Eating disorders in athletes: Overview of prevalence, risk factors and recommendations for prevention and treatment

Abstract

Abstract The prevalence of disordered eating and eating disorders vary from 0-19% in male athletes and 6-45% in female athletes. The objective of this paper is to present an overview of eating disorders in adolescent and adult athletes including: (1) prevalence data; (2) suggested sport- and gender-specific risk factors and (3) importance of early detection, management and prevention of eating disorders. Additionally, this paper presents suggestions for future research which includes: (1) the need for knowledge regarding possible gender-specific risk factors and sport- and gender-specific prevention programmes for eating disorders in sports; (2) suggestions for long-term follow-up for female and male athletes with eating disorders and (3) exploration of a possible male athlete triad.

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Eating disorders in athletes: Overview of prevalence,
risk factors and recommendations for prevention and
treatment
Solfrid Bratland-Sanda a & Jorunn Sundgot-Borgen b
a Department of Sport and Outdoor Life Science, Telemark University College, Bø, Norway
b Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
Published online: 13 Nov 2012.
To cite this article: Solfrid Bratland-Sanda & Jorunn Sundgot-Borgen (2012): Eating disorders in athletes: Overview
of prevalence, risk factors and recommendations for prevention and treatment, European Journal of Sport Science,
DOI:10.1080/17461391.2012.740504
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REVIEW ARTICLE
Eating disorders in athletes: Overview of prevalence, risk factors and
recommendations for prevention and treatment
SOLFRID BRATLAND-SANDA
1
& JORUNN SUNDGOT-BORGEN
2
1
Department of Sport and Outdoor Life Science, Telemark University College, Bø, Norway,
2
Department of Sports Medicine,
Norwegian School of Sport Sciences, Oslo, Norway
Abstract
The prevalence of disordered eating and eating disorders vary from 019% in male athletes and 645% in female athletes.
The objective of this paper is to present an overview of eating disorders in adolescent and adult athletes including: (1)
prevalence data; (2) suggested sport- and gender-specific risk factors and (3) importance of early detection, management
and prevention of eating disorders. Additionally, this paper presents suggestions for future research which includes: (1) the
need for knowledge regarding possible gender-specific risk factors and sport- and gender-specific prevention programmes
for eating disorders in sports; (2) suggestions for long-term follow-up for female and male athletes with eating disorders and
(3) exploration of a possible male athlete triad.
Keywords: Eating disorders, athletes, leanness, dieting
Introduction
Eating disorders are serious mental illnesses with
high-mortality rates (Smink, van Hoeken, & Hoek,
2012); they are often long-standing and make a
significant negative impact to the individual’s quality
of life (APA, 1994). These disorders are charac-
terised by a preoccupation with food, body weight
and shape that leads to behaviour such as starvation,
fasting, binge eating and purging and excessive
exercise (APA, 1994). This pathogenic behaviour
becomes the main focus in the daily life and other
areas in life such as family, school/work and social
life are given less priority because of this disorder
(Fairburn & Harrison, 2003). It was a belief that
eating disorders only occurred in females, however,
the last two decades have provided research showing
that eating disorders also occur among boys and men
(Domine, Berchtold, Akre, Michaud, & Suris,
2009).
The issue of sport, exercise and eating disorders
has also received increasing attention the last two
decades. The prevalence of disordered eating and
eating disorders is high among adolescent and adult
athletes, especially among athletes competing in
weight sensitive sports (Torstveit, Rosenvinge, &
Sundgot-Borgen, 2008). The higher prevalence of
eating disorders seen among females compared to
males in both athlete and non-athlete populations
have led to more focus upon the hazards of eating
disorders among females (Baum, 2006). Neverthe-
less, eating disorders appear more frequent in male
athletes compared to male non-athletes (Sundgot-
Borgen & Torstveit, 2004), and the disorders can be
just as hazardous for the males. It is, therefore,
crucial to thoroughly examine the gender issues of
eating disorders in sports.
Due to the seriousness of eating disorders, and
their frequent appearance in sports, it is important to
examine and understand why athletes seems to be
more at risk compared to non-athletes. Risk factors
for eating disorders including both predisposing and
trigger factors have been suggested (Sundgot-Bor-
gen, 1994). However, to identify such factors, a
causal relationship needs to be established (Striegel-
Moore & Bulik, 2007). Otherwise, the factors can
only be viewed as associating factors with eating
Correspondence: S. Bratland-Sanda, Department of Spor t and Outdoor Life Science, Telemark University College, Bø, Norway. E-mail:
solfrid.bratland-sanda@hit.no
European Journal of Sport Science
2012, 110, iFirst article
ISSN 1746-1391 print/ISSN 1536-7290 online #2012 European College of Sport Science
http://dx.doi.org/10.1080/17461391.2012.740504
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disorders, and not risk factor. Hence, an examina-
tion of the existing literature on general, sport- and
gender-specific risk factors is needed.
The International Olympic Committee (IOC),
American College of Sports Medicine (ACSM) and
the National Athletic Trainer Association (NATA) in
the USA have provided position stands for preven-
tion, identification and management of eating dis-
orders in sports (Bonci et al., 2008; Drinkwater,
Loucks, Sherman, Sundgot-Borgen, & Thompson,
2005; Nattiv et al., 2007). As these position stands
are presenting current recommendations in this field,
it is necessary to explore and discuss their strengths
and weaknesses. In that way, the next scientific steps
in this field can be elaborated on.
This paper will, therefore, provide an overview of
the prevalence and suggested sport- and gender-
specific risk factors for eating disorders among
adolescent and adult male and female athletes.
Furthermore, current recommendations for early
identification, prevention and management of eat-
ing disorders among male and female athletes are
presented and discussed. In this paper, we use the
terms disordered eating and eating disorders to show
the disordered eating behaviour continuum. This
continuum starts with healthy dieting (such as
lowering energy intake and gradual weight loss),
then goes on to use of more extreme weight loss
methods such as restrictive diets (B30 kcalkg
1
fat-free mass per day), chronic dieting, frequent
weight fluctuation, fasting, passive (e.g. sauna, hot
baths) or active dehydration (e.g. exercise with
sweat suits), use of laxatives, diuretics, vomiting,
diet pills and/or excessive exercise (Nattiv et al.,
2007). The eating disorders at a clinical level (i.e.
meeting the diagnostic criteria for anorexia nervosa,
bulimia nervosa or eating disorders not otherwise
specified) represents the end of this continuum
(APA, 1994).
Literature search
To ensure we included available relevant studies,
literature searches were conducted using PubMed,
Sport Discus, Psych Info and Google Scholar. The
searches were performed in January 2012, and
various combinations of the following words were
used for the search: ‘disordered eating’,‘eating
disorders’,‘dieting’,‘anorexia nervosa’,‘bulimia
nervosa’,‘muscle dysmorphia’,‘athletes’,‘sports’,
‘prevalence’,‘risk factors’,‘prevention’and ‘treat-
ment’. We included literature concerning both
adolescent athletes (i.e. high school athletes) and
adult athletes at collegiate, national and interna-
tional level.
Prevalence of eating disorders in sports
The entire spectrum from disordered eating to
Diagnostic and Statistical Manual for Mental Disorders,
4th ed. (DSM-IV) categorised eating disorders have
been shown more prevalent among both male and
female adult elite athletes compared to non-athlete
controls (Sundgot-Borgen & Torstveit, 2004).
Table I shows publications reporting prevalence of
disordered eating and eating disorders either among
athletes only or among athletes compared to con-
trols. The prevalence is lower among male athletes
compared to the female athletes (Byrne & McLean,
2002; Greenleaf, Petrie, Carter, & Reel, 2009;
Martinsen, Bratland-Sanda, Eriksson, & Sundgot-
Borgen, 2010; Petrie, Greenleaf, Reel, & Carter,
2008; Schaal et al., 2011; Sundgot-Borgen &
Torstveit, 2004), however, a similar frequency of
male elite athletes and female controls met the
criteria for eating disorders in one of the studies
(Sundgot-Borgen & Torstveit, 2004).
Schaal et al. (2011) report gender differences in
eating disorder prevalence rates among different
genres of sports. They found the highest prevalence
among female in the endurance and aesthetic sports,
whereas eating disorders among male athletes were
most common in weight-class sports (i.e. wrestling
and boxing). This is in agreement with findings
among Norwegian elite athletes (Sundgot-Borgen &
Torstveit, 2004). In contrast to findings on adult
athletes, a study on adolescent elite athletes only
found no sport-specific differences in prevalence
(Martinsen et al., 2010). We speculate that this
finding might be due to a shorter period of exposure
of sport-specific demands such as the experienced
pressure to diet, weight-in procedures, number of
weight fluctuations and subjective evaluation among
the adolescent compared to the adult elite athletes.
Interestingly, two studies on high school athletes
have found higher prevalence of disordered eating
among the controls compared to the athletes
(Martinsen et al., 2010; Rosendahl, Bormann,
Aschenbrenner, Aschenbrenner, & Strauss, 2009).
However, the results from these studies are based on
self-report, and studies on adult athletes using a two-
step approach (self-report via questionnaire followed
by clinical interview by experienced therapist) show
that athletes tend to underestimate disordered eating
and eating disorders (Sundgot-Borgen & Torstveit,
2004; Torstveit et al., 2008). Therefore, the pre-
valence of eating disorders among adolescent ath-
letes might be higher than indicated from the studies
using self-report.
Methodological considerations should be empha-
sised when discussing the published prevalence
studies. The challenges of the existing publications
are the variety of assessment instruments and
2S. Bratland-Sanda and J. Sundgot-Borgen
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Table I. Selected publications showing prevalence of disordered eating and/or eating disorders among athletes and controls
Study Population (n) Age (years)
Screening instrument and
criteria for ED Prevalence
Schaal et al. (2011),
France
Adolescent and adult
female and male elite
athletes (n2067)
Range: 1235 Psychological evaluation
using DSM-IV for AN,
BN and EDNOS
Ongoing eating disorders
Male athletes: 4%
Female athletes: 6%
Lifetime eating disorders
Male athletes: 5.5%
Female athletes: 11.2%
MalesBfemales
Thein-Nissenbaum
et al. (2011), USA
High-school female
athletes (n311)
Mean: 15.491.2 Self-report (EDE-Q) Disordered eating: 35.4%
Martinsen et al. (2010),
Norway
High-school elite female
and male athletes (n
606) and age-matched
female and male controls
(n355)
Range: 1516 Self-report (EDI), body
mass index B17.9 kg/m
2
(girls) and B17.5 kg/m
2
(boys), current and/or
]3 previous efforts to lose
weight, use of pathogenic
weight control methods
and self-reported menstrual
dysfunction
Symptoms of eating disorders
Athlete females: 44.7%
Athlete males: 13.1%
Control females: 70.9%
Control males: 30.5%
Males Bfemales, athletes
Bcontrols
Greenleaf et al. (2009),
USA
Collegiate female athletes
(n204)
Mean: 20.291.3 Self-report (QUEDD and
BULIT-R)
Eating disorders:2%
Symptoms of eating disorders:
25.5%
Quah, Poh, Ng, and
Noor (2009),
Malaysia
Adolescent and adult
female elite athletes
(n67)
Range: 1330 Self-report (EDI) Risk for eating disorders:
89.2%
Rosendahl et al. (2009),
Germany
High-school female
(n210) and male elite
athletes (n366) and
age-matched non-athletic
female (n169) and
male controls (n122)
Range: 1418 Self-report (EAT). Criteria
for ED: EAT ]10
Disordered eating
Athlete females: 26.7%
Athlete males: 10.4%
Control females: 36.1%
Control males: 12.3%
Males Bfemales, athletes
Bcontrols
Schtscherbyna et al.
(2009), Brazil
Adolescent female elite
swimmers (n78)
Range: 1119 Self-report (EAT, BITE and
BSQ)
Disordered eating: 44.9%
Petrie et al. (2008),
USA
Collegiate male athletes
(n203)
Mean: 20.391.6 Self-report (QEDD and
BULIT-R)
Eating disorders:0%
Symptoms of eating disorders:
19.2%
Torstveit et al. (2008),
Norway
Adolescent and adult
female elite athletes
(n186) and controls
(n145)
Range: 1339 Structured clinical interview
(EDE)
Eating disorders
Athletes: 32.8%
Controls: 21.4%
Athletes controls
Nichols et al. (2007),
USA
High-school female
athletes (n423)
Mean: 15.791.7 Self-report (EDE-Q) Disordered eating: 20.0%
Nichols et al. (2006),
USA
High-school female
athletes (n170)
Range: 1318 Self-report (EDE-Q) Disordered eating: 18.2%
Pernick et al. (2006),
USA
High-school female
athletes (n453)
Mean: 15.791.2 Self-report (EDE-Q) Disordered eating: 19.6%
Beals and Hill (2006),
USA
Collegiate female athletes
(n112)
Mean: 19.591.2 Self-report (EDI symptoms
check list, EDE-Q)
Disordered eating: 25%
Toro et al. (2005),
Spain
Female elite athletes
(n283)
Mean: 15.393.1 Self-report (EAT and
CETCA)
Eating disorders through EAT:
11%
Eating disorders through
CETCA: 22.9%
Sundgot-Borgen and
Torstveit (2004),
Norway
Adolescent and adult
female athletes (n120)
and controls (n76),
and male athletes
(n58) and controls
(n19)
Range: 1539 Structured clinical interview
(EDE)
Eating disorders
Female athletes: 20%
Male athletes: 8%
Female controls: 9%
Male controls: 0.5%
Male Bfemale, athletes
controls
Byrne and McLean
(2002), Australia
Adolescent and adult
female (n155) and
male (n108) elite
athletes and controls
(n263)
Range: 1536 Structured diagnostic
interview (CIDI)
Eating disorders
Female athletes: 22%
Male athletes: 4%
Female controls: 5.5%
Male controls: 0%
Male Bfemale, athletes
controls
Eating disorders in athletes 3
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definitions used. There is a wide range of definitions,
from vague signs and symptoms of disordered eating
to strict DSM-IV criteria for anorexia nervosa,
bulimia nervosa and eating disorders not otherwise
specified. This makes comparison between the
different studies very difficult. Most of the available
studies have used self-report through questionnaires
such as Eating Attitudes Test (Rosendahl et al.,
2009; Schtscherbyna, Soares, de Oliveira, & Ribeiro,
2009; Toro et al., 2005), Eating Disorders Inventory
(Beals & Hill, 2006; Johnson, Powers, & Dick, 1999;
Martinsen et al., 2010) and Eating Disorders Ex-
amination Questionnaire (Hulley & Hill, 2001;
Nichols, Rauh, Barrack, Barkai, & Pernick, 2007;
Nichols, Rauh, Lawson, Ji, & Barkai, 2006; Thein-
Nissenbaum, Rauh, Carr, Loud, & McGuine,
2011), and different choice of cut offs give differ-
ences in prevalence estimates. These wide ranges of
definitions may explain the variety of prevalence
rates in both athletes and controls in some of the
included studies. Nevertheless, in studies using
clinical evaluation such as Torstveit et al. (2008),
the prevalence of eating disorders among the female
controls was much higher than reported in other
studies. The control sample was representative of
Norwegian females aged 1339 years, but it is
possible that the responders had more eating dis-
orders psychopathology compared to the non-re-
sponding females. Although it is difficult to predict
actual prevalence of eating disorders based on self-
report, it gives an estimate of the numbers of athletes
and controls at risk. This is in our opinion valuable,
because it can help identify sub groups were preven-
tion is crucial. Another possible explanation for the
variety of prevalence rates is the difference in
performance level in the populations investigated.
What do we know about risk factors?
General risk factors
No controlled long-term prospective studies have
been conducted; hence it is difficult to determine
‘true’risk factors, which contributes to the develop-
ment of eating disorders in general or athletic
populations in particular. Cross-sectional and case
control studies suggest that the risk factors for
development of eating disorders are multi-factorial,
and that these factors can be divided into predispos-
ing factors, trigger factors and perpetuating factors
(Nattiv et al., 2007). The predisposing factors
includes biological (e.g. genetics), psychological
(e.g. body dissatisfaction, low self-esteem and per-
sonality traits such as perfectionism) and socio-
cultural factors (e.g. peer pressure, media influence
and history of bullying) (Mazzeo & Bulik, 2009;
Stice, 2002; Stice, Marti, & Durant, 2011). The
trigger factors are typically negative comments
regarding body weight and/or shape, traumatic
experiences, etc. (Stice, 2002). The eating disorders
are maintained by perpetuating factors such as
approval by the coach or significant others, the
physiological consequences of starvation or initial
success (Drinkwater et al., 2005). Suggested general
Table I (Continued )
Study Population (n) Age (years)
Screening instrument and
criteria for ED Prevalence
Hulley and Hill (2001),
UK
Adult female elite
runners (n181)
Mean: 28.5 Self-report (EDE-Q) Eating disorders: 16%
Johnson et al. (1999),
USA
Collegiate female (n
562) and male athletes
(n883)
Mean: 19.9 Self-report (EDI subscales
DT, BD and Bulimia)
Clinical Eating disorders (AN/
BN)
Females: 0%/1.1%
Males: 0%/0%
Subclinical AN/BN
Females: 2.85%/9.2%
Males: 0%/0.005%
Sundgot-Borgen
(1993), Norway
Adolescent and adult
female elite athletes
(n133) and controls
(n60)
Range: 1235 Structured clinical interview
(DSED)
Eating disorders
Athletes: 18%
Controls: 5%
Athletes controls
Thiel, Gottfried, and
Hesse (1993),
Germany
Male wrestlers and
rowers (n84)
Mean: 21.192.4 Self-report (EDI) Disordered eating: 11%
DSM-IV, diagnostic and statistical manual for mental disorders, 4th ed.; AN, anorexia nervosa; BN, bulimia nervosa; EDNOS, eating
disorders not otherwise specified; DT, drive for thinness; BD, body dissatisfaction; EDI, eating disorders inventory; EDE, eating disorders
examination; EAT, eating attitudes test; BITE, bulimic investigatory test Edinburgh; BULIT-R, bulimia test revised; BSQ, body
satisfaction questionnaire; CETCA, eating disorders assessment questionnaire based on DSM-III diagnostic criteria; QUEDD,
Questionnaire for Eating Disorders Diagnoses; CIDI, composite international diagnostic inter view; EDE-Q, eating disorders
examination questionnaire; DSED, diagnostic survey for eating disorders based on DSM-III criteria.
4S. Bratland-Sanda and J. Sundgot-Borgen
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risk factors for development of eating disorders are
summarised in Table II.
Sport-specific risk factors
Suggested sport-specific risk factors include frequent
weight regulation, dieting and experienced pressure
to lose weight, personality traits, early start of sport-
specific training, injuries, symptoms of overtraining,
impression motivation, threat perception and the
impact of coaching behaviour (Smolak, Murnen, &
Ruble, 2000; Sundgot-Borgen, 1994). Some of these
risk factors are shared with non-athletes; however, it
is suggested that the sport environment can make
athletes even more vulnerable to these risk factors
compared to non-athletes (Currie, 2010).
Weight cycling and dieting pressure. For athletes in
sports that emphasize leanness, reduction in body
mass or body fat can enhance performance (Currie,
2010). Often an initial loss of weight leads to a better
performance and this initial success can force the
athlete to continue dieting to lose weight and
unknowingly slip into an eating disorder (Rodriguez,
Di Marco, & Langley, 2009). Therefore, athletes
who are extreme dieters, those struggling with
making weight and athletes with deliberate or unin-
tended restrictive caloric intake are considered being
at increased risk for eating disorders (Drinkwater
et al., 2005). This can also lead to an unfortunate
domino effect when other athletes, both team
members and competitors, observe this initial suc-
cess. The awareness of hazardous dieting and weight
fluctuation among athletes has resulted in position
stands on safe weight loss and maintenance practices
from, e.g. the NATA and the ACSM (Rodriguez
et al., 2009; Turocy et al., 2011).
Personality. Thompson and Sherman (1999) have
suggested that some traits desired by coaches in their
athletes are similar to traits found in individuals with
eating disorders, such as excessive exercise, perfec-
tionism, and (over-)compliance. These athletes
also may have evidence of psychological traits such
as high achievement orientation and obsessive
compulsive tendencies commonly associated with
eating disorders, but also essential for successful
competitions (Thompson & Sherman, 1999).
Furthermore, a recent review suggested perfection-
ism as a central confounding factor in the relation-
ship between athletes and eating disorders (Forsberg
& Lock, 2006).
Early start of sport-specific training. The problem with
early start of sport-specific training is the chance of
choosing a sport inappropriate for the athlete’s body
type (Sundgot-Borgen, 1994). The pubertal changes
can, therefore, be arbitrary for performance.
Furthermore, socializing to extremely weight pre-
occupied sports such as weight-class sports at an
early and vulnerable age is also suggested to increase
risk of eating disorders (Currie, 2010).
Traumatic events including injuries. Traumatic events
are significant trigger factors among both athletes
and non-athletes. However, some events have been
characterized as traumatic and trigger factors for
eating disorders in a sport-specific context only.
Injury is an example of the latter (Currie, 2010).
When a non-athlete gets an injury that keeps him/her
out of training for a few weeks or months, it does not
have the same impact on the professional life as it
does with athletes. Injured athletes often experience
an undesired weight gain, and combined with the
negative affects an injury cause (e.g. not being able
to train and compete in championships etc.), this can
increase risk of eating disorders (Sundgot-Borgen,
1994).
Coaching behaviour. The environment provided by
the sports coaches can either reduce or increase risk
of eating disorders (Currie, 2010). A study by
Biesecker and Martz (1999) found a performance-
related and body weight pre-occupied coaching style
to increase body image anxiety, dieting and fear of
fatness. Similarly, a supportive and caring coaching
Table II. Summary of suggested risk factors for eating disorders
among athletes
General risk factors
Biology and genetics
Genetics
Age
Pubertal status
Psychology
Body dissatisfaction
Low self-esteem
Personality traits (e.g. perfectionism)
Negative affects
Socio-cultural
Eating disorders in the family
Peer pressure
Influence of media
Bullying
Physical and/or sexual abuse
Sport-specific risk factors
Weight cycling and dieting pressure
Personality
Early start of sport-specific training
Traumatic events including injuries
Coaching behaviour
Rules and regulations in sports
Gender-specific risk factors
Drive for muscularity
Anabolic-androgenic steroid use
Homosexuality
Eating disorders in athletes 5
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style may reduce the risk of eating disorders
(Biesecker & Martz, 1999; Currie, 2010).
Rules and regulations. Sports which emphasize lean-
ness (i.e. aesthetic, endurance and weight-class
sports) show higher frequencies of dieting behaviour
(Torstveit et al., 2008). In weight-class sports, the
weight classes and the weigh-in rules make use of
rapid weight loss regimens prior to competition
common (Currie, 2010). In aesthetic sports athletes
are evaluated on both technical skills and execution/
artist effects, and such esthetical evaluation creates
‘body paradigms’in these sports (Currie, 2010).
Body paradigms, rules and norms in the specific
sports can both make athletes more prone to eating
disorders, but it can also make it a challenge to
identify athletes at risk (Currie, 2010).
Gender-specific risk factors: the male athlete with an
eating disorder
There are more similarities than differences regard-
ing suggested risk factors for eating disorders be-
tween females and males (Baum, 2006). Some
shared risk factors among both females and males
are overweight, a history of being teased and
experience of violence (Domine et al., 2009).
Suggested gender-specific risk factors among males
are drive for muscularity, anabolic androgenic ster-
oid use, and homosexuality (Kanayama, Barry,
Hudson, & Pope, 2006; Lock, 2009; Russell &
Keel, 2002). These factors are further elaborated
in the next paragraphs.
Drive for muscularity. It is our opinion that one of the
limitations with today’s screening tools for eating
disorders is the focus upon drive for thinness and the
lack of focus upon drive for muscularity. The latter
has been found to be a more important construct
among both athletic and non-athletic males than the
drive for thinness (Cafri, Blevins, & Thompson,
2006). It has been suggested that drive for muscu-
larity is a risk factor for development of eating
disorders and muscle dysmorphia in males, and
that this construct is a more positive construct
among females compared to males (Bratland-Sanda
& Sundgot-Borgen, 2012; Pope, Gruber, Choi,
Olivardia, & Phillips, 1997). Muscle dysmorphia
refers to the preoccupation with being muscular
and lean, and this preoccupation results in extreme
dieting behaviour, exercise behaviour, and increased
risk of anabolic-androgenic steroids use. Muscle
dysmorphia is not yet accepted as a diagnosis
although criteria following the DSM-IV diagnosis
for Body Dysmorphic Disorder has been proposed
(Pope et al., 1997). There is disagreement in the
literature regarding whether muscle dysmorphia
should be viewed as an eating disorder or not (Cafri
et al., 2006; Murray, Rieger, Touyz, & De la Garza
Garcia Lic, 2010; Vandereycken, 2011). Muscle
dysmorphia has mostly been explored among ath-
letes in weight lifting and body building, but it is
possibly prevalent in other sports where muscle mass
and strength are important factors for performance
(Baghurst & Lirgg, 2009). The knowledge about
drive for muscularity as a risk factor for eating
disorders is, however, sparse, and this construct
needs to be more thoroughly explored in both male
and female athletes.
Anabolic-androgenic steroid use. Anabolic-androgenic
steroid use is frequent among those who meet the
suggested criteria for muscle dysmorphia (Pope
et al., 1997), and it is associated with disordered
eating in both female and male athletes (Vertalino,
Eisenberg, Story, & Neumark-Sztainer, 2007). Not
only is steroid use illegal in organized sports, but also
it is hazardous in a health perspective. Therefore, it is
important to further examine the associations be-
tween steroid use, muscle dysmorphia and eating
disorders among athletes from a greater range of
sports and the exercise/fitness groups. Similarly, use
of ‘diet doping’such as ephedrine among athletes
seems to co-occur with eating disorders and body
image disorders (Gruber & Pope, 1998), and this co-
occurrence needs further examination. A weakness
in the existing studies examining doping and eating
disorders is that these studies only have reported an
association between these factors. It is, therefore,
difficult to determine if use of doping is a risk factor
for eating disorder, or if it is actually a consequence
of eating disorders.
Homosexuality. The prevalence of eating disorders is
higher among homosexual males compared to het-
erosexual males, this difference has not been de-
tected between heterosexual and lesbian females
(Russell & Keel, 2002). The reasons for this
increased risk of eating disorders among homosexual
males are, yet, unknown. However, it has been
speculated that mechanisms such as history of
bullying, differences in emphasis on physical appear-
ance between homosexual and heterosexual males,
low self-esteem etc. might play a role (Striegel-
Moore & Bulik, 2007). In our search for literature,
we found no studies who examined differences in
prevalence of eating disorders between homosexual
and heterosexual athletes. Therefore, futures studies
are needed to examine to what degree homosexuality
is a specific risk factor for eating disorders among
male athletes.
A recent meta-analytic review of prospective and
experimental studies revealed that several accepted
risk factors for eating pathology have not received
6S. Bratland-Sanda and J. Sundgot-Borgen
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empirical support or have received contradictory
support (e.g. dieting) (Stice, 2002). Risk factors in
the sport setting have not been investigated in terms
of prospective studies, and the strength of these
findings is, therefore, in our opinion limited. Case-
control and cross-sectional study designs make it
difficult to determine whether the factors are actual
risk factors, or if they are consequences of eating
disorders behaviour. Thus, the listed sports-specific
risk factors (Table II) are not evidence based. We,
therefore, agree with the suggestions by Stice (2002)
that it will be important to search for additional risk
and maintenance factors, develop more comprehen-
sive multivariate models, and address methodologi-
cal limitations that attenuate effects.
The athlete triad: also occurring in males?
The female athlete triad concerns the relationship
between energy deficiency, menstrual irregularities
and low bone mass (Nattiv et al., 2007). It has been
reported that energy deficiency may lead to reduced
testosterone levels and low bone mass among males
(Rigotti, Neer, & Jameson, 1986). Thus, a male
athlete triad does exist but rarely comes to attention
because the reproductive consequences are not
perceived by men (Bennell, Brukner, & Malcolm,
1996; De Souza & Miller, 1997). Due to the
presence of the different triad components among
male athletes, future studies are needed to explore
this phenomenon more in depth.
Prevention and management of eating
disorders among athletes: overview and
discussion of the current position stands
The IOC, ACSM and NATA have published posi-
tion stands regarding prevention, early identification
and treatment of eating disorders among athletes
(Bonci et al., 2008; Nattiv et al., 2007; Sherman &
Thompson, 2006). The position stands from IOC
and ACSM concentrate on the female athlete triad,
whereas the position stand from NATA includes
disordered eating among female and male athletes.
Early identification and treatment
Early detection of eating disorders is crucial for the
prognosis and the process of recovery (Bonci et al.,
2008). It is important that the athletes with eating
disorders are considered ill and receive proper
medical, nutritional and psychiatric treatment. In
addition, when medically cleared, they are in need of
close follow-up on training (Nattiv et al., 2007;
Sherman & Thompson, 2006). The position stands
recommend a multi-disciplinary treatment ap-
proach, and athletes suffering from eating disorders
usually need to adjust exercise volume and type
(Nattiv et al., 2007). Unfortunately, the position
stands do not adequately cover that these adjust-
ments need to be guided by an exercise physiologist
in cooperation with the rest of the treatment team.
Although acknowledging that eating disorders also
occur in male athletes, the different position stands
do not adequately cover the importance of monitor-
ing male athletes at risk. Male athletes may, there-
fore, be neglected by coaches and medical staff. In
addition to the guidelines regarding training and
competition, the position stands emphasise the
importance of restricting competition for athletes
meeting the criteria for an eating disorder (Drink-
water et al., 2005; Nattiv et al., 2007). Restriction
from competition is mainly due to medical risks, but
also due to the possible effect on other athletes.
However, none of the current position stands present
guidelines regarding return to play.
When can athletes return to play?
There is no consensus regarding recovery criteria for
eating disorders in patients in general, or in athletes.
Also, the position stands are inconclusive when it
comes to the question when athletes with eating
disorders should be considered recovered to the
degree that they can compete (Bonci et al., 2008;
Drinkwater et al., 2005; Nattiv et al., 2007).
We, therefore, suggest that specific criteria for
return to play should be developed; this would be
beneficial to the medical staff, coaches and athletes.
Such criteria can be based on general recovery
criteria for eating disorders, but they need to be
made sport specific. A core question regarding
recovery and competition for the eating disordered
athlete is whether an athlete can be allowed to
compete before one is fully recovered. And when is
an athlete fully recovered? Is it with sufficient energy
availability, restored body weight, normalised cogni-
tion regarding food, body shape/weight etc., or when
the medical status, nutritional status, cognition and
behaviour combined are within healthy range? Fu-
ture position stands need to elaborate on this, and
provide guidelines which are easy to apply for the
treatment team.
Prevention
More knowledge about the possible gender-specific
risk factors associated with eating disorders in
athletes is needed before we can argue that the
prevention programmes need to be gender specific.
However, it seems quite clear that for female athletes
it is still the extreme focus upon ‘dieting to win’that
should be de-emphasised as described in the latest
position stand from the ACSM (Nattiv et al., 2007).
Eating disorders in athletes 7
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In addition, the focus on leanness among male
athletes representing sports such as weight-class
sports is a complex issue, since they are expected
to lose total body weight and at the same time
increase muscle mass (Cafri et al., 2006). For most
athletes this is impossible since positive energy
balance is needed to gain muscle mass (Rodriguez
et al., 2009). Although it has been shown possible to
increase lean body mass during a rapid weight loss
regime in elite athletes (Garthe, Raastad, Refsnes,
Koivisto, & Sundgot-Borgen, 2011) this is extremely
demanding, requires close follow-up by profes-
sionals, and possibly increases risk of eating dis-
orders. Since extreme dieting and eating disorders
are almost part of the culture within aesthetic and
weight-class sport (Currie, 2010), the recommenda-
tions for these sports should be more related to (1)
prevention of extreme dieting, (2) optimizing energy
and nutrient intake and (3) education about ap-
proaching athletes who wish to lose weight to
enhance performance (Rodriguez et al., 2009).
Furthermore, since body composition is considered
an important performance variable in many sports,
more knowledge within this area is needed. Assess-
ment of body composition may be used to assess the
effectiveness of an exercise or dietary intervention, or
be used to monitor the health status of an athlete.
Individual body composition goals should be identi-
fied by trained health care personnel, and body
composition data should be treated in the same
manner as other personal and confidential medical
information (Ackland et al., 2012).
Studies have reported poor awareness and knowl-
edge in coaches regarding eating disorders (Nattiv
et al., 2007; Turk, Prentice, Chappell, & Shields,
1999). One important aspect in preventing eating
disorders among athletes is to increase the coaches’
knowledge about risk and trigger factors, how to
identify signs and symptoms, and how to manage
concerns about eating disorders. Eating disorders
and the athlete triad are, therefore, suggested as
mandatory curriculum in education of coaches
across all sports (Bonci et al., 2008). In addition,
the position stands suggest development of common
guidelines for all national and international sport
federations, which states what to do with athletes
who suffer from disordered eating or eating
disorders.
Implications for future research
As most prevalence studies have assessed risk and
symptoms of eating disorders through self-report,
more studies also using clinical evaluation of the
athletes are needed. Future studies examining the
prevalence of eating disorders should include clinical
interview using the Eating Disorders Examination,
and highly trained personnel should conduct these
interviews. Furthermore, prospective studies follow-
ing cohorts of athletes can provide important data on
changes in eating and dieting behaviour from ado-
lescence to adulthood. Such prospective cohort
studies are also suitable for examination of risk
factors for eating disorders among athletes. Risk
factors that further needs to be examined are use of
doping, drive for muscularity and sexual orientation.
Although suggested as gender specific for males,
these risk factors need to be examined in both males
and females. In addition, multi-factorial risk factor
models for eating disorders in athletes need to be
developed and examined. Such models need to
include general, sport- and gender-specific risk
factors. Increased knowledge about risk factors for
development and maintenance of eating disorders
among female and male athletes is crucial for
enhancement of the prevention programmes. Similar
to the energy deficiency, low estrogenic levels and
reduced bone mass observed in the female athlete
triad, we need to explore the possibility of a male
athlete triad consisting of energy deficiency, low
testosterone levels and reduced bone mass. Future
studies also need long-term follow-up of athletes
with eating disorders to examine the course of
the disorder also after the end of the career as an
athlete. Studies exploring muscle dysmorphia in
both male and female athletes across a variety of
sports are also necessary for the awareness of the
complexity of the athletes’mental health issues.
The position stands for identification, treatment
and prevention need to be carefully evaluated to
explore the usefulness and effectiveness of such
recommendations.
Summarising and conclusion
The prevalence of eating disorders is higher among
female athletes/non-athletes compared to male ath-
letes/non-athletes, and among athletes compared to
non-athletes. It is especially athletes in sports that
emphasize leanness who are at risk, but there might
be gender differences as to which sports are most at
risk. Among male athletes, it is important to further
examine the concept of muscle dysmorphia as a
possible eating disorder. There is still a need for
increased openness and awareness related to eating
disorders among both male and female athletes.
Coaches and administrators have to accept the
seriousness of this issue, and all personnel involved
in athletes need to increase their competence on
early identification, treatment and prevention of
eating disorders in all athletes regardless of age and
gender.
8S. Bratland-Sanda and J. Sundgot-Borgen
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