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Body image and eating disorders in female athletes of different sports.

ABSTRACT

Oliveira GL, Oliveira TAP, Gongalves PSP, Valentim-Silva JR, Fernandes PR, Fernandes Filho J. Body Image and Eating Disorders in Female Athletes of Different Sports. JEPonline 2017;20(2):45-54. The purpose of this study was to analyze the prevalence of precursor syndromes of eating disorders and dissatisfaction with body image in 101 athletes of different sports. Two instruments were used for the purpose of the evaluation: (a) EAT-26 (presence of risk factors for the development of eating disorders); and (b) BSQ (dissatisfaction with body image). The BSQ analysis was supplemented by the indirect perception of the athletes' body weight. Anthropometric measurements were performed on all the subjects based on the ISAK standardization, obtaining the body composition of the athletes. Fat percentage was obtained by using the Siri equation from the estimate of body density based on the Withers or Slaughter equation according to the age range of the subjects. The study found that athletes who participate in sports in which body weight control is recommended (such as running, synchronized swimming, rowing, and gymnastics) showed dissatisfaction with their body image and the presence of risk factors for the development of eating disorders even in athletes who presented a healthy body composition according to their standards for age, group, and sex.

Key Words: Body Composition, Body Image, Eating Disorders, Female Athlete

INTRODUCTION

In modern society there is a growing concern with body aesthetics. The concern is a result of the imposition by the media of a stereotyped body image that corresponds to an unreal appearance of thinness. Also problematic is that the body image exists without considering aspects related to health and different physical characteristics of the population (4).

Unfortunately, the dissatisfaction with body image (BI) due to the idea that is important to adjust oneself to established standards in society leads to an increasing number of young people to adopt extremely harmful health measures to control body weight. Such behavior is commonly carried out without professional guidance. Young women, in particular, tend to adopt precursor behaviors of eating disorders that include severe food restrictions, the compulsive dedication to physical exercises, and often times the indiscriminate use of laxatives and diuretics. The result is a persistent dietary disturbance or altered eating behavior that causes a reduction in food consumption with significant impairment in the individual's physical health and psychosocial stability (13).

Some studies (12,24) have emphasized that athletes who practice sports characterized by the lightness of movements, flexibility, art of balance, and mastery of the body (such as artistic and rhythmic gymnastics, and figure skating) and sports that advocate low body weight and body fat percentage (e.g., cross-country running) present a greater prevalence of dissatisfaction with their body self-image and food restriction. Because these are modalities that reinforce the demand for a lean body, some authors consider these modalities as being at risk for the development and establishment of these disorders (4).

The purpose of this study was to analyze the prevalence of precursor syndromes of eating disorders and dissatisfaction with body image in 101 athletes from different sports.

METHODS

Subjects

One hundred and one female athletes from different sports participated in this study. The different sports included: (a) rhythmic gymnastics (GYM) (n = 29, 14.8 [+ or -] 2.8 yrs old); (b) running (RUN) (middle- and long-distance--above 800 m, n = 17; 15.0 [+ or -] 1.8 yrs old); (c) rowers (ROW) (n = 16; 19.0 [+ or -] 2.7 yrs old); (d) junior synchronized swimming (JSS) (n = 19; 15.6 [+ or -] 0.8 yrs old); (e) senior synchronized swimming (SSS) (n = 8, 19.0 [+ or -] 1.3 yrs old); and (f) university athletes (UAT) (n = 12, 20.4 [+ or -] 1.6 yrs old).

Procedures

Instruments

The Eating Attitudes Test (EAT-26), used to evaluate the prevalence of eating disorder precursors, was composed of 26 questions with six response options varying from "always" to "never", distributed throughout three different aspects: factor I (diet), factor II (bulimia and concern with food) and factor III (oral control) (17).

In order to evaluate body image (BI) dissatisfaction the Body Shape Questionnaire--BSQ (6) was applied, an instrument composed of 34 questions presenting six possibilities of answers ranging from "always" to "never". The dissatisfaction can be mild (score between 81 and 110); moderate (score between 111 and 140); severe (score greater than or equal to 140); or none (score less than or equal to 80). In order to complement the analysis of dissatisfaction with body image, the indirect perception of the athletes' body weight was verified by the difference in their current body weight, measured by the evaluators, and the body weight declared to be ideal by the athletes. We obtained the frequency in which the athletes declared a greater value (>2 kg) than their measured weight as the ideal body weight (= desire to gain weight); a lower value (<2 kg) than the measured body weight as the ideal body weight (= desire to weigh less), and a value similar to the measured body weight as the ideal body weight ([+ or -] 2 kg of body weight measured) as proposed by Nunes et al. (16).

Anthropometric Evaluation

All subjects underwent anthropometric evaluation in accordance with the standardization of the International Society for the Advancement of Kinanthropometry (ISAK) (15). Fat percentage (%F) was determined using the Siri equation (21) based on the estimate of body density proposed by Withers et al. (10). The Slaughter equation (22) was used to obtain fat percentage in subjects who were less than 18 yrs old. All the evaluators presented the acceptable technical error of up to 5% for anthropometric measures (19), thus guaranteeing the reliability of the measurements.

Ethical Aspects

This study was approved by the Ethics and Research Committee at the Clementino Fraga Filho University Hospital (CEP-HUCCF-UFRJ) of the Federal University of Rio de Janeiro under number 1.815.800, in compliance with Resolution 466 for human research from the National Health Council in December 12, 2012. All the athletes signed an informed consent form (ICF) authorizing their participation in the study. Among athletes under the age of 18, the legal guardian was invited to authorize the participation of the minor by signing the same consent form (ICF). The participants' anonymity and privacy were preserved throughout the study. Their adherence was spontaneous, exempt from any form of remuneration,

and each volunteer was able to abandon evaluations at any stage of the protocol.

Statistical Analyses

The descriptive statistics of the data were expressed by mean and standard deviation. As for testing the hypotheses, Shapiro-Wilks was performed initially in order to verify the normality of the data. Then, ANOVA ONE-WAY and Tukey's posterior test were adopted with a statistical significance set at 5%. To determine the correlation between the answers given to the two questionnaires (EAT-26 and BSQ), the Spearman test was used with 5% significance. Relative frequency (%) analysis with a sensitivity of 5% was applied to determine the prevalence of questionnaire answers. All statistical procedures were performed in the program SPSS 22.0 for Windows.

RESULTS

Characteristics of Subjects

Table 1 shows the general characteristics and body composition of the athletes in this study distributed by the different sports.

The average age of the athletes varied from 12 to 22 yrs old and, along with stature, presents a statistically significant difference between the athletes of different sports. The mean values of body weight presented by the athletes referring to the different sports considered in the study reflect the specificity of these sports. The group of athletes in rhythmic gymnastics, a sport in which having low body weight is an advantage, presents a lower average value for this variable while the rowers have higher values. Although they are taller and heavier, it is observed that the rowers have an average %BF similar to that of the rhythmic gymnasts. Thus, the difference in total body weight of the rowers can be attributed to a higher amount of lean mass. This lean body mass is attributed to resistance training in order to develop the strength that is important for this sport. Relative levels of body fat (%BF) tend to be lower in sports that require movement or lifting one's own body weight (4) as presented by rhythmic gymnasts and rowers. Table 2 shows the relative frequency of athletes who presented with altered results in EAT-26 (Eating Attitudes Test) and BSQ (Body Shape Questionnaire).

In Table 2, for the analysis of eating disorders, it can be observed that only the senior synchronized swimming and university athlete groups presented no changes in the EAT-26 result. In all the different sports, there was dissatisfaction with BI, at least at the mild level, showing concern with physical form among these athletes.

Table 3 contains questions that presented higher frequencies of answers regarding the most frequently adopted methods for body weight control by athletes.

Table 4 presents the result of the analysis of the athletes' indirect body weight perception. It can be seen in Table 4 that gymnasts, rowers, and swimmers felt fat compared to their current body weight. This result is directly related to those presented in Table 2 in which athletes are dissatisfied with BI and body weight control practices. Table 5 presents the results of the correlation coefficient between the results of the EAT-26 and BSQ questionnaires with body weight, height, and %BF obtained in the different sports.

This analysis attests that dissatisfaction with body weight has a positive and significant correlation with body weight and %BF. That is, the higher these variables are, the greater the dissatisfaction is with current body weight. The impact of this dissatisfaction with body shape, with dietary behavior expressed in EAT-26, and dissatisfaction with BI (BSQ) is also positive and significant.

DISCUSSION

The findings in the present study verified that athletes from all the evaluated sports had healthy body fat adiposity (12), and their %BF results were compatible with athletes from the same sport available in the literature: 22.6% for gymnasts, 17% to 21% for runners, 20.7% for rowers, 23.9% for swimmers, and 15.8% to 19% for athletes representing ball sports(11,13). Even so, most of the athletes in the different sports were dissatisfied with BI, with a higher prevalence for synchronized swimmers, runners, rowers, and gymnasts, according to the trend indicated in other studies (8) for different sports that recommend an ideal body pattern like these.

Due to a variety of intervening factors in the athlete's body composition, such as the metabolism of each athlete, the act of establishing an ideal body fat standard for athletes has been questioned in the literature (10). However, there are trends related to certain sports in which athletes present a greater or lesser amount of body fat.

In sports such rhythmic and artistic gymnastics, long-distance running, rowers, and high jumpers, the athlete has to move with agility. Any excess of body fat can impair performance while in sports such as long-distance swimmer, hammer thrower, shot put, and discus, a little extra subcutaneous body fat may help, provided that it is associated with the adequate development of other body composition components, such as muscle mass (18).

Due to the reduction in body weight being a fundamental characteristic for performance, sports technicians who value aesthetics or a specific body weight have exerted pressure on athletes to reduce body weight without considering the negative effects on the athlete's health, such as low energy availability, the development of menstrual and bone dysfunctions along with eating disorders, components that together characterize the Female Athlete Triad (FAT) (1). In fact, attention to female athletes' health, in particular in relation to dissatisfaction with body image have been verified by studies available in the international literature as triggering eating disorders and possible FAT in these young women (1,4,7).

Schweiger (20) observed among 487 swimmers aged between 9 and 18 yrs old, 62% self-imposed restrictive diets, 77% had food aversions, 12% self-induced vomiting, 2.5% used laxatives, and 1.5% used diuretics. These findings suggest that dissatisfaction with physical form is a strong motivator of these inadequate weight control behaviors.

Fortes et al. (8) showed with runners that 63% of the variance in food restriction presented by the athletes was explained by the scores obtained in the BSQ instrument, which indicates the dissatisfaction with body image as a possible promoter of the development of the athletes' eating disorders. Their work corroborates the findings in the present study. Concern with aesthetics and strong pressure to reduce body weight may be the general explanation for the increased prevalence of diet-related problems among athletes (2,9).

The instruments used in the present study pointed out the presence of at-risk precursor syndromes for the development of ED in 4 of the 6 groups of athletes analyzed. The sports that presented changes in EAT-26 (gymnastics, running, rowing, and junior synchronized swimming) are included among the sports that are classified in the literature as having the highest risk for developing ED (gymnastics, synchronized swimming, swimming, longdistance skiing, long-distance running, judo, weightlifting, and taekwondo) (4,9).

The BSQ pointed to the prevalence of varying degrees (mild, moderate, and severe) of dissatisfaction with body image in all the different sports considered. Although the senior synchronized swimmers presented a higher prevalence, it was restricted to the mild level. However, in the sport of gymnastics, rowing, and junior synchronized swimming, the prevalence of body image dissatisfaction was at the highest level of severity (Table 2). This finding suggests a greater vulnerability of these athletes to pressures to lose weight.

The prevalence of abnormal eating behaviors suggestive of being at risk for the development of ED presented in the questions by the groups (Table 3) supports the concern of controlling body weight and the athletes' use of inappropriate practices (such as self-applied and usually restrictive diets) to reach desired body weight standards. These attitudes may be motivated by dissatisfaction with physical form and the need to lose body weight, as pointed out in Table 4. Although some of these behaviors are totally incompatible with systematic and high level sports, they present high adherence among the evaluated athletes.

The changes in the athletes' dietary behavior observed in the present study come primarily from dissatisfaction with their body weight and body image (of which both were detected by the BSQ). Some studies (4,8,14,16) have shown that the standardization of an ideal body or body image influences changes in eating behavior, as verified in the findings of Coelho et al. (5) who showed that body dissatisfaction is one of the determinants of food restriction that may trigger eating disorders.

The results of the present study indicate that the athletes who are within or even below healthy standards for body weight and relative body fat (Table 1) presented notable changes in the instruments used to assess eating disorders and body image (BSQ) (Table 2). Consider how the ideal body weight (i.e., that which you would like to have) values below current (measured) body weight expresses a desire for body weight loss and dissatisfaction with current body weight. This dissatisfaction can lead to the frequent use of diets and other inadequate body weight control devices, thus creating the ideal environment for development of ED (16).

The analysis of the relationship between dissatisfaction with one's current body weight in the variables that express body size and shape (Body Weight, Stature and %BF), those that portray dietary behavior (EAT-26) and dissatisfaction with BI (BSQ) are presented in Table 5. The results for the positive correlation presented between the dissatisfaction with body weight and %BF presented by those evaluated corroborate the findings of Anton et al. (3) who also verified that the discrepancy between current and ideal body weight is associated with changes in eating behavior and the need to lose weight.

CONCLUSIONS

Athletes from at-risk modalities (depending on the aesthetics of movements and low body weight), such as runners, swimmers, gymnasts, and rowers, presented a high prevalence of syndromes at risk for the development of ED. Dissatisfaction with body image was observed in all groups, but its prevalence varied according to the sport, with higher values for athletes participating in sports that advocate leanness or a specific body weight such as synchronized swimming, rowers, and gymnasts.

This finding was supported in the complementary analysis of the indirect perception of the body weight of the athletes, since even though they were within the ideal standard of relative fat for athletes from these respective modalities, the athletes demonstrated dissatisfaction with their body weight portraying the need to lose weight. This result suggests that athletes from these sports are more vulnerable to pressures for weight control.

The present study found a positive correlation between dissatisfaction with body image and prevalence of at-risk precursor behaviors for the development of eating disorders in the sample of athletes selected in this study. It is recommended that coaches and family members work mainly with beginning teams that do not exert pressure on athletes in relation to body weight or ideal body image for their sport. Hence, it is imperative that athletes of different sports consult with doctors, nutritionists, psychologists, and exercise physiologists to help preserve the athletes' health and promote a longer and healthier athletic performance.

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Glauber Lameira de Oliveira (1), Talita Adao Perini de Oliveira (1), Patricia Soares de Pinho Goncalves (1), Joao Rafael Valentim Silva (2), Paula Roquetti Fernandes (3), JosE Fernandes Filho (1)

(1) School of Physical Education and Sports, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil, (2) Departament of Physical Education of Federal University of Rondonia, Rondonia, Brazil, (3) Center of Excellence in Physical Assessment, Rio de Janeiro, Brazil
Table 1. General Characteristics and Body Composition.

Different Sports   Age                       Stature
                  (yrs)                       (cm)

GYM (n = 29)      14.8 [+ or -] 2.8 (f)      157.0 [+ or -] 9.8
                                                   (c, d, e)
RUN (n = 17)      15.0 [+ or -] 1.8 (f)      161.9 [+ or -] 0.1 (c)
ROW (n = 16)      19.0 [+ or -] 2.7 (b a d)  172.9 [+ or -] 8.3
JSS (n = 19)      15.6 [+ or -] 0.8 (f e)    162.8 [+ or -] 5.1 (c)
SSS (n = 08)      19.0 [+ or -] 1.3 (b, a)   165.4 [+ or -] 6.5
UAT (n = 12;      20.4 [+ or -] 1.6          165.0 [+ or -] 0.0 (a)
ANOVA (P<0.05)     1.[10.sup.-17]              7.[10.sup.-8]

Different Sports   BW                           BF
                  (kg)                         (%)

GYM (n = 29)      47.9 [+ or -] 9.8 (c, d, e)  18.6 [+ or -] 4.1
RUN (n = 17)      49.3 [+ or -] 5.2 (c)        22.0 [+ or -] 4.2
ROW (n = 16)      67.6 [+ or -] 9.4            18.9 [+ or -] 3.7
JSS (n = 19)      53.5 [+ or -] 5.0 (c)        22.0 [+ or -] 3.6
SSS (n = 08)      57.4 [+ or -] 3.3 (c)        21.7 [+ or -] 2.0
UAT (n = 12;      59.1 [+ or -] 8.6 (a b)      23.1 [+ or -] 2.8
ANOVA (P<0.05)     1.[10.sup.-11]               4.[10.sup.-6]

BW = Body Weight; BF = Body Fat; SSS = Senior Synchronized Swimming;
JSS = Junior Synchronized Swimming; GYM = Gymnasts; RUN = Runners;
ROW = Rowers; UAT = University Athletes; a [not equal to] to
Gymnastics; b [not equal to] to Running; c [not equal to] to Rowing; d
[not equal to] to Junior Synchronized Swimming; e [not equal to] to
Senior Synchronized Swimming; f [not equal to] to University Athletes

Table 2. Prevalence of Positive Responses in EAT-26 and BSQ in the
Different Sports.

        Instruments   GYM      RUN       ROW      JSS       SSS
                     (n = 29)  (n = 17)  (n = 16) (n = 19)  (n = 08)

EAT-26  Positive     13.8%     23.6%     12.5%    15.8%        0%
        Normal       86.2%     76.4%     87.5%    84.2%      100%
BSQ     Severe        6.8%        0%      6.3%     5.3%        0%
        Moderate     13.7%        0%        0%    21.1%        0%
        Mild         13.7%     11.8%     31.2%     5.3%     62.5%
        Normal       65.8%     88.2%     62.5%    68.3%     37.5%

         UAT
         (n = 12)

EAT-26     0%
         100%
BSQ        0%
         8.3%
        25.0%
        66.7%

Table 3. Responses Suggestive of Altered Eating Behaviors.


                                       GYM       RUN
                                      (n = 29)  (n = 17)

Questions from EAT-26
1. I avoid trying "fattening" foods    65.5%    58.8%
2. I desire to be thinner              27.6%    11.8%
3. When I exercise I think about       37.9%    29.4%
   burning calories
4. I worry about the possibility of    27.6%    47.1%
   having body fat
   Questions from BSQ
5. Excessive worry about physical      58.7%    39.2%
   form to the point of feeling the
   need to go on a diet
6. Fear of getting fat                 66.7%      51%
7. Preference for having an empty      68.8%    34.3%
   stomach
8. Excessive worry about physical      73.9%      49%
   form to the point of feeling the
   need to exercise

                                        Modalities
                                       ROW       JSS
                                      (n = 16)  (n = 19)

Questions from EAT-26
1. I avoid trying "fattening" foods    87.5%    57.9%
2. I desire to be thinner              28.1%    26.3%
3. When I exercise I think about       53.1%    47.4%
   burning calories
4. I worry about the possibility of    56.3%    21.1%
   having body fat
   Questions from BSQ
5. Excessive worry about physical      53.1%    50.0%
   form to the point of feeling the
   need to go on a diet
6. Fear of getting fat                 52.1%    50.9%
7. Preference for having an empty      55.2%    51.8%
   stomach
8. Excessive worry about physical      53.1%    46.5%
   form to the point of feeling the
   need to exercise

                                       SSS      UAT
                                      (n = 8)  (n = 12)

Questions from EAT-26
1. I avoid trying "fattening" foods   50.0%    33.3%
2. I desire to be thinner             75.0%    25.0%
3. When I exercise I think about      62.5%    33.3%
   burning calories
4. I worry about the possibility of   12.5%    16.7%
   having body fat
   Questions from BSQ
5. Excessive worry about physical     66.7%    48.6%
   form to the point of feeling the
   need to go on a diet
6. Fear of getting fat                54.2%    45.8%
7. Preference for having an empty     60.4%    51.4%
   stomach
8. Excessive worry about physical     79.2%    51.4%
   form to the point of feeling the
   need to exercise

EAT-26 = Eating Attitudes Test; BSQ = Body Shape Questionnaire

Table 4. Self-Perception of Body Weight.

                                        Desire
      Modalities
                   Gain BW              Lose BW
                   Ideal BW 2 kg above  Ideal BW 2 kg below
                   that measured        that measured


GYM (n = 29)        4.3%                52.3%
RUN (n = 17)       12.5%                 6.3%
ROW (n =16)        13.0%                60.0%
JSS (n = 19)        5.9%                58.9%
SSS (n = 8)           0%                62.5%
UAT (n = 12)        8.3%                33.4%


      Modalities
                   Maintain BW
                   Ideal BW varying
                   between 2 kg above or
                   below that measured

GYM (n = 29)       43.4%
RUN (n = 17)       81.2%
ROW (n =16)        27.0%
JSS (n = 19)       35.2%
SSS (n = 8)        37.5%
UAT (n = 12)       58.3%

BW = Body Weight

Table 5. Matrix Correlation between the Variables that Express Body
Size and Shape, Perception of Body Image, and Precursor Syndromes of
Eating Disorders.

                 Dietary   Body Image        Body Size and Shape
                 Behavior
   Modalities
                 EAT-26    BSQ        BW        Stature  Relative Body
                                     (kg)      (cm)      Fat (%)

BSQ              0.48 (*)
BW (kg)          0.18      0.28 (*)
Stature (cm)     0.23 (*)  0.22 (*)  0.79 (*)
Relative Body    0.004     0.13      0.34 (*)  0.07
Fat (%)
Current_BW --    0.25 (*)  0.21      0.48 (*)  0.13      0.34 (*)
Ideal_BW

EAT-26 = Eating Attitudes Test; BSQ = Body Shape Questionnaire;
Current_BW--Ideal_BW = Difference between the Measured Body Weight and
the Desired Body Weight; (*) P<0.05; BW = Body Weight
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Author:de Oliveira, Glauber Lameira; de Oliveira, Talita Adao Perini; de Pinho Gongalves, Patricia Soares;
Publication:Journal of Exercise Physiology Online
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Date:Apr 1, 2017
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