The role of anxiety and depressive symptoms in the longitudinal relationship between body image and disordered eating behaviors among Tibetan young adults: a moderating serial mediation model

The role of anxiety and depressive symptoms in the longitudinal relationship between body image and disordered eating behaviors among Tibetan young adults: a moderating serial mediation model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The role of anxiety and depressive symptoms in the longitudinal relationship between body image and disordered eating behaviors among Tibetan young adults: a moderating serial mediation model Ruipeng Wu, Yeen Huang, Xinya Yan, Yingting Wang, Minxia Zhu, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4786119/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Apr, 2026 Read the published version in BMC Psychiatry → Version 1 posted 4 You are reading this latest preprint version Abstract Background: Body image significantly impacts emotional and behavioral health. This study investigates the relationship between body image dissatisfaction and disordered eating behaviors (DEBs) among Tibetan young adults, considering the mediating roles of anxiety and depression and the moderating role of ethnicity. Methods: A longitudinal survey was conducted among 2993 first- and second-year university students in Tibet, with initial data collection in September 2021 and follow-up in December 2021. Participants completed standardized questionnaires assessing body image, anxiety, depression, and DEBs. Statistical analyses included t-tests, ANOVA, Pearson correlation, and moderated serial mediation using the PROCESS macro. Results: Body image satisfaction significantly negatively predicted DEBs ( β = -0.031, 95% CI = -0.061~-0.001). Anxiety and depression independently and sequentially mediated this relationship (a 1 b 1 = -0.008, 95% CI = -0.015~-0.001; a 2 b 2 = -0.005, 95% CI = -0.010~-0.001; a 1 db 2 = -0.017, 95% CI = -0.026~-0.009). Ethnicity moderated the direct effect, with body image significantly predicting DEBs among Tibetan students but not Han Chinese students. Conclusions: This study highlights the critical roles of anxiety and depression in the link between body image and DEBs and the moderating effect of ethnicity. These findings suggest targeted interventions addressing body image and emotional health to mitigate DEBs, especially in ethnic minority populations. Body image Disordered eating behaviors Anxiety Depression Ethnicity Longitudinal study Figures Figure 1 Figure 2 Introduction Body image refers to an individual's perception or attitude towards their own body or appearance. More specifically, it encompasses a person's level of satisfaction with, importance placed on, or treatment of their body[1, 2]. Body image is crucial for behavioral and emotional health[3]. In contemporary society, body image is shaped through various micro-level social interactions[4]. Particularly among modern college students, the management of their bodies is increasingly influenced by external evaluations. The pursuit of bodily ideals, especially the "ideal thin" body, is prevalent among this group. Additionally, the accessibility of vast amounts of information has heightened their sensitivity to body image[4]. According to surveys, up to 70% of college students have engaged in dieting behaviors in pursuit of an ideal body[5]. This excessive pursuit of an ideal body and dissatisfaction with one's own image have become catalysts for "psychological weight gain" leading to potential psychological burdens[4, 6]. Negative body image can be closely associated with poor mental and physical health outcomes such as low self-esteem, anxiety, depression, and eating disorders (EDs)[7, 8]. Disordered Eating Behaviors (DEBs) refer to a range of eating-related problems, including unhealthy weight control behaviors or binge eating, such as dieting, food restriction, and vomiting[9]. These behaviors can increase the risk of clinically diagnosed EDs. A distorted body image and body dissatisfaction can elevate the risk of DEBs. For example, Karime et al. found that body dissatisfaction was a major factor related to the development of DEBs through a six-year observation of university students in Mexico[10]. Other studies, both domestic and international, focusing on adolescents and young adults, indicate that body image issues are potential predictors of eating disorders[11, 12]. DEBs are particularly prevalent among university students. For instance, the prevalence of DEBs among Mexican university students ranges from 25.0% to 38.3%, with potential differences across gender and weight groups [10, 13]. In the United States, the prevalence of DEBs among 18-year-old university students is 31.0%[14]. Another cross-cultural study showed that Chinese university students (16.7%) have a relatively lower prevalence of DEBs compared to international students (29.9%)[15]. Given the high prevalence of DEBs among young people and the significant impact of body image on DEBs, elucidating the potential intermediary mechanisms between the two is crucial for preventing negative body image, DEBs, and EDs. Body image dissatisfaction, as a proximal factor for DEBs, can not only directly lead to various DEBs (such as dieting) but also may be mediated by a range of negative emotions or behaviors. On one hand, negative emotions such as anxiety have repeatedly been linked to EDs (including anorexia nervosa, bulimia nervosa, and binge eating) and DEBs[16–18]. Depression is one of the most direct psychological factors leading to DEBs[19]. Research suggests that dieting or binge eating behaviors triggered by depressive emotions may be a way to alleviate negative emotions or escape negative self-perceptions[20]. On the other hand, body image dissatisfaction can directly or indirectly lead to the occurrence of negative emotions. Studies show that body image dissatisfaction may increase the risk of generalized anxiety, social anxiety, and appearance-related anxiety[8, 21, 22]. The cognitive model of depression posits that negative self-evaluation is central to the development of depression[23]. This negative self-evaluation includes evaluations of one's body. Studies in different populations show that the lower the body satisfaction, the more severe the depressive symptoms[24–26]. Additionally, there is a high comorbidity between anxiety and depression[27]. Therefore, it is reasonable to speculate that anxiety and depression independently and jointly mediate the relationship between body image and DEBs. In fact, similar studies have confirmed the existence of complex paths, such as independent or joint mediation by self-esteem, smartphone addiction, and negative emotions, in the relationship between body image and DEBs[7, 28, 29]. However, most previous studies are cross-sectional and lack the ability to determine causality. Longitudinal studies exploring the roles of anxiety and depression in the relationship between body image and DEBs are thus necessary. Additionally, research both domestically and internationally indicates significant ethnic and cultural differences in eating disorders and negative emotions[30–32]. For instance, a dietary survey of different ethnic groups in western China found that Han, Tibetan, Mongolian, and Hui ethnic groups exhibit distinct dietary patterns[33]. The prevalence of anxiety and depression among ethnic minorities in western China is significantly higher than that of the Han population, although this study did not include the Tibetan population[34]. Tibet, located in the southwestern region of China, has unique geographical features, historical development, and cultural background, characterized by its high altitude (with an average elevation exceeding 4000 meters), low air pressure, and low temperatures. The dietary habits of Tibetans differ significantly from those of the Han residents in the local or other regions of China. For example, Tibetans prefer tsampa and yak or mutton, and they enjoy drinking butter tea, barley wine, and dairy products. An early study showed that Tibetan adolescents in Tibet have body image perceptions different from those in the West [32]. Different ethnic customs and cultural differences may influence body image evaluation, thereby affecting their DEBs, anxiety, and depression. Currently, there is no research on this topic. Therefore, it is worth further exploring whether ethnic factors moderate the direct and indirect effects of body image on DEBs. In summary, the purpose of this study is to investigate the predictive role of body image on DEBs using a longitudinal design and to explore the possible mediating and moderating mechanisms in this relationship. We hypothesize that: 1) anxiety or depression independently mediates the relationship between body image and DEBs, 2) a sequence of anxiety and depression mediates this relationship, and 3) ethnicity may play a moderating role in the aforementioned processes. Methods Participants This study selected two universities affiliated with Tibet, targeting first- and second-year students as participants. The initial survey was conducted in September 2021, with a follow-up survey in December of the same year. Prior to the survey, student management personnel from both universities were contacted to convene student council members and class leaders for extensive promotion. They, in turn, informed the students in their respective classes about the purpose, significance, and precautions of the survey. The survey was conducted using a combination of centralized and individual approaches. Students were gathered in classrooms, where class leaders distributed pre-made questionnaire QR codes to the class group. All students completed the questionnaire by scanning the QR code. Those who were absent due to other commitments were later contacted by the class leaders to complete the questionnaire. All participants were informed that participation was voluntary and that they could withdraw at any time. Any questions during the questionnaire completion could be directed to trained surveyors present on-site. Excluding invalid questionnaires, a total of 2993 students completed both the initial and follow-up surveys. Measures Body image The satisfaction with body image was measured using the Multidimensional Body-Self Relations Questionnaire (MBSRQ) developed by Cash et al.[35]. This scale covers 10 dimensions and 67 items, assessing body image in individuals aged 15 and older. Each item is rated on a scale from 1 (very dissatisfied) to 5 (very satisfied). The Chinese version of the questionnaire, translated and validated by Wang et al.[36], has shown good reliability and validity. The subscale for satisfaction with body areas includes 9 items, such as "How satisfied are you with your height?" and "How satisfied are you with your upper torso (chest or breasts, shoulders, and arms)?". This study used the subscale for satisfaction with body areas, summing the scores of the 9 items, with higher scores indicating greater satisfaction. In this study, the Cronbach’s α coefficient for the T1 satisfaction with body areas subscale was 0.94. Disordered eating behaviors Disordered eating behaviors were measured using the Eating Attitude Test-26 (EAT-26)[37]. This scale consists of 26 items that reflect three dimensions: dieting, bulimia, and oral control. Each item is rated on a 6-point Likert scale, from 0 (never) to 5 (always), reflecting the frequency of the behavior. The scores are converted from a 6-point scale to a 4-point scale[38]. The total score is obtained by summing all item scores, with higher scores indicating more severe disordered eating. The Chinese version of the scale has demonstrated good reliability and validity[38, 39]. In this study, the Cronbach’s α coefficient for the EAT-26 at T1 and T2 was 0.91 and 0.93, respectively. Anxiety symptoms Anxiety symptoms were measured using the 7-item Generalized Anxiety Disorder module (GAD-7)[40]. This scale consists of 7 items that reflect the core anxiety symptoms experienced by the participants in the past two weeks. Each item is rated on a 4-point scale (0-3), reflecting the frequency of the symptoms. This scale is widely used across various populations. In this study, the Cronbach’s α coefficient for the GAD-7 at T1 and T2 was 0.93 and 0.94, respectively. Depressive symptoms Depressive symptoms were measured using the widely used Patient Health Questionnaire-9 (PHQ-9)[41]. This scale consists of 9 items that reflect the core depressive symptoms experienced by the individual in the past two weeks. Each item is rated on a 4-point scale (0-3), with the total score ranging from 0 to 27. Higher scores indicate more severe depressive symptoms. The questionnaire has demonstrated good reliability and validity in Chinese populations [42]. In this study, the Cronbach’s α coefficient for the PHQ-9 at T1 and T2 were 0.92. Covariates Basic demographic information was collected, including age, gender (male/female), ethnicity (Han/Tibetan and other ethnic minorities), family economic status, and parental marital status. Family economic status was self-perceived by the participants as very good or good / average / difficult or very difficult. Parental marital status options included harmonious, occasional quarrels, frequent quarrels, separation, divorce, or other. Statistical analysis Data analysis was conducted using SPSS 23.0 (IBM, Armonk, NY, USA). Qualitative data were described using composition ratios (%), and quantitative data were described using means ± standard deviations (x̅ ± SD). Differences between groups were analyzed using t-tests or analysis of variance (ANOVA). Pearson correlation analysis was used to examine the associations between different variables. The mediating role of T2 anxiety and depression in the relationship between T1 body image and T2 DEBs was explored using model 6 in the PROCESS 3.3 plugin[43]; The moderating role of ethnicity in the multiple serial mediation analysis was examined using model 85. A 95% confidence interval was calculated based on the bootstrap method (5000 bootstrap samples). Direct effects and indirect effects were calculated, and different indirect effects were compared. All models controlled for gender, age, family economic status, parental marital status, T1 anxiety, T1 depression, and T1 DEBs. All p-values in the study were two-tailed, with p < 0.05 indicating statistical significance. Results Descriptive analysis A total of 2993 participants completed both the initial and follow-up surveys, with an average age of 19.8 years (SD = 1.3). Among the participants, 34.3% were male, and 65.7% were female. Han Chinese comprised 43.2% of the students, while Tibetan and other ethnic minorities made up 56.8%. Regarding family economic status, 52.5% of the participants reported it as average, and 31.2% reported it as poor or very poor. For parental marital status, 57.5% of the participants reported a harmonious relationship, while 3.0% reported frequent quarrels. The results showed significant differences in DEBs scores across gender ( t = -2.41, p = 0.02), ethnicity ( t = 6.36, p < 0.001), and parental marital status ( F = 4.28, p < 0.001), as shown in Table 1. Correlational Analyses The correlations among the study variables are shown in Table 2. DEBs scores were significantly negatively correlated with body image satisfaction ( r = -0.166, p < 0.001) and ethnicity ( r = -0.117, p < 0.001), and significantly positively correlated with anxiety ( r = 0.359, p < 0.001) and depression ( r = 0.384, p < 0.001). Body image satisfaction was significantly positively correlated with ethnicity ( r = 0.049, p < 0.001) and significantly negatively correlated with anxiety ( r = -0.210, p < 0.001) and depressive symptoms ( r = -0.210, p < 0.001). Anxiety symptoms were positively correlated with depressive symptoms ( r = 0.825, p < 0.001) and significantly negatively correlated with ethnicity ( r = -0.083, p < 0.001). Depressive symptoms were significantly negatively correlated with ethnicity ( r = -0.064, p < 0.001). Serial multiple mediating analysis Serial multiple mediation analysis was conducted using model 6 in the PROCESS plugin for SPSS. All models controlled for gender, age, ethnicity, family economic status, parental marital status, T1 anxiety, T1 depressive symptoms, and T1 DEBs. The results showed that T1 body image satisfaction significantly negatively predicted T2 DEBs ( β = -0.031, 95% CI = -0.061~-0.001). The serial multiple mediation model included three indirect effects. First, T1 body image satisfaction negatively predicted T2 anxiety symptoms (a 1 = -0.063, 95% CI = -0.081~-0.044), which in turn positively predicted T2 DEBs (b 1 = 0.125, 95% CI = 0.033~0.217). The indirect effect of body image satisfaction on DEBs through anxiety symptoms was significant (a 1 b 1 = -0.008, 95% CI = -0.015~-0.001), indicating that anxiety symptoms mediated the relationship between body image satisfaction and DEBs. Second, T1 body image satisfaction negatively predicted T2 depressive symptoms (a 2 = -0.018, 95% CI = -0.032~-0.003), which in turn positively predicted T2 DEBs (b 2 = 0.299, 95% CI = 0.2200.378). The indirect effect of body image satisfaction on DEBs through depressive symptoms was significant (a 2 b 2 = -0.005, 95% CI = -0.010~-0.001), indicating that depressive symptoms mediated the relationship between body image satisfaction and DEBs. Third, T2 anxiety symptoms positively predicted depressive symptoms (d = 0.889, 95% CI = 0.862~0.916), and the serial indirect effect of T1 body image satisfaction on T2 DEBs through T2 anxiety and depressive symptoms was significant (a 1 db 2 = -0.017, 95% CI = -0.026~-0.009). This indicates that the relationship between body image satisfaction and DEBs was sequentially mediated by anxiety and depressive symptoms. See Figure 1 and Table 3. Moderated mediation analyzes The moderated mediation analysis (Table 4) showed that the interaction between ethnicity and body image satisfaction did not significantly predict anxiety and depressive symptoms. However, the interaction between ethnicity and body image satisfaction significantly predicted DEBs (ethnicity*body image satisfaction: β = -0.061, p = 0.047), indicating that ethnicity moderated the predictive effect of body image satisfaction on DEBs. Further simple slope analysis showed that body image satisfaction did not significantly predict DEBs among Han Chinese, but it significantly predicted DEBs among Tibetans and other ethnic minorities ( β simple = -0.118, p < 0.001). See Table 5 and Figure 2 for details. Discussion The current study employed short-term longitudinal survey data from university students in Tibet to investigate the direct and indirect effects of body image on DEBs, as well as the potential moderating role of ethnicity. The results indicated that anxiety and depression independently and sequentially mediated the relationship between body image and DEBs, with the sequential mediation effect being greater than the other two single mediation effects. Additionally, ethnicity moderated the direct relationship between body image and DEBs. Specifically, body image significantly predicted DEBs among Tibetan students but not among Han Chinese students. This study demonstrates that body image significantly predicts DEBs among university students in Tibet. This finding is consistent with previous research based on other countries or ethnic groups. Research has found a strong correlation between negative body image and maladaptive eating behaviors, as well as between positive body image and adaptive eating behaviors, indicating a close relationship between body image and DEBs[44]. A systematic review of 46 studies showed that, although there is not sufficient evidence to support a causal relationship between body image disturbance and anorexia nervosa (a type of EDs), evidence suggests that body image disturbance may be related to the course of anorexia nervosa. This review suggests that more experimental and longitudinal studies are needed to elucidate the complex relationships between body image and various symptoms of EDs[45]. The mechanisms by which body image affects EDs are not well-known. The Cognitive-Behavioral Theories of EDs proposed by Williamson et al. offer some explanations[46]. This model hypothesizes that certain types of stimuli (e.g., information related to the body and behavior) may activate an individual's body self-schema, further triggering cognitive biases. These cognitive biases, such as excessive focus on body size/shape, interact with negative emotions and maladaptive eating behaviors, leading to symptoms of EDs like restrictive eating, laxative abuse, and self-induced vomiting. These symptoms may serve as compensation or escape from negative emotions. From a more positive perspective, the Attuned Representational Model of Self, combined with the concept of flourishing in the context of body image and eating behaviors, suggests that fostering a positive body image through attunement and mindful self-care can be a viable treatment approach for individuals with EDs [47]. This study found that anxiety symptoms mediated the relationship between body image and DEBs. A longitudinal study by Anna Vannucci et al. on adolescents revealed that baseline body image dissatisfaction significantly predicted symptoms of generalized anxiety disorder, social anxiety disorder, and school avoidance, and might be closely related to the developmental trajectories of specific anxiety disorders[48]. This relationship can be explained based on sociocultural theory, where societal ideals of body image and appearance comparisons may be internalized, causing pressure. Students dissatisfied with their body image may develop anxiety or avoidance behaviors. Further, anxiety symptoms are associated with DEBs, demonstrating their mediating role. In fact, the mediating role of more specific types of anxiety has also been confirmed. For instance, Manuel et al. found that appearance comparison was related to disordered eating through social physique anxiety[49]. A study from Turkey confirmed that social physique anxiety fully mediated the relationship between body image and orthorexia nervosa[50]. Similarly, previous studies have reported the mediating role of depression in the relationship between body image and DEBs. For instance, research on Chinese university students has shown that body dissatisfaction is positively correlated with disordered eating (including dieting, emotional eating, and external eating), with this relationship being mediated by depression and smartphone addiction[28]. Studies by Soledad and Brechan have also confirmed the mediating role of depression in the relationship between body dissatisfaction and disordered eating[7, 29]. This study further validates that body image can predict DEBs and that depression mediates this relationship. It is evident that anxiety and depression symptoms, as direct adverse outcomes of body dissatisfaction, play an important role in the process by which body image dissatisfaction leads to DEBs. Moreover, individuals with anxiety are often at a higher risk of developing depression[51]. This study also explored the serial mediation role of anxiety and depression in the relationship between body image and DEBs, finding that this combined mediation effect was significantly greater than the two individual mediation effects. Our results support the notion that anxiety and depression are significant components in how body image influences DEBs, providing valuable evidence for current theories. Additionally, this study found that ethnicity moderates the relationship between body image and DEBs. Specifically, body image satisfaction is significantly negatively correlated with DEBs among Tibetan and other ethnic minority students compared to Han Chinese students. This is a significant finding that underscores the ethnic differences in the impact of body image on DEBs, suggesting that DEBs are more influenced by body image among Tibetan populations. A plausible explanation may relate to self-awareness, which could be positively correlated with body image satisfaction, and Tibetan students seem to have lower levels of self-awareness[52, 53]. Public health significance Previous research on eating disorders and body image has primarily focused on Western countries, with studies in China only emerging in recent years. Research involving ethnic minorities, including Tibetans, is particularly scarce. This study provides a valuable theoretical foundation and practical guidance for the field. Firstly, there is an urgent need for educational campaigns promoting healthy eating and nutritional concepts among university students. It is encouraging that the Chinese Nutrition Society has designated the third week of May as "National Nutrition Week" mobilizing societal efforts to promote dietary nutrition education among residents[54]. Pragmatic activities targeting specific populations, ethnic groups, and regions (such as the Qinghai-Tibet Plateau) should be further developed. Secondly, to improve psychological health issues like body image among university students, it is necessary for schools and relevant educational departments to implement targeted programs. Additionally, fostering a healthy aesthetic standard across society is crucial. Effective measures have already been initiated at the national level. In July 2024, the Chinese National Health Commission and other departments jointly announced the "Year of Weight Management" campaign, urging widespread participation and activities within schools. The campaign provided the public with essential knowledge about maintaining a healthy weight and the potential harms of extreme dieting, low-carbohydrate diets (avoiding staple foods), and ketogenic diets[55]. This offers a solid policy basis and action framework for enhancing the awareness of healthy body image among students and other related populations. Thirdly, when developing health intervention programs for eating disorders and body dissatisfaction, it is important to consider the significant impact of negative emotions, including anxiety and depression, as well as behavioral issues like smartphone addiction, to improve prevention or treatment outcomes. Finally, this study is the first to explore ethnic differences, and more in-depth research is needed to understand the underlying mechanisms. Nonetheless, ethnic identity should be considered a variable in any program aimed at preventing and treating eating disorders through body image satisfaction, to avoid overlooking ethnicity-related influencing factors. Limitations and Future Directions This study is not without limitations. Firstly, our research focused solely on university students. It is necessary to conduct studies on other age groups (such as adolescents) or specific populations (such as community and clinical populations). Additionally, while we focused on differences between Han and Tibetan ethnic groups, China is a country with 56 ethnic groups, and future research should include a broader range of ethnic minorities. Secondly, we used self-report questionnaires to collect data, which may be influenced by subjective factors. Future studies should incorporate more objective measurement indicators to improve accuracy. Thirdly, although we employed a longitudinal design to address the limitations of cross-sectional studies, this study included only a baseline and one follow-up, necessitating more follow-up studies to enhance causal inference. Finally, we did not consider other variables that may influence body image and disordered eating behaviors, such as internet use, self-esteem, and other potential factors. Conclusion This study provides empirical evidence for the pathways through which body image affects DEBs among Chinese university students. It elucidates the independent and combined mediating roles of anxiety and depression in the relationship between body image and DEBs, with the combined effect being greater than the individual mediation effects. Additionally, we found ethnic differences (Tibetan vs. Han) in the effect of body image on DEBs, highlighting the importance of ethnic or cultural background. Interventions aimed at improving body image satisfaction to address DEBs could benefit from strategies targeting the prevention and treatment of negative emotions. Future longitudinal and multi-ethnic studies are needed to provide stronger evidence on the mechanisms through which body image affects DEBs and potential ethnic differences. Abbreviations DEBs Disordered eating behaviors EDs Eating disorders Declarations Acknowledgements We would like to express our appreciation to all the study participants. Author statement contributions Conception and design of the paper: RW, SW, CL; data collection: XY, MZ, YW; statistical analysis: XC, ZG, QN; drafting manuscript: RW, YH; Supervision: SW, CL; interpretation of findings: RW, MZ, YW; revisions of the manuscript: XY, ZG, QN. All authors read and approved the final manuscript. Funding This work was supported by Scientific research plan projects of Shaanxi province Education Department [Grant No.22JK0205]; Project of Center for Collaborative Innovation in the Heritage and Development of Xizang Culture [XT-ZB202311]; Xizang Autonomous Region Higher Education Teaching Reform Project [JG2023-53]; Xizang Autonomous Region Student Innovation and Entrepreneurship Training Program [Grant No. s202410695093]; Shenzhen Science and Technology Program [Grant No. JCYJ20220531091212028]; Natural Science Foundation of Xizang Autonomous Region [Grant No.XZ202201ZR0055G]. Availability of data and materials The raw data supporting the conclusions of this article are available through the Xizang Minzu University. Contact Ruipeng Wu ( [email protected] ) for access approval. Competing interests The authors declare that they have no competing interests. Ethics approval and consent to participate The studies involving human participants were reviewed and approved by Xizang Minzu University. The participants provided their written informed consent to participate in this study. Consent for publication Not applicable. Author details 1 Key Laboratory for Molecular Genetic Mechanisms and Intervention Research On High Altitude Disease of Tibet Autonomous Region, School of Medicine, Xizang Minzu University, 712082 Xianyang, People’s Republic of China. 2 Clinical Medical Research Centre for Plateau Gastroenterological Disease of Xizang Autonomous Region, Xizang Minzu University, 712082 Xianyang, People’s Republic of China. 3 Key Laboratory of Environmental Medicine and Engineering of Ministry of Education, Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, 210009 Nanjing, People’s Republic of China. 4 Key Laboratory of High Altitude Hypoxia Environment and Life Health, School of Medicine, Xizang Minzu University, 712082 Xianyang, People’s Republic of China. 5 School of Public Health and Emergency Management, Southern University of Science and Technology, 510515 Shenzhen, Guangdong, China. 6 School of Marine Law and Humanities, Dalian Ocean University, 116023 Dalian, Liaoning, China. 7 Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-Sen University, 510080 Guangzhou, People’s Republic of China. 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The role of depression and anxiety in the relationship between poor sleep quality and subjective cognitive decline in Chinese elderly: Exploring parallel, serial, and moderated mediation. Journal of Affective Disorders. 2021;294:464–71. Hayes AF. Introduction to Mediation, Moderation, and Conditional Process Analysis, Second Edition: A Regression-Based Approach. Guilford Publications; 2017. Jackson AM, Parker L, Sano Y, Cox AE, Lanigan J. Associations between body image, eating behavior, and diet quality. Nutr Health. 2024;30:93–102. Glashouwer KA, van der Veer RML, Adipatria F, de Jong PJ, Vocks S. The role of body image disturbance in the onset, maintenance, and relapse of anorexia nervosa: A systematic review. Clin Psychol Rev. 2019;74:101771. Williamson DA, White MA, York-Crowe E, Stewart TM. Cognitive-behavioral theories of eating disorders. Behav Modif. 2004;28:711–38. Cook-Cottone CP. Incorporating positive body image into the treatment of eating disorders: A model for attunement and mindful self-care. Body Image. 2015;14:158–67. Vannucci A, Ohannessian CM. Body Image Dissatisfaction and Anxiety Trajectories During Adolescence. J Clin Child Adolesc Psychol. 2018;47:785–95. Alcaraz-Ibáñez M, Sicilia Á, Díez-Fernández DM, Paterna A. Physical appearance comparisons and symptoms of disordered eating: The mediating role of social physique anxiety in Spanish adolescents. Body Image. 2020;32:145–9. Uskun E, Batmaz K, Albayrak G, Develi M, Kişioğlu AN, Önal Ö. The Mediator Role of Social Physique Anxiety on Body Image and Orthorexia among Adult Women in a Province in the Mediterranean Region of Turkey. JBACHS. 2024;8:129–36. Kalin NH. The Critical Relationship Between Anxiety and Depression. AJP. 2020;177:365–7. Mert A, Kahraman M. Body Satisfaction and Well-Being Status as Predictors of Conscious Awareness. BUEFAD. 2019;8:645–65. Chang X, Shi J, Ma D. An analysis of the relationship between self-Awareness and coping styles among Tibetan middle school students in Shanghai. Chinese School Health. 2013;34:666–9. National Nutrition Week. https://www.cnsoc.org/background/. Accessed 16 Jul 2024. Transcript of the National Health Commission Press Conference on June 26, 2024. http://www.nhc.gov.cn/xcs/s3574/202406/aacac538c9fa48788747d2894274e430.shtml. Accessed 16 Jul 2024. Tables Tables 1 to 5 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Published Journal Publication published 13 Apr, 2026 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Revision requested 25 Jul, 2024 Editor assigned by journal 23 Jul, 2024 Submission checks completed at journal 23 Jul, 2024 First submitted to journal 23 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4786119","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":331657896,"identity":"aed961b4-e97b-4e3d-96f2-a4e57942afe4","order_by":0,"name":"Ruipeng Wu","email":"","orcid":"","institution":"Xizang Minzu University","correspondingAuthor":false,"prefix":"","firstName":"Ruipeng","middleName":"","lastName":"Wu","suffix":""},{"id":331657897,"identity":"d57ef31f-0f6b-4eef-83bf-7e45d8debd0e","order_by":1,"name":"Yeen Huang","email":"","orcid":"","institution":"Southern University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Yeen","middleName":"","lastName":"Huang","suffix":""},{"id":331657898,"identity":"0dc4fed5-acd3-46b9-9628-ffad9d18cfda","order_by":2,"name":"Xinya Yan","email":"","orcid":"","institution":"Dalian Ocean University","correspondingAuthor":false,"prefix":"","firstName":"Xinya","middleName":"","lastName":"Yan","suffix":""},{"id":331657899,"identity":"dd0ff187-f868-4860-92a5-abdcb8cae137","order_by":3,"name":"Yingting Wang","email":"","orcid":"","institution":"Xizang Minzu University","correspondingAuthor":false,"prefix":"","firstName":"Yingting","middleName":"","lastName":"Wang","suffix":""},{"id":331657900,"identity":"0945773c-d6e9-4e2d-8b78-dd60e0b0ade9","order_by":4,"name":"Minxia Zhu","email":"","orcid":"","institution":"Xizang Minzu University","correspondingAuthor":false,"prefix":"","firstName":"Minxia","middleName":"","lastName":"Zhu","suffix":""},{"id":331657901,"identity":"5a3e6122-b76c-439c-9f1a-bf3e2b9e258b","order_by":5,"name":"Xiangjun Chen","email":"","orcid":"","institution":"Xizang Minzu University","correspondingAuthor":false,"prefix":"","firstName":"Xiangjun","middleName":"","lastName":"Chen","suffix":""},{"id":331657902,"identity":"fdf05c93-29f2-4d5b-948c-962aa758c295","order_by":6,"name":"Zixuan Guang","email":"","orcid":"","institution":"Xizang Minzu University","correspondingAuthor":false,"prefix":"","firstName":"Zixuan","middleName":"","lastName":"Guang","suffix":""},{"id":331657903,"identity":"934bdb64-21b0-416c-b95a-c60bf4725dd4","order_by":7,"name":"Qiong Niu","email":"","orcid":"","institution":"Xizang Minzu University","correspondingAuthor":false,"prefix":"","firstName":"Qiong","middleName":"","lastName":"Niu","suffix":""},{"id":331657904,"identity":"b6a54f17-c253-4f40-9fd0-866ed7db426d","order_by":8,"name":"Ciyong Lu","email":"","orcid":"","institution":"Sun Yat-Sen University","correspondingAuthor":false,"prefix":"","firstName":"Ciyong","middleName":"","lastName":"Lu","suffix":""},{"id":331657905,"identity":"3f24b211-5c8e-483c-81ff-c36dbd63183d","order_by":9,"name":"Shaokang Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYDACCQYGxgYY5wOEMiBeC+MMkrUw8xCjRX5288OHM2ru2G04fvbwa5s/NokN7M3bJBhq7uDUYnDnmLHhhmPPkjecyUuzzm1LS2zgOVYmwXDsGW4tEglmkg/YDiebHcgxM85tOJzYIJFjJsHYcBi3w2akf5N88A+o5fwbM2OLP/8TG+Tf4NfCcCPHTHJj22E7sxs5xo8Z2A4AbeHBr8XgRk6x4cy+wwn2N96YMfa2JRu38aQVWyQcw+uwjQ97vh22l+zPMf7w44+dbD/74Y03PtTgcRgUJDYwMLBJgFhsICKBoAYGBnsgZv5AhMJRMApGwSgYgQAA5dtceoFZiv4AAAAASUVORK5CYII=","orcid":"","institution":"Xizang Minzu University","correspondingAuthor":true,"prefix":"","firstName":"Shaokang","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2024-07-23 06:30:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4786119/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4786119/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-026-08070-5","type":"published","date":"2026-04-13T15:56:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63314255,"identity":"666b1bd7-d745-43c9-bd64-e0a09a858a39","added_by":"auto","created_at":"2024-08-26 21:07:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":48989,"visible":true,"origin":"","legend":"\u003cp\u003eSerial multiple mediation model from body image satisfaction to DEBs and in which ethnicity moderate the relation of body image to DEBs.\u003csup\u003e ***\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001，\u003csup\u003e**\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026lt;0.01，\u003csup\u003e*\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05. DEBs, disordered eating behaviors/attitudes.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4786119/v1/e4c44db45a03a9d0697c5701.png"},{"id":63314256,"identity":"df2a51b0-e318-43c7-a23c-0bd8b433a265","added_by":"auto","created_at":"2024-08-26 21:07:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":19332,"visible":true,"origin":"","legend":"\u003cp\u003eThe moderating role of ethnicity in the relationship between body image satisfaction and DEBs.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4786119/v1/30a65e8a542b1e024673a9e4.png"},{"id":107350719,"identity":"2f61ed76-6555-46bc-ac04-c4300b24a150","added_by":"auto","created_at":"2026-04-20 16:01:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":410719,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4786119/v1/00ff8d72-264b-4f39-9bce-28009cec4c38.pdf"},{"id":63314254,"identity":"354691c7-1670-45bf-8cf5-9d27833b91ae","added_by":"auto","created_at":"2024-08-26 21:07:42","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":33366,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-4786119/v1/1f000dfb2636edd15f88330b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The role of anxiety and depressive symptoms in the longitudinal relationship between body image and disordered eating behaviors among Tibetan young adults: a moderating serial mediation model","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBody image refers to an individual's perception or attitude towards their own body or appearance. More specifically, it encompasses a person's level of satisfaction with, importance placed on, or treatment of their body[1, 2]. Body image is crucial for behavioral and emotional health[3]. In contemporary society, body image is shaped through various micro-level social interactions[4]. Particularly among modern college students, the management of their bodies is increasingly influenced by external evaluations. The pursuit of bodily ideals, especially the \"ideal thin\" body, is prevalent among this group. Additionally, the accessibility of vast amounts of information has heightened their sensitivity to body image[4]. According to surveys, up to 70% of college students have engaged in dieting behaviors in pursuit of an ideal body[5]. This excessive pursuit of an ideal body and dissatisfaction with one's own image have become catalysts for \"psychological weight gain\" leading to potential psychological burdens[4, 6]. Negative body image can be closely associated with poor mental and physical health outcomes such as low self-esteem, anxiety, depression, and eating disorders (EDs)[7, 8].\u003c/p\u003e\n\u003cp\u003eDisordered Eating Behaviors (DEBs) refer to a range of eating-related problems, including unhealthy weight control behaviors or binge eating, such as dieting, food restriction, and vomiting[9]. These behaviors can increase the risk of clinically diagnosed EDs. A distorted body image and body dissatisfaction can elevate the risk of DEBs. For example, Karime et al. found that body dissatisfaction was a major factor related to the development of DEBs through a six-year observation of university students in Mexico[10]. Other studies, both domestic and international, focusing on adolescents and young adults, indicate that body image issues are potential predictors of eating disorders[11, 12]. DEBs are particularly prevalent among university students. For instance, the prevalence of DEBs among Mexican university students ranges from 25.0% to 38.3%, with potential differences across gender and weight groups\u0026nbsp;[10, 13]. In the United States, the prevalence of DEBs among 18-year-old university students is 31.0%[14]. Another cross-cultural study showed that Chinese university students (16.7%) have a relatively lower prevalence of DEBs compared to international students (29.9%)[15]. Given the high prevalence of DEBs among young people and the significant impact of body image on DEBs, elucidating the potential intermediary mechanisms between the two is crucial for preventing negative body image, DEBs, and EDs.\u003c/p\u003e\n\u003cp\u003eBody image dissatisfaction, as a proximal factor for DEBs, can not only directly lead to various DEBs (such as dieting) but also may be mediated by a range of negative emotions or behaviors. On one hand, negative emotions such as anxiety have repeatedly been linked to EDs (including anorexia nervosa, bulimia nervosa, and binge eating) and DEBs[16–18]. Depression is one of the most direct psychological factors leading to DEBs[19]. Research suggests that dieting or binge eating behaviors triggered by depressive emotions may be a way to alleviate negative emotions or escape negative self-perceptions[20]. On the other hand, body image dissatisfaction can directly or indirectly lead to the occurrence of negative emotions. Studies show that body image dissatisfaction may increase the risk of generalized anxiety, social anxiety, and appearance-related anxiety[8, 21, 22]. The cognitive model of depression posits that negative self-evaluation is central to the development of depression[23]. This negative self-evaluation includes evaluations of one's body. Studies in different populations show that the lower the body satisfaction, the more severe the depressive symptoms[24–26]. Additionally, there is a high comorbidity between anxiety and depression[27]. Therefore, it is reasonable to speculate that anxiety and depression independently and jointly mediate the relationship between body image and DEBs. In fact, similar studies have confirmed the existence of complex paths, such as independent or joint mediation by self-esteem, smartphone addiction, and negative emotions, in the relationship between body image and DEBs[7, 28, 29]. However, most previous studies are cross-sectional and lack the ability to determine causality. Longitudinal studies exploring the roles of anxiety and depression in the relationship between body image and DEBs are thus necessary.\u003c/p\u003e\n\u003cp\u003eAdditionally, research both domestically and internationally indicates significant ethnic and cultural differences in eating disorders and negative emotions[30–32]. For instance, a dietary survey of different ethnic groups in western China found that Han, Tibetan, Mongolian, and Hui ethnic groups exhibit distinct dietary patterns[33]. The prevalence of anxiety and depression among ethnic minorities in western China is significantly higher than that of the Han population, although this study did not include the Tibetan population[34]. Tibet, located in the southwestern region of China, has unique geographical features, historical development, and cultural background, characterized by its high altitude (with an average elevation exceeding 4000 meters), low air pressure, and low temperatures. The dietary habits of Tibetans differ significantly from those of the Han residents in the local or other regions of China. For example, Tibetans prefer tsampa and yak or mutton, and they enjoy drinking butter tea, barley wine, and dairy products. An early study showed that Tibetan adolescents in Tibet have body image perceptions different from those in the West\u0026nbsp;[32]. Different ethnic customs and cultural differences may influence body image evaluation, thereby affecting their DEBs, anxiety, and depression. Currently, there is no research on this topic. Therefore, it is worth further exploring whether ethnic factors moderate the direct and indirect effects of body image on DEBs.\u003c/p\u003e\n\u003cp\u003eIn summary, the purpose of this study is to investigate the predictive role of body image on DEBs using a longitudinal design and to explore the possible mediating and moderating mechanisms in this relationship. We hypothesize that: 1) anxiety or depression independently mediates the relationship between body image and DEBs, 2) a sequence of anxiety and depression mediates this relationship, and 3) ethnicity may play a moderating role in the aforementioned processes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study selected two universities affiliated with Tibet, targeting first- and second-year students as participants. The initial survey was conducted in September 2021, with a follow-up survey in December of the same year. Prior to the survey, student management personnel from both universities were contacted to convene student council members and class leaders for extensive promotion. They, in turn, informed the students in their respective classes about the purpose, significance, and precautions of the survey. The survey was conducted using a combination of centralized and individual approaches. Students were gathered in classrooms, where class leaders distributed pre-made questionnaire QR codes to the class group. All students completed the questionnaire by scanning the QR code. Those who were absent due to other commitments were later contacted by the class leaders to complete the questionnaire. All participants were informed that participation was voluntary and that they could withdraw at any time. Any questions during the questionnaire completion could be directed to trained surveyors present on-site. Excluding invalid questionnaires, a total of 2993 students completed both the initial and follow-up surveys.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBody image\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe satisfaction with body image was measured using the Multidimensional Body-Self Relations Questionnaire (MBSRQ) developed by Cash et al.[35]. This scale covers 10 dimensions and 67 items, assessing body image in individuals aged 15 and older. Each item is rated on a scale from 1 (very dissatisfied) to 5 (very satisfied). The Chinese version of the questionnaire, translated and validated by Wang et al.[36], has shown good reliability and validity. The subscale for satisfaction with body areas includes 9 items, such as \"How satisfied are you with your height?\" and \"How satisfied are you with your upper torso (chest or breasts, shoulders, and arms)?\". This study used the subscale for satisfaction with body areas, summing the scores of the 9 items, with higher scores indicating greater satisfaction. In this study, the Cronbach’s α coefficient for the T1 satisfaction with body areas subscale was 0.94.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisordered eating behaviors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDisordered eating behaviors were measured using the Eating Attitude Test-26 (EAT-26)[37]. This scale consists of 26 items that reflect three dimensions: dieting, bulimia, and oral control. Each item is rated on a 6-point Likert scale, from 0 (never) to 5 (always), reflecting the frequency of the behavior. The scores are converted from a 6-point scale to a 4-point scale[38]. The total score is obtained by summing all item scores, with higher scores indicating more severe disordered eating. The Chinese version of the scale has demonstrated good reliability and validity[38, 39]. In this study, the Cronbach’s α coefficient for the EAT-26 at T1 and T2 was 0.91 and 0.93, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnxiety symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnxiety symptoms were measured using the 7-item Generalized Anxiety Disorder module (GAD-7)[40]. This scale consists of 7 items that reflect the core anxiety symptoms experienced by the participants in the past two weeks. Each item is rated on a 4-point scale (0-3), reflecting the frequency of the symptoms. This scale is widely used across various populations. In this study, the Cronbach’s α coefficient for the GAD-7 at T1 and T2 was 0.93 and 0.94, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDepressive symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepressive symptoms were measured using the widely used Patient Health Questionnaire-9 (PHQ-9)[41]. This scale consists of 9 items that reflect the core depressive symptoms experienced by the individual in the past two weeks. Each item is rated on a 4-point scale (0-3), with the total score ranging from 0 to 27. Higher scores indicate more severe depressive symptoms. The questionnaire has demonstrated good reliability and validity in Chinese populations\u0026nbsp;[42]. In this study, the Cronbach’s α coefficient for the PHQ-9 at T1 and T2 were 0.92.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCovariates\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBasic demographic information was collected, including age, gender (male/female), ethnicity (Han/Tibetan and other ethnic minorities), family economic status, and parental marital status. Family economic status was self-perceived by the participants as very good or good / average / difficult or very difficult. Parental marital status options included harmonious, occasional quarrels, frequent quarrels, separation, divorce, or other.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analysis was conducted using SPSS 23.0 (IBM, Armonk, NY, USA). Qualitative data were described using composition ratios (%), and quantitative data were described using means ± standard deviations (x̅ ± SD). Differences between groups were analyzed using t-tests or analysis of variance (ANOVA). Pearson correlation analysis was used to examine the associations between different variables. The mediating role of T2 anxiety and depression in the relationship between T1 body image and T2 DEBs was explored using model 6 in the PROCESS 3.3 plugin[43]; The moderating role of ethnicity in the multiple serial mediation analysis was examined using model 85. A 95% confidence interval was calculated based on the bootstrap method (5000 bootstrap samples). Direct effects and indirect effects were calculated, and different indirect effects were compared. All models controlled for gender, age, family economic status, parental marital status, T1 anxiety, T1 depression, and T1 DEBs. All p-values in the study were two-tailed, with \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05 indicating statistical significance.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDescriptive analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 2993 participants completed both the initial and follow-up surveys, with an average age of 19.8 years (SD = 1.3). Among the participants, 34.3% were male, and 65.7% were female. Han Chinese comprised 43.2% of the students, while Tibetan and other ethnic minorities made up 56.8%. Regarding family economic status, 52.5% of the participants reported it as average, and 31.2% reported it as poor or very poor. For parental marital status, 57.5% of the participants reported a harmonious relationship, while 3.0% reported frequent quarrels. The results showed significant differences in DEBs scores across gender (\u003cem\u003et\u003c/em\u003e = -2.41, \u003cem\u003ep\u003c/em\u003e = 0.02), ethnicity (\u003cem\u003et\u0026nbsp;\u003c/em\u003e= 6.36, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), and parental marital status (\u003cem\u003eF\u003c/em\u003e = 4.28, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), as shown in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelational Analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe correlations among the study variables are shown in Table 2. DEBs scores were significantly negatively correlated with body image satisfaction (\u003cem\u003er\u0026nbsp;\u003c/em\u003e= -0.166, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) and ethnicity (\u003cem\u003er\u003c/em\u003e = -0.117, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), and significantly positively correlated with anxiety (\u003cem\u003er\u003c/em\u003e = 0.359, p \u0026lt; 0.001) and depression (\u003cem\u003er\u003c/em\u003e = 0.384, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001). Body image satisfaction was significantly positively correlated with ethnicity (\u003cem\u003er\u003c/em\u003e = 0.049, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) and significantly negatively correlated with anxiety (\u003cem\u003er\u003c/em\u003e = -0.210, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) and depressive symptoms (\u003cem\u003er\u003c/em\u003e = -0.210, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). Anxiety symptoms were positively correlated with depressive symptoms (\u003cem\u003er\u003c/em\u003e = 0.825, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) and significantly negatively correlated with ethnicity (\u003cem\u003er\u003c/em\u003e = -0.083, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). Depressive symptoms were significantly negatively correlated with ethnicity (\u003cem\u003er\u003c/em\u003e = -0.064, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSerial multiple mediating analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSerial multiple mediation analysis was conducted using model 6 in the PROCESS plugin for SPSS. All models controlled for gender, age, ethnicity, family economic status, parental marital status, T1 anxiety, T1 depressive symptoms, and T1 DEBs. The results showed that T1 body image satisfaction significantly negatively predicted T2 DEBs (\u003cem\u003e\u0026beta;\u003c/em\u003e= -0.031, 95% \u003cem\u003eCI\u003c/em\u003e = -0.061~-0.001).\u003c/p\u003e\n\u003cp\u003eThe serial multiple mediation model included three indirect effects. First, T1 body image satisfaction negatively predicted T2 anxiety symptoms (a\u003csub\u003e1\u003c/sub\u003e= -0.063, 95% \u003cem\u003eCI\u003c/em\u003e = -0.081~-0.044), which in turn positively predicted T2 DEBs (b\u003csub\u003e1\u003c/sub\u003e = 0.125, 95% \u003cem\u003eCI\u003c/em\u003e = 0.033~0.217). The indirect effect of body image satisfaction on DEBs through anxiety symptoms was significant (a\u003csub\u003e1\u003c/sub\u003eb\u003csub\u003e1\u003c/sub\u003e = -0.008, 95% CI = -0.015~-0.001), indicating that anxiety symptoms mediated the relationship between body image satisfaction and DEBs. Second, T1 body image satisfaction negatively predicted T2 depressive symptoms (a\u003csub\u003e2\u003c/sub\u003e = -0.018, 95% \u003cem\u003eCI\u003c/em\u003e = -0.032~-0.003), which in turn positively predicted T2 DEBs (b\u003csub\u003e2\u003c/sub\u003e = 0.299, 95% \u003cem\u003eCI\u003c/em\u003e = 0.2200.378). The indirect effect of body image satisfaction on DEBs through depressive symptoms was significant (a\u003csub\u003e2\u003c/sub\u003eb\u003csub\u003e2\u003c/sub\u003e = -0.005, 95% CI = -0.010~-0.001), indicating that depressive symptoms mediated the relationship between body image satisfaction and DEBs. Third, T2 anxiety symptoms positively predicted depressive symptoms (d = 0.889, 95% CI = 0.862~0.916), and the serial indirect effect of T1 body image satisfaction on T2 DEBs through T2 anxiety and depressive symptoms was significant (a\u003csub\u003e1\u003c/sub\u003edb\u003csub\u003e2\u003c/sub\u003e = -0.017, 95% CI = -0.026~-0.009). This indicates that the relationship between body image satisfaction and DEBs was sequentially mediated by anxiety and depressive symptoms. See Figure 1 and Table 3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eModerated mediation analyzes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe moderated mediation analysis (Table 4) showed that the interaction between ethnicity and body image satisfaction did not significantly predict anxiety and depressive symptoms. However, the interaction between ethnicity and body image satisfaction significantly predicted DEBs (ethnicity*body image satisfaction: \u003cem\u003e\u0026beta;\u003c/em\u003e = -0.061, \u003cem\u003ep\u003c/em\u003e = 0.047), indicating that ethnicity moderated the predictive effect of body image satisfaction on DEBs. Further simple slope analysis showed that body image satisfaction did not significantly predict DEBs among Han Chinese, but it significantly predicted DEBs among Tibetans and other ethnic minorities (\u003cem\u003e\u0026beta;\u003csub\u003esimple\u003c/sub\u003e\u003c/em\u003e = -0.118, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). See Table 5 and Figure 2 for details.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current study employed short-term longitudinal survey data from university students in Tibet to investigate the direct and indirect effects of body image on DEBs, as well as the potential moderating role of ethnicity. The results indicated that anxiety and depression independently and sequentially mediated the relationship between body image and DEBs, with the sequential mediation effect being greater than the other two single mediation effects. Additionally, ethnicity moderated the direct relationship between body image and DEBs. Specifically, body image significantly predicted DEBs among Tibetan students but not among Han Chinese students.\u003c/p\u003e \u003cp\u003eThis study demonstrates that body image significantly predicts DEBs among university students in Tibet. This finding is consistent with previous research based on other countries or ethnic groups. Research has found a strong correlation between negative body image and maladaptive eating behaviors, as well as between positive body image and adaptive eating behaviors, indicating a close relationship between body image and DEBs[44]. A systematic review of 46 studies showed that, although there is not sufficient evidence to support a causal relationship between body image disturbance and anorexia nervosa (a type of EDs), evidence suggests that body image disturbance may be related to the course of anorexia nervosa. This review suggests that more experimental and longitudinal studies are needed to elucidate the complex relationships between body image and various symptoms of EDs[45]. The mechanisms by which body image affects EDs are not well-known. The Cognitive-Behavioral Theories of EDs proposed by Williamson et al. offer some explanations[46]. This model hypothesizes that certain types of stimuli (e.g., information related to the body and behavior) may activate an individual's body self-schema, further triggering cognitive biases. These cognitive biases, such as excessive focus on body size/shape, interact with negative emotions and maladaptive eating behaviors, leading to symptoms of EDs like restrictive eating, laxative abuse, and self-induced vomiting. These symptoms may serve as compensation or escape from negative emotions. From a more positive perspective, the Attuned Representational Model of Self, combined with the concept of flourishing in the context of body image and eating behaviors, suggests that fostering a positive body image through attunement and mindful self-care can be a viable treatment approach for individuals with EDs [47].\u003c/p\u003e \u003cp\u003eThis study found that anxiety symptoms mediated the relationship between body image and DEBs. A longitudinal study by Anna Vannucci et al. on adolescents revealed that baseline body image dissatisfaction significantly predicted symptoms of generalized anxiety disorder, social anxiety disorder, and school avoidance, and might be closely related to the developmental trajectories of specific anxiety disorders[48]. This relationship can be explained based on sociocultural theory, where societal ideals of body image and appearance comparisons may be internalized, causing pressure. Students dissatisfied with their body image may develop anxiety or avoidance behaviors. Further, anxiety symptoms are associated with DEBs, demonstrating their mediating role. In fact, the mediating role of more specific types of anxiety has also been confirmed. For instance, Manuel et al. found that appearance comparison was related to disordered eating through social physique anxiety[49]. A study from Turkey confirmed that social physique anxiety fully mediated the relationship between body image and orthorexia nervosa[50].\u003c/p\u003e \u003cp\u003eSimilarly, previous studies have reported the mediating role of depression in the relationship between body image and DEBs. For instance, research on Chinese university students has shown that body dissatisfaction is positively correlated with disordered eating (including dieting, emotional eating, and external eating), with this relationship being mediated by depression and smartphone addiction[28]. Studies by Soledad and Brechan have also confirmed the mediating role of depression in the relationship between body dissatisfaction and disordered eating[7, 29]. This study further validates that body image can predict DEBs and that depression mediates this relationship. It is evident that anxiety and depression symptoms, as direct adverse outcomes of body dissatisfaction, play an important role in the process by which body image dissatisfaction leads to DEBs. Moreover, individuals with anxiety are often at a higher risk of developing depression[51]. This study also explored the serial mediation role of anxiety and depression in the relationship between body image and DEBs, finding that this combined mediation effect was significantly greater than the two individual mediation effects. Our results support the notion that anxiety and depression are significant components in how body image influences DEBs, providing valuable evidence for current theories.\u003c/p\u003e \u003cp\u003eAdditionally, this study found that ethnicity moderates the relationship between body image and DEBs. Specifically, body image satisfaction is significantly negatively correlated with DEBs among Tibetan and other ethnic minority students compared to Han Chinese students. This is a significant finding that underscores the ethnic differences in the impact of body image on DEBs, suggesting that DEBs are more influenced by body image among Tibetan populations. A plausible explanation may relate to self-awareness, which could be positively correlated with body image satisfaction, and Tibetan students seem to have lower levels of self-awareness[52, 53].\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePublic health significance\u003c/h2\u003e \u003cp\u003ePrevious research on eating disorders and body image has primarily focused on Western countries, with studies in China only emerging in recent years. Research involving ethnic minorities, including Tibetans, is particularly scarce. This study provides a valuable theoretical foundation and practical guidance for the field. Firstly, there is an urgent need for educational campaigns promoting healthy eating and nutritional concepts among university students. It is encouraging that the Chinese Nutrition Society has designated the third week of May as \"National Nutrition Week\" mobilizing societal efforts to promote dietary nutrition education among residents[54]. Pragmatic activities targeting specific populations, ethnic groups, and regions (such as the Qinghai-Tibet Plateau) should be further developed. Secondly, to improve psychological health issues like body image among university students, it is necessary for schools and relevant educational departments to implement targeted programs. Additionally, fostering a healthy aesthetic standard across society is crucial. Effective measures have already been initiated at the national level. In July 2024, the Chinese National Health Commission and other departments jointly announced the \"Year of Weight Management\" campaign, urging widespread participation and activities within schools. The campaign provided the public with essential knowledge about maintaining a healthy weight and the potential harms of extreme dieting, low-carbohydrate diets (avoiding staple foods), and ketogenic diets[55]. This offers a solid policy basis and action framework for enhancing the awareness of healthy body image among students and other related populations. Thirdly, when developing health intervention programs for eating disorders and body dissatisfaction, it is important to consider the significant impact of negative emotions, including anxiety and depression, as well as behavioral issues like smartphone addiction, to improve prevention or treatment outcomes. Finally, this study is the first to explore ethnic differences, and more in-depth research is needed to understand the underlying mechanisms. Nonetheless, ethnic identity should be considered a variable in any program aimed at preventing and treating eating disorders through body image satisfaction, to avoid overlooking ethnicity-related influencing factors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e \u003cp\u003eThis study is not without limitations. Firstly, our research focused solely on university students. It is necessary to conduct studies on other age groups (such as adolescents) or specific populations (such as community and clinical populations). Additionally, while we focused on differences between Han and Tibetan ethnic groups, China is a country with 56 ethnic groups, and future research should include a broader range of ethnic minorities. Secondly, we used self-report questionnaires to collect data, which may be influenced by subjective factors. Future studies should incorporate more objective measurement indicators to improve accuracy. Thirdly, although we employed a longitudinal design to address the limitations of cross-sectional studies, this study included only a baseline and one follow-up, necessitating more follow-up studies to enhance causal inference. Finally, we did not consider other variables that may influence body image and disordered eating behaviors, such as internet use, self-esteem, and other potential factors.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides empirical evidence for the pathways through which body image affects DEBs among Chinese university students. It elucidates the independent and combined mediating roles of anxiety and depression in the relationship between body image and DEBs, with the combined effect being greater than the individual mediation effects. Additionally, we found ethnic differences (Tibetan vs. Han) in the effect of body image on DEBs, highlighting the importance of ethnic or cultural background. Interventions aimed at improving body image satisfaction to address DEBs could benefit from strategies targeting the prevention and treatment of negative emotions. Future longitudinal and multi-ethnic studies are needed to provide stronger evidence on the mechanisms through which body image affects DEBs and potential ethnic differences.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDEBs Disordered eating behaviors\u003c/p\u003e\n\u003cp\u003eEDs Eating disorders\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe would like to express our appreciation to all the study participants.\u003c/p\u003e\n\u003cp\u003eAuthor statement contributions\u003c/p\u003e\n\u003cp\u003eConception and design of the paper: RW, SW, CL; data collection: XY, MZ, YW; statistical analysis: XC, ZG, QN; drafting manuscript: RW, YH; Supervision: SW, CL; interpretation of findings: RW, MZ, YW; revisions of the manuscript: XY, ZG, QN. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis work was supported by Scientific research plan projects of Shaanxi province Education Department [Grant No.22JK0205]; Project of Center for Collaborative Innovation in the Heritage and Development of Xizang Culture [XT-ZB202311]; Xizang Autonomous Region Higher Education Teaching Reform Project [JG2023-53]; Xizang Autonomous Region Student Innovation and Entrepreneurship Training Program [Grant No. s202410695093]; Shenzhen Science and Technology Program [Grant No. JCYJ20220531091212028]; Natural Science Foundation of Xizang Autonomous Region [Grant No.XZ202201ZR0055G].\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe raw data supporting the conclusions of this article are available through the Xizang Minzu University. Contact Ruipeng Wu ( [email protected] ) for access approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe studies involving human participants were reviewed and approved by Xizang Minzu University. The participants provided their written informed consent to participate in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor details\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u0026nbsp;\u003c/sup\u003eKey Laboratory for Molecular Genetic Mechanisms and Intervention Research On High Altitude Disease of Tibet Autonomous Region, School of Medicine, Xizang Minzu University, 712082 Xianyang, People’s Republic of China.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e Clinical Medical Research Centre for Plateau Gastroenterological Disease of Xizang Autonomous Region, Xizang Minzu University, 712082 Xianyang, People’s Republic of China.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u0026nbsp;\u003c/sup\u003eKey Laboratory of Environmental Medicine and Engineering of Ministry of Education, Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, 210009 Nanjing, People’s Republic of China.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003e Key Laboratory of High Altitude Hypoxia Environment and Life Health, School of Medicine, Xizang Minzu University, 712082 Xianyang, People’s Republic of China.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e5\u003c/sup\u003e School of Public Health and Emergency Management, Southern University of Science and Technology, 510515 Shenzhen, Guangdong, China.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e6\u0026nbsp;\u003c/sup\u003eSchool of Marine Law and Humanities, Dalian Ocean University, 116023 Dalian, Liaoning, China.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e7\u003c/sup\u003e Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-Sen University, 510080 Guangzhou, People’s Republic of China.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGrogan S. 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The Mediator Role of Social Physique Anxiety on Body Image and Orthorexia among Adult Women in a Province in the Mediterranean Region of Turkey. JBACHS. 2024;8:129\u0026ndash;36.\u003c/li\u003e\n\u003cli\u003eKalin NH. The Critical Relationship Between Anxiety and Depression. AJP. 2020;177:365\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eMert A, Kahraman M. Body Satisfaction and Well-Being Status as Predictors of Conscious Awareness. BUEFAD. 2019;8:645\u0026ndash;65.\u003c/li\u003e\n\u003cli\u003eChang X, Shi J, Ma D. An analysis of the relationship between self-Awareness and coping styles among Tibetan middle school students in Shanghai. Chinese School Health. 2013;34:666\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eNational Nutrition Week. https://www.cnsoc.org/background/. Accessed 16 Jul 2024.\u003c/li\u003e\n\u003cli\u003eTranscript of the National Health Commission Press Conference on June 26, 2024. http://www.nhc.gov.cn/xcs/s3574/202406/aacac538c9fa48788747d2894274e430.shtml. Accessed 16 Jul 2024.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Body image, Disordered eating behaviors, Anxiety, Depression, Ethnicity, Longitudinal study ","lastPublishedDoi":"10.21203/rs.3.rs-4786119/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4786119/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Body image significantly impacts emotional and behavioral health. This study investigates the relationship between body image dissatisfaction and disordered eating behaviors (DEBs) among Tibetan young adults, considering the mediating roles of anxiety and depression and the moderating role of ethnicity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A longitudinal survey was conducted among 2993 first- and second-year university students in Tibet, with initial data collection in September 2021 and follow-up in December 2021. Participants completed standardized questionnaires assessing body image, anxiety, depression, and DEBs. Statistical analyses included t-tests, ANOVA, Pearson correlation, and moderated serial mediation using the PROCESS macro.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eBody image satisfaction significantly negatively predicted DEBs (\u003cem\u003eβ\u003c/em\u003e= -0.031, 95% \u003cem\u003eCI\u003c/em\u003e = -0.061~-0.001). Anxiety and depression independently and sequentially mediated this relationship (a\u003csub\u003e1\u003c/sub\u003eb\u003csub\u003e1 \u003c/sub\u003e= -0.008, 95% CI = -0.015~-0.001; a\u003csub\u003e2\u003c/sub\u003eb\u003csub\u003e2\u003c/sub\u003e = -0.005, 95% \u003cem\u003eCI\u003c/em\u003e = -0.010~-0.001; a\u003csub\u003e1\u003c/sub\u003edb\u003csub\u003e2\u003c/sub\u003e = -0.017, 95% CI = -0.026~-0.009). Ethnicity moderated the direct effect, with body image significantly predicting DEBs among Tibetan students but not Han Chinese students.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e This study highlights the critical roles of anxiety and depression in the link between body image and DEBs and the moderating effect of ethnicity. These findings suggest targeted interventions addressing body image and emotional health to mitigate DEBs, especially in ethnic minority populations.\u003c/p\u003e","manuscriptTitle":"The role of anxiety and depressive symptoms in the longitudinal relationship between body image and disordered eating behaviors among Tibetan young adults: a moderating serial mediation model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-26 21:07:37","doi":"10.21203/rs.3.rs-4786119/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-25T10:38:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-24T02:36:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-24T02:36:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2024-07-23T06:29:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"86add51d-fe91-490a-865c-bcea8f6551a4","owner":[],"postedDate":"August 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:00:26+00:00","versionOfRecord":{"articleIdentity":"rs-4786119","link":"https://doi.org/10.1186/s12888-026-08070-5","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2026-04-13 15:56:51","publishedOnDateReadable":"April 13th, 2026"},"versionCreatedAt":"2024-08-26 21:07:37","video":"","vorDoi":"10.1186/s12888-026-08070-5","vorDoiUrl":"https://doi.org/10.1186/s12888-026-08070-5","workflowStages":[]},"version":"v1","identity":"rs-4786119","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4786119","identity":"rs-4786119","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}