Eating disorders in athletes: overview of prevalence, risk factors and recommendations for prevention and treatment

Is it Possible for Individuals with Pre-Existing Mental Disorders to Perform Mountain Sports at High Altitude-First Evidence from a Pilot Cross-Sectional Questionnaire Study

Gstir, Claudia, Timo Schurr, Roxana Ehlers, Johannes Burtscher, Barbara Sperner-Unterweger, and Katharina Hüfner. Is it possible for individuals with pre-existing mental disorders to perform mountain sports at high altitude-First evidence from a pilot cross-sectional questionnaire study. High Alt Med Biol. 00:00-00, 2024. Introduction: Mountain sports at high altitude (HA) are gaining increasing popularity, but little is known about the effect of such activities on mental health, despite a great prevalence of mental disorders. Methods: Data were collected using an online self-report questionnaire assessing mental and somatic disorders in individuals performing mountain sports at HA (>2,500 m above sea level [ASL]) as well as their symptom change. Nonparametric tests were used for analyses. Results: 251 individuals without pre-existing disorders (noD), 34 with somatic disorders (somaD), and 38 with mental disorders (mentalD; mainly depressive, eating, and anxiety disorders) participated in this study. Overall, 44.7% of the mentalD group compared with 14.7% of somaD experienced ameliorated symptoms during mountain sports at HA, while 2.6% and 8.8%, respectively, reported a worsening (χ2[2] =8.13, p = 0.017). People in the mentalD compared with somaD group significantly less frequently inform tour partners (41.9% vs. 90.9%; χ2[2]=16.69, p < 0.001) about their condition or consult their physician (2.6% vs. 26.5%; χ2[1]=8.53, p = 0.003) regarding their plans to perform mountain sports at HA. 14.5% of all participants reported mental symptoms at 2,500-3,500 m ASL, 23.5% between >3,500-5,500 m ASL and 31.8% >5,500 m ASL. Conclusion: Individuals with mental disorders often report improved mental health during mountain sports at HA, possibly due to a combination of physical activity, the alpine natural environment, and/or moderate hypoxia. The fact that tour partners and physicians are rarely informed shows the need to reduce the stigma of mental disorders in the mountain sports community. The study was prospectively registered with the German Clinical Trials Registry (DRKS00024949).

Orthorexia nervosa tendencies and risk of eating disorders among culinary arts students: A comparative study with dietetics students

BACKGROUND

Students pursuing food-related academic fields such as dietetics have higher orthorexia nervosa (ON) tendencies and are at a greater risk of developing eating disorders (EDs). However, there is limited research available on ON tendencies and on the risk of EDs in the culinary arts field, which also revolves around food. The present study explored ON tendencies and the risk of EDs among culinary arts students and compared them with those of dietetics students.

METHODS

A cross-sectional study was conducted in France, using the eating habits questionnaire (EHQ) to measure ON tendencies, and the SCOFF as well as the eating disorders examination questionnaire (EDEQ) to evaluate the risk of EDs and ED symptoms. The study also included questions about sports practice. In total, 267 students participated in the study, including 144 culinary arts students (51 women, 92 men and one other) and 123 dietetics ones (106 women, 15 men and two others).

RESULTS

Culinary arts students exhibited similar means of EHQ scores as dietetics ones (32.99 vs. 33.34) but higher SCOFF scores (52.8% vs. 39.8%). In addition, a gender difference was evidenced: women in culinary arts showed higher EHQ, SCOFF and EDEQ scores than men in culinary arts. Linear regression models showed no effect of the type of academic field (culinary arts vs. dietetics) on the EDEQ score but revealed effects of gender, body mass index and hours of sports practice.

CONCLUSIONS

The study emphasises the need to monitor culinary students and implement interventions to prevent EDs. It also suggests a correlation between food-related education and the risk of EDs, which requires further research.

Junior athletes' nutritional demands: a narrative review of consumption and prevalence of eating disorders

Information regarding the dietary requirements and consumption of young athletes is limited. Hence, the aim of this narrative review is to provide a comprehensive combination of research and review papers on the nutritional status of young athletes aged 5-18 years old, as well as quantitative, qualitative, wholesome foods, food choices, and eating disordered data concerning the dietary requirements for growing young athletes. This study involved systematic searches of electronic databases, including Google Scholar, PubMed, Science Direct, Scopus, and Web of Science. The specific criteria for identifying research papers published in English from July 1980 until May 2024 were included. Only 48 studies out of 1,262 were included in this narrative review. The findings of this study suggest that, compared with adults, junior athletes need a unique approach to meet their dietary needs. Growth, development, and general athletic performance depend on macronutrients, as they are vital nutrients for young active athletes. However, research on enhancing junior athletes' performance is still in progress, and studies on hydration status, and eating disorders are limited.

Actions speak louder than coaches: Eating disorder behaviour among student-athletes

The objective of the current study was to examine the prevalence of eating disorder behaviours among student-athletes at a small, non-NCAA (Canadian) university, while evaluating the influence of gender, type of sport, and perceived social support. Two hundred participants (130 female, 70 male) completed an online survey that assessed participants eating disorder behaviours (EAT-26), behaviours consistent with the Adonis Complex (ACQ) and perceived social support (modified MPSS). The results revealed significant differences in eating disorder behaviour between female and male athletes, with females scoring significantly higher; yet no differences were found between how female and male athletes scored on the Adonis Complex Questionnaire. Significant differences were found between lean-sport and non-lean sport athletes, with lean sport athletes exhibiting more eating disorder behaviours. Furthermore, non-lean sport male athletes were found to score significantly higher than lean-sport male athletes for the Adonis Complex. Perceived social support was found to be negatively correlated to eating disorder behaviours and when considering gender and type of sport, accounted for unique variance in eating disorder behaviour. These results suggest that student-athletes are susceptible to negative mental health outcomes, even within the context of a smaller (and non-NCAA) university context, and eating behaviours vary among athlete and sport type. The results highlight the importance of continued research in this area and of having support systems in place for student-athletes and increasing awareness of athletic staff and coaches as to the seriousness and prevalence of eating disorder behaviours.

Nutrition for Children and Adolescents Who Practice Sport: A Narrative Review

At a developmental age, adequate physical activity is fundamental to overall health and well-being and preventing obesity. Moreover, establishing active behavior can help children and adolescents meet their growth and neurodevelopmental goals. Nutritional requirements vary according to intensity, frequency, and practiced physical activity or sport; therefore, pediatricians should give children and adolescents and their families adequate counseling, avoiding both nutrient deficiencies and excessive or inadequate supplement intake. The focus should be not only on sports performance but also on the child's well-being, growth, and neurodevelopment. Our narrative review aims to discuss the nutritional needs of children and adolescents who practice physical activity, non-competitive sports activity, and elite sports activity while also analyzing the role of food supplements and the risk of eating disorders within this category of subjects.

Unhealthy weight control behaviors and health risk behaviors in American youth: a repeated cross-sectional study

BACKGROUND

Unhealthy weight control behaviors (UWCBs) involve weight control strategies to reduce or maintain weight, such as fasting, taking diet pills, and vomiting or taking laxatives. UWCBs in teenagers can escalate into severe health issues such as eating disorders. Understanding the trends of UWCBs and their association with risk behaviors in teenagers is crucial, as early intervention and prevention strategies are pivotal.

METHODS

This study utilized eight waves of the youth risk behavior surveillance system (YRBSS) data from 1999 to 2013. Our primary outcome was UWCBs engagement. We used multinomial logistic models to analyze the association between UWCBs and risk behaviors among adolescents including driving after alcohol consumption, suicide attempts, smoking, alcohol use, and sexual intercourse.

RESULTS

Among 109,023 participants, UWCBs prevalence was 16.64%. Body Mass Index (BMI) was significantly associated with UWCBs risk. In addition, we found the intention of weight management confounded the relationship between BMI and UWCBs. The unadjusted logistic regression indicated a monotone-increasing association between BMI and the risk of UWCBs. In contrast, the adjusted logistic regression indicated a U-shaped curve with the lowest (BMI < 17 kg/m2) and highest (BMI > 30 kg/m2) BMI groups having significantly higher odds of engaging in UWCBs compared to the reference BMI group (18.5 ≤ BMI ≤ 24.9 kg/m2).

CONCLUSIONS

The intention of weight management confounded the relationship between Body Mass Index (BMI) and the risk of UWCBs. These findings suggest that healthcare interventions for weight management behaviors should be tailored to adolescents with BMI ≥ 25 and BMI < 18.5.

Athlete Body Image and Eating Disorders: A Systematic Review of Their Association and Influencing Factors

Body image and eating disorders pose significant challenges to the overall health of athletes. However, divergent findings exist regarding the potential association between athletes' body image and eating disorders. This systematic review aims to examine the relationship between these two variables and identify the modifiers of the association, such as gender, age, race, and exercise type. A search was conducted in five databases (Web of Science, PubMed, APA PsycINFO, ProQuest, and EBSCO), aiming to identify studies on athletes and involved body image and eating disorders in their conclusions. Ultimately, thirty-one studies were included for systematic evaluation. The results of the studies indicate that the relationship between athletes' body image and eating disorders is complex and inconclusive. In some types of sports, eating disorders can occur even when athletes are satisfied with their body image. Furthermore, female athletes, particularly young female athletes, and athletes involved in sports associated with leanness are more prone to eating disorders and body dissatisfaction. Due to limited resources in this type of research, there is a lack of comprehensive inclusivity across sports disciplines, genders, races, and levels of sports proficiency, which warrants further research.

Sex Differences in Mental Health Symptoms in Elite Athletes: A Systematic Review and Meta-analysis

CONTEXT

Mental health is a growing area of concern for elite athletes.

OBJECTIVE

To determine the sex differences in mental health symptoms in elite athletes.

DATA SOURCES

PubMed, EMBASE, and Cochrane Library databases were used.

STUDY SELECTION

Included studies included comparisons of mental health symptoms of athletes by sex.

STUDY DESIGN

Systematic review and meta-analysis were conducted following the PRISMA guidelines.

LEVEL OF EVIDENCE

Level 2a.

DATA EXTRACTION

The rate ratio (RR) was calculated as the rates in female and male athletes. Data were pooled using a random-effects model.

RESULTS

Of 1945 articles identified, 60 articles were included. Male athletes reported higher alcohol misuse (RR, 0.74; CI, 0.68-0.80), illicit drug abuse (RR, 0.82; CI, 0.75-0.89), and gambling problems (RR, 0.14; CI, 0.08-0.25). Female athletes reported higher overall anxiety (RR, 1.17; CI, 1.08-1.27), depression (RR, 1.42; CI, 1.31-1.54), distress (RR, 1.98; CI, 1.40-2.81), and disordered eating (RR, 2.19; CI, 1.58-3.02). Sleep disturbances were reported at similar rates in male and female athletes (RR, 1.13; CI, 0.98-1.30).

CONCLUSION

Female and male athletes have significant differences in reported mental health symptoms. Female athletes are more likely to report anxiety, depression, distress, and disordered eating, while male athletes report more alcohol misuse, illicit drug abuse, and gambling. Monitoring and evaluation of mental health is a necessary part of any sport, including access to resources. Longitudinal studies following athletes over time to determine the development and causation for mental health symptoms should be included in future research directions.

A systematic review and meta-synthesis of qualitative research investigating disordered eating and help-seeking in elite athletes

OBJECTIVE

Elite athletes are at elevated risk for disordered eating and eating disorders; however, little is known about risk and maintaining factors, or barriers and facilitators of help-seeking in this cohort. This systematic review synthesized qualitative findings regarding possible risk and maintaining factors for disordered eating, as well as barriers to and facilitators of help-seeking in elite athletes.

METHOD

We conducted a search for qualitative studies that included experiences with body image concerns or disordered eating in elite athletes. A systematic search of CINAHL, PsychINFO, MEDLINE, and Scopus databases identified 828 articles, with 87 retained after title and abstract screening, and 38 included in the review. Quality appraisal was conducted using the checklist for appraising qualitative research (CASP). Data were extracted from each article, including demographic information (e.g., biological sex, age, sport type, level of competition, current, or former athlete) and the text under the "results" or "findings" section. Meta-themes were identified using inductive thematic meta-synthesis.

RESULTS

The extracted data indicated that most studies sampled female athletes from the United States and UK. Eight meta-themes were identified: (1) the power imbalance; (2) hyperfocus on body, food, and exercise; (3) rigidity; (4) the athlete's balance; (5) the athlete identity; (6) overvaluation and oversimplification; (7) shame, fear, and stigma; and (8) knowledge, education, and self-identification.

DISCUSSION

These findings highlighted gaps in the demographic representation of specific groups in this research (e.g., males, para-athletes, and ethnic diversity) and propose hypotheses of how sport pressure might contribute to athletes' experiences with disordered eating.

PUBLIC SIGNIFICANCE

Disordered eating and body image concerns are prevalent and can have debilitating impacts for elite athletes; however, help-seeking is rare for this population. It remains unclear what factors contribute to disordered eating and/or inhibit help-seeking among elite athletes versus the general population. Understanding athletes' perspectives will inform the modification of prevention and treatment strategies to address athlete-specific factors.

An Umbrella Review of Body Image Concerns, Disordered Eating, and Eating Disorders in Elite Athletes

Background/Objectives: Several systematic reviews and meta-analyses have been conducted to date indicating a high prevalence of disordered eating in elite athletes and associated risk factors. However, the substantial time burden associated with locating and comparing these reviews, which are varied in methodology and sampling focus, may be a barrier for informing policy and best practice as well as directing future research. This umbrella review aimed to provide a summary of evidence across published reviews regarding the prevalence and risk factors for disordered eating (including body image concerns and eating disorders) in elite athletes. Methods: Five databases (CINAHL, PsycINFO, MEDLINE, Scopus, and SPORTDiscus) were systematically searched for peer-reviewed systematic reviews and meta-analyses that met the following inclusion criteria: (1) investigated prevalence and risk factors for disordered eating, (2) included a sample of elite athletes, and (3) available in English. The included studies underwent data extraction and risk of bias assessment using the AMSTAR 2. Results: The initial search identified 1828 articles that were screened for title and abstract and then full text, leaving 24 systematic reviews (including 10 meta-analyses). Disordered eating was prevalent across elite athletes, including males and females and across sport type. Elite athletes were at elevated risk for disordered eating and eating disorders but at lower risk for body image concerns versus non-athlete controls. Several risk factors were identified, including female gender, competing in lean sports, and experiencing career changes. Few reviews or meta-analyses examined perceived pressures within the sporting environment, and most had substantial risk of bias concerns. Conclusions: Elite athletes are at risk for the spectrum of disordered eating, and all should be considered for primary prevention and screening. Further research is needed regarding sport-specific versus general pressures and mediators of risk to better inform interventions.

Are Sub-elite Athletes at Higher Risk of Eating Disorders, Exercise Addiction, Depression, and Low Energy Availability Compared With Elite Athletes?

OBJECTIVE

The main objective of this study was to investigate the risk of eating disorders, exercise addiction, depression, and low energy availability (LEA) in Danish female and male elite compared with sub-elite athletes.

DESIGN

A cross-sectional study.

SETTING

An online survey.

PARTICIPANTS

A total of 410 elite athletes (mean age 20.1 years, 51% females) and 206 sub-elite athletes (mean age 21.3 years, 52% females) from 15 different sports.Assessment of Risk Factors: Eating Disorders, exercise addiction, depression, and LEA.

MAIN OUTCOME MEASURES

The Sick Control, One Stone (6.5 kg), Fat, Food, the Eating Disorder Examination-Questionnaire, the Exercise Addiction Inventory, the Major Depression Inventory, and the Low Energy Availability in Females Questionnaire or the Low Energy Availability in Males Questionnaire.

RESULTS

We found that more female sub-elite athletes compared with elite athletes had risk of eating disorders (EDs) (37.4% vs 23.4%; P < 0.012) and the same was found for males (23.2% vs 10.4%; P = 0.005). More athletes with risk of EDs had risk of exercise addiction (12.8 vs 5.4%, P = 0.006), depression (27.3 vs 4.2%, P < 0.001), and LEA (females 55.1 vs 40.7%, P = 0.024, and males 29.4 vs 13.7%, P = 0.036, respectively) compared with athletes without risk of EDs.

CONCLUSIONS

Sub-elite athletes have a higher risk of eating disorders compared with elite athletes. Regular screening of ED symptoms and associated conditions in elite and especially sub-elite athletes may ensure early identification.

Anxiety, eating disorders and menstrual disturbances risk in Spanish elite female paddlers

Affiliated athletes are frequently subject to higher levels of anxiety due to the intensity of training, competition and many other factors. This anxiety can cause alterations in their health, both physically and mentally, such as menstrual irregularities, eating disorders, etc. In this work we have analysed the anxiety levels of a population of female affiliated paddlers and the possible consequences for their health. The results showed that a third of the female paddlers analysed have a moderate/high risk of suffering from anxiety; and within this group, the less sporting experience the athlete has, the greater the probability is of suffering from anxiety. Moreover, almost half the total of the female paddlers suffers from menstrual dysfunction before an important competition, with this number rising among high performance athletes, even though three out of every four adjust their training schedule to their menstrual cycle. Less-experienced female athletes, who show higher anxiety levels, also present a greater risk of suffering from eating disorders.

Perfectionism, disordered eating and well-being in aesthetic sports: The mediating role of passion

Aesthetic athletes face higher risks of disordered eating, and perfectionism is one of the determinants involved. While research suggests that perfectionism in sport may play a role in physical and psychological well-being, its influence remains to be confirmed. As such, further examination of the influence of perfectionism on health is warranted as it could lead to better interventions. This preregistered research sought to shed new light on these relationships by investigating the mediating role of passion in the perfectionism-disordered eating relationship as well as physical and psychological well-being in aesthetic sports. In Study 1, 229 American recreational and competitive athletes practicing either gymnastics (n = 150) or artistic swimming (n = 79) were recruited on MTurk to complete an online questionnaire. The same recruitment procedure was used for Study 2, with 107 American gymnasts (n = 69) and artistic swimmers (n = 38) completing the questionnaire at two timepoints, one year apart. Results from path analyses showed that socially prescribed perfectionism was associated with obsessive passion, which in turn was associated with disordered eating. Self-oriented perfectionism was associated with both obsessive and harmonious passion, the latter being more adaptative as it was associated with physical and psychological well-being. Thus, the way one engages in aesthetic sports matters, as engaging with obsessive passion may take a toll on one's health and lead to disordered eating. Conversely, fostering harmonious engagement seems to temper the negative associations between perfectionism and health outcomes and promote positive relationships with athlete's well-being, but requires further study.

Eating disorder symptoms and weight pressure in female rowers: associations between self-concept, psychological well-being and body composition

BACKGROUND

Female rowers may be at risk of eating disorders and high weight pressure.

AIM

The purpose of the study was to investigate the prevalence of disordered eating symptoms and weight-related pressure and the associations with self-concept, psychological well-being, socio-demographic data, experience, performance level and body composition in female fixed-bench rowers.

METHODS

Female rowers (n = 208; age ranged mean ± SD 23.6 ± 6.5 years) completed the SCOFF scale, Weight-Pressures in Sport-Females (WPS-F), Physical Self-Concept Questionnaire and the Ryff scales of psychological well-being and provided information on their experience and level of competition. In a subgroup of 115 athletes, body composition was assessed using bioimpedance.

RESULTS

It was found that 42.3% of the athletes scored ≥ 2 on SCOFF and mean ± SD value of WPS-F score was 3.65 ± 0.82. Stepwise regression analysis revealed that self-concept of strength and pressure from teammates and the uniform were associated with higher ED symptoms, whereas better psychological well-being in terms of autonomy, self-concept of attractiveness, and age were protective factors for ED symptoms. BMI, athletes' physical condition, strength, and experience were associated with more weight-related pressure and better self-concept of attractiveness and physical well-being of autonomy were significantly associated with less pressure. In body composition analysis, higher extra cellular water, self-acceptance, and physical condition were associated with more weight-related pressure in female rowers, being attractiveness and the environmental mastery protective elements.

CONCLUSIONS

The prevalence of ED symptomatology and weight-related pressure are high in female fixed bench rowing. The psychological factors of well-being and self-concept, team environment, body image concerns and body composition analysis should be considered to promote healthy eating behaviours in female rowers.

Personal risk factors and types of sport associated with drive for thinness and drive for muscularity in NextGen athletes

Introduction

Professional and student-athletes are at risk of developing symptoms of eating disorders (ED), including drive for thinness and muscularity due to personal risk factors (e.g., low self-esteem) and sport-specific characteristics (e.g., sport requirements). However, limited studies have focused on ED symptoms among NextGen athletes (identified in Canada as élite or relève) who compete at the provincial, national, and international levels but are not yet part of national teams. As such, they have access to fewer financial resources and support from their sport federations, which can create additional stress for these athletes. The present study aimed to identify personal risk factors and types of sports associated with (a) drive for thinness and (b) drive for muscularity in NextGen athletes.

Methods

These athletes (n = 254) aged between 14 and 25 years old completed an online questionnaire. Perfectionism, self-esteem in sport, drive for thinness, and drive for muscularity were, respectively, assessed by the Multidimensional Inventory of Perfectionism in Sport, the Sport State Self-Esteem Scale, the Eating Attitude Test-26, and the Drive for Muscularity Scale. Other personal risk factor (e.g., athletic status) were measured using in-house questions. Each personal risk factor was included in two multiple linear regressions, respectively, to determine which factors were most associated with drive for thinness and drive for muscularity.

Results

Analyses revealed that perfectionist aspirations during training were linked to a stronger desire for thinness. In addition, not being in school or not having a job were also linked to a stronger desire for thinness. Several variables were found to be associated with a greater desire for muscularity: being a male athlete, playing team sport, weight category sport or endurance sport (as opposed to esthetic sport), having elite status, being less satisfied with one's current sporting performance and having higher perfectionist aspirations during training.

Discussion

This study offers initial insights into the factors influencing EDs among NextGen athletes, which provides a foundation for deeper exploration and the creation or modification of targeted interventions. These findings can guide sport organizations in creating guidelines and programs to better support the next generation of national athletes (e.g., create programs to help athletes maintain investments outside).

Mental health literacy, mental health experiences and help-seeking behaviours of Chinese elite athletes: a qualitative study

Introduction

Elite athletes' help-seeking on mental health might be influenced by their mental health literacy (MHL) and mental health experiences. The current study aimed to explore the MHL, experiences and help-seeking behaviours among elite athletes using a qualitative approach.

Methods

Face-to-face semi-structured interviews were conducted among 20 Chinese elite athletes, 12 coaches, and 5 team officials. Interview data was analyzed using content analysis.

Results

Seven main themes emerged from the analysis. The current study revealed that Chinese elite athletes suffered from various mental health issues and athletes' MHL levels, help-seeking attitudes and intentions, Chinese sports environments, and Chinese cultural background could impact their help-seeking behaviours.

Conclusion

Support for Chinese elite athletes' mental health and help-seeking requires improvement.

Associations between anthropometry, body composition, and body image in athletes: a systematic review

Introduction

Poor body image is a potent risk factor for disordered eating and eating disorders. Athletes are a population at increased risk for eating disorders despite reports of lower body image concerns compared to non-athletes. Body size and composition may influence an athlete's susceptibility to poor body image.

Methods

Five electronic databases (PubMed, Cochrane Library, PsycINFO, Web of Science, SPORTDiscus) were searched to systematically evaluate the literature regarding the association between body measures (i.e., anthropometric and body composition indicators) and body image in athletes. The systematic review was completed following PRISMA guidelines and 27 cross-sectional studies were identified for inclusion and evaluated using the Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies.

Results

Studies differed in methodological assessment of anthropometry or body composition (i.e., self-reported versus researcher-measured), methods for evaluating aspects of body image, geographic location, and sport type. Higher body mass index (BMI) or percent body fat (%BF) was significantly associated with greater body dissatisfaction in 16 of 22 studies (72.7%). Positive associations between body measures and aspects of negative body image were most consistently observed among studies that assessed BMI based on self-reported heights and weights, while significant associations between body composition measures (e.g., %BF, fat mass, fat-free mass) were less common. Four of seven studies assessing relationships between BMI and an aspect of positive body image reported significant inverse relationships, while three revealed insignificant associations.

Discussion

Overall, higher BMI and body fat were associated with body dissatisfaction among athletes. Future studies are needed to confirm these findings within focused populations and utilizing body composition methods (e.g., bioelectrical impedance techniques).

Systematic review registration

https://www.crd.york.ac.uk/prospero/, CRD42023446518.

Testing general sociocultural and coach-related appearance pressures as the factors associated with disordered eating in competitive female athletes participating in various sports

The aim of the present study was to test the sociocultural Petrie and Greenleaf's (2007) model of disordered eating (DE) in competitive female athletes. Specifically, we tested a model of general sociocultural and coach-related pressures towards body weight and appearance of female athletes as the factors associated with athletes' DE through the mediators such as internalization of appearance ideals and overweight preoccupation. 515 athletes participated in this study. The mean age of the sample was 19.0 ± 5.9 years. Athletes were provided with study measures on general sociocultural and coach-related appearance and body weight pressures, internalization of appearance ideals, overweight preoccupation and DE. Path analyses showed that general sociocultural pressures were associated with DE directly and through internalization of appearance ideals and overweight preoccupation. Pressures from coaches were associated with DE through overweight preoccupation and through the internalization of appearance ideals and overweight preoccupation. The models were invariant across body weight sensitivity in sports and age groups. These results inform DE prevention for female athletes. It is important to increase resistance to sociocultural pressures and pressures from coaches in DE prevention programmes for female competitive athletes of all ages and participating in sports irrespective of sports group (weight-sensitive or less weight-sensitive).

Cross-sectional and longitudinal associations between higher weight and eating disorder risk among collegiate athletes

OBJECTIVES

To examine whether higher weight status is associated with increased eating disorder risk in athletes.

DESIGN

Study 1 used cross-sectional (N = 942) and longitudinal (N = 483) data collected over a five-year period from Division I athletes at a Midwestern university. Study 2 used cross-sectional data from athletes competing at various levels at universities across the United States (N = 825).

METHODS

Weight and height were measured in Study 1 and self-reported in Study 2; higher weight was defined as body mass index ≥ 25 kg/m2. Eating disorder risk was assessed with preliminary (Study 1) and final (Study 2) versions of the Eating Disorders Screen for Athletes. Study 1 examined weight status in relation to both concurrent and one-year changes in Eating Disorder Screen for Athletes score. Study 2 examined weight status in relation to both the Eating Disorders Screen for Athletes score and elevated eating disorder risk using the established Eating Disorders Screen for Athletes cut-off. All models adjusted for gender and sport type; Study 2 additionally adjusted for race/ethnicity, age, and competition level.

RESULTS

Across studies, higher weight status was significantly associated with increased eating disorder risk among athletes. This association was observed both cross-sectionally and longitudinally, and the prevelence of elevated eating disorder risk was 43 % greater among athletes with higher weight status than among those without higher weight status.

CONCLUSIONS

Despite existing stereotypes that eating disorders tend to occur with low weight status, findings highlight the importance of screening all athletes for eating disorders, regardless of their weight status.

Relative energy deficiency in dance (RED-D): a consensus method approach to REDs in dance

Relative energy deficiency in sport (REDs) is a potentially severe, challenging, broad-spectrum syndrome with potential negative health and performance outcomes. The numerous research publications and International Olympic Committee consensus statements relating to REDs testify to the challenges faced in early identification or screening, diagnosis and management. Like sport, dance, in its simplest form, can be identified as an activity resulting in physiological energy demands and, as such, requires appropriate energy availability concerning energy expenditures. However, the specificity of physiological and psychological demands in dance must be considered when considering REDs. An environment where physical activity can exceed 30 hours per week and where culture may instil a value that thinness is required puts dancers at increased risk for REDs. The purpose of this study was to provide dance-specific guidance dance on this complex condition. An RAND/UCLA Delphi Panel method with nominal group technique was used to review the literature from REDs to evaluate how it may relate to dance. In addition to the EP, which was assembled from a multidisciplinary background with expertise in REDs and multiple genres of dance, six focus groups were commissioned. Four of the focus groups were drawn from the EP members and two additional focus groups formed by dancers and artistic leaders. These panels were used to guide the development of a RED-D diagnosis pathway, management plan and risk stratification and return to dance pathway. The dance-specific pathways are designed to be a practical tool for guiding and supporting clinicians managing RED-D. Furthermore, this paper represents an important focus of this area in dance and serves to stimulate discussion and further research within the sector.

Australian elite sport coaches' mental health literacy of eating disorders, orthorexia, and muscle dysmorphia in athletes: A qualitative study

Athletes have an increased risk of developing eating disorders (EDs) compared to non-athletes. Coaches are in a unique position to identify symptoms and promote timely support; however, research has not yet explored coaches' mental health literacy about DSM-5 EDs and related orthorexia and muscle dysmorphia conditions in elite athletes. Eighteen Australian elite sport coaches from aesthetic, weight-class, and endurance sports participated in individual semi-structured interviews to investigate their mental health literacy of EDs and related conditions. Four themes emerged from the data. Theme 1 (knowledge of EDs and related conditions) highlighted coaches' awareness of maladaptive perfectionism as a key risk factor, limited awareness of EDs without observable weight loss, and conceptualisation of EDs as a nutritional issue. Theme 2 (facilitators to managing EDs) highlighted the helpfulness of building trust with athletes, accessing support staff, emphasising body functionality, and lived experience. Theme 3 (barriers to managing EDs) highlighted coaches' challenges with communicating about body image, responding to denial, and funding constraints. Theme 4 (future ED education and training) highlighted coaches' desire for in-person, interactive training and to support junior-level coaches. These findings may assist in developing tailored educational resources to improve coaches' ability to identify and manage eating-related concerns in athletes.

The "Young Athlete Body Project"-A pilot study evaluating the acceptability of and results from an eating disorder prevention program for adolescent athletes

BACKGROUND

The high frequency of eating disorders (EDs) in sports speaks of a need for early-stage preventive measures.

OBJECTIVES

This study evaluated the acceptability of an age, sex, and sports adapted version of the "Body Project" and changes in mental health symptoms.

METHODS

This noncontrolled pilot study included a class of athletes from 18 sports (N = 73, 13-14 years) at a sport-specialized junior high school in six small-group workshops. We interviewed 34 athletes on program acceptability, and all athletes responded to questionnaires at pretest, posttest, and 6-month follow-up including the Body Appreciation Scale 2-Children, Social Attitudes towards Appearance Questionnaire-4 revised, Eating Disorder Examination Questionnaire Short form-12 modified, and questions about body appearance pressure (BAP).

RESULTS

Athletes found the program acceptable and beneficial, but some missed physically oriented activities or did not identify with the focus, particularly boys. There were acceptable levels in mental health constructs before the workshops. There were temporary changes in the percentage of boys experiencing "BAP in society" by -14.8% points (95% CI: -.6 to .0, p = .04), % in total group experiencing "BAP at school" by +11% points (95% CI: .0-.2, p = .05), thinness idealization by girls (g = .6, p = .002) and total group (g = .4, p = .006), and muscularity idealization by boys (g = .3, p = .05) and total group (g = .23, p = .04).

DISCUSSION

Athletes experienced benefits from the Young Athlete Body Project. Seeing stabilization in outcomes may mean a dampening of the otherwise expected worsening in body appreciation and ED symptoms over time.

PUBLIC SIGNIFICANCE

Adolescent athletes are at risk for developing EDs. Due to lack of prevention programs for this group, we adapted and evaluated a well-documented effective program, the Body Project, to fit male and female athletes <15 years. The athletes accepted the program and experienced participation benefits, with stronger acceptance among girls. Our promising findings encourage larger scaled randomized controlled trials to further evaluate a refined version this program among very young athletes.

Did Kant suffer from misophonia?

Misophonia is a disorder of decreased tolerance to specific sounds, often produced by humans but not always, which can trigger intense emotional reactions (anger, disgust etc.). This relatively prevalent disorder can cause a reduction in the quality of life. The causes of misophonia are still unclear. In this article, we develop a hypothesis suggesting that misophonia can be caused by a failure in the organization of the perceived world. The perceived world is the result of both the structure of human thought and the many conditioning factors that punctuate human life, particularly social conditioning. It is made up of abstract symbols that map the world and help humans to orient himself in a potentially dangerous environment. In this context, the role of social rules acquired throughout life is considerable. Table manners, for example, are a set of deeply regulated and controlled behaviors (it's considered impolite to eat with the mouth open and to make noise while eating), which contribute to shape the way the perceived world is organized. So it's not surprising to find sounds from the mouth (chewing etc.) among the most common misophonic sound triggers. Politeness can be seen as an act of obedience to moral rules or courtesy, which is a prerequisite for peaceful social relations. Beyond this example, we also argue that any sound can become a misophonic trigger as long as it is not integrated into the perceived ordered and harmonious world, because it is considered an "anomaly," i.e., a disorder, an immorality or a vulgarity.

Weight regain, body composition, and metabolic responses to weight loss in weight cycling athletes: A systematic review and meta-analyses

Depending on the nature of their sports, athletes may be engaged in successive weight loss (WL) and regain, conducing to "weight cycling." The aims of this paper were to systematically (and meta-analytically when possible) analyze the post-WL recovery of (i) body weight and (ii) fat mass; fat-free mass; and performance and metabolic responses in weight cycling athletes (18-55 years old, body mass index < 30 kg.m-2 ). MEDLINE, Embase, and SPORTDiscus databases were explored. The quality and risk of bias of the 74 included studies were assessed using the quality assessment tool for quantitative studies. Thirty-two studies were eligible for meta-analyses. Whatever the type of sports or methods used to lose weight, post-WL body weight does not seem affected compared with pre-WL. While similar results are observed for fat-free mass, strength sports athletes (also having longer WL and regain periods) do not seem to fully recover their initial fat mass (ES: -0.39, 95% CI: [-0.77; -0.00], p = 0.048, I2  = 0.0%). Although the methods used by athletes to achieve WL might prevent them from a potential post-WL fat overshooting, further studies are needed to better understand WL episodes consequences on athletes' performance as well as short- and long-term physical, metabolic, and mental health.

Differences in screening and treating relative energy deficiency in sport between the United States of America and Japan

BACKGROUND

The diagnosis and treatment of relative energy deficiency in sport (RED-S) are challenging owing to variations in symptoms and the absence of specific guidelines. This study aimed to investigate differences in the diagnosis and follow-up of RED-S, its consequences, and related factors among sports medicine physicians with different backgrounds in Japan and the USA and examine the differences between the two countries.

METHODS

An anonymous survey regarding the diagnosis and treatment processes of RED-S was distributed to sports medicine physicians via email. Respondents included 58 sports medicine physicians from the USA and 241 from Japan.

RESULTS

The findings showed that 77.6% of the US physicians screened athletes for RED-S, whereas 17.5% of their Japanese counterparts did so. Moreover, 98.3% and 36.7% of the US and Japanese physicians, respectively, answered that they screened athletes for eating disorders upon suspicion of low energy availability. Logistic regression analysis revealed that the number of US sports medicine physicians who screened athletes for the female athlete triad (Triad) and RED-S (odds ratio [OR] = 12.78, P<0.001) and adhered to specific criteria for athlete suspension and return-to-play (OR=33.67, P<0.01) was higher than that of their Japanese counterparts.

CONCLUSIONS

The prevalence of RED-S-related screening and treatment differed between US and Japanese sports medicine physicians. Educating sports medicine physicians about the diagnosis and treatment of athletes with possible signs of RED-S is important in treating female athletes and further investigations are required to identify why the physicians screened/not screened the athletes.

Sporting Mind: The Interplay of Physical Activity and Psychological Health

The symbiotic relationship between sports practice and psychological well-being has, in recent times, surged to the forefront of academic and public attention. The aim of this narrative review is to comprehensively explore the intricate pathways linking physical engagement in sports to its subsequent impacts on mental health and synthesize the multifarious effects of sports on psychological health, offering insights for integrating physical and psychological strategies to enhance well-being. From neurobiological underpinnings to therapeutic applications, this comprehensive manuscript provides an in-depth dive into the multifaceted world of sports and psychology. Highlighting evidence-based interventions, this review aspires to offer actionable insights for practitioners, athletes, and individuals alike, advocating for a holistic approach to mental well-being. This manuscript highlights the profound impact of sports on mental health, emphasizing its role in emotional regulation, resilience, cognitive function, and treating psychological conditions. It details how sports induce neurochemical changes, enhance brain functions like memory and learning, and aid against cognitive decline. This review also notes the benefits of regular exercise in mood improvement, stress management, and social skill enhancement, particularly when combined with mindfulness practices. It underscores the importance of considering cultural and gender perspectives in sports psychology, advocating for an integrated physical-psychological approach to promote overall well-being.

Direct and indirect impact of low energy availability on sports performance

Low energy availability (LEA) occurs inadvertently and purposefully in many athletes across numerous sports; and well planned, supervised periods with moderate LEA can improve body composition and power to weight ratio possibly enhancing performance in some sports. LEA however has the potential to have negative effects on a multitude of physiological and psychological systems in female and male athletes. Systems such as the endocrine, cardiovascular, metabolism, reproductive, immune, mental perception, and motivation as well as behaviors can all be impacted by severe (serious and/or prolonged or chronic) LEA. Such widely diverse effects can influence the health status, training adaptation, and performance outcomes of athletes leading to both direct changes (e.g., decreased strength and endurance) as well as indirect changes (e.g., reduced training response, increased risk of injury) in performance. To date, performance implications have not been well examined relative to LEA. Therefore, the intent of this narrative review is to characterize the effects of short-, medium-, and long-term exposure to LEA on direct and indirect sports performance outcomes. In doing so we have focused both on laboratory settings as well as descriptive athletic case-study-type experiential evidence.

A review of the nutritional guidance for athletes to prevent eating disorders

Since the 1980s eating disorders (ED) have gained increasing prevalence, with athletes proving to be at a higher risk compared to non-athletes. Eating disorders can significantly impact the health and performance of an athlete, however, certain guidelines are in place for prevention, treatment and management. NICE and UK Sport were two guidelines that were identified as being referenced within the UK. This paper aimed to evaluate their utility and establish whether modifications are required to prevent ED within athletic populations. A checklist was created based on peer-reviewed recommendations and used in conjunction with conceptualised case studies based on information sourced from proposed key informant interviews. Whilst both guidelines are extensive in the identification of symptoms associated with ED, they lack recognised recommended screening methods. Furthermore, although both contain some form of validated treatment, NICE recommends cognitive behavioural therapy despite acknowledging the lack of evidence supporting its beneficial application. In contrast to recommendations regarding physical therapy, NICE also states to avoid certain treatments, such as yoga, despite beneficial evidence of its treatment/rehabilitation for ED. When applied to case studies, both guidelines demonstrated the need for refinement and improvement in recommendations relating to weight loss and screening methods. To form an accurate critique of the guidelines, an assessment of their applicability and suitability in the prevention, treatment and management of ED in a practical sporting environment involving consenting participants is required.

Short-term effects and long-term changes of FUEL-a digital sports nutrition intervention on REDs related symptoms in female athletes

Female endurance athletes are at high risk for developing Relative Energy Deficiency in Sport (REDs), resulting in symptoms such as menstrual dysfunction and gastrointestinal (GI) problems. The primary aim of this study was to investigate effects of the FUEL (Food and nUtrition for Endurance athletes-a Learning program) intervention consisting of weekly online lectures combined with individual athlete-centered nutrition counseling every other week for sixteen weeks on REDs related symptoms in female endurance athletes at risk of low energy availability [Low Energy Availability in Females Questionnaire (LEAF-Q) score ≥8]. Female endurance athletes from Norway (n = 60), Sweden (n = 84), Ireland (n = 17), and Germany (n = 47) were recruited. Fifty athletes with risk of REDs (LEAF-Q score ≥8) and with low risk of eating disorders [Eating Disorder Examination Questionnaire (EDE-Q) global score <2.5], with no use of hormonal contraceptives and no chronic diseases, were allocated to either the FUEL intervention (n = 32) (FUEL) or a sixteen-week control period (n = 18) (CON). All but one completed FUEL and n = 15 completed CON. While no evidence for difference in change in LEAF-Q total or subscale scores between groups was detected post-intervention (BFincl < 1), the 6- and 12-months follow-up revealed strong evidence for improved LEAF-Q total (BFincl = 123) and menstrual score (BFincl = 840) and weak evidence for improved GI-score (BFincl = 2.3) among FUEL athletes. In addition, differences in change between groups was found for EDE-Q global score post-intervention (BFincl = 1.9). The reduction in EDE-Q score remained at 6- and 12- months follow-up among FUEL athletes. Therefore, the FUEL intervention may improve REDs related symptoms in female endurance athletes.

Clinical Trial Registration

www.clinicaltrials.gov (NCT04959565).

Body Weight Satisfaction, Comments, Nutrition and Injury Risk in 489 Adolescent Elite Athletes

Exposure to critical body weight comments in youth athletes could lead to decreased self-esteem, affect body image, and increase the risk of eating disorders and cause depressive symptoms. The aim was to explore differences between sex, body mass index, sports type, with regards to body weight satisfaction, exposure to critical body weight comments from their coach and nutrition status in adolescent elite athletes. A questionnaire about body weight, critical body weight comments and nutrition was distributed to 489 adolescent elite athletes and injury prevalence was monitored across 20 weeks. The results showed that almost one in four athletes (n=116, 24%) was not satisfied with their weight and 12% (n=59) had received critical body weight comments from their coach. Of the athletes who were unsatisfied with their body weight (n=116), 47% wanted to lose weight (n=55). A significant (p<0.05) higher proportion of ice hockey players and swimmers used nutritional supplements, were unsatisfied with their body weight, and were more exposed to critical body weight comments compared to athletes from other sports. Adolescent elite athletes as young as 15-16 years old are exposed to critical body weight comments from their coach and experience challenges with body weight satisfaction that is partly dependent on the sport-specific context.

Triggers for eating disorder onset in youth with anorexia nervosa across the weight spectrum

To aid in more targeted eating disorder (ED) prevention efforts, we sought to identify sociodemographic and weight-related risk factors for identified triggers for the onset of anorexia nervosa (AN) in youth. We conducted a retrospective chart review of youth admitted for medical treatment of AN between January 2015 and February 2020. From multidisciplinary admission notes, we extracted patient-reported reasons for diet/exercise changes. We used qualitative thematic analysis to identify ED triggers, then categorized each trigger as binary variables (presence/absence) for logistic regression analysis of risks associated with each trigger. Of 150 patients, mean (SD) age was 14.1(2.3) years. A total of 129 (86%) were female and 120 (80%) were Non-Hispanic White. Triggers included environmental stressors (reported by 30%), external pressures of the thin/fit ideal (29%), internalized thin/fit ideal (29%), weight-related teasing (19%), and receiving health education (14%). Younger age was associated with higher odds of weight-related teasing (p = .04) and health education (p = .03). Males had greater odds of internalized thin/fit ideal than females (p = .04). Those with premorbid body mass indices ≥85th percentile for age and sex had greater odds of reporting positive reinforcement (p = .03) and weight-related teasing (p = .04) than those with weights <85th percentile. We use these findings to detail potential targets for advancing ED prevention efforts.

An intervention mapping adaptation framework to develop a self-help intervention for athletes with eating disorder symptoms

OBJECTIVE

This research forum describes the use of the intervention mapping for adaptation (IMA) framework to develop and evaluate a novel intervention for athletes with mild eating disorder (ED) symptoms.

METHODS

The six IMA steps were followed. In step 1 (needs assessment), we conducted a systematic review of athlete ED interventions and held interviews/focus groups with athletes and sports professionals to inform intervention format and delivery. In step 2 (intervention search), needs assessment information guided the search for an evidence-based intervention suitable for adaptation to athletes. In steps 3 and 4 (intervention development), the identified intervention was adapted and feedback sought from athletes and sport professionals. In steps 5 and 6 (implementation and evaluation), a feasibility study was conducted with athletes (n = 35; females: n = 27; Mage  = 27.1).

RESULTS

The review highlighted poor evidence for the acceptability and relative efficacy of existing interventions, which were all delivered face-to-face in groups. Interview/focus group data suggested a need for more accessible intervention formats (e.g., self-help). One non-athlete self-help intervention was determined suitable for adaptation to athletes, and adaptations were made. Initial feedback suggested the adapted intervention was relevant within sport settings. The feasibility study revealed that the intervention (MOPED-A: Motivational and Psycho-Educational Self-Help Programme for Athletes with Mild Eating Disorder Symptoms) can be feasibly implemented, is acceptable to athletes and shows potential for reducing ED symptoms.

DISCUSSION

IMA is a useful framework for developing participant-centered and evidence-based interventions. The findings and approach taken provide a framework for other researchers and clinicians in developing similar interventions in the ED domain.

PUBLIC SIGNIFICANCE

The novel self-help intervention described in this article was developed using intervention mapping and provides promise as a tool for reducing eating disorder symptoms in athletes. We describe how adopting and systematically following a health intervention development approach, such as intervention mapping, can ensure that eating disorder interventions are participant-centered, contextually relevant, and evidence-based, which in turn could help to maximize their reach and effectiveness.

A case report of anorexia nervosa in a 23-year-old Ethiopian woman

Key Clinical Messages

Limited studies on AN in Africa, including Ethiopia. Internet and media have changed body image portrayal in developing countries. A need for a multidisciplinary approach to treatment, training on positive coaching styles, and future research.

Abstract

The Global Burden of Disease had estimated anorexia nervosa (AN) or bulimia nervosa to be 13.6 million people. The lifetime prevalence of AN ranges from 2.4 to 4.3 percent. During their lifetime, up to 4% of females and up to 0.3% of males suffer from anorexia nervosa. Studies assessing AN in Africa, including Ethiopia, are limited. This case report describes a 23-year-old female patient who presented with anorectic symptoms and signs in Ethiopia. This case report describes a 23-year-old female patient who participated in sports activities. She had a low body weight based on a BMI of 13.15 kg/m2 and lost around 10 kg within the past 6 months. She feared gaining weight or becoming fat, thus restricting food intake. The findings on psychiatric evaluation encompassing detailed history and mental state examination suggested the diagnosis of Extreme anorexia nervosa, restricting type; adult malnutrition; major depressive disorder (MDD) (in remission); low risk of aggression; low risk of suicide; severe functional impairment. The general management principles implemented in this patient included assessment of medical complications, weight restoration, psychological intervention, medication for comorbid depression, and long-term psychological and biological treatment follow-up to avoid relapse. The presented case of a 23-year-old Ethiopian female patient who is athletic shows weight-controlled sports activities and the manifestation of anorexia nervosa. Easy access to the Internet and media has changed body image portrayal in developing countries including Ethiopia. There is a need for a multidisciplinary approach involving psychiatrists, psychologists, internists, and nutritionists for the management of AN. The early screening and management of medical complications are crucial. There is a need for close monitoring of vital signs, restriction of caffeine, excess fluid, and salt, and limiting excessive exercise. Furthermore, to assess micronutrient deficiencies, vitamin supplements should be prescribed in the form of multivitamin and thiamine preparations. The need for future training about positive coaching styles for coaches is mandatory to reduce the future impacts on young athletes. There is a need for future research on eating disorders in developing countries such as Ethiopia.

Body dissatisfaction, disordered eating and exercise behaviours: associations with symptoms of REDs in male and female athletes

Objectives

Disordered eating and compulsive exercise behaviours are common among athletes and can increase the risk of relative energy deficiency in sport (REDs). Contrarily, the prevalence of muscle dysmorphia and its relationship with REDs are unknown. This cross-sectional study aimed to evaluate associations of all three with REDs symptoms.

Methods

Elite and subelite Icelandic athletes (n=83, 67.5% females) answered the Low Energy Availability in Females/Males Questionnaires (LEAF-Q/LEAM-Q), Eating Disorder Examination-Questionnaire Short (EDE-QS), Exercise Addiction Inventory (EAI) and Muscle Dysmorphic Disorder Inventory (MDDI). Body composition was assessed via dual-energy X-ray absorptiometry; resting metabolic rate via indirect calorimetry; and blood samples were drawn for analysis of nutrition and hormonal status. Females were compared based on LEAF-Q total score (≥8 (at risk) vs <8). Simple linear regression was applied to evaluate associations of (a) testosterone with other objective measures and LEAM-Q scores in males; and (b) LEAF-Q/LEAM-Q scores with EDE-QS, EAI and MDDI scores.

Results

In total, 8.4% of participants scored above cut-off on EDE-QS, 19.3% on EAI and 13.3% on MDDI. Females with LEAF-Q total score ≥8 had higher median scores on EDE-QS, EAI and MDDI compared with those scoring <8. Testosterone was positively associated with iron and inversely with total iron-binding capacity but was not associated with scoring on any of the administered questionnaires.

Conclusion

Drive for muscularity and aesthetic physique may play a role in the complex presentation of REDs. Screening for muscle dysmorphia, in addition to disordered eating and compulsive exercise, could therefore facilitate early detection of REDs.

Eating Disorder Risk and Pathogenic Behaviors Among Collegiate Student-Athletes

CONTEXT

Eating disorders (EDs) are a cluster of behavioral conditions characterized by uneasy thoughts and behaviors that grow into severe or persistent eating disturbances. The demands on student-athletes may create mental and physical stressors that increase the likelihood of EDs and disordered eating.

OBJECTIVE

To examine the ED risk through eating attitudes and behaviors in male and female student-athletes and across various sport types (endurance, aesthetic, power, ball or team, or technical sports).

DESIGN

Cross-sectional study.

SETTING

Collegiate athletics.

PATIENTS OR OTHER PARTICIPANTS

National Collegiate Athletic Association Division I and II student-athletes (n = 2054; males = 631; females = 1423) from 40 institutions.

MAIN OUTCOME MEASURE(S)

Participants completed a web-based demographic survey and the Eating Attitudes Test-26 (EAT-26). Multiple χ2 analyses examined participants classified as at risk for EDs. Independent-samples t tests and a 1-way analyses of variance compared sex and sport type across EAT-26 totals and subscale (Dieting, Bulimia, and Oral Control) scores.

RESULTS

Overall, 25.3% (n = 520/2054) of student-athletes were classified as at risk for EDs. Differences were found between sex and ED risk (χ21,2054 = 32.9, P ≤ .01; 17.3% [n = 109/631] males, 28.9% [n = 411/1423] females) and across ED risk and sport type (χ24,2054 = 13.4, P = .01). When examining females only, we observed differences across ED risk and sport type (χ24,1423 = 13.4, P ≤ .01). No differences were evident across ED risk and sport type for males. Differences were seen between sex and binge eating (χ21,2054 = 6.8, P = .009), sex and diet pill use (χ21,2054 = 19.6, P ≤ .01), and sport type and diet pill use (χ24,2054= 12.2, P = .016), excessive exercise (χ24,2054 = 32.1, P ≤ .01), and losing more than 20 lb (9 kg) in the last 6 months (χ24,2054 = 10.2, P ≤ .037).

CONCLUSIONS

Student-athletes in the collegiate setting are at risk for EDs. Medical professionals, such as athletic trainers, need to be educated on the potential risk factors that may lead to EDs. Protocols for prevention, screening and recognition, and referral should be developed for student-athletes at risk for EDs.

Mental Health in Ultra-Endurance Runners: A Systematic Review

BACKGROUND

Among ultra-endurance runners (UER), the mental, behavioral, and physical demands of training/competition can result in maladaptive outcomes. Mental health issues are common in athletes and can impact psychology, physical health, and performance.

OBJECTIVE

To synthesize information regarding the incidence/prevalence and factors associated with mental health issues among UER.

METHODS

Systematic searches were performed in PubMed, SPORTDiscus, Scopus, Cochrane databases, CINAHL, Web of Science, and Medline Ovid using key terms related to UER (e.g., trail running, road running) and psychological issues (e.g., exercise addiction, depression). Inclusion criteria included original articles published in peer-reviewed journals in English, using qualitative or quantitative approaches. We considered papers reporting incidence/prevalence and associated factors with mental health outcomes in UER of both sexes, all ages, and levels of competition (e.g., elite, nonprofessional runners). The Joanna Briggs Institute Analytical Cross-Sectional Studies critical appraisal tool was used for quality assessment.

RESULTS

A total of 282 studies were identified, and 11 studies were included in the final selection. A total of 3670 UER were included in the studies. The prevalence of mental health issues among UER ranged between 32.0% and 62.5% for eating disorders, from 11.5% to 18.2% for exercise addiction, 18.6% for depressive symptoms, and 24.5% for sleep disturbance. Exercise addiction was not related to weekly volume, but a strong relationship with exercise in an unstructured space, age, and body mass index was shown.

CONCLUSION

Mental health issues among UER are common, especially eating disorders, exercise addiction, sleep disturbances, and depressive symptoms. Further high-quality studies are needed to examine underlying factors and find preventative strategies to protect UER.

REGISTRATION

The protocol of this systematic review was registered at the PROSPERO-CRD42022338743.

Prevalence and Association of Exercise Dependence and Eating Disorder Risk in Collegiate Student-Athletes

CONTEXT

Exercise dependence (EXD) is a compulsive and addictive behavior that can negatively affect physical and mental health, leading to significant impairment or distress. Exercise dependence has been associated with symptoms of eating disorders (EDs). Student-athletes are an at-risk population for EXD and EDs given the physical and psychological demands of competitive sports.

OBJECTIVE

To examine the EXD and ED risks in student-athletes across sex and sport category and to determine the association between EXD and ED.

DESIGN

Cross-sectional study.

SETTING

Collegiate athletics.

PATIENTS OR OTHER PARTICIPANTS

National Collegiate Athletic Association Division I and II student-athletes (n = 1885; age = 19.8 ± 1.4 years; females = 69.6%, n = 1312; males = 30.4%, n = 573).

MAIN OUTCOME MEASURE(S)

A web-based survey including demographics, the Exercise Dependence Scale-21, the Eating Attitudes Test-26, and questions about pathogenic behaviors.

RESULTS

Overall, 4.9% (n = 92) of the student-athletes were categorized as at risk for EXD (females = 4.8%, n = 63/1312; males = 5.1%, n = 29/573), with differences across sex and sport categories (all: χ28,1885 = 99.1, P < .001). The ED risk in student-athletes (Eating Attitudes Test-2, pathogenic behavior use, or both) was 22.7% (n = 428; females = 25.5%, n = 334/1312; males = 16.4%, n = 94/573), with differences by sex (χ24,1885 = 10.1, P = .039). Multiple logistic regressions indicated a significant association between the risks of EXD and ED for all student-athletes; athletes at risk for EXD were also at greater risk for EDs (odds ratio = 5.104; 95% CI = 3.237, 8.046) than nondependent-asymptomatic athletes (odds ratio = 2.4068; 95% CI = 1.5618, 3.7089).

CONCLUSIONS

Although physical activity has become a public health intervention to improve overall health in populations, EXD can be considered a problem related to physical activity. Exercise dependence can negatively affect physical and mental health, whereas EDs may be psychiatric disorders influenced by EXD, as exercise can be a compensatory behavior to achieve weight loss. To minimize the overall risk of EDs in student-athletes, additional education and awareness are needed. Special attention should be given to any student-athletes, in particular females, who display signs of EXD.

2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs)

Relative Energy Deficiency in Sport (REDs) was first introduced in 2014 by the International Olympic Committee's expert writing panel, identifying a syndrome of deleterious health and performance outcomes experienced by female and male athletes exposed to low energy availability (LEA; inadequate energy intake in relation to exercise energy expenditure). Since the 2018 REDs consensus, there have been >170 original research publications advancing the field of REDs science, including emerging data demonstrating the growing role of low carbohydrate availability, further evidence of the interplay between mental health and REDs and more data elucidating the impact of LEA in males. Our knowledge of REDs signs and symptoms has resulted in updated Health and Performance Conceptual Models and the development of a novel Physiological Model. This Physiological Model is designed to demonstrate the complexity of either problematic or adaptable LEA exposure, coupled with individual moderating factors, leading to changes in health and performance outcomes. Guidelines for safe and effective body composition assessment to help prevent REDs are also outlined. A new REDs Clinical Assessment Tool-Version 2 is introduced to facilitate the detection and clinical diagnosis of REDs based on accumulated severity and risk stratification, with associated training and competition recommendations. Prevention and treatment principles of REDs are presented to encourage best practices for sports organisations and clinicians. Finally, methodological best practices for REDs research are outlined to stimulate future high-quality research to address important knowledge gaps.

Body image concerns across different sports and sporting levels: A systematic review and meta-analysis

Mixed findings exist regarding whether athletes have different levels of body image concerns to non-athletes. Such body image concerns have not been reviewed recently, meaning that new findings need to be incorporated into our understanding of the adult sporting population. This systematic review and meta-analysis aimed first to characterise body image in adult athletes versus non-athletes, and second to explore whether specific sub-groups of athletes report different body image concerns. Impact of gender and competition level were considered. A systematic search identified 21 relevant papers, mostly rated moderate quality. Following a narrative review, a meta-analysis was conducted to quantify the outcomes. While the narrative synthesis indicated possible differences between types of sport, the meta-analysis demonstrated that athletes in general reported lower body image concerns than non-athletes. In general, athletes had a better body image than non-athletes, with no reliable differences between different type of sport. A combination of prevention and intervention strategies might assist athletes in focusing on the benefits to their body image without encouraging restriction/compensation or overeating. Future research should define comparison groups clearly, along with attending to training background/intensity, external pressures, gender and gender identity.

Initial examination of the mental health disorders: screening instrument for athletes

Introduction

There is a need to psychometrically develop assessment instruments capable of screening mental health disorders in athlete populations. The current study was conducted to determine reliability, validity and clinical utility of the Mental Health Disorders Screening Instrument for Athletes (MHDSIA).

Methods and results

259 collegiate athletes completed the MHDSIA. Factor analysis determined a single factor with good internal consistency, and this factor was positively correlated with an established measure of psychiatric symptomology (Symptom Checklist 90-R), demonstrating its concurrent validity. An optimum clinical cutoff score (i.e., 32) was determined using Receiver Operating Characteristic (ROC) analyses to assist appropriate mental health referrals.

Discussion

Results suggest the MHSIA is a reliable, valid, and relatively quick and easy to interpret screen for the broad spectrum of mental health disorders in collegiate athletes. As expected, NCAA athletes reported lower MHDSIA scores than club and intramural athletes, while males reported similar severity scores as females.

A mixed method approach to evaluating eating-related psychopathologies in collegiate student-athletes

OBJECTIVE

To examine the presence of body image concerns, drive for muscularity, and disordered eating behaviors in collegiate student-athletes.

PARTICIPANTS

One hundred and one NCAA Division I student-athletes participated in Phase I; 15 of these also participated in Phase II.

METHODS

This study employed a mixed method, sequential explanatory design. Participants first completed survey measures assessing body image concern, drive for muscularity, and eating behaviors. These results influenced open-ended, semi-structured interviews, which were thematically analyzed.

RESULTS

Body image and disordered eating behaviors were of greater concern than drive for muscularity. Student-athletes reported engaging in eating behaviors as opposed to not eating, yet these eating behaviors trended toward disordered behaviors such as obsessive "healthy eating" or orthorexia.

CONCLUSIONS

This study took a novel methodological approach to examining student-athlete body image and eating behaviors. Results emphasize the need for further support and education for student-athletes around body image and eating behaviors.

The co-creation, initial piloting, and protocol for a cluster randomised controlled trial of a coach-led positive body image intervention for girls in sport

BACKGROUND

Globally, girls disengage from sports at an earlier age and higher rate than boys. This is, in part, due to the unique body image challenges that girls face, relative to their male peers. Existing intervention efforts that aim to reduce girls' negative body image and movement experiences have proven marginally effective, if not ineffective. This paper outlines the co-creation, initial piloting and protocol for a cluster randomised controlled trial of Body Confident Athletes (BCA); an in-person, coach-led intervention that aims to foster positive body image and sports enjoyment among girls.

METHODS

Following co-creation and an initial pilot, a two-armed cluster randomised controlled trial will assess the immediate (post-intervention) and short-term (1-month and 3-month follow-up) impact of BCA on girls' (N = 1,036; 11-17 years old) body image, sports enjoyment, and affect. Sport organisations will be randomly allocated (1:1) into either an intervention or waitlist control condition. Girls and coaches in the intervention condition will complete three 60-minute sessions over three consecutive weeks. The primary outcome will be the immediate change in girls' body esteem, with secondary outcomes assessing the immediate and short-term changes in girls' body appreciation, self-objectification, attuned self-care, sports enjoyment, and affect.

DISCUSSION

This research is the first to utilise an international multi-stakeholder partnership to co-create and evaluate an intervention that addresses the intersection of girls' body image and sport experiences. The theoretical and methodological considerations of this research have led to a feasible intervention and trial protocol, and if proven effective, BCA may assist in reducing the global gender disparity in sports participation.

TRIAL REGISTRATION NUMBER

NCT05594524 , registered 25^th October 2022.

The Comparison of Disordered Eating, Body Image, Sociocultural and Coach-Related Pressures in Athletes across Age Groups and Groups of Different Weight Sensitivity in Sports

The aim of the present study was to compare disordered eating (DE), body image, and sociocultural and coach-related pressures between athletes of different age groups (adolescents and adults) and between athletes participating in weight-sensitive (WS) and less WS groups. A total of 1003 athletes participated in this study. The age range of the sample was 15 to 44 years, and the mean age was 18.9 ± 5.8 years (51.3% were female). Athletes who voluntarily agreed to participate in the study were provided with the study measures on DE, body image and sociocultural attitudes towards appearance. Vomiting, laxative misuse and excessive exercise were more prevalent in adolescent female athletes than adults, while dietary restraint was more common in adult male athletes than adolescents. Adolescent female athletes experienced higher sociocultural (family, peers) and sport-related (coach) pressures and a less positive body image compared with adult female athletes. Adult male athletes experienced higher overweight preoccupation, more DE and unhealthy eating habits, and engaged in more frequent self-weighing behaviour compared with adolescent males. When the effect of weight sensitivity in sports was tested, a higher prevalence of DE and overweight preoccupation, more frequent self-weighing, and higher body-image-related pressure from coaches were observed in female athletes participating in aesthetic weight-sensitive (WS) sports as compared with those participating in less WS sports. No differences in positive body image were observed in female WS and less WS sports. Special DE prevention and positive body image promotion programs are necessary for female competitive athletes and parents of adolescent female athletes, especially those participating in aesthetic ones. For adult male athletes, special programs aiming to promote healthy eating should be implemented to prevent DE and body image concerns. Special education about DE prevention is compulsory for coaches who train female athletes.

Mental health help-seeking preferences and behaviour in elite male rugby players

Objectives

Mental health symptoms and mental illnesses are common in elite athletes. There is an urgent need to develop care systems to support the mental health of elite athletes. Understanding elite athletes' preferences in mental health help seeking can help explore strategies to develop such systems. Therefore, this study aims to investigate with whom/where elite athletes feel comfortable discussing mental health concerns and seeking help.

Methods

We analyse data from 219 Japanese male rugby players out of 612 players (565 Japanese, 47 foreigners) aged 18 and over who belong to the Japan Rugby Players Association using a cross-sectional design and an anonymous, web-based, self-administered questionnaire. In the questionnaire, the players are asked to rate on a 5-point Likert scale how comfortable they feel talking about their mental health concerns with affiliation/team staff, family/relatives, friends, mental health professionals, rugby-related seniors and teammates. Analysis of variance and Dunnett's test are performed to detect differences in their preferences for sources of help.

Results

Dunnett's test shows that the mean scores for preferring to consult affiliation/team staff are significantly lower than for all the other groups (p<0.001), indicating that players are reluctant to seek help for mental health concerns from affiliation/team staff. Fewer players sought help from affiliation/team staff or mental health professionals than from other groups.

Conclusion

Regarding mental health concerns, for elite male rugby players as elite athletes, it can be difficult to ask for help or talk to team staff.

The association between sport type and eating/body image concerns in high school students: a cross-sectional observational study

PURPOSE

Disordered eating and body image concerns are increasingly common among adolescents, possibly representing the underpinning of eating disorders (EDs). This cross-sectional observational study aimed at investigating the relationship between various patterns of sports involvement or inactivity, and the abovementioned psychopathological dimensions.

METHODS

All adolescents attending their 3rd-5th Italian grade in a single high school reported their sociodemographic and anthropometric data, their weekly sports involvement, and filled the Eating Disorders Examination Questionnaire 6.0 (EDE-Q), the Body Uneasiness Test, and the Muscle Dysmorphia Disorder Inventory (for boys). Comparisons were performed considering sex, weekly hours of activity, and different sports type (none, individual, or team sports).

RESULTS

Of 744 enrolled students, 522 (70.2%) completed the survey. Girls showed higher underweight rates, preference for inactivity or individual sports, and higher psychometric scores compared to boys. Among girls, no differences were found based on time spent exercising or sports type. Inactive boys displayed worse weight- and shape-based psychopathology, higher body uneasiness, and higher appearance intolerance compared to those who devoted more time to exercise. Among boys, individual and team sports were associated with lower EDE-Q scores compared to inactivity, whereas body uneasiness and appearance intolerance were lower only in team sports.

CONCLUSIONS

The study confirms the presence of remarkable sex differences in eating and body concerns of adolescents. Among boys, sports involvement is tied to lower ED psychopathology, and preference for team sports may be associated with reduced concerns. Wider longitudinal studies on will clarify the direction and specificity of these findings.

LEVEL OF EVIDENCE

Level V-Cross-sectional observational study.

Body Image, Social Physique Anxiety Levels and Self-Esteem among Adults Participating in Physical Activity Programs

(1) Background: individuals may benefit from being involved in physical and athletic activities in order to improve their body appearance and promote their physical and mental health. This study aimed to investigate body image, body mass index (BMI) characteristics, social physique anxiety, self-esteem and possible correlations between the above factors. (2) Methods: 245 adults engaged in training programs in gyms, as well as in track and field, football and basketball athletic activities completed (a) a sociodemographic questionnaire which recorded their BMI values and utilized the (b) Body-Esteem Scale for Adolescents and Adults, (c) the Social Physique Anxiety Scale and (d) the Rosenberg Self-Esteem Scale. (3) Results: Females and individuals with higher BMI reported statistically significant lower body-esteem and greater social physique anxiety levels compared to males and individuals with lower BMI, respectively (p < 0.05). A total of 25.3% of our participants were labeled as "overweight", while 20.4% had been overweight in the past. Significant differences were reported between body-esteem and social physique anxiety levels (p < 0.001); age (p = 0.001); BMI value (p < 0.001) and never having a problem with body weight (p = 0.008). Additionally, individuals with lower body-esteem and greater social physique anxiety levels presented lower global self-esteem (p < 0.001). (4) Conclusions: individuals' engagement in physical activity promotes physical as well as mental well-being, contributing to an improved quality of life, which may be the most important issue for health care professionals.

The Relationship Between Eating Disorders, Disordered Eating, and Injury in Athletes: A Critically Appraised Topic

CLINICAL SCENARIO

Eating disorders (EDs) and disordered eating (DE) result in numerous physical and psychological complications for female and male athletes. Besides bone-related injury, little research exists investigating what injuries EDs and/or DE contribute to.

CLINICAL QUESTION

Are EDs and/or DE a risk factor for injury incidence in athletes?

SUMMARY OF KEY FINDINGS

We searched for prospective studies assessing EDs or DE as a risk factor for injury in female or male athletes high school age and older. Our search returned 5 studies. One study found Eds, or DE were not a risk for any type of injury in female cross-country and track-and-field athletes. Two studies found a possible relationship between EDs or DE, as one contributing factor of others, in the incidence of bone stress injuries (BSIs) in female athletes who compete in various sports. One study found female, but not male, cross-country and track-and-field athletes with a history of EDs were more at risk for stress fractures than those without a history. One study found Eds, or DE were not a risk for BSI in female runners and triathletes.

CLINICAL BOTTOM LINE

Large and important gaps in the literature exist investigating injuries related to EDs or DE outside of BSIs. There is low-moderate evidence that EDs and/or DE are either a sole, or contributing, risk factor for BSIs in female athletes.

STRENGTH OF RECOMMENDATION

Grade B evidence exists to support the idea that EDs and/or DE are a risk factor for a specific type of injury (BSI) in female athletes only.

Prevalence of Relative Energy Deficiency in Sport (RED-S) among National Athletes in Malaysia

Relative energy deficiency in sport (RED-S), which underpins the concept of low energy availability (LEA), can negatively affect athletes’ health and performance. This study aims to investigate the prevalence of RED-S among national athletes in Malaysia. A total of 192 national athletes (97 males, 18–39 years old) responded to an online survey regarding the RED-S risk. Most athletes (67.2%) were classified as having a medium/high RED-S risk. Female (41.2%), weight-class (23.9%), and intermittent sports (20.3%) had the highest prevalence of medium/high RED-S risk. Overall, most athletes spent 2–5 h daily (55.2%) and 6–7 days weekly (53.6%) practicing or playing their sport, and 47.9% reported feeling tired recently. The athletes were also terrified of being overweight (61.5%), worried about what they eat (64.7%), concerned about having fat on their bodies (62.6%), and thinking about burning calories while exercising (69.3%). Only 16.7% of the athletes had a prior history of stress fractures, and 40.6% continued to participate in activities 6–7 days per week while injured. The majority of female athletes (88.3%) had regular menstrual cycles. These findings support the notion that RED-S screening should be addressed in the athletic community. Future research is needed to clinically assess these athletes and investigate the impacts of RED-S on their health and sports performance.

Body Composition, Energy Availability, Risk of Eating Disorder, and Sport Nutrition Knowledge in Young Athletes

Young athletes may be at risk for low energy availability (LEA) or dietary habits that are indicative of eating disorders. Thus, the purpose of the current study was to investigate the prevalence of LEA among high school athletes and examine those at risk for eating disorders. A secondary aim was to examine relationships between sport nutrition knowledge, body composition, and LEA.

METHODS

94 male (n = 42) and female (n = 52) mean ± SD age: 18.09 ± 2.44 y; height: 172.6 ± 9.8 cm; body mass: 68.7 ± 14.5 kg; BMI: 22.91 ± 3.3 kg·m^-2) athletes completed a body composition assessment and electronic versions of the abridged sports nutrition knowledge questionnaire (ASNK-Q), brief eating disorder in athletes questionnaire (BEDA-Q), and the low energy availability for females questionnaire (LEAF-Q; females only).

RESULTS

52.1% of female athletes were classified as being at risk for LEA. Moderate inverse relationships existed for computed LEAF-Q scores and BMI (r = -0.394; p < 0.01). A total of 42.9% of males (n = 18) and 68.6% of females (n = 35) were at risk for eating disorders, with females being at greater risk (p < 0.01). Body fat percentage was a predictor (β = -0.095; p = -0.01) for eating disorder risk status. For every 1 unit increase in body fat percentage, athletes were 0.909 (95% CI: 0.845-0.977) times less likely to be classified as at risk for an eating disorder. Male (46.5 ± 13.9) and female (46.9 ± 11.4) athletes scored poorly on the ASNK-Q, with no differences between sex (p = 0.895).

CONCLUSIONS

Female athletes were at a greater risk for eating disorders. No relationships existed between sport nutrition knowledge and %BF. Female athletes with a higher %BF had a lower risk for an eating disorder and risk for LEA.

The prevalence of orthorexia in exercising populations: a systematic review and meta-analysis

AIM

Orthorexia Nervosa (ON) describes a pathological obsession with proper and high-quality nutrition that is necessary to research further in order to elucidate its prevalence and correlates which may bear implications for prevention and treatment. The aim of this study was to review studies that report the prevalence of ON in people who exercise, calculate an overall prevalence through a random-effects meta-analysis approach and investigate the association of ON prevalence using a random-effects meta-regression. In addition, a sub-group-analysis based on ON-instruments and a sensitivity analysis excluding students samples, were conducted.

METHOD

Systematic searches were conducted in the following online databases: PubMed, Embase, Web of Science, PsychInfo, CINAHL, Google Scholar and OpenNet. The following search terms were used: Orthore* AND (prevalenc* OR incidenc* OR frequen* OR cut-off OR epidem*). A total of 613 unique hits were reviewed by two blinded authors, and 24 studies were coded and assessed for risk of bias (Holy et.al). The meta-regression included three independent variables (sex, type of sport, and sample size).

RESULTS

The overall prevalence of ON in the exercising population was 55.3% (95% CI 43.2-66.8). Cochran's Q was 11,436.38 (df = 23, p < 0.0000), and the I² was 98.4%, indicating high heterogeneity across studies. The sensitivity showed an overall prevalence of 51.3% (95% CI 51.3-70.0). There was a significant difference in prevalence estimates based on the instruments used (Q_bet = 33.6, df = 2, p < 0.01).

DISCUSSION

The overall prevalence of ON in exercising populations was very high. The between-study disparity was large and was partly explained by the ON-instrument administered. One fourth of the studies had a moderate risk of bias. The majority of the studies did not specify relevant demographic information about the sample, and information about the type of sport was frequently missing.