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Original Article

DISORDERED EATING ATTITUDES IN RELATION TO ANXIETY LEVELS, SELF-ESTEEM AND BODY IMAGE IN FEMALE BASKETBALL PLAYERS Maria Michou, Vassiliki Costarelli Human Ecology Laboratory, Department of Home Economics and Ecology, Harokopio University, Kallithea, Athens, GREECE

The purpose of the current study was to explore the possible differences in disordered eating (DE) attitudes, components of body image, self-esteem and anxiety levels in a group of female basketball players. A total of 154 women, 74 Greek basketball players (national and international level) and 80 women who were nonathletes, were recruited. Participants completed the following questionnaires: the Eating Attitudes Test (EAT26), the Multidimensional Body–Self Relations Questionnaire (MBSRQ), the State-Trait Anxiety Inventory (STAI), and Rosenberg’s Self-Esteem Scale (RSE). Analysis revealed that in the group of 154 young women (athletes and non-athletes), the women with DE attitudes had higher levels of anxiety and scored significantly more in components of the body image questionnaire (MBSRQ) such as appearance orientation (p = 0.002), health evaluation (p = 0.026), health orientation (p < 0.001), and illness orientation (p = 0.003). In addition, 11% of the basketball players and 15% of the non-athletes demonstrated DE attitudes. However, the differences between the two groups were not significant. The analysis of specific components of the body image questionnaire (MBSRQ) revealed that athletes scored significantly higher in fitness orientation (p = 0.021) and fitness evaluation (p = 0.019). There were no significant differences in the STAI and RSE results between athletes and non-athletes. The prevalence of DE attitudes in female basketball players was slightly lower than that in nonathletes, but the difference was not statistically significant. More studies specifically designed to investigate DE attitudes in females involved in team sports, such as basketball, are needed. [ J Exerc Sci Fit • Vol 9 • No 2 • 109–115 • 2011] Keywords: basketball, body image, eating attitudes

Introduction Disordered eating (DE) attitudes seem to have an important impact on physical health, psychosocial health and sports performance in athletes (Costarelli & Stamou 2009; Currie & Morse 2005; Filaire et al. 2001). Anorexia nervosa and bulimia nervosa represent only the extreme Corresponding Author Vassiliki Costarelli, Department of Home Economics and Ecology, Harokopio University of Athens, 70, E. Venizelou Avenue, 17671 Kallithea, Athens, GREECE. E-mail: [email protected]

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manifestations of abnormal eating attitudes. Milder variables related to DE attitudes such as obsessive thinking about food and dieting, body image dissatisfaction, overweight preoccupation and fear of fatness are also of paramount importance because their presence is strongly associated with an increased risk of developing clinical eating disorders (Currie & Crosland 2009; Goldschmidt et al. 2008). Studies suggest that for the majority of women, participation in sport contributes to significant health benefits, overall wellbeing, improved physical fitness, positive attitudes towards health, higher self-esteem and a healthier body image, in comparison to women

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who do not engage in physical activity (Costarelli et al. 2009; Putukian 1998). However, factors uniquely found in athletes such as excessive training, non-conventional eating patterns, extreme diets and restriction of food intake, might increase the risk of eating disorders in this population (Monthuy-Blanc et al. 2010; Fleming & Costarelli 2007; Vardar et al. 2007). There is good evidence that participation in competitive sport is an important risk factor for developing eating disorders (Sundgot-Borgen & Torstveit 2004), particularly in the case of female athletes (Greenleaf et al. 2009; Sundgot-Borgen & Torstveit 2004). A well-designed study that evaluated the presence of DE in Norwegian male and female elite athletes (n = 1,620) from 66 different sports and controls (n = 1,696) found that among female athletes competing in aesthetic sports, the prevalence of DE was 42%, which was higher than that observed in endurance (24%), technical (17%), and team sports (16%) (Sundgot-Borgen & Torstveit 2004). In a smaller-scale study conducted in Spain in 283 elite sportswomen competing in 20 different sports, the proportion of athletes suffering from some kind of eating disorder was five times higher than in the general population (22.6% vs. 4.1%) (Toro et al. 2005). It is important to clarify that athletes (male and female) in endurance, aesthetic and weight classification sports, where leanness or a specific weight are believed to favor sports performance, have a higher risk of developing eating disorders than athletes in team sports and than the general population (Cook & Hausenblas 2011; Resch & Haasz 2009; Smolak et al. 2000; SundgotBorgen 1994). As a result, most studies investigating the prevalence of DE and its underlying factors in athletes, to date, have focused either specifically on endurance, aesthetic and weight classification sports or have investigated athletes in general, regardless of the type of sport (Costarelli & Stamou 2009; Black et al. 2003; Yannakoulia et al. 2002). A comprehensive search of the literature has found no other study specifically designed to adequately investigate the prevalence of DE attitudes in female basketball players. While a number of studies that aimed to determine the prevalence of eating disorders and their risk factors in female athletes have been published, the nature of the relationship between athletic involvement and eating problems is unclear. Previous studies have shown that psychological factors such as anxiety, self-esteem, perfectionism, mood, emotion disregulation, and disturbed body image are implicated in the multifactorial etiology of eating disorders (Costarelli et al. 2009; Petrie

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et al. 2009; Markey & Vander Wal 2007; Sassaroli & Ruggiero 2005; Hewitt & Flett 1991). More specifically, low self-esteem seems to be an important additional factor associated with dieting, body image dissatisfaction and alterations in eating patterns, although it is difficult to know whether this is actually a cause or an effect (O’Dea 2009). The relationship between anxiety and eating disorders has also attracted considerable attention (Davey & Chapman 2009; Godart et al. 2000). Despite consistent findings suggesting links between emotions such as anxiety and eating disorder symptomatology, the precise role of anxiety in the etiology of eating disorders remains a subject of discussion (Davey & Chapman 2009). However, the role of self-esteem in relation to body image, anxiety levels and DE in athletes of team sports such as basketball has not yet been investigated. The purpose of the current study was to explore the possible differences in DE attitudes, components of body image, self-esteem and anxiety levels in a group of female basketball players and a group of non-athletes.

Methods Participants A total of 154 women, 74 Greek basketball players (national and international level) and 80 women, nonathletes, were recruited. The mean ages of the two groups were 24.92 ± 3.81 years and 25.21 ± 3.42 years for the athletes and non-athletes, respectively. All women were of normal body weight [body mass index < 25 kg·(m2)−1]. The basic characteristics of the participants are shown in Table 1. The athletes were recruited from the following 10 Greek basketball clubs: Kronos Agiou Dimitriou, Paianias Ktifison, Pagratiou, Astir Exarchion, Niki Leukadas, Hrakleio Kritis, Panionios, Esperides Kallitheas, Panathlitkos Sikeon, and Anagenisi Neou Rusiou. The control group, which was recruited from the student population of Harokopio University of Athens and the general population, did not engage in vigorous physical activity and did not engage in any competitive sport. Study design All participants signed consent forms and received a full verbal and written explanation of the purpose of the study and its anonymous nature. Participants also completed the following questionnaires: the Eating Attitudes Test (EAT-26), the Multidimensional Body– Self Relations Questionnaire (MBSRQ), the State-Trait

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Table 1. Basic characteristics of the participants*

Age (yr) Height (m) Weight (kg) Body mass index [kg ⭈ (m2)−1] Years of playing basketball No. of days practicing per week No. of hours practicing per week

Non-athletes (n = 80)

Athletes (n = 74)

Total (n = 154)

25.21 ± 3.42 1.68 ± 0.06† 60.54 ± 7.60† 21.37 ± 2.29 – – –

24.92 ± 3.81 1.75 ± 0.069† 65.97 ± 8.69† 21.61 ± 1.84 > 10 >5 15

25.07 ± 3.60 1.71 ± 0.71 63.15 ± 8.55 21.49 ± 2.08 – – –

*Data presented as mean ± standard deviation; †p < 0.05.

Anxiety Inventory (STAI), and Rosenberg’s Self-Esteem Scale (RSE). The RSE has been translated into Greek and an independent translator performed a second translation. The retranslated and original versions were compared by one of the researchers and were found to match closely. All the other questionnaires had already been translated and successfully used in Greek in the past (Costarelli et al. 2011, 2009; Fountoulakis et al. 2006). Prior to the start of the study, in order to identify possible ambiguous questions, the questionnaires were piloted to a group of six volunteers. The mean time taken to complete the questionnaires was 20 minutes. The questionnaires were given to the study participants in the form of a single booklet, together with specific completion instructions. They had a week to complete and return them to the investigator. A total of 100 questionnaires were distributed to the controls and 80 to the athletes; 80 and 74 were returned respectively, properly completed and on time. General background and lifestyle questionnaire A specially designed self-administered two-part questionnaire was used to collect background information on age, weight, height, ethnicity, education, general nutritional habits, weight loss diets used, physical activity involvement, and frequency of measuring body weight (Part A—completed by all participants), as well as the nature and extent of athletic involvement, training regimen, weight history, making weight and weight loss methods used (Part B—completed by the athletes). Participants were asked to rate their satisfaction with their body weight and to state whether they wished to lose or gain body weight. The EAT-26 The Greek version of the EAT-26 (Yannakoulia et al. 2004; Garner & Garfinkel 1979) was used. To complete the EAT-26, participants rate their agreement with 26

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statements about weight and food. The EAT-26 has three individual scales: the Dieting Scale (preoccupation with being thin and avoidance of fattening foods), the Bulimia and Food Preoccupation Scale, and the Oral Control Scale (self-control of eating and perceived pressure from others to gain weight). A total score ≥ 20 in the questionnaire indicates abnormal eating behavior. Cronbach’s alpha coefficient is 0.76. The MBSRQ The MBSRQ is an instrument for evaluating self-attitude aspects of body image and is determined from the 69-item self-evaluation tool comprised of 10 subscales (Cash 2004, 2000): Appearance Evaluation (AE), Appearance Orientation (AO), Fitness Evaluation (FE), Fitness Orientation (FO), Health Evaluation (HE), Health Orientation (HO), Illness Orientation (IO), Body Areas Satisfaction (BAS), Overweight Preoccupation (OP), and Self-Classified Weight (SCW). In the present study, only the first seven subscales were used. The MBSRQ uses a 5-point, fully anchored Likert-type scale (1 = definitely disagree, 2 = mostly disagree, 3 = neither agree nor disagree, 4 = mostly agree, 5 = definitely agree). High scores indicate positive feelings and satisfaction, while low scores reflect a general dissatisfaction. The Cronbach’s alpha coefficients of the subscales ranged from 0.77 to 0.88 in the present study. The STAI The 40-item STAI state instrument was used to measure anxiety symptoms (Spielberg 1983). Various reliability and validity tests have been conducted on the STAI and have provided sufficient evidence that the STAI is an appropriate and adequate measure for studying anxiety in research. It has been translated into 66 languages, including Greek. The 40 items are divided into two groups: 20 items record current anxiety symptoms (state anxiety) and the other 20 items record usual anxiety symptoms (trait anxiety). The STAI is scored

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on four levels of anxiety intensity from 1 (not at all) to 4 (very much) for the first 20 items and from 1 (nearly always) to 4 (nearly never) for the remaining 20 items. Some of the questions are inverted for the purpose of calculating the sum score, through a scoring key. Higher scores indicate higher levels of anxiety. In the present study, only the items that record usual anxiety symptoms (trait anxiety) were used. The Cronbach’s alpha coefficient is 0.81. The RSE The RSE is a 10-item self-report measure of global selfesteem. It consists of 10 statements related to overall feelings of self-worth or self-acceptance. The items are answered on a 4-point scale ranging from “strongly agree” to “strongly disagree” (Rosenberg 1965). The scale ranges from 10 to 40. Scores between 20 and 30 are within the normal range, while scores below 20 suggest low self-esteem. The Cronbach’s alpha coefficient is 0.72. Statistical analysis Comparisons between the two groups were made using the Mann-Whitney U test. Both the Pearson and Spearman Rank Order coefficient were used to test for possible correlations among the different variables

tested, depending on whether the data were normally distributed or not. All statistical analyses were performed using SPSS PC version 10.0 (SPSS Inc., Chicago, IL, USA) statistical software.

Results We found that 11% of the basketball players and 15% of the non-athletes demonstrated DE attitudes (EAT-26 > 20); the difference between the two groups, however, was not significant. In addition, 20.8% of all participants (athletes and non-athletes) were currently trying to lose weight either through diet or exercise, and 6.2% of them were measuring their body weight on a daily basis. There were no significant differences in the STAI and RSE between the athletes and non-athletes (Table 2). Analysis of specific components of the body image questionnaire (MBSRQ) revealed that athletes scored significantly higher in fitness evaluation (p = 0.019) and fitness orientation (p = 0.021) (Table 3). However, there was no statistically significant difference in appearance evaluation between the two groups. Analysis also revealed that in the group of 154 young women (athletes and non athletes), the women with DE

Table 2. Results from the Eating Attitudes Test (EAT-26) and its subscales, the State-Trait Anxiety Inventory (STAI) and Rosenberg’s Self-Esteem scale (RSE)* Non-athletes (n = 80)

Athletes (n = 74)

Total (n = 154)

EAT-26 Dieting Bulimia and Food Preoccupation Oral Control

10.72 ± 7.47 0.42 ± 0.42 0.41 ± 0.37 0.37 ± 0.41

10.78 ± 7.98 0.40 ± 0.39 0.43 ± 0.42 0.44 ± 0.44

10.75 ± 7.69 0.41 ± 0.41 0.42 ± 0.39 0.41 ± 0.42

STAI

40.48 ± 7.99

39.61 ± 7.59

40.06 ± 7.79

RSE

31.12 ± 4.36

31.70 ± 4.07

31.40 ± 4.22

*Data presented as mean ± standard deviation and comparisons between non-athletes and athletes using the Mann-Whitney U test.

Table 3. Results from the Multidimensional Body–Self Relations Questionnaire (MBSRQ) and the Collins Body Image Scale*

MBSRQ Appearance Evaluation Appearance Orientation Fitness Evaluation Fitness Orientation Health Evaluation Health Orientation Illness Orientation

Non-athletes (n = 80)

Athletes (n = 74)

Total (n = 154)

2.91 ± 0.31 3.31 ± 0.32 2.92 ± 0.35 2.93 ± 0.35 3.28 ± 0.38 3.46 ± 0.59 2.89 ± 0.41

2.88 ± 0.27 3.32 ± 0.32 3.07 ± 0.34† 3.05 ± 0.32† 3.30 ± 0.35 3.60 ± 0.42 2.88 ± 0.52

2.89 ± 0.29 3.31 ± 0.32 2.99 ± 0.36 2.99 ± 0.34 3.29 ± 0.37 3.53 ± 0.52 2.88 ± 0.47

*Data presented as mean ± standard deviation and comparisons between non-athletes and athletes using the Mann-Whitney U test; †p < 0.05.

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Table 4. Results from the Eating Attitudes Test (EAT-26) and its subscales, the State-Trait Anxiety Inventory (STAI), Rosenberg’s Self-Esteem Scale (RSE), and the Multidimensional Body–Self Relations Questionnaire (MBSRQ)* Women without DE attitudes (n = 134)

Women with DE attitudes (n = 20)

Total (n = 154)

8.43 ± 4.53 0.30 ± 0.27 0.35 ± 0.29 0.33 ± 0.32

26.35 ± 6.24† 1.14 ± 0.43† 0.90 ± 0.60† 0.89 ± 0.68†

10.75 ± 7.69 0.41 ± 0.41 0.42 ± 0.39 0.41 ± 0.42

EAT-26 Dieting Bulimia and Food Preoccupation Oral Control STAI

39.69 ± 8.07

42.55 ± 4.98

40.06 ± 7.79

RSE

31.34 ± 4.18

31.85 ± 4.60

31.40 ± 4.22

MBSRQ Appearance Evaluation Appearance Orientation Fitness Evaluation Fitness Orientation Health Evaluation Health Orientation Illness Orientation

2.89 ± 0.30 3.29 ± 0.31 2.98 ± 0.35 2.98 ± 0.34 3.26 ± 0.35 3.45 ± 0.47 2.84 ± 0.46

2.93 ± 0.25 3.51 ± 0.32‡ 3.06 ± 0.43 3.04 ± 0.33 3.47 ± 0.46† 4.05 ± 0.51¶ 3.16 ± 0.42‡

2.89 ± 0.29 3.31 ± 0.32 2.99 ± 0.36 2.99 ± 0.34 3.29 ± 0.37 3.53 ± 0.52 2.88 ± 0.47

*Data presented as mean ± standard deviation and comparisons between women without and with DE attitudes using the Mann-Whitney U test; †p < 0.05; ‡p < 0.01; ¶p < 0.001. DE = disordered eating.

Table 5. Spearman rank order correlation coefficients between the Eating Attitudes Test and other parameters Spearman’s rho STAI Appearance Orientation Health Evaluation Health Orientation Illness Orientation

0.260* 0.216* 0.177† 0.261* 0.203†

*p < 0.01; †p < 0.05. STAI = State-Trait Anxiety Inventory.

attitudes (n = 20) had higher levels of anxiety (Table 4) and scored significantly higher than women without DE attitudes in components of the body image questionnaire (MBSRQ) such as appearance orientation (p = 0.002), health evaluation (p = 0.026), health orientation (p < 0.001), and illness orientation (p = 0.003). All the above parameters were also significantly positively correlated (Spearman Rank Order coefficient, n = 154) with DE (EAT-26) (Table 5). The results also showed that anxiety levels (STAI) were significantly positively correlated with DE (EAT-26) (Spearman rho = 0.260, p < 0.01) and significantly negatively correlated with levels of selfesteem (Spearman rho = −0.545, p < 0.001).

Discussion In this study, we found no significant differences in DE attitudes (EAT-26) between female basketball players and non-athletes. The actual prevalence of DE attitudes

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in the basketball players (11%) was lower than in the non-athletes (15%), which is encouraging, given the fact that elite female athletes are more likely to develop DE than the general population (Torstveit & Sundgot-Borgen 2005; Sundgot-Borgen & Torstveit 2004). It is highly likely that basketball, as a team sport that does not emphasize a thin body and does not require making weight regularly to increase performance, is a sport that does not increase the risk of developing DE attitudes in females; it is probable that female basketball players adopt healthier eating attitudes compared to women who do not engage in any sport activity. However, more studies are needed to further explore the prevalence of DE in females involved in team sports. In the current study, there were no differences in levels of anxiety and self-esteem between athletes and non-athletes. However, correlation analysis for the whole group of women (n = 154) revealed that DE attitudes are significantly positively correlated with anxiety levels and an unhealthy body image (Table 5). In addition, anxiety levels were negatively correlated with self-esteem. These findings have been confirmed by a number of previous studies (Costarelli et al. 2011, 2009; Costarelli & Stamou 2009). It is important to investigate the prevalence of DE attitudes concurrently with psychosocial parameters such as anxiety and self-esteem because both factors can affect eating behavior, sports performance and general health and wellbeing in athletes and non-athletes (Haase 2011; Cook & Hausenblas 2008; Nattiv et al. 2007; Currie & Morse 2005).

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In the case of body image, a number of longitudinal studies have shown that body image dissatisfaction has consistently been identified as one of the most robust risk factors for eating disturbances (Abraham 2003; Stice & Bearman 2001). In the present study, athletes seemed to have a healthier body image than non-athletes (MBSRQ), but only in two components of the questionnaire: health evaluation and health orientation, which was anticipated. There were no other differences in terms of body image between the two groups, which is in contrast to the results of other studies where athletes reported a more positive body image than non-athletes (Hausenblas & Symons Down 2001). It has to be stressed that the relatively low prevalence of DE attitudes in the control group of this study (15%), compared to other studies in similar populations (> 20%), could partly be attributed to the fact that all participants were of normal weight and the majority appeared to have a healthy body image (Monthuy-Blanc et al. 2010; Costarelli et al. 2009; Gonidakis et al. 2009). There is a distinct lack of good quality papers on DE attitudes and their underlying causes in females participating in specific team sports such as basketball. There is evidence that eating behavior in athletes differs among different sports. The current study highlights the need for more studies in this area in order to facilitate the prevention and management of DE in this population. The prevalence of DE attitudes in female basketball players is slightly lower than in non-athletes; however, the difference was not statistically significant. More studies, specifically designed to investigate DE attitudes in females involved in team sports, such as basketball, are needed.

Acknowledgments Special thanks go to all the athletes and their coaches who helped us with recruitment, and all the other volunteers who took part in the study.

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