SCAGLIUSI et al., 2005

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Perceptual and Motor Skills, 2005, 101,25-41. O Perceptual and Motor Skills 2005

PSYCHOMETRIC TESTING AND APPLICATIONS OF THE BODY ATTITUDES QUESTIONNAIRE TRANSLATED INTO PORTUGUESE ' ' FERNANDA BAEZA SCAGLIUSI

Eating Disorder Program, Institute and Department of Psychiatry School of Physical Education and Sport

VIVIANE OZORES POLACOW

TAKI ATHANASSIOS CORDAS

School of Physical Education and Sport

Eating Disorder Program Institute and Department of Psychiatry

DESIRE COELHO

MARLE ALVARENGA

School of Physical Education and Sport

Eating Disorder Program Institute and Department of Psychiatry

SONIA TUCUNDUVA PHILIPPI

ANTONIO HERBERT LANCHA, JR.

Department of Nutrition School of Public Health

School of Physical Education and Sport Unliiersity of Szo Paulo

Summary.-Although many body attitudes scales have been developed, none have been translated into Portuguese. This study aimed to translate the Ben-Tovim and Walker Body Attitudes Questionnaire and assess validity and reliability for a Brazilian sample. Women with ( n= 39) and without ( n =57) eating disorders completed the scale, to assess discriminant validity. Convergent validity was assessed by the correlations between the scores and a measure of body dissatisfaction. The questionnaire was applied twice to controls after 1 mo. to evaluate reliability. Eating-disordered women had significantly higher mean scores on Feeling Fat, Disparagement, Salience and Lower Body Fatness, and lower scores on Attractiveness. No mean difference on Strength and Fitness was found. Most subscales were significantly correlated with the body-dissatisfaction measure. Test-retest coefficients ranged from .57 to .85. The translated version of the Body Attitudes Questionnaire seems to be a valid and reliable measure of body attitudes.

The study of body image has received a lot of attention in the last 20 years. Most authors recognized that body image has two components, per'The authors thank the subjects for their participation, Hamilton Roschel for the revision, and Patricia Berbel for helping in the tabulation of the uestionnaires. We also thank CNPq and FAPESP (Process Nos. 05/50233-5, 03ll2337-8, an2 02/11247-2) for their financial support. The authors attest that there were no conflicts of interest involved in this study. Address correspondence to Fernanda Baeza Scagliusi, University of Siio Paulo, School of Ph sical Education and S ort, Department of Biodpamics, Laboratory of Nutrition and ~ ~ ~ Metabolism, Av. Pro[ Mello Moraes 65, SBo Paulo/SP, Brazil 05508-900 or e-mail (fesc@usp. br).

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F. B. SCAGLIUSI, ET AL.

ception of current body size and shape and attitudes towards the body (Fernindez-Aranda, Dahme, & Meermann, 1999). It is important to state that body attitudes do not comprise only body dissatisfaction. In fact, the construct named 'body attitudes' has three facets: evaluation, i.e., evaluative thoughts and beliefs about one's appearance, affect or the discrete emotional body experiences, and investment which refers to the importance of appearance and the behaviors aimed to maintain or enhance it (Muth & Cash, 1997). Although the diagnostic criterion for eating disorders includes bodyimage disturbances (American Psychiatric Association, 1994), it is not exactly clear which one of these components is more affected in eating-disordered patients. As pointed out by Cash and Deagle (1997), Fernandez-Aranda, et al. (1999), and Skrzypeck, Wehmeire, and Remschmidt (2001), disturbances in body attitudes, such as body dissatisfaction, are much more common than perceptual size-estimation inaccuracy in these patients. It seems that weight concerns, fear of fat, and focus on physical appearance evident in eating-disordered patients are only pathological because they are felt very extremely (Ben-Tovim & Walker, 1992). However, it is necessary to have a valid and reliable measure of body attitudes actually to measure these body-related attitudes and quantify these concerns, feelings, beliefs, and thoughts. In their ) that the available body-attireview, Ben-Tovim and Walker ( 1 9 9 1 ~ affirmed tude scales were poorly developed psychometrically and had not been filled bl normative samples. Fortunately, this scenario has changed, and there are a number of psychometrically sound measures of body attitudes. Even so, few of them cover the broad domain of body attitudes; many of them focus only on body dissatisfaction and concern with weight and shape (Ben-Tovim & Walker, 1991a). In Brazil, there is some research on eating disorders and even some public assistance for patients (Negriio & Cordas, 1996; Alvarenga, Philippi, & Negriio, 2003; Fontenelle, Mendlowicz, Menezes, Papelbaum, Freitas, Coutinho, Appolinario, and Godoymatos, 2003). Some of these researchers actually studied body-image issues but their explorations were based on inventories which were not validated (Pope, Mangweth, Negriio, Hudson, & Cordis, 1994; Bronstein & Gomes, 1999; Vilela, Lamounier, Dellaretti Filho, Barros Neto, & Horta, 2004). Souto and Garcia (2002) developed and validated a body-image rating scale to be used in Brazil, but this inventory derived from a nursing setting, where physical impairment from illness or treatment promoted disturbances in body image. The scale, then, could not provide a basis for inference about body-image issues in persons with eating disorders. Scagliusi, Polacow, Cordis, Coelho, Alvarenga, Philippi, and Lancha (submitted) adapted the Stunkard Silhouettes of Body Size (Stunkard, Sorensen, & Schlusinger, 1983) into Portuguese and assessed its validity and

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reliability. They found that eating-disordered patients were more dissatisfied with their bodies and overestimated their body sizes more than the control group. Nevertheless, almost 80% of the anorexic group and 70% of the bulimic group did not overestimate their body sizes. It became clear that, to explore body-image disturbances in Brazilian eating-disordered patients, a scale must include more than body-size perception and body dissatisfaction. The Ben-Tovim and Walker Body Attitudes Questionnaire seemed to be a promising scale since it covered a wide range of body attitudes (the component of body image that is probably more disturbed in eating-disordered patients); it was soundly developed and tested and successfully applied to patients with eating disorders (Ben-Tovim & Walker, 1991a, 1992). So the aims of the present study were (a) to translate into Portuguese the Ben-Tovim and Walker Body Attitudes Questionnaire, a measure of women's attitudes towards their own bodies, (b) to assess its discriminant and convergent validities and test-retest reliability, and (c) to perform a preliminary analysis of body attitudes in Brazilian eating-disordered patients, comparing published data.

Participants Thirty-nine women with clinically severe eating disorders were recruited from two hospitals and one clinic. All patients were interviewed by a psychiatrist and met DSM-IV (American Psychiatric Association, 1994) criteria for anorexia nervosa ( n = 15) or bulimia nervosa (n =24). Mean ages were 29 yr. (SD = 8) for bulimic women and 27 yr. (SD = 6) for anorexic women. Mean Body Mass Indexes (based on self-reported weights and heights) were 25.3 kg/m2 (SD = 5.6) for bulimic subjects and 18.1 kg/m2 (SD = 4.6) for anorexic subjects. Mean differences between current weight and desirable weight were -13.8 kg (SD = 12.3) among bulimic and - 1.6 kg (SD = 10.1) among anorexic subjects. The control group was composed of 62 undergraduate women studying nutrition; all were in the third year. Five students' data were excluded from analysis: two reported having bulimia nervosa, one reported having bingeeating disorder, and two reported having a disordered relationship with food and their bodies. Mean age of the control group was 22 yr. (SD= 3) (significantly different from the bulimic and anorexic groups); mean Body Mass Index (based on self-reported weights and heights) was 20.9 kg/m2 (SD=2.1), fell short of significance at p,,, from bulimic subjects (p = .07), i.e., between students and anorexic patients. Mean difference between current weight and desirable weight was -2.6 kg (SD = 3.8), significantly different from the bulimic group.

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F. B. SCAGLIUSI, ET AL.

Measurement of Body Attitudes The Body Attitudes Questionnaire is a self-report inventory developed using the responses of a large sample of Australian women, and accurately reflecting those women's principal body-related concerns (Ben-Tovim, & Walker, 1991a). It uses a Likert-type scale, with five anchors for each question, 5: strongly agree and 1: strongly disagree. Nine questions, however, are reverse-scored. The answers for six subscales describe, respectively, (1) feelings of general fatness (Feeling Fat, composed of 13 questions, score range: 13-65); (2) feelings of self-loathing related to the body (Disparagement, composed of eight questions, score range: 8-40); (3) subjective assessment of individual's physical strength and fitness (Strength and Fitness, composed of six questions, score range: 6-30); (4) the personal relevance of body weight and shape (Salience, composed of eight questions, score range: 8-40); ( 5 ) overall sense of attractiveness, primarily in relation to the opposite sex (Attractiveness, composed of five questions, score range: 5-25); and (6) feelings that the lower body is fat (Lower Body Fatness, composed of four questions, score range: 4-20). A subscale total was the sum of item scores. High scores on the Feeling Fat, Disparagement, Salience, and Lower Body Fatness subscales imply negative body attitudes, as, for example, feeling too fat (for the Feeling Fat subscale); despising the body (for the Disparagement subscale); giving too much importance to body weight (for the Salience subscale), and feeling that the lower body is too fat (for the Lower Body Fatness subscale). High scores on the Strength and Fitness and Attractiveness subscales indicate positive body attitudes, as, for example, feeling strong and fit (for the Strength and Fitness subscale) and feeling physically attractive (for the Attractiveness subscale). Examples of each subscale's questions would be (a) "I worry that other people can see rolls of fat around my waist and stomach" (Feeling Fat); (b) "I have considered suicide because of the way I look to others" (Disparagement); (c) "I am proud of my physical strength" (Strength and Fitness); (d) "Thinking about the shape of my body stops me from concentrating" (Salience); (e) "I think I deserve the attention of the opposite sex" (Attractiveness); and (0"I feel that I have fat thighs" (Lower Body Fatness). The scale's internal consistency was 3 7 . Test-retest coefficients ranged from -64 to .91 (Ben-Tovim & Walker, 1991a). The Body Attitudes Questionnaire discriminated among eating-disordered and healthy women and those with other clinical disorders (Ben-Tovim & Walker, 1991a, 1992). It has already been used to compare body attitudes between smokers and nonsmokers (Ben-Tovim and Walker, 1991b) and to evaluate the influence of age and weight on women's body attitudes (Ben-Tovim & Walker, 1994). 'D. I. Ben-Tovim kindly gave authorization to translate the scale into Portuguese.

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Two dietitians who were fluent in English independently translated the scale into Portuguese. The two versions were compared and discussed, and a version was created. This version was back translated to English by one of the dietitians and compared to the original version. No discrepancies were found. The Portuguese version is shown in the Appendix (pp. 40-41).

Measurement of Body Dissatisfaction The Stunkard Silhouettes of Body Size, developed by Stunkard, et al. (1983) and adapted into Portuguese and validated by Scagliusi, et al. (submitted), were used to measure body dissatisfaction. The figural scale presents nine female figures approximately 1'14 in. tall, evenly spaced horizontally on an 8'12- x 11-in. sheet of paper. The figures range from very thin to very obese, with numbers underneath each one (1 to 9). Participants were asked to choose two figures, one which represented their body currently and one that represented the desirable body (as in Gardner, Stark, Jackson, & Friedman, 1999). A desirable discrepancy score was calculated subtracting the desirable silhouette correspondent number from the current silhouette correspondent number. This discrepancy score is a measure of body dissatisfaction. In the validation study of the Portuguese version, Scagliusi, et al. (submitted) reported a Spearman correlation coefficient of .59 (p 5 .OOOl) between the desirable discrepancy score and Body Mass Index, which indicated that the scale was valid. In the same study, Spearman test-retest correlation coefficient of the desirable discrepancy score was .77 (p I .0001).

Procedure Subjects were asked to volunteer to participate. They were told that the aim of the study was to validate a scale. They were allowed to identify their questionnaires with only their initials, and the research team guaranteed that the scales would not be shown to the hospital or clinic staff in the case of eating-disordered patients. Informed consent was gained from all subjects prior to administration of the measures. The study protocol was approved by the University of SHOPaulo Ethics Committee (from the School of Physical Education and Sport), as part of a larger research project wherein this scale will be applied. All participants were asked to respond as accurately as possible. Demographic data included age, current height, current weight, and desirable weight. With the current height and current weight data, we calculated the Body Mass Index (BMI= kg/m2). The discrepancy between desirable weight and current weight was also calculated. Control subjects were also asked if they had an eating disorder. The scales were administered to eating-disordered patients during cognitive-behavioral therapy and to students during class. Subjects were allowed as much time as needed. Two approaches were used to test if the Portuguese version of the Body

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F. B. SCAGLIUSI, ET AL.

Attitudes Questionnaire was valid. Firstly, since eating-disordered women have grossly inappropriate attitudes towards their bodies, it was hypothesized that if the questionnaire had discriminant validity, the mean scores of this group should differ from those of the control group. Secondly, it was also expected that the subscales, especially those more related to fatness, i.e., Feeling Fat, Salience, and Lower Body Fatness, would be correlated with the desirable discrepancy score, obtained on Stunkard's Silhouettes of Body Size because, in the original development of the Body Attitudes Questionnaire, the subscales were correlated with other measures of body dissatisfaction (Ben-Tovim & Walker, 1991a). This correlation would attest to the convergent validity of the Portuguese version of the Body Attitudes Questionnaire. To test reliability, internal consistency and reproducibility were analyzed. The scale's internal consistency was evaluated by means of Cronbach alpha, using data of the control group in the first administration of the scale. T o assess reproducibility, the scale was administered twice, over a I-mo. interval, only to the students. Fifty students responded to the scale at the second administration. Since the eating-disordered patients were receiving treatment, we expected that their scores might change, which would decrease the correlation between the two measures, not because the scale's stability was poor but because the scores actually changed. Each questionnaire was scored twice to ensure there were no errors.

Statistical Analysis Means and standard deviation for subscales were calculated. Statistical analysis was performed by the software Statistica (Version 5.0, released 1995, Starsoft, Tulsa, OK) and SPSS (Version 10.0, released 1999, SPSS Inc., Chicago, IL). The significance level adopted was p I .05. To check whether variables' distribution was normal, the Shapiro-Wilks test (among eating disordered patients) and the Kolomogorov-Smirnov's test (among control subjects) were performed. The Levene test assessed whether the error variance of the dependent variables was equal across groups. When the variables were not normally distributed or were without homogeneous variance, nonparametric statistics (such as Spearman correlation coefficient) were used. An analysis of variance, followed by Scheffi: post hoc test, was used to test differences of age, weight, height, Body Mass Index, and the discrepancy between desirable and current body weights among anorexic, bulimic, and control subjects. Analysis of variance was also used to compare each subscale mean for eating-disordered patients and control subjects. An analysis of covariance was also performed to compare subscale scores between the two groups, using Body Mass Index as a covariate. Pearson correlations coefficients were calculated between subscale scores and Body Mass Index within eating-disordered and control subjects. Spearman correlation coefficients between subscale scores and the desirable discrepancy scores (obtained by the

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Stunkard Silhouettes of Body Size) were utilized, within the two groups. Using Pearson correlation coefficients, a correlation matrix between subscale scores was calculated separately for eating-disordered patients and control subjects. To estimate stability over 1 mo., Spearman rank-order correlations were calculated between the subscale scores of control subjects at test and retest. Cronbach alpha assessed internal consistency. Only scores for the control group were assessed. RESULTS The eating-disordered subjects obtained a significantly higher mean than control subjects on the Feeling Fat subscale (respectively; 52.3, SD=9.0 vs 38.6, SD=10.0; F,,,,=45.7, p = .OOOl). Using analysis of covariance, this difference remained significant (F,., = 3 1.2, p = .0001). The eating-disordered patients also had a higher Disparagement score than controls (respectively; 25.8, SD=6.0 vs 14.3, SD =3.O; F,,, = 127.8, p = .0001). The analysis of covariance showed that, even when accounting for Body Mass Index, the effect of the group was robust (F,,,,= 110.1, p = .OOO1). There was no difference on the Strength and Fitness score between the groups (eating disordered: 16.6, SD = 4.0; controls: 16.8, SD = 4.0; F,,9,= .12, ns). Using Body Mass Index as a covariate decreased the F ratio even more (F,,,,=.OO1, ns). The Salience score was significantly higher among eating-disordered subjects than among control subjects (respectively; 29.4, SD = 4.0 vs 22.4, SD = 5.0; F,,,,= 53.4, p = .0001), which remained significant when Body Mass Index was used as a covariate (F,,,,= 40.8, p = .OOO1). Eating-disordered patients had a significantly lower mean on Attractiveness than controls (respectively; 13.2, SD = 4.0 vs 17.4, SD = 2 .O; F,,,, = 48.7, p = .0001). This difference between the groups slightly decreased when Body Mass Index was also used as a covariate (F,,*,= 33.4, p = ,0001). Eating-disordered patients presented higher scores on Lower Body Fatness than controls (respectively; 15.2, SD = 2.8 vs 12.9, SD = 3.0; F,,, = 13.6, p = .0001). There was almost no change in these statistics when Body Mass Index was introduced as a covariate (F,,,,= 11.2, p = .001). When Body Mass Index was introduced as a covariate, there was little change ( F ,,,= 11.2, p = .OOl). Table I presents the Pearson correlation coefficients between subscale scores and Body Mass Index for the eating-disordered and control groups. As the data from the analyses of covariance suggested, for both groups the effect of Body Mass Index was significant only for Feeling Fat, Disparage ment, and Salience subscales. Just among controls, Body Mass Index was significantly associated with Lower Body Fatness, but only for eating-disordered patients was there a tendency toward negative association between Body Mass Index and Strength and Fitness.

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F. B. SCAGLIUSI, ET AL. TABLE 1

Subscale

Group Eating-disordered Control .55" 47" -.28t 35" -.I3 .09

Feeling Fat Disparagement Strength and Fitness Salience Attractiveness Lower Body Fatness

Table 2 shows the Spearman correlation coefficients between subscale scores and the relevant desirable discrepancy score, which is a measure of body dissatisfaction on the other translated scale (Stunkard Silhouettes of Body Size). TABLE 2

Subscale

Group Eating-disordered Control

Feeling Fat .75" 73 Disparagement .71" 36" Strength and Fitness -.08 .22 Salience 49* .51* Attractiveness -.46* .16 Lower Body Fatness 375.57" aThe desirable discrepancy score is a measure of body dissatisfaction obtained on the Stunkard Silhouettes of Body Sizes. It is calculated as the number of the desirable body-size silhouette minus the number of the current body-size silhouette. +'p< .05. t p = .08. 7qc

Tables 3 and 4 display the Pearson correlation matrix between subscale scores for the eating-disordered and control groups, respectively. TABLE 3 PEARSON CORRELATIONS AMONGSUBSCALE SCORES FOREATING-DISORDERED GROUP(n = 39) Subscale 1. 2. 3. 4. 5.

Feeling Fat Disparagement Strength and Fitness Salience Attractiveness

2

3

4

.69"

-.2 1t

.65" .59" .ll

-.3 1"

5

Lower Body Fatness

36 44" .44" -.05 -

:#;

.53" 34" -. 04 .40" -.2 1

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PORTUGUESE BODY ATTITUDES QUESTIONNAIRE: VALIDITY TABLE 4 PEARSON CORRELATIONS AMONGSUBSCALE SCORES FORCONTROL GROUP(n = 57)

Subscale

2

3

1. Feeling Fat Disparagement Strength and Fitness Salience Attractiveness

.55"

.11 .05

2. 3. 4. 5.

4 .70* .58" .05

5

Lower Body Fatness

-.08 -.4 1" .3 0 -.201

.48"

.41" .01 .59" -.04

Test-retest correlation coefficients of the subscale scores were Feeling Fat (r = .85), Disparagement (r = .76), Strength and Fitness (r = .7), Salience (r = .7), Attractiveness (r = .57), and Lower Body Fatness (r = .75, all ps< .001). The total scale's internal consistency for the control group was 3 8 .

Discriminant Validity The scale distinguished between the eating-disordered subjects and the controls, which attests its discriminant validity. When Ben-Tovim and Walker developed the scale, they compared scores of 502 healthy women with those of 29 anorexic women (Ben-Tovim & Walker, 1991a). The anorexic patients presented a lower Attractiveness mean score, while their other subscale mean scores were higher than those for healthy women. In 1992, these authors compared those scores from the 502 women with the scores obtained by another sample of women with eating disorders, composed of 51 anorexics, 39 bulimics, and 15 women with eating disorders not otherwise specified (Ben-Tovim & Walker, 1992). The anorexic patients had higher scores on Feeling Fat, Disparagement, Salience, and Lower Body Fatness and a lower mean on Attractiveness than the healthy women. The bulimic group scored higher on all subscales, except for Attractiveness. Our results are similar to these, with the exception of the Strength and Fitness subscale, which showed no mean difference between controls and eating-disordered subjects. It is hard to explain this score pattern, since the results are controversial. In the first study, the authors found that anorexic subjects had a higher mean score on the Strength and Fitness subscale (compared to healthy women) (Ben-Tovim & Walker, 1991a), but this was not found in the second study, where the bulimic group obtained a higher score (BenTovim & Walker, 1992). Although it is known that eating disorder is associated with exercise (DiGioacchino DeBate, Wethington, & Sargent , 2002; Bamber, Cockerill, Rodgers, & Carroll, 2003) and that many eating-disordered patients, especially anorexics, practice excessive physical activity (Penas-Lledo, Vaz Leal, & Waller, 2002), it is unlikely that these patients considered themselves fit, since at the same time, the other subscale scores

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showed that they thought they were fat and despised their bodies. Because there are no cut-off values for the subscales, it is hard to say whether this lack of difference between the two groups means that the eating-disordered subjects scored high and considered themselves fit or that the control subjects scored low and considered themselves so unfit their means were equal to that of the patient group. Supporting this last idea, Koff, Benavage, and Wong (2001) showed that muscle tone contributes to satisfaction with body image almost as much as weight. It is a consistent finding that Western women are dissatisfied with their bodies (Muth & Cash, 1997; Packard & Krogstrand, 2002; Lokken , Ferraro, Kirchner , & Bowling, 2003), but these results may suggest that the reason for dissatisfaction is changing as nowadays the beauty standard is not just a thin body, but also a brawny one. O n the other hand, when Ben-Tovim and Walker (1991a) found higher Strength and Fitness scores among their anorexic group, they affirmed that these patients denied that they are in poor physical condition and actually, the thinner they are, the more good-tempered they feel. Lastly, we have to consider a language problem. In some of the sentences in the Strength and Fitness questions, the word 'strong' appears, as for example, "I have a strong body." In Brazil, this word is used sometimes with the meaning of 'fat' but in a less offensive way. The eating-disordered women may have understood this sentence as "I have a fat body" and so their scores were higher. We recommend that the researchers who use the Brazilian version explain to the subjects that 'strong' really means 'strong' and not 'fat'. We are aware that to validate this translation, a factor analysis would be of great interest. The limited number of subjects recruited for this study did not permit this analysis, which could identify if these items with the word 'strong' had inconclusive loadings and how these questions contributed to this subscale score. Therefore, we recommend the application of the translated scale to larger samples of Brazilian women to perform a factor analysis. This will certainly enhance our findings. One could argue that differences observed between students and eating-disordered subjects are due to the higher Body Mass Index of the patients (especially the bulimic ones). However, the analyses of covariance showed that the difference between the groups was statistically significant, even when the effect of Body Mass Index was partialled out (except for the Strength and Fitness subscale). These results suggested that there was a huge difference in body attitudes between the groups and that the Portuguese translation of the Body Attitudes Questionnaire detected this and thereby confirms the discriminant validity of the translation. The fact that the students were from a Nutrition school may limit our findings because some studies suggested that these students are at major risk of eating disorder (Reinstein, Koszewski, Chamberlin, & Smith-Johnson, 1992). Drake (1989) found that 24% of Dietetics students presented symp-

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toms of anorexia nervosa, and 11% of the home economics students did. A study conducted in Brazil also showed that Nutrition students were a high-risk group for eating disorder, with 15.7% vomiting and 7.8% using laxatives to lose weight (Antonaccio, 2001). It was not possible to screen the students for eating disorder symptoms because the scales used for this purpose have not been validated in Brazil, and it was not feasible to submit all the students to a clinical interview with a psychiatrist. Given these reasons, it was necessary to rely on self-report to exclude students with eating disorders, which certainly is a gross screen. However, some of the study's conditions might have improved this screen. Since the students received a class about eating disorder in that semester, one may wonder that their self-report would be more accurate. We also decided to exclude from analysis the two students who did not report a diagnosis of an eating disorder, but who affirmed that they had a complicated relationship with food and their bodies. Finally, some students had a Body Mass Index < 18.5 kg/m2, which could be seen as a reason for suspicion. Nevertheless, when these students were asked about their desirable weight, none of them wanted to lose weight. In fact, most of them (62.5%) declared that they wanted to gain weight. This is clearly the opposite of what is seen in eating-disordered women of low weight. Even so, it would be interesting to apply the scale to average women, without prior knowledge about body-image issues and less contact with weight and food concerns. Convergent Validity In the original development of the Body Attitudes Questionnaire, its convergent validity was assessed by the correlation coefficients between subscale scores and the scores of the Body Dissatisfaction subscale (from the Eating Disorder Inventory) and of the Body Shape Questionnaire, completed by 41 healthy women (Ben-Tovim & Walker, 1991a). The first is a measure of body dissatisfaction, and the last is a measure of concern with body weight and shape. It was known that the three scales measured somewhat similar constructs, but since there was no other measure of body attitudes available, these questionnaires were used. At the present moment, the only body-image scale in Portuguese, pertinent to the research on eating disorders and psychometrically tested, is the Stunkard Silhouettes of Body Size (Scagliusi, et al., submitted). Therefore Stunkard's scale was chosen to assess convergent validity of the Portuguese translation of the Body Attitudes Questionnaire. Since the desirable discrepancy score used in the present study is also a measure of body dissatisfaction, the correlations between this score and the Body Attitudes Questionnaire subscale scores are compared with correlations between Body Dissatisfaction scores (from the Eating Disorder Inventory) and those on the Body Attitudes Questionnaire subscales reported by Ben-Tovim and Walker (1991a).

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Comparing the data of our control group (presented in Table 2) with their sample, it is notable that both studies obtained positive and significant correlation coefficients between the body-dissatisfaction measure and the Feeling Fat (this sample: r = .73, p < .05; original sample: r = .83, p < .0 I ) , Disparagement (this sample: r = 3 6 , p < .05; original sample: r = .48, p < .OI); Salience (this sample: r = .5 1, p < .05; original sample: r = .59, p < .O1), and Lower Body Fatness subscales (this sample: r = 3 7 , p < .05; original sample: r = .55, p < .O1). Also both studies yielded no correlation between the body-dissatisfaction measure and the Strength and Fitness score. Their research gave a significant negative correlation between the body dissatisfaction scores and the Attractiveness scores (r = -.56, p < .01), which was verified in our study only among the eating-disordered group (control group: r = .16, ns; eatingdisordered group: r = -.46, p < .05). Except for this result, the correlations obtained by the eating-disordered group followed the same pattern observed in our control group and in the sample of 41 healthy women analyzed by Ben-Tovim and Walker (1991a). It seems that the Portuguese translation of the Body Attitudes Questionnaire has good convergent validity with the body-dissatisfaction measure obtained by the Stunkard Silhouettes of Body Size and also that this convergent validity is similar to the original presentation in the development of the Body Attitudes Questionnaire. Test-retest Reliability The reliability coefficients were all significant and, except for the Attractiveness score, all exceed .70, the cut-off value established by Nunnally (1970) as acceptable. Content of the Attractiveness subscale focuses mainly on how attractive the subject thinks she is, especially in relation to the opposite sex. It seems reasonable to suppose that this construct actually varies, given variations in relationships with the opposite sex. If this be true, then a smaller but significant coefficient would be expected for this subscale. Performing the test-retest with 41 healthy u70men, Ben-Tovim and Walker (1991a) reported reliability coefficients for Feeling Fat (r = .90), Disparagement (r = .76), Strength and Fitness (r = .79), Salience (r = .64), Attractiveness ( r = .65), and Lower Body Fatness (r = .91; ps < .01). These values are similar to those in the present study. Even in the original study the test-retest coefficient for the Attractiveness subscale did not reach the cut-off proposed by Nunnally (1970). Then, it appears that the Portuguese translation of the Body Attitudes Questionnaire has satisfactory reproducibility. Also, the Cronbach alpha of .88 was high and similar to the estimate ( 2 7 ) provided by Ben-Tovim and Walker (1991b). These data suggest the translated version maintained the stability and consistency of the original. Preliminary Analysis of Body Attitudes Among Brazilian Eating-disordered Patients Although it is known that feelings of fatness and excessive concern with

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body weight and shape are central aspects of eating disorders (Gowers & Shore, 2001)) this questionnaire originally identified other preliminary features of these disorders-lower sense of attractiveness and higher body disparagement. To gain insight into why eating-disordered women felt less attractive than the controls, we calculated the correlation coefficients among subscales within the eating-disordered group (presented in Table 3). The factors significantly associated with attractiveness were Disparagement (r = -.44), Strength and Fitness (r = .44), and Feeling Fat (r = -36). Obviously, a woman who despises her body cannot think it is attractive so the association between Feeling Fat and Attractiveness was also expected, but it is interesting to notice that, again, Strength and Fitness emerge as important concerns. It is notable that neither Feeling Fat and Strength and Fitness scores were correlated with Attractiveness scores among the control group (as shown in Table 4). This finding suggests that healthy women considered themselves attractive, even feeling they were fat or not fit, which is unlikely to happen among the eating-disordered patients. It is relevant to ask why eating-disordered women have higher Disparagement scores. Firstly, it is necessary to state that disparagement is very different from dissatisfaction for it implies revulsion with one's shape. An example of a question from the Disparagement subscale is "I feel that my body has been mutilated". Even obese people, who are strongly stigmatized in our society and usually feel very dissatisfied with their bodies, do not despise their bodies (Wadden, Foster, Stunkard, & Linowitz, 1989; Faith, Manibay, Kravitz, Griffith, & Allison, 1998; Hill & Williams, 1998). Body Mass Index had a weaker association with Disparagement scores among control subjects than among eating-disordered subjects, which indicates that only among eating-disordered women is weight a strong reason to despise the body. Interestingly, only among the eating-disordered group was the Feeling Fat score more associated with Disparagement than Body Mass Index, suggesting that more than actually being fat, feeling fat is associated with self-loathing. This may indicate that there is an interaction between a perceptual distortion (feeling fat when Body Mass Index is normal) and a negative body attitude (body disparagement). Nevertheless, one should remember that eating-disordered patients may have other psychiatric disorders, such as depression (Corcos, Guilbaud, Speranza, Paterniti, Loas, Stephan, & Jeammet, 2000)) obsessive-compulsive disorders (Jordan, Joyce, Carter, Horn, McIntosh, Luty, McKenzie, Mulder , & Bulik, 2003)) and anxiety disorders (Godart, Flament , Curt, Perdereau, Lang, Venisse, Halfon, Bizouard, Loas, Corcos, Jeammet, & Fermanian, 2003), which might influence body disparagement. Even so, when Ben-Tovim and Walker (1992) compared body disparagement scores between patients with eating disorders and other psychiatric patients (in-

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cluding those with major depression), eating-disordered subjects' scores were still higher. In summary, we believe that the Brazilian version of the Body Attitudes Questionnaire is valid and reliable in measuring several aspects of body attitudes of women. It goes beyond the traditional spectrum of body attitudes covered by many questionnaires, i.e., body dissatisfaction and weight and shape concerns, identifying other aspects of subjective experience of the body that might enhance research in eating disorders and body image. It would be interesting to apply the scale to a large sample of Brazilian healthy women. This application could permit development of cut-off values for the subscales, which are definitely necessary, and performing a factor analysis to understand better the validity of this translation. REFERENCES ALVARENGA, M. S., PHILIPPI,S. T., & NEGRLO,A. B. (2003) Nutritional aspects of eating episodes followed by vomiting in Brazilian patients with bulimia nervosa. Eating and Weight Dirorders, 8, 150-156. AMERICAN PSYCHIATRIC ASSOCIATION. (1994) Diagnostic and statistical manual of mental disordetevr. (4th ed.) Washington, DC: Author. ANTONACCIO, C. M. A. (2001) Students in dietetics: an overview of eating behavior and eating disorders. Master of Science thesis presented to School of Public Health, Univer. of SZo Paulo, Sao Paulo, Brazil. BAMBER, D. J., COCKERILL, I. M., RODGERS, S., &CARROLL, D. (2003) Diagnostic criteria for exercise dependence in women. British Journal of Sports lUedicine, 37, 393-400. BEN-TOVIM, D. I., &WALKER,M. K. (1991a) The develo ment of the Ben-Tovim Walker Body Attitudes Questionnaire (BAQ), a new measure o!n7ornens' attitudes towards their own bodies. Psychological Medicine, 2 1, 775-784. BEN-TOVIM,D. I., &WALKER, M. K. (1991b) Some body-related attitudes in women smokers and non-smokers. Briti.rh Journal of Addiction, 86, 1129-113 1. BEN-TOVIM, D. I., &WALKER, M. K. ( 1 9 9 1 ~ ) Women's body attitudes: a review of measurement techniques. International Journal of Eating Disorders, 10, 155-167. BEN-TOVIM, D. I., &WALKER, M. K. (1992) A quantitative study of body-related attitudes in patients with anorexia and bulimia nervosa. Psychological Medicine, 22, 961-969. BEN-TOVIM, D. I., &WALKER, M. K. (1994) The influence of age and weight on women's body attitudes as measured by the Body Attitudes Questionnaire (BAQ). Journal o f Psychosomatic Research, 38, 477-481. BRONSTEIN,M., & GOMES,I. C. (1999) An initial study on ersonality features survey and selfiimage with female patients with nervous anorexia antbulimia through a graphic projective technique. Poster session presented at the XVI International Congress of Rorschach and Projective Methods, Amsterdam, July. CASH,T. F., & DEAGLE, E.A. (1997) The nature and extent of body-image disturbances in anorexia nervosa and bulimia nervosa: a meta-analysis. Internatiorznl Journal of Eatizg Disorders, 22, 107-125, CORCOS,M., GUILBAUD, O., SPERANZA, M., PATERNITI, S., LOAS,G., STEPHAN,I?, & JEAMMET, l? (2000) Alexithymia and depression in eating disorders. Psychiatry Research, 93, 262-266. DIGIOACCHINO DEBATE,R., WETHINGTON, H., &SARGENT, R. (2002) Sub-clinical eating disorder characteristics among male and female triathletes. Eatifzg and Weight Disorders, 7 , 210220. DRAKE,M. A. (1989) Symptoms of anorexia nervosa in female university diatetic majors. lournnl of the Arnertca?z Dietetic Associatio?z. 89, 97-98 FAITH,M. S., MANIBAY, E., KRAVITZ,M., GRIFFITH,J., &ALLISON,D. B. (1998) Relative body weight and self-esteem among African-Americans in four nationally representative samples. Obesitji Research, 6, 430-437. FERN~NDEZ-ARANDA, F., DAHME,B., & MEERMANN, R. i1999) Body image in eating disorders and analysis of its relevance: a preliminary study. Journal of Psychosomatic Research, 47, 419-428. FONTENELLE, L., MENDLOWICZ, M., MENEZES, G. B., PAPELBAUM, M., FREITAS, S., GODOYMATOS, A.,

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COUTINHO, W., &APPOLINARIO, J. C. (2003) Psychiatric comorbidity in a Brazilian sample of patients with binge-eating disorder. Psychiatry Research, 119, 189.194. GARDNER, R. M., STARK, K., JACKSON, N. A., &FRIEDMAN, B. N. (1999) Development and validation of two new scales for assessment of body image. Perceptual and Motor Skills, 89, 98 1-993. GODART, N. T., FLAMENT, M. F., CURT,F., PERDEREAU, F., L N G ,F., VENISSE, J. L., HALFON, O., BIZOUARD, I?, LOAS,G., CORCOS, M., JEAMMET, I?, & FERMANIAN, J. (2003) Anxiety disorders in subjects seeking treatment for eating disorders: a DSM-IV controlled study. Psychiatry Research, 117, 245-258. GOWERS, S. G., &SHORE,A. (2001) Development of weight and shape concerns in the aetiology of eating disorders. British Journal of Psychiatry, 179, 236-232. HILL,A. J., & WILLIAMS, J. (1998) Psychological health in a non-clinical sample of obese women. InternationalJournal of Obesity and Related Metabolic Disorders, 22, 578-583. JORDAN, J., JOYCE,I? R., CARTER, F. A., HORN,J., MCINTOSH, V. V., L u n , S. E., MCKENZIE, J. M., MULDER, R. T., & BULIK,C. M. (2003) Anxiety and psychoactive substance use disorder comorbidity in anorexia nervosa or depression. International Journal of Eating Disorders, 34, 211-219. KOFF,E., BENAVAGE, A.,& WONG,B. (2001) Body-image attitudes and psychosocial functioning in Euro-American and Asian-American college women. Psychological Re orts, 88, 917-928. LOKKEN, K., FERRARO, F R., KIRCHNER, T., &BOWLING, M. (2003) Gender Lfferences in body size dissatisfaction among individuals with low, medium, or high levels of body focus. The Journal of General Psychology, 130, 305-3 10 MUTH,J. L., &CASH,T. F. (1997) Body-image attitudes: what difference does gender make? Journal of Applied Social Psychology, 27, 1438-1452. NEGR~O A., B., & CORDAS,T. A. (1996) Clinical characteristics and course of anorexia nervosa in Latin America, a Brazilian sample. Psychiatry Research, 62, 17-21. NUNNALLY, J. C. (1970) Psychometric theory. New York: McGraw-Hill. PACKARD, P., & KROGSTRAND, K. S. (2002) . ~ a l fof rural girls aged 8 to 17 years report weight concerns and dietary changes, with both more prevalent with increased age. Journal of the American Dietetic Association, 102, 672-677. PENAS-LLEDO, E., VAZLEAL,F. J., & WALLER, G. (2002) Excessive exercise in anorexia nervosa and bulimia nervosa: relation to eating characteristics and general psychopathology. International Journal of Eating Disorders, 3 1, 370-375. POPE,H. G., JR., MANGWETH, B., NEGRAO,A. B., HUDSON, J. I., &CORDAS,T. A. (1994) Childhood sexual abuse and bulimia nervosa: a comparison of American, Austrian, and Brazilian women. American Journal of Psychiatry, 151, 732-737. REINSTEIN, N., KOSZEWSKI, W. M., CHAMBERLIN, B., &SMITH-JOHNSON, C. (1992) Prevalence of eating disorders among dietetic students: does nutrition education make a difference: Journal of American Dietetic Association, 92, 949-953. SCAGLIUSI, F. B., POLACOW, V. O., CORDAS,T. A., COELHO,D. ALVARENGA, M., PHILIPPI,S. T., & LANCHA, A. H., JR. (submitted? Validity and reliability of the Stunkard body image scale adapted into Portuguese. SKRZYPECK, S., WEHMEIER, I? M., &REMSCHMIDT, H. (2001) Body image assessment using body size estimation in recent studies on anorexia nervosa: a brief review. European Child and Adolescent Psychiatry, 10, 215-221. SOUTO,C. M. R. M., &GARCIA, T. R. (2002) Construction and validation of a body image rating scale: a preliminary study. International Journal of Nursing Terminologies and Class$cations, 13, 117-126. STUNKARD, A.,SORENSEN, T., &SCHLUSINGER, F. (1983) Use of Danish adoption register for the study of obesity and thinness. In S. Kety, L. P. Rowland, R. L. Sidman, & S. W. Matthysse (Eds.) The genetics of neurological and psychiatric disorders. New York: Raven. Pp. 115-120. VILELA, J. E. M., LAMOUNIER, J. A,,DELLARETTI FILHO,M. A., BARROS NETO,J. R., & HORTA,G. M. (2004) Eating disorders in school children. Jomal de Pediatria, 80, 49-54. WADDEN, T. A.,FOSTER,G. D., STUNKARD, A. J., & LINOWITZ, J. R. (1989) Dissatisfaction with weight and figure in obese girls-discontent but not depression. International Journal of Obesity, 13, 89-97.

Accepted June 13, 2005.

F. B. SCAGLIUSI. ET AL.

APPENDIX PORTUGUESE VERSION OF THE BEN-TOVIM AND WALKER BODYATTITUDES QUESTIONNAIRE (l991)* Eu usualmente me sinto fisicamente atraente. Eu prefiro niio deixar que outras pessoas vejam meu corpo. As pessoas raramente me acham sexualmente atraente. Eu fico tgo preocupada com a minha forma fisica que sinto que precis0 fazer uma dieta. Eu me sinto gorda cpando niio consigo passar as roupas pelos meus quadris. As pessoas me evitam por causa da minha aparencia. Eu me sinto satisfeita com o meu rosto. Eu me preocupo se outras pessoas vem "pneus" de gordura ao redor da minha cintura e esthmago. Eu acho que merego a atengiio do sexo oposto. Eu dificilmente me sinto gorda. Existem coisas mais importantes na vida do que a f o r m do meu corpo. Eu acho ridiculo fazer cirurgias plasticas para melhorar a aparencia. Eu gosto de me pesar regularmente. Eu me sinto gorda quando uso roupas que s2o apertadas na cintura. Eu j i considerei suicidio por causa da forma como parego aos outros. Eu fico exausta rapidamente se fago muito exercicio. Eu tenho cintura fina. Minha vida esta se arruinando por causa da minha aparencia. Usar roupas largas faz-me sentir magra. Eu dificilmente penso a respeito da forma do meu corpo. Eu sinto que meu corpo foi mutilado. Eu tenho orgulho da minha forga fisica. Eu sinto que tenho coxas gordas. Eu n2o consigo participar de jogos e exercicios por causa da minha forma fisica. Comer doces, bolos ou outros alimentos cal6ricos faz-me sentir gorda. Eu tenho um corpo forte. Eu acho que minhas nidegas siio muito largas. Eu me sinto gorda quando saio em fotos. Eu tento e consigo me manter em forma. Pensar a respeito das formas do meu corpo tira a minha concentraggo. Eu gasto muito tempo pensando em comida. Eu estou preocupada com o meu desejo de ser mais leve. Se me vejo em um espelho ou vitrine, sinto-me ma1 quanto B minha forma fisica. As pessoas riem de mim por causa da minha aparencia. Eu freqiientemente me sinto gorda. Eu gasto muito tempo pensando sobre meu peso. Eu sou um pouco de um "Homem de Ferro." Eu me sinto gorda quando estou sozinha. Eu me preocupo que minhas coxas e n$degas tenham celulite. As pessoas frequentemente elogiam minha aparcncia. (continued on next page)

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APPENDIX (Cont'd) PORTUGUESE VERSION OF THE BEN-TOVIM AND WALKER QUESTIONNAIRE (199l)* BODYATTITUDES Perder um quilo de peso niio afetaria realmente meus sentimentos a respeito de mim mesma. 42. Eu me sinto gorda quando niio consigo entrar em roupas que antes me serviam. Eu nunca fui muito forte. 43. Eu tento evitar roupas que me fazem sentir especialmente ciente das minhas for44. mas. "The original version of the Body Attitudes Questionnaire (in English) was published in Ben-Tovim, D. I. & Walker, M. K. (1991) The development of the Ben-Tovim Walker Bod Attitudes Questionnaire (BAQ), a new measure of women's attitudes towards their own bodI ies. Psychological Medicine, 21, 775-784. Note.-Questions of each subscale: Attractiveness: 1, 3, 7, 9, 40; Disparagement: 2, 6, 15, 18, 21, 24, 33, 34; Feeling Fat: 4, 5, 8, 10, 14, 17, 19, 25, 28, 35, 38, 42, 44; Salience: 11, 12, 20, 30, 31, 32, 36, 41; Lower Body Fatness: 12, 23, 27, 39; Strengh and Fitness: 16, 22, 26, 29, 37, 43. All questions except the reverse-scored items which follow are scored using anchors of strongly agree = 5, agree = 4, neutral = 3, disagree = 2, strongly disagree= 1. The reverse-scored items are 3, 10, 11, 12, 16, 17, 20, 41, 43. For subscale totals simply add the corresponding item scores.

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