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Journal of Sport and Health Science 4 (2015) 211e221
www.jshs.org.cn

Review

Validity and reliability of eating disorder assessments

used with athletes: A review
Zachary Pope*, Yong Gao, Nicole Bolter, Mary Pritchard
Department of Kinesiology, Boise State University, Boise, ID 83725, USA
Received 11 October 2013; revised 1 February 2014; accepted 12 May 2014
Available online 20 September 2014

Abstract

Background: Prevalence of eating disorders (EDs) among college-aged athletes has risen in recent years. Although measures exist for assessing
EDs, these measures have not been thoroughly reviewed in athletes. This study reviewed the validity and reliability evidence of the commonly
used measures for assessing EDs in athlete populations aged 18e26 years.
Methods: Databases were searched for studies of regarding ED on male and/or female athletes. Inclusion criteria stated the study (a) assessed
EDs in an athlete population 18e26 years of age and (b) investigated EDs using a psychometric measure found valid and/or reliable in a non-
athlete population and/or athlete population.
Results: Fifty studies met the inclusion criteria. Seven and 22 articles, respectively, studied EDs behaviors in male and female athletes whereas
21 articles studied EDs in combined-gender samples. The five most commonly used measures were the Eating Attitudes Test (EAT), Eating
Disorder Inventory (EDI), Bulimia Test-Revised (BULIT-R), Questionnaire for Eating Disorder Diagnosis (QEDD), and the Eating Disorder
Examination Questionnaire (EDE-Q).
Conclusion: Only seven studies calculated validity coefficients within the study whereas 47 cited the validity coefficient. Twenty-six calculated a
reliability coefficient whereas 47 cited the reliability of the ED measures. Four studies found validity evidence for the EAT, EDI, BULIT-R,
QEDD, and EDE-Q in an athlete population. Few studies reviewed calculated validity and reliability coefficients of ED measures. Cross-
validation of these measures in athlete populations is clearly needed.
Copyright Ó 2014, Shanghai University of Sport. Production and hosting by Elsevier B.V. All rights reserved.

Keywords: Athletes; Eating disorders; Psychometrics; Reliability; Validity

1. Introduction Anorexia nervosa is characterized by a severe limitation in

caloric intake despite being severely underweight whereas
Eating disorders (EDs) encompass abnormal eating and BN features periods of abnormally high caloric intake in a
weight control patterns, such as caloric restriction, excessive short, distinct period of time (i.e., 2 h) during which the in-
exercise, binging and/or purging, and abnormal body dissat- dividual feels they have no control over their feeding be-
isfaction, over a prolonged period of time.1 According to the haviors followed by extreme purging measures (i.e., laxative
Diagnostic and Statistical Manual of Mental Disorders: Fifth use, vomiting, high amounts of exercise).1 Individuals with
Edition (DSM-5), common EDs include anorexia nervosa BED experience the same period of abnormally high caloric
(AN), bulimia nervosa (BN), binge eating disorder (BED), intake and lack of control over their feeding behaviors as seen
and other specified feeding or eating disorders (OSFEDs). in BN but do not engage in extreme purging measures
following the binge episode.1 OSFEDs refers to an ED
category wherein the individual meets a portion of the criteria
* Corresponding author.
for AN, BN, and/or BED but does not meet enough of these
E-mail address: [email protected] (Z. Pope) criteria to qualify as a clinical ED.1 EDs occur among fe-
Peer review under responsibility of Shanghai University of Sport. males and males in non-athlete populations and are

2095-2546/$ - see front matter Copyright Ó 2014, Shanghai University of Sport. Production and hosting by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.jshs.2014.05.001
212 Z. Pope et al.

concerning because of their negative effect on physical and female athletes trying to conform to society’s “ideal” body
mental health.1 Given the danger EDs pose to a person’s type, these individuals are also striving to achieve the body
physical and mental health, assessing an individual’s risk for type which enhances sport performance.10,12
EDs is vital for non-athletes as well as athlete populations. Male and female athletes are predisposed to engage in ED
EDs have been observed among female athletes and, more behaviors because of the sport context.13 There can be sport-
recently, some male athletes.2e6 Sanford-Martens et al.7 found specific weight restrictions14,15 and negative comments by
21.2% of a male athlete sample and 14.5% of female athletes coaches and teammates16,17 that make athletes susceptible to
possessed ED behaviors. In the seminal study of EDs in a large the development of EDs. Furthermore, research suggests that
sample of Division-I athletes (n ¼ 1445; 562 females, 883 EDs may be reinforced as coaches, teammates, and spectators
males), Johnson et al.3 found 13.02% of males and 10.85% of comment upon changes in body type and performance that
females engaged in binge eating at least once per week. more closely align with how an athlete in said sport should
Additionally, 5.52% and 2.04% of the female and male ath- appear or perform, respectively.8
letes, respectively, carried out some type of purging behavior Age and competitive level can also play a role in the onset
on a weekly basis (i.e., use of laxatives, excessive exercise, of EDs. Woodside and Garfinkel18 report individuals between
vomiting). Two landmark studies on EDs in male athletes from the age of 18 and 26 years are more susceptible to ED (see
a wide array of sports found 16.6%e19.2% to display ED also, Wright et al.19). This increased susceptibility to
behaviors.4,6 The preceding findings indicate EDs occur in engagement in ED behaviors can arise due to the stress
athlete populations and that both male and female athletes are associated with a lack of structure and boundaries, moving
affected. away from home, and becoming more independent when
Male and female athletes engaging in ED behaviors such as young adults attend a college or university.19 The preceding
binging/purging, laxative use, or excessive exercise are putting age range also corresponds to a time when athletes are often at
both their athletic performance and health in serious jeopardy. higher levels of sport competition (e.g., collegiate, national, or
For example, Sundgot-Borgen and Torstveit8 state prolonged international competitions). Athletes at higher levels of
periods of caloric restriction cannot only degrade physical/ competition are exposed to even greater sport pressures (e.g.,
psychological performance (e.g., strength production, fatigue weight restrictions imposed by sport or coach, the need to
levels, concentration, mental acuity) but also put the athlete in conform to the “ideal” body type for a specific sport, belief
danger of serious health problems. Endocrine, cardiovascular, weight reduction will enhance performance), which further
reproductive, and central nervous systems maladaptations, as predispose them to the development of EDs.20,21 Given that
well as gastrointestinal and renal problems, are all potential athletes are under significant societal and sport pressures (e.g.,
complications.8 Thus, a need exists to properly assess EDs in sport-specific weight restrictions, pressure from coaches/
male and female athletes to minimize any negative athletic teammates, conforming to both the male/female body ideal of
performance or health consequences. society and sport), it is important for sports psychologists to
Gender is an essential consideration when one examines have the tools necessary to assess EDs in this population.
why male and female athletes engage in ED behaviors. Soci- EDs can be assessed via various psychometric measures.
ety’s body ideals for each gender, and how these ideals affect Through the use of these measures, psychologists can assess the
athletes, may determine whether or not an athlete engages in severity of ED behaviors an athlete might engage in such as
ED behaviors. The “thin ideal” society projects upon female caloric restriction, binging/purging, and excessive exercise.
athletes may predispose them to engagement in weight control Some examples of measures used for assessment of EDs
practices (e.g., excessive exercise, vomiting, use of laxatives) include the Eating Attitudes Test (EAT),22 the Eating Disorder
to lose weightdeven if the loss in weight does not aid per- Inventory (EDI),23 the Bulimia Test-Revised (BULIT-R),24
formance. In the hopes of achieving this thin, athletic body, Questionnaire for Eating Disorder Diagnoses (QEDD),25 and
some female athletes put themselves at risk for the female the Eating Disorder Examination Questionnaire (EDE-Q).26
athlete triad (i.e., disordered eating, amenorrhea, and low bone The EAT and EDI have multiple versions. The EAT has been
mineral density)da dangerous health condition.9 In fact, shortened from its original 40-item version to a 26-item
29.4%e57.1% of female athletes (varied based on the classi- version, the EAT-26.27 The EDI has two subsequent versions,
fication of the sport as aesthetic, endurance, team, and the EDI-228 and EDI-3,29 which have been modified to reflect
anaerobic) reported a bone injury during their collegiate the most current definitions of EDs.
career. Over 30% displayed ED behaviors and 31% report an These five measures are similar in that the questionnaires
irregular menstrual cycle without the use of oral contracep- use dichotomous (i.e., yes/no) and/or Likert-type formatting to
tives during this same time period.9 assess EDs (e.g., anorexic and bulimic behaviors, dangerous
Conversely, some male athletes strive to reduce body fat weight control behaviors) present in the individual being
while increasing muscle massdproducing the muscular, lean evaluated. The QEDD, EAT, EDI, and BULIT-R were devel-
figure society deems most attractive.10 This desire for a lean, oped from pre-existing definitions of EDs in the
muscular figure can predispose male athletes to ED behaviors DSM.18e20,25,26 The EDE-Q was also based upon the defini-
such as binge eating, excessive exercise, and laxative use to tions of EDs from the DSM but was developed first into a
build muscle but reduce body fat which may or may not be structured interview format and then converted to a ques-
advantageous to the athlete’s sport.10,11 Not only are male and tionnaire.26 Each EDs measure aims to assess specific types of
Disordered eating assessments with athletes 213

ED behaviors. For instance, the BULIT-R was developed to and reliability evidence of the various psychometric measures
assess the degree of bulimic behavior present in an individual used for assessing EDs in male and female athlete populations
whereas the EAT was developed to gauge the severity of 18e26 years of age. To our knowledge, no other review has
anorexic behavior.18,20 Still other questionnaires, such as the undertaken this task. Ensuring valid and reliable ED assess-
EDI, QEDD, and EDE-Q, have subscales encompassing the ments in athlete populations will allow for the accurate mea-
assessment of both bulimic and anorexic tendencies.19,25,26 surement and potential treatment of EDs among athletes.
The EAT, EDI, BULIT-R, QEDD, and EDE-Q are all
capable of being completed within 10e15 min and yield 2. Methods
preliminary evidence as to the severity of ED and weight
control behaviors present in an individual. These question- The databases searched were SPORTDiscus, CINAHL, and
naires are cheaper and more time efficient than structured PsycINFO. The search process was completed using the key-
psychological interviews and, therefore, are used when there is words “validity”, “reliability”, “eating disorders”, “disordered
a need to test a large group of individuals at once. Scores are eating”, “college”, and “athletes” in varying combinations
most often summed and compared to cut-off scores (e.g., from September 1990 to June 2012. Disordered eating refers
scoring a 20 on the EAT-26 is indicative of an ED). It is to an individual possessing a disruption in feeding behaviors
important to note that although it is common to assess EDs that does not meet the criteria for a clinical ED diagnosis.1,35 It
using the preceding questionnaires, these assessments alone was included as a search term because the focus of the current
cannot be used to make an official diagnosis of EDs. Official study was on ED assessments, many of which are not only
diagnoses of EDs must take place via structured clinical used to assess EDs, but also commonly used to concurrently
interviews. examine disordered eating in the literature.
The EAT, EDI, BULIT-R, QEDD, and EDE-Q were all Three inclusion criteria were designated. First, the study
developed and validated for measuring EDs in non-athlete had to be an original research article written in English. Sec-
populations. However, it is unclear whether these measures ond, the study must have assessed EDs in an athletic popu-
are valid for the assessment of EDs in male and female ath- lation of 18e26 years of age. The age range of 18e26 years
letes. Petrie and Greenleaf30 state the study of EDs in athlete was chosen because this is a period in an athlete’s life when
populations is negatively impacted because many researchers she/he is competing in the highest level of sport competition
use measures with “questionable psychometric properties”. In (i.e., college, national, or international) as well as the time
line with Petrie and Greenleaf’s observation, Hagger and period when individuals are most susceptible to EDs.21,36
Chatzisarantis31 suggest one of the major problems in sport Third, the study had to investigate EDs using a measure
psychology research is researchers look to use measures found to be valid and/or reliable in non-athlete and/or athlete
validated in one population and administer these same mea- populations. Aside from the preceding inclusion criteria, no
sures to different populations. When a measure validated in exclusion criteria were present as the researchers were open to
one population is used with a new population without proper studies of any sport, gender, ED assessment, and sample size.
validation, the results of the study can be brought into question Upon retrieving the articles that met the inclusion criteria,
and the generalization of those results can be difficult.31 the following components of each article were stratified within
To ensure the trustworthiness of a study’s results, re- a Microsoft Excel Spreadsheet (Microsoft, Inc., Redmond,
searchers need to discern whether the measure they are using WA, USA): ED assessment used, study name, study authors,
on a new population is valid and reliable. Validity refers to year published, publishing journal, gender of population
whether a test/instrument measures what it is supposed to studied (female athletes, male athletes, combined male/female
measure (i.e., does an ED measure accurately assess the athlete population), sample size, sport, major findings (quan-
severity of eating disorder behaviors in athletes?) and can be titative vs. qualitative), and statistical methods used. Most
measured in a number of ways (e.g., concurrent, predictive, importantly, both validity and reliability coefficients for each
convergent).32 The validity of a measure can be further eval- ED measure were recorded within the spreadsheet. These
uated via tests of measurement invariance to determine whether coefficients were further delineated as one of two types: (1)
an instrument measures the same construct (e.g., severity of ED values calculated directly from the current study or (2) values
behaviors) across different groups (e.g., male/female, cycling/ cited from another study. The type of validity and/or reliability
swimming).33 Reliability refers to the consistency of the calculated/cited was also recorded. These excel data were then
measurement scores on a test/instrument measuring a certain used to (a) surmise the most commonly used ED assessments,
attribute (e.g., if the same individual is administered an ED (b) observe which studies calculated/cited the validity and
assessment twice, does the score remain the same and/or have reliability of the ED measure(s) used in studies investigating
very little variation?) and can also be measured in several ways EDs behaviors in the male and female athletes, and (c) assess
(e.g., test-retest reliability, internal consistency).34 the type of validity and reliability used. This methodology
To date, little is known about whether ED measures are allowed the researchers to make suggestions about ED
valid and reliable in both male and female athlete populations. assessments needing additional validity and reliability when
Therefore, the purpose of this study was two-fold: (1) gather investigating EDs among male and female athletes while also
information about which ED measures are most commonly suggesting which measures have demonstrated adequate val-
used with male and female athletes and (2) review the validity idity and reliability in this population.
Table 1

214
Validity and reliability coefficients for measures used with male athletes only.
ED assessment Authorsa Sample Sport typeb Validity Reliability
used size Calculated Cited validity Citation for Population Calculated Cited Citation for Population
validity coefficient (r) validitya used for reliability reliability reliabilitya used for
coefficient (r) validation coefficient (a) coefficient (a) reliability
EAT-26 Ferrand, 200444 42 Cyclists e 0.60e0.93 Garner, 198227 Women 0.61e0.77 0.90 Garner, 198227 Women
Riebl, 200747 124 Cyclists e 0.60e0.93 Garner, 198227 Women e 0.90 Garner, 198227 Women
EDI-2 Goldfield, 200645 74 Bodybuilders e 0.43e0.68 Garner, 198323 Women e 0.83e0.93 Garner, 198323 Women
Hallsworth, 200546 83 Bodybuilders, e 0.83 Garner, 199128 Women 0.59e0.85 0.83e0.93 Garner, 199128 Women
weightlifters
QEDD/BULIT-R Petrie, 20074 199 Football, basketball, 0.51e0.70 0.73e0.90 QEDD: QEDD: women; 0.87 0.85e0.98 QEDD: Mintz, QEDD: women;
track and field Mintz, 1997;25 BULIT-R: women 1997;25 BULIT-R: BULIT-R:
BULIT-R: Thelen, 199650 women
Thelen, 199650
Petrie, 20086 203 Football, 0.51e0.70 0.73e0.90 QEDD: QEDD: women; 0.92 0.85e0.98 QEDD: Mintz, QEDD: women;
basketball, Mintz, 1997;25 BULIT-R: women 1997;25 BULIT-R:
track and field BULIT-R: BULIT-R: women
Thelen, 199650 Thelen, 199650
WPSS-MA Galli, 201139 203 Football, 0.25e0.39 0.51e0.70 BULIT-R Male athletes 0.91e0.92 0.87 BULIT-R Male athletes
baseball, comparison: comparison:
track and field Thelen, 199124 Thelen, 199124
a
Citations have been listed by the first author’s last name in order to conserve space.
b
If study had more than three sports wherein ED behaviors were observed, only the three major sports studied are listed to conserve space.
Abbreviations: ED ¼ eating disorder; EAT ¼ Eating Attitudes Test; EDI ¼ Eating Disorder Inventory; QEDD ¼ Questionnaire for Eating Disorder Diagnosis; BULIT-R ¼ Bulimia Test-Revised;
WPSS-MA ¼ Weight Pressures in Sport Scale for Male Athletes.

Table 2
Validity and reliability coefficients for measures used with female athletes only.
ED assessment Authorsa Sample Sport typeb Validity Reliability
used size Calculated Cited Citation for Population used Calculated Cited Citation for Population
validity validity validitya for validation reliability reliability reliabilitya used for
coefficient coefficient coefficient coefficient reliability
(r) (a) (a)
AQ Hinton, 200540 167 Volleyball, swimming, basketball 0.46e0.79 e N/A Female athletes 0.77e0.91 e N/A Female athletes
BULIT-R Petrie, 199358 215 Gymnastics e 0.99 Thelen, 199124 Women e 0.95 Thelen, 199124 Women
EAT-26 Doninger, 200542 207 Rowing, soccer, track and field 0.18e0.88 0.60e0.93 Garner, 198227 Women 0.70e0.88 0.90 Garner, 198227 Women
Haase, 200959 137 Netball, soccer, sport aerobics e 0.60e0.93 Garner, 198227 Women 0.74e0.89 0.90 Garner, 198227 Women
Haase, 201160 136 Soccer, rowing, cycling e 0.60e0.93 Garner, 198227 Women 0.91 0.90 Garner, 198227 Women
Jankauskiene, 305 Track and field, cycling, ball sports e 0.60e0.93 Garner, 198227 Women 0.89 0.90 Garner, 198227 Women
201261
Kirk, 200162 403 Soccer, lacrosse, tennis e 0.60e0.93 Garner, 198227 Women 0.51e0.87 0.90 Garner, 198227 Women
Torres-McGehee, 138 Equestrian 0.60e0.93 Garner, 198227 Women 0.89 0.90 Garner, 198227 Women

Z. Pope et al.
e
201163
EDE-Q Beals, 200664 112 Field hockey, cross country e 0.78e0.85 Fairburn, 199426 Women e e e Women
de Bruin, 201165 52 Dance, volleyball, football e 0.78e0.85 Fairburn, 199426 Women e e e Women
Muscat, 200817 223 Volleyball, soccer, running e 0.78e0.85 Fairburn, 199426 Women 0.93 0.85e0.92 Fairburn, 199426 Women
 Disordered eating assessments with athletes
EDI-2 Malinauskas, 200766 115 Not specified e 0.83 Garner, 199128 Women e 0.83e0.93 Garner, 199128 Women
Reinking, 200567 146 Swimming, basketball, volleyball e 0.83 Garner, 199128 Women e 0.83e0.93 Garner, 199128 Women
Torstveit, 200868 331 Not specified e 0.83 Garner, 199128 Women 0.89e0.90 0.83e0.93 Garner, 199128 Women
QEDD Sears, 201212 423 Track and field, swimming, e 0.90 Mintz, 199725 Women 0.64e0.94 0.85e0.94 Mintz, 199725 Women
cross country
EAT-26/EDI-2 Beals, 20029 425 Basketball, cross country, e 0.43e0.93 EAT-26: EAT-26: women; e 0.83e0.93 EAT-26: Garner, EAT-26: women;
track and field Garner, 1982;27 EDI-2: women 1982; EDI-2: EDI-2: women
EDI-2: Garner, 198323
Garner, 198323
Picard, 199969 109 Cross country, rowing, basketball e 0.43e0.93 EAT-26: EAT-26: women; e 0.83e0.93 EAT-26: EAT-26: women;
Garner, 1982;27 EDI-2: women Garner, 1982;27 EDI-2: women
EDI-2: EDI-2: Garner,
Garner, 198323 198323
QEDD/BULIT-R Anderson, 201270 414 Gymnastics, swimming, diving e 0.73e0.90 QEDD: QEDD: women; e e QEDD: Mintz, QEDD: women;
Mintz, 1997;25 BULIT-R: women 1997;25 BULIT-R: BULIT-R: women
BULIT-R: Thelen, 199650
Thelen, 199650
Greenleaf, 200971 204 Soccer, softball, swimming e 0.60e0.90 QEDD: QEDD: women; e 0.85e0.98 QEDD: Mintz, QEDD: women;
Mintz, 1997;25 BULIT-R: women 1997;25 BULIT-R: BULIT-R: women
BULIT-R: Thelen, 199650
Thelen, 199650
Reel, 200772 451 Gymnastics, basketball, golf e 0.90 QEDD: QEDD: women; e 0.85e0.94 QEDD: Mintz, QEDD: women;
Mintz, 1997;25 BULIT-R: women 1997;25 BULIT-R: BULIT-R: women
BULIT-R: Thelen, 199650
Thelen, 199650
AMDQ/EDI-2 Nagel, 200041 149 Basketball, cheerleading, 0.55e0.62 0.60e0.65 BULIT-R: AMDQ: female 0.77e0.95 0.90e0.93 BULIT-R: AMDQ: female
/BULIT-R gymnastics Brelsford, 199273 athletes; EDI-2: Brelsford, 199273 athletes;
women; BULIT-R: EDI-2: women;
women BULIT-R: women
EDI-2/EAT Warren, 199037 126 Gymnastics, cross country, e 0.43e0.87 EDI-2: Garner, EDI-2: women; e 0.83e0.94 EDI-2: Garner, EDI-2: women;
basketball 1983;23 EAT: women 1983;23 EAT: EAT: women
EAT: Garner, Garner, 197922
197922
a
Citations have been listed by the first author’s last name in order to conserve space.
b
If study had more than three sports wherein ED behaviors were observed, only the three major sports studied are listed to conserve space.
Abbreviations: ED ¼ eating disorder; EAT ¼ Eating Attitudes Test; EDI ¼ Eating Disorder Inventory; QEDD ¼ Questionnaire for Eating Disorder Diagnosis; BULIT-R ¼ Bulimia Test-Revised; AQ ¼ ATHLETE
Questionnaire; EDE-Q ¼ Eating Disorder Examination Questionnaire; AMDQ ¼ Athletic Milieu Direct Questionnaire.

215
Table 3

216
Validity and reliability coefficients for measures used with combined male/female athlete samples.
ED assessment Authorsa Sample Sport typeb Validity Reliability
used size Calculated Cited validity Citation for Population Calculated Cited Citation for Population
validity coefficient (r) validitya assessment reliability reliability reliabilitya assessment
coefficient was found coefficient coefficient was found
(r) valid (a) (a) reliable
EAT-26 Blackmer, 201174 103 Not specified e 0.90 Mintz, 200088 Women e 0.90 Garner, 198227 Women
Costarelli, 200975 60 Taekwondo, judo e 0.87 Garner, 197922 Women e 0.93 Garner, 197922 Women
Lane, 200376 165 Football, ice hockey, e e Women 0.79 0.93 Garner, 197922 Women
swimming
Milligan, 200677 176 Basketball, track and e 0.90 Mintz, 200088 Women 0.96 0.51e0.87 Kirk, 200162 Female
field, wrestling athletes
Pritchard, 200778 194 Not specified e 0.90 Mintz, 200088 Women e 0.93 Garner, 197922 Women
Pritchard, 200779 354 Soccer, track and e 0.90 Mintz, 200088 Women 0.94 0.51e0.87 Kirk, 200162 Female
field, baseball athletes
Rouveix, 200615 55 Judo e 0.87 Garner, 197922 Women 0.63e0.76 0.93 Garner, 197922 Women
Sykora, 199314 162 Rowing e 0.87 Garner, 197922 Women e 0.93 Garner, 197922 Women
Van Zyl, 201238 272 Not specified e 0.60e0.93 Garner, 198227 Women 0.78 0.90 Garner, 198227 Women
EAT-40 Haase, 200280 316 Waterpolo, cricket, e 0.87 Garner, 197922 Women 0.88 0.93 Garner, 197922 Women
wrestling
EDE-Q Gomes, 201181 290 Basketball, karate, e 0.78e0.85 Fairburn, 199426 Women 0.94 0.81e0.92 Fairburn, 199426 Women
swimming
EDI-2 Engel, 200382 1445 Football, track and e 0.83 Garner, 199128 Women e 0.83e0.93 Garner, 199128 Women
field, swimming
Gapin, 201183 179 Runners e 0.43e0.68 Garner, 198323 Women 0.75e0.83 0.83e0.93 Garner, 198323 Women
Johnson, 19993 1445 Football, track and e 0.83 Garner, 199128 Women e 0.83e0.93 Garner, 199128 Women
field, swimming
Johnson, 20042 1445 Football, track and e 0.83 Garner, 199128 Women e 0.83e0.93 Garner, 199128 Women
field, swimming
Reel, 199884 124 Cheerleading e 0.83 Garner, 199128 Women e 0.83e0.93 Garner, 199128 Women
Sundgot-Borgen, 20045 3316 Track and field, e 0.83 Garner, 199128 Women e 0.83e0.93 Garner, 199128 Women
basketball, baseball
EDI-2/QEDD Hausenblas, 200485 412 Track and field e 0.98 QEDD: Mintz, EDI-2: women; 0.69e0.85 0.83e0.93 EDI-2: Garner, EDI-2: women;
199725 QEDD: women 1991;28 QEDD: QEDD: women
Mintz, 199725
EAT-26/EDE-Q Hopkinson, 200486 250 Swimming, e e e EAT-26: women; 0.81e0.94 0.81e0.92 EAT-26: Garner, EAT-26:
cross country, soccer EDI-2: women 1982;27 EDE-Q: women;
Fairburn, 199426 EDE-Q: women
EDI-2/EAT Marchand, 200787 305 Football, gymnastics, e 0.60e0.93 EDI-2: Garner, EDI-2: women; e 0.82e0.90 EDI-2: Garner, EDI-2: women;
rowing 1991;28 EAT: EAT: women 1991;28 EAT: EAT: women
Garner, 198227 Garner, 198227
QEDD/BULIT-R Sanford-Martens, 20057 489 Gymnastics, track 0.51e0.70 0.90 QEDD: Mintz, QEDD: women; e 0.85 QEDD: Mintz, QEDD: women;
and field, volleyball 199725 BULIT-R: women 199725 BULIT-R: women
a
Citations have been listed by the first author’s last name in order to conserve space.
b
If study had more than three sports wherein ED behaviors were observed, only the three major sports studied are listed to conserve space.
Abbreviations: ED ¼ eating disorder; EAT ¼ Eating Attitudes Test; EDI ¼ Eating Disorder Inventory; QEDD ¼ Questionnaire for Eating Disorder Diagnosis; BULIT-R ¼ Bulimia Test-Revised; EDE-Q ¼ Eating

Z. Pope et al.
Disorder Examination Questionnaire.
Disordered eating assessments with athletes 217

3. Results populations of male athletes. Finally, Sanford-Martens et al.7

also found validity evidence for the QEDD in a population
3.1. Characteristics of selected studies of male and female athletes.

Out of 450 articles identified, 50 met the inclusion criteria.

3.4. Types of validity and reliability calculated versus cited
The earliest study retrieved using the search terms listed and
databases queried was from 1990,37 whereas June 2012 was the
Table 4 presents the frequency with which different types of
most current study analyzed.38 Sample sizes ranged from 17 to
validity and reliability coefficients were calculated/cited for
3316 participants ðX ¼ 327Þ. Common individual sports studied
the 50 selected studies. Regarding the seven studies that
were track and field and swimming whereas soccer and
calculated validity coefficients, a majority of these studies
volleyball were the most frequent team sports to be examined.
calculated convergent validity (n ¼ 5). Studies that cited
The percentage of athletes with EDs ranged from 7.1% to 60.0%
validity coefficients primarily did so with convergent validity
ðX ¼ 23:9%Þ in these studies. In terms of gender, seven and 22
as well (n ¼ 31) followed by citations of discriminant validity
articles, respectively, evaluated exclusively male athletes or
(n ¼ 13). Although convergent validity and discriminant val-
female athletes, whereas 21 articles assessed ED behaviors of
idity were the most calculated/cited types of validity co-
male and female athletes within the same study. Tables 1e3
efficients, concurrent, predictive, and other indices of
categorize articles by exclusively male, exclusively female,
construct validity were also reported/cited.
and combined-gender athlete studies, respectively.
Across gender, only three studies evaluated the same ED
measure (i.e., BULIT-R) and calculated convergent validity
3.2. Most commonly used ED assessments
coefficients within the study; two studies used male college
athletes4,6 with validity coefficients ranging from 0.51 to
The five most commonly used measures were the EAT
0.70 (Table 1), and one used female athletes with validity
(n ¼ 2; EAT-26: n ¼ 21), EDI (n ¼ 2; EDI-2: n ¼ 15), BULIT-R
coefficients ranging from 0.55 to 0.6241 (Table 2). Although
(n ¼ 9), QEDD (n ¼ 8), and the EDE-Q (n ¼ 5). Of importance
many studies included athletes from different sports, no study
is that some studies (n ¼ 14) included multiple ED measures
examined the validity of an ED measure in a specific sport
(e.g., evaluated athletes with the EAT and EDI). None of the
type or compared validity across sport types. Moreover, no
preceding five measures were developed for use in athlete
study examined measurement invariance to determine whether
populations.
the same ED measure assesses similar ED construct across
Three ED assessments used were developed specifically for
athlete groups (e.g., male/female, cycling/swimming).
administration with athletes. These athlete-specific question-
Reliability coefficients were much more uniform in the type
naires were the Weight Pressures in Sport Scale for Male Ath-
calculated/cited. Most often researchers who calculated a
letes (WPSS-MA),39 the ATHLETE Questionnaire (AQ),40 and
reliability coefficient did so with internal consistency (n ¼ 24)
the Athletic Milieu Direct Questionnaire (AMDQ).41 These
whereas two studies also reported test-retest reliability. Re-
assessments were each used once in the studies reviewed.
searchers choosing to cite the reliability used in previous
studies did so more often with internal consistency (n ¼ 46)
3.3. Calculated versus cited validity and reliability
while nine studies also referenced test-retest reliability of the
coefficients
eating disorder measure used.
Tables 1e3 indicate the eating disorder measure(s) used,
the authors, sample sizes, sport, and whether the coefficient 4. Discussion
was calculated and/or cited for each male athlete, female
athlete, and combined-gender athlete study, respectively. Only Three major findings were unveiled as a result of this re-
seven studies calculated validity coefficients within the study view. Although not surprising, the first finding of this review
(r ¼ 0.51e0.88) whereas 47 cited the validity coefficient Table 4
(r ¼ 0.51e0.99) of the measure of that was established in Types of calculated/cited validity and reliability coefficients.
studies with non-athlete populations. Twenty-six calculated a Type Calculated Cited
reliability coefficient (a ¼ 0.51e0.96) while 47 cited the
Validity 7 47
reliability (a ¼ 0.81e0.98) of measures obtained, again, from Predictive 1 12
studies on non-athlete populations. Criterion e 8
Three studies attempted to validate the less frequently used Construct 1 1
WPSS-MA,39 the AQ,40 and the AMDQ41 in an athlete pop- Convergent 5 31
Discriminant e 13
ulation. Of the studies using the EAT, EDI, BULIT-R, QEDD,
Concurrent e 5
and EDE-Q, only four studies reported both validity and Reliability 26 47
reliability coefficients in these commonly used questionnaires Internal consistency 24 46
when assessing athletes for ED. Doninger et al.42 found val- Test-retest reliability 3 9
idity evidence for the EAT in a population of female athletes Note: some studies calculated and/or cited more than one type of validity and/
while Petrie et al.4,6 found validity evidence of the QEDD in or reliability coefficient.
218 Z. Pope et al.

revealed that the number of studies (14% of the 50 studies EDs among male athletes and the further validation of the
reviewed) completed on exclusively male athletes was much EAT, EDI, QEDD, BULIT-R, and EDE-Q for assessment of
lower in comparison to those conducted on exclusively female EDs in this population vital.
athletes. Secondly, this review found eight different measures
were used in the assessment of EDs in athletes. Specifically, 4.2. Most commonly used ED assessments
the use of the EAT, EDI, QEDD, BULIT-R, and EDE-Q
questionnaires, developed for non-athlete populations, was The second major finding of this review was that the use of
much more prevalent than the use of psychometric measures EAT, EDI, BULIT-R, QEDD, and EDE-Q was much more
assessing the same EDs constructed specifically for athle- frequent when assessing ED in athletes than the use of mea-
tesdnamely the WPSS-MA, AQ, and AMDQ. Finally, this sures developed specifically for administration to athle-
review found a majority of the literature available examining tesdWPSS-MA, AQ, and AMDQ. Only three studies, one for
EDs in athletes to cite the validity and reliability of EDs each questionnaire, used the WPSS-MA, AQ, and AMDQ.
questionnaires reported in previous studies but fewer calcu- The lack of studies using the WPSS-MA, AQ, and AMDQ is
lated their own validity and reliability coefficients with the not surprising considering these three ED measures are much
athletic population they studied. newer in relation to the EAT, EDI, BULIT-R, QEDD, and
EDE-Q (e.g., the AQ and WPSS-MA were developed/vali-
4.1. Gender of athlete population studied dated 8 and 2 years ago, respectively) and, thus, have not been
used with enough frequency for researchers to realize these
This review found research on EDs in exclusively male measures are available. Additionally, the lack of use of the
athlete populations is less prevalent than research examining WPSS-MA, AQ, and AMDQ might also be a result of the fact
these same behaviors in female athlete samples. Hudson the EAT, EDI, BULIT-R, QEDD, and EDE-Q have always
et al.43 found rates of anorexia and bulimia to be significantly been available for use in the assessment of EDs in athlete
higher in non-athlete males than previously thought. The same samples, despite the fact these ED measures may not be valid
is true within male athlete populations as the prevalence of in this population.
ED behaviors has also been increasing in this pop-
ulation.4,6,39,44e47 This increase in the prevalence of ED be- 4.3. Calculated versus cited validity and reliability
haviors indicates the need for sports psychologists to validate coefficients
ED assessments in this population to gain further knowledge
of predisposing factors that might be unique to the develop- Given the EAT, EDI, BULIT-R, QEDD, and EDE-Q are
ment of EDs in male athletes. Despite the limited amount of most frequently used within the literature to assess EDs in
research on exclusively male athlete samples and EDs, the athletes, it is important to know which ED measure are best
QEDD has been found to be a valid psychometric measure for suited (i.e., have adequate validity and reliability in assessing
the assessment of these abnormal behaviors in this EDs in athlete populations) for administration to male and
population.4,6 female athletes. This review found approximately half the
One barrier to studying EDs in male athletes might be that selected studies calculated a reliability coefficient within the
EDs have largely been considered a “woman’s problem” and, athlete population (n ¼ 26) and only seven studies calculated a
therefore, the development of psychometric measures for EDs validity coefficient, three of which were calculated for the
has been tailored toward the “thinness” ideal some women infrequently used WPSS-MA, AQ, and AMDQ questionnaires.
engage in ED behaviors to achieve.48 Male athletes are more Not only have the EAT, EDI, BULIT-R, QEDD, and EDE-Q
often concerned with increasing muscularity than with losing scarcely been validated in athlete populations, these five
body fat, as doing so projects the epitome of masculinity/male questionnaires have been validated almost exclusively in non-
athletes in contemporary culture.10,11 Although measures such athlete populations with samples of women (EAT,27 EDI,19,28
as the EAT, EDI, BULIT-R, QEDD, and EDE-Q may assess BULIT-R,50 QEDD,25 EDE-Q26). Only four studies found
some of the factors related to female athletes engaging in ED validity evidence for the EAT, EDI, BULIT-R, QEDD, and
behaviors to lose weight, these measures poorly assess male EDE-Q in an athlete population.
athletes’ desire to engage in behaviors to become larger and, Doninger et al.42 found validity evidence for the EAT-26 in
thus, bring into question the reliability and validity of these a population of 207 female athletes with convergent validity
measures for male athletes. Furthermore, many of the ED coefficients reported at r ¼ 0.18e0.88 when evaluated
measures available were developed over 20 years ago when the alongside the EDI-2 and internal consistency reliability co-
study of males in non-athlete populations, not to mention male efficients (a) reported ranging from 0.70 to 0.88. The r value
athletes, was not a common topic to be studying. Therefore, of 0.18 reported in the study was a product of the ability of the
the ED measures may not accurately account for factors EAT-26 to look at others’ perceptions of an individual’s eating
contributing to male patterns of EDs. Although new ED behaviors when the EAT-26 was compared to the EDI. The
measures such as the Eating Disorder Assessment for Men49 EDI does not assess others’ perceptions of eating, leading to
(EDAM) are being developed to better account EDs among the low r value.42 However, the preceding results regarding the
men, this measure has yet to be used to examine EDs among convergent validity between the EAT-26 and EDI demonstrate
male athletes. All of the preceding factors suggest the study of very little common variance between the two measures in
Disordered eating assessments with athletes 219

assessing others’ perceptions of eating behaviors, pointing to than a laboratory test (a gold standard) because many factors
the need for validation via other statistical methods besides such as running efficiency, road condition, or temperature can
convergent validity. introduce measurement errors in the 12-min running test. In
Additionally, evidence for the validity of the QEDD has also this regard, convergent validity is less preferred if criterion-
been found with an athlete population in three separate studies. related validity, determined by correlating scores from a
Petrie et al.4,6 examined ED with the QEDD in a population of field measure to those from a gold standard measure, of a
199 and 203 male athletes from both team and individual measure can be established. Regarding ED assessments, no
sports, respectively. Sanford-Martens et al.7 also found evidence measure is considered the “gold standard” within the field,
of the validity of the QEDD when studying a combined sample which renders the measurement of criterion-related validity
of 325 male and female athletes (159 females, 166 males). inadequate for ED measures.
Between the three studies, convergent validity coefficients for Regarding reliability, 24 studies calculated internal con-
the QEDD were r ¼ 0.51e0.70 with internal consistency sistency while only three studies calculated test-retest reli-
reliability coefficients reported at a ¼ 0.87. The negative ability. Although measures of internal consistency are
r value is expected because it was obtained through correlating commonly used, further tests of other types of reliability might
a subscale within QEDD that assesses body satisfaction with be advocated for reliability checking. Specifically, it may be
BULIT-R,4 indicating athletes with higher body satisfaction worthwhile to include test-retest reliability in the evaluation of
were less likely to have bulimic tendencies. Given the QEDD eating disorder measurements in athlete populations to assess
assesses the degree of both bulimic and anorexic behaviors and whether or not athletes achieve approximately the same EDs
demonstrated moderate to good validity and good reliability in score during multiple assessments53 and/or to ensure that
both male and female athletes, the QEDD appears best equip- changes of EDs scores over time are not the result of mea-
ped to gauge ED in athletes of both genders. surement property change of the eating disorder measures.
Once again, the studies researchers cite are most often the
validation studies conducted with non-athlete populations. In 4.5. Limitations and future directions
this accord, one needs to question the accuracy of the measure
with athlete populations.31 As stated above, only Doninger A limitation of the current study is that this review could
et al.,42 Petrie et al.,4,6 and Sanford-Martens et al.7 have found not present sufficient information about the validity and
validity evidence for two of the five most commonly used ED reliability of ED measures across genders and sport types.
measures (EAT, EDI, QEDD, BULIT-R, and EDE-Q), spe- As such, these results cannot provide recommendations on
cifically the EAT and QEDD. Because questionnaires devel- whether an ED measure assesses EDs similarly across
oped specifically for athletes (i.e., WPSS-MA, AQ, and different athlete groups because such information on
AMDQ) are used much less frequently than the EAT, EDI, comparing groups and measurement invariance was unavai-
QEDD, BULIT-R, and EDE-Q among the literature, calcu- lable in the current literature. If researchers want to make
lating, and reporting the validity and reliability coefficients of meaningful comparisons about the prevalence and severity
the EAT, EDI, QEDD, BULIT-R, and EDE-Q with athlete of EDs across athlete groups (e.g., male/female, different
populations is needed. sport types), it is essential to establish that a measure is not
only valid across groups but also evaluates the groups in the
4.4. Types of validity and reliability calculated or cited same way prior to comparing mean scores. Otherwise, dif-
ferences in EDs between groups cannot be appropriately
The results of this review indicate studies that did calculate interpreted.
validity and reliability coefficients for the ED assessment used Future research on EDs in athletes should also look to
to observe athletes did so with traditional psychometrical/ validate the psychometric measure used via advanced psy-
statistical methods (e.g., classic test theory (CTT)). While the chometrical approaches in addition to the use of CTT.
use of CTT is widespread in research, CTT does present some Advanced modern measurement approaches such as Item
inadequacies for constructing/validating psychometric mea- Response Theory54 and Rasch Modeling55 have been
sures; for example, CTT does not measure latent variables demonstrated to assess latent variables (e.g., abilities, attri-
such as ED severity adequately and is both sample- and item- butes) better than CTT,51,52,56,57 which might provide addi-
dependent, which increases the error of the measurement.51,52 tional insight into a better investigation of ED assessments and
Specific to the results of this review regarding validity and help discern whether these psychometric measures are valid
reliability, it is concerning the most frequently calculated/cited and reliable in an athlete population. Additionally, further
type of validity was convergent validity. Convergent validity is validation of ED measures in a male athlete population may
typically employed when a researcher wishes to draw a cor- allow for the development of rehabilitative programs to help
relation between a specific field measure and another field these individuals with EDs as well as contribute to the small
measure within an area of research.32 A field measure is amount of literature examining exclusively male athletes for
typically less accurate when used to assess an attribute EDs. Finally, future studies might look to complete an analysis
compared with a “gold standard” because field tests usually of measures that assess “drive for muscularity”. This form of
contain more errors. For example, when measuring aerobic body dysmorphia is becoming more prevalent in both male
fitness, a 12-min running test (a field test) is often less accurate and female athletes but was not analyzed in this study.11
220 Z. Pope et al.

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