Authors: Ksenia Power, M.S., Sara Kovacs, Ph.D., Lois Butcher-Poffley, Ph.D., Jingwei Wu, Ph.D., and David Sarwer, Ph.D.
Ksenia Power, PhD Candidate
1800 N. Broad Street, Pearson Hall, 242
Philadelphia PA, 19122
Ksenia Power is a Doctoral Candidate and an Instructor of Record in the Department of Kinesiology at Temple University, majoring in Psychology of Human Movement. She is also a Volunteer Assistant Women’s Tennis Coach at Temple University.
Disordered Eating and Compulsive Exercise in Collegiate Athletes: Applications for Sport and Research
Over the last three decades, a large body of research has examined the issue of eating disorders, both formal diagnoses and subclinical features, as well as compensatory behaviors in National Collegiate Athletic Association (NCAA) athletes. In general, this literature suggests that large numbers of student-athletes engage in disordered eating and compensatory behaviors; smaller percentages have symptoms that reach the threshold of formal diagnoses. Increased symptoms are associated with reduced athletic and academic performance, both of which may impact psychosocial functioning later in adulthood. Unfortunately, a number of methodological shortcomings across this body of research (e.g., studies with insufficient sample sizes, inappropriate comparison groups, and suboptimal or biased psychometric measures) limit the confidence that can be placed in these findings, underscoring the need for a new generation of studies. This paper provides an overview of this literature, focusing on issues of gender differences, sport type, and age. It also highlights the relationship between disordered eating and compulsive exercise, a compensatory behavior that is highly prevalent among collegiate athletes. The health and athletic performance consequences of eating disorders in conjunction with compulsive exercise are also discussed. In addition, a focus on more recently recognized eating disorders, such as binge eating disorder and the night eating syndrome is underscored. Future work in this area needs to include the most methodologically rigorous measures available in order to aid most appropriately coaches and athletic trainers in promptly identifying at-risk athletes and to inform future prevention and treatment efforts.
Key words: eating disorder, disordered eating, compulsive exercise
Over the past decade, a number of studies have examined the symptoms of disordered eating among National Collegiate Athletic Association (NCAA) athletes (9,12,13,24,30). Up to 84% of collegiate athletesreported engaging in maladaptive eating and weight control behaviors, such as binge eating, excessive exercise, strict dieting, fasting, self-induced vomiting, and the use of weight loss supplements (12,13,24). Subclinical symptoms or those that reach diagnostic criteria may contribute to poor physical and mental health, as well as suboptimal athletic and academic performance (29).
The substantial physical demands of being a student-athlete are believed to contribute to the development of eating pathology and compensatory behaviors (32). In season, student-athletes are restricted to 20 hours of weekly on-and-off the court/field physical workload, including the time spent in competition (1). However, the 20-hour rule if frequently violated, which results in excessive hours of physical activity and subsequent overtraining (39). For instance, Division I football, baseball, and basketball players reported the highest weekly in-season athletic commitments, averaging nearly 40 hours per week (39). In all other sports, the weekly times spent in training and competition averaged 32 hours (39). The combination of disordered eating and physical overtraining may further produce significant health impairments, such as low energy availability, muscle weakness, acquisition of overuse injuries, mineral bone deficiency, cardiac complications, impaired immune function, malnutrition, dehydration, fatigue, amenorrhea, and osteoporosis (5,15). Some of these conditions are sustained after the athlete has moved on from organized competition (29,44). Physical overtraining and inadequate nutrition can also negatively impact an athlete’s mood, contributing to poor academic and athletic performance (29,44,45).
Some collegiate athletes suffering from disordered eating are known to engage in compulsive exercise as a strategy to compensate for excessive caloric intake (33). Compulsive exercise, beyond sport-required training, places student-athletes at a high-risk for physical overtraining, overuse injuries, and subsequent diminished performance (12, 53). In addition, this compensatory behavior often occurs as a symptom of eating psychopathology (21, 33). Particularly worrisome is the finding that maladaptive eating with simultaneous engagement in compulsive exercise can often remain undetected in athletes and contribute to the progression of an eating disorder (36, 45). Like subclinical eating disorders, formal eating disorders can endure into adulthood and have a continued, negative impact on physical and psychosocial health (56). Unfortunately, most of these athletes experience eating disorder symptoms in isolation, as these behaviors often are missed by the coaching and athletic training staff (62,63). Thus, further studies are necessary for identifying eating disordered athletes (9,25,29).
Disordered Eating Symptoms and Eating Disorder Diagnoses
According to the Diagnostic and Statistical Manual (DSM-V) of the American Psychiatric Association (2013), eating disorders are characterized by severe alterations in an individual’s eating habits that are linked to physiological changes. Individuals with eating disorders become pre-occupied with food, body weight, and physical appearance. Common eating disorders that occur in collegiate athletes are Anorexia Nervosa (AN) and Bulimia Nervosa (BN) (4,10,12, 24, 42). For instance, in a mixed-sport sample of Division I collegiate athletes, 5.1% of all women scored in the clinical range for either Anorexia Nervosa or Bulimia Nervosa (49). Similar rates of clinical eating disorders were reported in a sample of 414 NCAA Division I athletes (6.3%), with Bulimia Nervosa being the most frequent one (4).
According to the American Psychiatric Association (2013), Anorexia Nervosa (AN)is characterized by persistent restriction of caloric intake, resulting in significantly low body weight (below the minimal norm considering an individual’s age, height, weight, and developmental trajectory). It also manifests through an intense fear of gaining weight and severe disturbances in one’s perceptions of his or her own body weight and shape (i.e., refusal to recognize the seriousness of one’s low body weight). Bulimia Nervosa (BN) is characterized by the following symptoms: (a) recurrent episodes of binge eating; (b) recurrent engagement in detrimental compensatory behaviors in order to prevent weight gain; (c) the binge eating and compensatory behaviors must occur at least once a week for three consecutive months; and (d) an individual’s body and shape become vital parts in his or her self-evaluation (3). Binge Eating Disorder (BED)includes the following symptoms: (a) recurrent engagement in episodes of binge eating; (b) occurrence of binge eating episodes, on average, at least once a week for three consecutive months; (c) manifestation of distress related to binge eating; and (d) disassociation with the recurrent use of compensatory behaviors as in Bulimia Nervosa or Anorexia Nervosa (3). Other Specified Feeding or Eating Disorder (OSFED) can be applied to cases, when a person engages in eating behaviors that cause clinically significant distress or impaired functioning, but does not meet full criteria for an eating disorder (3). Lastly, Night Eating Syndrome is characterized by recurring episodes of eating after awakening from sleep or by immoderate food consumption following the evening meal (3).
The Prevalence of Eating Disorders in Athletes
Although disordered eating and exercise behaviors have been highlighted as significant issues among collegiate athletes, the percentage of athletes who meet full diagnostic criteria for clinical or subclinical eating disorders vary greatly, from 1.1% to 49.2% across studies (4,10,12,24,30,42). For instance, Greenleaf et al. (2009) found that, in a group of female collegiate athletes, 2% met the criteria for an eating disorder diagnosis and another 25.5% exhibited subclinical symptoms of an eating disorder (e.g., binge eating, self-induced vomiting, and excessive dieting). Similarly, in Petrie et al.’s (2008) study, 19.2% of collegiate athletes reported maladaptive eating behaviors. Sanford-Martens et al. (2005) detected slightly lower rates of subclinical eating problems (14.5%).
In Anderson and Petrie’s (2012) study among female collegiate athletes, 26.8% of women reported disordered eating behaviors. Approximately 40% of the athletes engaged in at least two hours of daily physical activity, suggesting that many may be using this high level of activity as a compensatory strategy in response to binge eating. Up to 28% of athletes reported dieting or fasting at least two times over the past year (4). Kato and colleagues (2011) reported the highest rates of disordered eating in a sample of NCAA Division I and III athletes, ranging from 40.4% to 49.2%. In addition, 30.7% of all athletes reported body dissatisfaction, weight preoccupation, and bulimic tendencies. Wide-ranging rates of clinical and subclinical eating disorders in collegiate athletes call for additional research on eating disorders and associated symptoms, including compulsive exercise (9,29). Although previous studies provided useful prevalence data (4,12,24,30,42), new studies could potentially yield more accurate and consistent results of unhealthy eating and weight control behaviors in collegiate athletes.
Health Consequences of Eating Disorders
While each eating disorder has its distinct signs, symptoms, and health effects, the most frequent signs and symptoms of disordered eating and compensatory behaviors include: sudden weight loss, gain, or fluctuation; hypothermia (i.e., a dangerously low body temperature); and fatigue (29). Oral and dental problems caused by pathogenic weight control behaviors are dental erosion or caries, perimolysis (i.e., a dental condition linked to frequent regurgitation), and recurrent sore throats (64). Dermatological issues, such as hair loss, brittle nails, skin discoloration, and poor skin healing; also arise in individuals suffering from an eating disorder (54). Disordered eating behaviors also severely affect an individual’s endocrine system by resulting in irregular menstrual cycles or a complete absence of menstruation (i.e., amenorrhea), which could potentially lead to infertility (55). Furthermore, prolonged misuse of laxatives, diuretics, enemas, and diet pills, as well as self-induced vomiting lead to various gastrointestinal problems, such as abdominal pain, early satiety and delayed gastric emptying, constipation, hematemesis (i.e., the vomiting of blood), and hemorrhoids (40). The resulting damages of disordered eating on the cardiorespiratory system include, but are not limited to, chest pains, hypotension (i.e., low blood pressure), arrhythmia (i.e., irregular heart beat), bradycardia (i.e., an extremely low heart rate), and shortness of breath (11).
Another consequence of maladaptive eating and compensatory behaviors is the Female Athlete Triad, which is characterized by energy deficiency, menstrual irregularities, and low bone mass that occur as a consequence of malnutrition and disordered eating (40). Low bone mineral density can result in injuries, stress fractures, and potential osteoporosis (55). This may be especially hazardous for competitive athletes who are generally at higher risks for overuse injuries due to their continuous engagement in high amounts of intense physical training (61). For instance, disordered eating, amenorrhea, and low bone mineral density were associated with musculoskeletal injuries in interscholastic female athletes (46). Finally, neuropsychiatric symptoms, including memory loss or lack of concentration, insomnia, increased anxiety, depression, seizures, obsessive-compulsive behavior, and suicidal ideation can be seen in persons with eating disorders (50). Up to a third of athletes at-risk for an eating disorder tend to engage in multiple pathogenic behaviors, as opposed to a single behavior such as restrictive eating (41).
Consequences of Eating Disorders on Athletic Performance
Disordered eating can have an effect on athletic performance (18). In aesthetic (e.g., gymnastics, swimming, diving), endurance (e.g., cross-country), and weight-classsports (e.g., wrestling, rowing), it is believed that leanness leads to enhanced performance (9). However, many athletes achieve low weight through disordered eating and compensatory behaviors, which can significantly decrease athletic performance (18,29). Specifically, long-term disordered eating impairs the main components of muscular fitness (i.e., aerobic fitness, musculoskeletal fitness, motor fitness, and flexibility), thus resulting in poor athletic performance (18). In addition, the health consequences of restricted caloric intake, such as loss of fat, lean body mass, electrolyte imbalances, and dehydration, can contribute to diminished performance (29). In a study among junior elite female swimmers, Van Heest and colleagues (2014) found that female athletes who restricted caloric intake and increased energy expenditure in training frequently suffered from ovarian suppression (i.e., lack of estrogen production). Female athletes who trained in the presence of low energy availability and ovarian suppression exhibited significant declines in their swim velocity (59).
A similar study of high school athletes found a negative relationship between disordered eating and athletic performance (56). Among a large sample of high school athletes, 35.4% were found to suffer from disordered eating, 18.8% reported menstrual irregularities, while 65.6% reported suffering a sports-related musculoskeletal injury during the ongoing season. Athletes exhibiting disordered eating behaviors were twice as likely to sustain a sports-related injury during a competitive season, as compared to the athletes reporting healthy eating behaviors. Moreover, the inability to train and compete due to an injury further results in decreased athlete performance upon the athlete’s return to play (56).
In addition to physical consequences on sport performance, disordered eating may contribute to other psychosocial issues (18). In particular, obsessive concern about weight and body image, as well as continuous eating restriction have been associated with mood disorders, which may impact athletic but also academic performance (27). Furthermore, overvaluation of shape, weight and eating control, anxiety, and depression that often coexist in athletes at-risk for an eating disorder, are capable of decreasing athletes’ motivation to train and compete. The resulting poor performance may further increase the pressure experienced by athletes to train more intensely and adhere to even more rigid dieting for weight loss (18). Disordered eating behaviors in competitive athletes may not only severely undermine an athlete’s health, but may also produce deterioration in sport performance (18).
Eating Disorders by Gender
A number of studies have found higher rates of maladaptive eating habits in female athletes compared to male athletes (9,10,24,31). For example, in a sample of 800 NCAA Division I student-athletes, 19% of women and 12% of men reported unhealthy eating habits (10). Krebs et al. (2019) also found a higher rate of eating disorders in collegiate female athletes than males. Specifically, three times as many female distance runners screened positively for an eating disorder as compared to male (46% and 14%, respectively). In another study, 26% of student-athletes scored in the clinical range for an eating disorder, with five times more females (84%) than males (16%) reporting disordered eating behaviors (37).
The main explanation for this tendency is that female athletes are more subjected to socio-cultural pressure to diet and be thin, while male athletes tend to be more concerned with physical fitness and masculinity (51). Thus, fewer male athletes contemplate dieting as compared to female athletes, which represents a risk factor for the development of eating disordered in females (51). Nevertheless, disordered eating has been significantly increasing among male athletes (22,12,42,52). For instance, certain male athletes, specifically wrestlers, rowers, and long-distance runners, are more likely to engage in pathogenic weight control behaviors than female athletes in general due to an increased focus on physical appearance and weight (22,26).
Hinton and colleagues (2004) examined dietary intake and eating behaviors in 345 NCAA Division I student-athletes. They found that more male athletes than female athletes exhibited having inadequate nutrient intake. Specifically, only 10% of male athletes, as compared to 19% of female athletes, consumed the recommended minimum of carbohydrates per each kilogram of their body weight, while 19% of males and 32% of females consumed the minimum recommended amount of protein. Moreover, male athletes were more likely to exceed the Dietary Guidelines for fat, saturated fat, sodium, and cholesterol intakes, as compared to female athletes (26).
In contrast to female athletes, who indicated restricting their nutrient intakes for weight gain prevention, male athletes reported using dietary supplements (other than vitamins) for weight reduction (26). Also, approximately 6% of male athletes indicated restricting their fluid intake. These findings can potentially be understood in the context of men’s preoccupation with muscularity, resulting in a focus on diet, nutritional supplements, and excessive exercise (10). Hinton et al.’s (2004) study findings suggest that male athletes, just as female athletes, undergo psychological problems of body dissatisfaction and low self-esteem, which leads to the onset of eating pathologies. In regards to sport-specific factors, male athletes are equally pressured to diet and exercise compulsively in order to maintain low body weight and produce successful athletic results (14).
In summary, a substantial body of literature shows that rates of eating disorders and disordered eating symptoms among collegiate athletes range widely, 0-19% in male athletes and 6-45% in female athletes (9,29,31,34). While the occurrence of clinical eating disorders is more prevalent in female athletes than male athletes, male athletes, in sports such as wrestling, rowing, and cross country, are at greater risk for pathological weight control behaviors (26,49,52). Such findings highlight inconsistencies in the eating disorder area and emphasize the need for additional research on the prevalence of eating disorders among both male and female athletes.
Eating Disorders by Sport
A number of studies have determined that the sport type in which an athlete participates can serve as a risk-factor for the development of disordered eating (4,22,48,52). In eating disorder research, sports have been categorized according to the level of pressure an athlete faces to maintain a low body weight for aesthetic reasons and/or performance enhancement (14). Across several studies (4,22,29,42),the following categories have been described: aesthetic or lean sports (e.g., gymnastics, figure skating, swimming, diving, track and field), endurance sports (e.g., cross country, cycling), technical sports (e.g., tennis, golf, baseball, softball), ball game sports (e.g., soccer, volleyball, basketball, football), weight-class sports (e.g., wrestling, rowing), and anti-gravitational sports (e.g., skiing, pole vault jumping).
Higher rates of eating disorders in aesthetic, endurance, and weight-class sports have been consistently reported (9,29,57). For example, Thiemann et al. (2015) found a greater frequency of maladaptive eating in aesthetic sports (17%) than in ball-game sports (3%). In Sundgot-Borgen and Torstveit’s (2004) study on elite athletes, 42% of women in aesthetic sports had subclinical and clinical eating disorders (e.g., gymnastics, figure skating, diving), 24% in endurance sports (e.g., long-distance running, cycling, swimming), 17% in technical sports (e.g., golf, tennis), and 16% in ball game sports (e.g., soccer, volleyball, basketball). Among male athletes, 9% of eating disorders were seen in men participating in endurance sports and 5% in ball-game sports (52). There are three possible explanations of higher rates of eating disorders in aesthetic, endurance, and weight-class sports. First, in endurance sports, such as cross-country, weight higher than an athlete’s optimum performance weight is linked to decreased performance (14). Second, in weight category sports, such as wrestling, athletes are pressured to meet a specific weight requirement just to qualify for a competition (9). Third, in aesthetic sports, such as gymnastics, athletes’ physical appearance is a part of an aesthetic evaluation, which pressures athletes to attain a certain body composition (14).
While the prevalence of disordered eating in sports that emphasize leanness is high, the reported rates of eating disorders vary by sport (48,53,57). For instance, in a sample of 414 NCAA Division I female athletes competing in gymnastics and swimming/diving, 108 (26%) scored in the subclinical range for an eating disorder (4). In addition, 26 athletes (6.1% of gymnasts and 6.7% of swimmers/divers) were classified as having an eating disorder. Out of 26 athletes in the eating disorder group, 20 athletes were identified as having subthreshold Bulimia Nervosa, 4 with Non-bingeing Bulimia, and 2 with Binge Eating Disorder (4).
In contrast to Anderson and Petrie’s (2012) findings, Carter and Rudd (2005) detected lower rates of disordered eating considering the sport type. In a mixed-gender sample of 800 NCAA Division I athletes, Carter and Rudd (2005) found 9.2% of non-lean sport athletes and 17.5% of lean-sport athletes exhibiting subclinical features for an eating disorder. Additionally, 6.1% of athletes in lean sports suffered from “chronic dieting,” as compared to 2.5% of athletes in non-lean sports. Such high rates of disordered eating in gymnasts and swimmers/divers support the notion that athletes competing in lean and aesthetic sports are pressured to possess ideal body weight for reaching optimal performance. Thus, lean- and aesthetic-sport athletes are exposed to higher risks for developing an eating disorder than athletes competing in sports that do not overly emphasize body weight and physical appearance (4,10). Furthermore, Glazer (2008) found that athletes participating in lean sports averaged significantly higher on the Eating Attitudes Test (EAT) and the Social Physique Anxiety Scale (SPAS), suggesting greater disordered eating and physique anxiety, as compared to athletes participating in non-physique-salient sports. Glazer’s (2008) findings support the notion of increased prevalence of eating disorders in sports that emphasize leanness (e.g., gymnastics, long distance running). Participation in non physique-salient sports (e.g., basketball, softball, soccer) may be a protective factor for the development of disordered eating (22).
Although some studies have linked the sport team classification to disordered eating levels (4,10,48), other studies found no support for this relationship (24,42,49). For example, despite the high frequency of pathogenic eating in a sample of collegiate athletes (19.2%), no association was found between sport team classification and eating disorder status in Petrie et al.’s (2008) study. Similarly, Greenleaf et al. (2009) found no differences in the frequency of maladaptive eating behaviors across sport type. These results corroborated previous findings from Sanford-Martens and colleagues’ (2005) study, which also found no differences in eating disorder symptoms across sport types. These findings suggest that sport type may not be an influential factor in the development of maladaptive eating habits in competitive athletes (49).
To conclude, some studies suggested that lean-sport athletes (such as gymnasts, runners, swimmers, cyclists, and wrestlers) are more prone to developing an eating disorder than non-lean sport athletes, who do not overly emphasize body weight and physical appearance as part of their sport (4,10). However, other studies failed to establish the relationship between athletes’ sport classification and their propensity for unhealthy eating behaviors (24, 42). This observation calls for the need to broaden researchers’ perspectives on identification of at-risk athletes (9). Future studies may provide a clearer pattern between the sport type and disordered eating in collegiate athletes.
Eating Disorders and Age
While a great number of studies on the prevalence of eating disorders among athletes have reported their ages as a demographic variable (22,34,36,47,52), only a few studies assessed the direct link between disordered eating and college athletes’ age (23,24,42). For instance, in Petrie et al.’s (2008) study, disordered eating group status (symptomatic vs. asymptomatic) was not related to age, indicating that symptomatic athletes may be found among all different ages (42). Similarly, Greenleaf et al. (2009) found no differences in athletes’ eating disorder status (i.e., symptomatic vs. eating disordered) based on their age. These findings suggest that the age variable may not be an influential factor on collegiate athletes’ disordered eating symptomology (24). Similarly, in a sample of 290 elite athletes between 14 and 30 years of age, Gomes et al. (2011) assessed the relationship between unhealthy eating behaviors and age. No association was found between athletes’ age and each subscale of the Eating Disorder Examination Questionnaire (EDE-Q, 20). Thus, the findings indicate that athletes across different ages may be equally at-risk for developing maladaptive eating habits (23, 42).
Pettersen et al. (2016) further examined the prevalence of disordered eating in 225 Norwegian athletes in the age groups of 17, 18, and 19+ years old. In total, 18.7% of the athletes exhibited symptoms of disordered eating. Age was not a significant predictor of athletes’ maladaptive eating patterns. As Pettersen et al. (2016) explain, the peak risk for the development of an eating disorder occurs between childhood and early adolescence. However, the majority of the sample athletes were in their later adolescence and early adulthood, which may explain why age was unrelated to disordered eating symptoms. Specifically, adult athletes have acquired higher levels of confidence and self-esteem than athletes in their early adolescence, which could serve as a protective mechanism against the development of eating pathologies (43).
In summary, some studies suggest that the prevalence of maladaptive eating behaviors (e.g., fasting, self-induced vomiting, using laxatives and diuretics, binging followed by exercise, etc.) is higher in the college-aged athletes, as compared to competitive adolescent athletes (29, 30, 43). Nevertheless, a substantial body of literature indicates that competitive adolescent athletes experience severe eating disorder symptoms as do collegiate athletes (9, 29, 43). Additionally, the studies focusing specifically on the impact of age, failed to establish a significant association between age and athletes’ eating disorder status (24, 42 ,43). Thus, additional studies are necessary to establish a clearer association between athletes’ age and pathogenic eating.
Collegiate student-athletes represent a unique population of young adults who, because of the demands on their time associated with their sport, may be at particular risk for disordered eating and compulsive exercise (32). Specifically, many collegiate athletes appear to use excessive exercise as a compensatory behavior to control their body weight (4, 12, 36, 42, 48). Compulsive exercise, in combination with the sport-required training, place student-athletes at a high-risk for overuse injuries, and physical exhaustion, which can further impede athletic performance (12, 53). Therefore, there is a need to further examine disordered eating and compulsive exercise patterns among collegiate student-athletes in order to draw athletic staff’s, coaches’, and athletes’ attention to the deleterious health effects of these disordered behaviors.
APPLICATIONS IN SPORT
The roles of athletic trainers, administration, and coaches are paramount in recognizing detrimental eating and exercise patterns in athletes and providing them with the necessary professional assistance (14). First, expanding athletes’ knowledge about proper nutrition habits, maladaptive eating behaviors and their health consequences, and learning how to address the issue of disordered eating, are pivotal steps in primary prevention (40). There is a need to inform athletes that dietary restriction and purging behaviors for attainment of the desired body weight may lead to decreased athletic performance and adverse health consequences. Structured educational programs have shown to reduce the impact of risk factors of disordered eating (6, 17, 19). For instance, Becker et al. (2012) observed a significant reduction in bulimic symptoms just after 1 year following a peer-led educational intervention for athletes. In addition, the researchers found an increase in the number of athletes seeking medical assistance due to the concern that they may suffer from the Female Athlete Triad symptoms (6). Through educational programs, athletes, parents, and coaches can also learn that menstrual dysfunction occurs as a result of low energy availability due to deliberate dietary restriction, rather than a positive adaptation to high-intensity sport participation (17).
Changing perspectives on competitive sport participation for athletes and coaches could be another strategy for eating disorder prevention. Specifically, the way in which athletes evaluate their maladaptive eating and exercise habits can foster maintenance of an eating disorder (44,58). For instance, Thompson and Sherman (2010) found that athletes tend to underreport their eating disorder symptoms due to the misconception that dietary restriction and excessive exercise will result in enhanced sport performance. Athletes and coaches often reinforce maladaptive behaviors (i.e., dietary restriction, excessive exercise) because they believe that certain aspects of sport participation, such as mental toughness and continuous engagement in intense training, are pivotal in reaching optimal performance (44). As a result, athletes may perceive compulsive exercise as a demonstration of high commitment to their sport, rather than a symptom of an eating disorder (16,28). In addition, athletes and coaches falsely believe that weight loss achieved through food restriction and excessive exercise will imminently lead to increased performance (16). Thus, due to perfectionistic and result-oriented views of athletic participation, eating disorder symptoms are often overlooked and underreported (28). Consequently, an emphasis of educational programs should be placed on prompt recognition of maladaptive eating and exercise habits to prevent the development of a clinical eating disorder.
Furthermore, despite the availability of various eating disorder prevention strategies, Vaughan et al. (2004) found that only 1 in 4 (27%) of athletic trainers feel confident in identifying an athlete with an eating disorder. In addition, only 38% of athletic trainers feel confident in asking an athlete about disordered eating behavior (60). Although educational programs and counseling services have been created for collegiate student-athletes, proactive steps on behalf of the university athletic staff are necessary for early identification and prevention of eating disorders (8,35). Prompt detection of unhealthy eating behaviors through screening protocols has been associated with more effective treatment outcomes (8,57).
For instance, the Preparticipation Physical Examination (PPE) monograph, created by the American Medical Society for Sports Medicine (AMSSM) and the American College of Sports Medicine (ACSM), can serve as an effective screening tool for identification of disordered eating behaviors in athletes (7). This instrument assesses whether athletes suffer from body weight pre-occupation, restrict their caloric intake, use nutritional supplements for weight loss, and undergo pressure to lose weight by outside sources (7). The Female Athlete Triad Coalition developed an 11-question screening tool that could be successfully employed as a part of the Pre-participation Physical Examination (17). This measure evaluates a female athlete’s pre-occupation with body weight, dietary restriction, menstrual dysfunction, bone injuries, and low bone mineral density. Consequently, simultaneous use of these screening tools could play a key role in identifying at-risk athletes and providing immediate treatment prior to competitive season. By utilizing screening protocols, coaches and athletic trainers can ensure that student-athletes have rewarding collegiate experiences. In addition, this method can protect athletes against the development of eating disorders that otherwise may endure into adulthood, impacting their physical and psychosocial health long-term (18,27).
Directions for Future Research
Further studies investigating the patterns of disordered eating in conjunction with compulsive exercise in collegiate athletes are necessary for several reasons. First, it is pivotal to provide athletes, coaches, athletic trainers, and athletic administrators with accurate information about the severity of maladaptive eating and exercise in collegiate athletes. Second, various socio-cultural and sport-specific pressures have been identified as potential risk factors for the onset of eating disorders in athletes, which allows researchers to examine the links between these risk factors and the development of disordered eating behaviors (14,18,51). While numerous studies have investigated these issues in great depth, wide gaps still exist in the literature due to inconsistent prevalence rates of eating disorders based on athletes’ gender, age, and sport type (9,29). In addition, certain studies yielded contradictory results and failed to establish the relationships among athletes’ sport classification, age, and their propensity for unhealthy eating behaviors (23,24,42).
To date, there is a scarcity of literature focusing on more recently recognized eating disorders, such as Binge Eating Disorder and the Night Eating Syndrome (4,12). Studies investigating the prevalence of clinical eating disorders in collegiate athletes reported rare instances of BED and the NES, ranging from 0 to 0.5% (4,10,12,24,42). The low rates of BEDs can be explained by the difficulty to disassociate the recurrent use of compensatory behaviors, which are distinct symptoms of AN and BN only (3). In the majority of clinical cases, athletes’ disordered eating occurs in conjunction with pathogenic weight control behaviors (12), which results in higher rates of AN and BN, and significantly lower rates of BED diagnoses.
In addition, a great number of studies in eating disorder research used the Questionnaire for Eating Disorder Diagnoses (Q-EDD; 38) due to its high psychometric properties (4,10,12,24,42,49). Based on the DSM-IV (2) diagnostic criteria for eating disorders, the Q-EDD mainly assesses the symptoms of AN, BN, and BED, thus omitting questions related to the symptoms of the NES, an eating disorder that was later added the DSM-V (3). Consequently, questions exploring the NED symptoms, such as the frequency of recurring episodes of eating after awakening from sleep and the episodes of immoderate food consumption following the evening meal, should be added to the more recent eating disorder measures.
Considering limitations of the previously discussed studies of eating disorders in athletes, the following methodological recommendations could help future researchers to gain a better understanding of the nature and distribution of eating disorders. First, samples should include a large number of NCAA athletes to provide more reliable and valid results, and to ensure generalizability of the study findings. Second, athlete samples representative of each sport should be selected for accurate and valid comparisons by sport type. One way to achieve this goal is to categorize sports by their types (e.g., lean vs. non-lean, weight-class vs. non-weight-class) and recruit approximately an equal number of athletes for each sport category.
In regards to gender comparison, sufficient samples of both female and male athletes competing at the collegiate level need to be recruited to more accurately address the issue of gender differences in eating disorders. Although male athletes generally have a lower prevalence of eating disorders than female athletes, an increasingly large body of literature indicates that disordered eating among male athletes is on the rise (12,22,42,52). Moreover, male athletes in certain sports are more likely to engage in compensatory behaviors than female athletes (26). This conclusion could not be drawn if the study focused solely on one gender. Thus, excluding one gender from the investigation may result in biased reporting of the disordered eating problem and inaccurate conclusions about its prevalence rates across both genders.
Lastly, the conditions under which athletes report their eating behaviors must be assessed prior to data collection. Athletes tend to underreport their maladaptive eating and compulsive exercise habits due to the fear that their eating disorder may be discovered by their coaches and potentially affect their athletic careers (52). Consequently, athletes must be provided with confidentiality and a pressure-free environment in which they can answer instrument questions candidly. In addition, researchers need to choose appropriate measures that have been previously validated in athlete samples to successfully discriminate between eating disordered and healthy athletes.
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