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The body attitude test: Validation of the Spanish version

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 ORIGINAL
RESEARCH The body attitude test: Validation of the
PAPER Spanish version
A. Gila, J. Castro, M.J. Gómez, J. Toro, and M. Salamero
Child and Adolescent Psychiatric Section, Institute of Psychiatry and Psychology, Hospital Clínic Universitari,
Barcelona, Spain

ABSTRACT. A Spanish version of the Body Attitude Test (BAT) is presented. It was validated
with 165 eating disorder patients (79 anorexia nervosa, 86 bulimia nervosa) and 220 schoolgirls
from the general population. Factor analysis allowed the extraction of four factors, as in the
original questionnaire, but with different item loadings on each. Taken together, these four fac-
tors accounted for 67.1% of the variance. The alpha reliability coefficient was 0.92 in both
groups. The test-retest reliability with a one-week interval was 0.91 in a subgroup of 34 eating
disorder patients and in a subgroup of 43 girls from the general population. The difference
between the mean scores of the girls from the general population and the anorexics on one
hand and the bulimics on the other was highly significant (p<0.0001). On the basis of the discri-
minant validity study, the use of a cut-off point of 41 - which gives a sensitivity of 75.1% and a
specificity of 72.7% - is recommended.
(Eating Weight Disord. 4, 175-178, 1999). ©1999, Editrice Kurtis

INTRODUCTION with a Cronbach’s alpha coefficient of 0.93.

Key words:
Body attitude, body
dissatisfaction, adolescent
eating disorders.
Correspondence:
Araceli Gila, M.D., Child and
Adolescent Psychiatry
Section, Hospital Clínic
Universitari, Sabino de
Arana 1, Barcelona 08028,
Spain.
Received: May 21, 1999
Accepted: July 26, 1999
Body dissatisfaction is a basic characteris-
tic in eating disorders (1), though its
importance and nature are disputed (2).
Several authors have devised question-
naires to assess its subjective component
and abnormal attitudes towards one’s own
body (3-5) that deal with aspects of body
dissatisfaction such as evaluation and
behaviour (3), appearance-related cogni-
tions or state and trait anxiety related to
different body sites (5). Even so, it is diffi-
cult to obtain a complete evaluation of
body image (5). Probst et al. (6) have elabo-
rated a new questionnaire called the Body
Attitude Test (BAT) to assess global subjec-
tive body experience and attitude towards
one’s own body.
The BAT
The BAT is a self-report questionnaire of 20
items to be scored on a 6-point-scale.
Factor analysis has yielded four factors that
jointly account for 64.2% of the variance.
These are: “negative appreciation of body
size” (7 items), “lack of familiarity with
one’s own body” (7 items), “general body
dissatisfaction” (4 items) and a “rest” factor
(2 items). The internal consistency is high,
The test-retest reliability is very high for
patients and the general population. The
BAT distinguishes between patients and
normal girls, and the cut-off score of 36
offers the best proportion between sensi-
tivity and specificity, with a sensitivity
index of 0.69 and a specificity index of 0.80.
The test correlates with other question-
naires about body dissatisfaction such as
the Body Shape Questionnaire (4), with
questionnaires of abnormal eating attitudes
such as the Eating Attitudes Test (7), and
with measures of distortion of the estima-
tion of one’s body size such as the video
distortion technique (8). The BAT has been
translated into Italian (9).
In Spain, several studies carried out with a
range of questionnaires and techniques to
assess body concerns and dissatisfaction,
both in general and in eating disorder pop-
ulations (10-12), have shown the presence
of some body overconcern and dissatisfac-
tion in normal Spanish girls, though ano-
rexics display greater concern and overesti-
mation (12) than adolescents from the gen-
eral population. This paper describes the
validation of a Spanish version of the BAT
with a view to its use in clinical practice and
research.
175
 BAT: Spanish version

METHOD Table 1
Eigenvalues and variances of the rotated factors of the BAT
Subjects with all eating disorder patients (N=165).
A total of 165 eating disorder patients were
considered: 79 met the DSM-IV (13) criteria Factor Eigenvalue % Variance Cumulative variance
for anorexia nervosa [65 (82.3%) restrictive 1 9.99 50.0 50.0
and 14 (17.7%) purging)], and 86 for bulimia
nervosa. The mean age of the anorexics 2 1.30 6.5 56.5
group was 15.5 (±1.5) and their mean Body
3 1.08 5.4 62.0
Mass Index (BMI) was 16.7 (±0.5). The mean
age of the bulimics was 18.2 (±2.9) and their 4 1.02 5.1 67.1
mean BMI was 21.4 (±3.9). The mean period
from the onset of the disorder was 12.7
months (±10.1).
A total of 220 girls (mean age 15.8 ± 3.1 Reliability
and mean BMI 20.8 ± 2.9) from schools in Internal consistency measured by the
Barcelona constituted the comparison (gen- Cronbach’s alpha coefficient was 0.92 in
eral population) group. both groups.
The test-retest reliability with a one-week
Statistical analysis
A factor analysis was conducted on the
BAT ratings given by all the eating disorder Table 2
patients, using principal components analy- Item loading on the factors of the BAT (N=165).
sis with VARIMAX rotation as in the origi-
nal BAT (6). Only loadings greater than 0.4 Item Factor 1 Factor 2 Factor 3 Factor 4
were accepted as sufficiently high. The 1 .63 .49 .34 .19
internal consistencies of the global ques-
tionnaire and the resulting scales were 2 .60 .33 .44 .19
determined with Cronbach’s alpha coeffi- 3 .33 .64 .28 .23
cient, which had to be in excess of 0.7. Test-
retest reliability was analyzed by the 4 .53 .39 .30 .09
Pearson product moment correlation
5 .36 .67 .29 .30
between the scores obtained by the sub-
jects at two evaluations with a one-week 6 .04 .79 .03 -.09
interval. Student’s t test for independent
samples was used to compare the means 7 .66 .37 .28 .02
for the groups. The discriminant validity 8 .69 .44 .33 .23
was determined by dividing the two groups
according to two cut-off points that recom- 9 .62 .17 -.06 -.09
mended by the authors of the question-
10 .38 .69 .32 .30
naire, and another that offered a better bal-
ance between specificity and sensitivity in 11 .07 .17 .73 .03
the Spanish sample.
12 .51 .47 .41 .24

13 .48 .43 .42 .29

RESULTS
14 .33 .26 .61 .15
Factor analysis
15 .35 .33 -.37 .62
The factor analysis was carried out by taking
together the BAT scores of all eating disor- 16 .44 .39 .43 .19
der patients. The only four factors with an
eigenvalue higher than 1 accounted for 17 .74 .07 .02 .39
67.1% of the common variance of the 20 18 .39 .45 .21 .53
items. Table 1 shows the eigenvalues and the
percentage of variance found for each factor. 19 .65 -.01 .42 .07
The items for each factor and the item
20 -.07 -.00 .24 .82
loading are shown in Table 2.
176
 A. Gila, J. Castro, M.J. Gómez, et al.

interval was 0.91 in both a subgroup of 34 Table 3

eating disorder patients and a subgroup of Comparison (t-test) between the means obtained in the BAT by
43 schoolgirls. anorexic patients (N=79), bulimic patients (N=86) and a com-
parison group from the general population (N=220).
Results obtained by normal and
eating disorder subjects Anorexic patients Bulimic patients
Table 3 shows the means for the two mean SD mean SD t p
groups. There were no statistically signifi- 59.1 27.5 65.1 23.3 -1.5 0.131
cant differences between anorexics and
bulimics, but the latter obtained a higher Anorexic patients Comparison group
mean score. The differences between both mean SD mean SD t p
anorexics and bulimics and the schoolgirls
were significant. 59.1 27.5 31.6 19.5 9.6
0.000***
The cut-off score of 36 proposed by the
authors of the original BAT as having the Bulimic patients Comparison group
best specificity and sensitivity indexes
yielded a sensitivity of 79.4% and a specific-
ity of 67.7%. A cut-off score of 41 offered a
better balance, with a sensitivity of 75.1% The mean age of a sample also determines
and a specificity of 72.7% (Table 4). the time elapsed since the beginning of the
disorder; in the original study, the duration
of the disorder averaged 5.5 years, and in
DISCUSSION the present study only one year.
As to the global mean score, there were
The good internal consistency of the no statistically significant differences
Spanish version was very similar to that of between anorexics and bulimics, even
the original version (6). The test-retest relia- though (as in the original sample) bulimics
bility, too, was acceptable for both groups obtained a higher mean score. Never-
and comparable to that obtained for the theless, the difference between the bulimics
original BAT. and the comparison group may be biased
Factor analysis of the Spanish version by the different mean age. The differences
yielded some differences with regard to the between the schoolgirls and both the ano-
items obtaining high loadings in each fac- rexics and the bulimics were statistically
tor. These differences may be related to the significant. The mean scores of the compar-
differences in our sample, such as age, cul- ison group and the bulimics were not very
ture or the percentage of individual eating different from those in the validation of the
disorders. The original study included non- original test (6). By contrast, the Spanish
specified eating disorders and its percent- adolescent anorexics obtained a higher
age of anorexia nervosa versus bulimia was mean score than the Belgian adult anorex-
higher. Bulimic patients present more vari- ics. Understanding of the causes of these
ability in their perception of body image
(14) and this may interfere with consistency
in differentiating between the various
aspects of body concept. Patient ages also Table 4
Sensitivity and specificity.
vary from one study to another; mean age
was 24 in the original sample and about Eating disorder Comparison
16.5 in ours. This difference may be impor-
tant because the original sample consisted patients (N=165) group (N=220)
of young adults as opposed to adolescents. Score equal to false negatives true negatives
Adolescence is a very important period for
the psychological development of the self or less than 36 34 (20.6%) 149 (67.7%)
(15); adolescents have a less stable idea of
Score higher true positives false positives
their body and find it more difficult to feel
or consider separately the aspects the BAT than 36 131 (79.4%) 71 (32.3%)
differentiates in adults: negative apprecia-
tion of body size, lack of familiarity with Score equal to false negatives true negatives
one’s body, or general body dissatisfaction.
177
 BAT: Spanish version
differences would require further studies
with samples of similar age, clinical charac-
teristics and socioeconomic level.
In the present study, the cut-off point of 36
recommended by the authors of the BAT had
a good sensitivity, but not a very high speci-
ficity, whereas a cut-off point of 41 offered a
better balance between sensitivity and speci-
ficity. In conclusion, the Spanish version of
the BAT is a good questionnaire for assess-
ing global attitudes towards the body in
Spanish eating disorder patients. It has a
good test-retest reliability and internal con-
sistency. It differentiates patients from nor-
mal schoolgirls and can thus be employed in
clinical practice and research.
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