The Whole Image for Athletes: A Body Image Enhancement & Disordered Eating Prevention Online Program
Athena Robinson PhD, Stanford University, School of Medicine, Department of Psychiatry & Behavioral Sciences
Disordered Eating (DE) and body image (BI) concerns, prevalent among college athletes, significantly and negatively impact physical and emotional well-being, academic and sports performance, peers, and the campus community. Online BI platforms have several advantages over in-person interventions (i.e., anonymity, personalization, easy anytime access among a mobile generation, and dissemination potential). This study 1) developed the Whole Image for Athletes (WIA), an online BI enhancement course with college athlete tailored content and 2) piloted WIA among Stanford athletesto investigate its effectiveness and
acceptability. WIA Program: WIA is comprised of 8 weekly modules (approximately 15-20 minutes each) which included psychoeducation and BI enhancement techniques empirically supported for college students and athletes. Content, including videos, images, examples, exercises, and interactive questions, were all tailored to be highly relevant to the college athlete experience (Image 1). Participants: Of the 29 Stanford athletes enrolled in WIA, 8 (38%) were male, 19 (65.5%) were receiving scholarship for their sport participation, 24 (85%) self-identified as White, and 7 (25%) had been approached with concerns about their eating or weight over the previous 6 months. Thirteen different sports were represented. Participants completed questionnaires pre- and post-WIA. Course Acceptability: Results show that WIA was highly acceptable as indicated by participant engagement (Figure 1). Specifically, WIA yielded 96.6% module completion, 96.6% post-WIA assessment completion, and 97% interactive question completion. The content of all 8 WIA modules were rated as at least moderately relevant and or greater. Finally, 89% of WIA participants reported they would recommend the program to a friend in need. Course Effectiveness: Nearly all measures demonstrated modest decreases in BI and DE concerns from pre- to post-WIA with corresponding small to medium effect sizes (Figure 2). Preliminary Conclusions: WIA, a brief 8-week online intervention lasting approximately 120 minutes total, yielded small to moderate reductions in potential risk factors for ED onset among college athletes. Stated differently, WIA, the first online BI and DE intervention tailored specifically for
both male and female athletes, achieved modest
improvements in BI and DE concerns and high acceptability among a small pilot sample of Stanford athletes. Dissemination: Limited on-campus BI and DE treatment resources make dissemination of innovative online interventions a priority. However, constrained financial and personnel resources hinder college campuses’ willingness and ability to adopt, implement, and maintain intervention programs. The short- and long-term viability of such programs could greatly increase if the NCAA implemented guidelines or recommendations for campuses to integrate and administer them.
Figure 2. Preliminary Effectiveness Results
Figure 1. Program Component Completion Rates Image 1. WIA Online Interface Screenshot
The Whole Image for Athletes: A Body Image Enhancement & Disordered Eating Prevention Online Program
Principal Investigator: Athena Robinson, PhD
Site: Stanford University, School of Medicine, Department of Psychiatry and Behavioral Science
I. WIA Project AbstractEating Disorders (ED) and body image (BI) concerns, prevalent among college athletes, significantly and
negatively impact physical and emotional well-being, academic and sports performance, peers, and the campus community. Online BI platforms have several advantages over in-person interventions (i.e., personalization, anonymity, easy anytime access among a mobile generation, and dissemination potential). This study 1) developed the Whole Image for Athletes (WIA), an online BI course with collage athlete-tailored content and BI enhancement techniques and 2) piloted WIA among Stanford college athletesto investigate its effectiveness and acceptability. Limited on-campus ED and BI treatment make innovative online college athlete-tailored interventions a priority.
II. PROBLEM STATEMENT
For most, sport participation is a positive experience, providing physical and psychological benefits (1). For some, however, sport may be potential risk factor for developing eating disorders (EDs) and/or exacerbating negative body image (BI;1-2). EDs have significant negative impact upon college athletes’ physical and emotional well-being, academic and sports performance, and affect their peers and the campus community. Although athletes with sub-clinical ED and poor BI may not develop severe, life-threatening consequences, they typically experience many of the same associated psychological, physical, and behavioral problems found among athletes with diagnostic-level symptoms (3). Given the high prevalence of ED and BI concerns among college athletes, researchers recognize the need to reduce risk factors and protect against the development of severe clinical concerns (4). ED prevention, including BI enhancement, programs for college non-athletes have prevented ED onset and improved BI in this population (5-11). A recent study tested such a program among female college athletes with success (12). However, such programs are limited in
generalizability and accessibility specifically due to their in-person intervention delivery protocols. In addition, their specific evidence is nonexistent for males, and very preliminary and limited for college female athletes. ED and BI experts agree that such programs must be tailored specifically for college athletes in order to achieve favorable uptake and efficacy (13). Thus, the current study proposed to develop the WIA, an ED prevention and BI enhancement online course tailored specifically for college athletes, and pilot WIA among Stanford athletes. The proposal is innovative in its match of a clinical need and service (i.e., low BI and ED prevention among a vulnerable and unique population) within a relevant and easily accessible online learning platform, practical and feasible to implement among a mobile and internet-integrated generation.
III. LITERATURE REVIEW
Eating Disorders and Body Image Concerns among College Athletes
Disordered eating behaviors and attitudes are prevalent among college athletes who are at greater risk for developing EDs than college non-athletes (1;14). Among female college athletes, the point prevalence of meeting DSM-IV ED criteria was 7% (15), while 35% and 38% were assessed as at risk for anorexia and bulimia nervosa respectively (16). Although male college athletes reported experiencing relatively less weight-related pressure than their female counterparts (17), about 12% endorsed binge eating, and 9.5 and 38% were assessed as at risk for anorexia and bulimia nervosa respectively (16).
EDs have a multitude of significant negative repercussions upon both male and female college athletes (see Table 1). In fact, anorexia nervosa has the highest mortality rate of any psychiatric disorder.
Table 1. ED Consequences for Male and Female College Athletes
Physical Health Female Athlete Triad (i.e., inadequate energy intake,
irregular/cessation of menses, and decreased bone mineral density); osteoporosis; enamel erosion; esophageal rupture; electrolyte imbalance; reproductive disorders and sexual dysfunction (low estrogen/testosterone); cardiovascular disease; bradycardia; cardiac arrest; death
Mental Health Depression; anxiety; low self-esteem; guilt; shame; hopelessness; difficulty adjusting to college environment; suicidal ideation/attempt Sports
Performance
Recurrent stress fracture/injury; dehydration; performance anxiety; increased recovery time; decreased concentration, strength, and performance
Online Platforms for ED Prevention and BI Enhancement
Currently available ED prevention and BI enhancement programs have limited generalizability and
accessibility due to their in-person delivery. Research also lacks application of such programs among both male andfemale college athletes. Indeed, college athletes’ help seeking barriers include lack of time, and fears of negative career repercussions and risk of discovery by school officials/coaches/teammates (18). Thus an online platform, practically integrated into college athletes’ academic lives, which offers a higher degree of anonymity and discretion, is a relevant and intriguing proposal.
A large body of programmatic research, launched and conducted at Stanford over the past decade, developed and honed online ED prevention programs. TheHealthy Body Image Program, whose suite of programs includes the original The Whole Image course, set a national standard for ED prevention and BI enhancement, and is currently implemented on 30+ campuses (cite). The Whole Image is an online
interactive course that enhances student’s BI by changing both individual and collective culturalnorms and attitudesabout body appearance expectations (19; see Image 1). The Whole Image is feasible to deliver and reduced factors associated with EDs including weight and shape concerns, negative verbal communication about body image, and thinness ideal beliefs (20). This study developed and piloted WIA, a significant adaptation of The Whole Image, specifically tailored for both male and female college athletes. Image 1. Sample Screen-Shot from the Original Whole Image Online Course
Application in a Practical Environment and Educational Setting
This study innovatively matches a clinical need and service (i.e., ED prevention and BI enhancement programming among college athletes) within an easily accessible online learning platform. Moreover, the course is well-designed in style, content, and layout, making browsing easily navigable and appealing (see Image 1).
The integration of WIA into college athletes’ academic lives is logistically and practically achievable via an online course format. Delivery of WIA as an online course has specific advantages over in-person access within existing health promotion and clinical services (see Table 2).
This study has significant short- and long-term impact potential. WIA will directly serve and benefit Stanford’s athletic community. Subsequent WIA iterations will be enhanced and refined as a direct result of this study’s results. Moreover, given online learning platform flexibility, WIA can readily be upscaled to reach college campuses nationwide, significantly broadening its impact and benefit.
Table 2. Specific Benefits of Online Platform Delivery
1. Increase speed and ease of access through personal laptops and mobile devices at any convenient time 24 hours per day 7 days per week
2. Increase anonymity and de-stigmatize participation 3. Relevant and desirable platform to a mobile generation
4. An effective online model of adaptive learning and user-tailored personalization to augment comprehension
5. Facilitate stakeholder partnership and collaboration in innovative online programming while addressing a significant physical and mental-health concern among athletes IV. CONCEPTUAL FRAMEWORK
WIA aims to enhance CA’s BI by changing both individual and collective cultural norms and attitudes about body appearance expectations specific to college athletes. WIA is based on and employs theoretical principals and techniques from two approaches efficacious among college students: cognitive dissonance-based prevention (DBP) and healthy weight intervention (HWI).
DBP utilizes cognitive dissonance theory which postulates that inconsistencies between behavior and beliefs will produce dissonance, and behavior change must occur to alleviate dissonance (21). In DBP for BI, for example, participants speak and act against the thin-ideal standard of feminine beauty through activities designed specifically to produce cognitive dissonance (12). Impressively, DBP is effective among various high-risk samples (5;6;9;21) and reduced ED onset by 60% compared to assessment only control (10). Image 1 is a sample screen shot from the original Whole Image program whose content is based on DBP ideals. HWI encourages small changes in eating and exercise to help maintain a healthy weight. HWI reduced prevalence of ED risks factors among adolescent girls and female sorority members (7;9;10). Both DBP and HWI were efficacious in improving target variables at post-treatment and 1year follow-up (e.g., negative affect, bulimic pathology, shape concern) when delivered in-person via team-matched athlete-peers to female college athletes within a specific team (i.e., only volleyball players together) (12).
Relevant Data and Research Guiding the Proposed Pilot Program
WIA is based on the success of three previous lines of research (detailed above):
1) Empirical support for DBP and HWI theoretical principals and techniques among college students and preliminary data among college female athletes (12).
2) The programmatic line of online ED prevention and BI interventions that demonstrated implementation feasibility, user acceptability, and ability to change intervention outcomes among college students (11;19).
3) The original Whole Image course effectively improved student’s BI as indexed by lowered post-program scores (thinness idealization (p = 0.01); weight and shape concerns (p = 0.03); fat talk (p = 0.01); 20).
V. DATA AND METHODOLOGY Research Phases
This study was completed in two research phases as originally proposed (Figure 1). In Phase I (5 months), WIA was developed. In Phase II (5 months) 1) participants were recruited, enrolled, and completed WIA, 2) data was analyzed and interpreted, and 3) the final project report completed.
Figure 1. Project Timeline
2014 Apr May Jun Jul Aug Sep Oct Nov Dec
WIA adaptation Recruit;
Baseline
WIA Active Post- Treatment
2015 Jan
Report; Study End
Note: Phase I=green; Phase II=gray; WIA=Whole Image for Athletes; Recruit=participant recruitment; Baseline=baseline assessment; Post-Treatment=post-treatment assessment; Report=final project report provided to NCAA.
Recruitment
Recruitment methods included paper- (brochures placed in Stanford dorms, lockers rooms, dining halls, Sports Medicine, Student Health Services, Department of Psychiatry) and electronic-based advertisements (email distribution lists via the Athletic Department, Peer Health Educators, and student athlete activist groups).
Screening and Eligibility
If eligible, athletes were consented to participate. If ineligible, appropriate referrals were provided as needed. The study initially proposed to enroll 30 Stanford athletes which increased to 40 subsequent to the Interim Report. Participant inclusion criteria were: current Stanford undergraduate student and athlete; available and committed to complete WIA and assessments; literate in English (required because WIA materials are in English); internet access. The only exclusion criteria was current psychosis or severe depression with suicidal risk.
Assessment Protocol
There were two comprehensive 1 hour online assessments: baseline (BL) and post-treatment (PT; see Table 3).Each assessment was comprised of the same battery of measures, with the exception of the Client Satisfaction Questionnaire which was obtained at PT only. Questionnaires measured both the program’s effectiveness in changing outcomes and course acceptability (including program use and learning metrics), which represent the study’s two primary aims.
Table 3. Assessment Timing
Measure Baseline WIA Post-Treatment
Course Effectiveness Body Image Measures
1. Satisfaction & Dissatisfaction with Body Parts Scale (22) x x
2. Body Image Culture Survey (23) x x
3. Contextual Body Image Questionnaire for Athletes (24) x x
Disordered Eating Behavior Measures
1. Compulsive Exercise Test (25) x x
2. Eating Disorder Examination Questionnaire (26) x x
3. Disordered Eating among Athletes Questionnaire (27) x x
Course Acceptability
Client Satisfaction Questionnaire (28) x
Single ‘Relevancy’ Item (per WIA module) x x
Note. WIA=the Whole Image Athletes online course; numbers in parentheses are the measure’s reference number.
Course Effectiveness: Body Image Measures
Items from the Satisfaction and Dissatisfaction with Body Parts Scale (22) will be used to assess body dissatisfaction with nine body parts (e.g., stomach, thighs, hips). This scale has shown internal consistency, test–retest reliability, predictive validity, and sensitivity to detecting intervention effects (29). Responses ranged from 0 (extremely satisfied) to 6 (extremely dissatisfied); a total score is calculated as an average of all items. The Body Image Culture Survey (also referred to as the Idealization of Thinness Scale) was recently used among college populations with robust validity and test-retest reliability (23). Responses are on a likert scale and range from 0 (no chance) to 5 (certain to happen; example item: “Being thinner than I am now would increase my sense of self-worth”); a total score is calculated as an average of all items. The Contextual Body Image Questionnaire for Athletes (CBIQA) is well validated (24) and assesses how satisfied athletes are with their body image/appearance in both sport and non-sport (i.e., daily life) contexts. The total scores for both sport and daily body image sections will be presented and are calculated as an average of all items pertaining to either section.
Course Effectiveness: Disordered Eating Behavior Measures
The Compulsive Exercise Test (CET) is a validated 24 item measure assessing attitudes about exercise (25). Responses are based on a 6 point likert scale ranging from 0 (never true of me) to 5 (always true of me), and a total score for the CET is calculated as a sum of all items (yielding a total of 120 possible). The Eating Disorder Examination Questionnaire (EDE-Q) is a validated self-report version of the EDE structured clinical interview (26) which yields 4 subscales eating, weight, and shape concerns, and restraint. Responses are in likert scales and range from 0 (none of the previous 28 days) to 6 (every day of the previous 28 days). The Disordered Eating among Athletes – Questionnaire (
DEA-Q
) was developed by this research team (as indicated in the Interim Report) given focus group data with Stanford athletes (n=18; 50% male; 12 teams represented) which indicated that, as expected, college athletes experience with low BI and DE may differ importantly from their non-athlete peers (27). For example, college athletes may encounter:• Criticisms/suggestions about weight, shape, physique, and percent body fat from coaches, athletic trainers, and/or sports medicine physicians;
• Competitor and spectator comments about weight, shape, physique, percent body fat, and/or performance;
• Weight requirements for classification and/or participation in sport
• High energy demands of recurrent, intensive, and long practices/games/competitions;
• A potential additional risk of recurrent injury given the high training and performance demands in sport. Thus, a new measure, the DEA-Q, containing such subculture-specific language and tailored inquiry into college athletes specific experience was warranted and consequently developed and added to the current study’s assessment battery. The DEA-Q is comprised of 47 items with Likert scale response formats ranging from 1 to 5 (with higher scores indicating greater symptom severity) and a total score is calculated as an average of all items. Items from the Stanford-Washington University ED Screen (30) were administered to categorize participant’s current ED behaviors and risk level so that appropriate referrals for treatment for disordered eating could be provided as needed.
Course Acceptability Measures
The Client Satisfaction Questionnaire (CSQ-8; 28) is an internally consistent 8-item self-report scale measuring satisfaction with treatment and was administered at PT. A total score is calculated via a sum with a possible range of 8 to 32, with higher scores indicating higher levels of satisfaction. A single item rating the relevancy of each module’s content to the participant’s experience as a college athlete, based on a 6 point likert scale from 0 (not at all relevant) to 6 (extremely relevant), will be included at the end of each module. Program use (e.g., user log-in rates, interactive online exercise completion rates) and learning metrics (qualitative and quantitative indices of participant learning) are readily attainable from the online platform.
WIA Online Course Format
WIA is comprised of 8 weekly modules that were completed by the participants within one academic quarter. Each module required approximately 15-20 minutes to complete and included psychoeducation and BI enhancement techniques empirically supported for college students and athletes. Content, including images, exercises, and provided examples, were all tailored to be highly relevant to the college athlete experience. A list of topics by module is listed in Table 4. Each module contained a melody of: reading material, video, and multiple choice, true false, and free response questions. Each week one new module was released on the website. This was done in order to allow athletes time to focus on each new module, without becoming overburdened by the entire program simultaneously. Modules that were released in previous weeks were always available after they debuted. Modules were comprised of several sections in order to break up the amount of material to be presented within one module. Sections were designed to take no more than a few minutes each. Practice, application, and generalization of learning material was encouraged through weekly off-line assignments, called Bold Move. Examples of Bold Move assignments included: avoid negative or demeaning comments and thoughts about your body in both sport and non-sport contexts; challenge yourself to stop troublesome food talk; increase one of your current behaviors that will improve your attitudes and thoughts about your body; praise a teammate for their performance instead of their physique. The first section of each module included a Bold Move Review which invited reflection on how successful and/or difficult it was to implement the previous week’s Bold Move and consider solutions to the barriers that impeded success.
Table 4. List of Topics by Module
Week Module
1 WIA Welcome 1 Body Aesthetics
2 The Continuum: From Healthy to Disordered Eating and Exercise Behavior 3 Prevention and Intervention: Short-Term Repercussions
4 Prevention and Intervention: Long-Term Repercussions 5 Team Culture Change
6 Changing Body Talk and Food Talk
7 Building and Sustaining a Balanced and Sport-Focused Approach to Eating and Exercise 8 Mindfulness in Improving Body Image and Reducing Disordered Eating
WIA Close Out WIA Website Interface
The WIA website interface with all 8 modules available is highlighted in Image 2. At the top of the screen is the course and student name. Along the left hand side column, highlighted with a red box, are the 8 weekly modules. The horizontal tabs above the section header (“Section 2 of 7”), highlighted with a green box, allowed browsing through all sections within a particular module. The section title (“Team Culture”),
highlighted with a purple box, is located directly above that’s sections corresponding core content which was located in the screen’s main frame. Image 2 highlights Week 5’s Culture Change Module with a video on Team Culture and Teasing.
Image 2. Example of WIA Website Interface
Note. Red box=menu of modules by week; green box=scrollable menu of sections per module; purple box=module section title.
Data Analysis
Given the preliminary nature of the proposed pilot study and small sample size, analytic emphasis was placed on describing observed data trends, rather than making strong casual inferences. Thus, descriptive analyses will surmise participant demographic information, acceptability measures, and program use and learning metrics, and effect sizes (Cohen’s d;31) will reflect course effectiveness (i.e., BI change over time). Standard conventions for interpreting Cohen’s d (.2=small, .5=medium, and .8=large) were used. Effect sizes were calculated for 1) the total sample baseline to post-treatment, and 2) group differences between female and male athletes at both BL and PT.
VI. RESULTS Participants
The flow of entry and retention of all WIA participants is detailed in Figure 2. A total of 58 students contacted our office to inquire about WIA. Of these, 27 students did not respond to our attempts to establish further
contact with them. The 31 remaining students were administered the telephone screen to assess for program eligibility. Two were excluded based on the telephone screen (1=not a student athlete; 1=not available for the duration of the study due to competing sport time demands). The remaining 29 student athletes were screened in-person, consented, enrolled, and began the study. While the study successfully recruited 29 participants, it was not able to reach its revised target sample of n=40 (from the Interim Report; see Discussion for further details). Of the 29 who began WIA, 28 completed the PT assessment.
Figure 2. Entry of WIA Participants
Note. n=number of participants; m=male participants; f=female participants Completed Week 1 n=27 (93%) m=6 (75%) f=21 (100%) Completed Week 2 n=28 (96%) m=8 (100%) f=20 (95%) Completed Week 3 n=28 (96%) m=8 (100%) f=20 (95%) Completed Week 4 n=28 (96%) m=8 (100%) f=20 (95%) Completed Week 5 n=28 (96%) m=8 (100%) f=20 (95%) Completed Week 6 n=28 (96%) m=8 (100%) f=19 (90%) Completed Week 7 n=28 (96%) m=8 (100%) f=19 (90%) Completed Week 8 n=28 (96%) m=8 (100%) f=20 (95%) Contacted WIA Team to inquire
about the study n=58
Lost Contact n=27
Participants did not return emails or calls after they made initial
Phone Screen n=31
Ineligible by phone screen n=2 Not an athlete n=1
Not available to complete study activities=1
In-person Screen n=29
Began WIA n=29 Eligible, Consented, & Enrolled
n=29
Post-Treatment Assessment n=28
Sample demographics are presented in Table 5. Of the 29 student athletes enrolled, 8 (38%) were male, 9 (31%) were juniors in their academic tenure, 19 (65.5%) were receiving scholarship for their sport participation, 24 (85%) self-identified as White, 0 self-identified as Hispanic, and 7 (25%) had been approached with
concerns about their eating or weight over the previous 6 months. Thirteen different sports were represented. Table 5. Sample Demographics
Demographics Female 21 (72%) Male n=8 (38%) Total Sample n=29
Age (M, SD) in years 19.81 (1.12) 20.50 (1.51) 20.0 (1.25); range: 18-22
BMI (M, SD) 22.70 (2.36) 24.44 (.81) 23.18 (2.18)
Ethnicity Non-Hispanic=21 (100%) Non-Hispanic=8 (100%) Non-Hispanic = 29 (100%)
Race Asian=2 (9%); Black=1
(5%); White=18 (86%)
Asian=1 (12.5%); Black=1 (12.5%); White=6 (75%)
Asian=3 (10%); Black=2 (7%); White = 24 (83%)
Sport Cross country =2
Track and field =1 Field hockey =5 Gymnastics =5 Lacrosse =1
Lightweight crew =2 Open weight crew =1 Softball =1 Soccer =1 Swimming =1 Volleyball =1 Total Sports =11 Fencing =2 Soccer =2 Swimming =2 Wrestling =2 Total Sports =4
Grand total of 13 sports represented
In competitive season Yes=10 (48%) No=11 (52%) Yes=6 (75%) No=2 (25%) Yes=16 (55%) No=13 (45%) Scholarship Yes=15 (71%) No=6(29%) Yes=4 (50%) No=4 (50%) Yes=19 (65.5%) No=10 (34.5%) Academic Year Freshman=2 (9%)
Sophomore=6 (29%) Junior=7 (33%) Senior=6 (29%) Freshman=1 (12.5%) Sophomore=1 (12.5%) Junior=2 (25%) Senior=4 (50%) Freshman=3 (10%) Sophomore=7 (24%) Junior=9 (31%) Senior=10 (35%) Athletic Year Freshman=3 (14%)
Sophomore=5 (24%) Junior=8 (38%) Senior=4 (19%) 5th Year Senior=1 (5%) Freshman=1 (12.5%) Sophomore=2 (25%) Junior=1 (12.5%) Senior=3 (37.5%) 5th Year Senior=1 (12.5%) Freshman=4 (14%) Sophomore=7 (24%) Junior=9 (31%) Senior=7 (24%) 5th Year Senior=2 (7%) Approached with
weight and/or eating concerns?
Yes: 4 (19%) No: 17 (81%) Yes: 3 (38%) No: 5 (63%) Yes: 7 (25%) No: 22 (75%)
Note. M=mean; SD=standard deviation; n=number of participants; Approached=refers to the full question item: “Over the past 6 months have you been approached by a teammate, coach, athletic trainer, family member or friend who expressed concerns about your eating or weight?”.
Study Aim 1–To explore the preliminary efficacy of WIA as a BI enhancement and DE Prevention Program BL and PT measures assessed BI and DE behaviors before and after WIA, respectively. Of the 29 original participants, 1 did not complete the PT assessment (PT n=28).
DE Behavior Frequency (Figure 3)
At BL, approximately 45% (n=13) of the total sample (52% female; 25% male) reported at least 1 objective binge episode (OBE) over the previous month. OBEs are defined as eating an objectively large amount of food within a discrete period of time while simultaneously experiencing a sense of loss of control over the eating. At PT, OBE endorsement decreased to 36% (n=10; 40% female; 25% male). At BL, approximately 7% (n=2) of the total sample (3% female; 13% male) reported at least 1 episode of self-induced vomiting to compensate for calories or fat ingested during a OBE. At PT, vomiting was 14% (n=4; 10% female; 25% male). At BL, approximately 10% (n=3) of the total sample (6% female; 13% male) reported using restriction or fasting to compensate for calories or fat ingested during a OBE. At PT, restriction or fasting was 14% (n=4; 10% female; 25% male). Among females, 3% (n=1) at both BL at PT reported laxative use to
compensate for calories or fat ingested during a OBE. Similarly, 6% (n=2) at BL and 3% (n=1) of females at PT reported diet pill use for the same purpose. No males endorsed laxative or diet pill use at BL or PT.
Figure 3. Percent Prevalence of Reported Disordered Eating Behaviors by Gender and Total Sample
Note. BL=baseline; PT=post-treatment; OBEs=objective binge episodes.
Table 6. WIA Course Effectiveness Results
BASELINE POST-TREATMENT Total Baseline v
Total Post-Treatment
d Measure or Subscale Female
n=21 Male n=8 Female v Male d Total n=29 Female n=20 Male n=8 Female v Male d Total n=28 completers BODY IMAGE MEASURES
1. Satisfaction Dissatisfaction with Body Parts Scale
2.80 (.72) 1.73 (.83) d=1.38 2.50 (.89) 2.64 (.76) 1.73 (.99) d=1.03 2.39 (.91) d=.12
2. Body Image Culture Survey
23.38 (12.77) 23.38 (16.01) d=0 23.38 (13.43) 21.1 (10.16) 15.5(16.05) d=.42 19.50 (12.08) d=.30
3. Contextual Body Image Scale
Daily BI total score 4.42 (.33) 4.33 (.19) d=.33 4.39 (.30) 4.31 (.26) 4.39 (.12) d= .39 4.33 (.23) d=.22 Sport BI total score 4.39 (.35) 4.44 (.25) d= .16 4.40 (.32) 4.36 (.43) 4.38 (.20) d= .06 4.37 (.37) d=.09
DISORDERED EATING BEHAVIOR MEASURES
1. Compulsive Exercise Test
39.52 (10.02) 29.75 (3.15) d=1.32 36.83 (9.69) 34.5 (10.17) 26.0 (6.05) d=1.01 32.07 (9.88) d=.49
2. Eating Disorder Examination Questionnaire
Restraint 1.27 (1.08) .92 (.96) d=.34 1.17 (1.04) .84 (.998) .77 (1.09) d=.07 .82 (.99) d=.34 Eating concerns .78 (.90) .43 (.53) d=.47 .68 (.82) .66 (1.10) .25 (.49) d=.48 .54 (.97) d=.16 Shape Concerns 1.88 (1.35) 1.08 (.89) d=.70 1.66 (1.28) 1.51 (1.13) .63 (.88) d=.87 1.25 (1.12) d=.34 Weight concerns 1.63 (1.08) .70 (.88) d=.94 1.37 (1.10) 1.53 (1.02) .70 (1.05) d=.80 1.29 (1.08) d=.07 Global 1.39 (.99) .78 (.69) d=.71 1.22 (.95) 1.13 (.96) .59 (.80) d=.61 .98 (.93) d=.26 3. DEA-Q 1.58 (.43) 1.58 (.56) d=0 1.40 (.35) 1.24 (.20) 1.30 (.46) d=.17 1.25 (.29) d=.47
Note. Baseline=the assessment battery administered before WIA; Post-Treatment= the assessment battery administered after WIA; n=number of subjects within a group; p=the p-value/significance level yielded from the between groups t-test; ns=not-significant; d=Cohen’s d effect size; Completers=participants who completed all 8 WIA modules and the post-treatment assessment.
52 40 3 10 6 10 3 3 6 3 0 10 20 30 40 50 60 %
Female
25 25 13 25 13 25 0 0 0 0 0 5 10 15 20 25 30 %Male
45 36 7 14 10 14 3 3 3 3 0 10 20 30 40 50 %Total Sample
Course Effectiveness: Body Image Measures 1. Satisfaction Dissatisfaction with Body Parts Scale
The Satisfaction Dissatisfaction with Body Parts Scale yielded the primary outcome for the current study. Higher scores indicate more dissatisfaction with body parts. While there was a modest
decrease in body dissatisfaction, there was no meaningful effect size on this scale for the total sample. At both BL and PT there were large effect sizes between female and male athletes indicating that female athletes had significantly higher body dissatisfaction than their male counterparts at both time points.
2. The Body Image Culture Survey
Higher scores on the Body Image Culture Survey indicate more idealization of stereotypical female and male body ideals. Overall, there was a decrease in scores, yielding a small to medium effect size (d=.30), between BL and PT for the total sample. The reductions indicated that idealization of body ideals decreased from BL to PT. While there was no meaningful effect size between female and male athletes on this scale at BL (as they were equivalent in their BL scores), there was a medium effect difference at PT (d=.42) which indicated that male athletes reported much less idealization of body ideals than did their female counterparts.
3. The Contextual Body Image Questionnaire for Athletes (CBIQA)
All but one score for the CBIQA showed slight decreases from BL to PT. While the CBIQA sport body image total score had no meaningful effect size for the total sample, the daily body image total score yielded a small effect size (d=.22) from BL to PT indicating a small improvement in daily body image. There were small to medium effects sizes between female and male athletes at both BL (d=.33) and PT (d=.39) on the daily body image total score. Female athletes had higher, meaning poorer, daily body image than males at BL which reversed at PT when males had poorer daily body image than females. There were no meaningful effect sizes between females and male athletes at BL or PT on the sport body image total score.
Graph 1. Results for the Satisfaction Dissatisfaction with Body Parts Scale
Graph 2. Results for the Body Image Culture Survey
Graph 3. Results for the Contextual Body Image Questionnaire for Athletes
2.5 2.39 2.8 2.64 1.73 1.73 1.5 2 2.5 3 Baseline Post-Treatment
Total Sample Females Males
23.38 19.5 21.1 15.5 14 16 18 20 22 24 Baseline Post-Treatment
Total Sample Females Males
4.39 4.33 4.42 4.31 4.33 4.39 4.4 4.37 4.39 4.36 4.44 4.38 4.25 4.5 Baseline Post-Treatment Total Sample Daily BI Females Daily BI Males Daily BI Total Sample Sport BI Females Sport BI Males Sport BI
Course Effectiveness: Disordered Eating Behavior Measures
1. The Compulsive Exercise Test (CET)
Overall, there was a decrease in CET scores from BL to PT, yielding a medium effect size (.49) for the total sample. The reduction indicates that exercise compulsiveness decreased from BL to PT for the total sample. There were large effect sizes between female and male athletes at both BL (d=1.32) and PT (d=1.01) with females athletes indicating higher exercise compulsiveness than their male
counterparts at both time points, although the difference between the groups was somewhat smaller at PT.
2. The Eating Disorder Examination Questionnaire (EDE-Q)
All EDE-Q scores decreased moderately from BL to PT. There was a small to medium effect size
(d=.34) in the mean restraint subscale score from BL to PT for the total sample (featured in Graph 5). There was a small to medium effect size on
restraint between female and male athletes at BL (d=.34) that was no longer present at PT, meaning the two groups yielded closer scores at PT. Effect sizes for the other EDE-Q subscales for the total sample ranged from negligible (eating and weight concerns subscales) to small to medium (shape concerns subscale and global score). There were medium to large effect sizes between female and male athletes at BL and PT on all subscales with females indicating higher DE pathology than their male counterparts.
3. The Disordered Eating among Athletes Questionnaire (DEA-Q)
The DEA-Q score for the total sample decreased from BL to PT yielding a medium effect size (d=.47) and indicating a decrease in overall DE pathology. There was no difference between female and male athletes at baseline, however there was a small effect size between them at post-treatment with males having slightly higher DEA-Q scores than their female counterparts.
Graph 4. Results for the Compulsive Exercise Test
Graph 5. Results for the EDE-Q Restraint Scale
Graph 6. Results for the DEA-Q
36.83 32.07 39.52 34.5 29.75 26 25 30 35 40 Baseline Post-Treatment
Total Sample Females Males
1.17 0.82 1.27 0.84 0.92 0.77 0.5 1 1.5 Baseline Post-Treatment
Total Sample Females Males
1.4 1.25 1.58 1.24 1.3 1 1.5 2 Baseline Post-Treatment
Study Aim 2 – To explore the acceptability of WIA
WIA course acceptability was assessed via course satisfaction ratings, module relevancy rankings, and completion rates for WIA modules, assessments, and interactive questions.
Client Satisfaction Questionnaire
WIA participants responses on the CSQ-8 yielded an average of 24 (SD=2.60) out of 32 possible. Of note, 25 of 29 participants (89%) indicated that they would recommend the program to a friend in need.
Relevancy
Weekly relevancy scores ranged between 4 to 5, out of 6 possible, for each of the 8 modules with a grand mean of 4.66 across all modules (see Table 7). This indicated that on average, participants viewed the modules as at least moderately relevant.
WIA Module Completion
Module completion was defined as opening/viewing each WIA module. Weekly module completion rates ranged from 93 to 96% and are listed in Table 7. Twenty-eight of 29 participants (96.6%) completed WIA all 8 modules. One participant viewed only 1 module and therefore was considered a treatment drop. Thus, there was 1 treatment drop in WIA; stated differently there was a 96.6% participant retention rate.
Assessment Completion
All participants completed the BL assessment as it was required for entry into the study. Twenty-eight of 29 participants (96.6%) completed the full PT assessment battery. One participant completed only a portion of the PT battery citing international travel as a time and logistical impediment to completing it in its entirety.
WIA Interactive Intervention Question Completion
WIA had various interactive questions in each module. The purpose of these questions was to engage the learner, assess learner comprehension, and provide a forum for learner provided free response. The free response questions garnered participants’ perspectives on topics drawn directly from the BI enhancement exercises under Cognitive Dissonance Theory, the theory on which WIA was predicated. Table 7 outlines response rates. Nearly every single question throughout WIA was answered, with an overall completion rate of 97%. The answers provided in the free response questions were well-thought out demonstrations of how the participants applied the material to their personal experience as an athlete.
Table 7. Course Acceptability Results Module Relevancy Rankings
mean (sd) Module Completion Rates Interactive Question Completion Rates
Module 1 4.5 (1.30) 93% 6.75 out of 7 (96%) Module 2 4.93 (.997) 96% 3.0 out of 3 (100%) Module 3 4.64 (1.28) 96% 7.82 out of 8 (98%) Module 4 4.75 (1.38) 96% 5.86 out of 6 (98%) Module 5 4.71 (1.21) 96% 3.82 out of 4 (95%) Module 6 4.46 (1.58) 96% 11.67 out of 12 (97%) Module 7 4.63 (1.15) 96% 10.67 out of 11 (97%) Module 8 4.69 (1.57) 96% 1.89 out of 2 (95%) Total 4.66 95.6% 51.48 out of 53 (97%)
Note. SD=standard deviation. VII. DISCUSSION
BI and DE concerns, prevalent among college athletes, significantly and negatively impact physical and emotional well-being, academic and sports performance, peers, and the campus community. Online BI platforms have several advantages over in-person interventions (i.e., personalization, anonymity, easy anytime access among a mobile generation, and dissemination potential). This study 1) developed the Whole Image for Athletes (WIA), an online BI enhancement and DE prevention course complete with college athlete-tailored content and empirically supported BI enhancement techniques, and 2) piloted WIA among Stanford college athletesto investigate its preliminary effectiveness and acceptability.
Participant Symptomatology
A notable subset of WIA participants endorsed DE behaviors. Indeed, nearly half (45%) WIA participants reported at least 1 OBE over the previous month. Previous reports found similar rates of binge eating; specifically 38% of both male and female college athletes were found to be at risk for bulimia nervosa which includes OBEs and compensatory behavior (16). While there was a notable decrease in number of participants endorsing an OBE by PT (from 45% to 36%; reduction of n=1 female and n=1 male), self-induced vomiting and restriction/fasting and behaviors increased. The small sample size of this pilot study precludes concluding that WIA lead to an increase in these behaviors. Nonetheless, WIA should not be used as the sole treatment for full criteria eating disorders, and it was not designed for this purpose. Rather, it may be conceptualized as a: 1) preventative intervention, 2) potential augment to other, more intensive, treatment, and/or 3) an option for stepped-down care (e.g., after completion and discharge from outpatient treatment).
Interestingly, the majority of WIA participants did not endorse any OBEs or purging behaviors over the previous month yet still volunteered to participate in the program. This may indicate that there is general interest in the topic and pursuit of BE enhancement and DE prevention among college athletes, even among those athletes who are note currently enduring the distress of these particular DE behaviors. WIA Course Effectiveness
Nearly all measures, and subscales when applicable, demonstrated modest decreases from BL to PT with corresponding small to medium effect sizes. The largest effect sizes were for the CET and DEA-Q, which gauge self-reported experiences of exercise compulsion and DE pathology (the DEA-Q measures DE-related thoughts, eating, and exercise behaviors), respectively. Similarly, there was a small to medium effect size in decrease on the EDE-Q restraint subscale. This is noteworthy as some studies suggest that only 15% and 26% of collegiate female and male athletes respectively ingest sufficient carbohydrate and protein to meet dietary recommendations for athletes (32) making dietary restriction reduction in this population paramount. It is important to note that only 1 subscale of 6 totals measures, the CBIQA Daily Body Image score for men, increased from BL to PT. The small sample size of this pilot study precludes concluding that WIA worsened males’ daily body image. However, it is possible that the intervention drew more attention to this construct than was previously considered by male participants.
Small to medium, rather than large, effect sizes are to be expected in a prevention study of this sort. Prevention studies, like WIA, welcome a self-selected sample of volunteers, who range from
non-disordered to non-disordered in their BI and DE concerns and for whom future clinical outcomes can not be yet known. Conversely, results from studies which purposefully include only diagnostic level clinically-ill
participants may be apt to see larger effect sizes because there is literally more room for improvement to be made. In the present study, many WIA participants did not need to make substantive changes to their BI and DE concerns as they were already functioning in the normative range. Preliminary WIA data suggest that the intervention was able to, on average, retain said individuals in these normative ranges. In sum then, WIA, an 8-week online intervention lasting approximately 120 minute total, yielded small to moderate reductions in potential risk factors for ED onset among college athletes. Stated differently, WIA generally appeared to modestly improve or at minimum, prevent worsening of college athletes’ BI and DE pathology. Of course further larger-scale studies of WIA in a randomized controlled trial with a wait list control condition would be necessary to test this hypothesis. While other online ED prevention
interventions, have also demonstrated reductions in risk factor for ED onset (11;33), none are tailored specifically for both male and female college athletes like WIA.
WIA Acceptability
Based on the data presented herein, it appears that WIA was a highly acceptable program as indicated by level of participant engagement. Specifically, WIA yielded 96.6% module completion, 96.6% PT
assessment completion, and an average 97% interactive question completion rate. The content of all 8 WIA modules were rated as at least moderately relevant and or greater. An average participant
satisfaction level of 24 indicated moderate satisfaction with the program in its entirety. Finally 89% of WIA participants would recommend the program to a friend in need.
Stice and colleagues, recognized experts in Cognitive Dissonance based interventions for BI
enhancement, recently published data on an internet version of their program (34). They report similarly high PT assessment completion rates of 98.2% and high acceptability of the internet program with 17 of 19 participants (89%) completing all 6 available modules. The original Whole Image pilot intervention, which was overhauled in the present study to create WIA, yielded a somewhat lower yet still impressive PT assessment completion rate of 84% (121 of 144 college participants; 23). Thus, WIA, although tailored specifically for male and female college athletes unlike other online BI intervention programs, appears to mimic the latter’s high rates of completion and acceptability (35-37). Since, there appears to be no
significant differences between internet and in-person group based delivery modalities for BI enhancement programs (34), further research and testing of WIA, ideally toward national dissemination, is warranted. Limitations of the present research are important to note. First, the small sample size limits confidence one can place in result interpretation. Consequently, emphasis was placed on effect sizes rather than statistical tests of significance. Second, the study was not able to recruit the full sample of n=40 it aspired to. Recruitment during the fall quarter may have been hindered by: athletes returning to campus and sport practice from (varying lengths of) summer break, moving into and acclimating to new living situations for the start of the academic year, and/or freshmans’ unfamiliarity with how to seek out these voluntary research experiences and their difficulty guesstimating whether or not they will have sufficient time to participate. Indeed, when this research team conducted focus groups with Stanford athletes during the Spring 2014 academic quarter, we were able to recruit n=18 participants within 2 weeks while WIA’s recruitment efforts extended 6 weeks to obtain n=29 participants. Future research may consider launching programs during Winter or Spring academic quarters in order to potentially boost recruitment rates.
Despite limitations associated with the present study, there are several strengths. Critical to the success of the program was the ongoing collaboration between this research team and the Stanford Athletics
Department. Indeed, several Sports Medicine Doctors, Athletics Trainers, and Athletics Administrative personnel spread the word about the program, distributed WIA pamphlets, and encouraged athletes’ involvement. Moreover, staff from Stanford University’s Student Health Care Center, (Dr Robyn Tepper, Medical Director; Jennifer Waldrop, Dietician) and Athletics Department (Sarah Lyons, Athletic Trainer) facilitated with content contribution and/or editing. Thus, WIA was truly a collaborative and
multidisciplinary effort. Other notable strengths include the final WIA platform and product; it was easily accessible from any mobile device, offered a variety of learning modalities (psychoeducation, video, interactive true/false, multiple choice, and free response question formats), and similar to other online platforms, offered participants anonymity in their participation. The interface between the research team and the website’s technology support team was seamless, allowing ongoing attention to website content and flow. Without this, user experience may otherwise suffer (38). In addition, WIA content was informed by focus group research conducted with Stanford athletes which provided insight about how to best tailor topics, language, examples, and activities to heighten relevance for said population. ED and BI experts agree that such programs must be tailored specifically for college athletes in order to achieve favorable uptake and efficacy (13).
These data replicate previous findings that BI and DE concerns exist among a substantial portion of college athletes. The risk of physical, emotional, academic, and sport-performance consequences likely increase if BI and DE concerns are ignored and/or left untreated. Limited on-campus BI and DE interventions, coupled with college athletes’ potential fear of discovery or perceptions about associated stigma, may exacerbate failure to access treatment timely and thoroughly. Innovative online platform are therefore critical for campuses to have at the ready; such platforms offer an important clinical service to an online and mobile population in need. Ensuring that such interventions are tailored specifically to both male and female college athletes (i.e., offering relevant topics and examples for both groups across multiple sports; use of standard sports language) may increase the likelihood of uptake and relatabilty. WIA, the first online BI and DE
intervention tailored for both male and female athletes, was able to achieve modest improvements in BI and DE concerns and high acceptability among a small pilot sample of Stanford athletes.
VIII. CAMPUS-LEVEL PROGRAMMING IMPLICATIONS.
This proposal successfully created and launched WIA; an online product with an empirically supported theoretical basis that has shown small to medium effects in improving college athletes’ BI and DE. WIA is poised for Stanford uptake and broader dissemination efforts. However, limited financial and personnel resources at Stanford and other campuses nationwide often hinder administration’s willingness and ability for new program adoption, implementation, and maintenance. Even online programs, which do not require much time and effort, may not become easily integrated. However, if the NCAA implemented guidelines or recommendations for campuses to regularly host a BI enhancement and DE prevention course, the short- and long-term viability of such programs could greatly increase. Indeed, such guidelines or
recommendations may be the most compelling way to strongly and directly encourage campuses nationwide to appropriately address a real-time and significant need among their college athletes.
Project contributors included:
-Principal Investigator: Athena Robinson PhD, Clinical Assistant Professor -Co-Investigator: Megan Jones PsyD, Clinical Assistant Professor
-Athletics Consultant: Sarah Lyons MS, ATC, PES, Athletic Trainer, Stanford Sports Medicine
-Research Assistants: Sarah Pajarito; Miriam Parrott, Clinical Psychology Doctoral Candidate; Katerina Gregoriou, Bachelors of Arts Candidate, Varsity Rowing
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The Whole Image for Athletes: A Body Image Enhancement & Disordered Eating Prevention Online Program
Principal Investigator: Athena Robinson, PhD
Site: Stanford University, School of Medicine, Department of Psychiatry and Behavioral Science
APPENDIX.This WIA Appendix is comprised of sample WIA screenshots. Screenshot 1. WIA Website Interface
