Eating Disorders, 19308–322, 2011Copyright © Taylor & Franc

Eating Disorders, 19:308–322, 2011
Copyright © Taylor & Francis Group, LLC
ISSN: 1064-0266 print/1532-530X online
DOI: 10.1080/10640266.2011.584804
Stability of Eating Disorder Diagnostic
Classifications in Adolescents: Five-Year
Longitudinal Findings From
a Population-Based Study
DIANN M. ACKARD
Private Practice; and Division of Epidemiology and Community
Health, School of Public
Health, University of Minnesota, Minneapolis, Minnesota, USA
JAYNE A. FULKERSON
School of Nursing, University of Minnesota, Minneapolis,
Minnesota, USA
DIANNE NEUMARK-SZTAINER
Division of Epidemiology and Community Health, School of
Public Health, University
of Minnesota, Minneapolis, Minnesota, USA
This study examined the stability of eating disorder (ED) clas -
sifications among a population-based sample of male and
female adolescents (n = 2,516) who participated in Project
EAT-II, a five-year longitudinal study. Cross-tabulations using
weighted data identified diagnostic stability across six

classifica-
tions (Anorexia Nervosa, Bulimia Nervosa, Binge Eating
Disorder,
Binge Eating and/or Compensatory Behaviors not meeting ED
diagnosis, Body Image Disturbance without disordered eating,
and Asymptomatic). One-third (32.6%) of adolescents who were
asymptomatic at baseline and over half of those who were
symp-
tomatic at baseline reported symptoms five years later. All
males
and 82% of females with a threshold diagnosis at baseline
remained symptomatic five years later, but rarely within the
same
Parts of this manuscript were presented at the annual meeting of
the Academy for Eating
Disorders in May, 2008 in Seattle, WA.
This study was supported by grants R40 MC 00319 and R40 MC
00319-02 from the
Maternal and Child Health Bureau (Title V, Social Security
Act), Health Resources and Services
Administration, Department of Health and Human Services (D.
Neumark-Sztainer, principal
investigator).
Address correspondence to Diann M. Ackard, PhD, LP, 5101
Olson Memorial Highway,
Suite 4001, Minneapolis, MN 55422, USA. E-mail:
[email protected]
308
Eating Disorder Diagnostic Stability 309

classification. In conclusion, the presence of ED symptoms in
ado-
lescence strongly predicts ED symptoms five years later. ED
diag-
noses and classifications were unstable over time, under scoring
the critical need for prevention efforts and periodic assessment
and
encouraging early detection and intervention among
adolescents.
In clinical populations of adults with eating disorders, it has
been well
documented that eating disorder diagnoses are unstable over
time (Eddy
et al., 2008; Fichter & Quadflieg, 2007; Keel, Mitchell, Miller,
Davis, & Crow,
1999; Milos, Spindler, Schnyder, & Fairburn, 2005; Quadflieg
& Fichter, 2003;
Shisslak, Crago, & Estes, 1995; Tozzi et al., 2005). This may
be, in part, due
to patients improving throughout the course of treatment, or
worsening by
adopting new and different means to influence weight. An
important ques-
tion, with implications for eating disorder classifications and
for the planning
of interventions, regards the stability of these problems over
time; however,
many affected individuals do not receive or seek treatment for
an eating
disorder, and thus is it important to understand the diagnostic
presenta-
tion and fluctuation among non-clinical samples. For example,
disordered
eating behaviors and body image concerns have been found to
fluctuate

among a non-clinical sample of adult college students followed
over 20
years (Keel, Baxter, Heatherton, & Joiner, 2007). Yet only a
few studies have
investigated fluctuations in disordered eating behaviors and
body dispar-
agement during adolescence (Sancho, Arija, Asorey, & Canals,
2007; Stice,
Marti, Shaw, & Jaconis, 2009), a time often identified as high
risk for the
onset of significant eating disturbances (Shisslak, Crago, &
Estes, 1995; Stice
et al., 2009). Investigating the stability (or instability) of eating
and body
image disturbances among youth serves to elucidate whether
early detec-
tion and intervention efforts are necessary among younger
populations in
order to avoid or lessen the quality of life (Bamford & Sly,
2010) and finan-
cial (Crow et al., 2009) ramifications of eating disorders evident
among adult
populations.
Findings from a two-year follow-up study of 200 Spanish boys
and girls
aged 9–13 indicate that while most youth do not engage in
disordered eating,
of those youth who did endorse eating disturbances, the most
common
diagnosis was eating disorder not otherwise specified (EDNOS;
Sancho et al.,
2007). Of the 21 boys and 25 girls who demonstrated disordered
eating
disturbances at Time 1, scores at Time 2 indicated that for some
individuals

(11 boys, 6 girls) symptoms had remitted. For a few others (2
boys, 4 girls)
symptoms had been confirmed as an eating disorder, and for the
remaining
individuals (4 boys, 14 girls) symptoms had shifted to a
different cluster of
behaviors (Sancho et al., 2007).
More recently, an eight-year longitudinal study of a community
sample
of 496 adolescent girls found significant fluctuations over the
study period,
310 D. M. Ackard et al.
including improvement in symptoms congruent with recovery
and remis-
sion, as well as diagnostic migration, most commonly and
bidirectionally
between bulimia nervosa (BN) and binge eating disorder (BED;
Stice et al.,
2009). Specifically, over 90% of the 32 and 24 girls with
subthreshold or
threshold BN or BED, respectively, diagnosed at any point in
the study,
were determined to be in remission one year later, and the
percentage in
remission rose to 100% within two years of diagnosis. However,
across the
entire follow-up period, the picture is less promising, with
relapse rates
approximately 30–40% across the eight-year study duration.
Furthermore,
migration from one eating disorder diagnosis to another was

evident across
all diagnoses over the course of the follow-up period. For
example, of those
with BN at baseline, 19% migrated to BED at follow-up; of
those with BED
at baseline, 42% migrated to BN and 4% migrated to purging
disorder at
follow-up.
Assessing the fluctuation of disordered eating over time,
particularly
from early to older adolescence, is important for health
promotion among
youth. Stice and colleagues conducted eight annual assessments
with adoles-
cent girls starting in 7th-8th grade (Stice et al., 2009). Of those
who did not
already have an eating disorder diagnosis at baseline, the peak
period of risk
for an eating disorder was between ages 15 and 17 for BN. A
more gradual
progression of risk from age 16 to 19 was evident for BED.
Unfortunately,
there were no data provided regarding peak risk for anorexia
nervosa (AN;
likely due to no or too few cases of AN within the study
sample), nor for sub-
threshold symptomatic classifications that may best describe the
majority of
symptomatic youth (Ackard, Fulkerson, & Neumark-Sztainer,
2007; Shisslak
et al., 1995).
The current study aims to evaluate the stability of eating disor -
der diagnoses and classifications over a five-year period among
a large

population-based sample of female and male adolescents.
Participants were
followed during key periods of transition during adolescence
and early
young adulthood, and the sample was specifically weighted for
ethnic diver-
sity to aid in generalization to other samples across the United
States.
Data were analyzed to determine the stability across six eating
disorder
classifications, ranging from full threshold eating disorder to no
eating
disorder or body image symptoms. The six classifications
included three
threshold symptomatic diagnoses (AN, BN, and BED), two
subthreshold
symptomatic diagnoses (Binge Eating/Compensatory Behaviors
not meet-
ing full diagnostic criteria and Body Image Disturbance without
disordered
eating behaviors), and one asymptomatic classification,
indicating no symp-
toms or behaviors of an eating or body image disorder. These
classifications
were based on previous empirical research evaluating the
clinical utility of
eating disorder diagnoses among a school-based sample of
youth (Ackard
et al., 2007). Examining patterns among a sample of older
adolescents
can help with our understanding of the prevalence and stability
of eating

disorder diagnoses during a critical time in youth development;
the years
between adolescence and young adulthood are identified as high
risk for
the development or worsening of eating disorder symptoms
(Stice et al.,
2009). Furthermore, results from the current study will help to
determine
the patterns of symptom changes in both males and females that
might
influence targeted treatment and intervention approaches.
Similar to results
found in clinical populations, we hypothesized that we would
find poor
eating disorder diagnostic stability across the five-year study
period, among
both male and female older adolescents.
METHOD
Study Population
Data were drawn from Project EAT, an epidemiologic study of
adolescent
eating behaviors and weight-related issues with two times of
data col-
lection from the same individuals, five years apart (Time 1 in
1999 and
Time 2 in 2004; mean age 20.4 at follow-up assessment, SD =
0.8; Neumark-
Sztainer, Story, Hannan, & Croll, 2002; Neumark-Sztainer,
Story, Hannan,
Perry, & Irving, 2002). Project EAT participants were from 31
public middle
and high schools in urban and suburban school districts in the

greater St.
Paul/Minneapolis, Minnesota area. Participants were diverse by
age, race,
BMI, and socioeconomic status. Each Time 1 participant
completed Project
EAT surveys and anthropometric measures of height and
weight. At Time 1,
consent procedures were completed in accordance with the
requirements
of the participating schools’ research boards. In some schools,
parents were
required to return signed consent forms agreeing to have their
child par-
ticipate in the study; in other schools, parents were only
required to return
signed consent forms if they did not want their child to
participate. All Time 1
participants signed an assent form before survey completion. At
Time 2, par-
ents of adolescents younger than age 18 were sent a consent
form before
sending out the surveys; surveys were not sent to adolescents
whose par-
ents mailed back a signed consent form indicating their refusal
to have their
child participate. Adolescents were then sent an assent form
with the sur-
vey and asked to sign and return the form if they were not
interested in
study participation. Completion of the survey at Time 2 implied
written con-
sent. Approval for the study was granted by the University of
Minnesota’s
Institutional Review Board Human Subjects Committee and by
the research
boards of the participating school districts.

Only Time 1 participants were eligible to participate in the
Time 2 assess-
ment; no new participants were recruited for Time 2 who did
not participate
in Time 1. The Project EAT Time 2 surveys were sent by mail
to the address
provided by the participant during Time 1. Data collection ran
from April
2003 to June 2004. Of the original Time 1 cohort, 1,074
(22.6%) were lost to
follow-up for various reasons, primarily missing contact
information at Time 1
and no address found at follow-up. Of the remaining 3,672
participants con-
tacted, 2,516 completed surveys, representing 53% of the
original cohort and
68.4% of participants who were contacted for Time 2.
For the current study, the final sample included 2,516 youth
(45%
males; 55% females) who completed the Project EAT Time 1
survey and
also completed the Project EAT Time 2 survey. The sample was
well-
distributed across socioeconomic status; 17.8% in the lower
quintile, 18.9%
lower-middle, 26.7% middle, 23.3% upper middle, and 13.3%
upper quintile.
Participants described themselves as white (48.3%), Asian
(19.6%), black

(18.9%), Hispanic (5.8%), or mixed/other (3.8%) ethnicity/race.
Each DSM-IV (American Psychiatric Association [APA], 1994)
criterion
for AN, BN and BED was mapped to survey questions based on
discussions
and consensus by a multidisciplinary group of researchers and
clinicians
with expertise in the field. Project EAT items were selected
based on how
well the items represented each clinical criterion within the
DSM-IV diagnos-
tic classification. The mapping of Project EAT survey items to
each criterion
is described in detail in another publication (Ackard et al.,
2007) and spe-
cific criterion are outlined below by Threshold Symptomatic,
Subthreshold
Symptomatic, and Asymptomatic categories. The eating disorder
classifica-
tions among the current study sample at baseline (Time 1) were:
AN (n = 0
female, 0 males), BN (n = 10 females, 0 males), BED (n = 18
females, 6
males), Binge Eating and/or Compensatory Behaviors not
meeting threshold
diagnoses (n = 321 females, 185 males), Body Image
Disturbance without
disordered eating (n = 301 females, 180 males), and
Asymptomatic (n = 736
females, 759 males).
Measures
The following eating disorder classifications were measured via
self-

report using questions from the Project EAT survey. Using the
available
survey items, criteria for each classification described below
were deter-
mined following discussions and consensus by a
multidisciplinary group
of researchers and clinicians with expertise in the field (see
Ackard,
Fulkerson, & Neumark-Sztainer, 2007).
THRESHOLD SYMPTOMATIC
Anorexia Nervosa. Criterion A (refusal to maintain body weight
at or
above a minimally normal weight for age and height) is met if
the partic-
ipant’s observed BMI is less than the 15th percentile for age
and gender,
and the participant responds “yes” to the question, “During the
past year
have you done anything to try to lose weight or keep from
gaining weight?”
Criterion B (intense fear of gaining weight or becoming fat,
even though
underweight) is met if an underweight (BMI < 15th percentile)
participant
answers “strongly agree” to the statement, “I am worried about
gaining
weight.” Criterion C (disturbance in the way in which one’s
body weight
or shape is experienced, undue influence of body weight or

shape on self-
evaluation, or denial of the seriousness of the current low body
weight)
could be met: (a) if an underweight (BMI < 15th percentile)
participant
responds that they are “somewhat overweight” or “very
overweight”; (b) if
the participant responds, “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” to the
question
“During the past six months, how important has your weight or
shape been
in how you feel about yourself?”; or (c) if an underweight (BMI
< 15th per-
centile) participant responds that his or her best weight is less
than his or
her observed weight when answering the question, “At what
weight do you
think you would look best?” Criterion D (amenorrhea) was not
assessed in
the original Project EAT survey.
Bulimia Nervosa. Criterion A (recurrent episodes of binge
eating) is
met if the participant answers “yes” to both of the following: (a)
“In the
past year, have you ever eaten so much food in a short period of
time
that you would be embarrassed if others saw you (binge
eating)?” and (b)
“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?” Criterion

B (recur-
rent inappropriate compensatory behavior) is met if the
participant answers
“yes” to either of the behaviors listed in the question, “During
the past
week, did you do any of the following to lose weight or keep
from gain-
ing weight . . . made myself vomit (throw up)? Used laxatives?”
or reported
engaging in 12 or more hours per week of moderate (not
exhausting, such
as walking quickly, baseball, gymnastics, easy bicycling,
volleyball, skiing,
dancing, skateboarding, snowboarding) and strenuous exercise
(heart beats
rapidly, such as biking fast, aerobic dancing, running, jogging,
swimming
laps, rollerblading, skating, lacrosse, tennis, cross-country
skiing, soccer,
basketball, football). Criterion C (binge eating and
inappropriate compen-
satory behaviors both occur, on average, at least twice a week
for three
months) is met when the participant responds “nearly every
day” or “a
few times a week” to the question, “How often, on average, did
you
have times when you ate this way—that is, large amounts of
food plus
the feeling that your eating was out of control?” and reported
“yes” to
vomiting or using laxatives in response to the question, “During
the past
week, did you do any of the following to lose weight or keep
from
gaining weight?” or reported at least 12 hours per week of

moderate or
strenuous exercise. Criterion D is met if the participant
responds “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” to the question “During the past six
months,
how important has your weight or shape been in how you feel
about
yourself?”
Binge Eating Disorder. Criterion A (recurrent episodes of binge
eat-
ing) is met if the participant answers “yes” to both of the
following: (a)
“In the past year, have you ever eaten so much food in a short
period of
time that you would be embarrassed if others saw you (binge
eating)?” and
(b) “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?”
Criterion B
(binge eating episodes are associated with three or more of the
following:
eating much more rapidly than normal, eating until feeling
uncomfortably
full, eating large amounts of food when not feeling physically
hungry, eat-

ing alone because of being embarrassed by how much one is
eating, and
feeling disgusted with oneself, depressed, or very guilty after
overeating) is
unable to be mapped because similar questions were not
included in the
Project EAT survey. Criterion C (marked distress regarding
binge eating) is
met if the participant meets Criterion A and answers “some” or
“a lot” to
the question, “In general, how upset were you by overeating
(eating more
than you think is best for you)?” Criterion D (frequency of
binge eating
at least two days a week for six months) is met if the participant
meets
Criterion A and answers “nearly every day” or “a few times a
week” to the
question, “How often, on average, did you have times when you
ate this
way—that is, large amounts of food plus the feeling that your
eating was
out of control?” Criterion E (binge eating is not associated with
the regu-
lar use of inappropriate compensatory behaviors) is met if the
participant
answers “no” to both of the compensatory behaviors listed in
the question,
“During the past week, did you do any of the following to lose
weight
or keep from gaining weight . . . made myself vomit (throw up)?
Used laxa-
tives?” and reports engaging in less than 12 hours of moderate
and strenuous
exercise.

SUBTHRESHOLD SYMPTOMATIC
Binge eating/Compensatory behaviors. Individuals included in
this clas-
sification could report Binge Eating and/or Compensatory
Behaviors not
meeting criteria for Bulimia Nervosa or Binge Eating Disorder
as noted
above, and could have any level of body image disturbance as
noted
below. More specifically, individuals were classified into this
category if
they endorsed engaging in binge eating behaviors (see Criteria
A and B for
Binge Eating Disorder, above) but did not report significant
distress regard-
ing the binge eating (see Criterion C for Binge Eating Disorder,
above) or
did not meet frequency criteria for Binge Eating Disorder (see
Criterion D
for Binge Eating Disorder, above). Other individuals were
classified into this
“Binge Eating/Compensatory Behaviors” classification if they
reported the
use of compensatory behaviors (see Criterion B for Bulimia
Nervosa, above)
but did not meet frequency criteria for Bulimia Nervosa (see
Criterion C for
Bulimia Nervosa, above).
Body image disturbance. Individuals in this category did not

report
binge eating and did not report the use of compensatory
behaviors. They
were classified as having “Body Image Disturbance” if they
responded
“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” to the question “During the past six
months, how
important has your weight or shape been in how you feel about
yourself?”
(same as Criterion D for Bulimia Nervosa).
ASYMPTOMATIC
Individuals were classified as asymptomatic if they did not
report binge eat-
ing, did not report the use of compensatory behaviors, and, to
the question
“During the past six months, how important has your weight or
shape been
in how you feel about yourself?” responded either that “weight
and shape
were not very important” or “weight and shape played a part in
how I felt
about myself.”
Data Analysis
Crosstabulations were conducted to assess diagnostic transition
from
Time 1 to Time 2. Crosstabulations were conducted at the
Threshold
Symptomatic/Subthreshold Symptomatic/Asymptomatic level as

well as at
the finer eating disorder classification level. Data were
weighted to adjust
for differential response rates in the Project EAT Ti me 2 survey
with the
use of the response propensity method (Little, 1986). All
weighted values
are rounded where case numbers are reported. All analyses were
conducted
with SAS software, version 9.1.
RESULTS
Progression of Diagnostic Severity Among Males
Table 1 presents the stability of eating disorder classifications
from Time 1 to
Time 2 among male adolescents. Nearly 30% of male
adolescents who were
asymptomatic at Time 1 developed some type of problem by
Time 2; 12.1%
developed a body image disturbance, 14.9% reported binge
eating or com-
pensatory behaviors, and 0.5% developed either BED or BN.
Furthermore,
40–45% of those with subthreshold symptoms at Time 1
remained symp-
tomatic at the subthreshold or threshold level at Time 2. With
respect to
threshold diagnoses, although there were no cases of Anorexia
Nervosa at
either Time 1 or Time 2, and no cases of Bulimia Nervosa at
Time 1, four

TA
B
LE
1
D
ia
gn
o
st
ic
St
ab
ili
ty
o
f
E
at
in
g
D
is
o
rd
er
C

la
ss
ifi
ca
tio
n
s
A
cr
o
ss
5
Y
ea
rs
Fr
o
m
A
d
o
le
sc
en
ce

to
E
ar
ly
Y
o
u
n
g
A
d
u
lth
o
o
d
:
M
al
es
E
at
in
g
d
is
o

rd
er
cl
as
si
fi
ca
tio
n
at
tim
e
2
(M
al
es
)
Su
b
th
re
sh
o
ld

sy
m
p
to
m
at
ic
T
h
re
sh
o
ld
sy
m
p
to
m
at
ic
B
o
d
y
B
in

ge
B
in
ge
im
ag
e
ea
tin
g/
co
m
p
en
sa
to
ry
ea
tin
g
B
u
lim
ia

A
n
o
re
xi
a
A
sy
m
p
to
m
at
ic
d
is
tu
rb
an
ce
b
eh
av
io
r

d
is
o
rd
er
n
er
vo
sa
n
er
vo
sa
(n
=
76
0)
(n
=
17
3)
(n
=
18
7)

(n
=
5)
(n
=
4)
(n
=
0)
E
at
in
g
d
is
o
rd
er
cl
as
si
fi
ca

tio
n
at
T
im
e
1
(m
al
es
)
A
sy
m
p
to
m
at
ic
(n
=
75
9)
72
.6

%
12
.1
%
14
.9
%
0.
2%
0.
3%
0.
0%
Su
b
th
re
sh
o
ld
sy
m
p
to

m
at
ic
B
o
d
y
im
ag
e
d
is
tu
rb
an
ce
(n
=
18
0)
60
.7
%
25
.3

%
11
.8
%
1.
3%
0.
9%
0.
0%
B
in
ge
ea
tin
g/
co
m
p
en
sa
to
ry
b

eh
av
io
r
(n
=
18
5)
54
.0
%
17
.1
%
28
.0
%
0.
9%
0.
0%
0.
0%
T

h
re
sh
o
ld
sy
m
p
to
m
at
ic
B
in
ge
E
at
in
g
D
is
o
rd
er
(n

=
6)
0.
0%
75
.7
%
24
.3
%
0.
0%
0.
0%
0.
0%
B
u
lim
ia
N
er
vo
sa

(n
=
0)
N
/
A
(n
=
0)
N
/
A
(n
=
0)
N
/
A
(n
=
0)
N
/
A

(n
=
0)
N
/
A
(n
=
0)
N
/
A
(n
=
0)
A
n
o
re
xi
a
N
er
vo
sa

(n
=
0)
N
/
A
(n
=
0)
N
/
A
(n
=
0)
N
o
te
:
A
ll
n
s
ar

e
w
ei
gh
te
d
.
N
/
A
=
n
o
t
ap
p
lic
ab
le
b
ec
au
se
th
er

e
w
er
e
n
o
ca
se
s
o
f
A
n
o
re
xi
a
N
er
vo
sa
o
r
B
u
lim

ia
N
er
vo
sa
am
o
n
g
m
al
es
at
T
im
e
1.
316
cases of Bulimia Nervosa emerged by Time 2, and all cases of
BED at Time 1
remained symptomatic at Time 2.

Progression of Diagnostic Severity Among Females
Table 2 shows the migration across eating disorder
classifications from
Time 1 to Time 2 among female adolescents. Nearly 40% of the
girls who
were asymptomatic at Time 1 developed problems during
middle or late
adolescence. Furthermore, among the 301 girls at Time 1 with
body image
disturbance who did not endorse any binge eating or use of
compensatory
behaviors, nearly 30% worsened such that they reported binge
eating, the
use of compensatory behaviors, or met threshold diagnostic
criteria for BN or
BED. Furthermore, while 40.2% of those in the Binge
Eating/Compensatory
Behavior classification at Time 1 remained in that same
classification at
Time 2, 3.7% worsened to meet threshold criteria for BED or
BN. Finally, less
than one-fifth of the girls with BED or BN at Time 1 were able
to become
asymptomatic at Time 2.
DISCUSSION
The current study used data from a large, population-based
study of male
and female adolescents to evaluate the stability of eating
disorder classi-
fications over a peak period of eating disorder development
(Stice et al.,
2009). Because the majority of youth who endorse disordered
eating and

body image concerns do not meet criteria for an eating disorder
(Shisslak
et al., 1995) according to DSM-IV diagnostic criteria (APA,
1994), we included
subthreshold classifications, previously derived (Ackard et al.,
2007), in addi-
tion to threshold diagnoses of anorexia nervosa, bulimia
nervosa, and binge
eating disorder. Our findings show that nearly 30% of male
adolescents
and 40% of female adolescents without any eating or body
image distur-
bance at Time 1 developed problems by Time 2. Of concern,
approximately
15% of the male adolescents and 30% of the female adolescents
who only
displayed body image disturbance at Time 1 worsened by Time
2, and
reported either binge eating, the use of compensatory behaviors,
or met
threshold diagnostic criteria for BN or BED. Among youth
meeting cri-
teria for a subthreshold symptomatic classification at Time 1,
nearly half
of the boys and two-thirds of the girls remained symptomatic at
Time 2,
with several cases progressing to meet criteria for a threshold
eating
disorder.
Results from the current study underscore the critical need for
pre-
vention efforts and early detection among adolescents. An
alarmingly
high number of adolescents went from being asymptomatic to
having

either subthreshold or threshold conditions over the five-year
study period,
TA
B
LE
2
D
ia
gn
o
st
ic
St
ab
ili
ty
o
f
E
at
in
g
D
is

o
rd
er
C
la
ss
ifi
ca
tio
n
s
A
cr
o
ss
5
Y
ea
rs
Fr
o
m
A
d
o
le

sc
en
ce
to
E
ar
ly
Y
o
u
n
g
A
d
u
lth
o
o
d
:
Fe
m
al
es
E
at

in
g
d
is
o
rd
er
cl
as
si
fi
ca
tio
n
at
T
im
e
2
(F
em
al
es
)

Su
b
th
re
sh
o
ld
sy
m
p
to
m
at
ic
T
h
re
sh
o
ld
sy
m
p
to
m
at

ic
B
o
d
y
B
in
ge
B
in
ge
im
ag
e
ea
tin
g/
co
m
p
en
sa
to
ry

ea
tin
g
B
u
lim
ia
A
n
o
re
xi
a
A
sy
m
p
to
m
at
ic
d
is
tu
rb

an
ce
b
eh
av
io
r
d
is
o
rd
er
n
er
vo
sa
n
er
vo
sa
(n
=
67
9)
(n

=
31
2)
(n
=
36
4)
(n
=
10
)
(n
=
20
)
(n
=
1)
E
at
in
g
d
is

o
rd
er
cl
as
si
fi
ca
tio
n
at
T
im
e
1
(f
em
al
es
)
A
sy
m
p

to
m
at
ic
(n
=
73
7)
62
.0
%
17
.3
%
19
.3
%
0.
3%
0.
9%
0.
2%
Su

b
th
re
sh
o
ld
sy
m
p
to
m
at
ic
B
o
d
y
im
ag
e
d
is
tu
rb
an

ce
(n
=
30
1)
36
.5
%
35
.2
%
26
.2
%
0.
8%
1.
4%
0.
0%
B
in
ge
ea

tin
g/
co
m
p
en
sa
to
ry
b
eh
av
io
r
(n
=
32
1)
33
.5
%
22
.5
%

40
.2
%
1.
7%
2.
0%
0.
0%
T
h
re
sh
o
ld
sy
m
p
to
m
at
ic
B
in
ge

E
at
in
g
D
is
o
rd
er
(n
=
19
)
19
.6
%
28
.7
%
42
.4
%
0.
0%

9.
4%
0.
0%
B
u
lim
ia
N
er
vo
sa
(n
=
10
)
15
.1
%
13
.4
%
63
.1

%
0.
0%
8.
4%
0.
0%
A
n
o
re
xi
a
N
er
vo
sa
(n
=
0)
N
/
A
(n
=

0)
N
/
A
(n
=
0)
N
/
A
(n
=
0)
N
/
A
(n
=
0)
N
/
A
(n
=

0)
N
/
A
(n
=
0)
N
o
te
:
A
ll
n
s
ar
e
w
ei
gh
te
d
.
N

/
A
=
n
o
t
ap
p
lic
ab
le
b
ec
au
se
th
er
e
w
er
e
n
o
ca
se

s
o
f
A
n
o
re
xi
a
N
er
vo
sa
am
o
n
g
fe
m
al
es
at
T
im
e
1.

318
indicating that adolescence is not “too late” for the
implementation of
interventions. The high prevalence of adolescents “progressing”
from body
image disturbance only to conditions involving harmful
disordered eating
behaviors demonstrates the importance of addressing body
image concerns
during adolescents. Our findings are in line with previous
studies that have
found body dissatisfaction to be a strong predictor of unhealthy
weight
control practices, binge eating, and disordered eating behaviors
(Neumark-
Sztainer, Wall, Story, & Perry, 2003). Furthermore, as findings
from the
current study suggest, many of the youth meeting criteria for a
full threshold
disorder at Time 2 did not have a full threshold disorder at Time
1. These
findings are consistent with recent longitudinal work by Stice et
al. that
emphasizes the peak risk for Bulimia Nervosa and Binge Eating
Disorder
during mid to late adolescence (Stice et al., 2009). Thus, there
is ample
opportunity during this critical time in adolescent development
to address
concerns that might lead to the development or worsening of
eating and

body image disturbances. In sum, findings from the current
study build
upon the extant literature suggesting the importance of
prevention work
with adolescent populations.
Furthermore, because subthreshold classifications have been
found to
have similar levels of psychopathology compared to threshold
diagnoses
(Ackard, Fulkerson, & Neumark-Sztainer, 2011; Chamay-
Weber, Narring, &
Michaud, 2005; Thomas, Vartanian, & Brownell, 2009), it is
critically impor-
tant to detect the early development of disordered eating
behaviors and body
image disturbances and intervene as soon as possible to reduce
the risk of
maintaining subthreshold symptoms or developing a threshold
eating disor-
der. Future research should evaluate the associations between
psychological
and behavioral health and diagnostic stability, as awareness of
an individ-
uals’ functioning is integral to understanding and evaluating
more fully the
severity of a range of eating disorder diagnostic classifications
(Ro & Clark,
2009).
In the current study, among the subthreshold and threshold
classifica-
tions, there were patterns of improvement, stability, and
worsening among
both males and females. In the current study, the poor stability
of eating

disorder diagnoses found based on current diagnostic nosology
supports a
call for action by Eddy and colleagues to investigate the
temporal stability
of diagnoses (Eddy et al., 2009). Our findings also suggest
greater flexibility
and less rigidity in eating disorder classifications, at least for
youth, given
the lack of stability between different classifications, and the
associations
between even subthreshold classifications and compromised
psychological
health are concerning (Ackard et al., 2011). Further longitudinal
research,
similar to that conducted here and by Stice and colleagues
(Stice et al., 2009),
should be conducted with male and female adolescents to
evaluate the sta-
bility of individual eating disorder behaviors, body image
disturbances, and
weight- and shape-focused experiences over time.
Strengths and Limitations
A significant strength of the current study is the use of data
from a large,
population-based sample of males and females selected to
reflect socioeco-
nomic diversity in urban areas of the United States. The Project
EAT study
was designed to look at population-based problems with a focus
on the

eating disorder and body image symptoms and experiences that
affect a
large portion of the study population, not simply on the current
eating
disorder clinical diagnoses. The large dataset of both males and
females
allowed us to investigate finer nuances in diagnostic
classification than pre-
vious research of general adolescent populations. Another study
strength
includes the comprehensive nature of the data collected, mapped
to current
DSM-IV diagnostic nosology and evaluated over time, and
including both
threshold and subthreshold diagnostic classifications.
A limitation of the present study is the small sample sizes of the
AN
and BN groups, which may have prohibited us from detecting
meaning-
ful differences between these groups and the other diagnostic
groups. It
is not clear whether the prevalence of conditions such as AN
were truly
non-existent among our population or, rather, that young people
with this
condition self-selected out of responding. In addition, given the
compre-
hensive nature of the Project EAT survey, we were not able to
assess eating
disorders, per se, as one would during a structured clinical
interview, which
would allow for an assessment of clinical impairment as well as
duration
and frequency of symptoms over time. Thus, the validity
between our

eating disorder symptom classifications and those specific to
the DSM-IV
diagnostic criteria are unknown. Additionally, it may be that
certain cases
of AN were not detected in the Project EAT study population.
Finally, the
Project EAT survey did not gather information on whether
participants had
received any early education or intervention or treatment for an
eating dis-
order or disordered eating concern. Some individuals previously
at risk or
affected by an eating disorder may have received early
intervention or treat-
ment before Time 1 or between Time 1 and Time 2 assessments.
However,
given the prevalence of adolescents who receive treatment for
an eating
disturbance, we believe that this reflects a very small portion of
the study
population.
Overall, the strengths of this study allow for a thorough
discussion of the
stability of subthreshold and threshold eating disorder
classifications among
male and female youth over a five-year period of time, and
results may be
generalized to samples other than those seeking or participating
in treatment.
However, the body of knowledge on diagnostic stability will
benefit from
further evaluations of both male and female youth across longer
follow-up
periods, and investigations of possible fluctuations in mental
health con-

cerns (e.g., depression, low self-esteem, suicide risk) as eating
disorder
classifications improve, stay stable, or worsen over time.
In conclusion, this study found that there is substantial
worsening
of symptoms among youth over a five-year study period.
Furthermore,
although the majority of youth with disordered eating and body
image con-
cerns do not meet criteria for a full threshold eating disorder,
most of the
subthreshold cases remained symptomatic and a few worsened
to meet a
full threshold eating disorder diagnosis across the five-year
study period.
Our findings underscore the critical importance of early
detection and early
intervention during mid to late adolescence.
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