Eating disorders in athletes

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By Therese S. Waterhous PhD/LD, Owner of Willamette Nutrition Source, LLC.

Collegiate athletics offer a tremendous opportunity for individual skills building, team-building, and scholarship. At the same time, the college sports environment may promote and/or maintain unhealthy eating behaviors or disordered eating, with formally diagnosed eating disorders being on the far end of the spectrum.

Eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified (EDNOS), as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), as well as other variants of disordered eating. This article will focus mainly on the eating disorders defined in the DSM-V. The diagnostic criteria are provided in Appendix A.

Eating Disorder Myths

There are some common myths about disordered eating and eating disorders that athletic personnel need to be aware of. One is that a diagnosed eating disorder is a personal choice and therefore the affected person can easily give it up. This is false. Eating disorders are a distinct class of mental, genetic, and neurobiological illnesses that are triggered by environmental stressors, including weight loss or maintaining weight at a chronically low level. An eating disorder needs prompt and effective treatment.1

Another myth is that eating disorders are caused by dysfunctional families. Eating disorders often co-exist with other personality traits and mental conditions that run in families, such as perfectionism, anxiety, depression, and obsessive compulsive disorder. However, there is no evidence of a particular family style that gives rise to eating disorders. Furthermore, collegeaged athletes with diagnosed eating disorders may need the assistance of their families as they work toward wellness and recovery.

Disordered eating is a category of unhealthy eating habits that are not a formal DSM-V diagnosis, yet deserves attention these behaviors can lead to health consequences and impaired athletic performance.

Who is at Risk for an Eating Disorder?

Eating disorders develop from a genetic and neurobiological basis within an individual, and can be triggered by environmental stressors and abnormal eating. The pressures of elite sports may be a trigger for eating disorders, especially in sports where thinness is valued for performance or appearance.2 Pressure may be external, such as performance or competition demands, or a coach advising an athlete to maintain a given weight or lose weight. Pressure may also be selfinflicted, stemming from personality traits such as perfectionism, or relying on the opinions of others for one's identity. For example, time off due to injury can be felt as a tremendous failure

to the perfectionist athlete and may lead to food intake restriction in order to avoid weight gain. High dietary restraint, dieting, and weight loss are often preludes to development of eating disorders.

There is evidence for a connection between certain sports and disordered eating and eating disorder risk. Some clinicians think that certain types of personalities, which may also be connected to genetic predisposition to eating disorders, are drawn to competitive sports. For example, obsessive compulsive disorder (OCD) affects training, eating, and overall health. It may be very difficult for an athlete with OCD tendencies and exercise compulsions to maintain the proper training level.

It is also possible that people genetically predisposed to an eating disorder are drawn to sports where thinness is valued in order to "hide" while being active in their sport. Thinness is pursued in some sports because it is still widely believed that thinness is necessary for superior performance, in spite of evidence that this is not necessarily true.3 Sports are high-risk when they promote thinness to the point that body functions are compromised.

Certain sports offer a place to engage in what is called exercise purging behavior without the fear of being judged. Exercise purging or compulsive exercise is done not just for the love of the sport or training, but to burn calories and maintain leanness. High-endurance sports, for example, often draw in those who feel compulsive about exercise. One study found that almost 20 percent of female cross country runners had a previous or current clinical eating disorder.4

Eating-disordered behaviors are found in men as well as women. Thinness for performance in men is a risk factor for eating disorder development.5 Male light weight rowers and low weight wrestlers score high in dietary restraint and body dissatisfaction. Men in sports that require increased muscularity along with low body fat (football, basketball, baseball, and hockey) may resort to anabolic steroid use and develop "muscle dysmorphic disorder," whereby they never feel "big enough." Disordered eating, such as restrictive eating followed by binge eating, is common in this group.2

Role of Athletic Staff in Prevention of Eating Disorders

Coaches play a critical role in whether an athlete seeks help for or continues his or her disordered eating or eating disorder. They can create an environment that is either conducive to health, or promotes disordered eating and eating disorders. By discarding the "win at all costs" attitude and promoting sound health practices, athletic staff can create a healthy environment.

Trainers, coaches, medical staff, parents, and team members all need to be familiar with some of the basic outward signs that an eating disorder or disordered eating may be present in an athlete. These may include a change in attitude, noticeable anxiety, weight changes not followed by the team physician or RD, odd eating behaviors (such as not wanting to eat in front of others or seeming to eat very little or a lot of food with others), and frequent mention of being dissatisfied with one's body. Lightheadedness and fainting would be more serious signs that an eating disorder may be present. Screening for eating disorders using a simple technique, such as the SCOFF questionnaire6, is an important strategy for identifying athletes in need of further evaluation. Regular medical follow-up needs to occur to detect symptoms that might be suggestive of an eating disorder (e.g., low body temperature, low pulse, lack of menses, weight

loss, orthostasis, poor dentition, parotid swelling, electrolyte abnormalities).2 Team physicians can consult the Academy of Eating Disorders Clinical Guidelines at for quick reference to differential diagnostics, hospitalization criteria and symptoms of an eating disorders.

Having a Certified Specialist in Sports Dietetics (CSSD) RD available to counsel on proper fueling for their sport and appropriate weight management practices is protective. Healthy weights and weight maintenance should be promoted and dieting discouraged, unless for a documented health reason and followed by a team that includes both MD and RD.

Colleges need to have policies in place regarding whether to allow sick athletes to continue to participate in sports. For example, if a female athlete is not menstruating, this ought to be evaluated, hormone levels checked, and a determination made about overall health and the advisability for continued play.

The culture of sports that define aesthetically pleasing body types or what body type will perform best in the sport can promote disordered eating or eating disorders. One study found a reduction in eating disorder risk factors in female athletes when they were given a cognitive dissonance-based prevention program or a healthy weight intervention program, both of which aimed to reduce over evaluation of the thin ideal.7

Female athletes tend to have more body dissatisfaction when asked to perform in revealing attire8, therefore this is another place where work can be done to change the culture and create a more protective environment. Research has shown that a coaching style that is accepting and tolerant of various body types and that emphasizes a young athlete's health, work ethic, attitude, and team spirit is promoting a healthy environment that does not contribute to disordered eating or eating disorder pressures.

An online Tool Kit for Trainers and Coaches produced by the National Eating Disorder Association (NEDA) is available at .

Author Written by SCAN/CPSDA Registered Dietitians (RDs). For advice on customizing an eating plan to meet your nutrition goals, consult an RD who specializes in sports, particularly a Board Certified Specialist in Sports Dietetics (CSSD). Find a qualified RD at or .

References 1. Waterhous T, Jacob M. Practice paper of the American Dietetic Association: Nutrition intervention in the treatment of eating disorders. J Am Diet Assoc. 2011;111:1261. 2. Mehler P, Anderson A. Eating disorders: A guide to medical care and complications. Baltimore: The John's Hopkins University Press, 2010. 3. Powers P. Athletes and eating disorders: some ramifications of the NCAA study. Eating Disorders Review. 1999;10:1-3. 4. Thompson S. Characteristics of the female athlete triad in collegiate cross country runners. J Am Coll Health. 2007;56:129-36. 5. Filare E, Rouveix M, Pannafieux C, Ferrand C. eating attitudes, perfectionism and body esteem of elite male judoists and cyclists. J Sports Sci Med. 2007;6:50-7. 6. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: a new screening tool for eating disorders. West J Med. 2000;172:164-5. 7. Becker C, McDaniel L, Bull S, Powell M, McIntyre K. "Can we reduce eating disorder risk factors in female college athletes? A randomized exploratory investigations of two peer reviewed interventions." Body Image. 2012;9:31-42. 8. Torres-McGehee T, Monsma E, Dompier T, Washburn S. Eating disorder risk and the role of clothing in collegiate cheerleaders body images. J Athl Train. 2012;47:541-8.

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