What is the prevalence of eating disorders among female athletes?

Lee Knight Caffery

% Eating Disorders After Retirement From Athletics

% Comparison With a General Population

INTRODUCTION

Athletes are among the quickest, strongest, most flexible people in the world, so one would expect them to adhere to the latest health and fitness information, right? Not always. The problem is that the athletes often believe that more fit equals less fat. The death of Olympic gymnast Christy Henrich from anorexia nervosa began to bring the topic of athletes and eating disorders to the forefront. Research into the topic of eating disorders and athletes shows a few interesting findings. Most of the studies focus on women and specific sports, namely gymnastics, figure skating, diving, and other weight-dependent sports. Some research, however, shows prevelance findings of eating disorders in female athletes congruent with the general population.

FEMALE ATHLETE TRIAD

The female athlete triad of disordered eating, amenorrhea, and osteoporosis affects many active women, especially those in sports that emphasize appearance or leanness. Physical signs and symptoms include unexplained recurrent or stress fracture, dry hair, low body temperature, lanugo, and fatigue (Joy, Clark, Ireland, Martire, Nattiv, and Varechok, 1997). Prevalence of the triad is hard to assess because data is limited to a few studies. In the United States, studies suggest, (based on limited data) a prevalence in female athletes between 15 percent and 62 percent (Dummer, Rosen, Heusner, et. al 1987; Rosen, Hough 1988; Rosen, McKeag, Hough, et. al, 1986). Women who have the triad can typically be characterized as being a perfectionist with high goals, being very critical of herself and having very high expectations, and having fairly low self esteem (Nattiv, 1997). Most of the women with the triad are dedicated athletes, very motivated, achievement oriented, and have a strong work ethic. They tend to ignore or minimize minor injuries (Varechok, 1997).

Within the triad are the classic eating disorders. Joy (1997) states that women with the restricting type of eating disorder (like anorexia) classically have physical signs of starvation. They often appear very thin and have low body weight for their height and low body fat. Bulimia is harder to identify because those with the disorder tend to be normal weight although they may show signs through erosion of the tooth enamel, face and extremity edema, and bloodshot eyes (Joy, Clark, Ireland, Martire, Nattiv, & Varechok, 1997).

FEMALE GYMNASTS

Much emphasis has been given to a focus of female gymnasts in literature concerning eating disorders and athletes presumably because the appearance and performance demands of gymnastics lead these athletes to diet in an effort to attain or maintain sub optimal weights (Rosen & Hough, 1988; Thompson & Sherman, 1993; Yeates, 1991). Dieting and attempted weight loss many times precipitate the development of an eating disorder (Garfinkel & Garner, 1982; ). Thus, attempts to lose weight increase the athlete's risk of developing an eating disorder.

Over the past thirty years a trend has shown that U.S. Olympic female gymnasts have become significantly smaller in terms of body size and weight (Nattiv & Mandelbaum, 1993). Many gymnasts diet and attempt to lose weight to improve athletic performance. Wilmore (1992, 1993) suggests that the higher the body weight, generally the poorer the athletic performance. He reports that, more specifically, the higher the body fat, the poorer the performance. Harris and Greco (1990) reported that 61 percent of the gymnasts in their study were trying to lose weight, and Rosen and Hough (1988) found that all of the participants in their study were dieting. Other studies with gymnastics have found the frequent use of pathogenic weight control methods (Petri & Stoever; Rosen, McKeag, Hough, & Curley, 1986).

Sherman, Thompson, & Rose investigated the relationship between body mass index and athletic performance of elite female gymnasts. Subjects were the top 36 finishers in the allaround competition at the 1991 World Gymnastic Championships. The purpose of the research was to determine the relationship between thinness and performance in elite gymnasts. Allaround scores for the participants were used to rank each gymnast and compare her performance against her body mass indexJ(weight in kilograms/height in meters squared.) The results showed that a lower body mass index appeared to be related to better performance, but performance became poorer as body mass index became very low. Thus, even though weight loss typically results in enhanced athletic performance, there is a point beyond which continued weight loss will lead to poorer performance. These findings suggest that thinner is not always better; an abnormally low body mass index does not mean enhanced performance.

OTHER ELITE ATHLETES

In a study by Sundgot-Borgen (1994), 603 elite female athletes aged 12-35 from Norway were given assessment questionnaires. Based on their responses, 117 were identified as at-risk for eating disorders. A structured clinical interview was administered to 103 of the subjects, and 89 percent ulfilled criteria for anorexia nervosa, bulimia nervosa, or anorexia athletica. Rosen found that the prevalence of eating disorders was significantly higher among athletes in aesthetic sports such as diving, figure skating, and gymnastics, and in weight dependent sports than in other sports. Also, Rosen discovered that a significant number of athletes who began dieting to improve their performance reported that their coaches recommended that they loose weight.

EATING DISORDERS AFTER RETIREMENT FROM ATHLETICS

An investigation was conducted by O'Connor, Lewis, Kirchner, and Cook to describe eating disorder symptoms in former college gymnasts around the age of 36 as well as relations between body dissatisfaction and body composition. Early reports from one group indicated that pathogenic weight-control behaviors were extraordinarily high in college gymnasts (Rosen et al., 1986). However, recent studies showed that eating-related disturbances in college gymnasts are not as prevalent or extreme as initially reported (Harris & Greco, 1990; O'Connor, Lewis, Kirchner, 1995 ). Twenty-two former college gymnasts and a control group with no reported history of participation in college athletics participated in the study. The Eating Disorders Inventory-2 was used to measure 11 constructs that have theoretical relevance to eating disorders and a body-weight discrepancy score was also obtained by subtracting the self-reported ideal body weight from actual body weight. Visual analog scales were used to quantify the participants recollections about "preoccupation with thinness" and "satisfaction with body shape." The one main findings of the study was that there were not many eating disorder symptoms in female gymnasts fifteen years after their retirement from the sport. The former gymnasts did have a lower percentage of body fat than the control subjects, and they did have lower body dissatisfaction scores than the control subjects. The former gymnasts did also report that they were more satisfied with the shape of their body and less weight-preoccupied after retiring from gymnastics than when they were participating in the sport during college. Thus, the data gathered by O'Connor, Lewis, Kirchner, and Cook suggests that preoccupation about weight occurring in association with participation in college gymnastics abates after retirement from the sport.

INFORMATION FOR COACHES

Coaches of elite athletes can help prevent the onset of eating disorders. by educating and breaking down athletes' misconceptions about eating. Research (Garner & Rosen, 1991; Petrie & Stoever, 1993; Rhea, 1992) has shown that female athletes are especially vulnerable to eating disorders, pathogenic weight behaviors, and food as tools to control their athletic performance, as well as other aspects of life. Many athletes believe that losing weight will enhance their performance level (Rosen, McKeag, Hough, & Curley, 1986.) Thus coaches could convey information about the effects of eating disorders targeted at their athletes, although coaches should not be expected to assume full responsibility for their athletes.

Many athletes do not understand the difference between body fat and body weight. Some athletes equate dietary fat with body fat and cut fat out of their diet completely in an attempt to reduce their body fat. They may lose weight as a result of lost body water and body tissue, without reducing their actual body fat (Rhea, Jambor, Wiginton, 1996). It is common for athletes to diet in an attempt to increase performance (Clark, Nelson, & Evans, 1988; Rosen et al., 1986; Taub & Blinde, 1992), and some athletes practice pathogenic weight control techniques, such as using laxatives, diuretic, diet pills, and self-induced vomiting. Coaches can discourage this behavior by focusing on the negative effects of dieting and pathogenic weight techniques.

Coaches should have knowledge of basic information about diet and nutrition, as well as an understanding of the causes and consequences of eating disorders in female athletes. Some warning signs of an eating disorder include: constant patterns of dieting, perfectionist qualities, high dissatisfaction with body shape, low self-esteem, and use of pathogenic weight techniques. Coaches should also be aware that excessive weight loss causes amenorrhea (abnormal absence of menstruation) and extremely low body fat level and they should be aware that their comments may have an effect on their athletes. Derogatory statements and misguided advice are potentially harmful to athletes. Many athletes will go to extreme measures to avoid being considered "too fat" (Rosen & Hough, 1988; Sundgot-Borgen, 1994.) Strategies for risk reduction (Rhea, Jambor, Wiginton, 1996):

1. De-emphasize body weight. Body fat percentage and proper nutrition are much more relevant to athletic performance than body weight. Coaches should not equate weight with performance simply because it is easy to measure.
2. Eliminate group weigh-ins. Many drill team and cheerleader coaches insist on weigh-ins, and some call out each athlete's weight in front of the entire team. One study showed that eating disorders were more prevalent among drill team members than any other group of athletes (Rhea, 1992), and dancers and gymnasts are another high-risk group (Borgen & Corbin, 1987; Zucker, 1985).
3. Discourage pathogenic weight techniques. Sometimes pathogenic weight techniques are accepted, condoned, and even valued by athletes as part of athletics (Taub & Blinde, 1992; Davis & Cowles, 1989; Rosen et al., 1986). Coaches need to define some healthy guidelines for athletes to follow. They must also devalue the use of pathogenic weight techniques and warn athletes of the consequences of such practices.
4. Recognize individual differences. Every individual is different and needs to be treated accordingly. Genetic distinctions and individual limitations need to be considered.

Guidelines for appropriate weight loss (Rhea, Jambor, Wiginton, 1996):

1. A health care professional experienced in working with eating disorders should assess the athlete to determine that she is at minimal risk for developing an eating disorder as a result of a weight loss plan.
2. The athlete's weight should be higher than her recommended body weight.
3. The athlete should agree with the decision to lose weight.
4. A dietitian should be responsible for determining the target weight range, designing an eating plan, and monitoring the program.
5. The weight loss program should be discontinued if any weight-related or psychological difficulties emerge.
6. Athletic performance should be closely monitored by sport personnel to determine if performance is actually increasing as weight decreases.
7. If performance is not enhanced, the weight loss program should be discontinued.
8. If performance is enhanced, the weight loss regimen should not be continued beyond the target weight range.

COMPARISON WITH A GENERAL POPULATION

Much attention has been given to the prevalence of eating disorders among women athletes in recent years, and a widespread belief is held that athletes are at a greater risk for eating disorders. However, evidence from a study done by Skowron & Friedlander (1994) suggests that the extent of weight preoccupation among elite women swimmers, as a group, is comparable to published reports of the general population of college women. Garner and Garfinkel (1980) reported 12 percent of college women to be weight preoccupied and Klemchuk et al. (1990) found 10.1 percent of college women to be weight preoccupied. Both the non athletic college women and women athletes in Skowron & Friedlander's study (1994) most at risk for eating disorders seemed to be those who were experiencing considerable distress achieving an adequate sense of self and who engaged in destructive forms of self-restraint. According to studies (Black & Burkes-Miller, 1988; l tend to use such methods (Mintz & Betz, 1988). The conclusion that elite athletes are at increased risk for eating disorders may be inaccurate. Nonetheless, athletes should be monitored by their coaches for abnormal weight loss and eating behavior.

SUMMARY

Much research points toward the theory that female athletes seem to be at a high risk for developing eating disorders because of different pressures surrounding performance and aesthetics. Coaches may be somewhat to blame, but they may also be part of a solution through education about healthy lifestyles. More studies should be conducted with athletes outside the realm of the "aesthetic" sports like gymnastics; collegiate female basketball player, lacrosse players, tennis players, etc. should be studied because not as much emphasis is placed on appearance and petitness in these sports. More overviews should also be given in comparison to the general population in order to put the findings in context of today's society.

BIBLIOGRAPHY

Dummer, G., Rosen, L., Heusner, W. et al. (1987). Pathogenic Weight- Control Behaviors of Young Competative Swimmers. Physician and Sportsmedicine , 15, 75-86.

Harris, M., & Greco, D. (1990). Weight Control and Weight Concern in Competitive Female Gymnasts. Journal of Sport and Psychology , 12, 427-433.

Joy, E., Clark, N., Ireland, M., Martire, J., Nattiv, A., & Varechok, S. 1997. Team Management of the Female Athlete Triad. The Physician and Sportsmedi5, 95-109.

O'Connor, P., Lewis, R., Kirchner, E., & Cook, D. (1996). Eating Disorder Symptoms in Former Female College Gymnasta: Relations With Body Composition. The American Journal of Clinical Nutrition , 64, 840-846.

Petri, T., & Stoever S. (1993). The Incidence of Bulimia Nervosa and Pathogenic Weight Control Behaviors in Female College Gymnasts. Research Quarterly in Exercise and Sport , 56, 245-250.

Rhea, D., Jambor, E., Wiginton, K. (1996). Preventing Eating Disorders in Female Athletes. Journal of Physical Education, Recreation, and Dance,

67, 66-70.

Rosen, L., & Hough, D. (1988). Pathogenic Weight Control Behaviors in Female College Gymnasts. Physician and Sportsmedicine , 16, 141-146.

Rosen, L., & McKeag, D. (1986). Pathogenic Weight Control Behaviors in Female Athletes. Physician and Sportsmedicine , 14, 79-86.