ABSTRACT
Many athletes are asked to gain weight and even overeat to “bulk up” for their respective sport(s). In addictive behaviors, early exposure and habit formation during the brain’s developing years are highly predictive of continued problems later in life. As with commonly abused drugs, research indicates foods high in sugars and fat also cause large increases in dopamine, serotonin, and, possibly the most important for those who struggle with food dependency, opioids/endorphins. Due to the brain’s hardwired limbic system circuitry and the naturally reinforcing biochemical mechanisms of eating, there are many physical and psychological factors that influence eating behaviors. Psychological eating factors include stress, depression, anxiety, body dissatisfaction, low self-esteem/self-efficacy, and a preoccupation with food, weight, and body shape. Interpersonal factors stem from social interactions and psychosocial variables such as cultural and ecological influences. For drugs of abuse, abstinence only programs are often the only effective method of eliminating dependency; however, these programs are not a possible with eating. Therefore, this review introduces research on mindfulness, which has been shown to be an effective impulse-control strategy for behaviors, such as eating, that are also a basic part of life. Any intervention plan for treating binge and emotional eating should include methods to help increase awareness and emotional resilience. Client-centered positive health behavior change techniques such as Motivational interviewing (MI) also appear to be highly effective in the treatment of emotional and binge eating.
Introduction
Eating pathologies are common among athletes where body image and size are emphasized due to the nature of their respective sports (8, 15, 25, 28). Long-term eating behaviors are reinforced and hard to change because of complex interactions between physical, psychological, and psychosocial factors. This critical research review addresses the often unrecognized issues associated with emotional and binge eating. Highly effective treatment options such as mindfulness-based therapies and Motivational Interviewing (MI) are introduced to help coaches and sport psychology consultants recognize and get even better at supporting the athletes they serve.
Emotional eating (EE) is characterized by episodes of binge eating to cope with unwanted feelings or serve as a positive reward, and the binges are often followed by feelings of guilt or loss of control. Binge eating is defined as“eating in a discrete period of time an amount of food that is definitely larger than most individuals would eat under similar circumstances” (2, p. 589). Whereas binge eating disorder (BED) is defined as “recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of Bulimia Nervosa” (2, p. 595).
Kemp, Bui, & Grier (2011) describe EE as the “invisible plague” and as eating (often over consuming) linked to an individual’s emotional states, characterized by episodes of binging,grazing, and/or eating when not hungry in an effort to change feelings. Therefore, the function of emotional eating is to change one’s emotional state (whether to reduce perceived stress or pain, or to enhance positive emotions), or to experience instant gratification by using food as a coping mechanism/reward (31). Binge eating is characterized by significant reoccurring disturbances or episodes of overeating followed by feelings of lack of control over food and distress about body shape and weight. Consequently, it may also be associated with depression, low self-esteem, and decreased quality of life (10, 14, 36, 41, 50). Emotional and binge eating are common behaviors that plausibly contribute to the growing obesity endemic with over half of U.S. adults being classified as overweight or obese (31, 36). Because we must consume food to live, it is difficult for some to find the balance between healthy consumption and over or under consumption.
Many athletes are asked to gain weight and even overeat in an attempt to bulk up for their sports (e.g., football). In all addictive behaviors, early exposure and habit development alters the mesolimbic system during the brain’s developing years. Such changes are highly predictive of continued problems later in life (11). Additionally, cultural obsessions with body image and the use of food for entertainment or celebrating social events (e.g., overcoming boredom, football tailgates, Superbowl parties, and weddings) further confound the developmental issues related to the formation of eating habits. Social norms and fast-paced lifestyles contribute to the obesity pandemic and the etiology of emotional and binge eating disorders. Eating disorders such as anorexia, bulimia, and binge eating can be characterized by food and body image causing distress and issues with emotions, attitudes, and behaviors (44). Furthermore, EE may be a major predisposing factor to the development of eating disorders along with other predisposing factors such as depression, stress, anxiety, body dissatisfaction, poor coping skills, low self-esteem and self-efficacy, low emotional awareness, a preoccupation with weight, body shape, and food intake (20, 36, 41, 48, 52, 57).
Neuropsychological Mechanisms
Many factors influence food consumption: physiological needs, psychological and emotional connections, and psychosocial elements. Water and food are essential for survival (i.e., metabolic requirements). To differentiate the critical need versus desire to eat, hunger is the biological craving for food based on survival needs whereas appetite describes the psychological desire for food (21). The neuro-physiologic response to hunger and control of food intake is regulated by the hypothalamus which stimulates the release of hormones such as leptin and ghrelin. The functions of leptin and ghrelin are mainly to stimulate hunger/satiety and regulate metabolism (21, 31).
Ghrelin has emerged as the first circulating hunger hormone and has been shown to increase food intake and fat mass in humans (33). Ghrelin is a fast acting hormone produced mainly by the lining of the stomach and the pancreas to stimulate hunger. Ghrelin levels increase rapidly before meals causing cravings for food and eating behavior initiation. Conversely, fat cells produce the hormone leptin which is responsible for causing full feelings and appetite suppression. Ghrelin-responsiveness is both leptin and insulin-sensitive. In relation to food addiction, ghrelin activates the mesolimbic cholinergic-dopaminergic reward link, which is a circuit that communicates the hedonistic and reinforcing aspects of natural rewards, (e.g., food) as well as of addictive drugs (27). Understanding the strength of this addictive mechanism helps to understand why people continue to eat despite the negative consequences of obesity. It has been established that obese individuals are leptin-resistant, but the role of leptin and ghrelin in the development or maintenance of obesity is still unclear (21, 31). Although physiological needs regulate “true” hunger, there are also psychological, emotional, psychosocial, and environmental factors that influence this complicated process.
Lustig’s (2006) biochemical model of obesity provides a clear application of the research on hormonal and biochemical influences to obesity prevention and intervention programs. His model illustrates how an obese individual’s hormonal signaling may inappropriately be triggering a hunger response. This process causes the body to store more energy as fat and to reduce energy expenditure while, at the same time, increasing appetite and biochemical motivations for overeating. Thus, a child may be gaining weight due to a biochemical imbalance that is causing him/her to experience hunger and sluggishness even though he/she is ingesting more calories than required (51).
Psychological and emotional factors that may predict or impact eating disorders are (a) varying levels of emotional awareness and regulation, (b) negative emotional states, (c) negative core beliefs and low self-efficacy, and (d) fundamental emotional dysfunction. Barchard et al. (2010) explain that emotional awareness is essential for an individual to have the ability to self-reflect and regulate emotional states. People with eating disorders may have difficulty identifying emotions and utilizing adaptive coping strategies to resolve negative feelings (31, 52). Without access to these coping strategies, some individuals use food as a solution to alleviate aversive emotional states. This often results in a learned behavior or conditioned response that over/under eating will soothe their problems or reduce negative affect (31, 52). The learned behavior may originate from childhood rewards consisting of food-related treats to encourage emotional regulation (19). This continued practice frequently breeds more disordered eating among adults later in life.
Likewise, negative self-beliefs play a causal role in both eating behaviors and depressed moods (48). The effects of low self-esteem in relation to body dissatisfaction and body disturbance have been extensively researched creating a reliable paradigm for accurately predicting disordered eating (20). Sim and Zeman (2006) consider body dissatisfaction as “normative discontent” because it is common among adolescent girls. Body dissatisfaction also appears to sustain a cyclic relationship with negative affect as it contributes to increased negative affect, and negative affect can contribute to increased feelings of body dissatisfaction (52).
There are numerous rudimentary elements that affect emotional states and well-being, which ultimately influence and can be used to predict eating disorders. Emotional dysfunction can encompass a multitude of feelings related to disordered eating such as anger, anxiety, depression, fear, loneliness, tiredness, sadness, and stress (7, 19, 36, 41, 52). Stress, specifically, can be quite influential to food intake. Stress is defined as the occurrence of an imbalance between demands (stressors) and coping resources (psychosocial resources) with the mediating factor of cognitive control in connection with“stress-eating” (57). Stress-induced eating typically occurs with a desire to escape from the negative emotion and can cause individuals to either engage in EE or restrictive eating (57). Other predisposing characteristics may include high levels of insecurity, submissive behaviors, social phobias, negative self-evaluation and low self-esteem, poor coping skills, neuroticism, maladaptive perfectionism, restrictive emotional expression, difficulty regulating intensity/duration of emotional states, internalization of behaviors, and/or ruminating thoughts about food items (7, 20, 23, 31). These personal variables interact with psychosocial and physiological variables to create a complex interaction of issues contributing to EE and BED.
Eating Disorders among Athletes
Multiple studies show that athletes report a higher incidence of eating disorders than comparable non-athlete populations (8, 15, 25, 28). Even among athletes with subclinical symptoms, there exists an increased risk of disordered attitudes or behaviors related to dietary practices. Sundgot-Borgenand Torstveit (2004) estimated that 13.5% of Norwegian elite athletes demonstrated clinical or subclinical eating disorders compared to only 4.6% of control groups. While rates of disordered eating are generally higher among females (16, 26), male athletes also exhibit risky eating behaviors related to body image (47). Furthermore, the type of competition is known to correlate with increased risk of eating disorders. Athletes in appearance-based sports such as gymnastics, figure skating, and diving, as well as weight-sensitive sports such as wrestling, jumping events, and endurance running have long been the focus of prevention and intervention efforts because of their demonstrated risk of disordered eating (12, 17, 55). More specifically, prevalence of eating disorders among sport types differs for males and females. Males participating in jumping sports and females in aesthetic sports have higher prevalence of eating disorders than other types of sport participation (55). Multiple influential factors have been linked to increased risk of eating disorders among athletes. Important risk factors include social pressures to adhere to the ideal body, perceived norm of sport body appearance, and perceived performance gains from weight control (56). Considering the associated problems related to both physical (e.g., body mass impact, fatigue, insomnia) and mental health (e.g., depression, anxiety, substance abuse), disordered eating represents a significant health concern among athletes (43).
While much research has historically focused on eating disorders which result in low body mass (e.g., anorexia), more recent research on the high prevalence of overweight and obese athletes has revealed the need for more comprehensive approaches to disordered eating prevention. For example, the premium placed on size in American football often leads to unhealthy practices(e.g., anabolic steroid use, binge-eating) to increase size, with as many as 74% of college football players purposefully participating in regular binge-eating (3, 13, 16).
Increasing attention has been given to the weight-related health risks of professional football players in recent years (22). While binge eating increases the risk of health complications similar to those linked to obesity including hypertension, diabetes, and heart disease (43), there are other notable complications related to the increased size of football players. A recent study indicated that overweight, retired football players were more likely to suffer from decreased cognitive functioning and neurodegenerative disease than normal weight former players (58). While this study examined professional football players, the average size of football players has also increased at both the high school and college levels over the last several decades (40, 42, 45, 46). Given the assumption that binge-eating may be linked to increases in athletes’ size, the health risks may be even more significant. Because sport-related eating disorders often persist after sport participation has ceased, the importance of recognition, prevention, or early diagnosis and treatment of these conditions in essential (8).
Understanding Health Behavior Change
As explained in the Theory of Planned Behavior (TPB), intention is not the exclusive determinant of behavior, meaning that perceived behavioral control includes factors outside of the individual’s control that can affect both intention and behavior (31, 51). TPB supports the belief that psychosocial,environmental, and intrapersonal factors also influence disordered eating. The three overarching factors recognized by researchers are (a) food advertising,(b) sociocultural pressures, and (c) relational variables (20, 31). Kemp et al. (2011) suggest that exposure to food advertising heavily influences unhealthy food consumption and tendencies to overeat and snack, possibly serving as an external trigger to activate hedonic desires for food.
Sociocultural pressures include a variety of social norms (i.e., beliefs about a behavior that reflect the perceived social pressure to perform or not perform a behavior) such as the high value placed on a thin female body, the overall encouragement to eat more, and unfavorable social comparisons (20, 23, 31). Research indicates the drive to be thin among girls and women produces a negative emotional response and body dissatisfaction because of the feelings of failure to live up to perceptions of what is considered the ideal of beauty (20, 52). Markedly, many people who engage in EE have learned the behavior overtime and may be socially facilitated by family and friends who exhibit similar behaviors (31). The severity of eating disorders can be measured on a continuum and take into account all of the influential factors.
Diagnostic Statistical Manual-V (DSM-V) updates
To update older versions of the Diagnostic Statistical Manual (DSM), the American Psychiatric Association (APA) suggested that BED be included in the DSM-V because of several reliable predictive factors such as family history and its comorbid associations with mood disorders (1). In the DSM-V, BED is marked by recurrent episodes of binge eating and is characterized by both of the following:
1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances, and 2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). The binge eating episodes are associated with three or more of the following: 1) eating much more rapidly than normal, 2) eating until feeling uncomfortably full, 3) eating large amounts of food when not feeling physically hungry, 4) eating alone because of feeling embarrassed by how much one is eating, 5) feeling disgusted with oneself, depressed, or very guilty afterwards. Marked distress regarding binge eating is also present. Additionally, the behavior occurs, on average, at least once a week for three months.
Binge eating is not associated with the recurrent use of inappropriate compensatory behavior such as purging and does not occur exclusively during the course of anorexia, bulimia, or restrictive food intake disorder.
Treatment options
Mindfulness has been described as an intentional, nonjudgmental awareness of one’s present-moment thoughts, feelings, sensations, and perceptions as they occur and fade away in an ongoing stream, without being swept away in preconceived expectations (5, 29, 30). Research evaluating mindfulness-based therapy has begun to proliferate in the health literature (32) and has demonstrated effectiveness in treating a variety of health concerns including addictive disorders (54), and emotional disorders due to HIV/AIDS (53). Several mindfulness-based therapies are commonly found in clinical and counseling psychology literature. Among these are dialectical behavior therapy (DBT; 37,38), acceptance and commitment therapy (ACT; 24), mindfulness-based eating awareness training (MB-EAT; 35), and mindfulness-based cognitive therapy (MBCT; 49). Researchers (6, 35) have found MBCT and MB-EAT to be effective in the treatment of eating disorders. MBCT and MB-EAT programs frequently consist of 8-10 sessions. The initial sessions serve to introduce the basic tenets of mindfulness, while subsequent sessions help participants address the thoughts (and feelings) associated with food and eating through mindful eating. Binge triggers, hunger cues, and taste and stomach satiety are identified. Participants, then, learn how to use mindful eating to reduce the frequency and severity of unhealthy eating episodes (e.g., binge eating).
The presence and influence of coaches (and, frequently, sport psychology consultants) in many sport environments, makes them well positioned to identify patterns or evidence of disordered eating among athletes. Furthermore, mindfulness-based approaches to athletic performance enhancement (e.g., 9, 18) are being increasingly adopted by coaches and sport psychology consultants. These interventions may provide an existing infrastructure and understanding in which other concerns such as EE and BED may be more readily addressed through MBCT and MB-EAT. The close relationship between the affected athlete and coach may allow the coach to be more aware of difficulties the athlete may be experiencing. Furthermore, MBCT and MB-EAT interventions may be enhanced and reinforced on a more regular basis, too, by including coaches in the training. Sport psychology consultants should be made aware that mindfulness-based interventions can serve much broader purposes than performance enhancement (4) and should at least be made aware of existing modalities (e.g., MBCT, MB-EAT) for such purposes.
A variety of treatment options have been associated with positive outcomes regarding eating disorders. Mental health interventions that increase emotional awareness are highly beneficial for emotional eaters, and because binge eating disorder and addictive disorders possess a number of overlapping symptoms, treatments that are successful in treating addictive disorders are also typically considered beneficial in treating binge eating (7, 10). Other assumptions for treating eating disorders include (a) education alone will not be sufficient; (b) goal orientation and coaching to better manage emotions and resist overeating temptations may positively impact behaviors; (c) engaging in stress management techniques (like meditation or relaxation) may help regulate emotions; and (d) parenting skills may help to model positive behavior for children, as explained by the social learning theory (31).
Cognitive-behavioral therapy (CBT) is still considered the treatment of choice for binge eating and is successful in reducing binging behaviors and improving psychosocial functioning (14). CBT in self-help programs and group settings provide positive outcomes, not only for BED, but also in treating depressive disorders, maladaptive body image, and social self-esteem by addressing negative self-beliefs and teaching effective coping strategies (14, 48, 50).
More recent advances in the treatment of eating disorders use the practice of motivational interviewing (MI), a client-centered directive method for enhancing intrinsic motivation for change (10, 14). MI is effective in treating substance use, diet, exercise, and other lifestyle behaviors including eating disorders, and is as effective as CBT in reducing the frequency of binge eating (10, 14). MI encourages reflection on the behavior and resolution of ambivalence towards changing the behavior Moreover, MI introduces/considers the idea of change, and may increase self-esteem, self-efficacy, and motivation for change, while decreasing depressive symptoms (10).
The positive psychological principles of MI can also be used by practitioners along with other therapeutic approaches and positive strategies when working with clients. Clinician behaviors may significantly influence a client’s motivation for change. Therefore, a strategic model could be integrated to help improve existing therapeutic practices. When working with clients who struggle with EE or BED, practitioners can use the following MI strategies to guide treatment/counseling sessions. First, express acceptance towards the client and maintain an empathetic manner. Also, affirm the client’s freedom of choice and self-direction. Elicit both the client’s concerns about the behavior as well as ideas for healthier alternative behaviors. Change talk should also be elicited from the client. Next, explore the client’s ambivalence towards changing the behavior while assessing their confidence and readiness for change (10, 14). It is also advisable to discuss the various stages of change (i.e., transtheoretical model) and assess the client’s current stage while eliciting self-motivational statements. These statements may then be reframed to amplify motivation and self-efficacy. Proceed by exploring the client’s values and encourage a written decisional balance of the pros and cons for changing the behavior. Strive to practice active listening with the client and work collaboratively on a change plan in which the client is vested. Similar treatment models for composure and coping may also be helpful in treating clients with eating pathologies.
Ultimately, there are numerous physiological, intrapersonal (i.e., cognitive and affective), interpersonal (i.e., relational), and psychosocial (i.e., environmental and sociocultural) factors that influence behaviors associated with disordered emotional and binge eating. Similarly, there are also a range of therapies and treatments that can be used to positively affect the frequency and severity of these behaviors. Practitioners should stay abreast of this literature as treatment protocols continue to expand and become further refined and more efficacious.
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