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Higher Prevalence of Eating Disorders among
Adolescent Elite Athletes than Controls
MARIANNE MARTINSEN
1
and JORUNN SUNDGOT-BORGEN
2
1
Oslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences,
Oslo, NORWAY; and
2
Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, NORWAY
ABSTRACT
MARTINSEN, M., and J. SUNDGOT-BORGEN. Higher Prevalence of Eating Disorders among Adolescent Elite Athletes than Con-
trols. Med. Sci. Sports Exerc., Vol. 45, No. 6, pp. 1188–1197, 2013. Purpose: The objective of this study is to examine the prevalence of
eating disorders (ED) among female and male adolescent elite athletes and nonathletic controls. Methods: This was a two-phase study,
including a self-report questionnaire (part I) followed by clinical interviews (part II). The total population of first-year students at 16
Norwegian Elite Sport High Schools (n= 677) and two randomly selected high schools (controls, n= 421) were invited to participate.
The questionnaire was completed by 611 (90%) athletes and 355 (84%) controls. The subjects reporting symptoms associated with ED
were classified as ‘‘at risk’’ for ED. In part II, all ‘‘at-risk’’ athletes (n= 153), a random sample of not ‘‘at risk’’ (n= 153), and a random
sample of 50% of the controls classified as ‘‘at risk’’ (n= 91) and not ‘‘at risk’’ (n= 88) were invited to the clinical interview to screen for
ED (i.e., meeting the Diagnostic and Statistical Manual of Mental Disorders criteria for anorexia nervosa, bulimia nervosa, or ED not
otherwise specified). Results: In part I, more controls than athletes were classified as ‘‘at risk’’ for ED (50.7% vs 25.0%, PG0.001). In
part II, the prevalence of ED among the total population of athletes and controls was estimated to be 7.0% versus 2.3%, with a difference
of 4.7% (95% confidence interval, 3.4–6.0; P= 0.001), with the ED prevalence being higher for female than male athletes (14.0% vs
3.2%, PG0.001) and female and male controls (5.1% vs 0%, PG0.001). No difference in the prevalence of ED was detected between the
females in weight-sensitive and less weight-sensitive sport groups (19.7% vs 11.9%, P= 0.136). Conclusion: The prevalence of ED is
higher in adolescent elite athletes than controls and higher in female than male athletes. Clinical interview is needed to determine accurate
prevalence of ED. Key Words: ANOREXIA NERVOSA, BULIMIA NERVOSA, EDNOS, SPORT, ELITE, CLINICAL INTERVIEW
Most elite athletic participation and competition
take place during adolescence or early adulthood
(6). This is also when eating disorders (ED) often
develop, when females, especially, experience a rapid change
in the body composition and shape. For athletes, these possi-
ble changes might affect not only their attitudes toward weight
and shape but also their athletic performance (6).
For high school athletes, most studies do not report a
greater risk for the development of an ED than among age-
matched controls (15,17,26,29). However, most studies have
used only questionnaires to assess symptoms associated with
ED rather than clinical interviews. Questionnaires have
limitations, and it has been argued that clinical interviews
are needed to obtain accurate prevalence data (20,32). The
few studies available that have used a two-tiered approach
(questionnaire screening followed by clinical interviews)
have reported that adult elite athletes tend to underreport ED
symptoms to a higher degree than controls, and that when
clinical interviews are used, a higher proportion of elite fe-
male and male athletes actually have ED than that estimated
from questionnaires (Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV)) (35,38,39).
Among the elite female and male adolescent athletes, no
previous study has examined the prevalence of ED using
clinical interviews. However, it has been reported that young
athletes are at substantial risk for ED (27,29), and in one of
our previous studies, most of the adult elite athletes who met
the criteria for an ED reported having started dieting and
developing an ED during puberty or adolescence (32). Thus,
there is a need for a study that includes a representative
population of young elite athletes representing a wide range
of sports examining the prevalence of athletes classified as
‘‘at risk’’ for ED and then identifying how many meet the
diagnostic criteria. Therefore, the aim of this study was to
examine the prevalence of clinical ED in adolescent female
and male elite athletes and age-matched controls by using
a two-tiered approach, including a questionnaire screening
followed by clinical interviews.
METHODS
We conducted this study in two phases: self-reported
questionnaire (part I) and clinical interview (part II).
Address for correspondence: Marianne Martinsen, MSc, Oslo Sports Trauma
Research Center, Norwegian School of Sport Sciences, PB 4014 Ullevål
Stadion, N-0806 Oslo, Norway; E-mail: marianne.martinsen@nih.no.
Submitted for publication September 2012.
Accepted for publication December 2012.
0195-9131/13/4506-1188/0
MEDICINE & SCIENCE IN SPORTS & EXERCISE
Ò
Copyright Ó2013 by the American College of Sports Medicine
DOI: 10.1249/MSS.0b013e318281a939
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Copyright © 2013 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Participants
We invited adolescent elite athletes attending Elite Sport
High Schools (n= 16) in Norway and age-matched con-
trols from two randomly selected regular high schools in
Buskerud county in Norway to participate. The inclusion
criteria for part I of the study were enrollment as a first-year
student and a birth date in 1992. Norwegian Elite Sport High
Schools are private and public high schools with programs
designed for talented athletes. We invited 1211 first-year
students, 711 athletes, and 500 controls, to participate in the
initial screening during the 2008–2009 school year. Of
these, 34 athletes and 79 controls were excluded (because of
age: 29 athletes and 60 controls; because of failure to obtain
parental consent: 5 athletes and 19 controls). Of the re-
maining 677 athletes and 421 controls, 66 athletes and 66
controls did not participate because they were not able to
attend school during the test day. The reasons reported for
the athletes not attending school that day were training
camp, competition, or illness. When it comes to the controls,
no specific reasons for not attending school were reported.
This resulted in a final sample of 611 athletes (response rate,
90%) and 355 controls (84%), representing 50 different
sports/disciplines, and for part of the analysis and in accor-
dance with recent research, they were classified into weight-
sensitive and less weight-sensitive sports (Table 1) (1).
The Regional Committee for Medical and Health Science
Research Ethics in Southern Norway and the Norwegian
Social Science Data Services approved the study. The
respondents and their parents provided written consent to
participate. We also obtained permission to collect data from
each school principal.
Assessment Procedures
Part I: Screening. We asked the respondents to com-
plete a questionnaire that included a battery of assessment
questions regarding training history, physical activity and
nutritional patterns, menstrual history, oral contraceptive use,
dieting and weight fluctuation history, use of pathogenic
weight control methods, injuries, self-report of previous
and/or current ED and the standardized questionnaire Eating
Disorders Inventory-2 (EDI-2), and the short version of
Hopkins Symptom Checklist (SCL-5). The questionnaire has
been described in detail previously (17), except for the SCL-5.
The SCL-5 is a five-item scale designed to measure symp-
toms of anxiety and depression. These five items are scored on
a four-point scale ranging from 1 = ‘‘not at all’’ to 4 = ‘‘ex-
tremely.’’ The item score is calculated by dividing the total
score of the number of items answered (ranging between 1
and 4), and a cutoff score of 2 indicates psychological dis-
tress (30). The SCL-5 has been proven reliable, and it is
significantly correlated to the original instrument (37). In ad-
dition, a comparison study of several instruments found the
reliability of this short version acceptable, with the rec-
ommendation to use the short version if included in a
comprehensive questionnaire (30).
To be classified as ‘‘at risk’’ for ED, subjects had to meet
at least one of the following criteria: a) drive for thinness
(DT) score Q15 for girls and Q10 for boys; b) body dissat-
isfaction (BD) score Q14 for girls and Q10 for boys; c) body
mass index (BMI) corresponding to the underweight value
(8); d) trying to lose weight now; e) tried to lose weight
before three times or more; e) current and/or previous use of
pathogenic weight control methods: use of diet pills, laxatives,
diuretics, or vomiting to reduce weight; or f) self-reported
menstrual dysfunction: primary amenorrhea or secondary
amenorrhea (previous 6 months). The athletes and controls
completed the questionnaire at school during school hours in
the presence of one or two members of the research group.
Physical activity was defined as the total hours of physical
activity per week, including physical education lessons,
recreational sports, and active daily living like walking. We
classified those who reported Q7 h of physical activity per
week as physically active (equivalent to the Norwegian
physical activity recommendations of 1 hId
j1
of moderate
activity) (19). Training volume was reported as the number
of training hours per week in the following categories: e5,
6–10, 11–15, 16–20, or Q21.
Part II: Clinical interview. Based on the data from part
I, 102 female and 51 male athletes (n= 153, 25.0%) and 113
female and 67 male controls (n= 180, 50.7%) were classi-
fied as being ‘‘at risk’’ with symptoms associated with ED
TABLE 1. Classification of the 50 different sports into weight-sensitive and less weight-sensitive sports.
Weight-Sensitive Sports (n= 163)
Gravitational Less Weight-Sensitive Sports (n= 448)
Aesthetic Weight Class Technical Endurance Ballgames Power Technical High Mass
Dancing Judo High jump Cycling Table tennis Sprint Golf Alpine skiing
Gymnastics Karate Ski jump Nordic combined Tennis Shooting Ice hockey
Tae kwon do Long jump Cross-country skiing Basketball Motocross Hammer
Triple jump Biathlon Soccer Snow cross Discus
Hurdle Paddling Handball Horse riding Javelin
Heptathlon Orienteering Floorball Sailing
Decathlon Middle- and long-distance running Volleyball Surfing
Dog racing Beach volleyball Fencing
BMX cycling Chess
Mountain biking Freestyle
Rowing/sculling
a
Snowboard
Swimming
a
Light weight.
EATING DISORDERS AMONG YOUNG ELITE ATHLETES Medicine & Science in Sports & Exercise
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(Fig. 1). We invited all ‘‘at-risk’’ athletes (n= 153) and a
randomly selected sample (50%) of ‘‘at-risk’’ controls (n=91,
57 girls and 34 boys) to participate in a clinical inter-
view. In addition, to match the ‘‘at-risk’’ subjects, a random
sample of athletes (102 girls and 51 boys) and controls (22
girls and 66 boys) not classified as ‘‘at risk’’ after the
screening examination was also invited to attend a clinical
interview.
The clinical interview was based on the Eating Disorder
Examination 16:0 (EDE) (14), including sport-specific ques-
tions regarding the suggested predisposing, precipitating,
and perpetuating factors related to ED risk, as well as the
Eating Disorder Examination Questionnaire 6.0 (EDE-Q)
(12). The EDE is an investigator-based interview that assesses
ED psychopathology, i.e., undue importance of weight and
shape in determining self-worth, as well as key ED behaviors.
It is generally considered the best established instrument for
assessing ED and is used for diagnostic purposes (7,13,40).
The EDE-Q is a 36-item self-report measure derived from
EDE focusing on the past 28 d and uses the same seven-
point rating scale (0–6). Both EDE and EDE-Q are com-
posed of four scales: restraint, weight concern, shape concern,
and eating concern, with higher score representing greater
severity of psychopathology. Both EDE and EDE-Q have
been translated into Norwegian-language versions and vali-
dated (23,25).
We included the clinical interview to determine whether
athletes and controls classified as being ‘‘at risk’’ for ED
during the screening met the DSM-IV criteria for anorexia
nervosa (AN), bulimia nervosa (BN), or ED not otherwise
specified (EDNOS) (2) and to determine the presence and
frequency of core ED symptoms. Four people did the
interviews, one psychiatrist and three people trained in using
the EDE. All had clinical experience with ED patients and
special competence in physical activity and sports. A ran-
dom selection of the 37 subjects (16 who fulfilled and 21
who did not meet the ED criteria) was interviewed again by
a second interviewer. In all cases, there was complete
agreement between the two interviewers concerning the di-
agnostic classification.
Statistical Analysis and Data Presentation
The statistical analyses were carried out using PASW
Statistics 18 for Windows (IBM Corporation, Route, Somers,
NY). The results are expressed as absolute numbers (N)and
percentages (%) for categorical data and mean values with
their SD for continuous data. We classified the athletes into
weight-sensitive and less weight-sensitive sports as described
previously (17). To compare the mean differences, an inde-
pendent sample t-test was used, whereas we used chi-square
tests to compare the categorical frequencies. We calculated
the sensitivity as the proportion of the athletes and controls
FIGURE 1—Number and percentage of subjects participating in parts I and II of the study.
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correctly identified as having ED and specificity as the pro-
portion correctly identified as healthy. The negative predictive
value (true negative) was calculated among the proportion of
the athletes and controls classified as not ‘‘at risk’’ correctly
identified as healthy. We estimated the total prevalence of ED
from the prevalence of ‘‘at-risk’’ and healthy subjects partici-
pating in the clinical interview, factoring the distribution of ‘‘at-
risk’’ and not ‘‘at-risk’’ subjects in the total sample. This was
done separately for the athletes and controls with the use of the
following formula: P
pop
=P
1
W
1
+P
2
W
2
,whereP
pop
=esti-
mated prevalence in the total population, P
1
=prevalenceof
the disorder in ‘‘at-risk’’ subjects in part I, W
1
=weighted
distribution of at-risk subjects in part I, P
2
= prevalence of the
disorder in subjects classified as not ‘‘at-risk’’ subjects in the
clinical interview, W
2
= weighted distribution of not at-risk
subjects in part I.
The significance level was set to 0.05.
RESULTS
Part I
Subject characteristics. The athletes were slightly
younger than the controls at the time of data collection (16.5 T
0.3 vs 16.9 T0.3, PG0.001). A higher number of female
controls than female athletes were classified as overweight
according to age- and sex-adjusted BMI criteria (P= 0.003)
(8). Among the controls, 55% reported being physically active.
Among the athletes, 1.5% reported training for e5hIwk
j1
,
16.5% for 6–10 hIwk
j1
, 46.2% for 11–15 hIwk
j1
,25.7%
for 16–20 hIwk
j1
, and 10.2% for Q21 hIwk
j1
. Moreover,
17% of the athletes were selected for the national team
(recruit, junior, or senior level). We observed no differences
in the anthropometry between the controls participating in
part I compared with those in part II.
Prevalence of symptoms associated with ED. A
higher proportion of controls than athletes were classified as
‘‘at risk’’ for ED (50.7% vs 25.0%, PG0.001) (Fig. 1). Fur-
thermore, a higher proportion of females compared with males
were classified as ‘‘at risk’’ for ED in both groups (athletes:
46.2% vs 13.1%, PG0.001; controls: 72.4% vs 33.7%, PG
0.001). We observed no difference in the proportion classified
as being ‘‘at risk’’ for ED between weight-sensitive (26.4%)
and less weight-sensitive sports (24.6%, P= 0.65).
Part II
Prevalence of athletes and nonathletes meeting
the DSM-IV criteria for ED. Because we gave priority to
those classified as being ‘‘at risk’’ based on the questionnaire
screening, there was a difference in the time from finishing
the data collection from the screening part to attending the
interview between those ‘‘at risk’’ and not ‘‘at risk’’ (12.1 T
4.0 (SD) vs 16.3 T3.1 months, PG0.0001). There was no
difference between the athletes and nonathletes (14.2. T
5.0 months vs 14.0 T2.2, P= 0.435).
The number of the athletes and controls who participated in
the clinical interviews and met the DSM-IV criteria is shown
in Figure 1. As seen, 24 of 96 female athletes and 5 of 48
male athletes classified as ‘‘at risk’’ based on the question-
naire fulfilled the criteria for ED. For the female controls, four
of 57 ‘‘at risk’’ who participated in the clinical interview met
the criteria (Fig. 1). Among the 34 athletes who met the cri-
teria, 73.5% were diagnosed with EDNOS (20 females, 5
males), 23.5% with BN (7 females, 1 male), and 2.9% with
AN (1 female), whereas all the female controls (n=4)diag-
nosed with an ED were diagnosed with EDNOS.
As part of the analysis, the prevalence of the athletes and
controls meeting the criteria for ED was standardized
according to the total distribution of ‘‘at-risk’’ and not at-risk
subjects for ED in part I of the study (Fig. 1). In this way, we
estimated that 7.0% of the athletes and 2.3% of the controls
met the criteria for an ED, with a difference of 4.7% (95%
confidence interval (CI), 3.4–6.0; P= 0.001). The estimated
prevalence was higher among the female athletes (14.0%)
compared with the female controls (5.1%), with a difference
of 8.9% (95% CI, 6.0–11.8; P= 0.005). Among the male
athletes, 3.2% were estimated to meet the diagnostic criteria,
with a difference from the female athletes of 10.8% (95%
CI, 8.3–13.3; PG0.001). We detected no difference in the
prevalence of ED between the females representing weight-
sensitive and less weight-sensitive sport groups (19.7% vs
11.9%, P= 0.136). Because of the few cases of ED among
the male athletes, no subgroup comparisons were possible.
Five of 136 (3.7%) athletes and no controls classified as
healthy from the screening examination were diagnosed
with an ED (false negatives). The sensitivity of the screening
examination was 0.85 versus 1.00 for the athletes and con-
trols, respectively, whereas the specificity was 0.53 vs 0.50.
Characteristics of athletes meeting the criteria
for an ED. Table 2 shows that there were significant
differences between the female and male athletes with ED
compared with the athletes classified as healthy on several
variables reported to be associated with ED. The athletes
diagnosed with an ED had higher EDE-Q global score and
subscale scores than healthy athletes (Table 3). The shape
concern was the subscale with the highest mean score
among both the athletes and controls with an ED. As
expected, all of the 34 athletes with ED reported current
dieting, 25 reported current and/or previous use of patho-
genic weight control methods, and among these, 22 reported
vomiting regularly at present. However, only eight reported
binging and vomiting to such extent that they met the BN
criteria (Table 4). Further characteristics of the severity and
morbidity among the different athletes and controls with
ED are given in Tables 4 and 5.
DISCUSSION
This is the first study to present prevalence data on ED
among adolescent male and female athletes representing al-
most all European sports and a sample of adolescent controls.
The novelty of this study is the two-tiered design including
both the questionnaire screening and clinical interview and the
EATING DISORDERS AMONG YOUNG ELITE ATHLETES Medicine & Science in Sports & Exercise
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high prevalence of clinical ED among adolescent elite male
and female athletes.
The Prevalence of ED Is High among Adolescent
Elite Athletes
Our finding revealed a high prevalence of ED among
adolescent elite athletes. The prevalence was higher than
among the controls, although more controls than athletes
self-reported symptoms associated with ED. In addition,
many athletes underreported the use of unhealthy behaviors
such as pathogenic weight control methods at the screening
compared with the reported use in the clinical interview,
which is consistent with previous studies on adult elite ath-
letes (18,31,36).
Among the athletes, it has been reported that some look at
their disordered eating (DE) behavior as a natural part of
their sport and are not necessarily generally dissatisfied with
their body shape or weight (6,21,36), do not realize that they
have a problem (4), and thus do not report DE problems. In
addition, it has been argued that the DE behavior may reflect
a rational response to pressure to achieve a body shape that
will ensure optimal performance and reflect dedication to
their sport rather than psychopathology (6). Therefore, it
seems reasonable that the specific psychological concerns of
adolescent elite athletes are somewhat different to those of
nonathletes presenting a similar clinical picture, and that
prevalence studies based on self-reported questionnaires will
not be able to distinguish these differences. Consequently,
by using the clinical interview EDE and sport-specific ques-
tions, we were able to get more accurate information about
the intensity and duration of the most severe symptoms
being essential to diagnose ED among both the athletes and
the controls. Case number 2 (Tables 4 and 5) is a good il-
lustration of this. This female athlete had BN, but at the
screening, she reported no use of pathogenic weight con-
trol methods, had scores below the cutoff for ‘‘at risk’’ at the
EDI subscales BD and DT, and was only classified as ‘‘at
risk’’ because of the present dieting. However, at the clini-
cal interview, it was clear that her dieting behavior primar-
ily was related to sport-specific weight concern. Moreover,
her thoughts about weight, shape, and food were at such
an intensity that they affected her self-worth and concen-
tration and had resulted in key ED behaviors such as binging
and self-induced vomiting. As a result, she met the DSM-IV
criteria for BN. Subsequently, our use of a two-tiered ap-
proach confirms the difficulties that exist when it comes to
identifying athletes at risk for ED, or those who already
have developed an ED, and explains why it is important to
use clinical interviews to assess the specific psychopathol-
ogy of ED.
Because there are no previous studies that have used a
two-tiered approach when investigating ED in adolescent
elite athletes, it is difficult to compare the prevalence
reported in our study with other studies. In general, com-
paring prevalence data is difficult because most studies use a
variety of methodological approaches. Different populations
are investigated (adolescent vs adult, collegiate vs elite vs
recreational), and the number of athletes studied (n= size),
the number and type of sports included, and which part of
the training or competition season the data were collected
vary between studies (36). Taking this into account, our
findings are in accordance with the studies on older elite
athletes using a two-tiered approach (7,35,38). However, the
TABLE 3. EDE-Q subscale scores for healthy and eating disordered elite athletes and controls given as mean TSD.
Athletes Controls
Females Males Females Males
ED Healthy ED Healthy ED Healthy Healthy
n=28 n= 154 Pn=6 n=90 Pn=4 n=74 Pn=82
Global score 3.2 T1.1 0.8 T0.8 G0.001 2.7 T0.5 0.5 T0.7 G0.001 3.1 T1.5 1.0 T0.8 0.065 0.4 T0.5
Restraint 2.8 T1.5 0.6 T0.8 G0.001 2.5 T0.9 0.5 T0.8 G0.001 2.6 T2.1 0.7 T0.8 0.170 0.4 T0.6
Shape concern 4.2 T1.3 1.4 T1.2 G0.001 3.4 T0.8 0.7 T0.8 G0.001 4.0 T1.2 1.6 T1.2 G0.001 0.7 T0.9
Weight concern 3.7 T1.4 1.1 T1.2 G0.001 2.8 T0.7 0.5 T0.8 G0.001 3.4 T1.9 1.3 T1.2 0.001 0.6 T0.8
Eating concern 2.2 T1.4 0.3 T0.6 G0.001 2.2 T0.6 0.2 T0.5 G0.001 2.6 T1.4 0.3 T0.5 0.045 0.1 T0.2
Pgives significance level for comparison of ED and healthy.
TABLE 2. Characteristics of female and male adolescent elite athletes diagnosed with clinical ED or as healthy after the clinical interview.
Age at Sport
Specialization (yr)
Training
Volume (hIwk
j1
)
Age at First
Dieting Attempt (yr)
a
Dieting to Enhance
Performance
a
Diet to Improve
Appearance
a
DT BD
BMI
(kgIm
j2
)
Females
ED (n= 28) 13.0 (1.7) 14.4 (4.2) 13.2 (1.3)
b
16 (72.7) 22 (95.7) 6.7 (5.3)
c
13.6 (6.7)
c
21.5 (2.5)
Healthy (n= 156) 13.4 (1.7) 13.0 (4.4) 14.1 (1.3) 29 (61.7) 44 (86.3) 2.4 (4.0) 6.5 (6.5) 21.2 (2.1)
Males
ED (n=6) 12.8 (1.8) 10.5 (4.2)
d
14.6 (1.1) 5 (100.0) 5 (83.3) 5.5 (7.1) 6.5 (7.0) 24.5 (3.6)
e
Healthy (n= 90) 12.6 (2.1) 14.7 (3.7) 14.0 (1.5) 28 (90.3) 21 (67.7) 1.4 (2.9) 3.6 (4.5) 21.9 (2.2)
Results are given as means with SD or numbers with percentages, as appropriate. Values are given in absolute numbers and valid percentage when only cases without missing values are
considered.
a
The percentage is based on the number of athletes that had tried to diet.
b
P= 0.014 compared with healthy females.
c
PG0.001 compared with healthy females.
d
P= 0.009 compared with healthy males.
e
P= 0.012 compared with healthy males.
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prevalence was, as expected, lower than found among older
Norwegian elite athletes in 2004 (35). In contrast to our
present study, Sundgot-Borgen and Torstveit (35) included
the subclinical ED anorexia athletica (AA) in their prevalence
study. Still, it may be argued that these athletes would have
been diagnosed with EDNOS if AA had not been included.
Furthermore, if AA was eliminated as a diagnosis and these
athletes were classified as healthy, the percentage of ED
would still be higher among both female (16.3%) and male
(7.4%) athletes when using the same estimate calculation as
we used in this present study. Similarly, Torstveit et al. (38)
found a higher percentage of ED among adult female elite
athletes as compared with the prevalence among the females
in our study. Thus, although adolescence is considered to be
the period of greatest vulnerability and the time when ED
typically occurs, the prevalence of ED seems to be higher
among adult elite athletes.
Several explanations may be relevant for the higher prev-
alence of ED among the adult elite athletes than the young
elite athletes in this study, for example, longer duration of
sport-specific demands such as competing in sports with
weight class system and where the procedure during compet-
itive events may allow use of extreme weight loss methods,
physique-revealing uniforms, or competing in sports in which
appearance and performance are being judged. In addition,
frequent weight fluctuation has been suggested to be an im-
portant trigger factor for the development of ED in athletes
(32). In our study, the athletes are in the beginning of their
athletic career, whereas in Sundgot-Borgen and Torstveit’s
study (35) the athletes were older and had been competing at
the highest national and international level for years. Fur-
thermore, and in contrast to previous studies on adult elite
athletes (7,35,38), we found no difference in the prevalence
of ED among athletes in weight-sensitive sports compared
with less weight-sensitive sports. Although BD is consid-
ered an important symptom of ED (2), 50% of the athletes
in our study diagnosed with an ED had BD scores above
clinical values, but all reported sport-specific BD. Byrne and
TABLE 4. BMI, menstrual function, and dieting behavior in subjects meeting the DSM-IV criteria for AN, BN, or EDNOS.
ID Diagnosis Sex BMI
Present
Dieting
Pathogenic
Weight
Control
Methods
a
Compulsive
Exercise
b
(no.Iwk
j1
)
Binge
Eating
(no.Iwk
j1
)
Vomiting
(no.Iwk
j1
)
Diet
Pills Diuretics Laxatives
Menstrual
Dysfunction
Athletes
1AN F 15.9 + + G1 Secondary amenorrhea
2BN F 19.0 + + 2 7
3BN F 21.5 + + 3 2 2 Oral contraceptives
c
4BN F 21.8 + + 7 4 2
5BN F 22.9 + + 7 2 Secondary amenorrhea
6BN F 23.8 + + 7 7 + Oligomenorrhea
7BN F 24.4 + + 7 7 2 + +
8BN F – + + 5 2 7 Oral contraceptives
c
9BN M 22.0 + + 5 4
10 EDNOS F 18.3 + + 1 1 Oral contraceptives
c
11 EDNOS F 19.6 + Secondary amenorrhea
12 EDNOS F 20.4 + 4
13 EDNOS F 21.0 + + 3
14 EDNOS F 21.1 + + G1 Oral contraceptives
c
15 EDNOS F 21.2 + 5 Oral contraceptives
c
16 EDNOS F 21.9 + + 2 1 Oligomenorrhea
17 EDNOS F 22.0 + + 2 G1
18 EDNOS F 22.2 + + 3
19 EDNOS F 22.2 + + 7 2 1
20 EDNOS F 22.6 + + 7 2 + Oral contraceptives
c
21 EDNOS F 23.4 + + 2 1 Oral contraceptives
c
22 EDNOS F 23.6 + + 3 G1
23 EDNOS F 23.7 + + 2 +
24 EDNOS F 23.7 + 2 Oral contraceptives
c
25 EDNOS F 23.9 + + 1 1
26 EDNOS F 24.3 + + 4 3 Oral contraceptives
c
27 EDNOS F 26.0 + 7 3
28 EDNOS F 27.7 + + 2 2
29 EDNOS F 32.0 + 2 5
30 EDNOS M 22.6 + + 3 +
31 EDNOS M 25.7 +
32 EDNOS M 26.9 + 3
33 EDNOS M 27.3 + 7 3
34 EDNOS M 33.5 + + 4
Controls
35 EDNOS F 21.2 + 2 Oligomenorrhea
36 EDNOS F 22.1 + + G1 + + + Secondary amenorrhea
37 EDNOS F 22.1 + 2
38 EDNOS F 26.3 + 1
a
Pathogenic weight control methods (use of diet pills, laxatives, vomiting, or diuretics to lose weight).
b
Training beyond that required to enhance for the athletes sports to purge their bodies of the effect of eating.
c
Contraceptives initiated to establish spontaneous bleeding (normalizing menstrual cycle).
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McLean (7) suggest that the demands of a sport to meet a
particular body requirement alone, even without a high level
of BD, may be enough to lead to the development of an
ED. In addition, Torstveit et al. (38) found that even though
the prevalence of ED was highest among athletes compet-
ing in weight-sensitive sports, fewer were dissatisfied with
their bodies compared with athletes in less weight-sensitive
sports and controls. This indicate that other factors than
general BD may be essential for the development of ED
among athletes, and it may be speculated that the higher
prevalence among adult elite athletes is due to a longer du-
ration of exposure to sports environment factors that can
contribute to heightened concerns regarding weight and pro-
mote pathogenic weight control behaviors.
ED Diagnosis and the Severity
As expected, the most frequent ED was EDNOS, which
is the most common ED encountered in outpatient (24)
and inpatient settings (10). EDNOS is sometimes called the
residual category in the DSM-IV classification because it is a
‘‘catch-all’’ category for eating problems that are considered
to be of clinical severity but do not fulfill the criteria for AN
or BN (22). EDNOS is therefore sometimes viewed as a
‘‘less severe’’ form of ED, but a recent study observed a
crude mortality of 5.2%, similar to those found in AN (9).
However, EDNOS is a residual category, and some of the
athletes fulfilling the EDNOS criteria closely resemble cases
of AN and BN, whereas others differ in terms of psycho-
pathology and medical condition. As an example, one of the
female athletes diagnosed with EDNOS reported fear of
weight gain, loss of concentration due to bodyweight and
shape and food concern, high BD, binge eating at least twice
a week, and daily compulsive exercise (in addition to her
planned sport-specific training) (case number 19, Tables 4
and 5). Because she reported vomiting only once a week for
the last 3 months, she did not fulfill the criteria for BN.
Another athlete (case number 12, Tables 4 and 5) did not
TABLE 5. Psychological and behavioral characteristics of subjects meeting the DSM-IV criteria for AN, BN, or EDNOS.
ID Diagnosis Sex
BD
(0–27)
General
Weight
Concern
Sport-specific
Weight
Concern
a
DT
(0–21)
Fear of
Weight
Gain (0–6)
Loss of
Concentration
b
(0–6)
Empty
Stomach
(0–6)
Shape
Concern
(0–6)
Anxiety/Depression
(SCL-5)
c
(1–4)
Athletes
1AN F 8 + + 9 6 6 6 6 1.8
2BN F 11 + 10 6 4 6 5 2.6
3BN F 14 + + 6 4 5 4 5 3.0
4BN F 27 + + 20 4 6 6 5 3.0
5BN F 4 + + 6 6 5 5 5 1.4
6BN F 22 + + 14 6 6 6 5 2.4
7BN F 7 + + 10 6 5 3 5 2.0
8BN F 24 + + 9 6 3 3 4 1.6
9BN M 0 + + 0 6 5 6 4 1.6
10 EDNOS F 20 + + 2 6 2 6 5 1.4
11 EDNOS F 5 + + 1 4 4 6 6 1.5
12 EDNOS F 6 + + 3 4 3 5 4 2.0
13 EDNOS F 1 + 3 6 6 5 4 1.0
14 EDNOS F 15 + + 0 4 4 4 5 2.8
15 EDNOS F 16 + + 14 6 6 6 6 1.2
16 EDNOS F 13 + + 2 4 4 5 5 1.8
17 EDNOS F 8 + + 8 6 5 4 4 2.2
18 EDNOS F 6 + + 0 5 5 4 5 1.4
19 EDNOS F 16 + 11 6 6 6 5 2.0
20 EDNOS F 15 + + 4 4 4 4 5 2.0
21 EDNOS F 15 + + 0 6 3 6 6 1.4
22 EDNOS F 11 + + 8 6 4 4 5 2.0
23 EDNOS F 14 + + 9 6 6 5 4 2.2
24 EDNOS F 9 + + 0 4 4 4 5 2.8
25 EDNOS F 11 + + 12 5 5 5 4 1.2
26 EDNOS F 24 + + 13 6 4 4 4 2.4
27 EDNOS F 22 + + 5 6 6 6 5 2.2
28 EDNOS F 17 + + 9 6 6 6 6 1.4
29 EDNOS F 19 + + 1 6 6 6 5 1.2
30 EDNOS M 2 + + 4 6 5 6 5 1.8
31 EDNOS M 8 + + 3 3 3 4 5 –
32 EDNOS M 0 + + 0 4 5 5 5 1.4
33 EDNOS M 12 + + 19 6 5 6 5 2.2
34 EDNOS M 16 + + 7 4 4 4 5 2.4
Controls
35 EDNOS F 7 + 5 3 2 3 5 2.6
36 EDNOS F 26 + 20 4 4 4 4 3.2
37 EDNOS F 7 13 3 3 3 2 4.0
38 EDNOS F 26 + 13 6 2 4 4 3.2
a
The dissatisfaction and concern about weight and the desire to lose weight is sports related.
b
Difficult to concentrate on things that are interested in or after a conversation or reading because of thoughts about weight, shape, food, eating, or calories.
c
A cutoff point of 2 indicates the presence of a mental disorder (29).
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report use of pathogenic weight control methods and had
regular menstruation. However, she reported binge eating
four times a week and fulfilled the psychological criteria for
EDNOS (the binge ED). The many hours of training (16–20
hIwk
j1
) may explain her normal weight for age and height,
despite the binge eating. Finally, case number 15 (Tables 4
and 5) fulfilled all the criteria for AN except that she had a
normal weight for her age and height, and therefore, the
correct diagnosis was EDNOS (partial or subclinical AN). In
sum, this means that those who fulfill the EDNOS criteria
differ in the degree of psychological and medical severity
and chronicity. In addition to this, the characteristics of their
competitive sport and the duration and intensity of the
symptoms will influence the consequences of their ED behav-
ior on acute and long-term health as well as performance (34).
Frequent binging and vomiting are examples of behavior
that can lead to both health and performance consequences
on a short- and long-term basis (4). For instance, bingeing
generally results in gastric distention where the severity
increases with an increase in the amount of food consumed
during the binge (4), whereas purging by self-induced
vomiting, laxative abuse, or diuretic abuse may lead to de-
hydration, acid–base and electrolyte imbalances, cardiac
arrhythmia as well as different chronic physical problems
(4). Furthermore, the combination of binging and compul-
sive exercise for young athletes will increase the risk of
overtraining, chronic fatigue, illness, overuse injuries, and
menstrual dysfunction (4).
ED athletes in this study reported use of pathogenic
weight control methods ranging from not at all to daily. The
same range was found for binge eating. The use of these
methods and/or the extreme weight and body shape (related)
stress experienced underline the acute need for treatment.
Consequently, some athletes should be withdrawn from
competition as well as training, whereas others can continue
training during treatment (11). These challenge the type of
treatment and prevention strategies that should be chosen, as
well as the balance between taking risk behavior seriously,
but do not morbidly challenge the behavioral or psycho-
logical traits that are common and accepted in some sports
needed for success. It is therefore essential to determine
whether the athletes’ abnormal eating and dieting behaviors
are transient, safely managed behaviors associated with the
specific demands of the sport or if the symptoms are more
stable and represent a clinical ED (11,33).
Higher Prevalence of ED among Athletes
Than Controls
In our study, we found a higher prevalence of ED among
the athletes compared with the controls and general preva-
lence estimates (28). In addition to the unique pressure ath-
letes face compared with nonathletic controls, the Elite
Sport High School setting may be an additional factor that
increases the risk for DE and the development of an ED.
Some of the factors that may lay a high pressure on these
young athletes to perform on the sport field as well as in
the classroom are greater personal responsibility and mat-
uration, perceived loss of social support, competing with
the best athletes in the country, evaluation by coaches on an
almost daily basis, increased training volume, lack of per-
formance, and not being the best anymore. Some might also
feel indebted to their family to achieve good results. For
some, such sudden changes and high pressure might be ex-
perienced as traumatic events and serve as trigger conditions
for the onset of ED. In addition, Barker and Galambos (3)
found that moving away from home to attend college in-
creased the likelihood of binge eating among young women.
Other factors such as loss of coach or an illness or injury
might also be conceptualized as traumatic events and trigger
conditions (32).
Why more controls than athletes reported symptoms as-
sociated with ED without having an ED may be explained
by the higher percentage of overweight (BMI), higher per-
centage with BD, and percentage reporting dieting (17). The
fact that more female controls than athletes are classified as
overweight in this study, with the focus on the importance of
a lean body and the general experienced pressure of a thin
ideal body, might have influenced the controls’ perception
of their bodies and partly explain the high number with BD
and DT scores above the cutoff for the ‘‘at-risk’’ criteria.
Previous findings also indicate that females especially are
dissatisfied with their bodies and tend to report DE or have
high scores on the EDI without being actively dieting or
using extreme methods to reduce or control weight (32).
Also, the questionnaire being used may have had an effect.
The EDI subscale BD is for instance not sport specific and
assesses dissatisfaction with areas of the body such as
stomach and hips that well-trained athletes most likely are
generally satisfied with. Furthermore, the reasons for dieting
or being dissatisfied with one’s own body may be differ-
ent for males compared with females (16). In male athletes,
high BD does not necessarily mean a desire to lose weight
and or getting thinner. For instance, only 4 of our 17 male
athletes with a BD score over the cutoff (Q10) present diet-
ing, and only two of them were diagnosed with an ED
(Table 4). The many false-positive male athletes and one
false-negative athlete diagnosed with EDNOS also indicate
that the questionnaires being used do not have the sensitiv-
ity to differentiate between male athletes who are dissatis-
fied with their body because they want to be more muscular,
athletes who are dissatisfied because of the extra fat, or those
with ED.
Methodological Considerations
As expected, the use of a wide range of at-risk criteria for
ED led to a high number of false positives, but more strict
criteria could have resulted in too many false negatives (38).
Because this study is part of an intervention aiming to pre-
vent the development of ED, a high number of false negative
would have been less advisable.
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A cross-sectional study design has its limitations, but our
use of a two-tiered approach by including the clinical inter-
view EDE is considered to be the ‘‘gold standard’’ for di-
agnosing ED (7,13). Furthermore, all measurements have
some weaknesses limiting their validity and reliability, but
until more sport-specific measurements are developed, a
two-tiered design is a good solution.
Because of ethical consideration, we prioritized to inter-
view those classified as being ‘‘at risk’’ based on the ques-
tionnaire screening first. This resulted in a time difference
from the screening to attending the interview between those
‘‘at risk’’ and not ‘‘at risk’’ and the athletes and controls.
Because certain features of diagnostic importance in the in-
terview are assessed over a 3-month period, and also a ran-
dom selection of those diagnosed and not diagnosed with an
ED was interviewed again by the second interviewer with
complete agreement; we believe that this time difference
most likely has not had any effect on the results. Because so
many of the participants classified as healthy at the screen-
ing attended the clinical interview and only 5 of 218 were
false negatives (all of them were athletes), we believe an-
swering our questionnaire did not lead to focus more on
weight, body shape, and dieting among the participants.
Furthermore, when interviewing these five false-negative
athletes, they all reported a history of ED, indicating that
they were already experiencing ED when they fulfilled the
questionnaire at screening.
The causes reported for athletes not attending school at
the test day indicate that there are no reasons to believe that
those not attending differed from the sample of athletes who
participated in the study. Because we have no specific rea-
sons for controls not attending school at the test day, we
could speculate that some did not attend because of the test
related to DE. However, it could also be due to ordinary
reasons for not attending school. Based on this, we believe
that the nonresponders did not skew the sample in any di-
rection. Furthermore, the high response rate, the large
number of sports included, and the fact that a representative
sample of both those classified as ‘‘at risk’’ and healthy
attended the clinical interview show that these data are
generalizable to other adolescent elite athletes and controls.
However, the lack of instruments designed for athletes may
have had an effect on the prevalence of athletes classified as
‘‘at risk.’’ For instance, the BD scale might not be suited for
those who are dissatisfied because they want to gain weight
(increase muscle mass), which is of special interest for the
male athletes representing ice hockey, team handball, alpine
skiing, and some athletic events as well as discriminate be-
tween general BD and more sport-specific BD. Furthermore,
because dieting is usually seen as the primary precursor to
the development of DE and ED, we included the present
dieting as one of our at-risk criteria. However, dieting in this
special setting should maybe more correctly be considered
as a ‘‘collection’’ factor for other symptoms not detected.
Finally, it is worth noting that when comparing female
athletes with ED in weight-sensitive sports and less weight-
sensitive sports, we calculated the lowest detectable differ-
ence to 17.1% when the observed was 7.8%. The difference
in these populations could only be detected if the number
per group had been fourfold if the power had been at
least 80%.
PERSPECTIVES
Our results support two previous important statements: 1)
a clinical interview is the best available method to identify
ED among both elite athletes and controls, and 2) there is a
need for further development and validation of screening
instruments designed for athletes. A sport-specific instru-
ment should be designed for athletes in different kinds of
sports and competition levels. Until this is established,
clinical interviews should be used for accurate identification
of ED.
Education about health and performance-related nutrition
and body composition should be administered at an earlier
age than high school. Females should especially be educated
on the health and performance consequences of menstrual
irregularities and the importance of seeking timely medical
intervention at the first sign of abnormalities (5). Coaches as
well as other athletic staff members are in a prime position to
monitor their athletes’ behaviors and reactions, and there-
fore, mandatory education programs should be implemented
on an annual basis. Finally, sports-governing organiza-
tions and federations should give support to the coaches
and provide education for coaches, athletic staff, and ath-
letes (36).
CONCLUSION
This study is the first to confirm that the prevalence of ED
is higher among adolescent elite athletes than controls and
higher in female than male adolescent elite athletes. It also
confirms the difficulties that exist when it comes to identi-
fying male and female athletes ‘‘at risk’’ for ED and the need
for a clinical interview to identify athletes who already have
developed an ED.
The authors thank Professor Roald Bahr for his helpful comments
on this article and Professor Ingar Holme for his assistance with
the statistical analysis. We also thank all the subjects and their
coaches for full cooperation and support during this study, and
Audun Erikson, Guro RLen, Laila Sundgot Schneider, Runi BLrresen
and Kristin Brinchman Lundestad with regard to the collection of data.
The Oslo Sports Trauma Research Center has been established at
the Norwegian School of Sport Sciences through generous grants
from the Royal Norwegian Ministry of Culture, the South-Eastern
Norway Regional Health Authority, the International Olympic Commit-
tee, the Norwegian Olympic Committee and Confederation of Sport,
and Norsk Tipping AS. The project has been established through a
grant from The Norwegian Olympic Sports Center (Olympiatoppen).
There are no potential conflicts of interest.
The results of the study do not constitute endorsement by the
American College of Sports Medicine.
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