Disordered Eating in Athletes – a Review

The BMC’s Journal of Eating Disorders reviews disordered eating in athletes. September 2020.

Ryley P. MancineDonald W. GusfaAli Moshrefi & Samantha F. Kennedy

Journal of Eating Disorders volume 8, Article number: 47 (2020)

Background

Disordered Eating (DE) shows a strong association with athletics and can lead to several negative mental and physical health effects. Traditionally, sports have been grouped based upon whether or not the sport emphasizes leanness as a competing factor. Due to sociocultural factors, risk for DE may also be associated with the sport type. The aim of this review is to critically analyze the available research and data in this field to consider the relationship between DE and sport type to see which factors influence prevalence among athletes

Method

A systematic review was completed using keywords specific to DE and sport types. Articles were either excluded due to lack of specification of athlete type or failure to use a standardized screening tool or interview for data collection.

Results

6 out of 7 studies found a significant increase in DE rates among lean sport types. When classifying by sport type reports were less consistent, but show non-lean sports also have increased rates of DE.

Conclusion

There are variations in prevalence of DE behaviors depending on athlete type. It is important to identify the risk for DE early in athletes so emphasis can be placed on treatment options to nullify progression to an eating disorder, lower negative impacts on an athlete’s performance, and prevent other negative health effects. Using sport groups is important to clinical practice as well as research, as certain sports may have a higher risk for development of DE.

Plain english summary

For athletes, disordered eating can progress to an eating disorder, which has a multitude of physical and mental health consequences. Certain types of athletes may be at an increased risk for disordered eating behaviors. This manuscript attempts to categorize sport types to determine which groups of athletes may have the highest incidence of disordered eating. It also attempts to determine if there are major differences in the presentation of disordered eating behaviors between different sport types. It is important to identify the risk for disordered eating in athletes of all types so that disordered eating behaviors may be halted before they progress to an eating disorder, which is much more difficult to treat. This systematic review of the literature aims to discover differences between the different types of sport as they relate to disordered eating behavior rates, risks, and pathologies.

Introduction

Over the past fifteen years, there has been an increase in research on eating pathology in sports [1]. Eating pathology is often described as a continuum ranging from disordered eating (DE) to a clinical eating disorder (ED). DE encompasses symptoms of dysfunctional eating patterns such as fasting, dieting, vomiting, over-eating, binge eating and use of laxatives and/or diet pills [2]. In athletes, DE frequently occurs due to the desire to achieve a sport-specific body-ideal and alleviate sport-specific body dissatisfaction [3]. DE can lead to EDs if left unaddressed and can cause increased incidence of mood, anxiety, and substance abuse disorders [45]. ED are clinical diagnoses that meet DSM-5 criteria, including Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Other Specified Feeding and Eating Disorder (OSFED) [67].

Estimates of the prevalence of DE among athletes varies widely in research due to the different populations of athletes studied (different sports, ages, levels of competitiveness, gender, etc.). In a study of DE amongst elite adolescent athletes by Martinsen et al., 606 Norwegian first year elite sport high school athletes reported higher prevalence of DE compared to the control group [8]. It was found that in the athlete group there was a significantly higher prevalence of DE in females who participated in lean sports compared to males in the same group [8]. Athletes competing in sports such as gymnastics, figure skating, diving, and dancing, where leanness is emphasized, have been found to be at higher risk of DE, which frequently leads to a decrease in sport performance [9].

Perfectionism plays a role in the psychological impact of DE in an athlete, acting both as a symptom and a risk factor for DE [10]. Perfectionism often influences an athlete to have unrealistic expectations, which can result in dissatisfaction with body image and sport performance [5]. Research has found a correlation between DE and perfectionism, with an emphasis on precision and personal expectation for an athlete to achieve a sport-specific body to improve performance [10].

The female athlete triad encompasses three disorders in female athletes: DE, amenorrhea and osteoporosis [11]. This is demonstrated in the desire to lose weight to achieve a sport-specific body ideal, commonly resulting in an energy deficit, which may lead to amenorrhea and osteoporosis. Additionally, this energy deficit will ultimately result in poor performance [10]. A study by Cobb et al. examined 91 competitive female distance runners ages 18–26 years and found that female runners with poor nutrition and irregular eating patterns had an energy imbalance, which often led to amenorrhea [12]. The female athlete triad refers to female athletes of all kinds of sports, regardless of sport type category. While the term ‘female athlete triad’ has been established for many years, more recently the term ‘Relative Energy Deficiency in Sport’ (RED-S) has been used to describe these same three traits coupled with a multitude of other systemic consequences that are associated with low energy availability [13]. RED-S syndrome demonstrates the multitude of physiological consequences associated with DE, such as hematological, cardiovascular, and gastrointestinal disruptions.

Athletes can be divided into lean and non-lean categories. Lean sports emphasize achieving and maintaining a lower body weight due to the belief that lower body weight improves performance [8]. A few examples of lean sports include dancing, judo, long-distance running, swimming, and diving [814]. Alternatively, non-lean sports do not require a low body weight in order for an athlete to be competitive [15]. Some non-lean sports include golf, basketball, table tennis, and horse riding [8]. Lean sports may increase risk for DE because athletes may engage in pathogenic weight-control behavior to achieve a lower body weight [16]. A study by Kong et al. found athletes participating in lean sports scored higher on the Eating Attitudes Test (EAT-26) compared to athletes competing in non-lean sports. Additionally, lean sport athletes reported significantly more eating pathology compared to non-competitive athletes with 84% of the female athletes who screened positive participating in lean sports [1517]. Examples of sports that fit into each category, along with categories of sports that make up lean and non-lean sports, are referenced in Fig. 1.

figure1
Fig. 1

Sports can be further divided into six categories: aesthetic, weight-dependent, endurance, ball game, power, and technical sports [18]. Of these categories, aesthetic, weight-dependent and endurance sports are typically considered lean sports, whereas ball game, power and technical sports are considered non-lean sports.

In aesthetic sports, the performance of an individual or team is assessed by a judge or judges of the competition [19]. In aesthetic sports, the winner is determined by judging an individual or team performance using a complex set of rules [19]. Thus, appearance is a major factor in the judging. Examples of aesthetic sports include gymnastics, diving, figure skating, dancing, ballet [16]. All of these sports are considered lean sports due to the pervasive belief that a lower body weight results in more favorable judging [20].

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