kristinawieghmink_ed693_mastersproject

Prevention Program Development for Eating Disorders among College Female Athletes by Kristina Wieghmink August 2012

Master’s Project Submitted to the College of Education At Grand Valley State University In partial fulfillment of the Degree of Master of Education

Acknowledgments My inspiration for this final project is due to the concern I have for women’s health and well - being, to live long and happy lives through proper exercise and nutrition. I owe my deep appreciation to my wonderful husband for his immense support and belief in my potential. He has given me the encouragement and motivation to persevere and always strive to do my best in all things in life. I also extend my gratitude towards our children and family, for everyone’s inspiration, support, and patience. In addition, several mentors and colleagues have provided guidance and constructive criticism, helping to develop me into a higher educational professional.

Kristina Wieghmink

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Abstract Eating disorders are prevalent among female college athlete students, due to increased pressures from sport, social, cultural, and academic environments, along with added expectations placed on this female population. While many higher educational institutions offer resources for college women athletes struggling with eating disorders or weight management, many do not have interactive programs in place to prevent eating disorder attitudes and behaviors. An evaluation of research concludes that in order to prevent eating disorder diseases, such as anorexia nervosa and bulimia nervosa, emphasis needs to be placed on creating positive body image and increasing body satisfaction and self-esteem.

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Table of Contents Acknowledgments …………………………………………………………………….… i Abstract …………………………………………………………………………….……. ii Table of Contents ………………………………………………………………….……. iii Chapter One: Project Proposal Problem Statement …………………………………………………………………… 1 Importance and Rationale of the Study ………………………………………………. 2 Background of the Project ……………………………………………………...……. 4 Statement of Purpose …………………………………………………………...……. 7 Objectives of the Project ………………………………………………………...….... 7 Definition of Terms ………………………………………...………………………… 8 Scope of the Project …………………………………………...……………………. 11 Chapter Two: Literature Review …………………………………………………...….. 12 Introduction …………………………………………………………………...…….. 12 Theory/Rationale …………………………………………………………...……….. 13 Behaviorism …………………………………………………………...………… 13 Cognitive Dissonance …………………………………………………...………. 15 Research/Evaluation ……………………………………………………...………… 17 Eating disorder types and symptoms ……………………………………………. 17 Anorexia nervosa (AN) ………………………………………………………. 19 Binge eating disorder ………………………………………………………… 20 Bulimia nervosa (BN) ……………………………………………...………… 21

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Compensatory behavior …………………………………………..………….. 22 Disordered eating ……………………………………………….…………… 23 Eating disorder contributors ………………………………………………..……. 24 Athletic body image ………………………………………………..…………. 24 Body dissatisfaction …………………………………………..…..………….. 25 Drive for thinness ………………………………………………….…………. 26 Gender …………………………………………………………..…………… 27 Pressures ……………………………………………………….……………. 27 Psychological ………………………………………………………………… 29 Eating disorder side effects ……………………………………………………… 30 Biological …………………………………………………………………….. 30 Psychological ………………………………………………………………… 31 Substance Abuse ……………………………………………………………… 32 Eating disorder prevention ………………………………………………...…….. 32 Screening ……………………………………………………………...……… 32 Psychoeducational ……………………………..…………………………….. 33 Interactive ……………………………………………………..…………….. 34 Summary ………………………………………………………………………...…. 37 Conclusion …………………………………………………………………………. 39 Chapter Three: Project Description ……………………………………………………. 40 Introduction …………………………………………………………….…………… 40 Project Components ……………………………………………..………………….. 41 Background of the project …………………………………….…………………. 41

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Statement of purpose ……………………………………………..……………… 44 Objectives of the project ……………………………………………..…………. 45 Rationale of the project ………………………………………………….………. 45 Project description ………………………………………………………………. 47 Project Evaluation ………………………………………………………..………… 51 Project Conclusion ………………………………………………………..………… 52 Plans for Implementation ……………………………………...……………………. 53 References ……………………………...………………………………………………. 55 Appendixes Appendix A: Healthy Bodies: Building Positive Body Image – Workshop Curriculum..59 Appendix B: Healthy Bodies Goals & Fitness Journal Form ………………………… 147 Appendix C: Healthy Bodies Self-Assessment Questionnaire ……………………..… 148 Appendix D: Healthy Bodies Poster ………………………………………..………… 149 Appendix E: Healthy Bodies Exit Survey ………………………………………….… 150 ED 693/695 Data Form ………………………………………………………………. 151

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Chapter One: Project Proposal Problem Statement College female athletes with an average age of 19.9 years, in a National Collegiate Athletic Association study (Johnson, Powers, & Dick, 1999), are found to be at high risk for developing eating disorder syndromes, with high competitive sports and lean sports bearing the greatest risk factors for these pathologies (Carter & Rudd, 2005).

Student athletes are at greater risk for eating disorders than the typical college student due to excessive pressure and anxiety with trying to balance sports and academics, leading to increased struggles with obtaining proper nutrition (Etzel, Watson, Visek, & Maniar, 2006). Particularly, college female athletes are prone to engage in unhealthy behaviors to control their weight, due to the “unique pressures that female athletes face in the sports environment,” within the college setting (Greenleaf, Petrie, Carter, & Reel, 2009, p. 489).

Of the female college athletes, “white female college athletes appear to be most at risk for having difficulty with eating disorders” versus black female and black and white male college athletes (Johnson, Crosby, Engel, Mitchell, Powers, Wittrock, & Wonderlich, 2004, p. 147).

Unless higher education institution administrators, athletic coaches, trainers, and female athletes change the way body satisfaction, body image, and drive for thinness are perceived (Krane, Stiles-Shipley, Waldron, & Michalenok, 2001) and become educated in identifying signs and symptoms of eating disorders (Etzel et al., 2006), these women will continue to put their health and potentially their lives in danger, resulting in “deaths and serious illnesses from eating disorders” (Johnson et al., 1999, p. 179).

2 Importance and Rationale of the Study Understanding the onset causes and precursor symptoms associated with eating disorders is most important in deterring the hard to treat conditions of eating disorders, most commonly associated with young women (Holm-Denoma, Scaringi, Gordon, Van Orden, & Joiner, 2008). A careful study of eating disorders will better help higher educational institution administrators, coaches, trainers, and fellow student teammates to develop prevention programs and implement intervention policies and practices.

According to Schwitzer, Rodriguez, Thomas, and Salimi (2001), university campuses need to develop structured responses to reach out to college females, particularly high risk populations, such as female college athletes, through the development, marketing, and implementation of prevention programs. According to the NCAA Sports Medicine Handbook, “… it is the responsibility of each member institute to protect the health of, and provide a safe environment for, each of its participating student-athletes” (NCAA, 2012, p. 2). This clearly states the importance of higher educational institution’s role and responsibility to be proactive in the well-being of their student athletes. Prevention approaches need to provide educational material on nutrition, dieting, and proper exercise.

Studying eating disorders, in order to create the most effective programming and intervention methods, is essential to target the students most at risk before eating disorders emerge or advance to stages of serious illness or even death (Johnson et al., 1999). It is the obligation of higher education administrators to intervene disordered eating cycles at the earliest possible stage to ensure the safety of their students (Thome & Espelage, 2007) and to have a good understanding of student athlete’s issues and needs (Etzel et al., 2006).

3 College female students are concerned with body image, weight control management, and body shape and size. Recent studies report that 6% of undergraduate female students are concerned with bulimia and anorexia, while 25% to 40% reported moderate problems (Schwitzer et al., 2001). Schwitzer’s (2001) study reported an alarming 83% of female college students are concerned with eating and weight management. With such a high percentage of the female college population struggling with a broad spectrum of disordered eating, ranging from poor nutrition to binge eating and purging, the importance of this study is precedent; especially since less than one third of those with eating disorders actually receive treatment (Stice & Shaw, 2004).

Untreated eating disorders or the lack of preventive intervention strategies is detrimental to each young college female from the disease itself to it being a leading factor and perpetuator of other habilitating conditions such as obesity, depression and substance abuse (Stice, 2002).

The results from a national study by Johnson et al. (1999) confirms the importance of focusing preventive and intervention efforts specifically on female college student athletes, who reported “significantly higher rates of disordered eating attitudes and behaviors� (Johnson et al, 1999, p. 187). Johnson et al. (1999) continues to state the priority of eating disorder programming and education efforts should not only be geared towards female college student athletes, but to also include coaches, athletic department directors, trainers, student athletes and teammates, regulatory board members, and parents of athletes to increase awareness of the serious physiological and psychological side effects.

4 Background of the Project College life transition can be a challenging time for students (Stice, 2002). For many adolescents, attending a university is a way to explore the transition into adulthood.

Significant life changes occur during the college years, in addition to new stressors introduced to young women during this time (Cooley & Toray, 2001). New socialization opportunities surmount, opportunities to define their own identities, more emotional stress, and separation from parents challenge the psychological capacity of college women (Barker & Galambos, 2006; Kaminski & McNamara, 1996). When young women attend college during a high-risk developmental period (Berg, Frazier, & Sherr, 2009), increased risk for disordered eating can occur due to social and academic pressures that come with the college environment. Barker and Galambos (2006) state that the high-risk of college life transitions can contribute to stressors that may exceed coping resources, resulting in increased risk for eating problems. According to Delinsky and Wilson (2008), during the first year of college, disordered eating increases and is considered a high-risk period for the development of eating disorders. Results from research studies indicated that “25% of college women are thought to be at risk for developing eating disorders�

(Winzelberg, Eppstein, Eldredge, Wilfley, Dasmahapatra, Dev, & Taylor., 2000, p. 346; Berg et al., 2009). Specifically, according to Cooley and Toray (2001), body dissatisfaction was the leading factor that contributed to increased eating pathologies for women entering college. Prior research indicated other factors such as lowered selfesteem, negative body image, drive for thinness, and obsessive concerns regarding weight and appearance (Kaminski & McNamara, 1996) are precursors of eating disorders.

Females who are unhappy with their body image are more susceptible to developing

5 eating disorders (Cooley & Toray, 2001). With nearly one third of female college students at risk for developing these harmful diseases, higher educational institutions need to be a part of the cohort to intervene and treat their students.

Athletes are the female college student sub-population that is at an even greater risk for developing eating disorders (Etzel et al., 2006; Rudd & Carter, 2006; Greenleaf et al., 2009; Holm-Denoma et al., 2009; Johnson et al., 1999). A NCAA Division I study of college athletes, by Johnson et al. (1999), found that 58% of females were at high risk for developing eating disordered behavior. In addition to the socio-cultural pressures, college life transitions, and the psychological developmental period college students encounter, student athletes have added pressures from the sports world, such as pressure from competition, training, travel, balancing academics and sports, appearance and weight management, perfectionism, high need for achievement, athletic performance, and pressure from coaches, trainers, and teammates (Etzel et al., 2006). Any combination of these various factors could potentially lead to anxiety, stress, or depression, which may perpetuate the increased risk of developing eating disorders. According to Etzel et al.

(2006), women are twice as likely than men to experience depression, with 9.5% of the general population suffering from a depressive illness. This is of great concern, especially since student athletes are at greater risk of developing depressive symptoms, due to compounded pressures and stressors that may compile on female college athletes.

Athletic environments may increase the risk for eating disorders (Greenleaf, 2002). Female student athletes are faced with certain pressures from their sports, such as evaluation of their bodies, revealing uniforms, weigh-ins, appearance and dealing with having their bodies in the lime light. These factors place added pressure on the female

6 college athlete to conform to the ideals of what the female body should look like, both from socio-culture pressure and self-induced pressure, resulting in the athletic body image or the perception the athlete has of her own body in the athletic context. As a result from these pressures placed on college female athletes, conditions such as weight concerns, dieting, and body dissatisfaction become issues that could potentially lead up to eating disorders (Thome & Eselage, 2007). A study by Krane, Stiles-Shipley, Waldron, and Michalenok (2001) indicates that female college athletes have a higher drive for perfectionism and a higher drive for thinness, which also increases eating disorder risks.

These unhealthy behaviors are all factors that contribute to the continuum of eating disorders, which range from mild conditions, such as yo-yo dieting and excessive exercising to moderate conditions, such as weight and shape preoccupations, diet pills and laxatives, compulsive overeating, and calorie counting to more severe conditions of fasting, distorted body image, binge eating, bulimia, vomiting, and anorexia (Rudd & Carter, 2006).

Since certain aspects of campus environments are conducive to eating disorders (Kaminski & McNamara, 1996), various departments need to work collectively to identify and intervene before serious illness or death occur to female college student athletes. Collaboration between coaches, students, faculty, the Athletic Department, Student Wellness Centers, Fitness and Recreation Centers, Counseling Services, Women’s Centers, Student Affairs, and Residency Halls (Rudd & Carter, 2006), all within the higher educational context, will create a sense of awareness and urgency to prevent and treat eating disorders and symptoms (Etzel et al., 2006).

7 Statement of Purpose The purpose of this project is to eliminate the onset of eating disorders before problems emerge, by creating positive body image and increasing body satisfaction, among the targeted female college student athlete population. The preventive measures of this project will address the issue of hard to treat eating disorders, typically left untreated, before serious illness and death occur. Specifically, this project will outline intervention strategies, provide a self-assessment questionnaire, prevention programming, accessible online resources, a peer support group, and establish an interdepartmental collaborative task force team, based on the results of current eating disorder causes and symptoms research. This project will educate, create awareness, and modify negative eating and nutrition behavior that female college student athletes may engage in. This project is unique by utilizing a holistic approach, through offering preventive techniques that address cognitive dissonance and implementing behavior modification strategies.

Objectives of the Project The objective of this project is to create a comprehensive plan that will guide female college student athletes through building a positive body image and body satisfaction, establishing healthy eating patterns, proper nutrition, and exercise plans that will prevent the signs, symptoms, and behaviors of disordered eating. This plan will address the needs that female college athletes have in balancing both the sports world and college environment, in addition to addressing the obstacles and associated problems that perpetuate eating disorders.

8 Definition of Terms Below is a list of terms that will be used throughout the project.

Amenorrhea – an absence of or irregular menstrual periods (Etzel et al, 2006; Rudd & Carter, 2006).

Anorexia Nervosa (AN) – behavior which involves restriction of food intake, extreme emaciation. AN is characterized by extreme weight loss; intense fear of weight gain or becoming fat despite a low body weight; body image disturbance; denial of the seriousness of low body weight; and in women, the absence of menstruation (Cook & Hausenblas, 2011) Athletic body image – internal image one has of his or her body (self perception and value) and the evaluation of that image within an athletic context (Greenleaf, 2002).

Behavior modification theory – theory developed by B.F. Skinner, which is the application of conditioning to change behavior. The exchange of undesired responses for desired responses (Delprato & Midgley, 1992).

Binge eating disorder – repeated episodes of uncontrollable eating of unusually large quantities of food, characterized by rapid eating or eating alone because of embarrassment. Defining feature of Bulimia Nervosa (Cook & Hausenblas, 2011; Barker & Galambos, 2006).

Body dissatisfaction – thoughts related to misperceptions or overestimations of different parts of the body, typically underlies risky behaviors such as eating disorders (Rudd & Carter, 2006; Schwitzer et al., 2001).

9 Body image – refers to the perceptions, thoughts and feelings (mental image) a person has about their body (Greenleaf, 2002; Rudd & Carter, 2006).

Bulimia Nervosa (BN) – behavior which involves recurrent episodes of binge eating accompanied by purging behaviors, such as self-induced vomiting, fasting, misuse of laxatives and/or excessive or obligatory exercise (Cook & Hausenblas, 2011; Schwitzer et al., 2001).

Clinical eating disorder – are those that do meet the criteria for eating disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association (1994). Eating disorders are serious psychological and medical conditions, usually beginning with a preoccupation with weight and dieting that result in severe disturbance in eating habits and other problem behavior (Rudd & Carter, 2006).

Disordered eating – refers to the continuum of abnormal eating behaviors, ranging from poor nutritional habits all the way to clinical eating disorders. Behaviors may include dieting strictly to maintain or lose weight, binge eating, fasting, or using appetite control pills (Rudd & Carter, 2006).

Dissonance theory – theory developed by L. Festinger, states that the possession of inconsistent cognitions creates psychological discomfort, which motivates people to alter their cognitions to restore consistency. Cognitive dissonance inductions lead people to change their beliefs, attitudes, and behaviors in service of restoring consistency (Stice et al, 2002).

Drive for thinness – intense need to be thinner and fear of gaining weight (Schwitzer et al., 2001).

10 Female Athletic Triad – a three-part syndrome of disordered eating, which also includes amenorrhea and osteoporosis (Etzel et al, 2006; Rudd & Carter, 2006).

Health – as defined by the World Health Organization (1946), is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (Etzel et al., 2006).

NCAA – National Collegiate Athletic Association Obligatory exercise – continual or excessive participation in physical activity despite pain, interference with significant relationships or work, lack of time for leisurely pursuits, obsession with the activity, and other psychopathology (Thome & Espelage, 2007).

Perfectionism – excessive expectations of superior achievement (Schwitzer et al., 2001).

Self-ideal discrepancy theory – states that people compare themselves to an internalized ideal and the discrepancy between a person’s perceived actual self and their idealized self may result in body image dissatisfaction and disordered eating (Greenleaf, 2002).

Social comparison theory - theory developed by L. Festinger, states that people tend to compare themselves to others in their social environment, thus in a sports environment, comparisons may be made against one’s teammates (Greenleaf, 2002).

Sub-clinical eating disorders – also known as sub-threshold or symptomatic, are those that do not fully meet the criteria for eating disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the

11 American Psychiatric Association (1994) (Petrie et al., 2009; Rudd & Carter, 2006).

Scope of the Project This project will address eating disorder signs, symptoms, and behaviors before they become life threatening, among female college student athletes. The scope of this project is to address the need for preventive programming and developmental intervention responses on campuses in higher education. This project will not specifically address long-term health care for severe cases of eating disorders, which ultimately will need to be referred out to licensed professional psychiatrists, nutritionists, or other health care professionals.

This project is limited in its implementation and effectiveness, based on the willingness, self-assessment, and proactive initiative of female college student athlete participation. Often times, young women may not self-identify with having an eating disorder, no matter the level of severity. Embarrassment, feelings of weakness or inferiority, or lack of discipline, will often defer young women from seeking help or even acknowledging preventive resources (Carter & Rudd, 2005). In addition, with the high rate of hard to detect sub-clinical eating disorders, problems and symptoms often go unnoticed (Carter & Rudd, 2005; Greenleaf et. al., 2009), leaving young women in a state of negative well-being and neglected detrimental cycles.

12 Chapter Two: Literature Review Introduction College female athletes with an average age of 19.9 years, in a National Collegiate Athletic Association study (Johnson, Powers, & Dick, 1999), are found to be at high risk for developing eating disorder syndromes, with high competitive sports and lean sports bearing the greatest risk factors for these pathologies (Carter & Rudd, 2005).

Student athletes are at greater risk for eating disorders than the typical college student due to excessive pressure and anxiety with trying to balance sports and academics, leading to increased struggles with obtaining proper nutrition (Etzel, Watson, Visek, & Maniar, 2006). Particularly, college female athletes are prone to engage in unhealthy behaviors to control their weight, due to the “unique pressures that female athletes face in the sports environment,” within the college setting (Greenleaf, Petrie, Carter, & Reel, 2009, p. 489).

Unless higher education institution administrators, athletic coaches, trainers, and female athletes change the way body satisfaction, body image, and drive for thinness are perceived (Krane, Stiles-Shipley, Waldron, & Michalenok, 2001) and become educated in identifying signs and symptoms of eating disorders (Etzel et al., 2006), these women will continue to put their health and potentially their lives in danger, resulting in “deaths and serious illnesses from eating disorders” (Johnson et al., 1999, p. 179).

This literature review will first examine two different theoretical perspectives, behaviorism and cognitive dissonance theory, in the theory/rationale section. The purpose of applying these theories is to provide a lens or filter to better understand an issue that is problematic in higher education for female college student athletes. Next, the literature review will discuss three main topics, in the research/evaluation section.

13 These topics will discuss the various eating disorder types, along with associated signs and symptoms, eating disorder contributors, and eating disorder side effects. Finally, this review will explore various prevention programs for eating disorders to be implemented in higher education, utilizing the theoretical perspectives previously examined.

Theory/Rationale Behaviorism B.F. Skinner brought to scientific psychology the study of behavior. Skinner asserted that behavior is the action of the whole organism, animal, or individual (Skinner, 1953). In particular, Skinner studied behavior modification. Skinner conducted controlled laboratory experiments using reinforcement techniques, in order to change behavior. Behavior that has been reinforced tends to be repeated or strengthened (Skinner, 1953). This technique is known as operant conditioning. Reinforcements can be either positive (reward) or negative (removal of an unpleasant experience) and are given after the desired response (Skinner, 1953). Simply stated, behavioral psychology is how an individual learns to behave in certain ways. Since learning new behavior is continual, behaviorism is a psychological approach that empirically analyzes how learning occurs (Skinner, 1953).

Skinner stated that behavior cannot be understood unless it is observed and measured (Gilbert & Gilbert, 1991). He was meticulous with observing, testing, and retesting his experiments in order to develop practical theories. Through observation of how an individual interacts with his/her environment or relation with the outside world, we can then begin to understand behavior (Delprato & Midgley, 1992). Skinner’s new approach to behavior is applicable to various practices, especially in the areas of therapy

14 and rehabilitation (Holland, 1991), which makes this theoretical perspective appropriate for eating disorder prevention or treatment programs.

Skinner’s attitude towards theory was based on three basic concepts. The first was to use simple explanations and not to overcomplicate ideas. The second concept was to utilize parts of a theory that fit neatly together. Third, theory should be useful and applicable to society and the advancement of science (Gilbert & Gilbert, 1991). Skinner, as cited by Delprato and Midgley (1992), stated that theory must be useful to do something about the problems of the world, rather than simply talking about them. This attitude towards applied science makes behavior theory practical and useful for this project.

Delprato and Midgley (1992) cite Skinner as stating that repeated reinforcements could potentially change an individual. As a result the individual should then behave in a different way. Changing a person’s attitudes, beliefs, or behavior is dependant on selection of certain reinforcement variables (Holland, 1991), such as rewarding someone for each time they come closer to their objectives (Gilbert & Gilbert, 1991). In order to make behavior theory practical for educators, reinforcements need to occur, such as clearly stating the learning objectives, providing evaluation, and continual feedback.

These methods will gradually reshape human behavior (Gilbert & Gilbert, 1991).

An example of behavior theory is in the Stice et al. (2002) study, where eightyseven young-adult females (modal age = 19), with self-reported body image concerns were assigned to a healthy weight control conditioning group. Participants were instructed or reinforced with healthy lifestyles, including nutritional balanced diet and regular moderate exercise plans. Results of this group reported decreases in drive for

15 thinness, body dissatisfaction, risky dieting, negative affect and bulimic symptoms, due to permanent behavioral modifications (Stice et al., 2002). The success of the healthy weight control conditioning group reduced eating pathologies among the high-risk population (young-adult females), by effecting lifestyle changes. Body satisfaction attitudes were a positive consequence from developing and maintaining healthy weight goals, discussions on healthy eating, awareness of eating disorder symptoms and consequences, sharing of personal stories, observations, group support, developing meal and exercise plans, setting obtainable goals, moderation attitudes, and self-assessments (Stice et al., 2002). The Stice et al (2002) study is an example of how the removal of adverse stimulus and the addition of reinforcements will change and strengthen behavior.

The use of reinforcement techniques shaped positive and healthy outcomes, proving to be long lasting and effective eating disorder prevention methods (Stice et al., 2002).

Cognitive Dissonance L. Festinger’s (1957) cognitive dissonance theory states that people will alter their cognitions (attitudes and beliefs) in order to maintain consistency or harmony. When dissonance or disharmony occurs, an individual will be induced to change their attitudes, beliefs, and behaviors (Stice et. al, 2002) to restore comfort and balance in their lives.

According to Festinger (1957), when an individual is highly motivated to seek alternate cognitions, irrational or sometimes maladaptive behavior may occur. Each individual has their own perception and cognition about the world around them and their own self perceptions. When discrepancies develop among these cognitions, tension or cognitive dissonance creates unpleasant feelings (Festinger, 1957). People will generally seek ways in reducing or eliminating these uncomfortable feelings.

16 Cognitive dissonance theory may be applied to eating disorder concerns, among female college athletes who are at risk for developing symptoms. When this high-risk population of women hold attitudes of low self-esteem, body dissatisfaction, or negative body image (Kaminski & McNamara, 1996; Rudd & Carter, 2006), often times they will compare their own beliefs concerning their bodies, with opposing sociocultural beliefs or thin idealization. This results in a strong desire to seek out harmony, yielding to alterations in behaviors, even if they are maladaptive or risky. Intensified sociocultural pressures, certain aspects of athletic and campus environments, separation from parents, new identity formation, or emotional stress (Kaminski & McNamara, 1996) are all contributors that may bring disharmony and perpetuate eating disorder symptoms.

Especially when the motivation or desire to create consistency is severe, due to women’s drive for thinness, obsessive thoughts concerning weight and appearance, fear of becoming fat, depression, anxiety, or overall appearance pressures (Kaminski & McNamara, 1996). In an effort to restore consistency or realign their own cognitions with the cognition of sociocultural pressures, women may develop irrational or maladaptive behaviors, including extreme dieting, fasting, bingeing, purging, or excessive exercise (Petrie et al., 2009).

In the Stice et al. (2002) study, the goal was to develop eating disorder prevention programs that focused on alternative methods for achieving change in attitudes. Utilizing cognitive dissonance theory, Stice et al. (2002) targeted high-risk populations and designed a prevention program that focused on reducing drive for thinness or thin-ideal internalization. The objective was to reduce psychological discomfort, by motivating individuals to alter their cognitions and restore consistency (Stice, et al., 2002). Through

17 verbal, written, and behavioral exercises, participants were encouraged to objectively analyze sociocultural thin-ideal perspectives. By reducing the extent of how women perceived thin-idealization, Stice et al. (2002) aimed at decreasing eating disorder symptoms. Results of the Stice et al. (2002) study yielded significant reductions in thinideal internalization, negative body image, and bulimic symptoms for participants, but not so much decrease in body dissatisfaction or dieting. Individual change in attitude and beliefs occurred due to participants’ reduced subscription to sociocultural pressures, thinidealization, or strive for difficult body shape attainment.

Prior research by Aronson (1997) applies dissonance theory by stating that individuals strive for three main objectives: “to preserve a consistent, stable, predictable sense of self, to preserve a competent sense of self, and to preserve a morally good sense of self” (Aronson, 1997, p. 131). People don’t want to have cognitions associated with shock, guilt, or obtuseness. These feelings may occur in women when their body image has varying discrepancies with the expected body image associated with sociocultural pressures or athletic environments (Greenleaf et al., 2009). Women may often strive to obtain consistency between attitudes and behaviors, even if it entails employing irrational methods to achieve this harmony (Festinger, 1957).

Research/Evaluation Eating disorder types and symptoms Health is the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (Etzel et al., 2006), as defined by the World Health Organization (1946). Each human being needs to maintain optimal health, in order to sustain life and enjoy it with longevity. When people engage in behavior that is

18 detrimental to the continuation of life and their well-being, serious consequences and even death may occur (Johnson et al., 1999). Eating disorders are serious psychological and medical conditions. Various types of pathologies, usually beginning with a preoccupation with weight and dieting, may result in severe disturbances in eating habits and other problem behavior (Rudd & Carter, 2006). Eating disorders are complicated pathologies, with complex diagnosis and treatment options.

Eating disorders vary in degree, from potential to significant to severe health risks.

Clinical eating disorders are those that do meet the criteria for eating disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association (1994). Sub-clinical eating disorders, also known as sub-threshold or symptomatic, are those that do not fully meet the criteria for eating disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association (1994) (Petrie et al., 2009; Rudd & Carter, 2006). Sub-clinical eating disorders are problematic, hard to detect, usually go unnoticed, and are often not treated (Greenleaf et al., 2009). The results of the Greenleaf et al. (2009) study indicate that a large number of female college athletes suffer from eating disorders, with most experiencing sub-clinical symptoms. In the Carter and Rudd (2005) study, of approximately eight hundred student athletes at Ohio State University, 17% to 19.2% of female athletes reported sub-clinical problems for eating disorders. Both clinical and sub-clinical eating disorders engage in unhealthy behaviors to manage weight and even emotions (Greenleaf et al, 2009), that makes the development of prevention programs extremely necessary. Research has proven that regardless of the eating disorder range or potential for it, there is always cause for concern, due to the

19 relatively few differences between clinical and sub-clinical eating disorders (Greenleaf et al., 2009).

Anorexia nervosa (AN). Anorexia nervosa (AN) is behavior which involves restriction of food eating or extreme emaciation (Stice, 2002). AN is characterized by excessive weight loss, intense fear of weight gain or becoming fat despite a low body weight, negative body image, denial of the seriousness of low body weight, and in women, the absence of menstruation (Cook & Hausenblas, 2011). Behaviors that may potentially lead to anorexia nervosa include fasting or strict dieting (Greenleaf et al, 2009). For young adult women in the general public, 0.5% to 1% are diagnosed with anorexia nervosa (Petrie et al., 2009; Rudd & Carter, 2006), while for female college athletes the rate is up to 2% (Petrie et al., 2009).

In the Johnson et al. (1999) study with the National College Athletic Association, 1,445 student athletes from 11 Division I schools were administered a questionnaire of a 133-item survey. This study found that 2.85% of the females surveyed have a clinically significant issue with anorexia nervosa (Johnson et al, 1999). While the Johnson (1999) study yielded a relatively low percentage of females with clinical anorexia nervosa, 25% were identified as being at risk for developing this disorder. Another study by Rudd and Carter (2006) reported that approximately 1% of athletes develop clinical anorexia nervosa. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for clinical anorexia nervosa requires that a female’s Body Mass Index (BMI) be less than or equal to 15 kg/M2, refusal to maintain normal body weight (Schwitzer et al., 2001), amenorrhea or the absence of or irregular menstrual periods (Etzel et al, 2006;

20 Rudd & Carter, 2006), an elevated drive for thinness and body dissatisfaction subscales of the Eating Disorder Inventory-2 (EDI-2) (American Psychiatric Association, 1994).

Binge eating disorder. Binge eating disorder involves repeated episodes of uncontrollable eating of unusually large quantities of food (Stice, 2002). This is often characterized by rapid eating or eating alone because of embarrassment (Johnson et al., 2004). Binge eating disorder is associated with mood changes (Berg et al., 2009) and is often a precursor to bulimia nervosa (Barker & Galambos, 2006; Cook & Hausenblas, 2011). The Barker and Galambos (2006) study indicated that binge eating pathologies primarily emerge between the ages of 18 to 25 years of age or college-aged women. The Johnson et al. (1999) study found that almost 11% of the 562 female student athletes surveyed engaged in binge eating behaviors on a weekly basis. In the Schwitzer et al.

(2001) study, 79% of the 130 female college participants, reported binge eating behaviors on a weekly to daily basis. The Berg et al. (2009) study reported that 49% of women in the 186 participation sample engaged in binge eating or compensatory behaviors at least once per week for the first sampling and 40% reported these behaviors at the second sampling. The Greenleaf et al. (2009) study reported that over 18% of college athletes reported binge eating at least once per week. Although the range for binge eating disorder varies across studies, research confirms that this disorder is a concern among college females, especially athlete students. Binge eating often occurs due to sociocultural pressures to be thin and excessive dieting (Stice, 2002). Dietary restraint or caloric deprivation increases the risk for binge eating (and bulimia nervosa), due to an individual who may crave high-carbohydrate food to restore tryptophan or serotonin levels or to improve mood (Stice, 2002).

21 Bulimia nervosa (BN). Bulimia Nervosa (BN) is behavior that involves regular episodes of binge eating followed by purging behaviors (Stice, 2002), such as selfinduced vomiting, fasting, misuse of laxatives or excessive exercise, also known as obligatory exercise (Cook & Hausenblas, 2011; Schwitzer et al., 2001). Approximately 1% to 3% of young adult women are diagnosed with bulimia nervosa (Barker & Galambos, 2007; Petrie et al., 2009; Rudd & Carter, 2006; Winzelberg et al., 2000). In the Johnson et al. (1999) study, 9.2% of the 562 female college athlete participants were found to have clinically significant issues with bulimia. In the Schwitzer et al. (2001) study, 17% of female college students reported purging by vomiting at least monthly and 5% had reported purging by using laxatives. This study analyzed the correlation between eating-related health and mental health behaviors associated with bulimia (and anorexia), including intense fear of gaining weight, over drive for thinness, and negative body image (Schwitzer et al., 2001). Results from the Krane et al. (2001) study yielded 0.7% of the 402 female participants were reported to have clinical bulimic disorders, with the most prominent predictors being body dissatisfaction and drive for thinness. Additionally confirmed in the Holm-Denoma et al. (2009) study, female college athletes are at a greater risk for developing bulimic (and anorexic) symptoms, associated with high levels of sports anxiety and drive for thinness.

Other bulimic symptoms perpetuate from attitudes that include perfectionism, negative body image, unhealthy weight management, and low self-esteem (Kaminski & McNamara, 1996), typically resulting in obsessive weight control behaviors, such as excessive dieting, bingeing, and purging (Berg et al, 2009; Stice, 2002). Contrary to common belief regarding eating disorders causing low and unhealthy body weight,

22 research found that women who deal with bulimic symptoms are found to have higher Body Mass Index (BMI) levels (Cooley & Toray, 2001) or higher amounts of body fat versus muscle ratios. This is due to unhealthy cycles of over consumption of food and trying to compensate by extreme dieting or purging, leading to compulsive behaviors or obsession over food. Often times the cycle continues to perpetuate, since women battling with bulimia will not get immediate treatment and may delay seeking help for up to four years or more (Kaminski & McNamara, 1996).

Compensatory behavior. Compensatory behavior often involves behaviors such as excessive exercising, restrictive eating, or purging. Restrictive eating, intense dieting, or purging behaviors are a way women may compensate for previous episodes of binge eating or vice versa, individuals may engage in binge eating due to certain periods of time restricting calories or avoiding most or certain foods (Stice, 2002). Dieting may be a risk factor for binge eating and bulimic symptoms when an individual can no longer sustain the will power to restrict eating. In the Johnson et al. (1999) study, 5.5% of the 562 female college athletes surveyed were found to engage in purging behaviors, such as vomiting or using laxatives or diuretics on a weekly basis. In the Greenleaf et al. (2009) study, 2.9% to 16.2% of the 204 college athletes, from three universities surveyed, reported engagement in fasting or strict dieting at least one time in the past year. Women who engage in food restriction practices will often give in and partake in over consumption of food (Stice, 2002), resulting in compensatory behavior of vomiting. This binge-purge cycle fosters various eating pathologies, such as bulimia nervosa.

Another compensatory behavior is seen in activity levels. Of the 204 college athlete participants in the Greenleaf et al. (2009) study, nearly 25% reported exercising at

23 least two hours per day in addition to their sport training, in order to control their weight.

This weight control behavior of excessive exercise has been linked to disturbed eating behaviors, since engagement in regular sports training is usually sufficient enough physical activity to maintain normal weight (Greenleaf et al., 2009).

Disordered eating. Disordered eating is a range of abnormal eating behaviors that varies from poor nutritional habits to clinical eating disorders. These behaviors may include dieting strictly to maintain or lose weight, binge eating, fasting, or using appetite control pills (Rudd & Carter, 2006). Dieting (or food intake restriction) is shown to be linked with the development of disordered eating behavior, such as binge eating, resulting in weight gain instead of the desired weight loss as seen in the Delinsky and Wilson (2008) study of 336 first-year female undergraduate students. Disordered eating may meet some of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria, but does not meet all the criteria for a formal diagnosis (Etzel et al., 2006). In the Johnson et al. (1999) study, results indicated that female college athletes were at high risk for developing disordered eating attitudes and behaviors. The Greenleaf (2002) research also confirms that sports are an at risk environment for body concerns and disordered eating. The Rudd and Carter (2006) study yielded 15% of the 1,200 college athletes surveyed reported symptoms of disordered eating behaviors. In addition, the Berg et al.

(2009) study of 186 participants, results indicated that college campuses propagate disordered eating among female college students, due to psychological and environmental stressors.

24 Eating disorder contributors Female college athletes are at risk for developing eating disorders, due to various psychological, behavioral, and sociocultural contributors or risk factors (Stice, 2002).

Risk factors are variables that have been known to produce the onset of eating disorders and are not isolated occurrences, but are interrelated as co-contributors to these pathologies. Cook and Hausenblas (2011) reported that nearly 50% of college-aged students engage in eating disorder symptoms at least once per week, showing the serious need to address prevention methods through a thorough examination of the contributing factors.

Athletic body image. Body image in general refers to the perceptions, thoughts, feelings, or mental image a person has about his/her body (Greenleaf, 2002; Rudd & Carter, 2006). Athletic body image deals with this same perception, but within an athletic context (Greenleaf, 2002). Rudd and Carter (2006) found that between 28% and 60% of college-aged females engaged in hazardous behaviors associated with body image. In the Carter and Rudd (2005) study of 800 surveyed participants from Ohio State University, 56% of female athletes wanted to lose weight. These women, on average, wanted to lose approximately seven pounds. Only 15% of athletes felt good about their body image and wanted to maintain their current body weight (Carter & Rudd 2005). In another study by Greenleaf et al. (2009), of 204 surveyed participants, female college athletes reported an astounding 54.4% were not satisfied with their current weight and 88.2% believed that they were overweight, wanting to lose nearly fourteen pounds on average. In a similar study by Petrie et al. (2009), of the 442 female college athletes surveyed, 46% were not satisfied with their weight and of those almost 94% thought they

25 were overweight. These statistics clearly show how a large percentage of women have cognitive issues with their appearance or body image perceptions.

Negative body image concerns are one of the primary factors for developing eating pathologies (Cooley & Toray, 2001). Greenleaf (2002) discusses the concept of self-ideal discrepancy theory and how it relates to negative body image. This theory states that people compare themselves to an internalized ideal. Negative body image may develop due to the discrepancy that is found between a woman’s perceived actual self and her idealized self (Greenleaf, 2002). This research leads to the conclusion that negative body image is seen as one of the leading causes for eating disorders (Rudd & Carter, 2006) and needs to be seriously examined when developing prevention programs.

Body dissatisfaction. Body dissatisfaction is defined as the negative thoughts or perceptions a person has regarding various parts of his/her body, which typically results in risky behaviors such as eating disorders (Rudd & Carter, 2006; Schwitzer et al., 2001).

These misperceptions or overestimations of one’s body are often related to sociocultural pressures that frequently define the ideal for attractiveness as favoring thinness (Stice, 2002). Rudd and Carter (2006) found that between 75% and 95% of women were dissatisfied with their bodies. In this same study, of the 1,200 surveyed college athlete participants, up to 38% felt that parts of their bodies were too fat. Women who were more dissatisfied with their bodies were three times as likely to report binge eating behaviors (Barker & Galambos, 2007). Often times women who are not satisfied with their bodies will engage in risky dieting or compensatory behaviors (bingeing, fasting, or purging), which increases the risk for clinical eating disorders (Stice, 2002).

26 College life is found to be a risk factor in the development of body dissatisfaction, due to significant life changes and stressors (Cooley & Torey, 2001). These pressures may drive an individual to engage in excessive dieting behaviors and drive for thinness attitudes, leading to body dissatisfaction, negative body image and eating disorders, such as bulimic symptoms (Stice, 2002). In the Barker and Galambos (2007) study of 101 female college students, binge eating was seen to occur due to body dissatisfaction and challenges associated with the transition to college life. Another study by Berg et al.

(2009), determined there exists a relationship between changing or decreasing risk factors, such as body dissatisfaction and depression, which leads to decreases in binge eating.

Research clearly indicates that body dissatisfaction is one of the most prevalent clinical eating disorder contributors, especially among women entering college (Barker & Galambos, 2007; Cooley & Toray, 2001). Prevention programs that focus on addressing and increasing body satisfaction and self-esteem will decrease eating disorder symptoms (Berg et al., 2009), since body dissatisfaction is strongly related to these conditions (Petrie et al., 2009).

Drive for thinness. Drive for thinness is an intense need to be thinner and a fear of gaining weight (Schwitzer et al., 2001). This is associated with an increase in body dissatisfaction (Cooley & Toray, 2001), excessive dieting, and negative body image (Stice, 2002). These cognitions or attitudes and behaviors may potentially lead to increased eating disorder symptoms, such as binge eating and bulimia (Stice, 2002). In the Krane et al. (2001) study of 204 female college athletes, participants reported drive for thinness (and body dissatisfaction) as the most prevalent eating disorder contributors.

27 Sociocultural ideals on thinness strongly influence a women’s motivation to engage in dysfunctional eating behaviors and the way they perceive their bodies (Krane et al., 2001).

Gender. Female college student athletes are at greater risk for developing eating disorders than male athletes (Holm-Denoma et al., 2009, Johnson et al., 1999), particularly White female college athletes (Johnson et al., 2004). In the Johnson et al.

(1999) study, females reported significantly lower self-esteem, higher rates of disordered eating attitudes and behaviors, and a strong desire to achieve a body fat content that could potentially result in amenorrhea, compared to male athletes. In this same study, Johnson et al. (2004), later reported that White female college athletes reported a higher drive for thinness, body dissatisfaction, and had a greater risk for disordered eating behaviors, compared to Black female and both White and Black male college athletes. In addition, Rudd and Carter (2006) found that female athletes comprise 90% of those found to have an eating disorder.

Pressures. College student athletes face additional pressures, in addition to the challenges of academic life, than the average college student (NCAA, 2012). These added stressors include pressures from coaches, trainers, judges, teammates, scheduling and time demands, extra physical demands, travel, and intensified training (Etzel et al., 2006; Petrie et al., 2009). These may have a significant impact on student health as they try to balance so many components in life. Another athletic related pressure comes from competitive sport environments, which may possibly bring about peer comparisons (Greenleaf, 2002). Social comparison theory states that an individual will tend to compare himself/herself to other people within a social setting (Festinger, 1954). This theory also suggests that people make upward comparisons, or rather compare themselves

28 to someone who is superior as a way to make improvements (Greenleaf, 2002). This may increase drive or performance, but could potentially cause emotional distress (Greenleaf, 2002).

Also, within the athletic environment are the pressures from lean sports, which research shows is a contributor to eating disorders (Krane et al., 2001; Rudd & Carter, 2006). Lean sports are those that have increased pressure to be lean for aesthetic, performance reasons, or may require revealing uniforms (Carter & Rudd, 2005; Greenleaf, 2002; Krane et al., 2001), such as gymnastics, cheerleading, figure skating, swimming, cross-country, or running (Rudd & Carter, 2006). Female athletes who are involved in lean sports also have a greater drive for thinness (Petrie et al, 2009). Overall, athletics for women, places their bodies on center stage, where they are prone to constant evaluation, not solely on performance, but also on appearance (Greenleaf, 2002).

Transition to university life may be a challenging time for college students and a contributor to eating disorders, especially for female students’ first year of college (Delinsky & Wilson, 2008). This period in life is a significant socialization process, a journey to adulthood, a time of separation from parents, and opportunity to develop self identity (Barker & Galambos, 2007; Kaminski & McNamara, 1996). Up to 33% of college females in the Schwitzer et al. (2001) study indicated concerns regarding academic pressure. The Petrie et al (2009) study indicated that female college athletes are influenced by social pressures, with constant exposure to various forms of mass media and thin internalization. Berg et al. (2009) also confirms that social and academic stressors or pressures associated with college life could potentially place women at risk for developing eating disorders.

29 Psychological. As previously mentioned, athletes are at greater risk for developing health or mental conditions, due to the added stressors that they need to balance, including, but not limited to academics, sports, social and personal development.

Mental health or psychological conditions, such as anxiety, will often time lead to eating disorder symptoms for female college athletes (Etzel et al., 2006; Krane et al., 2001). In the Schwitzer et al. (2001) study, of 130 female college students, 75% of the participants were experiencing moderate stress and anxiety and 40% were experiencing moderate depression. Additionally, research by Holm-Denoma (2009) found that female athletes, who had high levels of sports anxiety, were at greater risk for developing eating disorder symptoms. Particularly, this research reported that anxiety is linked to higher rates of bulimic symptoms and a strong drive for thinness (Holm-Denoma, 2009).

Lack of self control or impulsivity is another contributor that often leads to episodes of uncontrollable binge eating (Stice, 2002). This behavior will often create emotional distress or adverse emotions, continuing the cycle of binge eating, in an effort to seek emotional comfort (Stice, 2002). As a result, a woman may engage in obligatory or excessive exercise (Thome & Espelage, 2007) and purging, known as types of compensatory behavior (Rudd & Carter, 2006), due to intense feelings of guilt or anxiety.

Obligatory exercisers will often have increased emotions of guilt or anxiety when they are not able to exercise (Thome & Espelage, 2007). These symptoms are indicators of pathological motivations to lose weight, often related to feelings of remorse from food over consumption or associations with skewed body image and body dissatisfaction (Cook & Hausenblas, 2011).

30 Other psychological conditions associated with eating disorders are low selfesteem, which is a risk factor for developing bulimic symptoms (Cooley & Toray, 2001; Johnson et al., 2004), and contrasting low self-esteem is the drive for perfectionism.

Perfectionism is a contributor to eating disorders for athletes (Stice, 2002), due to this personality characteristic promoting an insistent pursuit for thin-idealization or drive for thinness. Excessive expectations or a high need for achievement to improve athletic performance or aesthetics (Schwitzer et al., 2001) are other components of perfectionism.

Overall, research has shown that women who are diagnosed with clinical eating disorders are reported to have more symptoms or adverse emotions of depression, anxiety, stress, guilt, and esteem concerns (Petrie et al., 2009).

Eating disorder side effects Biological. A common eating disorder syndrome, among female college athlete students is the female athletic triad (Etzel et al, 2006). This is comprised of the symptoms associated with eating disorders, amenorrhea (the absence of or irregular menstrual periods) (Etzel et al, 2006; Rudd & Carter, 2006) and osteoporosis (Etzel et al., 2006). In order to maintain healthy menstruation cycles, women need to maintain an average body fat greater than 17% (Johnson et al, 1999). When body fat falls below 17%, due to eating disorder conditions, amenorrhea develops, which decreases the levels of estrogen women’s bodies produce (Etzel et al., 2006). Estrogen is responsible for preserving normal calcium levels and bone density. When women engage in eating disorder behaviors and enable biological dangers to occur, this will often result in the high risk of developing osteoporosis within one year (Johnson et al., 1999).

31 Other physical health problems that may occur from eating disorder behaviors include fatigue, weakness, muscle loss, disordered eating patterns, severe dehydrations, electrolyte imbalance, tooth loss, stunted growth, infertility, damage to the brain and heart, vitamin and mineral deficiencies, cardiac arrest (Greenleaf et al., 2009), and even obesity (Stice, 2002). In the Johnson et al. study (2009), female college athletes reported a desire to achieve a body fat content that would result in amenorrhea. In addition, this sample of women surveyed believed that by achieving a lower weight and lower body fat percentage would enhance their athletic performance, but realistically, these behaviors could result in serious biological damage.

Psychological. Mood and self-esteem are closely linked with weight concerns, attitudes, and behaviors (Etzel et al., 2006). Research indicates that eating disorders increase the risk for depression (Stice, 2002). This is even more dangerous, considering that one out of every ten persons suffers from depression, with women being twice as likely to develop depression symptoms (Etzel et al., 2006). Mental health conditions or psychological pathologies, such as depression and disordered eating may occur due to body dissatisfaction attitudes (Greenleaf, 2002). As previously discussed, body dissatisfaction attitudes lead to risky dieting or compensatory behaviors (bingeing, fasting, or purging), which increases the risk for clinical eating disorders (Stice, 2002).

Engagement in compensatory behaviors to reduce guilt or anxiety, due to the lack of selfcontrol from over eating, is often an emotional or psychological reaction (Stice, 2002).

When women are caught in a detrimental cycle of struggling with weight concerns and negative body image, psychological conditions often occur.

32 Substance Abuse. Eating disorders increase the risk for depression and substance abuse (Stice, 2002). The pathological patterns associated with eating disorders (especially binge eating) and substance abuse behaviors (such as addiction to drugs, tobacco, laxatives, steroids, diuretics, or alcohol) are positively associated with the amount of alcohol use and abuse an individual may consume (Krahn et al., 2005). The study by Krahn et al. (2005) indicated that at-risk dieters (22% of the survey sample) were 50% more likely to engage in alcoholic consumption. This correlation indicates the association between various pathologic patterns of behavior, as seen in impulsivity or the lack of self control, which leaves individuals vulnerable to episodes of either uncontrollable binge eating or possible substance abuse disorders (Stice, 2002). In addition, it has been reported that women who have bulimia nervosa tend to develop a propensity towards alcohol problems or abuse, with dependence ranging from 9% to 50% (Krahn et al., 2005).

Eating disorder prevention Screening. The development of prevention programs is essential since less than a third of individuals with eating disorders actually receive treatment (Stice & Shaw, 2004).

Often time, women may not ask for help, for fear of being perceived as weak or disturbed.

They may also feel that they don’t even have a problem, or they do not see their unhealthy behaviors as damaging to their health (Carter & Rudd, 2005). Several survey instruments or questionnaires have been administered to determine the extent of eating disorder symptoms or pathologies among participants (Barker & Galambos, 2007; Berg et al., 2009; Carter & Rudd, 2005; Greenleaf et al., 2009; Holm-Denoma et al., 2009; Johnson et al., 1999; Krane, 2001; Petrie et al., 2009). In the Etzel et al. (2006) research

33 on understanding and promoting college student-athlete health, it is suggested that athletes should go through a screening process and physical exam prior to sport participation and at regular intervals, in order to detect eating disorder symptoms.

Awareness to and finding symptoms such as preoccupation with food, binge eating, restricting food intake, feelings that food controls one’s life, forced vomiting after a meal, abuse of laxatives, and obsession with body and weight are screening methods to determine whether or not an individual has a variation of an eating disorder, whether it is clinically diagnosed or a problematic sub-clinical condition (Stice et al., 2002). In addition, Petrie et al. (2009) also concur that screenings should look for symptoms at both the clinical and sub-clinical levels. This study found that approximately 25% of the 442 female college athlete participants had clinical or sub-clinical eating disorder attitudes and behaviors, indicating the importance of screening and preventive methods.

Psychoeducational. Another method for prevention is the psychoeducational approach (Stice & Shaw, 2004). A psychoeducational method is the attempt to educate or provide informational material to women at risk for eating disorders on the adverse effects of these pathologies (Stice et al., 2002), and educate particularly in the areas of nutrition, dieting, and exercise (Schwitzer et al, 2001). In the Schwitzer et al. (2001) study of 130 female college students who had already participated in an eating disorder intervention program, Schwitzer et al. advocate for educational workshops that address eating disorder contributors such as gender issues, self-esteem, and social pressures. In the Rudd and Carter (2006) study of more than 1,200 surveyed participants, various methods were implemented in order to develop healthy and positive body image attitudes and behaviors, among female college athletes. An eating disorder policy was developed,

34 where athletes were required to participate in treatment programs if diagnosed with an eating disorder, in order to continue in their sport. In addition to creating policies, Rudd and Carter (2006) developed educational material about positive body image and presented the information to coaches and athletes, along with organizing and promoting an annual body image bazaar and forming a health task force team.

An earlier study by Winzelberg et al. (2000), surveyed and facilitated an on-line discussion group of sixty participants. This study determined that an internet based or computer-assisted health education program designed to decrease body dissatisfaction (a contributor to eating disorders) was effective and improved body image, along with decreasing drive for thinness. The Carter and Rudd (2005) study of 773 athletes (which 19% of participants were problematic for disordered eating) collaborated with sport dietitians to offer psychoeducational material to athletes, who reported sub-clinical symptoms, and their coaches to address body image concerns, in an attempt to develop healthy behaviors. Psychoeducational material is often delivered by various methods of distribution, such as support group sessions, individual counseling, informative presentations, printed brochures, and internet resources (Greenleaf et al., 2009) to coaches, students, parents, and higher educational professionals. These methods and materials endorse early education and detection in the signs and symptoms of disordered eating, clinical eating disorders, and the female athlete triad for female college athlete students. However, psychoeducational delivery methods can be limiting and have minimal effect on long term behavioral changes (Stice et al, 2002).

Interactive. Simply talking about eating disorders, signs, symptoms, and side effects is not enough, rather interactive programs that engage participants and teach new

35 skills are more effective (Stice & Shaw, 2004). Women need to engage in both a dissonance-based approach and a healthy weight intervention approach (Stice et al., 2002). The dissonance-based approach involves a change in attitude. Since many of the eating disorder contributors are attitude based cognitions, such as negative body image, body dissatisfaction, drive for thinness, perfectionism, and psychological dysfunctions, programs designed to encourage women to critique these beliefs and attitudes could potentially reduce eating disorder symptoms and behaviors (Stice et al., 2002).

The Cooley and Toray (2001) study recommends prevention programs that focus on addressing body dissatisfaction attitudes in order to minimize eating disorder symptoms. In addition, seriously analyzing sociocultural pressures, media and sport environment pressures, and gender expectations, along with engagement in body acceptance exercises, will decrease negative attitude effects, by taking a stance against or reducing subscription to pressures and preconceived body ideals (Stice et al., 2002).

Proven to be more effective in reducing eating disorder pathologies, than solely the dissonance-based approach, is the healthy weight intervention approach. This focuses on behavior modification through the promotion of permanent lifestyle changes, social support, and increasing self-esteem (Stice et al., 2002). The healthy weight intervention method is geared towards helping participants develop lifestyle changes by teaching women to consume nutritionally balanced diets (including reduced intake of high-sugar and saturated fat foods) and engaging in regular moderate exercise. Balanced and nutritional diets, combined with effective moderation patterns of eating will curb overeating tendencies or bingeing behaviors (Stice, 2002). The emphasis using this

36 approach is to promote the importance of health over appearance, set attainable goals, and to generate realistic expectations of body image.

In addition, when women have the opportunity to share their own stories or hear the personal journeys of other women, these interactions have beneficial correlations to attitude and behavioral changes (Stice et al., 2002), through providing encouragement and support. In the Kaminski and McNamara (1996) study, twenty-nine of the 315 female college students, at a midsize American university, surveyed showed evidence for developing bulimic symptoms. These women participated in an eight week group therapy program (approximately ninety minutes each) that focused on enhancing body image, through discussions on sociocultural pressures and the role of the media. Results showed a decline in body dissatisfaction and improved self-esteem (Kaminski & McNamar, 1996). In the Stice and Shaw (2004) study, research found 53% of the interactive prevention programs evaluated were more effective at reducing eating disorder symptoms than pyschoeducational programs (Stice & Shaw, 2004). This same study suggests that longer multi-session programs are more effective than brief singlesession programs, since the former allows participants time to reflect on the material between sessions, implement new practices and skills, and return to the group for discussion and support.

Interactive prevention programs were found to produce changes in behavior, due to the content focusing on reassessment of maladaptive attitudes towards drive for thinness and body dissatisfaction (Stice & Shaw, 2004), rather than simply talking about eating disorders. Furthermore, Stice and Shaw (2004) reported that the most successful prevention programs are those that are geared towards a specific target audience, high-

37 risk individuals, rather than developing generic programs. In addition, when program objectives promote body acceptance attitudes versus a sole focus on eating disorder pathologies, more effective outcomes occur, with positive attitude and behavioral changes, instead of creating hostility or defensive attitudes.

The Johnson et al. (2004) study regarding gender, ethnicity, and self-esteem as it relates to disordered eating among college athletes, found that certain factors exist in the Black female culture that protect them from low self-esteem and disordered eating behaviors. These factors include a sense of empowerment, lower subscription to cultural idealization of thinness, higher body satisfaction, and acceptance of larger body size attitudes (Johnson et al., 2004). When interactive programs promote a sense of empowerment, challenge ideals of thinness, educate on healthy lifestyles, and offer support, positive outcomes are more likely to occur. In addition, higher educational departments, such as athletic departments, counseling centers, food services, residence halls, wellness centers, women’s centers, and recreational facilities (Etzel et al., 2006) need to work together to help implement and promote eating disorder prevention programs to help female college student athletes (Rudd & Carter, 2006).

Summary The most effective way to combat eating disorders is to address the attitudes and behaviors that contribute to these pathologies before problems emerge (Schwitzer et al., 2001). Development and promotion of prevention programs needs to combine various components that include screening processes, psychoeducational material distribution, and interactive methods, to change behavioral symptoms (Schwitzer et al., 2001) for long-term physical and psychological health. Research indicates nearly 25% of college

38 women are considered to be at risk for developing an eating disorder (Winzelberg et al., 2000) and that up to 61% of college women were found to have some form of either a clinical or sub-clinical eating behavior problem (Kaminski & McNamara, 1996). The study by Johnson et al. (1999) yielded that as high as 58% of female NCAA Division I athletes were at risk for developing eating disordered behavior. In addition, an astounding 83% of women are generally concerned about their eating habits or weight management (Schwitzer et al, 2001). The study conducted by Petrie et al. (2009) indicated that 18% of college female athletes specifically had symptomatic or sub-clinical behavior, while 5.7% had clinical eating disorders. Another study conducted by Greenleaf et al. (2009) indicated that 25.5% of this high-risk population of female college athletes had symptomatic or sub-clinical behavior, while 2% had clinical eating disorders.

College female athletes are at greater risk for developing anorexic and bulimic symptoms, along with disordered eating behaviors (Holm et al., 2008). With the higher percentage of sub-clinical eating disorder symptoms for female athletes (Carter & Rudd, 2009), where women experience complex problematic behavior (Etzel et al., 2006), typically unnoticed, untreated, and is a long-term process to treat (Greenleaf et al., 2009), these factors result in an urgent need for prevention programs in higher education. As seen in the Berg et al. (2009) study, where 186 female participants completed measures of eating disorder symptoms and risk factors, results showed that the implementation of prevention programs that target the most common eating disorder contributors—body dissatisfaction and low-self esteem—are more likely to avert the serious health hazards associated with these pathologies and college female athlete students (Berg et al., 2009).

39 Conclusion Higher educational professionals, who work alongside, provide mentorship, or coach female college athlete students, need to take an astute awareness regarding signs and symptoms of possible clinical or sub-clinical eating disorder behaviors, since nearly one third of women are at risk for developing eating disorders while in college (Winzelber et al., 2000). Given that eating disorders are difficult to treat, prevention and intervention programs targeted towards female college athlete students, coaches, trainers, parents, and higher educational professionals is important and socially responsible.

Combating the preventive or controllable contributors associated with the onslaught of eating disorders, before they occur, such as sociocultural, academic, sport environment, and peer pressures or ideals, psychological factors, excessive weight concerns, drive for thinness, negative body image, and body dissatisfaction (Winzelberg et al., 2000), will create healthy and positive self perception attitudes and life style behaviors. Paramount health for students can only occur if educators encourage and teach lifelong wellness cognitions to create a cultural change (Rudd & Carter, 2006). Administrative professionals in higher education, who may regularly be involved with helping college students, need to develop an understanding of the issues female student athletes face and implement best practices for helping them overcome these problems (Etzel et al., 2006).

40 Chapter Three: Project Description Introduction College female athletes with an average age of 19.9 years, in a National Collegiate Athletic Association study (Johnson et al., 1999), are found to be at high risk for developing eating disorder syndromes, with high competitive sports and lean sports bearing the greatest risk factors for these pathologies (Carter & Rudd, 2005). Student athletes are at greater risk for eating disorders than the typical college student due to excessive pressure and anxiety with trying to balance sports and academics, leading to increased struggles with obtaining proper nutrition (Etzel et al., 2006). Particularly, college female athletes are prone to engage in unhealthy behaviors to control their weight, due to the “unique pressures that female athletes face in the sports environment,” within the college setting (Greenleaf et al., 2009, p. 489).

Unless higher education institution administrators, athletic coaches, trainers, and female athletes change the way body satisfaction, body image, and drive for thinness are perceived (Krane et al., 2001) and become educated in identifying signs and symptoms of eating disorders (Etzel et al., 2006), these women will continue to put their health and potentially their lives in danger, resulting in “deaths and serious illnesses from eating disorders” (Johnson et al., 1999, p. 179).

This chapter will first describe the background, desired objectives, rationale, and components for this project. Then the measures used to determine the success of this project will be explained. Next, the conclusion of this chapter will show how the research from chapter two has directly resulted in the development of this project to address the issue of eating disorders among college female athlete students. Finally, the

41 last section of this chapter will explain how the workshop will be implemented, how and when the information will be shared, and with whom it will be shared.

Project Components Many colleges and universities have accessible resources or psychoeducational material available for college female athletes to learn more about eating disorder signs, symptoms, and side effects. However, many higher educational institutions do not offer interactive programs that result in long-term attitude and behavioral changes. The goal of this project is to create a program, fostering relationships through connecting with the program facilitator, peer group support and meeting the health ambassador panel, which will enable women to openly communicate the challenges and obstacles associated with weight management and body satisfaction. The aim of this program will result in improved body image and body satisfaction to prevent eating disorders. Based on the research conducted in this project, an interactive four-week workshop (see Appendix A) has been developed to meet the goals of this project. Each workshop will meet for sixty minutes, one time per week at a date, time, and location on campus convenient to female college athlete students.

Background of the project College life transition can be a challenging time for students (Stice, 2002). For many adolescents, attending a university is a way to explore the transition into adulthood.

Significant life changes occur during the college years, in addition to new stressors introduced to young women during this time (Cooley & Toray, 2001). New socialization opportunities surmount, opportunities to define their own identities, more emotional stress, and separation from parents challenge the psychological capacity of college

42 women (Barker & Galambos, 2006; Kaminski & McNamara, 1996). When young women attend college, during this high-risk developmental period (Berg et al., 2009), increased risk for disordered eating can occur due to social and academic pressures that come with the college environment. Barker and Galambos (2006) state that the high-risk of college life transitions can contribute to stressors that may exceed coping resources, resulting in increased risk for eating problems. According to Delinsky and Wilson (2008), during the first year of college, disordered eating increases and is considered a high-risk period for the development of eating disorders. Results from research studies indicate “25% of college women are thought to be at risk for developing eating disorders� (Winzelberg et. al., 2000, p. 346; Berg et al., 2009).

Specifically, according to Cooley and Toray (2001), body dissatisfaction was the leading factor that contributed to increased eating pathologies for women entering college.

Prior research indicated other factors such as lowered self-esteem, negative body image, drive for thinness, and obsessive concerns regarding weight and appearance (Kaminski & McNamara, 1996) are precursors of eating disorders. Females who are unhappy with their body image are more susceptible to developing eating disorders (Cooley & Toray, 2001). With nearly one third of female college students at risk for developing these harmful diseases, higher educational institutions need to be a part of the cohort to intervene and treat their students.

Athletes are the female college student sub-population that is at an even greater risk for developing eating disorders (Etzel et al., 2006; Rudd & Carter, 2006; Greenleaf et al., 2009; Holm-Denoma et al., 2009; Johnson et al., 1999). A NCAA Division I study of college athletes, by Johnson et al. (1999), found that 58% of females were at high risk for

43 developing eating disordered behavior. In addition to the socio-cultural pressures, college life transitions, and the psychological developmental period college students encounter, student athletes have added pressures from the sports world, such as pressure from competition, training, travel, balancing academics and sports, appearance and weight management, perfectionism, high need for achievement, athletic performance, and pressure from coaches, trainers, and teammates (Etzel et al., 2006). Any combination of these various factors could potentially lead to anxiety, stress, or depression, which may perpetuate the increased risk of developing eating disorders.

Athletic environments may increase the risk for eating disorders (Greenleaf, 2002). Female student athletes are faced with certain pressures from their sports, such as evaluation of their bodies, revealing uniforms, weigh-ins, appearance and dealing with having their bodies in the limelight. These factors place added pressure on the female college athlete to conform to the ideals of what the female body should look like, both from socio-culture pressure and self-induced pressure, resulting in the athletic body image or the perception the athlete has of her own body in the athletic context. As a result from these pressures placed on college female athletes, conditions such as weight concerns, dieting, and body dissatisfaction become issues that could potentially lead up to eating disorders (Thome & Eselage, 2007). A study by Krane et al. (2001) indicates that female college athletes have a higher drive for perfectionism and a higher drive for thinness, which also increases eating disorder risks. These unhealthy behaviors are all factors that contribute to the continuum of eating disorders, which range from mild conditions, such as yo-yo dieting and excessive exercising to moderate conditions, such as weight and shape preoccupations, diet pills and laxatives, compulsive overeating, and

44 calorie counting to more severe conditions of fasting, distorted body image, binge eating, bulimia, vomiting, and anorexia (Rudd & Carter, 2006).

Since certain aspects of campus environments are conducive to eating disorders (Kaminski & McNamara, 1996), various departments need to work collectively to identify and intervene before serious illness or death occur to female college student athletes. Collaboration between coaches, students, faculty, the Athletic Department, Student Wellness Centers, Fitness and Recreation Centers, Counseling Services, Women’s Centers, Student Affairs, Dining Halls and Residency Halls (Rudd & Carter, 2006), all within the higher educational context, will create a sense of awareness and urgency to prevent and treat eating disorders and symptoms (Etzel et al., 2006).

Statement of purpose The purpose of this project is to eliminate the onset of eating disorders before problems emerge, by creating positive body image and increasing body satisfaction, among the targeted female college student athlete population. The preventive measures of this project will address the issue of hard to treat eating disorders, typically left untreated, before serious illness and death occur. Specifically, this project has outlined intervention strategies, provided a self-assessment questionnaire, developed a prevention program, created an environment for a peer support group, and has developed plans for establishing an interdepartmental collaborative task force team, based on the results of current eating disorder causes and symptoms researched. This project will educate, create awareness, and modify negative eating and nutrition behavior that female college student athletes may engage in. This project is unique by utilizing a holistic approach,

45 through offering preventive techniques that address cognitive dissonance and implementing behavior modification strategies.

Objectives of the project The objective of this project is to create a comprehensive plan that will guide female college student athletes through building a positive body image and body satisfaction, establishing healthy eating patterns, proper nutrition, and exercise plans that will prevent the signs, symptoms, and behaviors of disordered eating. This plan will address the needs that female college athletes have in balancing both the sports world and college environment, in addition to addressing the obstacles and associated problems that perpetuate eating disorders.

Rationale of the project Understanding the onset causes and precursor symptoms associated with eating disorders is most important in deterring the hard to treat conditions of eating disorders, most commonly associated with young women (Holm-Denoma et al., 2008). A careful study of eating disorders will better help higher educational institution administrators, coaches, trainers, and fellow student teammates to develop prevention programs and implement intervention policies and practices. According to Schwitzer et al. (2001), university campuses need to develop structured responses to reach out to college females, particularly high risk populations, such as female college athletes, through the development, marketing, and implementation of prevention programs. According to the NCAA Sports Medicine Handbook, â€œâ€Ś it is the responsibility of each member institute to protect the health of, and provide a safe environment for, each of its participating studentathletesâ€? (NCAA, 2012, p. 2). This clearly states the importance of higher educational

46 institution’s role and responsibility to be proactive in the well being of their student athletes. Prevention approaches need to provide educational material on nutrition, dieting, and proper exercise. Studying eating disorders, in order to create the most effective programming and intervention methods, is essential to target the students most at risk before eating disorders emerge or advance to stages of serious illness or even death (Johnson et al., 1999). It is the obligation of higher education administrators to intervene disordered eating cycles at the earliest possible stage to ensure the safety of their students (Thome & Espelage, 2007) and to have a good understanding of student athlete’s issues and needs (Etzel et al., 2006).

College female students are concerned with body image, weight control management, and body shape and size. Recent studies report that 6% of undergraduate female students are concerned with bulimia and anorexia, while 25% to 40% reported moderate problems (Schwitzer et al., 2001). Schwitzer’s (2001) study reported an alarming 83% of female college students are concerned with eating and weight management. With such a high percentage of the female college population struggling with a broad spectrum of disordered eating, ranging from poor nutrition to binge eating and purging, the importance of this study is precedent; especially since less than one third of those with eating disorders actually receive treatment (Stice & Shaw, 2004).

Untreated eating disorders or the lack of preventive intervention strategies is detrimental to each young college female from the disease itself to it being a leading factor and perpetuator of other habilitating conditions such as obesity, depression and substance abuse (Stice, 2002).

47 The results from a national study by Johnson et al. (1999) confirms the importance of focusing preventive and intervention efforts specifically on female college student athletes, who reported “significantly higher rates of disordered eating attitudes and behaviors” (Johnson et al, 1999, p. 187). Johnson et al. (1999) continues to state the priority of eating disorder programming and education efforts should not only be geared towards female college student athletes, but to also include coaches, athletic department directors, trainers, student athletes and teammates, regulatory board members, and parents of athletes to increase awareness of the serious physiological and psychological side effects.

Project description An interactive four-week workshop (see Appendix A), called Healthy Bodies: Building Positive Body Image Among College Female Athlete Students, has been developed to meet the goals of this project. Each workshop will meet for sixty minutes, one time per week at a date, time, and location on campus convenient to female college athlete students. The facilitator of the workshop will either be myself, the author of this project, or a Healthy Bodies program ambassador from one of the task force team departments (Women’s Center, Wellness Center, Dining Hall, Residence Hall, Recreation Center, Athletic Department, Counseling Center, or Campus Health Services).

The target audience will be college female athlete students. The workshop capacity will contain ten to twelve student participants per four-week session. The objectives of the workshop sessions will be to create a safe and supportive environment, to educate and establish healthy eating patterns, to motivate and engage moderate physical activity, to create and affirm positive body image and increase body satisfaction, and to prevent

48 eating disorders and symptoms. The materials needed are a computer, projector, screen (or white wall/board), journals (or paper filled three-ring binders for all participants), writing utensils, fashion, health, beauty, and fitness magazines (twelve to fifteen publications).

Week one, titled “My Identity,� is an opportunity for participants to meet one another and the workshop facilitator, in order to build trusting and safe relationships. The week one session will begin with a ten-minute introduction session. This gives each participant the chance to meet one another, learn about each other, and start to develop a connection. Next, each participant will take five-minutes to read through twelve questions to herself and reflect on her own thoughts and reactions to the self-assessment.

To articulate her feelings, each participant will have the optional opportunity to engage in a fifteen-minute group discussion to share her reactions, share personal stories, and share obstacles associated with body image concerns. The next interactive component of week one will be for each participant to engage in journal writing for twenty minutes. Based on the questions outlined in Appendix A, each participant will record her thoughts and reactions on the topics of body perception, life balance, and goal setting, to build positive affirmations and increase self-esteem. The last component of week one will involve a ten-minute explanation of the Healthy Bodies assignment. The week one assignment includes recording in a food and activity journal, written journal entries about body appreciation and discussion reflection, along with watching a video on eating disorders.

The objective of creating assignments each week is to keep participants engaged in the workshop throughout the week leading up to the next workshop session. The

49 assignments are also geared towards creating accountability for each participant, in order to apply the principles learned in the workshop material to everyday life.

Week two, titled “Optimal Health,” is an opportunity for participants to receive psychoeducational material and information to better understand the meaning of health versus maladaptive behaviors associated with a drive for thinness. The workshop will open with a ten-minute discussion, reflecting and sharing on the previous week’s journal writing, food and activity recordings, goal setting and obtainment, and sharing positive attributes about oneself with one another. Next, the program facilitator will present thirty minutes of psychoeducational material to the group participants, engaging participants in eating disorder types, symptoms, contributors, and side effect information, which will create awareness and prevention from developing eating disorders. Ending the workshop for week two, will involve a ten-minute discussion, based on the information presented, and allowing for questions or sharing of thoughts, concerns, or personal stories. Week two will conclude with a ten-minute discussion on the Healthy Bodies assignment, to be due the following week. Once again, this involves recording in the food and activity journal, written journal entries, pertaining to thoughts and concerns about the week two material presentation, and finding at least three magazine advertisements that influence each participants drive for thinness or each one’s ideal body image to bring to the week three workshop session.

Week three, titled “Sociocultural Ideals,” is an opportunity for participants to seriously critique the socially constructed ideals of thinness and beauty, to challenge these perceptions and how they relate to healthy and unhealthy behavioral outcomes. The workshop will open with a ten-minute discussion, reflecting and sharing on the previous

50 week’s journal writing, food and activity recordings, goal setting and obtainment, and sharing at least two of the body image concerns or obstacles each participant encounters.

Next, participants will take ten-minutes to browse through fashion, beauty, health, nutrition, and food magazines to identify advertisements that influence perceptions of thinness, negatively portray women, and positively portray women. Then, participants will engage in a fifteen-minute discussion challenging these advertisements, how the publication piece makes each participant feel, the business of the beauty industry, realistic aspirations of thinness, and the pursuit of perfectionism. The open discussion will continue next for ten more minutes, as participants reflect on the sociocultural ideals of thinness and how it applies to each of their lives. This segment will also include aspects of empowerment and building self-esteem, based on the engaging questions in Appendix A. Week three will conclude with a ten-minute discussion on the Healthy Bodies assignment, to be due the following week. Once again, this involves recording in the food and activity journal, written journal entries, pertaining to perceptions each participant feels have changed regarding thin idealization due to the material presented so far in the workshop sessions, reflection on the self-assessment questions (see Appendix C), preparation of questions for the health ambassador panel, and bringing a healthy dish to share with the group for the week four session.

Week four, titled “Healthy Life,” is an opportunity for participants to gain additional resources for the continual pursuit of eating disorder prevention information, healthy life style behavior implementation, treatment options (if applicable), and develop connections with on and off campus resources. The workshop will open with a tenminute discussion, reflecting and sharing on the previous week’s journal writing, food

51 and activity recordings, goal setting and obtainment, and sharing two of the perceptions that each participant feels has changed regarding their original thoughts on thin idealization based on previous material and sociocultural critique. During this time, participants will take the opportunity to write out their short and long term healthy lifestyle goals in their written journals. Next, psychoeducational material will be presented by the workshop facilitator for ten-minutes to share information on clean eating and moderate activity. The next segment of the week four workshop will involve a twenty minute open forum with a health ambassador from the Women’s Center, Wellness Center, Dining Hall, Residence Hall, Recreation Center, Athletic Department, Counseling Center, and Campus Health Services. Each ambassador will introduce his/herself, identify the resources available to each participant that will help enable or encourage them to meet their healthy lifestyle goals, and be available for comments and questions.

Ambassadors have the option to hand out additional resource flyers, pamphlets, brochures, or Internet sources to participants. The program will conclude with a twentyminute clean eating potluck. The objective of this socialization period is to solidify the relationships built during the four-week workshop session, build new relationships with the health ambassadors, focus on food as nutrition and life giving, rather than an obsession or perpetrator, and to strengthen positive affirmations with one another.

Project Evaluation The project will be evaluated for success via various formats. The first evaluation will be personal and only for the participant’s benefit. During the first week workshop, each participant will partake in a self-assessment and reflection session (see Appendix C).

After the third week workshop, participants will compare and contrast their initial first

52 week responses and reactions to the third week responses and reactions, in their written journal entry assignment, based on the self-assessment questions (see Appendix C). The next evaluation will be participant observation by the workshop facilitator. Based on each participant’s initial responses, reactions, and discussions from the week one workshop, the facilitator will compare participant’s attitudes and behaviors over the fourweek sessions, to evaluate learner outcomes. The final evaluation tool will be the administration of the program exit survey (see Appendix E). This survey will provide program developers and facilitators with effective measures for determining the success of the program and ways for improvement.

Project Conclusion The conclusion of this project has been developed from the original problem stated in Chapter One and the research previously conducted in Chapter Two. Chapter One outlined the problem of eating disorders among college female athlete students and the need for higher educational professionals, who work alongside, provide mentorship, or coach female college athlete students, to take an astute awareness regarding signs and symptoms of possible clinical or sub-clinical eating disorder behaviors, since nearly one third of women are at risk for developing eating disorders while in college (Winzelber et al., 2000). Given that eating disorders are difficult to treat, prevention and intervention programs targeted towards female college athlete students, coaches, trainers, parents, and higher educational professionals is important and socially responsible, hence the development of the Healthy Bodies four-week program. Combating the preventive or controllable contributors associated with the onslaught of eating disorders, before they occur, such as sociocultural, academic, sport environment, and peer pressures or ideals,

53 psychological factors, excessive weight concerns, drive for thinness, negative body image, and body dissatisfaction (Winzelberg et al., 2000), will create healthy and positive self perception attitudes and life style behaviors. Paramount health for students can only occur if educators encourage and teach lifelong wellness cognitions to create a cultural change (Rudd & Carter, 2006). Administrative professionals in higher education, who may regularly be involved with helping college students, need to develop an understanding of the issues female student athletes face and implement best practices for helping them overcome these problems (Etzel et al., 2006). It is advised, by the author of this project, that not only should college female athlete students participate in the Healthy Bodies four-week program, but administrative professionals should also be provided with the workshop information.

Questions that remain unanswered about eating disorders not covered in this project are how to treat individuals already diagnosed with severe clinical eating disorders. This information and psychological condition should be researched and covered by a licensed professional psychiatrist on an individual and case-by-case basis.

However, this program will provide resources made available to participants who may be concerned about long-term physical and psychological concerns regarding eating disorders and methods for prevention.

Plans for Implementation The Healthy Bodies: Building Positive Body Image Among College Female Athlete Students four-week program should be made available to administrative professionals in higher education institutions, associated with the Women’s Center, Wellness Center, Dining Hall, Residence Hall, Recreation Center, Athletic Department,

54 Counseling Center, and Campus Health Services. Each department director should be contacted and presented with the project information, by the author of the project once this Master’s Project has been submitted to, approved, and accepted by the College of Education at Grand Valley State University. Upon sharing this project with these departments, a health ambassador panel needs to be established. Ideally, a representative from each of the previously listed departments needs to be appointed as a health ambassador. The time and effort commitment for this task force team is minimal and simply requires open lines of communication, an awareness of program content, identification of possible college female athlete students who may benefit from the Healthy Bodies program, ability to refer students, assist in distributing program marketing media pieces, and participation in the week four open forum panel discussion and clean eating potluck session. The program shall be offered to college female athlete students at no charge. Any associated expenses, such as facilitator staff compensation, presentation equipment, or program materials, should be budgeted by the department requesting the program to be provided to its students.

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Healthy Bodies Building Positive Body Image Among College Female Athlete Students Created by Kristina Wieghmink Master’s Project 2012 (Appendix A)

4 Week Interactive Workshop  Week

1 – My Identity

 Week

2 – Optimal Health

 Week

3 – Sociocultural Ideals

 Week

4 – Healthy Life

Target Audience College Female Athlete Students

Workshop Capacity 10 – 12 students per 4 week session

Workshop Objectives  To

create a safe and supportive environment.  To educate and establish healthy eating patterns.  To motivate and engage moderate physical activity.  To create and affirm positive body image and increase body satisfaction.  To prevent eating disorders and symptoms.

Materials Needed  Computer  Projector  Screen/white

wall/board  Journals or paper filled 3-ring binders for all participants  Writing utensils  Fashion, health, beauty, and fitness magazines/publications (12-15)

Healthy Bodies Week 1

(60 minute workshop)

My Identity

Image Source: http://athletics.wheatoncollege.edu/sports/wvball/2011-12/releases/20110829m72jji

Group Introductions (10 minutes)  Name  Age  Sport  Major  Hometown  Favorite

. . . (color, show/movie, pet, interest, etc.)  Why Attend Workshop?  What Hope to Gain, Achieve, Change, etc.?

Self-Assessment (5 minutes)  Read

& answer questions to yourself (found on next slide)

 Assess

your reaction or feelings

(hurt, angry, sad, lonely, depressed, out of control, hungry, happy, confused, anxious, etc.)

Image Source: http://flywithdreams23.blogspot.com/2011/09/nana-lonely_10.html

    

      

Do you continually think about food?

Do you feel that food has control over your life?

Do you find it hard to stop eating at times?

How does that make you feel?

To compensate, do you vomit, use laxatives, restrict your food intake, or excessively exercise to overcome guilt and/or lose weight?

Do you think you are fat?

Do you constantly weigh yourself?

Are you obsessed with your appearance and/or weight?

Do you eat when you are bored, lonely, sad, or stressed?

Does food give you comfort or relief?

Are you happy with yourself?

Do you wish you could change something about yourself? What? Why? How?

Created by Kristina Wieghmink, 2012 (Appendix C) Image Source: http://www.empowher.com/sites/default/files/herarticle/female-athlete-triad-disorders.jpg

Open Discussion (15 minutes)

 Share

thoughts, feelings, and reactions

 Share

personal stories and obstacles

Journaling (20 minutes)

 Reflect

on each of the following 3 slides

 Record

your responses and feelings

Image Source: http://promotional-gifts.biz/E735-promotional-journals.htm

Perception  How

do you perceive yourself?

 Who

is your ideal self?

 Why?  Is

this realistic?

 Is

this healthy?

Image Source: http://www.rockautismexperience.com/2011/06/quiet-and-lonely.html

Balance Do you feel balanced in the following areas:  Mentally  Physically  Emotionally  Academics  Sports Training & Competition  Socially  Time Management  Financially  Family Image Source: http://touchstonesofthesacred.com/3-steps-to-balance-mind-body-and-spirit/

Goal Setting  What

goals do you have for your health & well-being?  What do you do now to achieve these goals?  What would you like to do?  How do you think you can reach these goals?  What changes do you feel you need to make to reach your goals?  What challenges or obstacles prevent you from achieving your goals?

Healthy Bodies Assignment (10 minutes)

Food Journal Instructions (see Appendix B)  Record

current weight  Record current BMI

http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/ english_bmi_calculator/bmi_calculator.html

 Record

desired goals  Record 1 week of food intake  Record 1 week of exercise activity  Be honest and measure if necessary  Nutritional Information Guide

https://www.choosemyplate.gov/SuperTracker/

Written Journal Instructions  Record

at least 3 things you like or appreciate about yourself  Be positive and value yourself  Take time to reflect and assess your feelings  Write additional thoughts and reflection from today’s workshop journaling  Watch

PBS – Dying to be thin video

http://www.pbs.org/wgbh/nova/body/dying-to-be-thin.html

Have a Great Week  Be

positive!

 Be

motivated!

 Be

happy!

 Be

healthy!

Healthy Bodies Week 2

(60 minute workshop)

Optimal Health

Image Source: http://www.natural-weightloss-energy.com/wholefoods/

Open Discussion (10 minutes)

 Review

1st week of written journal  Share thoughts & reactions on video  Review 1st week of food & exercise journal  Check goals – Obtained? Realistic? Healthy?  Share obstacles & challenges  Share positive attributes about self

Health (30 minutes)

Health is the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (Etzel et al., 2006), as defined by the World Health Organization (1946).

Image Source: http://www.catholicvote.org/discuss/index.php?p=26596

Eating Disorders 



 

 

83% of women are generally concerned about their eating habits or weight management (Schwitzer et al, 2001) College female athletes are found to be at high risk for developing eating disorder syndromes, with high competitive sports and lean sports bearing the greatest risk factors for these pathologies (Carter & Rudd, 2005) Disrupt the ability to sustain life and enjoy it with longevity Detrimental to well-being and results in serious psychological and physical consequences, even death may occur (Johnson et al., 1999) Relatively few differences between clinical and subclinical eating disorders (Greenleaf et al., 2009) Typically unnoticed, untreated, and is a long-term process to treat (Greenleaf et al., 2009),

Eating Disorder Types  Anorexia  Binge

nervosa (AN)

eating disorder

 Bulimia

nervosa (BN)

 Compensatory  Disordered

behavior

eating

Anorexia Nervosa (AN)  Restriction

of food eating (extreme emaciation) (Stice, 2002)  Excessive weight loss  Intense fear of weight gain or becoming fat despite a low body weight  Negative body image  Denial of the seriousness of low body weight  Absence of menstruation (Cook & Hausenblas, 2011)  Fasting or strict dieting (Greenleaf et al, 2009).

 General

public, 0.5% to 1% are diagnosed with anorexia nervosa (Petrie et al., 2009; Rudd & Carter, 2006), while for female college athletes the rate is up to 2% (Petrie et al., 2009)

 25%

were identified as being at risk for developing clinical anorexia nervosa (Johnson et al., 1999)

Binge Eating Disorder Repeated episodes of uncontrollable eating of unusually large quantities of food (Stice, 2002)  Often characterized by rapid eating or eating alone because of embarrassment (Johnson et al., 2004)  Associated with mood changes (Berg et al., 2009)  Often a precursor to bulimia nervosa (Barker & Galambos, 2006; Cook & Hausenblas, 2011) 

Primarily emerge between the ages of 18 to 25 years  Johnson et al. (1999) study found that almost 11% of the 562 female student athletes surveyed engaged in binge eating behaviors on a weekly basis  Schwitzer et al. (2001) study, 79% of the 130 female college participants, reported binge eating behaviors on a weekly to daily basis  Berg et al. (2009) study reported that 49% of women in the 186 participation sample engaged in binge eating or compensatory behaviors at least once per week for the first sampling and 40% reported these behaviors at the second sampling.  Greenleaf et al. (2009) study reported that over 18% of college athletes reported binge eating at least once per week. 

 Often

occurs due to sociocultural pressures to be thin  Excessive dieting (Stice, 2002)  Dietary restraint or caloric deprivation increases the risk for binge eating (and bulimia nervosa), due to an individual who may crave high-carbohydrate food to restore tryptophan or serotonin levels or to improve mood (Stice, 2002).

Bulimia Nervosa (BN) Behavior that involves regular episodes of binge eating followed by purging behaviors (Stice, 2002)  Self-induced vomiting, fasting, misuse of laxatives or excessive exercise, also known as obligatory exercise (Cook & Hausenblas, 2011; Schwitzer et al., 2001)  Perfectionism, negative body image, unhealthy weight management, and low self-esteem (Kaminski & McNamara, 1996) 

 Approximately

1% to 3% of young adult women are diagnosed with bulimia nervosa (Barker & Galambos, 2007; Petrie et al., 2009; Rudd & Carter, 2006; Winzelberg et al., 2000)  Johnson et al. (1999) study, 9.2% of the 562 female college athlete participants were found to have clinically significant issues with bulimia  Schwitzer et al. (2001) study, 17% of female college students reported purging by vomiting at least monthly and 5% had reported purging by using laxatives

Compensatory Behavior  Excessive

exercising  Restrictive eating  Purging  Way women may compensate for previous episodes of binge eating

Johnson et al. (1999) study, 5.5% of the 562 female college athletes surveyed were found to engage in purging behaviors, such as vomiting or using laxatives or diuretics on a weekly basis  Greenleaf et al. (2009) study, 2.9% to 16.2% of the 204 college athletes, from three universities surveyed, reported engagement in fasting or strict dieting at least one time in the past year  Of the 204 college athlete participants in the Greenleaf et al. (2009) study, nearly 25% reported exercising at least two hours per day in addition to their sport training, in order to control their weight 

Disordered Eating  Range

of abnormal eating behaviors  Varies from poor nutritional habits to clinical eating disorders  Dieting strictly to maintain or lose weight  Binge eating  Fasting  Using appetite control pills (Rudd & Carter, 2006)

 Rudd

and Carter (2006) study yielded 15% of the 1,200 college athletes surveyed reported symptoms of disordered eating behaviors  Berg et al. (2009) study of 186 participants, results indicated that college campuses propagate disordered eating among female college students, due to psychological and environmental stressors.

Eating Disorder Contributors  Negative

athletic body image  Body dissatisfaction  Drive for thinness  Gender  Pressures  Psychological

Cook and Hausenblas (2011) reported that nearly 50% of college-aged students engage in eating disorder symptoms at least once per week, showing the serious need to address prevention methods through a thorough examination of the contributing factors.

Athletic Body Image Perceptions, thoughts, feelings, or mental image a person has about his/her body, within the athletic context (Greenleaf, 2002; Rudd & Carter, 2006)











Rudd and Carter (2006) found that between 28% and 60% of college-aged females engaged in hazardous behaviors associated with body image Carter and Rudd (2005) study of 800 surveyed participants from Ohio State University, 56% of female athletes wanted to lose weight. These women, on average, wanted to lose approximately seven pounds.

Only 15% of athletes felt good about their body image and wanted to maintain their current body weight (Carter & Rudd 2005) Greenleaf et al. (2009), of 204 surveyed participants, female college athletes reported an astounding 54.4% were not satisfied with their current weight and 88.2% believed that they were overweight, wanting to lose nearly fourteen pounds on average Petrie et al. (2009), of the 442 female college athletes surveyed, 46% were not satisfied with their weight and of those almost 94% thought they were overweight

Body Dissatisfaction Negative thoughts or perceptions a person has regarding various parts of his/her body  Typically results in risky behaviors such as eating disorders (Rudd & Carter, 2006; Schwitzer et al., 2001)  Often related to sociocultural pressures that frequently define the ideal for attractiveness as favoring thinness (Stice, 2002). 

Rudd and Carter (2006) found that between 75% and 95% of women were dissatisfied with their bodies of the 1,200 surveyed college athlete participants  Up to 38% felt that parts of their bodies were too fat  Women who were more dissatisfied with their bodies were three times as likely to report binge eating behaviors (Barker & Galambos, 2007).  Often times women who are not satisfied with their bodies will engage in risky dieting or compensatory behaviors (bingeing, fasting, or purging), which increases the risk for clinical eating disorders (Stice, 2002). 

Drive for Thinness Intense need to be thinner and a fear of gaining weight (Schwitzer et al., 2001)  May potentially lead to increased eating disorder symptoms, such as binge eating and bulimia (Stice, 2002)  Sociocultural ideals on thinness strongly influence a women s motivation to engage in dysfunctional eating behaviors and the way they perceive their bodies (Krane et al., 2001) 

Gender Female college student athletes are at greater risk for developing eating disorders than male athletes (Holm-Denoma et al., 2009, Johnson et al., 1999)  In the Johnson et al. (1999) study, females reported significantly lower self-esteem, higher rates of disordered eating attitudes and behaviors, and a strong desire to achieve a body fat content that could potentially result in amenorrhea, compared to male athletes.  Rudd and Carter (2006) found that female athletes comprise 90% of those found to have an eating disorder 

Pressures 



 

College life transition - significant socialization process, a journey to adulthood, a time of separation from parents, and opportunity to develop self identity (Barker & Galambos, 2007; Kaminski & McNamara, 1996) Sport environment pressures from coaches, trainers, judges, teammates, scheduling and time demands, extra physical demands, travel, and intensified training (Etzel et al., 2006; Petrie et al., 2009) Competitive sport environments, which may possibly bring about peer comparisons (Greenleaf, 2002) Lean sports - increased pressure to be lean for aesthetic, performance reasons, or may require revealing uniforms (Carter & Rudd, 2005; Greenleaf, 2002; Krane et al., 2001), such as gymnastics, cheerleading, figure skating, swimming, cross-country, or running (Rudd & Carter, 2006)

Psychological Anxiety - In the Schwitzer et al. (2001) study, of 130 female college students, 75% of the participants were experiencing moderate stress and anxiety and 40% were experiencing moderate depression  Lack of self control or impulsivity is another contributor that often leads to episodes of uncontrollable binge eating (Stice, 2002)  Low self-esteem  Perfectionism - insistent pursuit for thin-idealization or drive for thinness, excessive expectations or a high need for achievement to improve athletic performance or aesthetics (Schwitzer et al., 2001)  Guilt – from overeating or not excessively exercising 

Eating Disorder Side Effects  Biological  Psychological  Substance

Abuse

Biological Female athletic triad - symptoms associated with eating disorders, amenorrhea (the absence of or irregular menstrual periods) (Etzel et al, 2006; Rudd & Carter, 2006) and osteoporosis (Etzel et al., 2006)  Fatigue, weakness, muscle loss, disordered eating patterns, severe dehydrations, electrolyte imbalance, tooth loss, stunted growth, infertility, damage to the brain and heart, vitamin and mineral deficiencies, cardiac arrest (Greenleaf et al., 2009), and even obesity (Stice, 2002) 

Psychological  Increased

risk for depression (Stice, 2002)

 Compensatory

behaviors to reduce guilt or anxiety, due to the lack of self-control from over eating

 Low

self-esteem

Substance Abuse Krahn et al. (2005) indicated that at-risk dieters (22% of the survey sample) were 50% more likely to engage in alcoholic consumption  Impulsivity or the lack of self control, which leaves individuals vulnerable to episodes of either uncontrollable binge eating or possible substance abuse disorders (Stice, 2002)  Women who have bulimia nervosa tend to develop a propensity towards alcohol problems or abuse, with dependence ranging from 9% to 50% (Krahn et al., 2005) 

Who is at Risk?

Study conducted by Petrie et al. (2009) indicated that 18% of college female athletes specifically had symptomatic or sub-clinical behavior, while 5.7% had clinical eating disorders  Study conducted by Greenleaf et al. (2009) indicated that 25.5% of female college athletes had symptomatic or sub-clinical behavior, while 2% had clinical eating disorders  Research indicates nearly 25% of college women are considered to be at risk for developing an eating disorder (Winzelberg et al., 2000) and that up to 61% of college women were found to have some form of either a clinical or sub-clinical eating behavior problem (Kaminski & McNamara, 1996)  Study by Johnson et al. (1999) yielded that as high as 58% of female NCAA Division I athletes were at risk for developing eating disordered behaviors 

Prevention   The

most effective way to combat eating disorders is to address the attitudes and behaviors that contribute to these pathologies before problems emerge (Schwitzer et al., 2001)

Image Source: http://www.anorexia10.com/anorexia/tips-for-anorexics-2/

References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Aronson, E. (1997). Back to the future: Retrospective review of Leon Festingers: A theory of cognitive dissonance. The American Journal of Psychology, 110(1), 127-137.

Barker, E. & Galambos, N. (2007). Body dissatisfaction, living away from parents, and poor social adjustment predict binge eating symptoms in young women making the transition to university. Journal of Youth and Adolescence, 36(7), 904-911.

Berg, K. C., Frazier, P., & Sherr, L. (2009). Change in eating disorder attitudes and behavior in college women: Prevalence and predictors. Eating Behaviors, 10(3), 137-142. doi:10.1016/j.eatbeh.2009.03.003 Carter, J. E. & Rudd, N. A. (2005). Disordered eating assessment for college studentathletes. Women in Sport & Physical Activity Journal, 14(1), 62-71.

Cooley, E. & Toray, T. (2001), Body image and personality predictors of eating disorder symptoms during the college years. International Journal of Eating Disorders, 30, 28–36. doi: 10.1002/eat.1051

Cook, B., & Hausenblas, H. (2011). Eating disorder-specific health-related quality of life and exercise in college females. Quality of Life Research, 20(9), 1385-1390. doi:10.1007/s11136-011-9879-6.

Delinsky, S. S., & Wilson, G. T. (2008). Weight gain, dietary restraint, and disordered eating in the freshman year of college. Eating Behaviors, 9(1), 82-90. doi:10.1016/j.eatbeh.2007.06.001 Delprato, D. J., & Midgley, B. D. (1992). Some fundamentals of B. F. Skinners behaviorism. American Psychologist, 47(11), 1507-1520. doi:10.1037/0003066X.47.11.1507 Etzel, E. F., Watson, J. C., Visek, A. J., & Maniar, S. D. (2006). Understanding and promoting college student-athlete health: Essential issues for student affairs professionals. National Association of Student Personnel Administrators, 43(3), 518-546.

Festinger, L. (1954). A theory of social comparison processes. Human Relations, 7, 117140.

Festinger, L. (1957). A theory of cognitive dissonance. Stanford: Stanford University Press.

Gilbert, M. B., & Gilbert, T. F. (1991). What skinner gave us. Training, 28(9), 42-42.

Greenleaf, C. (2002). Athletic body image: Exploratory interviews with former competitive female athlete. Women in Sport & Physical Activity Journal, 11(1), 63-88.

Greenleaf, C., Petrie, T. A., Carter, J., & Reel, J. J. (2009). Female collegiate athletes: Prevalence of eating disorders and disordered eating behaviors. Journal of American College Health, 57(5), 489-496.

Holland, J. G. (1991). B. F. Skinner, 1904-1990. Behavior modification, 15(2), 131 Holm-Denoma, J. M., Scaringi, V., Gordon, K. H., Van Orden, K. A., & Joiner Jr., T. E. (2009). Eating disorder symptoms among undergraduate varsity athletes, club athletes, independent exercisers, and nonexercisers. International Journal of Eating Disorders, 42(1), 47-53. doi:10.1002/eat.20560

Johnson, C., Crosby, R., Engel, S., Mitchell, J., Powers, P., Wittrock, D., & Wonderlich, S. (2004). Gender, ethnicity, self-esteem and disordered eating among college athletes. Eating Behaviors, 5(2), 147-156. doi:10.1016/j.eatbeh.2004.01.004.

Johnson, C., Powers, P., & Dick, R. (1999). Athletes and eating disorders: The National Collegiate Athletic Association Study. International Journal of Eating Disorders, 26(2), 179 188.

Kaminski, P. L., & McNamara, K. (1996). A treatment for college women at risk for bulimia: A controlled evaluation. Journal of Counseling and Development, 74(3), 288-288.

Krane, V., Stiles-Shipley, J. A., Waldron, J., & Michalenok, J. (2001). Relationships among body satisfaction, social physique anxiety, and eating behaviors in female athletes and exercisers. Journal of Sport Behavior, 24(3), 247.

National Collegiate Athletic Association. (2012). 2011-2012 Sports Medicine Handbook.

Retrieved from http://www.ncaapublications.com/productdownloads/MD11.pdf Petrie, T. A., Greenleaf, C., Reel, J. J., & Carter, J. E. (2009). An examination of psychosocial correlates of eating disorders among female collegiate athletes.

Research Quarterly for Exercise & Sport, 80(3), 621-632.

Rudd, N. A. & Carter, J. (2006). Building positive body image among college athletes: A socially responsible approach. Clothing and Textiles Research Journal, 24, 363380. doi:10.1177/0887302X06293073.

Schwitzer, A. M., Rodriguez, L. E., Thomas, C., & Salimi, L. (2001). The eating disorders NOS diagnostic profile among college women. Journal of American College Health, 49(11), 157-166.

Skinner, B.F. (1953). Science and human behavior. New York: Free Press.

Stice, E. (2002). Risk and maintenance factors for eating pathology: A meta-analytic review. Psychological Bulletin, 128(5), 825-848. doi:10.1037/00332909.128.5.825 Stice, E., Trost, A., & Chase, A. (2002). Healthy weight control and dissonance-based eating disorder prevention programs: Results from a controlled trial. International Journal of Eating Disorders, 33(1), 10-21.

Stice, E., & Shaw, H. (2004). Eating disorder prevention programs: A meta-analytic review. Psychological Bulletin, 130(2), 206-227. doi:10.1037/00332909.130.2.206 Thome, J. L., & Espelage, D. L. (2007). Obligatory exercise and eating pathology in college females: Replication and development of a structural model. Eating Behaviors, 8(3), 334-349. doi:10.1016/j.eatbeh.2006.11.009.

Winzelberg, A. J., Eppstein, D., Eldredge, K.L., Wilfley, D., Dasmahapatra, R., Dev, P. & Taylor, C.B. (2000). Effectiveness of an Internet-based program for reducing risk factors for eating disorders. Journal of Consulting and Clinical Psychology, 68(2), 346 350.

World Health Organization. (2006, October). Basic Documents, Forty-fifth edition, Supplement, Constitution of the World Health Organization, Geneva, 1946.

Retrieved from http://www.who.int/governance/eb/who_constitution_en.pdf

Open Discussion (10 minutes)

 Questions  Thoughts  Share

& Concerns

personal stories, journeys, & struggles

Healthy Bodies Assignment (10 minutes)

Food Journal Instructions (see Appendix B)  Record

current weight  Record desired goals  Record 1 week of food intake  Record 1 week of exercise activity  Be honest and measure if necessary  Nutritional Information Guide

https://www.choosemyplate.gov/SuperTracker/

Written Journal Instructions  Record

at least 2 things you feel are a concern in your life, based on the material presented today  Be positive and value yourself  Take time to reflect and assess your feelings  Write additional thoughts and reflection from today’s workshop journaling

Preparation for Next Week   Find

and bring in at least 3 ads (from the internet, television, billboards, magazines, or other media) that influence you and your drive for thinness or your ideal body image

Have a Great Week  Be

positive!

 Be

motivated!

 Be

happy!

 Be

healthy!

Healthy Bodies Week 3

(60 minute workshop)

Sociocultural Ideals

Image Source: http://deviance.iheartsociology.com/tag/becoming-deviant/

Open Discussion (10 minutes)

 Review

2nd week of written journal  Share thoughts & reactions  Review 2nd week of food & exercise journal  Check goals – Obtained? Realistic? Healthy?  Share obstacles & challenges  Share the 2 items that are of concern in your life based on last week s material

Health & Beauty Activity (10 minutes) 

Go through the stacks of fashion, beauty, fitness, food, and health magazines brought in today • Identify ads that influence your perceptions of thinness • Identify ads that negatively portray women • Identify ads that positively portray women

Image Source: http://www.marketingmediachildhood.com

Sociocultural Ideals (15 minutes) 

Share the media ads brought in from last week s assignment and identified today, that influence your drive for thinness and the pursuit of your ideal body image

• Give examples of how women are negatively portrayed in these media ads • How does the media s portrayal of women make you feel?

Image Source: http://www.marketingmediachildhood.com

Sociocultural Ideals  How

is the beauty industry cashing in on this idealization of thinness?

 Is

the dream of physical perfection or thin idealization realistic?

 What

is realistic and obtainable in your mind?

Thin Challenge (10 minutes)  Discuss

the pressures associated with a drive for thinness  How do you pursue your ideal body?  How does it make you feel?  Is your ideal of thinness realistic?  Is it healthy?  How has the media influenced your drive for thinness, body image, and body satisfaction?

Empowerment Now that you ve challenged the messages of the media and society, have you gained a new perspective of what it means to be thin?  What is more important to you, being thin or being healthy?  Are you happy with your body? Are you confident? Do you accept who you are?  Focus again on the positive attributes you identified last week – build on that and think of 2 more positive attributes (record in your journal) 

Healthy Bodies Assignment (10 minutes)

Food Journal Instructions (see Appendix B)  Record

current weight  Record desired goals  Record 1 week of food intake  Record 1 week of exercise activity  Be honest and measure if necessary  Nutritional Information Guide

https://www.choosemyplate.gov/SuperTracker/

Written Journal Instructions  Record

at least 2 of your perceptions you feel have changed regarding your thin idealization due to the material presented so far in the workshop sessions (see Week 1 self-assessment questions – Appendix C)

 Be

positive and value yourself  Take time to reflect and assess your feelings  Write additional thoughts and reflection from today’s workshop journaling

Preparation for Next Week  Bring

a dish to pass for next week s clean eating potluck

 Be

prepared with questions and discussion topics for the Health Ambassador Panel visiting next week

Have a Great Week  Be

positive!

 Be

motivated!

 Be

happy!

 Be

healthy!

Healthy Bodies Week 4

(60 minute workshop)

Healthy Life

Image Source: http://fitsit360.com/2011/10/06/the-benefits-of-eating-clean/

Open Discussion (10 minutes)

Review 3rd week of written journal  Share thoughts & reactions  Review 3rd week of food & exercise journal  Check goals – Obtained? Realistic? Healthy?  Share obstacles & challenges  Share the 2 of your perceptions you feel have changed regarding your thin idealization based on last week s material  Record BMI 

http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/ english_bmi_calculator/bmi_calculator.html



Write out next week s goals, 3 months, 6 months, 1 year in your journals

Clean Eating (10 minutes)  Lean

proteins  Fruits & veggies  Low-fat dairy  Whole grains  Water & 100% juices  Healthy fats & oils, such as nuts and olive oil  Always read ingredients  Portion control and moderation Image Source: http://zupansmarkets.wordpress.com/2012/03/03/foods-that-will-boost-your-immune-system/

Minimize or Avoid  Refined

sugars  Bleached flours  Simple carbohydrates  Saturated & Trans fats  Soda  Hydrogenated oils  High fructose corn syrup  Fast foods  Processed or packaged foods Image Source: http://healthdoctrine.com/fatty-foods-the-hidden-secret-behind-brighten-our-bad-mood/

Moderate Activity  Stay

active daily  Find routines that work for you and your time schedule  Incorporate cardio and strength training  Focus on building strength, endurance, stamina, and health - not on a pursuit for thinness  Maintain consistency Image source: http://essentialsurvival.org/best-diet-weight-loss-health/

Health Ambassador Discussion Panel (20 minutes)

 Women

s Center  Wellness Center  Dining Hall  Residence Hall  Recreation Center  Athletic Department  Counseling Center  Campus Health Services

 Be

positive!

 Be

motivated!

 Be

happy!

 Be

healthy!

 Keep

journaling!

 Keep

setting goals!

Clean Eating Potluck (20 minutes)  Focus

on food nourishing your body  Life giving nutrition  Fun socialization with friends  Positive affirmations  Handout resources from Health Ambassador Panel

Thank you

for attending!

Sunday Menu

Monday Cal

Prot

Carb

Sug

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Tuesday Cal

Prot

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Sug

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Wednesday Cal

Prot

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Prot

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Sug

Time

Total

Workout

Workout

Workout

Workout

Min

Min

Min

Min

Reps

Rep

Rep

Rep

Thursday Menu

Friday Cal

Prot

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Sug

Menu

Saturday Cal

Prot

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Sug

Menu

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Total

Workout

Workout

Workout

Min

Min

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Week of: _____________________________ ------------------------------------------Start Weight: ________BMI________ Start Measure: B_______W_______ H_______ T________ A________ _____________________________ -------------------------------------------------Targeted Goal Weight:____________________________ ------------------------------------------------ End Weight: __________________________ End Meausre: B_______W_______ H_______ T________A_________ _____________________________ -------------------------------------------------Weekly Weight Loss/Gain Goal: _______ Weight Loss/Gain Goal Total: _________ Created by: Kristina Wieghmink, 2012

! ! ! ! !

! ! ! ! ! ! !

Do you continually think about food?

Do you feel that food has control over your life?

Do you find it hard to stop eating at times?

How does that make you feel?

To compensate, do you vomit, use laxatives, restrict your food intake, or excessively exercise to overcome guilt and/or lose weight?

Do you think you are fat?

Do you constantly weigh yourself?

Are you obsessed with your appearance and/or weight?

Do you eat when you are bored, lonely, sad, or stressed?

Does food give you comfort or relief?

Are you happy with yourself?

Do you wish you could change something about yourself? What? Why? How?

Created by Kristina Wieghmink, 2012 (Appendix C) Image Source: http://www.empowher.com/sites/default/files/herarticle/female-athlete-triad-disorders.jpg

Healthy Bodies Program Survey

1. How did you hear about the Healthy Bodies workshop?

2. Why did you decide to participate in the workshop?

3. How satisfied are you with the information presented in the workshop?

4. How satisfied are you with the activities provided in the workshop?

5. How satisfied are you with the assignments required by the facilitator?

6. How satisfied are you with the performance of the facilitator?

7. Were the date, time, and/or location convenient for you? If not, what would make this better?

8. Do you feel that you have made positive changes or outcomes in your life, based on attending and participating in this workshop? Why or why not?

9. Are you likely to tell a friend or teammate about the next workshop offered?

10. How may we improve this workshop to better suit your needs?

Created by Kristina Wieghmink, 2012 (Appendix E)

GRAND VALLEY STATE UNIVERSITY ED 693/695 Data Form NAME: Kristina Wieghmink MAJOR: (Choose only1) __X__ Adult & Higher Ed Advanced Content Spec

_____ Ed Differentiation

_____ Library Media

_____ Ed Leadership

_____ Middle Level Ed

_____ Cognitive Impairment

_____ Ed Technology

_____ Reading

_____ CSAL

_____ Elementary Ed

_____ School Counseling

_____ Early Childhood

_____ Emotional Impairment

_____ Secondary Level Ed

_____ ECDD

_____ Learning Disabilities

_____ Special Ed Admin _____ TESOL

TITLE: Prevention Program Development for Eating Disorders Among College Female Athletes PAPER TYPE: (Choose only 1)

SEM/YR COMPLETED: __Summer 2012______

__X__ Project _____ Thesis SUPERVISOR’S SIGNATURE OF APPROVAL___________________________ Using key words or phrases, choose several ERIC descriptors (5 - 7 minimum) to describe the contents of your project. ERIC descriptors can be found online at: http://www.eric.ed.gov/ERICWebPortal/Home.portal?_nfpb=true&_pageLabel=Thesaurus&_nfls=false 1.

eating disorders

6. anorexia

2.

eating habits

7. bulimia

3.

body image

8. disordered eating

4.

body satisfaction

9. health

5.

college athlete

10. nutrition