Eating disorders in female athletes: why anorexia athletica is a concern

If you're an athlete aiming to optimise performance in your sport, you can obviously reap benefits from paying attention to what you eat. However, for some people this interest develops into an unhealthy obsession with food, calories and body weight. They worry continuously about what they are going to eat, when and where they're going to eat, how much weight they'll put on if they go out for a meal with friends, how many hours they'll have to exercise to burn off those calories, how they can avoid eating 'banned' foods, and so on. Such an obsession with food and body weight is termed an eating disorder. Eating disorders appear to be on the increase in the population as a whole. For example, the number of people seeking treatment for anorexia and bulimia in one London hospital has increased by 360 per cent over nine years. Experts have argued that one factor is a fashion ideal of the perfect body which has become progressively thinner over the last 40 years. Such media-based pressure used to apply predominantly to women, but in recent years use of the male 'body beautiful' in advertising has increased, leading to growing concern among men about whether their body conforms to the ideal. Increased awareness and diagnosis may have also made an impact on the statistics.

Research has identified a number of other factors thought to contribute to the development of eating disorders. Studies of twins indicate that genetic factors may play a part. Biological factors such as imbalances in neurotransmitters in the brain may be involved. Various psychological factors have also been proposed. Here, the eating disorder is seen as a reaction to one or more of the following: being brought up in a family which has difficulty in resolving conflict and expressing emotions, actual or feared sexual abuse, difficulty in coping with stress, low self-esteem (leading to a need to bolster self-esteem by external approval). Overly simplistic diagnoses of causes should be avoided, however, as individuals will vary with respect to the primary causes.

Increased risk of eating disorders for athletes
Studies have shown that athletes are far more prone to developing eating disorders than non-athletes. In addition to all the factors outlined above, athletes face additional pressures related to performance and, for some, aesthetic demands. For some athletes, such as distance runners, sprinters and swimmers, low body weight is thought to confer a competitive advantage. On the other hand, competitors in sports where a subjective judging element is involved, such as gymnastics, diving, skating and dancing may feel that their body size will influence their score. And certain sports where weight categories are involved, such as wrestling and rowing, can lead to cycles of weight gain followed by sudden weight loss.

Athletes, too, often have heightened body awareness, making them more prone to body image concerns. Finally, perfectionism, compulsiveness and high achievement expectations are personality traits thought to be advantageous for the competitive athlete; however these very traits are commonly associated with the development of an eating disorder.

Thus, as might be expected, the highest prevalence of eating disorders is in female athletes competing in sports where leanness and/or a specific weight are considered important for either performance or appearance. Males also suffer from eating disorders, but at a lesser rate - the estimated proportion is one male for every 10 females.

Anorexia, bulimia and subclinical disorders
The eating disorders, anorexia nervosa and bulimia nervosa, are recognised as types of psychiatric illness, and are clinically defined by a set of diagnostic criteria (see boxes). These go beyond a concern with weight and body image, and also include serious psychological problems. A number of studies have identified a significant proportion of athletes who suffer from one of these disorders. Others, however, will exhibit less severe, or 'subclinical', forms of eating disorders that meet some but not all of the diagnostic criteria. Some experts have proposed that eating disorders are best conceptualised as a spectrum - for example, Fries (Monograph, Acta Psychiatr. Scand Vol 248(suppl)) has proposed a continuum hypothesis of eating/dieting behaviour which suggests that dieting may lead to disordered eating behaviours, which in tum may lead to anorexia nervosa or bulimia.

The concept of subclinical anorexia was first examined by researchers in the 1970s. It was later identified in adolescents exhibiting a pattern of growth failure and/or delayed puberty, due to self-imposed calorie restriction arising from a fear of becoming obese.

Using case study information, another researcher adapted the concept of subclinical anorexia to athletes. The 'subclinical anorexic' was described as a young male athlete strongly committed to his sport, who underwent extreme weight loss as a means of improving his chances of success. Eventually, the dieting and maintenance of an unrealistically low body fat were no longer the means to an end (ie, athletic success), but became the end in itself (Smith, 'Excessive weight loss and food aversion in athletes simulating anorexia nervosa', Pediatrics Vol 66(1), ppl39-142). More recently, a Norwegian nutritionist has proposed a set of distinguishing features of a form of subclinical anorexia she refers to as 'anorexia athletica' (Sundgot-Borgen, 'Prevalence of eating disorders in elite female athletes', Int J Sport Nut Vol3 pp29-40) .

Attempts to define anorexia athletica
Sundgot-Borgen defines anorexia athletica in terms of absolute criteria (which must be present) and relative criteria (may be present). These are: Criteria that must be met:

Weight loss, gastrointestinal complaints, absence of medical illness or affective disorder explaining the weight reduction, excessive fear of becoming obese, restriction of calorie intake One or more of the following:

Delayed puberty, menstrual dysfunction, disturbance in body image, use of purging methods, binge eating, compulsive exercising.

Researchers from Arizona State University have claimed that these criteria are somewhat ill-defined and indiscriminate (Beals and Manore, Int J Sport Nut, Vol 4, ppl75-195). They suggest that more research is needed to further delineate and define the unique characteristics of those with subclinical eating disorders such as anorexia athletica. They make their own suggested list of absolute and relative diagnostic criteria, with the caveat that the number of criteria needing to be met remains to be determined. Their list is summarised as follows: Absolute criteria:

1 Preoccupation with food, calories and body shape
2 Distorted body image
3 Intense fear of gaining weight or becoming fat even though moderately or extremely underweight
4 Over at least a one-year period, the athlete maintains a body weight below 'normal' (5-15%) for age and height, using one or a combination of the following: a) restricting energy intake b) severely limiting food choices or food groups c) excessive exercise (ie, more than necessary for success in sport or as compared to athletes of similar fitness levels).
5 Absence of medical illness or affective disorder explaining the weight loss or maintenance of low body weight Relative criteria:
6 Gastrointestinal complaints.

7 Menstrual dysfunction.
8 Frequent use of purging methods (self-induced vomiting, or use of laxatives or diuretics for at least one month)
9 Bingeing (at least eight episodes a month for at least 3 months).

Causes?

There has been considerable speculation about why athletes are at such increased risk for eating disorders (clinical and subclinical). It' s hard to pin down which comes first - is it a predisposing personality or life circumstances which lead both to athletic participation and an eating disorder, or does participation in certain sports cause the onset of the eating disorder? It seems likely that there will be some interaction.

A comprehensive study of elite female athletes undertaken in Norway sought to identify risk factors for eating disorders, along with trigger factors responsible for precipitating their onset or exacerbation (Sundgot-Borgen, 'Risk and trigger factors for the development of eating disorders in female elite athletes', Medicine and Science in Sport and Exercise, Sept 1993 pp414-419). An initial screening questionnaire was sent to all elite female athletes in Norway (defined as one who qualified for the national team at junior or senior levels, or was a member of a recruiting squad for these teams, aged between 12 and 35). The 522 athletes responding represented six groups of sports: technical, endurance, aesthetic, weight dependent, ball games, and power sports. The Eating Disorder Inventory was used to classify individuals at risk for eating disorders (Manual of Eating Disorder Inventory, Odessa, FL: Psychological Assessments Resources, Inc, 1984).117 (22.4 per cent) were thereby defined as at risk, and 103 of these agreed to being given a clinical interview to diagnose eating disorders. A comparison group was also interviewed, consisting of 30 athletes chosen at random from a pool not at risk (ie, they were found to have low scores on the initial Eating Disorders screening questionnaire). These controlsubjects were matched to the at-risk subjects for age, community of residence, and sport.

Ninety-two of the at-risk athletes met criteria for anorexia nervosa, bulimia nervosa, or anorexia athletica. All of these athletes were asked if they had any suggestions as to why they had developed an eating disorder. 85 per cent of these gave reasons. Information collected during the interviews was then combined with the specific reasons given by the athletes to define possible trigger factors associated with the development of eating disorders.

The results showed that athletes competing in the aesthetic and endurance sports were leaner and had a significantly higher training volume than athletes competing in the other sports. The prevalence of eating disorders was significantly higher among athletes in aesthetic and weight dependent sports than in the other sport groups.

Risk factors for eating disorders in athletes
Several risk factors were identified. Dieting at an early age appeared to be associated with the onset of an eating disorder. A significant number of athletes who began dieting to improve performance reported that their coach recommended they lose weight. For young and impressionable athletes, such a recommendation may be perceived as a requirement for improved performance. Other researchers have reported a similar syndrome - for example, finding that 75 per cent of female gymnasts who were told by coaches that they were too heavy used unhealthy weight control measures.

The results of the Norwegian study also suggested that the risk for eating disorders is increased if dieting is unsupervised. Athletes with eating disorders may not seek supervision for fear their disorder will be discovered. In addition, many athletes have little knowledge about proper weight loss methods and receive their information in haphazard ways, from friends, magazine crash diets, and so on.. Such diets are unlikely to account for the high energy requirements resulting from training, or the fact that maturing females have special nutritional requirements. Unsuitable crash diets may appeal to athletes if they feel that rapid weight loss is necessary to make the team or to remain competitive. Finally, the restrictive diets and fluctuations in body weight that accompany these efforts may also increase risk for eating disorders.

Early start of sport-specific training was also associated with disordered eating. A higher percentage of athletic controls than of eating-disorder athletes participated in other sports before choosing their preferred sport. An individual' s natural body type usually steers the athlete to specific sports, and body type dictates in part whether the athlete will be successful. Beginning training for a specific sport before the body matures might have hindered these athletes from choosing a suitable sport for their adult body type. This could Provoke a conflict in which the athlete struggles to prevent or counter the natural physical changes precipitated by growth and maturity.

Extreme exercise in itself has previously been cited as a potential causal factor in anorexia nervosa. In the Norwegian study, many of the athletes who did not give specific reasons for the onset of their eating disorder reported a large increase in training volume and a significant weight-loss associated with the increased activity. Athletes who increase their training volume may experience relative calorie deprivation, possibly because of not realising that they need to eat more to meet the increased energy demand, or perhaps due to reduced appetite produced by changes in endorphins. This calorie deprivation may create a biological or psychological climate in which eating disorders are more likely to develop. It has been observed previously that starvation itself can bring about symptoms of eating disorders - eg, obsession with food and hyperactivity('The psychology of eating and drinking', AW Logue, pub Freeman, NY, 1986,pl56) Finally, the loss of a coach occurred in some athletes with eating disorders. These athletes described their coaches as vital to their athletic careers. Other athletes reported that they developed eating disorders at the time of injury or illness, which left them unable to train at high levels. Thus, the loss of a coach, injury, or illness must be seen as traumatic events that become trigger events for the onset of eating disorders.

Prevention
Prevention is the key to addressing the problem of disordered eating, and education is a necessary first step. Athletes, parents, coaches, athletic administrators, training staff and doctors need to be educated about the risks (as detailed above) and warning signals of disordered eating. Mimi Johnson, in 'Disordered Eating in Active and Athletic Women' (Clinics in Sportsmedicine Vol 13, no.2, p532-537, April 1994) identifies the following checklist of warning signs:
1. A preoccupation with food, calories and weight

2. Repeated expressed concerns about being or feeling fat, even when weight is average, or below average
3. Increasing criticism of one's body

4. Secretly eating, or stealing food
5. Eating large meals, then disappearing, or making trips to the bathroom
6. Consumption of large amounts of food not consistent with the athlete' s weight
7. Bloodshot eyes, especially after trips to the bathroom
8. Swollen parotid glands at the angle of the jaw, giving a chipmunk-like appearance
9. Vomiting, or odour of vomiting in the bathroom

10. Wide fluctuations in weight over short periods

11.Periods of severe calorie restriction

12.Excessive laxative use
13.Compulsive, excessive exercise that is not part of the athlete' s training regimen
14. Unwillingness to eat in front of others (eg, teammates on road trips)
15. Expression of self-deprecating thoughts following eating
16. Wearing layered or baggy clothing 17. Mood swings
18. Appearing preoccupied with the eating behaviour of others

19. Continuous drinking of diet soda or water
If you are concerned that someone you know may be suffering from an eating disorder, you need to go softly in approaching them about it. People who are truly anorexic or bulimic will often deny the problem, insisting that there' s nothing wrong. Share your concerns about physical symptoms such as light-headedness, chronic fatigue or lack of concentration. These health changes are more likely to be stepping stones for accepting help. Don't discuss weight or eating habits directly. Avoid mentioning starving/bingeing as the issue, and focus on life concerns. Offer a list of sources of professional help. Although the athlete may deny the problem to your face, they may secretly be desperate for help.

Getting help
Ask your GP about eating disorder clinics at hospitals in your area. Both medical and psychological help may be required, and therapy may need to involve the whole family. Other potential resources are:

1 The Eating Disorders Association, Sackville Place, 44 Magdalen Street, Norwich, Norfolk NR3 lJE. Telephone (0603) 621414. An umbrella organisation which coordinates a network of local groups (many run by people who have suffered anorexia or bulimia) and provides information, telephone help and a newsletter. Send an sae for details of local groups.

2 Overeaters Anonymous, PO Box 19, Stratford, Manchester M32 9EB. A self-help organisation for men and women with eating disorders that uses a '12 steps' recovery programme modelled on that of Alcoholics Anonymous. They can put you in touch with the nearest of more than 100 groups nationwide.
Janet Pidcock