Eating disorders present a serious problem of contemporary
society where an increased attention is paid to body
appearance, where a fit and lean body portrays a cultural
ideal. Although eating disorders used to be perceived
as exclusively female problems, latest studies show
that there are males suffering from this problem as
Comparing to general population, athletes are anticipated
to be at higher risk for eating disorders development
due to their personality traits, requirements of particular
sports, stress levels etc. However, it is very difficult
to estimate prevalence of eating disorders among athletes
due to various factors such as secretive nature of disease
or methodologies used.
It is necessary to define clinical eating disorders
and to distinguish them from sub-clinical eating disorders.
Disordered eating practices (typical for certain sports)
as possible trigger factors for an eating disorder onset
must be evaluated.
Classification of eating
Eating disorder is defined as a behavior, which is
beyond one’s personal control and has harmful
impact on psychological, sociological, or physical functioning
(Houtkooper 2000:213). American Psychiatric Association
determined criteria of eating disorders in DSM-IV, where
eating disorders are listed under obsessive-compulsive
As Houtkooper (2000) presented, DSM-IV* determines
three types of eating disorders and their diagnostic
- Anorexia Nervosa
- Bulimia Nervosa
- Eating disorder not otherwise specified
Anorexia nervosa is a psychosomatic disorder
characterised by self starvation stemming from distorted
body mass, size or shape perception and fear to gain
weight, even though underweight, which leads to body
mass below 15% that expected. Denial of their problems
is typical for anorexic patients. Amenorrhea is a symptom
in post-menarchal females.
Engaging in binge eating* or purging behaviour* divides
anorexia nervosa into two subcategories- restricting
type and binge eating/purging type.
Bulimia nervosa is described as a pathological
gluttony leading to rapid ingestion of extremely large
amounts of food that is usually followed by purging.
Diagnostic criteria include repetitive episodes of binge
eating, purging, fasting, and/or excessive exercise
occurring at least twice a week for period of up to
three months. A bulimic person's self-evaluation is
strongly influenced by their body image perception.
Engaging in purging behaviour divides bulimic patients
into two subcategories- purging type and non-purging
type where non-purging type bulimics use fasting or
excessive exercise as compensatory behaviors after binge
To be diagnosed as anorexic or bulimic, a patient must
meet all criteria stated in DSM-IV for anorexia nervosa
or bulimia nervosa.
Eating disorder not otherwise specified presents
a category currently added to DSM-IV to distinguish
disorders of eating that do not meet all criteria for
anorexia nervosa or bulimia nervosa. This category includes
i.e. a female meeting all criteria of anorexia nervosa
except of having regular menses or weight within normal
Assessment of eating and
body image disorders
Houtkooper (2000) stated that “Eating disorders
as defined by the DSM-IV criteria of the American Psychiatric
Association are difficult to detect and diagnose, even
for professionals, because of the complex and secretive
nature of these disorders.
However, a psychiatric clinical interview and checklist
using DSM-IV criteria are required for diagnosing patient
with an eating disorder.
Self- report of eating behaviors such as Eating Attitude
Test (EAT) and Eating Disorder Inventory (EDI) are commonly
used for diagnosis of eating disorders in non-clinical
settings. EDI and EAT assess attitudes and behaviors
shown in patients diagnosed with anorexia nervosa or
bulimia nervosa and thus they are not able to distinguish
causes of the problems. Although considered to be reliable
and valid for non-athletic individuals, the validity
in athletic individuals was reported as not very high.
An inconsistency between studies can be caused by using
different methodologies and criteria and different numbers
of athletes in each study (Houtkooper 2000:212).
Other methodologies include self-diagnoses and questionnaires
assessing behaviors and attitudes related to diet, weight,
eating etc. Reliability and validity of such tools is
Steen and Brownell (1990) designed the only questionnaire
used in athletes that meets criteria for reliability
and validity. This questionnaire evaluates behaviours
related to dieting and weight-control practices of weight-categories
sports (Houtkooper 2000:212).
The general problems of questionnaires and self-assessment
methods are issues such as denial and faked responses.
However, EDI, EAT and other similar methods can be used
as initial screening tools (Lebrun 2001:178).
Risk factors for eating disorders
Risk factors for an eating disorder development, as
stated in Fact Sheet 14 of AIS (2001), may include following:
- Gender- the female to male ratio at least 10 to
1 (estimating gender prevalence is complicated, especially
in male population; further research necessary)
- Genetics- genetically predisposed to develop an
- Personality traits- high levels to sensitivity to
others, perfectionism, negative self-evaluation, food
- Dieting- can present trigger
- Traumatic events in life- physical, sexual, or emotional
abuse, death, or illness of family members etc.
Eating disorders, disordered
eating and sports
As stated in Fact Sheet 14 of AIS (2001), it is unidentified
whether sport plays a contributory or preventive role
in the onset of eating disorders. However, an increased
prevalence has been recorded in sports emphasising size,
weight, and appearance.
Trattner-Sherman & Thompson (2001) said, “Sport
participation plays a direct role in disordered eating
when athletes feel pressure to decrease body fat, lose
weight, maintain a sub-optimal weight, or attain a small
or thin body size and shape for their sport “.
Houtkooper (2001) divides risk factors into three categories-
psychological, exercise participation and sport-related
Prevalence of eating disorders in athletes
Lebrun (2001) mentioned that 0.5-1% of general population
suffers from anorexia nervosa whereas patients diagnosed
with bulimia nervosa present 2-3% of general population.
Reports of prevalence of eating disorders among athletes
range from 1% to 39% as presented by Houtkooper (2000).
The discrepancies in estimates of athletes suffering
from eating disorders can be caused by various factors
- Different methodologies have been used in different
studies to assess eating disorders (American Psychiatric
Association diagnostic criteria versus various questionnaires
and self-reporting methods). As mentioned earlier
in the text, athletes with an eating disorder tend
to be secretive about their problem and thus often
lie in questionnaires.
- Most of the surveys studied participants of one
- Some studies haven’t included an appropriate
- Some studies have used inappropriate statistical
analyses (Houtkooper 2000:220)
Studies comparing occurrence of eating disorders between
athletes and non-athletes are inconsistent due to methodological
limitations of studies (Houtkooper 2000:220-222).
Sports at high risk for development of disordered
Houtkooper (2000), Krane et al.(2001), Lebrun (2001)
defined three categories of sports presenting increased
risk for development of eating disorders:
- Aesthetic sports- figure skating, ballet, gymnastics,
- Sports where low body weight and low fat levels
are considered a physical or biomechanical advantage-
distance running, road cycling, and triathlon.
- Weight-categories sports- wrestling, boxing, lightweight
rowing, weight lifting, martial arts.
Anorexia athletica is defined as sub-clinical eating
disorder associated to the abovementioned sports meeting
some criteria of anorexia nervosa and bulimia nervosa.
According to Williams (2005) listed criteria for anorexia
athletica, an athlete must meet five criteria for anorexia
athletica; this criteria include excessive fear of becoming
fat or obese, restriction of caloric intake, weight
loss, no medical disorder to explain extreme leanness,
gastrointestinal complaints. In addition, an athlete
must meet one or more of related criteria such as disturbance
in body image, compulsive exercise, binge eating, purging,
delayed puberty, or menstrual dysfunction.
Further research of this condition is necessary as
some athletes practice disordered behaviours (purging,
fasting etc.) to achieve desired weight for competition
and do not continue these practices after season (Houtkooper
2000:218-219). This behavior is defined as secondary
sub-clinical eating disorder, which can possibly trigger
an eating disorder onset in a vulnerable athlete.
Most of the studies related to eating disorders were
focused on females, whereas it is difficult to obtain
estimates of male athletes suffering from eating disorder.
Disordered eating behaviours are well known in male
athletes participating in sports with weight restrictions
(jockeys, boxers, bodybuilders, wrestlers). The extreme
weight loss practices can lead to development of an
eating disorder (Houtkooper 2000:222-223). Females are
generally estimated to be at higher risk for eating
disorders development. However, further research is
Possible warning signs of eating disorders in athletes
were listed in Fact Sheet 14 of AIS (2001) and include
rapid weight loss, weight loss below ideal competitive
weight, constant referrals of being fat, competitive
nature with other athletes about their size and weight,
weight loss and/or high training loads continuing after
season, preoccupations with food, secretive eating,
disappearing after meals, mood swings, depression. Symptoms
such as weakness, dizziness, headaches, and fainting
with no apparent medical cause are typical.
The consequences of eating disorders
in athletes involve both physiological and psychological
impairment that include decreased performance and health
status due to poor nutrient and energy intake and severe
medical complications (i.e. related to self-induced
vomiting or laxative abuse) (Houtkooper 2000:226).
One of the consequences of disordered eating is female
athlete triad, which is syndrome of three interrelated
complications occurring in physically active females:
disordered eating, osteopenia (osteoporosis) and amenorrhea.
Each of these complications presents a health risk of
which has a negative impact on athletic performance
and requires treatment (Lebrun 200:178).
Eating disorders present risk for both male and female
athletes, especially those who participate in sports
focusing on weight, leanness and encourage extreme practices,
which are used to achieve a desired weight or shape.
Female athletes may be at higher risk due to the cultural
ideal of fit and thin female bodies promoted by the
media. Whether sport is or is not a factor contributing
to the development of disordered eating and body perception
is still not clear. However, certain types of sports
can possibly trigger the problem in a vulnerable athlete
with some predispositions for developing such a disorder.
Eating disorders is a complex problem which requires
further research with special attention to the prevention
of such disorders in athletes as well as in the general
- Andersen, R., Barlett, S.J., Morgan, G.D., Brownell,
K.D. (1995). Weight Loss, Psychological, and Nutritional
Patterns in Competitive male Bodybuilders. [Electronic
version] International Journal of Eating Disorders,
18 (1): 49-57.
- Brubaker, D.A., Leddy, J.J. (2003). Behavioral Contracting
in the Treatment of Eating Disorders. Physician
and Sportsmedicine, 31(9). Retrieved May 20,
2005, from Academic Search Elite.
- Burke, L., Hawley, J.(Eds.). (1998). Changing Body
Size and Shape. In Peak Performance: Training
and Nutritional Strategies for Sport (pp.223-260).
Sydney: Allen &Unwin.
- Hornak, N.J., Hornak, J.E., Cappaert, T.A.(2003).
The Athletic Trainer and Eating Disorder: Part 1,
Recognition and Prevention. [Electronic version] Athletic
Therapy Today, 9 (3): 42-43.
- Houtkooper, L. (2000). Eating disorders and disordered
eating in athletes. In L. Burke & V. Deakin (Eds.).
Clinical Sports Nutrition (pp.210-240). Sydney:
- Krane, V., Stilles- Shipley, J.A., Waldrou, J.,
Michalenok, J. (2001). Relationship among body satisfaction,
social physique, anxiety, and eating behaviors in
female athletes and exercisers. Journal of Sport
Behavior, 24 (3). Retrieved May 20, 2005, from
Academic Search Elite.
- Lebrun, C.M. (2001). Female Athlete Triad. In N.
Mafulli et al.(Eds.). Sports medicine for specific
ages and abilities (pp.177-185). Edinburgh: Churchill
- Sherman-Trattner,R., Thompson, R.A. (2001). Athletes
and Disordered Eating: Four Major Issues for the Professional
Psychologist. [Electronic version] Professional
Psychology: Research and Practice, 32 (1): 27-33.
- Williams, M.H. (Ed.). (2005). Body Weight and Composition
for Health and Sport. In Nutrition for Health,
Fitness, and Sport (pp.377-410). New York: McGraw-
- Fact Sheet 14: Eating Disorders in Athletes. (2001).
Retrieved May 20, 2005, from www.ais.org.au.
* DSM-IV- Manual of Mental Disorders (1994)
* Binge eating episode- ingesting excessively
large amount of food in discrete time period (e.g.
within 2-hour period) with lack of control over
eating, depression, and guilt as a typical features.
* Purging behaviour- self-induced vomiting, misuse
of laxatives, diuretics, enemas (DSM-IV, 1994).