Eating Disorders

An athlete aiming to optimise performance in their sport can obviously reap benefits from paying attention to what they eat. However, for some athletes this interest develops into an unhealthy obsession with food, calories and body weight. Such an obsession with food and body weight is termed an eating disorder.

Increased risk of eating disorders for athletes

Sundgot Borgen et al. (2004)^[4] studies have shown that athletes are far more prone to developing eating disorders than non-athletes. For some athletes, such as distance runners, sprinters and swimmers, low body weight is thought to provide 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. In addition, certain sports where weight categories are involved, such as wrestling and rowing, can lead to cycles of weight gain followed by sudden weight loss.

The personality traits of perfectionism, compulsiveness and high achievement expectations are considered advantageous for the competitive athlete are also the traits commonly associated with the development of an eating disorder.

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 - estimated at one male for every 10 females.

Anorexia nervosa and Bulimia nervosa

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. These go beyond a concern with weight and body image, and 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 "sub type", forms of eating disorders that meet some but not all of the diagnostic criteria.

Diagnostic criteria for bulimia nervosa

• Re-current episodes of binge eating. An episode of binge eating is characterised by both of the following:
  • Eating in a discrete period (e.g., within any two hour period) an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances, and
  • A sense of lack of control over eating during the episode (e.g. a feeling that one can not stop eating or control how much one is eating)
• Recurrent, inappropriate compensatory behaviour to prevent weight gain such as: self-induced vomiting, misuse of laxatives, diuretics or other medications, fasting, or excessive exercise
• The binge eating and inappropriate compensatory behaviours both occur, on average, at least twice a week for 3 months
• Self evaluation is unduly influenced by body shape and weight
• The disturbance does not occur exclusively during episodes of anorexia nervosa

Subtypes

• Purging type
  • The person regularly engages in self induced vomiting or the misuse of laxatives or diuretics
• Non purging types
  • The person uses other inappropriate compensatory behaviours, such as fasting or excessive exercise, but does not regularly engage in self induced vomiting or the misuse of laxatives or diuretics

Diagnostic criteria for anorexia nervosa

• Refusal to maintain body weight at or above a minimally normal weight for age and height e.g. weight loss leading to maintenance of body weight less than 85% of that expected, or failure to make expected weight gain during a period of growth, leading to body weight less than 85% of that expected
• Intense fear of gaining weight or becoming fat even when under weight
• Disturbance in the way one's body weight or shape is perceived, undue influence of body weight or shape on self evaluation or denial of the seriousness of the current low body weight
• In females who have been menstruation the absence of at least three consecutive menstrual cycles

Subtypes

• Restricting types
  • Do not regularly engage in binge eating or purging behaviour (self induced vomiting or the misuse of laxatives or diuretics)
• Binge eating and purging types
  • Regularly engage in binge eating or purging behaviour

Risk factors for eating disorders in athletes

A comprehensive study (Sundgot-Borgen 1993, 2004)^[2,4] 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. 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.

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% 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.

The results of the study 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 (smith n.d)^[3].

Early start of sport specific training was also associated with disordered eating. 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.

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.

Female Athlete Triad

Disordered eating decreases energy availability, reducing body mass and body fat to a point at which the menstrual cycle becomes irregular (oligomenorrhea) or actually ceases and can eventually lead to osteoporosis (calcium deficiency). Disordered eating, amenorrhea and osteoporosis is clinically labelled the "female athlete triad".

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 and warning signals of disordered eating. Johnson (1994)^[1] identifies the following checklist of warning signs:

• A preoccupation with food, calories and weight
• Repeated expressed concerns about being or feeling fat, even when weight is average, or below average
• Increasing criticism of one's body
• Secretly eating, or stealing food
• Eating large meals, then disappearing, or making trips to the bathroom
• Consumption of large amounts of food not consistent with the athlete's weight
• Bloodshot eyes, especially after trips to the bathroom
• Swollen parotid glands at the angle of the jaw, giving a chipmunk like appearance
• Vomiting, or odour of vomiting in the bathroom
• Wide fluctuations in weight over short periods
• Periods of severe calorie restriction
• Excessive laxative use
• Compulsive, excessive exercise that is not part of the athlete's training regimen
• Unwillingness to eat in front of others (e.g., team mates on road trips)
• Expression of self deprecating thoughts following eating
• Wearing layered or baggy clothing
• Mood swings
• Appearing preoccupied with the eating behaviour of others
• 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 is 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. Do not 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.

Referenced Material

1. JOHNSON, M. (1994), Disordered Eating in Active and Athletic Women. Sports Medicine, 13 (2), p. 357-369
2. SUNDGOT-BORGEN (1993) Risk and trigger factors for the development of eating disorders in female elite athletes. Medicine and Science in Sport and Exercise, Sept 1993, p. 414-419
3. SMITH (n.d) Excessive weight loss and food aversion in athletes simulating anorexia nervosa. Pediatrics, 66 (1), p. 139-142
4. SUNDGOT-BORGEN and TORSTVEIT, J. and KLUNGLAND, M. (2004) Prevalence of Eating disorders in elite athletes is higher than in the general population. Clinical Journal of Sport Medicine, 14 (1), p. 25-32
5. PIDCOCK, J (1995) Female athletes who are obsessed by food and body weight can develop anorexia athletica. Peak Performance, 52, p. 3-7

Article Reference

The information on this page is adapted from Pidcock (1995)^[5] with the kind permission of Electric Word plc, the publishers of Peak Performance and Sports Injury Bulletin.

Page Reference

The reference for this page is:

• MACKENZIE, B. (2002) Eating Disorders [WWW] Available from: http://www.brianmac.co.uk/anorexia.htm [Accessed

Associated Pages

The following Sports Coach pages should be read in conjunction with this page:

• Articles on Nutrition
• Eating Disorders
• Glycaemic Index
• Healthy Eating
• Nutrition
• Nutritional Tips
• Sports Drinks