Eating Disorders in Sports
- Prevalence rates of Eating Disorders in Sports are not necessarily higher than in the general population.
- Sport participants are still however at higher risk of developing Eating Disorders than the general population.
- There is no single cause to an Eating Disorder
- Subclinical and Partial diagnoses of Eating Disorders in Sport are high!
- All Sport Participants have a responsibility to be aware of the added risk factors unique to sport that might promote the development of an Eating Disorder.
Its Eating Disorders Awareness week, and I wanted to write a blog with some useful information that might help with raising awareness of Eating Disorders, especially as they relate to Sport.
How common are Eating Disorders in Sport?
When it comes to estimating prevalence, its tricky ground for a number of reasons. For one, the diagnostic criteria of Eating Disorders (ED) has recently changed. Those who were not diagnosed before the release of DSM-V in 2013 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) could now be classified. For example, amenorrhea is no longer a necessary characteristic for the diagnosis of Anorexia Nervosa. Classifications of different types of sports, lean or nonlean, aesthetic etc also differ between studies and further the picture. Consider also, that those who suffer from an Eating Disorder often might not consider themselves to have a problem (think therefore what they might or might not say when filling out a questionnaire). Individuals also have a funny way of not fitting neatly into one box or another, and can also move from one ED to another. When you look at the research I’ll be the first to admit, there are clear limitations in some of the studies that churn out these numbers, and some quite conflicting information produced.
Some suggest that sport participation seems to have a positive effect on behaviours and attitudes relating to eating and our bodies. In others there seems to be clear patterns where individuals (especially women) competing in lean, aesthetic, endurance sport are more likely to have ED than non-athletes. But before you’ve made up your mind you can find a host of work that suggests quite the opposite, that some athletes are actually healthier, are at less risk and do not have more eating problems than non-athletes.
So do sport participants suffer from more ED than those that don’t do sport? On balance, probably a little. But the same messy research landscape presents itself when we ask other questions about ED prevalence within sport. For example, does the level of competition influence the prevalence? Again, its hard to say. You’d probably think the more competitive the worse it gets - stakes are higher, margins are finer. Eventual Conclusion? More relaxed competitive levels of sport are probably not protective, and elite levels aren’t necessarily predictive of ED.
So where does this leave us? Prevalence rates of ED within sport are variable. Its probably safer to assume that sport is but a microcosm of wider society. Personally, I am not sure that prevalence is of that great a relevance or use to the general population anyway. For those that have been through them, worked with people with ED or have had friends or family battle against them, the fact that they exist at all is bad enough. What is important to appreciate is that because the development on ED depends upon a host of developmental, genetic, and environmental factors (i.e. there is no single cause to an ED), we all have a responsibility to be aware of, and manage those risks that specific to our environment. We know that sport participants are exposed to the same risk factors as the general population, as well as those that come from sport. Although this is not necessarily expressed in higher prevalence when it comes to the development of ‘full on’ Eating Disorder, sport does expose its participants to a greater number of risk factors associated with ED.
What is worrying, that when you drop down to partial or subclinical diagnoses of ED, we are faced with a far bleaker picture. These are the people that we might consider to suffer from disordered eating, or are symptomatic of a greater classification but don’t quite tick all the boxes. I have seen estimations of disordered eating within sport (and particularly those at higher levels of sport) range from 18-46%! Sport participation is often referred to as part of the ‘solution’ to the a worsening picture of global health (obesity, inactivity and chronic illness). I can’t help but wonder what might happen as this discussion continues to evolve. Might we exert further pressure on those in sport who are already symptomatic? Might we be trading one potential health risk for another by directing people towards sport?
Eating Disorders in Sport - What are the risks?
In order to understand, treat and potentially prevent eating disorders is it useful to know the difference between what are the general risk factors we all face, and the additional ones we might be facing that are specific to sport. As I mentioned previously there is no single cause to an eating disorder and their occurrence will come from a multitude of genetic and sociocultural (media, family, peers) factors. We don’t need to avoid sport therefore, but we should be cognisant of, and do our best to avoid/lessen the specific risk factors it brings with it.
Weight/Body Fat = Enhanced performance
This is often taken as gospel, yet you might be surprised to know that the literature is can be quite equivocal when you look at the relationship between bodyweight/fat and performance. I am sure the old school amongst you will be turning your noses up in disgust at this point. I am not denying that bodyweight is a factor in sporting performance, but neither is it an independent variable we can manipulate without consequence. Pay attention to this next sentence. It is unethical for any individual, coach or practitioner to advise weight loss to an athlete or another individual without specialist knowledge and training. If you don’t have this expertise and have not consulted with health professionals that understand the implications both from a nutritional and psychological perspective, you should not be saying anything. In sport you definitely can do more harm than good. If you work with athletes. de-emphasise weight and know your limitations.
Similarities between a 'good athlete’ and characteristics of eating disorders
The ability to perform despite pain and discomfort, mental toughness, unrelenting commitment and pursuit of excellence are all traits that are associated with what most might consider a ‘good athlete’. These are therefore behaviours that are positively rewarded within sport. These traits however are very similar to several characteristics of eating disorders. The denial of discomfort, asceticism, excessive exercise and perfectionism are all traits that might put an individual at risk of developing an eating disorder. Sport is not black and white, lines get blurred, and nothing is clear cut. Not only might these traits expose certain athletes to greater risk, but the fact that they potentially complicate the identification of a problem should also be considered a risk.
As alluded to above, the positive reinforcement of behaviour symptomatic of an eating disorder is also a big problem in sport. Consider these two examples. Excessive exercise and dieting for weight loss. I’m sure we all know many in the endurance community who might fall into these categories. You may be shaking your head here too, but bottom line is, almost all those that suffer from ED have dieted (often multiple times). For certain people it can be a precipitant of ED, or make their current ED worse. I’ll say it again, de-emphasise weight. If you want to reward and encourage others, make it about things they have done to improve their health, not lose weight (even if these might sometimes be related in overweight individuals). When it comes to excessive exercise, this can be something a bulimic does instead of purging, or to justify eating, or as a result of eating. Its also a common characteristic in Anorexia also. Often one the last symptoms to disappear and one that can cause the persistence of an eating disorder, be careful what you say. Its difficult to identify, especially in ultra-endurance sports but before you next congratulate your friend on their ‘epic run streak’, just stop and think, what else could you say?
Sport specific expectations, ideals and norms
Each sport has its own subcultural idiosyncrasies. Be aware of these. Pathogenic behaviour relating to cutting weight or maintaining a low weight are common in jockeys, in boxing, wrestling etc. Think of body ideals. Triathlon is a particularly tricky one, as each sport emphasises different ‘ideal’ body shapes. Its impossible to be all three. Are you promoting these ways of thinking in what you say, are others? If so you could be increasing the pressure on an individual to conform. When it comes to pressure relating to shape, weight and body image this is a big no-no!!
While there are other potential risk factors relating to sport I hope this has provided a bit of insight into some of the more significant and obvious dangers that sport might present with regard to the development of eating disorders. Sport can either pose a direct risk, exacerbate or obscure the identification and delay treatment of full and subclinical eating disorders.
If anyone has any questions or interested in any references that I have not mentioned, please email me (firstname.lastname@example.org) or contact me on @acbcoaching through twitter and I’d be happy to discuss. Again, I’d love it you could share this article in the spirit of eating disorder awareness week. If anyone would like to find out more about Eating Disorders, I’d recommend visiting the National Centre for Eating Disorders website.