Table 5.

Summary of Themes and Subthemes for Early Life Influences and Emergence of Symptoms

Topic	Theme(s)	Subtheme(s)	Description	Example quote
Early life influences	Pressure to be Healthy (n = 29)	Diet Culture in Family Restrictive Environment Body Image Pressures	Participants expressed growing up in environments that had an emphasis on an ideal body weight or physique. They often were restricted on what foods they were allowed to eat, with parents or other role models modeling restrictive behaviors and placing this on participants	“My mom was a nurse and she’s very big on health, so I don’t think there was ever a month going by where she wasn’t on a new diet, so diet culture was very big in my house, with like Skinny Pop and special smoothies, that stuff was just constantly on me” “It came to the point where like the pantry was locked, so anytime there was food I would eat as much of whatever I could find, especially if it was something I wasn’t normally allowed to eat”
	Positive Family Emphasis on Food (n = 19)		Participants described growing up in an environment where family mealtime was important, with an emphasis on togetherness and positive memories being associated with mealtime	“We’ve always tried to do a family dinner every night to just kind of come together and reconnect, which is really nice. It’s definitely a social aspect, we make time for it even with my extended family”
	Unhealthy Eating Environment (n = 16)		Participants felt they had no guidance on healthy eating or portion control or grew up in a family that relied on cheap, unhealthy foods due to budget constraints	“I was given like no guidance on nutrition or portion sizes or things like that, so I just remember growing up eating huge, gigantic portions and just not understanding that that’s not good for me”
	Negative Influence of Family Dinner (n = 9)		Participants associated family mealtime with negative memories, such as conflict or being pressured to finish their meal to the point of discomfort	“It was always that I would try not to talk too much because my mom would attack anything you say or do if it’s not to her standards and then I would just want to finish it all up and then leave”
Emergence of symptoms	Transition to College (n = 22)	Newfound Freedom	Participants felt that their symptoms began to emerge once they began college, partially due to the increased stress of the transition, and others feeling it was the widespread access to food. Participants expressed that the new ability to make their own food choices led them to overconsume unhealthy foods	“It became me always seeking that moment of being able to eat and associating food with freedom and having some time to myself and being happy, so I began to pursue that more and it kind of spiraled out of control from there”
	Pressures in School and Relationships (n = 14)		Participants noticed their symptoms emerge once they began to feel pressures to adhere to an ideal body type in middle school and high school. They often described comparing themselves to peers and often turned to foods for comfort at this time	“I was in middle school, and I just kept thinking everyone else was better than me because I knew I was bigger, and food was there all the time, so I was just like ‘here’s my pal’”
	Triggering Event (n = 19)		Participants could recall a specific event or situation that led to their emergence of symptoms. These included parental divorce, moving, the end of a sport, or the end of a relationship. Food provided stability for many participants during these uncertain times	“My dad was always switching jobs so we would move state to state when it wasn’t really necessary, so I never had a stable environment, I wanted to have control over something so that’s a huge part of it”
	Worsening Mental Health (n = 12)		Participants saw a direct correlation between when their depression or anxiety worsened, and their symptoms started to become a problem	“I was diagnosed with depression, and I started having anxiety and all of that stuff and it just kind of became a crutch for me, honestly”
	Unhealthy Relationship from the Start (n = 9)		Participants felt that they couldn’t remember when the symptoms started, but that they have always had problems with eating and with food	“I wasn’t eating unhealthy foods in excess, but I would eat 7 bananas in one sitting…. we used to grow cherry tomatoes and I would eat 100 of them in one sitting. I know healthy food is good for you, but everything is supposed to be in moderation. I’ve never known moderation. I’ve known all the way or nothing so it’s a really bad thing”