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to explore the possible differences in emotional intelligence, body image and ... Women in the DE atttitudes group had lower levels of Emotional Intelligence.
Journal of Human Nutrition and Dietetics

RESEARCH PAPER Disordered eating attitudes in relation to body image and emotional intelligence in young women V. Costarelli, M. Demerzi & D. Stamou Human Ecology Laboratory, Department of Home Economics and Ecology, Harokopio University, Athens, Greece

Keywords body image, disordered eating, emotional intelligence. Correspondence Dr Vassiliki Costarelli, Senior Lecturer, Department of Home Economics and Ecology, Harokopio University, El. Venizelou 70, Kallithea, 176-71 Athens, Greece. Tel.: +30 210 9549 368 Fax: +30 210 9577 050 E-mail: [email protected] doi:10.1111/j.1365-277X.2009.00949.x

Abstract Background: A number of different psychological factors have been implicated in the multifactorial aetiology of disordered eating (DE) attitudes and behaviours; however, the possible role of emotional intelligence in DE symptomatology has not been thoroughly investigated in the past. The present study aimed to explore the possible differences in emotional intelligence, body image and anxiety levels in young females with DE attitudes and healthy controls. Methods: A total of 92 Greek female university students, 18–30 years old, were recruited. Subjects completed the following questionnaires: the Eating Attitudes Test (EAT-26), the Multidimensional Body-Self Questionnaire (MBRSQ), the State-Trait Anxiety Inventory (STAI) and the BarOn Emotional Intelligence Questionnaire (BarOn EQ-I). Results: The EAT-26 revealed that 23% of the subjects presented DE attitudes. Women in the DE atttitudes group had lower levels of Emotional Intelligence (EI) in comparison to the control group, particularly in factors such as emotional self-awareness (P < 0.05), empathy (P < 0.05), interpersonal relationships (P < 0.001), stress management (P < 0.05) and happiness (P < 0.05). The MBRSQ has revealed significant differences between the two groups in terms of overweight preoccupation (P < 0.001) and illlness orientation (P < 0.01). The DE atttitudes group had higher anxiety scores (STAI), although the differences were not significant. Finally, anxiety levels (STAI) were significantly correlated with levels of EI (BarOn EQ-I) (P < 0.001). Conclusions: The young women enrolled in the present study with DE attitudes, a potential precursor to eating disorders, appear to have significant differences in many psychometrical parameters of emotional intelligence, such as emotional self-awareness and interpersonal relationships, which is an important finding in terms of the prevention and management of DE, and warrants further investigation.

Introduction Disordered eating attitudes and behaviours are common in young women in western countries, where a thin body is considered as desirable (Leichner, 2002; Goldschmidt et al., 2008; Olesti Baiges et al., 2008). A number of recent studies suggest that the prevalence of these disorders is rising and that the age of onset is gradually falling (Machado et al., 2007). The prevalence of obesity in ª 2009 The Authors. Journal compilation. ª 2009 The British Dietetic Association Ltd 2009 J Hum Nutr Diet, 22, pp. 239–245

young women in Greece is amongst the highest in Europe and many young women report feeling dissatisfied with their weight and want to lose weight (Tzotzas & Krassas, 2004; Hyde, 2008). In a cross-sectional study assessing body image perception and satisfaction in the European Union, it was shown that Greece had the highest percentage of subjects who wished to be considerably lighter (18%), whereas Denmark had the lowest (7%) (McElhone et al., 1999). 239

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Eating disorder symptomatology appears to have a serious impact on the physical and psychosocial health of young women, and is strongly related to body weight gain. It has to be stressed that anorexia and bulimia nervosa represent only the extreme manifestations of abnormal eating attitudes. Milder variables related to disordered eating (DE) attitudes, such as obsessive thinking about food and dieting, body image disatisfaction, overweight preocupation and fear of fatness, are also of paramount imporance. Although most of the above attitudes and weight loss practices are often benign, their presence is strongly associated with an increased risk of developing clinical eating disorders (Goldschmidt et al., 2008). Psychological factors such as anxiety, mood, perfectionism, emotion dysregulation, disturbed body image and self-esteem are implicated in the multifactorial aetiology of eating disorders (Hewitt & Flett, 1991; Sassaroli & Ruggiero, 2005; Markey & Vander Wal, 2007). In addition, self-esteem also appears to be an important risk factor for body dissatisfaction and eating disturbance (Fairburn et al., 2003). Emotional intelligence (EI) involves the ability to carry out accurate reasoning about emotions and the ability to use emotions and emotional knowledge to enhance thought (Mayer et al., 2008). More specifically, Mayer & Salovey (1997: 10) defined EI as: ‘The ability to perceive accurately, appraise and express emotion; the ability to access and/or generate feelings when they facilitate thought; the ability to understand emotion and emotional knowledge; and the ability to regulate emotions to promote emotional and intellectual growth’. There is evidence that increased EI leads to more positive attitudes, improved relationships, higher orientation towards positive values and greater adaptability (Akerjordet & Severinsson, 2007). EI has also been found to be positively correlated with other measures of psychological well-being, such as life satisfaction and happiness, whereas associations with measures such as depression, loneliness and stress were found to be negative (Slaski & Cartwright, 2002). Positive associations of EI with higher levels of self-rated physical health have also been reported (Tsaousis & Nikolaou, 2005). Only one study investigated the links between emotional intelligence and DE. The results obtained highlighted the role of emotion in DE behaviours and support the negative affect and emotion dysregulation theories of eating disorders (Markey & Vander Wal, 2007). The present study aimed to explore the possible differences in EI, body image and anxiety levels in a group of young women with DE symptomatogy and healthy controls. The inter-relationships of the above parameters were also examined. 240

Materials and methods Subjects A total of 92 young Caucasian females [mean (SD) age 23 (3.53) years] were recruited from the student population of Harokopio University and the Technological Institution of Athens, Greece. The baseline characteristics of the subjects are shown in Table 1. None of the subjects reported suffering from a diagnosed eating disorder, or any other mental illness and none engaged in any competitive sport. Body mass index (BMI) was calculated from self-reported heights and weights. None of the subjects was obese (BMI ‡ 30 kg m)2; World Health Organization, 2000). All participants provided their written consent and received a full verbal and written explanation of the purpose of the study, its anonymous nature, and of their ability to withdraw from the study at any time. Approval to conduct the study was granted by the Ethical Committee of Harokopio University of Athens. Study design Subjects had to complete the following questionnaires: the Eating Attitudes Test (EAT-26), the Multidimensional Body-Self Questionnaire (MBRSQ), the State-Trait Anxiety Inventory (STAI) and the BarOn Emotional Intelligence Questionnaire (BarOn EQ-I); they also had to complete a specially designed General Background Questionnaire. The MBRSQ has been translated into Greek, and then an independent translator performed a second translation. Retranslated and original versions were compared by one of the researchers and were found to match closely. All the other questionnaires, apart from the

Table 1 Eating Attitudes Test (EAT-26) score, age, anthropometric characteristics and overweight status of the participants

EAT-26 score Age (years) Weight (kg) Height (cm) BMI (kg m)2) Normal weight prevalence % (n) BMI 18.50–24.99 kg m)2 Overweight prevalence % (n) BMI ‡ 25–30 kg m)2 Underweight prevalence % (n) BMI < 18.50 kg m)2

Disordered eating attitudes group (n = 21)

Healthy controls (n = 71)

28.04 23.08 65.52 1.68 22.95 76.2%

10.19 22.71 60.54 1.66 21.91 92.95

(6.31) (3.68) (10.65) (0.64) (2.54) (16)

23.8% (5) None

(3.70) (3.00) (7.59) (0.6) (2.18) (66)

5.6% (4) 2.8% (2)

Data are mean (SD). BMI, body mass index. ª 2009 The Authors. Journal compilation. ª 2009 The British Dietetic Association Ltd 2009 J Hum Nutr Diet, 22, pp. 239–245

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MBRSQ which is used for the first time, after validation, have already been translated and successfully used in the Greek language, (Yannakoulia et al., 2004; MaridakiKassotaki & Koumoundourou, 2005; Fountoulakis et al., 2006). Prior to the start of the study the questionnaires were also piloted to a group of six volunteers aiming to identify possible ambiguous questions. The questionnaires were given to the subjects in the form of single a booklet, together with specific completion instructions, and the subjects had 1 week to complete and return to the investigator. The vast majority of the subjects, however, returned the completed questionnaires the next day. Out of a total of 102 questionnaires that were distributed, 92 were returned properly completed on time. General Background and Lifestyle Questionnaire A specially designed self-administered questionnaire was used to collect information such as: age, weight, height, ethnicity, education, pre-existent mental illness and general nutritional and exercise habits. Eating Attitudes Test The EAT-26 is a 26-item questionnaire widely used, validated and designed to identify eating habits and concerns about weight (Garner & Garfinkel, 1979). To complete the EAT-26, participants rate their agreement with statements about weight and food. A total score at or above 20 in the questionnaire indicates abnormal eating behaviour. The subjects were allocated into two groups, 21 with DE attitudes (EAT-26 ‡ 20) and 71 controls (EAT26 < 20). The mean (SD) EAT-26 score was 10.19 (3.7) for the control group and 28.04 (6.31) for the DE attitudes group (Table 1). Multidimensional Body-Self Relations Questionnaire 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 ten subscales (Cash & Henry, 1995; Cash, 2000): Appearance Evaluation, Appearance Orientation, Fitness Orientation, Health Evaluation, Health Orientation, Illness Orientation, Body Areas Satisfaction, Overweight Preoccupation, Fitness Evaluation and Self-Classified Weight. The MBSRQ uses a five-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, whereas low scores reflect a general dissatisfaction. ª 2009 The Authors. Journal compilation. ª 2009 The British Dietetic Association Ltd 2009 J Hum Nutr Diet, 22, pp. 239–245

Emotional characteristics and disordered eating

State-Trait Anxiety Inventory The 40-item STAI state instrument was used to measure anxiety symptoms (Spielberger, 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. The STAI has been translated into 66 languages, including Greek. The 40 items are divided into two groups: 20 items are formed to record current anxiety symptoms (state anxiety) and the remaining 20 items are scored to record usual anxiety symptoms (trait anxiety). The STAI state scale is scored 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 (Spielberger, 1983). The higher score indicates higher levels of anxiety. BarOn Emotional Intelligence Questionnaire EI can be summarised as the ability to understand and recognise emotional states and to use such an understanding to manage one’s self and other individuals or teams (Fernandez-Berrocal & Extremera, 2006). The EQ-I is a 133-item self-assessment instrument that uses a five-point Likert scale (ranging from ‘Not True of Me’ to ‘True of Me’) to measure EI on five composite scales and 15 content subscales: Intrapersonal (Self-Regard, Emotional Self-Awareness, Assertiveness, Independence and Self-Actualisation), Interpersonal (Empathy, Social Responsibility and Interpersonal Relationship), Stress Management (Stress Tolerance and Impulse Control), Adaptability (Reality Testing, Flexibility, and Problem Solving), General Mood Scale (Optimism and Happiness) (Bar-On, 1997; (Bar-On, 2006). Data from each of these scales are used to create one overall composite EQ-I score together with other aggregate group scores for composite scales and content subscales. Higher scores signify higher levels of EI. Statistical analysis Comparisons between the two groups were made using the Mann–Withney U-test. The Spearman rank order correlation coefficient was used to test for possible correlations among the different variables. Finally, regression analyses were conducted to examine major determining factors that affect DE attitudes, EI, weight preoccupation and anxiety levels. All statistical analyses were performed with SPSS software (version 10.0; SPSS inc., Chicago, IL, USA). 241

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Results

Table 3 Results from State-Trait Anxiety Inventory (STAI) and the Multidimensional Body-Self Questionnaire (MBRSQ)

EAT-26 revealed that 23% of the subjects presented DE attitudes. The mean (SD) BMI was 22.95 (2.54) kg m)2 and 21.91 (2.18) kg m)2 for the DE attitudes group and the control group respectively (Table 1). It is important to note that, of the 21 subjects in the DE attitudes group, only five were overweight (BMI ‡ 25–30 kg m)2) and the remaining 16 subjects were of normal weight (18.50– 24.99 kg m)2). The results indicate that women in the DE atttitudes group had lower levels of EI compared to the control group, particularly in factors such as emotional self-awareness (P < 0.05), empathy (P < 0.05), interpersonal relationships (P < 0.001), stress management (P < 0.05) and happiness (P < 0.05) (Table 2). The differences in body image between the two groups were generally not significant (P > 0.05). More specifically, the MBRSQ has revealed significant differences only in terms of overweight preoccupation (P < 0.001) and illlness orientation (P < 0.01). In addition, the DE attitudes group had higher anxiety scores (STAI); however, the differences were not significant (Table 3). The statistical analysis has shown that anxiety levels (STAI) were significantly correlated with levels of EI (BarOn EQ-I) (P < 0.001) and many of its constituents, such as assertiveness (P < 0.01), self-regard (P < 0.001) adaptability (P < 0.001), reality testing (P < 0.01), flexibility (P < 0.001), stress tolerance (P < 0.001), happiness and optimism (P < 0.001) (Table 4). The BarOn total score of EI was also significantly positively correlated with health evaluation (P < 0.05), health orientation (P < 0.001), height (P < 0.05) and body areas satisfaction (P < 0.05) (Table 5).

Table 2 Total score of Emotional Intelligence (EI) and scores of the statistically significant EI constituents [BarOn Emotional Intelligence Questionnaire (BarOn EQ-I)]

BarOn total score Intrapersonal Emotional Self-Awareness Interpersonal Empathy Interpersonal Relationship Stress Management Adaptability General Mood Scale Happiness

Disordered eating attitudes group (n = 21)

Healthy controls (n = 71)

409.861 143.05 25.52 103.67 27.86 38.71 54.86 89.67 63.14 34.00

424.31 144.15 28.54 114.76 31.41 42.79 58.55 89.90 65.14 36.71

(32.85) (15.43) (4.12)* (18.74)** (6.78)** (5.26)*** (5.69)* (11.65) (6.81) (4.70)*

(45.79) (21.46) (4.78) (11.12) (4.03) (3.93) (8.41) (12.68) (9.55) (5.15)

Data are mean (SD). Mann–Whitney test: *P < 0.05, **P < 0.01, *** P < 0.001.

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STAI MBSRQ Appearance Evaluation Appearance Orientation Fitness Evaluation Fitness Orientation Health Evaluation Health Orientation Illness Orientation Body Areas Satisfaction Overweight Preoccupation Self-Classified Weight

Disordered Eating Attitudes Group (n = 21)

Healthy Controls (n = 71)

86.98 (15.51)

79.66 (14.01)

3.01 3.24 2.99 2.85 3.31 3.44 2.70 3.61 3.25 3.11

(0.50) (0.25) (0.37) (0.27) (0.24) (0.36) (0.21)** (0.44) (0.77)*** (1.38)

2.99 3.29 2.96 2.86 3.12 3.45 2.94 3.54 2.42 3.21

(0.36) (0.27) (0.36) (3.24) (0.39) (0.33) (0.46) (0.61) (0.51) (0.79)

Data are mean (SD). Mann–Whitney test: **P < 0.01, ***P < 0.001.

Table 4 Spearman rank order correlation coefficients between Anxiety levels (State-Trait Anxiety Inventory) and different psychometric parameters of emotional intelligence [BarOn Emotional Intelligence Questionnaire (BarOn EQ-I)] (n = 92) Spearman rho BarOn total score Intrapersonal Emotional Self-Awareness Assertiveness Self-regard Self-Actualisation Adaptability Reality Testing Interpersonal Relationship Flexibility Stress Management Stress Tolerance Impulse Control Mood Factors Happiness Optimism

)0.555*** )0.494*** )0.339** )0.298** )0.558*** )0.488*** )0.417*** )0.307** )0.256* )0.432*** )0.535*** )0.573*** )0.339** )0.571*** )0.54*** )0.58***

*P < 0.05, **P < 0.01, ***P < 0.001.

Table 5 Spearman rank order correlation coefficients between BarOn total score and different variables measured (n = 92) Spearman rho Height State-Trait Anxiety Inventory Health Evaluation (MBSRQ-HE) Health Orientation (MBSRQ-HO) Body Areas Satisfaction (MBSRQ-BAS)

0.234* )0.555*** 0.239* 0.382*** 0.266*

*P < 0.05, ***P < 0.001. MBRSQ, Multidimensional Body-Self Questionnaire. ª 2009 The Authors. Journal compilation. ª 2009 The British Dietetic Association Ltd 2009 J Hum Nutr Diet, 22, pp. 239–245

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Table 6 Spearman rank order correlation coefficients between Overweight Preoccupation (MBSRQ-OP) and different variables measured (n = 92) Spearman rho Body weight Body mass index Emotional Self-Awareness Stress Management Stress Tolerance Overweight Preoccupation (MBSRQ-OP)

0.206* 0.245* )0.291** )0.243* )0.214* 0.444***

*P < 0.05, **P < 0.01, ***P < 0.001. MBRSQ, Multidimensional Body-Self Questionnaire.

Table 7 Spearman rank order correlation coefficients between Disordered Eating Attitudes (EAT-26) and different variables measured (n = 92) Spearman rho Body weight Body mass index EAT-26 Intrapersonal Self-Regard Self Classified Weight

0.406*** 0.487*** 0.444*** )0.228* )0.263* 0.377***

*P < 0.05, ***P < 0.001.

Significant positive correlations have also been shown between overweight preoccupation (MBSRQ-OP) and body weight (P < 0.001), BMI (P < 0.001) and EAT-26 (P < 0.001) scores and negative correlations with self-regard (P < 0.05) and intrapersonal factors (P < 0.05) (Table 6). The Spearman rank order correlation coefficients between DE attitudes (Eat-26) and different variables are shown in Table 5. There were significant negative correlations with emotional self-awareness (P < 0.01), stress management (P < 0.05), stress tolerance (P < 0.05) and overweight preoccupation (P < 0.001) (Table 7). Finally, regression analysis has shown that overweight preoccupation was a very highly significant factor in predicting DE attitudes (b = 0.520, t = 5.11, P = 0.000). Discussion In western countries, DE is reported to affect 9–22% of adolescent girls and young females (le Grange et al., 1998a,b; Jones et al., 2001; Leichner, 2002). In the present study, EAT-26 revealed that almost one in four young women (23%) presented DE attitudes symptomatology, which is a high prevelance given the fact that the majority of the subjects in the DE attitudes group (76.2%) were of normal weight (Table 1). ª 2009 The Authors. Journal compilation. ª 2009 The British Dietetic Association Ltd 2009 J Hum Nutr Diet, 22, pp. 239–245

It is noteworthy that, although DE is frequently associated with psychological, psychiatric and personality difficulties (Kaye, 2008), the role of EI in eating disorders has not been thoroughly investigated in the past. The only relevant study found so far indicated that young women with bulimic symptomatology appear to be more likely to have lower scores of EI, lower levels of adaptability, higher levels of alexithymia and stronger negative emotions compared to women who endorse a less bulimic symptomatology (Markey & Vander Wal, 2007). The results of the present study indicated that women in the DE attitudes group have lower levels of EI compared to the control group, particularly in factors such as emotional self-awareness (P < 0.05), empathy (P < 0.05), interpersonal relationships (P < 0.001), stress management (P < 0.05) and happiness (P < 0.05) (Table 2). Having a high EI is generally regarded as having a better ability to control emotions and to cope with everyday difficulties, both of which contribute to better mental health. There is evidence that early interventions aimed at improving self-esteem and emotional self-awareness, encouraging interpersonal communication and improving general mood, might also prevent women who are ‘at risk’ from developing eating disorders (O’Dea & Abraham, 2000; Abraham, 2003). Regression analysis has also shown that overweight preoccupation is a significant factor in predicting DE attitudes, which is in accordance with many other studies (Fung & Yuen, 2003; Desai et al., 2008). Previous studies suggest that the onset of eating disorders is often associated with chronic stress (Rojo et al., 2006; Lo Sauro et al., 2008). The results of the current study indicate that the DE atttitudes group had higher anxiety scores (STAI), although the differences were not significant. It is important to note, however, that anxiety levels (STAI) were significantly correlated with levels of EI (BarOn EQ-I) (P < 0.001) and most if its constituents. To enhance our understanding of weight concerns and pressures to be thin, it is necessary to consider the psychological determinants of body image. There is evidence available demonstrating that body image dissatisfaction is one of the most robust risk factors for eating disturbances (Stice, 2002). In the present study, there were few differences in terms of body image variables (MBSRQ) between the two groups, with women in the DE attitudes group reporting significantly higher levels of overweight preoccupation, as anticipated, and a significantly lower illness orientation score (Table 3). The higher levels of overweight preoccupation in the DE attitudes group were anticipated because DE symptomatology is often seen in women with an obsessive preoccupation with being overweight (Desai et al., 2008). The overweight preoccupation scale assesses 243

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fat anxiety, weight vigilance, dieting and eating restraint, whereas the illness orientation subscale assesses reactivity to becoming ill. High scorers are alert to personal symptoms of physical illness and identify those who are apt to seek medical attention, whereas lower scorers are not especially alert or reactive to the physical symptoms of illness. There were no differences between the two groups in terms of body areas satisfaction (MBSRQ), which is encouraging given the fact that body image disatisfaction has been reported in people with DE attitudes and with clinical eating disorders (Fung & Yuen, 2003). Finally, EI was significantly positively correlated with health evaluation, health orientation, height and body areas satisfaction, which implies that an increased EI is associated with a healthier body–self relationship, which is a very important factor in the prevention and management of DE. Future studies, with larger sample populations, should focus in more detail on investigating emotional characteristics associated with EI, in both men and women and in different age groups, in order to provide better insight into the existant inter-relationships with DE and hence facilitate the possible formation of better preventive and management strategies. Conclusions In the present study, young women who demonstrated DE attitudes had lower levels of EI and higher levels of overweight preoccupation compared to females with normal eating attitudes. Due to the reported susceptibility of young females to developing eating disorders, an investigation of the possible role of EI, anxiety levels and disturbed body image, as well their inter-relationships, in the aetiology of DE, warrants further study. Acknowledgments Special thanks to all the participants for their valuable contribution to the study. Conflict of interests, source of funding and authorship The authors declare that they have no conflicts of interest. The study enjoyed institutional support. All three authors contributed to the study design, management and data collection, analysis and interpretation. The manuscript was written by Dr V. Costarelli, who was the supervisor of the undergraduate project. All authors critically reviewed the manuscript and approved the final version submitted for publication.

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