The Relationship Between Eating Disorders and Athletic Participation

By: Annie Plessinger

Introduction

Over the past few decades, there has been a great increase in the prevalence of anorexia nervosa and bulimia nervosa which have emerged as major psychological and health problems. This increase in eating disorders has resulted from the intense societal pressure to diet and conform to an unrealistic weight and body size. For the general population of women, the lifetime prevalence of anorexia nervosa is approximately 0.7%, and that of bulimia nervosa is as high as 10.3% ( Taub & Blinde, 1992). Since many athletes contain similar behaviors to those with eating disorders, there has also been an increase in interest in whether athletes are at a risk for eating disorders.
An increase risk of eating disorders among athletes has been proposed for several reasons. For starters, athletes tend to exemplify many personality characteristics such as perfectionism and the strive for high achievement which are found in patients with eating disorders. Other correlates include high self-expectation, competitiveness, compulsiveness, drive, self-motivation, and great pressure to be thin (Piracy, 1999). In order to improve performance, athletes may need to maintain a strong control and constantly monitor their body shape. This behavior has been identified as a risk factor for both anorexia and bulimia (Piracy, 99). In addition to the societal pressure to be thin, athletes have extra pressure for increased performance and ranking, which make them more cautious of their body size and shape leading them to become more susceptible for eating disorders. Although these characteristics may predispose athletes to eating disorders, some of these behaviors can also be beneficial to their sport. For example, the drive for perfectionism can help increase athletic performance and success. It may also help in other areas of their live such as school and in social relationships.

Studies

     Several of the early studies which attempted to estimate the prevalence of eating disorders among athletes yielded many mixed results. Some studies labeled college athletes as high risk, whereas others have found no support for such a label. The estimates widely varied going from 1% in anorexia and up to 30% in bulimia. In 1993, Sundgot-Borden and Larsen compared eating disorder correlates across sport categories with female college students and a female clinical population. Their results revealed that athletes involved in endurance and ball game sports did not differ on eating disorder correlates, and were not at risk for eating disorder correlates. Unfortunately, these early studies were not properly conducted, for there existed a variety of methodological limitations such as sampling procedure problems as well as small sample sizes which cannot be representative of an entire population. A more rigorous 1994 study by Sundgot-Borgen, used a self-report combined with an interview, which questioned 522 elite female athletes. His results indicated that 1.3% met the DSM-IV criteria for anorexia and 8% for bulimia (Johnson, Powers, & Dick, 1999).
    However an even more rigorous study to find the prevalence of eating disorders in college athletes was conducted in collaboration with the National College Athletic Association (NCAA). Out of 11 Division I schools and 11 different sports, 1,445 (562 females, 883 males) were selected via a brief survey the NCAA conducted to identify the high risk sports for eating disorders. They gave each participant a 133 item questionnaire to assess the athletes involvement in eating-related behaviors and attitudes concerning body image and weight-related issues. This questionnaire also included three subclass from the Eating Disorder Inventory-2 (EDI-2).
    The results of this study showed that male athletes were more likely to have episodes of overeating on a daily basis, but female athletes were much more likely to feel out of control during an episode of overeating (81% to 45%). Therefore, when dealing with the criteria for a binge, more female athletes (23%) binged than the males (12%). More female than male athletes had vomited as a means of losing weight at some time in their life in addition to monthly, weekly, or daily. Similarly the female athletes were more likely to have used laxatives and diuretics. In fact, the only technique in which males used more to lose weight were saunas or steam baths.
     When using the stringent criteria of the DSM-IV, none of the athletes were diagnosed as having anorexia, and 1.1% of females and no males met these criteria for bulimia. When using less strict criteria of binge eating or purging monthly, 9.2% of females and .005% of males had symptoms of bulimia. When they used the criteria of a BMI less than 20, amenorrhea, or a high score on the two key EDI-2 subscales: drive for thinness or body dissatisfaction, the percentages went up drastically. Twenty five percent of females and 9.5% of male athletes were considered at risk for anorexia. 58% of females and 38% of the male athletes were at risk for vomiting, laxative, or diuretic abuse.
    When comparing the scores of the EDI for the different sports, the results revealed that female gymnasts scored significantly higher between the swimmers and the basketball players. For the body dissatisfaction subscale, the only difference lied between the male football players (which were higher) and the male cross-country athletes. To sum up this study, the prevalence of disordered eating behavior and attitudes is lower than that of some earlier studies. However, despite the underreporting in this study, there still exists a prevalence of eating disorders in elite athletes, mostly female (Johnson et al, 1999).
     More recent studies have revealed that the prevalence of an eating disorder depends on the type of sport, and that certain subgroups of athletes may be more vulnerable to disordered eating than others. Sports that emphasize leanness or appearance (such as figure skating and gymnastics), and sports with strict weight restrictions (such as wrestling) show a higher prevalence of disordered eating when compared to other sports without these attributes (Piracy, 1999). Stoutjesdyk and Jevne (1993) found that the lean sports of gymnastics and diving had the highest percentage of females scoring in the
anorexic range.
     It has also been hypothesized that athletes in refereed sports (such as basketball), may be at a lower risk for developing an eating disorder than those athletes involved in judged sports like gymnastics.   Zucker et al., held structured interviews and handed out self-report questionnaires to assess the presence of eating disorders, the presence of body weight concerns, psychopathology, and body mass index (BMI) among female college athletes. This study involved three samples: 62 nonathletic students, 33 student athletes in refereed sports, and 37 student athletes involved in judged sports. As expected, the rate of diagnoses among the judged sport athletes was the highest at 13% with the nonjudged athletes and regular students each at 3%. The athletes in the judged sports did not differ from the nonathletic students involving measures on body shape and size. However, the people in the refereed sports scored lower on these measures when compared to the nonathletes and the judged group athletes. These findings posit that refereed sports could be a protective factor that reduces the risk of developing concern over body fears (Zucker et al, 1999).
     As shown above, specific types of sports are at higher risk for developing eating disorders than other. Yet another factor that might be related to eating disorders is the level of competition. To examine this, Picard sampled 38 NCAA Division I female athletes and 40 Division III athletes. There was also a nonathletic group for comparison as well. The results showed that athletes of higher levels of competition may be more at risk for eating disorders than the lower level athletes. Picard assessed the participants using the Eating Attitudes Test (EAT-26), the EDI-2, and a demographic and health questionnaire. Both the lean and the non-lean Division I sports had significantly higher scores on the EAT and EDI scales, positing a higher prevalence of preoccupation with thinness, preoccupation with weight and diet , and a morbid fear of fat. In general the lean sport athletes, regardless of division, showed many of the signs and symptoms of typical eating disorder patients, such as an overwhelming fear of fatness, dissatisfaction with body. Moreover, this group had feelings of self-discipline, denial, and control. All of these characteristics have been identified as risk factors for both anorexia and bulimia (Picard, 1999).
     Since most of the studies discussed involved college elite athletes, a question arises of whether it is possible to detect risk factors for disturbed eating patterns in lower level, younger athletes. Taub and Blinde attempted to answer this question by assessing the difference between high school female athletes and nonathletes in terms of behavioral traits associated with eating disorders and the use of pathogenic weight control techniques such as vomiting , fasting, and laxative. In addition, the different sports were compared to see if certain sports were more at risk for disordered eating. Each participant filled out a questionnaire and was assessed using the EDI. Significant differences were found on two of the eight subclass of the EDI: perfectionism and bulimia. Athletes were more apt to be perfectionistic and more at risk for engaging in bulimic behavior. However, it is interesting to note that the athletes scored significantly higher on self-esteem scores. Even though many athletes are perfectionists like those with anorexia, these athletes still showed lower on the EDI scales than compared to anorexia patients. However, the female athletes who were more perfectionistic were more likely to strive for thinness and were more likely to be restrained eaters. While it is logical to think that having a perfectionist attitude may benefit their performance in sport, this attitude may eventually put an athlete at risk for an eating disorder.
     The results exploring the differences of pathogenic weight control techniques showed no significant difference between athletes and nonathletes. In addition, they also did not differ on current dieting practices. In order to determine if different sports were more prone to eating disorders, comparisons were made between basketball, volleyball, track/cross-country and softball. The results revealed no significant differences among specific sport teams using the EDI subscale correlates of eating disorders.   In addition, there were no significant differences between the teams in self-esteem levels. In general athletes had high levels of self-esteem regardless of the specific sport. However, a large percentage of athletes scored above the mean known for anorexics on the scales of body dissatisfaction and perfectionism (Taub & Blinde, 1992).
      Fulkerson et al, provides us with another study on high school athletes that assessed whether high school athletes are at risk for an eating disorder, whether personality characteristics are different in athletes, and whether high levels of perfectionism also put athletes at risk. The sample consisted of 309 females and 369 males. The 318 students who were athletes were then randomly compared to 360 nonathletes. The comparisons were done by using the EDI, restraint scale, risk symptom
checklist, MPQ, and BMI. The results once again revealed no significant difference between athletes and nonathletes in the majority of the eating disordered behavior and attitudes. When differences were found, the athletes had more positive attitudes and behaviors. Furthermore, female athletes had more self-efficacy. In addition, both male and female athletes had less negative views of life than the nonathletes. Hence, it is possible that participation in high school athletics may be beneficial by increasing self perceptions of ability and competence.

Conclusion

In sum, the research on the risk of eating disorders for athletes is contradictory and still a little inconclusive. The question of whether athletes are in fact at risk is still debatable. However, in seems more certain that specific sports are more at risk than others, especially those sports that emphasize leanness and are being judged rather than refereed. The level of competition also appears to make a difference, with the advanced athletes being more at risk. However, more studies need to be done concerning this topic. Future research should examine national or international levels of athletic competition. The studies involved in high school athletes are contradictory to many studies with elite college athletes. Only minor differences were found between adolescent athletes and nonathletes involving measures of eating disorder tendencies and use of pathogenic weight control techniques. Moreover, among adolescents no significant differences were found between the types of sports they competed in. Some reasons for this difference between elite level and high school athletes may arise from the highly competitive and pressurized environment, demands of coaches, and financial gains based on performance that advanced level athletes have to deal with. Furthermore, sports for adolescents usually are not the central part of their lives and thus the athletic role may not dominate other individual identities and important life decisions as found in higher level athletes. Even though all athletes do not show to be more susceptible to eating disorders than nonathletes when using the DSM-IV criteria, they still show many at risk traits and behaviors and may still be vulnerable.

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