Pauline S. Powers, MD

In the last 20 years, girls and women have become increasingly involved in athletics. There have been multiple positive benefits associated with this increased participation. Females who participate in sports and athletics during childhood and adolescence have higher self-esteem and are more likely to be active later in life (1). However, during the last decade, evidence has accumulated that some athletes, particularly female athletes, are at greater risk for the development of eating disorders. In a recent study, we found that over one-third of Division 1 National Collegiate Athletic Association (NCAA) female athletes had attitudes and symptoms that place them at risk for anorexia nervosa (2). Physiologic risks associated with disordered eating have been highlighted by the identification of the female athlete triad of disordered eating, amenorrhea, and osteoporosis (3).

Risk factors

Participation in certain sports increases risk. Athletes in the so-called “lean sports” such as gymnastics or distance running have an increased risk. Anaerobic sports such as body building or gymnastics confer greater risk than aerobic sports. Judged sports in which a thin or child-like appearance confers an advantage, such as figure skating and tennis, increase risk. Finally, individual versus team sports increase risk of an eating disorder. For example, swimming confers greater risk than basketball (4).

In addition to the well-known cultural drive for thinness, athletes are also vulnerable to what has been termed the “performance-related” drive for thinness (4). Among athletes and coaches, there is an unproven belief that weight loss, especially loss of body fat, will invariably improve athletic performance. Although performance may improve with weight loss in athletes who are overweight, performance may deteriorate in normal weight individuals who lose weight. The factors known to improve athletic performance include genetic inheritance, muscle mass, and motivation (5,6).

One model for the development of eating disorder symptoms in female athletes suggests that body concern (i.e., dissatisfaction with size and shape) may mediate between several antecedent factors and the development of an eating disorder. These antecedent factors include social influence (social pressure from coaches and peers for thinness), performance anxiety, and a negative appraisal of athletic performance. With all three factors present, there was increased body dissatisfaction that correlated with an increased likelihood of eating disorder symptoms (7).

Protective factors

Even though female athletes are at an increased risk of eating disorders, the great majority of athletes do not develop eating disorders. What protects these athletes?

Work in this area is in its infancy, but there are some promising studies. A positive person-oriented coaching style resulted in less weight preoccupation and fewer negative attitudes toward size and shape when compared to a negative performance-oriented coaching style (8). Certain aspects of social support may also be protective. For example, healthy attitudes toward size and shape among other team members are likely to be protective. In studying how to prevent steroid abuse, it has been found that Division 1 NCAA athletes with higher grade point averages were more likely to believe that steroids are a threat to health and less likely to believe that steroids enhance performance than students with lower grade point averages (9).

Several other variables may confer protection. If coaches emphasize factors known to improve athletic performance (e.g., muscle mass and motivation), this might decrease emphasis on weight loss. Identification of potentially protective personality traits would be helpful in designing prevention programs. Our group is currently studying the personality trait called “hardiness,” which refers to resilience, attitudes toward stress, and behaviors used to cope with stress. Perhaps certain aspects of “hardiness” protect athletes from eating disorders. Other personality or temperament characteristics may also be protective.

What can be done to help?

Coaches, parents, team physicians, and fellow athletes often are able to identify an athlete with an eating disorder early in the course of the condition. Several brief questionnaires that elicit eating disorder symptoms in females can be used to identify athletes at risk (10,11). Athletes could participate in screening as part of an educational program within the athletic community. Besides identifying at-risk athletes, such a program could provide information about prevention, treatment, and community resources to at-risk athletes and their supporters.

Once a diagnosis is confirmed, intervention can begin. It is often helpful for athletes to continue participation in sports, but a graded level of activities dependent on weight and physical findings may be needed. For example, a gymnast with anorexia nervosa might be able to practice twice a week until her weight is within 15 percent of ideal body weight and then three times weekly until her weight is within 10 percent of ideal weight. This type of gradual reintroduction of physical activity may allow the athlete to remain a part of the team.

Coaches are very influential with athletes, especially elite athletes. Karin Kratina, an eating disorder consultant with the Renfrew Center, lists 10 things coaches can do to help prevent eating disorders in their athletes (12). This list includes early identification of eating disorder symptoms by coaches and other athletes, early intervention with trained personnel, treatment approaches that permit the athlete with eating disorder symptoms to remain on the team, and a call for increased sensitivity of the coach to the meaning of weight to female athletes.

Concerned parents may be able to recognize warning signs of an eating disorder in young athletes. A parent’s guide (see table) may be helpful (13).

Multiple factors have been identified that increase the risk for an eating disorder in athletes. Some preliminary work has identified a few protective factors. We now have methods for identifying most athletes with eating disorders and guidelines for their treatment. Although prevention would be ideal, effective methods of prevention have yet to be developed.

Student Athletes and Eating Disorders: A Parent’s Guide

1. Weight loss. Many teens beginning a sport lose some weight. However, if the amount seems large, it is helpful to see if the athlete is still on his or her growth curve. Most pediatricians track individual differences in growth and can determine if the athlete has fallen below his or her usual growth curve.
2. Resetting of weight goals. Since the majority of adolescent girls (and perhaps boys) diet at some point, it can be difficult to determine if a small weight loss is an early sign of an emerging eating disorder. If your teenager decides to lose a modest amount of weight, loses this weight, and is satisfied, probably there is no problem. However, if the initial weight goal is achieved and the person resets it to a lower weight, this may indicate a problem.
3. Amenorrhea. If your daughter loses her menstrual periods, take it seriously. Although the stress of physical exercise can cause amenorrhea, loss of menses can also be an early sign of an eating disorder. Irrespective of the cause, amenorrhea during adolescence is dangerous because it is associated with stunting of growth and the early development of osteoporosis (thinning of the bones and bone fractures).
4. Excessive exercise. Although this can be difficult to judge, exercising more than is expected for the particular sport or level in that sport warrants discussion with your teenager and the coach. For example, if your teen is on the basketball team and the coach expects players to run a mile on 2 days of the week and your teen runs 2 miles everyday, this could be a problem. On the other hand, an elite athlete in training for a marathon may be exercising many hours per day.
5. Inappropriate dieting behavior. If your teenager is in a group of athletes who are following extreme or unusual dieting practices, this requires your attention. If more than one athlete in her group has an eating disorder, check for undue emphasis on dieting by the coach or by the other athletes. Use of fat-burning aids, laxatives, or diuretics is also hazardous.
6. Negative comments by trainers. If you learn that the coach or trainer has made negative comments about the weight, shape, or performance of any of the athletes in the sport, attend a few practices or competitions to assess the coach’s attitude. Then meet with the coach and ask him or her to refrain from such comments. If the coach has not attended an educational program on eating disorders and how to prevent them in athletes, recommend attendance at one of these seminars.
7. Use of exercise to purge. If the teen exercises regularly after consuming food, he or she may be using exercise to “burn up” calories, which may be a form of purge behavior.
8. Use of exercise to cope. Intense exercise or pursuit of a sport may be used to cope after a significant disappointment. For example, if your teenager is usually quite sociable, but then her boyfriend broke up with her, and she no longer sees her friends but devotes many hours daily to exercise, this may be a problem.
9. Avoidance of tasks of adolescence. Athletes who become preoccupied with exercise such that they are no longer socializing, achieving in school, or engaged in the process of emancipation from parents may be using exercise as an inappropriate solution to a problem in one of these areas.
10. Athletic performance and weight loss. The belief that weight loss per se will improve athletic performance is incorrect. Genetic endowment, muscle mass, and motivation are the three factors that most influence performance. If the athlete or coach believes that ever-increasing weight loss will continue to improve performance, this may place the adolescent at risk for an eating disorder.
11. Participation in high-risk sports. Certain sports, such as gymnastics or body building, are judged on both athletic performance and appearance and may place the adolescent athlete at particular risk. Prior to participation in these sports, it is wise to know the attitude of the coach and the training he or she has in prevention of eating disorders.
12. Unrealistic sport achievement expectations. It is counterproductive and perhaps dangerous to encourage an athlete who is not able to become an elite athlete to try to do so. A realistic appraisal of the athlete’s potential by the parent, coach, and athlete will decrease the likelihood of a severe later disappointment.

Pauline Powers, MD, is a professor of psychiatry and behavioral medicine at the College of Medicine, University of South Florida, Tampa, and medical director of the Eating Disorder Program at Fairwinds Residential Treatment Center.

References

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11. Garner DM. Eating Disorders Inventory-2. Odessa, FL: Psychological Assessment Resources, 1991.
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This article is from the Healthy Weight Journal (Health at Every Size Journal) and can be cited as Pauline Powers, MD, “Athletes and Eating Disorders: Protective and Risk Factors,” from Health At Every Size 14:4 (July/August 2000).