Eating problems in athletes: light at the end of the tunnel

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.