Sports and Eating Disorders

Eating disorders are complex, destructive disorders that can impact people of all ages and demographics. When inadequately treated, eating disorders can be life-threatening, which is particularly concerning given their prevalence. The National Eating Disorders Association (NEDA) estimates that 20 million women and 10 million men in America meet criteria for an eating disorder at some point during their lives, with the 2 most common types being anorexia nervosa and bulimia nervosa.1

Anorexia nervosa (known more commonly as simply “anorexia”) refers to extreme restriction of food, overwhelming fear of gaining weight or becoming fat, and distorted body image (perceiving yourself as overweight or flawed in some way that objective reality does not support). Those with anorexia prize thinness and take severe measures—such as excessive exercise or restrictions in dieting—to achieve this goal.2

As a result of these behaviors, they may experience serious health problems, such as iron deficiency, dehydration, muscle wasting, bone thinning, brain damage, and damage to the heart.2 NEDA estimates that approximately 0.9% of women and 0.3% of men meet criteria for anorexia at some point in their lives.1

Bulimia nervosa (known more often as simply “bulimia”) refers to the act of binge eating (quickly consuming large quantities of food) along with compensatory behaviors, such as purging, abusing laxatives or diuretics, or engaging in excessive exercise and food restriction. People with bulimia also fear weight gain and have a distorted body image, though they are more likely to be of average weight.2

Bulimia is also associated with several significant health issues such as worn tooth enamel and decay (due to continuous vomiting), acid reflux, intestinal distress, severe dehydration, and electrolyte imbalance.2 More common than anorexia, bulimia affects about 1.5% of women and 0.5% of men at some point in their lives.1

While eating disorders affect all populations, some athletes are uniquely susceptible due to performance anxiety and pressures, high levels of competition, and sports that emphasize physical thinness and finesse. Athletes who compete in weight-sensitive sports appear to be most vulnerable to these messages, such as:3

  • Gravitational sports (wherein moving the body against gravity is a key determinant of performance potential): Cross-country/track running, cross-country skiing, cycling, and ski jumping.
  • Weight-class sports: Wrestling, judo, boxing, taekwondo, weightlifting, and lightweight rowing.
  • Aesthetically judged sports: Gymnastics, figure skating, diving, synchronized swimming, diving, and ballet.

Risk Factors

Research suggests that there are 3 key reasons why eating disorders are more common in sports where weight has a significant impact on the athlete’s performance:4

  • Athletes weighing more than an “optimal” weight risk performing less effectively.
  • Athletes weighing above an upper limit for weight-class sports risk being unable to compete in an event.
  • Athletes competing in aesthetically judged sports tend to receive tremendous focus and attention on their body composition and weight.

Although evidence suggests that a positive body image is correlated with physical activity, athletes in these types of sports often experience pressure to achieve and maintain unrealistic body weights and shapes—especially during the teen years when bodies tend to mature and change. They also receive constant messages from coaches and teammates that thinness can enhance and even maximize athletic performance.5

These issues appear to be incredibly pervasive within the athletic community. For example, research shows that athletes who report dieting out of the desire to be leaner so they can improve physical performance are more likely to develop eating disorders. Even more concerning, as many as 94% of elite athletes competing in weight-sensitive sports acknowledge using extreme diet, restriction, or weight-control measures to achieve or maintain target weight goals.3 This figure dramatically differs from weight-loss measures in team sports, in which eating disorders are seen in 5% of elite male athletes and 15% of elite female athletes.3

While athletes might initially seek dieting or weight loss to achieve better performance, such emphasis can lead people into destructive eating patterns. This is especially risky for female adolescent athletes. During puberty, it is common for the female body to mature and develop in ways that seem incongruent with the “preferred look” of the athlete’s sport. In these environments, as a woman’s body naturally changes, her self-worth and performance may be adversely affected, which can result in disordered eating habits.5

Similar to many other mental illnesses, there is no singular cause for the development of an eating disorder. Instead, research continues to evolve in demonstrating how multiple interactions with genetic, psychological, societal, and behavioral factors can impact a person’s vulnerability. These risk factors are most often associated with the development of anorexia and bulimia:6

  • Genetics: Research shows that eating disorders often run in families. If an athlete has a first-degree relative with an eating disorder, her chance of developing one increases.
  • Type 1 diabetes: Interestingly, 25% of women diagnosed with type 1 diabetes develop an eating disorder. Diabulimia refers to a pattern of skipping insulin injections, which can be fatal.
  • Perfectionism: Self-oriented perfectionism, which entails having abnormally high expectations for personal performance and success, is a major risk factor for eating disorder development. Because athletes often feel a pressure to “be the best” at their sport, it is likely that this risk factor is highly common among athletes with eating disorders.
  • Anxiety disorders: As many as 2/3 of people with anorexia also show comorbid signs of an anxiety disorder such as generalized anxiety or social phobia, or another mental health condition with a pronounced anxiety component (such as obsessive-compulsive disorder) before the onset of their eating disorder.
  • Rigidity and inflexibility: Many people with anorexia acknowledge rule-abiding tendencies, meaning they believe they must follow a very specific way of doing things without deviating. This same rigidity can also be seen in athletic training within elite performance levels.
  • Other notable risk factors: Additional factors include having a history of being teased or bullied for weight, body image dissatisfaction, identification as LGBTQ, or acculturation difficulties (due to Westernized ideals for thinness).

Assessment and Treatment

Due to the numerous health dangers and potentially lethal outcomes associated with eating disorders, early identification, intervention, and assessment is crucial. However, athletes’ eating disorders can be difficult to diagnose, since most do not self-identify with having these struggles.5

Frequently, physical examinations provide the initial screening opportunity for eating disorders. For athletes, these exams are usually a routine, mandatory practice meant to give clearance to safely compete. Thorough exams can explore topics relevant to nutrition, menstruation, bone mineral loss, and body image, and if it appears that the athlete is at risk for an eating disorder, the physician might provide a questionnaire about food attitudes and eating disorder behaviors. Common tests include the Eating Attitudes Test (EAT) and the Eating Disorders Inventory (EDI). To differentiate from the general population, specific tests for athletes include the Survey of Eating Disorders Among Athletes (SEDAA) and the Female Athletes Screening Tool (FAST).5

While eating disorders can be complex and sometimes devastating for athletes and their families, treatment options exist to help them at every point along the eating disorder severity spectrum.

Treatment Levels of Care

For the most severe eating disorders cases, inpatient medical stabilization is usually the first step. Life-threatening physical issues such as dehydration, heart arrhythmias, or severe malnourishment can be treated in this properly supervised environment.2 The goal of this level of treatment is medical stabilization.

Once a patient has stabilized, they are frequently referred to an inpatient treatment program where they can continue to receive around-the-clock medical supervision along with a series of psychological services, such as individual and family counseling, group counseling, and nutritional education.

Athletes with mild-to-moderate eating disorders may be referred to the following services:

  • Day treatment programs
  • Partial hospitalization programs
  • Outpatient care

These programs provide stabilization and support, but are less intensive and structured than inpatient care. People often continue to work or go to school and commute from home to these facilities for treatment. Medical professionals offer eating disorder treatment in a variety of settings, including hospitals, free-standing eating disorder clinics, and dual-diagnosis settings.

Psychotherapy

Athletes with eating disorders can benefit from group and individual therapy to help improve their self-esteem and to learn to cope with the difficult emotions and changes associated with recovery. While there are many theoretical orientations and styles of therapy, the following evidence-based practices have been effectively proven for eating disorder recovery:5

  • Cognitive behavioral therapy (CBT): This form of therapy helps eating disordered patients connect unhealthy thoughts to unpleasant emotions and negative behaviors, particularly around eating habits and body image. Clients focus on fears related to “getting fat” or “losing control” and may engage in activities like eating “unsafe” foods with a therapist or practicing positive affirmations about their appearance.
  • Maudsley approach: This type of family-based therapy focuses on creating a healthy and positive eating environment at home. Commonly used for anorexia treatment, this approach focuses on family members learning to engage in positive communication and move away from enabling the athlete’s eating disordered behaviors.

Medications

Research shows that psychotropic medications, such as antidepressants and mood stabilizers, may help alleviate symptoms of bulimia and binge-eating in some patients.5 Studies for medication options continue to evolve as eating disorder awareness increases.

Prevention

While eating disorders cannot be entirely avoided, research suggests that preventative measures can help susceptible athletes from middle school through college.

The American Academy of Pediatrics, the IOC Medical Commission, and the American College of Sports Medicine suggest these preventative policies for athletes:3

  • Provide thorough education about the risks of extreme dieting and how eating disorders develop. This way, athletes understand the dangers of restricting food and which risk factors may increase the likelihood of developing an eating disorder.
  • Focus on early identification and intervention of at-risk females (typically around 9 to 11 years old for elite athletes).
  • Require any nutritional assessment or intake changes to be monitored by a sports dietitian.

These organizations also suggest several macro-level changes including:3

  • Increasing the number of weight categories, particularly in female weight classes, of certain sports.
  • Increasing acceptance of some variation in weights to decrease the frequency of extreme weight-loss measures.
  • Designating a “competition certificate” where athletes agree to commit to minimum body weight, mass, fat, and hydration levels.

Because of the complex nature of eating disorders, many people—including coaches, doctors, therapists, and family members—can play a pivotal role in raising awareness and intervening for struggling athletes.

Additional resources are available through NEDA’s website, which connects you with informational sites and national and regional support groups.

Sources

  1. National Eating Disorders Association. (2016). What Are Eating Disorders?
  2. Substance Abuse and Mental Health Services Administration. (2017). Eating Disorders.
  3. Sundgot-Borgen, J., Meyer, N., Lohman, T., Ackland, T., Maughan, R., Stewart, A., et al. (2013). How to minimise the health risks to athletes who compete in weight-sensitive sports review and position statement on behalf of the Ad Hoc Research Working Group on Body Composition, Health and Performance, under the auspices of the IOC Medical Commission. British Journal of Sports Medicine, (47), 1012–1022.
  4. Currie, A. (2010). Sport and Eating Disorders—Understanding and Managing the Risks. Asian Journal of Sports Medicine, 1(2), 63–68.
  5. Coelho, G.M. de O., Gomes, A.I. da S., Ribeiro, B.G., Soares, E. de A. Prevention of eating disorders in female athletes. Open Access Journal of Sports Medicine, 5, 105­–113.
  6. National Eating Disorders Association. (2016). Risk Factors .
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