- Eating Disorders & Athletes
- Eating Disorders in Male Athletes
- Harmful Dieting Affects Both Genders
- Statistics on Eating Disorders in Athletes
- An Interview with an Expert
- Why are eating disorders in male athletes on the rise? How common is it?
- What is the most common type of eating disorder in males?
- How do eating disorders differ in males and females? What are the risk factors?
- Are eating disorders more common in a certain age group?
- The signs of undernutrition are sometimes quite visible in female athletes, described by the Female Athlete Triad. What are the signs in male athletes?
- What advice do you have for parents and coaches?
- How can we increase awareness of eating disorders in males?
- Words from a College Coach
- Why Athletes Develop Eating Disorders
- Eating Disorders
- What are eating disorders?
- Risk factors for eating disorders
- Medical & Performance complications
- Treatment approaches
- Risk reduction strategies
- Elite female athletes at greater risk of eating disorders
Eating Disorders & Athletes
Athletics are a great way to build self-esteem, promote physical conditioning, and demonstrate the value of teamwork, but not all athletic stressors are positive. The pressure to win and an emphasis on body weight and shape can create a toxic combination. Athletic competition can also be a factor contributing to severe psychological and physical stress. When the pressures of athletic competition are added to an existing cultural emphasis on thinness, the risks increase for athletes to develop disordered eating.
In a study of Division 1 NCAA athletes, over one-third of female athletes reported attitudes and symptoms placing them at risk for anorexia nervosa. Though most athletes with eating disorders are female, male athletes are also at risk—especially those competing in sports that tend to place an emphasis on the athlete’s diet, appearance, size, and weight requirements, such as wrestling, bodybuilding, crew, and running.
RISK FACTORS FOR ATHLETES
- Sports that emphasize appearance, weight requirements, or muscularity (gymnastics, diving, bodybuilding, or wrestling).
- Sports that focus on the individual rather than the entire team (gymnastics, running, figure skating, dance or diving, versus teams sports such as basketball or soccer).
- Endurance sports such as track and field, running, swimming.
- Overvalued belief that lower body weight will improve performance.
- Training for a sport since childhood or being an elite athlete.
- Low self-esteem; family dysfunction (including parents who live through the success of their child in sport); families with eating disorders; chronic dieting; history of physical or sexual abuse; peer, family and cultural pressures to be thin, and other traumatic life experiences.
- Coaches who focus primarily on success and performance rather than on the athlete as a whole person. Check out tips for coaches >
- Three risk factors are thought to particularly contribute to a female athlete’s vulnerability to developing an eating disorder: social influences emphasizing thinness, performance anxiety, and negative self-appraisal of athletic achievement. A fourth factor is identity solely based on participation in athletics.
PROTECTIVE FACTORS FOR ATHLETES
- Positive, person-oriented coaching style rather than negative, performance-oriented coaching style.
- Social influence and support from teammates with healthy attitudes towards size and shape.
- Coaches who emphasize factors that contribute to personal success such as motivation and enthusiasm rather than body weight or shape.
- Coaches and parents who educate, talk about, and support the changing female body
Infographic: Athletes & Eating Disorders
Get the facts on eating disorders and athletes with our infographic!
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THE FEMALE ATHLETE TRIAD
The Female Athlete Triad includes disordered eating, amenorrhea, and osteoporosis. The lack of nutrition resulting from disordered eating can cause the loss of several or more consecutive periods. This in turn leads to calcium and bone loss, putting the athlete at greatly increased risk for stress fractures of the bones. Each of these conditions is a medical concern. Together they create serious health risks that may be life threatening. While any female athlete can develop the triad, adolescent girls are most at risk because of the active biological changes and growth spurts, peer and social pressures, and rapidly changing life circumstances that go along with the teenage years.
Early intervention is critical in eating disorders recovery.
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Eating Disorders in Male Athletes
Harmful Dieting Affects Both Genders
By Natalie Bickford, MS
We go into a lot more detail in Run Fast. Cook Fast. Eat Slow about eating disorders (EDs) in female athletes and the Female Athlete Triad. We have recently gotten inquiries from coaches and concerned parents about the lack of information for male athletes. We would love to address that here and reassure male runners, struggling with disordered eating habits, that they are not alone. The content and information within the Run Fast. Eat Slow. cookbooks will also help young men develop a healthier relationship with food.
It’s often assumed that EDs only affect female athletes, but they are also very prevalent in male athletes. In fact, only in 1994 were males able to meet the DSM criteria for anorexia after removing ‘amenorrhea’ as diagnostic criteria (1). This goes to show how our culture has largely focused on women and ignored men in this department.
Statistics on Eating Disorders in Athletes
- Athletes are 2-3 times more likely than the average individual to develop an eating disorder (BED) (2).
- Males constitute 25% of individuals with anorexia and about 40% of those with binge eating disorder (2).
- A study on 583 male and female triathletes showed that 11% of participants were preoccupied with food and weight, 23% were engaging in restrictive calorie-controlling behaviors, and 100% of the sample were unhappy with their current BMI (4).
- Of all NCAA institutions, only about 7% employ a full time Registered Dietitian (RD) within the sports program and they are all D1 level.
An Interview with an Expert
I interviewed Dr. Paula Quatromoni, DSc, MS, RD, LDN who is one of the nation’s top minds on the intersection of sports nutrition and eating disorders. She is a Nutrition professor at Boston University and a senior consultant for Walden Behavioral Care.
Why are eating disorders in male athletes on the rise? How common is it?
ED’s in males are increasing because of the increasing pressure in our culture to perform combined with the fact that more males are coming forward and seeking treatment. Some ED treatment facilities don’t even accept men and there are only three ED programs in the country that offer athlete-specific treatment programs. This is how under-recognized the issue has been.
ED’s are so secretive, poorly understood, and under-treated that we only know about a fraction of the cases. A lot of men who have EDs, specifically BED, don’t know what it is or that it is a disorder and don’t know that there is help available. These are obstacles to early intervention and treatment.
Male eating disorders are so poorly understood and there is so little awareness, in general and in sport. The data in the literature only reflect people who come into treatment; yet there are so many people who struggle with ED’s in silence that are not accounted for in the statistics. Nonetheless, there is data showing that ED’s in males are on the rise.
What is the most common type of eating disorder in males?
Binge Eating Disorder (BED) is the most prevalent type of ED in males yet it often goes undetected because it is so poorly understood. In general, eating disorders are described as maladaptive coping mechanisms for stress. The hallmark of BED is an experience of loss of control over eating behavior (the binge episode) that occurs in response to a stressful trigger or negative emotional state. The binge soothes the emotional pain but is followed by extreme feelings of guilt and shame. There is often a lot of negative self-talk and low self-worth that accompanies this phase – ‘I’m supposed to be dieting! Now I’m a failure.” BED is characterized by a cycle of restrict, binge, feel better, feel guilt, restrict again on a weekly or sometimes daily basis. When they come into treatment, patients describe that they feel exhausted by the cycle that has consumed their life and their ability to function.
BED is hard to detect with naked eye. Those affected by BED do not fit the stereotypical eating disorder appearance of being markedly underweight; they usually appear at a relatively consistent weight or have a larger body size. They may be experiencing discrimination, bullying, shame or other psycho-social factors that contribute to BED. For athletes, there is additional pressure to be a certain body shape or size for sport and athletes may be receiving direct advice to lose weight and/or increase training to improve performance or gain a competitive edge. Without access to a sports dietitian to assess, plan and monitor appropriate goals and strategies, athletes may go to extremes, particularly when under stress or feeling desperate to measure up to performance expectations. The body’s natural response to starvation to is seek food. So an athlete who is intentionally dieting, unintentionally under-fueling or chronically restricting his diet by “clean eating” or following an elimination diet (like gluten-free, vegan, ketogenic, etc) is putting himself at risk for BED.
How do eating disorders differ in males and females? What are the risk factors?
Male and female athletes with ED’s share some similar characteristics that are common in the sports environment: competitive nature, driven by performance goals, committed to sport, extremely disciplined with training and diet. These interpersonal characteristics can also fuel an eating or exercise disorder when an athlete is under stress and/or has a predisposing mental health condition like anxiety or depression. Other stressors like academics, finances, scholarships, relationships, and sports injuries increase an athlete’s vulnerability. Athletes are more likely to under-report their symptoms and/or consider them to be benign, perhaps even required in order to be elite.
The tendency to recognize eating disorders in females more readily than in males, and to recognize anorexia nervosa more readily than BED, makes the detection of eating disorders in male athletes more challenging. In general, males with ED’s tend to have a worse prognosis than females because they tend to wait longer before they come into treatment. By the time they seek help, males are often sicker and have more serious health consequences. We need to do better about raising awareness and identifying risk in males.
Are eating disorders more common in a certain age group?
In my clinical experience, ED’s do not discriminate. They affect all genders, a variety of racial/ethnic groups and occur in all sports. They occur in adults, adolescents and now in children. Stereotypes and stigma that depict eating disorders only as underweight, adolescent females, female but not male athletes, or athletes only in “lean,” weight-based or aesthetic sports are misinformed.
College-age adolescents and young adults constitute a high risk category. The life transition to college can involve a lot of stress related to the need to establish a support system and build new relationships. The college setting can increase ED risk related to social expectations, dating culture, substance use/abuse, academic stress, role modeling of unhealthy eating or exercise behaviors, etc… College athletes have to manage all of that along with the pressures of competitive sport, putting them at increased risk for an ED.
The signs of undernutrition are sometimes quite visible in female athletes, described by the Female Athlete Triad. What are the signs in male athletes?
One point to remember is that some people experience disordered eating or compulsive exercise patterns that may not meet the diagnostic criteria for a clinical eating disorder. Nonetheless, they are at risk of malnutrition and they are at risk for developing a full blown eating disorder. For this reason, assessment and early intervention are very important eating disorder prevention strategies for individuals displaying these habits.
As well, there are many athlete eating disorder cases that don’t fall into the classic Female Athlete Triad or anorexic picture. Amenorrhea is certainly a common symptom in females with anorexia nervosa, but that symptom is not always present. In fact, it is no longer required as part of the diagnostic criteria. As well, consequences to bone health are not the only cause for concern.
With better research, we now know that the health consequences of eating disorders in sport are far greater than the Female Athlete Triad suggests. In 2014, the clinical picture was redefined as Relative Energy Deficiency in Sport (RED-S), removing the stereotype attached to female sex. RED-S occurs when energy intake chronically falls short of energy requirements and/or when energy expenditure (through training and exercise) chronically exceeds energy intake from diet. RED-S affects both male and female athletes and has consequences that affect every organ system of the body including the heart, brain, endocrine, immune and reproductive systems.
Because the physical damage of RED-S can be invisible to the eye or may be detected quite late in the syndrome, it is essential to focus not just on physical signs, but on the behavioral signs like mood changes, affect, social engagement versus isolation, and ability to focus and perform in school. An athlete who stops attending social events, won’t eat in public, refuses to eat restaurant or dining hall food, or exhibits signs of anxiety or depression is of concern.
What advice do you have for parents and coaches?
Eating disorders are life-threatening conditions. They have the highest death rate of any psychiatric disease. A major cause of death associated with eating disorders is suicide. The keys to effective treatment and recovery from an eating disorder are early identification and timely intervention. For these reasons, do not ignore the signs you observe or any concerns that you have. It is important to trust your gut and act on your concerns to avoid delaying a diagnosis and treatment plan. Treatment for eating disorders involves a multidisciplinary team that includes a physician, therapist or other mental health professional, and a registered dietitian. For athletes, it is important to find professional providers who have expertise in eating disorders and also in sports/sports medicine.
Our research shows that athletes who have struggled with an eating disorder report that one factor that contributed to their ability to seek and accept help was being addressed by someone in their life who was important to them who expressed concern. People tend to dismiss the warning signs and some even consider what they are seeing a sign of an athlete’s commitment and dedication to their sport. It is important to trust your gut, and ask a professional for advice if you are unsure about what to do. Coaches may turn to their athletic trainer, school nurse or school counselor. Parents should discuss concerns with their child’s pediatrician and may seek the advice of a Registered Dietitian. Parents who notice signs and symptoms of an eating disorder have authority to say to their child, “I am concerned. Let’s make an appointment with your doctor to get a professional evaluation.”
Many people are uncomfortable thinking about raising their concerns with someone who they think might be experiencing an eating disorder, fearing that they will say the wrong thing. But ignoring the warning signs is dangerous and jeopardizes the athlete’s well-being. Choosing not to act also silently condones the disordered behavior. Do not wait until a dramatic weight loss is apparent, the athlete suffers an injury, or something more catastrophic happens.
My advice is to have a calm and caring conversation in private. Start it by saying, “I’m really concerned about you because I’ve noticed XYZ (state the specific behavioral signs you have observed)… Is something going on? Can you talk about it with me, or with someone else who can help?” Stick to firm facts and observations while you express your concerns. Offer an empathic, understanding, non-judgemental tone of support. Do not try to diagnose or label the individual as having an eating disorder. Show your unconditional support by acknowledging, “It can be really hard for an athlete to get the proper nutrition they need or to manage the competitive pressures of sport. Sometimes, we need help.” Expect that the athlete may deny any problem and attempt to dismiss your concerns. Denial is a characteristic feature of the disorder. Let them know that you are there for them, keep the door open for follow up conversations, and check back in a few days to revisit the discussion.
Athletes work hard at keeping their personal and emotional struggles a secret, particularly if the sports culture expects or rewards invincibility and frames mental health struggles as a sign of weakness. The “man-up” messages and the “win at all cost” mentality inside some sports environments are examples of cultures where eating disorders stay hidden. Coaches and team leaders who actively work to create and sustain an open culture of acceptance and positivity that is free from stigma, stereotypes, body-shaming or bullying can help to lower risks for eating disorders in sport. It is important for athletes to have access to trusted professionals whose doors are open where they can come in and say, “I’m having a hard time. Can we talk?” On a college campus, these roles may be filled by coaches, assistant coaches, athletic trainers, counselors, dietitians, captains, teammates, academic advisors, and resident advisors in the dorm.
How can we increase awareness of eating disorders in males?
Compared to other public health concerns, eating disorder research is extremely underfunded. Athletes are understudied in ED research, and research on EDs in males is practically non-existent. Clearly, we need more research. But in the meantime, we need to write about it, talk about it, teach parents, coaches and athletes about it, and have male athletes share their lived experiences with eating disorders in sport. Part of the work is to raise awareness, address the stigma, and break the stereotypes so men feel more comfortable speaking out about it. We need to acknowledge the diversity of eating disorders and disordered eating — they are more common than you think and they occur in all sports, body shapes and sizes.
As well, we need nutrition education, mental health counseling and wellness teams in athletic and collegiate environments. This means that we need access to trained professionals inside the sports culture to monitor the risks and to do the work of prevention and intervention. We need ongoing education for coaches, athletes, parents, and professionals. It’s important to work collaboratively and to formulate action plans for addressing eating disorders in sport.
Words from a College Coach
We wanted to finish with some insightful words from Dylan Sorensen, the Assistant Coach at Stanford University for Track & Field / Cross Country – Men’s Distance.
“From my perspective, having run in college (at Georgetown) and then having coached now here at Stanford, the greatest insight I have is the intersection between developing a trusting relationship with an athlete and clear communication about how to achieve their goals in both life and running.
For example, I am incredibly grateful that the athletes with whom I’ve worked with feel confident enough in their relationship with me that they are willing to share the struggle with which they face each day. I can’t stress enough how important it is to foster that relationship between athlete and coach. I fully believe that having a healthy relationship with eating will make everything in life better, from having more consistent sleep and developing consistency with training, to even improving the ability to pay better attention in class and building more positive relationships with friends/family.
The underlying message is that, when in doubt of a potential destructive relationship with eating, reach out to your coach or mentor, as in this sport, there is a good chance they’ve dealt with it through their own experiences and can empathize. I meet with each of my athlete’s 1-on-1 every 12-15 days and make it a point to talk about how their nutrition planning has gone as it is so crucial to not just success in running, but happiness in life. Every relationship has an ebb and flow, including the one each person has with food!”
Interview with Dr. Quatromoni and David Proctor
Joey Julius – a Penn State football player who suffered from an ED
Rachael Steil who is the author of the book Running in Silence.
Tale of Two Runners: A Case Report of Athletes’ Experiences with Eating Disorders in College
RED-S The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport
Natalie is a nutritionist and personal chef in Portland, OR who specializes in women’s health and sports nutrition. She loves creating simple, nourishing meals and recipes to fuel your life. Find Natalie at nataliecooks.com.
Why Athletes Develop Eating Disorders
The National Eating Disorders Association is a good online resource for athletes and coaches to understand how to prevent, recognize, and treat potential eating disorders.
It is also important to make sure the athlete eats healthfully. “The ideal diet for athletes doesn’t differ much from the diet for non-athletes,” says Nina Eng, RD, chief clinical dietitian at Plainview Hospital in New York. “You should include all food groups, adjusting the amounts you eat depending on your sport, the amount you train and the time you spend in each training session.”
Eng, who has worked with athletes and eating disorder patients, offers the following tips: Eat plenty of complex carbohydrates, like fruit, brown rice, cereal and whole wheat pasta and bread. Make sure to get enough lean protein to support muscle and body tissue repair. Good sources include lean meats, low fat dairy, and beans. Drink lots of water — 2 cups two hours before exercise, and one-half to 1 cup every 15 to 20 minutes during exercise.
When in doubt about what you should be eating, consult an expert.
What are eating disorders? Anorexia nervosa, bulimia nervosa, binge-eating disorder and EDNOS (Eating Disorder Not Otherwise Specified) are clinically diagnosed psychological illnesses affecting health and performance. Restricted food intakes, episodes of binge eating, as well as distress or excessive concern about body shape or weight, poor self-worth and feelings of guilt or control are commonly associated with eating disorders.
What are eating disorders?
Anorexia nervosa, bulimia nervosa, binge-eating disorder and EDNOS (Eating Disorder Not Otherwise Specified) are clinically diagnosed psychological illnesses affecting health and performance. Restricted food intakes, episodes of binge eating, as well as distress or excessive concern about body shape or weight, poor self-worth, and feelings of guilt or control are commonly associated with eating disorders. Abnormal eating patterns may vary from mild to serious and some may fall outside the clinical definitions. Health care professionals, coaches, and personal trainers should not ignore athletes with disordered eating behaviours and should recognise that a collaborative team approach to managing the athlete is essential.
Eating disorders have been associated with athletes at all levels of sport and in both male and female athletes. At times, eating disorders may be undiagnosed or concealed due to the intense physical and mental stress that athletes endure in their training and competition cycles. Sports performance usually drops in athletes with eating disorders due to poor nutrition and poor mental function. If untreated or undiagnosed, eating disorders can have serious medical outcomes.
Risk factors for eating disorders
There are a number of factors that increase the risk of developing an eating disorder in both athletes and non-athletes. These include:
- Biological factors
- Personality traits (e.g. high levels of sensitivity, perfectionism, negative self-evaluation)
- Dieting (especially yo-yo dieting)
- Traumatic life events
Sportspeople also have a number of unique traits or pressures that increase the risk of developing an eating disorder including:
- Desire to optimise performance
- Involvement in sport that emphasises physical appearance, size or leanness for performance
- Increased body awareness, which may exacerbate body image concerns
- Personality characteristics often prized in athletes (competitive, perfectionist, disciplined)
- High stakes associated with winning (and losing)
- Injury as a trigger for the onset of an eating disorder
- Influence of parents, coaches and fellow athletes
In addition to the above risk factors, some sports are associated with an increased risk of eating disorders. These can be broadly classified into three categories:
Medical & Performance complications
The impact of eating disorders can be long lasting and devastating to the individual, their families, and their performance. Poor nutrient and energy intakes can result in a number of medical complications including:
- Dehydration is common in people that restrict food and/or fluids
- Vomiting and use of laxatives can result in electrolyte imbalances increasing the risk of heart problems and kidney damage
- Amenorrhoea (loss of periods) and low bone density, which increases chance of stress fractures that can significantly hamper training and competition
- Reduced muscle protein and low glycogen stores
- Erosion of tooth enamel, sore and damaged throat, and pancreatitis are often seen in sufferers of bulimia
Eating disorders are very serious and potentially life threatening and having a non-judgemental approach is always helpful. It’s important to never punish or abandon an athlete or dismiss them from the team for an eating disorder. A multidisciplinary team is needed to manage an athlete with an eating disorder, including a sports physician, psychologist, sports dietitian, coach, and the family of the athlete. Treatment can be challenging and prolonged, and may require hospitalisation in severe cases.
Risk reduction strategies
Athletes, coaches and trainers must be realistic when setting weight loss goals (both amount of weight lost and time frame). Dieting, weight loss, and pre-event diet superstitions or rituals do not necessarily mean the athlete has an eating disorder however there are signs and behaviours that should not be ignored, including:
- Rapid weight loss
- Weight loss below ideal competitive weight
- Constant referrals to being, or feeling, fat when often the reverse is true
- Competitive nature with other athletes about their size or weight
- Weight loss or high training loads that continue into the off season
- Excessive exercise over and above the recommended training load from the coach
- A distracting preoccupation with food, fat, calories/kilojoules, carbohydrate, etc.
- Secretive eating or disappearing after meals or snacks to the toilet or shower
- Weakness, dizziness, headaches or fainting, with no apparent medical cause
- Denial that anything is wrong (e.g. no reason for weight loss or other behaviours)
Eating disorders adversely affect sporting performance and life-long health and wellbeing. People working with athletes need to understand the warning signs and risk factors associated with eating disorders and implement risk reduction strategies in their environment. Eating disorders are serious and need a multidisciplinary team approach for correct diagnosis and proper treatment. The sooner help is sought, the sooner the athlete begins their road to recovery.
For more information on this or other sports nutrition topics, subscribe to our newsletter or book to see an Accredited Sports Dietitian.
By Ron Thompson
Participation in sports has a number of positive effects on student-athletes. They tend to live healthier lives than non-athletes, and they gain skills in teamwork, discipline and decision-making that their non-athlete peers may not.
However, some aspects of the sports environment can increase the risk of disordered eating (and eating disorders). That means student-athletes and those who oversee athletics must be vigilant to detect signs of trouble.
Disordered eating and eating disorders are related but not always the same. All eating disorders involve disordered eating, but not all disordered eating meets diagnostic criteria for an eating disorder.
As first conceived, the term “disordered eating” was a component of the female athlete triad – a syndrome that also includes decreased bone mineral density and osteoporosis – and defined as “a wide spectrum of harmful and often ineffective eating behaviors used in attempts to lose weight or attain a lean appearance.” The term was later supplanted by “low energy availability” to reflect the role insufficient energy plays in accounting for all physical activity, as well as to fuel normal bodily processes of health, growth and development.
Eating disorders are not simply disorders of eating, but rather conditions characterized by a persistent disturbance of eating or an eating-related behavior that significantly impairs physical health or psychosocial functioning. The eating disorders most often diagnosed are:
Anorexia nervosa is characterized by persistent caloric intake restriction, fear of gaining weight/becoming fat, persistent behavior impeding weight gain, and a disturbance in perceived weight or shape.
Bulimia nervosa is recurrent binge eating, recurrent inappropriate compensatory behaviors to prevent weight gain (for example, induced vomiting and excessive exercise), and self-evaluation unduly influenced by shape and weight.
Binge-eating disorder is recurrent episodes of binge eating without compensatory behaviors but with marked distress with the binge eating.
Why student-athletes are at risk
Prevalence. Eating disorders occur in all sports, but not equally in all sports. As in society, eating disorders in sport occur more frequently in females than males. One area in which research findings are more definitive is for “lean” sports for which a thin/lean body or low weight is believed to provide a biomechanical advantage in performance or in the judging of performance. Women in these sports are considered to be at the highest risk.
Genetics. Epidemiological and molecular genetics studies suggest a strong genetic predisposition to develop an eating disorder, and that these disorders aggregate in families in part due to genetics. Family and twin studies have found heritability estimates of 76 percent for anorexia nervosa and 83 percent for bulimia nervosa. Not all individuals with a genetic predisposition develop the disorder, as other factors are involved.
Sociocultural factors. Before genetics-related findings, the primary explanation for the development of eating disorders involved sociocultural factors. Certainly, from a sociocultural perspective, most individuals are exposed to societal or cultural pressures regarding weight or appearance, but again, not all will develop an eating disorder. Most who do are female, and the disorder’s onset often occurs during adolescence.
A simple conceptualization is that genetics sets the stage for the disorder, but sociocultural pressures can precipitate it. Once the disorder begins, sociocultural pressures usually assist in maintaining the disorder. Also, from a sociocultural perspective, eating problems can begin or worsen during transition periods, which makes freshman student-athletes particularly vulnerable.
Additionally, student-athletes may experience more stress than non-athletes because they deal not only with the transition away from home and pressures related to academic demands of college but also the pressures associated with sport participation. Eating problems are often the way individuals deal with such stressors.
Sport-related factors. Just as society and culture emphasize the “thin ideal,” similar pressures exist in the sport environment regarding being thin/lean and its purported positive effect on sport performance.
This emphasis on reducing body weight/fat to enhance sport performance can result in weight pressures on the student-athlete from coaches (or even teammates) that increase the risk of restrictive dieting, as well as the use of pathogenic weight loss methods and disordered eating. Even the student-athlete’s perception that her coach thinks she needs to lose weight can heighten weight pressures and increase the risk of disordered eating.
For some student-athletes, revealing uniforms can increase body consciousness, body dissatisfaction, and the use of pathogenic weight loss methods. One study found that 45 percent of swimmers surveyed reported a revealing swimsuit as a stressor. Another study in volleyball found not only that revealing uniforms contributed to decreased body esteem but also distracted players and negatively affected sport performance.
The relationship between body image and body dissatisfaction in female student-athletes is more conflicted and confused than in the general population. Sportswomen have two body images – one within sport and one outside of sport, and disordered eating or an eating disorder can occur in either context or both. Additionally, some female student-athletes are conflicted about having a muscular body that facilitates sport performance but may not conform to the socially desired body type and may be perceived as being too muscular when compared to societal norms regarding femininity.
Coaches have considerable influence with their athletes, and it appears that their relationship with their student-athletes – and more specifically their motivational climate – can influence the risk of disordered eating. A relationship between coach and athlete characterized by high conflict and low support has been associated with increased eating pathology among athletes. Additionally, an ego/performance-centered motivational climate (vs. a skills-mastery climate) that some coaches use has been associated with an increased risk of disordered eating.
Another risk to student-athletes relates to aspects of the sport environment that make identification of disordered eating/eating disorders more difficult. In society and sport, athletes are often expected to display a particular body size or shape that becomes characteristic of a particular sport, such as distance runners being thin. Such “sport body stereotypes” can affect coaches’ perceptions of athletes, and athletes who fit the “thin” stereotype are less apt to be identified as having an eating problem. Identification by coaches is sometimes influenced by sport performance, and student-athletes are less likely to be identified if their sport performance is good.
Finally, eating disorder symptoms (such as dieting, weight loss and excessive training) may be misperceived as “normal” or even desirable in the sport environment, and personality characteristics/behaviors similar to those of eating disorder patients (such as perfectionism and excessive training) may be misperceived as “good athlete” traits.
Treatment. As a special subpopulation of eating-disorder patients, student-athletes need specialized approaches to treatment. However, treatment per se is not different; that is, standard treatment approaches (such as cognitive behavioral therapy) work as well for athletes as for non-athletes.
Recommended treatment differences relate to treatment staff. Treatment professionals working with student-athletes need experience and expertise in treating eating disorders and athletes, but more importantly need to understand and appreciate the importance of sport in the life of a serious student-athlete.
Student-athletes often resist treatment for the same reasons as non-athletes but also for additional ones related to sport. Some resist because they assume they will gain so much weight that it will negatively affect sport performance. They may resist due to a concern that having a mental health problem will result in a loss of status or playing time. Some fear that being in treatment for a mental health problem will displease significant others (like family, coaches and teammates).
Also, student-athletes sometimes resist treatment because they fear their treating professional(s) will not value the importance of sport in their lives. Given these common reasons to resist treatment, motivation for treatment and recovery is particularly important. Regarding treatment motivation, research investigating factors that facilitated student-athletes’ recovery from their eating disorder found the desire to be healthy enough to perform in sport to be most helpful.
Where do we go from here?
Given the prevalence of eating disorders in the college and sport populations, athletics departments are encouraged to develop a treatment protocol for student-athletes with eating disorders. Included in that protocol should be guidelines regarding how affected student-athletes are identified, managed and referred for evaluation and treatment by sport personnel. Sport personnel charged with these responsibilities should be trained by health care professionals with experience and expertise regarding student-athletes and eating disorders.
The protocol should also include recommendations regarding education for both student-athletes and sport personnel. Education is the first step in prevention, but more is needed in the form of a program designed to change student-athletes’ attitudes and behaviors that are associated with disordered eating/eating disorders. Some NCAA schools already employ such a program.
Early identification of “at risk” and affected student-athletes is most important. Eating disorders can be more easily treated early in the process. More importantly, timely and appropriate treatment can prevent medical and psychological complications of these disorders, thereby decreasing the risk to the student-athlete and decreasing time away from sport.
Coaches and other sport personnel are encouraged to improve their identification skills, as well as their skills in making an appropriate referral for an evaluation and treatment. Such training can be made available to coaches, athletic trainers and other sport personnel, and can be endorsed and strongly recommended by sport administrators. Such training opportunities are even more important for smaller colleges that may have fewer treatment options available on campus.
The primary risk for developing disordered eating/eating disorders involves the emphasis on a lean body and its purported relationship with enhanced sport performance. Coaches and others in the sport environment are urged to recognize that such an emphasis on weight or leanness puts the student-athlete at greatest risk for developing eating problems.
Finally, the stigma associated with seeking mental health treatment must be eliminated. Those with influence in the sport environment can play a key role by recommending and encouraging timely and appropriate mental health treatment for their student-athletes.
Ron Thompson is a consulting psychologist for the Indiana University department of athletics and co-director of the Victory Program at McCallum Place, which offers a specialized eating disorder treatment staff to meet the unique needs of athletes. Thompson has served as a consultant on eating disorders to the NCAA and on the Female Athlete Triad with the International Olympic Committee Medical Commission. He can be reached at [email protected]
Elite female athletes at greater risk of eating disorders
An extremely slender and toned body, strict diet, low body fat and a BMI of 18.5, but still worried about her body shape. Are these the traits of a person with an eating disorder? A top athlete? Or both?
In many sports where body weight is associated with performance or aesthetics, the pursuit of low body weight may overshadow other more important parameters for optimal performance, such as consuming enough carbohydrates.
In fact, a wealth of research collectively shows that more than 40% of women engaged in aesthetic sports to a professional level, like dance and gymnastics, show signs of an eating disorder.
And similar figures apply to endurance sports, like running, where you move your own body weight over a longer period of time and low body weight is an advantage.
When do you have an eating disorder?
An eating disorder is a mental illness. It is characterised by a high level of body dissatisfaction and an attempt to regulate body mass by restrictive eating, over-training or vomiting. It is often accompanied by a loss of control of eating habits, leading to overeating and fluctuating body weight.
Women develop eating disorders more often than men, though the prevalence of male eating disorders seems to be rising. In Denmark, about 1% of young girls suffer from anorexia, while bulimia is up to 4%.
Disordered eating, which is not classed as a disease, may be a precursor to developing an actual eating disorder. It is typically described as an unhealthy diet where people worry about calories and their body, they train obsessively, and perhaps show initial signs of being malnourished. We don’t know the exact number of people in this grey area.
Aesthetic and endurance athletes are most at risk of eating disorders. Sports such as cycling, dance and high jump, often perceive a slender body and a very low fat percentage as crucial for optimal performance. Here the expectation of a defined, trim body may lead to an exaggerated preoccupation with body shape, diet and weight loss – the precursors to disordered eating and extreme weight loss.
This is especially worrying, given that sports people often have higher self-esteem compared with people in the general population. But while most athletes prioritise performance and strength over looks, other athletes can easily be pushed in the wrong direction. Research shows that eating disorders often occur in sports where body weight has an aesthetic significance (such as gymnastics), in weight-bearing activities (such as running) and weight-class sports (martial arts), where you fight against others within the same bodyweight category.
Some 42% of elite female athletes in aesthetic sports and 24% of female endurance athletes show symptoms of having an eating disorder, according to a 2004 Norwegian study. Elsewhere, 21-45% of high-level competitive swimmers have disordered eating and 7% have an actual eating disorder.
A 2000 meta-analysis summarised 34 studies of eating disorders in young female professional athletes and showed that elite athletes have an increased risk of eating disorders compared with both non-elite athletes and non-athletes. Again, this was particularly prevalent in sports where bodyweight is crucial to performance.
And it affects young athletes, too. A 2013 study of first-year high-school athletes in Norway reported an increased incidence of eating disorders (7%) compared with a control group (2.3%) and a higher prevalence among girls than boys.
Female athletes more at risk than men
These trends have been replicated in several studies from around the world and reveal that professional female athletes are more susceptible to eating disorders than their male colleagues.
In the US, female runners have reported a higher level of body dissatisfaction and symptoms of eating disorders than male runners, according to a 2016 study of 400 runners. A high degree of body dissatisfaction was linked to an increased risk of eating disorders.
A study from the Netherlands also found a clear link between a negative body perception and eating disorders among top female athletes. Women with eating disorder symptoms reported feeling fatter than their female colleagues who did not suffer from an eating disorder, even though there were no real differences in either body weight or shape between the two groups.
Professional athletes more at risk than amateur athletes
An Australian study from 2002 investigated 263 elite athletes and compared them to 263 non-athletes matched on gender and age. They showed that the top athletes experienced a pressure to be slim and reported more eating disorder symptoms compared to non-athletes.
Again, this was especially true for women, where 15% of elite female athletes met the criteria for anorexia and bulimia, while another 16% showed signs of having an eating disorder. Among the non-athletes, the numbers were far lower. Only 1% of non-athletes met the criteria for anorexia or bulimia, and 5% showed signs of having an eating disorder.
None of the male non-athletes suffered from eating disorders, compared with 6% of elite male athletes
Body dissatisfaction driven by surroundings
So how can we explain some of these trends? We know that athletes often compare their own bodies to that of their competitor, and that this might be one of the triggering factors for body dissatisfaction. And research shows that female athletes judge their bodies more negatively when they compare themselves to their competitors rather than the general population. So body perception is not stable but depends on a person’s surroundings. For example, an at-risk athlete with 15% body fat surrounded by competitors with 10% body fat, could slip into bad eating habits and body dissatisfaction, even though 15% body fat is relatively low, especially for women.
At the same time, low self-esteem, high body ideals, performance anxiety, and pressure of meeting expectations of trainers and friends, are all clearly linked to restrictive and disordered eating. But despite the wealth of research to document the phenomenon of eating disorders among elite athletes, we still lack initiatives to prevent and reduce the problem.
One exception is Norway where athletes representing Norway now have to have health certificates. If the athlete is deemed to be in a nutrition deficit condition or have an eating disorder, they do not get the certificate and get restrictions on their training. Whether the Norwegian approach is the right one to reduce incidences of eating disorders, especially among female elite athletes, is yet to be determined.
Estrogen may reduce disordered eating in female athletes with irregular periods Provided by The Conversation
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