Eating Disorders in Athletes

Chapter 39
Eating Disorders in Athletes
JORUNN SUNDGOT-BORGEN
Introduction
Athletes seem to be at increased risk of developing eating disorders, and studies indicate that
specific risk factors for the development of eating
disorders occur in some sport settings.
The diagnosis of an eating disorder in athletes
can easily be missed unless specifically searched
for. Counselling on wise food choices and eating
habits will be helpful for most athletes and the
role of the sport nutritionist in working with athletes with eating disorders is crucial. Therefore,
nutritionists should have good knowledge of
the symptomatology of eating disorders, how to
approach the athlete and how to establish trust
that can lead to effective treatment.
If untreated, eating disorders can have longlasting physiological and psychological effects
and may even be fatal. For a number of reasons,
there is a strong pattern of denial, and a standardized scale or a diagnostic interview specific
for athletes must be obtained.
This chapter reviews the characteristics of
eating disorders, their prevalence, and risk
factors for the development of eating disorders in
sport. Practical implications for the identification
and treatment of eating-disordered athletes and
the need for future research are also discussed.
Characteristics of eating disorders
As described in the Diagnostic and Statistical
Manual of Mental Disorders (DSM), eating disorders are characterized by gross disturbances
510
in eating behaviour. They include anorexia
nervosa, bulimia nervosa and eating disorder not
otherwise specified (American Psychiatric Association 1987).
Anorexia nervosa is characterized in individuals by a refusal to maintain body weight over a
minimal level considered normal for age and
height, a distorted body image, an intense fear of
fatness or weight gain while being underweight,
and amenorrhoea (the absence of at least three
consecutive menstrual cycles). Individuals with
anorexia ‘feel fat’ while they are underweight
(American Psychiatric Association 1987).
Bulimia nervosa is characterized by binge
eating (rapid consumption of a large amount of
food in a discrete period of time) and purging.
This typically involves consumption of caloriedense food, usually eaten inconspicuously or
secretly. By relieving abdominal discomfort
through vomiting, the individual can continue to
binge (American Psychiatric Association 1987).
The eating disorder not otherwise specified
category is for disorders of eating that do not
meet the criteria for any specific eating disorder
(American Psychiatric Association 1994).
Athletes constitute a unique population and
special diagnostic considerations should be
applied when working with this group (Szmuckler et al. 1985; Sundgot-Borgen 1993; Thompson
& Trattner-Sherman 1993). An attempt has been
made to identify athletes who show significant
symptoms of eating disorders, but who do not
meet the DSM criteria for anorexia nervosa
or bulimia nervosa. These athletes have been
eating disorders in athletes
classified as having a subclinical eating disorder
termed anorexia athletica (Sundgot-Borgen
1994a).
It is assumed that many cases of anorexia
nervosa and bulimia nervosa begin as subclinical
variants of these disorders. Early identification
and treatment may prevent development of the
full disorder (Bassoe 1990). Subclinical cases are
more prevalent than those meeting the formal
diagnostic criteria for anorexia nervosa and
bulimia nervosa (Sundgot-Borgen 1994a).
Prevalence
Data on the prevalence of eating disorders in athletic populations are limited and equivocal.
Most studies have looked at symptoms of eating
disorders such as preoccupation with food and
weight, disturbed body image, or the use of
pathogenic weight control methods.
511
Methodological weaknesses such as small
sample size, lack of definition of the competitive
level or type of sport(s) and lack of definition of
the data collection method used characterize
most of the studies attempting to study the
prevalence of eating disorders (Sundgot-Borgen
1994b).
Only one study has used clinical evaluation
and the DSM criteria applied across athletes and
controls (Sundgot-Borgen 1994a). The prevalence of anorexia nervosa (1.3%) seems to
be within the same range as that reported in
non-athletes (Andersen 1990), whereas bulimia
nervosa (8.2%) and subclinical eating disoders
(8%) seem to be more prevalent among female
athletes than non-athletes (Sundgot-Borgen
1994a). The prevalence of eating disorders was
significantly higher among athletes competing
in aesthetic and weight-dependent sports than
among other sport groups where leanness is considered less important (Fig. 39.1).
Female athletes
Estimates of the prevalence of the symptoms
of eating disorders and true eating disorders
among female athletes range from less than 1% to
as high as 75% (Gadpalle et al. 1987; BurckesMiller & Black 1988; Warren et al. 1990; SundgotBorgen 1994a).
Male athletes
Results from existing studies on male athletes
indicate that the frequency of eating disturbances and pathological dieting practices varies
from none to 57%, depending on the definition
used and the population studied (Dummer et al.
Fig. 39.1 Prevalence of eating
disorders in female elite athletes
representing: G1, technical sports
(n = 98); G2, endurance sports
(n = 119); G3, aesthetic sports
(n = 64); G4, weight-dependent
sports (n = 41); G5, ball games
(n = 183); G6, power sports
(n = 17); and non-athletes
(n = 522). The data are shown as
mean and 95% confidence
intervals. The shaded area is the
95% confidence interval for the
control group of non-athletes.
Subjects with eating disorder (%)
50
40
30
20
10
*
0
G1
G2
G3
G4
Sports groups
G5
G6
Non-athletes
512
practical issues
1987; Burckes-Miller & Black 1988; Rosen &
Hough 1988; Rucinski 1989).
Only one study on male athletes has used the
DSM criteria to diagnose eating disturbances.
The prevalence of clinically diagnosed eating
disorders in Norwegian male elite athletes is 8%
compared to 0.5% in matched controls (Torstveit
et al. 1998).
In a study by Blouin and Goldfield (1995),
bodybuilders reported significantly greater body
dissatisfaction, a high drive for bulk, a high drive
for thinness, increased bulimic tendencies and
more liberal attitudes towards using steroids
than runners and martial artists.
Sykora et al. (1993) compared eating, weight
and dieting disturbances in male and female
lightweight and heavyweight rowers. Females
displayed more disturbed eating and weight
control methods than did males. Male rowers
were more affected by weight restriction than
were female rowers, probably because they
gained more during the off-season. Lightweight
males showed greater weight fluctuation during
the season and gained more weight during the
off season than did lightweight females and
heavyweight males and females. Despite the
methodological weaknesses, existing studies
are consistent in showing that symptoms of
eating disorders and pathogenic weight-control
methods are more prevalent in athletes than
non-athletes, and more prevalent in sports in
which leanness or a specific weight are considered important, than among athletes competing
in sports where these factors are considered less
important (Hamilton et al. 1985, 1988; Rosen et al.
1986; Dummer et al. 1987; Sundgot-Borgen &
Corbin 1987; Rosen & Hough 1988; Wilmore
1991; Sundgot-Borgen 1994b; O’Connor et al.
1996).
Furthermore, the frequency of eating disorder
problems determined by questionnaire only is
much higher than the frequency reported when
athletes have been clinically evaluated (Rosen
& Hough 1988; Rucinski 1989; Sundgot-Borgen
1994b).
Self reports vs. clinical interview
Elite athletes underreport the use of purging
methods such as laxatives, diuretics and vomiting and the presence of an eating disorder, and
overreport the use of binge eating when data are
obtained in the questionnaire (Sundgot-Borgen
1994a). Therefore, it is the author’s opinion that
to determine whether an athlete actually suffers
from any of the eating disorders described, an
interview with a clinician is necessary to assess
an athlete’s physical and emotional condition,
and whether this interferes with everyday
functioning.
Firm conclusions about the optimum methods
of assessment and the prevalence of disordered
eating at different competitive level cannot be
drawn without longitudinal studies with a
careful classification and description of the competitive level of the athletes investigated.
Risk factors
Psychological, biological and social factors are
implicated in the development of eating disorders (Katz 1985; Garner et al. 1987). Athletes
appear to be more vulnerable to eating disorders
than the general population, because of additional stresses associated with the athletic
environment (Hamilton et al. 1985; Szmuckler
et al. 1985). It is assumed that some risk factors
(e.g. intense pressure to be lean, increased
training volume and perfectionism) are more
pronounced in elite athletes.
Hamilton et al. (1988) found that less skilled
dancers in the United States reported significantly more eating problems than the more
skilled dancers. On the other hand, Garner et al.
(1987) found that dancers at the highest competitive level had a higher prevalence of eating disorders than dancers at lower competitive levels.
A biobehavioural model of activity-based
anorexia nervosa was proposed in a series of
studies by Epling and Pierce (1988) and Epling et
al. (1983) and there are some studies indicating
that the increased training load may induce an
energy deficit in endurance athletes, which in
eating disorders in athletes
turn may elicit biological and social reinforcements leading to the development of eating
disorders (Sundgot-Borgen 1994a). Thus, longitudinal studies with close monitoring of a
number of sport-specific factors such as volume,
type and intensity of the training in athletes representing different sports are needed before the
question regarding the role played by different
sports in the development of eating disorders can
be answered.
Also, starting sport-specific training at prepubertal age may prevent athletes from choosing
the sport most suitable for their adult body type.
Athletes with eating disorders have been shown
to start sport-specific training at an earlier age
than athletes who do not meet the criteria for
eating disorders (Sundgot-Borgen 1994a).
In addition to the pressure to reduce weight,
athletes are often pressed for time, and they may
have to lose weight rapidly to make or stay on
the team. As a result, they often experience frequent periods of restrictive dieting or weight
cycling (Sundgot-Borgen 1994a). Such periods
have been suggested as important risk or trigger
factors for the development of eating disorders
in athletes (Brownell et al. 1987; Sundgot-Borgen
1994a).
Pressure to reduce weight has been the general
explanation for the increased prevalence of
eating-related problems among athletes. It is not
necessarily dieting per se, but the situation in
which the athlete is told to lose weight, the words
used, and whether the athlete receives guidance
or not, that are important.
The characteristics of a sport (e.g. emphasis on
leanness or individual competition) may interact
with the personality traits of the athlete to start
or perpetuate an eating disorder (Wilson &
Eldredge 1992). Finally, athletes have reported
that they developed eating disorders as a result
of an injury or illness that left them temporarily
unable to continue their normal level of exercise
(Katz 1985; Sundgot-Borgen 1994a). An injury
can curtail the athlete’s exercise and training
habits. As a result, the athlete may gain weight
due to the reduced energy expenditure, or the
athlete may develop an irrational fear of weight
513
gain. In either case, the athlete may begin to diet
as a means of compensating (Thompson &
Trattner-Sherman 1993). Thus, the loss of a coach
or unexpected illness or injury can probably be
regarded as traumatic events similar to those
described as trigger mechanisms for eating disorders in non-athletes (Bassoe 1990).
Most researchers agree that coaches do not
cause eating disorders in athletes, although inappropriate coaching may trigger the problem
or exacerbate it in vulnerable individuals
(Wilmore 1991). Therefore, in most cases the role
of coaches in the development of eating disorders in athletes should be seen as a part of a
complex interplay of factors.
Figure 39.2 illustrates an aetiological model for
the development of eating disorders in athletes.
Medical issues
Whereas most complications of anorexia nervosa
occur as a direct or indirect result of starvation,
complications of bulimia nervosa occur as a
result of binge eating and purging (Thompson &
Trattner-Sherman 1993). Hsu (1990), Johnson and
Connor (1987) and Michell (1990) provide information on the medical problems encountered in
eating-disordered patients.
Studies have reported mortality rates from
less than 1% to as high as 18% in patients
with anorexia nervosa in the general population
(Thompson & Trattner-Sherman 1993).
Death is usually attributable to fluid and electrolyte abnormalities or to suicide (Brownell
& Rodin 1992). Mortality in bulimia nervosa is
less well studied, but deaths do occur, usually
secondary to the complications of the binge–
purging cycle or to suicide. Mortality rates
from eating disorders among athletes are not
known.
For years, athletes have used and abused
drugs to control weight. Some athletes use
dieting, bingeing, vomiting, sweating and fluid
restriction for weight control. It is clear that many
of these behaviours exist on a continuum, and
may present health hazards for the athlete. Laxatives, diet pills and diuretics are probably the
514
practical issues
Restrictive eating
Weight loss and
improved performance
Positive feedback from
'important others'
Athlete has feeling of total control
Intensified behaviour
Loss of control, reduced
performance
type of drugs most commonly abused by athletes
while eating-disordered dancers also report the
use of marijuana, cocaine, tranquillizers and
amphetamines (Holderness et al. 1994). Eight per
cent of the Norwegian elite athletes suffering
from eating disorders reported a regular use of
diuretics and a significantly higher number
reported the use of laxatives, vomiting, and diet
pills (Sundgot-Borgen & Larsen 1993b). It should
be noted that diet pills often contain drugs in the
stimulant class, and that both these and diuretics
are banned by the IOC.
Identifying athletes with eating disorders
anorexia nervosa and
anorexia athletica
Most individuals with anorexia athletica do not
realize that they have a problem, and therefore
do not seek treatment on their own. Only if these
athletes see that their performance level is levelling off might they consider seeking help. The
following physical and psychological characteristics may indicate the presence of anorexia
nervosa or anorexia athletica.
The physical symptoms of athletes with
anorexia nervosa or anorexia athletica (Thompson & Trattner-Sherman 1993) include:
1 significant weight loss beyond that necessary
for adequate sport performance;
2 amenorrhoea or menstrual dysfunction;
Eating disorders
Fig. 39.2 Aetiological model for
the development of eating
disorders in athletes.
3 dehydration;
4 fatigue beyond that normally expected in
training or competition;
5 gastrointestinal problems (i.e. constipation,
diarrhoea, bloating, postprandial distress);
6 hyperactivity;
7 hypothermia;
8 bradycardia;
9 lanugo;
10 muscle weakness;
11 overuse injuries;
12 reduce bone mineral density;
13 stress fractures.
The psychological and behavioral characteristics of athletes with anorexia nervosa and
anorexia athletica (Thompson & TrattnerSherman 1993; Sundgot-Borgen 1994b) include:
1 anxiety, both related and unrelated to sport
performance;
2 avoidance of eating and eating situations;
3 claims of ‘feeling fat’ despite being thin;
4 resistance to weight gain or maintenance
recommended by sport support staff;
5 unusual weighing behavior (i.e. excessive
weighing, refusal to weigh, negative reaction to
being weighed);
6 compulsiveness and rigidity, especially
regarding eating and exercise;
7 excessive or obligatory exercise beyond that
required for a particular sport;
8 exercising while injured despite prohibitions
by medical and training staff;
eating disorders in athletes
9 restlessness — relaxing
is
difficult
or
impossible;
10 social withdrawal from teammates and sport
support staff, as well as from people outside
sports;
11 depression;
12 insomnia.
b u l i m i a n e rvo sa
Most athletes suffering from bulimia nervosa
are at or near normal weight. Bulimic athletes
usually try to hide their disorder until they feel
that they are out of control, or when they realize
that the disorder negatively affects sport performance. Therefore, the team staff must be able to
recognize the following physical symptoms and
psychological characteristics.
The physical symptoms of athletes with
bulimia nervosa (Thompson & Trattner-Sherman
1993) include:
1 callus or abrasion on back of hand from
inducing vomiting;
2 dehydration, especially in the absence of
training or competition;
3 dental and gum problems;
4 Oedema, complaints of bloating, or both;
5 electrolyte abnormalities;
6 frequent and often extreme weight fluctuations (i.e. mood worsens as weight goes up);
7 gastrointestinal problems;
8 low weight despite eating large volumes;
9 menstrual irregularity;
10 muscle cramps, weakness, or both;
11 swollen parotid glands.
The psychological and behavioural characteristics of athletes with bulimia nervosa
(Thompson & Trattner-Sherman 1993) include:
1 binge eating;
2 agitation when bingeing is interrupted;
3 depression;
4 dieting that is unnecessary for appearance,
health or sport performance;
5 evidence of vomiting unrelated to illness;
6 excessive exercise beyond that required for
the athlete’s sport;
7 excessive use of the restroom;
515
8 going to the restroom or ‘disappearing’ after
eating;
9 self-critical, especially concerning body,
weight and sport performance
10 secretive eating;
11 substance abuse — whether legal, illegal, prescribed, or over-the-counter drugs, medications
or other substances;
12 use of laxatives, diuretics (or both) that is
unsanctioned by medical or training staff.
Laboratory investigations recommended for
all eating-disordered patients, those indicated
for particular patients and those of academic
interest with expected finding are discussed by
Beumont et al. (1993).
Eating pattern and dietary intake in
elite eating-disordered athletes
The eating-disordered athlete’s attitude to eating
and nutrition is often based on myths and misconceptions. Most eating-disordered athletes
report that the onset of their eating disorder
was preceded by a period of dieting or weight
cycling. Apart from the binge eating, most bulimics, as well as the anorexia athletica and anorexia
nervosa patients, show restrictive eating pattern.
In a study of female elite athletes, as many as
29% of the anorexia nervosa, 14% of the anorexia
athletica and 60% of the bulimia nervosa, and
13% of the healthy athletes reported having two
or fewer meals a day (Sundgot-Borgen & Larsen
1993a). Bulimic athletes have fewer meals per
day than athletes with anorectic symptoms. For a
number of eating-disordered athletes, the duration between meals is 7–11 h. Thus, it is not difficult to understand why such a high number of
eating-disordered athletes binge and purge on
a regular basis. In the same study, eatingdisordered athletes reported that they had irregular eating pattern even before the eating disorder developed. Therefore, this may be an
adapted and ‘normal’ eating pattern for these
young female athletes, and as such, a possible
risk factor for the development of eating disorders. These results indicate the need for teaching young athletes and their parents about
516
practical issues
the importance of meal planning and to make
it possible to have the meals fitted into their
schedule.
Eating-disordered athletes, except for the
bulimic athletes, consume a diet that is too low in
energy and nutrients. The mean levels of energy
and carbohydrate intake for anorexia athletica
are lower than recommended for active females,
and a significant number of eating-disordered
athletes do not reach the protein level recommended for athletes. In addition, low intakes
of several micronutrients are reported, most
notably calcium, vitamin D and iron (SundgotBorgen & Larsen 1993a). The inadequacy
reported, combined with the use of different
purging methods, are of major concern since
a number of eating-disordered athletes are
young and still growing individuals. Again,
the guidance of qualified nutritionists for the
athletic population in general and specifically
for the athlete at risk for eating disorder is
crucial.
Athletes representing sports emphasizing
leanness such as the rhythmic gymnasts are
exposed to nutrition and weight-control myths.
The author has worked specifically with national
level rhythmic gymnasts and these athletes
reported a number of nutritional myths that
partly explain why such a high number of
those athletes are suffering from eating disorders. These include: never eat after 5 p.m.;
3360 kJ · day–1 (800 kcal · day–1) is enough for
rhythmic gymnasts; eat only cold food because
you spend more energy digesting cold food; do
not eat meat, bread or potatoes; and drinking
during training will destroy your practice.
Athletes, coaches, and in some sports also
the parents, need to be educated about weight
control, sound nutrition, and ‘natural’ growth
and development. The focus on leanness must be
de-emphasized and the unwritten rules in some
sports changed. Eating disorders are likely to be
a special problem within those sports where the
competitors are young (still growing) and leanness is considered important for top performance, unless limits are placed on age and
percentage fat for participants in sports.
Effect of eating disorders on
sport performance
The nature and the magnitude of the effect of
eating disorders on athletic performance are
influenced by the severity and chronicity of the
eating disorder and the physical and psychological demands of the sport. Loss of endurance due
to dehydration impairs exercise performance
(Fogelholm 1994). Absolute maximal oxygen
uptake (measured as litres per minute) is
unchanged or decreased after rapid body weight
loss, but maximal oxygen uptake expressed in
relation to body weight (millilitres per kilogram
body weight per minute) may increase after
gradual body weight reduction (Ingjer &
Sundgot-Borgen 1991; Fogelholm 1994).
Anaerobic performance and muscle strength
are typically decreased after rapid weight reduction even after 1–3 h of rehydration. When tested
after 5–24 h of rehydration, performance is
maintained at euhydrated levels (Klinzing &
Karpowicz 1986; Fogelholm et al. 1993). Loss of
coordination due to dehydration is also reported
to impair exercise performance (Fogelholm
1994).
Reduced plasma volume, impaired thermoregulation and nutrient exchange, decreased
glycogen availability and decreased buffer
capacity in the blood are plausible explanations
for reduced performance in aerobic, anaerobic
and muscle endurance work, especially after
rapid weight reduction (Fogelholm 1994).
Psychological effects
Studies on the psychological effect of dieting and
weight cycling are lacking in female athletes, but
it is reported that many young wrestlers experience mood alterations (increased fatigue, anger,
or anxiety) when attempting to lose body weight
rapidly (Fogelholm et al. 1993).
Long-term health effects
The long-term effects of body-weight cycling and
eating disorders in athletes are not clear. Biologi-
eating disorders in athletes
cal maturation and growth have been studied in
girl gymnasts before and during puberty: there
are sufficient data to conclude that young female
gymnasts are smaller and mature later than
females in sports which do not require extreme
leanness, e.g. swimming (Mansfield & Emans
1993; Theintz et al. 1993). It is, however, difficult
to separate the effects of physical strain, energy
restriction and genetic predisposition to delayed
puberty.
Besides increasing the likelihood of stress fractures, early bone loss may prevent normal peak
bone mass from being achieved. Thus, female
athletes with frequent or longer periods of
amenorrhoea may be at high risk of sustaining
fractures.
More longitudinal data on fast and gradual
body-weight reduction and cycling in relation to
health and performance parameters in different
groups of athletes are clearly needed.
Treatment of eating disorders
Eating-disordered athletes usually are involved
in outpatient treatment and are likely to be
included in several modes of treatment. Typically, these include individual, group and family
therapy. Nutritional counselling is usually
combined with cognitive therapy. For some
athletes, pharmacotherapy may be included as
an adjunct. The different types of treatment
strategies have been described elsewhere
(Thompson & Trattner-Sherman 1993). Nutrition
counselling is discussed in this chapter.
Since most athletes with eating disorders are
females, the athlete/patient will be referred to as
she.
The formal treatment of athletes with eating
disorders should be undertaken only by health
care professionals. Ideally, these individuals
should also be familiar with the sport environment. Treatment of eating-disordered athletes
ideally involves a team of a physician, physiologist, nutritionist and, in some cases, a psychologist. The dietitians should be trained and
experienced in working with individuals with
eating disorders and understand the demands of
517
the specific sports. The nutritionist must understand how strongly the athlete identifies with the
sport as well as what the athlete perceives as
demands from coaches and ‘important’ others.
Once the eating disorder is diagnosed, the goal
is to modify the behavioural, cognitive and affective components of the athlete’s eating disorder
and to develop a rational approach for achieving
self-management of healthy diet, optimal weight
and integration of these in the training programme (Clark 1993).
Nutritional counselling
Individuals with eating disorders do not remember what constitutes a balanced meal or ‘normal’
eating. The major roles for the nutritionist seems
to be an evaluator, nutrition educator and counsellor, behaviour manager, and active member of
the treatment team. The suggested nutritional
counselling programme is the one developed by
Hsu (1990). This nutritional programme is based
on the assumption that eating disorders are initiated and maintained by semistarvation, and that
adequate nutrition knowledge will, in most
instances, result in healthy eating behaviour,
which in turn will eliminate the semistarvation
and the binge–purge cycle. The aims of the nutritional counselling programme are: (i) to enable
the patient to understand principles of good
nutrition, her nutritional needs, and the relationships between dieting and overeating and (ii) to
establish and maintain a pattern of regular eating
through meal planning.
Nutritional status and body-weight history
Nutrition counselling can help the athlete overcome an eating disorder by clarifying misconceptions and focusing on the role of nutrition in
promoting health and athletic performance. For
athletes who have been suffering for years, readiness to listen should be assessed in conjunction
with a mental health professional. Before nutritional counselling can begin, training volume,
training intensity, body-weight history and
nutritional status should be determined. Body-
518
practical issues
weight history of the parents and siblings should
be obtained. The eating-disordered athlete’s
weight and bodybuild expectations may be
beyond that which is genetically possible. After
gaining the athlete’s trust, the dietitian should
conduct body-fat measurements. It is crucial to
obtain a measure of body fat in order to establish
realistic goals, which also depend on the athlete’s
sport (Eisenman et al. 1990).
Laboratory tests
Blood and urine laboratory tests will provide
differential diagnoses for observed symptoms.
Such values as haemoglobin, haematocrit,
albumin, ferritin, glucose, potassium, sodium,
total and high-density lipoprotein cholesterol,
and oestrogen (if applicable) should be obtained
initially and monitored over time. These can
be shared with the athlete during treatment to
indicate restoration of health (Beumont et al.
1993).
Self-esteem of eating-disordered athletes who
have suffered for a longer period tends to be
quite low and this may be associated with an
experience of decreased performance level and
often unrealistic expectations. Therefore, one
important issue is to determine the athlete’s
motivation for continuing competitive sport. The
author’s experience is that some athletes even try
to simulate an eating disorder to legalize the end
of their career.
Treatment goals and expectations
The primary focuses of the nutrition counselling
are normalizing eating behaviours, body weight
and exercise behaviour. Athletes have the same
general concerns as non-athletes about increasing their weight, but they also have concerns
from a sport point of view. What they think is an
ideal competitive weight, one that they believe
helps them be successful in their sport, may be
significantly lower than their treatment goal
weight. As a result, athletes may have concerns
about their ability to perform in their sport following treatment.
Training and competition
Once an athlete has been found to be in need of
treatment, an important question is whether she
should be allowed to continue to train and
compete while recovering from the disorder.
To continue competition and training, the
following list represents what Thompson and
Trattner-Sherman (1993) believe are the minimal
criteria in this regard.
1 The athlete must agree to comply with all treatment strategies as best she can.
2 She must genuinely want to compete.
3 She must be closely monitored on an ongoing
basis by the medical and psychological health
care professionals handling her treatment and by
the sport-related personnel who are working
with her in her sport.
4 The treatment must always take precedence
over sport.
5 If any question arises at any time regarding
whether the athlete is meeting or is able to meet
the preceding criteria, competition is not to be
considered a viable option while the athlete is in
treatment (Clark 1993; Thompson & TrattnerSherman 1993).
Some athletes should be allowed to compete
while in aftercare if not medically or psychologically contraindicated. As mentioned previously,
it is extremely important to examine whether the
athlete really wants to go back to competitive
sport. If so, she should be allowed to do so as
soon as she feels ready for it when finishing treatment and if she is in good health.
Limited training and competition
while in treatment
If the criteria mentioned above for competing
cannot be met, or if competition rather than
physical exertion is a problem, some athletes
who are not competing may still be allowed to
engage in limited training. The same criteria
used to assess the safety of competition (i.e.
diagnosis, problem severity, type of sport,
competitive level and health maintenance) apply
(Thompson & Trattner-Sherman 1993).
eating disorders in athletes
If the athlete is ready to get over her disorder,
allowing her to continue with her sport with
minimal risk when she really wants to continue
can enhance the motivation for and the effect of
treatment.
It is the author’s experience that a total suspension is not a good solution. Therefore, if she
wants to compete after treatment and no medical
complications are present, she should be allowed
to train, but usually at a lower volume and at a
decreased intensity.
The athlete’s family may be involved in the
process of getting the athlete into treatment.
One factor affecting this involvement is the
athlete’s age — the younger the athlete, the more
the family’s involvement is recommended.
Health maintenance standards
If the athlete meets the criteria just mentioned,
the ‘bottom-line standards’ regarding health
maintenance must be imposed to protect the
athlete. The treatment staff determine these
and individually tailor them according to the
athlete’s particular condition. These standards
may vary between individual athletes or by
sport.
According to Thomson and TrattnerShermann (1993), athletes should maintain at a
minimum a weight of no less than 90% of ‘ideal’
weight. This is not sport-related, but healthrelated body weight. The athlete should eat at
least three balanced meals a day, consisting of
enough energy to sustain the pre-established
weight standard the dietitian has proposed.
Athletes who have been amenorrhoeic for 6
months or more should undergo a gynaecological examination to consider hormone replacement therapy. In addition, bone-mineral density
should be assessed and results should be within
the normal range.
Prevention of eating disorders
in athletes
Since the exact causes of eating disorders are
unknown, it is difficult to draw up preventive
519
strategies. Coaches should realize that they can
strongly influence their athletes. Coaches or
others involved with young athletes should not
comment on an individual’s body size, or require
weight loss in young and still-growing athletes.
Without offering further guidance, dieting may
result in unhealthy eating behaviour or eating
disorders in highly motivated and uninformed
athletes (Eisenman et al. 1990). Early intervention
is also important, since eating disorders are
more difficult to treat the longer they progress.
However, most important of all is the prevention
of circumstances or factors which could lead to
an eating disorder. Therefore, professionals
working with athletes should be informed about
the possible risk factors for the development of
eating disorders, the early signs and symptoms,
the medical, psychological and social consequences of these disorders, how to approach the
problem if it occurs, and what treatment options
are available.
Weight-loss recommendation
A change in body composition and weight loss
can be achieved safely if the weight goal is realistic and based on body composition rather than
weight-for-height standards.
1 The weight-loss programme should start well
before the season begins. Athletes must consume
regular meals, sufficient energy and nutrients to
avoid menstrual irregularities, loss of bone mass,
loss of muscle tissue and the experience of compromised performance.
2 The health care personnel should set realistic
goals that address methods of dieting, rate of
weight change, and a reasonable target range of
weight and body fat.
3 Change in body composition should be monitored on a regular basis to detect any continued
or unwarranted losses or weight fluctuations.
4 Measurements of body composition should be
done in private to reduce the stress, anxiety, and
embarrassment of public assessment.
5 A registered dietitian who knows the demands
of the specific sport should be involved to
plan individual nutritionally adequate diets.
520
practical issues
Throughout this process, the role of overall good
nutrition practices in optimizing performance
should be emphasized.
6 If the athlete exhibits symptoms of an eating
disorder, the athlete should be confronted with
the possible problem.
7 Coaches should not try to diagnose or treat
eating disorders, but they should be specific
about their suspicions and talk with the athlete
about the fears or anxieties they may be having
about food and performance. Medical evaluation
should be encouraged and appropriate support
given to the athlete.
8 The coach should assist and support the
athlete during treatment.
Conclusion
1 The prevalence of eating disorders is higher
among female athletes than non-athletes, but the
relationship to performance or training level is
unknown. Athletes competing in sports where
leanness or a specific weight are considered
important are more prone to eating disorders
than athletes competing in sports where these
factors are considered less important. The
number of male athletes who meet the eating disorder criteria is unknown and such prevalence
studies are needed.
2 It is not known whether eating disorders are
more common among elite athletes than among
less successful athletes. Therefore, it is necessary
to examine anorexia nervosa, bulimia nervosa,
and subclinical eating disorders and the range of
behaviours and attitudes associated with eating
disturbances in athletes representing different
sport and competitive level to learn how these
clinical and subclinical disorders are related.
3 Clinical interviews seem to be superior to
self-report methods for determining the prevalence of eating disorders. However, because
of methodological weaknesses in the existing
studies, including deficient description of the
populations investigated and procedures for
data collection, the best instruments or interview
methods are not known. Therefore, there is a
need to validate self-report and interview guides
with athletes and identify the conditions under
which self-reporting of eating disturbances is
most likely to be accurate.
4 Interesting suggestions about possible sportspecific risk factors for the development of eating
disorders in athletes exist, but large-scale longitudinal studies are needed to learn more about
risk factors and the aetiology of eating disorders
in athletes at different competitive levels and
within different sports.
5 Once the eating disorder is diagnosed, the
goal is to modify the behavioural, cognitive,
and affective components of the athlete’s eating
disorder. Treatment of athletes ideally involves
a team of a physician, physiologist, nutritionist
and, in some cases, a psychologist. The dietitians
should be trained and experienced in working
with individuals with eating disorders and
understand the demands of different sports.
6 More knowledge about the short- and longterm effects of weight cycling and eating disorders upon the health and performance of athletes
is needed.
References
American Psychiatric Association (1987) Diagnostic
and Statistical Manual of Mental Disorders, 3rd edn.
American Psychiatric Association, Washington,
DC.
American Psychiatric Association (1994) Diagnostic
and Statistical Manual of Mental Disorders, 4th edn.
American Psychiatric Association, Washington, DC.
Andersen, A.E. (1990) Diagnosis and treatment of
males with eating disorders. In Males with Eating
Disorders (ed. A.E. Andersen), pp. 133–162.
Brunner/Mazel, New York.
Bassoe, H.H. (1990) Anorexia/Bulimia nervosa: the
development of anorexia nervosa and of mental
symptoms — treatment and the outcome of the
disease. Acta Psychiatrica Scandinavica 82, 7–13.
Beumont, P.J.V., Russell, J.D. & Touyz, S.W. (1993)
Treatment of anorexia nervosa. Lancet 26, 1635–1640.
Blouin, A.G. & Goldfield, G.S. (1995) Body image and
steroid use in male body builders. International
Journal of Eating Disorders 2, 159–165.
Brownell, K.D. & Rodin, J. (1992) Prevalence of eating
disorders in athletes. In Eating, Body Weight and Performance in Athletes: Disorders of Modern Society (ed.
K.D. Brownell, J. Rodin & J.H. Wilmore), pp. 128–143.
Lea and Febiger, Philadelphia.
eating disorders in athletes
Brownell, K.D., Steen, S.N. & Wilmore, J.H. (1987)
Weight regulation practices in athletes: analysis of
metabolic and health effects. Medicine and Science in
Sports and Exercise 6, 546–560.
Burckes-Miller, M.E. & Black, D.R. (1988) Male and
female college athletes: prevalence of anorexia
nervosa and bulimia nervosa. Athletic Training 2,
137–140.
Clark, N. (1993) How to help the athlete with bulimia:
practical tips and case study. International Journal of
Sport Nutrition 3, 450–460.
Dummer, G.M., Rosen, L.W. & Heusner, W.W. (1987)
Pathogenic weight-control behaviors of young competitive swimmers. Physician and Sportsmedicine 5,
75–86.
Eisenman, P.A., Johnson, S.C. & Benson, J.E. (1990)
Coaches Guide to Nutrition and Weight Control, 2nd
edn. Leisure Press, Champaign, IL.
Epling, W.F. & Pierce, W.D. (1988) Activity based
anorexia nervosa. International Journal of Eating Disorders 7, 475–485.
Epling, W.F., Pierce, W.D. & Stefan, L. (1983) A theory of
activity based anorexia. International Journal of Eating
Disorders 3, 27–46.
Fogelholm, M. (1994) Effects of bodyweight reduction
on sports performance. Sports Medicine 4, 249–267.
Fogelholm, G.M., Koskinen, R. & Laakso, J. (1993)
Gradual and rapid weight loss: effects on nutrition
and performance in male athletes. Medicine and
Science in Sports and Exercise 25, 371–377.
Gadpalle, W.J., Sandborn, C.F. & Wagner, W.W. (1987)
Athletic amenorrhea, major affective disorders and
eating disorders. American Journal of Psychiatry 144,
939–943.
Garner, M.D., Garfinkel, P.E., Rockert, W. & Olmsted,
M.P. (1987) A prospective study of eating disturbances in the ballet. Psychotherapy and Psychosomatics
48, 170–175.
Hamilton, L.H., Brocks-Gunn, J. & Warren, M.P. (1985)
Sociocultural influences on eating disorders in professional female ballet dancers. International Journal
of Eating Disorders 4, 465–477.
Hamilton, L.H., Brocks-Gunn, J., Warren, M.P. &
Hamilton, W.G. (1988) The role of selectivity in the
pathogenesis of eating problems in ballet dancers.
Medicine and Science in Sports and Exercise 20, 560–565.
Holderness, C.C., Brooks-Gunn, J. & Warren, M.P.
(1994) Eating disorders and substance use: a dancing
vs. nondancing population. Medicine and Science in
Sports and Exercise 3, 297–302.
Hsu, L.K.G. (1990) Eating Disorders. Guilford Press,
New York.
Ingjer, F. & Sundgot-Borgen, J. (1991) Influence of body
weight reduction on maximal oxygen uptake in
female elite athletes. Scandinavian Journal of Medicine
and Science in Sports 1, 141–146.
521
Johnson, C. & Connor, S.M. (1987) The Etiology and
Treatment of Bulimia Nervosa. Basic Books, New York.
Katz, J.L. (1985) Some reflections on the nature of
the eating disorders. International Journal of Eating
Disorders 4, 617–626.
Klinzing, J.E. & Karpowicz, W. (1986) The effect of
rapid weight loss and rehydration on a wrestling
performance test. Journal of Sports Medicine and Physical Fitness 26, 149–156.
Mansfield, M.J. & Emans, S.J. (1993) Growth in female
gymnasts: should training decrease during puberty?
Pediatrics 122, 237–240.
Mitchell, J.E. (1990) Bulimia Nervosa. University of
Minnesota Press, Minneapolis.
O’Connor, P.J., Lewis, R.D. & Kirchner, E.M. (1996)
Eating disorder symptoms in female college gymnasts. Medicine and Science in Sports Exercise 4,
550–555.
Rosen, L.W. & Hough, D.O. (1988) Pathogenic weightcontrol behaviors of female college gymnasts. Physician and Sportsmedicine 9, 141–144.
Rosen, L.W., McKeag, D.B. & Hough, D.O. (1986) Pathogenic weight-control behaviors in female athletes.
Physician and Sportsmedicine 14, 79–86.
Rucinski, A. (1989) Relationship of body image and
dietary intake of competitive ice skaters. Journal of the
American Dietetic Association 89, 98–100.
Sundgot-Borgen, J. (1993) Prevalence of eating disorders in female elite athletes. International Journal of
Sport Nutrition 3, 29–40.
Sundgot-Borgen, J. (1994a) Risk and trigger factors for
the development of eating disorders in female elite
athletes. Medicine and Science in Sports and Exercise 4,
414–419.
Sundgot-Borgen, J. (1994b) Eating disorders in female
athletes. Sports Medicine 3, 176–188.
Sundgot-Borgen, J. & Corbin, C.B. (1987) Eating disorders among female athletes. Physician and Sportsmedicine 15, 89–95.
Sundgot-Borgen, J. & Larsen, S. (1993a) Nutrient intake
and eating behavior of female elite athletes suffering
from anorexia nervosa, anorexia athletica and
bulimia nervosa. International Journal of Sport
Nutrition 3, 431–442.
Sundgot-Borgen, J. & Larsen, S. (1993b) Pathogenic
weight-control methods and self-reported eating
disorders in female elite athletes and controls.
Scandinavian Journal of Medicine and Science in Sports
3, 150–155.
Sykora, C., Grilo, C.M., Wilfly, D.E. & Brownell, K.D.
(1993) Eating, weight and dieting disturbances in
male and female lightweight and heavyweight
rowers. International Journal of Eating Disorders 2,
203–211.
Szmuckler, G.I., Eisler, I., Gillies, C. & Hayward, M.E.
(1985) The implications of anorexia nervosa in a
522
practical issues
ballet school. Journal of Psychiatric Research 19,
177–181.
Theintz, M.J., Howald, H. & Weiss, U. (1993) Evidence
of a reduction of growth potential in adolescent
female gymnasts. Journal of Pediatrics 122, 306–313.
Thompson, R.A. & Trattner-Sherman, R. (1993) Helping
Athletes with Eating Disorders. Human Kinetics,
Champaign, IL.
Torstveit, G., Rolland, C.G. & Sundgot-Borgen, J. (1998)
Pathogenic weight control methods and selfreported eating disorders among elite athletes.
Medicine and Science in Sports and Exercise 5 (Suppl.),
181.
Warren, B.J., Stanton, A.L. & Blessing, D.L. (1990) Disordered eating patterns in competitive female
athletes. International Journal of Eating Disorders 5,
565–569.
Wilmore, J.H. (1991) Eating and weight disorders in
female athletes. International Journal of Sport Nutrition
1, 104–117.
Wilson, T. & Eldredge, K.L. (1992) Pathology and
development of eating disorders: implications for
athletes. In Eating, Body Weight and Performance in
Athletes: Disorders of Modern Society (ed. K.D.
Brownell, J. Rodin & J.H. Wilmore), pp. 115–127. Lea
and Febiger, Philadelphia.