 participants from this cohort (Quick et al., 2013), the validity of self-reported BMI relative to measured BMI was excellent (r=0.95 for men and r=0.98 for women). We elected to control for BMI and SES at EAT-I rather than EAT-IV because childhood maltreatment has been shown to directly impact these variables across the lifespan (Merrick et al., 2019; Schroeder et al., 2021; Zielinski, 2009), which themselves alter risk for disordered eating attitudes and behaviors (Mitchison, et al., 2014; Nagata, et al., 2018b). As such, BMI and SES in adulthood may mediate the associations among childhood maltreatment and later disordered eating attitudes and behaviors rather than simply acting as confounders of these relationships. Consequently, controlling for adult BMI and SES measured at EAT-IV has the potential to adjust away effects that we are trying to measure and may introduce unnecessary bias (Wang et al., 2017).

3.1. Statistical Analysis

Analyses were conducted using SAS 9.4 (SAS Institute Inc., Cary, NC). The primary study aims were tested using a series of relative risk (log-binomial) regression models. The first set of analyses examined the relationship between any versus no experience of childhood maltreatment and each disordered eating attitude and behavior (overeating, binge eating, extreme weight control behaviors, unhealthy weight control behaviors, chronic dieting, and weight and shape concerns). These models were then stratified by gender to document the pattern of these associations across men and women. A gender interaction was subsequently tested to determine whether these associations statistically differed between men and women.

The second set of analyses aimed to examine how distinct types of childhood maltreatment (sexual abuse, physical abuse, emotional abuse, and emotional neglect) individually related to each disordered eating attitude and behavior. The second set of analyses was conducted similarly to the first set, whereby the individual relationships between each type of childhood maltreatment and each disordered eating attitude and behavior were examined.

These models were then stratified by gender. However, due to small cell sizes, comparisons between men and women were considered exploratory and gender interactions with individual types of abuse were not assessed.

All models included the main effect of either any childhood maltreatment or type of childhood maltreatment on individual disordered eating attitudes and behaviors, with the reference variable being no childhood maltreatment. The models were adjusted for age, race, SES, and BMI assessed at EAT-I. Gender was adjusted in the full analytic sample (where it was not being used as a stratification variable). Models testing gender differences in these associations additionally included an interaction term between any versus no childhood maltreatment and gender.

Because higher weight status has been linked to disordered eating attitudes and behaviors and could be associated with childhood maltreatment, BMI at EAT-I was considered a potential confounder. However, it is also possible that BMI at EAT-I (during adolescence) has already been affected by earlier maltreatment, and its inclusion in the model could be an over-adjustment. Thus, models were run with and without BMI at EAT-I. As expected, additional adjustment for BMI attenuated all associations, though the overall pattern of findings remained the same. As such, only the fully adjusted models (with BMI) are presented.

To examine whether certain types of maltreatment had particularly strong associations with the outcomes, supplemental analyses were run on each outcome, with mutual adjustment for each maltreatment type. Due to small cell sizes, the mutually adjusted models were only able to be run in the full analytic sample and not the gender-stratified models. As shown in Supplemental Table 2, mutual adjustment for maltreatment types was found to attenuate most associations, though the pattern of results remained the same. As such, the models without mutual adjustment are presented herein. To account for participant attrition between EAT-I and EAT-IV, all models were weighted using response propensities (Little, 1986) as previously discussed (Larson et al., 2007; Neumark-Sztainer et al., 2006). The weighted sample is designed to be representative of and generalizable to the original EAT-I sample. Given growing criticisms of null hypothesis significance testing and its associated limitations (Lash, 2017; Lovell, 2020), we emphasize effect estimation over statistical significance when reporting our results.

4.1. Results

4.1.2. Sample characteristics

On average, participants were 31.1±1.6 years old with a BMI of 27.3±6.1 kg/m2 at EAT-IV. Over one-third of the analytic sample (n=567, 34.4%) reported a history of childhood maltreatment, with emotional neglect (n=325, 19.7%) and physical abuse (n=262, 15.9%) being the most frequently reported maltreatment types. Individuals with a history of emotional abuse were found to be more likely to also report a history of physical abuse and emotional neglect (ps <0.001). No additional positive associations were found between maltreatment types. Moreover, 58.7% (n=967) of the analytic sample reported engaging in at least one disordered eating attitude or behavior in adulthood, with the most frequently reported being unhealthy weight control behaviors (n=694, 42.1%), weight and shape concerns (n=484, 29.4%), and overeating (n=371, 22.5%). EAT-I sample characteristics are presented in Table 1.

Table 1.

Baseline characteristics of participants with and without childhood maltreatment (N = 1,647)

Any Childhood Maltreatment
Variable No
(n = 1,080, 65.6%)		 Yes
(n = 567, 34.4%)
Mean ± SD Mean ± SD
Age, years 15.0 ± 1.6 14.9 ± 1.6
BMI, kg/m2 22.0 ± 3.9 22.6 ± 4.5
n (%) n (%)
Gender
 Male 488 (45.1%) 233 (41.1%)
 Female 592 (54.8%) 334 (58.9%)
Race
 White 839 (77.7%) 320 (56.4%)
 Non-White 241 (22.3%) 247 (43.6%)
Parent Education (SES)
 ≤ High School Degree 867 (80.3%) 361 (63.7%)
 > High School Degree 213 (19.7%) 206 (36.3%)
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Note: Column percentages are reported. BMI = body mass index; SES = socioeconomic status; SD = standard deviation.

4.1.3. Any childhood maltreatment and risk for disordered eating attitudes and behaviors in adulthood

Results from the relative risk regression models examining the relationship between any versus no childhood maltreatment and disordered eating attitudes and behaviors are presented in Table 2. After adjustment for EAT-I demographic factors and BMI, participants reporting any childhood maltreatment were at greater risk for chronic dieting (Relative Risk [RR]: 1.7, 95% Confidence Interval [CI]: [1.2, 2.4]), overeating (RR: 1.6, 95% CI: [1.3, 2.0]), binge eating (RR: 1.3, 95% CI: [1.1, 1.6]), weight and shape concerns (RR: 1.3, 95% CI: [1.1, 1.5]), and unhealthy weight control behaviors (RR: 1.3, 95% CI: [1.1, 1.5]) in adulthood compared to those reporting no childhood maltreatment. The RR for extreme weight control behaviors in those with versus without any maltreatment was similar, though the 95% CI was wider and included the null (RR: 1.3, 95% CI: [0.9, 1.7]), possibly due to smaller numbers of those engaging in these behaviors.

Table 2.

Relative risk models examining risk for disordered eating attitudes and behaviors by any childhood maltreatment in the full sample (N = 1,647)

No Maltreatment
(n = 1,080, 65.6%)
 Any Maltreatment
(n = 567, 34.4%)
n (%) RR [95% CI] n (%) RR [95% CI]
Overeating 214 (19.8%) 1.00 [--] 157 (27.7%) 1.6 [1.3, 2.0]
Binge Eating 110 (10.2%) 1.00 [--] 96 (16.9%) 1.3 [1.1, 1.6]
Extreme weight control behaviors 102 (9.4%) 1.00 [--] 89 (15.7%) 1.3 [0.9, 1.7]
Unhealthy weight control behaviors 392 (36.3%) 1.00 [--] 302 (53.3%) 1.3 [1.1, 1.5]
Chronic dieting 70 (6.5%) 1.00 [--] 67 (11.8%) 1.7 [1.2, 2.4]
Weight and shape concerns 279 (25.8%) 1.00 [--] 205 (36.2%) 1.3 [1.1, 1.5]
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Note: Column percentages are reported. All models adjusted for baseline age, race, gender, socioeconomic status, and body mass index. The reference variable was no childhood maltreatment. Boldfaced values indicate significance (p < 0.05). CI = confidence interval; RR = relative risk.

Results from the gender-stratified relative risk regression models are presented in Table 3. After adjustment for EAT-I demographic factors and BMI, men reporting a history of any childhood maltreatment were at greater risk for binge eating (RR: 1.6, 95% CI: [1.0, 2.4]) and overeating (RR: 1.6, 95% CI: [1.1, 2.3]) compared to those reporting no childhood maltreatment. There were smaller associations with extreme weight control behaviors, chronic dieting, weight and shape concerns, and unhealthy weight control behaviors, with 95% CIs that overlapped the null. Meanwhile, women reporting a history of any childhood maltreatment were at greater risk for chronic dieting (RR: 2.0, 95% CI: [1.3, 3.1]), overeating (RR: 1.7, 95% CI: [1.3, 2.2]), unhealthy weight control behaviors (RR: 1.4, 95% CI: [1.2, 1.6]), and weight and shape concerns (RR: 1.3, 95% CI: [1.1, 1.6]) compared to those reporting no childhood maltreatment. Associations with extreme weight control behaviors and binge eating were closer to the null, with 95% CIs that overlapped the null.

Table 3.

Relative risk models examining risk for disordered eating attitudes and behaviors by any childhood maltreatment, stratified by gender (N = 1,647)

No Childhood Maltreatment (n = 1,080, 65.6%) Men
(n = 488, 45.2%)
 Women
(n = 592, 54.8%)
n (%) RR [95% CI] n (%) RR [95% CI]
Overeating 78 (16.0%) 1.00 [--] 136 (23.0%) 1.00 [--]
Binge Eating 33 (6.8%) 1.00 [--] 77 (13.0%) 1.00 [--]
Extreme weight control behaviors 21 (4.3%) 1.00 [--] 81 (13.7%) 1.00 [--]
Unhealthy weight control behaviors 155 (31.8%) 1.00 [--] 237 (40.0%) 1.00 [--]
Chronic dieting 24 (4.9%) 1.00 [--] 46 (7.8%) 1.00 [--]
Weight and shape concerns 86 (17.6%) 1.00 [--] 193 (32.6%) 1.00 [--]
Any Childhood Maltreatment (n = 567, 34.4%) Men
(n = 233, 41.1%)
 Women
(n = 334, 58.9%)
n (%) RR [95% CI] n (%) RR [95% CI]
Overeating 50 (21.5%) 1.6 [1.1, 2.3] 107 (32.0%) 1.7 [1.3, 2.2]
Binge Eating 25 (10.7%) 1.6 [1.0, 2.4] 71 (21.3%) 1.2 [0.9, 1.5]
Extreme weight control behaviors 22 (9.4%) 1.4 [0.7, 3.0] 67 (20.0%) 1.2 [0.8, 1.7]
Unhealthy weight control behaviors 96 (41.2%) 1.1 [0.9, 1.4] 206 (61.7%) 1.4 [1.2, 1.6]
Chronic dieting 19 (8.2%) 1.3 [0.6, 2.7] 48 (14.4%) 2.0 [1.3, 3.1]
Weight and shape concerns 53 (22.7%) 1.2 [0.8, 1.7] 152 (45.5%) 1.3 [1.1, 1.6]
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Note: Column percentages are reported. All models adjusted for baseline age, race, socioeconomic status, and body mass index. The reference variable was no childhood maltreatment. Boldfaced values indicate significance (p < 0.05). CI = confidence interval; RR = relative risk.

Although childhood maltreatment was more consistently associated with disordered eating behaviors among women than men, there were no statistically significant interactions between gender and childhood maltreatment in relation to any of the disordered eating attitudes and behaviors assessed (ps>0.1), indicating that variation in these relationships between men and women did not reach statistical significance.

4.1.4. Type of childhood maltreatment and risk for disordered eating attitudes and behaviors in adulthood

Results from the relative risk regression models examining the relationship between different types of childhood maltreatment and disordered eating attitudes and behaviors are presented in Table 4. As shown, sexual abuse was associated with increased risk for overeating (RR: 1.4, 95% CI: [1.0, 2.0]) and weight and shape concerns (RR: 1.3, 95% CI: [1.0, 1.7]). The RR for the association of sexual abuse with chronic dieting was also elevated but with wide 95% CIs that overlapped the null (RR: 1.6, 95% CI: [0.9, 2.8]). The RRs for physical abuse were close to the null for all disordered eating attitudes and behaviors, with indications of elevated risk for overeating (RR: 1.3, 95% CI: [1.0, 1.7]) and chronic dieting (RR: 1.5, 95% CI: [0.9, 2.4]). Emotional abuse related to increased risk for binge eating (RR: 1.4, 95% CI: [1.1, 1.8]), with elevated risk also indicated for extreme weight control behaviors (RR: 1.5 95% CI: [1.0, 2.2]). Meanwhile, emotional neglect was associated with increased risk for overeating (RR: 1.4, 95% CI: [1.1, 1.8]), binge eating, (RR: 1.4, 95% CI: [1.2, 1.8]) and unhealthy weight control behaviors (RR: 1.3, 95% CI: [1.1, 1.4]), with indications of elevated risk for extreme weight control behaviors (RR: 1.3, 95% CI: [0.9, 1.8]) and chronic dieting (RR: 1.4, 95% CI: [0.9, 2.2]).

Table 4.

Relative risk models examining risk for disordered eating attitudes and behaviors by different types of childhood maltreatment (N = 1,647)

Sexual Abuse (n = 162, 9.8%)
 Physical Abuse (n = 262, 15.9%)
n (%) RR [95% CI] n (%) RR [95% CI]
Overeating 51 (31.5%) 1.4 [1.0, 2.0] 67 (25.6%) 1.3 [1.0, 1.7]
Binge Eating 31 (19.1%) 0.9 [0.7, 1.3] 37 (14.1%) 0.9 [0.6, 1.2]
Extreme weight control behaviors 26 (16.0%) 1.1 [0.6, 1.8] 40 (15.2%) 1.1 [0.7, 1.6]
Unhealthy weight control behaviors 90 (55.6%) 1.1 [0.9, 1.3] 141 (53.8%) 1.2 [1.0, 1.3]
Chronic dieting 21 (13.0%) 1.6 [0.9, 2.8] 34 (13.0%) 1.5 [0.9, 2.4]
Weight and shape concerns 70 (43.2%) 1.3 [1.0, 1.7] 93 (35.9%) 1.2 [1.0, 1.5]
Emotional Abuse
(n = 146, 8.8%)
 Emotional Neglect
(n = 325, 19.7%)
n (%) RR [95% CI] n (%) RR [95% CI]
Overeating 40 (27.4%) 1.1 [0.8, 1.6] 90 (27.7%) 1.4 [1.1, 1.8]
Binge Eating 28 (19.2%) 1.4 [1.1, 1.8] 59 (18.2%) 1.4 [1.2, 1.8]
Extreme weight control behaviors 28 (19.2%) 1.5 [1.0, 2.2] 54 (16.6%) 1.3 [0.9, 1.8]
Unhealthy weight control behaviors 77 (52.7%) 1.1 [0.9, 1.3] 178 (54.8%) 1.3 [1.1, 1.4]
Chronic dieting 16 (11.0%) 0.9 [0.5, 1.5] 40 (12.3%) 1.4 [0.9, 2.2]
Weight and shape concerns 51 (34.9%) 1.1 [0.8, 1.4] 122 (37.5%) 1.2 [1.0, 1.5]
Open in a new tab

Note: Column percentages are reported. All models adjusted for baseline age, race, gender, socioeconomic status, and body mass index. The reference variable was no experience of the type of childhood maltreatment being examined. Boldfaced values indicate significance (p < 0.05). CI = confidence interval; RR = relative risk.

Results from the gender-stratified relative risk regression models are presented in Supplemental Table 1. Among men, sexual abuse showed positive RRs for overeating (RR: 1.8, 95% CI: [0.9, 3.6]), extreme weight control behaviors (RR: 2.3, 95% CI: [0.9, 6.0]), chronic dieting (RR: 2.3, 95% CI: [0.7, 7.6]), and weight and shape concerns (RR: 2.1, 95% CI: [1.2, 3.7]), though cell sizes were small and few 95% CIs excluded the null. In addition, emotional neglect was associated with heightened risk for binge eating among men (RR: 2.1, 95% CI: [1.4, 3.2]), with indications of positive associations between emotional abuse and binge eating (RR: 1.3 95% CI: [0.7, 3.0]) and between emotional abuse and extreme weight control behaviors (RR: 1.7, 95% CI: [0.9, 3.3]). Meanwhile, women with a history of physical abuse or emotional neglect were at greater risk for unhealthy weight control behaviors (physical abuse RR: 1.3, 95% CI: [1.1, 1.5]; emotional neglect (RR: 1.4, 95% CI: [1.2, 1.6]), chronic dieting (physical abuse RR: 2.3, 95% CI: [1.4, 3.8]; emotional neglect (RR: 1.7, 95% CI: [1.1, 2.7]), and weight and shape concerns (physical abuse RR: 1.4, 95% CI: [1.1, 1.7]; emotional neglect (RR: 1.3, 95% CI: [1.1, 1.6]) compared to those without such histories. Emotional neglect and emotional abuse were also respectively associated with heightened risk for overeating (RR: 1.6, 95% CI: [1.2, 2.1]) and binge eating (RR: 1.4, 95% CI: [1.1, 1.7]) among women. Additional indications of risk were found for women with a history of varied abuse types, though the 95% CIs were wide and included the null.

5.0. Discussion

This study supports previous findings by indicating that childhood maltreatment is linked to a range of disordered eating attitudes and behaviors in adulthood (Burns et al., 2012; Dworkin et al., 2014; Fuemmeler et al., 2009; Kent & Waller, 2000; Mason et al., 2013; Miskinyte et al., 2006; Smolak & Murnen, 2002; Smyth et al., 2008). In this population-based sample of early adults, a history of childhood maltreatment was related to heightened risk for chronic dieting, overeating, binge eating, weight and shape concerns, and unhealthy weight control behaviors. These associations were further shown to vary across distinct types of childhood maltreatment, with emotional neglect emerging as the most consistent childhood maltreatment type associated with heightened risk for disordered eating attitudes and behaviors. Interestingly, the present study found no statistically significant gender differences in the association between childhood maltreatment and disordered eating attitudes and behaviors, though the patterning of these effects highlighted unique qualitative similarities and differences in the relationships among these variables between men and women.

Although any history of childhood maltreatment was generally associated with greater risk for each disordered eating attitude and behavior assessed, the precision of these estimates varied depending on the outcome. Unlike previous studies documenting a strong association between childhood maltreatment and more severe eating disorder pathology in adulthood (Caslini et al., 2016; Dworkin et al., 2014; Molendijk et al., 2017; Smyth et al., 2008), the positive relationship between childhood maltreatment and extreme weight control behaviors in this study indicated a smaller risk ratio estimate accompanied by wide confidence intervals, making interpretation of this effect difficult. This non-significant finding may be due to the smaller proportion of participants endorsing more extreme weight control behaviors (e.g., self-induced vomiting) in the present sample. In contrast, any childhood maltreatment was associated with more than 60% greater risk for chronic dieting and overeating, with additional positive associations found for binge eating, weight and shape concerns, and unhealthy weight control behaviors. These findings identify a history of any childhood maltreatment as an important risk factor for numerous disordered eating attitudes and behaviors in adulthood, thereby underscoring the importance of understanding how childhood maltreatment relates to a broad range of eating related outcomes, particularly as these factors can enhance risk for developing more severe eating disorder pathology over time (Emery et al., 2013; Espinoza et al., 2010). Although prior research has tended to focus on how childhood maltreatment contributes to clinically significant eating disorders and related pathology (Brown et al., 2014; Caslini et al., 2016; Molendijk et al., 2017), accumulating evidence indicates that childhood maltreatment has substantial impact on more general eating attitudes and behaviors, such as palatable food intake (Abajobir et al., 2017; Vilija & Romualdas, 2014) and body dissatisfaction (Brooke & Mussap, 2013). Thus, this study is consistent with others indicating that childhood maltreatment has wide-ranging effects on eating attitudes and behaviors in adulthood.

This study additionally documented that the associations between childhood maltreatment and disordered eating attitudes and behaviors vary across different types of childhood maltreatment. Similar to previous studies (Fischer et al., 2010; Grilo & Masheb, 2001; Villarroel et al., 2012), physical abuse was not found to significantly relate to increased risk for any disordered eating attitude or behavior assessed. Meanwhile, sexual abuse, emotional abuse, and emotional neglect each related to heightened risk for varied disordered eating attitudes and behaviors. Emotional abuse and neglect were both associated with more than a 40% higher risk for binge eating, a finding consistent with previous work demonstrating that emotional traumas in childhood are potent predictors for binge eating in adulthood (Amianto et al., 2018). Sexual abuse was further shown to be the only type of childhood maltreatment significantly related to shape and weight concerns and was additionally related to heightened risk for overeating, as was emotional neglect. Importantly, emotional neglect was both the most prevalent type of childhood maltreatment in this sample and the only type of childhood maltreatment to consistently show point estimates indicating higher risk for each disordered eating attitude and behavior assessed, though confidence intervals did not always exclude the null. Thus, although prior research has often focused on childhood abuse rather than neglect in relation to disordered eating attitudes and behaviors, these findings indicate that emotional neglect may be a particularly meaningful contributor to problematic eating outcomes. Indeed, previous work has theorized that children exposed to emotional traumas, as opposed to physical or sexual traumas, may be at specific risk for disordered eating (Waller et al., 2007) and other psychopathology (Berzenski, 2018) because of a greater tendency towards emotion dysregulation that stems from being raised in an emotionally invalidating environment. Given the particular relevance of emotion dysregulation in the development and maintenance of disordered eating (Monell et al., 2018), and the high rates of childhood emotional traumas (Spinazzola et al., 2014), these findings underscore the need for future research to more critically examine the associations among disordered eating outcomes and exposure to emotional abuse and neglect in childhood.

These findings further extend previous research by examining gender differences in the association between childhood maltreatment and disordered eating attitudes and behaviors in early adulthood. Similar to prior work (Abajobir et al., 2017; Dworkin et al., 2014; Smyth et al., 2008), there was no evidence of a gender interaction with childhood maltreatment in predicting disordered eating attitudes and behaviors, indicating that both men and women with a history of childhood maltreatment are at increased risk for several disordered eating attitudes and behaviors. However, the associations among childhood maltreatment and disordered eating attitudes and behaviors revealed interesting qualitative similarities and differences in these relationships between men and women. Consistent with previous literature (Merrick et al., 2018; Striegel-Moore et al., 2009), women in the present study reported higher rates of both childhood maltreatment and disordered eating attitudes and behaviors than did men. Moreover, a history of childhood maltreatment was found to be more strongly and consistently related to increased risk for disordered eating attitudes and behaviors in women than in men. Although both men and women who experience childhood maltreatment are at elevated risk for a range of problematic emotional and behavioral sequelae across the lifespan (Gallo et al., 2018; Goldstein et al., 2010), it is likely that women with a history of childhood maltreatment are at particular risk for engaging in disordered eating due to unique sociocultural pressures to be thin that are especially salient to women beginning in early adolescence and span across early adulthood (Keel & Forney, 2013). Nevertheless, these findings ultimately indicate that men exposed to childhood maltreatment are also at risk for engaging in disordered eating in adulthood. In this study, any history of childhood maltreatment was linked to heightened risk for both overeating and binge eating among men, suggesting that men may be more prone to engaging in overeating and related behavior in response to childhood maltreatment as opposed to dieting and other weight controlling behaviors. There is indeed some evidence to suggest that men engage in overeating more frequently than women (Striegel-Moore et al., 2009) and are at similar risk for binge eating as women (Mithcison & Mond, 2015; Striegel-Moore et al., 2012). Despite this, the majority of previous work evaluating the relationship between childhood maltreatment and disordered eating has focused almost exclusively on these outcomes in women. As such, these findings highlight the need for future work to better understand whether and how childhood maltreatment differentially relates to disordered eating attitudes and behaviors in both men and women.

It is important to consider these findings in the context of certain limitations. First, childhood maltreatment and disordered eating attitudes and behaviors were assessed through retrospective self-report in adulthood, which may have resulted in recall bias. Second, several variables examined in this study (e.g., overeating, binge eating) were assessed using a single item. Although single-item questions are commonly used when conducting large epidemiologic surveys to gain a general assessment of population health and allow for ease of identification of high-risk individuals, they do not allow for detailed clinical assessments and may result in unintentional measurement errors. As such, future research is needed to extend these findings using more extensive questionnaire measures. Third, the study was geographically restricted and predominantly comprised of white participants, which may limit generalizability. Fourth, this study used a population-based sample of community participants, thus findings may not generalize to individuals with more severe experiences of abuse or disordered eating attitudes and behaviors. Despite these limitations, there are also several noteworthy strengths of this study, including a large longitudinal cohort that allowed us to adjust for prospectively measured confounders (e.g., BMI and parental SES), the availability of several abuse and neglect variables to assess childhood maltreatment, and inclusion of numerous disordered eating attitudes and behaviors. The size of the cohort and breadth of measures allowed for a comprehensive investigation, including assessment of gender interactions, of the associations among childhood maltreatment and disordered eating attitudes and behaviors.

This study replicates and extends previous work by demonstrating that childhood maltreatment enhances risk for a range of disordered eating attitudes and behaviors and that these associations vary across distinct types of childhood maltreatment. Although gender did not moderate these associations, the patterning of results suggested unique qualitative differences in the relationships among childhood maltreatment and distinct disordered eating attitudes and behaviors between men and women, which warrant further investigation. Taken together, these findings implicate childhood maltreatment as a meaningful risk factor for problematic eating outcomes in both men and women during adulthood and emphasizes the need for more effective public health efforts to prevent childhood maltreatment. The longstanding associations of childhood maltreatment with the eating-related health of adults further underscores the need for prevention and intervention efforts across the lifespan to mitigate engagement in disordered eating attitudes and behaviors among those exposed to childhood maltreatment.

Supplementary Material

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Ethics Statement.

All research was performed in accordance with the Declaration of Helsinki. The Institutional Review Board Human Subjects Committee at the University of Minnesota approved all protocols used in Project EAT at each time point and all participants provided informed consent before taking part in study procedures.

Funding:

Data collection for the study was supported by the National Heart, Lung, and Blood Institute (R01 HL116892; PI: Neumark-Sztainer). Rebecca Emery’s time was supported by the National Center for Advancing Translational Sciences under TL1 R002493 (PI: Fulkerson) and UL1 TR002494 (PI: Blazar). Cynthia Yoon’s time was supported by the National Institute of Diabetes and Digestive and Kidney Diseases under T32 DK083250 (PI: Jeffery) from. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute; the National Center for Advancing Translational Sciences; or the National Institute of Diabetes and Digestive and Kidney Diseases.

Footnotes

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Declarations of interest: None.

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NIHMS1686456-supplement-1.xml (244B, xml)
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