An athlete aiming to optimise performance in their sport can 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) 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. Also, individual 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 essential for either performance or appearance. Males also suffer from eating disorders, but at a lesser rate - estimated at one male for every ten 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 severe psychological problems. Several studies have identified a significant proportion of athletes who suffer from one of these disorders. Others, however, will exhibit less severe, or "subtype", forms of eating disorders that meet some but not all of the diagnostic criteria.
Diagnostic criteria for bulimia nervosa
Diagnostic criteria for anorexia nervosa
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 sports groups.
The results of the study suggested that the risk of eating disorders is increased if dieting is unsupervised. Athletes with eating disorders may not seek supervision for fear their disorder will be discovered. Also, 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 needs. 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 the risk of eating disorders (Smith n.d).
Early start of sports-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 particular 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.
Disordered eating decreases energy availability, reducing body mass and body fat to a point at which the menstrual cycle becomes irregular (oligomenorrhea) or ceases and can eventually lead to osteoporosis (calcium deficiency). Disordered eating, amenorrhea and osteoporosis are clinically labelled the "female athlete triad".
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) identifies the following checklist of warning signs:
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 genuinely anorexic or bulimic will often deny the problem, insisting that there is nothing wrong. Share your concerns about physical symptoms such as lightheadedness, 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.
The Female Athlete Triad is an energy deficiency relative to the balance between dietary energy intake and energy expenditure. Still, this energy deficiency also affects many aspects of physiological function including metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular and psychological health. To address this, Mountjoy et al. (2014) introduced a more general term: Relative Energy Deficiency in Sport (RED-S). More detailed information on RED-S is provided in the following document: The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S).
Energy deficits may sometimes occur without an eating disorder or even without any dietary restriction. Most athletes with relative energy deficiency, however, have consciously reduced dietary energy intake without reducing their energy expenditure on exercise, or have increased energy expenditure on exercise without increasing their energy intake.
Some of the potential effects of RED-S on sports performance are depression, irritability, impaired judgement, increased injury risk, a decrease in concentration, coordination, training response, endurance performance, muscle strength, glycogen stores.
Joasia Zakrzewski, a GP and ultra-distance athlete explains in Athletics Weekly, her personal experience of RED-S and how she dealt with it.
The information on this page is adapted from Pidcock (1995) with the kind permission of Electric Word plc.
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