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Feb 14

Disordered Eating and Compulsive Exercise in Collegiate Athletes: Applications for Sport and Research – United States Sports Academy Sports Journal

Long Term Weight Loss Comments Off on Disordered Eating and Compulsive Exercise in Collegiate Athletes: Applications for Sport and Research – United States Sports Academy Sports Journal

Authors: Ksenia Power, M.S., Sara Kovacs, Ph.D., Lois Butcher-Poffley, Ph.D., Jingwei Wu, Ph.D., and David Sarwer, Ph.D.

Corresponding Author:Ksenia Power, PhD Candidate1800 N. Broad Street, Pearson Hall, 242Philadelphia PA, 19122tug82764@temple.edu267-766-8938

Ksenia Power is a Doctoral Candidate and an Instructor of Record inthe Department of Kinesiology at Temple University, majoring in Psychology ofHuman Movement. She is also a VolunteerAssistant Womens Tennis Coach at Temple University.

ABSTRACT

Over the lastthree decades, a large body of research has examined the issue of eatingdisorders, both formal diagnoses and subclinical features, as well ascompensatory behaviors in National Collegiate Athletic Association (NCAA)athletes. In general, this literature suggests that large numbers ofstudent-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 academicperformance, both of which may impact psychosocial functioning later inadulthood. Unfortunately, a number of methodological shortcomings across thisbody of research (e.g., studies with insufficient sample sizes, inappropriatecomparison groups, and suboptimal or biased psychometric measures) limit theconfidence that can be placed in these findings, underscoring the need for anew generation of studies. This paper provides an overview of this literature,focusing on issues of gender differences, sport type, and age. It alsohighlights the relationship between disordered eating and compulsive exercise,a compensatory behavior that is highly prevalent among collegiateathletes. The health and athleticperformance consequences of eating disorders in conjunction with compulsiveexercise are also discussed. Inaddition, a focus on more recently recognized eating disorders, such as bingeeating disorder and the night eating syndrome is underscored. Future work in this area needs to include themost methodologically rigorous measures available in order to aid mostappropriately coaches and athletic trainers in promptlyidentifying at-risk athletes and to inform future prevention and treatmentefforts.

Key words: eating disorder, disordered eating, compulsive exercise

INTRODUCTION

Over the past decade, a number of studies have examined thesymptoms of disordered eating among National Collegiate Athletic Association(NCAA) athletes (9,12,13,24,30).Up to 84% of collegiate athletesreportedengaging in maladaptive eating and weight control behaviors, such as bingeeating, excessive exercise, strict dieting, fasting, self-induced vomiting, andthe use of weight loss supplements (12,13,24).Subclinical symptoms or those that reach diagnostic criteria maycontribute to poor physical and mental health, as well as suboptimal athleticand 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 athletes 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 EatingDisorder Diagnoses

According to the Diagnostic and Statistical Manual (DSM-V) of theAmerican Psychiatric Association (2013), eating disorders are characterized bysevere alterations in an individuals eating habits that are linked tophysiological changes.Individuals with eating disorders becomepre-occupied with food, body weight, and physical appearance. Common eating disorders that occur incollegiate athletes are Anorexia Nervosa (AN) and Bulimia Nervosa (BN) (4,10,12,24, 42). For instance, in a mixed-sportsample of Division I collegiate athletes, 5.1% of all women scored in theclinical range for either Anorexia Nervosa or Bulimia Nervosa (49). Similarrates of clinical eating disorders were reported in a sample of 414 NCAADivision I athletes (6.3%), with Bulimia Nervosa being the most frequent one(4).

According to the American Psychiatric Association (2013), AnorexiaNervosa (AN)is characterized bypersistent restriction of caloric intake, resulting in significantly low bodyweight (below the minimal norm considering an individuals age, height, weight,and developmental trajectory). It alsomanifests through an intense fear of gaining weight and severe disturbances inones perceptions of his or her own body weight and shape (i.e., refusal torecognize the seriousness of ones low body weight). Bulimia Nervosa (BN) is characterized by thefollowing symptoms: (a) recurrent episodes of binge eating; (b) recurrentengagement in detrimental compensatory behaviors in order to prevent weightgain; (c) the binge eating and compensatory behaviors must occur at least oncea week for three consecutive months; and (d) an individuals body and shapebecome vital parts in his or her self-evaluation (3). Binge Eating Disorder(BED)includes the followingsymptoms: (a) recurrent engagement in episodes of binge eating; (b) occurrenceof binge eating episodes, on average, at least once a week for threeconsecutive months; (c) manifestation of distress related to binge eating; and(d) disassociation with the recurrent use of compensatory behaviors as inBulimia Nervosa or Anorexia Nervosa (3).Other Specified Feeding or Eating Disorder (OSFED) can be applied tocases, when a person engages in eating behaviors that cause clinicallysignificant distress or impaired functioning, but does not meet full criteria foran eating disorder (3). Lastly, NightEating Syndrome is characterized by recurring episodes of eating afterawakening from sleep or by immoderate food consumption following the eveningmeal (3).

The Prevalence ofEating Disorders in Athletes

Although disordered eating and exercise behaviors have beenhighlighted as significant issues among collegiate athletes, the percentage of athletes who meet fulldiagnostic 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) foundthat, in a group of female collegiate athletes, 2% met the criteria for aneating disorder diagnosis and another 25.5% exhibited subclinical symptoms ofan eating disorder (e.g., binge eating, self-induced vomiting, and excessivedieting). Similarly, in Petrie et al.s(2008) study, 19.2% of collegiate athletes reported maladaptive eatingbehaviors. Sanford-Martens et al. (2005)detected slightly lower rates of subclinical eating problems (14.5%).

In Anderson and Petries (2012)study among female collegiate athletes, 26.8% of women reported disorderedeating behaviors. Approximately 40% of the athletes engaged in at least twohours of daily physical activity, suggesting that many may be using this highlevel of activity as a compensatory strategy in response to binge eating. Up to 28% of athletes reported dieting orfasting at least two times over the past year (4). Kato and colleagues (2011) reported thehighest rates of disordered eating in a sample of NCAA Division I and IIIathletes, ranging from 40.4% to 49.2%.In addition, 30.7% of all athletes reported body dissatisfaction, weightpreoccupation, and bulimic tendencies. Wide-ranging rates of clinical and subclinical eatingdisorders in collegiate athletes call for additional research on eatingdisorders and associated symptoms, including compulsive exercise (9,29). Although previous studies provided usefulprevalence data (4,12,24,30,42), new studies could potentially yield more accurateand consistent results of unhealthy eating and weight control behaviors incollegiate athletes.

Health Consequences of Eating Disorders

While each eatingdisorder has its distinct signs, symptoms, and health effects, the mostfrequent signs and symptoms of disordered eating and compensatory behaviorsinclude: sudden weight loss, gain, or fluctuation; hypothermia (i.e., adangerously low body temperature); and fatigue (29). Oral and dental problems caused by pathogenicweight control behaviors are dental erosion or caries, perimolysis (i.e., adental condition linked to frequent regurgitation), and recurrent sore throats(64). Dermatological issues, such ashair loss, brittle nails, skin discoloration, and poor skin healing; also arisein individuals suffering from an eating disorder (54). Disordered eating behaviors also severelyaffect an individuals endocrine system by resulting in irregular menstrualcycles or a complete absence of menstruation (i.e., amenorrhea), which couldpotentially lead to infertility (55).Furthermore, prolonged misuse of laxatives, diuretics, enemas, and dietpills, as well as self-induced vomiting lead to various gastrointestinalproblems, 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 onthe cardiorespiratory system include, but are not limited to, chest pains,hypotension (i.e., low blood pressure), arrhythmia (i.e., irregular heartbeat), bradycardia (i.e., an extremely low heart rate), and shortness of breath(11).

Anotherconsequence of maladaptive eating and compensatory behaviors is the FemaleAthlete Triad, which is characterized by energy deficiency, menstrualirregularities, and low bone mass that occur as a consequence of malnutritionand disordered eating (40). Low bonemineral density can result in injuries, stress fractures, and potentialosteoporosis (55). This may be especially hazardous for competitive athleteswho are generally at higher risks for overuse injuries due to their continuousengagement in high amounts of intense physical training (61). For instance, disordered eating, amenorrhea,and low bone mineral density were associated with musculoskeletal injuries ininterscholastic female athletes (46). Finally, neuropsychiatric symptoms, includingmemory loss or lack of concentration, insomnia, increased anxiety, depression,seizures, obsessive-compulsive behavior, and suicidal ideation can be seen inpersons with eating disorders (50). Up to a third of athletes at-risk for an eating disordertend to engage in multiple pathogenic behaviors, as opposed to a singlebehavior such as restrictive eating (41).

Consequences of Eating Disorders on Athletic Performance

Disordered eatingcan have an effect on athletic performance (18). In aesthetic (e.g.,gymnastics, swimming, diving), endurance (e.g., cross-country), andweight-classsports (e.g., wrestling, rowing), itis believed that leanness leads to enhanced performance (9). However, many athletesachieve low weight through disordered eating and compensatory behaviors, whichcan significantly decrease athletic performance (18,29). Specifically, long-term disordered eatingimpairs the main components of muscular fitness (i.e., aerobic fitness, musculoskeletalfitness, motor fitness, and flexibility), thus resulting in poor athleticperformance (18). In addition, thehealth consequences of restricted caloric intake, such as loss of fat, leanbody mass, electrolyte imbalances, and dehydration, can contribute todiminished performance (29). In a studyamong junior elite female swimmers, Van Heest and colleagues (2014) found thatfemale athletes who restricted caloric intake and increased energy expenditurein training frequently suffered from ovarian suppression (i.e., lack ofestrogen production). Female athleteswho trained in the presence of low energy availability and ovarian suppressionexhibited significant declines in their swim velocity (59).

A similar study of high school athletes found a negativerelationship 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 menstrualirregularities, while 65.6% reported suffering a sports-related musculoskeletalinjury during the ongoing season. Athletesexhibiting disordered eating behaviors were twice as likely to sustain asports-related injury during a competitive season, as compared to the athletesreporting healthy eating behaviors.Moreover, the inability to train and compete due to an injury furtherresults in decreased athlete performance upon the athletes 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 weightand body image, as well as continuous eating restriction have been associatedwith mood disorders, which may impact athletic but also academic performance(27). Furthermore, overvaluation ofshape, weight and eating control, anxiety, and depression that often coexist inathletes at-risk for an eating disorder, are capable of decreasing athletesmotivation to train and compete. Theresulting poor performance may further increase the pressure experienced byathletes to train more intensely and adhere to even more rigid dieting forweight loss (18). Disordered eatingbehaviors in competitive athletes may not only severely undermine an athleteshealth, but may also produce deterioration in sport performance (18).

Eating Disorders by Gender

A number of studies have foundhigher rates of maladaptive eating habits in female athletes compared to maleathletes (9,10,24,31). Forexample, in a sample of 800 NCAA Division I student-athletes, 19% of women and 12% of menreported unhealthy eating habits (10).Krebs et al. (2019) also found a higher rate of eating disorders in collegiate femaleathletes than males. Specifically, threetimes as many female distance runners screened positively for an eatingdisorder as compared to male (46% and 14%, respectively). In another study, 26% of student-athletesscored in the clinical range for an eating disorder, with five times morefemales (84%) than males (16%) reporting disordered eating behaviors (37).

The main explanation for this tendency isthat female athletes are more subjected to socio-cultural pressure to diet andbe thin, while male athletes tend to be more concerned with physical fitness andmasculinity (51). Thus, fewer male athletescontemplate dieting as compared to female athletes, which represents a riskfactor for the development of eating disordered in females (51). Nevertheless, disordered eating has beensignificantly increasing among male athletes (22,12,42,52). For instance, certain male athletes,specifically wrestlers, rowers, and long-distance runners, are more likely toengage in pathogenic weight control behaviors than female athletes in generaldue 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 Istudent-athletes. They found that moremale athletes than female athletes exhibited having inadequate nutrient intake. Specifically, only 10% of male athletes, ascompared to 19% of female athletes, consumed the recommended minimum ofcarbohydrates per each kilogram of their body weight, while 19% of males and32% of females consumed the minimum recommended amount of protein. Moreover, male athletes were more likely toexceed the Dietary Guidelines for fat, saturated fat, sodium, and cholesterolintakes, 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) forweight reduction (26). Also,approximately 6% of male athletes indicated restricting their fluidintake. These findings can potentiallybe understood in the context of mens preoccupation with muscularity, resultingin a focus on diet, nutritional supplements, and excessive exercise (10). Hintonet al.s (2004) study findings suggest that male athletes, just as femaleathletes, 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 equallypressured to diet and exercise compulsively in order to maintain low bodyweight and produce successful athletic results (14).

In summary, asubstantial body of literature shows that rates of eating disorders anddisordered eating symptoms among collegiate athletes range widely, 0-19% inmale athletes and 6-45% in female athletes (9,29,31,34). While the occurrence of clinical eating disorders is more prevalent infemale athletes than male athletes, male athletes, in sports such as wrestling,rowing, and cross country, are at greater risk for pathological weight controlbehaviors (26,49,52). Such findings highlight inconsistencies in the eatingdisorder area and emphasize the need for additional research on the prevalenceof eating disorders among both male and female athletes.

EatingDisorders by Sport

A number of studieshave determined that the sport type in which an athlete participates can serveas a risk-factor for the development of disordered eating (4,22,48,52). In eating disorder research, sports have beencategorized according to the level of pressure an athlete faces to maintain alow body weight for aesthetic reasons and/or performance enhancement (14). Across several studies (4,22,29,42),thefollowing categories have been described: aesthetic or lean sports (e.g.,gymnastics, figure skating, swimming, diving, track and field), endurancesports (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), andanti-gravitational sports (e.g., skiing, pole vault jumping).

Higher rates ofeating disorders in aesthetic, endurance, and weight-class sports have been consistentlyreported (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%). InSundgot-Borgen and Torstveits (2004) study on elite athletes, 42% of women inaesthetic 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% ofeating disorders were seen in men participating in endurance sports and 5% inball-game sports (52). There are three possible explanations ofhigher rates of eating disorders in aesthetic, endurance, and weight-classsports. First, in endurance sports, suchas cross-country, weight higher than an athletes optimum performance weight islinked to decreased performance (14).Second, in weight category sports, such as wrestling, athletes arepressured to meet a specific weight requirement just to qualify for acompetition (9). Third, in aestheticsports, such as gymnastics, athletes physical appearance is a part of anaesthetic evaluation, which pressures athletes to attain a certain bodycomposition (14).

While the prevalence ofdisordered eating in sports that emphasize leanness is high, the reported ratesof eating disorders vary by sport (48,53,57).For instance, in a sample of 414 NCAA Division I female athletescompeting in gymnastics and swimming/diving, 108 (26%) scored in thesubclinical 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 wereidentified as having subthreshold Bulimia Nervosa, 4 with Non-bingeing Bulimia,and 2 with Binge Eating Disorder (4).

In contrast to Anderson andPetries (2012) findings, Carter and Rudd (2005) detected lower rates ofdisordered eating considering the sport type.In a mixed-gender sample of 800 NCAA Division I athletes, Carter andRudd (2005) found 9.2% of non-lean sport athletes and 17.5% of lean-sportathletes exhibiting subclinical features for an eating disorder. Additionally, 6.1% of athletes in lean sportssuffered from chronic dieting, as compared to 2.5% of athletes in non-leansports. Such high rates of disorderedeating in gymnasts and swimmers/divers support the notion that athletescompeting in lean and aesthetic sports are pressured to possess ideal bodyweight for reaching optimal performance.Thus, lean- and aesthetic-sport athletes are exposed to higher risks fordeveloping an eating disorder than athletes competing in sports that do notoverly emphasize body weight and physical appearance (4,10). Furthermore, Glazer (2008) found that athletesparticipating in lean sports averaged significantly higher on the EatingAttitudes Test (EAT) and the Social Physique Anxiety Scale (SPAS), suggestinggreater disordered eating and physique anxiety, as compared to athletesparticipating in non-physique-salient sports.Glazers (2008) findings support the notion of increased prevalence ofeating disorders in sports that emphasize leanness (e.g., gymnastics, longdistance running). Participation in nonphysique-salient sports (e.g., basketball, softball, soccer) may be aprotective factor for the development of disordered eating (22).

Although some studies have linkedthe sport team classification to disordered eating levels (4,10,48), otherstudies found no support for this relationship (24,42,49). For example, despite the high frequency ofpathogenic eating in a sample of collegiate athletes (19.2%), no associationwas found between sport team classification and eating disorder status inPetrie et al.s (2008) study. Similarly,Greenleaf et al. (2009) found no differences in the frequency of maladaptiveeating behaviors across sport type. These results corroborated previousfindings from Sanford-Martens and colleagues (2005) study, which also found nodifferences in eating disorder symptoms across sport types. These findings suggest that sport type maynot be an influential factor in the development of maladaptive eating habits incompetitive athletes (49).

To conclude, somestudies suggested that lean-sport athletes (such as gymnasts, runners,swimmers, cyclists, and wrestlers) are more prone to developing an eatingdisorder than non-lean sport athletes, who do not overly emphasize body weightand physical appearance as part of their sport (4,10). However, other studies failed to establishthe relationship between athletes sport classification and their propensityfor unhealthy eating behaviors (24, 42).This observation calls for the need to broaden researchers perspectiveson identification of at-risk athletes (9).Future studies may provide a clearer pattern between the sport type anddisordered eating in collegiate athletes.

Eating Disorders and Age

While a great number of studieson the prevalence of eating disorders among athletes have reported their agesas a demographic variable (22,34,36,47,52), only a few studies assessed thedirect 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 notrelated to age, indicating that symptomatic athletes may be found among alldifferent ages (42). Similarly,Greenleaf et al. (2009) found no differences in athletes eating disorderstatus (i.e., symptomatic vs. eating disordered) based on their age. These findings suggest that the age variablemay not be an influential factor on collegiate athletes disordered eatingsymptomology (24). Similarly, in asample of 290 elite athletes between 14 and 30 years of age, Gomes et al.(2011) assessed the relationship between unhealthy eating behaviors andage. No association was found betweenathletes age and each subscale of the Eating Disorder ExaminationQuestionnaire (EDE-Q, 20). Thus, thefindings indicate that athletes across different ages may be equally at-riskfor developing maladaptive eating habits (23, 42).

Pettersen et al. (2016) furtherexamined the prevalence of disordered eating in 225 Norwegian athletes in theage groups of 17, 18, and 19+ years old.In total, 18.7% of the athletes exhibited symptoms of disorderedeating. Age was not a significantpredictor of athletes maladaptive eating patterns. As Pettersen et al. (2016) explain, the peakrisk for the development of an eating disorder occurs between childhood andearly adolescence. However, the majorityof 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 andself-esteem than athletes in their early adolescence, which could serve as aprotective mechanism against the development of eating pathologies (43).

In summary, some studies suggestthat the prevalence of maladaptive eating behaviors (e.g., fasting,self-induced vomiting, using laxatives and diuretics, binging followed byexercise, etc.) is higher in the college-aged athletes, as compared tocompetitive adolescent athletes (29, 30, 43).Nevertheless, a substantial body of literature indicates thatcompetitive adolescent athletes experience severe eating disorder symptoms asdo collegiate athletes (9, 29, 43). Additionally, the studies focusingspecifically on the impact of age, failed to establish a significantassociation between age and athletes eating disorder status (24, 42 ,43). Thus, additional studies are necessary toestablish a clearer association between athletes age and pathogeniceating.

CONCLUSIONS

Collegiate student-athletesrepresent a unique population of young adults who, because of the demands ontheir time associated with their sport, may be at particular risk fordisordered eating and compulsive exercise (32). Specifically,many collegiate athletes appear to use excessive exercise as a compensatorybehavior to control their body weight (4, 12, 36, 42, 48). Compulsive exercise, in combination with thesport-required training, place student-athletes at a high-risk for overuseinjuries, and physical exhaustion, which can further impede athleticperformance (12, 53). Therefore, thereis a need to further examine disordered eating and compulsive exercise patternsamong collegiate student-athletes in order to draw athletic staffs, coaches,and athletes attention to the deleterious health effects of these disorderedbehaviors.

APPLICATIONS IN SPORT

The roles of athletic trainers, administration, and coachesare paramount in recognizing detrimental eating and exercise patterns inathletes and providing them with the necessary professional assistance (14). First, expanding athletes knowledge aboutproper nutrition habits, maladaptive eating behaviors and their healthconsequences, and learning how to address the issue of disordered eating, arepivotal steps in primary prevention (40).There is a need to inform athletes that dietary restriction and purgingbehaviors for attainment of the desired body weight may lead to decreasedathletic performance and adverse health consequences. Structured educational programs have shown toreduce the impact of risk factors of disordered eating (6, 17, 19). For instance, Becker et al. (2012) observed asignificant reduction in bulimic symptoms just after 1 year following apeer-led educational intervention for athletes.In addition, the researchers found an increase in the number of athletesseeking medical assistance due to the concern that they may suffer from theFemale Athlete Triad symptoms (6).Through educational programs, athletes, parents, and coaches can alsolearn that menstrual dysfunction occurs as a result of low energy availabilitydue to deliberate dietary restriction, rather than a positive adaptation tohigh-intensity sport participation (17).

Changing perspectives on competitive sport participationfor athletes and coaches could be another strategy for eating disorderprevention. Specifically, the way inwhich athletes evaluate their maladaptive eating and exercise habits can fostermaintenance of an eating disorder (44,58).For instance, Thompson and Sherman (2010) found that athletes tend tounderreport their eating disorder symptoms due to the misconception thatdietary restriction and excessive exercise will result in enhanced sportperformance. Athletes and coaches oftenreinforce maladaptive behaviors (i.e., dietary restriction, excessive exercise)because they believe that certain aspects of sport participation, such asmental toughness and continuous engagement in intense training, are pivotal inreaching optimal performance (44). As aresult, athletes may perceive compulsive exercise as a demonstration of highcommitment to their sport, rather than a symptom of an eating disorder (16,28). In addition, athletes and coaches falselybelieve that weight loss achieved through food restriction and excessiveexercise will imminently lead to increased performance (16). Thus, due to perfectionistic andresult-oriented views of athletic participation, eating disorder symptoms areoften overlooked and underreported (28).Consequently, an emphasis of educational programs should be placed onprompt recognition of maladaptive eating and exercise habits to prevent thedevelopment of a clinical eating disorder.

Furthermore, despite the availability of various eatingdisorder prevention strategies, Vaughanet al. (2004) found that only 1 in 4 (27%) of athletic trainers feel confidentin identifying an athlete with an eating disorder. In addition, only 38% of athletic trainersfeel confident in asking an athlete about disordered eating behavior (60). Although educational programs and counselingservices have been created for collegiate student-athletes, proactive steps onbehalf of the university athletic staff are necessary for early identificationand prevention of eating disorders (8,35).Prompt detection of unhealthy eating behaviors through screeningprotocols 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 aneffective screening tool for identification of disordered eating behaviors inathletes (7). This instrument assesseswhether athletes suffer from body weight pre-occupation, restrict their caloricintake, use nutritional supplements for weight loss, and undergo pressure tolose weight by outside sources (7). TheFemale Athlete Triad Coalition developed an 11-question screening tool thatcould be successfully employed as a part of the Pre-participation PhysicalExamination (17). This measure evaluatesa female athletes pre-occupation with body weight, dietary restriction,menstrual dysfunction, bone injuries, and low bone mineral density. Consequently, simultaneous use of thesescreening tools could play a key role in identifying at-risk athletes andproviding immediate treatment prior to competitive season. Byutilizing screening protocols, coaches and athletic trainers can ensure thatstudent-athletes have rewarding collegiate experiences. In addition, this method can protect athletesagainst the development of eating disorders that otherwise mayendure into adulthood, impacting their physical and psychosocial health long-term(18,27).

Directions forFuture Research

Further studies investigating the patterns of disorderedeating in conjunction with compulsive exercise in collegiate athletes arenecessary for several reasons. First, itis pivotal to provide athletes, coaches, athletic trainers, and athleticadministrators with accurate information about the severity of maladaptiveeating and exercise in collegiate athletes.Second, various socio-cultural and sport-specific pressures have beenidentified as potential risk factors for the onset of eating disorders inathletes, which allows researchers to examine the links between these riskfactors and the development of disordered eating behaviors (14,18,51). While numerous studies have investigatedthese issues in great depth, wide gaps still exist in the literature due toinconsistent prevalence rates of eating disorders based on athletes gender,age, and sport type (9,29). In addition, certain studies yieldedcontradictory results and failed to establish the relationships among athletes sport classification, age, and theirpropensity 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, agreat number of studies in eating disorder research used the Questionnaire forEating 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 thesymptoms of AN, BN, and BED, thus omitting questions related to the symptoms ofthe NES, an eating disorder that was later added the DSM-V (3). Consequently,questions exploring the NED symptoms, such as the frequency of recurringepisodes of eating after awakening from sleep and the episodes of immoderatefood consumption following the evening meal, should be added to the more recenteating 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 bothfemale and male athletes competing at the collegiate level need to be recruitedto more accurately address the issue of gender differences in eatingdisorders. Although male athletesgenerally have a lower prevalence of eating disorders than female athletes, anincreasingly large body of literature indicates that disordered eating amongmale athletes is on the rise (12,22,42,52).Moreover, male athletes in certainsports are more likely to engage in compensatory behaviors than female athletes(26). This conclusion could not be drawnif the study focused solely on one gender.Thus, excluding one gender from theinvestigation may result in biased reporting of the disordered eating problemand inaccurate conclusions about its prevalence rates across both genders.

Lastly, the conditions under which athletes reporttheir eating behaviors must be assessed prior to data collection. Athletes tend to underreport theirmaladaptive eating and compulsive exercise habits due to the fear that theireating disorder may be discovered by their coaches and potentially affect theirathletic careers (52). Consequently,athletes must be provided with confidentiality and a pressure-free environmentin which they can answer instrument questions candidly. In addition, researchers need to chooseappropriate measures that have been previously validated in athlete samples tosuccessfully discriminate between eating disordered and healthy athletes.

ACKNOWLEDGMENTS

None

REFERENCES

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Disordered Eating and Compulsive Exercise in Collegiate Athletes: Applications for Sport and Research - United States Sports Academy Sports Journal

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