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Mind, Body and Sport: Eating disorders

An excerpt from the Sport Science Institute’s guide to understanding and supporting student-athlete mental wellness

By Ron Thompson

Participation in sports has a number of positive effects on student-athletes. They tend to live healthier lives than non-athletes, and they gain skills in teamwork, discipline and decision-making that their non-athlete peers may not.

However, some aspects of the sports environment can increase the risk of disordered eating (and eating disorders). That means student-athletes and those who oversee athletics must be vigilant to detect signs of trouble.

Disordered eating and eating disorders are related but not always the same. All eating disorders involve disordered eating, but not all disordered eating meets diagnostic criteria for an eating disorder.

As first conceived, the term "disordered eating" was a component of the female athlete triad – a syndrome that also includes decreased bone mineral density and osteoporosis – and defined as "a wide spectrum of harmful and often ineffective eating behaviors used in attempts to lose weight or attain a lean appearance." The term was later supplanted by "low energy availability" to reflect the role insufficient energy plays in accounting for all physical activity, as well as to fuel normal bodily processes of health, growth and development.

Eating disorders are not simply disorders of eating, but rather conditions characterized by a persistent disturbance of eating or an eating-related behavior that significantly impairs physical health or psychosocial functioning. The eating disorders most often diagnosed are:

Anorexia nervosa is characterized by persistent caloric intake restriction, fear of gaining weight/becoming fat, persistent behavior impeding weight gain, and a disturbance in perceived weight or shape.

Bulimia nervosa is recurrent binge eating, recurrent inappropriate compensatory behaviors to prevent weight gain (for example, induced vomiting and excessive exercise), and self-evaluation unduly influenced by shape and weight.

Binge-eating disorder is recurrent episodes of binge eating without compensatory behaviors but with marked distress with the binge eating.

Why student-athletes are at risk

Prevalence. Eating disorders occur in all sports, but not equally in all sports. As in society, eating disorders in sport occur more frequently in females than males. One area in which research findings are more definitive is for "lean" sports for which a thin/lean body or low weight is believed to provide a biomechanical advantage in performance or in the judging of performance. Women in these sports are considered to be at the highest risk.  

Genetics. Epidemiological and molecular genetics studies suggest a strong genetic predisposition to develop an eating disorder, and that these disorders aggregate in families in part due to genetics. Family and twin studies have found heritability estimates of 76 percent for anorexia nervosa and 83 percent for bulimia nervosa. Not all individuals with a genetic predisposition develop the disorder, as other factors are involved.

Sociocultural factors. Before genetics-related findings, the primary explanation for the development of eating disorders involved sociocultural factors. Certainly, from a sociocultural perspective, most individuals are exposed to societal or cultural pressures regarding weight or appearance, but again, not all will develop an eating disorder. Most who do are female, and the disorder’s onset often occurs during adolescence.

A simple conceptualization is that genetics sets the stage for the disorder, but sociocultural pressures can precipitate it. Once the disorder begins, sociocultural pressures usually assist in maintaining the disorder. Also, from a sociocultural perspective, eating problems can begin or worsen during transition periods, which makes freshman student-athletes particularly vulnerable.

Additionally, student-athletes may experience more stress than non-athletes because they deal not only with the transition away from home and pressures related to academic demands of college but also the pressures associated with sport participation. Eating problems are often the way individuals deal with such stressors.

Sport-related factors. Just as society and culture emphasize the "thin ideal," similar pressures exist in the sport environment regarding being thin/lean and its purported positive effect on sport performance.

This emphasis on reducing body weight/fat to enhance sport performance can result in weight pressures on the student-athlete from coaches (or even teammates) that increase the risk of restrictive dieting, as well as the use of pathogenic weight loss methods and disordered eating. Even the student-athlete’s perception that her coach thinks she needs to lose weight can heighten weight pressures and increase the risk of disordered eating.

For some student-athletes, revealing uniforms can increase body consciousness, body dissatisfaction, and the use of pathogenic weight loss methods. One study found that 45 percent of swimmers surveyed reported a revealing swimsuit as a stressor. Another study in volleyball found not only that revealing uniforms contributed to decreased body esteem but also distracted players and negatively affected sport performance.

The relationship between body image and body dissatisfaction in female student-athletes is more conflicted and confused than in the general population. Sportswomen have two body images – one within sport and one outside of sport, and disordered eating or an eating disorder can occur in either context or both. Additionally, some female student-athletes are conflicted about having a muscular body that facilitates sport performance but may not conform to the socially desired body type and may be perceived as being too muscular when compared to societal norms regarding femininity.

Coaches have considerable influence with their athletes, and it appears that their relationship with their student-athletes – and more specifically their motivational climate – can influence the risk of disordered eating. A relationship between coach and athlete characterized by high conflict and low support has been associated with increased eating pathology among athletes. Additionally, an ego/performance-centered motivational climate (vs. a skills-mastery climate) that some coaches use has been associated with an increased risk of disordered eating.

Another risk to student-athletes relates to aspects of the sport environment that make identification of disordered eating/eating disorders more difficult. In society and sport, athletes are often expected to display a particular body size or shape that becomes characteristic of a particular sport, such as distance runners being thin. Such "sport body stereotypes" can affect coaches’ perceptions of athletes, and athletes who fit the "thin" stereotype are less apt to be identified as having an eating problem. Identification by coaches is sometimes influenced by sport performance, and student-athletes are less likely to be identified if their sport performance is good.

Finally, eating disorder symptoms (such as dieting, weight loss and excessive training) may be misperceived as "normal" or even desirable in the sport environment, and personality characteristics/behaviors similar to those of eating disorder patients (such as perfectionism and excessive training) may be misperceived as "good athlete" traits.

Treatment. As a special subpopulation of eating-disorder patients, student-athletes need specialized approaches to treatment. However, treatment per se is not different; that is, standard treatment approaches (such as cognitive behavioral therapy) work as well for athletes as for non-athletes.

Recommended treatment differences relate to treatment staff. Treatment professionals working with student-athletes need experience and expertise in treating eating disorders and athletes, but more importantly need to understand and appreciate the importance of sport in the life of a serious student-athlete.

Student-athletes often resist treatment for the same reasons as non-athletes but also for additional ones related to sport. Some resist because they assume they will gain so much weight that it will negatively affect sport performance. They may resist due to a concern that having a mental health problem will result in a loss of status or playing time. Some fear that being in treatment for a mental health problem will displease significant others (like family, coaches and teammates).

Also, student-athletes sometimes resist treatment because they fear their treating professional(s) will not value the importance of sport in their lives. Given these common reasons to resist treatment, motivation for treatment and recovery is particularly important. Regarding treatment motivation, research investigating factors that facilitated student-athletes’ recovery from their eating disorder found the desire to be healthy enough to perform in sport to be most helpful.

Where do we go from here?

Given the prevalence of eating disorders in the college and sport populations, athletics departments are encouraged to develop a treatment protocol for student-athletes with eating disorders. Included in that protocol should be guidelines regarding how affected student-athletes are identified, managed and referred for evaluation and treatment by sport personnel. Sport personnel charged with these responsibilities should be trained by health care professionals with experience and expertise regarding student-athletes and eating disorders.

The protocol should also include recommendations regarding education for both student-athletes and sport personnel. Education is the first step in prevention, but more is needed in the form of a program designed to change student-athletes’ attitudes and behaviors that are associated with disordered eating/eating disorders. Some NCAA schools already employ such a program.

Early identification of "at risk" and affected student-athletes is most important. Eating disorders can be more easily treated early in the process. More importantly, timely and appropriate treatment can prevent medical and psychological complications of these disorders, thereby decreasing the risk to the student-athlete and decreasing time away from sport.

Coaches and other sport personnel are encouraged to improve their identification skills, as well as their skills in making an appropriate referral for an evaluation and treatment. Such training can be made available to coaches, athletic trainers and other sport personnel, and can be endorsed and strongly recommended by sport administrators. Such training opportunities are even more important for smaller colleges that may have fewer treatment options available on campus.

The primary risk for developing disordered eating/eating disorders involves the emphasis on a lean body and its purported relationship with enhanced sport performance. Coaches and others in the sport environment are urged to recognize that such an emphasis on weight or leanness puts the student-athlete at greatest risk for developing eating problems.  

Finally, the stigma associated with seeking mental health treatment must be eliminated. Those with influence in the sport environment can play a key role by recommending and encouraging timely and appropriate mental health treatment for their student-athletes.

Ron Thompson is a consulting psychologist for the Indiana University department of athletics and co-director of the Victory Program at McCallum Place, which offers a specialized eating disorder treatment staff to meet the unique needs of athletes. Thompson has served as a consultant on eating disorders to the NCAA and on the Female Athlete Triad with the International Olympic Committee Medical Commission. He can be reached at rthomps2@sbcglobal.net.

Physical/medical signs and symptoms

  • Amenorrhea
  • Dehydration
  • Gastrointestinal problems
  • Hypothermia (cold intolerance)
  • Stress fractures (and overuse injuries)
  • Significant weight loss
  • Muscle cramps, weakness or fatigue
  • Dental and gum problems

Psychological/behavioral signs and symptoms

  • Anxiety and/or depression
  • Claims of “feeling fat” despite being thin
  • Excessive exercise
  • Excessive use of restroom
  • Difficulty concentrating
  • Preoccupation with weight and eating
  • Avoidance of eating and eating situations
  • Use of laxatives and diet pills

Risk factors in the sport enviroment

  • Sport body stereotypes and belief that losing weight will increase sport performance
  • Pressure (real or perceived) from coaches and others to lose weight
  • Observed eating and exercise behaviors of teammates and competitors
  • Revealing uniforms
  • Similarity between “good athlete” traits and symptoms of disordered eating
  • Presumption of health based on good performance

Health consequences

  • Purging behaviors that cause electrolyte imbalances with possible irregular heartbeats and heart failure
  • Premature osteoporosis
  • Peptic ulcers, pancreatitis and gastric rupture

Performance consequences

  • Restricting carbohydrates can lead to glycogen depletion, forcing the body to compensate by converting protein into a less efficient form of energy and increasing the risk of muscle injury and weakness.
  • Intense dieting can negatively affect VO2 max and running speed for some student-athletes.
  • Because of inadequate nutrition, student-athletes with eating disorders tend to be malnourished, dehydrated, depressed, anxious and obsessed with eating, food and weight. These problems decrease concentration and the capacity to manage emotions.
  • Behaviors such as vomiting, excessive exercise and restricting carbohydrates often lead to dehydration, which can compromise performance.
  • Male and female student-athletes who are inadequately fueling their bodies may experience hormonal disruptions that lead to compromised bone density and increased risk of bone injuries, including stress fractures.

For more information, visit http://bjsm.bmj.com/content/48/7/491.full

Questions for reflection

  • Do you have a sense how to identify when a student-athlete is engaged in disordered eating?
  • Do you feel comfortable talking to student-athletes about weight and body composition?
  • Do you emphasize the importance of sound nutrition for optimal performance?
  • Do you communicate with other stakeholders about prevention, detection and treatment of disordered eating?
  • Do you know how to make a referral for a student-athlete with disordered eating?