Long-term Outcomes of the ATHENA (Athletes Targeting Healthy Exercise \u0026 Nutrition Alternatives)...

$: Long-term Outcomes of the ATHENA (Athletes Targeting Healthy Exercise \u0026 Nutrition Alternatives) Program for Female High School Athletes$
Long-term Outcomes of the ATHENA(Athletes Targeting Healthy Exercise

& Nutrition Alternatives) Program forFemale High School Athletes

Diane L. Elliot, M.D., Linn Goldberg, M.D.,Esther L. Moe, Ph.D., M.RH.,

Carol A. DeFranceseo, M.A., R.D.,Melissa B. Durham, M.P.H., Wendy McGinnis, M.S.

& Chondra Lockwood, Ph.D.Division of Health Promotion and Sports Medicine;

Department of Medicine;Oregon Health & Science University

ABSTRACT

Adolescence and emerging adulthood are critical windows forestablishing life-long behaviors. We assessed long-term outcomesof a prospective randomized harm reduction/health promo-tion program for female high school athletes. The interventionsimmediate beneficial effects on diet pill use and unhealthy eat-ing behaviors have been reported; however, tobacco, alcohol andmarifuana use were not immediately altered (Elliot et al, 2004).One to three years following graduation, positive benefits in thosedomains became evident and intervention students reported sig-nificantly less lifetime use of cigarettes, marifuana, and alcohol.Sport teams may be effective vehicles for gender-specific interven-tions to promote competency skills and deter harmful actions andthose benefits may manifest when acquired abilities are applied innew environments following high school graduation.

Keywords: adolescents, emerging adults, team-centered, school-based, harm reduction, alcohol, tobacco, marifuana, disorderedeating

73

74 LONG-TERM OUTCOMES OF THE ATHENA PROGRAM

High school is a critical window for drug prevention. Duringlate adolescence, substance use approximately doubles,

and unhealthy behaviors established as teenagers can have life-time adverse consequences (Johnston, O'Malley, Bachman, &Schulenberg, 2004; National Center on Addiction and SubstanceAbuse, 1997). Although evidence-based prevention curricula areavailable for middle sehool students (Robertson, David, & Rao,2003; U.S. Department of Health and Human Services, 2001),high school classroom-based activities appear less effective, per-haps because gender-specific issues and peer-group influencesbecome more prominent (Botvin, & Griffin, 2003; Faggiano etal., 2005; Rohrbach & Milam, 2003). Few school-based programswith documented efficacy are available for older adolescents(SAMHSA, 2008).

School sport teams are natural formats for bonded student-ath-letes to meet for gender-specific health promotion. The ATHENA(Athletes Targeting Healthy Exercise & Nutrition Alternatives)program is a sport team-based harm reduction and health promo-tion program. Its development and positive immediate outcomeshave been reported (Elliot et al., 2004; Elliot et al , 2006). Theprogram achieved significant short-term reductions in new andongoing diet pill use and appropriate changes in targeted risk andprotective factors. However, alcohol, tobacco, and marijuana usealso were addressed in the curriculum; and, when assessed imme-diately following the program, intervention participants did notalter their self-reported use of those substances.

High school graduation and the transition to college or M\-time employment begins a period of increased vulnerability tosubstance abuse (Johnston et al., 2005; Mohler-Kuo, Lee, &Wechsler, 2003; O'Malley & Johnston, 2002). Because theATHENA program emphasized decreasing risk factors for healthcompromising actions and augmenting life competency skills,we hypothesized that additional positive outcomes may becomeevident over time. To identify longer-term effects, we reassessedcontrol and intervention ATHENA study participants one to threeyears following high school graduation.

METHODS

Details of ATHENA's development and its immediate out-comes have been reported (Elliot et al., 2004; Elliot et al., 2006).

LONG-TERM OUTCOMES OF THE ATHENA PROGRAM 75

Eighteen public high schools from northwest Oregon and south-west Washington participated in a prospective randomized trial ofthe ATHENA intervention. Schools had a spectrum of locales toreduce potential cross-contamination. They were matched in dyadsbased on size and student demographics. An individual unfamiliarwith participating schools used a program for generating randomnumbers to assign one member of paired sehools to the interven-tion or control group, with the other school going to the alter-native condition. After randomization, we met with interventionschools' athletic direetors and coaches and offered participationto all women's sports, dance and eheerleading teams. For inter-vention teams eleeting to participate, we successfully recruitedthe similar team from its matching control school. Study enroll-ment was offered to all student-athletes from involved teams.

Immediate outcomes were assessed with confidential pre andpost-sport season questionnaires, and students and their parents orguardians provided written informed consent. Because the mailedsurvey was not ineluded in our original study consent, studentseould not be tracked with confidential surveys following highschool graduation and anonymous instruments were used. For thefollow-up data reported here, we mailed surveys to graduates whowere older than 18 years of age at the time assessed, and passiveconsent was used for the graduates' mailed anonymous follow-upquestionnaires. The Institutional Review Board of Oregon Health& Science University approved all proeedures.

Intervention

The ATHENA eurrieulum was delivered during eight 45-min-ute team meetings, scheduled at the coach's discretion and inte-grated into a team's usual practiee activities. The curriculum'sdevelopment and seope have been described (Elliot et al., 2004;Elliot et al., 2006). It addressed depression prevention, self-esteem, healthy norms and societal pressures to be thin. Mediainfluenees were countered by directing student athletes to discuss,deconstruct, and remake magazine advertisements for eigarettes,alcohol, and nutritional supplements. Participants establishedshared healthy behavioral expectations, practiced refusal skills,and created and presented to teammates public service eampaignsto diseourage drug use and disordered eating practices. The cur-riculum provided information about strength training and sports

7 6 LONG-TERM OUTCOMES OF THE ATHENA PROGRAM

nutrition, including adequate carbohydrates, sufficient proteinand appropriate ealcium intakes.

During the season, team members met as a single group, parti-tioned into coach assigned six member squads, each with a coachassigned student leader. The coach and squad leaders used manu-als with scripted lessons, and others had matching workbooks.The female-only, peer-led format may have further increased par-ticipants' self-esteem, assertiveness, and social skills (AmerieanAssociation of University Women Education Foundation, 1995;Sadker & Sadker, 1994). All team members received pocket-sized sport nutrition and training guides, which contained refer-ence information and worksheets used with curriculum activities.Between ATHENA sessions, manuals and workbooks were storedin a team box in the equipment room or coach's office. Controlteams were offered preprinted pamphlets concerning disorderedeating, drug use and sports nutrition information.

Assessment

Intervention and control participants completed confiden-tial questionnaires prior to and immediately following the sportseason. We assessed knowledge, influences on drug use and dis-ordered eating, and participant characteristics using items fromour earlier research (Goldberg et a!., 2000); surveys concern-ing disordered eating (Neumark-Sztainer, Wail, Story, & Perry,2003 and Rosen, & Silberg, 1988). depression (Radloff, 1977),self-image (Offer & Howard, 1972) and self-esteem (Rosenberg,1965). Substance abuse questions used a format similar to theYouth Risk Behavior Survey (Eaton et al, 2006).

In the summer of 2004, one year after the intervention's lastyear, we sent a one page anonymous survey and a self-addressed,stamped envelope, using original addressses to all interventionand control participants who had completed high school and were18 years of age and older. After approximately two weeks, non-respondents received a second mailing. Because response ratemay vary inversely with survey length (Jepson, Asch, Hershey,& Ubel, 2005), the mailed questionnaire was brief and limitedto demographics, drug use and eating behaviors, and selectedattitudes. We indexed aleohol, tobacco and illicit drug use anddisordered eating behaviors using our original standardized for-mat. For less frequent behaviors (smoking and marijuana use).


we compared last year and lifetime use, and for the more preva-lent alcohol use, we indexed past three month and last year use.We also presented a spectrum of female physiques (Stunkard,Sorensen, & Schulsinger, 1983) and asked respondents to iden-tify the most healthy and most attractive representation. The finalmailed instrument eould be completed in fewer than 10 minutes.

Data Analyses

Baseline equivalence and shorter-term intervention effectswere examined using an analysis of covariance-based approachwithin the generalized estimating equations random effects modelframework (Hardin & Hilbe, 2003). For the follow-up survey, sub-jeets were no longer clustered on teams and in schools. Drug usemeasures were recoded into dichotomous responses, as is typicalof many long-term outcome studies (Botvin, Baker, Dusenbury,Botvin, & Diaz, 1995; Skara & Sussman, 2003). We examinedthe association between participants' study condition and theirlong-term drug and alcohol use with logistic regression, usingyears since graduation as a eovariate in the analyses; and, sincewe hypothesized specific a priori directional findings, inferenceswere based on one-tailed significance tests (Hardin & Hilbe,2003; Winer, 1971). Odds ratios less than 1 indicate success ofthe ATHENA program on reducing drug use among graduates.Body image responses were assessed with t-tests.

• RESULTS

Baseline Participant Characteristics, Attrition and Program Fidelity

At initial enrollment intervention and control participants hadsimilar demographic parameters, baseline drug use and disorderedeating indices and pre to post-season attrition (Table 1). All inter-vention coaches implemented ATHENA, and all intervention andcontrol teams were retained in the study. Fidelity to the ATHENAeurriculum was high, and intervention teams were observed toimplement 80.8 ± 0.2% (mean + SD) of content items.

Immediate Effects

The initial pre to post-sport season findings have been reported(Elliot et al., 2004; Elliot et al , 2006). Following ATHENA par-ticipation, intervention student-athletes reported significantly less


TABLE 1

Initial Study Baseline Characteristics

Number of schoolsTotal participating teamsStudents preseasonStudents postseason (% retained)Mean ajie in years (SD)Pereent CaucasianSelf-reported prior aleohol useSelf-reported prior tobaeeo useSelf-reported prior marijuana useSelf-reported prior diet pill useSelf-reported prior fasting to lose weight

Intervention920457337 (74%)15.4(1.2)93.6%52%27%19%14%28%

Control920471331(70%)15.3(1.2)91.4%47%33%19%11%26%

TABLE 2

Follow-up Survey Participant CharacteristicsIntervention Control

Total responses 203CurrentCollege or trade school 188(90%^ 1841-90%^Working _LZ(S%IOther 6 (3%)Years since graduation

104 95Two 67 (32%) 72Three 39(19%) 37 n 8%)Continued participation in sports,cheerleading nr dance.

132(63%) 122(60%)


ongoing and new use of diet pills and less new use of athleticenhancing substances (amphetamines, anabolic steroids and sportsupplements) (p<0.05 for each). The program's curriculum com-ponents were altered appropriately (better able to control mood[/?<0.005], less belief in the media [;7<0.001], greater strengthtraining self-efficacy [/i<0.005] and healthier eating behaviorsI/KO.OOI]). During the initial ATHENA study, the pre to post-sportseason use of tobacco, alcohol and marijuana were unchangedand did not differ between conditions.

Graduates 'Findings

All eligible participants (graduates older than 18 years of age)were included in the follow-up mailing. A total of 757 youngwomen were sent surveys (368 intervention, 389 control). Afteran initial and second mailing, response rates for the two condi-tions were similar, and intervention and control respondents didnot differ in years sinee graduation, their current situation andwhether they continued to participate in sports, cheerleading anddanee (Table 2).

Self-reported drug use at the time of the follow-up survey isshown in Table 3. One to three years following high school grad-uation, ATHENA intervention participants had significantly lessregular marijuana use {p<0.0\ for both last year and lifetime use)and reduced alcohol use indexed as three-month {p<0.0]) and lastyear use (p<0.05). Although the prevalence of cigarette use waslow overall, it was significantly less for ATHENA interventiongraduates when assessing those with regular ongoing use (definedas > 40 times lifetime use) {p<0.05). Self-reported use of othersubstances (e.g., club drugs, ecstasy, GHB, 'roofies,' LSD) waslow (less than five percent of all respondents reported any use inthe last year), and that prevalence did not differ between groups.Overall use of diet pills, diuretics, laxatives and self-inducedvomiting also became less prevalent over time, with less than tenpercent of all subjects indicating those activities in the last threemonths; no difference was observed between conditions in thatoutcome.

More ATHENA program participants knew their daily eal-cium requirement (66.3% intervention versus 40.0% control,/?<0.0001), and that knowledge difference was reflected in inter-vention graduates being more likely to indicate adequate calcium

LONG-TERM OUTCOMES OF THE ATHENA PROGRAM

TABLE 3

Findings One to Three Years Following High School Graduation

VariableIntervention{prevalence

[%])

Control{prevalence

[%])

Udds Ratio(95%

confidenceIntervaHfl'

Mariiuana UseUsed >40 times in lastyear

Used >40 times inlifetime

2%

5%

7%

13%

0.26**(0.09-0.82)

0.38**(0.18-0.79)**

Alcohol Use

Use >6 times in last 3months

Use >20 times in last year

27%

25%

41%

35%

0.55**(0.36-0.84)

0.61*(0.39-0.95)

Cigarette UseUsed >20 times in lastyear

Used >40 times inlifetime

8%

9%

12%

16%

0.63(0.33-1.22)

0.52*(0.28-0.94)

^Control participants were used as the referetice group in cal-culating the odds ratio, and calculations were controlled for grad-uation year. An odds ratio < 1 indicates ATHENA interventionparticipants were less likely to engage in the behavior.

*/7<0.05, **;?<0.01

intake (odds ratio 2.15 [1.44 - 3.21], p<0.000\). Interestingly,when asked to select the most healthy and most attractive femalephysiques, for both situations, the ATHENA intervention gradu-ates indicated a significantly heavier body image than control par-ticipants {p<0.05 and/?<0.01, respectively)(Figure 1 ). ^

DISCUSSION

In short-term study, the ATHENA program succeeded in its cur-riculum objectives and achieved a decrement in disordered eatingpractices and body-shaping drug use (Elliot et aL, 2004; Elliot etal., 2006). However, when habits were assessed immediately afterthe program, participation did not appear to alter use of alcohol.


FIGURE 1

Most Healthy and Most Attractive Physiques

Intervention

Control

Most healthy*

3.9(0.6) #

3.8(0.7) O

Most attractive**

3.4(0.7) •

3.2(0.8) •

Mean (S.D.) *p<0.05 **ixO.O1

marijuana, or tobacco. Although middle school drug preventionprograms can impact immediate substance use, that short-termefficacy may be attenuated as students mature (EUickson, Bell,& McGuigan, 1993; Skara & Sussman, 2003). In contrast to thedecrement in favorable effects over time observed among middleschool students, the ATHENA program's beneficial behavioraloutcomes seemed to increase over time and were evident follow-ing high school graduation.

Two types of influences may have accounted for the observedlong-term reductions in substance use. First, as with most othereffective drug prevention programs (Botvin, 2000; Brook, Brook,


Richter, & Whiteman, 2003; Goldberg et al, 2000), the ATHENAcurriculum advances drug resistance abilities, along with generalsocial, communication, and decision-making skills. However,unlike middle school programs where students usually are reas-signed to new classes each year, ATHENA is delivered to a sportteam, and even after the season, ongoing teammate contact mayprovide a mechanism to continue practicing and reinforcing thosepositive life competency skills. - - .i

Evidence for that mechanism comes from findings with theATLAS (Athletes Training & Learning to Avoid Steroids) pro-gram, which is a parallel sport team-based drug use preventionand health promotion program for adolescent male athletes.ATLAS was assessed prospectively among football teams from16 control and 15 intervention high schools pre-season, post-sea-son and one year later (Goldberg et al., 1996; Goldberg et al.,2000). Immediate significant positive effects included reduceduse of anabolic steroids and an index of illicit drug and alcoholuse (p<0.04 andp<0.01, respectively), along with appropriatelyaltered mediators of those outcomes (MacKinnon et al., 2001).Observing changes pre to post-season and one year later, someimmediate benefits appeared attenuated at one-year, such ashealthy eating habits. However, other actions showed greaterlonger-term effects. For example, cumulative new occurrencesof driving under the influence were not different between groupsimmediately after ATLAS, while at one year, they were signifi-cantly less among intervention participants (p<0.005) (Goldberget al-, 2000), suggesting healthy norms and decision-making mayhave been endorsed and practiced among team members follow-ing football season.

A second factor relates to a change in students' environment.High school-based programs are embedded in a developmentaland social context that may constrain behavior change and limitinitial drug use efficacy (Lilja, Wiihelmsen, Larsson, & Hamilton,2003; Zigler, Taussig, & Black, 1992). In the short term, the harm-ful actions favorably impacted by the ATHENA program werediet pill use and disordered eating behaviors, which often aresolitary or secretive activities among young women. The existinghigh school norms for alcohol and other drug use may have lim-ited the program's impact on those substances' use. However, theATHENA intervention reduced risk factors and enhanced protec-tive factors. Similar to its male counterpart ATLAS and other effee-


tive prevention programs (Botvin, 2000; Brook, Brook, Richter,& Whiteman, 2003; Goldberg et al., 2000), were designed to tar-get psychological well being and social competence. Beneficialdrug use effects only may have become evident when ATHENAgraduates faced new challenges and choices and could apply thoseabilities in different settings following high school.

Tn addition to harm reduction, the ATHENA interventionappeared to have sustained positive effects on dietary behavior.The differences in calcium knowledge and reported intake arestriking and may relate to the information's relevance when pre-sented to young women athletes (Ireland & Ott, 2004). The find-ing especially may be important because of the recognized rela-tionship between adolescents' adequate calcium intake and bonehealth later in life (Greer & Krebs, 2006).

Although the relative differences in the figure representationsare small, they were significant and are of magnitudes foundwhen examining differences between sexes or across generations(Fallón & Rozin, 1985; Rozin & Fallón, 1988). In other settings,body satisfaction was a predictor of healthier behaviors (Neumark-Sztainer, Paxton, Hannan, Haines, & Story, 2006). The interplayof body image, media representations, psychological states anddietary habits are complex (Borzekowski & Bayer, 2005; Stice,2002). However, reductions in young women's normative discon-tent towards their physiques also may be a durable positive pro-grammatic outcome.

We recognize that our findings have limitations. Assessmentfollowing high school graduation was not included in the originalstudy consent, and accordingly, we were limited to anonymousfollow-up and could not link subjects' short-term outcomes withtheir mailed survey results. Although mailed questionnaires havelimitations, the percent returned surveys and participant charac-teristics were similar for intervention and control respondents.Conclusions from mailed surveys achieving comparable responserates generally are valid (Brogger, Bakke, Eide, & Gulsvik, 2003;Gilbert, Longmate, «& Branch, 1992). Ethnic minorities wereunderrepresented among our study subjects, reflecting both localdemographics and the relatively lower participation of femaleminority students in school sports (Lopiano, 2003), and our find-ings may not be applicable to those groups.


Because our findings are based on self-report, they can be biasedby situational and cognitive factors (Brener, Billy, & Grady, 2003).Never-the-less, when participats are assured of confidentiality oranonymity, survey findings are considered valid, and biochemicalmeasures usually confirm self-reports (Harrison 8L Hughes, 1997).In addition, the lack of efficacy reported for most school-basedsmoking prevention interventions suggest that program participa-tion alone does not bias outcomes (Wiehe, Garrison, Christakis,Ebel, & Rivara, 2005). Finally, when specifically studied, youngwomen's response to a prevention intervention did not appear tobe biased by social desirability, and self-report was a valid indica-tor of program effects (Tiigner, Wertheim, & Paxton, 2004).

Although conventional wisdom may associate athletics withcharacter building and healthy habits, support for those is mixed,at best. Male and female high school sport participants are notuniformly protected from harmful behaviors, including alcoholand other drug use (Fisher, Juszczak, & Friedman, 1996; French,Story, Downes, Resnick, & Blum, 1995; Naylor, Gardner, &Zaichkowsky, 2001). In fact, the jock mentality, for males andfemales, may be associated with greater health risks (Miller,Melnick, Barnes, Sabo, & Farrell, 2007). Young male athleteshave more binge drinking (Miller, Melnick, Farreli, Sabo, &Barnes, 2006), and young women may be more predisposed todisordered eating habits (Ireland & Ott, 2004), which may predictgreater risk for later alcohol abuse (Franko, Dorer, Keel, Jackson,Manzo & Herzog, 2005). Combining the lack of documentedbenefits from athletics with an over emphasis on winning at allcosts has caused some to question the wisdom of school sports ingeneral (Miracle & Rees, 1994).

However, athletics are growing in popularity; currently halfof female and male adolescents participate in school-sponsoredsports (U.S. Department of Health & Human Services, 1996).Coaches' incorporating health enhancement programs, such asATHENA and ATLAS, into existing team activities has severalunique advantages beyond a natural non-stigmatizing gender-specific setting. First, programs can be introduced without addingtime to existing class hours. Second, athlete led training activitiesare common on sport teams, and program facilitation by team-mates may add to efficacy. Meta-analysis of drug-preventionprograms concluded that peer-led interventions can be superiorto teacher-directed programs (Black, Tobler, & Sciacca, 1998).


Finally, coaches, due to their many student contact hours andinfluential positions, have been termed 'missing links' in adoles-cent health promotion (Brown & Butterfield, 1992). Their famil-iarity with playbooks and limited prep time may have augmentedcoaches' adherence to scripted lesson plans and avoided the rein-vention and reduced efïïcacy of drug-use programs that has beenobserved among classroom teachers (Silvia & Thome, 1997).

High school sport team-based programs are an effective newparadigm to promote healthy lifestyles and deter harmful behav-iors. Further beneficial effects may accrue following the sportseason and become even more apparent following graduation,when these emerging adults establish relationships with new peergroups and apply those abilities. The findings support augmentingsports' health-enhancing mission by incorporating effective harmreduction and health promotion curriculum into those settings.

Correspondence concerning this article should be address to:Diane L. Elliot, M.D., Division of Health Promotion & SportsMedicine, Oregon Health & Science University CR110, 3181 SWSam Jackson Park Road, Portland, OR 97239-3098; (503) 494-6554; (FAX) 494-1310; email: elliotd(giohsu.edu.

AUTHOR NOTE

This project was funded by a grant from the National Instituteon Drug Abuse 5R01 DA07356, with assistance from PHS Grant5 MOI RR000334.

ATHENA is a program on the Substance Abuse and MentalHealth Services Administration's National Registry of Evidence-based Programs and Practices (http://www.nrepp.samhsa.gov/programfijlldetails.asp?PROGRAM_ID=lll), and it is distrib-uted through the Center for Health Promotion Research at OregonHealth & Science University (OHSU). OHSU and Drs. Elliot andGoldberg have a significant financial interest from the commercialsale of technologies used in this research. This potential conflictof interest has been reviewed and managed by the OHSU Conflictof Interest in Research Committee.


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