**Practical Screening Methods for Eating Disorders for Collegiate Athletics**

Toni M. Torres-McGehee and Kendra Olgetree-Cusaac *University of South Carolina, Columbia, SC United States* 

### **1. Introduction**

Eating disorders are distinct severe disturbances in eating behavior (e.g., Anorexia Nervosa, Bulimia Nervosa, and Eating Disorders Not Otherwise Specified; American Psychiatric Association [APA], 2000, pg.583). Sociocultural, biological, and psychological factors are intricate in the development of eating disorders (Beals & Manore, 1999; Beals, 2004); though causation may be multifactoral. Extensive research has been conducted in eating disorders and body image disturbances, and many psychologists (e.g. Daniel & Bridges, 2010; Fredrickson & Roberts, 1997; Mazzeo & Espelage, 2002; Tylka & Subich, 2004) have presented model frameworks that eloquently combine variables to explain eating disorder and body image dissatisfaction symptomology in males and females. In the last decade, eating disorders and body image disturbances in the collegiate athletic population has received increasing attention (Black et al., 2003; Greenleaf et al., 2009; Johnson et al. 1999; Petrie et al., 2008; Sundgot-Borgen & Torstveit, 2004). Older research by Johnson, Powers, and Dick (1999) revealed in a hetergeneous sample of collegiate athletes that both females and males were at risk for eating disorders (males: 38% at risk for Bulimia Nervosa and 9.5% risk for Anorexia Nervosa; females: 38% at risk for Bulimia Nervosa and 34.75% at risk for Anorexia Nervosa). Whereas, more current research has estimated 20% for men (Petrie et al, 2008) and 25.5% for female collegiate athletes (Greenleaf et al., 2009). However, estimated prevalence in these studies have been conducted in an anonymous and controlled research environments; thus no data has been presented while examining eating disorder symptomology in a practical setting (pre-participation physical examinations [PPE]) screening for associated risk factors in collegiate athletes.

The sport context is influential on athletes in positive as well as negative ways, thus it is expected that the sport environment could have a considerable impact on the occurrence of eating disorders. Sports can be perceived as its own culture, with its own rules, customs and traditions, and expectations. A culture bound syndrome, as defined by Prince (1985), is "a collection of signs and symptoms (excluding notions of cause) which is restricted to a limited number of cultures primarily by reason of certain of their psychosocial features" (p.201). In a review, Keel and Klump (2003) suggested that Bulimia Nervosa may be a culture-bound syndrome, influenced by weight concerns, anonymous access to large quantities of food, and a motivation to prevent the effects of binge eating on weight through the use of inappropriate compensatory behavior (e.g. self-induced vomiting, excessive exercise, use of diet pills or laxatives, or fasting). Consequently, if the sport environment is

Practical Screening Methods for Eating Disorders for Collegiate Athletics 53

through the use of gender-specific BMI-based SILs is to represent images of actual physique appearance compared to ideal appearance (Stunkard et al., 1983; Bulik et al., 2001). In addition, a recent strategy by Torres-McGehee et al. (2009), undercovered possible sources of negative body image (actual – ideal > 0) by associating SILs scales with reference questions pertaining to daily clothing verses uniform type in aesthetic (Torres-McGehee et al., 2009; Torres-McGehee et al., In Press) and perceptions by others (e.g., friends/peers, parents, cosches; Torres-McGehee & Monsma, n.d); however non-aesthetic sports were not represented in these samples. This strategy is useful for detecting differences from specific

Due to the large number of athletes at NCAA Division I institutions, screening athletes for potential eating disorder symptomology may be challenging during PPEs. Therefore, this study seeks to examine a retrospective data set compiled from two consecutive years of PPE screening for eating disorder risk and associated symptoms in Division I collegiate athletics. Practitioners utilized reliable and validated instruments commonly used for the general population were used (e.g., EAT-26, Center for Epidemiological Studies Depression Scale, Rosenberg's Self-Esteem Scale, BMI-based silhouette scale, Exercise Dependence Scale). Furthermore, this study will present preliminary findings associated with: (1) estimated prevalence of eating disorder risk, depression, low self-esteem and exercise dependence among female and male athletes; (2) weight pressures, (3) distribution of compensatory behaviors, and (3) body image disturbances associated with clothing type and perceptions of others. Due to the sensitivity of screening for eating disorder symptomology, it is expected that the estimated prevalences among eating disorders risk, associated symtomology, and compensatory behaviors will be lower than estimated prevalence among previous studies (Black & Burckes-Miller, 1988; Carter & Rudd, 2005; Johnson et al.,1999; Greenleaf et al., 2009, Petrie et al., 2008). It is proposed that negative body images thought to be held by others (i.e., actual – ideal), or perceived body ideals from others, are generated in reference to specific social agents (e.g., friends, parents, coaches), with the greatest influence from the

This study was a retrospective, descriptive and cross-sectional study design. After acquiring appropriate institutional review board approval, two consecutive years of data were obtained from a secure online pre-participation physical examination for eating disorder and mental health screening database used by one NCAA Division I institution. For the protection of the athletes, specific dates of screening is not disclosed; however the two years of data obtained was within the last 5 years. Screening instruments included: (1) Eating Attitudes Test (EAT-26), (2) Center for Epidemiological Studies Depression Scale (CES-D), (3) Rosenberg's Self-Esteem Scale (RSES), (4) BMI-based silhouette scale, (5) Exercise Dependence Scale (EDS), (6) questions regarding weight and pressures in sport and (7) demographic information included athlete's age, gender, and sport, race/ethnicity.

One NCAA Division I institution's retrospective data from pre-participation eating disorder and mental health screening was used to examine athletes over a 2 year period (Year 1: *n* = 355, females: *n* = 243 and males: *n* = 112; Year 2: *n* = 340, females: *n* = 208, and males *n*: =

social agents.

coach.

**2. Method** 

**2.2 Participants** 

**2.1 Design and procedure** 

conceptualized as its own culture, then the incidence of eating disorders, such as Bulimia in athletes would potentially have similar and dissimilar etiology from nonathletic populations. In addition, it is plausible that precursors to binge-eating, which is the disordered eating behavior that can lead to Bulimia, appear to be depression symptoms and low self-esteem.

It was theorized by Koenig and Wasserman (1995) that the high rates of co-morbidity found between eating disorders and depression may, in part, be caused by common features such as negative self-evaluation and general dissatisfaction with one's physical appearance (Muscat & Long, 2008). Therefore, to better understand the etiology of eating disorders, researchers have focused on the role of body image. Theorists agree that perceptions such as body image distortion and dissatisfaction play a crucial role in the development of disordered eating (Henriques et al., 1996; Ackard et al., 2002) and maladaptive weight control behaviors such as dietary restriction, excessive dieting, laxative use, over exercising and purging (Fredrickson & Roberts, 1997; Stice & Agras,1999; Sundgot-Borgen & Torstveit, 2004; Tylka & Subich, 2004). Some theorist (e.g., Fredrickson & Roberts, 1997; Maine, 2000; Pipher, 1994; Thompson et al., 1999) suggested that sociocultural pressures for thinness directly predict perceptions of poor social support and negative affect (e.g., low self-esteem). It is suggested that being pressured to obtain an unrealistic body image (e.g. thin) by others is more likely to lead into feeling unsupported (Pipher, 1994). Similarly, previous research examining athletes have revealed pressures from coaches (Beisecker & Martz, 1999; Griffin & Harris; 1996; Petrie et al., 2009), family members and peers (Field et al. 2001; Petrie et al. 2009; Vincent & McCabe, 1999) in the development of body image concerns and unhealthy weight-loss practices in athletes.

Body image disturbance, depression, and low self-esteem have been shown to have an association with eating disorders; however they are often not included in the screening process for athletes during PPEs. The National Athletic Trainers' Association and the American College of Sports Medicine have developed position statements for assisting clinicians by providing recommendations for screening and diagnosis of eating disorders and the female athlete triad in athletes (Bonci, et al., 2008; Nativi et al, 2007). Although both statements are very thorough, little attention is given to screening other psychological constructs (body image disturbance, depression, and low self-esteem) that are associated with eating disorders. Self-reported psychometric questionnaires such as the Eating Disorder Inventory (EDI; Garner, et al, 1983, pg.173-184), the Eating Disorders Examination (EDE-Q; Fairburn & Cooper, 1993) and the Eating Attitudes Test (EAT; Garner et al., 1982) are commonly used in the athletic population. Although these questionnaires have well established reliability and validity, it is recognized that most test administrators in the athletic setting for PPEs (e.g., athletic trainers) are either relatively unfamiliar with screening tests or have minimal knowledge or background in standardized test administration or psychometrics. Questionnaire can be fee-based or time consuming (e.g., EDI or EDE-Q), therefore with institutions with limited resources may utilize the EAT-26 because it's free, short in nature, and easy to score.

When it comes to examining body image dissatisfaction, both the EDI and the EDE-Q have subscales; however a more practical alternative used in the literature is the Stunkard Figural Stimuli Scale (Stunkard et al., 1983). A common version of the scale involves nine genderspecific BMI-based silhouettes (SILs). Bulik et al. (2001) examined 16,728 females and 11,366 males ranging in age from 18-100 and transformed the nine SILS and associated each pictorial image with a specific BMI increment. One way of understanding body image is through the use of gender-specific BMI-based SILs is to represent images of actual physique appearance compared to ideal appearance (Stunkard et al., 1983; Bulik et al., 2001). In addition, a recent strategy by Torres-McGehee et al. (2009), undercovered possible sources of negative body image (actual – ideal > 0) by associating SILs scales with reference questions pertaining to daily clothing verses uniform type in aesthetic (Torres-McGehee et al., 2009; Torres-McGehee et al., In Press) and perceptions by others (e.g., friends/peers, parents, cosches; Torres-McGehee & Monsma, n.d); however non-aesthetic sports were not represented in these samples. This strategy is useful for detecting differences from specific social agents.

Due to the large number of athletes at NCAA Division I institutions, screening athletes for potential eating disorder symptomology may be challenging during PPEs. Therefore, this study seeks to examine a retrospective data set compiled from two consecutive years of PPE screening for eating disorder risk and associated symptoms in Division I collegiate athletics. Practitioners utilized reliable and validated instruments commonly used for the general population were used (e.g., EAT-26, Center for Epidemiological Studies Depression Scale, Rosenberg's Self-Esteem Scale, BMI-based silhouette scale, Exercise Dependence Scale). Furthermore, this study will present preliminary findings associated with: (1) estimated prevalence of eating disorder risk, depression, low self-esteem and exercise dependence among female and male athletes; (2) weight pressures, (3) distribution of compensatory behaviors, and (3) body image disturbances associated with clothing type and perceptions of others. Due to the sensitivity of screening for eating disorder symptomology, it is expected that the estimated prevalences among eating disorders risk, associated symtomology, and compensatory behaviors will be lower than estimated prevalence among previous studies (Black & Burckes-Miller, 1988; Carter & Rudd, 2005; Johnson et al.,1999; Greenleaf et al., 2009, Petrie et al., 2008). It is proposed that negative body images thought to be held by others (i.e., actual – ideal), or perceived body ideals from others, are generated in reference to specific social agents (e.g., friends, parents, coaches), with the greatest influence from the coach.
