A Review of Eating Disorders in Athletes

SUMMARY

The current review aims to evaluate the literature on eating disorders and athletes with the purpose of making recommendations for sport psychologists and other relevant personnel on how to proceed in identifying, managing, and preventing eating disorders in school settings. Whereas the intention of this review is to make recommendations for secondary educational settings, research on other populations such as collegiate and young adult athletes was also reviewed where helpful or where information on adolescent athletes was not available. Recommendations for prevention and intervention include ongoing education of athletes and coaches regarding nutrition, body composition, and performance, using appropriate screening to detect eating disorders, and use of a sport management team to aid in athlete recovery.     

Development and validation of the Eating Disorders Screen for Athletes (EDSA): A brief screening tool for male and female athletes

ObjectivesTo develop and validate the Eating Disorders Screen for Athletes (EDSA), a brief eating disorders screening tool for use in both male and female athletes. Methods: Data from Division I athletes at a Midwestern university (N = 434) were used to conduct exploratory factor analysis (EFA) by gender. Data from athletes competing at various levels at universities across the United States (N = 862) were then used to conduct confirmatory factor analysis (CFA) and receiver operator characteristic (ROC) curve analysis by gender. Athletes from a range of lean and non-lean sports were included. Gender-specific empirically derived cut-offs on the Eating Disorder Examination-Questionnaire were used to classify high eating disorder risk for ROC curve analysis. Measurement invariance by gender, level of competition, and sport type was also examined. Results: A six-item, one-factor structure for the EDSA was supported by EFA and CFA in both genders, and internal consistency was good for both male (α = 0.80) and female athletes (α = 0.86). ROC curve analyses indicated that the EDSA was highly accurate in predicting eating disorder risk status and identified a score of 3.33 as the optimal cut-off for both male (sensitivity = 0.96, specificity = .80) and female athletes (sensitivity = 0.96, specificity = .64). Results also supported strong measurement invariance for the EDSA by gender, level of competition (Division I versus club), and sport type (lean versus non-lean). Conclusions: The EDSA shows promise as a brief screening tool to identify male and female athletes at risk for eating disorders.     

Eating disorders in elite female distance runners: Effects of nationality and running environment

ObjectivesTo compare UK and Kenyan athletes and to examine the influence of nationality and involvement in elite distance running on the presence of eating disorders, eating disorder psychopathology and menstrual dysfunction, in young women.DesignIndependent groups, with nationality and running status as independent variables.MethodsElite female distance runners were identified based on their performances in track, road and cross-country events. Questionnaire packs were sent to UK athletes and Kenyan athletes were approached at race meetings or a training camp. In all, 82 UK and 75 Kenyan athletes participated (70% and 90% of those invited) along with 97 and 101 non-athlete, age-matched controls from the two countries. All participants completed the Eating Disorder Examination Questionnaire (EDE-Q) and assessments of dieting, mental health, self-esteem and menstrual function.ResultsUK women had significantly higher levels of eating disorder psychopathology and more probable present and past eating disorders than enyan women. Overall, 19.5% of the UK runners had a probable present or past eating disorder, confirming the results of our earlier study (Hulley & Hill, 2001). Kenyan runners had the lowest proportion of probable cases compared with all other groups and the least eating disorder psychopathology. Athletic participation was associated with less regular menstrual periods, regardless of nationality.ConclusionThese findings confirm that participation in distance running at an elite level does not in itself predispose to an eating disorder. Eating disorder risk is better represented as a combination of cultural values, elite sporting environment and person variables.     

Identifying and preventing disordered eating among athletes: Perceptions of track and field coaches

ObjectiveThis study aimed to identify the strategies employed by coaches when identifying disordered eating (DE) among track and field athletes.DesignThis was a qualitative study and an inductive thematic analysis was conducted.MethodSemi structured interviews were conducted with eleven track and field coaches, with experience of coaching at national and international level. The interviews were recorded, transcribed verbatim and analysis was conducted.ResultsTrack and field coaches reported using physical, social and performance indicators to identify disordered eating in their athletes. Coaches also monitored their athletes' eating attitudes and behaviors. Weight loss (both observed and objectively monitored) was considered to be a key indicator of disordered eating. Coaches placed a high level of importance on weight for performance, and an “ideal” female athlete body. Previous experiences of detecting disordered eating and a close relationship with the athlete facilitated the identification of disordered eating. Athlete secrecy and masking behaviors, difficulties in communication and coaches' stereotypical beliefs were found to complicate the identification process.ConclusionsThis study highlights the need for additional information, advice and guidance for track and field coaches to improve their knowledge and confidence in identifying disordered eating among their athletes.     

The role of body-esteem in predicting disordered eating symptoms: A comparison of French aesthetic athletes and non-athletic females

ObjectivesTo explore the relative contributions of self-esteem, body-esteem components and body mass index to disordered eating in aesthetic female athletes and non-athletic females and specifically to determine if the body-esteem components are risk factors for disordered eating.MethodsOne hundred and fifty two participants, of which 61 rhythmic gymnasts, 42 synchronized swimmers and a non-athletic group of 49 female college students completed the self-esteem scale, the body-esteem scale (satisfaction with general appearance, weight satisfaction and others' evaluations of one's body and appearance), the eating attitudes test, and the body mass index was computed.ResultsResults showed a strong heteroscedasticity for EAT-26 and therefore scores were modeled separately for the three groups. For rhythmic gymnasts, the final regression model only emphasizes the role of body-esteem attribution. For the synchronized swimmers, the final regression model combines two body-esteem dimensions (body-esteem for weight and body-esteem attribution) and their interaction. For the non-athletic group, the final regression model only emphasizes body-esteem for weight. Body mass index and low self-esteem were not predictive of disordered eating and no significant relationship was found between body-esteem for appearance and eating attitudes scores. The use of exploratory graphs such as graphs of conditioning and level plots provided more detailed information on the relationship between body-esteem dimensions and eating attitude scores.ConclusionsResults contributed to the growing literature on disordered eating suggesting that attention must be paid to body-esteem for weight and attribution in the understanding of disordered eating and their interaction. Future research should take into consideration the complexity of these results and use a larger sample of aesthetic athletes to elaborate on the current findings.     

Pinning down the problems and influences: Disordered eating and body satisfaction in male wrestlers

ObjectivesDisordered eating and body dissatisfaction are common concerns among athletes. However, these variables have been minimally explored in male wrestlers. Sociocultural influences can impact drive for muscularity, body satisfaction, and disordered eating, but it is unclear which influences are most prominent in this population. The present study had two aims: 1) examine the nature of drive for muscularity, body satisfaction, and disordered eating in collegiate wrestlers, and 2) investigate which sociocultural influence (general, coach/teammate, sport appearance pressures) most strongly predicts drive for muscularity, body satisfaction, and disordered eating.Methods and designThis study was cross-sectional. Participants included 103 National Collegiate Athletic Association Division I male collegiate wrestlers in the U.S. who completed surveys in season on sociocultural influences, drive for muscularity, body satisfaction, and disordered eating.ResultsWrestlers had a high drive for muscularity and engaged in many unhealthy behaviors to lose weight; however, they had relatively high body satisfaction. Relative weight analyses showed that sport appearance pressures were the strongest predictor of drive for muscularity while general pressures were the strongest predictor of body satisfaction and restricting eating behaviors.ConclusionsFindings suggests that disordered eating needs to be addressed among wrestlers and potential influences to target.     

The Sporting Body: Body Image and Eating Disorder Symptomatology Among Female Athletes from Leanness Focused and Nonleanness Focused Sports

Female athletes experience pressure to conform to social and sporting norms concerning body weight. This study compared general and sporting body dissatisfaction and disordered eating symptomatology among 320 elite, recreational, and noncompetitive female athletes aged 17 to 30 years competing in leanness focused sports and nonleanness focused sports. Participants completed an online questionnaire including demographic questions, the Eating Attitudes Test, and the Figure Rating Scale. Athletes from leanness focused sports reported higher levels of body dissatisfaction and greater disordered eating symptomatology regardless of participation level. Elite athletes reported higher levels of body dissatisfaction and greater disordered eating symptomatology regardless of sport type, and differences between recreational and noncompetitive athletes were not found. More than 60% of elite athletes from leanness focused and nonleanness focused sports reported pressure from coaches concerning body shape. The findings have important implications for identifying risk factors for eating disorders among female athletes, where athletes who compete at elite level and those who compete in leanness focused sports at any level may be at higher risk for developing eating disorders.     

Eating Disorders Among Urban and Rural African American and European American Women

Abstract

It is alleged that eating disorders are nonexistent in African American women and that eating disorder symptomatology occurs predominantly among White middle class women (Kumanyika, Wilson, & Guilford-Davenport, 1993; Smolak & Striegel-Moore, 2001). This research attempted to identify differences in eating disorder symptomatology in African American and White American women. An eating disorder is a disability because it can damage the person physically, emotionally and socially. It can be undetected for years and society may reinforce the hidden disorder by being complimentary regarding the thin appearance of the person. The Eating Disorder Inventory (EDI) was used to measure psychological traits and symptom clusters associated with the understanding and treatment of eating disorders (Garner, 1990). Measures of self-esteem, depression and coping were also examined. Findings indicated differences between African American and White women on the Ineffectiveness scale of the EDI, differences between the urban/rural women on Ineffectiveness and Perfectionism, and differences in coping strategies and education among this sample group of women. Successful treatment usually involves psychotherapy and/or medication for depression.     

Exploring adversity and the potential for growth among elite female athletes

ObjectivesThe purposes of this study were to (a) explore experiences of adversity and (b) to examine perceptions of growth following adversity among elite female athletes.MethodsSemi-structured interviews were conducted with five elite female athletes (ages 18–23 years) who competed internationally in track and field, swimming, long-distance running, and basketball. Interviews were analyzed using an interpretative phenomenological approach (Smith, Flowers, & Larkin, 2009).ResultsIncidents of performance slumps, coach conflicts, bullying, eating disorders, sexual abuse, and injuries were reported. The shared ‘essential’ features of participants’ experiences of adversity were isolation/withdrawal, emotional disruption, questioning identity as an athlete, and understanding experiences within a context of perceived expectations. It appeared that as participants sought and found meaning in their experiences, they identified opportunities for growth associated with social support and also as they realized the role of sport in their lives. Aspects of growth include realizing strength, gaining perspective of their problems, and gaining a desire to help others. Athletes’ experiences with adversity were seen as part of an ongoing journey through elite sport.ConclusionsAthletes’ experiences of adversity may have initiated a process of questioning their identities and searching for meaning in their experiences. Findings highlighted the complexity associated with social support and athletes’ growth following adversity. Growth following adversity appears to be a valuable area of research among elite athletes.     

Team weigh-ins and self-weighing: Relations to body-related perceptions and disordered eating in collegiate male athletes

ObjectivesIn this study we examined the relation of team weigh-ins and self-weighing frequency on collegiate male athletes' internalization of body ideals, social pressures about weight/body, body satisfaction, dietary intent, negative affect, drive for muscularity, and bulimic symptomatology.Design and methodsWe used a cross-sectional survey design, and collected data electronically from 738 male intercollegiate athletes in the U.S.ResultsAthletes who self-weighed 7 + times per week reported the most pressure to lose weight and be lean and muscular, engaged in muscle-building behaviors most frequently, dieted most often, and had the highest level of bulimic symptomatology. Further, athletes on teams that conducted mandatory weigh-ins (vs. not) engaged in more muscularity behaviors and dietary restriction.ConclusionWeighing, but in particularly that conducted voluntarily, may contribute to an overconcern with appearance, body size/shape, and weight, which in turn can lead to a variety of behaviors related to eating and body change.     

Defining features of unhealthy exercise associated with disordered eating and eating disorder diagnoses

ObjectivesThe current study sought to compare different features of unhealthy exercise on associations with disordered eating and their ability to identify individuals with eating disorders. A secondary aim of the study was to compare prevalence and overlap of different aspects of unhealthy exercise and potential differences in their gender distribution.DesignCross-sectional epidemiological study.MethodsA community-based sample of men (n = 592) and women (n = 1468) completed surveys of health and eating patterns, including questions regarding exercise habits and eating disorder symptoms.ResultsCompulsive and compensatory features of exercise were the best predictors of disordered eating and eating disorder diagnoses compared to exercise that was excessive in quantity. Further, compulsive and compensatory aspects of unhealthy exercise represented overlapping, yet distinct qualities in both men and women.ConclusionsIncluding the compulsive quality among the defining features of unhealthy exercise may improve identification of eating disorders, particularly in men. Results suggest that the compensatory aspect of unhealthy exercise is not adequately captured by the compulsive aspect of unhealthy exercise. Thus, interventions that target unhealthy exercise behaviors among high-risk individuals, such as athletes, may benefit from addressing both the compulsive and compensatory aspects of unhealthy exercise. Future prospective longitudinal studies will aid in determining the direction of the association between these features of unhealthy exercise and the onset of eating pathology.     

On Targeting Emotion Regulation Deficits in Eating Disorders through Defense Analysis

ABSTRACT

Psychodynamic approaches to the treatment of individuals with eating disorders are underrepresented in research and in academia. This will increasingly deprive patients of a viable therapeutic alternate to the dominant behavioral family-based models. As psychodynamic approaches may have unique benefits, there is value in resolving this loss. Recent models of dynamic therapies for eating disorders within modern, empirically derived theory show promise for future psychodynamic viability. An attachment-focused approach targeting disordered attachment patterns that are common in individuals with eating disorders has recently been introduced. To complement this model, this article proposes an approach for individuals with eating disorders that is hypothesized to target emotion regulation deficits that are also commonly found in individuals with eating disorders. Observed parallels between the implicit branch of the emotion regulation system and that of contemporary constructs of defense mechanisms guide this proposal. Developmental considerations reveal important connections between this biologically based model and a two-person model based in attachment theory. In this way, this proposal offers a flexible psychodynamic approach that integrates with the existing literature. Further development of this approach could one day help patients to have a greater range of therapeutic options for recovery from eating disorders.     

Can we reduce eating disorder risk factors in female college athletes? A randomized exploratory investigation of two peer-led interventions

Female athletes are at least as at risk as other women for eating disorders (EDs) and at risk for the female athlete triad (i.e., inadequate energy availability, menstrual disorders, and osteoporosis). This study investigated whether two evidence-based programs appear promising for future study if modified to address the unique needs of female athletes. Athletes were randomly assigned to athlete-modified dissonance prevention or healthy weight intervention (AM-HWI). ED risk factors were assessed pre/post-treatment, and 6-week and 1-year follow-up. Results (analyzed sample, N = 157) indicated that both interventions reduced thin-ideal internalization, dietary restraint, bulimic pathology, shape and weight concern, and negative affect at 6 weeks, and bulimic pathology, shape concern, and negative affect at 1 year. Unexpectedly we observed an increase in students spontaneously seeking medical consultation for the triad. Qualitative results suggested that AM-HWI may be more preferred by athletes.     

Longitudinal trajectories of emotions among athletes in sports competitions: Does emotional intelligence matter?

ObjectivesThis research explored whether several subgroups of athletes representing distinct emotional trajectories could be shown to exist within the latent class growth analysis (LCGA) of pleasant and unpleasant sport emotions (anger, anxiety, dejection, excitement, happiness). A secondary aim was to explore whether athletes belonging to distinct emotional trajectories reported distinct scores of trait-emotional intelligence (EI) at time 1 (T1).DesignA longitudinal three-wave measurement design (beginning, middle, and end of a competitive season) was used in the present study.MethodA sample of 460 athletes completed the sport emotion questionnaire across three measurement times and the brief emotional intelligence scale at T1.ResultsResults of LCGAs showed five trajectories for anger, anxiety and happiness, and six trajectories for dejection and excitement. Furthermore, athletes belonging to distinct (adaptive or maladaptive) trajectories reported significantly different scores of EI.ConclusionsLCGA results highlighted the athlete heterogeneity in longitudinal sport emotions. Higher scores of EI were reported by athletes belonging to adaptive emotional trajectories. These results could be used to help coaches and sport psychologists to identify athletes at risk of developing dysfunctional emotional trajectories across the competitive season. Moreover, this study suggested potential benefits of EI-centred interventions to help athletes to experience adaptive emotional trajectories. Finally, these results highlighted that heterogeneity in sport emotions must be accounted for in future research.     

Jumping to the next level: A qualitative examination of within-career transition in adolescent event riders

ObjectiveThe aim of this study was to examine the perceptions of a within-career transition, as experienced by adolescent athletes in the developmental stage of their careers.Design and methodQualitative interviews were used to examine the perceptions of 10 young event riders who had made a transition to regional level. Interviews were based on the developmental model [Wylleman, P., & Lavallee, D. (2004). A developmental perspective on transitions faced by athletes. In Weiss, M. (Ed.), Developmental sport psychology. Morgantown, WV: Fitness Information Technology] and the model of human adaptation to transition [Schlossberg, N. (1981). A model for analyzing human adaptation. The Counseling Psychologist, 9(2), 2–18]. Data analysis procedures drew upon guidelines from Strauss, A. L., and Corbin, J. [(1998). Basics of qualitative research: Techniques and procedures for developing grounded theory (2nd ed.). Beverly Hills, CA: Sage] and Patton, M. Q. [(2002). Qualitative research and evaluation methods (3rd ed.). Thousand Oaks, CA: Sage].Results and conclusionFive categories have been identified (motivation for the transition, perceptions of the transition, sources of stress, support for athletic development, post-transition changes), which follow the process of transition as experienced by the athletes. Consistent with research, parents and peers were important at this stage, often prompting the motivation to make the transition, which was facilitated by considerable social support. Riders made considerable sacrifices during these adolescent years, and development in other areas (such as academic and social) was affected by this commitment, suggesting a risk for identity foreclosure at this formative time. Young athletes should be encouraged to develop a rounded identity to minimize the risk of foreclosure and the associated negative effects at retirement. Further within-career transition research is needed in order that programs can be designed which facilitate athlete development, mitigate negative influences, and minimize talent loss.     

Differential association between food craving,food addiction and eating-related characteristics in persons at risk for eating disorders

IntroductionFood craving is a key feature of eating disorders, but its association with medical and psychological outcome might depend on the type of eating disorder.ObjectivesThis study investigated the factors associated with food craving in individuals at risk for DSM-5 eating disorder.MethodSeventy-six women were recruited from a non-clinical population (n = 372) based on their positive screening (EDDS, QEWP-R) for binge eating disorder (BED; n = 29), anorexia nervosa (AN; n = 28) or bulimia nervosa (BN; n = 19). They completed self-administered questionnaires assessing food craving (FCQ- T-r), Body Mass Index (BMI), eating behaviour (DEBQ), food addiction (YFAS 2.0), and anxiety and depressive symptoms (HADS).ResultsIndividuals at risk for BED or BN had higher food craving than those at risk for AN. Food craving was associated with BMI only in the BED group. Food craving was positively correlated with external eating in all groups, and with emotional eating in the AN and BED groups and correlated with anxiety only in BN. Food addiction prevalence was higher in the BN group than in the AN or BED groups (respectively 94.7%, 46.4% and 65.5%; p < 0.01). In this non-clinical population, we demonstrated that food craving was differentially associated with BMI and eating-related characteristics according to the type of eating disorder.ConclusionThis suggests that food craving is a transdiagnostic dimension that should be differentially targeted depending on the type of eating disorder; future studies should test this hypothesis in clinical populations.     

Eating Disorders,Impaired Mentalization,and Attachment: Implications for Child and Adolescent Family Treatment

ABSTRACT

This article reviews the attachment and neuroscience model of Mentalization Based Treatment (MBT) (Allen, Fonagy, & Bateman, 2008) and its application for understanding and treating eating disorders (Skarderud & Fonagy, 2012). Mentalization, or mentalizing, refers to the capacity to apprehend one’s own and others’ behavior in terms of underlying mental states (needs, emotions, desires, beliefs, goals, reasons, and thoughts). Evidence from prospective studies suggests that insecure attachment and poor mentalizing difficulties may be risk factors for the development of eating pathology (Jewell et al., 2015; Rothschild-Yakar, Levy-Shiff, Fridman-Balaban, Gur, & Stein, 2010; Rothschild-Yakar & Stein, 2013). Preliminary research on the use of MBT for treating eating disorders, with nonsuicidal self-injury co-morbidity, suggests some promise for this model (Robinson et al., 2015). The theoretical rationale and key interventions of the MBT eating disorder model (MBT-ED) used in a multicenter research and treatment project are discussed (Skarderud & Fonagy, 2012; Robinson et al., 2015). Modifications of MBT-ED’s structure and techniques are proposed for family treatment of adolescent and child patients with eating disorders. Case example illustrates the impact of problems in the family system with mentalizing capacities on family cohesion, the therapeutic process, and the family’s ability to help the child recover.     

Clinical perfectionism and eating psychopathology in athletes: The role of gender

Clinical perfectionism is considered to be a core psychopathological mechanism involved in the aetiology and maintenance of eating disorders. Recent clinical evidence suggests pathological self-criticism, which underlines clinical perfectionism, exerts a greater influence on eating disordered symptoms than high standards perfectionism. However, little attention has been paid to this line of research within the athletic population. The current study examined the association between various advocated measures of clinical perfectionism and eating psychopathology among athletes, and the moderating effect of gender in such association. A total of 192 competitive level athletes completed self-report measures assessing perfectionism and eating psychopathology. Results revealed self-critical perfectionism as the only independent predictor of athletes’ eating psychopathology. Such relationship was found to be moderated by gender, with increases in self-critical perfectionism resulting in increases in eating psychopathology for female athletes only. The present findings further reinforce self-critical perfectionism as a robust contributor of eating psychopathology.