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Prevalence of eating disorders and eating-disordered behavior among undergraduate health education major students in the United States

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Title:
Prevalence of eating disorders and eating-disordered behavior among undergraduate health education major students in the United States
Creator:
Brey, Rebecca Ann
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English
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vii, 191 leaves : ; 29 cm.

Subjects

Subjects / Keywords:
Anorexia nervosa ( jstor )
Bulimia nervosa ( jstor )
College students ( jstor )
Eating disorders ( jstor )
Food ( jstor )
Health education ( jstor )
Statistical results ( jstor )
Statistical significance ( jstor )
Weight control ( jstor )
Women ( jstor )
Appetite disorders ( lcsh )
Dissertations, Academic -- Health and Human Performance -- UF
Health and Human Performance thesis Ph. D
Women athletes -- Health and hygiene -- Psychological aspects ( lcsh )
Women college students -- Health and hygiene -- Psychological aspects ( lcsh )
Genre:
bibliography ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 1993
Bibliography:
Includes bibliographical references (leaves 176-190).
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Rebecca Ann Brey.

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The University of Florida George A. Smathers Libraries respect the intellectual property rights of others and do not claim any copyright interest in this item. This item may be protected by copyright but is made available here under a claim of fair use (17 U.S.C. §107) for non-profit research and educational purposes. Users of this work have responsibility for determining copyright status prior to reusing, publishing or reproducing this item for purposes other than what is allowed by fair use or other copyright exemptions. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder. The Smathers Libraries would like to learn more about this item and invite individuals or organizations to contact the RDS coordinator (ufdissertations@uflib.ufl.edu) with any additional information they can provide.
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PREVALENCE OF EATING DISORDERS AND EATING-DISORDERED
BEHAVIOR AMONG UNDERGRADUATE HEALTH EDUCATION
MAJOR STUDENTS IN THE UNITED STATES


















By

REBECCA ANN BREY


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS fOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1993














ACKNOWLEDGEMENTS

I could not have asked for a better committee or husband and express great appreciation to these six wonderful people for their help in completing this study:

Dr. R. Morgan Pigg, Jr. for his hard work, support, and most importantly, infinite patience.

Dr. W. William Chen for encouraging my best work.

Dr. Phyllis M. Meek for her knowledge and valuable insights in the area of eating disorders.

Dr. M. David Miller for an open appointment book and for sharing his statistical expertise.

Dr. Barbara A. Rienzo for her help in theory development and study conceptualization.

My husband, Dave, for reminding me at appropriate times, "If it were easy, everyone would have one!"















TABLE OF CONTENTS

ipacte

ACKNOWLEDGEMENTS ....................................... ii

ABSTRACT ............................................... v

CHAPTERS

1 INTRODUCTION .................................... 1

%Statement of Research Problem ..................... 7
"Purpose of the Study .......................... 7
Need for the Study ............................ 7
Delimitations ................................. 11
Limitations .................................... 11
Assumptions .................................... 12
Null Hypotheses ................................ 13
Definition of Terms ............................ 14

2 REVIEW OF LITERATURE ........................... 20

�Introduction ................................... 20
Sex Role Development and Sociocultural
Factors Related to Eating Disorders ............ 20
Adults ......................................... 31
Children and Adolescents ....................... 35
rCollege Students ............................... 41
Students in Preprofessional Programs ............. 52
Summary ........................................ 54

3 PROCEDURES FOR COLLECTION OF DATA ................. 55

Introduction ................................... 55
Subjects ....................................... 55
Instrumentation ................................ 57
Data Collection Procedures ......................... 63
Analysis of Data ............................... 64

4 ANALYSIS ....................................... 65

Introduction ................................... 65
Sample Characteristics ......................... 65
Results ........................................ 71
Discussion of Results .......................... 117

iii









5 SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS ......


Summary ........................................ 129
Conclusions .................................... 131
Recommendations ................................ 133

APPENDICES

A UNIVERSITY OF FLORIDA INSTITUTIONAL REVIEW
BOARD HUMAN SUBJECTS APPROVAL ................... 137

B CORRESPONDENCE WITH COLLEGE/UNIVERSITY
PERSONNEL .................................... 139

C STUDY INSTRUMENTS .............................. 152

D CORRESPONDENCE WITH AND INSTRUMENT DEVELOPED
BY BLACK AND BURCKES-MILLER ..................... 162

E LIST OF PARTICIPATING INSTITUTIONS AND TEST
SITE COORDINATORS ............................ 167

F STUDENTS' WRITTEN COMMENTS ..................... 171

LIST OF REFERENCES ..................................... 176

BIOGRAPHICAL SKETCH .................................... 191


129














Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy PREVALENCE OF EATING DISORDERS AND EATING-DISORDERED
BEHAVIOR AMONG UNDERGRADUATE HEALTH EDUCATION
MAJOR STUDENTS IN THE UNITED STATES By

Rebecca Ann Brey

May 1993

Chairperson: Dr. R. Morgan Pigg, Jr. Major Department: Health Science Education

This study assessed the nature and scope of selfreported eating disorders and eating-disordered behavior among undergraduate health education major students in the United States. A random sample was drawn of 394 health education students attending 28 colleges and universities throughout the United States. Test sites were obtained from a random sample of 25% of all institutions (28% of institutions listed as offering an undergraduate program in Health Education) in Eta SiQma Gamma: A National Directory of College and University Health Education Programs and Faculties (1988). The Eating Disorder Inventory and the Eating Habits of Athletes Survey were used to assess selfreported eating disorders and eating-disordered behavior.








Weight differences were analyzed using repeated

measures analysis of variance. The statistical relationship between each Eating Disorder Inventory subscale and demographic variables, weight differences, and items on the Eating Habits of Athletes Survey was determined using multiple regression.

The difference between self-reported current and ideal weight was nonsignificant for males; female subjects selfreported their ideal weight thinner than their current weight at a statistically significant level, suggesting (1) male undergraduate health education major students were generally satisfied with their current weight and (2) female undergraduate health education major students were generally dissatisfied with their current weight and wanted to be thinner. Using Diagnostical and Statistical Manual IIIRevised criteria, 1% of females (n = 3) and 0% of males met all the criteria for bulimia nervosa; no males or females met all the criteria for anorexia nervosa diagnosis. Selecting weight management as an area of professional interest was statistically related to an increase in the Drive for Thinness subscale score on the Eating Disorder Inventory.

Results suggest (1) undergraduate health education major students, particularly females, are not immune to societal pressure to maintain a thin body weight, (2) many undergraduate health education major students engaged in vi








eating-disordered behavior, and (3) students with a professional interest in weight management/control may potentially perpetuate the cultural obsession with thinness through their professional activities.


vii














CHAPTER 1
INTRODUCTION

Americans today have a cultural obsession with thinness and a fixation on food and our bodies. Consequently, concerns about diet and exercise constitute a national obsession (Schwartz, Thompson, & Johnson, 1982). An increase in eating disorders (anorexia nervosa and bulimia nervosa) and eating-disordered behavior is thought to be one effect of "thinness mania" (Silverstein, Perdue, Peterson, & Kelly, 1986).

Individuals suffering from anorexia nervosa, bulimia nervosa, and eating-disordered behavior present a complex and difficult challenge for all professionals (Gordon, 1989; Schwartz, Thompson, & Johnson, 1982), including health educators. Eating disorders and eating-disordered behavior are best described along a continuum (Rodin, Silberstein & Striegel-Moore, 1985), ranging from normal eating and unconcern with weight, to what is called normative discontent with weight resulting in moderately disregulated/restrained eating (eating-disordered behavior), to bulimia nervosa or anorexia nervosa. Anorexia nervosa is primarily characterized by self-4starvation, while bulimia nervosa involves binge eating followed by some form of








2

purging behavior, such as self-induced vomiting, excessive exercise, fasting, or laxative abuse (Sacker & Zimmer, 1987) and a preoccupation with control over weight and body shape (Gordon, 1989). Serious medical complications can occur from both anorexia nervosa and bulimia nervosa (Mitchell, Specker, & de Zwaan, 1991).

Credit for first describing anorexia nervosa is

generally given to Sir William W. Gull of London's Guy's Hospital, who in 1874 called it "anorexia nervosa." Charles Lasegue of Paris' Sorbonne and Hospital La Pitite, used the term "l'anorexie hysterique" in 1873. Samuel Fenwick, of London, has been suggested as writing the most detailed and thorough description of anorexia nervosa by anyone in the 19th century (Silverman, 1992). Anorexia nervosa may have individual, family, and possibly cultural predisposing factors (Garner & Garfinkel, 1980).

Bulimia nervosa was first recognized as a psychiatric disorder in the American Psychiatric Association Diagnostical and Statistical Manual - III in 1980. Shortly after its inclusion, the end of the year edition of Newsweek proclaimed 1981 as "the year of the binge purge syndrome" (Adler, 1982, p. 29)

The age of the onset of anorexia nervosa is usually between 12 and 18 years of age (Siegel, Brisman, & Weinshel, 1988). Bulimia nervosa usually begins in adolescence or early adulthood. The binge-purge cycle, an








3

important characteristic of bulimia nervosa, often begins at transition points of independence (Siegel, Brisman, & Weinshel, 1988). Siegel, Brisman, and Weinshel (1988) cited leaving for college and leaving home as examples of transition points. Since high expectations potentially make the transition from adolescence to adulthood difficult, bulimia nervosa can develop into a coping mechanism (Wooley & Wooley, 1986). For females, a common precipitant involves the breakup of a relationship with a boyfriend or spouse (Siegel, Brisman, & Weinshel, 1988). "Bulimia nervosa has reached epidemic proportions since the late 1970s among college-age females" (Gordon, 1989, p. 41).

Many college women, but few men, show behavioral

patterns associated with an eating disorder (Hesse-Biber, 1989). Consequently, some estimate as many as 20% of women between ages 13 and 40 may be affected by anorexia nervosa or bulimia nervosa (Sandbek, 1986). Women comprise 95% of all anorexics and 90 - 95% of all bulimics in the United States (Siegel, Brisman, & Weinshel, 1988).

Since eating disorders (Silverstein, Perdue, Peterson, & Kelly, 1986) and eating-disordered behavior (Hesse-Biber, 1989) are much more common among women than men, theories of sex role development including the cognitive-developmental theory (Kohlberg, 1966); the social learning theory (Bandura, 1977); later renamed social cognitive theory (Bandura, 1986); and the gender-schema theory (Bem, 1981)








4
deserve attention. In particular, modeling or observational learning, a component of the social learning theory (Bandura, 1977), has been suggested as an explanation for eating-disordered behavior (Crandall, 1988). Eating disorders and eating-disordered behavior are generally regarded as complicated issues (Gordon, 1989; Schwartz, Thompson, & Johnson, 1982). Bandura (1977) suggested complex behaviors are learned more efficiently through modeling than through operant learning.

"In particular, gender roles and sociocultural

expectations appear strongly implicated in the development of eating disorders" (Thornton, Leo, & Alberg, 1991, p. 470). A generalized sociocultural pressure for women to be thin (Garner & Garfinkel, 1980) and the treatment of women (Chernin, 1981; Kaplan, 1980; Orbach, 1978) in modern American society were suggested as two of the several predisposing factors prompting the development of eating disorders in women. Silverstein, Peterson, and Perdue (1986) suggested the root of eating disorders involves societal pressure of a thin standard of bodily attractiveness for women. The 1970s produced "a shift in the idealized female shape from a curved voluptuous figure to the angular, lean look of today. The impact of this changing idealized female shape is exemplified by the pervasiveness of dieting among women." (Garner, Garfinkel, Schwartz, & Thompson, 1980, p. 483).








5

Uniform standards of beauty and fashion for females imposed by 20th century mass media (Mazur, 1986) compound the cultural pressure for women to diet and assume a thin body shape. Other researchers pointed out the irony between the mass media giving anorexia nervosa the most attention of all eating disorders while promoting slimness "as the criterion for attractiveness in women" (Furnham & HumeWright, 1992, p. 21). After studying the role of mass media in promoting a thin standard of attractiveness for women, Silverstein, Perdue, Peterson, and Kelly (1986) determined their results necessary but not sufficient to conclude that mass media play a role in promoting a thin standard of attractiveness that may help explain the recent outbreak of eating disorders among women.

In studying the 10 most read magazines by persons 18 to 24 years of age, Anderson and DiDomenico (1992) suggested a "dose-response" relationship between sex differences in eating disorder prevalence and the number of articles related to diet. Women's magazines contained 10 times more diet articles than did men's magazines, a ratio almost identical to the 10 times higher rate of eating disorder prevalence in females compared to males. However, the cover of the February 1993 issue of Men's Health magazine proclaimed in large purple letters "Get Rid of That Gut!" (Laliberte, 1993), suggesting the sociocultural pressure may be expanding to include, rather than exclude, males.








6

The etiology of eating problems also may relate to women wanting to be thinner than is medically desirable, representing a response of typical women to the new, more demanding cultural standards for thinness (Hesse-Biber, 1989). One study found most college women (85%) want to lose weight, compared to 40% of college men, and 45% of the men wanted to gain weight (Drewnowski & Yee, 1987). Consequently, many college women reported high rates of body dissatisfaction, viewed as a significant risk factor for development of an eating disorder (Klemchuck, Hutchinson, & Frank, 1990). Among adolescents, "the high prevalence of body weight dissatisfaction and the potential harmful weight loss practices underscore the potential influence of social norms that equate thinness with attractiveness and social approval" (Centers for Disease Control, 1991, p. 748).

Dramatic increases in certain eating problems among

students attending colleges and universities throughout the United States (Hesse-Biber, 1989) present a problem clearly compromising the psychological and physical health of significant numbers of college females (Gordon, 1989). Presumed to be at highest risk for eating disorders are college females (Schotte & Stunkard, 1987), causing concern among professional communities as well as the general public (Striegel-Moore, Silberstein, Frensch, & Rodin, 1989).









7

Statement of Research Problem

This study assessed the nature and scope of selfreported eating disorders and eating-disordered behavior among undergraduate health education major students in the United States. Analyses were conducted based on students' health education focus, area of professional interest, demographic variables, and differences between self-reported current weight, highest past weight, lowest weight as an adult, and ideal weight to determine if differences exist in the prevalence of eating disorders and eating-disordered behavior.


Purpose of the Study

This study assessed the nature and scope of selfreported eating disorders and eating-disordered behavior among undergraduate health education major students in the United States to (1) establish a baseline regarding the prevalence of such disorders among this specialized group of subjects and (2) provide information concerning appropriate professional preparation to address the needs of these subjects as individuals and as future health educators.


Need for the Study

College students are considered most at risk for

developing an eating disorder (Johnson, Tobin, & Steinberg, 1989). The college experience actually may increase the risk for developing an eating disorder, with intense social








8
and academic pressures as well as specific pressure toward thinness cited as possible factors (Striegel-Moore, Silberstein, Frensch, & Rodin, 1989). Furthermore, Striegel-Moore, Silberstein, Frensch, and Rodin, (1989) suggested that a competitive school environment may encourage not only academic achievement, but a thin body as evidence of achievement in the area of personal weight. In addition, certain environments may increase the risk for eating disorder development; for example, colleges and boarding schools are thought to "breed" eating disorders, such as bulimia nervosa (Squire, 1983). The destructive impact of eating disorders has been documented by researchers (Schwartz, Thompson, & Johnson, 1982).

Health education major students operate in a

specialized sociocultural environment. In addition to the "thin is in" messages from the general public, they feel additional pressure to maintain the healthy lifestyle they advocate for others. While many unhealthy behaviors are easily concealed, such as smoking, alcohol or other drug abuse, or poor stress management, the effect of consuming more calories than expended is obvious to everyone. Consequently, "other kinds of subcultures also appear to amplify sociocultural pressures and hence place their members at greater risk for bulimia. Prime examples are those subcultures in which optimal weight is specified, explicitly or implicitly, for the performance of one's








9

vocation" (Striegel-Moore, Silberstein, & Rodin, 1986, p. 248). Since efforts to lose weight require tremendous amounts of energy, interest, time, and money, "concern with weight leads, in many women, to a virtual collapse of selfesteem and sense of effectiveness" (Wooley & Wooley, 1979, p. 69).

College students, particularly females, are considered at high risk for developing eating disorders (Schotte & Stunkard, 1987; Schwartz, Thompson, & Johnson, 1982). Women in college who believed they were unattractive and needed to lose weight felt a greater overall sense of academic, social, and psychological impairment (Hesse-Biber, ClaytonMatthews, & Downey, 1987) compared to other college women. Since individuals with bulima nervosa tend to feel ashamed about their binging and purging behavior, onset of symptoms may precede treatment by as long as three to five years (Herzog, Keller, Lavori, & Sacks, 1991). One study found only a minority of bulimic college women sought professional help for an eating disorder during their first six months on campus (Drewnowski, Yee, & Krahn, 1988). Therefore, many students with an eating disorder go virtually undetected by university personnel; the potential effects of an increase in eating disorder prevalence is reason for concern (Schwartz, Thompson, & Johnson, 1982).

Early studies addressing eating disorders among

college students generally involved surveying students








10

enrolled in undergraduate courses, such as large psychology (Gray & Ford, 1985; Katzman, Wolchik, & Braver, 1984; Mintz & Betz, 1988; Thelen, Mann, Pruitt, & Smith, 1987) or English classes (Pyle, Mitchell, Eckert, Halvorson, Neuman, & Goff, 1983). However, recent studies have focused on special groups of college students including dietetics majors (Crockett & Littrell, 1985; Drake, 1989), medical students (Futch, Wingard, & Felice, 1988; Herzog, Norman, Rigotti & Pepose, 1986), and student athletes (Black & Burckes-Miller, 1988; Burckes-Miller & Black, 1988; Evers, 1987; Rosen, McKeag, Hough, & Curley, 1986).

Thus, several factors support the need for this study. First, no study has been conducted specifically addressing eating disorders and eating-disordered behavior among undergraduate health education major students in the United States. Second, many undergraduate health education majors are female, increasing their potential risk. Third, studying eating disorder cases in a clinical setting to understand the increasing preoccupation with thinness and increased prevalence among females with eating disorders has not led to understanding the etiology of eating disorders (Feldman, Feldman, & Goodman, 1988). Fourth, the health education discipline constitutes a subculture which places additional pressure on practitioners to maintain an ideal body weight. Consequently, data regarding the nature and scope of eating disorders and eating-disordered behavior









11

among this group have important implications for professional preparation and practice in health education as well as comprising a contribution to the growing eatingdisorder literature base.

Delimitations

1. Test sites were obtained from a random sample of 25% of

institutions in the United States offering a graduate

or undergraduate major in health education (28% of

institutions offering an undergraduate major in health

education). Institutions were drawn randomly from

programs listed in Eta Sigma Gamma: A National

Directory of ColleQe and University Health Education

Programs and Faculties (1988).

2. Subjects enrolled in a major course selected by the

test site coordinator at each institution were invited

to participate in the study.

3. Data were collected during Spring 1992.

4. The Eating Disorder Inventory and the Eating Habits of

Athletes Survey were used to assess self-reported

eating disorders and eating-disordered behavior

among undergraduate health education majors.


Limitations
1. Eta Sicrma Gamma: A National Directory of College and

University Hearth Education Proarams and Faculties

(1988) does not list all institutions in the United









12

States that report offering an undergraduate major in

health education.

2. The test site coordinator at each institution selected

the major course in which data were collected.

3. Data were obtained from subjects present in class

on the day of data collection.

4. Findings depended on the ability of the Eating Disorder

Inventory and the Eating Habits of Athletes Survey to

accurately assess eating disorders and eatingdisordered behavior among subjects.


Assumptions

1. Eta Siqma Gamma: A National Directory of ColleQe and

University Health Education Proqrams and Faculties

(1988) confirmed the quality of an undergraduate health education program as sufficient to justify inclusion in

the study.

2. Courses selected by the test site coordinators

adequately represented their group of undergraduate

health education majors.

3. Subjects participating in the study adequately

represented the population of undergraduate health

education majors at the respective institutions.

4. The Eating Disorder Inventqry and the Eating Habits of

Athletes Survey were adequate to obtain data necessary

for the study.









13
5. Subject motivation and candor were adequate for the

purpose of the study.


Null Hypotheses


1. Ho: No statistically significant differences exist

between subjects' self-reported current weight, highest

past weight, lowest weight as an adult, and ideal

weight by sex.

Follow-up Tests:

a. current weight and ideal weight for females

b. current weight and ideal weight for males

c. current weight and lowest weight as an adult for

females

d. current weight and lowest weight as an adult for

males

e. current weight and highest past weight for females

f. current weight and highest past weight for males

g. highest past weight and lowest weight as an adult

for females

h. highest past weight and lowest weight as an adult

for males

i. highest past weight and ideal weight for females

j. highest past weight and ideal weight for males k. ideal weight and lowest weight as an adult for

females









14

1. ideal weight and lowest weight as an adult for

males

2. Ho: No statistically significant differences exist

in Eating Disorder Inventory subscale scores by

a. Sex b. Race

c. Year in college

d. Current living arrangement

e. Marital status

f. Health education focus

g. Area of professional interest

h. Self-reported eating-disordered behavior

i. Difference between current weight and highest

past weight

j. Difference between current weight and ideal

weight

k. Difference between current weight and lowest

weight as an adult


Definition of Terms

Anorexia (nervosa) diagnosis includes the following: A. Refusal to maintain body weight over a minimal
normal weight for age and height, e.g., weight loss leading to maintenance of body weight 15%
below that expected; or failure to make expected
weight gain during peiiod of growth, leading to
body weight 15% below expected.
B. Intense fear of gaining weight or becoming fat,
even though underweight.
C. Disturbance in the way in which one's body weight,
size, or shape is experienced, e.g., the person
claims to "feel fat" even when emaciated, believes








15
that one area of the body is "too fat" even when
obviously underweight.
D. In females, absence of at least three consecutive
menstrual cycles when otherwise expected to occur
(primary or secondary amenorrhea). (A woman is
considered to have amenorrhea if her periods occur
only following hormone, e.g., estrogen,
administration.) (American Psychiatric Association
DSM IIIr, 1987, p. 67.)

Bulimia (nervosa) diagnosis includes the following:

A. Recurrent episodes of binge eating (rapid
consumption of a large amount of food in a
discrete period of time).
B. A feeling of lack of control over eating behavior
during the eating binges.
C. The person regularly engages in either
self-induced vomiting, use of laxatives or
diuretics, strict dieting or fasting, or vigorous
exercise in order to prevent weight gain.
D. A minimum average of two binge eating episodes a
week for at least three months.
E. Persistent overconcern with body shape and weight.
(APA DSM IIIr, 1987, pp. 68-69.)

Diagnostical and Statistical Manual III Criteria for

Anorexia Nervosa includes loss of more than 25% of original

body weight; refusal to maintain normal body weight; intense

fear of becoming fat; and no known medical illness leading

to weight loss (American Psychiatric Association, 1980).

Diagnostical and Statistical Manual III Criteria for

Bulimia Nervosa includes recurrent episodes of binge eating,

awareness that the eating pattern is abnormal and fear of

not being able to stop eating voluntarily, depressed mood

following eating binges, bulimic episodes not due to

anorexia nervosa or any known physical disorder, and at

least three of the following: consumption of high-caloric,

easily digested food during a binge, inconspicuous eating










during a binge, termination of binges by abdominal pain,

social interruption or self-induced vomiting, repeated

attempts to lose weight by severely restrictive diets, selfinduced vomiting or use of laxatives or diuretics, frequent

weight fluctuations greater than 10 pounds due to binges and

fasts (American Psychiatric Association, 1980).

Proposed diaqnostic criteria for anorexia nervosa in Diaqnostical and Statistical Manual IV:

A. Refusal to maintain body weight over a minimally
normal weight for age and height, e.g., weight loss leading to maintenance of body weight 15%
below that expected; or failure to make expected
weight gain during period of growth, leading to
body weight 15% below expected.
B. Intense fear of gaining weight or becoming fat,
even though underweight.
C. Disturbance in the way in which one's body weight,
size, or shape is experienced, undue influence of
body shape or weight on self-evaluation, or denial of the seriousness of the current low body weight.
D. In females, absence of at least three consecutive
menstrual cycles when otherwise expected to occur
(primary or secondary amenorrhea). (A woman is
considered to have amenorrhea if her periods occur
only following hormone, e.g., estrogen,
administration.)
Bulimic type: During the episode of anorexia nervosa,
the person engages in recurrent episodes of binge
eating.
Nonbulimic type: During the episode of anorexia nervosa, the person does not engage in recurrent episodes of binge eating. (Walsh, 1992, p. 304.)

Proposed diaQnostic criteria for bulimia nervosa in Diaqnostical and Statistical Manual IV:

A. Recurrent episodes of binge eating. An episode of
binge eating is characterized by both
(1) eating, in a disqrete period of time (e.g., within any 2 hour period) an amount of food that
is definitely larger than most people would eat in
a similar period of time, and,
(2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating.)










Criterion B: Options for compensatory behavior
Option #1: (Restrict to vomiting or use of laxatives)
B. The person regularly engages in either selfinduced vomiting or the use of laxatives in order
to prevent weight gain.
Option #2: (The addition of purging and nonpurging
subtypes)
B. The person regularly engages in either selfinduced vomiting, use of laxatives or diuretics,
strict dieting or fasting, or vigorous exercise in
order to prevent weight gain.
C. A minimum average of two binge eating episodes a
week for at least 3 months.
D. Self-evaluation is unduly influenced by body shape
and weight.
E. This disturbance does not occur exclusively during
episodes of anorexia nervosa.
Specify type: (applies to Option #2 above)
Purging type: If the person regularly engages in selfinduced vomiting or the use of laxatives or diuretics.
Nonpurging type: Use of strict dieting, fasting, or
vigorous exercise but does not regularly engage in
purging. (Walsh, 1992, p. 304.)

Proposed diaQnostic criteria for binge eating disorder in Diagnostical and Statistical Manual IV:

A. Recurrent episodes of binge eating. An episode of
binge eating is characterized by both
(1) eating, in a discrete period of time (e.g., within any 2 hour period) an amount of food that
is definitely larger than most people would eat in
a similar period of time, and,
(2) a sense of lack of control over eating during
the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating.)
B. During most binge episodes, at least three of the
following behavioral indicators of loss of control
are present:
(1) Eating much more rapidly than usual
(2) Eating until feeling uncomfortably full
(3) Eating large amounts of food when not feeling
physically hungry
(4) Eating large amounts of food throughout the
day with no planned mealtimes
(5) Eating alone because of being embarrassed by
how much one is eating.
(6) Feeling disgusted with oneself, depressed, or
feeling very guilty after overeating.
C. The binge eating occurs, on average, at least
twice a month for a 6 month period.
D. The binge eating causes marked distress.








18

E. Does not occur exclusively during the course of
Bulimia Nervosa and the individual does not abuse
medication (e.g., diet pills) in an attempt to
avoid weight gain. (Walsh, 1992, p. 304.)

Area of professional interest, for purposes of this study, involves the 11 subject areas of aging/death and dying, alcohol/drug education, cancer/cardiovascular disease, environmental health, exercise and fitness, mental health/health counseling, nutrition education, sexuality, stress management, weight control/management, or wellness.

EatinQ-disordered behavior involves symptoms of eating disorders such as fasting, fad dieting, binge eating, purging behaviors (including self-induced vomiting, laxative abuse, excessive exercise, etc.), and extreme fear of gaining weight (Striegel-Moore, Silberstein, Frensch, and Rodin, 1989; Zuckerman, Colby, Ware, and Lazerson, 1986).

Eta Sicma Gamma Directory: A National Directory of College and University Health Education Procrrams and Faculties (1988) provides a listing of health education programs and faculty offering at least an undergraduate major specifically in health education. Faculty members must hold a minimum of a half-time appointment to be listed. The 1988 edition, the most current available at the time of data collection, listed 161 institutions deemed appropriate for inclusion in the directory. :,

Health education focus refers to six potential "majors" or potential worksites where the student desires to specialize: public health, patient education, safety








19
education, school/college health, worksite health promotion, or community health.

Russell's criteria for bulimia include powerful urges to overeat, avoidance of the "fattening" effects of food by self-induced vomiting, abusing laxatives, or both, and a morbid fear of becoming fat (Russell, 1979).

Test site coordinator is the faculty member who

coordinates all on-site activities at their institution, including test administration and collection.

Undergraduate health education majors are students

identifying themselves as health education majors attending an institution surveyed.















CHAPTER 2
REVIEW OF LITERATURE


Introduction

Chapter 2 reviews literature focusing on eating

disorders and eating-disordered behavior among college students. The chapter includes the following sections: (1) Sex Role Development and Sociocultural Factors Related to Eating Disorders, (2) Adults, (3) Children and Adolescents,

(4) College Students, (5) College Students in Preprofessional Programs, and (6) Summary.

Sex Role Development and Sociocultural Factors

Related to Eatinq Disorders

Nearly all societies provide different roles and

expectations for males and females (Greenberg, Bruess, & Sands, 1986). Children must first understand they are boys or girls and integrate this knowledge into their selfconcept to conform to these expectations (Shaffer, 1985).

Kohlberg's (1966) cognitive-developmental theory of sex role development proposed basic gender identity (recognizing he or she is male or female) precedes attention to same sex models. The gender schema theory (Bem, 1981) suggested that children learn to incorporate information in gender related terms about themselves and others through a developing








21
gender schema. Gender is used as a cognitive organizing principle (or schema), since it is a prominent or salient characteristic (Matlin, 1987).

Among health education professionals, the social

learning theory (Bandura, 1977), renamed social cognitive theory (Bandura, 1986), is presently viewed as a formally developed theory (Glanz, Lewis, & Rimer, 1990). Social cognitive theory proposes that behavior is determined by expectancies about environmental cues, consequences of one's actions, and one's competence to perform the behavior. Behavior is also regulated by reinforcement or incentives, as they are interpreted by the individual (Bandura, 1986). In addition, Bandura (1986) suggested that observational learning, or modeling, is one of the most effective ways to transmit not only values and attitudes, but also behavior and thought patterns. Social learning theory proponent Albert Bandura (1977) suggested that sex role development is acquired through direct tuition (the tendency of parents, teachers, and other social agents to reinforce sexappropriate responses and to punish behaviors considered more appropriate for the other sex) and modeling or observational learning.

Silverstein, Perdue, Peterson, Vogel, and Fantini

(1986) suggested that an important cause of eating disorders among women is the association between (1) curvaceousness and femininity and (2) femininity and incompetence. Wooley








22
and Wooley (1986) suggested that bulimia nervosa arises from an intense thinness obsession, central to some women's identity.

Dickstein (1989) suggested that sociocultural pressures stemming from women's sex role socialization may also precipitate the development of bulimia nervosa in vulnerable females. Two cultural events impacting women significantly within the last 25 years included (1) destabilization of sex role norms and (2) drive for thinness (Johnson, Tobin, & Steinberg, 1989). These sociocultural influences make anorexia nervosa, bulimia nervosa, and eating-disordered behavior adaptive responses to the developmental demands of growing up female in certain populations at this time in history (Steiner-Adair, 1986).

Levine (1987) proposed that the meaning of femininity in modern Western society has something to do with the development of anorexia nervosa and bulimia nervosa, since 95% of persons with eating disorders are women. Wooley and Wooley (1986) suggested that, for the American woman of today, thinness has become symbolic not only of attractiveness, but of independence, strength, and achievement.

The importance of an attractive appearance is a constant message for females (Matlin, 1987); children growing up today experience powerful media messages regarding appearance (Collins, 1991b). Children of all body








23

sizes and both sexes adopt the current negative stereotypes associated with fatness; females are more affected by this prejudicial environment than are males (Wooley, Wooley, & Dyrenforth, 1979).

In a study of female adolescents, subjects who thought they had attractive bodies had the most positive selfconcepts (Lerner, Orlos, & Knapp, 1976). In addition, adolescent women seemed to be more concerned with others' views of them (Matlin, 1987) and people generally weigh physical appearance more heavily when they are evaluating women than when they are evaluating men (Bar-Tal & Saxe, 1976).

Women receive gender specific messages from the media; they must stay in shape and be thin, while at the same time they must think about food and cooking (Silverstein, Perdue, Peterson, & Kelly, 1986). Levine (1987) indicated that magazines provide a display of thin models, articles about exercise and dieting, recipes for sweet foods, and numerous photographs of delicious food in binge amounts. Advertisers for diet programs and products promise thinness (Johnson, Tobin, & Steinberg, 1989). A 1984 survey of Glamour magazine readers indicated that 45% of underweight women felt they were too fat; more women (42%) reported that losing weight would make them the happiest when presented with other options including success at work, a date with a








24
man she admired, or hearing from an old friend (Wooley & Wooley, 1984).

For the past 20 years, an attractive appearance has been equated with thinness, particularly for females (Freedman, 1984; Johnson, Tobin, & Steinberg, 1989). Garner, Garfinkel, Schwartz, and Thompson (1980) compiled measurements of two examples of culturally "ideal" females (Playboy centerfolds and Miss America contestants) over a 20 year period. The mean weight of both groups was significantly less than the mean weight of the general population. The popular actresses provided as role models for what an attractive woman should look like have become thinner in the recent past (Silverstein, Perdue, Peterson, & Kelly, (1986). These results relate to Bandura's (1977) vicarious reinforcement concept, suggesting that the observation of behavior succeeding for others increases the tendency to behave in similar ways. Since 1970, Miss America winners have weighed significantly less than have losing contestants (Garner, Garfinkel, Schwartz, & Thompson, 1980), transmitting the message that being thin is rewarded.

Recently, (using data from 1979 to 1988) Wiseman, Gray, Mosimann, and Ahrens (1992) reported that 69% of Playboy centerfolds and 60% of Miss America contestants weigh 15% or more below the expected weight ?or their height and age, one major criterion for anorexia nervosa diagnosis (American Psychiatric Association, 1987). Since American women today








25
are under pressure to be unrealistically thin, some women may respond to this extreme pressure toward slimness by becoming dissatisfied with their bodies, sometimes resulting in anorexia nervosa or bulimia nervosa (Silverstein, Perdue, Peterson, & Kelly, 1986). Ironically, this relentless pursuit of thinness is occurring at a time when population averages for weight have increased, largely resulting from better nutrition (Johnson, Tobin, & Steinberg, 1989).

The mass media may play an important role in

reinforcing the pressure to be thin (Silverstein, Perdue, Peterson, & Kelly, 1986). Television may promote unrealistic conclusions regarding eating and body weight because of the low frequency of obesity among televised characters and the frequent food related references in programming and commercials (Dietz, 1990). Boston Globe columnist Ellen Goodman recently summarized the contents of a popular women's magazine by writing "we find dozens of skinny role-models, a cover story on weight warnings, and one requisite page about dieting, eating disorders, and self-esteem. It sits as self-consciously and uselessly as the warning on a cigarette pack" (Goodman, 1993, p. 8A). Media messages have the potential to influence personal attitudes, beliefs, and behaviors; television shows thinness being equated with the "good life" (Feldman, Feldman, & Goodman, 1988, p. 193).








26

Silverstein, Perdue, Peterson, and Kelly (1986)

concluded that female television characters were more likely to be slim and less likely to be fat than male television characters. Magazines, movies, and television consistently present unrealistically thin role models for women (Willmuth, 1986). In addition, a content analysis of women's and men's magazines provided strong support for the hypothesis that women receive more messages to be slim and to stay in shape than do men (Silverstein, Perdue, Peterson, & Kelly, 1986).

Garner, Garfinkel, Schwartz, and Thompson (1980)

said that "this shrinking ideal may exert intense pressure on some women to diet in spite of possible adverse physical and emotional consequences" (p. 490). Nasser (1988) indicated that increased emphasis on thinness is probably related to the increase in eating disorders over the past 20 years. Other researchers indicated that the thinness ideal and use of drastic weight control methods to achieve the ideal body shape are the most obvious factors in the increase of anorexia nervosa and bulimia nervosa since the 1960s (Gordon, 1989). The current standard of thinness for females portrayed in magazines may have played a role in producing the recent outbreak of eating disorders among women (Silverstein, Perdue, Peterson, & Kelly, 1986).

Since the current standard of living in Western culture is higher for all classes and body fat is no longer a sign








27

of wealth or power (Levine, 1987), "excess body fat is probably the most stigmatized physical feature, except skin color, but unlike color is thought to be under voluntary control" (Wooley & Wooley, 1979, p. 69). Many women are so fearful of being fat, they are driven to diet, regardless of their present body size and despite the fact that dieting does not work (Willmuth, 1986). In addition, the current ideal female body (tall, narrow-hipped, thin thighs) is biogenetically difficult for most women to achieve (Johnson, Tobin, & Steinberg, 1989).

Sex differences in figure perceptions exist among college students. When asking college students to make selections of current and ideal figures, Fallon and Rozin (1985) found the difference between current and ideal figures for males to be statistically insignificant; females selected ideal figures smaller than their current figure at a statistically significant level. Another study focusing on college students and their parents produced similar results and found that sex seemed to predict attitudes regarding weight concern better than did generation (Rozin & Fallon, 1988). Ford, Dolan, and Evans (1990) found similar results among a sample of Arab students attending an English-speaking university, suggesting an effect of exposure to Western influences.

Furnham & Hume-Wright (1992) summarized the

sociocultural theory of eating disorders by writing,








28

the ordinary woman, it is argued, is faced with a
widening discrepancy between her actual weight and the
weight that she has been persuaded to believe is
attractive. Anorexia nervosa is particularly prevalent
among women who are in professions that place an emphasis on physical beauty and thin appearance:
opportunities for employment for models depend on their
maintaining a low body weight; dancers too are under
considerable pressure to be slight. However, the media
select thin models to portray sophistication and
glamour to the general female population as well, to
the extent that ordinary women are so bombarded with an
unrealistic standard to thinness that they are
indoctrinated into believing it is desirable as an end
in itself. (p. 23)

Although it is difficult to establish the influence of culture on psychopathology, Levine (1987) suggested that little doubt exists that sociocultural factors are encouraging the development of eating disorders.

The degree of disordered eating among a sample of

college females may be correlated with an increased tendency to endorse sociocultural beliefs regarding the desirability of female thinness (Mintz & Betz, 1988). Rucker and Cash (1992) suggested that African American college females may have a lower predisposition for the development of anorexia nervosa or bulimia nervosa, since they generally experience less internalization of the thin standard of beauty. Ferrero and Rouget (1991) indicated that one explanation for gender differences in eating disorders and eating-disordered behavior lies in females having a lower threshold of weight satisfaction than males have. Females attempt to lose weight sooner than do males, who tend to gain weight








29

gradually, reach a high level of dissatisfaction with their weight, and begin dieting.

Consequently, many individuals are concerned about their weight, particularly female adolescents. Moss, Jennings, McFarland, and Carter (1984) found that, of a group of adolescent females, 43.1% reported being terrified of being overweight, 39.1% were preoccupied with a desire to be thinner, and 35.3% were preoccupied with the thought of having fat on their bodies. Since half of a group of underweight female adolescents reported extreme anxiety about being overweight, Moses, Banilivy, and Lifshitz (1989) suggested that distorted perceptions of ideal body weight may be a contributor to a thin body weight and eatingdisordered behavior. Sociocultural emphasis on thinness may be linked to the increase in eating-disordered behavior in women (Moss, Jennings, McFarland, & Carter, 1984). These generalized concerns about food and weight have been cited as eating-disorder risk factors among adolescents (Patton, 1988).

The dieting behavior necessary to attain the female

ideal has been suggested as a precursor to eating-disordered behavior (Patton, 1988). O'Connell, Price, Roberts, Jurs, and McKinley (1985) found that the most powerful predictor of dieting behavior among nonobese adolescents was susceptibility to the causes of obesity. Half of female college athletes engaging in eating-disordered behavior








30
perceived a personal history of obesity (Rosen, McKeag, Hough, & Curley, 1986). Chronic dieting during adolescence is thought to slow metabolic rate, resulting in weight gain under normal caloric intake, contributing to lifelong weight control problems (Freedman, 1984).

Binge eating (Crandall, 1988) and eating-disordered behavior (Gordon, 1989) are commonly learned through information and modeling. Gordon (1989) goes a step further, suggesting that bulimia nervosa is frequently learned through the process of modeling. College friends and media influence were cited as influences in learning eating-disordered behavior (Dickstein, 1989). Since Bandura (1977) suggested that rewarded modeling increases the tendency to engage in similar behavior patterns more than does modeling alone, it may be likely that persons who observe rewarded eating-disordered behavior help initiate these behaviors.

Currently, no one theory dominates the discipline of health education (Glanz, Lewis, & Rimer, 1990). Using the most appropriate theory for a given situation is accepted practice, since the complex nature of health behavior cannot be explained by any one theory (Glanz, Lewis & Rimer, 1990).

The Health Belief Model, developed to explain why

people do or do not use health services (Hochbaum, 1958; Rosenstock, 1966) is considered by some the most influential and popular model for explaining health-related behavior








31
(Rosenstock, 1990). Components of the Health Belief Model include Threat (perceived susceptibility and severity of a health condition), Outcome Expectations (perceived benefits of and barriers to engaging in a health behavior), and SelfEfficacy (Bandura, 1977), the belief that a person can successfully perform behavior necessary to produce desired outcomes (Rosenstock, 1990). Self-efficacy was added to the Health Belief Model in 1988 (Rosenstock, Strecher, & Becker, 1988).

Using the Health Belief Model as a basis for their

study, Hayes and Ross (1987) studied a representative sample of 400 Illinois adults regarding their eating habits. For the average person, appearance concerns had a somewhat stronger effect on eating habits than did health concerns. Hayes and Ross (1987) suggested appearance as a motivating factor in eating disorders, since people try to maintain extreme thinness at high risk to health. Women were more likely than men to diet for cosmetic rather than health reasons (Johnson, Tobin, & Steinberg, 1989).


Adults

Several researchers have examined eating disorders and eating-disordered behavior among groups other than college students. Eating disorder prevalence rates were variable among the young women comprising the majority of subjects. In addition to the U.S., studies have been conducted in








32

Sweden (Cullberg & Engstrom-Lindberg, 1988), New Zealand (Bushnell, Wells, Hornblow, Oakley-Browne, & Joyce, 1990), Australia (Ben-Tovim, 1988), and Great Britain (Cooper & Fairburn, 1983; King, 1989; Meadows, Palmer, Newball, & Kenrick, 1986).

Subjects studied in U.S. general population studies using Diagnostical and Statistical Manual III criteria included female shoppers (Pope, Hudson, & Yurgelun-Todd, 1984), women employed by a large banking institution compared with female college students (Hart & Ollendick, 1985), respondents to an invitation in Glamour magazine for women with bulimic problems (Yager, Landsverk, & Edelstein, 1987), women at Massachusetts bingo tournaments (Pope, Champoux, & Hudson, 1987), and a probability sample of adult residents in Alachua County, Florida (Rand & Kuldau, 1992).

These studies yielded anorexia nervosa prevalence rates ranging from 0.7% (Pope, Hudson, & Yurgelun-Todd, 1984) to

0.5% for upper socioeconomic class subjects and 1.5% for low socioeconomic class subjects (Pope, Champoux, & Hudson, 1987). Reported bulimia nervosa prevalence rates were higher and more variable than anorexia nervosa rates. Pope, Champoux, and Hudson (1987) reported bulimia nervosa prevalence rates at 17.3% for low socioeconomic subjects and 13.4% for upper socioeconomic subjects. Pope, Hudson, and Yurgelun-Todd (1984) indicated 10.3% of female shoppers were








33

bulimic. In contrast, Hart and Ollendick (1985) reported five percent of university women and one percent of working women as bulimic.

In a random sample of adults residing in a Florida

county, bulimia nervosa prevalence was estimated at 1.1% for adults ages 18 to 96, and 4.1% among women ages 18 to 30 (Rand & Kuldau, 1992). As expected, Rand and Kuldau (1992) reported eating-disordered behavior was more common among women than men, and younger than older respondents. However, no racial differences were found among bulimia nervosa prevalence rates and eight of the 23 bulimia nervosa cases existed in adults over age 45.

Persons attending medical facilities in countries

outside the U.S. have comprised other subject pools. Cooper and Fairburn (1983) provided one of the initial studies of of non-student adult women, by surveying English family planning clinic patients regarding eating-disordered behavior. Results indicated nearly 21% reported current binge eating episodes, nearly 3% reported self-induced vomiting, and nearly 5% reported currently using laxatives for weight control. The mean age of this sample was about 24 years, fairly close to the age of most college students. Young women, ages 18-22, registered by two general medical group practices in Great Britain, were surveyed by Meadows, Palmer, Newball, and Kenrick (1986). Of the 411 subjects, only one case of anorexia nervosa and one case of bulimia









34

nervosa existed. King (1989) studied male and female patients in four medical practices located in Great Britain and found only 1.1% of the 534 women surveyed had bulimia nervosa and no cases of anorexia nervosa were reported.

Ben-Tovim (1988) studied Australian female shoppers,

female patients attending a family practice group, and high school students. Bulimia nervosa prevalence among females using Diagnostical and Statistical Manual III criteria was 12.7%.

Cullberg and Engstrom-Lindberg (1988) explored beyond a primary care medical setting to ask Swedish general and child psychiatric, social, and primary care personnel for patient information. For the 78,000 suburban population, they calculated a two year prevalence of 66/100,000 (22 cases of anorexia nervosa and 44 cases of bulimia nervosa). Using nationwide psychiatric admission records from 19731987, Nielsen (1990) reported a yearly anorexia nervosa prevalence of 6.7 per 100,000 women and 0.6 per 100,000 men.

New Zealand researchers, Bushnell, Wells, Hornblow,

Oakley-Browne, and Joyce (1990), determined bulimia nervosa prevalence from a cross-sectional population survey of nearly 1,500 adults. Using Diagnostical and Statistical Manual III criteria, one percent of adults ages 18-64 could expect to have bulimia nervosa in their life time, and most cases were younger women.








35

Glamour magazine readers (almost exclusively female) reported "sometimes" using the following weight control methods: crash dieting (40%), exercise (38%), diet pills (38%), diuretics (14%), fasting/starving (34%), or selfinduced vomiting (10%) (Wooley & Wooley, 1984). Wooley and Wooley (1984) also indicated significant numbers of Glamour magazine readers used those same weight control methods "often": crash dieting (18%), exercise (57%), diet pills (12%), diuretics (4%), fasting (11%), and self-induced vomiting (5%).


Children and Adolescents

Since childhood and adolescent experiences may impact the development of an eating disorder, it is critical to examine these to provide context for the college experience. While several studies focused specifically on adolescents and eating disorders, Collins (1991a) studied body figure preferences among 1118 preadolescent children. When comparing the discrepancy between Ideal Self and Current Self, "subjects varied only by gender with females preferring statistically thinner figures than males" (Collins, 1991a, p. 204). Based on these results, Collins (1991a) suggested attitudes regarding thinness, particularly among females, may be present at, six or seven years of age. Wardle and Marsland -(1990) arrived at similar conclusions, following their study of 846 London school children ages 11 to 18. In addition to wanting to lose more weight than









36
boys, girls were less satisfied with their bodies. Both generalized weight concern (Wardle & Marsland, 1990) and eating-disordered behavior (Myers & Burket, 1989) may already be well established in females by the early teenage years.

Marchi and Cohen (1990) longitudinally studied problem eating behaviors among a large sample of children over a ten year interval and found "by late childhood and adolescence, girls were much more concerned about weight reduction than boys." In addition, Marchi and Cohen (1990) found eatingdisordered behavior was more frequently found in girls than boys, and was seen by some researchers (Abraham, Mira, Beumont, Sowerbutts, & Llewellyn-Jones, 1983) as a normal developmental phase for young females. Suggested risk factors for anorexia nervosa include childhood digestive problems and picky eating, while risk factors for bulimia nervosa include reducing efforts and development of food fads (Marchi & Cohen, 1990).


Adolescent Females

Since eating disorders and eating-disordered behavior are more common in girls than boys (Marchi & Cohen, 1990), adolescent females comprised frequent subject pools for researchers studying eating disorders. Such studies generally focused orf bulimia nervosa and eating-disordered behavior, but one early study of 151 adolescent females reported nearly 12% were considered anorexic according to








37

their responses to the Eating Attitudes Test (Moss, Jennings, McFarland, & Carter, 1984).

Using Diagnostical and Statistical Manual III criteria for bulimia nervosa, reported bulimia nervosa prevalence rates ranged from 5% (Johnson, Lewis, Love, Lewis, & Stuckey, 1984), to 6-7% (Moss, Jennings, McFarland, & Carter, 1984), to 7.7% (Crowther, Post, & Zaynor, 1985). VanThorre and Vogel (1985) reported adolescent females classified as "probably bulimic" ranged from 20.1.% to 12.5% for four age groups. Out of 72 adolescent females, 59 subjects were classified as normal, nine as dieters, eight as suspected bulimics, and one as bulimic based on Eating Disorder Inventory scores and a clinical interview using Diagnostical and Statistical Manual III criteria (Williams, Schaefer, Shisslak, Gronwaldt, & Comerci, 1986).

Using Russell's bulimia nervosa diagnostic criteria

(Russell, 1979), Dacey, Nelson, and Aikman (1990) reported a prevalence rate of 5.7% for female adolescents. Myers and Burket (1989) studied the prevalence of eating disorders among female juvenile delinquents to be 7.5% for bulimia nervosa, 2.5% for bulimia nervosa and anorexia nervosa, and 12% meeting some, but not all of the Diagnostical and Statistical Manual III-Revised criteria for bulimia nervosa or anorexia nervosa.

Choudry and Mumford (1992) and Mumford, Whitehouse, and Choudry (1992) studied eating disorders among samples of 271








38

and 369 Pakistani school girls and reported only one case of bulimia nervosa in each sample, using Diagnostical and Statistical Manual III - Revised criteria. Although cultural influences may not be a necessary condition for eating disorder development, Western influence may be associated with increased concerns about food intake and weight and may increase risk for eating disorder development (Mumford, Whitehouse, & Choudry, 1992).

In addition to eating disorders, studies also reported greater numbers of adolescent females engage in eatingdisordered behavior. Hendren, Barber, and Sigafoos (1986) found 18% of female adolescents reported engaging in one or more eating-disordered behavior including thinking about food and weight "all of the time", using laxatives, selfinduced vomiting, or using fasting or starving as a form of weight control. Binge eating appeared to be the most common eating-disordered behavior, with self-reported sample percentages ranging from 46% (another 4.4% engaging in "problematic" binge eating) (Crowther, Post, & Zaynor, 1985), 22% (Williams, Schaefer, Shisslak, Gronwaldt, & Comerci, 1986) to 16.6% (Moss, Jennings, McFarland, & Carter, 1984).

As an eating-disordered behavior, 36.4% of adolescent females self-reported using fasting as a form of weight control (Crowther, Post, & Zaynor, 1985), while Williams, Schaefer, Shisslak, Gronwaldt, and Comerci (1986) found 25%








39
of their sample of adolescent females were currently dieting and 60% reported regularly skipping meals in an attempt to lose weight.

Self-induced vomiting occurred less frequently than binge eating, fasting, dieting, or meal skipping. Selfreported prevalence rates ranged from 11.2% (Crowther, Post, & Zaynor, 1985) to 9% (Carter & Duncan, 1984) to 6.6% (Moss, Jennings, McFarland, & Carter 1984). Laxative abuse was relatively rare, with one study reporting a 4.7% prevalence (Crowther, Post & Zaynor, 1985). Only 4% reported using drugs to lose weight (Williams, Schaefer, Shisslak, Gronwaldt, & Comerci, 1986).

Underweight and normal weight girls reported a

distorted perception of their ideal body weight for height more often than did the overweight girls, with half of the underweight adolescents reporting extreme anxiety about being overweight (Moses, Banilivy, & Lifshitz, 1989). Disordered eating prevalence is greater among young women under pressure to maintain a low body weight (Abraham, Mira, Beumont, Sowerbutts, & Llewellyn-Jones, 1983) and these distorted perceptions of ideal body weight may be an important contributor to their actual, thin body weight and to inappropriate eating attitudes and behaviors (Moses, Banilivy, & Lifshitz, 1989).










Adolescent Females and Males

When comparing male and female adolescents, males as a group generally indicated lower self-reported prevalence rates of bulimia nervosa than females. Gross and Rosen (1988) studied bulimia nervosa in 1,373 high school boys and girls. Using Diagnostical and Statistical Manual III criteria, 9.6% of adolescent girls and 1.2% of adolescent boys were considered bulimic. Much lower prevalence rates were reported by Whitaker, Davies, Shaffer, Johnson, Abrams, Walsh, and Kalikow (1989), who found prevalence rates of anorexia nervosa and bulimia nervosa less than 1% for both males and females using Diagnostical and Statistical Manual III criteria. When Diagnostical and Statistical Manual III Revised criteria was employed in a study of high school students, bulimia nervosa prevalence was only 2% for girls and 0.1% for boys (Timmerman, Wells, & Chen, 1989).

Though most adolescents self-reported adequate

nutritional intake, girls indicated a high prevalence of dieting and consumption of low calorie foods (Leon, Perry, Mangelsdorf, & Tell, 1989). Of a sample of 504 high school students, approximately one-fourth of females and only 2.4% of males indicated they were currently dieting. Nearly three-fourths (73.4%) of girls indicated they had tried to lose weight before, compared to only 18.9% of the boys (Leon, Perry, Mangelsdorf & Tell, 1989). In contrast to boys, girls were more likely to engage in eating-disordered








41
behavior (Whitaker, Davies, Shaffer, Johnson, Abrams, Walsh, & Kalikow, 1989), were more concerned about their weight, and were more likely to want to lose weight (Snow & Harris, 1989).

Eating disorders and eating-disordered behavior affects not only Caucasian, high socioeconomic adolescents. VanThorre and Vogel (1985) found the distribution of adolescent females diagnosed as "probably bulimic" was proportionate across racial groups (African Americans, Caucasians, and Others). With a nearly equal number of African American and Caucasian female juvenile delinquents, 7.5% were bulimic according to Diagnostical and Statistical Manual III Criteria (Myers & Burket, 1989). Balentine, Stitt, Bonner, and Clark (1991) reported that of 2,000 African American low-income adolescents, 12% thought they might have an eating disorder. Eleven percent of low income Pueblo Indian and Hispanic female adolescents met Diagnostical and Statistical Manual III criteria for bulimia nervosa, suggesting eating disorders and concern about obesity affects a variety of ethnic and socioeconomic groups in the United States (Snow & Harris, 1989).


College Students

General

The college campus environment may support unhealthy norms and behaviors contributing to the development of eating disorders (Hotelling, 1989). College females with








42
personality characteristics described as common to persons with eating disorders, appeared vulnerable to using eatingdisordered behavior to meet their culturally based and personally controlled criteria for their appearance (Dickstein, 1989). Johnson, Tobin, and Steinberg (1989) indicated college and university professionals can expect to encounter a large, diverse group of young females engaging in eating-disordered behavior.

Bulimia nervosa prevalence using Diagnostical and

Statistical Manual III criteria is more frequently reported in the professional literature than anorexia nervosa. However, Pope, Hudson, Yurgelun-Todd, and Hudson, (1984) found 1.0% to 4.2% of female college and secondary school students reported a history of anorexia nervosa, while 6.5% to 18.6% had a history of bulimia nervosa; using a similar sample, Howatt and Saxton, (1988) determined a bulimia nervosa prevalence of 6.73%. Among college females, the highest reported bulimia nervosa prevalence rate for a female college student population was 19% (Halmi, Falk, & Schwartz, 1981), followed by 13% (Gray & Ford, 1985). Nevo (1985) reported a 4.6% to 11% range in bulimia nervosa prevalence in different groups of college females. Tamburrino, Franco, Bernal, Carrol, and McSweeny (1987) reported 15.3% of college women had Eating Attitudes Test scores high enough to be considered at risk for developing an eating disorder.








43
Pyle, Halvorson, Neuman, and Mitchell (1986) indicated the incidence of bulimia nervosa among college females increased from 1.0% in 1980 to 3.2% in 1983. Using a random sample of college freshman and seniors, Zuckerman, Colby, Ware, and Lazerson (1986) determined 5% of the women were bulimic. Similar prevalence rates of 4.5% (Pyle, Mitchell, Eckert, Halvorson, Neuman, & Goff, 1983), 4% (Katzman, Wolchik, & Braver, 1984), 3.8% (Striegel-Moore, Silberstein, Frensch, & Rodin, 1989), and a range of 2.0% to

3.8% (Thelen, Mann, Pruitt, & Smith, 1987) were reported.

Reported bulimia nervosa prevalence was much lower in college males than females. Halmi, Falk, and Schwartz (1981) reported the highest prevalence of 5%; Gray and Ford (1985) indicated a similar prevalence of 4.2%. Nearly 3% (2.8%) of male college students had an Eating Attitudes Test score high enough to put them at risk for developing an eating disorder (Tamburrino, Franco, Bernal, Carrol, & McSweeny, 1987). However, Collier, Stallings, Wolman, and Cullen (1990) found a higher percentage of bulimic tendencies (2.2%) among the males in their sample.

Several studies cited the prevalence of bulimia nervosa under one percent for college males. These prevalence rates ranged from 0.7% (Zuckerman, Colby, Ware, & Lazerson, 1986), to 0.4% (Pyle, Mitchell, Eckert, Halvorson, Neuman, & Goff, 1983), to 0.2% (Howatt & Saxton, 1988; Striegel-Moore, Silberstein, Frensch & Rodin, 1989).








44
Compared to Diagnostical and Statistical Manual III criteria, the criteria for anorexia nervosa and bulimia nervosa is more stringent using the Diagnostical and Statistical Manual III-Revised criteria. Consequently, reported prevalence rates using the Diagnostical and Statistical Manual III-Revised criteria were generally lower. Drewnowski, Yee, and Krahn (1988) in completing a longitudinal survey of female college freshman, determined the incidence of bulimia nervosa to be 2.9% in the fall and

3.3% in the spring. Schotte and Stunkard (1987) reported

1.3% of college females and 0.1% of college males at a single university were bulimic; Drewnowski, Hopkins, and Kessler (1988) indicated similar results with a national probability sample of male and female college students from 53 universities (1% of women and 0.2% of men). Prevalence of anorexia nervosa for college females was 0.04%, 5.4% for bulimia nervosa; bulimia nervosa prevalence for college males was 0.2% (Collier, Stallings, Wolman, & Cullen, 1990). Of nearly 2,000 college freshman, only 2.2% of females and 0.3% of males were currently bulimic, and no males and 0.1% of females were currently anorexic (Pyle, Neuman, Halvorson, & Mitchell, 1991).

Mintz and Betz (1988) studied a sample of 682

undergraduate women enrolled in an introductory psychology course. Only 1% were anorexic, 3% were bulimic, and 61% engaged in some form of eating-disordered behavior and were








45
classified as chronic dieters, bingers, purgers, or subclinical bulimics. Only one-third were considered normal eaters.

Some groups may be at increased risk for developing an eating disorder. Undergraduate women living in group housing on campus were considered at highest risk for bulimia nervosa (Drewnowski, Hopkins, & Kessler, 1988). Collier, Stallings, Wolman, and Cullen (1990) found bulimic tendencies were most frequent in freshmen as a group, and among students in the school of education, followed by students in the College of Arts and Sciences. Only a minority of bulimics seek professional help (Drewnowski, Yee, & Krahn, 1988), with one study reporting that only two out of five bulimics sought professional treatment (Drewnowski, Hopkins, & Kessler, 1988).

Studies of college students outside the United States produced conflicting results. Whitehouse and Button (1988) studied eating disorder prevalence among college women in the United Kingdom, and re-examined data from a 1981 study and concluded their findings were not consistent with the apparent increase in eating disorder prevalence in the United States. However, Healy, Conroy, and Walsh (1985) surveyed Irish college students using Diagnostical and Statistical Manual III criteria and determined 1.1% of the males and 10.8% of the females were bulimic. Bulimia nervosa prevalence, not based upon strict Diagnostical and








46
Statistical Manual III - Revised criteria among Swiss college students was estimated to be 4% for females and 0.7% for males (Ferrero & Rouget, 1991), comparable with reported prevalence rates among U.S. college students.

Greene, Achterberg, Crumbaugh, and Soper (1990) studied bulimic (recruited through advertising) and nonbulimic (students in an introductory nutrition course) college females using the Eating Disorder Inventory. Bulimics had lower weight goals and a greater difference between current weight and goal weight than nonbulimic women. Students engaging in eating-disordered behavior were more likely to be overweight compared to the rest of the sample (Halmi, Falk, & Schwartz, 1981).

Significantly more women than men reported "ever being on a weight loss diet" prior to college, a history of binge eating, and using purging to control their weight. A significant number of subjects experienced an increase in disordered eating their first year in college and onefourth put themselves on a diet for the first time that year (Striegel-Moore, Silberstein, Frensch, & Rodin, 1989). Dieting behavior was highest among freshmen women, with 21% of women and 8% of men reporting being on a diet at some time (Drewnowski, Hopkins, & Kessler, 1988). However, Zuckerman, Colby, Ware, and Lazerson (1986) indicated that while half of the women and 13% of the men thought they were overweight, only 10% of the women and 11% of the men were








47

actually overweight. Nevo (1985) indicated 50% of college females reported trying to lose weight at least once a month and more than half (60%) worry a great deal about their weight.

The perception of being overweight may contribute to eating-disordered behavior among college students. Of college freshman and seniors, Zuckerman, Colby, Ware, and Lazerson (1986) found 23% of women and 9% of men reported using one of four methods of weight control: fasting, diuretics, laxatives, or self-induced vomiting. Purging behavior was reported by 11% of a college female sample (Nevo, 1985). Eating-disordered behavior is thought to peak among students in grades 11 to 13, with those involved in physical education, athletics, gymnastics, journalism, art, and allied health (including dietetics majors) at highest risk (Howat & Saxton, 1988).

The reported incidence of binge eating ranged from 61% (Gray & Ford, 1985), to 49% (Katzman, Wolchik, & Braver, 1984) for college males and females. Of college females, forty percent reported binge eating once a month (Nevo, 1985), while 10% binge ate at least once a week (Drewnowski, Yee, & Krahn, 1988). Zuckerman, Colby, Ware, and Lazerson, (1986) indicated 23% of women and 14% of men engaged in binge eating episodes. Clearly an epidemic of selfreported overeating with or without purging exists among the








48

college population, particularly among females (Schotte & Stunkard, 1987).


African Americans

Comparing African American and Caucasian college

females, White, Hudson, and Campbell (1985) reported though African American women were heavier, they were more positive regarding body image and current weight than Caucasian women. African American women with a negative attitude toward their weight were more likely to engage in purging behavior. White, Hudson, and Campbell (1985) suggested obesity may be the best predictor of bulimia nervosa among African American college women.

Gray, Ford, and Kelly (1987) studied the prevalence of bulimia nervosa and attitudes toward food and weight in an African American college population. Only 3% of African American women met the Diagnostical and Statistical Manual III bulimia nervosa criteria, compared with 13% in a similar Caucasian population. Binge eating (71%) and restrictive dieting (51%) were frequent among this group of African American females. However, African American college women were less likely to experience a sense of fear and discouragement regarding food and weight control than Caucasian women. Bulimia nervosa prevalence among African American and Caucasian males was virtually nonexistent.

In general, Gray, Ford, and Kelly (1987) reported immediate families of African American college students








49
placed significantly less emphasis on food and weight control than Caucasians. Caucasian females considered themselves overweight and believed they possessed a body type which easily puts on weight more frequently than African American females. When African American females did binge, the binge was less likely to cause depression. African American females experienced less fear of weight gain and were less likely to believe a gain of five pounds would make a significant difference in their attractiveness (Gray, Ford, & Kelly, 1987). Rucker and Cash (1992) found African American college females displayed less concern about dieting and fatness than Caucasian college females.

However, no difference existed between African American and Caucasian females in the prevalence of believing themselves a failure at dieting. The researchers suggested with less emphasis on thinness, fewer African American women felt compelled to use eating-disordered behavior to achieve thinness; however, some weight preoccupation exists (Gray, Ford, & Kelly, 1987).


Student Athletes

Conflicting results exist in reported eating disorder prevalence among college student athletes. Kurtzman, Yager, Landsverk, Wiesmier, and Bodurka (1989) surveyed several student groups using the Eating Disorder Inventory and determined female student athletes had the lowest rates of self-reported eating-disordered behavior. Other researchers








5o
reported female student athletes engaged in life threatening eating-disordered behavior that may adversely affect athletic performance (Rosen, McKeag, Hough, & Curley, 1986) and college student athletes seemed more likely to engage in eating-disordered behavior than other college students (Black & Burckes-Miller, 1988).

Burckes-Miller and Black (1988) found eating-disordered behavior and attitudes were not gender specific, since 14% perceived themselves as fat though they are not and onethird report routinely thinking about food and weight. Rosen, McKeag, Hough, and Curley (1986) studied 182 college female athletes regarding pathogenic weight control behavior. Fourteen percent of the sample engaged in selfinduced vomiting, 16% laxative abuse, and 32% used diet pills. Nearly three-fourths (74%) of gymnasts and 47% of distance runners engaged in pathogenic weight control behavior.

Of a sample of male and female athletes (Black &

Burckes-Miller 1988), 58% reported losing weight by using excessive exercise (significantly more men than women), 23.5% consumed 600 or less calories per day (significantly more women than men), 11.9% fasting (significantly more women than men), 10.6% went on fad diets (significantly more women than men), and 5.6% used self-induced vomiting (significantly more women than men).










Sorority Members

Crandall (1988) surveyed two sororities, using

questionnaires addressing social ties, personal factors, and binge eating. In one sorority, binge eating and popularity were directly related; the more a sorority member binged, the more her popularity increased. In the other sorority, popularity was associated with binging the right amount. Also, social influences were identified regarding the amount of binge eating, since a woman's binge eating could be predicted by her friend's binge eating. Some sorority members indicated it is not uncommon for a group of women to "pig out" at a fraternity house, return to the sorority house and engage in self-induced vomiting together (Gordon, 1989).

Meilman, von Hippel, and Gaylor (1991) studied 229

college females and found 4.8% reported engaging in selfinduced vomiting only after eating, 7.4% after both eating and consuming alcohol. Over half (55%) of women on campus belonged to a sorority, and 72.7% of nonfreshmen eating purgers were members of a house, compared with 46.2% of nonpurgers.


Dancers

Evers (1987) studied 21 female university student
4
dancers compared with 29 control women and found 33% scored in the symptomatic range of anorexia nervosa on the Eating Attitudes Test, compared to only 13.8% of the controls.








52
Compared to several groups of college females, Kurtzman, Yager, Landsverk, Wiesmier, and Bodurka (1989) found dance majors reported the highest rates of eating-disordered behavior.


Students in Preprofessional ProQrams

Few studies have examined the specialized and selective student populations enrolled in preprofessional programs. Crockett and Littrell (1985) studied college female junior and senior dietetic majors, home economics majors, and social science and humanities majors. Dietetic majors recorded significantly higher scores on the positive eating habits scale and the self-induced vomiting scale. Nearly one-fourth (24%) of junior and senior dietetic majors scored in the anorexic range of the Eating Attitudes Test, compared with only 11% of control subjects (Drake, 1989). In addition, dietetics majors in the anorexic range placed themselves in a weight category one level higher than where they belonged, indicating a distorted body image, a symptom of anorexia nervosa, according to the Diagnostical and Statistical Manual III-Revised criteria (Drake, 1989).

From a group of 121 female medical students, 4.1% were currently bulimic, 8.3% reported a history of bulimia nervosa, and 4% reported a history of anorexia nervosa (Herzog, Pepose, Norman, & Rigotti, 1985). Nearly half (43%) of the sample were weight preoccupied and binged at least once a month. Nearly 6% were currently engaging in








53
self-induced vomiting and 12.5% used laxatives, diuretics, or diet pills at least once a month (Herzog, Pepose, Norman, & Rigotti, 1985).

Futch, Wingard, and Felice (1988) used the Eating

Disorder Inventory to survey 219 female graduate students and 132 female medical students. Results indicated none were anorexic and 3.3% were bulimic, lower rates than younger students. Medical students reported more excessive dieting concerns (Drive for Thinness scale) and a higher incidence of bulimic eating patterns than female graduate students.

Of male and female first and second year medical students, 16.5% were considered at risk for an eating disorder, with generalized increased risk for females (Herzog, Borus, Hamburg, Ott, & Concus, 1987). Herzog, Norman, Rigotti, and Pepose (1986) studied 550 medical, business, and law students using Diagnostical and Statistical Manual III criteria. About ten percent (10.2%) of the total sample met the criteria for bulimia nervosa, while 11.7% of the law school students, 7.9% of the medical school students and 8.8% of the business school respondents were bulimic.

In a study of freshman Chinese medical students, no anorexics were found, and only l.1% were bulimic using Diagnostical and Statistical Manual III-Revised criteria. Only six percent of males and 6.7% of females reported








54
having used weight control measures. However, nearly 80% of females and 42.5% of males expressed a fear of being fat; one-fourth of males and nearly 40% of females reported engaging in binge eating episodes (Chun, Mitchell, Li, Yu, Lan, Jun, Rong, Huan, Filice, Pomeroy, & Pyle, 1992).


Summary
The literature review underscores the societal

importance of an attractive appearance, particularly for females. The contemporary view of an extremely thin ideal body shape for women has been suggested as a possible agent for eating disorders and eating-disordered behavior. Modeling, or observational learning, a component of social learning theory, may play a part in eating-disordered behavior and eating disorder development.

Adolescents and college students, particularly females, reported higher rates of eating disorders and eatingdisordered behavior than non-college student adults. College students enrolled in preprofessional programs report somewhat higher rates of eating disorders than college students in general. Among all groups studied, eating-disordered behavior was more common than the clinical eating disorders of anorexia nervosa and bulimia nervosa.














CHAPTER 3
PROCEDURES FOR COLLECTION OF DATA


Introduction

This study assessed the prevalence of self-reported eating disorders and eating-disordered behavior among undergraduate health education major students in the United States to (1) establish a baseline regarding the prevalence of such disorders among this specialized group of subjects, and (2) provide information to address the needs of these subjects as individuals and as future health educators. Chapter 3 includes the following sections: (1) subjects,

(2) instrumentation, (3) procedures, and (4) analysis.


Subjects

Approximately 300 institutions report offering

undergraduate professional preparation in Health Education (Association for the Advancement of Health Education, 1991; Eta Sigma Gamma, 1988). While some published program directories rely on self-report, Eta Sigma Gamma: A National Directory of College and University Health Education ProQrams and Faculties (1988) sets specific standards regarding faculty and.curriculum before a program may be listed in the-directory. Thus, to ensure program quality, test sites were identified exclusively through the 55








56
Eta Sigma Gamma Directory (1988), which included 161 institutions. The 1988 edition was the most current version available at the time of data collection.

Using a computer generated listing of random numbers, a random sample of 25% (n = 40) of institutions was selected, with 10 additional institutions identified for replacement. Of the 40 institutions initially identified, nine specifically declined to participate and were replaced from the additional list of ten randomly identified sites. In total, 28 institutions participated in the study, five agreed to participate but did not return completed materials, and eight did not respond to the invitation to participate.

Through the process of random selection, the 28

participating institutions provided broad demographic and geographical representation of professional preparation programs in the field (See Appendix E). The institutional response rate was calculated at 70%, with 28 of 40 institutions returning completed questionnaires.

Test site coordinators at participating institutions selected a class (or classes) most representative of their group of undergraduate health education majors to survey. All students enrolled in classes selected by the test site coordinators were invited to participate in the study. The Eating Disorder Inventory and the Eating Habits of Athletes








57

Survey were used for data collection. The 28 institutions returned a total of 664 questionnaires; analyses were conducted only on 394 confirmed health education major students. Approval through the University of Florida Human Subjects Approval Board was obtained (see Appendix A).


Instrumentation


Eating Disorder Inventory (EDI)

The Eating Disorder Inventory (Garner, Olmsted, &

Polivy, 1983) is a self-report, paper/pencil instrument with 91 forced-choice items. Subjects indicate their responses using a six-point scale ranging from "always" to "never". The Eating Disorder Inventory, considered appropriate for persons ages 12 or older, can be completed in about 20 minutes. A brief description of each subscale is provided below:

(Original Subscales)

1. Drive for Thinness subscale addresses excessive concern

with dieting, fear of weight gain, and preoccupation

with weight.

2. Body Dissatisfaction subscale measures dissatisfaction

with specific body parts (e.g., hips, stomach, thighs)

as well as overall body size and shape.

3. Perfectionism subscale measures beliefs of other's

expectations regarding their own performance and

thoughts.








58
4. Interoceptive Awareness subscale measures uncertainty

in identifying sensations relating to hunger and satiety and addresses confusion in responding and

recognizing emotional states.

5. Bulimia subscale addresses the tendency to think about

and engage in periods of uncontrollable eating or

binging.

6. Ineffectiveness subscale measures feelings of

insecurity, emptiness, worthlessness, inadequacy, and

lack of control over one's life.

7. Interpersonal Distrust subscale addresses a person's

reluctance to form intimate relationships and feelings

of alienation.

8. Maturity Fears subscale focuses on the wish to retreat

into childhood.

(Provisional Subscales)

9. Social Insecurity subscale assesses belief that social

relationships are unrewarding, tense, and

disappointing.

10. Impulse Regulation subscale measures tendencies toward

substance abuse, hostility, impulsivity, and

destructiveness toward oneself and others.

11. Asceticism subscale assesses the extent to which one

seeks virtue through self-discipline, self-denial, self-restraint, self-sacrifice, and the control of

bodily urges. (Garner, 1990)









59

Eating Disorder Inventory test-retest reliability for nonpatient samples is presented in Table 1. Column A presents results from 70 student and staff nurses, with one week between the original test and retest (Welch, 1988). Wear and Pratz (1987) surveyed 70 college students, with a three week time lapse (Column B). Column C provides results from a sample of 282 college students, with one year between testing (Crowther, Lilly, Crawford, Shepherd, & Oliver, 1990).


Table 1. Test-Retest Reliability for Nonpatient Samples (Eating Disorder Inventory-2 Manual, 1990)


EDI Subscale A B C Drive for Thinness .85 .92 .72 Bulimia .79 .90 .44 Body Dissatisfaction .95 .97 .75 Ineffectiveness .92 .85 .55 Perfectionism .86 .88 .65 Interpersonal Distrust .80 .81 .60 Interoceptive Awareness .67 .85 .41 Maturity Fears .84 .65 .48



Table 2 presents internal consistency reliability

estimates for the eight original Eating Disorder Inventory Subscales. As indicated in Column A, Raciti, and Norcross (1987) reported internal consistencies from .92 to .79 for 268 college freshman women. Column B summarizes internal consistencies of .9} to .69 for a sample of 158 first and second year female psychology students (Vanderheyden, Fekken, & Boland 1988).









60

Table 2. Internal Consistency Reliability Estimates for Nonpatient Female Comparison Groups. EDI Subscale A B Drive for Thinness .90 .91 Bulimia .82 .82 Body Dissatisfaction .92 .93 Ineffectiveness .90 .90 Perfectionism .79 .69 Interpersonal Distrust .81 .86 Interoceptive Awareness .81 .78 Maturity Fears .80 .77



Table 3 presents internal consistency reliability

estimates for the present study. Estimates for the present study, which ranged from .83 to .87 for the eight original subscales, were generally similar to results presented in Table 2.

No test-retest reliability studies have been conducted with the three provisional subscales. Only internal consistency reliability estimates of .80 for the Social Insecurity subscale, .79 for the Impulse Regulation subscale, and .44 for the Asceticism subscale for 205 nonpatient college females were reported (Garner, 1990). As reported in Table 3, similar internal consistency reliability estimates of .84 for both the Social Insecurity and Impulse Regulation subscales and .85 for the Asceticism subscale were obtained for the present study.








61

Table 3. Internal Consistency Reliability Estimates for Study Sample.


EDI Subscale Reliability Coefficient Drive for Thinness (DT) .85 Bulimia (B) .84 Body Dissatisfaction (BD) .86 Ineffectiveness (I) .84 Perfectionism (P) .87 Interpersonal Distrust (ID) .85 Interoceptive Awareness (IA) .83 Maturity Fears (MF) .86 Asceticism (A) .85 Social Insecurity (SI) .84 Impulse Regulation (IR) .84



Content validation for the Eating Disorder Inventory

was established with items suggested by individuals familiar with eating disorder literature who worked with eating disorder patients. A complete discussion on validity of the Eating Disorder Inventory is presented in the Eating Disorder Inventory-2 Professional Manual (Garner, 1990).

Table 4 presents correlations between the eight

original Eating Disorder Inventory subscales and the Eating Attitudes Test (EAT-26) (Garner, Olmsted, Bohr, & Garfinkel, 1982). A total of 553 eating disorder patients served as subjects for the study. EatinQ Habits of Athletes Survey

In addition to the Eating Disorder Inventory, the

Eating Habits of Athletes Survey developed by Dr. David R. Black and Dr. Mardie Burckes-Miller was used in this study








62

(Black & Burckes-Miller, 1988). Test-retest reliability was .81 for 30 college students who completed the instrument twice in approximately three months (Black & Burckes-Miller, 1988).


Table 4. Correlations between Eating Disorder Inventory Subscales and the Eating Attitudes Test-26 (Eating Disorder Inventory-2 Manual, 1990)


Measures Eating Disorder Inventory Subscales EAT Scores DT B BD I P ID IA MF

Total Score .71* .26* .44* .46* .35* .29* .51* .27* Dieting .74* .20* .49* .43* .33* .25* .44* .24*
Bulimia & Food .53* .72* .33* .29* .14 .07 .39* .09
Preoccupation
Oral Control .61* .57* .44* .37* .26* .15 .38* .07

*p<.001 for each comparison; for family of 40 comparisons, p<.04 (Myers, 1979).


Four items not applicable to this study population or study purpose were deleted: two items related specifically to athletics, one item related to calorie intake, and one item that addressed weight fluctuation. Items added to the Eating Habits of Athletes Survey included three demographic questions (race, current living arrangement, and marital status); three questions related to body weight (highest past weight, lowest weight as an adult, and ideal weight); and three questions related to health education. Written permission to use the questionnaire was obtained from Dr. Burckes-Miller (See Appendix D).











Data Collection Procedures

On March 19, 1992, an initial packet (refer to Appendix B) was sent to the 50 institutions randomly selected through a computer generated list from the Eta Sigma Gamma: A National Directory of ColleQe and University Health Education Programs and Faculties (1988). Each packet contained: a cover letter describing the study; a copy of the student testing packet (See Appendix C); an oral script; a description of the instruments; a participation form; and a pre-addressed, postage-paid return envelope. A response was requested by April 3, 1992. Test site coordinators at participating schools received a cover letter, an oral script to read to students prior to test administration, the requested number of student testing packets and #2 pencils, and a pre-addressed, postage-paid return envelope for return of the completed questionnaires.

Beginning the week of April 12, 1992, each

nonresponding school received a follow-up telephone call. In addition, a follow-up letter, participation form, and a pre-addressed, stamped envelope were mailed on May 11, 1992 indicating extension of data collection into the Summer 1992 term. Three versions of the letter were mailed to the three groups: (1) institutions indicating they were unable to participate due to no major courses offered during Spring 1992 or a miscommunication among faculty members, (2) institutions that had not returned completed questionnaires,








64

and (3) nonrespondents. A letter of appreciation and a summary of study results were forwarded to each test site coordinator following completion of the study.


Analysis of Data

A total of 664 subjects participated in the study. Of this number, 250 indicated they were not health education majors and 20 individuals did not respond to the question. Thus, to maintain the integrity of the sample, analyses were conducted on 394 subjects confirmed as health education majors.

Repeated measures analysis of variance was used to test hypothesis #1. Follow-ups of hypothesis #1 were computed using the F-ratio, using a .05 alpha level critical value (with Bonferroni correction). Hypothesis #2 was tested using regression. Alpha level for the null hypotheses was set at .05. Analyses were completed using the Statistical Analysis System (SAS).














CHAPTER 4
ANALYSIS


Introduction

This study assessed the prevalence of self-reported eating disorders and eating-disordered behavior among undergraduate health education major students in the United States to (1) establish a baseline regarding the prevalence of such disorders among this specialized group of subjects, and (2) provide information to address the needs of these subjects as individuals and as future health educators. Chapter 4 includes the following sections: (1) introduction, (2) sample characteristics, (3) results, and

(4) discussion of results.


Sample Characteristics

The study sample of 394 undergraduate health education major students was drawn from 28 colleges and universities (See Appendix E) in the United States. Participating colleges and universities were selected randomly from Eta Sigma Gamma: A National Directory of ColleQe and University Health Education ProQrams and Faculties (1988). Students enrolled in a health education major course selected by each institution's test site coordinator were invited to participate in the study.








66

The sample was comprised of 289 (73.4%) females and 104 (26.4%) males, ranging in age from 18 to 59 years. Some 197 (50%) were seniors, 146 (37.1%) were juniors, 29 (7.4%) were sophomores, 19 (4.8%) were graduate/post baccalaureate students, and three (0.8%) were freshmen.

Most (85.2%, n = 336) subjects were Caucasian, followed by 29 (7.4%) Blacks, eight (2.0%) Native Americans, seven (1.8%) Hispanics, and four (1.0%) Asians. Nine (2.3%) responded as "Other".

The sample consisted of 258 subjects (65.4%) living in an off campus apartment or house. Nearly one-fifth (19.3%, n = 76) indicated living in on campus housing, 10.2% (n = 40) with parents, and 4.3% (n = 17) in a sorority or fraternity house.

About three-fourths (77.2%) indicated they were never married. Married subjects comprised 18.0% (n = 71) of the sample, 3.0% (n = 12) were divorced, 1.3% (n = 5) were separated, and one subject (0.3%) was widowed.

Most subjects reported Community Health (34.5%, n = 137) or School/College Health (28.7%, n = 113) as their Health Education Focus. Nearly 13% (n = 50) chose Worksite Health Promotion, 15.5% (n = 61) selected Public Health,

5.1% (n = 20) selected Patient Education, and 0.7% (n = 3) indicated Safety Education.

Subjects could select one or more Health Education Area of Professional Interest: Aging/Death and Dying,








67
Alcohol/Drug Education, Cancer/Cardiovascular Disease, Environmental Health, Exercise and Fitness, Mental Health/Health Counseling, Nutrition Education, Sexuality, Stress Management, Weight Control/Management, and Wellness. Most students selected Wellness (79.7%, n = 314), followed by Exercise and Fitness (78.9%, n = 311), Nutrition (74.6%, n = 294), Weight Control/Management (63.2%, n = 249), Alcohol/Drug Education (59.9%, n = 236), Sexuality (59.1%, n = 233), Stress Management (58.1%, n = 229), and Cancer/Cardiovascular Disease (52.8%, n = 208). Other Areas of Professional Interest included Mental Health (48.2%, n = 190), Environmental Health (46.4%, n = 183), and Aging/Death and Dying (32.0%, n = 126).

Selected demographic variables of the sample including sex, year in college, race, current living arrangement, and marital status are presented in Table 5. Table 6 consists of frequencies and percentages of Health Education major interest areas. Each variable is presented by sex in the following tables: Year in College (Table 7), Race (Table 8), Current Living Arrangement (Table 9), Marital Status (Table 10), Health Education Focus (Table 11), and Area of Professional Interest (Table 12).











Table 5. Frequencies and Percentages of Demographic Variables (n = 394)


Variable and Category # of Subjects % of Total


Sex

Female 289 73.4 Male 104 26.4 Missing Response 1 0.2

Year in College

Freshman 3 0.8 Sophomore 29 7.4 Junior 146 37.1 Senior 197 50.0 Post-bac 19 4.8 Missing Responses 0 0.0

Race

Asian 4 1.0 Black 29 7.4 Caucasian 336 85.2 Hispanic 7 1.8 Native American 8 2.0 Other 9 2.3 Missing Response 1 0.3

Current Living Arrangement

Sorority/Fraternity House 17 4.3 On Campus Residence Hall 76 19.3 Off Campus Apartment/House 258 65.4 With Parents 40 10.2 Missing Responses 3 0.8

Marital Status

Never Married 304 77.2 Married 71 18.0 Separated 5 1.2 Divorced 12 3.0 Widowed 1 0.3 Missing Response 1 0.3










Table 6. Frequencies and Percentages of Major Interest Areas (Note: For Area of Professional Interest, each subject was asked to check all that apply.) (n = 394)


Variable and Category # of Subjects % of Total


Health Education Focus

Public Health 61 15.5 Patient Education 20 5.1 Safety Education 3 0.7 School/College Health 113 28.7 Worksite Health Promotion 50 12.7 Community Health 137 34.5 Missing Responses 11 2.8

Area of Professional Interest

Aging/Death & Dying 126 32.0
Missing Responses 20
Alcohol/Drug Education 236 59.9
Missing Responses 19
Cancer/CVD 208 52.8
Missing Responses 17
Environmental Health 183 46.4
Missing Responses 17
Exercise and Fitness 311 78.9
Missing Responses 14
Mental Health 190 48.2
Missing Responses 18
Nutrition 294 74.6
Missing Responses 15
Sexuality 233 59.1
Missing Responses 17
Stress Management 229 58.1
Missing Responses 18
Weight Control/Management 249 63.2
Missing Responses 16
Wellness 314 79.7
Missing Responses 16










Table 7. Frequencies and Percentages of Year in College by Sex (n = 393)


Year in College Females Males (n = 289) (n = 104)


Freshman 2 (0.7%) 1 (1.0%) Sophomore 24 (8.3%) 5 (4.8%) Junior 108 (37.3%) 38 (36.5%) Senior 138 (47.8%) 58 (55.8%) Post-bac 17 (5.9%) 2 (1.9%) Missing Responses 0 (0.0%) 0 (0.0%)



Table 8. Frequencies and Percentages of Race by Sex (n = 393)


Race Females Males (n = 289) (n = 104)


Asian 2 (0.7%) 2 (1.9%) Black 22 (7.6%) 7 (6.7%) Caucasian 247 (85.5%) 88 (84.6%) Hispanic 6 (2.1%) 1 (1.0%) Native American 5 (1.7%) 3 (2.9%) Other 6 (2.1%) 3 (2.9%) Missing Response 1 (0.3%) 0 (0.0%)



Table 9. Frequencies and Percentages of Current Living Arrangement by Sex (n = 393)


Current Living Arrangement Females Males (n = 289) (n = 104)


Sorority/Fraternity House 13 (4.6%) 4 (3.9%) On Campus Residence Hall 53 (18.3%) 23 (22.1%) Off Campus Apartment/House I 5 (64.0%) 73 (70.2%) With Parents 35 (12.1%) 4 (3.9%) Missing Responses - 3 (1.0%) 0 (0.0%)










Table 10. Frequencies and Percentages of Marital Status by Sex (n = 393)

Marital Status Females Males (n = 289) (n = 104)


Never Married 219 (75.8%) 85 (81.7%) Married 56 (19.4%) 15 (14.4%) Separated 4 (1.4%) 1 (1.0%) Divorced 9 (3.1%) 3 (2.9%) Widowed 1 (0.4%) 0 (0.0%) Missing Responses 0 (0.0%) 0 (0.0%)



Table 11. Frequencies and Percentages of Health Education Focus by Sex (n = 393)


Health Education Focus Females Males (n = 289) (n = 104)

Public Health 45 (15.6%) 16 (15.4%) Patient Education 14 (4.8%) 6 (5.8%) Safety Education 0 (0.0%) 3 (2.9%) School/College Health 79 (27.3%) 34 (32.6%) Worksite Health Promotion 36 (12.5%) 14 (13.5%) Community Health 107 (37.0%) 29 (27.9%) Missing Responses 8 (2.8%) 2 (1.9%)


Results

Physical Characteristics of Subjects


The average female in the sample was 24.48 years of
age, 65.39 inches tall, and currently weighed 138.65 pounds. As a group, females reported a mean of 124.20 pounds as their lowest weight as an adult and 148.64 pounds as their highest past weight. The mean ideal weight was 126.37


pounds.










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Table 12. Frequencies and Percentages of Area of Professional Interest by Sex (Note: Each subject was instructed to check all that apply.) (n = 393)


Area of Professional Females Males Interest (n = 289) (n = 104)


Aging/Death & Dying 96 (33.2%) 29 (27.9%)
Missing Responses 13 6
Alcohol/Drug Education 175 (60.6%) 60 (57.7%)
Missing Responses 13 5
Cancer/Cardiovascular Disease 149 (51.6%) 58 (55.8%)
Missing Responses 13 3
Environmental Health 135 (46.7%) 48 (46.2%)
Missing Responses 12 4
Exercise and Fitness 224 (77.5%) 86 (82.7%)
Missing Responses 11 2
Mental Health/Counseling 157 (54.3%) 32 (30.8%)
Missing Responses 11 6
Nutrition Education 219 (77.8%) 74 (71.2%)
Missing Responses 10 4
Sexuality 180 (62.3%) 52 (50.0%)
Missing Responses 12 4
Stress Management 175 (60.6%) 54 (51.9%)
Missing Responses 11 6
Weight Control/Management 189 (65.4%) 59 (56.7%)
Missing Responses 10 5
Wellness 231 (80.0%) 82 (78.8%)
Missing Responses 11 4



The average male in the sample was nearly 24 (23.86)

years of age. On average, males were 70.69 inches tall and

reported currently weighing 185.08 pounds. With a mean

highest past weight of 194.81 pounds and lowest weight as an

adult of 166.73 pounds, males on average indicated 183.93

pounds as their ideal weight. Table 13 provides the means

and standard deviations of age, height, current weight,

ideal weight, highest past weight, and lowest weight as an

adult for males and females.








73

Table 13. Means and Standard Deviations of Age, Height, Current Weight, Highest Past Weight, Lowest Weight as an Adult, and Ideal Weight by Sex (n = 393)


Category and Variable Mean Stand. Dev.


Age

Females 24.48 6.72 Males 23.86 5.62

Height (in inches)

Females 65.39 2.60 Males 70.69 3.12

Current Weight (in pounds)

Females 138.65 26.67 Males 185.08 33.43

Highest Past Weight

Females 148.64 30.21 Males 194.81 37.20

Lowest Weight as an Adult
Females 124.20 21.92 Males 166.73 29.10

Ideal Weight

Females 126.37 16.79 Males 183.93 29.82



Some sex differences in ideal weight versus current

weight existed in this sample. Males as a group reported a difference of less than two pounds between current and ideal weight. In contrast, females a a group reported a 12.33 pound difference between ideal and lowest weight.









74

While a nearly 11 pound difference between highest past weight and ideal weight was present for males, females reported a 22 pound difference. Females reported a 1.96 pound difference between ideal weight and lowest weight. In comparison, males reported a 17.30 pound difference. Mean differences and standard deviations between self-reported current weight, highest past weight, lowest weight as an adult, and ideal weight by sex are presented in Table 14.


Table 14. Difference Between Self-Reported Current Weight, Highest Past Weight, Lowest Weight as an Adult, and Ideal Weight by Sex (n = 393)

Variable Females Males (n = 289) (n = 104) Mean Stand. Dev. Mean Stand. Dev. Highest Weight Minus
Current Weight 10.00 11.49 9.08 12.04 Lowest Weight 24.02 16.64 28.08 19.86 Ideal Weight 22.22 18.15 10.91 21.57 Current Weight Minus
Lowest Weight 14.17 13.36 18.90 16.25 Ideal Weight 12.34 13.79 1.88 16.20 Ideal Weight Minus
Lowest Weight 1.96 10.62 17.30 18.99


In 1990, The United States Department of Agriculture and the United States Department of Health and Human Services published revised suggested weights for adults. (See Table 15). Using the United States Department of Agriculture Suggested Weights for Adults, the breakdown for









75

Table 15. Suggested Weights for Adults


Height


Weight in Pounds


19 to 34 years

97-128 101-132 104-137 107-141 111-146 114-150 118-155 121-160 125-164 129-169 132-174 136-179 140-184 144-189 148-195 152-200 156-205 160-211 164-216


35 years and over

108-138 111-143 115-148 119-142 122-157 126-162 130-167 134-172 138-178 142-183 146-188 151-194 155-199 159-205 164-210 168-216 173-222 177-228 182-234


Height: Without shoes

Weight: Without clothes, the higher weights in the ranges
generally apply to men, who tend to have more muscle
and bone; the lower weights more often apply to women,
who have less muscle and bone.

Source: U.S. Department of Agriculture


males and females for current weight, ideal weight, highest past weight, and lowest weight as an adult is presented in Table 16. More males (53%, n = 55) than females (28%, n = 81) reported a current weight above the suggested weight for their height. More females (18%, n = 52) than males (5%, n


5'0i" 5'2"Ot 5/1,' 5 4,,
5 '3"O
5'4"

5 '7" 5'8"1


5'"10
5'11"


6'0"

6 '5"1
6'61"









76

= 5) self-reported their ideal weight below the suggested weight for their height.


Table 16. Comparison of Current Weight, Ideal Weight, Lowest Weight as an Adult, and Highest Past Weight with U.S.D.A. Weight Guidelines (n = 393)


Females
(n = 289)


Males (n = 104)


Current WeiQht

Above Within Below

Ideal WeiQht

Above Within Below

Lowest Weight as an Adult

Above Within Below

Highest Past Weight

Above Within Below


81
180 28


(28%) (62%) (10%)


(53%)
(46%)
(1%)


45 (16%) 192 (66%) 52 (18%)


57 (55%) 42 (40%) 5 (5%)


49 (17%) 158 (55%)
82 (28%)


107 168 14


30 (29%)
67 (64%) 7 (7%)


(63%)
(34%)
(4%)


(37%) (58%)
(5%)


EatinQ-Disordered Behavior

Table 17 provides a summary of self-reported regularly used weight control methods. Nearly 44% (n = 173) of subjects indicated using excessive or vigorous exercise as a form of weight control followed by fad dieting (14.2%, n = 56), fasting (6.3%, n = 25), and diet pills (5.3%, n = 21).











Table 17. Self-Reported Frequency of Regularly Used Weight Control Methods for All Subjects (n = 394)


Method # of Subjects % of Total


Fad Dieting 56 14.2
Missing Responses 9
Excessive/Vigorous Exercise 173 43.9
Missing Responses 6
Fasting 25 6.3
Missing Responses 7
Diet Pills 21 5.3
Missing Responses 7
Laxatives 11 2.8
Missing Responses 8
Diuretics (Water Pills) 9 2.3
Missing Responses 8
Self-Induced Vomiting 11 2.8
Missing Responses 8



Table 18. Self-Reported Frequency of Regularly Used Weight Control Methods by Sex (n = 393)

Method Females Males (n 289) (n = 104)

Fad Dieting 44 (15.2%) 11 (10.6%)
Missing Responses 7 1
Excessive/Vigorous Exercise 115 (39.8%) 57 (54.8%)
Missing Responses 5 0
Fasting 17 (5.9%) 8 (7.7%)
Missing Responses 5 1
Diet Pills 16 (5.5%) 5 (4.8%)
Missing Responses 5 1
Laxatives 10 (3.5%) 1 (1.0%)
Missing Responses 6 1
Diuretics (Water Pills) 6 (2.1%) 3 (2.9%)
Missing Responses 6 1
Self-Induced Vomiting 9 (3.1%) 2 (1.9%)
Missing Responses 6 1



Eleven subjects (2.8%) reported using either laxatives or

self-induced vomiting and nine (2.3%) indicated using

diuretics for weight control. Self-reported frequency of









78
regularly used weight control methods by sex is reported in Table 18.

Self-reported frequencies of specific weight control

measures are presented in Tables 19 - 28. Table 19 displays the self-reported frequency of fad dieting for all subjects. Approximately one-third (35.4%) of females self-reported using fad dieting as a means of weight control at least once a month, compared with 19.3% of male subjects (See Table 20). Table 21 displays self-reported frequency of fasting as a form of weight control for all subjects. As indicated in Table 22, 10.6% of males and 14.2% of females selfreported using fasting as a form of weight control at least once a month. Subjects' self-reported frequency of eating small quantities of food (600 calories a day or less) as a form of weight control for all subjects is displayed in Table 23. As presented in Table 24, 52.0% of females and 26.9% of males self-reported eating small quantities of food as a form of weight control at least once a month. Table 25 displays the self-reported frequency of laxative use for all subjects. Two percent of males and 7.6% of females selfreported using laxatives at least once a month as a form of weight control (See Table 26). Table 27 displays selfreported frequency of self-induced vomiting for all subjects. As indicated in Table 28, 3.0% of males and 8.5% of females self-reported using self-induced vomiting at least once a month as a form of weight control.










Table 19. Self-Reported Frequency of Weight Control for All Subjects


of Fad Dieting as a Form (n = 394)


Frequency # of Subjects % of Total

Never 266 67.5 Rarely - 1 day a month 59 15.0 2 - 3 days a month 25 6.3 1 time a week 13 3.3 More than once a week 25 6.3 Missing Responses 6 1.6



Table 20. Self-Reported Frequency of Fad Dieting as a Form of Weight Control by Sex (n = 393)


Frequency Females Males (n = 289) (n = 104)


Never 182 (62.9%) 83 (79.7%) Rarely - 1 day a month 53 (18.3%) 6 (5.8%) 2 - 3 days a month 19 (6.7%) 6 (5.8%) 1 time a week 8 (2.8%) 5 (4.8%) More than once a week 22 (7.6%) 3 (2.9%) Missing Responses 5 (1.7%) 1 (1.0%)



Table 21. Self-Reported Frequency of Fasting (no food for at least 24 hours) as a Form of Weight Control for All Subjects (n = 394)


Frequency # of Subjects % of Total

Never 335 85.0 Rarely - 1 day a month 29 7.4 2 - 3 days a month 15 3.8 1 day a week 7 1.8 More than one day a -week 2 0.5 Missing Responses 6 1.5











Table 22. Self-Reported Frequency of Fasting (no food for at least 24 hours) as a Form of Weight Control by Sex (n = 393)


Frequency Females Males (n = 289) (n = 104)


Never 243 (84.1%) 92 (88.4%) Rarely - 1 day a month 25 (8.7%) 3 (2.9%) 2 - 3 days a month 9 (3.1%) 6 (5.8%) 1 day a week 5 (1.7%) 2 (1.9%) More than one day a week 2 (0.7%) 0 (0.0%) Missing Responses 5 (1.7%) 1 (1.0%)



Table 23. Self-Reported Frequency of Eating Small Quantities of Food (600 calories a day or less) as a Form of Weight Control for All Subjects (n = 394)


Frequency # of Subjects % of Total

Never 209 53.0 Rarely - 1 day a month 85 21.6 2 - 3 days a month 41 10.4 1 day a week 30 7.6 2 or more days a week 22 5.6 Missing Responses 7 1.8



Table 24. Self-Reported Frequency of Eating Small Quantities of Food (600 calories a day or less) as a Form of Weight Control by Sex (n = 393)


Frequency Females Males (n = 289) (n = 104)


Never 134 (46.43%) 75 (72.1%) Rarely - 1 day a month 75 (26.0%) 10 (9.6%) 2 - 3 days a month - 35 (12.1%) 6 (5.8%) 1 day a week 23 (8.0%) 7 (6.7%) 2 or more days a week 17 (5.9%) 5 (4.8%) Missing Responses 5 (1.7%) 1 (1.0%)











Table 25. Self-Reported Frequency of Laxatives as a Form of Weight Control for All Subjects (n = 394)


Frequency # of Subjects % of Total

Never 361 91.5 Rarely - 1 time a month 11 2.8 2 - 3 times a month 6 1.5 1 time a week 5 1.0 2 - 3 times a week 1 0.3 4 - 6 times a week 1 0.3 At least once every day 1 0.3 Missing Responses 9 2.3



Table 26. Self-Reported Frequency of Laxatives as a Form of Weight Control by Sex (n = 393)


Frequency Females Males (n = 289) (n = 104)


Never 262 (90.7%) 99 (95.1%) Rarely - 1 time a month 10 (3.5%) 1 (1.0%) 2 - 3 times a month 5 (1.7%) 1 (1.0%) 1 time a week 4 (1.4%) 0 (0.0%) 2 - 3 times a week 3 (1.0%) 0 (0.0%) 4 - 6 times a week 0 (0.0%) 0 (0.0%) At least once every day 0 (0.0%) 0 (0.0%) Missing Responses 5 (1.7%) 3 (3.0%)











Table 27. Self-Reported Frequency of Self-Induced Vomiting as a Form of Weight Control for All Subjects (n = 394)


Frequency # of Subjects % of Total


Never 358 90.8 Rarely - one time a month 14 3.5 2 - 3 times a month 6 1.5 1 time a week 5 1.3 2 -3 times a week 1 0.3 4 - 6 times a week 1 0.3 At least once every day 1 0.3 Missing Responses 8 2.0



Table 28. Self-Reported Frequency of Self-Induced Vomiting as a Form of Weight Control by Sex (n = 393)


Frequency Females Males (n = 289) (n = 104)


Never 260 (90.1%) 98 (94.1%) Rarely - one time a month 13 (4.5%) 1 (1.0%) 2 - 3 times a month 5 (1.7%) 1 (1.0%) 1 time a week 5 (1.7%) 0 (0.0%) 2 -3 times a week 1 (0.3%) 0 (0.0%) 4 - 6 times a week 1 (0.3%) 0 (0.0%) At least once every day 0 (0.0%) 1 (1.0%) Missing Responses 4 (1.4%) 3 (2.9%)



Listed below is each code followed by the item on the

Eating Habits of Athletes Survey:

FAD = Fad Dieting used regularly for weight control

VE = Excessive/Vigorous Exercise used regularly for weight
control

FAST = Fasting used -regularly for weight control

PILLS = Diet Pills used regularly for weight control

LAX = Laxatives used regularly for weight control









83

DIU = Diuretics used regularly for weight control VOM = Self-Induced Vomiting used regularly for weight
control

BE = I have regular episodes of binge eating (rapid
consumption of foods that are easy to digest and high
in calories in a short period of time).

PAIN = I frequently eat until my stomach hurts too much to
continue, or I am interrupted by other people, or I
fall asleep, or I vomit.

ALONE = I don't like to have people present when I eat. NCON = During eating binges, I have a distinct feeling of
not having control over my eating.

SIV = I binge eat, then frequently self-induce vomiting
because I am afraid I will gain weight.

CON = I have a persistent concern with my body shape and
weight.

AN = My weight is 15% or more below normal for my age and
height.

FEAR = I have an intense fear of becoming obese, even though
I am underweight or normal weight now.

MEN = I have had the absence of at least three consecutive
menstrual cycles when they should have occurred.
(Females only)

TOO = Other people think I am too thin. THINK = I think about food and weight all the time. FAT = I think I am fat although I am underweight. GAIN = I am terrified of gaining weight. DOWN = I feel depressed and down on myself after I eat. DIET = How often do you use popular diets . . NOFOOD = How often do you fast . . SMALL = How often do you eat small quantities (600 calories
a day or less) of food . . .

LAXWC = How often do you use laxatives . .








84

SIVWC = How often do you use self-induced vomiting . . . NUMBI = What is your average number of eating binges within
the last three months?

DIAGED = Have you ever been diagnosed with an eating
disorder?

YOUED = Do you think you might have an eating disorder?


Table 29 summarizes self-reported eating-disordered

behavior and personal beliefs regarding food and weight for all subjects. Thirty-six subjects (9.1%) reported engaging in regular binge eating episodes and 4.3% (n = 17) indicated frequently eating until their stomach hurts too much to continue, interrupted by others, falling asleep, or vomiting. One-fifth (20.8%, n = 82) felt depressed and down on themselves after eating and 11.4% (n = 45) reported a distinct feeling of not having control over their eating during eating binges. Twelve subjects (3.0%) indicated they frequently self-induce vomiting following binge eating episodes to prevent weight gain and 9.1% (n = 36) reported not wanting people present when they are eating.

Thirty-two (8.1%) subjects reported having a body

weight 15% or more below normal for their age and height. Sixteen percent (n = 63) indicated others think they are too thin.
A persistent concern with body shape and weight was

reported by 59.9% (n = 236) of subjects; one-third (33.2%, n = 131) indicated thinking about food and their weight all the time. Nearly one-third (32.2%, n = 127) reported being










85

terrified of gaining weight and 19 (4.8%) believed they are

fat though they are underweight. Nearly one-fourth (24.9%,

n = 98) were normal or underweight subjects reporting an

intense fear of becoming obese. Nearly nine percent (8.7%,

n = 25) of females reported the absence of at least three

consecutive menstrual cycles when they should have occurred

(See Table 30).


Table 29. Self-Reported Eating Disordered Behavior and Personal Beliefs Regarding Food and Weight for All Subjects (n = 394)


Variable # of Subjects % of Total


Regular binge eating episodes (BE) 36 9.1
Missing Responses 4
Eat until stomach hurts, etc (PAIN) 17 4.3
Missing Responses 4
Don't like others present when eating (ALONE) 36 9.1
Missing Responses 6
No control during eating binges (NCON) 45 11.4
Missing Responses 7
Self-induce vomit after binge eating (SIV) 12 3.0
Missing Responses 8
Persistent concern w/body shape/weight (CON) 236 59.9
Missing Responses 6
Weight 15% or more below normal (AN) 32 8.1
Missing Responses 6
Intense fear of becoming obese (FEAR) 98 24.9
Missing Responses 8
Others think I am too thin (TOO) 63 16.0
Missing Responses 8
Think about food/weight all the time (THINK) 131 33.2
Missing Responses 8
Think I am fat though underweight (FAT) 19 4.8
Missing Responses 10
Terrified of gaining weight (GAIN) 127 32.2
Missing Responses 8
Depressed & down on self after eating (DOWN) 82 20.8
Missing Responses 7

:4
Nearly two-thirds of female (63.6%) and one-half

(49.0%) of male subjects indicated they have a persistent

concern with body shape and weight. One-fourth (25%) of












males and 36.0% of females indicated they think about food

and weight all of the time. An intense fear of becoming

obese though presently at a normal weight or underweight was

reported by 28.4% of female and 14.4% of male subjects.

Over one-third (38.1%) of females and 15.4% of males

indicated being terrified of gaining weight and 24.6% of

females and 9.6% of males reported feeling depressed and

down on themselves after eating (Refer to Table 30).


Table 30. Self-Reported Eating Disordered Behavior and Personal Beliefs Regarding Food and Weight by Sex (n = 393)


Variable Females Males (n = 289) (n = 104)
n/% of females n/% of males


Regular binge eating episodes (BE) 28/9.7 8/7.7
Missing Responses 3 0
Eat until stomach hurts, etc. (PAIN) 14/4.8 3/2.9
Missing Responses 3 0
Don't like others present when eating (ALONE) 27/9.3 8/7.7
Missing Responses 5 0
No control during eating binges (NCON) 38/13.1 6/5.8
Missing Responses 6 0
Self-induce vomit after binge eating (SIV) 11/3.8 1/1.0
Missing Responses 7 0
Persistent concern w/body shape/weight (CON) 184/63.7 51/49.0
Missing Responses 4 1
Weight 15% or more below normal (AN) 22/7.6 10/9.6
Missing Responses 4 1
Intense fear of becoming obese (FEAR) 82/28.4 15/14.4
Missing Responses 6 1
3 consecutive menstrual cycle absence (MEN) 25/8.7 N/A
Missing Responses 7
Others think I am too thin (TOO) 46/15.9 17/16.3
Missing Responses 6 1
Think about food/weight all the time (THINK) 104/36.0 26/25.0
Missing Responses 6 1
Think I am fat though underweight (FAT) 15/5.2 4/3.8
Missing Responses 8 1
Terrified of gaining weight (GAIN) 110/38.1 16/15.4
Missing Responses 6 1
Depressed & down on self after eating (DOWN) 71/24.6 10/9.6
Missing Responses 5 1











EatinQ Disorders


As presented in Table 31, in the past three months, nearly ten percent (9.4%, n = 37) of the sample reported engaging in binge eating two to six times, 13 (3.3%) binge once per week, and nine (2.3%) reported two or more binge eating episodes per week (one of the Diagnostical and Statistical Manual III-Revised criteria for bulimia nervosa diagnosis). Self-reported binge eating frequency in the last three months by sex is reported in Table 32.


Table 31. Self-Reported Average Number of Eating Binges Within the Last 3 Months for All Subjects (n = 394)


Frequency # of Subjects % of Total

0 - 1 binge 324 82.0 2 - 6 times in 3 months 37 9.4 1 binge per week 13 3.3 2 or more per week 9 2.3 Missing Responses 12 3.0



Table 32. Self-Reported Average Number of Eating Binges Within the Last 3 Months by Sex (n = 393)


Frequency Females Males (n = 289) (n = 104)


0 - 1 binge 237 (82.0%) 86 (82.7%) 2 - 6 times in 3 months 28 (9.7%) 9 (8.7%) 1 binge per week 11 (3.8%) 2 (1.9%) 2 or more per week 5 (1.7%) 4 (3.8%) Missing Responses - 8 (2.8%) 3 (2.9%)








88

A total of 3.6% of subjects reported ever being

diagnosed with an eating disorder; four (1.0%) anorexia nervosa, seven (1.8%) bulimia nervosa, and three (0.8%) both anorexia nervosa and seven bulimia nervosa (refer to Table 33). Nearly five percent (4.6%) thought they might have an eating disorder; four (1.0%) anorexia nervosa, 11 (2.8%) bulimia nervosa, and three (0.8%) both anorexia nervosa and bulimia nervosa (see Table 35).

According to Table 34, 2.9% of males (n = 3) have been diagnosed with an eating disorder, compared to 3.8% (n = 11) of females. In the questionnaire section asking for written student comments, one student reported a possible eating disorder that was never formally diagnosed. Table 33. Have You Ever Been Diagnosed with an Eating Disorder? (All Subjects) (n = 394)


Frequency # of Subjects % of Total

No 372 94.4 Yes, anorexia nervosa 4 1.0 Yes, bulimia nervosa 7 1.8 Yes, anorexia & bulimia 3 0.8 Missing Responses 8 2.0








89

Table 34. Have You Ever Been Diagnosed with an Eating Disorder? (by Sex) (n = 393)


Frequency Females Males (n = 289) (n = 104)


No 274 (94.8%) 98 (94.2%) Yes, anorexia nervosa 2 (0.7%) 2 (1.9%) Yes, bulimia nervosa 6 (2.1%) 1 (1.0%) Yes, anorexia & bulimia 3 (1.0%) 0 (0.0%) Missing Responses 4 (1.4%) 3 (2.9%)



Ten (3.5%) females thought they have bulimia nervosa

compared with one (1%) male. One percent of females (n = 3) and males (n = 1) thought they have anorexia nervosa. Two (0.7%) females and one male (1.0%) thought they might have both anorexia nervosa and bulimia nervosa. In total, 5.2% (n = 15) of females and 3% (n = 3) of males thought they might have either anorexia nervosa or bulimia nervosa, or both (refer to Table 36).


Table 35. Do You Think You Might Have an Eating Disorder? (All Subjects) (n = 394)


Frequency # of Subjects % of Total


No 367 93.1 Yes, anorexia nervosa 4 1.0 Yes, bulimia nervosa 11 2.8 Yes, both anorexia and bulimia 3 0.8 Missing Responses 9 2.3








90
Table 36. Do You Think You Might Have an Eating Disorder? (By Sex) (n = 393)


Frequency Females Males (n = 289) (n = 104)


No 269 (93.1%) 98 (94.0%) Yes, anorexia nervosa 3 (1.0%) 1 (1.0%) Yes, bulimia nervosa 10 (3.5%) 1 (1.0%) Yes, anorexia & bulimia 2 (0.7%) 1 (1.0%) Missing Responses 5 (1.7%) 3 (3.0%)



The means, standard deviations, and t-test comparisons by sex of the Eating Disorder Inventory subscale scores are presented in Table 37. As a group, males scored higher at a statistically significant level than females on the Perfectionism subscale. Females scored higher than males at a statistically significant level on the Drive for Thinness and Body Dissatisfaction subscales. Table 38 presents means and standard deviations of Eating Disorder Inventory scores of nonpatient college students (n = 101 for male students; n = 205 for female students), as reported in the Eating Disorder Inventory - 2 Professional Manual (Garner, 1990). The means and standard deviations of both groups appeared to be similar.










91

Table 37. Eating Disorder Inventory Subscale Scores by Sex


Subscale Mean Stand. Dev. T-Value


Drive for Thinness
Females 5.2 5.4 6.75** Males 2.1 3.3 5.42**

Bulimia
Females 1.3 2.7 1.04 Males 1.0 2.6 1.03

Body Dissatisfaction
Females 11.5 8.2 9.68** Males 4.8 5.0 7.76**

Ineffectiveness
Females 2.5 4.2 1.96 Males 1.8 2.7 1.60

Perfectionism
Females 4.9 4.0 -2.51*
Males 6.1 4.3 -2.60**

Interpersonal Distrust
Females 2.5 3.1 -0.22 Males 2.5 2.6 -0.20

Interoceptive Awareness
Females 2.1 3.4 1.24 Males 1.7 3.3 1.21

Maturity Fears
Females 2.7 2.7 -1.02 Males 3.1 3.6 -1.17

Asceticism
Females 3.6 2.3 0.40 Males 3.4 2.5 0.42

Impulse Regulation
Females 1.8 3.0 -1.69 Males 2.5 3.9 -1.91

Social Insecurity
Females 3.6 3.4 0.96 Males 3.2 2.9 0.89


*p < .05, **p < .01










Table 38. Eating Disorder Inventory Subscale Scores of College Students by Sex (EDI Manual, 1990)


Subscale Mean Stand. Dev.


Drive for Thinness
Females 5.5 5.5 Males 2.2 4.0

Bulimia
Females 1.2 1.9 Males 1.0 1.7

Body Dissatisfaction
Females 12.2 8.3 Males 4.9 5.6

Ineffectiveness
Females 2.3 3.6 Males 1.8 3.0

Perfectionism
Females 6.2 3.9 Males 7.1 4.7

Interpersonal Distrust
Females 2.0 3.1 Males 2.4 2.5

Interoceptive Awareness
Females 3.0 3.9 Males 2.0 3.0

Maturity Fears
Females 2.7 2.9 Males 2.8 3.4

Asceticism
Females 3.4 2.2 Males 3.8 2.9

Impulse Regulation
Females 2.3 3.6 Males 2.8 3.8

Social Insecurity
Females 3.3 3.3 Males 3.3 3.2








93

The null hypotheses for this study presented in Chapter 1 are listed below.

1. Ho: No statistically significant differences exist

between subject's self-reported current weight, highest

past weight, lowest weight as an adult, and ideal

weight by sex.

Follow-up Tests:

a. current weight and ideal weight for females

b. current weight and ideal weight for males

c. current weight and lowest weight as an adult for

females

d. current weight and lowest weight as an adult for

males

e. current weight and highest past weight for females

f. current weight and highest past weight for males

g. highest past weight and lowest weight as an adult

for females

h. highest past weight and lowest weight as an adult

for males

i. highest past weight and ideal weight for females

j. highest past weight and ideal weight for males k. ideal weight and lowest weight as an adult for

females

1. ideal weight and lowest weight as an adult for

males




Full Text

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PREVALENCE OF EATING DISORDERS AND EATING-DISORDERED BEHAVIOR AMONG UNDERGRADUATE HEALTH EDUCATION MAJOR STUDENTS IN THE UNITED STATES By REBECCA ANN BREY A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS £oR THE DEGREE OF -DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 1993

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ACKNOWLEDGEMENTS I could not have asked for a better committee or husband and express great appreciation to these six wonderful people for their help in completing this study: Dr. R. Morgan Pigg, Jr. for his hard work, support, and most importantly, infinite patience. Dr. W. William Chen for encouraging my best work. Dr. Phyllis M. Meek for her knowledge and valuable insights in the area of eating disorders. Dr. M. David Miller for an open appointment book and for sharing his statistical expertise. Dr. Barbara A. Rienzo for her help in theory development and study conceptualization. My husband, Dave, for reminding me at appropriate times, "If it were easy, everyone would have one!" ii

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TABLE OF CONTENTS P. aq e ACKNOWLEDGEMENTS ii P ABSTRACT V CHAPTERS 1 INTRODUCTION 1 •Statement of Research Problem 7 “Purpose of the Study 7 Need for the Study 7 Delimitations 11 Limitations 11 Assumptions 12 Null Hypotheses 13 Definition of Terms 14 2 REVIEW OF LITERATURE 20 « Introduction 2 0 Sex Role Development and Sociocultural Factors Related to Eating Disorders 2 0 Adults 31 Children and Adolescents 35 ? College Students 41 Students in Preprofessional Programs 52 Summary 54 3 PROCEDURES FOR COLLECTION OF DATA 55 Introduction 55 Subjects 55 Instrumentation 57 Data Collection Procedures 63 Analysis of Data 64 4 ANALYSIS 65 Introduction t 65 Sample Characteristics 65 Results 71 Discussion of Results 117 iii

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5 SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS 129 Summary 129 Conclusions 131 Recommendations 13 3 APPENDICES A UNIVERSITY OF FLORIDA INSTITUTIONAL REVIEW BOARD HUMAN SUBJECTS APPROVAL 137 B CORRESPONDENCE WITH COLLEGE/UNIVERSITY PERSONNEL 13 9 C STUDY INSTRUMENTS 152 D CORRESPONDENCE WITH AND INSTRUMENT DEVELOPED BY BLACK AND BURCKES-MILLER 162 E LIST OF PARTICIPATING INSTITUTIONS AND TEST SITE COORDINATORS 167 F STUDENTS' WRITTEN COMMENTS 171 LIST OF REFERENCES 176 BIOGRAPHICAL SKETCH 191 W iv

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Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy PREVALENCE OF EATING DISORDERS AND EATING-DISORDERED BEHAVIOR AMONG UNDERGRADUATE HEALTH EDUCATION MAJOR STUDENTS IN THE UNITED STATES By Rebecca Ann Brey May 1993 Chairperson: Dr. R. Morgan Pigg, Jr. Major Department: Health Science Education This study assessed the nature and scope of selfreported eating disorders and eating-disordered behavior among undergraduate health education major students in the United States. A random sample was drawn of 394 health education students attending 28 colleges and universities throughout the United States. Test sites were obtained from a random sample of 25% of all institutions (28% of institutions listed as offering an undergraduate program in Health Education) in Eta Sicrma Gamma: A National Directory of College and University Health Education Programs and Faculties (1988). The Eating Disorder Inventory and the Eating Habits of Athletes Survey were used to assess selfreported eating disorders and eating-disordered behavior. v

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Weight differences were analyzed using repeated measures analysis of variance. The statistical relationship between each Eating Disorder Inventory subscale and demographic variables, weight differences, and items on the Eating Habits of Athletes Survey was determined using multiple regression. The difference between self-reported current and ideal weight was nonsignificant for males; female subjects selfreported their ideal weight thinner than their current weight at a statistically significant level, suggesting (1) male undergraduate health education major students were generally satisfied with their current weight and (2) female undergraduate health education major students were generally dissatisfied with their current weight and wanted to be thinner. Using Diagnostical and Statistical Manual IllRevised criteria, 1% of females (n = 3) and 0% of males met all the criteria for bulimia nervosa; no males or females met all the criteria for anorexia nervosa diagnosis. Selecting weight management as an area of professional interest was statistically related to an increase in the Drive for Thinness subscale score on the Eating Disorder Inventory. Results suggest (1) undergraduate health education major students, particularly females, are not immune to societal pressure to maintain a thin body weight, (2) many undergraduate health education major students engaged in vi

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eating-disordered behavior, and (3) students with a professional interest in weight management/ control may potentially perpetuate the cultural obsession with thinness through their professional activities. vii

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CHAPTER 1 INTRODUCTION Americans today have a cultural obsession with thinness and a fixation on food and our bodies. Consequently, concerns about diet and exercise constitute a national obsession (Schwartz, Thompson, & Johnson, 1982). An increase in eating disorders (anorexia nervosa and bulimia nervosa) and eating-disordered behavior is thought to be one effect of "thinness mania" (Silverstein, Perdue, Peterson, & Kelly, 1986) . Individuals suffering from anorexia nervosa, bulimia nervosa, and eating-disordered behavior present a complex and difficult challenge for all professionals (Gordon, 1989; Schwartz, Thompson, & Johnson, 1982), including health educators. Eating disorders and eating-disordered behavior are best described along a continuum (Rodin, Silberstein & Striegel-Moore, 1985) , ranging from normal eating and unconcern with weight, to what is called normative discontent with weight resulting in moderately disregulated/restrained eating (eating-disordered behavior) , to bulimia nervosa or anorexia nervosa. Anorexia nervosa is primarily characterized by self-starvation, while bulimia nervosa involves binge eating followed by some form of 1

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2 purging behavior, such as self-induced vomiting, excessive exercise, fasting, or laxative abuse (Sacker & Zimmer, 1987) and a preoccupation with control over weight and body shape (Gordon, 1989). Serious medical complications can occur from both anorexia nervosa and bulimia nervosa (Mitchell, Specker, & de Zwaan, 1991) . Credit for first describing anorexia nervosa is generally given to Sir William W. Gull of London's Guy's Hospital, who in 1874 called it "anorexia nervosa." Charles Lasegue of Paris' Sorbonne and Hospital La Pitite, used the term "l'anorexie hysterique" in 1873. Samuel Fenwick, of London, has been suggested as writing the most detailed and thorough description of anorexia nervosa by anyone in the 19th century (Silverman, 1992) . Anorexia nervosa may have individual, family, and possibly cultural predisposing factors (Garner & Garfinkel, 1980) . Bulimia nervosa was first recognized as a psychiatric disorder in the American Psychiatric Association Diagnostical and Statistical Manual III in 1980. Shortly after its inclusion, the end of the year edition of Newsweek proclaimed 1981 as "the year of the binge purge syndrome" (Adler, 1982, p. 29) The age of the onset of anorexia nervosa is usually between 12 and 18 years of age (“siegel, Brisman, & Weinshel , 1988). Bulimia nervosa usually begins in adolescence or early adulthood. The binge— purge cycle, an

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3 important characteristic of bulimia nervosa, often begins at transition points of independence (Siegel, Brisman, & Weinshel, 1988). Siegel, Brisman, and Weinshel (1988) cited leaving for college and leaving home as examples of transition points. Since high expectations potentially make the transition from adolescence to adulthood difficult, bulimia nervosa can develop into a coping mechanism (Wooley & Wooley, 1986). For females, a common precipitant involves the breakup of a relationship with a boyfriend or spouse (Siegel, Brisman, & Weinshel, 1988). "Bulimia nervosa has reached epidemic proportions since the late 1970s among college-age females" (Gordon, 1989, p. 41). Many college women, but few men, show behavioral patterns associated with an eating disorder (Hesse-Biber , 1989) . Consequently, some estimate as many as 20% of women between ages 13 and 40 may be affected by anorexia nervosa or bulimia nervosa (Sandbek, 1986) . Women comprise 95% of all anorexics and 90 95% of all bulimics in the United States (Siegel, Brisman, & Weinshel, 1988) . Since eating disorders (Silverstein, Perdue, Peterson, & Kelly, 1986) and eating-disordered behavior (Hesse-Biber, 1989) are much more common among women than men, theories of sex role development including the cognitive-developmental theory (Kohlberg, 1966); the social learning theory (Bandura, 1977) ; later renamed social cognitive theory (Bandura, 1986) ; and the gender-schema theory (Bern, 1981)

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4 deserve attention. In particular, modeling or observational learning, a component of the social learning theory (Bandura, 1977) , has been suggested as an explanation for eating-disordered behavior (Crandall, 1988) . Eating disorders and eating-disordered behavior are generally regarded as complicated issues (Gordon, 1989; Schwartz, Thompson, & Johnson, 1982) . Bandura (1977) suggested complex behaviors are learned more efficiently through modeling than through operant learning. "In particular, gender roles and sociocultural expectations appear strongly implicated in the development of eating disorders" (Thornton, Leo, & Alberg, 1991, p. 470) . A generalized sociocultural pressure for women to be thin (Garner & Garfinkel, 1980) and the treatment of women (Chernin, 1981; Kaplan, 1980; Orbach, 1978) in modern American society were suggested as two of the several predisposing factors prompting the development of eating disorders in women. Silverstein, Peterson, and Perdue (1986) suggested the root of eating disorders involves societal pressure of a thin standard of bodily attractiveness for women. The 1970s produced "a shift in the idealized female shape from a curved voluptuous figure to the angular, lean look of today. The impact of this • • • "'i changing idealized female shape is exemplified by the pervasiveness of dieting among women." (Garner, Garfinkel, Schwartz, & Thompson, 1980, p. 483).

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5 Uniform standards of beauty and fashion for females imposed by 20th century mass media (Mazur, 1986) compound the cultural pressure for women to diet and assume a thin body shape. Other researchers pointed out the irony between the mass media giving anorexia nervosa the most attention of all eating disorders while promoting slimness "as the criterion for attractiveness in women" (Furnham & Hume— Wright, 1992, p. 21). After studying the role of mass media in promoting a thin standard of attractiveness for women, Silverstein, Perdue, Peterson, and Kelly (1986) determined their results necessary but not sufficient to conclude that mass media play a role in promoting a thin standard of attractiveness that may help explain the recent outbreak of eating disorders among women. In studying the 10 most read magazines by persons 18 to 24 years of age, Anderson and DiDomenico (1992) suggested a "dose— response" relationship between sex differences in eating disorder prevalence and the number of articles related to diet. Women's magazines contained 10 times more diet articles than did men's magazines, a ratio almost identical to the 10 times higher rate of eating disorder prevalence in females compared to males. However, the cover of the February 1993 issue of Men's Health magazine proclaimed in large purple letters "Get Rid of That Gut!" (Laliberte, 1993) , suggesting the sociocultural pressure may be expanding to include, rather than exclude, males.

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6 The etiology of eating problems also may relate to women wanting to be thinner than is medically desirable, representing a response of typical women to the new, more demanding cultural standards for thinness (Hesse-Biber , 1989) . One study found most college women (85%) want to lose weight, compared to 40% of college men, and 45% of the men wanted to gain weight (Drewnowski & Yee, 1987) . Consequently, many college women reported high rates of body dissatisfaction, viewed as a significant risk factor for development of an eating disorder (Klemchuck, Hutchinson, & Frank, 1990) . Among adolescents, "the high prevalence of body weight dissatisfaction and the potential harmful weight loss practices underscore the potential influence of social norms that equate thinness with attractiveness and social approval" (Centers for Disease Control, 1991, p. 748) . Dramatic increases in certain eating problems among students attending colleges and universities throughout the United States (Hesse-Biber, 1989) present a problem clearly compromising the psychological and physical health of significant numbers of college females (Gordon, 1989) . Presumed to be at highest risk for eating disorders are college females (Schotte & Stunkard, 1987), causing concern among professional communities as well as the general public * (Stnegel-Moore, Silberstein, Frensch, & Rodin, 1989) .

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7 Statement of Research Problem This study assessed the nature and scope of selfreported eating disorders and eating-disordered behavior among undergraduate health education major students in the United States. Analyses were conducted based on students' health education focus, area of professional interest, demographic variables, and differences between self-reported current weight, highest past weight, lowest weight as an adult, and ideal weight to determine if differences exist in the prevalence of eating disorders and eating-disordered behavior. Purpose of the Study This study assessed the nature and scope of selfreported eating disorders and eating-disordered behavior among undergraduate health education major students in the United States to (1) establish a baseline regarding the prevalence of such disorders among this specialized group of subjects and (2) provide information concerning appropriate professional preparation to address the needs of these subjects as individuals and as future health educators. Need for the Study College students are considered most at risk for developing an eating disorder (Johnson, Tobin, & Steinberg, 1989) . The college experience actually may increase the risk for developing an eating disorder, with intense social

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8 and academic pressures as well as specific pressure toward thinness cited as possible factors (Striegel-Moore, Silberstein, Frensch, & Rodin, 1989) . Furthermore, Striegel-Moore, Silberstein, Frensch, and Rodin, (1989) suggested that a competitive school environment may encourage not only academic achievement, but a thin body as evidence of achievement in the area of personal weight. In addition, certain environments may increase the risk for eating disorder development; for example, colleges and boarding schools are thought to "breed" eating disorders, such as bulimia nervosa (Squire, 1983) . The destructive impact of eating disorders has been documented by researchers (Schwartz, Thompson, & Johnson, 1982). Health education major students operate in a specialized sociocultural environment. In addition to the "thin is in" messages from the general public, they feel additional pressure to maintain the healthy lifestyle they advocate for others. While many unhealthy behaviors are easily concealed, such as smoking, alcohol or other drug abuse, or poor stress management, the effect of consuming more calories than expended is obvious to everyone. Consequently, "other kinds of subcultures also appear to amplify sociocultural pressures and hence place their members at greater risk for bulimia. Prime examples are those subcultures in which optimal weight is specified, explicitly or implicitly, for the performance of one's

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9 vocation" (Striegel-Moore, Silberstein, & Rodin, 1986, p. 248) . Since efforts to lose weight require tremendous amounts of energy, interest, time, and money, "concern with weight leads, in many women, to a virtual collapse of selfesteem and sense of effectiveness" (Wooley & Wooley, 1979, p. 69) . College students, particularly females, are considered at high risk for developing eating disorders (Schotte & Stunkard, 1987; Schwartz, Thompson, & Johnson, 1982) . Women in college who believed they were unattractive and needed to lose weight felt a greater overall sense of academic, social, and psychological impairment (Hesse-Biber , ClaytonMatthews, & Downey, 1987) compared to other college women. Since individuals with bulimia nervosa tend to feel ashamed about their binging and purging behavior, onset of symptoms may precede treatment by as long as three to five years (Herzog, Keller, Lavori, & Sacks, 1991) . One study found only a minority of bulimic college women sought professional help for an eating disorder during their first six months on campus (Drewnowski, Yee, & Krahn, 1988) . Therefore, many students with an eating disorder go virtually undetected by university personnel; the potential effects of an increase in eating disorder prevalence is reason for concern (Schwartz, Thompson, & Johnson, *1982) . Early studies addressing eating disorders among college students generally involved surveying students

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10 enrolled in undergraduate courses, such as large psychology (Gray & Ford, 1985; Katzman, Wolchik, & Braver, 1984; Mintz & Betz, 1988; Thelen, Mann, Pruitt, & Smith, 1987) or English classes (Pyle, Mitchell, Eckert, Halvorson, Neuman, & Goff, 1983). However, recent studies have focused on special groups of college students including dietetics majors (Crockett & Littrell, 1985; Drake, 1989), medical students (Futch, Wingard, & Felice, 1988; Herzog, Norman, Rigotti & Pepose, 1986) , and student athletes (Black & Burckes-Miller , 1988; Burckes-Miller & Black, 1988; Evers, 1987; Rosen, McKeag, Hough, & Curley, 1986). Thus, several factors support the need for this study. First, no study has been conducted specifically addressing eating disorders and eating-disordered behavior among undergraduate health education major students in the United States. Second, many undergraduate health education majors are female, increasing their potential risk. Third, studying eating disorder cases in a clinical setting to understand the increasing preoccupation with thinness and increased prevalence among females with eating disorders has not led to understanding the etiology of eating disorders (Feldman, Feldman, & Goodman, 1988) . Fourth, the health education discipline constitutes a subculture which places additional pressure on practitioners to maintain an ideal body weight. Consequently, data regarding the nature and scope of eating disorders and eating-disordered behavior

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11 among this group have important implications for professional preparation and practice in health education as well as comprising a contribution to the growing eatingdisorder literature base. Delimitations 1. Test sites were obtained from a random sample of 25% of institutions in the United States offering a graduate or undergraduate major in health education (28% of institutions offering an undergraduate major in health education) . Institutions were drawn randomly from programs listed in Eta Sicrma Gamma: A National Directory of College and University Health Education Programs and Faculties (1988) . 2. Subjects enrolled in a major course selected by the test site coordinator at each institution were invited to participate in the study. 3. Data were collected during Spring 1992. 4 . The Eating Disorder Inventory and the Eating Habits of Athletes Survey were used to assess self-reported eating disorders and eating-disordered behavior among undergraduate health education majors. Limitations 1 • Eta Sicrma Gamma: A National Directory of College and University Hearth Education Programs and Faculties (1988) does not list all institutions in the United

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12 States that report offering an undergraduate major in health education. 2. The test site coordinator at each institution selected the major course in which data were collected. 3. Data were obtained from subjects present in class on the day of data collection. 4. Findings depended on the ability of the Eating Disorder Inventory and the Eating Habits of Athletes Survey to accurately assess eating disorders and eatingdisordered behavior among subjects. Assumptions 1 • Eta Sigma Gamma: A National Directory of College and University Health Education Programs and Faculties (1988) confirmed the quality of an undergraduate health education program as sufficient to justify inclusion in the study. 2. Courses selected by the test site coordinators adequately represented their group of undergraduate health education majors. 3. Subjects participating in the study adequately represented the population of undergraduate health education majors at the respective institutions. 4. The Eating Disorder Inventqry and the Eating Habits of Athletes Survey were adequate to obtain data necessary for the study.

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13 5. Subject motivation and candor were adequate for the purpose of the study. Null Hypotheses 1. Ho: No statistically significant differences exist between subjects' self-reported current weight, highest past weight, lowest weight as an adult, and ideal weight by sex. Follow-up Tests: a. current weight and ideal weight for females b. current weight and ideal weight for males c. current weight and lowest weight as an adult for females d. current weight and lowest weight as an adult for males e. current weight and highest past weight for females f. current weight and highest past weight for males g . highest past weight and lowest weight as an adult for females h. highest past weight and lowest weight as an adult for males i. highest past weight and ideal weight for females j . highest past weight and ideal weight for males k. ideal weight and lowest weight as an adult for females

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14 1. ideal weight and lowest weight as an adult for males 2. Ho: No statistically significant differences exist in Eating Disorder Inventory subscale scores by a. Sex b. Race c. Year in college d. Current living arrangement e. Marital status f. Health education focus g. Area of professional interest h. Self-reported eating-disordered behavior i. Difference between current weight and highest past weight j . Difference between current weight and ideal weight k. Difference between current weight and lowest weight as an adult Definition of Terms Anorexia (nervosa) diagnosis includes the following: A. Refusal to maintain body weight over a minimal normal weight for age and height, e.g., weight loss leading to maintenance of body weight 15% below that expected; or failure to make expected weight gain during period of growth, leading to body weight 15% below expected. B. Intense fear of gaining weight or becoming fat, even though underweight. C. Disturbance in the way in which one's body weight, size, or shape is experienced, e.g., the person claims to "feel fat" even when emaciated, believes

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15 that one area of the body is "too fat" even when obviously underweight. D. In females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenorrhea) . (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.) (American Psychiatric Association DSM Illr , 1987, p. 67.) Bulimia (nervosa) diagnosis includes the following: A. Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time) . B. A feeling of lack of control over eating behavior during the eating binges. C. The person regularly engages in either self -induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise in order to prevent weight gain. D. A minimum average of two binge eating episodes a week for at least three months. E. Persistent overconcern with body shape and weight. (APA DSM Illr , 1987, pp. 68-69.) Diagnostical and Statistical Manual III Criteria for Anorexia Nervosa includes loss of more than 25% of original body weight; refusal to maintain normal body weight; intense fear of becoming fat; and no known medical illness leading to weight loss (American Psychiatric Association, 1980) . Diagnostical and Statistical Manual III Criteria for Bulimia Nervosa includes recurrent episodes of binge eating, awareness that the eating pattern is abnormal and fear of not being able to stop eating voluntarily, depressed mood following eating binges, bulimic episodes not due to anorexia nervosa or any known physical disorder, and at least three of the following: consumption of high-caloric, easily digested food during a binge, inconspicuous eating

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16 during a binge, termination of binges by abdominal pain, social interruption or self-induced vomiting, repeated attempts to lose weight by severely restrictive diets, selfinduced vomiting or use of laxatives or diuretics, frequent weight fluctuations greater than 10 pounds due to binges and fasts (American Psychiatric Association, 1980) . Proposed diagnostic criteria for anorexia nervosa in Diagnostical and Statistical Manual IV: A. Refusal to maintain body weight over a minimally normal weight for age and height, e.g., weight loss leading to maintenance of body weight 15% below that expected; or failure to make expected weight gain during period of growth, leading to body weight 15% below expected. B. Intense fear of gaining weight or becoming fat, even though underweight. C. Disturbance in the way in which one's body weight, size, or shape is experienced, undue influence of body shape or weight on self-evaluation, or denial of the seriousness of the current low body weight. D. In females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenorrhea) . (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration. ) Bulimic type: During the episode of anorexia nervosa, the person engages in recurrent episodes of binge eating. Nonbulimic type: During the episode of anorexia nervosa, the person does not engage in recurrent episodes of binge eating. (Walsh, 1992, p. 304.) Proposed diagnostic criteria for bulimia nervosa in Diagnostical and Statistical Manual IV: A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both (1) eating, in a disqrete period of time (e.g., within any 2 hour period) an amount of food that is definitely larger than most people would eat in a similar period of time, and, (2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating.)

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17 Criterion B: Options for compensatory behavior Option #1: (Restrict to vomiting or use of laxatives) B. The person regularly engages in either selfinduced vomiting or the use of laxatives in order to prevent weight gain. Option #2: (The addition of purging and nonpurging subtypes) B. The person regularly engages in either selfinduced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise in order to prevent weight gain. C. A minimum average of two binge eating episodes a week for at least 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. This disturbance does not occur exclusively during episodes of anorexia nervosa. Specify type: (applies to Option #2 above) Purging type: If the person regularly engages in selfinduced vomiting or the use of laxatives or diuretics. Nonpurging type: Use of strict dieting, fasting, or vigorous exercise but does not regularly engage in purging. (Walsh, 1992, p. 304.) Proposed diagnostic criteria for binge eating disorder in Diagnostical and Statistical Manual IV: A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both (1) eating, in a discrete period of time (e.g., within any 2 hour period) an amount of food that is definitely larger than most people would eat in a similar period of time, and, (2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating.) B. During most binge episodes, at least three of the following behavioral indicators of loss of control are present: (1) Eating much more rapidly than usual (2) Eating until feeling uncomfortably full (3) Eating large amounts of food when not feeling physically hungry (4) Eating large amounts of food throughout the day with no planned mealtimes (5) Eating alone because of being embarrassed by how much one is eating. (6) Feeling disgusted with oneself, depressed, or feeling very guilty after overeating. C. The binge eating occurs, on average, at least twice a month for a 6 month period. D. The binge eating causes marked distress.

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18 E. Does not occur exclusively during the course of Bulimia Nervosa and the individual does not abuse medication (e.g., diet pills) in an attempt to avoid weight gain. (Walsh, 1992, p. 304.) Area of profession a l interest , for purposes of this study, involves the 11 subject areas of aging/death and dying, alcohol/drug education, cancer/cardiovascular disease, environmental health, exercise and fitness, mental health/health counseling, nutrition education, sexuality, stress management, weight control/management, or wellness. Eating-disorde red behavior involves symptoms of eating disorders such as fasting, fad dieting, binge eating, purging behaviors (including self— induced vomiting, laxative abuse, excessive exercise, etc.), and extreme fear of gaining weight (Striegel-Moore , Silberstein, Frensch, and Rodin, 1989; Zuckerman, Colby, Ware, and Lazerson, 1986). E ta Sigma Gamma Directory: A National Directory of College a nd Un iversity Health Education Programs and Faculties (1988) provides a listing of health education programs and faculty offering at least an undergraduate major specifically in health education. Faculty members must hold a minimum of a half-time appointment to be listed. The 1988 edition, the most current available at the time of data collection, listed 161 institutions deemed appropriate for inclusion in the directory. Health education focus refers to six potential "majors" or " potential worksites where the student desires to specialize: public health, patient education, safety

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19 education, school/college health, worksite health promotion, or community health. Russell's criteria for bulimia include powerful urges to overeat, avoidance of the "fattening" effects of food by self -induced vomiting, abusing laxatives, or both, and a morbid fear of becoming fat (Russell, 1979) . Test site coordinator is the faculty member who coordinates all on-site activities at their institution, including test administration and collection. Undergraduate health education manors are students identifying themselves as health education majors attending an institution surveyed.

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CHAPTER 2 REVIEW OF LITERATURE Introduction Chapter 2 reviews literature focusing on eating disorders and eating-disordered behavior among college students. The chapter includes the following sections: (1) Sex Role Development and Sociocultural Factors Related to Eating Disorders, (2) Adults, (3) Children and Adolescents, (4) College Students, (5) College Students in Preprofessional Programs, and (6) Summary. Sex Role Development and Sociocultural Factors Related to Eating Disorders Nearly all societies provide different roles and expectations for males and females (Greenberg, Bruess, & Sands, 1986). Children must first understand they are boys or girls and integrate this knowledge into their selfconcept to conform to these expectations (Shaffer, 1985) . Kohlberg's (1966) cognitive-developmental theory of sex role development proposed basic gender identity (recognizing he or she is male or female) precedes attention to same sex models. The gender schema theory (Bern, 1981) suggested that children learn to incorporate information in gender related terms about themselves and others through a developing 20

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21 gender schema. Gender is used as a cognitive organizing principle (or schema) , since it is a prominent or salient characteristic (Matlin, 1987) . Among health education professionals, the social learning theory (Bandura, 1977) , renamed social cognitive theory (Bandura, 1986) , is presently viewed as a formally developed theory (Glanz, Lewis, & Rimer, 1990) . Social cognitive theory proposes that behavior is determined by expectancies about environmental cues, consequences of one's actions, and one's competence to perform the behavior. Behavior is also regulated by reinforcement or incentives, as they are interpreted by the individual (Bandura, 1986) . In addition, Bandura (1986) suggested that observational learning, or modeling, is one of the most effective ways to transmit not only values and attitudes, but also behavior and thought patterns. Social learning theory proponent Albert Bandura (1977) suggested that sex role development is acquired through direct tuition (the tendency of parents, teachers, and other social agents to reinforce sexappropriate responses and to punish behaviors considered more appropriate for the other sex) and modeling or observational learning. Silverstein, Perdue, Peterson, Vogel, and Fantini (1986) suggested that an important cause of eating disorders among women is the association between (1) curvaceousness and femininity and (2) femininity and incompetence. Wooley

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22 and Wooley (1986) suggested that bulimia nervosa arises from an intense thinness obsession, central to some women's identity. Dickstein (1989) suggested that sociocultural pressures stemming from women's sex role socialization may also precipitate the development of bulimia nervosa in vulnerable females. Two cultural events impacting women significantly within the last 25 years included (1) destabilization of sex role norms and (2) drive for thinness (Johnson, Tobin, & Steinberg, 1989). These sociocultural influences make anorexia nervosa, bulimia nervosa, and eating— disordered behavior adaptive responses to the developmental demands of growing up female in certain populations at this time in history (Steiner-Adair , 1986) . Levine (1987) proposed that the meaning of femininity in modern Western society has something to do with the development of anorexia nervosa and bulimia nervosa, since 95% of persons with eating disorders are women. Wooley and Wooley (1986) suggested that, for the American woman of today, thinness has become symbolic not only of attractiveness, but of independence, strength, and achievement . The importance of an attractive appearance is a constant message for females (Matlin, 1987) ; children growing up today experience powerful media messages regarding appearance (Collins, 1991b) . Children of all body

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23 sizes and both sexes adopt the current negative stereotypes associated with fatness; females are more affected by this prejudicial environment than are males (Wooley, Wooley, & Dyrenforth, 1979) . In a study of female adolescents, subjects who thought they had attractive bodies had the most positive selfconcepts (Lerner, Orlos, & Knapp, 1976). In addition, adolescent women seemed to be more concerned with others' views of them (Matlin, 1987) and people generally weigh physical appearance more heavily when they are evaluating women than when they are evaluating men (Bar-Tal & Saxe, 1976) . Women receive gender specific messages from the media; they must stay in shape and be thin, while at the same time they must think about food and cooking (Silverstein, Perdue, Peterson, & Kelly, 1986). Levine (1987) indicated that magazines provide a display of thin models, articles about exercise and dieting, recipes for sweet foods, and numerous photographs of delicious food in binge amounts. Advertisers for diet programs and products promise thinness (Johnson, Tobin, & Steinberg, 1989) . A 1984 survey of Glamour magazine readers indicated that 45% of underweight women felt they were too fat; more women (42%) reported that losing weight would make them the happiest when presented with other options including success at work, a date with a

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24 man she admired, or hearing from an old friend (Wooley & Wooley, 1984) . For the past 20 years, an attractive appearance has been equated with thinness, particularly for females (Freedman, 1984; Johnson, Tobin, & Steinberg, 1989) . Garner, Garfinkel, Schwartz, and Thompson (1980) compiled measurements of two examples of culturally "ideal" females (Playboy centerfolds and Miss America contestants) over a 20 year period. The mean weight of both groups was significantly less than the mean weight of the general population. The popular actresses provided as role models for what an attractive woman should look like have become thinner in the recent past (Silverstein, Perdue, Peterson, & Kelly, (1986). These results relate to Bandura's (1977) vicarious reinforcement concept, suggesting that the observation of behavior succeeding for others increases the tendency to behave in similar ways. Since 1970, Miss America winners have weighed significantly less than have losing contestants (Garner, Garfinkel, Schwartz, & Thompson, 1980) , transmitting the message that being thin is rewarded. Recently, (using data from 1979 to 1988) Wiseman, Gray, Mosimann, and Ahrens (1992) reported that 69% of Playboy centerfolds and 60% of Miss America contestants weigh 15% or more below the expected weight tor their height and age, one major criterion for anorexia nervosa diagnosis (American Psychiatric Association, 1987) . Since American women today

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25 are under pressure to be unrealistically thin, some women may respond to this extreme pressure toward slimness by becoming dissatisfied with their bodies, sometimes resulting in anorexia nervosa or bulimia nervosa (Silver stein, Perdue, Peterson, & Kelly, 1986) . Ironically, this relentless pursuit of thinness is occurring at a time when population averages for weight have increased, largely resulting from better nutrition (Johnson, Tobin, & Steinberg, 1989) . The mass media may play an important role in reinforcing the pressure to be thin (Silverstein, Perdue, Peterson, & Kelly, 1986) . Television may promote unrealistic conclusions regarding eating and body weight because of the low freguency of obesity among televised characters and the frequent food related references in programming and commercials (Dietz, 1990). Boston Globe columnist Ellen Goodman recently summarized the contents of a popular women's magazine by writing "we find dozens of skinny role-models, a cover story on weight warnings, and one requisite page about dieting, eating disorders, and self-esteem. It sits as self-consciously and uselessly as the warning on a cigarette pack" (Goodman, 1993, p. 8A) . Media messages have the potential to influence personal attitudes, beliefs, and behaviors; television shows thinness being equated with the "good life" (Feldman, Feldman, & Goodman, 1988, p. 193).

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26 Silverstein, Perdue, Peterson, and Kelly (1986) concluded that female television characters were more likely to be slim and less likely to be fat than male television characters. Magazines, movies, and television consistently present unrealistically thin role models for women (Willmuth, 1986) . In addition, a content analysis of women's and men's magazines provided strong support for the hypothesis that women receive more messages to be slim and to stay in shape than do men (Silverstein, Perdue, Peterson, & Kelly, 1986) . Garner, Garfinkel, Schwartz, and Thompson (1980) said that "this shrinking ideal may exert intense pressure on some women to diet in spite of possible adverse physical and emotional consequences" (p. 490) . Nasser (1988) indicated that increased emphasis on thinness is probably related to the increase in eating disorders over the past 20 years. Other researchers indicated that the thinness ideal and use of drastic weight control methods to achieve the ideal body shape are the most obvious factors in the increase of anorexia nervosa and bulimia nervosa since the 1960s (Gordon, 1989) . The current standard of thinness for females portrayed in magazines may have played a role in producing the recent outbreak of eating disorders among women (Silverstein, Perdue, Peterson, & Kelly, 1986) . Since the current standard of living in Western culture is higher for all classes and body fat is no longer a sign

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27 of wealth or power (Levine, 1987), "excess body fat is probably the most stigmatized physical feature, except skin color, but unlike color is thought to be under voluntary control" (Wooley & Wooley, 1979, p. 69). Many women are so fearful of being fat, they are driven to diet, regardless of their present body size and despite the fact that dieting does not work (Willmuth, 1986) . In addition, the current ideal female body (tall, narrow-hipped, thin thighs) is biogenetically difficult for most women to achieve (Johnson, Tobin, & Steinberg, 1989) . Sex differences in figure perceptions exist among college students. When asking college students to make selections of current and ideal figures, Fallon and Rozin (1985) found the difference between current and ideal figures for males to be statistically insignificant; females selected ideal figures smaller than their current figure at a statistically significant level. Another study focusing on college students and their parents produced similar results and found that sex seemed to predict attitudes regarding weight concern better than did generation (Rozin & Fallon, 1988). Ford, Dolan, and Evans (1990) found similar results among a sample of Arab students attending an English-speaking university, suggesting an effect of exposure to Western influences. Furnham & Hume-Wright (1992) summarized the sociocultural theory of eating disorders by writing.

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28 the ordinary woman, it is argued, is faced with a widening discrepancy between her actual weight and the weight that she has been persuaded to believe is attractive. Anorexia nervosa is particularly prevalent among women who are in professions that place an emphasis on physical beauty and thin appearance: opportunities for employment for models depend on their maintaining a low body weight; dancers too are under considerable pressure to be slight. However, the media select thin models to portray sophistication and glamour to the general female population as well, to the extent that ordinary women are so bombarded with an unrealistic standard to thinness that they are indoctrinated into believing it is desirable as an end in itself. (p. 23) Although it is difficult to establish the influence of culture on psychopathology, Levine (1987) suggested that little doubt exists that sociocultural factors are encouraging the development of eating disorders. The degree of disordered eating among a sample of college females may be correlated with an increased tendency to endorse sociocultural beliefs regarding the desirability of female thinness (Mintz & Betz, 1988). Rucker and Cash (1992) suggested that African American college females may have a lower predisposition for the development of anorexia nervosa or bulimia nervosa, since they generally experience less internalization of the thin standard of beauty. Ferrero and Rouget (1991) indicated that one explanation for gender differences in eating disorders and eating-disordered behavior lies in females having a lower threshold of weight satisfaction than males have. Females attempt to lose weight sooner than do males, who tend to gain weight

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29 gradually, reach a high level of dissatisfaction with their weight, and begin dieting. Consequently, many individuals are concerned about their weight, particularly female adolescents. Moss, Jennings, McFarland, and Carter (1984) found that, of a group of adolescent females, 43.1% reported being terrified of being overweight, 39.1% were preoccupied with a desire to be thinner, and 35.3% were preoccupied with the thought of having fat on their bodies. Since half of a group of underweight female adolescents reported extreme anxiety about being overweight, Moses, Banilivy, and Lifshitz (1989) suggested that distorted perceptions of ideal body weight may be a contributor to a thin body weight and eatingdisordered behavior. Sociocultural emphasis on thinness may be linked to the increase in eating-disordered behavior in women (Moss, Jennings, McFarland, & Carter, 1984) . These generalized concerns about food and weight have been cited as eating-disorder risk factors among adolescents (Patton, 1988) . The dieting behavior necessary to attain the female ideal has been suggested as a precursor to eating-disordered behavior (Patton, 1988). O'Connell, Price, Roberts, Jurs, and McKinley (1985) found that the most powerful predictor of dieting behavior among nonobese adolescents was susceptibility to the causes of obesity. Half of female college athletes engaging in eating-disordered behavior

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30 perceived a personal history of obesity (Rosen, McKeag, Hough, & Curley, 1986). Chronic dieting during adolescence is thought to slow metabolic rate, resulting in weight gain under normal caloric intake, contributing to lifelong weight control problems (Freedman, 1984) . Binge eating (Crandall, 1988) and eating-disordered behavior (Gordon, 1989) are commonly learned through information and modeling. Gordon (1989) goes a step further, suggesting that bulimia nervosa is frequently learned through the process of modeling. College friends and media influence were cited as influences in learning eating-disordered behavior (Dickstein, 1989) . Since Bandura (1977) suggested that rewarded modeling increases the tendency to engage in similar behavior patterns more than does modeling alone, it may be likely that persons who observe rewarded eating-disordered behavior help initiate these behaviors. Currently, no one theory dominates the discipline of health education (Glanz, Lewis, & Rimer, 1990). Using the most appropriate theory for a given situation is accepted practice, since the complex nature of health behavior cannot be explained by any one theory (Glanz, Lewis & Rimer, 1990). The Health Belief Model, developed to explain why people do or do not use health services (Hochbaum, 1958; Rosenstock, 1966) is considered by some the most influential and popular model for explaining health-related behavior

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31 (Rosenstock, 1990) . Components of the Health Belief Model include Threat (perceived susceptibility and severity of a health condition) , Outcome Expectations (perceived benefits of and barriers to engaging in a health behavior) , and SelfEfficacy (Bandura, 1977) , the belief that a person can successfully perform behavior necessary to produce desired outcomes (Rosenstock, 1990) . Self-efficacy was added to the Health Belief Model in 1988 (Rosenstock, Strecher, & Becker, 1988) . Using the Health Belief Model as a basis for their study, Hayes and Ross (1987) studied a representative sample of 400 Illinois adults regarding their eating habits. For the average person, appearance concerns had a somewhat stronger effect on eating habits than did health concerns. Hayes and Ross (1987) suggested appearance as a motivating factor in eating disorders, since people try to maintain extreme thinness at high risk to health. Women were more likely than men to diet for cosmetic rather than health reasons (Johnson, Tobin, & Steinberg, 1989) . Adults Several researchers have examined eating disorders and eating-disordered behavior among groups other than college students. Eating disorder prevalence rates were variable among the young women comprising the majority of subjects. In addition to the U.S., studies have been conducted in

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32 Sweden (Cullberg & Engstrom-Lindberg, 1988) , New Zealand (Bushnell, Wells, Hornblow, Oakley-Browne, & Joyce, 1990) , Australia (Ben-Tovim, 1988), and Great Britain (Cooper & Fairburn, 1983; King, 1989; Meadows, Palmer, Newball, & Kenrick, 1986) . Subjects studied in U.S. general population studies using Diagnostical and Statistical Manual III criteria included female shoppers (Pope, Hudson, & Yurgelun-Todd, 1984) , women employed by a large banking institution compared with female college students (Hart & Ollendick, 1985) , respondents to an invitation in Glamour magazine for women with bulimic problems (Yager, Landsverk, & Edelstein, 1987) , women at Massachusetts bingo tournaments (Pope, Champoux, & Hudson, 1987) , and a probability sample of adult residents in Alachua County, Florida (Rand & Kuldau, 1992) . These studies yielded anorexia nervosa prevalence rates ranging from 0.7% (Pope, Hudson, & Yurgelun-Todd, 1984) to 0.5% for upper socioeconomic class subjects and 1.5% for low socioeconomic class subjects (Pope, Champoux, & Hudson, 1987) . Reported bulimia nervosa prevalence rates were higher and more variable than anorexia nervosa rates. Pope, Champoux, and Hudson (1987) reported bulimia nervosa prevalence rates at 17.3% for low socioeconomic subjects and 13.4% for upper socioeconomic subjects. Pope, Hudson, and Yurgelun-Todd (1984) indicated 10.3% of female shoppers were

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33 bulimic. In contrast. Hart and Ollendick (1985) reported five percent of university women and one percent of working women as bulimic. In a random sample of adults residing in a Florida county, bulimia nervosa prevalence was estimated at 1.1% for adults ages 18 to 96, and 4.1% among women ages 18 to 30 (Rand & Kuldau, 1992). As expected, Rand and Kuldau (1992) reported eating-disordered behavior was more common among women than men, and younger than older respondents. However, no racial differences were found among bulimia nervosa prevalence rates and eight of the 23 bulimia nervosa cases existed in adults over age 45. Persons attending medical facilities in countries outside the U.S. have comprised other subject pools. Cooper and Fairburn (1983) provided one of the initial studies of of non-student adult women, by surveying English family planning clinic patients regarding eating-disordered behavior. Results indicated nearly 21% reported current binge eating episodes, nearly 3% reported self-induced vomiting, and nearly 5% reported currently using laxatives for weight control. The mean age of this sample was about 24 years, fairly close to the age of most college students. Young women, ages 18-22, registered by two general medical , : 4 group practices in Great Britain, were surveyed by Meadows, Palmer, Newball, and Kenrick (1986). Of the 411 subjects, only one case of anorexia nervosa and one case of bulimia

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34 nervosa existed. King (1989) studied male and female patients in four medical practices located in Great Britain and found only 1.1% of the 534 women surveyed had bulimia nervosa and no cases of anorexia nervosa were reported. Ben-Tovim (1988) studied Australian female shoppers, female patients attending a family practice group, and high school students. Bulimia nervosa prevalence among females using Diagnostical and Statistical Manual III criteria was 12.7%. Cullberg and Engstrom-Lindberg (1988) explored beyond a primary care medical setting to ask Swedish general and child psychiatric, social, and primary care personnel for patient information. For the 78,000 suburban population, they calculated a two year prevalence of 66/100,000 (22 cases of anorexia nervosa and 44 cases of bulimia nervosa) . Using nationwide psychiatric admission records from 19731987, Nielsen (1990) reported a yearly anorexia nervosa prevalence of 6.7 per 100,000 women and 0.6 per 100,000 men. New Zealand researchers, Bushnell, Wells, Hornblow, Oakley-Browne, and Joyce (1990) , determined bulimia nervosa prevalence from a cross-sectional population survey of nearly 1,500 adults. Using Diagnostical and Statistical Manual III criteria, one percent of adults ages 18-64 could expect to have bulimia nervosa in their life time, and most cases were younger women.

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35 Glamour magazine readers (almost exclusively female) reported "sometimes" using the following weight control methods: crash dieting (40%), exercise (38%), diet pills (38%), diuretics (14%), fasting/starving (34%), or selfinduced vomiting (10%) (Wooley & Wooley, 1984). Wooley and Wooley (1984) also indicated significant numbers of Glamour magazine readers used those same weight control methods "often": crash dieting (18%), exercise (57%), diet pills (12%), diuretics (4%), fasting (11%), and self-induced vomiting (5%) . Children and Adolescents Since childhood and adolescent experiences may impact the development of an eating disorder, it is critical to examine these to provide context for the college experience. While several studies focused specifically on adolescents and eating disorders, Collins (1991a) studied body figure preferences among 1118 preadolescent children. When comparing the discrepancy between Ideal Self and Current Self, "subjects varied only by gender with females preferring statistically thinner figures than males" (Collins, 1991a, p. 204). Based on these results, Collins (1991a) suggested attitudes regarding thinness, particularly among females, may be present at, six or seven years of age. Wardle and Marsland -( 1990) arrived at similar conclusions, following their study of 846 London school children ages 11 to 18. In addition to wanting to lose more weight than

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36 boys, girls were less satisfied with their bodies. Both generalized weight concern (Wardle & Marsland, 1990) and eating-disordered behavior (Myers & Burket, 1989) may already be well established in females by the early teenage years. Marchi and Cohen (1990) longitudinally studied problem eating behaviors among a large sample of children over a ten year interval and found "by late childhood and adolescence, girls were much more concerned about weight reduction than boys." In addition, Marchi and Cohen (1990) found eatingdisordered behavior was more frequently found in girls than boys, and was seen by some researchers (Abraham, Mira, Beumont, Sowerbutts, & Llewellyn-Jones , 1983) as a normal developmental phase for young females. Suggested risk factors for anorexia nervosa include childhood digestive problems and picky eating, while risk factors for bulimia nervosa include reducing efforts and development of food fads (Marchi & Cohen, 1990) . Adolescent Females Since eating disorders and eating-disordered behavior are more common in girls than boys (Marchi & Cohen, 1990) , adolescent females comprised frequent subject pools for researchers studying eating disorders. Such studies generally focused orf bulimia nervosa and eating-disordered behavior, but one early study of 151 adolescent females reported nearly 12% were considered anorexic according to

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37 their responses to the Eating Attitudes Test (Moss, Jennings, McFarland, & Carter, 1984). Using Diagnostical and Statistical Manual III criteria for bulimia nervosa, reported bulimia nervosa prevalence rates ranged from 5% (Johnson, Lewis, Love, Lewis, & Stuckey, 1984), to 6-7% (Moss, Jennings, McFarland, & Carter, 1984), to 7.7% (Crowther, Post, & Zaynor, 1985). VanThorre and Vogel (1985) reported adolescent females classified as "probably bulimic" ranged from 20.1.% to 12.5% for four age groups. Out of 72 adolescent females, 59 subjects were classified as normal, nine as dieters, eight as suspected bulimics, and one as bulimic based on Eating Disorder Inventory scores and a clinical interview using Diagnostical and Statistical Manual III criteria (Williams, Schaefer, Shisslak, Gronwaldt, & Comerci, 1986) . Using Russell's bulimia nervosa diagnostic criteria (Russell, 1979), Dacey, Nelson, and Aikman (1990) reported a prevalence rate of 5.7% for female adolescents. Myers and Burket (1989) studied the prevalence of eating disorders among female juvenile delinquents to be 7.5% for bulimia nervosa, 2.5% for bulimia nervosa and anorexia nervosa, and 12% meeting some, but not all of the Diagnostical and Statistical Manual Ill-Revised criteria for bulimia nervosa . '* or anorexia nervosa. Choudry and Mumford (1992) and Mumford, Whitehouse, and Choudry (1992) studied eating disorders among samples of 271

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38 and 369 Pakistani school girls and reported only one case of bulimia nervosa in each sample, using Diagnostical and Statistical Manual III Revised criteria. Although cultural influences may not be a necessary condition for eating disorder development, Western influence may be associated with increased concerns about food intake and weight and may increase risk for eating disorder development (Mumford, Whitehouse, & Choudry, 1992) . In addition to eating disorders, studies also reported greater numbers of adolescent females engage in eatingdisordered behavior. Hendren, Barber, and Sigafoos (1986) found 18% of female adolescents reported engaging in one or more eating-disordered behavior including thinking about food and weight "all of the time", using laxatives, selfinduced vomiting, or using fasting or starving as a form of weight control. Binge eating appeared to be the most common eating-disordered behavior, with self-reported sample percentages ranging from 46% (another 4.4% engaging in "problematic" binge eating) (Crowther, Post, & Zaynor, 1985) , 22% (Williams, Schaefer, Shisslak, Gronwaldt, & Comerci, 1986) to 16.6% (Moss, Jennings, McFarland, & Carter, 1984) . As an eating-disordered behavior, 36.4% of adolescent females self-reported using fasting as a form of weight control (Crowther, Post, & Zaynor, 1985), while Williams, Schaefer, Shisslak, Gronwaldt, and Comerci (1986) found 25%

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39 of their sample of adolescent females were currently dieting and 60% reported regularly skipping meals in an attempt to lose weight. Self-induced vomiting occurred less frequently than binge eating, fasting, dieting, or meal skipping. Selfreported prevalence rates ranged from 11.2% (Crowther, Post, & Zaynor, 1985) to 9% (Carter & Duncan, 1984) to 6.6% (Moss, Jennings, McFarland, & Carter 1984). Laxative abuse was relatively rare, with one study reporting a 4.7% prevalence (Crowther, Post & Zaynor, 1985) . Only 4% reported using drugs to lose weight (Williams, Schaefer, Shisslak, Gronwaldt, & Comerci, 1986) . Underweight and normal weight girls reported a distorted perception of their ideal body weight for height more often than did the overweight girls, with half of the underweight adolescents reporting extreme anxiety about being over weight (Moses, Banilivy, & Lifshitz, 1989). Disordered eating prevalence is greater among young women under pressure to maintain a low body weight (Abraham, Mira, Beumont, Sowerbutts, & Llewellyn-Jones , 1983) and these distorted perceptions of ideal body weight may be an important contributor to their actual, thin body weight and to inappropriate eating attitudes and behaviors (Moses, Banilivy, & Lifshitz, 1989) .

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40 Adolescent Females and Males When comparing male and female adolescents, males as a group generally indicated lower self-reported prevalence rates of bulimia nervosa than females. Gross and Rosen (1988) studied bulimia nervosa in 1,373 high school boys and girls. Using Diagnostical and Statistical Manual III criteria, 9.6% of adolescent girls and 1.2% of adolescent boys were considered bulimic. Much lower prevalence rates were reported by Whitaker, Davies, Shaffer, Johnson, Abrams, Walsh, and Kalikow (1989), who found prevalence rates of anorexia nervosa and bulimia nervosa less than 1% for both males and females using Diagnostical and Statistical Manual III criteria. When Diagnostical and Statistical Manual III Revised criteria was employed in a study of high school students, bulimia nervosa prevalence was only 2% for girls and 0.1% for boys (Timmerman, Wells, & Chen, 1989). Though most adolescents self-reported adequate nutritional intake, girls indicated a high prevalence of dieting and consumption of low calorie foods (Leon, Perry, Mangelsdorf , & Tell, 1989) . Of a sample of 504 high school students, approximately one-fourth of females and only 2.4% of males indicated they were currently dieting. Nearly three-fourths (73.4%) of girls indicated they had tried to lose weight before, compared to only 18.9% of the boys (Leon, Perry, Mangelsdorf & Tell, 1989) . In contrast to boys, girls were more likely to engage in eating-disordered

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41 behavior (Whitaker, Davies, Shaffer, Johnson, Abrams, Walsh, & Kalikow, 1989) , were more concerned about their weight, and were more likely to want to lose weight (Snow & Harris, 1989) . Eating disorders and eating-disordered behavior affects not only Caucasian, high socioeconomic adolescents. VanThorre and Vogel (1985) found the distribution of adolescent females diagnosed as "probably bulimic" was proportionate across racial groups (African Americans, Caucasians, and Others) . With a nearly equal number of African American and Caucasian female juvenile delinquents, 7 . 5% were bulimic according to Diagnostical and Statistical Manual III Criteria (Myers & Burket, 1989) . Balentine, Stitt, Bonner, and Clark (1991) reported that of 2,000 African American low-income adolescents, 12% thought they might have an eating disorder. Eleven percent of low income Pueblo Indian and Hispanic female adolescents met Diagnostical and Statistical Manual III criteria for bulimia nervosa, suggesting eating disorders and concern about obesity affects a variety of ethnic and socioeconomic groups in the United States (Snow & Harris, 1989) . College Students General 4 The college campus environment may support unhealthy norms and behaviors contributing to the development of eating disorders (Hotelling, 1989) . College females with

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42 personality characteristics described as common to persons with eating disorders, appeared vulnerable to using eatingdisordered behavior to meet their culturally based and personally controlled criteria for their appearance (Dickstein, 1989) . Johnson, Tobin, and Steinberg (1989) indicated college and university professionals can expect to encounter a large, diverse group of young females engaging in eating-disordered behavior. Bulimia nervosa prevalence using Diagnostical and Statistical Manual III criteria is more frequently reported in the professional literature than anorexia nervosa. However, Pope, Hudson, Yurgelun-Todd, and Hudson, (1984) found 1.0% to 4.2% of female college and secondary school students reported a history of anorexia nervosa, while 6.5% to 18.6% had a history of bulimia nervosa; using a similar sample, Howatt and Saxton, (1988) determined a bulimia nervosa prevalence of 6.73%. Among college females, the highest reported bulimia nervosa prevalence rate for a female college student population was 19% (Halmi, Falk, & Schwartz, 1981), followed by 13% (Gray & Ford, 1985). Nevo (1985) reported a 4.6% to 11% range in bulimia nervosa prevalence in different groups of college females. Tamburrino, Franco, Bernal, Carrol, and McSweeny (1987) reported 15.3% of college women had Eating Attitudes Test scores high enough to be considered at risk for developing an eating disorder.

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43 Pyle, Halvorson, Neuman, and Mitchell (1986) indicated the incidence of bulimia nervosa among college females increased from 1.0% in 1980 to 3.2% in 1983. Using a random sample of college freshman and seniors, Zuckerman, Colby, Ware, and Lazerson (1986) determined 5% of the women were bulimic. Similar prevalence rates of 4.5% (Pyle, Mitchell, Eckert, Halvorson, Neuman, & Goff, 1983), 4% (Katzman, Wolchik, & Braver, 1984), 3.8% (Striegel-Moore, Silberstein, Frensch, & Rodin, 1989), and a range of 2.0% to 3.8% (Thelen, Mann, Pruitt, & Smith, 1987) were reported. Reported bulimia nervosa prevalence was much lower in college males than females. Halmi, Falk, and Schwartz (1981) reported the highest prevalence of 5%; Gray and Ford (1985) indicated a similar prevalence of 4.2%. Nearly 3% (2.8%) of male college students had an Eating Attitudes Test score high enough to put them at risk for developing an eating disorder (Tamburrino, Franco, Bernal, Carrol, & McSweeny , 1987). However, Collier, Stallings, Wolman, and Cullen (1990) found a higher percentage of bulimic tendencies (2.2%) among the males in their sample. Several studies cited the prevalence of bulimia nervosa under one percent for college males. These prevalence rates ranged from 0.7% (Zuckerman, Colby, Ware, & Lazerson, 1986), to 0.4% (Pyle, Mitchell, Eckert, Halvorson, Neuman, & Goff, 1983), to 0.2% (Howatt & Saxton, 1988; Striegel-Moore, Silberstein, Frensch & Rodin, 1989) .

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44 Compared to Diagnostical and Statistical Manual III criteria, the criteria for anorexia nervosa and bulimia nervosa is more stringent using the Diagnostical and Statistical Manual Ill-Revised criteria. Consequently, reported prevalence rates using the Diagnostical and Statistical Manual Ill-Revised criteria were generally lower. Drewnowski, Yee, and Krahn (1988) in completing a longitudinal survey of female college freshman, determined the incidence of bulimia nervosa to be 2.9% in the fall and 3.3% in the spring. Schotte and Stunkard (1987) reported 1.3% of college females and 0.1% of college males at a single university were bulimic; Drewnowski, Hopkins, and Kessler (1988) indicated similar results with a national probability sample of male and female college students from 53 universities (1% of women and 0.2% of men). Prevalence of anorexia nervosa for college females was 0.04%, 5.4% for bulimia nervosa; bulimia nervosa prevalence for college males was 0.2% (Collier, Stallings, Wolman, & Cullen, 1990) Of nearly 2,000 college freshman, only 2.2% of females and 0.3% of males were currently bulimic, and no males and 0.1% of females were currently anorexic (Pyle, Neuman, Halvorson & Mitchell, 1991). Mintz and Betz (1988) studied a sample of 682 * ^ undergraduate women enrolled in an introductory psychology course. Only 1% were anorexic, 3% were bulimic, and 61% engaged in some form of eating-disordered behavior and were

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45 classified as chronic dieters, bingers, purgers, or subclinical bulimics. Only one-third were considered normal eaters . Some groups may be at increased risk for developing an eating disorder. Undergraduate women living in group housing on campus were considered at highest risk for bulimia nervosa (Drewnowski, Hopkins, & Kessler, 1988) . Collier, Stallings, Wolman, and Cullen (1990) found bulimic tendencies were most frequent in freshmen as a group, and among students in the school of education, followed by students in the College of Arts and Sciences. Only a minority of bulimics seek professional help (Drewnowski, Yee, & Krahn, 1988) , with one study reporting that only two out of five bulimics sought professional treatment (Drewnowski, Hopkins, & Kessler, 1988) . Studies of college students outside the United States produced conflicting results. Whitehouse and Button (1988) studied eating disorder prevalence among college women in the United Kingdom, and re-examined data from a 1981 study and concluded their findings were not consistent with the apparent increase in eating disorder prevalence in the United States. However, Healy, Conroy, and Walsh (1985) surveyed Irish college students using Diagnostical and Statistical Manual III criteria and determined 1.1% of the males and 10.8% of the females were bulimic. Bulimia nervosa prevalence, not based upon strict Diagnostical and

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46 Statistical Manual III Revised criteria among Swiss college students was estimated to be 4% for females and 0.7% for males (Ferrero & Rouget, 1991) , comparable with reported prevalence rates among U.S. college students. Greene, Achterberg, Crumbaugh, and Soper (1990) studied bulimic (recruited through advertising) and nonbulimic (students in an introductory nutrition course) college females using the Eating Disorder Inventory. Bulimics had lower weight goals and a greater difference between current weight and goal weight than nonbulimic women. Students engaging in eating-disordered behavior were more likely to be overweight compared to the rest of the sample (Halmi, Falk, & Schwartz, 1981). Significantly more women than men reported "ever being on a weight loss diet" prior to college, a history of binge eating, and using purging to control their weight. A significant number of subjects experienced an increase in disordered eating their first year in college and onefourth put themselves on a diet for the first time that year (Striegel-Moore, Silberstein, Frensch, & Rodin, 1989) . Dieting behavior was highest among freshmen women, with 21% of women and 8% of men reporting being on a diet at some time (Drewnowski, Hopkins, & Kessler, 1988) . However, Zuckerman, Colby, Ware, and Lazerson (1986) indicated that while half of the women and 13% of the men thought they were overweight, only 10% of the women and 11% of the men were

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47 actually overweight. Nevo (1985) indicated 50% of college females reported trying to lose weight at least once a month and more than half (60%) worry a great deal about their weight. The perception of being overweight may contribute to eating-disordered behavior among college students. Of college freshman and seniors, Zuckerman, Colby, Ware, and Lazerson (1986) found 23% of women and 9% of men reported using one of four methods of weight control: fasting, diuretics, laxatives, or self-induced vomiting. Purging behavior was reported by 11% of a college female sample (Nevo, 1985) . Eating-disordered behavior is thought to peak among students in grades 11 to 13 , with those involved in physical education, athletics, gymnastics, journalism, art, and allied health (including dietetics majors) at highest risk (Howat & Saxton, 1988) . The reported incidence of binge eating ranged from 61% (Gray & Ford, 1985), to 49% (Katzman, Wolchik, & Braver, 1984) for college males and females. Of college females, forty percent reported binge eating once a month (Nevo, 1985) , while 10% binge ate at least once a week (Drewnowski, Yee, & Krahn, 1988). Zuckerman, Colby, Ware, and Lazerson, (1986) indicated 23% of women and 14% of men engaged in binge eating episodes. Clearly,* an epidemic of selfreported overeating with or without purging exists among the

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48 college population, particularly among females (Schotte & Stunkard, 1987) . African Americans Comparing African American and Caucasian college females, White, Hudson, and Campbell (1985) reported though African American women were heavier, they were more positive regarding body image and current weight than Caucasian women. African American women with a negative attitude toward their weight were more likely to engage in purging behavior. White, Hudson, and Campbell (1985) suggested obesity may be the best predictor of bulimia nervosa among African American college women. Gray, Ford, and Kelly (1987) studied the prevalence of bulimia nervosa and attitudes toward food and weight in an African American college population. Only 3% of African American women met the Diagnostical and Statistical Manual III bulimia nervosa criteria, compared with 13% in a similar Caucasian population. Binge eating (71%) and restrictive dieting (51%) were frequent among this group of African American females. However, African American college women were less likely to experience a sense of fear and discouragement regarding food and weight control than Caucasian women. Bulimia nervosa prevalence among African American and Caucasian males was virtually nonexistent. In general, Gray, Ford, and Kelly (1987) reported immediate families of African American college students

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49 placed significantly less emphasis on food and weight control than Caucasians. Caucasian females considered themselves overweight and believed they possessed a body type which easily puts on weight more frequently than African American females. When African American females did binge, the binge was less likely to cause depression. African American females experienced less fear of weight gain and were less likely to believe a gain of five pounds would make a significant difference in their attractiveness (Gray, Ford, & Kelly, 1987). Rucker and Cash (1992) found African American college females displayed less concern about dieting and fatness than Caucasian college females. However, no difference existed between African American and Caucasian females in the prevalence of believing themselves a failure at dieting. The researchers suggested with less emphasis on thinness, fewer African American women felt compelled to use eating-disordered behavior to achieve thinness; however, some weight preoccupation exists (Gray, Ford, & Kelly, 1987). Student Athletes Conflicting results exist in reported eating disorder prevalence among college student athletes. Kurtzman, Yager, Landsverk, Wiesmier, and Bodurka < (1989) surveyed several student groups using the Eating Disorder Inventory and determined female student athletes had the lowest rates of se lf “reported eating-disordered behavior. Other researchers

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50 reported female student athletes engaged in life threatening eating-disordered behavior that may adversely affect athletic performance (Rosen, McKeag, Hough, & Curley, 1986) and college student athletes seemed more likely to engage in eating-disordered behavior than other college students (Black & Burckes-Miller , 1988) . Burckes-Miller and Black (1988) found eating-disordered behavior and attitudes were not gender specific, since 14% perceived themselves as fat though they are not and onethird report routinely thinking about food and weight. Rosen, McKeag, Hough, and Curley (1986) studied 182 college female athletes regarding pathogenic weight control behavior. Fourteen percent of the sample engaged in selfinduced vomiting, 16% laxative abuse, and 32% used diet pills. Nearly three-fourths (74%) of gymnasts and 47% of distance runners engaged in pathogenic weight control behavior. Of a sample of male and female athletes (Black & Burckes-Miller 1988) , 58% reported losing weight by using excessive exercise (significantly more men than women) , 23.5% consumed 600 or less calories per day (significantly more women than men), 11.9% fasting (significantly more women than men), 10.6% went on fad diets (significantly more women than men), and 5.6% used self-induced vomiting (significantly more women than men) .

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51 / Sorority Members Crandall (1988) surveyed two sororities, using questionnaires addressing social ties, personal factors, and binge eating. In one sorority, binge eating and popularity were directly related; the more a sorority member binged, the more her popularity increased. In the other sorority, popularity was associated with binging the right amount. Also, social influences were identified regarding the amount of binge eating, since a woman's binge eating could be predicted by her friend's binge eating. Some sorority members indicated it is not uncommon for a group of women to "pig out" at a fraternity house, return to the sorority house and engage in self-induced vomiting together (Gordon, 1989) . Meilman, von Hippel, and Gaylor (1991) studied 229 college females and found 4.8% reported engaging in selfinduced vomiting only after eating, 7.4% after both eating and consuming alcohol. Over half (55%) of women on campus belonged to a sorority, and 72.7% of nonfreshmen eating purgers were members of a house, compared with 46.2% of nonpurgers . Dancers Evers (1987) studied 21 female university student dancers compared with 29 control women and found 33% scored in the symptomatic range of anorexia nervosa on the Eating Attitudes Test, compared to only 13.8% of the controls.

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52 Compared to several groups of college females, Kurtzman, Yager, Landsverk, Wiesmier, and Bodurka (1989) found dance majors reported the highest rates of eating-disordered behavior. Students in Preprofessional Programs Few studies have examined the specialized and selective student populations enrolled in preprofessional programs. Crockett and Littrell (1985) studied college female junior and senior dietetic majors, home economics majors, and social science and humanities majors. Dietetic majors recorded significantly higher scores on the positive eating habits scale and the self-induced vomiting scale. Nearly one-fourth (24%) of junior and senior dietetic majors scored in the anorexic range of the Eating Attitudes Test, compared with only 11% of control subjects (Drake, 1989) . In addition, dietetics majors in the anorexic range placed themselves in a weight category one level higher than where they belonged, indicating a distorted body image, a symptom of anorexia nervosa, according to the Diagnostical and Statistical Manual Ill-Revised criteria (Drake, 1989) . From a group of 121 female medical students, 4.1% were currently bulimic, 8.3% reported a history of bulimia nervosa, and 4% reported a history of anorexia nervosa (Herzog, Pepose, Norman, & Rigotti, 1985). Nearly half (43%) of the sample were weight preoccupied and binged at least once a month. Nearly 6% were currently engaging in

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53 se lf -induced vomiting and 12.5% used laxatives, diuretics, or diet pills at least once a month (Herzog, Pepose, Norman, & Rigotti, 1985) . Futch, Wingard, and Felice (1988) used the Eating Disorder Inventory to survey 219 female graduate students and 132 female medical students. Results indicated none were anorexic and 3.3% were bulimic, lower rates than younger students. Medical students reported more excessive dieting concerns (Drive for Thinness scale) and a higher incidence of bulimic eating patterns than female graduate students . Of male and female first and second year medical students, 16.5% were considered at risk for an eating disorder, with generalized increased risk for females (Herzog, Borus, Hamburg, Ott, & Concus, 1987) . Herzog, Norman, Rigotti, and Pepose (1986) studied 550 medical, business, and law students using Diagnostical and Statistical Manual III criteria. About ten percent (10.2%) of the total sample met the criteria for bulimia nervosa, while 11.7% of the law school students, 7.9% of the medical school students and 8.8% of the business school respondents were bulimic. In a study of freshman Chinese medical students, no anorexics were found, and* only 1.1% were bulimic using Diagnostical and Statistical Manual Ill-Revised criteria. Only six percent of males and 6.7% of females reported

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53 se lf -induced vomiting and 12.5% used laxatives, diuretics, or diet pills at least once a month (Herzog, Pepose, Norman, & Rigotti, 1985) . Futch, Wingard, and Felice (1988) used the Eating Disorder Inventory to survey 219 female graduate students and 132 female medical students. Results indicated none were anorexic and 3.3% were bulimic, lower rates than younger students. Medical students reported more excessive dieting concerns (Drive for Thinness scale) and a higher incidence of bulimic eating patterns than female graduate students . Of male and female first and second year medical students, 16.5% were considered at risk for an eating disorder, with generalized increased risk for females (Herzog, Borus, Hamburg, Ott, & Concus, 1987) . Herzog, Norman, Rigotti, and Pepose (1986) studied 550 medical, business, and law students using Diagnostical and Statistical Manual III criteria. About ten percent (10.2%) of the total sample met the criteria for bulimia nervosa, while 11.7% of the law school students, 7.9% of the medical school students and 8.8% of the business school respondents were bulimic. In a study of freshman Chinese medical students, no anorexics were found, and only 1*. 1% were bulimic using Diagnostical and Statistical Manual Ill-Revised criteria. Only six percent of males and 6.7% of females reported

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54 having used weight control measures. However, nearly 80% of females and 42.5% of males expressed a fear of being fat; one-fourth of males and nearly 40% of females reported engaging in binge eating episodes (Chun, Mitchell, Li, Yu, Lan, Jun, Rong, Huan, Filice, Pomeroy, & Pyle, 1992) . Summary The literature review underscores the societal importance of an attractive appearance, particularly for females. The contemporary view of an extremely thin ideal body shape for women has been suggested as a possible agent for eating disorders and eating-disordered behavior. Modeling, or observational learning, a component of social learning theory, may play a part in eating-disordered behavior and eating disorder development. Adolescents and college students, particularly females, reported higher rates of eating disorders and eatingdisordered behavior than non-college student adults. College students enrolled in preprofessional programs report somewhat higher rates of eating disorders than college students in general. Among all groups studied, eating-disordered behavior was more common than the clinical eating disorders of anorexia nervosa and bulimia nervosa .

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CHAPTER 3 PROCEDURES FOR COLLECTION OF DATA Introduction This study assessed the prevalence of self-reported eating disorders and eating— disordered behavior among undergraduate health education major students in the United States to (1) establish a baseline regarding the prevalence of such disorders among this specialized group of subjects, and (2) provide information to address the needs of these subjects as individuals and as future health educators. Chapter 3 includes the following sections: (1) subjects, (2) instrumentation, (3) procedures, and (4) analysis. Subjects Approximately 300 institutions report offering undergraduate professional preparation in Health Education (Association for the Advancement of Health Education, 1991; Eta Sigma Gamma, 1988). While some published program directories rely on self-report, Eta Siama Gamma: A National Directory of College and University Health Education Programs and Faculties (1988) sets specific standards regarding faculty and curriculum before a program may be listed in thedirectory . Thus, to ensure program quality, test sites were identified exclusively through the 55

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56 Eta Sigma Gamma Directory (1988) , which included 161 institutions. The 1988 edition was the most current version available at the time of data collection. Using a computer generated listing of random numbers, a random sample of 25% (n = 40) of institutions was selected, with 10 additional institutions identified for replacement. Of the 40 institutions initially identified, nine specifically declined to participate and were replaced from the additional list of ten randomly identified sites. In total, 28 institutions participated in the study, five agreed to participate but did not return completed materials, and eight did not respond to the invitation to participate. Through the process of random selection, the 28 participating institutions provided broad demographic and geographical representation of professional preparation programs in the field (See Appendix E) . The institutional response rate was calculated at 70%, with 28 of 40 institutions returning completed questionnaires. Test site coordinators at participating institutions selected a class (or classes) most representative of their group of undergraduate health education majors to survey. All students enrolled in classes selected by the test site coordinators were invited to participate in the study. The Eating Disorder Inventory and the Eating Habits of Athletes

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56 Eta Sigma Gamma Directory (1988), which included 161 institutions. The 1988 edition was the most current version available at the time of data collection. Using a computer generated listing of random numbers, a random sample of 25% (n = 40) of institutions was selected, with 10 additional institutions identified for replacement. Of the 40 institutions initially identified, nine specifically declined to participate and were replaced from the additional list of ten randomly identified sites. In total, 28 institutions participated in the study, five agreed to participate but did not return completed materials, and eight did not respond to the invitation to participate. Through the process of random selection, the 28 participating institutions provided broad demographic and geographical representation of professional preparation programs in the field (See Appendix E) . The institutional response rate was calculated at 70%, with 28 of 40 institutions returning completed questionnaires. Test site coordinators at participating institutions selected a class (or classes) most representative of their group of undergraduate health education majors to survey. All students enrolled in classes selected by the test site coordinators were invited to participate in the study. The Eating Disorder Inventory and the Eating Habits of Athletes

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57 Survey were used for data collection. The 28 institutions returned a total of 664 questionnaires; analyses were conducted only on 394 confirmed health education major students. Approval through the University of Florida Human Subjects Approval Board was obtained (see Appendix A) . Instrumentation Eating Disorder Inventory (EDI) The Eating Disorder Inventory (Garner, Olmsted, & Polivy, 1983) is a self-report, paper/pencil instrument with 91 forced-choice items. Subjects indicate their responses using a six-point scale ranging from "always" to "never". The Eating Disorder Inventory, considered appropriate for persons ages 12 or older, can be completed in about 20 minutes. A brief description of each subscale is provided below: (Original Subscales) 1. Drive for Thinness subscale addresses excessive concern with dieting, fear of weight gain, and preoccupation with weight. 2. Body Dissatisfaction subscale measures dissatisfaction with specific body parts (e.g., hips, stomach, thighs) as well as overall body size and shape. . . "* 3. Perfectionism subscale measures beliefs of other's expectations regarding their own performance and thoughts .

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58 4 • Interoceptive Awareness subscale measures uncertainty in identifying sensations relating to hunger and satiety and addresses confusion in responding and recognizing emotional states. 5 . Bulimia subscale addresses the tendency to think about and engage in periods of uncontrollable eating or binging. 6. Ineffectiveness subscale measures feelings of insecurity, emptiness, worthlessness, inadeguacy, and lack of control over one's life. 7. Interpersonal Distrust subscale addresses a person's reluctance to form intimate relationships and feelings of alienation. 8. Maturity Fears subscale focuses on the wish to retreat into childhood. (Provisional Subscales) 9. Social Insecurity subscale assesses belief that social relationships are unrewarding, tense, and disappointing . 10. Impulse Regulation subscale measures tendencies toward substance abuse, hostility, impulsivity, and destructiveness toward oneself and others. 11 • Asceticism subscale assesses the extent to which one seeks virtue through self-discipline, self-denial, self-restraint, self-sacrifice, and the control of bodily urges. (Garner, 1990)

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59 Eating Disorder Inventory test-retest reliability for nonpatient samples is presented in Table 1. Column A presents results from 70 student and staff nurses, with one week between the original test and retest (Welch, 1988) . Wear and Pratz (1987) surveyed 70 college students, with a three week time lapse (Column B) . Column C provides results from a sample of 282 college students, with one year between testing (Crowther, Lilly, Crawford, Shepherd, & Oliver, 1990) . Table 1. Test-Retest Reliability for Nonpatient Samples (Eating Disorder Inventory-2 Manual, 1990) EDI Subscale A B C Drive for Thinness .85 . 92 .72 Bulimia .79 .90 .44 Body Dissatisfaction .95 .97 .75 Ineffectiveness .92 .85 . 55 Perfectionism .86 .88 . 65 Interpersonal Distrust .80 .81 . 60 Interoceptive Awareness .67 .85 .41 Maturity Fears .84 . 65 .48 Table 2 presents internal consistency reliability estimates for the eight original Eating Disorder Inventory Subscales. As indicated in Column A, Raciti, and Norcross (1987) reported internal consistencies from .92 to .79 for 268 college freshman women. Column B summarizes internal consistencies of .93to .69 for a sample of 158 first and second year female psychology students (Vanderheyden, Fekken, & Boland 1988) .

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60 Table 2. Internal Consistency Reliability Estimates for Nonpatient Female Comparison Groups. EDI Subscale A B Drive for Thinness .90 .91 Bulimia . 82 . 82 Body Dissatisfaction .92 .93 Ineffectiveness .90 . 90 Perfectionism .79 . 69 Interpersonal Distrust .81 .86 Interoceptive Awareness .81 .78 Maturity Fears .80 .77 Table 3 presents internal consistency reliability estimates for the present study. Estimates for the present study, which ranged from .83 to .87 for the eight original subscales, were generally similar to results presented in Table 2. No test-retest reliability studies have been conducted with the three provisional subscales. Only internal consistency reliability estimates of .80 for the Social Insecurity subscale, .79 for the Impulse Regulation subscale, and .44 for the Asceticism subscale for 205 nonpatient college females were reported (Garner, 1990) . As reported in Table 3 , similar internal consistency reliability estimates of .84 for both the Social Insecurity and Impulse Regulation subscales and .85 for the Asceticism subscale were obtained for the present study.

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61 Table 3. Internal Consistency Reliability Estimates for Study Sample. EDI Subscale Reliability Coefficient Drive for Thinness (DT) .85 Bulimia (B) .84 Body Dissatisfaction (BD) .86 Ineffectiveness (I) .84 Perfectionism (P) .87 Interpersonal Distrust (ID) .85 Interoceptive Awareness (IA) . 83 Maturity Fears (MF) .86 Asceticism (A) .85 Social Insecurity (SI) .84 Impulse Regulation (IR) .84 Content validation for the Eating Disorder Inventory was established with items suggested by individuals familiar with eating disorder literature who worked with eating disorder patients. A complete discussion on validity of the Eating Disorder Inventory is presented in the Eating Disorder Inventory-2 Professional Manual (Garner, 1990) . Table 4 presents correlations between the eight original Eating Disorder Inventory subscales and the Eating Attitudes Test (EAT-26) (Garner, Olmsted, Bohr, & Garfinkel, 1982). A total of 553 eating disorder patients served as subjects for the study. Eating Habits of Athletes Survey In addition to the Eating Disorder Inventory, the Eating Habits of Athletes Survey developed by Dr. David R. Black and Dr. Mardie Burckes-Miller was used in this study

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62 (Black & Burckes-Miller , 1988) . Test-retest reliability was .81 for 30 college students who completed the instrument twice in approximately three months (Black & Burckes-Miller, 1988) . Table 4. Correlations between Eating Disorder Inventory Subscales and the Eating Attitudes Test-26 (Eating Disorder Inventory-2 Manual, 1990) Measures Eating Disorder Inventory Subscales EAT Scores DT B Total Score .71* .26* Dieting .74* .20* Bulimia & Food .53* .72* Preoccupat ion Oral Control . 61* .57* BD I P ID IA MF .44* .46* . 35* .29* .51* .27* .49* .43* .33* .25* .44* . 24* . 33* .29* . 14 . 07 .39* . 09 .44* . 37* .26* . 15 .38* . 07 *p<.001 for each comparison; for family of 40 comparisons, p< • 04 (Myers, 1979) . Four items not applicable to this study population or study purpose were deleted: two items related specifically to athletics, one item related to calorie intake, and one item that addressed weight fluctuation. Items added to the Eating Habits of Athletes Survey included three demographic questions (race, current living arrangement, and marital status) ; three questions related to body weight (highest past weight, lowest weight as an adult, and ideal weight) ; and three questions related to health education. Written permission to use the questionnaire was obtained from Dr. Burckes-Miller (See Appendix D) .

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63 Data Collection Procedures On March 19, 1992, an initial packet (refer to Appendix B) was sent to the 50 institutions randomly selected through a computer generated list from the Eta Sigma Gamma: A National Directory of College and University Health Education Programs and Faculties (1988) . Each packet contained: a cover letter describing the study; a copy of the student testing packet (See Appendix C) ; an oral script; a description of the instruments; a participation form; and a pre-addressed, postage-paid return envelope. A response was requested by April 3, 1992. Test site coordinators at participating schools received a cover letter, an oral script to read to students prior to test administration, the requested number of student testing packets and #2 pencils, and a pre-addressed, postage-paid return envelope for return of the completed questionnaires. Beginning the week of April 12, 1992, each nonresponding school received a follow-up telephone call. In addition, a follow-up letter, participation form, and a pre-addressed, stamped envelope were mailed on May 11, 1992 indicating extension of data collection into the Summer 1992 term. Three versions of the letter were mailed to the three groups: (1) institutions indicating they were unable to participate due to no major courses offered during Spring 1992 or a miscommunication among faculty members, (2) institutions that had not returned completed questionnaires,

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64 and (3) nonrespondents. A letter of appreciation and a summary of study results were forwarded to each test site coordinator following completion of the study. Analysis of Data A total of 664 subjects participated in the study. Of this number, 250 indicated they were not health education majors and 20 individuals did not respond to the question. Thus, to maintain the integrity of the sample, analyses were conducted on 394 subjects confirmed as health education majors . Repeated measures analysis of variance was used to test hypothesis #1. Follow-ups of hypothesis #1 were computed using the F-ratio, using a .05 alpha level critical value (with Bonferroni correction) . Hypothesis #2 was tested using regression. Alpha level for the null hypotheses was set at .05. Analyses were completed using the Statistical Analysis System (SAS) .

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CHAPTER 4 ANALYSIS Introduction This study assessed the prevalence of self-reported eating disorders and eating-disordered behavior among undergraduate health education major students in the United States to (1) establish a baseline regarding the prevalence of such disorders among this specialized group of subjects, and (2) provide information to address the needs of these subjects as individuals and as future health educators. Chapter 4 includes the following sections: (1) introduction, (2) sample characteristics, (3) results, and (4) discussion of results. Sample Characteristics The study sample of 394 undergraduate health education major students was drawn from 28 colleges and universities (See Appendix E) in the United States. Participating colleges and universities were selected randomly from Eta Sigma Gamma: A National Directory of College and University Health Education Programs and Faculties (1988) . Students enrolled in a health education major course selected by each institution's test sate coordinator were invited to participate in the study. 65

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66 The sample was comprised of 289 (73.4%) females and 104 (26.4%) males, ranging in age from 18 to 59 years. Some 197 (50%) were seniors, 146 (37.1%) were juniors, 29 (7.4%) were sophomores, 19 (4.8%) were graduate/post baccalaureate students, and three (0.8%) were freshmen. Most (85.2%, n = 336) subjects were Caucasian, followed by 29 (7.4%) Blacks, eight (2.0%) Native Americans, seven (1.8%) Hispanics, and four (1.0%) Asians. Nine (2.3%) responded as "Other" . The sample consisted of 258 subjects (65.4%) living in an off campus apartment or house. Nearly one-fifth (19.3%, n = 76) indicated living in on campus housing, 10.2% (n = 40) with parents, and 4.3% (n = 17) in a sorority or fraternity house. About three-fourths (77.2%) indicated they were never married. Married subjects comprised 18.0% (n = 71) of the sample, 3.0% (n = 12) were divorced, 1.3% (n = 5) were separated, and one subject (0.3%) was widowed. Most subjects reported Community Health (34.5%, n = 137) or School/College Health (28.7%, n = 113) as their Health Education Focus. Nearly 13% (n = 50) chose Worksite Health Promotion, 15.5% (n = 61) selected Public Health, 5.1% (n = 20) selected Patient Education, and 0.7% (n = 3) indicated Safety Education. * Subjects could select one or more Health Education Area of Professional Interest: Aging/Death and Dying,

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67 Alcohol/Drug Education, Cancer/Cardiovascular Disease, Environmental Health, Exercise and Fitness, Mental Health/Health Counseling, Nutrition Education, Sexuality, Stress Management, Weight Control/Management , and Wellness. Most students selected Wellness (79.7%, n = 314), followed by Exercise and Fitness (78.9%, n = 311), Nutrition (74.6%, n = 294), Weight Control /Management (63.2%, n = 249), Alcohol/Drug Education (59.9%, n = 236), Sexuality (59.1%, n = 233), Stress Management (58.1%, n = 229), and Cancer/Cardiovascular Disease (52.8%, n = 208). Other Areas of Professional Interest included Mental Health (48.2%, n = 190), Environmental Health (46.4%, n = 183), and Aging/Death and Dying (32.0%, n = 126). Selected demographic variables of the sample including sex, year in college, race, current living arrangement, and marital status are presented in Table 5. Table 6 consists of frequencies and percentages of Health Education major interest areas. Each variable is presented by sex in the following tables: Year in College (Table 7), Race (Table 8) , Current Living Arrangement (Table 9) , Marital Status (Table 10) , Health Education Focus (Table 11) , and Area of Professional Interest (Table 12) . -4

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68 Variables and Percentages of Demographic Variable and Category # of Subjects of Total Sex Female Male Missing Response Year in College Freshman Sophomore Junior Senior Post-bac Missing Responses Race Asian Black Caucasian Hispanic Native American Other Missing Response Current Living Arrangement Sorority/Fraternity House On Campus Residence Hall Off Campus Apartment /House With Parents Missing Responses Marital Status Never Married Married Separated Divorced Widowed Missing Response 289 73.4 104 26.4 1 0.2 3 0.8 29 7.4 146 37.1 197 50.0 19 4.8 0 0.0 4 1.0 29 7.4 336 85.2 7 1.8 8 2 . 0 9 2.3 1 0.3 17 4.3 76 19.3 258 65.4 40 10.2 3 0.8 304 77.2 71 18.0 5 1.2 12 3 . 0 1 0.3 1 0.3

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69 Table 6. Frequencies and Percentages of Major Interest Areas (Note: For Area of Professional Interest, each subject was asked to check all that apply.) (n = 394) Variable and Category # of Subjects % of Total Health Education Focus Public Health 61 15.5 Patient Education 20 5.1 Safety Education 3 0.7 School/College Health 113 28.7 Worksite Health Promotion 50 12.7 Community Health 137 34.5 Missing Responses 11 2.8 Area of Professional Interest Aging/Death & Dying 126 32.0 Missing Responses 20 Alcohol/Drug Education 236 59.9 Missing Responses 19 Cancer/ CVD 208 52.8 Missing Responses 17 Environmental Health 183 46.4 Missing Responses 17 Exercise and Fitness 311 78.9 Missing Responses 14 Mental Health 190 48.2 Missing Responses 18 Nutrition 294 74.6 Missing Responses 15 Sexuality 233 59.1 Missing Responses 17 Stress Management 229 58 . 1 Missing Responses 18 Weight Control/Management 249 63.2 Missing Responses 16 Wellness 314 79.7 Missing Responses 16

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70 Table 7. Frequencies and Percentages of Year in College by Sex (n = 393) Year in College Females (n = 289) Males (n = 104) Freshman 2 (0.7%) 1 (1.0%) Sophomore 24 (8.3%) 5 (4.8%) Junior 108 (37.3%) 38 (36.5%) Senior 138 (47.8%) 58 (55.8%) Post-bac 17 (5.9%) 2 (1.9%) Missing Responses 0 (0.0%) 0 (0.0%) Table 8 . Frequencies and Percentages of Race by Sex (n = 393) Race Females Males (n = 289) (n = 104) Asian 2 (0.7%) 2 (1.9%) Black 22 (7.6%) 7 (6.7%) Caucasian 247 (85.5%) 88 (84.6%) Hispanic 6 (2.1%) 1 (1.0%) Native American 5 (1.7%) 3 (2.9%) Other 6 (2.1%) 3 (2.9%) Missing Response 1 (0.3%) 0 (0.0%) Table 9. Frequencies and Percentages of Current Living Arrangement by Sex (n = 393) Current Living Arrangement Females Males (n = 289) (n = 104) Sorority/ Fraternity House 13 (4.6%) 4 (3.9%) On Campus Residence Hall 53 (18.3%) 23 (22 . 1%) Off Campus Apartment /House 185 (64.0%) 73 (70.2%) With Parents 35 (12.1%) 4 (3.9%) Missing Responses 3 (1.0%) 0 (0.0%)

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71 Table 10. Frequencies and Percentages of Marital Status by Sex (n = 393) Marital Status Females (n = 289) Males (n = 104) Never Married 219 (75.8%) 85 (81.7%) Married 56 (19.4%) 15 (14.4%) Separated 4 (1.4%) 1 (1.0%) Divorced 9 (3.1%) 3 (2.9%) Widowed 1 (0.4%) 0 (0.0%) Missing Responses 0 (0.0%) 0 (0.0%) Table Focus 11. Frequencies by Sex (n = 393) and Percentages of Health Education Health Education Focus Females (n = 289) Males (n = 104) Public Health Patient Education Safety Education School/College Health Worksite Health Promotion Community Health Missing Responses 45 (15.6%) 16 (15.4%) 14 (4.8%) 6 (5.8%) 0 (0.0%) 3 (2.9%) 79 (27.3%) 34 (32.6%) 36 (12.5%) 14 (13.5%) 107 (37.0%) 29 (27.9%) 8 (2.8%) 2 (1.9%) Results Physical Characteristics of Subjects The average female in the sample was 24.48 years of age, 65.39 inches tall, and currently weighed 138.65 pounds. As a group, females reported a mean of 124.20 pounds as their lowest weight as an adult and 148.64 pounds as their highest past weight. The mean ideal weight was 126.37 pounds .

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72 Table 12 . Frequencies and Percentages of Area of Professional Interest by Sex (Note: Each subject was instructed to check all that apply.) (n = 393) Area of Professional Interest Females (n = 289) Males (n = 104) Aging/Death & Dying 96 (33.2%) 29 (27.9%) Missing Responses 13 6 Alcohol/Drug Education 175 (60.6%) 60 (57.7%) Missing Responses 13 5 Cancer/Cardiovascular Disease 149 (51.6%) 58 (55.8%) Missing Responses 13 3 Environmental Health 135 (46.7%) 48 (46.2%) Missing Responses 12 4 Exercise and Fitness 224 (77.5%) 86 (82.7%) Missing Responses 11 2 Mental Health/Counseling 157 (54.3%) 32 (30.8%) Missing Responses 11 6 Nutrition Education 219 (77.8%) 74 (71.2%) Missing Responses 10 4 Sexuality 180 (62.3%) 52 (50.0%) Missing Responses 12 4 Stress Management 175 (60.6%) 54 (51.9%) Missing Responses 11 6 Weight Control/Management 189 (65.4%) 59 (56.7%) Missing Responses 10 5 Wellness 231 (80.0%) 82 (78.8%) Missing Responses 11 4 The average male in the sample was nearly 24 (23.86) years of age. On average, males were 70.69 inches tall and reported currently weighing 185.08 pounds. With a mean highest past weight of 194.81 pounds and lowest weight as an adult of 166.73 pounds, males on average indicated 183.93 pounds as their ideal weight. Table 13 provides the means and standard deviations of age, height, current weight, ideal weight, highest past weight, and lowest weight as an adult for males and females. 4

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73 Table 13. Means and Standard Deviations of Age, Height, Current Weight, Highest Past Weight, Lowest Weight as an Adult, and Ideal Weight by Sex (n = 393) Category and Variable Mean Stand. Dev. Age Females 24.48 6.72 Males 23.86 5.62 Height (in inches) Females 65.39 2 . 60 Males 70.69 3.12 Current Weight (in pounds) Females 138.65 26.67 Males 185.08 33.43 Highest Past Weight Females 148.64 30.21 Males 194.81 37.20 Lowest Weight as an Adult Females 124.20 21.92 Males 166.73 29 . 10 Ideal Weight Females 126.37 16.79 Males 183.93 29.82 Some sex differences in ideal weight versus current weight existed in this sample. Males as a group reported a difference of less than two pounds between current and ideal weight. In contrast, females as a group reported a 12.33 pound difference between ideal and lowest weight.

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74 While a nearly 11 pound difference between highest past weight and ideal weight was present for males, females reported a 22 pound difference. Females reported a 1.96 pound difference between ideal weight and lowest weight. In comparison, males reported a 17.30 pound difference. Mean differences and standard deviations between self-reported current weight, highest past weight, lowest weight as an adult, and ideal weight by sex are presented in Table 14. Table 14. Difference Between Self-Reported Current Weight, Highest Past Weight, Lowest Weight as an Adult, and Ideal Weight by Sex (n = 393) Variable Females Males (n = 289) (n = 104) Mean Stand. Dev. Mean Stand. Dev. Highest Weight Minus Current Weight 10.00 11.49 9.08 12.04 Lowest Weight 24.02 16.64 28.08 19.86 Ideal Weight 22.22 18.15 10.91 21.57 Current Weight Minus Lowest Weight 14.17 13.36 18.90 16.25 Ideal Weight 12.34 13.79 1.88 16.20 Ideal Weight Minus Lowest Weight 1.96 10.62 17.30 18.99 In 1990, The United States Department of Agriculture and the United States Department of Health and Human Services published revised suggested weights for adults. (See Table 15). Using the United States Department of Agriculture Suggested Weights for Adults, the breakdown for

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75 Table 15. Suggested Weights for Adults Height Weight in Pounds 19 to 34 35 years years and over 5 7 0" 97-128 108-138 5 7 1" 101-132 111-143 5' 2" 104-137 115-148 5 7 3 " 107-141 119-142 5' 4" 111-146 122-157 5' 5" 114-150 126-162 5 7 6" 118-155 130-167 5 7 7" 121-160 134-172 5 '8" 125-164 138-178 5' 9" 129-169 142-183 5 7 10" 132-174 146-188 5 7 11" 136-179 151-194 6 7 0" 140-184 155-199 6 7 1" 144-189 159-205 6 7 2" 148-195 164-210 6 7 3" 152-200 168-216 6 7 4" 156-205 173-222 6 7 5" 160-211 177-228 6 7 6" 164-216 182-234 Height: Without shoes Weight: Without clothes, the higher weights in the ranges generally apply to men, who tend to have more muscle and bone; the lower weights more often apply to women, who have less muscle and bone. Source : U.S. Department of Agriculture males and females for current weight, ideal weight, highest past weight, and lowest weight as an adult is presented in Table 16. More males (53%, n = 55) than females (28%, n = 81) reported a current weight above the suggested weight for their height. More females (18%, n = 52) than males (5%, n

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76 — 5) self-reported their ideal weight below the suggested weight for their height. Table 16. Comparison of Current Weight, Ideal Weight, Lowest Weight as an Adult, and Highest Past Weight with U.S.D.A. Weight Guidelines (n = 393) Females Males (n = 289) (n = 104) Current Weight Above 81 (28%) 55 (53%) Within 180 (62%) 48 (46%) (1%) Below 28 (10%) 1 Ideal Weight Above 45 (16%) 57 (55%) Within 192 (66%) 42 (40%) (5%) Below 52 (18%) 5 Lowest Weight as an Adult Above 49 (17%) 30 (29%) Within 158 (55%) 67 (64%) (7%) Below 82 (28%) 7 Highest Past Weight Above 107 (37%) 65 (63%) (34%) (4%) Within 168 (58%) 35 Below 14 (5%) 4 Eating-Disordered Behavior Table 17 provides a summary of self-reported regularly used weight control methods. Nearly 44% (n = 173) of # 4 subjects indicated using excessive or vigorous exercise as a form of weight control followed by fad dieting (14.2%, n = 56), fasting (6.3%, n = 25) , and diet pills (5.3%, n = 21) .

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77 Table 17 . Self-Reported Frequency of Regularly Used Weight Control Methods for All Subjects (n = 394) Method # of Subjects % of Total Fad Dieting 56 14.2 Missing Responses 9 Excessive/Vigorous Exercise 173 43.9 Missing Responses 6 Fasting 25 6.3 Missing Responses 7 Diet Pills 21 5.3 Missing Responses 7 Laxatives 11 2 . 8 Missing Responses 8 Diuretics (Water Pills) 9 2 . 3 Missing Responses 8 Self-Induced Vomiting 11 2.8 Missing Responses 8 Table 18. Self-Reported Frequency of Regularly Used Weight Control Methods by Sex (n = 393) Method Females Males (n = 289) (n = 104) Fad Dieting 44 (15.2%) 11 (10.6%) Missing Responses 7 1 Excessive/Vigorous Exercise 115 (39.8%) 57 (54.8%) Missing Responses 5 0 Fasting 17 (5.9%) 8 (7.7%) Missing Responses 5 1 Diet Pills 16 (5.5%) 5 (4.8%) Missing Responses 5 1 Laxatives 10 (3.5%) 1 (1.0%) Missing Responses 6 1 Diuretics (Water Pills) 6 (2.1%) 3 (2.9%) Missing Responses 6 1 Self-Induced Vomiting 9 (3.1%) 2 (1.9%) Missing Responses 6 1 Eleven subjects (2.8_%) reported using either laxatives or self-induced vomiting and nine (2.3%) indicated using diuretics for weight control. Self-reported frequency of

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78 regularly used weight control methods by sex is reported in Table 18. Self-reported freguencies of specific weight control measures are presented in Tables 19 28. Table 19 displays the self-reported frequency of fad dieting for all subjects. Approximately one-third (35.4%) of females self-reported using fad dieting as a means of weight control at least once a month, compared with 19.3% of male subjects (See Table 20) . Table 21 displays self-reported frequency of fasting as a form of weight control for all subjects. As indicated in Table 22, 10.6% of males and 14.2% of females selfreported using fasting as a form of weight control at least once a month. Subjects' self-reported frequency of eating small quantities of food (600 calories a day or less) as a form of weight control for all subjects is displayed in Table 23. As presented in Table 24, 52.0% of females and 26.9% of males self-reported eating small quantities of food as a form of weight control at least once a month. Table 25 displays the self-reported frequency of laxative use for all subjects. Two percent of males and 7.6% of females selfreported using laxatives at least once a month as a form of weight control (See Table 26) . Table 27 displays selfreported frequency of self-induced vomiting for all 4 subjects. As indicated in Table 28, 3 . 0% of males and 8.5% of females self-reported using self-induced vomiting at least once a month as a form of weight control.

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Table 19. Self-Reported Frequency of Fad Dieting as a Form of Weight Control for All Subjects (n = 394) Frequency # of Subjects % Of Total Never 266 67 . 5 Rarely 1 day a month 59 15.0 2-3 days a month 25 6.3 1 time a week 13 3 . 3 More than once a week 25 6.3 Missing Responses 6 1.6 Table 20. Self-Reported of Weight Control by Sex Frequency of (n = 393) Fad Dieting as a Form Frequency Females Males (n = = 289) (n = 104) Never 182 (62.9%) 83 (79.7%) Rarely 1 day a month 53 (18 . 3%) 6 (5.8%) 2-3 days a month 19 (6.7%) 6 (5.8%) 1 time a week 8 (2.8%) 5 (4.8%) More than once a week 22 (7.6%) 3 (2.9%) Missing Responses 5 (1.7%) 1 (1.0%) Table 21. Self-Reported Frequency of Fasting (no food for at least 24 hours) as a Form of Weight Control for All Subjects (n = 394) Frequency # of Subjects % of Total Never 335 85.0 Rarely 1 day a month 29 7.4 2-3 days a month 15 3.8 1 day a week 7 1.8 More than one day a -week 2 0.5 Missing Responses 6 1.5

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80 Table 22. Self-Reported Frequency of Fasting (no food for at least 24 hours) as a Form of Weight Control by Sex (n = 393) Frequency Females Males (n = 289) (n = 104) Never 243 (84.1%) 92 (88 . 4%) Rarely 1 day a month 25 (8.7%) 3 (2.9%) 2-3 days a month 9 (3.1%) 6 (5.8%) 1 day a week 5 (1.7%) 2 (1.9%) More than one day a week 2 (0.7%) 0 (0.0%) Missing Responses 5 (1.7%) 1 (1.0%) Table 23. Self-Reported Frequency Quantities of Food (600 calories a Weight Control for All Subjects (n of Eating Small day or less) as a = 394) Form of Frequency # of Subjects % of Total Never 209 53 . 0 Rarely 1 day a month 85 21.6 2-3 days a month 41 10.4 1 day a week 30 7 . 6 2 or more i days a week 22 5.6 Missing Responses 7 1.8 Table 24. Self-Reported Quantities of Food (600 Weight Control by Sex (n Frequency calories a = 393) of Eating Small day or less) as a Form of Frequency Females (n = 289) Males (n = 104) Never 134 (46.,3%) 75 (72.1%) Rarely 1 day a month 75 (26.0%) 10 (9.6%) 2-3 days a month 35 (12.1%) 6 (5.8%) 1 day a week 23 (8.0%) 7 (6.7%) 2 or more days a week 17 (5.9%) 5 (4.8%) Missing Responses 5 (1.7%) 1 (1.0%)

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81 Table 25. Self-Reported Frequency of Laxatives as a Form of Weight Control for All Subjects (n = 394) Frequency # of Subjects % Of Total Never 361 91.5 Rarely 1 time a month 11 2 . 8 2-3 times a month 6 1.5 1 time a week 5 1.0 2-3 times a week 1 0.3 4-6 times a week 1 0.3 At least once every day 1 0.3 Missing Responses 9 2 . 3 Table 26. Self-Reported Weight Control by Sex (n Frequency of = 393) Laxatives as a Form of Frequency Females (n = 289) Males (n = 104) Never 262 (90.7%) 99 (95.1%) Rarely 1 time a month 10 (3.5%) 1 (1.0%) 2-3 times a month 5 (1.7%) 1 (1.0%) 1 time a week 4 (1.4%) 0 (0.0%) 2-3 times a week 3 (1.0%) 0 (0.0%) 4-6 times a week 0 (0.0%) 0 (0.0%) At least once every day 0 (0.0%) 0 (0.0%) Missing Responses 5 (1.7%) 3 (3.0%)

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82 Table 27. Self-Reported Frequency of Self-Induced Vomiting as a Form of Weight Control for All Subjects (n = 394) Frequency # of Subjects % of Total Never 358 90.8 Rarely one time a month 14 3 . 5 2-3 times a month 6 1 . 5 1 time a week 5 1 . 3 2 -3 times a week 1 0 . 3 4-6 times a week 1 0 . 3 At least once every day 1 0.3 Missing Responses 8 2 . 0 Table 28. Self-Reported Frequency of Self-Induced Vomiting as a Form of Weight Control by Sex (n = 393) Frequency Females (n = 289) Males (n = 104) Never 260 Rarely one time a month 13 2-3 times a month 5 1 time a week 5 2 -3 times a week 1 4-6 times a week 1 At least once every day o Missing Responses 4 (90.1%) (4.5%) (1.7%) (1.7%) (0.3%) (0.3%) ( 0 . 0 %) (1.4%) 98 (94.1%) 1 ( 1 . 0 %) 1 ( 1 . 0 %) 0 ( 0 . 0 %) 0 ( 0 . 0 %) 0 ( 0 . 0 %) 1 ( 1 . 0 %) 3 (2.9%) Listed below is each code followed by the item on the Eating Habits of Athletes Survey: FAD = Fad Dieting used regularly for weight control VE = Excessive/Vigorous Exercise used regularly for weight control FAST = Fasting used -regularly for weight control PILLS = Diet Pills used regularly for weight control LAX = Laxatives used regularly for weight control

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83 DIU = Diuretics used regularly for weight control VOM = Self-Induced Vomiting used regularly for weight control BE = I have regular episodes of binge eating (rapid consumption of foods that are easy to digest and high in calories in a short period of time) . PAIN = I frequently eat until my stomach hurts too much to continue, or I am interrupted by other people, or I fall asleep, or I vomit. ALONE = I don't like to have people present when I eat. NCON = During eating binges, I have a distinct feeling of not having control over my eating. SIV = I binge eat, then frequently self -induce vomiting because I am afraid I will gain weight. CON = I have a persistent concern with my body shape and weight. AN = My weight is 15% or more below normal for my age and height . FEAR = I have an intense fear of becoming obese, even though I am underweight or normal weight now. MEN = I have had the absence of at least three consecutive menstrual cycles when they should have occurred. (Females only) TOO = Other people think I am too thin. THINK = I think about food and weight all the time. FAT = I think I am fat although I am underweight. GAIN = I am terrified of gaining weight. DOWN = I feel depressed and down on myself after I eat. DIET = How often do you use popular diets . . . NOFOOD = How often do you fast . . . SMALL = How often do you eat small quantities (600 calories a day or less) of food . . . LAXWC = How often do you use laxatives . . .

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84 SIVWC — How often do you use self-induced vomiting . . . NUMBI = What is your average number of eating binges within the last three months? DIAGED = Have you ever been diagnosed with an eating disorder? YOUED = Do you think you might have an eating disorder? Table 29 summarizes self-reported eating-disordered behavior and personal beliefs regarding food and weight for all subjects. Thirty-six subjects (9.1%) reported engaging in regular binge eating episodes and 4.3% (n = 17) indicated frequently eating until their stomach hurts too much to continue, interrupted by others, falling asleep, or vomiting. One-fifth (20.8%, n = 82) felt depressed and down on themselves after eating and 11.4% (n = 45) reported a distinct feeling of not having control over their eating during eating binges. Twelve subjects (3.0%) indicated they frequently self-induce vomiting following binge eating episodes to prevent weight gain and 9.1% (n = 36) reported not wanting people present when they are eating. Thirty-two (8.1%) subjects reported having a body weight 15% or more below normal for their age and height. Sixteen percent (n = 63) indicated others think they are too thin. A persistent concern with body shape and weight was reported by 59.9% (n = 236) of subjects; one-third (33.2%, n = 131) indicated thinking about food and their weight all the time. Nearly one-third (32.2%, n = 127) reported being

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85 terrified of gaining weight and 19 (4.8%) believed they are fat though they are underweight. Nearly one-fourth (24.9%, n = 98) were normal or underweight subjects reporting an intense fear of becoming obese. Nearly nine percent (8.7%, n = 25) of females reported the absence of at least three consecutive menstrual cycles when they should have occurred (See Table 30) . Table 29. Self-Reported Eating Disordered Behavior and Personal Beliefs Regarding Food and Weight for All Subjects (n = 394) Variable # of Subjects % of Total Regular binge eating episodes (BE) 36 9.1 Missing Responses 4 Eat until stomach hurts, etc (PAIN) 17 4.3 Missing Responses 4 Don't like others present when eating (ALONE) 36 9.1 Missing Responses 6 No control during eating binges (NC0N) 45 11.4 Missing Responses 7 Self-induce vomit after binge eating (SIV) 12 3.0 Missing Responses 8 Persistent concern w/body shape/weight (CON) 236 59.9 Missing Responses 6 Weight 15% or more below normal (AN) 32 8.1 Missing Responses 6 Intense fear of becoming obese (FEAR) 98 24.9 Missing Responses 8 Others think I am too thin (TOO) 63 16.0 Missing Responses 8 Think about food/weight all the time (THINK) 131 33.2 Missing Responses 8 Think I am fat though underweight (FAT) 19 4.8 Missing Responses 10 Terrified of gaining weight (GAIN) 127 32.2 Missing Responses 8 Depressed & down on self after eating (DOWN) 82 20.8 Missing Responses 7 Nearly two-thirds of female (63.6%) and one-half (49.0%) of male subjects indicated they have a persistent concern with body shape and weight. One-fourth (25%) of

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86 males and 36.0% of females indicated they think about food and weight all of the time. An intense fear of becoming obese though presently at a normal weight or underweight was reported by 28.4% of female and 14.4% of male subjects. Over one-third (38.1%) of females and 15.4% of males indicated being terrified of gaining weight and 24.6% of females and 9.6% of males reported feeling depressed and down on themselves after eating (Refer to Table 30) . Table 30. Self-Reported Eating Disordered Behavior and Personal Beliefs Regarding Food and Weight by Sex (n = 393) Variable Females Males (n = 289) (n = 104) n/% of females n/% of males Regular binge eating episodes (BE) 28/9.7 Missing Responses 3 Eat until stomach hurts, etc. (PAIN) 14/4.8 Missing Responses 3 Don't like others present when eating (ALONE) 27/9.3 Missing Responses 5 No control during eating binges (NCON) 38/13.1 Missing Responses g Self-induce vomit after binge eating (SIV) 11/3.8 Missing Responses 7 Persistent concern w/body shape/weight (CON) 184/63.7 Missing Responses 4 Weight 15% or more below normal (AN) 22/7.6 Missing Responses 4 Intense fear of becoming obese (FEAR) 82/28.4 Missing Responses g 3 consecutive menstrual cycle absence (MEN) 25/8.7 Missing Responses 7 Others think I am too thin (TOO) 46/15.9 Missing Responses 5 Think about food/weight all the time (THINK) 104/36.0 Missing Responses 5 Think I am fat though underweight (FAT) 15/5.2 Missing Responses 8 Terrified of gaining weight (GAIN) 110/38.1 Missing Responses * 5 Depressed & down on self^ after eating (DOWN) 71/24.6 Missing Responses 5 8/7.7 0 3/2.9 0 8/7.7 0 6/5.8 0 1 / 1.0 0 51/49.0 1 10/9.6 1 15/14.4 1 N/A 17/16.3 1 26/25.0 1 4/3.8 1 16/15.4 1 10/9.6 1

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87 Eating Disorders As presented in Table 31, in the past three months, nearly ten percent (9.4%, n = 37) of the sample reported engaging in binge eating two to six times, 13 (3.3%) binge once per week, and nine (2.3%) reported two or more binge eating episodes per week (one of the Diagnostical and Statistical Manual Ill-Revised criteria for bulimia nervosa diagnosis) . Self-reported binge eating frequency in the last three months by sex is reported in Table 32. Table 31. Self-Reported Average Number of Eating Binges Within the Last 3 Months for All Subjects (n = 394) Frequency # of Subjects % of Total 0-1 binge 324 82 . 0 2-6 times in 3 months 37 9.4 1 binge per week 13 3.3 2 or more per week 9 2 . 3 Missing Responses 12 3 . 0 Table 32. Self-Reported Average Number of Eating Binges Within the Last 3 Months by Sex (n = 393) Frequency Females Males (n = 289) (n = 104) 0-1 binge 2-6 times in 3 months 1 binge per week 2 or more per week Missing Responses 237 (82.0%) 28 (9.7%) 11 (3..8%) 5 (1.7%) 8 ( 2 . 8 %) 86 (82.7%) 9 (8.7%) 2 (1.9%) 4 (3.8%) 3 (2.9%)

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88 A total of 3.6% of subjects reported ever being diagnosed with an eating disorder; four (1.0%) anorexia nervosa, seven (1.8%) bulimia nervosa, and three (0.8%) both anorexia nervosa and seven bulimia nervosa (refer to Table 33). Nearly five percent (4.6%) thought they might have an eating disorder; four (1.0%) anorexia nervosa, 11 (2.8%) bulimia nervosa, and three (0.8%) both anorexia nervosa and bulimia nervosa (see Table 35) . According to Table 34, 2.9% of males (n = 3) have been diagnosed with an eating disorder, compared to 3.8% (n = 11) of females. In the questionnaire section asking for written student comments, one student reported a possible eating disorder that was never formally diagnosed. Table 33. Have You Ever Been Diagnosed with an Eating Disorder? (All Subjects) (n = 394) Frequency # of Subjects % Of Total No 372 94.4 Yes, anorexia nervosa 4 1.0 Yes, bulimia nervosa 7 1.8 Yes, anorexia & bulimia 3 0.8 Missing Responses 8 2 . 0

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89 Table 34. Have You Ever Been Diagnosed with an Eating Disorder? (by Sex) (n = 393) Freguency Females Males (n = 289) (n = 104) No Yes, anorexia nervosa Yes, bulimia nervosa Yes, anorexia & bulimia Missing Responses 274 (94.8%) 2 (0.7%) 6 ( 2 . 1 %) 3 (1.0%) 4 (1.4%) 98 (94.2%) 2 (1.9%) 1 ( 1 . 0 %) 0 ( 0 . 0 %) 3 (2.9%) Ten (3.5-s) females thought they have bulimia nervosa compared with one (1%) male. One percent of females (n = 3) and males (n = 1) thought they have anorexia nervosa. Two (0.7%) females and one male (1.0%) thought they might have both anorexia nervosa and bulimia nervosa. In total, 5.2% ( n = 15) of females and 3% (n = 3) of males thought they might have either anorexia nervosa or bulimia nervosa, or both (refer to Table 36) . Table 35. Do You Think You Might Have an Eating Disorder? (All Subjects) (n = 394) Frequency # of Subjects % of Total No 367 93 . 1 Yes, anorexia nervosa 4 1 . 0 Yes, bulimia nervosa 11 2 . 8 Yes, both anorexia and bulimia 3 0 . 8 Missing Responses 9 « 2 . 3

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90 Table 36. Do You Think You Might Have an Eating Disorder? (By Sex) (n = 393) Frequency Females Males (n = 289) (n = 104) No 269 (93 . 1%) 98 (94.0%) Yes, anorexia nervosa 3 (1.0%) 1 (1.0%) Yes, bulimia nervosa 10 (3.5%) 1 (1.0%) Yes, anorexia & bulimia 2 (0.7%) 1 (1.0%) Missing Responses 5 (1.7%) 3 (3.0%) The means, standard deviations, and t-test comparisons by sex of the Eating Disorder Inventory subscale scores are presented in Table 37. As a group, males scored higher at a statistically significant level than females on the Perfectionism subscale. Females scored higher than males at a statistically significant level on the Drive for Thinness and Body Dissatisfaction subscales. Table 38 presents means and standard deviations of Eating Disorder Inventory scores of nonpatient college students (n = 101 for male students; n = 205 for female students) , as reported in the Eating Disorder Inventory 2 Professional Manual (Garner, 1990) . The means and standard deviations of both groups appeared to be similar.

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91 Table 37 . Eating Disorder Inventory Subscale Scores by Sex Subscale Mean Stand. Dev. T-Value Drive for Thinness Females 5.2 5.4 6.75** Males 2.1 3.3 5.42** Bulimia Females 1.3 2.7 1.04 Males 1.0 2.6 1.03 Body Dissatisfaction Females 11.5 8.2 9.68** Males 4.8 5.0 7.76** Ineffectiveness Females 2.5 4.2 1.96 Males 1.8 2.7 1.60 Perfectionism Females 4.9 4.0 -2.51* Males 6.1 4.3 -2.60** Interpersonal Distrust Females 2.5 3.1 -0.22 Males 2.5 2.6 -0.20 Interoceptive Awareness Females 2.1 3.4 1.24 Males 1.7 3.3 1.21 Maturity Fears Females 2.7 2.7 -1.02 Males 3.1 3.6 -1.17 Asceticism Females 3.6 2.3 0.40 Males 3.4 2.5 0.42 Impulse Regulation Females 1.8 3.0 -1.69 Males 2.5 3.9 -1.91 Social Insecurity Females 3.6 3.4 0.96 Males 3.2 2.9 0.89 *p < .05, **p < .01 4

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92 Table 38. Eating Disorder Inventory Subscale Scores of College Students by Sex (EDI Manual, 1990) Subscale Mean Stand. Dev. Drive for Thinness Females 5.5 5.5 Males 2 . 2 4 . 0 Bulimia Females 1.2 1.9 Males 1.0 1.7 Body Dissatisfaction Females 12.2 8 . 3 Males 4.9 5.6 Ineffectiveness Females 2 . 3 3 . 6 Males 1.8 3 . 0 Perfectionism Females 6.2 3 . 9 Males 7 . 1 4.7 Interpersonal Distrust Females 2 . 0 3 . 1 Males 2.4 2 . 5 Interoceptive Awareness Females 3 . 0 3 . 9 Males 2 . 0 3 . 0 Maturity Fears Females 2.7 2 . 9 Males 2.8 3.4 Asceticism Females 3.4 2 . 2 Males 3 . 8 2 . 9 Impulse Regulation Females 2.3 3 . 6 Males 2.8 4 3.8 Social Insecurity Females 3 . 3 3 . 3 Males 3 . 3 3.2

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93 The null hypotheses for this study presented in Chapter 1 are listed below. 1. Ho: No statistically significant differences exist between subject's self-reported current weight, highest past weight, lowest weight as an adult, and ideal weight by sex. Follow-up Tests: a. current weight and ideal weight for females b. current weight and ideal weight for males c. current weight and lowest weight as an adult for females d. current weight and lowest weight as an adult for males e. current weight and highest past weight for females f. current weight and highest past weight for males g. highest past weight and lowest weight as an adult for females h. highest past weight and lowest weight as an adult for males i. highest past weight and ideal weight for females j . highest past weight and ideal weight for males k. ideal weight and lowest weight as an adult for females l. ideal weight and lowest weight as an adult for males

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94 2. Ho: No statistically significant differences exist in Eating Disorder Inventory subscale scores by a . Sex b . Race c. Year in college d. Current living arrangement e. Marital status f . Health education focus gArea of professional interest h. Self-reported eating disordered behavior i . Difference between current weight and highest past weight j • Difference between current weight and ideal weight k. Difference between current weight and lowest weight as an adult Null Hypothesis #1 No statistically significant difference exists between subjects' self-reported current weight, highest past weight, lowest weight as an adult, and ideal weight by sex. Table 39 presents the Repeated Measures Analysis of Variance (ANOVA) for subjects' self-reported current weight, highest past weight, lowest weight as an adult, and ideal weight for between and within subjects effects by sex. The calculated F-Value of 261.45 for the sex effect was statistically significant at the 0.01 alpha level. The

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95 information presented in Table 39 indicates a statistically significant interaction of weight by sex (F = 24.10, p < .01). Consequently, the null hypothesis of no statistically significant difference between current weight, highest past weight, lowest weight as an adult, and ideal weight by sex was rejected. Table 39. Repeated Measures Analysis of Variance for Between and Within Subjects Effect for Weight by Sex Source of Variation Degrees of Freedom F-Value Between Sex 1 261.45* Error 357 Within Weight 3 292 . 13** Weight*Sex 3 24 . 10** Error 1071 *p < .01; **p < .01 with Huynh-Feldt correction Null Hypothesis #la, #lb, #lc, #ld, #le, #lf, #lg, #lh, #li, #lj, #lk, #11 Follow Up Tests to Ho: #1: a. current weight and ideal weight for females b. current weight and ideal weight for males c. current weight and lowest weight as an adult for < females d. current weight and lowest weight as an adult for males

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96 Table 40. Follow-up Pairwise Comparisons for Difference Between Current, Weight, Highest Past Weight, Lowest Weight as an Adult, and Ideal Weight by Sex Comparison F-Value for Females F-Value for Males Current Weight Minus Ideal Weight 178 . 09** . 61 Highest Weight 118 . 50** 39.93** Lowest Weight 248 . 10** 143 . 68** Highest Weight Minus Lowest Weight 706 .46** 335 . 09** Ideal Weight 581.65** 49.69** Ideal Weight Minus Lowest Weight 5.73 121.71** ** p < .05 with Bonferroni correction e. current weight and highest past weight for females f. current weight and highest past weight for males g. highest past weight and lowest weight as an adult for females h. highest past weight and lowest weight as an adult for males i. highest past weight and ideal weight for females j . highest past weight and ideal weight for males k. ideal weight and lowest weight as an adult for females l. ideal weight and lowest weight as an adult for males ‘ As presented in Table 40, all pairwise comparisons listed in Null Hypothesis la 11 were statistically

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97 significant (p < .05 with Bonferroni correction) except for the difference between ideal weight and lowest weight as an adult for females and the difference between ideal weight and current weight for males. Consequently, the null hypotheses of no statistically significant difference was rejected except for the difference between current weight and ideal weight for males and the difference between ideal weight and lowest weight as an adult for females. Using the Statistical Analysis System multiple regression technique, Null Hypothesis #2 was tested. The following variables were entered for each Eating Disorder Inventory subscale: difference between current and highest past weight, lowest weight as an adult, and ideal weight; sex, year in college, race, current living arrangement, marital status, health education focus, area of professional interest, and items on the Eating Habits of Athletes Survey (eating-disordered behavior) . Null Hypothesis #2a No statistically significant difference exists in Eating Disorder Inventory subscale scores by sex. Using Type III sum of squares to control for other variable effects, sex was not a statistically significant variable in any of the Eating Disorder Inventory subscale scores. Therefore, the null hypothesis of no statistically significant difference was accepted.

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98 Null Hypothesis #2b No statistically significant difference exists in Eating Disorder Inventory subscale scores by race. Using Type III sum of squares to control for other variable effects, race was not a statistically significant variable in any of the Eating Disorder Inventory subscale scores. Therefore, the null hypothesis of no statistically significant difference was accepted. Null Hypothesis #2c No statistically significant difference exists in Eating Disorder Inventory subscale scores by year in college . Using Type III sum of squares to control for other variable effects, year in college was not a statistically significant variable in any of the Eating Disorder Inventory subscale scores. Therefore, the null hypothesis of no statistically significant difference was accepted. Null Hypothesis #2d No statistically significant difference exists in Eating Disorder Inventory subscale scores by current living arrangement . Using Type III sum of squares to control for other variable effects, current living arrangement was a statistically significant variable at the .05 alpha level for the Social Insecurity subscale. The Social Insecurity subscale score increased as the current living arrangement

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99 increased (B-value = 0.57). Consequently, subjects who reported living in a sorority or fraternity House (code = 0) scored the lowest on the Social Insecurity subscale. Subjects living in an on campus residence hall (code = 1) scored .57 higher than those living in a fraternity or sorority house. Off campus apartment/house (code = 2) dwellers scored .57 higher than those living on campus. Subjects living with parents (code = 3) , scored the highest on the Social Insecurity subscale, .57 higher than subjects living off campus. Therefore, the null hypothesis of no statistically significant difference in Social Insecurity subscale scores by current living arrangement was rejected. Null Hypothesis #2e No statistically significant difference exists in Eating Disorder Inventory subscale scores by marital status. Using Type III sum of squares to control for other variable effects, marital status was not a statistically significant variable in any of the Eating Disorder Inventory subscale scores. Therefore, the null hypothesis of no statistically significant difference was accepted. Null Hypothesis #2f No statistically significant difference exists in Eating Disorder Inventory subscale scores by health education focus. Using Type III sum of squares to control for other variable effects, health education focus was not a

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100 statistically significant variable in any of the Eating Disorder Inventory subscale scores. Therefore, the null hypothesis of no statistically significant difference was accepted. Null Hypothesis #2g No statistically significant difference exists in Eating Disorder Inventory subscale scores by area of professional interest. Using Type III sum of squares to control for other variable effects, weight management was a statistically significant variable at the .01 alpha level for the Drive for Thinness subscale. The Drive for Thinness subscale score increased as weight management decreased (B-value = 1.5). Therefore, the null hypothesis of no statistically significant difference in Drive for Thinness subscale scores by professional interest area of weight management was rejected. Subjects who selected weight management as an area of professional interest were more likely to have a higher Drive for Thinness subscale score. Table 41 provides a summary of Area of Professional Interest B-Values for the Drive for Thinness subscale. Using Type III sum of squares to control for other variable effects, sexuality was a statistically significant variable at the .05 alpha level ‘for the Asceticism subscale. The Asceticism subscale score increased as the variable assessing professional interest in sexuality increased (B-

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101 Table 41. Area of Professional Interest B-Values for the Drive for Thinness Subscale. Area of Professional Interest B-Value Weight Management -1.50 Cancer/Cardiovascular Disease -0.48 Aging/ Death and Dying -0.29 Environmental Health -0.24 Sexuality -0.18 Stress Management 0.48 Wellness 0.00 Exercise and Fitness 0.23 Alcohol/Drug Education 0.42 Mental Health 0.49 Nutrition 0.66 Table 42. Area of Professional Asceticism Subscale. Interest B-Values for the Area of Professional Interest B-Value Cancer/Cardiovascular Disease -0.45 Wellness -0.27 Alcohol/Drug Education -0.13 Mental Health -0.04 Aging/Death and Dying -0.03 Environmental Health 0.01 Nutrition 0 . 07 Weight Management 0.18 Stress Management 0.20 Exercise and Fitness 0.23 Sexuality 0.73 value = 0.73). Therefore, the null hypothesis of no statistically significant difference in Asceticism subscale scores by the professional interest area of sexuality was rejected. Subjects who did not select sexuality as an area of professional interest were more likely to have a higher

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102 Asceticism subscale score. Table 42 provides a summary of Area of Professional Interest B-Values for the Asceticism subscale . Null Hypothesis #2h No statistically significant difference exists between Eating Disorder Inventory subscale scores and self-reported eating-disordered behavior. Drive For Thinness Subscale: Using Type III sum of squares to control for other variable effects, PAIN, FEAR, GAIN, DOWN, and YOUED were statistically significant variables at the .01 alpha level for the Drive for Thinness subscale. The Drive for Thinness subscale score increased as PAIN (B-value = 3.48) increased, FEAR (B-value = -1.71) decreased, GAIN (B-value = -2.73) decreased, DOWN (B-value = -4.47) decreased, and YOUED (Bvalue = 2.06) increased. Therefore, the null hypothesis of no statistically significant difference in Drive for Thinness subscale score by eating-disordered behavior was rejected for the following variables: PAIN, FEAR, GAIN, DOWN, and YOUED (See Table 43). Body Dissatisfaction subscale: Using Type III sum of squares to control for other variable effects, FAD, CON, and DOWN were statistically significant variables at the .01 alpha level for the Body Dissatisfaction subscale. The Body Dissatisfaction subscale score increased as FAD (B-value = -4.45) decreased, CON (B-

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103 Table 43. Multiple Regression of Demographics, Items on the Eating Habits of Athletes Survey and Difference Between Current Weight and Highest Past Weight, Ideal Weight, and Lowest Weight as an Adult and the Drive for Thinness and Body Dissatisfaction Subscales Variable Drive B-Value for F Thinness (Type III SS) Body Dissatisfaction B-Value F (Type III SS) SEX 0.30 0.11 -1.54 0.93 YEAR 0.09 0.10 -0.64 1.60 RACE -0.02 0.00 -0.46 0.78 CLA 0.28 0.94 -0.69 1.73 MS -0.15 0.22 -0.50 0.84 HEF 0.16 1.98 0.12 0.36 DD -0.29 0.48 0.03 0.00 DE 0.42 0.90 0.87 1.21 CVD -0.48 1.40 -0.42 0.34 EH -0.24 0.35 -0.94 1.70 EX 0.23 0.18 0.69 0.49 MH 0.49 1.28 0.99 1.66 NUT 0.66 1.62 0.63 0.48 SE -0.18 0.14 -0.91 1.13 ST 0.48 1.07 1.26 2.34 WM -1.50 9.27** -0.60 0.47 WE 0.00 0.00 0.35 0.12 FAD -0.61 0.63 -4.45 10.57** VE -0.15 0.14 0.71 0.99 FAST 1.40 1.68 -0.12 0.00 PILLS 2.07 2.80 -2.09 0.89 LAX 0.16 0.01 3.49 0.93 DIU 0.26 0.03 0.41 0.02 VOM 2.32 1.26 0.48 0.02 BE -0.66 0.46 -0.57 0.11 PAIN 3.48 8.19** 3.73 2.99 ALONE -0.92 1.78 -0.28 0.05 NCON -0.25 0.10 -0.20 0.02 SIV -1.18 0.62 3.03 1.32 CON -0.82 3.47 -3.19 16.65** AN 0.18 0.06 -0.02 0.00 FEAR -1.71 8.71** 0.02 0.00 MEN -0.77 1.13 -1.98 2.35 TOO 0.45 0.78 0.37 0.17 THINK -0.87 2.87 -0.66 0.53 FAT 1.45 3.02 3.16 4.57* GAIN -2.53 19.07** -2.39 5.36* DOWN -4.47 48.01** -3.28 8 . 34** DIET -0.07 0.06 -0.55 1.22 NOFOOD 0.37 0.78 -0.72 0.95 SMALL 0.25 1.42 0.26 0.47 LAXWC 1.05 1.54 0.86 0.52 SIVWC 0.13 0.04 2.43 4.35* NUMB I -0.90 2.96 0.03 0.00 D I AGED -0.42 0.60 -1.87 3.79 YOUED 2.06 9.50** * 0.25 0.05 HWCW 0.00 0.02 0.07 5.44* CWLW -0.02 1.37 0.03 0.55 CWIW ** n * n 1 0.04 k -r-, ^ nc 6.20* 0.14 19.35** R-square = .70 R-square 58

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104 Table 44. Multiple Regression of Demographics, Items on the Eating Habits of Athletes Survey and Difference Between Current Weight and Highest Past Weight, Ideal Weight, and Lowest Weight as an Adult and the Bulimia and Ineffectiveness Subscales Bulimia Ineffectiveness Variable B-Value F (Type III SS) B-Value ] ? (Type III SS) SEX 0.04 0.60 -0.49 0.29 YEAR 0.17 1.05 0.03 0.01 RACE 0.00 0.00 0.05 0.02 CLA 0.13 0.59 0.46 2.18 MS 0.00 0.00 -0.10 0.10 HEF -0.07 1.21 0.15 1.64 DD -0.07 0.08 0.28 0.40 DE -0.14 0.28 -0.57 1.56 CVD -0.02 0.00 0.10 0.06 EH -0.18 0.57 0.14 0.12 EX 0.04 0.01 0.21 0.14 MH 0.29 1.33 -0.68 2.27 NUT 0.07 0.05 -0.19 0.13 SE 0.09 0.11 0.89 3.30 ST 0.42 2.45 0.52 1.18 WM -0.39 1.94 -0.53 1.09 WE 0.43 1.78 0.56 0.92 FAD -0.58 1.68 -1.08 1.82 VE -0.07 0.08 0.32 0.59 FAST 1.02 2.69 1.28 1.32 PILLS -0.37 0.27 0.87 0.47 LAX -0.25 0.05 -4.29 4.45* DIU -1.05 1.29 0.46 0.08 VOM 0.69 0.35 -1.11 0.28 BE -0.87 2.41 1.19 1.41 PAIN -1.12 2.55 2.28 3.29 ALONE -0.07 0.03 -1.01 2.06 NCON -0.86 3.30 -0.61 0.52 SIV -0.42 0.24 -0.91 0.36 CON -0.12 0.24 -1.05 5.41* AN -0.49 1.25 -0.72 0.84 FEAR -0.39 1.36 -0.47 0.63 MEN 0.12 0.08 1.33 1.77 TOO -0.24 0.66 -0.94 3.22 THINK 0.47 2.56 0.79 2.27 FAT 1.03 4.59* 1.77 4.23* GAIN 0.01 0.00 -0.19 0.10 DOWN -1.92 27.27** -3.09 21.35** DIET -0.30 3.57 -0.27 0.90 NOFOOD 0.45 3.50 0.34 0.61 SMALL -0.15 1.46 -0.17 0.64 LAXWC -0.52 1.77 -2.12 9.21** SIVWC 0.04 0.01 -0.22 0.11 NUMB I 0.64 4.41* 0.09 0.03 DIAGED -0.31 1.03 -0.69 1.54 YOUED 0.79 4.26* 2.74 15.80** HWCW 0.00 0.12 0.03 3.88* CWLW -0.01 0.42 0.03 2.05 CWIW 0.04 15.13** 0.02 1.06 ** p < .01, * p < .05 R-square = .53 R-square = .32

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105 Table 45. Multiple Regression of Demographics, Items on the Eating Habits of Athletes Survey and Difference Between Current Weight and Highest Past Weight, Ideal Weight, and Lowest Weight as an Adult and the Perfectionism and Asceticism Subscales Variable Perfectionism B-Value F (Type III SS) Asceticism B-Value F (Type III SS) SEX 1.48 1.51 0.21 0.11 YEAR -0.36 0.90 0.16 0.68 RACE -0.07 0.03 0.28 1.61 CLA 0.26 0.43 0.39 3.61 MS -0.14 0.11 -0.01 0.00 HEF -0.24 2.57 -0.01 0.01 DD -0.27 0.23 -0.03 0.01 DE 0.20 0.11 -0.13 0.19 CVD -0.40 0.53 -0.45 0.03 EH 0.33 0.37 0.01 0.00 EX -0.46 0.39 0.23 0.38 MH -0.19 0.11 -0.04 0.02 NUT -0.39 0.33 0.07 0.04 SE 0.13 0.04 0.73 4.99* ST 1.18 3.60 0.20 0.38 WM 0.25 0.14 0.18 0.27 WE -0.44 0.34 -0.27 0.46 FAD 0.18 0.03 -0.25 0.22 VE -0.60 1.27 -0.30 1.13 FAST 2.15 2.25 1.24 2.63 PILLS -2.48 2.28 -1.31 2.31 LAX -0.63 0.06 0.94 0.47 DIU 1.74 0.67 -0.27 0.06 VOM -2.80 1.08 -0.05 0.00 BE -0.89 0.43 -0.85 1.59 PAIN 1.20 0.55 0.27 0.10 ALONE -1.52 2.73 -0.66 1.92 NCON -2.00 3.26 -0.23 0.17 SIV 5.07 6.59* -0.29 0.08 CON 0.41 0.49 -0.10 0.10 AN -0.13 0.02 -0.80 2.25 FEAR -0.77 1.02 -0.58 2.03 MEN -0.28 0.08 -0.00 0.00 TOO 0.39 0.33 -0.29 0.68 THINK -0.45 0.44 -0.34 0.93 FAT 0.79 0.51 0.92 2.51 GAIN 0.67 0.75 0.08 0.04 DOWN 1.15 1.82 -0.55 1.52 DIET -0.33 0.79 -0.03 0.03 NOFOOD 1.01 3.33 0.05 0.04 SMALL 0.37 1.73 0.11 0.57 LAXWC -0.60 0.44 0.61 1.71 SIVWC 1.30 2.22 -0.35 0.59 NUMB I -1.21 2.56 -0.24 0.43 D I AGED 1.27 3.13 -0.12 0.11 YOUED 0.54 0.38 0.61 1.77 HWCW 0.00 0.03 -0.00 0.18 CWLW 0.03 1.33 0.00 0.11 CWIW 0.02 0.74 0.02 3.95* ** p < .01, * p < .05 R-square = .18 R-square = .24

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106 Table 46. Multiple Regression of Demographics, Items on the Eating Habits of Athletes Survey and Difference Between Current Weight and Highest Past Weight, Ideal Weight, and Lowest Weight as an Adult and the Social Insecurity and Impulse Regulation Subscales Variable Social Insecurity Impulse Regulation B-Value F (Type III SS) B-Value F (Type III SS) SEX -0.92 1.19 1.48 3.14 YEAR -0.11 0.17 0.08 0.10 RACE 0.03 0.01 0.12 0.17 CLA 0.57 4.07* 0.40 1.95 MS -0.41 2.02 0.07 0.07 HEF 0.11 1.12 0.15 2.07 DD 0.44 1.22 -0.38 0.95 DE -0.50 1.45 -0.61 2.18 CVD 0.10 0.07 0.48 1.64 EH -0.23 0.35 0.25 0.42 EX 0.04 0.01 0.37 0.51 MH -0.44 1.16 -0.44 1.18 NUT -0.32 0.45 0.51 1.17 SE 0.43 0.92 0.76 3.00 ST 0.24 0.30 -0.31 0.51 WM 0.13 0.07 -0.17 0.14 WE 0.60 1.29 -0.32 0.37 FAD 0.48 0.43 -1.03 2.07 VE 0.53 1.95 0.01 0.00 FAST -1.10 1.12 1.13 1.22 PILLS 1.88 2.60 1.22 1.12 LAX -0.06 0.00 -0.26 0.02 DIU -1.70 1.26 -0.79 0.28 VOM -2.60 1.80 -1.12 0.34 BE 0.69 0.57 0.40 0.20 PAIN 2.40 4.42* 0.78 0.48 ALONE -2.81 19.08** -1.19 3.52 NCON -0.59 0.58 -0.06 0.01 SIV -0.13 0.01 -1.50 1.19 CON -1.17 8.11** -0.91 4.98* AN -0.22 0.10 -1.25 3.07 FEAR -0.25 0.20 -0.79 2.10 MEN 1.07 2.46 -0.22 0.11 TOO -1.30 7.37** -0.51 1.15 THINK 0.25 0.27 0.58 1.52 FAT 0.47 0.35 1.08 1.91 GAIN -0.24 0.20 -0.03 0.00 DOWN -1.38 5.12* -2 . 18 13.11** DIET 0.05 0.03 0.19 0.55 NOFOOD -0.46 1.35 0.35 0.80 SMALL 0.01 0.00 -0.15 0.60 LAXWC -0.92 2.10 -0.06 0.01 SIVWC 0.05 0.01 0.46 0.56 NUMB I 0.22 0.21 0.33 0.45 D I AGED -0.46 0.81 : -0.66 1.74 YOUED 1.13 3.29 -0.12 0.04 HWCW 0.00 0.03 0.02 1.10 CWLW 0.05 7.37** 0.00 0.00 CWIW -0.01 0.09 0.02 1.17 ** p < .01, * p < .05 R-square = .29 R-square = .29

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107 Table 47. Multiple Regression of Demographics, Items on the Eating Habits of Athletes Survey and Difference Between Current Weight and Highest Past Weight, Ideal Weight, and Lowest Weight as an Adult and the Maturity Fears and Interoceptive Awareness Subscales Variable Maturity B-Value F Fears (Type III SS) Interoceptive Awareness B-Value F (Type III SS) SEX 0.15 0.04 0.41 0.27 YEAR 0.02 0.00 0.43 2.92 RACE 0.06 0.05 0.20 0.59 CLA 0.34 1.73 0.08 0.11 MS 0.27 0.99 0.02 0.01 HEF 0.11 1.17 0.05 0.28 DD 0.25 0.45 0.19 0.26 DE 0.61 2.45 0.19 0.24 CVD 0.05 0.02 0.66 3.46 EH 0.08 0.05 0.22 0.38 EX 0.37 0.59 0.24 0.23 MH 0.22 0.33 0.33 0.75 NUT 0.05 0.01 0.21 0.22 SE 0.72 2.90 0.76 3.28 ST 0.34 0.70 0.04 0.01 WM 0.04 0.01 0.70 2.65 WE 0.42 0.70 0.66 1.78 FAD 0.54 0.65 1.12 2.72 VE 0.28 0.66 0.02 0.01 FAST 0.26 0.08 3.59 14 . 28 ** PILLS 1.32 1.48 2 . 14 3 . 89 * LAX 0.53 0.09 1.73 1.01 DIU 3.70 6 . 82 ** 3.46 6 . 03 * VOM 1.15 0.41 1.29 0.52 BE 0.23 0.07 0.73 0.73 PAIN 2.48 5 . 39 * 0.15 0.02 ALONE 0.63 1.07 0.46 0.58 NCON 0.89 1.52 1.21 2.41 SIV 3.33 5 . 20 * 1.68 1.66 CON 0.67 3.04 0.54 1.96 AN 1.11 2.78 1.11 2.74 FEAR 0.42 0.67 0.69 1.81 MEN 0.57 0.79 0.32 0.25 TOO 1.28 8 . 20 ** 0.50 1.24 THINK 0.76 2.86 0.80 3.16 FAT 0.59 0.64 1.63 4 . 93 * GAIN 0.20 0.15 0.27 0.28 DOWN 1.74 9 . 67 ** 3.32 34 . 93 ** DIET 0.35 2.05 0.23 0.86 NOFOOD 0.37 1.02 1.39 14 . 21 ** SMALL 0.06 0.12 0.19 1.01 LAXWC 0.32 0.29 1.02 2.92 SIVWC 1.17 3 . 99 * 0.27 0.23 NUMB I 0.90 3.72 0.29 0.40 D I AGED 0.89 3.53 0.39 0.69 YOUED 0.32 0.31 1.29 4 . 80 * HWCW 0.03 3.56 0.01 0.81 CWLW 0.00 0.01 0.02 1.24 CWIW *
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108 Table 48. Multiple Regression of Demographics, Items on the Eating Habits of Athletes Survey and Difference Between Current Weight and Highest Past Weight, Ideal Weight, and Lowest Weight as an Adult and the Interpersonal Distrust Subscale Variable B-Value F-Value (Type III SS) SEX -0.48 0.35 YEAR -0.04 0.03 RACE -0.05 0.03 CLA 0.29 1.22 MS -0.38 1.92 HEF 0.05 0.28 DD 0.64 2.79 DE -0.03 0.01 CVD 0.08 0.05 EH 0.09 0.07 EX -0.03 0.00 MH -0.01 0.00 NUT 0.47 1.01 SE 0.25 0.33 ST 0.21 0.26 WM -0.17 0.15 WE 0.72 2.01 FAD 0.66 0.91 VE 0.35 0.95 FAST -0.44 0.21 PILLS 1.15 1.09 LAX 0.47 0.07 DIU 0.07 0.00 VOM -0.21 0.01 BE -0.05 0.00 PAIN 1.76 2.61 ALONE -1.22 3.91 NCON -0.79 1.13 SIV -0.14 0.01 CON -0.48 1.47 AN -0.90 1.76 FEAR -0.32 0.37 MEN 0.66 1.02 TOO -0.29 0.40 THINK 0.24 0.27 FAT 1.18 2.49 GAIN 0.54 1.09 DOWN -1.80 9.80** DIET 0.05 0.03 NOFOOD -0.15 0.17 SMALL 0.06 0.11 LAXWC -0.21 0.12 SIVWC 0.36 0.37 NUMB I 0.34 0.52 D I AGED -0.30 0.39 YOUED 0.38 0.40 HWCW 0.00 0.04 CWLW 0.03 3.06 CWIW -0.01 0.14 ** p < .01, * p < .05 R-square = .18

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109 value = -3.19) decreased, and DOWN (B-value = -3.28) decreased. Using Type III sum of squares to control for other variable effects, FAT, GAIN, and SIVWC were statistically significant variables at the .05 alpha level for the Body Dissatisfaction subscale. The Body Dissatisfaction subscale score increased as FAT (B-value = 3.16) increased, GAIN (Bvalue = -2.39) decreased, and SIVWC (B-value = 2.43) increased. Therefore, the null hypothesis of no statistically significant difference in Body Dissatisfaction subscale score by eating-disordered behavior was rejected for the following variables: FAD, CON, DOWN, FAT, GAIN, and SIVWC (Refer to Table 43) . Bulimia Subscale: Using Type III sum of squares to control for other variable effects, DOWN was a statistically significant variable at the .01 alpha level for the Bulimia subscale. The Bulimia subscale score increased as DOWN (B-value = -1.92) decreased. Using Type III sum of squares to control for other variable effects, FAT, NUMBI, and YOUED were statistically significant variables at the .05 alpha level for the Bulimia subscale. The Bulimia subscale score increased as FAT (Bvalue = 1.03) increased, NUMBI (B-value = 0.64) increased, and YOUED (B-value = 0.79) increased. Therefore, the null hypothesis of no statistically significant difference in

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110 Bulimia subscale score by eating-disordered behavior was rejected for the following variables: DOWN, FAT, NUMBI, and YOUED (See Table 44). Ineffectiveness Subscale: Using Type III sum of squares to control for other variable effects, DOWN, LAXWC, and YOUED were statistically significant variables at the .01 alpha level for the Ineffectiveness subscale. The Ineffectiveness subscale score increased as DOWN (B-value = -3.09) decreased, LAXWC (B-value = -2.12) decreased, and YOUED (B-value = 2.74) increased. Using Type III sum of squares to control for other variable effects, LAX, CON, and FAT were statistically significant variables at the .05 alpha level for the Ineffectiveness subscale. The Ineffectiveness subscale score increased as LAX (B-value = -4.29) decreased, CON (Bvalue = -1.05) decreased, and FAT (B-value = 1.77) increased. Therefore, the null hypothesis of no statistically significant difference in Ineffectiveness subscale score by eating-disordered behavior was rejected for the following variables: DOWN, LAXWC, YOUED, LAX, CON, and FAT (See Table 44) . Perfectionism Subscale: Using Type III sum of squares to control for other variable effects, SIV was a statistically significant variable at the .05 alpha level for the Perfectionism

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Ill subscale. The Perfectionism subscale score increased as SIV (B-value = -0.29) decreased. Therefore, the null hypothesis of no statistically significant difference in Perfectionism subscale score by eating-disordered behavior was rejected for the variable SIV (Refer to Table 45) . Asceticism Subscale: Using Type III sum of squares to control for other variable effects, no items on the Eating Habits of Athletes Survey were statistically significant in the Asceticism subscale score. Therefore, the null hypothesis of no statistically significant difference in Asceticism subscale score by eating-disordered behavior was accepted (Refer to Table 45) . Social Insecurity Subscale: Using Type III sum of squares to control for other variable effects, ALONE, CON, TOO were statistically significant variables at the .01 alpha level for the Social Insecurity subscale. The Social Insecurity subscale score increased as ALONE (B-value = -2.81) decreased, CON (B-value = -1.17) decreased, and TOO (B-value = -1.30) decreased. Using Type III sum of squares to control for other variable effects, PAIN and DOWN were statistically significant variables at the .05 alpha level for the Social Insecurity subscale. The Social Insecurity subscale score increased as PAIN (B-value = 2.40) increased and DOWN (Bvalue = -1.38) decreased. Therefore, the null hypothesis of

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112 no statistically significant difference in Social Insecurity subscale score by eating-disordered behavior was rejected for the following variables: ALONE, CON, TOO, PAIN, and DOWN (See Table 46) . Impulse Regulation Subscale: Using Type III sum of squares to control for other variable effects, DOWN was a statistically significant variable at the .01 alpha level for the Impulse Regulation subscale. The Impulse Regulation subscale score increased as DOWN (B— value = -2.18) decreased. Using Type III sum of squares to control for other variable effects, CON was a statistically significant variable at the .05 alpha level for the Impulse Regulation subscale. The Impulse Regulation subscale score increased as CON (B-value = -0.91) decreased. Therefore, the null hypothesis of no statistically significant difference in Impulse Regulation subscale score by eating-disordered behavior was rejected for the following variables: DOWN and CON (See Table 46) . Maturity Fears Subscale: Using Type III sum of squares to control for other variable effects, DIU, TOO, and DOWN were statistically significant variables at the .01 alpha level for the Maturity Fears subscale. The Maturity Fears subscale score increased as DIU (B-value = -3.70) decreased, TOO (B-value = -1.28) decreased, and DOWN (B-value = -1.28) decreased.

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113 Using Type III sum of squares to control for other variable effects, PAIN, SIV, and SIVWC were statistically significant variables at the .05 alpha level for the Maturity Fears subscale. The Maturity Fears subscale score increased as PAIN (B-value = 2.48) increased, SIV (B-value = 3.33) increased, and SIVWC (B-value = 1.17) increased. Therefore, the null hypothesis of no statistically significant difference in Maturity Fears subscale score by eating-disordered behavior was rejected for the following variables: DIU, TOO, DOWN, PAIN, SIV, and SIVWC (Refer to Table 47) . Interoceptive Awareness Subscale: Using Type III sum of squares to control for other variable effects, FAST, DOWN, and NOFOOD were statistically significant variables at the .01 alpha level for the Interoceptive Awareness subscale. The Interoceptive Awareness subscale score increased as FAST (B-value = 3.59) increased, DOWN (B-value = -3.32) decreased, and NOFOOD (Bvalue = 1.39) increased. Using Type III sum of squares to control for other variable effects, PILLS, DIU, FAT, and YOUED were statistically significant variables at the .05 alpha level for the Interoceptive Awareness subscale. The Interoceptive ' 4 Awareness subscale score increased as PILLS (B-value = 2.14) increased, DIU (B-value = -3.46) decreased, and FAT (B-value = 1.63) increased, and YOUED (B-value = 1.29) increased.

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114 Therefore, the null hypothesis of no statistically significant difference in Interoceptive Awareness subscale score by eating-disordered behavior was rejected for the following variables: FAST, DOWN, NOFOOD, PILLS, DIU, FAT, and YOUED (Refer to Table 47) . Interpersonal Distrust Subscale: Using Type III sum of squares to control for other variable effects, DOWN was a statistically significant variables at the .01 alpha level for the Interpersonal Distrust subscale. The Interpersonal Distrust subscale score increased as PILLS (B-value = -1.80) decreased. Therefore, the null hypothesis of no statistically significant difference in Interpersonal Distrust subscale score by eating-disordered behavior was rejected for the variable DOWN (See Table 48) . Null Hypothesis #2i No statistically significant difference exists between Eating Disorder Inventory subscale scores and difference between current weight and highest past weight. Using Type III sum of squares to control for other variable effects, the difference between current weight and highest past weight was a statistically significant variable at the .05 alpha level for the Ineffectiveness and Body 4 Dissatisfaction subscales. The Ineffectiveness subscale score increased as the difference between current and highest past weight increased (B-value = 0.03). The Body

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115 Dissatisfaction subscale score increased as the difference between current and highest past weight increased (B-value = 0.07). Therefore, the null hypothesis of no statistically significant difference in Ineffectiveness and Body Dissatisfaction subscale scores by the difference between current weight and highest past weight was rejected. Null Hypothesis #2j No statistically significant difference exists between Eating Disorder Inventory subscale scores and difference between current weight and ideal weight. Using Type III sum of squares to control for other variable effects, the difference between current weight and ideal weight was a statistically significant variable at the .05 alpha level for the Drive for Thinness and Asceticism subscales. The Drive for Thinness score increased as the difference between current and ideal weight increased (Bvalue = 0.04) . The Asceticism subscale score increased as the difference between current and ideal weight increased (B-value = 0.02). Therefore, the null hypothesis of no statistically significant difference in Drive for Thinness and Asceticism subscale scores by the difference between current weight and ideal weight was rejected. Using Type III sum of squares to control for other Â’ 4 variable effects, the difference between current weight and ideal weight was a statistically significant variable at the .01 alpha level for the Body Dissatisfaction and Bulimia

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116 subscales. The Body Dissatisfaction subscale score increased as the difference between current and ideal weight increased (B-value = 0.14). The Bulimia subscale score increased as the difference between current and ideal weight increased (B-value = 0.04). Therefore, the null hypothesis of no statistically significant difference in Body Dissatisfaction and Bulimia subscale scores by the difference between current weight and ideal weight was rejected. Null Hypothesis #2k No statistically significant difference exists between Eating Disorder Inventory subscale scores and difference between current weight and lowest weight. Using Type III sum of squares to control for other variable effects, the difference between current weight and lowest weight as an adult was a statistically significant variable at the .05 alpha level for the Social Insecurity subscale. The Social Insecurity subscale score increased as the difference between current and lowest weight as an adult increased (B-value = 0.05). Therefore, the null hypothesis of no statistically significant difference in Social Insecurity subscale scores by the difference between current weight and lowest weight as an adult ideal weight was rejected.

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117 Summary of Subjects' Written Comments Fifty-six students wrote additional comments on the end of the questionnaire (see Appendix F) . Fourteen students added comments indicating the questionnaire was too long, inappropriate, or repetitious. Several students wished this writer good luck; two students suggested additional questions for use in future research. One student thought he/ she had an eating disorder in the past, but was never diagnosed. Four students indicated they thought they had an eating disorder other than anorexia nervosa or bulimia nervosa. One student was pleased the health education field is addressing the disordered eating issue. Four students wrote they had or were presently seeking counseling related to eating problems. Seven students expressed concern with their weight. One student wrote, "When I diet, I use Slim Fast and exercise." Discussion of Results Introduction A discussion of the study results is provided in this portion. This section is organized into the following parts: (1) Weight Comparisons by Sex, (2) Estimated Eating Disorder Prevalence, (3) Self-Reported Eating-Disordered * Behavior Prevalence, (4) Attitudes and Beliefs Regarding Food and Weight, (5) Eating Disorder Inventory Subscales, and (6) Summary of Discussion of Results.

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118 Weight Comparisons by Sex All possible pair-wise comparisons between selfreported current weight, highest past weight, lowest weight as an adult, and ideal weight by sex were calculated. All comparisons were statistically significant at the .05 alpha level (with Bonferroni correction) except for the difference between ideal weight and lowest weight as an adult for females and the difference between current weight and ideal weight for males. The statistically significant difference between current weight and ideal weight for females suggests support for Rodin, Silberstein, and Striegel-Moore ' s (1985) proposition that females experience a "normative discontent" with weight. In addition, the difference between ideal weight and lowest weight as an adult was nonsignificant for females, but statistically significant for males, suggesting a thin standard (Garner, Garfinkel, Schwartz, & Thompson, 1980) of ideal weight for this group of female health education major students. Only 16% of females reported their ideal weight above the United States Department of Agriculture (1990) Suggested Weights for Adults, compared with 55% of male subjects. Asking male and female college students to select ideal and current figures instead of body weight, Fallon and Rozin's (1985) study yielded similar results regarding sex differences. They found the difference between current and

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119 ideal figures nonsignificant for males. For females, the same comparison was statistically significant, with females preferring a smaller figure as ideal compared to their current figure. Estimated Eating Disorder Prevalence Estimated eating disorder prevalence among undergraduate health education major students was calculated using three methods: (1) subjects' response to the question "Have you ever been diagnosed with an eating disorder?" (2) subjects' response to the question "Do you think you have an eating disorder?", and (3) subjects' responses to specific items relating to Diagnostical and Statistical Manual IllRevised diagnosis of bulimia nervosa and anorexia nervosa. As a cautionary note, a definite clinical diagnosis of an eating disorder is inappropriate without a clinical interview by a trained professional (Garner, 1990) . Therefore, these eating disorder prevalence figures should be viewed solely as estimates. Three percent (n = 3) of male subjects and 5.2% (n = 15) of females subjects indicated they thought they had an eating disorder. Three females and one male thought they had anorexia nervosa, ten females and one male thought they had bulimia nervosa, and two females and one male thought they had both anorexia nervosa and bulimia nervosa. Two males (1.9%) and two females (0.7%) reported being diagnosed with anorexia nervosa. Six females (2.1%) and one

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120 male (1.0%) indicated being diagnosed with bulimia nervosa. Three females (0.8%) and no males reported being diagnosed with both anorexia nervosa and bulimia nervosa. One student indicated in the section asking for written comments that they were never formally diagnosed, but family and friends thought they had an eating disorder. Four items on the Eating Habits of Athletes Survey related specifically to the Diagnostical and Statistical Manual Ill-Revised diagnostical criteria for anorexia nervosa. They included the following: (1) My weight is 15% or more below normal for my age and height (AN) , (2) I have an intense fear of becoming obese even though I am underweight or normal weight now (FEAR), (3) I think I am fat although I am underweight (FAT), and (4) I have had the absence of at least 3 consecutive menstrual cycles when they should have occurred (females only) (MEN) . No subjects met a ll criteria for a clinical diagnosis of anorexia nervosa. However, two females met criteria one, two, and three for the diagnosis of anorexia nervosa. Five items on the Eating Habits of Athletes Survey related specifically to the Diagnostical and Statistical Manual Ill-Revised diagnostical criteria for bulimia nervosa. They included the following: (1) I have regular episodes of binge eating (rapid consumption of foods that are easy to digest and high in calories in a short period of time) (BE), (2) During eating binges, I have a distinct

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121 feeling of not having control over my eating (NCON) , (3) I have a persistent concern with my body shape and weight (CON) , (4) What is your average number of eating binges within the last three months? (2 or more binge eating episodes per week) (NUMBI) , and (5) Using at least one of the following methods regularly for weight control: selfinduced vomiting, diuretics, laxatives, fasting, excessive or vigorous exercise, or fad dieting. No males and three females (1%) self-reported meeting all five criteria for bulimia nervosa. In general, these are much lower eating disorder prevalence rates than reported for students in other preprofessional programs. However, many previous studies used Diagnostical and Statistical Manual III criteria for bulimia nervosa and anorexia nervosa diagnosis, rather than the more stringent Diagnostical and Statistical Manual III Revised criteria. Individually addressing the Diagnostical and Statistical Manual III Revised criteria for anorexia nervosa, having a body weight of 15% or more below expected for age and height was reported by 7.6% of women and 9.6% of males. Nearly nine percent (8.7%) of females reported the absence of at least three consecutive menstrual cycles. Twenty-eight percent of females and 14.4% of males indicated ' « a fear of becoming obese though underweight. Nearly sixteen percent of females and 16.3% of males reported other people think they are too thin.

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122 Nearly four percent (3.8%) of males and 1.7% of females reported engaging in binge eating episodes two or more times per week in the last three months, one Diagnostical and Statistical Manual III Revised criterion for bulimia nervosa. Nearly 10% of females and 7.7% of males reported regular episodes of binge eating; 13.1% of females and 5.8% of males reported a distinct feeling of not having control over eating during eating binges. Nearly two-thirds (63.7) of females and 49% of males indicated a persistent concern with body shape and weight. In the written comments section (See Appendix F) , three students indicated they thought they had an eating disorder other than anorexia nervosa or bulimia nervosa. These students labeled their eating disorder "compulsive overeating". A new eating disorder, the binge eating disorder, has been proposed as a new addition to the Diagnostical and Statistical Manual IV (Walsh, 1992). Since limited data exists to support the binge eating disorder, it is considered the most controversial addition to the Diagnostical and Statistical Manual IV (Herzog, Walsh, Mitchell, Kaye, & Agras, 1991) . Self-Reported Eating-Disordered Behavior Prevalence Self-reported frequency of methods used for weight control at least once a month included: nearly one-fifth (19.3%) of males and 35.4% of females reported using fad dieting, fasting (no food for at least 24 hours) was used by

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122 Nearly four percent (3.8%) of males and 1.7% of females reported engaging in binge eating episodes two or more times per week in the last three months, one Diagnostical and Statistical Manual III Revised criterion for bulimia nervosa. Nearly 10% of females and 7.7% of males reported regular episodes of binge eating; 13.1% of females and 5.8% of males reported a distinct feeling of not having control over eating during eating binges. Nearly two-thirds (63.7) of females and 49% of males indicated a persistent concern with body shape and weight. In the written comments section (See Appendix F) , three students indicated they thought they had an eating disorder other than anorexia nervosa or bulimia nervosa. These students labeled their eating disorder "compulsive overeating". A new eating disorder, the binge eating disorder, has been proposed as a new addition to the Diagnostical and Statistical Manual IV (Walsh, 1992) . Since limited data exists to support the binge eating disorder, it is considered the most controversial addition to the Diagnostical and Statistical Manual IV (Herzog, Walsh, Mitchell, Kaye, & Agras, 1991) . Self-Reported Eating-Disordered Behavior Prevalence Self-reported frequency of ^methods used for weight control at least once a month included: nearly one-fifth (19.3%) of males and 35.4% of females reported using fad dieting, fasting (no food for at least 24 hours) was used by

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123 14.2% of females and 10.6% of males. Eating small quantities of food (less than 600 calories a day) was reported by 52.0% of females and 26.9% of males; laxative use was indicated by 7.6% of females and 2.0% of males. Three percent of males and 8.5% of females reported using self-induced vomiting. In studying college student athletes, Black and Burckes-Miller (1988) found 13.4% of women and 7.3% of men used fad dieting, 14.7% of women and 8.5% of men used fasting, 25.1% of women and 21.4% of men ate small quantities of food, 4.5% of women and 2.9% of men used laxatives, and 7.3% of females and 3.5% of males used selfinduced vomiting as forms of weight control at least one day a month. Compared to Black and Burckes-Miller ' s (1988) female subjects, more female undergraduate health education major students used fad dieting, eating small quantities of food, laxatives, and self-induced vomiting as forms of weight control at least one time a month. More undergraduate male health education major students used fad dicing and fasting than the males in Black and BurckesMiller ' s (1988) sample. Attitudes and Beliefs Regarding Food and Weight One-fourth of males and 36%. of females reported thinking about food -and their weight all the time and 15.4% of males and 38.1% of females were terrified of gaining weight. Nearly one-fourth (24.6%) of female subjects and

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124 9.6% of male subjects indicated feeling depressed and down on themselves after eating. Eating Disorder Inventory Subscales The Eating Disorder Inventory subscale score means and standard deviations for this group of health education major students were similar to a group of nonpatient college students. Selecting weight management as an area of professional interest was statistically related to a higher score on the Drive for Thinness subscale. A higher Asceticism score was statistically significantly related to not selecting sexuality as an area of professional interest. A fear of becoming obese though normal or underweight; being terrified of gaining weight; feeling down and depressed after eating; a professional interest in weight management/control; eating until stomach pain, interruptions by others, sleep, or vomiting; an increase in the difference between current weight and ideal weight; and thinking one has an eating disorder were statistically significant variables related to an increase in the Drive for Thinness subscale score. Using fad dieting regularly for weight control, a persistent concern with body shape and weight, feeling depressed and down after eating, being terrified of gaining weight, thinking one is fat although underweight, being terrified of gaining weight, feeling down and depressed after eating, using self-induced vomiting for weight control, an increase in the difference between

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125 highest past weight and current weight, and an increase in the difference between current weight and ideal weight were statistically significant variables related to an increase in the Body Dissatisfaction subscale score. Feeling depressed and down after eating, not thinking one is fat though underweight, and increase in number of eating binges in the last three months, thinking one has an eating disorder, and an increase in the difference between current weight and ideal weight were statistically significant variables related to an increase in the Bulimia subscale score . Using laxatives regularly for weight control, a persistent concern with body shape and weight, not thinking one is fat though underweight, feeling depressed and down after eating, increased frequency of using laxatives for weight control, thinking one has an eating disorder, and an increase in the difference between highest past weight and current weight were statistically significant variables related to an increase in the Ineffectiveness subscale score. An increase in the difference between current weight and ideal weight and not selecting sexuality education as an area of professional interest were statistically significant variables related to an increase in the Asceticism subscale ’ € score. Not liking people present when eating; persistent concern with body shape and weight; eating until stomach

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126 pain, interruptions from others, sleep, or self-induced vomiting; other people thinking one is too thin; feeling depressed and down after eating; and the difference between current weight and lowest weight as an adult were statistically significant variables related to an increase in the Social Insecurity subscale score. Feeling depressed and down after eating was a statistically significant variable related to an increase in the Interpersonal Distrust subscale. Using diuretics regularly for weight control; binge eating, then frequently self-inducing vomiting because of fear of gaining weight; other people thinking one is too thin; feeling depressed and down after eating; binge eating until stomach pain, interruptions from others, sleep, or self-induced vomiting; and increased use of self -induced vomiting for weight control were statistically significant variables related to an increase in the Maturity Fears subscale. Binge eating, followed by frequently selfinducing vomiting because of fear of gaining weight was a statistically significant variable related to an increase in the Perfectionism subscale score. A persistent concern with body shape and weight and feeling depressed and down after eating were statistically significant variables related to an increase in the Impulse Regulation subscale score. Not using fasting or diet pills regularly as a method of weight control, using diuretics

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127 regularly as a form of weight control, feeling down and depressed after eating, increased frequency of using fasting as a method of weight control, and thinking one has an eating disorder were statistically significant variables related to an increase in the Interoceptive Awareness subscale score. As a group, males scored at a statistically significantly higher level than females on the Perfectionism subscale. Females had higher scores of statistical significance than males on the Drive for Thinness and Body Dissatisfaction subscales. Summary of Discussion of Results Important results from this study are summarized as follows: (1) self-reported ideal weight was statistically significantly lower than current weight for female subjects, which suggests body dissatisfaction exists in female undergraduate health education major students (2) no statistically significant difference exists between male subjects' self-reported current weight and ideal weight, suggesting satisfaction with current body weight for male undergraduate health education major students (3) nonsignificance between female subjects' lowest weight as an adult and ideal weight suggests a thin standard of ideal weight for undergraduate female health education major students (4) using Diagnostical and Statistical Manual IllRevised criteria for anorexia nervosa and bulimia nervosa

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128 diagnosis, estimated prevalence of bulimia nervosa was 1.0% (n = 3) for females and 0% for males, lower reported eating disorder prevalence rates compared to students in other preprofessional programs, (5) no females or males met all the Diagnostical and Statistical Manual Ill-Revised criteria for anorexia nervosa, (6) many subjects met some of the Diagnostical and Statistical Manual Ill-Revised criteria for anorexia nervosa or bulimia nervosa, (7) many undergraduate health education major students use fad dieting, fasting, eating small quantities of food, laxatives, and self-induced vomiting as forms of weight control at least one time a month, (8) many subjects reported thinking about food and their weight all the time and/or are terrified of gaining weight, and (9) controlling for other variables, the only statistically significant relationships between professional interest areas and an increase Eating Disorder Inventory subscale scores included selecting weight management as an area of professional interest was statistically related to an increase in the Drive for Thinness subscale score and not selecting sexuality education was statistically related to an increase in the Asceticism subscale score.

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CHAPTER 5 SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS Summary This study assessed the nature and scope of selfreported eating disorders and eating-disordered behavior among undergraduate health education major students in the United States to (1) establish a baseline regarding the prevalence of such disorders among this specialized group of subjects and (2) provide information concerning appropriate professional preparation to address the needs of these subjects as individuals and as future health educators. A random sample was drawn of 394 health education major students attending 28 colleges and universities throughout the United States during Spring 1992. Test sites were obtained from a random sample of 25% of institutions in the United States offering an undergraduate or graduate major in Health Education (28% of institutions offering an undergraduate major in Health Education) in Eta Sicrma Gamma: A National Directory of College and University Health Education Programs and Faculties (1988) . The Eating Disorder Inventory and the Eating Habits of Athletes Survey were used to assess self-reported eating disorders and eating-disordered behavior. 129

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130 Resulting data were analyzed using the Statistical Analysis System. Differences between self-reported current weight, highest past weight, lowest weight as an adult, and ideal weight for all subjects and by sex were analyzed using repeated measures analysis of variance. Follow-ups of within sex differences were manually computed using the Fvalue formula, using a .05 alpha level critical value (with Bonferroni correction) . The statistical relationship between each Eating Disorder Inventory subscale and demographic variables, items on the Eating Habits of Athletes Survey, and difference between current weight and highest past weight, lowest weight as an adult, and ideal weight was determined using multiple regression. The difference between self-reported current and ideal weight was statistically insignificant for males; female subjects self-reported their ideal weight thinner than their current weight at a statistically significant level, suggesting (1) male undergraduate health education major students are generally satisfied with their current weight and (2) female undergraduate health education major students are generally dissatisfied with their current weight and want to be thinner. Using Diagnostical and Statistical Manual Ill-Revised criteria, 1% of females (n = 3) and 0% of males met all the criteria for bulimia nervosa; no males or females met all the criteria for anorexia nervosa diagnosis. Many students reported using eating-disordered behavior (fad

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131 dieting, laxatives, self-induced vomiting, fasting, eating small guantities of food, or excessive/vigorous exercise) for weight control. Means and standard deviations for the Eating Disorder Inventory subscale scores for this study were similar to another sample of nonpatient college students. Selecting weight management as an area of professional interest was statistically related to an increase in the Drive for Thinness subscale score on the Eating Disorder Inventory. Results suggest (1) undergraduate health education major students, particularly females, are not immune to societal pressure to maintain a thin body weight, (2) many undergraduate health education major students engage in eating-disordered behavior, and (3) students with a professional interest in weight management/ control may potentially perpetuate the current cultural obsession with thinness through their professional activities. Conclusions 1. Female undergraduate health education majors selfreported their ideal weight lower than their current weight at a statistically significant level; the difference between male subjects' current and ideal weight was nonsignificant, suggesting support for Rodin, SiJ.berstein, and StriegelMoore's (1985) view -that females experience a "normative discontent" with weight. In addition, the nonsignificant difference between ideal weight and lowest weight as an

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132 adult for females suggests a thin standard of ideal weight (Garner, Garfinkel, Schwartz, & Thompson, 1980) for female undergraduate health education major students. 2. Using Diagnostical and Statistical Manual III Revised criteria, bulimia nervosa prevalence was estimated at 1% (n = 3) for females and 0% for males. No cases of anorexia nervosa existed for males and females in this sample. Since (1) participation in this study was voluntary, (2) the informed consent procedure clearly indicated the study assessed eating disorder prevalence, and (3) eating disorder prevalence may be overrepresented in women choosing not to participate in eating disorder surveys (Beglin & Fairburn, 1992) , these reported prevalence rates may be lower than actual rates. Since a definite clinical diagnosis of anorexia nervosa or bulimia nervosa is impossible without a clinical interview (Garner, 1990) , the reported prevalence rates must be viewed solely as estimates. Resulting eating disorder prevalence rates for this study were lower compared to students in other pre-professional programs, possibly because the more stringent Diagnostical and Statistical Manual III Revised criteria was used in this study, rather than the Diagnostical and Statistical Manual III criteria. 3. Many male and female health education major students self-reported using eating-disordered behavior for weight control. In addition, many indicated concern with food, weight, and body shape.

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133 4. Selecting weight management as an area of professional interest was statistically related to an increase in the Drive for Thinness subscale score on the Eating Disorder Inventory . Recommendations 1. Results from this study demonstrated undergraduate health education major students, particularly females, did not appear immune from societal pressures equating attractiveness with a thin body. Females subjects' body dissatisfaction was exhibited by selecting an ideal weight statistically significantly less than their current weight. In addition, many male and female undergraduate health education major students self-reported engaging in eatingdisordered behavior and concern with food and body weight. As a consequence of these results. Health Education faculty and professional organizations need to (1) recognize status as a undergraduate health education major student does not exclude one from societal pressure to conform to unrealistically thin appearance standards and (2) include eating disorder information as an important and necessary component of professional preparation. 2. Students selecting weight management/ control as an area of professional interest were more likely to have a higher Drive for Thinness subscale score. Since persons of appropriate weight may seek out weight management/control workshops, the professional leading these activities needs

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134 to challenge their participation as inappropriate (Hotelling, 1989) . A future health educator suffering from an eating disorder or engaging in eating-disordered behavior could potentially transmit these attitudes to their clients. 3. Helping students resist societal pressure to conform to unrealistic appearance standards is critical for prevention of eating disorders and eating-disordered behavior (Nagel & Jones, 1992). Levine (1987) suggested two specific eating disorder prevention strategies for educators: (1) examine one's own attitudes, beliefs, and behaviors regarding emphasis on thinness and/or prejudice against overweight and even normal weight persons and to (2) eliminate negative statements about overweight persons from language and educational media. Collins (1991b) indicated healthy body image may be encouraged by (1) modeling acceptance of body size and shape diversity among persons of all ages and (2) presenting strategies to cope with life problems often hidden in weight preoccupation. Healthy acceptance of self and others may be promoted through education and personal example. 4. Further studies are needed to replicate these results, since this is the first such study directed at health education preprofessional programs. 5. Four quotes relevant to study results and scope follow:

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135 a. "When dieting ceases to be seen as an acceptable solution, it may be possible to shift the focus . . . away from weight and onto living" (Willmuth, 1986, p. 35) . b. Boston Globe columnist, Ellen Goodman, suggested schools need "eating education. In the meantime, if you find an American woman who doesn't know her weight, never counted a single fat gram and is delighted with her body, send her name to the tabloids. That's an American story as rare as anything you'll find across the aisle from the Snickers" (Goodman, 1993, 8A) . c. "As the media appear to be able to influence people's thoughts, desires, and self-concepts, their role in promoting obsession with weight, chronic dieting, and eating disorders among women deserves not only further study, but also, perhaps, pressure for change" (Silverstein, Perdue, Peterson, & Kelly, 1986, p. 532). d. "It is precisely because thinness is unattainable by more than a fortunate few in our society that it is so valued" (Wooley, Wooley, & Dyrenforth, 1979, p. 81) .

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APPENDIX A UNIVERSITY OF FLORIDA INSTITUTIONAL REVIEW BOARD HUMAN SUBJECTS APPROVAL

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UNIVERSITY OF FLORIDA INSTITUTIONAL REVIEW BOARD 114 PSYCHOLOGY BUILDING GAINESVILLE. FL 32811-2068 19041 332 0433 March 12, 1992 TO: FROM: Ms. Rebecca A. Brev 5 FLG C. Michael Levy, Chah£\\\ University of Florida Irisfli Review Board d utionai SUBJECT: Approval of Projea #92.081 E a t i n g disorders & eanng disordered behavior among undergraduate health education major students in the United States I am pleased to advise you that the University of Florida Institutional Review Board has recommended the approval of this project. The Board concluded that your subjects will not be placed at risk m this research, and that it is not essential that you obtain legally effective (signed, witnessed) informed consent from each participant. If you wish to make any changes in this protocol, you must disclose your plans before you implement them so that the Board can assess their imp a ct on your project. In addition, you must report to the Board any unexpected complications arising from the projea which affea your subjects. If you have not completed this projea by March 12, 1993, please telephone our office (392-0433) and we will tell you how to obtain a renewal. By a copy of this memorandum, your Chair is reminded of the importance of being fully informed about the status of all projects involving human subjects in your department, and for reviewing these projects as often as necessary to insure that each projea is being conducted in the mann er approved by this memorandum. CML/her cc Vice President for Research Grad Student Research Grant College Dean Dr. R. Morgan Pigg EQUAL EMPLOYMENT OPPO*T\**TY/AF«*MAT1V« ACTION EMPLOYE* 137

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APPENDIX B CORRESPONDENCE WITH UNIVERSITY/ COLLEGE PERSONNEL

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March 19, 1992 Dr. Charles F. Kegley Dept, of Adult, Counseling, Health & Vocational Education 316 White Hall Kent State University Kent, OH 44242 Dear Dr. Kegley: I am writing to request your help in conducting a national study concerning eating disorders (anorexia nervosa and bulimia) and eating-disordered behavior among undergraduate health education majors. As a doctoral candidate in the Department of Health Science Education at the University of Florida, I hope your institution can participate in my dissertation research. Dr. R. Morgan Pigg, Jr. is serving as Ph.D. committee chair for the project. Your institution has been selected at random as a possible participating institution. Recognizing your heavy workload, I have minimized the time required for this project. I am asking your department to: 1. Name a contact person to coordinate on-site activities at your institution. (For purposes of professional accountability, this person will be formally recognized as the "Test Site Coordinator" to receive due credit.) 2. Identify at least one course in your curriculum that is generally representative of your undergraduate majors. I need about 25 students from each institution, but programs with smaller or larger classes are welcome to participate.

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140 3. Administer the questionnaires to students enrolled in the course. The questionnaires require some 30 minutes to complete. I will provide instructions, answer sheets, pencils, and copies of the instrument. 4. Collect and return the questionnaires to me in the postage-paid enveloped provided. Please note that at no time will specific institutions or individuals be identified for purposes of comparisons. You will receive results from the study following its completion. To facilitate your decision, I have provided information concerning the instrument, a copy of the student testing packet, and administrator instructions. After reviewing the information, please indicate your decision, contact person, and estimated number of questionnaires needed on the enclosed form. If you prefer, feel free to provide your response by telephone (904/392-0583) or FAX (904/392-3186). I would appreciate hearing from you by April 3, 1992. A copy of approval for this study from the University of Florida Institutional Review Board is available upon request. Please feel free to contact me or Dr. Pigg if you have questions or desire additional information. Thank you for your consideration. Sincerely, Rebecca A. Brey, M.S. Doctoral Candidate R. Morgan Pigg, Jr., H.S.D. Professor and Chair Enclosures

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141 Prevalence of Eating Disorders and Eating-Disordered Behavior Among Undergraduate Health Education Major Students in the United States STUDY PARTICIPATION FORM Yes, our institution can participate in the study. We need more information before making a decision. Please contact us at your earliest convenience. No, we cannot participate. Contact Person Address Institution City, State, ZIP Telephone (Work) Telephone (Home Optional) FAX Number How many questionnaires do you need? How many undergraduate health education majors are enrolled in your program? Please indicate the best days and times to reach you by telephone at work: Please complete and return in the enclosed pre-addressed envelope by April 3, 1992. Thank you for your assistance.

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142 April 23, 1992 Dr. Mardie E. Burckes-Miller Dept, of Health Education Pecenter/Holdemess Rd. Plymouth State College Plymouth, NH 03264 Dear Dr. Burckes-Miller: Thank you for agreeing to serve as Test Site Coordinator for my study focusing on eating disorders and eating-disordered behavior among undergraduate health education majors. I have enclosed the number of questionnaires you requested, an oral script to read to students prior to administration, and a pre-addressed, postage-paid return envelope. Pencils will be mailed in a separate envelope. Please read the enclosed Oral Script aloud prior to distributing the instruments to students enrolled in a one or more of your courses that are the most representative of your undergraduate health education majors. The questionnaires require about 30 minutes to complete. Please mail the completed materials to me in the postage paid envelope no later than May 22, 1992. Please contact me if you have questions or encounter unanticipated problems. Following completion of the study, you will receive for your professional files a letter documenting your role as Test Site Coordinator for the project. In addition, your department will receive results of the study. Again, thank you for your assistance. Sincerely, Rebecca A. Brey, M.S. Doctoral Candidate

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143 July 24, 1992 Dr. Marlene K. Tappe Dept, of Health Promotion & Education 106 Lambert Bldg. Purdue University West Lafayette, IN 47907 Dear Dr. Tappe: Thank you for taking time from a full schedule to serve as Test Site Coordinator for my dissertation "Eating Disorders and Eating-Disordered Behavior Among Undergraduate Health Education Major Students in the United States". Without your assistance and expertise, the study would not have been possible. I will forward a copy of the results to you upon completion of the study. Again, thank you for your assistance! Sincerely, Rebecca A. Brey, M.S. Doctoral Candidate

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144 May 11, 1992 Dr. Kathleen A. Rohaly Health & Physical Education Dept. Robins Center University of Richmond Richmond, VA 23173 Dear Dr. Rohaly: Thank you for returning the Study Participation Form for my dissertation study "Prevalence of Eating Disorders and Eating-Disordered Behavior Among Undergraduate Health Education Major Students in the United States". The time table for data collection has been revised to include the 1992 Summer term. Consequently, students enrolled in an appropriate health education major summer course may participate. If your institution would like to participate under this revised schedule, please fill out the enclosed Study Participation Form and mail it to me in the stamped, preaddressed envelope. If you prefer, feel free to provide your response by telephone (Work 904/392-0583; Home 904/374-8231) or FAX (904/392-3186). Please contact me if you have questions or desire additional information. Thank you for your assistance. Sincerely, Rebecca A. Brey, M.S. Doctoral Candidate

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145 May 11, 1992 Dr. Carolyn Mathews Dept, of Health & Human Performance MC 2050 Auburn University Auburn, AL 36849-5323 Dear Dr. Mathews: Thank you for agreeing to participate in my dissertation study, "Prevalence of Eating Disorders and Eating-Disordered Behavior Among Undergraduate Health Education Major Students in the United States". I appreciate your help with this project. The timetable for data collection has been revised to include the 1992 Summer term. Consequently, if you were unable to administer the questionnaires by the end of the 1992 Spring term, undergraduate health education major students enrolled in an equivalent summer course may be substituted. If a Summer 1992 course is used, please enclose a note with the returned questionnaires. Please contact me at home (904-374-8231) or at work (904-392-0583) if you need additional questionnaires and pencils. Thank you again for your assistance. Kindly disregard this letter if you have already mailed the completed questionnaires. Please contact me if you have any questions. Sincerely, Rebecca A. Brey, M.S. Doctoral Candidate

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146 May 11, 1992 Dr. Robert Huff Dept, of Health Education 18111 Nordhoff St. California State University, Northridge Northridge, CA 91330 Dear Dr. Huff: Recently, I wrote requesting your help with my dissertation study "Prevalence of Eating Disorders and Eating-Disordered Behavior Among Undergraduate Health Education Major Students in the United States". The time table for data collection has been revised to include the 1992 Summer term. Consequently, students enrolled in an appropriate health education major summer course may participate. If your institution would like to participate under this revised schedule, please fill out the enclosed Study Participation Form and mail it to me in the stamped, preaddressed envelope. If you prefer, feel free to provide your response by telephone (Work 904/392-0583; Home 904/374-8231) or FAX (904/392-3186). Please contact me if you have questions or desire additional information. Thank you for your assistance. Sincerely, Rebecca A. Brey, M.S. Doctoral Candidate

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146 May 11, 1992 Dr. Robert Huff Dept, of Health Education 18111 Nordhoff St. California State University, Northridge Northridge, CA 91330 Dear Dr. Huff: Recently, I wrote requesting your help with my dissertation study "Prevalence of Eating Disorders and Eating-Disordered Behavior Among Undergraduate Health Education Major Students in the United States". The time table for data collection has been revised to include the 1992 Summer term. Consequently, students enrolled in an appropriate health education major summer course may participate. If your institution would like to participate under this revised schedule, please fill out the enclosed Study Participation Form and mail it to me in the stamped, preaddressed envelope. If you prefer, feel free to provide your response by telephone (Work 904/392-0583; Home 904/374-8231) or FAX (904/392-3186). Please contact me if you have questions or desire additional information. Thank you for your assistance. Sincerely, Rebecca A. Brey, M.S. Doctoral Candidate

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147 Prevalence of Eating Disorders and Eating-Disordered Behavior Among Undergraduate Health Education Major Students in the United States STUDY PARTICIPATION FORM Yes, our institution can participate in the study. We need more information before making a decision. Please contact us at your earliest convenience. No, we cannot participate. Contact Person Address Institution City, State, ZIP Telephone (Work) Telephone (Home Optional) FAX Number How many questionnaires do you need? How many undergraduate health education majors are enrolled in your program? When will questionnaires be administered? Spring 1992 or Summer 1992 Please indicate the best days and times to reach you by telephone at work: Please complete ancTretum in the enclosed pre-addressed envelope. Thank you for your assistance.

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148 EATING DISORDER INVENTORY Instrument Description The Eating Disorder Inventory (EDI), (Gamer, Olmsted, and Polivy, 1983) available through Psychological Assessment Resources, Inc, is a self-report instrument measuring symptoms associated with anorexia nervosa and bulimia nervosa. The EDI provides standardized subscale scores on 1 1 dimensions clinically relevant to eating disorders. Respondents are required to respond to each item on a six-point scale, indicating whether the item applies to them "always", "usually", "often", "sometimes", "rarely", or "never". The original 64-item instrument contained eight subscales: Bulimia, Drive for Thinness, Body Dissatisfaction, Ineffectiveness, Perfection, Interpersonal Distrust, Interoceptive Awareness, and Maturity Fears. In addition to the eight original subscales, the current version contains three provisional subscales: Asceticism, Impulse Regulation, and Social Insecurity. The EDI is not considered a diagnostic instrument; it only identifies individuals who may have "subclinical" eating problems or are at risk for developing an eating disorder. Gamer, D. M., Olmsted, M.P., & Polivy, J. « (1983). Development and validation of a multidimensional Eating Disorder Inventory for anorexia nervosa and bulimia. International Journal of Eating Disorders . 2, 15-34.

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149 Step II Additional Items Instrument Description This self-report instrument was adapted (with written permission) from the Eating Habits of Athletes Survey developed by Dr. Mardie E. Burckes-Miller and Dr. David R. Black. Designed to assess behaviors and attitudes associated with anorexia nervosa and bulimia nervosa, the original version has been modified to include additional demographic and professional interest items relevant to this study. Burckes-Miller, M.E. & Black, D. R. (1988). Behaviors and attitudes associated with eating disorders: Perceptions of college athletes about food and weight. Health Education Research. Theory, and Practice . 3(2), 203-208.

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150 Oral Script for Test Site Coordinator (Please read this script to students at the beginning of the testing session .) Rebecca Brey, a Ph.D. candidate in the Department of Health Science Education at the University of Florida, is asking you to participate in her study "Prevalence of Eating Disorders and Eating Disordered-Behavior Among Undergraduate Health Education Major Students in the United States. She hopes you choose to participate. No personal risk or benefit is expected due to your participation. You will not be compensated for participating. Participation or nonparticipaton will not affect your grade or work load in this class. Your participation in this study is strictly voluntary; you may decline to participate at any time during the testing session. If you choose not to participate, please work quietly on another project and return your blank testing packet at the end of the survey session. The questionnaires take about 30 minutes to complete. Your responses shall remain anonymous and no attempt shall be made to identify you individually. Do not write your name on any of the forms. Your computerized bubble sheet and Additional Items Form have a code number only for the purpose of matching your responses for analysis. As soon as I finish reading these instructions, you will be given a testing packet and a #2 pencil. Read the directions for each of the questionnaires before answering any of the questions. Although the directions indicate you should complete all the items, you do not have to answer any question you do not wish to answer. However, your effort to answer all questions is appreciated. Please use the #2 pencil to respond all items. When you are finished, please return your testing packet to me. You may keep the #2 pencil. For your information, our department will receive results of this study upon its completion. If you would like more information about the study, I have RebeccaÂ’s address and telephone number. (Distribute the testing packets and pencils.) Please take a moment to read the directions before completing the surveys. Thanks so much for your help with this project. I really appreciate it!! Please contact me if you have questions or require assistance: Rebecca A. Brey, M.S. Department of Health Science Education FLG 5 University* of Florida Gainesville, FL 32611-2034 904/392-0583

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APPENDIX C STUDY INSTRUMENTS

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DIRECTIONS Your testing packet contains: 1. A test booklet 2. 4 pages of additional questions 3. A computerized bubble sheet 4. A #2 pencil This questionnaire contains 2 parts: Step I Please complete ALL items 1 91 in the test booklet, following the directions on the next page using a #2 pencil and the computerized bubble sheet to record your answers. Do not write your name on the computerized bubble sheet or on any of the other forms. Step n Please complete ALL the additional items on the 4 page insert. Write your responses for the first 6 items directly on the form. Use the computerized bubble sheet and a #2 pencil to record your answers to the rest of the questions. ************************************************************** After youÂ’re finished, please return all materials to your instructor. You may keep the pencil. Thank you for participating in this study. Your time and effort are appreciated! 152

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153 STEP I INSTRUCTIONS Please rate the items below on the computerized bubble sheet with a #2 pencil. For each item, decide if it is true about you ALWAYS = 0, USUALLY = 1, OFTEN = 2, SOMETIMES = 3, RARELY = 4, NEVER = 5. Bubble in the number on the answer sheet that corresponds to your rating. For example, if your rating for an item is OFTEN, you would bubble in response #2. Respond to ALL items, making sure you bubble in the rating that is true about you. 1. I eat sweets and carbohydrates without feeling nervous. 2. I think that my stomach is too big. 3. I wish that I could return to the security of childhood. 4. I eat when I am upset. 5. I stuff myself with food. 6. I wish that I could be younger. 7. I think about dieting. 8. I get frightened when my feelings are too strong. 9. I think that my thighs are too large. 10. I feel ineffective as a person 11. I feel extremely guilty after overeating. 12. I think that my stomach is just the right size. 13. Only outstanding performance is good enough in my family. 14. The happiest time in life is when you are a child. 15. I am open about my feelings. 16. I am terrified of gaining weight. 17. I trust others. 18. I feel alone in the world. 19. I feel satisfied with the shape of my body. 20. I feel generally in control of things in my life. 21. I get confused about what emotions I am feeling. 22. I would rather be an adult than a child. 23. I can communicate with others easily. 24. I wish I were someone else. 25. I exaggerate or magnify the importance of weight. 26. I can clearly identify what emotion I am feeling. 27. I feel inadequate. « 28. I have gone on eating binges where I felt that I could not stop. 29. As a child, I tried very hard to avoid disappointing my parents and teachers. 30. I have close relationships. 31. I like the shape of my buttocks.

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154 32. I am preoccupied with the desire to be thinner. 33. I donÂ’t know whatÂ’s going on inside me. 34. I have trouble expressing my emotions to others. 35. The demands of adulthood are too great. 36. I hate being less than best at things. 37. I feel secure about myself. 38. I think about bingeing (overeating). 39. I feel happy that I am not a child anymore. 40. I get confused as to whether or not I am hungry. 41. I have a low opinion of myself. 42. I feel that I can achieve my standards. 43. My parents have expected excellence of me. 44. I worry that my feelings will get out of control. 45. I think my hips are too big. 46. I eat moderately in front of others and stuff myself when theyÂ’re gone. 47. I feel bloated after eating a normal meal. 48. I feel that people are happiest when they are children. 49. If I gain a pound, I worry that I will keep gaining. 50. I feel that I am a worthwhile person. 51. When I am upset, I donÂ’t know if I am sad frightened, or angry. 52. I feel that I must do things perfectly or not do them at all. 53. I have the thought of trying to vomit in order to lose weight. 54. I need to keep people at a certain distance (feel uncomfortable if someone tries to get too close). 55. I think that my thighs are just the right size. 56. I feel empty inside (emotionally). 57. I can talk about personal thoughts or feelings. 58. The best years of your life are when you become an adult. 59. i think my buttocks are too large. 60. I have feelings I canÂ’t quite identify. 61. I eat or drink in secrecy. 62. I think that my hips are just the right size. 63. I have extremely high goals. 64. When I am upset, I worry that I will start eating. 65. People I really like end up disappointing me. 66. I am ashamed of my human weaknesses. 67. Other people would say that I am emotionally unstable. 68. I would like to be in total control of my bodily urges. 69. I feel relaxed in most group situations. 70. I say things impulsively that I regret having said. 71. I go out of my way to experience pleasure.

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155 72. I have to be careful of my tendency to abuse drugs. 73. I am outgoing with most people. 74. I feel trapped in relationships. 75. Self-denial makes me feel stronger spiritually. 76. People understand my real problems. 77. I canÂ’t get strange thoughts out of my head. 78. Eating for pleasure is a sign of moral weakness. 79. Iam prone to outbursts of anger or rage. 80. I feel that people give me the credit I deserve. 81. I have to be careful of my tendency to abuse alcohol. 82. I believe that relaxing is simply a waste of time. 83. Others would say that I get irritated easily. 84. I feel like I am losing out everywhere. 85. I experience marked mood shifts. 86. I am embarrassed by my bodily urges. 87. I would rather spend time by myself than with others. 88. Suffering makes you a better person. 89. I know that people love me. 90. I feel like I must hurt myself or others. 91. I feel that I really know who I am. Adapted and reproduced by special permission of Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, Florida, 33549, from The Eating Disorder Inventory, by Gamer, Olmstead, Polivy, Copyright, 1984 by Psychological Assessment Resources, Inc. Further reproduction is prohibited without prior permission from PAR, Inc.

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156 STEP II ADDITIONAL ITEMS Please write your responses on this sheet for items A F. A. Age B. Height feet inches C. Weight pounds D. Highest past weight (excluding pregnancy): pounds E. Lowest weight as an adult: pounds F. How much would you like to weigh? pounds Please mark the following answers on your bubble sheet: 92. Sex: 0 = Female 1 = Male 93. Year in College: 0 = Freshman 1 = Sophomore 2 = Junior 3 = Senior 4 = Post graduate 94. Race: 0 = Asian 1 = Black 2 = Caucasian 3 = Hispanic 4 = Native American 5 = Other 95. Current Living Arrangement: 0 = Sorority/Fraternity House * 1 = On Campus Residence Hall 2 = Off Campus Apartment/House 3 = With Parents

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157 96. Marital Status: 0 = Never Married 1 = Married 2 = Separated 3 = Divorced 4 = Widowed 97. Major; 0 = Health Education (Go to question 98) 1 = Other (Bubble in #1, skip questions 98 through 109 and go to question 110) 98. Health Education Focus: 0 = Public Health 1 = Patient Education 2 = Safety Education 3 = School/College Health 4 = Worksite Health Promotion 5 = Community Health Which of the following best describe your area(s) of professional interest? (check all that apply) 99. Aging/Death and Dying 0 = Yes 1 = No 100. Alcohol/Drug Education 0 = Yes 1 = No 101. Cancer/Cardiovascular Disease 0 = Yes 1 = No 102. Environmental Health 0 = Yes 1 = No 103. Exercise and Fitness 0 = Yes 1 = No 104. Mental Health/Health Counseling 0 = Yes 1 = No 105. Nutrition Education 0 = Yes 1 = No 106. Sexuality 0 = Yes 1 = No 107. Stress Management 0 = Yes 1 = No 108. Weight Control/Management 0 = Yes 1 = No 109. Wellness 0 = Yes 1 = No Which of the following methods do you use regularly for weight control? 110. Fad Dieting 0 = Yes 1 = No 111. Excessive or Vigorous Exercise 0 = Yes 1 = No 112. Fasting (no food for at least 24 hours) 0 = Yes 1 = No 113. Diet Pills ‘ 0 = Yes 1 = No 114. Laxatives 0 = Yes 1 = No 115. Diuretics (Water Pills) 0 = Yes 1 = No 116. Self-Induced Vomiting 0 = Yes 1 = No

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158 117. I have regular episodes of binge eating (rapid consumption of foods that are easy to digest and high in calories in a short period of time). 0 = Yes 1 = No 118. I frequently eat until my stomach hurts too much to continue, or I am interrupted by other people, or I fall asleep, or I vomit. 0 = Yes 1 = No 119. I donÂ’t like to have people present when I eat. 0 = Yes 1 = No 120. During eating binges, I have a distinct feeling of not having control over my eating. 0 = Yes 1 = No 121. I binge eat, then frequently self-induce vomiting because I am afraid I will gain weight. 0 = Yes 1 = No 122. I have a persistent concern with my body shape and weight. 0 = Yes 1 = No 123. My weight is 15% or more below normal for my age and height. 0 = Yes 1 = No 124. I have an intense fear of becoming obese even though I am underweight or normal weight now. 0 = Yes 1 = No 125. I have had the absence of at least 3 consecutive menstrual cycles when they should have occurred. (Males mark #2; females mark #0 or tt 1.) 0 = Yes for Females 1 = No for Females 2 = Males

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For each item, please mark the responses best describing your thoughts about food and weight. 126. Other people think I am too thin. 0 = Yes 1 = No 127. I think about food and my weight all the time. 0 = Yes 1 = No 128. I think I am fat although I am underweight. 0 = Yes 1 = No 129. I am terrified of gaining weight. 0 = Yes 1 = No 130. I feel depressed and down on myself after I eat. 0 = Yes 1 = No 131. How often do you use fad diets (popular diets, eating only certain foods, and etc.) as a means of weight control? 0 = Never 1 = Rarely 1 day a month 2 = 2-3 days a month 3 = 1 time a week 4 = More than once a week 132. How often do you fast (no food for at least 24 hours) as a means of weight control? 0 = Never 1 = Rarely 1 day a month 2 = 2-3 days a month 3 = 1 day a week 4 = More than one day a week 133. How often do you eat small quantities (600 calories a day or less) of food as a means of weight control? 0 = Never 1 = Rarely 1 day a month 2 = 2-3 days a month 3 = 1 day a week 4 = 2 or more days a week 134. How often do you use laxatives as a means of weight control? 0 = Never 1 = Rarely 1 time a month 2 = 2-3 times a month 3=1 time a week 4 = 2-3 times a week 5 = 4-6 times a week 6 = At least once every day

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160 135. How often do you use self-induced vomiting as a means of weight control? 0 = Never 1 = Rarely one time a month 2 = 2-3 times a month 3 = 1 time a week 4 = 2-3 times a week 5 = 4-6 times a week 6 = At least once every day 136. What is your average number of eating binges within the last 3 months? 0 = 0-1 binge 1 = 2-6 times in 3 months 2 = 1 binge eating episode per week 3 = 2 or more binge eating episodes per week 137. Have you ever been diagnosed with an eating disorder? 0 = No 1 = Yes, anorexia nervosa 2 = Yes, bulimic nervosa 3 = Yes, both anorexia and bulimia 138. Do you think you might have an eating disorder? 0 = No 1 = Yes, anorexia nervosa 2 = Yes, bulimia nervosa 3 = Yes, both anorexia nervosa and bulimia nervosa Thank you for completing these questionnaires. Please feel free to include any comments in the space provided below.

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APPENDIX D CORRESPONDENCE WITH AND INSTRUMENT DEVELOPED BY BLACK AND BURCKES-MILLER

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PLYMOUTH STATE COLLEGE OF THE UNIVERSITY SYSTEM OF NEW HAMPSHIRE PLYMOUTH. NEW HAMPSHIRE 03264 Ms. Rebecca Brey, M.S. University of Florida College of Health and Human Performance 4 LG Gainsville, FL 32611 Dear Ms. Brey: I vould be more than happy to extend to you my permission to use my survey, Eating Habits of Athletes (EHA), in your research. It is found in the new book published by A.A.H.P.E.R.D. , "Eating Disorders and Athletes: Theory, Issues and Research" (1981). My co-researcher, Randy Block of Purdue University, is editor. We developed EHA in 1983-84 and revised it again in 1988-89 based on the nev diagnostic criteria. I wish you success in your endeavor and vould appreciate an abstract of your dissertation at your completion. Healthfully, Mardie E. Burckes-Miller , Ed.D. CHES Health Education Coordinator 162

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163 EHA Social Security Number Instructions This survey is designed to analyze eating habits. Please answer the questions honestly. There are no right or wrong answers. Circle your response or check yes or no. 1. Sex A. Male B. Female 2. Age 3. Height ft in 4. Weight 5. 6 . Year in collge A. Freshman B. Sophomore C. Junior A. None of the sports B. Basketball C. Cheerleading D. Cross Country/Track & Field A. None of the sports below B. Skiing, Ski jumping C. Soccer D. Softball/baseball What is your average caloric intake per day? A. Have no idea B. <600 calories C. 601-749 D. 750-999 E. 1000-1199 at one time) and dieting within the past year? A. 0-5 lbs B. 6-9 lbs (Yes or No) D. Senior E. Post graduate i level? (circle all that apply) E. Football F. Gymnastics G. Hockey (field, ice) H. Lacrosse ! level? (circle all that apply) E. Swimming F. Tennis G. Wrestling H. Volleyball F. 1200-1499 G. 1500-1799 H. 1800-2399 I. 2400-2999 J. 3000+ due to bingeing (eating a lot of C. 10+ lbs larly for weight control? Check Yes No 10. fad diet 11. excessive or vigorous exercise 12. fasting (no food for at least 24 hours) 13. diet pills 14. laxatives 15. enemas '* 16. diuretics --(water pills) 17. self-induced vomiting

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164 The following describes me. (Answer yes or no) | 18. I have regular episodes of binge eating (rapid consumption of foods in a short period of tim that are easy-to-digest and are high in calories). 1 19. I frequently eat until my stomach hurts too much to continue, or I am interrupted by other people, or I am interrupted by other people, or I fall asleep, or I vomit. | 20. I don't like to have people present when I eat. | 21. During eating binges, I have a distinct feeling of not having control over my eating. | 22. I binge eat, then frequently self-induce vomiting because I am afraid I will gain weight. | 23. I have a persistent concern with my body shape and weight. | 24. My weight is 15% or more below normal for my age and height. | 25. I have an intense fear of becoming obese even though I am underweight or normal weight now. | 26. I have had the absence of at least 3 consecutive menstrual cycles when they should have occurred, (females only) Please mark the response that best describes your thoughts about food and weight. Yes No | 27. Other people think I am too thin. 28. I think about food and my weight all the time. 29. I think I am fat although I am underweight. 30. I am terrified of gaining weight. 31. I feel depressed and down on myself after I eat. Please answer the following: (Circle your response) 32. How often do you use fad diets as a means of weight control? (fad diets, popular diets, eating only certain foods, different than most people's food intake) A. Never D. 1 time a week B. Rarely E. more than once a week C. 2-3 days a month 33. How often do you fast as a means of weight control? (Fast = no food for at least 24 hours) A. Never D. 1 time a week B. Rarely 1 day a month < E. 2 or more times a week C. 2-3 times a month 34. How often do you eat small quantities of food? (600 calories a day or less as a means of weight control) A. Never D. 1 day a week B. Rarely 1 day a month E. 2 or more days a week C. 2-3 times a month

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165 35. How often do you use laxatives as a means of weight control? A. Never E. 2-3 times a week B. Rarely 1 day a month F. 4-6 times a week C. 2-3 times a month G. at least once every D. 1 time a week day 36. How often do you use self-induce vomiting as a means of weight control? A. Never E. 2-3 times a week B. Rarely 1 day a month F. 4-6 times a week C. 2-3 times a month G. at least once every D. 1 time a week day 37. What is your average number of eating binges within the last 3 months? A. 0-1 binge C. 1 binge eating episode per week B. 2-6 times in 3 months D. 2 or more binge eating episodes per week 38. Have you ever been diagnosed with an eating disorder? A. No B. Yes, anorexia nervosa 39. Do you think you might have an eating A. No B Yes, anorexia nervosa C. Yes, bulimia nervosa D. Yes, both anorexia and bulimia disorder? C. Yes, bulimia nervosa D. Yes, both anorexia nervosa and bulimia nervosa

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APPENDIX E LIST OF PARTICIPATING INSTITUTIONS AND TEST SITE COORDINATORS

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Test Site Coordinators and Participating Institutions 1. Dr. M. Ann Smith Chadron State College Chadron, Nebraska 2. Dr. Joseph W. McIntosh Columbus College Columbus, Georgia 3. Dr. Rick Barnes East Carolina University Greenville, North Carolina 4. Dr. Carol Underwood East Stroudsburg University East Stroudsburg, Pennsylvania 5. Dr. Shirley L. Morgan East Tennessee State University Johnson City, Tennessee 6. Dr. Erin Francfort Idaho State University Pocatello, Idaho 7. Dr. Nicholas Galli Lehman College CUNY Bronx, New York 8. Dr. Debra L. Sutton Morehead State University Morehead, Kentucky 9. Dr. Jeffrey E. Brandon New Mexico State University Las Cruces, New Mexico 10. Dr. Jan Richter Oklahoma State University Stillwater, Oklahoma •< 11. Dr. Mardie E. Burckes-Miller Plymouth State College Plymouth, New Hampshire 167

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168 12. Dr. Marlene K. Tappe Purdue University West Lafayette, Indiana 13. Dr. Nelson F. Wood Rhode Island College Providence, Rhode Island 14. Dr. Rod Dobey St. Cloud State University St. Cloud, Minnesota 15. Dr. Michael J. Cleary Slippery Rock University Slippery Rock, Pennsylvania 16. Dr. Mark Kittleson Southern Illinois University Carbondale, Illinois 17. Dr. Kathleen S. Hillman Springfield College Springfield, Massachusetts 18. Dr. Emogene Fox University of Central Arkansas Conway, Arkansas 19. Dr. Barbara A. Rienzo University of Florida Gainesville, Florida 20. Dr. Peter Doran University of Maine at Farmington Farmington, Maine 21. Dr. Chuck Regin University of Nevada, Las Vegas Las Vegas, Nevada 22. Dr. Jane E. Richards University of Northern Iowa Cedar Falls, Iowa 23. Dr. Jack S. Ellison University of Tennessee v Knoxville, Tennessee Dr. R. Daniel Duquette University of Wisconsin Lacrosse Lacrosse, Wisconsin 24 .

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169 25. Dr. Charles R. Baffi Virginia Tech University Blacksburg, Virginia 26. Dr. Ralph Perrin Walla Walla College College Place, Washington 27. Dr. Michele Groder William Paterson College Wayne, New Jersey 28. Dr. Kathie C. Garbe Youngstown State University Youngstown, Ohio

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APPENDIX F STUDENTS' WRITTEN COMMENTS

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Students' Written Comments 1. I am a football player that also uses anabolic steroids. I sometimes vomit just to make me feel better on a high caloric diet. 2. I eat a lot of junk food but a normal amount of nutritious food. I would like to be thinner but I know I have some personal fears about it and feel my fat protects me or at least allows me to avoid situations I don't want to be in. I don't feel guilty and I don't diet. I would just like to be able to deal with some things more appropriately. 3. It's too damn long. 4. Why ask the same questions twice just in a different way. 5. I know I have an eating problem, but it isn't anorexia or bulimia, more like compulsive overeating at times when I can't control my emotions/feelings. I think it is very important and I'm glad to see the health field pay more attention to disordered eating as it is extremely prevalent. (I am seeking help and doing better. ) 6. There are too many questions. Many seem to be repetitious. Good luck. 7. Your questions center on anorexia/bulimia and little on obesity per se. It would be good to also inquire how many are trying to use healthful means to reduce weight and maintain good health. 8. The survey is a little long! 9. Now I have bulimic tendencies, but I'm doing well. I went to counseling. 10. When I diet, I use Slim Fast and exercise. 11. Good Luck!! (ESU) 171

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172 12. Overall, it is a good questionnaire. I would have liked to see more questions about exercise. Do you exercise regularly? How often do you exercise? Do you think you watch too much T.V.? Do you think you are a sedentary person? Do you concentrate more on diet than exercise? 13. Nice and very specific survey good luck! 14. Questionnaire is too long, people may just fill in bubbles just to get through it even though it is strictly voluntary. 15. I feel very secure about my body, but I'm a competitive body builder so I am concerned about my diet and appearance! 16. This was a good questionnaire that made me think of my eating habits. 17. I have IBS (Irritable Bowel Syndrome) and that definitely influences what and when (if) I eat. The IBS is due to stress. 18. Many college students deal with stress by eating. Maybe not to the extent of anorexia nervosa or bulimia nervosa but simply junk food eating. Possibly additional research on what is being eaten could be beneficial? 19. It seems just when I am in control of eating, I get nervous or depressed, I am really insecure right now, because of my weight. 20. As a junior in high school I was diagnosed with anorexia nervosa. I lost to my lowest weight of 85 lbs. before getting help. I feel I have come a long way since then but I will always be self-conscious of my weight and shape. 21. I think questions could have been more consistent and presented in an unbiased form. 22. I hate taking long tests. 23. Stupid for men! 24. Stupid for men.' 25. Same questions, just worded differently. Too monotonous .

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173 26. I am a body builder and my weight fluctuates during the seasons . 27. I have been an athlete in the past and still am moderately active. Since 16, I have weighed 141 lbs. except when I got sick (135 lbs) . Actually, because of sports I have tried (and failed) to bulk up. I am definitely atypical. 28. Some questions are ambiguous. Do you believe that anyone with a real problem would answer these questions honestly . 29. I also believe that overeating is an eating disorder. What causes people to overeat (not binging)? How do you feel about your body no matter what you weight? How do you think other people perceive your body type? Are you healthy even though your doctor has told you that you could lose a few pounds? I am. Do you feel your parents are partly responsible for some of your eating habits? These may be some possible questions you may want to add for further questionnaires! 30. Good luck with your research. 31. The results of this should be well publicized. I don't think society realizes it's effects on women's emotional state and their image of themselves. Attitudes need to change and the teaching of selfrespect as a person and to love who you are needs to be emphasized. 32. Question 137 was for only a short period of time. I was counseled and have now recovered fully. 33. Change some questions because I think about my weight but because I lift weights I'm 20 pounds over my age/weight bracket. This doesn't concern me at all. I'm fit and I like to eat snacks as well. Other than that I'm happy to have participated. 34. You asked many of the same questions over and over. This was an interesting questionnaire (some questions over and over) . 35 .

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174 36. I am a 25 year old female athlete. At 18, I had my knee rebuilt. I ate the same amount of food, but, obviously, my routine was "sit still" in a cast for 6 months, plus 30 pounds, 12 months after surgery plus 50 pounds. I can not resume past exercise level, but continue same eating habits. At 165 (pounds) , I was "cut", large frame, lots of muscles, athletic body. 37. I could not relate to this questionnaire. Yet, my answers may help you! 38. Eating disorders run in my family. 39. Scale for questions 1-91 should have been reversed. Never should be 0, always should be 5. It's just logical . 40. I don't think my age makes me suitable for these questionnaires. The rating scale was not easy to follow. 41. I know that I do not have an eating disorder, but I also know that I am like a lot of other girls who are very self conscious about their weight and looks. Living and being in a sorority pressures me to feel that I must be skinny and look good at all times. I do want to lose weight but I wish I didn't have to do it just to be accepted. 42. When depressed I can eat almost nothing. Low weight of 92 pounds after divorce. Compulsive overeater and alcoholic in treatment for both for 18 months. 43. #137: I was never diagnosed by a doctor, but family and friends thought I was. The summer before my freshman year, I lost a lot of weight. I then gained it all back, and more, and then I started vomiting. I no longer do this. I haven't in years. I control my weight with exercise. 44. You must of had a reason for asking each question 3 or 4 times in different wordings. But why? Some of the questions are sort of vague they may apply but not the way the question is asked. 45. I want to gain weight. I am not the least bit concerned about gaining weight. In fact, I would rather gain weight, but I don't want to gain fat, just lean muscle mass. 46 .

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175 47. I was diagnosed with anorexia nervosa and bulimia when I was 15. I've undergone intense therapy. After 2 1/2 years of therapy, my life became orderly. I'm very healthy now! If I can help you in any way, I can be reached at (deleted to protect subject anonymity) . 48. I have a "pear-shaped" body type that influences my answers on hips, thighs, and buttocks. 49. I think perhaps one of the options should have been "does not apply". Other than that, it was a thought provoking questionnaire. 50. I am concerned about my weight and eating habits because of health issues. I believe in "everything in moderation" . 51. Sometimes I think I eat when for security. When I'm bored I look for something to eat. 52. When my boyfriend broke up with me about 1 1/2 years ago, I lost about 15 pounds from not eating. I didn't intentionally want to lose weight, but when I get very emotional I don't eat. Also, it's pretty sad, but I'm always concerned with weight and gaining it. 53. I don't feel I have an eating disorder of this kind, but I do feel guilty about eating the wrong types of foods. Junk food with empty calories that I know I should not eat, and contributes to my weight being higher than I desire. 54. I think I have an eating disorder, but not the one's stated above. At times I am a compulsive overeater. 55. I was brought up in a home where my Dad was a food addict. In realism I sort of feel comfortable with my weight after 34 years but I still have a preoccupation with my weight and body due to the environment I was raised in. Early in life I may have been borderline with eating disorder but with education, selfdiscipline, and counseling, I was very fortunate not to have developed into full anorexia and/or bulimia. Though the obsession is still a bother. 56. Excellent questionnaire foi; people who are obsessed with weight control or who have an eating disorder. Many of the questions pertained to my older sister who would have answered yes to many if not all of the questions.

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182 Hendren, R. L. , Barber, J. K. , & Sigafoos, A. (1986). Eating-disordered symptoms in a nonclinical population: A study of female adolescents in two private schools. Journal of the American Academy of Child Psychiatry . 25(6) , 836-840. Herzog, D. B., Borus, J. F., Hamburg, P., Ott, I. L. & Concus, A. (1987). Substance use, eating behaviors, and social impairment of medical students. Journal of Medical Education . 62.(8), 651-657. Herzog, D. B., Keller, M. B., Lavori, P. W. , & Sacks, N. R. (1991). The course and outcome of bulimia nervosa. Journal of Clinical Psychiatry . 52.(10, suppl) , 4-8. Herzog, D. B., Norman, D. K. , Rigotti, N. A. , & Pepose, M. (1986). Frequency of bulimic behaviors and associated social maladjustment in female graduate students. Journal of Psychiatric Research . 20(4), 355-361. Herzog, D. B., Popose, M. , Norman, D. K. , & Rigotti, N. A. (1985). Eating disorders and social maladjustment in female medical students. The Journal of Nervous and Mental Disease . 173(12), 734-737. Herzog, D. B., Walsh, B. T., Mitchell, J. E. , Kaye, W. H. , & Agras, W. S. (1991). Recent advances in bulimia nervosa (Discussion) . Journal of Clinical Psychiatry . 52(10, suppl), 39-43. Hesse-Biber, S. (1989). Eating patterns and disorders in a college population: Are college women's eating problems a new phenomenon? Sex Roles . 20(1/2), 71-89. Hesse-Biber, S., Clayton-Matthews , A., & Downey, J. A. (1987). The differential importance of weight and body image among college men and women. Genetic. Social, and General Psychology Monographs . 113 (4) . 511-528. Hochbaum, G. M. (1958). Public participation in medical screening programs: A sociopsvchological study . (Report No. 572). Washington, DC: Public Health Service . Hotelling, K. (1989). A model for addressing the problem of bulimia on college campuses. Journal of College Student Psychotherapy . 3.(2/3/4) , 241-252. Howat, P. M. , & Saxton, A. M. (1988). The incidence of bulimic behavior in a secondary and university school population. Journal of Youth and Adolescence . 17(3) . 221-231.

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BIOGRAPHICAL SKETCH A native of Minnesota, Rebecca Ann (Becci) Brey received a Bachelor of Science degree in psychology and a Master of Science degree in community health from Mankato (Minnesota) State University and a Ph.D. with a specialization in health behavior from the University of Florida. Following graduation, Becci intends to obtain a university faculty position. 191

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I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the deqree o^Doctor of Ph^Tipsophy. R. ^org^ Professor Educatioir I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the deqree of Doctor of Philosophy. W. William Chen Associate Professor of Health Science Education I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the deqree of Doctor of Philosophy. Phyllis M. Meek Associate Professor of Education I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the deqree of Doctor of Philosophy. Associate Professor of Foundations of Educaton I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, a dissertation for the degree of Doctor of Philosophy. Barbara A. Rien Associate Profess Science Education as Health

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This dissertation was submitted to the Graduate Faculty of the College of Education and to the^Graduate^School and was accepted as partial fulfillment orf (the* requirements for the degree of Doctor of Philosophy./^ / May, 1993 _ Dean, College of Health and Human Performance