Journal of Adolescence 69 (2018) 130–139

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Journal of Adolescence
journal homepage: www.elsevier.com/locate/adolescence

Body image predictors of depressive symptoms in adolescence

T
Kristen Murraya,b,∗, Elizabeth Riegerb, Don Byrnec
a
Centre for Applied Psychology, University of Canberra, Canberra, Australia
b
Research School of Psychology, Australian National University, Canberra, Australia
c
Medical School, Australian National University, Canberra, Australia

A R T IC LE I N F O ABS TRA CT

Keywords: Introduction: Depression rises significantly in adolescence, with females reporting twice the
adolescent depression prevalence of males into adulthood. In accordance with cognitive vulnerability theories, eating
Body image and weight-related disturbances have been implicated in this increase, but a broader assessment
Body dissatisfaction of body image constructs within this framework is needed.
Body importance
Methods: The current prospective study examined body importance, body dissatisfaction, and
Body change strategies
body change strategies to lose weight and increase muscularity as predictors of depressive
symptoms over one year in N = 298 adolescents in Canberra, Australia (at Time 2, the sample
comprised n = 161 female adolescents, Mage = 15.36 years, SD = 1.10; n = 137 male adoles-
cents, Mage = 15.54 years, SD = 1.15). The moderating role of sex was also assessed.
Results & conclusions: Results revealed that body importance and body change strategies to in-
crease muscularity explained significant variance in depressive symptoms beyond baseline cov-
ariates of depressive symptoms and stress, with the effect of body importance relevant in female
but not male adolescents. The findings support the use of more comprehensive assessments of
body image constructs to inform cognitive vulnerability theories of adolescent depression, and
corresponding prevention and intervention programs.

Depression is a leading cause of disability worldwide (Whiteford et al., 2013), with rates in adolescence increasing significantly
from childhood (Hankin, 2006; Thapar, Collishaw, Pine, & Thapar, 2012). A range of theories have been proposed to explain this
increased risk, with the cognitive vulnerability framework arguing that a number of thought processes or patterns, such as dys-
functional attitudes and self-criticism, interact with stressful life events to contribute to depression (Abela & Hankin, 2008; Hankin,
2006; Hyde, Mezulis, & Abramson, 2008). During adolescence, these vulnerabilities are believed to stabilise and act as risk factors
into adulthood (Abela & Hankin, 2008; Hankin, 2006), making this an important period for their identification and amelioration
through prevention and intervention. Recent research suggests that a range of eating and weight-related disturbances act as cognitive
and behavioural vulnerabilities in adolescent depression (Rawana, 2013; Rawana, Morgan, Nuguyen, & Craig, 2010). Furthermore,
these may explain the increased risk for females who report twice the rate of depression compared with males from early adolescence
into adulthood (Hankin, 2006; Hyde et al., 2008; Lewinsohn et al., 1994; Lewinsohn, Rohde, Seeley, Klein, & Gotlib, 2000; Rawana
et al., 2010; Rawana & Morgan, 2014).

1. Eating and weight-related vulnerabilities in depression

Eating and weight-related disturbances are “negative or maladaptive cognitions, attitudes and behaviours directly or indirectly

∗
Corresponding author. Centre for Applied Psychology, Building 12, University of Canberra, Bruce ACT, 2617, Australia.
E-mail address: kristen.murray@canberra.edu.au (K. Murray).

https://doi.org/10.1016/j.adolescence.2018.10.002
Received 2 May 2018; Received in revised form 4 October 2018; Accepted 5 October 2018
Available online 10 October 2018
0140-1971/ © 2018 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
K. Murray et al. Journal of Adolescence 69 (2018) 130–139

related to eating and weight” (Rawana et al., 2010, p. 213) which have been proposed to predict the onset of both eating disorders
(Bearman & Stice, 2008) and depression (Rawana & Morgan, 2014). In accordance with the cognitive vulnerability framework, these
constructs are conceptualised as stable characteristics which increase depression risk through interactions with life stressors (Abela &
Hankin, 2008). One construct frequently considered in this context is body image, a complex multidimensional construct including
cognitive, affective-evaluative, and behavioural relations with the body (Cash, 2011).
Body dissatisfaction forms part of the affective-evaluative dimension of body image (Croghan et al., 2006; Muth & Cash, 1997;
Smolak, 2004), and is the most frequently assessed eating and weight-related vulnerability in depression (Rawana et al., 2010).
Prospective studies have found that body dissatisfaction predicts depression over two years in female and male adolescents (Ferreiro,
Seoane, & Senra, 2011), and over five years in female early adolescents and male mid-adolescents (Paxton, Neumark-Sztainer,
Hannan, & Eisenberg, 2006). In female adolescents, the combination of body dissatisfaction, dietary restraint, and binge-purge
symptoms has also been shown to predict depression onset over four years (Stice, Hayward, Cameron, Killen, & Barr Taylor, 2000).
Body dissatisfaction has been reported to increase depressive symptoms in addition to perceived pressure to be thin, thin-ideal
internalisation, dieting, and symptoms of bulimia when controlling for self-esteem and demographic factors (Stice & Bearman, 2001),
and is implicated in the persistence of depressive symptoms over time (Rierdan, Koff, & Stubbs, 1989). Evident by late childhood and
early adolescence (Rawana et al., 2010), this may be a particularly relevant vulnerability for depression in females given they report
greater dissatisfaction compared to males (Bearman, Presnell, Martinez, & Stice, 2006; Rawana et al., 2010).
Body dissatisfaction can trigger maladaptive efforts to change the body. Body change strategies reflect the frequency of thoughts,
feelings, and behaviours aimed at altering the size and/or shape of one's body (Ricciardelli & McCabe, 2002). They include strategies
to decrease body size and increase muscularity, which are endorsed more frequently by females and males respectively in line with
cultural body ideals (McCabe & Ricciardelli, 2004; Rawana, 2013; Ricciardelli & McCabe, 2002; Ricciardelli, McCabe, Mussap, &
Holt, 2009). Since engagement in body change strategies is often unsuccessful given the unrealistic nature of these ideals, greater use
of such strategies might increase depression vulnerability (Rawana et al., 2010). In a nationally representative sample of female and
male adolescents in the United States, wanting to lose weight and use of weight loss behaviours predicted depressive symptoms over
one year after controlling for gender and social support, whereas wanting to gain weight and use of weight gain strategies did not
(Rawana, 2013). This is consistent with a cross-sectional study showing no relationship between drive for muscularity and depressive
symptoms in female and male emerging adults (Rawana, McPhie, & Hassibi, 2016). Although these findings suggest that weight loss
strategies may play a greater role in predicting depressive symptoms, it is noteworthy that studies more commonly assess weight loss
efforts (Bearman & Stice, 2008; Stice & Bearman, 2001; Stice et al., 2000) compared with weight or muscle gain, and few have
explicitly tested sex differences (Rawana, 2013). Given that drive for muscularity has been associated with depressive symptoms in
males and not females (McCreary & Sasse, 2000), there remains a need to further assess sex differences in the relationship between
weight loss and weight or muscle gain strategies in adolescent depression (Rawana, 2013; Rawana et al., 2010, 2016). It is possible,
for example, that these predict depression in female and male adolescents respectively, but these differences are obscured when they
are combined.
To further inform prevention and intervention in depression, there is a need to explore body image constructs in addition to body
dissatisfaction and body change strategies. Body importance, which forms part of the cognitive body image dimension, is one po-
tentially informative construct (Rawana et al., 2010). It reflects the importance, meaning, and influence of appearance in an in-
dividual's life (Cash, 2011; Thompson, 2004), with females reporting greater investment in appearance compared to males (de Vries,
Peter, Nikken, & de Graaf, 2014). Body importance has been associated with body dissatisfaction and body change strategies to lose
weight and increase muscularity (Banfield & McCabe, 2002; McCabe & Ricciardelli, 2001, 2003; Muris, Meesters, van de Blom, &
Mayer, 2005; White & Halliwell, 2010), and could also confer increased vulnerability to depression during adolescence. As there has
been limited investigation of this construct, body importance is worthy of investigation in adolescent depression.

2. Sex differences in body image vulnerabilities for depression

Although studies have more frequently focused on females (Rawana et al., 2010), those examining sex differences suggest that
body image concerns may explain their higher rates of depression (Hankin & Abramson, 1999, 2001). Stice and Bearman (2001) have
shown support for the gender additive model, which argues that these body image disturbances exert additional risk for depression in
females compared to males. For example, once established risk factors for depression shared by females and males (such as social
support and stressful life events) were controlled, body dissatisfaction and dietary restraint predicted depression in female but not
male adolescents over two years (Bearman & Stice, 2008). Furthermore, studies have also reported that sex differences in depression
disappear once body image is controlled (Siegel, Yancey, Aneshensel, & Schuler, 1999), and that body dissatisfaction predicts in-
ternalising symptoms over one year in female early adolescents but not males (Patalay, Sharpe, & Wolpert, 2015). However, given the
use of early adolescent samples in these studies, it is possible that developmental factors such as differences in pubertal timing could
explain the failure to identify a body dissatisfaction-depression link in males (Bearman & Stice, 2008), especially since mid-ado-
lescents may be the highest risk group for depression (Rawana & Morgan, 2014). Furthermore, a recent review concluded that studies
assessing body image support a role in depression for both females and males (Rawana et al., 2010). Given the presence of sex
differences in depression and body image, assessment of a range of dimensions including body dissatisfaction, strategies to decrease
body size and increase muscularity, and body importance can offer insight into shared and unique risk factors for depression in
adolescent females and males.
Importantly, the divergent role of body image in depression needs to be considered within the context of other established risk
factors (Bearman & Stice, 2008; Rawana, 2013). Stressful life events are hypothesised to activate cognitive vulnerabilities for

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depression (Abela & Hankin, 2008), and self-esteem displays a close association with both body image variables and depression
(Allgood Merton e al., 1990; Rawana, 2013). As such, both stress and self-esteem must be considered when assessing the relative
contribution of body image variables in adolescent depression.
The current study aims to investigate body image predictors of depressive symptoms over one year in female and male adoles-
cents. A range of dimensions have been selected to reflect the breadth of the body image construct, specifically body dissatisfaction,
body importance, and body change strategies to lose weight and increase muscularity. Their role as predictors of depressive
symptoms will be tested once baseline depressive symptoms, stress, self-esteem, and demographic variables (i.e., age and body mass
index [(BMI = kg/m2)]) have been controlled. Female or male sex will be investigated as a moderator of the association between
body image and depression. It is hypothesised that higher levels of body dissatisfaction and greater body change strategies to lose
weight and increase muscularity will predict greater depressive symptoms over one year, over and above the covariates (H1). Second,
sex differences in these relationships are expected, such that body dissatisfaction and strategies to lose weight are expected to be more
strongly related to depression in female adolescents, and strategies to increase muscularity stronger in male adolescents (H2). Given
its relative neglect in previous research, it is unclear how body importance will relate to depressive symptoms and, as such, its role is
explored in the current study.

3. Method

3.1. Participants

The present prospective study comprised 298 adolescents from Canberra, Australia who completed a one-year follow-up survey
from a sample of N = 496 at Time 1 (Murray, Rieger, & Byrne, 2013). The Time 2 sample comprised n = 161 female adolescents
(Mage = 15.36 years, SD = 1.10) and n = 137 male adolescents (Mage = 15.54 years, SD = 1.15), with a grade level breakdown of
n = 101 in Grade 8 (Mage = 14.22, SD = 0.37), 58 in Grade 9 (Mage = 15.20, SD = 0.44), 87 in Grade 10 (Mage = 16.04, SD = 0.32),
and 52 in Grade 11 (Mage = 17.12, SD = 0.37). Three fee-paying non-government co-educational schools (one Independent, two
Catholic) participated in the study, with recruitment based on class availability. Although cultural background was not measured,
given the demographic profile of the city from which the sample was drawn, it is reasonable to assume that the majority of the sample
was Caucasian. Permission to conduct the study was obtained from the Australian National University Human Research Ethics
Committee on 23 September 2009 (2009/390) and the Catholic Education Office on 7 October 2009 (2008/926).

3.2. Measures

Participants provided demographic information related to sex (female or male), age (in years and months), and grade level (Grade
8, 9, 10 or 11 at Time 2), and had their height (in metres using a stadiometer) and weight (in kilograms) measured by the first author
to calculate BMI. Participants completed the following questionnaires at both time points, with Cronbach's alpha coefficients for the
total, female, and male samples at both time points shown in Table 1.

3.2.1. Depressive symptoms

Depressive symptoms were measured by the Feelings Scale II, a 15-item self-report scale assessing depressive symptomatology
(Byrne, Davenport, & Mazanov, 2007). This instrument was developed for use in adolescents based on symptoms defined in the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association [APA], 2000), with no change to
criteria in the updated DSM-5 (APA, 2013). Respondents indicate how often they have experienced depressive symptoms in the past
week (e.g., ‘I have felt like I have failed’) on a 5-point Likert scale from 0 = never to 4 = always. Scores are a sum total ranging from 0
to 60, with higher scores indicating greater depressive symptoms. The scale has a high internal consistency and validity in adolescents
(Byrne et al., 2007).

3.2.2. Body dissatisfaction

Body dissatisfaction was measured using the Body Image subscale from the Self-Image Questionnaire for Young Adolescents
(SIQYA) (Petersen, Schulenberg, Abramowitz, Offer, & Jarcho, 1984). It contains 11 items (e.g., ‘I am not satisfied with my weight’),
with the current study modifying one item with the permission of the author. Specifically, ‘I am not satisfied with my weight’ was
included twice with the specification ‘because I am too light’ and ‘because I am too heavy’ to be more sensitive to sex differences,
resulting in a 12-item measure. Respondents use a six-point Likert scale ranging from 1 = describes me very well to 6 = does not
describe me at all, with total scores (after reversing some items) between 12 and 72. Lower scores reflect greater body dissatisfaction.
The original scale displays internal consistencies of α = 0.81 and 0.77 for males and females, respectively (Petersen et al., 1984).

3.2.3. Body change strategies

Body change strategies were measured using two scales from the Body Image and Body Change Inventory (Ricciardelli & McCabe,
2002). The scales assess thoughts, feelings, and behaviours relating to body change strategies to (1) decrease body size (e.g., ‘How
often do you worry about changing your eating to decrease your body size’) and (2) increase muscularity (e.g., ‘How often do you
change your levels of exercise to increase the size of your muscles’), with each scale containing six items rated on a 5-point Likert
scale ranging from 1 = always to 5 = never. Scores range from 6 to 30 with lower scores indicating greater body change strategies.
The scales demonstrate good internal consistency and validity in adolescent females and males (Ricciardelli & McCabe, 2002).

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Table 1
Descriptive Statistics, Sex Comparisons at Time 1 and Cronbach's Alpha Coefficients.
Mean SD Comparison η2 Cronbach's α Time 1 Cronbach's α Time 2

Age 14.41 (1.16) F (1, 290) = 2.62 .009 – –

Females 14.31 (1.13) – –
Males 14.53 (1.19) – –
BMI 20.82 (3.09) F (1, 291) = .04 .000 – –
Females 20.78 (3.00) – –
Males 20.86 (3.20) – –
Depressive Symptoms 21.21 (10.61) F (1, 291) = 15.10*** .049 .92 .92
Females 23.35 (11.12) .92 .92
Males 18.63 (9.38) .90 .90
Body Dissatisfaction 51.12 (10.42) F (1, 291) = 21.99*** .070 .82 .83
Females 48.61 (10.63) .83 .84
Males 54.15 (9.35) .75 .81
Decrease Body Size 23.85 (6.12) F (1, 291) = 23.42*** .074 .95 .95
Females 22.33 (6.47) .91 .95
Males 25.68 (5.12) .91 .91
Increase Muscles 25.25 (4.86) F (1, 291) = 55.68*** .161 .94 .94
Females 27.03 (3.80) .94 .94
Males 23.12 (5.15) .93 .93
Body Importance 10.03 (2.83) F (1, 291) = 2.31 .130 .74 .75
Females 9.80 (2.79) .77 .73
Males 10.30 (2.86) .86 .88
Stress 133.28 (41.29) F (1, 291) = 13.42*** .044 .96 .96
Females 141.17 (42.43) .96 .96
Males 123.79 (37.89) .96 .96
Self Esteem 29.99 (5.46) F (1, 291) = 18.98*** .061 .90 .90
Females 28.76 (5.94) .90 .92
Males 31.47 (4.41) .86 .84

Note. *** denotes significant at p < .001.

3.2.4. Body importance

Body importance was assessed using three questions from the Body Image and Body Change Inventory (Ricciardelli & McCabe,
2000) reflecting the importance of weight, shape, and the size and strength of muscles (e.g., ‘How important to you is the shape of
your body compared to other things in your life?’). Each item is responded to on a 5-point Likert scale ranging from 1 = extremely
important to 5 = not important at all, with scores ranging from 3 to 15 and lower scores indicating greater body importance.

3.2.5. Stress
Adolescent stress was measured by the Adolescent Stress Questionnaire (ASQ) (Byrne et al., 2007), a 58-item measure assessing
subjective stress across 10 domains (i.e., home life, peer pressure, romantic relationships, school performance, school attendance,
teacher interaction, financial pressure, future uncertainty, emerging adult responsibility, and school leisure conflict). Respondents
rate perceived stress over the past year on a 5-point Likert scale ranging from 1 = not at all stressful or irrelevant to me to 5 = very
stressful. With the permission of its author, two items which referred to body image and were considered confounds for body image
measures in the study were excluded from calculations of stress scores (i.e., ‘satisfaction with how you look’ and ‘changes in physical
appearance with growing up’), resulting in a range from 56 to 280, with higher scores indicating greater perceived stress. The original
version of the ASQ displays acceptable reliability and validity (Byrne et al., 2007), with the measure employed in this study cor-
relating with the original at r = 0.999 (p < .01).

3.2.6. Self-esteem
Global self-esteem was measured using the Rosenberg Self-Esteem Scale (Rosenberg, 1965). Individuals respond to 10 items, such
as ‘I certainly feel useless at times’, on a 4-point Likert scale from 0 = strongly disagree to 3 = strongly agree. Scores range from 0 to 30
(after reverse-scoring some items), with higher scores indicating more positive self-esteem. The measure displays strong internal
consistency (Gray-Little, Williams, & Hancock, 1997; Polce-Lynch, Myers, Kliewer, & Kilmartin, 2001) and validity (Robins, Hendin,
& Trzesnieski, 2001).

3.3. Procedure

The present research was a one-year longitudinal study. Participants completed a paper and pencil self-report survey during class
time. Given the low-risk nature of the study, a combination of ‘opt-in’ and ‘opt-out’ procedures were approved and employed. Letters
were distributed to parents/guardians prior to the day of data collection informing them of the study and providing them the
opportunity to withdraw their child from participating (i.e., opt-out). Following an institutional change at Time 2, ‘opt-in’ written
consent was required from a parent/guardian of young people aged 12–13 years (comprising n = 27 of the possible sample). On the
day of data collection at both time points, verbal and written information were provided to eligible participants about the study,

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along with an opportunity to ask questions. Young people signed a Participant Consent Form to indicate their choice to ‘opt-in’ to
participate. Surveys took approximately 50 min with up to 50 students taking part at one time with teacher supervision. During
survey completion, students had their height and weight measured one by the first author in a private room, and were not informed of
their measurements. Students were debriefed after each period of data collection, and provided with a Participant Information Sheet
including contacts for support services. Attempts to follow-up students who missed scheduled sessions were made in consultation
with the school where possible, and a three-digit code was used to match responses.

3.4. Statistical analysis

All statistical analyses were conducted using IBM SPSS Statistics 23. Prior to analysis, attrition bias was investigated by comparing
completers and non-completers using a series of one-way between-subjects ANOVAs. Exploration of body image predictors of de-
pressive symptoms employed hierarchical regression, with linear models used initially controlling for Time 1 baseline depressive
symptoms to determine which body image predictors and covariates to include in the multiple model to retain power. Multiple
models addressing the study hypotheses were tested with Time 1 depressive symptoms and covariates controlled in Block 1. The main
effect for sex was entered in Block 2, then the body image predictors in Block 3, and two-way interactions constructed between sex
(dummy coded, female as reference category) and Block 3 predictors in Block 4. Interaction effects were interpreted using PROCESS
Model 1 with a bootstrap sample of 5000 (Hayes, 2018). The p-level was set at 0.05 for all analyses, with the exception of sex
comparisons for Time 1 predictors using one-way ANOVA in which a p-level of .005 was set to adjust for family-wise error.

4. Results

4.1. Completion rates and data screening

The attrition rate for the sample was 40%, with the majority (74.7%) not attending their scheduled session for data collection or
leaving the school (12.1%). To assess generalisability, comparisons between completers and non-completers (Goodman & Blum,
1996) using one-way ANOVA on demographic and psychological variables was undertaken. As reported in Murray et al. (2013), no
differences were evident on BMI, self-esteem, stress, body dissatisfaction, or body importance. In the current analysis, no difference
was evident for depressive symptoms, F(1, 494) = 0.58, η2 = 0.001, EMM = 21.22 completers, 21.95 non-completers; body change
strategies to decrease body size, F(1, 493) = 1.31, η2 = 0.003, EMM = 23.86, 24.50; or body change strategies to increase muscu-
larity, F(1, 493) = 0.05, η2 = 0.000, EMM = 25.21, 25.10 respectively. Age displayed a significant effect at p < .05, reflecting the
greater attrition in older participants, however, the follow-up sample was deemed appropriate for analysis given no differences on
scale variables. Data screening led to removal of two cases with greater than 5% missing responses, with no variables containing
greater than 5% missing values. Mean substitution was employed for missing items on continuous variables except cases missing a
majority of items, in which case listwise deletion was used. For the ASQ, missing items were imputed with 1. Three multivariate
outliers were removed and one retained following case review, with assumption testing indicating the data was appropriate for use in
multiple regression (Tabachnick & Fidell, 2014). The final sample for analysis comprised N = 293 (n = 160 females, n = 133 males).
Table 1 displays sex differences examined using one-way ANOVA at Time 1, showing females reported greater depressive
symptoms, stress, body dissatisfaction, and body change strategies to decrease weight, and lower self-esteem and fewer body change
strategies to increase muscularity, compared to males. No difference was evident for body importance. A significant difference for
depressive symptoms at Time 2 was also evident, F(1, 289) = 0.20.57, p < .001, η2 = 0.066, M (SD) females = 25.08 (10.89),
males = 19.58 (9.57). Table 2 depicts bivariate correlations between key variables in the model.

Table 2
Bivariate Correlations Between Time 1 Predictors and With Time 2 Depressive Symptoms.
Depressive Age BMI Body Decrease Body Increase Body Stress Self Esteem
Symptoms T2 Dissatisfaction Size Muscles Importance

Depressive Symptoms .622∗∗

Age .051 -
BMI .085 .183** -
Self Esteem -.705** .002 -.110
Body Dissatisfaction -.645** -.025 -.150∗ -
Decrease Body Size -.517** .041 -.370** .598** -
Increase Muscles -.159** -.166∗∗ -.086 .179** .206** -
Body Importance -.458** -.009 -.249** .526** .546** .435** -
Stress .626** .088 .070 -.512** -.475** -.226** -.455** -
Self Esteem -.705** .002 -.110 .730** .516** .110 .422** -.475** -

Note. Lower values reflect greater body dissatisfaction, body importance and body change strategies; italics reflect correlations between Time 1
predictors and Time 2 depressive symptoms; T2 = Time 2.
**denotes significant at p < .01, *denotes significant at p < .05.

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Table 3
Hierarchical Linear Regression Testing Time 1 Predictors on Time 2 Depressive Symptoms (controlling Time 1 Depressive Symptoms).
IV R2 change F Change (df1, df2) B (SE) 95%CI [L, U] β sr2 p-value

Block 1
Depressive Symptoms Time 1 .387 182.52 (1, 289) .62 (.05) [.53, .71] .62 .39 < .001
Block 2
Age .007 3.159 (1, 287) .75 (.42) [-.08, 1.58] .08 .01 .077
BMI .002 1.109 (1, 288) .17 (.16) [-.15, .48] .05 .00 .293
Sex .015 7.345 (1, 288) −2.71 (1.00) [-4.67, −.74] -.13 .02 .007
Body Dissatisfaction .008 3.995 (1, 288) -.12 (.06) [-.24, −.002] -.12 .01 .047
Decrease Body Size .006 2.684 (1, 288) -.15 (.09) [-.34, .03] -.09 .01 .102
Increase Muscles .011 5.253 (1, 288) -.23 (.10) [-.43, −.03] -.11 .01 .023
Body Importance .034 17.123 (1, 288) -.79 (.19) [-1.16, −.41] -.21 .03 < .001
Stress .029 14.208 (1, 288) .06 (.02) [.03, .09] .22 .03 < .001
Self-Esteem .002 1.070 (1, 288) -.13 (.13) [-.38, .12] -.07 .00 .302

Note. BMI: Body Mass Index (kg/m2). Age model Block 1 F-value = 181.93 (1, 288)***.
***denotes significant at p < .001, ** denotes significant at p < .01, * denotes significant at p < .05.

4.2. Body dissatisfaction, body change strategies and body importance as predictors of depressive symptoms

Table 3 shows results from the hierarchical linear regressions. Controlling for Time 1 depressive symptoms, body dissatisfaction,
body importance, body change strategies to increase muscularity, sex and stress were all significant predictors of Time 2 depressive
symptoms, but body change strategies to decrease body size, self-esteem, age and BMI were not.
Table 4 depicts results from the hierarchical multiple regression, with the total model accounting for 47% of variance in Time 2
depressive symptoms. Controlling for Time 1 depressive symptoms and stress, sex added 1.2% predictive variance to the model in
Block 2 (p = .016), and body image predictors added 3.2% variance in Block 3 (p = .001). However, only body importance
(p = .025) and body change strategies to increase muscularity (p = .037) contributed significant unique variance within Block 3,
with body dissatisfaction non-significant. Although Block 4 overall did not contribute significant additional variance, the sex × body
importance unique effect was significant (p = .038). To explore this unique effect, the sex × body importance interaction effect was
interpreted using PROCESS, with body importance entered as the antecedent variable, sex as the moderator, and Time 1 depressive
symptoms, stress, increase muscles and body dissatisfaction as covariates. The interaction effect overall was significant (R2 = 0.01, F
(1, 283) = 5.37, p = .02), and conditional effects revealed a significant effect for females, B (SE) = −0.83 (0.26), 95% CI [-1.35,
−0.32], p = .002, but not males B (SE) = −0.04 (0.29), 95% CI [-0.62, 0.53], p = .88. Conditional effects were plotted for females
and males at values above, at and below the mean of body importance in Fig. 1 (as low scores represent high body importance, values
have been plotted to reflect low to high importance on the x-axis for ease of interpretation). Results suggest that placing a higher
importance on the body predicts greater depressive symptoms over time in females, but no difference in depressive symptoms was
evident by level of body importance in males.

5. Discussion

The present study investigated body dissatisfaction, body change strategies to decrease body size and increase muscularity, and
body importance as predictors of depressive symptoms over one year in adolescent females and males, and sex differences in these
relationships. The results partially supported hypotheses and suggest that body importance (particularly in female adolescents), and
body change strategies to increase muscularity, predict increases in depressive symptoms over one year, controlling for baseline

Table 4
Hierarchical Multiple Regression Testing Body Image as a Predictor of Depressive Symptoms.
IV R2 Change F Change (df1, df2) B (SE) 95%CI [L, U] β sr2 p-value

Block 1 .416 102.54 (2, 288)*** < .001

Depressive Symptoms Time 1 .49 (.06) [.37, .60] .49 .14 .000***
Stress Time 1 .06 (.02) [.03, .09] .22 .03 .000***
Block 2 .012 5.84 (1, 287)* .016*
Sex −2.38 (.98) [-4.31, −.44] -.11 .01 .016
Block 3 .032 5.53 (3, 284)+ .001+
Body Dissatisfaction Time 1 .01 (.06) [-.12, .13] .01 .00 .894
Increase Muscles Time 1 -.26 (.12) [-.50, −.02] -.12 .01 .037*
Body Importance Time 1 -.49 (.22) [-.92, −.06] -.13 .01 .025*
Block 4 .011 1.97 (3, 281) .118
Sex × Body Dissatisfaction Time 1 -.09 (.11) [-.31, .14] -.05 .00 .450
Sex × Increase Muscles Time 1 .041 (.25) [-.46, .53] .01 .00 .878
Sex × Body Importance Time 1 .91 (.44) [.05, 1.76] .16 .01 .038*

Note. *** denotes significant at p < .001, + denotes significant at p = .001, ** denotes significant at p < .01, * denotes significant at p < .05.

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Fig. 1. Conditional effects plot for sex × body importance interaction effect on depressive symptoms.

depressive symptoms and stress.

5.1. Body image predictors of depressive symptoms

The first hypothesis (H1), that body dissatisfaction and body change strategies to decrease body size and increase muscularity
would predict depressive symptoms over time, received partial support. Body importance and body change strategies to increase
muscularity displayed significant main effects in the model, but body dissatisfaction (despite a linear effect) and body change
strategies to decrease body size did not. These findings are surprising and contrast with a number of studies showing that body
dissatisfaction (Ferreiro et al., 2011; Paxton, Eisenberg, & Neumark-Sztainer, 2006) and strategies to lose weight (Bearman & Stice,
2008; Rawana, 2013; Stice & Bearman, 2001; Stice et al., 2000) predict depressive symptoms, particularly in female adolescents.
However, these constructs have been the subject of more frequent study than body importance and strategies to increase muscularity
(Rawana et al., 2010), and few studies have explicitly tested sex differences and controlled for established risk factors (Bearman &
Stice, 2008; Rawana, 2013; Stice & Bearman, 2001). Therefore, it may be that body importance, strategies to increase muscularity,
and stress account for variance that has been attributed to body dissatisfaction and strategies to lose weight in previous research.
Consistent with this suggestion are findings supporting associations between body dissatisfaction and body importance (McCabe &
Ricciardelli, 2003; Muth & Cash, 1997; White & Halliwell, 2010), body change strategies to decrease body size (McCabe &
Ricciardelli, 2001, 2003a,b; Banfield & McCabe, 2002; Muris et al., 2005), and stress (Murray, Byrne, & Rieger, 2011). As such, these
correlates may play a greater role as cognitive and behavioural vulnerabilities for adolescent depression than previously indicated. In
addition, there may be complex interactions between cognitive vulnerabilities, such as body image dimensions and other constructs,
which predict adolescent depression. For example, self-esteem and body importance have been shown to mediate the relationship
between stress and body dissatisfaction (Murray et al., 2013), and so future studies examining more complex pathways over time are
recommended.
Results suggest that body importance may be a significant predictor of depressive symptoms in female adolescents in the present
study, which is unique in the existing literature. Consistent with the cognitive vulnerability framework (Abela & Hankin, 2008; Hyde
et al., 2008; Rawana et al., 2010), placing greater importance on the body may enhance the negative impact of developmental
changes related to the body on self-worth, and unsuccessful attempts to change the body, thereby increasing depression risk. This
effect may be due to the greater objectification of the female body (Hyde et al., 2008), and may help to explain the preponderance of
depression in females compared to males across the lifespan (Hankin, 2006; Hyde et al., 2008; Lewinsohn et al., 1994, 2000). It
should be acknowledged, however, that although this interaction effect was significant, the overall block within the hierarchical
multiple regression was not, suggesting further investigation of this effect is warranted.
Body change strategies to increase muscularity were also shown to predict increases in depression in both female and male
adolescents. This is in contrast with findings indicating that drive for muscularity is associated with depressive symptoms in male
adolescents but not female adolescents (McCreary & Sasse, 2000), and Rawana (2013) who found support for a relationship between
weight loss (but not weight gain) strategies and depression. Yet, akin to the current research, a number of studies have supported a
relationship between negative affect and body change strategies to increase muscularity in female and male adolescents (McCabe &
Ricciardelli, 2001, 2003; McCabe, Ricciardelli, & Holt, 2005; Muris et al., 2005; Ricciardelli & McCabe, 2001). This may reflect the
use of the Body Change Inventory (Ricciardelli & McCabe, 2002) in the latter studies, which may be a more sensitive measure of
problematic thoughts, feelings, and behaviours related to increasing muscularity. In contrast, other studies have assessed general
weight gain efforts (Rawana, 2013) or drive for muscularity (McCreary & Sasse, 2000), which may better account for male-specific
concerns. That only one set of body change strategies received support in the present study may also reflect the tendency for males in
particular to engage in strategies to lose weight and increase muscularity simultaneously (McCabe & Ricciardelli, 2004; Ricciardelli
et al., 2009; Ricciardelli & McCabe, 2002), with the possibility that both are implicitly captured in the muscularity measure. In
accordance with the cognitive vulnerability model, thoughts, feelings, and behaviours focused on increasing muscularity may in-
crease depression risk, particularly when maladaptive efforts to change the body are unsuccessful.
In addition to body importance and body change strategies to increase muscularity, the results supported stress as a predictor of

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depressive symptoms in all models. This is consistent with previous studies (Allgood-Merten, Lewinsohn, & Hops, 1990; Grant et al.,
2003; Hankin, 2006) and underscores its importance in adolescent mental health. Yet, the present findings contrast with those
highlighting a role for self-esteem, which may reflect the use of a one-month follow-up in Allgood-Merten et al. (1990), and inclusion
of gender as a covariate in Rawana (2013), which differ from the current study.

5.2. Sex differences in body image predictors of depression

The second hypothesis (H2) tested sex as a moderator of body image predictors in models of depressive symptoms. Consistent
with previous research, female adolescents reported greater depressive symptoms (Hankin, 2006; Rawana & Morgan, 2014), stress
(Grant et al., 2006), body dissatisfaction (Bearman et al., 2006), strategies to decrease body size, and fewer strategies to increase
muscularity (Muris et al., 2005; Ricciardelli & McCabe, 2002) and lower self-esteem (Rawana & Morgan, 2014) compared to male
adolescents. No difference on body importance was identified which contrasts with previous research (de Vries et al., 2014).
Moreover, the current findings suggest that some eating and weight-related disturbances are risk factors for both female and male
adolescents (Rawana et al., 2010). For example, body change strategies to increase muscularity, which may reflect the use of
measures sensitive to body image concerns for both sexes in the current study (Ricciardelli & McCabe, 2002). However, the findings
also suggest that some vulnerabilities may exert a unique or additive effect in female adolescents, as proposed by the gender additive
model (Bearman & Stice, 2008; Patalay et al., 2015; Stice & Bearman, 2001; Stice et al., 2000), with body importance perhaps the
most relevant dimension to understand sex differences in depression in future studies.

5.3. Limitations and implications

The study has a number of limitations that should be acknowledged, including the use of self-report data and an attrition rate of
40%, although comparisons between completers and non-completers suggest that the sample had appropriate generalisability in this
regard. However, it should be noted that the region from which data was collected demonstrates a higher percentage of educational
attainment at Bachelor Degree level of above, employment in government or professional roles, and a higher median income than the
overall Australian population, as well as lower rates of Aboriginal and Torres Strait Islander peoples and migrants compared with
other states and territories in the country (Australian Bureau of Statistics, 2016, 2017). In addition, while the study expanded the risk
factors used to investigate adolescent depression, key variables such as measures of self-objectification (Hyde et al., 2008), disordered
eating and muscularity-oriented behaviours, social support (Rawana, 2013), and demographic variables including socioeconomic
status, cultural background, and gender identity, could further enhance these models. It is also important that future studies examine
protective influences, and given body appreciation has been associated with lower levels of depression (Rawana et al., 2016), other
positive body image constructs such as functional body image and body image flexibility (Webb, Wood-Barcalow, & Tylka, 2015)
warrant consideration. Finally, the study did not consider different stages of adolescent development, which is relevant as body image
vulnerabilities may stabilise at different times for female and male adolescents, which may explain findings inconsistent with past
research.
The study has several important implications. First, it supports eating and weight-related disturbances as vulnerabilities for
adolescent depression over and above established risk factors. Second, it highlights the need to consider a range of these vulner-
abilities to understand and address sex differences in prevention and intervention programs for depression. That is, body importance
may be a specific vulnerability in female adolescents, whereas strategies to increase muscularity may be relevant for female and male
adolescents. In contrast, body dissatisfaction and body change strategies to decrease body size did not contribute predictive variance.
The findings enhance existing theories by expanding understandings of cognitive and behavioural body image vulnerabilities in
adolescent depression, and suggest a need to consider the complex interrelationships between these variables in understanding risk
factors for depression in future research. By examining these vulnerabilities, and sex differences, prevention and intervention efforts
in adolescent depression can be improved.

Declaration of interest

None.

Acknowledgements

This work was supported by an Australian Postgraduate Award for the primary author at the Australian National University.

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