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“After a workout …” Beliefs about exercise, eating and appearance in female exercisers with and without eating disorder features
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Psychology of Sport and Exercise 7 (2006) 425–436 www.elsevier.com/locate/psychsport
‘‘After a workout y’’ Beliefs about exercise, eating and appearance in female exercisers with and without eating disorder features Zara Lipseya, Stephen B. Bartonb, Angela Hulleyc, Andrew J. Hilla, a
Academic Unit of Psychiatry & Behavioural Sciences, School of Medicine, University of Leeds, 15 Hyde Terrace, Leeds LS2 9LT, UK b Department of Clinical Psychology, University of Newcastle, Ridley Building, Newcastle NE1 7RU, UK c Centre for Sport and Exercise Sciences, University of Leeds, Leeds LS2 9JT, UK Available online 28 February 2006
Abstract Objective. This study investigated the relationship between exercise and eating disorder features in a community sample of adult women with and without eating disorder psychopathology. The research focus was on the cognitions of exercisers who scored high and low on eating disorder symptoms. It was hypothesized that women with eating disorder symptoms would have more negative thoughts and beliefs about eating and body appearance but would not differ in cognitions relating to exercise. Design. A cross-sectional comparative study. Method. A community sample of 260 female sports center users completed a measure of eating disorder psychopathology (EDE-Q), the sentence completion test for eating and exercise (SCEE), assessments of depression, exercise commitment and an exercise diary. Results. In the whole sample, EDE-Q global score was positively correlated with commitment to exercise but unrelated to frequency or duration. High EDE-Q scoring women (n ¼ 30) had more dysfunctional beliefs and negative thoughts than medium or low scoring comparison groups, particularly concerning body appearance. They exercised with the same frequency as comparison women and were equally positive about exercise, in spite of being more negative about their appearance. Conclusion. The association between commitment to exercise and eating disorder psychopathology is consistent with previous research. The positive cognitions regarding exercise, concurrent with negative Corresponding author. Tel.: +44 113 343 2734; fax: +44 113 243 3719.
E-mail address: [email protected] (A.J. Hill). 1469-0292/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.psychsport.2006.01.005
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thoughts and dysfunctional beliefs about eating and body appearance, suggest a functional value for exercise in eating disorder symptomatic women. r 2006 Elsevier Ltd. All rights reserved. Keywords: Eating disorder psychopathology; Exercise; Cognitions; Negative thoughts; Dysfunctional beliefs
Introduction Sport or exercise participation is implicated in both the development and maintenance of eating disorders (Garner, Rosen, & Barry, 1998). Hospitalized eating disorder patients are more physically active and more involved in regular sport or exercise activities prior to their disorder than controls (Davis, Kennedy, Ravelski, & Dionne, 1994). More than half engage in very high levels of exercise during the acute phase of their disorder (Davis et al., 1997). Conversely, studies of elite female athletes show a much higher than expected prevalence of eating disorders. This is true for elite female distance runners (Hulley & Hill, 2001) and those whose disciplines demand a thin body build (Sundgot-Borgen & Torstveit, 2004). The relationship between exercise and eating disorders is less certain outside the elite athlete and clinical eating disorder arenas. Following a meta-analysis of studies relating athletic participation and eating problems, Smolak, Murnen & Ruble (2000) concluded there are circumstances where sports participation is a risk factor for eating disorders, but other situations where it appears to be protective. For example, non-elite athletes, especially those in high school, have a reduced risk of eating disorders compared with their non-athlete peers. In the main, the risk or protective nature of exercise participation may be difficult to evaluate without knowledge of participant’s underlying feelings about body shape and weight. Sundgot-Borgen (2004) describes the exercise patterns of some body dissatisfied individuals as treading a fine line between optimal performance and health damaging behaviour. A better understanding of motives or beliefs about exercise in people with shape and weight dissatisfactions may assist in this evaluation. Weight management, or responding to fear of weight gain, is prominent in accounts of sport or exercise participation prior to the development of eating disorders (Davis et al., 1994). Unsurprisingly, weight management also figures highly in nonclinical groups. Appearance/weight management was the only motive associated with frequency of exercise by female college students (Cash, Novy, & Grant, 1994). Similarly, exercise for weight management typified female adolescents who perceived themselves as overweight (Ingledew & Sullivan, 2002). In general, one would expect to find positive beliefs about exercise to be present alongside varying negative beliefs about shape and weight. A cognitive perspective on this issue may offer insight into these functions and benefits and has the potential to build on previous narrative-based qualitative approaches (Bamber, Cockerill, Rodgers, & Carroll, 2000). A cognitive–behavioural theoretical view is prominent in both anorexia and bulimia nervosa and cognitive–behavioural therapy is the leading evidence-based treatment (Fairburn, 2002). Research interest into cognitive processes in eating disorders has paralleled the popularity of the therapeutic approach. Investigations include the operation of information processing biases and, more recently, the core beliefs or schema-level cognitions characteristic of eating disorders (Waller, 2003; Waller, Shah, Ohanian, & Elliott, 2001).
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Attempts at describing the thoughts characteristic of eating disorders has been another investigational approach. The methods used include thought-sampling (Zotter & Crowther, 1991), thought checklists and concurrent verbalization (Cooper & Fairburn, 1992). The latter methodologies have revealed something important to the current study. Collecting thoughts prompted by tasks such as participants looking at themselves in a full length mirror, weighing themselves or eating showed those with an eating disorder to have more negative thoughts than dieters or non-dieting controls. Of particular note was a degree of specificity in thought content that distinguished women with anorexia nervosa from those with bulimia nervosa. More negative thoughts about eating were recorded in participants with anorexia nervosa while those with bulimia nervosa had more negative thoughts about weight and appearance. This suggests the value of examining thoughts about different situations or relevant but separate domains. A more common methodology, given the difficulties in approaches such as concurrent verbalization, has been the use of thought questionnaires (e.g. Clark, Feldman, & Channon, 1989; Mizes, 1992). However, questionnaires have been criticized for their lack of empirical base, their pre-determined structure and retrospective nature (Cooper, 1997). At worst questionnaires simply confirm clinical hypotheses without providing a full picture of cognitive content. A similar criticism has been made of the assessment of depressive cognitions—that questionnaire statements approximate a patient’s thoughts rather than capture them in a precise fashion (Barton & Morley, 1999). Sentence completions offer an alternative method of eliciting thought-content and a sentence completion test for depression has been developed that has good psychometric properties (Barton, Morley, Bloxham, Kitson, & Platts, 2005). An advantage of this methodology over questionnaire assessment is the absence of a systematic negative response bias. There are no negative statements in this format, only sentence stems. In addition, the stems can be tailored towards theoretically driven content domains, in this case, appearance, eating and exercise. Within these specified domains propositional meanings can be generated, that is, thoughts that have positive, negative or neutral content (for example, ‘‘For me eating y is important’’). Assumptions or beliefs that are conditional on various states of affairs can also be elicited (e.g. ‘‘If I was forced to overexercise y I would like it’’). These can be classified as adaptive and therefore functional responses (such as responding appropriately or taking positive action), maladaptive or dysfunctional responses (typically catastrophic or magical thinking), or responses that are neutral in nature. In this fashion, measures of positive thinking, negative thinking, functional assumptions and dysfunctional assumptions can be generated in the specific domains of interest. The present paper describes the use of a sentence completion test directed at thought content (i.e. propositions) and conditional beliefs/assumptions in these three domains: appearance, eating and exercise. This measure has been used successfully to characterize cognitions in obese adolescents attending a residential weight loss camp and to evaluate cognitive change over the duration of the camp (Barton, Walker, Lambert, Gately, & Hill, 2004). The study showed a reduction over time in negative thoughts and increase in positive thoughts, especially in those related to exercise and appearance. The pathological use of exercise by individuals with eating disorders was not the focus of this research. Rather, the study was directed at young women who were users of local exercise facilities, including fitness and aerobics classes. They were expected to bring with them a range of weight and shape concerns and a variety of reasons for exercising and perceived functions of
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exercise. The study was designed to collect information on eating disorder psychopathology, mood and exercise frequency and commitment from a large sample of women, permitting an analysis of the relationships between these variables. In addition, the sample would provide an opportunity to compare the cognitions of female exercisers who scored high and low on eating disorder symptoms. It was hypothesized that compared with non-symptomatic women, those with eating disorder psychopathology would have more negative thoughts and dysfunctional beliefs about eating and body appearance, but would not differ in their positive thoughts and beliefs about exercise.
Method Participants Women were recruited from three sports centres in a city in the North of England. One was University based and the others were operated by the city council. All offered exercise facilities and several daily fitness and aerobics classes. Female sports centre users were given questionnaire packs on entry to the building. Participation was voluntary and the questionnaire packs were returned by post. Of 600 questionnaires given out, 260 were returned fully completed, a response rate of 43%. Nearly 60% of the respondents attended the University sports centre. No information is available on the non-completers. Participants’ mean age was 29.4 years (range 18–63 years), with almost half below the age of 28 and one-third between 28 and 38 years. Over 90% were Caucasian. Measures Demographics/general information Background information included date of birth, current weight and height, weight history, and menstrual regularity. Exercise diary A 2-week retrospective diary was adapted from formats used by others (e.g. Davis, Brewer, & Ratusny, 1993) and asked participants to list on each day the type and duration of any exercise engaged in. This information was collected over 14 days in order to increase representativeness. A supplemental question asked whether this pattern was typical of the participant’s exercise pattern and if not, to outline the usual pattern. This information was used to calculate the weekly frequency of physical activity (number of days exercised per week), the weekly duration of physical activity (total amount of time), and the mean exercise bout duration (weekly duration divided by weekly frequency). Commitment to exercise scale (CES) The CES is an 8-item visual analogue scale measuring psychological commitment to exercise (Davis et al., 1993). Central attitudes and behavioural features relating to over-exercising include obligatory aspects of exercising (e.g. feeling guilty when exercise session is missed) and
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pathological aspects of exercise (e.g. continuing to exercise when injured). The CES has been shown to have good total scale internal consistency (a ¼ 0.88; McLaren, Gauvin, & White, 2001). Eating disorder examination questionnaire (EDE-Q) The EDE-Q is a 36-item questionnaire measuring both the frequency of specific eating disorder behaviours and attitudinal aspects of eating disorders (Fairburn & Beglin, 1994). Eating disorder psychopathology is assessed on four sub-scales: dietary restraint, eating concern, weight concern and shape concern. These sub-scales have good internal consistency (a ¼ 0.88–0.93) and test–retest reliability (r ¼ 0.81–0.94; Luce & Crowther, 1999). This measure was included to characterize eating disorder features across the whole sample, and particularly to identify the subsample of women with the highest levels of psychopathology. Beck depression inventory (BDI) The BDI is a 21-item scale widely used in clinical and research settings to measure depression. Participants are asked to identify a statement from each item that best describes the way they have been feeling over the past 2 weeks. The measure has high concurrent validity (r ¼ 0.72 with clinical ratings) and good psychometric properties (a ¼ 0.81 in non-psychiatric patients; Beck, Steer, & Garbin, 1988) and was used to control for possible group differences in depression and associated negative thoughts. Sentence completion test for eating and exercise (SCEE) This 24-item cognitive measure has been developed to elicit thought patterns and conditional beliefs relating to eating behaviour, body appearance, and exercise behaviour (Barton et al., 2004). Participants were presented with sentence stems and their task was to finish each sentence using their own words. Half the stems elicited thoughts at the propositional level, and these were balanced between eating (e.g. ‘‘For me eating y’’), body appearance (e.g. ‘‘I feel that my body y’’), and exercise (e.g. ‘‘Physical activity makes me feel y’’). The other 12 stems elicited conditional beliefs, these sentence stems having an ‘‘if–then’’ structure to elicit inferences about the consequences of different hypothetical scenarios. These sentence stems were directed at eating (e.g. ‘‘If I decided to stop eating regular meals y’’), exercise (e.g. ‘‘If I was prevented from taking regular exercise y’’), and life imbalance (e.g. ‘‘If I feel that my plans are blocked y’’). A coding manual was developed from previous research using sentence completion to measure depressive thinking (Barton & Morley, 1999; Barton et al., 2005).1 The propositional thought responses were classified into negative, positive or neutral types, and the conditional beliefs classified as dysfunctional, functional or neutral. This produced four main measures of interest: (1) negative thoughts; (2) positive thoughts; (3) functional beliefs; (4) dysfunctional beliefs, and these were examined in relation to the eating, body appearance and exercise domains. Procedure Participants received a questionnaire pack that contained an A4 Freepost envelope, an information sheet and two A5 envelopes. The information sheet explained that the research was 1
The test and coding manual are available from SBB or AJH upon request.
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investigating lifestyle and exercise behaviour and that all information collected would be kept confidential. Participants were asked to complete the questionnaires and return them in the envelope provided. One of the A5 envelopes had a blue dot and participants were instructed to open this first. This contained the background information sheet and the SCEE. Participants were instructed to return the completed questionnaires to the envelope before opening the second yellow-dotted envelope, containing the other measures. Separating the stem completions from the questionnaires was intended to alleviate potential priming effects. In the event that volunteers wished to suspend their co-operation they were asked to return all the measures. Data analysis Correlational analysis on the whole sample (n ¼ 260) explored the relationship between eating disorder psychopathology, exercise behaviour, and commitment to exercise. EDE-Q global scores were then used to identify a high scoring group (top 30 scores) and two comparison groups, medium (30 nearest the median) and low (lowest 30 scores), to test for cognitive differences on the SCEE. Group size was pre-determined, aiming at including the SCEE responses of participants in the top 10% of EDEQ scores. One-way analysis of variance and post-hoc Student–Neuman– Keuls tests compared the propositional thoughts and conditional beliefs in these three groups. Analysis of co-variance was used to control for the effects of depression (BDI) and body weight (BMI) following the necessary checks and adjustments for outliers, normality and homogeneity of variance.
Results Whole sample The mean age of the whole sample was 29.4 (SE ¼ 0.9) and BMI was 23.2 (SE ¼ 0.4). Three women had a BMI below 18 and 12 were obese (BMI430). This variability was also apparent in their reports of lowest and heaviest body weights. The 2-week exercise diary showed the mean amount of time spent exercising per week was 274 min (or 4.5 h). These women exercised on average 3.8 (SE ¼ 0.2) times per week and each bout of physical activity lasted 69 (SE ¼ 3.1) min. Commitment to exercise also varied across the sample with a mean score of 49.0 (SE ¼ 1.9), just below the mid-point of the scale. None of the women met the full criteria for anorexia nervosa (only three had a current weight less than 85% of expected) and only two fulfilled the criteria for bulimia nervosa. Recurrent binge eating (more than 8 days during the past month) was reported by a further two women and 16 (7% of sample) reported recurrent compensatory behaviour (more than 4 days in past month). A marked-to-moderate importance of weight and shape was reported by one-third of the women. EDE-Q global score was positively correlated with commitment to exercise ðrð258Þ ¼ 0:37; po0:01Þ, depression ðr ¼ 0:48; po0:01Þ and body mass index ðr ¼ 0:30; po0:01Þ, but was unrelated to either exercise frequency ðr ¼ 0:01Þ or total exercise duration ðr ¼ 0:09Þ. In contrast, commitment to exercise was positively related to exercise frequency ðr ¼ 0:17; po0:01Þ but not duration ðr ¼ 0:08Þ.
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Group comparisons Consistent with these correlations, there were significant between-group differences on commitment to exercise (F(2,87) ¼ 9.01, po0.001), depression (F(2,87) ¼ 21.48, po0.001) and BMI (F(2,87) ¼ 4.20, po0.05), the high EDE-Q group scoring higher on all measures (Table 1). Again, there were no group differences in exercise frequency or duration. For the SCEE analysis, two authors (S.B.B., A.J.H.) independently classified all the sentence completions for the three groups (2160 completions). There was a mean of 1.5 missing responses per subject (i.e. 6% missing data). Inter-rater reliability was calculated for all completed items using intra-class correlations for negative thoughts (ICC ¼ 0.95), positive thoughts (ICC ¼ 0.97), dysfunctional beliefs (ICC ¼ 0.89), and functional beliefs (ICC ¼ 0.93). These confirmed highly reliable inter-rater agreements on all classification types. One set of coding was selected at random to provide the main results. Table 2 shows the SCEE measures for these groups (high, medium and low). There were significant group differences in the number of negative and positive thoughts and dysfunctional and functional beliefs (smallest F(2,87) ¼ 5.63, po0.01). Specifically, the high EDE-Q group had significantly more negative thoughts and dysfunctional beliefs and fewer Table 1 Mean (SE) scores on the main measures High EDE-Q (n ¼ 30)
Medium EDE-Q (n ¼ 30)
Low EDE-Q (n ¼ 30)
3.37a (0.18) 2.79a (0.18) 3.98a (0.17) 3.71a (0.10)
2.04b (0.19) 0.41b (0.06) 1.51b (0.12) 1.54b (0.05)
0.17c (0.05) 0.07c (0.02) 0.18c (0.05) 0.20c (0.03)
Exercise frequency (sessions per week)
4.1 (0.3)
3.3 (0.3)
4.1 (0.3)
Exercise duration (minutes per session)
68.9 (5.8)
62.0 (3.2)
75.5 (6.5)
Commitment to exercise
55.9a (3.3)
52.2a (3.0)
38.6b (2.7)
***
Depression (BDI)
14.2a (1.8)
6.0b (1.0)
3.2b (0.6)
***
BMI (kg/m2)
24.9a (1.0)
22.7b (0.4)
22.0b (0.6)
*
EDEQ Restraint Eating concern Weight concern Global
*** *** *** ***
Significant group difference (*po0.05, **po0.01, ***po0.001). Means with different superscripts are significantly different from each other (post-hoc comparison po0.05).
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Table 2 Mean (SE) sentence completion classifications High EDE-Q (n ¼ 30)
Medium EDE-Q (n ¼ 30)
Low EDE-Q (n ¼ 30)
Negative thoughts
3.10a (0.37)
1.03b (0.20)
0.37b (0.12)
***
Positive thoughts
4.20a (0.35)
6.17b (0.39)
7.93b (0.42)
***
Dysfunctional beliefs
3.20a (0.43)
1.93b (0.29)
1.40b (0.21)
**
Functional beliefs
1.67a (0.19)
2.43b (0.32)
3.07b (0.36)
**
Maximum score is 12 in each of the categories. Significant group difference (**po0.01, ***po0.001). Means with different superscripts are significantly different from each other (post-hoc comparison po0.05).
positive thoughts and functional beliefs than the low EDE-Q group. In many cases, the high EDEQ group was also significantly different to the medium EDE-Q group. Including BMI and depression as covariates had no effect on the difference in negative or positive thoughts. However, depression did remove the between-group differences in dysfunctional (F(2,86) ¼ 1.54, NS) and functional beliefs (F(2,86) ¼ 1.93, NS). For this reason, we concentrated on analyzing the propositional thoughts rather than the conditional beliefs, because responses to these items were associated with eating disorder psychopathology uncontaminated by co-morbid depression. There were significant group differences in responses to the stems relating to eating (smallest F(2,87) ¼ 4.68, po0.05) and body appearance (smallest F(2,87) ¼ 23.37, po0.001), but not exercise (largest F(2,87) ¼ 1.20, NS). The high EDE-Q group had the greatest number of negative thoughts about eating and body appearance and the least number of positive thoughts, post-hoc tests showing them to be significantly different to the low EDE-Q group in all cases. For exercise stems, all groups had more positive than negative responses. The addition of BMI and depression as covariates eliminated group differences in thoughts about eating, but those for body appearance remained statistically significant (negative F(2,84) ¼ 12.50, po0.001; positive F(2,84) ¼ 18.54, po0.001). Table 3 illustrates the individual sentence stems in each of the domains together with the responses for three randomly selected participants, one from each of the groups. The type and nature of the completions are apparent, as are the predominantly positive thoughts regarding exercise.
Discussion In this community sample of female exercisers, eating disorder psychopathology was associated with commitment to exercise, body weight and depression, suggesting that exercise commitment was linked to weight and mood regulation in women with eating disorder features. However, these features were not associated with how frequently the women exercised, or the duration of their
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Table 3 SCEE thought patterns for three randomly selected participants in each of the groups SCEE item Eating items For me eating y For me going to a restaurant y After eating a meal y Eating makes me feel y Exercise items For me exercising y For me going to the gym y After a workout y Physical activity makes me feel y Body items I feel my shape y I feel my weight y I feel my body y I feel my appearance y
Participant A: High EDE-Q
Participant B: Medium EDE-Q
Participant C: Low EDE-Q
y I don’t have to do much () y is not something I like doing () y I always feel really fat () y self-obsessed ()
y is important (+)
y is good (+)
y is a nice luxury (+) y I have a drink (0)
y is usually disappointing () y I like to relax (+)
y satisfied (+)
y ready (+)
y helps me to get rid of stress (+) y is a sense of release (+) y I feel really glad and healthy (+) y better about myself (+)
y makes me feel good about myself (+) y is a way of releasing frustration (+) y I need a shower and lots of water (0) y healthy and good about myself (+)
y is fun (+)
y is bigger than most people’s () y is too heavy () y is not very attractive () y is beginning to get worse ()
y could be better (0)
y is OK (+)
y is too high () y needs toning ()
y is fine (+) y is strong (+)
y used to be better (0)
y is fine (+)
y is something to look forward to (+) y I feel satisfied (+) y good/strong/happy (+)
(+), positive code; (0), neutral code; (), negative code.
exercise bouts, refuting any simple notion that psychopathology can be inferred from exercise behaviour alone. Previous research has linked eating disorder psychopathology with commitment to exercise, but not exercise frequency or duration (Davis et al., 1993; Adkins & Keel, 2005), and the same pattern of association was found here. Furthermore, exercise commitment was not a simple correlate of psychopathology since there were similar commitment levels in the high and medium EDE-Q groups. This suggests the value of looking in detail at thoughts and beliefs about exercise. This study took a cognitive approach to investigate whether certain patterns of belief or thought-content would be specific to the high EDE-Q group and might give some indication of their motivation to commit to exercise. The sentence completion method was successful in eliciting propositional thoughts and conditional assumptions about eating, appearance and exercise, and since the response format involved participants generating cognitions rather than endorsing
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pre-set statements, we can be more confident that the outcome directly reflected participant’s thoughts on these topics. In addition, since the SCEE sentence stems were emotionally neutral, participant responses were not artefactually influenced by negative response biases. As expected, young women in the high EDE-Q group produced significantly more negative thoughts and fewer positive thoughts than the medium and low scoring women. This negative valence of cognitions is in line with previous research using other methods to elicit thoughtcontent in the eating disorder literature (Zotter & Crowther, 1991; Cooper & Fairburn, 1992). The high EDE-Q group also generated significantly more dysfunctional beliefs and fewer functional beliefs, but these differences were explained by co-morbid depression, not eating disorder psychopathology, so they were not the main focus of this study. Future studies could investigate relationships between mood-related and eating disorder-related cognitions in more depth. When the valence of thoughts was analyzed across the three domains, a more variable pattern emerged. As expected, in the high EDE-Q group thoughts about body appearance remained significantly less positive and more negative than the other groups, again even after controlling for differences in depression and body weight. However, the high EDE-Q group was similarly positive about exercise as both of the comparison groups. To make sense of this positive construal of exercise in the context of eating disorder features and depressed mood it is necessary to draw on other research. For example, collecting data from an undergraduate community sample, Thome and Espelage (2004) found that in males exercise engagement was associated with positive affect and reduced anxiety and depression. In contrast, exercise in females was associated with both positive and negative affect. A clearer picture emerged when eating disorder psychopathology was entered into the analysis. There was an association between exercise frequency and positive affect in those scoring low on psychopathology and an association between exercise frequency and negative affect in those with eating disorder features. Exercise use in clinical samples supports this latter association. Excessive exercise was found to be associated with greater levels of depression regardless of eating disorder diagnosis (Pen˜as-Lledo, Vaz Leal, & Waller, 2002). In addition, anorexia nervosa patients who exercised had higher levels of anxiety than those who did not use exercise. It is argued that some anorexic patients use exercise to regulate their mood, to compensate for, relieve or suppress their emotional state. This functional value of exercise should be less appealing to those with bulimia nervosa since bingeing and purging serve the same emotion regulatory functions and they do so more rapidly. Similar processes may be operating in the women we recruited. As previously noted, engagement in regular exercise is typically directed at preventing increases in body weight and addressing dissatisfaction with shape and weight (Davis et al., 1994; Cash et al., 1994; Ingledew & Sullivan, 2002). If successful, such a strategy could prevent or at least slow the development of eating disorder psychopathology. In this respect regular exercise may be beneficial and is likely to be reflected in the positive cognitions apparent in the present study. This beneficial or ameliorating effect of exercise in someone with an eating disorder has been reported in qualitative research (Bamber et al., 2000). However, there are alternative scenarios to be considered. Using exercise to regulate body weight, self-image and mood could act to further inflate the importance attached to body appearance and maintain cycles of self-evaluation based on body shape and weight. Here, exercise becomes part of the clinical picture. Enforced absence from exercise via injury or illness is likely to be viewed as catastrophic, leading to resorting to weight and shape-controlling strategies that
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more directly exacerbate eating disorder features (e.g. purging, binging), a process also observed in qualitative research (Bamber, Cockerill, Rodgers & Carroll, 2003). In conclusion, there is sufficient evidence relating eating disorders and exercise participation, be it excessive or compulsive. In addition to the acknowledged risk to eating disorder development, for some individuals exercise plays a role in the maintenance of the syndrome. The present study has used a novel methodology to elicit and compare thoughts about exercise with those in domains that are characteristically negative. The finding that cognitions about exercise were positive in women with eating disorder psychopathology and negative affect is suggestive of several functions for their exercise participation. Further studies are needed to test these coping strategies. Particularly valuable would be further investigations of thoughts and beliefs, especially in exercisers with fully developed eating disorders, before and during treatment.
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Garner, D. M., Rosen, L. W., & Barry, D. (1998). Eating disorders among athletes. Child and Adolescent Psychiatric Clinics of North America, 7, 839–857. Hulley, A. J., & Hill, A. J. (2001). Eating disorders and health in elite women distance runners. International Journal of Eating Disorders, 30, 312–317. Ingledew, D. K., & Sullivan, G. (2002). Effects of body mass and body image on exercise motives in adolescence. Psychology of Sport and Exercise, 3, 323–338. Luce, K. H., & Crowther, J. H. (1999). The reliability of the eating disorders examination—self report questionnaire version (EDE-Q). International Journal of Eating Disorders, 25, 349–351. McLaren, L., Gauvin, L., & White, D. (2001). The role of perfectionism and excessive commitment to exercise in explaining dietary restraint: replication and extension. International Journal of Eating Disorders, 29, 307–313. Mizes, J. S. (1992). Validity of the Mizes anorectic cognitions scale: a comparison between anorectics, bulimics, and psychiatric controls. Addictive Behaviours, 17, 283–289. Pen˜as-Lledo, E., Vaz Leal, F. J., & Waller, G. (2002). Excessive exercise in anorexia and bulimia nervosa: relation to eating characteristics and general psychopathology. International Journal of Eating Disorders, 31, 370–375. Smolak, L., Murnen, S. K., & Ruble, A. E. (2000). Female athletes and eating problems: a meta-analysis. International Journal of Eating Disorders, 27, 371–380. Sundgot-Borgen, J. (Ed.). (2004). Editorial: disordered eating and exercise. Scandinavian Journal of Medicine & Science in Sports, 14, 205–207. Sundgot-Borgen, J., & Torstveit, M. K. (2004). Prevalence of eating disorders in elite athletes is higher than in the general population. Clinical Journal of Sports Medicine, 14, 25–32. Thome, J., & Espelage, D. L. (2004). Relations among exercise, coping, disordered eating, and psychological health among college students. Eating Behaviours, 5, 337–351. Waller, G. (2003). Schema-level cognitions in patients with binge eating disorder: a case control study. International Journal of Eating Disorders, 33, 458–464. Waller, G., Shah, R., Ohanian, V., & Elliott, P. (2001). Core beliefs in bulimia nervosa and depression. Behaviour Therapy, 32, 139–153. Zotter, D. L., & Crowther, J. H. (1991). The role of cognitions in bulimia nervosa. Cognitive Therapy & Research, 15, 413–426.
Psychology of Sport and Exercise 7 (2006) 425–436 www.elsevier.com/locate/psychsport
‘‘After a workout y’’ Beliefs about exercise, eating and appearance in female exercisers with and without eating disorder features Zara Lipseya, Stephen B. Bartonb, Angela Hulleyc, Andrew J. Hilla, a
Academic Unit of Psychiatry & Behavioural Sciences, School of Medicine, University of Leeds, 15 Hyde Terrace, Leeds LS2 9LT, UK b Department of Clinical Psychology, University of Newcastle, Ridley Building, Newcastle NE1 7RU, UK c Centre for Sport and Exercise Sciences, University of Leeds, Leeds LS2 9JT, UK Available online 28 February 2006
Abstract Objective. This study investigated the relationship between exercise and eating disorder features in a community sample of adult women with and without eating disorder psychopathology. The research focus was on the cognitions of exercisers who scored high and low on eating disorder symptoms. It was hypothesized that women with eating disorder symptoms would have more negative thoughts and beliefs about eating and body appearance but would not differ in cognitions relating to exercise. Design. A cross-sectional comparative study. Method. A community sample of 260 female sports center users completed a measure of eating disorder psychopathology (EDE-Q), the sentence completion test for eating and exercise (SCEE), assessments of depression, exercise commitment and an exercise diary. Results. In the whole sample, EDE-Q global score was positively correlated with commitment to exercise but unrelated to frequency or duration. High EDE-Q scoring women (n ¼ 30) had more dysfunctional beliefs and negative thoughts than medium or low scoring comparison groups, particularly concerning body appearance. They exercised with the same frequency as comparison women and were equally positive about exercise, in spite of being more negative about their appearance. Conclusion. The association between commitment to exercise and eating disorder psychopathology is consistent with previous research. The positive cognitions regarding exercise, concurrent with negative Corresponding author. Tel.: +44 113 343 2734; fax: +44 113 243 3719.
E-mail address: [email protected] (A.J. Hill). 1469-0292/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.psychsport.2006.01.005
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thoughts and dysfunctional beliefs about eating and body appearance, suggest a functional value for exercise in eating disorder symptomatic women. r 2006 Elsevier Ltd. All rights reserved. Keywords: Eating disorder psychopathology; Exercise; Cognitions; Negative thoughts; Dysfunctional beliefs
Introduction Sport or exercise participation is implicated in both the development and maintenance of eating disorders (Garner, Rosen, & Barry, 1998). Hospitalized eating disorder patients are more physically active and more involved in regular sport or exercise activities prior to their disorder than controls (Davis, Kennedy, Ravelski, & Dionne, 1994). More than half engage in very high levels of exercise during the acute phase of their disorder (Davis et al., 1997). Conversely, studies of elite female athletes show a much higher than expected prevalence of eating disorders. This is true for elite female distance runners (Hulley & Hill, 2001) and those whose disciplines demand a thin body build (Sundgot-Borgen & Torstveit, 2004). The relationship between exercise and eating disorders is less certain outside the elite athlete and clinical eating disorder arenas. Following a meta-analysis of studies relating athletic participation and eating problems, Smolak, Murnen & Ruble (2000) concluded there are circumstances where sports participation is a risk factor for eating disorders, but other situations where it appears to be protective. For example, non-elite athletes, especially those in high school, have a reduced risk of eating disorders compared with their non-athlete peers. In the main, the risk or protective nature of exercise participation may be difficult to evaluate without knowledge of participant’s underlying feelings about body shape and weight. Sundgot-Borgen (2004) describes the exercise patterns of some body dissatisfied individuals as treading a fine line between optimal performance and health damaging behaviour. A better understanding of motives or beliefs about exercise in people with shape and weight dissatisfactions may assist in this evaluation. Weight management, or responding to fear of weight gain, is prominent in accounts of sport or exercise participation prior to the development of eating disorders (Davis et al., 1994). Unsurprisingly, weight management also figures highly in nonclinical groups. Appearance/weight management was the only motive associated with frequency of exercise by female college students (Cash, Novy, & Grant, 1994). Similarly, exercise for weight management typified female adolescents who perceived themselves as overweight (Ingledew & Sullivan, 2002). In general, one would expect to find positive beliefs about exercise to be present alongside varying negative beliefs about shape and weight. A cognitive perspective on this issue may offer insight into these functions and benefits and has the potential to build on previous narrative-based qualitative approaches (Bamber, Cockerill, Rodgers, & Carroll, 2000). A cognitive–behavioural theoretical view is prominent in both anorexia and bulimia nervosa and cognitive–behavioural therapy is the leading evidence-based treatment (Fairburn, 2002). Research interest into cognitive processes in eating disorders has paralleled the popularity of the therapeutic approach. Investigations include the operation of information processing biases and, more recently, the core beliefs or schema-level cognitions characteristic of eating disorders (Waller, 2003; Waller, Shah, Ohanian, & Elliott, 2001).
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Attempts at describing the thoughts characteristic of eating disorders has been another investigational approach. The methods used include thought-sampling (Zotter & Crowther, 1991), thought checklists and concurrent verbalization (Cooper & Fairburn, 1992). The latter methodologies have revealed something important to the current study. Collecting thoughts prompted by tasks such as participants looking at themselves in a full length mirror, weighing themselves or eating showed those with an eating disorder to have more negative thoughts than dieters or non-dieting controls. Of particular note was a degree of specificity in thought content that distinguished women with anorexia nervosa from those with bulimia nervosa. More negative thoughts about eating were recorded in participants with anorexia nervosa while those with bulimia nervosa had more negative thoughts about weight and appearance. This suggests the value of examining thoughts about different situations or relevant but separate domains. A more common methodology, given the difficulties in approaches such as concurrent verbalization, has been the use of thought questionnaires (e.g. Clark, Feldman, & Channon, 1989; Mizes, 1992). However, questionnaires have been criticized for their lack of empirical base, their pre-determined structure and retrospective nature (Cooper, 1997). At worst questionnaires simply confirm clinical hypotheses without providing a full picture of cognitive content. A similar criticism has been made of the assessment of depressive cognitions—that questionnaire statements approximate a patient’s thoughts rather than capture them in a precise fashion (Barton & Morley, 1999). Sentence completions offer an alternative method of eliciting thought-content and a sentence completion test for depression has been developed that has good psychometric properties (Barton, Morley, Bloxham, Kitson, & Platts, 2005). An advantage of this methodology over questionnaire assessment is the absence of a systematic negative response bias. There are no negative statements in this format, only sentence stems. In addition, the stems can be tailored towards theoretically driven content domains, in this case, appearance, eating and exercise. Within these specified domains propositional meanings can be generated, that is, thoughts that have positive, negative or neutral content (for example, ‘‘For me eating y is important’’). Assumptions or beliefs that are conditional on various states of affairs can also be elicited (e.g. ‘‘If I was forced to overexercise y I would like it’’). These can be classified as adaptive and therefore functional responses (such as responding appropriately or taking positive action), maladaptive or dysfunctional responses (typically catastrophic or magical thinking), or responses that are neutral in nature. In this fashion, measures of positive thinking, negative thinking, functional assumptions and dysfunctional assumptions can be generated in the specific domains of interest. The present paper describes the use of a sentence completion test directed at thought content (i.e. propositions) and conditional beliefs/assumptions in these three domains: appearance, eating and exercise. This measure has been used successfully to characterize cognitions in obese adolescents attending a residential weight loss camp and to evaluate cognitive change over the duration of the camp (Barton, Walker, Lambert, Gately, & Hill, 2004). The study showed a reduction over time in negative thoughts and increase in positive thoughts, especially in those related to exercise and appearance. The pathological use of exercise by individuals with eating disorders was not the focus of this research. Rather, the study was directed at young women who were users of local exercise facilities, including fitness and aerobics classes. They were expected to bring with them a range of weight and shape concerns and a variety of reasons for exercising and perceived functions of
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exercise. The study was designed to collect information on eating disorder psychopathology, mood and exercise frequency and commitment from a large sample of women, permitting an analysis of the relationships between these variables. In addition, the sample would provide an opportunity to compare the cognitions of female exercisers who scored high and low on eating disorder symptoms. It was hypothesized that compared with non-symptomatic women, those with eating disorder psychopathology would have more negative thoughts and dysfunctional beliefs about eating and body appearance, but would not differ in their positive thoughts and beliefs about exercise.
Method Participants Women were recruited from three sports centres in a city in the North of England. One was University based and the others were operated by the city council. All offered exercise facilities and several daily fitness and aerobics classes. Female sports centre users were given questionnaire packs on entry to the building. Participation was voluntary and the questionnaire packs were returned by post. Of 600 questionnaires given out, 260 were returned fully completed, a response rate of 43%. Nearly 60% of the respondents attended the University sports centre. No information is available on the non-completers. Participants’ mean age was 29.4 years (range 18–63 years), with almost half below the age of 28 and one-third between 28 and 38 years. Over 90% were Caucasian. Measures Demographics/general information Background information included date of birth, current weight and height, weight history, and menstrual regularity. Exercise diary A 2-week retrospective diary was adapted from formats used by others (e.g. Davis, Brewer, & Ratusny, 1993) and asked participants to list on each day the type and duration of any exercise engaged in. This information was collected over 14 days in order to increase representativeness. A supplemental question asked whether this pattern was typical of the participant’s exercise pattern and if not, to outline the usual pattern. This information was used to calculate the weekly frequency of physical activity (number of days exercised per week), the weekly duration of physical activity (total amount of time), and the mean exercise bout duration (weekly duration divided by weekly frequency). Commitment to exercise scale (CES) The CES is an 8-item visual analogue scale measuring psychological commitment to exercise (Davis et al., 1993). Central attitudes and behavioural features relating to over-exercising include obligatory aspects of exercising (e.g. feeling guilty when exercise session is missed) and
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pathological aspects of exercise (e.g. continuing to exercise when injured). The CES has been shown to have good total scale internal consistency (a ¼ 0.88; McLaren, Gauvin, & White, 2001). Eating disorder examination questionnaire (EDE-Q) The EDE-Q is a 36-item questionnaire measuring both the frequency of specific eating disorder behaviours and attitudinal aspects of eating disorders (Fairburn & Beglin, 1994). Eating disorder psychopathology is assessed on four sub-scales: dietary restraint, eating concern, weight concern and shape concern. These sub-scales have good internal consistency (a ¼ 0.88–0.93) and test–retest reliability (r ¼ 0.81–0.94; Luce & Crowther, 1999). This measure was included to characterize eating disorder features across the whole sample, and particularly to identify the subsample of women with the highest levels of psychopathology. Beck depression inventory (BDI) The BDI is a 21-item scale widely used in clinical and research settings to measure depression. Participants are asked to identify a statement from each item that best describes the way they have been feeling over the past 2 weeks. The measure has high concurrent validity (r ¼ 0.72 with clinical ratings) and good psychometric properties (a ¼ 0.81 in non-psychiatric patients; Beck, Steer, & Garbin, 1988) and was used to control for possible group differences in depression and associated negative thoughts. Sentence completion test for eating and exercise (SCEE) This 24-item cognitive measure has been developed to elicit thought patterns and conditional beliefs relating to eating behaviour, body appearance, and exercise behaviour (Barton et al., 2004). Participants were presented with sentence stems and their task was to finish each sentence using their own words. Half the stems elicited thoughts at the propositional level, and these were balanced between eating (e.g. ‘‘For me eating y’’), body appearance (e.g. ‘‘I feel that my body y’’), and exercise (e.g. ‘‘Physical activity makes me feel y’’). The other 12 stems elicited conditional beliefs, these sentence stems having an ‘‘if–then’’ structure to elicit inferences about the consequences of different hypothetical scenarios. These sentence stems were directed at eating (e.g. ‘‘If I decided to stop eating regular meals y’’), exercise (e.g. ‘‘If I was prevented from taking regular exercise y’’), and life imbalance (e.g. ‘‘If I feel that my plans are blocked y’’). A coding manual was developed from previous research using sentence completion to measure depressive thinking (Barton & Morley, 1999; Barton et al., 2005).1 The propositional thought responses were classified into negative, positive or neutral types, and the conditional beliefs classified as dysfunctional, functional or neutral. This produced four main measures of interest: (1) negative thoughts; (2) positive thoughts; (3) functional beliefs; (4) dysfunctional beliefs, and these were examined in relation to the eating, body appearance and exercise domains. Procedure Participants received a questionnaire pack that contained an A4 Freepost envelope, an information sheet and two A5 envelopes. The information sheet explained that the research was 1
The test and coding manual are available from SBB or AJH upon request.
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investigating lifestyle and exercise behaviour and that all information collected would be kept confidential. Participants were asked to complete the questionnaires and return them in the envelope provided. One of the A5 envelopes had a blue dot and participants were instructed to open this first. This contained the background information sheet and the SCEE. Participants were instructed to return the completed questionnaires to the envelope before opening the second yellow-dotted envelope, containing the other measures. Separating the stem completions from the questionnaires was intended to alleviate potential priming effects. In the event that volunteers wished to suspend their co-operation they were asked to return all the measures. Data analysis Correlational analysis on the whole sample (n ¼ 260) explored the relationship between eating disorder psychopathology, exercise behaviour, and commitment to exercise. EDE-Q global scores were then used to identify a high scoring group (top 30 scores) and two comparison groups, medium (30 nearest the median) and low (lowest 30 scores), to test for cognitive differences on the SCEE. Group size was pre-determined, aiming at including the SCEE responses of participants in the top 10% of EDEQ scores. One-way analysis of variance and post-hoc Student–Neuman– Keuls tests compared the propositional thoughts and conditional beliefs in these three groups. Analysis of co-variance was used to control for the effects of depression (BDI) and body weight (BMI) following the necessary checks and adjustments for outliers, normality and homogeneity of variance.
Results Whole sample The mean age of the whole sample was 29.4 (SE ¼ 0.9) and BMI was 23.2 (SE ¼ 0.4). Three women had a BMI below 18 and 12 were obese (BMI430). This variability was also apparent in their reports of lowest and heaviest body weights. The 2-week exercise diary showed the mean amount of time spent exercising per week was 274 min (or 4.5 h). These women exercised on average 3.8 (SE ¼ 0.2) times per week and each bout of physical activity lasted 69 (SE ¼ 3.1) min. Commitment to exercise also varied across the sample with a mean score of 49.0 (SE ¼ 1.9), just below the mid-point of the scale. None of the women met the full criteria for anorexia nervosa (only three had a current weight less than 85% of expected) and only two fulfilled the criteria for bulimia nervosa. Recurrent binge eating (more than 8 days during the past month) was reported by a further two women and 16 (7% of sample) reported recurrent compensatory behaviour (more than 4 days in past month). A marked-to-moderate importance of weight and shape was reported by one-third of the women. EDE-Q global score was positively correlated with commitment to exercise ðrð258Þ ¼ 0:37; po0:01Þ, depression ðr ¼ 0:48; po0:01Þ and body mass index ðr ¼ 0:30; po0:01Þ, but was unrelated to either exercise frequency ðr ¼ 0:01Þ or total exercise duration ðr ¼ 0:09Þ. In contrast, commitment to exercise was positively related to exercise frequency ðr ¼ 0:17; po0:01Þ but not duration ðr ¼ 0:08Þ.
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Group comparisons Consistent with these correlations, there were significant between-group differences on commitment to exercise (F(2,87) ¼ 9.01, po0.001), depression (F(2,87) ¼ 21.48, po0.001) and BMI (F(2,87) ¼ 4.20, po0.05), the high EDE-Q group scoring higher on all measures (Table 1). Again, there were no group differences in exercise frequency or duration. For the SCEE analysis, two authors (S.B.B., A.J.H.) independently classified all the sentence completions for the three groups (2160 completions). There was a mean of 1.5 missing responses per subject (i.e. 6% missing data). Inter-rater reliability was calculated for all completed items using intra-class correlations for negative thoughts (ICC ¼ 0.95), positive thoughts (ICC ¼ 0.97), dysfunctional beliefs (ICC ¼ 0.89), and functional beliefs (ICC ¼ 0.93). These confirmed highly reliable inter-rater agreements on all classification types. One set of coding was selected at random to provide the main results. Table 2 shows the SCEE measures for these groups (high, medium and low). There were significant group differences in the number of negative and positive thoughts and dysfunctional and functional beliefs (smallest F(2,87) ¼ 5.63, po0.01). Specifically, the high EDE-Q group had significantly more negative thoughts and dysfunctional beliefs and fewer Table 1 Mean (SE) scores on the main measures High EDE-Q (n ¼ 30)
Medium EDE-Q (n ¼ 30)
Low EDE-Q (n ¼ 30)
3.37a (0.18) 2.79a (0.18) 3.98a (0.17) 3.71a (0.10)
2.04b (0.19) 0.41b (0.06) 1.51b (0.12) 1.54b (0.05)
0.17c (0.05) 0.07c (0.02) 0.18c (0.05) 0.20c (0.03)
Exercise frequency (sessions per week)
4.1 (0.3)
3.3 (0.3)
4.1 (0.3)
Exercise duration (minutes per session)
68.9 (5.8)
62.0 (3.2)
75.5 (6.5)
Commitment to exercise
55.9a (3.3)
52.2a (3.0)
38.6b (2.7)
***
Depression (BDI)
14.2a (1.8)
6.0b (1.0)
3.2b (0.6)
***
BMI (kg/m2)
24.9a (1.0)
22.7b (0.4)
22.0b (0.6)
*
EDEQ Restraint Eating concern Weight concern Global
*** *** *** ***
Significant group difference (*po0.05, **po0.01, ***po0.001). Means with different superscripts are significantly different from each other (post-hoc comparison po0.05).
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Table 2 Mean (SE) sentence completion classifications High EDE-Q (n ¼ 30)
Medium EDE-Q (n ¼ 30)
Low EDE-Q (n ¼ 30)
Negative thoughts
3.10a (0.37)
1.03b (0.20)
0.37b (0.12)
***
Positive thoughts
4.20a (0.35)
6.17b (0.39)
7.93b (0.42)
***
Dysfunctional beliefs
3.20a (0.43)
1.93b (0.29)
1.40b (0.21)
**
Functional beliefs
1.67a (0.19)
2.43b (0.32)
3.07b (0.36)
**
Maximum score is 12 in each of the categories. Significant group difference (**po0.01, ***po0.001). Means with different superscripts are significantly different from each other (post-hoc comparison po0.05).
positive thoughts and functional beliefs than the low EDE-Q group. In many cases, the high EDEQ group was also significantly different to the medium EDE-Q group. Including BMI and depression as covariates had no effect on the difference in negative or positive thoughts. However, depression did remove the between-group differences in dysfunctional (F(2,86) ¼ 1.54, NS) and functional beliefs (F(2,86) ¼ 1.93, NS). For this reason, we concentrated on analyzing the propositional thoughts rather than the conditional beliefs, because responses to these items were associated with eating disorder psychopathology uncontaminated by co-morbid depression. There were significant group differences in responses to the stems relating to eating (smallest F(2,87) ¼ 4.68, po0.05) and body appearance (smallest F(2,87) ¼ 23.37, po0.001), but not exercise (largest F(2,87) ¼ 1.20, NS). The high EDE-Q group had the greatest number of negative thoughts about eating and body appearance and the least number of positive thoughts, post-hoc tests showing them to be significantly different to the low EDE-Q group in all cases. For exercise stems, all groups had more positive than negative responses. The addition of BMI and depression as covariates eliminated group differences in thoughts about eating, but those for body appearance remained statistically significant (negative F(2,84) ¼ 12.50, po0.001; positive F(2,84) ¼ 18.54, po0.001). Table 3 illustrates the individual sentence stems in each of the domains together with the responses for three randomly selected participants, one from each of the groups. The type and nature of the completions are apparent, as are the predominantly positive thoughts regarding exercise.
Discussion In this community sample of female exercisers, eating disorder psychopathology was associated with commitment to exercise, body weight and depression, suggesting that exercise commitment was linked to weight and mood regulation in women with eating disorder features. However, these features were not associated with how frequently the women exercised, or the duration of their
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Table 3 SCEE thought patterns for three randomly selected participants in each of the groups SCEE item Eating items For me eating y For me going to a restaurant y After eating a meal y Eating makes me feel y Exercise items For me exercising y For me going to the gym y After a workout y Physical activity makes me feel y Body items I feel my shape y I feel my weight y I feel my body y I feel my appearance y
Participant A: High EDE-Q
Participant B: Medium EDE-Q
Participant C: Low EDE-Q
y I don’t have to do much () y is not something I like doing () y I always feel really fat () y self-obsessed ()
y is important (+)
y is good (+)
y is a nice luxury (+) y I have a drink (0)
y is usually disappointing () y I like to relax (+)
y satisfied (+)
y ready (+)
y helps me to get rid of stress (+) y is a sense of release (+) y I feel really glad and healthy (+) y better about myself (+)
y makes me feel good about myself (+) y is a way of releasing frustration (+) y I need a shower and lots of water (0) y healthy and good about myself (+)
y is fun (+)
y is bigger than most people’s () y is too heavy () y is not very attractive () y is beginning to get worse ()
y could be better (0)
y is OK (+)
y is too high () y needs toning ()
y is fine (+) y is strong (+)
y used to be better (0)
y is fine (+)
y is something to look forward to (+) y I feel satisfied (+) y good/strong/happy (+)
(+), positive code; (0), neutral code; (), negative code.
exercise bouts, refuting any simple notion that psychopathology can be inferred from exercise behaviour alone. Previous research has linked eating disorder psychopathology with commitment to exercise, but not exercise frequency or duration (Davis et al., 1993; Adkins & Keel, 2005), and the same pattern of association was found here. Furthermore, exercise commitment was not a simple correlate of psychopathology since there were similar commitment levels in the high and medium EDE-Q groups. This suggests the value of looking in detail at thoughts and beliefs about exercise. This study took a cognitive approach to investigate whether certain patterns of belief or thought-content would be specific to the high EDE-Q group and might give some indication of their motivation to commit to exercise. The sentence completion method was successful in eliciting propositional thoughts and conditional assumptions about eating, appearance and exercise, and since the response format involved participants generating cognitions rather than endorsing
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pre-set statements, we can be more confident that the outcome directly reflected participant’s thoughts on these topics. In addition, since the SCEE sentence stems were emotionally neutral, participant responses were not artefactually influenced by negative response biases. As expected, young women in the high EDE-Q group produced significantly more negative thoughts and fewer positive thoughts than the medium and low scoring women. This negative valence of cognitions is in line with previous research using other methods to elicit thoughtcontent in the eating disorder literature (Zotter & Crowther, 1991; Cooper & Fairburn, 1992). The high EDE-Q group also generated significantly more dysfunctional beliefs and fewer functional beliefs, but these differences were explained by co-morbid depression, not eating disorder psychopathology, so they were not the main focus of this study. Future studies could investigate relationships between mood-related and eating disorder-related cognitions in more depth. When the valence of thoughts was analyzed across the three domains, a more variable pattern emerged. As expected, in the high EDE-Q group thoughts about body appearance remained significantly less positive and more negative than the other groups, again even after controlling for differences in depression and body weight. However, the high EDE-Q group was similarly positive about exercise as both of the comparison groups. To make sense of this positive construal of exercise in the context of eating disorder features and depressed mood it is necessary to draw on other research. For example, collecting data from an undergraduate community sample, Thome and Espelage (2004) found that in males exercise engagement was associated with positive affect and reduced anxiety and depression. In contrast, exercise in females was associated with both positive and negative affect. A clearer picture emerged when eating disorder psychopathology was entered into the analysis. There was an association between exercise frequency and positive affect in those scoring low on psychopathology and an association between exercise frequency and negative affect in those with eating disorder features. Exercise use in clinical samples supports this latter association. Excessive exercise was found to be associated with greater levels of depression regardless of eating disorder diagnosis (Pen˜as-Lledo, Vaz Leal, & Waller, 2002). In addition, anorexia nervosa patients who exercised had higher levels of anxiety than those who did not use exercise. It is argued that some anorexic patients use exercise to regulate their mood, to compensate for, relieve or suppress their emotional state. This functional value of exercise should be less appealing to those with bulimia nervosa since bingeing and purging serve the same emotion regulatory functions and they do so more rapidly. Similar processes may be operating in the women we recruited. As previously noted, engagement in regular exercise is typically directed at preventing increases in body weight and addressing dissatisfaction with shape and weight (Davis et al., 1994; Cash et al., 1994; Ingledew & Sullivan, 2002). If successful, such a strategy could prevent or at least slow the development of eating disorder psychopathology. In this respect regular exercise may be beneficial and is likely to be reflected in the positive cognitions apparent in the present study. This beneficial or ameliorating effect of exercise in someone with an eating disorder has been reported in qualitative research (Bamber et al., 2000). However, there are alternative scenarios to be considered. Using exercise to regulate body weight, self-image and mood could act to further inflate the importance attached to body appearance and maintain cycles of self-evaluation based on body shape and weight. Here, exercise becomes part of the clinical picture. Enforced absence from exercise via injury or illness is likely to be viewed as catastrophic, leading to resorting to weight and shape-controlling strategies that
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more directly exacerbate eating disorder features (e.g. purging, binging), a process also observed in qualitative research (Bamber, Cockerill, Rodgers & Carroll, 2003). In conclusion, there is sufficient evidence relating eating disorders and exercise participation, be it excessive or compulsive. In addition to the acknowledged risk to eating disorder development, for some individuals exercise plays a role in the maintenance of the syndrome. The present study has used a novel methodology to elicit and compare thoughts about exercise with those in domains that are characteristically negative. The finding that cognitions about exercise were positive in women with eating disorder psychopathology and negative affect is suggestive of several functions for their exercise participation. Further studies are needed to test these coping strategies. Particularly valuable would be further investigations of thoughts and beliefs, especially in exercisers with fully developed eating disorders, before and during treatment.
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