Nutrition Research and Ethics

Hun 3800- 81384

Module 6- Literature Review

A Literature Review: The Risk of Eating

Disorders in Lean and Non-Lean Athletes

Kristen Robinson

N00612108

10/25/2015
 A Literature Review: The Risk of Eating Disorders in Lean and Non-Lean Athletes

Introduction
Eating Disorders are found not only within the regular population but they are also found in the

athletic population. Eating disorders are a physical illness as well as a mental illness and are

found in many competitive sports including weight sensitive sports, or lean sports, and non-lean

sports. Eating disorders have been known to be more prevalent in women than in men. Even

though this is true it has been found that the highest prevalence is found among females in

endurance and aesthetic sports whereas eating disorders among males were most common in

weight class sports including wrestling and boxing (3). There are five different types of eating

disorders including Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder, Purging

Disorder, and Night eating syndrome (8). The three main types of eating disorders we will

discuss in this review are Anorexia Nervosa, Bulimia Nervosa and Binge-eating disorder.

Anorexia Nervosa is characterized by a distorted body image with a pathological fear of

becoming fat that leads to excessive dieting and severe weight loss (8). Bulimia Nervosa is

characterized by frequent episodes of binge eating followed by behaviors to avoid weight gain,

such as self-induced vomiting; abuse of laxatives, diuretics, or other medications; fasting; or

excessive exercise (8). Binge Eating disorder is defined as recurring episodes of eating

significantly more food in a short period of time than most people would eat under similar

circumstances, with episodes marked by feelings of lack of control (8). This is a very important

topic to research because as the pressure increases in athletes then eating disorder prevalence

increases. This can lead to illnesses, injuries and even death. Determining the exact prevalence

of eating disorders and disordered eating behaviors is difficult because those affected may not
report the behavior or not seek treatment thus making occurrence estimates somewhat unreliable

(7). The reason for this literature review is to look at the eating disorders found in sports.

Looking at these disorders we will focus on the increased risk in lean or non-lean sports while

also looking at the risk factors associated with these eating disorders and the prevalence of males

and females with eating disorders in sports.

Prevalence of Eating Disorders in athletes participating in Lean and Non-Lean sports

There are many types of sports in the world which can be qualified into categories such as lean

or non-lean sports. Lean sports maintain a competitive or aesthetic value on leanness (13). In

lean sports, a competitive advantage can be gained by minimizing fat mass in order to maximize

their power while maintaining a minimum body weight (13). Sports that focus on minimum

body weight for a competitive advantage include cross country, track and field, swimming,

rowing, etc. Those that focus on the aesthetic value, by focusing on the athletes body size and

shape which is often highlighted by a form fitting uniform are cheerleading, volleyball,

wrestling, ballet, gymnastics, skating, etc. Non-Lean sports are those which do not emphasize

body weight or lean physique. The different sports in this category are hockey, softball, tennis,

field track events, basketball, football, etc.

Within lean build sports the prevalence of eating disorders is higher. The average body weight

for athletes participating in lean-build sports was lower than that of athletes participating in non-

lean build sports and also body fat percentage was also lower in lean build sports compared to

non-lean build sports (2). In a 2009 study (Beals and Hill 2009) of 112 athletes from 7 different

sports two athletes were diagnosed with anorexia and one with bulimia (2). Four of the athletes

believed that they had an eating disorder while 22 athletes met the criteria for disordered eating

behaviors. Within this study 23% of athletes indicated they participated in binging and 16%
reported that they regularly experienced out of control eating. In sports with a weight class

rapid weight loss regimens prior to competition tend to happen as well as the body parameters

being specific and making athletes more prone to eating disorders. Not only do we see an

increase risk in lean sports we can also see the difference in risk between individual and team

sports. In a 2009 study (Haase 2009), while looking at social physique anxiety, the results

showed that there was significantly higher social physique anxiety in individual sport athletes

compared to team sports athletes (6). Dieting and Bulimia were also significantly higher in

individual sport athletes compared to team sport athletes (6).

We can look even further into the eating disorders in individualized sports. Ballet dancers,

volleyball players and cheerleaders show a higher prevalence of eating disorders. These sports

focus highly on body appearance as they involve tight fitting clothing. Looking at ballet dancers

they severely restrict their diet or engage in abnormal eating behaviors so much so that according

to the study Development and evaluation of an Educational Intervention Program for Pre-

professional Adolescent Ballet Dancers professional dancers consume 70%-80% less than the

recommended dietary allowance for total energy and are often 10%-12% below the ideal body

weight (5). The current recommendations for athletes are 6-10g/kg/day of carbohydrates, 1.2-1.7

g/kg per day of protein for optimal tissue recovery and repair and a fat intake of 20-35 %. In the

last 10 years cheerleading has become more competitive and athletic requiring more physical

demands and skill. We can break the cheerleading population into two groups. The bases and

backspots which are required to be stronger and more built where the flyer needs to be leaner and

thinner. The overall likelihood of being at risk for eating disorders was 33.1% for all

cheerleaders although flyers were at a greater risk for eating disorders (36.1%) compared to

backspots which were the lowest (28.6%) (11). Within the 33.1% of cheerleaders classified as at
risk for eating disorders with regards to pathogenic weight control behaviors, 11.8% reported

binge eating at least 2-3 times a month, 9.6% vomited to control weight or shape at least once a

month, 19.9% used laxatives, diet pills or diuretics to control weight at least once a month, 1.5%

exercised more than 60 minutes at least once a day to control weight or shape, and 2.2% reported

losing 20 pounds or more in the past 6 months (11). Volleyball is often an overlooked sport for

eating disorders. Fifty percent of volleyball players met the criteria for At Risk disordered

eating characteristics and behaviors (12). Additional questions revealed that 100% of the At

Risk engaged in binge eating at least one time a month and one individual reported vomiting to

control weight or shape (12). Eating disorders in other sports include (aerobics, cross-country,

gymnastic, etc.) ranging from 24%-50% with gymnastic at the highest at 50% and auxiliary

performers (majorettes, color guard, etc.) at 29.7% (11). You can see that the prevalence of

eating disorders can be found in leaner built sports, although they can also be found in non-lean

sports. Risk factors can vary within two types of sports and there can be many different factors

and treatments available.

Risk Factor and Symptoms of Eating Disorders in Athletes

Eating Disorders are multi-factorial and these factors can be divided into predisposing factors,

trigger factors and perpetuating factors (3). Predisposing factors can include genetics, low self-

esteem, personality for perfectionism, bullying, peer pressure, etc. Trigger factors can include

negative comments regarding body weight and/or shape, traumatic experiences, etc.

Perpetuating factors include approval by the coach, physiological consequences of starvation or

initial success. Suggested sport specific risk factors include weight regulation, dieting, pressure

to lose weight, personality traits, injuries, symptoms of overtraining, impression motivation,

threat perception and the impact of coaching behavior (3). Athlete can also pick up traits from
their coaches such as excessive exercise, perfectionism and over compliance. Coaches must be

sure to not be pre-occupied by body weight and its effect on performance as this can lead to

triggering that individual into an eating disorder. Injuries can trigger eating disorders because of

the significant impact it has on you physically and psychologically. You will be limited in

mobility which can lead to weight gain and not being able to compete. Starting an athlete early

in competition of a weight class sport can increase their risk for an eating disorder because of the

delicate mental state in adolescence. Also if the individual is participating in a sport that is not

appropriate for that persons body type they can develop an eating disorder to try and fit into the

body image of that sport.

Risk factors within sports for eating disorders can vary throughout each type of sport. In the lean

and non-lean sports many athletes start with an initial weight loss which in turn leads to better

performance, because of this success the athlete will continue to diet to lose weight and

unknowingly slip into an eating disorder (3). Male specific risk factors can include a drive for

muscularity, anabolic androgenic steroid use and homosexuality. Wrestlers achieve weight loss

most commonly by dieting, dehydration, starvation, and exercise intensity (10). The pressure to

meet a certain weight class accompanied by a certain body image can be risk factors for

wrestlers. The National Wrestling Coaches Association along with the National Federation of

State High School Association implemented a new weight management rule in 2008 designed to

minimize the use of weight cutting and to improve the nutritional and health status of high school

wrestlers around the country (10). As a result of poor nutrition one can be more prone to injury.

In a 2010 study (Rauh, Nichols and Barrack 2010) 37.4% of athletes had at least one sport-

related musculoskeletal injury severe enough to result in their removal from, or nonparticipation

in, a practice, game or meet (9).

In most aesthetic sports the pressure to be thin and to look physically fit are prominent because

of the subjective evaluation embedded in selection and competition success (11). Fifty-three

percent of collegiate cheerleaders indicated that revealing team uniforms contributed to weight

pressures suggesting that body image may depend on the clothing type (11). Perception of body

image can also depend on the uniform type. Those whose uniforms show their midriff may have

and increase in body pressure compared to those who wear a full uniform.

Eating disorders over a period of time can cause things like reproductive dysfunction, impaired

bone health, decreased resting metabolic rate, increased cardiovascular risk factors,

gastrointestinal problems, and deficiencies of micronutrients such as iron and calcium (8). Injury

and illness are concerns and can be career limiting if they occur before or during competition.

There are several factors that can start recovery. Experiencing negative consequences of the

eating disorders initiated recovery for 69% of athletes, 63% stated that confrontation or

intervention motivated recovery, 50% desired for a better life, 38% wanted improvement in self-

esteem or mood, 38% say opening up to others sparked recovery and 25% say a change in

environment was an important initiator of recovery. Athletes expressed how important

confrontation was since many had been in denial and reported that they likely would not have

initiated treatment or made changes on their own (3). An intervention program can be an

effective tool to increase nutrition knowledge, perceived severity and self-efficacy (5).

Management and prevention of eating disorders need to focus on supporting and encouraging

athletes to practice proper nutrition and exercise behaviors and not focus on management. Using

proper nutritional information and exercise program participation in sports can have health

benefits including increased bone density, improved fitness and increased chance for individuals

to maintain an active lifestyle.

Prevalence of Eating Disorders in Male and Female Athletes

Male athletes may have higher prevalence rates of disordered eating due to an increased focus on

body, appearance, and weight that exists within lean, aesthetic, and weight class sports (4).

When looking at male sports, particularly in high school, 5.4% who compete in ball game sports,

10% in endurance sports (running and swimming), 17% in weight class sports (rowing and

wrestling) and 42% in anti-gravitational sports (gymnastics and skating) scored above diagnostic

cutoffs indicating they were at risk for disordered eating (4). Male athletes in weight class sports

(44.2%) were more likely to be in the disordered eating group compared to endurance (12.8%) or

ball game (16.7%) athletes (4). In wrestling 80% engage in dieting, more than 50% use fasting,

75% increase their training load to lose weight and 1/3 of wrestlers felt terrified about being

overweight (10). A study found that 45% of 713 high school wrestlers in Wisconsin met two or

more criteria for bulimia nervosa (10). It has been said that a male athlete triad does exist but is

rarely seen because it does not have reproductive consequences but can lead to low testosterone

levels and low one mass (3). In a study from 2013 (Chatterton and Petrie 2013) 21.4% reported

binge eating 2-3 times a month, 79% of athletes reported they did not binge eat, 3% had been

binge eating for less than three months, 3% had been binge eating for 3 months to a year, 5.9%

for the past one-three years and 9.2% for the last three years or more.

Females with eating disorders can develop what is called the Female Athlete Triad. The Female

Athlete Triad includes eating disorders, amenorrhea and decreased bone mineral density.

Menstrual dysfunction was reported by 26% of athletes, more prevalent in lean build (32%)

compared to non-lean build (17%) (2). The Female Athlete Triad can decrease performance level

and create health risks for female athletes. Bone mineral density has shown to be lower in lean

build athletes compared to non-lean build athletes (2). Twenty one out of 112 athletes reported
suffering from stress fractures during their career (2). In the 2009 study (Haase 2009) female

athletes in individuals sports demonstrated greater social physique anxiety, dieting and bulimic

attitudes compared to females in team sports (6). In female high school sports an estimated

18.2% experienced disordered eating, 23.5% experienced menstrual irregularity, and 21.8%

experienced low bone mass. Athletes that were experiencing the full triad was at 1.2% while

48.2% met criteria for one triad component (9). In previous research they estimated that 35% of

female athletes were at risk for anorexia nervosa, 38% for bulimia nervosa, 5.5% of the control

population, 25% of the elite female athletes compared to 9% of the general population (11).

Eating Disorders are not as prevalent in male athletes as they are in females. It was found that

males in elite sports and female control group showed similar frequency in eating disorders (3).

The highest prevalence in females was found in endurance and aesthetic sports and in males

eating disorders were common in weight-class sports (3). Female athletes are at risk for having a

higher prevalence of disordered eating; approximately 14%-19%, compared to males (13). There

are many similarities of risk factors between male and female athletes. Risk factor similarities

between them are overweight, history of being teased and experience of violence.

Conclusion

Eating disorders in athletes are becoming more prevalent in all sports. There are now increasing

pressures among athletes and their ability to perform. As the popularity of sports increases the

pressure to perform increases as well. This will in turn increase eating disorders within sports.

Female sports are typically where we see the highest number of eating disorders because of the

low self-esteem. Although this may be true, eating disorders in male athletes is starting to show

more often. There is not enough information on this topic to make an accurate conclusion of just

how many are affected. This topic needs to be further researched. It requires a broader and
larger group of athletes to study including different types of sports, now that there are many new

sports starting to become popular such as lacrosse, and to include more male athletes.

Adolescents are also greatly affected by this as they are also under great pressure not only in

sports but also in school. Puberty is such a delicate age that they tend to be more susceptible to

eating disorders whether in athletics or not. Further research also needs to be done in this area to

help discover more management and treatment options. In the study Development and

Evaluation of an Educational Intervention Program for Pre-professional Adolescent Ballet

Dancers they used an intervention program in which reported dietary fat, saturated fat, candy

intake and diet soda intake decreased and milk intake increased (5). This may be a good start to

helping those with eating disorders or stopping them from happening.

The research I have done on this topic implies that there are still many things to be learned. This

is a very important topic as it can lead to injury, illness, and even death. There is very little

being done to educate not only athletes but also coaches on eating disorders and their signs and

symptoms. We need to do more research and start implementing programs for the higher risk

sports. As dietitians, we can help with the research and come up with educational programs and

diet plans to help affected athletes which could potentially save many lives. We could also start

an awareness campaign and support groups to help those with eating disorders or stop those who

may be thinking of starting. We could also continue our research so that we can better

understand how to help those with, or are thinking of starting, an eating disorder.
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