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

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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 019% in male athletes and 645% 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, 110, 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 kcalkg
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,preventionand 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 (n2067)
Range: 1235 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 (n311)
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
(n355)
Range: 1516 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
(n204)
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
(n67)
Range: 1330 Self-report (EDI) Risk for eating disorders:
89.2%
Rosendahl et al. (2009),
Germany
High-school female
(n210) and male elite
athletes (n366) and
age-matched non-athletic
female (n169) and
male controls (n122)
Range: 1418 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 (n78)
Range: 1119 Self-report (EAT, BITE and
BSQ)
Disordered eating: 44.9%
Petrie et al. (2008),
USA
Collegiate male athletes
(n203)
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
(n186) and controls
(n145)
Range: 1339 Structured clinical interview
(EDE)
Eating disorders
Athletes: 32.8%
Controls: 21.4%
Athletes controls
Nichols et al. (2007),
USA
High-school female
athletes (n423)
Mean: 15.791.7 Self-report (EDE-Q) Disordered eating: 20.0%
Nichols et al. (2006),
USA
High-school female
athletes (n170)
Range: 1318 Self-report (EDE-Q) Disordered eating: 18.2%
Pernick et al. (2006),
USA
High-school female
athletes (n453)
Mean: 15.791.2 Self-report (EDE-Q) Disordered eating: 19.6%
Beals and Hill (2006),
USA
Collegiate female athletes
(n112)
Mean: 19.591.2 Self-report (EDI symptoms
check list, EDE-Q)
Disordered eating: 25%
Toro et al. (2005),
Spain
Female elite athletes
(n283)
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 (n120)
and controls (n76),
and male athletes
(n58) and controls
(n19)
Range: 1539 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 (n155) and
male (n108) elite
athletes and controls
(n263)
Range: 1536 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 1339 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
truerisk 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 (n181)
Mean: 28.5 Self-report (EDE-Q) Eating disorders: 16%
Johnson et al. (1999),
USA
Collegiate female (n
562) and male athletes
(n883)
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
(n133) and controls
(n60)
Range: 1235 Structured clinical interview
(DSED)
Eating disorders
Athletes: 18%
Controls: 5%
Athletes controls
Thiel, Gottfried, and
Hesse (1993),
Germany
Male wrestlers and
rowers (n84)
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 athletes 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 paradigmsin 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 todays 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 dopingsuch 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 winthat
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 athletesmental 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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10 S. Bratland-Sanda and J. Sundgot-Borgen
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... Body-shape and body (dis)satisfaction are relevant problems in society with many women regularly dieting [1][2][3]. Food behaviour in athletes has also gained increasing awareness [4][5][6]. There are concerns about the number of reports on eating disorders (ED) and disordered eating (DE) among elite but also recreational athletes [7,8], coinciding with a growing preoccupation with nutrition and fitness in the media and general population [9][10][11]. ...
... In the context of DE and ED the literature differentiates between predisposing factors, trigger factors and perpetuating factors [13]. Biological factors such as age, pubertal status, genetics, psychological profile (perfectionism, self-esteem, negative affect etc.) and socio-cultural aspects (body ideal, peer pressure or family influence etc.) are regarded as predisposing factors [4,14,15].Trigger factors can be pubertal changes that make it difficult to achieve perceived weight or body-shape requirements [16]. External comments (e.g. by coaching staff ), injuries leading to reduced training intensity or weight class requirements are additional examples [16][17][18]. ...
... External comments (e.g. by coaching staff ), injuries leading to reduced training intensity or weight class requirements are additional examples [16][17][18]. Finally, positive feedback after weight-loss, or the initial improvement in performance play important roles as perpetuating factors [4]. To efficiently prevent the development of DE or ED at the individual but also at the system level of professional sports, awareness for the topic is paramount. ...
... All rights reserved. Not for commercial use or unauthorized distribution 66 develop an eating disorder, despite the fact cutting weight does not always lead to enhanced performance (Bratland-Sanda & Sundgot-Borgen, 2013). Male college athletes are most likely to develop an eating disorder to address coach/teammate pressure, lose or gain weight for weigh-in, enhance sport performance, or because of their internal association that more fit college athletes receive more playing time (Ahlich et al., 2019;Baum, 2006;Chatterton & Petrie, 2013;Galli et al., 2011). ...
... While the recommended core multidisciplinary team for treatment of athletes with disordered eating and eating disorders includes a doctor, sports dietitian, and psychologist (Wells et al., 2020), it is important for ATs to be aware of the risk factors and warning signs of eating disorders so that they can work effectively within the sport system to best support outcomes for athletes. Early identification and treatment of disordered eating improves the speed of recovery, reduces symptoms, and improves the likelihood of better health outcomes (Bratland-Sanda & Sundgot-Borgen, 2013). This is of particular importance as Flatt et al.'s research found that college athletes underutilized supports for eating disorders and disordered eating. ...
Article
One subset of the college population that is at-risk of developing an eating disorder or signs of disordered eating are college athletes. College athletes face both internal and external pressures to remain fit. Of particular importance for this study is the role of the athletic trainer (ATs) in helping college athletes with a diagnosed eating disorder or patterns of disordered eating. This study followed a logical, systematic, and multiphase phenomenological approach to capturing reflections of athletic trainers’ (n = 7) subjective experiences related to managing student-athletes who have a diagnosed eating disorder. Using an open-ended interview guide, athletic trainers participated in an intensive interview with one of the researchers. Researchers categorized statements into one of three themes: (1) AT and college athlete relationship, (2) barriers to care, and (3) opportunities for improvement. These results provide insight concerning the intersection of ATs and their role in addressing eating disorders with college athletes. ATs play an important role in providing both support to aid physical recovery from ailments and injuries and also serve as a source of psychosocial referral and support.
... Athletes are required to fulfill expectations such as physical perfection, achieving and maintaining standardized body weight, strict implementation of nutrition programs, and good performance (Petrie & Greenleaf, 2007). However, reasons such as beauty standards, media influence, peer pressure, body dissatisfaction, perfectionism, and low self-esteem may lead athletes to behave in ways that cause eating disorders (Bratland-Sanda & Sundgot-Borgen, 2013). A regular and good diet is an extremely important factor for good athlete performance. ...
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The increase in eating disorders in the athlete population is remarkable. Disorders concerning eating impulse, bodyweight obsession, negative thoughts about body shape, and accompanying affective disorders are psychological disorders in which eating behavior is seriously affected. A narcissistic personality disorder is defined as a continuous pattern that includes a superiority complex, inability to empathize, and the need to be approved. Some narcissistic characteristics such as a desire for unlimited power, success, beauty, and approval may be related to the eating habits of athletes. This study was to examine the relationship between the tendency of narcissism and eating disorders in elite athletes. Participants of the study were 223 elite athletes (99 men, 124 women) from different sports branches aged between 18-36 years old. The Narcissistic Personality Inventory-16 and the Eating Attitude Test were used as data collection tools. Spearman Correlation Analysis and Mann- Whitney U Test were used in the analysis of the data. A very weak positive relationship was found between eating disorder scores and narcissism scores (p<0.05). A very weak positive correlation was found between the exhibitionism sub-dimension and eating disorders tendency (p<0.01). There is a very weak positive relationship between narcissism tendency and eating disorder tendency variables and also between exhibitionism and eating disorders tendency. Therefore, athletes should be informed about nutrition for their performance by following interdisciplinary approaches.
... In severe cases, it can cause serious health consequences, including cardiac problems, osteoporosis, infertility, or missing menstrual periods [4,5]. It is well known that disordered eating behaviours or eating disorders are more common among elite and competitive athletes compared to the normal population, especially in disciplines that emphasize thinness, low weight, or lean aesthetics [6,7]. Although male athletes can be affected by eating disorders, females represent about 90% of those who need medical care [8,9]. ...
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Unlabelled: Eating disorders are characterized by abnormal, unhealthy eating habits, and disordered body image. In severe cases, it can cause serious health consequences, including cardiac problems, osteoporosis, infertility, or missing menstrual periods. In women competitively training sports, the main cause for disordered eating behaviours are factors associated with dissatisfaction with their appearance and body image and a need to reduce body weight. Factors related to dissatisfaction with one's own appearance and body image, a need to reduce body weight, a negative perception of themselves and their bodies, the pressure in sports circles, and stress are predictors for eating disorders. The aim of the study was to compare eating behaviours, body satisfaction, and taking various actions related to body mass reduction among women training competitively in volleyball, athletics, gymnastics, and young women not participating in sports. Material and methods: The study covered a group of girls and young women from the Silesian, Poland, who represented three sports disciplines (volleyball, athletics, and gymnastics), of which 30 girls were used as a control group (B). The study was conducted using a study questionnaire. Results: The study participants ate regularly and consumed all food groups during a week. The majority of girls from A1 (83.33%), A3 (53.33%), and B (80%) groups expressed their dissatisfaction with their body weight. In the group of gymnasts, a positive correlation was noted between the need to reduce body weight and regular eating (r = 0.449; p = 0.013). In the group of volleyball players, it was demonstrated that the higher the competitive experience and the greater the training load, the more regular their eating was (r = 0.475; p = 0.009). Conclusions: The importance of a diagnosis of early signs of eating disorders in girls and women as a basic component contributing to FAT development implies that further studies in this area, as well as education of the entire sports circle are necessary.
... Studies included in this review observed a high prevalence of eating disorders with data up to 18.7% of athletes [60], with gender differences and significant relationships with age and body composition [61]. Therefore, early detection of these symptoms should be a priority in the nutritional programmes of these athletes, especially in high-risk populations such as adolescents or female athletes [79][80][81]. Moreover, given the wide range of nutritional information that falls on these athletes (TV, magazines, radio, colleagues, coaches, etc.), the implementation of an education programme on the players themselves, coaches or health professionals involved may be a key factor in the primary prevention of eating disorders and low AE in both male and female track and beach handball athletes [21,28,40,49,79,82,83]. ...
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Introduction: Modern handball was introduced as an Olympic sport in 1972 and is played by more than 19 million people worldwide. Beach handball was born as an adaptation of court handball in the 1990s. Both modalities are complex and multifactorial ball games characterised by a fast pace and variable game intensities, as well as the strong influence of tactical concepts, social factors and cognitive aspects. Objective: To analyse the nutritional status of both male and female players to assess whether it is in line with specific and general dietary intake demands. Methodology: A systematic search of databases was carried out using keywords with relevant Boolean operators. Results: A total of 468 studies was identified, of which 44 studies were included: 7 on hydration; 22 studies related to energy, macronutrient and fibre intake; 23 that assessed micronutrients; 4 studies on nutritional knowledge and information sources; and 2 articles on eating disorders. A further 85 articles were included in order to cross-check results. Discussion: The need for a state of euhydration and normal plasma electrolyte levels is clear. Adequate energy intake is the cornerstone of the handball athlete’s diet to support optimal body function. The ACSM sets daily recommendations of 6–10 g CHO/kg body weight for handball, and daily protein recommendations range from 1.2 to 2.0 g PRO/kg/day and 14 g dietary fibre per 1000 kcal. Conclusion: The nutritional habits of handball players do not seem to be adequate to the demands of the sport, although these demands are not clarified. The inclusion of nutrition professionals could be a key element in the performance of these athletes.
... Some studies have demonstrated a sex difference in eating disorder prevalence. One study found that the prevalence of disordered eating symptoms varied from 0-19% in male athletes and 6-45% in female athletes (Bratland-Sanda & Sundgot-Borgen, 2013). Another study conducted in Spain on both male and female elite athletes (n=646) across sport types, found that 5.1% of all athletes were identified as being at risk for eating disorders, and 75.8% of the 5.1% were females. ...
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Eating disorders, a spectrum of psychological diseases (e.g., anorexia nervosa, bulimia nervosa, binge eating disorders) that can cause adverse impacts on health, are prevalent in athletes. Female athletes in aesthetic sports, where the thin-ideal body figure is highly valued by judges and audiences, are at highest risk of developing eating disorders. This review paper examines current research on major risk factors, diagnosis, and interventions regarding aesthetic athletes’ abnormal eating behaviors and eating disorders. The interconnected influence of social and sport pressures, including parents & coaches’ influences, body dissatisfaction, and achievement goals have been found to be the major risk factors. Culture can also exert influence on the development of eating disorders. This paper reviews the screening tools, which primarily consist of self-reported questionnaires, used to identify eating disorders as well as education-based preventions and intervention programs. Finally, the limitations of current research in the field majorly lies in the validation of screening tools and interventions.
... Sociocultural factors (e.g., peer pressure and media influence) have been reported as risk factors for ED and/or DE in athletic populations [9]. Through such factors, there can be sociological pressures for athletes to manipulate body composition to align with what is deemed optimal for their sport [38]. ...
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This article reports on the findings from a scoping review on eating disorders and disor�dered eating in competitive cycling. The review was informed by a scoping review methodological framework as well as the Preferred Reporting Items for Systematic Reviews and Meta-analysis ex�tension for scoping reviews (PRISMA-ScR) reporting guidelines. PubMed, SPORTDiscus and Web of Science were used to identify relevant literature for review. Fourteen studies met the eligibility criteria and were included in the full review. A narrative synthesis was used to summarise the main findings and themes across the included literature. Findings from the review are presented under the following themes: cycling as an ‘at-risk’ discipline; power to weight ratio; energy requirements and risk of low energy availability; the social environment of cycling; nutrition support provision; rela�tionship between eating disorders/disordered eating and exercise addiction; and recommendations made in identified literature. Overall, the literature suggests competitive cycling is a sport with a high prevalence of disordered eating and/or eating disorders and a sport with unique risk factors that contribute to this. Crucially, more research is needed in this area. The article concludes with the gaps in the literature highlighted, implications for future research, and applications to policy and practice suggested.
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This study investigated whether female aesthetic athletes (a subset of athletes including dancers, gymnasts, figure skaters) who recall receiving critical comments about their weight/shape report poorer wellbeing compared to those who do not. Female aesthetic athletes ( N = 381) completed measures assessing psychological wellbeing (self-esteem, anxiety), disordered eating and compulsive exercise behaviours/attitudes. Participants who recalled receiving a critical comment about their weight/ shape ( N = 251) reported higher levels of disordered eating, compulsive exercise, and anxiety, and lower levels of self-esteem. Greater awareness is needed of the potential negative impact that such critical comments may have on athlete wellbeing.
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Objective: The current study tested whether proposed sport-related risk factors for disordered eating behaviors were associated with increases in disordered eating over first-year college athletes' first four months of collegiate sport participation. Participants: Participants included a sample of first-year college athletes (N = 59, 45% female) from a Division I National Collegiate Athletics Association (DI) university. Method: This follow-up study tested whether 1) wearing a uniform that emphasizes body concerns, 2) participating in a lean sport, and 3) perceived pressure for thinness from coaches and teammates would lead to increases in weight/shape concerns and disordered eating behaviors over the first four months of collegiate sport participation. Results: Wearing a uniform that emphasizes body concerns and perceived coach pressure for thinness predicted increases in weight/shape concern. Both teammate and coach pressure for thinness predicted increases in restrained eating behaviors. Conclusion: Findings suggest that there are identifiable, athlete-specific risk factors for the development of disordered eating behaviors among first-year college athletes.
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This analog study examined the impact of coaching style on athletes' vulnerability for eating problems using a 2 (positive vs. negative coaching vignette) by 2 (male vs. female) factorial experiment with the following dependent variables: mood, dieting, fear of fat. and body image anxiety. One hundred ten college students were randomly assigned to vignette conditions. The negative vignette portrayed a coach who was performance-centered and focused on weight in a threatening manner. The coach in the positive vignette was also focused on weight, but in a person centered and caring manner. It was hypothesized females compared to males would react more pathologically to the negative versus positive vignette condition. Contrary to expectations, gender failed to interact with vignette condition. However, participants in the negative vignette exhibited higher instances of dieting, body image anxiety, and fear of fat. This research implies coaching style could create an increased vulnerability for body image and eating problems in student athletes.
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Male athletes have been hypothesized to be at increased risk for disordered eating attitudes and behaviors due to unique pressures in the sport environment. In this study, 203 male collegiate athletes from three universities completed the Questionnaire for Eating Disorder Diagnosis (QEDD; Mintz, O'Halloran, Mulholland, & Schneider, 1997) as well as provided information on binge eating and pathogenic weight control behaviors. None were classified with a clinical eating disorder, though almost 20% reported a sufficient number and level of symptoms to be considered symptomatic. Just over 80% had no significant eating disorder concerns and were classified as asymptomatic. Neither year in school, race/ethnicity, sport type, nor age were related to whether or not the athletes were symptomatic or asymptomatic. In terms of the athletes' body mass, fewer than 2% were underweight and 66% were classified as overweight or obese according to CDC guidelines; over 60% were satisfied with their current body weight. Although the frequency of pathogenic behaviors was low, exercise (37%) and fasting/dieting (14.2%) were the primary and secondary means for controlling weight; fewer than 10% used vomiting, laxatives, or diuretics. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Eating disorders are relatively rare among the general population. This review discusses the literature on the incidence, prevalence and mortality rates of eating disorders. We searched online Medline/Pubmed, Embase and PsycINFO databases for articles published in English using several keyterms relating to eating disorders and epidemiology. Anorexia nervosa is relatively common among young women. While the overall incidence rate remained stable over the past decades, there has been an increase in the high risk-group of 15-19 year old girls. It is unclear whether this reflects earlier detection of anorexia nervosa cases or an earlier age at onset. The occurrence of bulimia nervosa might have decreased since the early nineties of the last century. All eating disorders have an elevated mortality risk; anorexia nervosa the most striking. Compared with the other eating disorders, binge eating disorder is more common among males and older individuals.
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This meta-analytic review of prospective and experimental studies reveals that several accepted risk factors for eating pathology have not received empirical support (e.g., sexual abuse) or have received contradictory support (e.g., dieting). There was consistent support for less-accepted risk factors(e.g., thin-ideal internalization) as well as emerging evidence for variables that potentiate and mitigate the effects of risk factors(e.g., social support) and factors that predict eating pathology maintenance(e.g., negative affect). In addition, certain multivariate etiologic and maintenance models received preliminary support. However, the predictive power of individual risk and maintenance factors was limited, suggesting it will be important to search for additional risk and maintenance factors, develop more comprehensive multivariate models, and address methodological limitations that attenuate effects.
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This study investigated the possibility that male athletes who, owing to the rules of their sport, are pressured to maintain a low weight show an elevated prevalence of subclinical eating disorders. Twenty-five wrestlers and 59 rowers in the lower weight categories were investigated using the Eating Disorder Inventory (EDI). Fifty-two percent of the athletes reported the occurrence of binging. The EDI profiles of 11% of the athletes suggested the presence of a subclinical eating disorder. These figures are clearly elevated compared with the normal male population. Low-weight wrestlers and rowers should be considered a high-risk male population for subclinical eating disorders. These findings are comparable to high-risk groups consisting mainly of women (such as ballet and modelling students). The causal relationship between the specific sport and the development of a psychogenic eating disorder is discussed.
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Women with anorexia nervosa have reduced skeletal mass. Both anorexia and osteopenia are less common in men. We describe a 22-year-old man with anorexia nervosa and severe osteopenia involving both cortical and trabecular bone who developed a pelvic fracture and multiple vertebral compression fractures. He was found to have secondary hypogonadotropic hypogonadism that was reversible with weight gain. This case illustrates the need to consider osteopenia as a potential complication of anorexia nervosa in males as well as females. (JAMA 1986;256:385-388)
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Eating disorders are believed to be a significant problem for many athletes. It has been suggested that aspects of the athletic environment not only increase the athlete's risk of developing such a disorder, but also make identification of at-risk athletes more difficult. The literature regarding “good athlete” characteristics and the literature with respect to personality characteristics associated with anorexia nervosa were briefly reviewed. Six traits were drawn from the anorexia literature and compared with six corresponding traits from the athlete literature and athletic environment. Comparisons revealed similarities between athlete and anorexic traits. Implications regarding identification and treatment are discussed.
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The female athlete triad consists of the interrelated problems of disordered eating, amenorrhea, and osteoporosis, and it is believed to affect female athletes in all sports and at all levels of competition. The current article highlights the Position Stand on the Female Athlete Triad of the International Olympic Committee's Medical Commission (IOCMC). The literature related to disordered eating, energy availability, amenorrhea, and bone loss in athletes is briefly reviewed. A hypothetical case is presented to illustrate some of the common issues and problems encountered when working with athletes affected by the triad, such as the effect of weight on performance in “thin” sports, coach involvement, sport participation by symptomatic athletes, and treatment resistance/motivation. Strategies recommended by the position stand for managing those issues and problems are presented regarding the referral, evaluation, and treatment phases of the management process. Implications of the position stand are discussed in terms of the IOCMC's endorsement of the athlete's health being primary to her performance. © 2006 by Wiley Periodicals, Inc., Int J Eat Disord, 2006