Program Goals/Target Population
ATHENA (Athletes Targeting Healthy Exercise & Nutrition Alternatives) is a sports team–based, peer-led harm reduction and health promotion program for high school female athletes. The program parallels ATLAS (Adolescents Training & Learning to Avoid Steroids), a drug and alcohol prevention program for male athletes. Both are school-based, team-centered programs that promote healthy nutrition and effective exercise training as alternatives to harmful behavior.
The primary objectives of ATHENA are to reduce young female athletes’ disordered eating habits and to deter the use of body-shaping substances, such as steroids and diet pills.
The curriculum specifically targets modifiable risk and protective factors associated with disordered eating and body-shaping drug use. ATHENA is delivered during a team’s sport season and includes eight 45-minute classroom sessions integrated into a team’s usual practice activities. The coach assigns team members to groups of approximately six students (known as squads) and designates one athlete per group as squad leader. Before the first classroom session, squad leaders attend a 90-minute orientation session. During the sessions, squad leaders direct most of the ATHENA group activities, with the coach or other team staff acting as facilitator or timekeeper. The act of players’ participating in the program with their coach and peers was designed to teach participants that their coach and peers endorse healthy norms.
Each classroom session is composed of three to five activities designed to foster learning and application of new abilities. Topics address such issues as depression prevention, mood and self-esteem, norms of behavior, effects of media depictions of women, perceptions of healthy body weight, and societal pressures to be thin. Media influences are countered by having female athletes discuss, deconstruct, and remake magazine advertisements for cigarettes, alcohol, and nutritional supplements. Participants share healthy behavioral expectations, practice refusal skills, and create and present public service campaigns to discourage drug use and disordered eating practices. At each session, participants also receive a specific short-term health goal, such as eating breakfast daily, to complete before the next session.
The squad leaders and coach use scripted lessons to lead meetings, while the other squad members use workbooks to follow along. All participants also receive a pocket-sized sport nutrition and training guide. The guide contains reference information and can be used by participants to monitor protein and calcium intake and to track their daily mood and enjoyable activities.
A 2004 study by Elliot and colleagues included 18 public high schools from northwest Oregon and southwest Washington who participated in a prospective randomized trial of the Athletes Targeting Healthy Exercise & Nutrition Alternatives (ATHENA) intervention. Schools were matched in pairs based on size, socioeconomic status, and student demographics, and then were randomly assigned to either the treatment or control group. Schools that were randomized into the treatment group were offered the chance to allow all female student–athletes in sports, dance, and cheerleading teams to participate in the ATHENA program. At least one team per school agreed to participate. For every treatment team that agreed to participate in the ATHENA program, a similar team from the matching control school agreed to participate in an alternative condition. The control teams were offered preprinted pamphlets concerning disordered eating, drug use, and sports nutrition. Participating schools came from various locations to minimize cross-contamination.
The study examined the immediate posttest outcomes from the year 1 cohort. The intervention group consisted of nine schools, with 457 students surveyed in the preseason and 337 students surveyed in the postseason (74 percent retained). The average age of the female students in the intervention group was 15.4 years, and 93.6 percent were white. The control group consisted of nine matched schools, with 471 students surveyed in the preseason and 331 students surveyed in the postseason (70 percent retained). The average age in the control group was 15.3 years, and 91.4 percent were white. Before the ATHENA intervention, the treatment and control groups reported similar demographics, drug use indices, knowledge scores, and self-assessed behaviors and attitudes.
Immediate outcomes were assessed with pre–sports and post–sports season self-report questionnaires. The pretest was given before participants began the ATHENA program; the posttest measures were gathered within 2 weeks following the end of the sport season. The questionnaires assessed knowledge, potential influences on drug use and disordered eating (including those of peers, coaches, the media, and society), and participant characteristics. The survey questions were based on items from earlier research and other surveys concerning disordered eating, depression, self-image, and self-esteem. Behavioral intent was assessed by asking about future actions using a seven-point Likert scale, with responses ranging from “strongly disagree” to “strongly agree.” Substance abuse questions used a format similar to Monitoring the Future and the Youth Risk Behavior Surveillance to assess supplement use and disordered eating behaviors.
To determine baseline equivalence and intervention effects, the study used an analysis of covariance–based approach within the generalized estimating equations random-effects model framework, which extends generalized linear models to deal with time dependence and hierarchical structure. The incidence of new users (i.e., athletes who began a behavior after the baseline assessments) was determined and conditions were compared using a chi-squared test analysis. An analogous format was used to examine participants who stopped a behavior.
The 2008 study by Elliot and colleagues was a follow-up to the earlier randomized study (Elliot et al. 2004) that examined the short-term effectiveness of ATHENA. The 2008 study analyzed the results from a follow-up survey that was sent to all treatment and control participants who had completed high school and were 18 years and older 1 year after the ATHENA intervention’s last year. A one-page anonymous survey was sent, along with a self-addressed, stamped envelope, to participants’ original addresses. The mailed questionnaire was brief and was limited to demographics, drug use, eating behaviors, and selected attitudes.
The follow-up surveys were mailed to 368 students in the intervention group; 203 (55 percent) returned responses. The surveys were also mailed to 389 students in the control group, and 197 (51 percent) returned responses. For treatment group participants who returned the follow-up survey, 90 percent were in college or trade school, and 51 percent had graduated from high school a year before responding to the survey, while 49 percent had graduated 2 or 3 years before. For control group participants, 90 percent were in college or trade school, and about 45 percent had graduated from high school a year before responding to the survey, while 55 percent had graduated 2 or 3 years earlier.
Alcohol use, tobacco use, other drug use, and disordered eating behaviors were indexed using the original standardized format. For less-frequent behaviors, such as smoking and marijuana use, the study compared use in the last year and lifetime use. For more prevalent behaviors, such as alcohol use, use in the past 3 months and in the last year were indexed and compared. The questionnaire also presented respondents with a spectrum of female physiques and asked them to identify the healthiest and most attractive representation.
Baseline equivalence and shorter-term intervention effects were examined using an analysis of covariance–based approach within the generalized estimating equations random-effects model framework. Students were no longer clustered on teams and in schools. The association between participants’ study condition and their long-term drug and alcohol use was examined with logistic regression using years since graduation as a covariate in the analysis. Body image responses were assessed with t–tests.
Disordered Eating Behavior
The results of the Athletes Targeting Healthy Exercise & Nutrition Alternatives (ATHENA) intervention showed a few significant effects. Elliot and colleagues (2004) found that female athletes who had participated in ATHENA self-reported significantly less use of diet pills in the previous 3 months. Although there were no significant differences between the ATHENA intervention group and the control group on questions asking if participants had vomited to lose weight or on use of athletic-enhancing substances (such as creatine), there were significantly more new users of muscle-building supplements in the control group.
There were significant differences on measures of intentions toward future disordered eating behaviors and drug use. The ATHENA intervention group reported that they were significantly less likely in the future to use diet pills, to vomit to lose weight, and to use athletic-enhancing substances such as creatine.
Although both the ATHENA intervention group and the control group reported reductions in smoking cigarettes in the previous 3 months, overall there were no significant differences between the groups on tobacco use. In regard to measures of intentions toward future drug use, the ATHENA intervention group did report that they were significantly less likely to smoke cigarettes in the future.
Disordered Eating Behavior
Overall, Elliot and colleagues (2008) studying Athletes Targeting Healthy Exercise & Nutrition Alternatives (ATHENA) found that graduates’ self-reported use of diet pills, diuretics, laxatives, and self-induced vomiting from both the intervention and control groups became less prevalent over time, with fewer than 10 percent of all graduates indicating those behaviors in the past 3 months. There were no significant differences between the self-reported behaviors of the groups.
Alcohol, Tobacco, and Illicit Drug Use
Graduates who had participated in the ATHENA intervention self-reported significantly less alcohol use in the past 3 months, compared with control group graduates (27 percent, versus 41 percent). ATHENA graduates also self-reported significantly less alcohol use in the past year (25 percent, versus 35 percent).
Although the prevalence of tobacco use was low overall for all graduates, ATHENA graduates self-reported significantly less regular ongoing tobacco use in their lifetime (9 percent, versus 16 percent). However, there was no significant difference between the groups on self-reported tobacco use in the past year.
ATHENA intervention graduates self-reported significantly less regular marijuana use, compared with graduates in the control group. Graduates in the ATHENA group self-reported less regular marijuana use in the past year (2 percent, versus 7 percent) and in their lifetime (5 percent, versus 13 percent).
Self-reported use of other substances (such as club drugs, ecstasy, GHC, or LSD) was low (fewer than 5 percent of all graduates reported any use in the past year). There were no significant differences between the groups on self-reported use of these substances.