Can we reduce eating disorder risk factors in female college athletes? A randomized exploratory investigation of two peer-led interventions☆
Highlights
► Dissonance prevention reduced all eating disorder risk factors at six weeks. ► The healthy weight program reduced all eating disorder risk factors at six weeks. ► Dissonance reduced bulimic pathology, shape concern, and negative affect at 1-year. ► Healthy weight yielded similar results to dissonance at one year. ► Healthy weight was qualitatively better received compared to dissonance.
Introduction
Eating disorders (EDs) such as anorexia nervosa (AN) and bulimia nervosa (BN) are associated with significant increases in morbidity, medical complications (Kaplan and Woodside, 1987, Mitchell and Crow, 2006), and even mortality (Crow et al., 2009, Herzog et al., 2000). Research suggests that approximately 10% of collegiate females may meet criteria for a clinical ED (Cohen & Petrie, 2005), and approximately 50% of college women may exhibit subclinical ED symptoms such as binge-eating, purging, or other compensatory behaviors (Berg et al., 2009, Mintz and Betz, 1988). Such high prevalence rates are worrisome given that only 44% of those completing the most empirically supported treatment for BN (i.e., cognitive behavioral therapy) typically cease binge eating and purging post-treatment (Fairburn, Norman, Welch, O’Connor, Doll, & Peveler, 1995). For those with AN, treatment is even less effective (Fairburn, 2005). Due to the high prevalence of EDs and subclinical EDs as well as the often bleak prospects in treating these disorders, prevention efforts have received increased interest.
Early ED prevention programs typically consisted of psychoeducational interventions. Research, however, generally indicates that although didactic psychoeducation is effective at increasing knowledge, it is substantially less effective at reducing ED pathology (Fingeret et al., 2006, Stice and Shaw, 2004, Stice et al., 2007). ED prevention has improved, however, and one program that has garnered staunch empirical support is cognitive dissonance-based prevention (DBP: see Stice, Shaw, Becker, & Rohde, 2008). DBP utilizes the theory of cognitive dissonance, which holds that inconsistencies between behavior and beliefs will produce dissonance, and in order to reduce dissonance a change in beliefs should occur (Festinger, 1957). In DBP, participants speak and act against the thin-ideal standard of female beauty through a series of interactive activities with the aim of creating cognitive dissonance.
DBP has generated positive results in high- and mixed-risk samples, and findings have been independently replicated by a number of researchers (see Stice, Shaw, et al., 2008 for review; see also Becker et al., 2008, Becker et al., 2006, Green et al., 2005, Matusek et al., 2004). In fact, DBP has been supported to the extent that it meets the American Psychological Association's (APA) criteria for an efficacious intervention (i.e., DBP outperformed no-treatment control groups, an alternative intervention, and findings have been replicated by independent laboratories/researchers), which is rare for ED prevention programs. Promisingly, effects from DPB appear to be long lasting with reductions in ED risk factors being maintained through 2- and 3-year follow-up periods (Stice, Marti, Spoor, Presnell, & Shaw, 2008), and DBP has been shown to reduce the onset of EDs by 60% compared to an assessment only control.
Additionally, there is some support for a healthy weight prevention intervention (HWI: Stice et al., 2001, Stice et al., 2006) in adolescent girls with body dissatisfaction. In HWI, participants are encouraged to make small lifestyle changes in eating and exercise to help maintain a healthy weight. Like DBP, HWI has produced reductions in most ED risk factors (i.e., thin-ideal internalization, body dissatisfaction, negative affect, and bulimic pathology) that persist through a long-term follow-up period of three years (Stice, Marti, et al., 2008). Additionally, a peer-led modified version of HWI reduced ED risk factors in female sorority members, with reductions lasting through 14 months after the intervention (Becker, Wilson, Williams, Kelly, McDaniel, & Elmquist, 2010). At this time, initial results for HWI have now been replicated by two independent groups of researchers (Becker et al., 2010, Matusek et al., 2004).
Despite positive findings from both DBP and HWI, research is still needed in order to assess the generalizability of these interventions to other groups of females. Notably, neither intervention has been rigorously tested in female athletes. This is of concern given that females in sport may not respond to interventions in the same way as non-sport populations. Indeed, female athletes may be unusually resistant to ED prevention efforts because of entrenched ideologies inherent in the culture of sport. For instance, despite equivocal empirical support, many coaches and athletes firmly believe that weight or body fat reduction enhances performance (Thompson and Sherman, 1993, Thompson and Sherman, 2010), and some leaders in the ED sport community have concluded that it may be futile to try and directly confront this belief (Thompson, personal communication). This belief also could make successful delivery of interventions like DBP difficult if not impossible.
In addition, much of the sport world believes that it is noble to continue to compete even if one risks serious physical harm. Thus, physical health effects of EDs may be viewed as just one more acceptable cost in the pursuit of athletic excellence. The norms of an athletic community also may inadvertently legitimize or encourage an ED by reinforcing unhealthy eating and/or exercise behaviors. For example, low weight may go unnoticed, or even be lauded in a sport environment that reinforces low weight or thin shape (Thompson and Sherman, 1993, Thompson and Sherman, 2010) or promotes a certain body ideal (e.g., the thin distance runner; Thompson & Sherman, 2010). It also has been proposed that certain personality traits common to “good athletes” may be common in those with EDs (Thompson and Sherman, 1999, Thompson and Sherman, 2010).
Although some studies have found evidence that athletes may sometimes have more positive body image than non-athletes (see Hausenblas and Downs, 2001, Smolak et al., 2000), research also indicates that female athletes may be more at risk of developing EDs than their non-athlete peers (Burckes-Miller and Black, 1988, Greenleaf et al., 2009, Sundgot-Borgen, 1993, Sundgot-Borgen and Torstveit, 2004) and are at least at equal risk (Johnson, Powers, & Dick, 1999). For example, Torstveit, Rosenvinge, and Sundgot-Borgen (2008) found that 46% and 20% of elite females in lean and non-lean sports respectively evidenced clinical eating pathology. It also is clear that female college athletes exhibit a significant amount of subclinical ED pathology. For instance, in one study of female college athletes from 10 different sports, 32% of the athletes exhibited some subclinical ED pathology (i.e., using laxatives, diuretics, diet pills, vomiting, and/or binging more than twice per week) (Rosen, McKeag, Hough, & Curly, 1986). This finding was replicated more recently by Greenleaf et al. (2009) who found that almost 28% of Division I collegiate athletes were either eating disordered or symptomatic.
Poor eating – even if not part of a clinical or subclinical ED – also puts female athletes at risk for the female athlete triad. The female athlete triad refers to three interrelated health threats consisting of inadequate energy availability, menstrual disorders, and decreased bone mineral density (Manore, Kam, & Loucks, 2007). If female athletes do not consume adequate energy to fuel their activity levels, disruption of normal reproductive functions may occur such that females experience menstrual disorders (e.g., cessation of menses aka amenorrhea). Low energy availability and menstrual disorders have been shown to disrupt normal bone formation and resorption and are proposed to contribute to low bone mineral density (DeSouza, West, Jamal, Hawker, Gundberg & Williams, 2008). Thus, athletes with the triad are at an increased risk for stress fractures (Myburgh, Hutchins, Fataar, Hough, & Noakes, 1990) and osteoporosis, among other skeletal problems (Warren & Perlroth, 2001).
Different components of the triad occur in female athletes at different frequencies, but it is clear that symptoms of the triad may be present in a significant proportion of female athletes. By one estimate, 70% of female college athletes do not consume adequate calories to fuel their active lifestyles (Hinton, 2005), and up to 79% of female athletes in some sports may suffer from menstrual irregularities, although prevalence of menstrual disorders (including amenorrhea) may be closer to 10–20% in most sports (Warren, 1999). Further, the low energy intake level needed to reach the mean desired body fat composition (13%) reported by female athletes in Johnson et al. (1999) would likely be associated with a cessation of menses.
Despite health risks posed to athletes by disordered eating and the triad, there have been very few ED prevention studies with female athletes. In one notable exception, high school female athletes participated in an 8-week program, ATHENA, designed to reduce disordered eating and other unhealthy behaviors (e.g., substance use) (Elliot, Goldberg, Moe, DeFrancesco, Durham, & Hix-Small, 2004). The ATHENA program used both a coach-led and peer-led format, and targeted an array of potential concerns, including: depression, self-esteem, healthy norms, societal pressures to be thin, knowledge and expectancies about steroid use. Participants created public service campaigns to discourage EDs and drug use and also practiced refusal skills. ATHENA also included a media advocacy component and sought to establish shared healthy behavior expectations. Athletes who received ATHENA reported less diet pill use and positive change in diet habits and exercise self-efficacy compared to athletes who just received educational pamphlets. One to 3 years later, athletes in ATHENA showed reductions in marijuana and alcohol use, but not eating pathology (Elliot et al., 2008). One limitation is that follow-up was conducted as a second study, and the authors were unable to match follow-up data with baseline data. Another study investigated the effectiveness of an 8-week health education program focusing on self-esteem, performance pressure, nutrition, and stress management in female collegiate athletes (Abood & Black, 2000). This intervention reduced body dissatisfaction and drive for thinness more than the control condition two weeks after the intervention. Despite positive findings, both interventions required significant time commitments (i.e., approximately 8 hours) and the Abood and Black study did not involve any long-term follow-up measures.
Two recent exploratory studies suffer from small sample size and/or design problems. Buchholz, Mack, McVey, Feder, and Barrowman (2008) tested an intervention guided by community health professionals for adolescents, parents, and coaches of gymnastics clubs. Adolescent female gymnasts who participated in “Body Sense” reported less pressure from their clubs to be thin, but no difference was apparent on measures of dieting and bulimic pathology, compared to controls. Only 62 total athletes participated in the study, however. Thus, statistical power may have been inadequate.
Another small study was conducted with 29 female collegiate athletes, comparing DBP with HWI and wait-list control (Smith & Petrie, 2008). No improvements were seen for either intervention compared to wait-list. Although this study is limited by both a small sample and the fact that the authors only made slight modifications to DBP or HWI to account for unique aspects of this population, it is important to highlight that this is the only study conducted to date with DBP and HWI to find no significant benefit for participants in the main analyses. Moreover, in contrast to the existing literature on DBP and HWI, no improvements at all were seen within groups on thin-ideal internalization and bulimic pathology at post-treatment suggesting that traditional versions of DBP and HWI, even when slightly tailored, may be unusually ineffective in this population compared to results obtained with non-sport participants.
The purpose of this exploratory study was to investigate whether or not DBP and/or HWI could be adequately tailored to yield results promising enough to support further research of DBP and/or HWI in sport populations. More specifically, it is possible that no amount of modification will make these interventions viable for female athletes. Thus, we sought to gather pilot data regarding the effectiveness of athlete-modified peer-led versions of DBP (AM-DBP) and HWI (AM-HWI) at reducing ED risk factors in female collegiate athletes to determine which intervention, if any, might be appropriate for future research in a larger, better powered, study with a control condition. In order for ED prevention to be effective for female athletes, we contend that such programs must address unique needs of athletes (e.g., female athlete triad) while realistically considering the dual body image pressures athletes face from their competitive environments (i.e., an emphasis on body weight/composition affecting performance, sport-specific body stereotypes) and the western thin-ideal standard of female beauty. Recent research by de Bruin (2010) indicates that body image is not a stable construct for female athletes and varies between their sport lives and daily lives. Thus, we altered both DBP and HWI in an attempt to address these concerns. The tailoring of DBP and HWI to align with the language and needs of a particular social system (i.e., athletics) has been successfully undertaken before (i.e., in sororities) and may be a crucial factor in creating evidence-based programs that social systems will want to sustainably disseminate (Becker, Stice, Shaw, & Woda, 2009).
We opted to work with peer-led models of these interventions for several reasons. First, peers have been found in another social system to be good, cost effective endogenous providers, which can facilitate dissemination (see Becker et al., 2009). Second, we had been directly approached by female athletes requesting that a peer-led program modeled after the one we run with sororities be developed for female athletes. Finally, the department of athletics expressed enthusiasm for this model as it would offer student athletes a new option for gaining additional leadership experience. All peer-leaders in this study were current varsity-level (versus club-level) student athletes.
Although it would have been ideal from a research perspective to include a waitlist control group, this pilot study was developed using the principles of community participatory research (see Becker et al., 2009 for discussion of use of participatory methods in increasing dissemination of evidence-based interventions). Participatory research involves creating egalitarian partnerships that give all key stakeholders an equal voice in the research design. Secondary to ethical concerns involving the denying of a potentially beneficial intervention to their athletes, the department of athletics refused to accept a waitlist control group for this exploratory study. Given that (a) the main purpose of the study was simply to determine if either modified intervention was promising enough to warrant additional research in this population, and (b) given the failure of DBP or HWI to yield significant benefits in the Smith and Petrie (2008) study we decided to proceed with two intervention groups, while acknowledging that this is a significant limitation.
As just noted, DBP and HWI were not effective for athletes in Smith and Petrie (2008). These authors, however, failed to make the full range of modifications we believed were necessary for a sport population. Thus, based on previous efficacy and effectiveness research supporting the use of both DBP and HWI interventions (Becker et al., 2010, Stice et al., 2006) we cautiously hypothesized that both AM-DBP and AM-HWI would reduce ED risk factors (negative affect, thin-ideal internalization, dietary restraint, shape concern, weight concern and bulimic pathology) in collegiate female athletes post-intervention and at 6-week and 1-year follow-ups. We made no hypotheses about which intervention would perform better in this highly unique population because we felt there were inadequate grounds for doing so. For instance, although DBP has performed better in non-athlete populations at post-intervention compared to HWI, we and other researchers (e.g., reviewers for the first submission of the grant supporting this study) have been concerned that athletes may not respond to DBP as well as non-athletes given potential entrenched beliefs about the performance benefits of losing weight and the fact that DBP would more directly challenge these beliefs. We also had no hypotheses about which intervention would qualitatively seem better suited to this population, but planned to use audiotape review and peer-leader debriefing to see if clear differences emerged in the qualitative fit between this population and the two interventions.
Section snippets
Participants
Participants consisted of female college students (N = 168) participating in all 9 varsity sports teams (basketball, n = 18; swimming & diving, n = 28; softball, n = 15; tennis, n = 16; cross country, n = 21; soccer, n = 23; volleyball, n = 15; golf, n = 4; and track & field, n = 12) and on the varsity cheerleading squad (n = 16) at a highly competitive NCAA Division III university between Fall 2007 and Spring 2009. As in previous studies (Becker et al., 2006, Becker et al., 2008), participants (n = 8) who appeared to
Statistical Analyses
Independent samples t-tests run with all baseline measures, BMI, and age indicated no significant differences between interventions. For our main analyses we elected to use Hierarchical Linear Modeling (HLM). HLM provides unique advantages over General Linear Modeling (GLM) because it accounts for correlated data (i.e., repeated measurements on individuals) and unequal variances. Additionally, HLM allows for participants not measured at all time points to be included in analyses. Since no
Discussion
This exploratory study investigated whether it was possible to sufficiently modify dissonance based prevention (DBP) and a healthy weight intervention (HWI) to meet the unique needs of female athletes. This is the first study to attempt to significantly modify DBP and HWI for athletes, and is a much larger study than the only other published study of DBP and HWI conducted with female athletes (Smith & Petrie, 2008: N = 29). To our knowledge this is also the only ED prevention study with athletes
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