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Eating Disorders & Exercise

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 well.

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 disorders

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 disorders.

As Houtkooper (2000) presented, DSM-IV* determines three types of eating disorders and their diagnostic criteria:

  • 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 eating episodes.

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 range.

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 not known.
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 development

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 eating disorder
  • Personality traits- high levels to sensitivity to others, perfectionism, negative self-evaluation, food obsession
  • 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 factors.

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 such as:

  • 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 certain sport.
  • Some studies haven’t included an appropriate control group.
  • 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 eating behaviors

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, synchronized swimming
  • 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

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.

Gender Issues

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 necessary.

Warning Signs

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.

Consequences

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).

Conclusion

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 population.

References

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. Houtkooper, L. (2000). Eating disorders and disordered eating in athletes. In L. Burke & V. Deakin (Eds.). Clinical Sports Nutrition (pp.210-240). Sydney: MCGraw-Hill.
  6. 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.
  7. 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 Livingstone.
  8. 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.
  9. 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- Hill.
  1. 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).


 
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