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What is the Relationship Between Eating Disorders and Female Athletes?

Keith Nichols

What are eating disorders?

Eating disorders are characterized by gross disturbances in eating behavior and include anorexia nervosa, bulimia nervosa, eating disorders not otherwise specified(NOS), and binge eating disorder. Also, several researchers have coined the term anorexia athletics.

Anorexia nervosa is characterized by refusal to maintain body weight over a minimum level considered normal for age and height, along with distorted body image, fear of fat and weight gain, and amenorrhea (absence of menstruation). Bulimia nervosa is characterized by binge eating followed by purging. These behaviors should occur at least twice a week for three months. Binge eating disorder typically occurs in patients who binge but do not purge. One must have bulimic episodes at least two days a week for six months but must not fit the criteria for bulimia nervosa. Eating disorders not otherwise specified (EDNOS) includes a wide array of eating disturbances that do not fall into the anorexia, bulimia, or binge eating diagnosis. Anorexia athletics features an intense fear of becoming fat even though one is at least 5 percent below the expected normal weight range. Also, excessive exercising, restrictive energy intake, use of laxatives or diuretics, as well as planned binge eating (even around training schedules) all classify anorexia athletics. (Sundgot-Borgen, 1994)

Eating disorders in athletes do not fit neatly into anorexia nervosa or bulimia nervosa, but rather a combination of both. In athletes, anorexia nervosa may often present itself as over-exercising rather than undereating. In the athletic population, it is difficult to define weight a weight loss criteria for an eating disorder diagnosis to be made, often because most athletes already start out at normal or below-normal weights. (Slavin, 1987). Prolonged amenorrhea (5 months or longer without a menstrual period) is seen in some athletic groups. It may be associated with eating problems and dieting behavior, or simply with high levels of physical activity. (Brooks-Gunn, et al.)

Who is at risk?

Numerous studies have shown that athletes are more prone to developing eating disorders than nonathletes, as well as female athletes being more at risk than their male counterparts. Disordered eating is seen in athletes of all sports. (Johnson, 1994). The prevalence of eating disorders in the female athletic population ranges from anywhere between one and forty percent, depending on the athletes questioned, and the methodology used (Sundgot-Borgen, 1994). Rosen and Hough (1988) found that 32 percent of athletes practiced at least one pathogenic weight-control technique(141). A study done by Sundgot-Borgen, in 1994, controlled for the possibility that self-report data could be unreliable in numerous ways, including not informing coaches of their intentions, and assuring 100 percent confidentiality to the athletes who participated. It found that the risk for eating disorders is increased if an athlete's dieting is unsupervised, if there is an early start to sport-specific training, and/or extreme exercise (Sundgot-Borgen, 418).

Does the nature or type of sport matter?

Yes and no. It is believed that the highest prevalence of eating disorders is in female athletes competing in sports where leanness and/or a specific weight are considered important for either performance or appearance (Sundgot-Borgen, 418). Some sports can place athletes at a higher risk for development of these behaviors. Gymnastics, diving, and synchronized swimming, as well as long distance running, swimming, cross-country skiing, rowing, judo, weightlifting, and taekwondo, are all thought to be prime candidates (Johnson, 1994). Sundgot-Borgen (1987) found that in a study of college students, 6 percent of nonathietes, 20 percent of athletes in sports that emphasize leanness, and 10 percent of alI athletes were either exceptionally preoccupied with weight or had tendencies toward eating disorders(89). However, research results are conflicting. Athletes in sports not emphasizing leanness (i.e. volleyball) showed no exceptional preoccupation with weight or any tendency towards eating disorder. Studies of Canadian field hockey players show that eating disordered behavior does not appear to be an issue (Harber & Marshall, 1996). Warren et al. (1990) found that the competitive female cross-country runner actually may be at slightly less risk for body dissatisfaction than her nonathlete counterpart, whereas the gymnast may be at somewhat of a greater risk for weight preoccupation. Therefore, they found that sports emphasizing low body weight do not necessarily mean they correlate with disordered eating (565). Research done by Weight and Noakes (1987) indicates that it is often the better athletes who are more likely to exhibit the physical and psychological features of anorexia nervosa (213).

Could it be something other than athletics that causes an eating disorder.?

Yes. Odds are that it is a combination or interaction of variables including personality-type, family interaction, preexisting eating problems. However, there are risk factors associated with athletic performance which may help exacerbate, or trigger eating disorders. Sundgot (1 994) found that prolonged periods of dieting, frequent weight fluctuations, a sudden increase in training volume, and traumatic events such as the loss of a coach or personal injury may predispose a girl or woman to an eating disorder.

A correlational study by Williamson et al. (1995) indicates that eating disorder symptoms in college athletes are significantly influenced by the interaction of sociocultural pressures for thinness, athletic performance anxiety, and negative self-appraisal of athletic achievement (387). It is also possible that eating disorders exist long before sports participation. This is known as the 'attraction to sport' hypothesis. Anorexics may be attracted to sports to hide their illness, or may use the sport as an additional means of weight reduction. Yet, this doesn't explain how gymnasts who are selected at age six or eight, show signs of eating disorders ten years later.(Sundgot-Borgen, 1994).

So what's the big deal?

The big deal is that eating disorders are incredibly dangerous, and can be deadly. At the very least, disordered eating can impair athletic performance and increase injury risk. In the short term, one might think that the effects of the disorder are positive. Give it some time though, and things will change. Decreased caloric intake and fluid and electrolyte imbalances will result in decreased endurance, strength, reaction time, speed, and ability to concentrate. Causes of death include suicide, cardiovascular collapse or arrest, sepsis, and gastric or intestinal perforation(Johnson, 1994).

What should a coach look for?.

Coaches and trainers are usually in a good position to detect symptoms and encourage treatment. As Sundgot-Borgen indicates, tests given to diagnose eating disorders, such as the Eating Disorder Inventory (EDI) may not be

accurate tools, because as Wilmore et al. points out, 'athletes with eating disorders may be reluctant to respond truthfully to questionnaires because of the secretive nature of the disorders and because of fear of negative reactions from their coaches, teammates and parents". This is why it is up to coaches, as well as parents, to constantly be on the lookout.

The cafeteria at home or on road trips is a great place to start to observe your team member's individual eating habits. Pushing food around the plate is usually not a good thing (Bickford, 1990). An athlete often begins restricting her food intake by eliminating red meat and sweets from her diet. Her repertoire of acceptable foods will narrow (Johnson, 1994). An athlete who eats a huge amount of food not consistent with her weight should be "suspect".

An athlete who excuses herself from the table to "brush her teeth", "wash her hair", and/or "take a quick shower' may have an eating disorder. Bloodshot eyes, vomit smelling bathrooms, and diet pills should also clue a coach into a problem. Athletes with eating disorders are usually constantly aware of their appearance and are constantly comparing themselves to an ideal. Besides the obvious symptoms one would associate with eating disorders such as emaciation and preoccupation with food, coaches should be concerned if an athlete repeatedly makes complaints about being or feeling fat, especially if that athlete is at or below a normal body weight. References to death, killing, or dying (i.e. I'll die if I eat another bite) should also 'raise a red flag" (Bickford, 1990). Also, the performance of aerobic exercise outside of her routine workouts, and/or hundreds of sit-ups and other calisthenics each day" may indicate a problem(Johnson, 1994).

A message to coaches:

Casual comments about weight are easily taken to heart by the youngsters you coach. Believe it or not, "comments from someone critically important in an athiete's life, someone whom the athlete always wishes to please, carry much weight"(Rosen & Hough, 1988). According to Slavin, coaches should be sensitive to weight issues and not make careless references that someone "looks fat" or "has gained weight'. Coaches should never reinforce or encourage "think thin" behavior, thoughts or comments. (Bickford, 1990) As a general consensus, coaches do not cause eating disorders. However, through inappropriate coaching, the problem in vulnerable individuals can be triggered or exacerbated (Sundgot-Borgen, 1994). Seventy-five percent of gymnasts who were told by their coach that they were too heavy resorted to dangerous techniques to reduce their weight (Rosen & Hough, 1988). Coaches and trainers should develop guidelines to assist athletes in attaining a desirable weight and body fat without resorting to eating disorders. Slavin recommends that coaches and trainers should:

1) define the optimum body fat and weights for individual sports

2) monitor these optimums weekly to make sure that athletes are staying within them,

3) set a reasonable time frame to achieve goals if weight is inappropriate

4) help to establish a reputable nutritional source who can help athletes set up realistic nutritionally sound diets.

If you suspect a girl has an eating disorder, you may be the only one who recognizes it. Keep a careful eye on eating habits when the girls are with the team, as well as excessive exercising, beyond what you have recommended as a regimented training program. Obvious physical symptoms and signs of a problem include, but are not limited to, dry skin, brittle hair and nails, cold intolerance, amenorrhea, lightheartedness, constipation, bloating, decreased subcutaneous

No fat and muscle, cold and discolored hands, parotid gland enlargement, erosion of dental enamel, and callouses on the hand(Johnson, 1994). If you think you have Justification, or perhaps if you don't, question the girl about her problem. According to Johnson (1994), a girl should be approached thoughtfully and gently. Those persons concerned with her behavior might meet with her as a group to express their concerns. The athlete should not be confronted or accused of wrongdoing. Instead, evidence of her distorted behavior should be presented, along with expressions of concern about her health. (362) Offer to find her help by referring her to counseling. This is the only true way to change the behavior of what may be a severely psychologically damaged athlete. A coach should assist and support an athlete during treatment(Sundgot-Borgen, 1994).

In conclusion:

More research on athletes and eating disorders is needed. We will never know the true prevalence of eating disorders amongst athletes, or any other group in the population due to methodology problems. However, we need not worry about the prevalence. We are aware that eating disorders exist and we can take steps to reduce them. Coaches need to be more sensitive to their young athlete's needs. Athletes must not succumb to pressures placed upon them from all different angles. Rather, they must realize that thinness is not necessary for athletic success. Athletes should be educated on the physiologic, psychological, nutritional, and performance-affecting effects of disordered eating. Educational tools should include physicians familiar with eating disorders, as well as videos available from the NCAA and other agencies(Johnson, 1994). 1 have provided the physical signs to look for. Eating disorders can be deadly if they go

unrecognized and/or untreated.


Bickford, Barbara. (1 990) Eating Disorders Part 11, Scholastic Coach, 59(6)

Borgen, J.S. & C.B. Corbin (1987). Eating disorders among female athletes. Physician and SportsMedicine 15 (2)

Brooks-Gunn, J., C. Burrow, & M.P. Warren (1988). Attitudes toward eating and body weight in Different Groups of Female Adolescent Athletes. Intemational Joumal Of Eating Disorders Vol. 7

Harber, V.J. & J. D. Marshall (1 996) Body Dissatisfaction and Drive for Thinness in High Performance Field Hockey Athletes. Intemational Joumal of Sports Medicine 17(7)

Johnson, M.D. (1 994). Disordered Eating In Active and Athletic Women. Clinics in Sports Medicine 13(2)

Rosen, L. W. & D. 0. Hough. (1 988). Pathogenic Weight-Control Behavior of Female College Gymnasts, The Physician and SportsMedicine, 16(9)

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Warren, B.J., A.L. Stanton, & D.L. Blessing,. (1990) Disordered eating patterns in competitive female athletes. Intemational Joumal of Eating Disorders, 9(5)

Weight, L. M. & T. D. Noakes. (1987) Is running an analog of anorexia? Medicine and Science in Sport and Exer-cise, 19(3)

Williamson, D., R.G. Netemeyer, L.P. Jackman, D.A. Anderson, C.L. Funsch, & J.Y. Rabalais. (1 995). Structural Equation Modeling of Risk Factors for the Development of Eating Disorder Symptoms in Female Athletes, Intemational Joumal of Eating Disorders, 17(4)



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