Are inappropriate eating behaviors and anxiety related with track and field in adolescent athletes?Abstract
OBJECTIVE: The study analyzed the relationship between anxiety and inappropriate eating behaviors in adolescent female athletes.
METHODS: Eighty-eight track and field athletes aged 12 to 17 years participated in the study. We used the Eating Attitudes Test-26 subscales to assess inappropriate eating behaviors and the Brazilian State - Trait Anxiety Inventory subscales to assess State and Trait anxiety.
RESULTS: State - Trait Anxiety Inventory - State (p=0.18) or State - Trait Anxiety Inventory - Trait (p=0.14) had no significant influence on the Dieting subscale score. The Bulimia and Food Preoccupation subscale score was also not influenced by State - Trait Anxiety Inventory - State (p=0.25) or State - Trait Anxiety Inventory - Trait (p=0.21). However, State - Trait Anxiety Inventory - Trait (p=0.048) had a significant impact on the Oral Control subscale score, but State - Trait Anxiety Inventory - State (p=0.19) did not explain its variance.
CONCLUSION: Only State - Trait Anxiety Inventory - Trait was related to oral control and the environmental and social forces that encourage food intake in female athletes.
Anxiety; Athletes; Eating disorders; Track and field
Resumo
OBJETIVO: O objetivo deste estudo foi analisar a relação da ansiedade com os comportamentos alimentares inadequados em atletas adolescentes do sexo feminino.
MÉTODOS: Participaram 88 atletas de atletismo com idade entre 12 e 17 anos. Utilizaram-se as subescalas do Eating Attitudes Test para avaliar o comportamento alimentar. As subescalas de Avaliação do Inventário de Ansiedade Traço-Estado foram utilizadas para avaliar a ansiedade estado e traço.
RESULTADOS: Os achados não apresentam influência estatisticamente significativa da Avaliação do Inventário de Ansiedade Traço - Estado (p=0,18), nem da Avaliação do Inventário de Ansiedade Traço - Traço (p=0,14) sobre os escores da subescala Dieta. A respeito da subescala Bulimia e Preocupação com Alimento, os resultados não apontaram influência estatisticamente significativa da Avaliação do Inventário de Ansiedade Traço - Estado (p=0,25) e da Avaliação do Inventário de Ansiedade Traço - Traço (p=0,21). Em relação à subescala Autocontrole Oral, a Avaliação do Inventário de Ansiedade Traço - Traço demonstrou impacto significante (p=0,048), enquanto a Avaliação do Inventário de Ansiedade Traço - Estado (p=0,19) não explicou sua variância.
CONCLUSÃO: Concluiu-se que apenas a Avaliação do Inventário de Ansiedade Traço - Traço esteve relacionada ao autocontrole em relação à comida e às forças ambientais e sociais estimulantes à ingestão alimentar nessas atletas.
Ansiedade; Atletas; Transtornos alimentares; Atletismo
INTRODUCTION
Inappropriate Eating Behaviors (IEB) are classified as health-damaging behaviors1 , 2. Long-term food restriction, the use of laxatives and diuretics, self-induced vomiting, binge eating, and the use of anabolic-androgenic steroids are some examples of IEB3 , 4. Schaal et al. 5 consider IEB the main symptoms of eating disorders, such as anorexia nervosa and bulimia nervosa. The prevalence of IEB in Brazil varies from 10 to 20%6 , 7. It is higher in adolescents8 , 9, especially female adolescents10, and even higher in athletes5 , 11 - 13, affecting approximately 50% of this population3 , 14.
Competition sports have many requirements to optimize performance2 , 4, which may somehow encourage athletes to adopt IEB. Fortes et al. 15 point out that coaches are the main promoters of vulnerability to IEB. These same authors claim that coaches' demands for better performance are excessive. However, food restriction and self-induced vomiting may reduce athletes' anaerobic power16. In this sense, some track and field athletes (100 meters, 200 meters, 100-meter hurdles, pole vault, long jump) whose performance is determined by anaerobic power can damage their careers by engaging in IEB daily.
Moreover, competition sports generate psychological stress in athletes17 and psychological stress may increase anxiety18. Anxiety, an emotional state, is divided into state anxiety and trait anxiety4. State anxiety refers to a transitory emotional state characterized by subjective feelings or tension of varying intensity and duration. Trait anxiety regards the stable relation of responding to stress and a tendency to perceive stress- or tension-generating situations.
Anxiety has been related to IEB in athletes. Gomes et al. 19 studied male and female Portuguese Karate, Taekwondo, swimming, basketball, handball, and volleyball athletes and found that IEB frequency increased with anxiety. Vargar et al. 20, who studied male and female Turk basketball, volleyball, swimming, track and field, wrestling, handball, rhythmic gymnastics, tennis, Taekwondo, and dance athletes, and Silva et al. 12, who studied male and female Portuguese handball, basketball, volleyball, swimming, track and field, Taekwondo, and karate athletes, found that athletes at risk of developing eating disorders experienced more anxiety than those not at risk. On the other hand, Rouveix et al. 4 did not find a relationship between anxiety and IEB in male French judo athletes. However, all these studies regarded European athletes. The Medical Literature Analysis and Retrieval System Online (Medline), Web of Science, Scientific Eletronic Library Online (SciELO), and Scopus databases were searched using the keywords eating disorders, eating behaviors, anxiety, and sport. Except for the study by Fortes et al. 21 with artistic gymnastics athletes, no other study Brazilian study analyzed the relationship between IEB and anxiety in Brazilian athletes.
This type of study is critical for track and field coaches. If anxiety is related to IEB in female Brazilian athletes, coaches will be able to identify those susceptible to eating disorders by investigating their competition anxiety. Thence, the objective of this study was to analyze the relationship between anxiety and IEB in adolescent female track and field athletes.
METHODS
This study was approved by the Human Research Ethics Committee of the School of Philosophy, Sciences, and Letters of Universidade de São Paulo (USP) under protocol number 119/2012 (CAE - 05166712.8.0000.5407). The athletes and their guardians signed an informed consent form that explained the study objectives and procedures. Anonymity and complete data confidentiality were guaranteed to the participants.
Participants
According to the State of Rio de Janeiro's Track and Field Federation, the adolescent female track and field population in 2013 numbered roughly 445 athletes. The participants were recruited by simple random sampling a convenience sample. A total of 99 adolescent female track and field (sprints, jumps, and throws) athletes aged 12 to 17 years from sports clubs in the city of Rio de Janeiro (RJ) participated in the study. Although adolescence encompasses ages 10 to 19 years8 , 15, the literature emphasizes that adolescents below 12 years of age normally have difficulty filling out psychometric questionnaires5 , 19. Hence, athletes aged less than 12 years were not included in the study. Additionally, athletes aged more than 17 years were not recruited because the participating sports clubs included only athletes aged less than 18 years.
The inclusion criteria were: having signed the Informed Consent Form; training at least two hours a day, five days a week; having participated in a regional competition in 2013; having answered the questionnaires; and having undergone anthropometric assessment. The exclusion criteria were: having physical and/or intellectual disabilities; and taking psychoactive medication periodically. Eleven athletes were excluded from the study because they did not answer the questionnaires fully. Thus, the final sample consisted of 88 athletes [100 meters (n=24), 200 meters (n=15), 100-meter hurdles (n=11), 400-meter hurdles (n=9), pole vault (n=7), long jump (n=10), high jump (n=6), and javelin throw (n=6)] with a mean age of 15.03 (±1.74) years and mean percentage of body fat of 17.44 (±2.37), training 3.22 (±0.84) hours a day. According to sexual maturation classification, 20% were prepubertal, 35% were pubertal, and 45% were postpubertal.
Instruments
The female version of the Eating Attitudes Test-26 (EAT-26) validated by Bighetti et al. 1, with an internal consistency of 0.82, investigated IEB. This questionnaire consists of 26 questions distributed into three factors: 1) Dieting: Investigates the pathological refusal of high-calorie foods and preoccupation with physical appearance; 2) Bulimia and Food Preoccupation: Investigates binge eating followed by self-induced vomiting to lose/control body weight; and 3) Oral Control: Investigates self-control with food and assess environmental and social promoters of food intake. The final EAT-26 score is given by adding the item scores, and the cut-off score that indicates risk of eating disorders is 21. The study sample has an internal consistency (Cronbach's alpha) of 0.83.
The short version of the Brazilian State-Trait Anxiety Inventory (STAI) validated for the Brazilian population by Fioravanti-Bastos et al. 18 assessed anxiety. STAI has twelve 4-point Likert-scale items (absolutely not = 1; a little = 2; some = 3; and very much = 4) divided into two subscales: a) State anxiety (STAI-S), which regards how the interviewee feels at that moment; and b) Trait anxiety (STAI-T), which regards how the interviewee generally feels. The STAI validation study18 found internal consistencies of 0.90 and 0.89 for STAI-S and STAI-T, respectively. Cronbach's alphas for the present sample were 0.85 for STAI-S and 0.87 for STAI-T, indicating good internal consistency.
The Body Shape Questionnaire (BSQ) validated for Brazilian adolescents assessed body dissatisfaction22. The instrument has good internal consistency, with a Cronbach's alpha (α) of 0.96 and a significant correlation coefficient between the test and retest scores (0.89 for girls). The study sample had α=0.91, demonstrating good instrument consistency. The self-assessment questionnaire consists of 34 Likert-scale questions on the adolescent's preoccupation with her body weight and physical appearance. The BSQ results are classified into four levels of body dissatisfaction as follows: no dissatisfaction when the score is below 80; mild dissatisfaction when the score is between 80 and 110; moderate dissatisfaction when the score is between 110 and 140; and severe dissatisfaction when the score is 140 or more. Since body dissatisfaction promotes eating behaviors associated with risk of eating disorders11 , 23, the BSQ scores were controlled in some statistical analyses.
Percentage of body fat was calculated as recommended by Slaughter et al. 24 for adolescents. The triceps and subscapular skinfold thicknesses were measured as recommended by the International Society for Advancement for Kineanthropometry25, using the skinfold caliper (adipometer) LANGE(r) (Cambridge Scientific Industries Inc.) with accuracy of 1 mm. The measurements were taken rotationally three times, using the mean in the analyses. The authors created a sociodemographic questionnaire for the athletes to report their race (white, black, yellow, brown) as required by the protocol proposed by Slaughter et al. 24. Sexual maturation was determined by Tanner's criteria26, validated for Brazilians by Matsudo & Matsudo27. Since body fat influences IEB11 , 15, the percentage of body fat was used as covariate in some statistical analyses.
Procedures
First, the researchers contacted the track and field coaches of sports clubs in the city of Rio de Janeiro (RJ). After the study procedures and objectives were properly explained, the researchers asked the coaches' permission for the athletes to participate in the study.
After the coaches authorized the study, the researchers held a meeting with each team to inform the athletes about all the study procedures and hand them the informed consent form for their guardians to sign, thereby giving their authorization in writing for the athletes to participate in the study.
Data were collected in two different occasions in appropriate rooms at the sports clubs. In the first meeting, the athletes answered the EAT-26, STAI, and BSQ questionnaires, and in the second meeting, the skinfold thicknesses were measured. The athletes were instructed verbally on how to fill out the questionnaires, and their doubts were clarified. The questionnaires also contained filling instructions. The questionnaires were administered in a group setting but answered individually, which took roughly 30 minutes.
Data analysis
The Kolmogorov Smirnov test checked data normality. Since the data had a normal distribution, the variables were expressed as central tendency (mean) and dispersion (minimum, maximum, and standard deviation). The mean STAI (26.53) was used as the cut-off point to classify athletes by level of anxiety: high anxiety >26.53 and low anxiety <26.53. Three simple linear regression models were constructed to verify the influence of: 1) STAI-S and STAI-T on EAT-26's Dieting subscale score; 2) STAI-S and STAI-T on EAT-26's Bulimia and Food Preoccupation subscale score; and 3) STAI-S and STAI-T on EAT-26's Oral Control subscale score. Multivariate Analysis of Variance (Manova) compared the EAT-26 subscale scores by anxiety (STAI score) group. Then Bonferroni post hoc correction identified the statistical differences. BSQ and percentage of body fat were controlled in all analyses. The software Statistical Package for the Social Sciences (SPSS) 17.0 treated the data with a significance level of 5%.
RESULTS
The Eating Attitudes test-26 results showed that 16% of the athletes were at risk of eating disorders. Furthermore, 46.7% of the sample experienced high anxiety (STAI >26.53). Table 1 shows the descriptive data of all study variables.
The regression model in Table 2 shows that neither STAI-S (F(1, 87)=2.99; p=0.18) nor STAI-T (F(1, 87)=3.24; p=0.14) influenced EAT-26 Dieting subscale scores significantly.
Table 3 shows the regression model that used Bulimia and Food Preoccupation subscale score as the criterion variable. Again, STAI-S (F(1, 87)=1.95; p=0.25) and STAI-T (F(1, 87)=2.36; p=0.21) had no significant influence on this score.
The last regression model used the Oral Control subscale score as the dependent variable (Table 4). Only STAI-T (F(1, 87)=6.61; p=0.048) had a significant impact on this score at the 5% level. STAI-S (F(1, 87)=3.07; p=0.19) did not explain the oral control variance in young track and field athletes.
Some findings regarding the comparison of EAT-26 subscales by anxiety group deserve emphasis (Table 5): 1) The Dieting subscale scores of high- and low-anxiety athletes did not differ significantly (F(1, 86)=2.16; p=0.27); 2) Low-anxiety athletes had higher Bulimia and Food Preoccupation subscale scores than high-anxiety athletes (F(1, 86)=17.02; p=0.018); and 3) The Oral Control subscale scores of high- and low-anxiety athletes did not differ significantly (F(1, 86)=4.64; p=0.15).
DISCUSSION
The objective of the present study was to analyze the relationship between anxiety and IEB in adolescent female track and field athletes. Some authors have recommended studies to determine whether anxiety can predispose athletes to IEB. So far, such studies have found a relationship between anxiety and IEB12 , 19 , 20. However, these studies regarded European athletes. The only study that investigated the relationship between anxiety and IEB in Brazilian athletes confirmed the positive relationship between these variables, but this study was performed on gymnasts21. Thus, there are no studies analyzing the relationship between anxiety and IEB in female Brazilian track and field athletes.
The study results show a prevalence of IEB of 16% (EAT+). This finding is corroborated by other studies on female Brazilian athletes11 , 28. IEB prevalence in athletes of competitive team sports or those that require anaerobic power (track and field, basketball, and soccer) is usually lower than that in athletes of aesthetic sports (synchronized swimming, diving, and artistic gymnastics)28. Scoffier et al. 17 argued that the main trigger of abnormal eating behaviors is the coaches' insistence for the athletes to lose weight to optimize performance. Indeed, according to the scientific literature, track and field athletes are not considered a group at risk of eating disorders3.
The mean percentage of body fat was 17.44 (±2.37), which may be considered low for females11 , 16. However, athletes require a percentage of body fat close to this number for good performance in most sports14 , 23. Athletes with a percentage of body fat below 15% may have menstrual disorders3 and malnutrition11, which may hinder both their performance and health16. Moreover, researchers have suggested that a low percentage of body fat may be closely associated with higher anxiety20, which may explain the 46.7% prevalence of high anxiety in athletes.
The results of the first regression model (Dieting subscale) show that state and trait anxiety were not associated with long fasting periods in female athletes, which is corroborated by Vargar et al. 20. These authors have also not evidenced a relationship between food restriction and anxiety in Turk athletes of various sports. Hence, an anxious athlete does not seem to restrict food intake. Rouveix et al. 4 claims that anxious athletes are probably more prone to binge eating than to food restriction.
The regression model using the Bulimia subscale score as the criterion variable showed that anxiety was not related to self-induced vomiting and binge eating in female athletes, contrary to what some studies have indicated19 , 20. The present results may be explained by the fact that physical training reduces anxiety20, and training is a daily habit for athletes. Therefore, young athletes probably have low anxiety levels, which would indicate low susceptibility to binge eating. Physically active individuals experience less anxiety than inactive individuals12. This relationship may stem from the fact that physical activity increases the release of the neurotransmitters serotonin and dopamine, associated with happiness and psychological wellbeing, attenuating negative emotional states such as anxiety20. Given that track and field athletes train systematically, they may have low anxiety levels. Corroborating this idea, Rouveix et al. 4 found lower anxiety levels in athletes than in non-athletes. On the other hand, some authors emphasize that athletes with anxiety disorder may binge eat high-carbohydrate foods because these foods promote the release of neurotransmitters, such as serotonin12 , 29.
The last regression model showed that trait anxiety influences the type and amount of foods consumed by the athletes. Silva et al. 12 asserted that anxious adolescents may learn about healthy and not-so-healthy foods from their coaches and family members more easily than adolescents with low anxiety levels.
Comparison of the EAT-26 subscales by anxiety group based on the mean STAI score showed that food restriction frequency and environmental pressure to control food intake were similar in both groups (high- versus low-anxiety levels), contrary to Gomes et al. 19. On the other hand, athletes who experience high anxiety binge eat and self-induce vomiting more often than those who experience low anxiety, corroborating Vargar et al. 20.
Although the present results are original, the study has some limitations. One is the cross-sectional study design, preventing the inference of causality. This means that it is not possible to assess the intensity and direction of the associations found between the outcome variable and the independent variables. Another limitation may be the non-assessment of the athletes' menstrual cycle phase since the menstrual cycle may affect anxiety.
CONCLUSION
The study results indicate that only trait anxiety is related to oral control and the environmental and social forces that encourage food intake in female athletes. Trait anxiety in track and field athletes may make them vulnerable to poor oral control and environmental food intake promoters. Finally, low-anxiety athletes are more vulnerable to bulimic symptoms (binge eating and compensatory behaviors).
More specifically, coaches should pay attention to anxiety symptoms in their young athletes. Additionally, athletes' anxiety level should be assessed by STAI. Coaches should watch high-anxiety athletes for binge eating and self-induced vomiting, and keep track of the types and amounts of foods they consume. Athletes with abnormal eating behaviors should be referred to a psychologist, psychiatrist, and/or dietician.
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