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Eating problems in athletes: light at the end of the tunnel
The issue of eating disorders among athletes, especially younger sportswomen, is nothing new. But as Andrew Hamilton explains, more recent research points to improved treatment and prevention strategies...
There’s no universally accepted definition of what constitutes ‘disordered eating’ in athletes, not least because there are several types of disordered eating behaviour, each with its own characteristics (see box 1). What can be said however is that an eating disorder (ED) is characterised by an abnormal attitude towards food, which causes an athlete to change their eating habits and behaviour. In most cases, athletes with disordered eating tend to focus excessively on their weight and shape, leading them to make unhealthy choices about food, with damaging results to their long-term health and performance.
Box 1: Types of eating disorders
There are many types of clinically defined eating disorder but some of the most common found in athletes are described below:
Anorexia athletica - Although not recognised formally by the standard mental health diagnostic manuals(2), the term anorexia athletica is commonly used in mental health literature to denote a disorder characterised by excessive, obsessive exercise. Anorexia athletica is most commonly found in pre-professional and elite athletes, although it can exist in the general population as well. People suffering from anorexia athletica frequently engage in both excessive workouts/training as well as calorie restriction, increasing the risk of malnutrition. Symptoms of anorexia athletica may include over-exercising, obsession with calories, fat, and weight, especially as compared to elite athletes, a self-worth being determined by physical performance, and a lack of pleasure from exercising. Advanced cases of anorexia athletica may result in physical, psychological, and social consequences as sufferers deny that their excessive exercising patterns are a problem.
Bulimia nervosa is involves cyclical bingeing and purging episodes and is characterised by a psychological craving for food, which results in uncontrollable eating (bingeing) often followed by ‘purging’ (eg vomiting, excessive use of laxatives, diuretics and diet pills etc.). Bingeing is defined as the consumption of more food than most other people would eat in a similar circumstance over a discrete period of time accompanied by a sense of lack of control over the food consumption. Bulimia nervosa exists when bingeing and compensatory behaviours occur on average two or more times weekly for a period of at least three months. The eating behaviour is frequently in order to numb feelings and/or to provide comfort – but usually results increased feelings of guilt, shame, withdrawal and self-deprecation.
Orthorexia Nervosa (also known as "orthoexia") is not a traditionally recognised type of eating disorder but it does share some characteristics with both anorexia nervosa and bulimia, most specifically obsession with food. Orthorexia refers to a fixation on eating only ‘pure’ or ‘right’ or ‘proper’ foods. In this respect, there are parallels with workaholism or exercise addiction in that something that is normally considered good or healthy is done in excess and to the point that a person becomes obsessed with the activity. Like other obsessive disorders, orthorexia nervosa sufferers experience cyclical extremes, changes in mood, and isolate themselves. Most of their life is spent planning and preparing meals and resisting temptation to the exclusion of other activities. They may even go to the extreme of avoiding certain people who do not share in their dietary beliefs or carry their own supply of food wherever they go. The result of this can be social isolation and physical deterioration.
How common are eating disorders?
Despite the increased awareness among athletes and coaches about the issue of eating disorders, and the increased body of research into this topic, it remains an intractable problem in male and (particularly) female athletes, and across a wide range of participation levels. For example, a Norwegian study looked at over 1600 male and female elite athletes and compared the incidence of an ED with that in the general population(1). It found that many more athletes (13.5%) than controls (4.6%) had subclinical or clinical EDs. The prevalence of EDs among male athletes was four times higher in sports involving work against gravity (where low weight is an advantage) than in ball games (22% vs. 5%).
Meanwhile, the rate of ED among male endurance athletes was 9%. The prevalence of EDs among female athletes competing in aesthetic sports (high visibility sports such as swimming, gymnastics etc) was as much as 42% - higher than that observed in endurance sports (24%), technical sports (17%), and ball game sports (16%). The authors summed up their findings thus: “The prevalence of EDs is higher in athletes than in controls, higher in female athletes than in male athletes, and more common among those competing in leanness-dependent and weight-dependent sports than in other sports.”
Other studies into the problem of eating disorders have produced similar findings – ie that athletes participating in sports where ‘leaness’ is advantage or in aesthetic sports such as gymnastics are particularly at risk, especially female athletes. Moreover, this issue is one that is found across a wide range of sports and in many different nationalities and cultures; for example, studies report a high prevalence of eating disorders in French judo athletes(3)., Brazilian swimmers(4), US runners and high school athletes(5,6) – the list goes on. Common to many studies in this area is the incidence of the ‘female triad’ among female athletes, and this condition has been the subject of much research.
The female triad
According to the 2007 American College of Sports Medicine position stand, the female athlete triad is defined as the interrelatedness of energy availability, menstrual function, and bone mineral density (BMD)(7). Energy availability is defined as dietary energy intake minus the energy required for exercise – ie the amount of dietary energy remaining for other body functions after exercise training.
Energy availability can be affected by disordered eating behaviours such as those described in box 1. Abnormal menstrual function may manifest as oligomenorrhea or amenorrhea while changes in bone mineral density may present as stress fractures, osteopenia, or osteoporosis. Compared to the general female population, studies have found a higher prevalence of abnormal menstrual function in the female athletic population(8-10).
In particular, menstrual irregularity is worrying because of its negative impact on bone mineral density. Irregular menstruation during adolescence has been associated with decreased bone mineral density(11), and it is known that approximately 50% of peak bone mass is accrued during adolescence, which is a critical time to attain maximal bone mass(12). There’s also emerging evidence that menstrual irregularity in athletes is associated with an increased risk of musculoskeletal injury – see box 2(13).
Box 2: The link between menstrual irregularity and increased injury risk
There’s robust evidence of a link between menstrual irregularity and increased musculoskeletal injury(14). But why should this be the case? One theory is that low energy availability causes alterations in cellular maintenance, growth, and thermoregulation. Therefore, just as a female with low energy availability may not have enough energy availability to support normal menstruation, she may also not have enough calories to support the growth and repair of injured tissues. In addition, levels of leptin, a modulator of hormones such as growth hormone, cortisol, and thyroid-stimulating hormone, are known to be low in undernourished states and may ultimately affect tissue growth and repair(15).
Approaches to overcome eating disorders in athletes
Over the past two decades, a very large body of evidence has accumulated demonstrating the widespread incidence of EDs among athletes, and the negative consequences of disordered eating behaviours. The obvious question for athletes and coaches therefore is what support and treatment approaches might be best to help overcome disordered eating behaviour - or even better, prevent it occurring in the first place?
Many of the early ED prevention programs typically consisted of psychological/educational interventions; unfortunately however, while this type of intervention has proved effective at increasing knowledge about the problem, it appears to be substantially less effective at actually changing eating behaviours(16,17). In more recent years, ED prevention programs have improved and one program with good empirical support is ‘cognitive dissonance-based prevention’ (abbreviated DBP – see box 3). In DBP, participants speak and act against the thin-ideal standard of female beauty through a series of interactive activities with the aim of creating cognitive dissonance and thus the motivation to change their eating behaviour.
Box 3: What is cognitive dissonance?
Cognitive dissonance is one of the most influential and extensively studied theories in social psychology. It basically proposes that when people hold two or more conflicting cognitions (ideas, beliefs, values or emotional reactions), they feel emotional discomfort or ‘dissonance’. This dissonance can give rise to feelings of frustration, hunger, dread, guilt, anger, embarrassment, anxiety etc.
The theory of cognitive dissonance proposes that most individuals try to reduce dissonance by altering existing their cognitions, adding new ones to create a consistent belief system, or alternatively by reducing the importance of any one of the dissonant elements. This drive arises from the desire to reduce the mental discomfort that tends to arise when people find themselves doing things that don’t fit with what they know, or having opinions that do not fit with other opinions they hold. This of course assumes that most people want their expectations to meet reality, thereby creating a sense of equilibrium. Likewise, another assumption is that a person will avoid situations or information sources that give rise to feelings of uneasiness, or dissonance.
The use of DBP to help address eating disorders has been backed by the American Psychological Association and studies on the use of DBP to help EDs have proved positive; the benefits gained from a DPB approach appear to be long lasting, with reductions in ED risk factors being maintained through 2 and 3-year follow-up periods, and DBP has also been shown to reduce the onset of EDs by 60%(18).
Another approach that has had some success in combating EDs is ‘Healthy Weight Prevention Intervention (HWPI). In HWPI, participants are encouraged to make small lifestyle changes to their eating and exercise habits in order to help maintain a healthy weight. Like DBP, HWPI has produced reductions in ED risk factors (eg thin-ideal internalisation, body dissatisfaction and bulimic pathology) – reductions that appeared to persist through a long-term follow-up period of three years(19,20).
The problem with athletes
Despite the positive findings when using DBP and HWPI approaches to combat EDs, the problem is that neither has been properly tested on athletes – a population that may be particularly resistant to making changes in eating behaviour. This is partly because (despite evidence to the contrary) many coaches and athletes firmly believe that weight or body fat reduction always enhances performance, which can make interventions such as DBP difficult if not impossible.
Also, the culture of sport can give rise to the belief that serious competition demands ‘personal sacrifice’, even if that leads to serious physical harm. Therefore, the adverse health effects of EDs may be seen as just another ‘acceptable cost’ in the pursuit of athletic excellence. In addition, the norms in an athletic community may inadvertently legitimise or encourage an ED by reinforcing unhealthy eating and/or exercise behaviours (eg low weight may go unnoticed, or even be lauded in a sport environment that reinforces low weight or thin shape such as in distance running). Add to this the fact that certain personality traits common among ‘good’ athletes may also be common in those with EDs(21) and it’s easy to see why athletes present a particular challenge.
Practical intervention: athlete modified ED prevention programs
In order to try and overcome these problems, sports psychologists have investigated practical ‘athlete-modified’ eating disorder prevention programs – specifically modified versions of the successful (in non-athletes) DBP and HWPI programs. In a very carefully constructed and comprehensive study carried at the University of San Antonio, Texas, researchers looked at the effects of both of these modified programs on 167 female athletes(22). As well as completing three peer-led counselling sessions, the participants were asked to fill out surveys at four different times (pre-intervention, post-intervention, 6-week follow-up and 1-year follow-up). In order to reduce coercion, coaches were not present when athletes completed questionnaires (or at any point during the actual program).
· Athlete-modified DBP program - This intervention was based on the DBP manual but with additions including information on the female athlete triad as well as a discussion of the body image pressures placed on athletes in their specific sport. For instance, athletes defined not only the traditional thin-ideal standard of female beauty but also the sport-specific thin-ideal (ie what a sport tends to view as the ideal body type). The modified intervention also attempted to tailor the language to athletics. For example, the healthy-ideal was changed to the ‘athlete-specific healthy-ideal’ - defined as what an athlete’s body looks like when she is doing everything possible to simultaneously maximise physical health, mental health, quality of life and sport performance. Role plays also were modified to be sport focused (for detailed info on the three sessions, see box 4).
· Athlete-modified HWPI program - This intervention was based on the HWI manual, but with additions – eg information on the female athlete triad as well as a discussion of the sport-specific thin-ideal and the athlete-specific healthy-ideal. The language was also changed to recognise that athletes do not always need to increase their activity level and that at times, athletes benefit from a reduction in training, particularly those athletes who are training extensively above and beyond that recommended by their coaches. The intervention also asked athletes to consider differences in their behaviour in and out of season. A further modification was to make the intervention more appropriate for peer leadership (eg providing dialogue so that peer leaders led participants through a self-review of food logs rather than having peer leaders review logs). There was also an additional focus on increasing nutritional density (ie eating foods that provide a high degree of nutrients relative to calories), reducing the consumption of highly processed foods, and managing sleep, in order to make it easier for participants to understand that the goal was health – NOT pursuit of a thin-ideal. Finally, there were also questions asking athletes to consider what other things they could do besides weight loss to improve performance (see box 5).
Box 4: Summary of peer-led sessions in modified DBP intervention
• Session 1: Participants defined both the sport-specific and traditional thin ideals and contrasted them with the athlete-specific healthy-ideal, examined the ways in which the traditional thin-ideal may influence the sport-specific thin-ideal, explored the costs of pursuing both thin-ideals (via writing and discussion), and were asked to complete a homework assignment. This consisted of a mirror exercise in which participants were instructed to write down positive qualities about themselves (both physical and emotional) while standing in front of a mirror with as little clothing as they felt comfortable wearing.
• Session 2: Participants discussed the female athlete triad, listed ways to avoid the triad, participated in role plays which included speaking against the sport-specific thin-ideal, and were given a homework assignment, consisting of writing a letter to a hypothetical teammate who they felt might be at risk for or struggling with an ED or body image.
• Session 3: Participants created verbal challenges for times when they felt pressure to pursue either thin-ideal (participants typically focused on the sport-specific thin-ideal) and listed the top ten ways to resist the sport-specific thin-ideal. The homework assignment consisted of a self-affirmation exercise in which participants could choose from such things as: making a pact with a friend to end negative body talk or practicing accepting compliments.
Box 5: Summary of peer-led sessions in modified HWPI intervention
• Session 1: As in DBP, participants defined the traditional thin-ideal, sport-specific thin ideal, and athlete-specific healthy-ideal, contrasted the athlete-specific healthy-ideal with both thin-ideals so that all participants could agree with regards to definitions. In contrast to the modified DBP approach however, the participants then discussed benefits of pursuing the athlete-specific healthy-ideal, discussed energy intake/output balance and discussed the female athlete triad. The homework assignment consisted of filling out a food and exercise log for three days (two week days and one weekend day) and filling out a ‘healthy changes goal setting’ worksheet in which they wrote down specific goals pertaining to eating, exercising and sleep behaviours.
• Session 2: Participants contrasted healthy and unhealthy dietary restriction, discussed society’s effect on food choices, discussed ways to make participants’ diets healthier, discussed benefits of exercise/physical activity, discussed the importance of sleep, and were asked to repeat the eating and exercise/sleep goal setting activity from last week for homework (participants were expected to choose new goals).
• Session 3: In this session, participants created a list of top ten reasons to pursue the athlete specific healthy-ideal, discussed barriers to pursuing the healthy-ideal and ways to overcome those barriers, and discussed ways to promote the athlete-specific healthy-ideal as a team and/or as an athletics department.
Excellent results
The results from these interventions were extremely encouraging. In the 157 athletes who completed the programs, it was apparent that after six weeks, both interventions had reduced the desire to pursue the thin-ideal, dietary restraint, bulimic pathology, shape and weight concern, and the negative feelings associated with EDs. Moreover, one year on, both interventions had continued to reduce the incidence of bulimic pathology, body shape concern, and negative feelings.
In general, the more team-oriented sports (eg basketball, volleyball, football etc) appeared to do slightly better with modified DBP than the more individual sports (eg distance running), possibly because of personality characteristics that help to draw particular people to different sports. However, the researchers also noted that peer-leaders, athletes, and coaches expressed a strong a preference for the modified WPI intervention. Not only did it seem to be more appropriate for athletes, the participants reported preferring a nutrition-oriented intervention because it intuitively made sense to them that this could help performance and health, as opposed to one that appeared to be more body image focused.
One unexpected result was the fact that during the study, seven athletes came forward to the head athletic trainer concerned that they might have the female athlete triad – notable because this had never previously happened during the entire course of the head athletic trainer’s extended career. Moreover, none of these students were flagged on their beginning of the year medical screening questionnaire; all reported menstruating regularly. When asked about the inconsistency, some reported not remembering why they had answered the way they did on the questionnaire even though their menstrual disorders had been present for some time. Others, however, reported that they didn’t think the question was important and wanted to just say what they thought sports medicine staff wanted to hear!
Take home message
Eating disorders in athletes span a wide variety of undesirable behaviours and recent research shows that they are still all too common, especially among female athletes practicing aesthetic sports or those performed ‘against gravity’ (distance running, jumping etc). The good news is that over the past few years, approaches to combat eating disorders using athlete-modified versions of DBP and HWPI have been developed. Not only are these approaches easy to implement, they also appear to produce excellent results. And while these interventions were initially tested on female athletes, there’s good evidence that that are equally effective for male athletes also(23).
When coaches encounter athletes who they suspect might be at risk of an eating disorder, it is important not to ignore them. How can coaches be sure to spot the signs and symptoms, and how can they go about addressing the issue with tact and sensitivity? The Australian National Eating Disorders Collaboration (www.nedc.com.au) has a downloadable PDF document titled “Eating Disorders in Sport and Fitness: Prevention, Early Identification and Response”, which provides excellent guidance on this topic. It is a good starting point and can be accessed here. In the longer term, the athlete-modified HWPI intervention is recommended as a way of helping athletes who struggle with their eating. Coaches and their athletes seeking advice and support are strongly encouraged to find a sports psychologist who is familiar and experienced with this approach.
References
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2. American Psychiatric Association: “Diagnostic and Statistical Manual of Mental Disorders” (DSM-IV-TR), 4th Edition, June 2000
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6. Phys Ther Sport. 2011 Aug;12(3):108-16
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8. Int J Sport Nutr Exerc Metab. 2002;12(3):281-293
9. Clin J Sport Med. 2009;19(5):421-428
I0. Acta Obstet Gynecol Scand. 2007;86(1):65-72
11. Bone. 2007;41(3):371-377
12. Arch Pediatr Adolesc Med. 2006; 160(1 0): 1026-1 032.
13. J Athl Train 2012:47(1):74-82
14. Clin J Sport Med. 2000; 10(2): 110-116
15. Am J Physiol Endocrinol Metab. 2005;289(3):E373-E381
16. Psychological Bulletin. 2004; 130:206–227
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18. Prevention Science. 2008; 9:114–128
19. J Consulting Clin Psychology. 2008; 76:329–340
20. Body Image. 2010; 7:280–288.
21. J Treatment & Prevention. 1999; 7:181–190
22. Body Image. 2012 January ; 9(1): 31–42
23. Body Image 2017. 23, 93-102
Andrew Hamilton
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