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Lichtenstein MB, Hertz SPT, Johansen KK, Rytter J, Sundgot-Borgen J, Torstveit MK, Holm L, Melin AK. Are Sub-elite Athletes at Higher Risk of Eating Disorders, Exercise Addiction, Depression, and Low Energy Availability Compared With Elite Athletes? Clin J Sport Med 2024:00042752-990000000-00216. [PMID: 39012244 DOI: 10.1097/jsm.0000000000001257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 04/28/2024] [Indexed: 07/17/2024]
Abstract
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.
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Affiliation(s)
- Mia Beck Lichtenstein
- Department of Psychology, University of Southern Denmark, Denmark
- Centre for Digital Psychiatry, Odense, Denmark
| | | | | | - Josefine Rytter
- Department of Psychology, University of Southern Denmark, Denmark
- Centre for Digital Psychiatry, Odense, Denmark
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Denmark
- Department of Sports Medicine, the Norwegian School of Sport Sciences, Oslo, Norway
- Department of Sport Science and Physical Education, University of Agder, Kristiansand, Norway
- Team Danmark, The Danish Elite Sport Institution, Broendby, Denmark; and
- Department of Sports Science, Linnaeus University, Växjö/Kalmar, Sweden
| | - Jorunn Sundgot-Borgen
- Department of Psychology, University of Southern Denmark, Denmark
- Centre for Digital Psychiatry, Odense, Denmark
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Denmark
- Department of Sports Medicine, the Norwegian School of Sport Sciences, Oslo, Norway
- Department of Sport Science and Physical Education, University of Agder, Kristiansand, Norway
- Team Danmark, The Danish Elite Sport Institution, Broendby, Denmark; and
- Department of Sports Science, Linnaeus University, Växjö/Kalmar, Sweden
| | | | - Lars Holm
- Team Danmark, The Danish Elite Sport Institution, Broendby, Denmark; and
| | - Anna K Melin
- Department of Sports Science, Linnaeus University, Växjö/Kalmar, Sweden
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Forys WJ, Tokuhama-Espinosa T. The Athlete’s Paradox: Adaptable Depression. Sports (Basel) 2022; 10:sports10070105. [PMID: 35878116 PMCID: PMC9320389 DOI: 10.3390/sports10070105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 02/01/2023] Open
Abstract
We proposed that an athlete’s depressive symptoms may be different from the general population in etiology if considered from the context of a depressive disorder. By shifting focus from a limited notion of symptoms onto a comprehensive model of depression, the full scope of the phenomenon becomes clearer. This paper investigated the relationship between neurotransmitters and allostatic load to explain the incidence of depression among elite athletes. This literature review extensively analyzed exercise-induced neurohormonal imbalance resulting in depressive states among athletes. The research revealed that 5-HTTLPR polymorphism, brain-derived neurotrophic factor (BDNF), extensive psychological demands, social stigma, and overtraining syndrome (OTS) may all contribute to a unique version of depression. The research revealed that the biological standards of athletes differ from those of non-athletes, to the point that the new model may be useful, thereby introducing the new term “Adaptable Depression (AD)” to the literature. This framework suggests a new direction for future research to precisely measure the neurotransmitter-related brain changes that result in “Adaptable Depression” in athletes and to establish a better understanding of the depressive tipping point.
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Affiliation(s)
- Weronika Jasmina Forys
- Division of Continuing Education, Harvard University, 51 Brattle Street, Cambridge, MA 01238, USA
- Correspondence:
| | - Tracey Tokuhama-Espinosa
- Faculty of Arts and Sciences, Extension School, Harvard University, 51 Brattle Street, Cambridge, MA 01238, USA;
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Lichtenstein MB, Johansen KK, Runge E, Hansen MB, Holmberg TT, Tarp K. Behind the athletic body: a clinical interview study of identification of eating disorder symptoms and diagnoses in elite athletes. BMJ Open Sport Exerc Med 2022; 8:e001265. [PMID: 35813128 PMCID: PMC9214368 DOI: 10.1136/bmjsem-2021-001265] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2022] [Indexed: 11/15/2022] Open
Abstract
Eating disorders are more prevalent in athletes than in the general population and may have severe consequences for sports performance and health. Identifying symptoms can be difficult in athletes because restrictive eating and slim body images are often idealised in a sports setting. The Eating Disorders Examination Questionnaire (EDE-Q) and the SCOFF (Sick, Control, One stone, Fat and Food) questionnaire (SCOFF) are widely used generic instruments to identify symptoms of eating disorders. This study aimed to investigate the instruments’ validity and explore eating disorder symptoms in a sample of athletes. A sample of 28 athletes (25 females) competing at a national level was interviewed based on the diagnostic criteria for eating disorders. We interviewed 18 athletes with a high score on EDE-Q and 10 with a low score. All interviews were transcribed and analysed from a general inductive approach. We identified 20 athletes with an eating disorder diagnosis, while 8 had no diagnosis. EDE-Q found 90% of the cases, while SCOFF found 94%. EDE-Q found no false-positive cases, while SCOFF found one. The qualitative results showed that most athletes reported eating concerns, restrictive eating, eating control (counting calories), weight concerns, body dissatisfaction (feeling fat and non-athletic), excessive exercise and health problems (eg, pain, fatigue). In conclusion, EDE-Q and SCOFF seem valid instruments to screen athletes’ samples but may fail to find 6%–10% cases with eating disorders. Despite athletic bodies and normal body mass index, many athletes report severe eating problems and dissatisfaction with weight and body appearance. Implementation of regular screening may identify these symptoms at an early stage.
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Affiliation(s)
- Mia Beck Lichtenstein
- Department of Clinical Research, Syddansk Universitet Det Samfundsvidenskabelige Fakultet, Odense, Denmark
| | - Karen Krogh Johansen
- Research Unit for Digital Psychiatry, Mental Health Services in the Region of Southern Denmark, Odense, Denmark
| | - Eik Runge
- Research Unit for Digital Psychiatry, Mental Health Services in the Region of Southern Denmark, Odense, Denmark
| | - Marina Bohn Hansen
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Trine Theresa Holmberg
- Research Unit for Digital Psychiatry, Mental Health Services in the Region of Southern Denmark, Odense, Denmark
| | - Kristine Tarp
- Research Unit for Digital Psychiatry, Mental Health Services in the Region of Southern Denmark, Odense, Denmark
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Flatt RE, Miller AJ, Foreman T, Shannon J. Considerations for Athletes with Eating Disorders Based on Levels of Care. Curr Sports Med Rep 2022; 21:92-99. [PMID: 35245244 DOI: 10.1249/jsr.0000000000000942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT This article provides an overview of levels of care for eating disorders (EDs) and considerations that are specific to elite athletes. We discuss the following levels of care in terms of ED pathology and treatment aspects that may be unique to athletes: 1) inpatient and residential care, 2) intensive outpatient and partial hospitalization treatment, and 3) outpatient. Illustrative case studies also are presented to highlight distinctions between levels of care and athlete-specific nuances to treatment approaches and health care teams. Finally, we review aspects of return to play plans for elite athletes with EDs.
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Affiliation(s)
| | - Alexandra J Miller
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Tonya Foreman
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jeni Shannon
- Department of Sports Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Uriegas NA, Winkelmann ZK, Pritchett K, Torres-McGehee TM. Examining Eating Attitudes and Behaviors in Collegiate Athletes, the Association Between Orthorexia Nervosa and Eating Disorders. Front Nutr 2021; 8:763838. [PMID: 34859033 PMCID: PMC8632486 DOI: 10.3389/fnut.2021.763838] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose: Orthorexia nervosa (Orthorexia) is an eating attitude and behavior associated with a fixation on healthy eating, while eating disorders (EDs) are clinically diagnosed psychiatric disorders associated with marked disturbances in eating that may cause impairment to psychosocial and physical health. The purpose of this study was to examine risk for Orthorexia and EDs in student-athletes across sex and sport type and determine the association between the two. Methods: Student-athletes (n = 1,090; age: 19.6 ± 1.4 years; females = 756; males = 334) completed a survey including demographics, the ORTO-15 test (<40 and <35 threshold values), the Eating Attitudes Test-26 (EAT-26; >20 score), and additional questions about pathogenic behaviors to screen for EDs. Results: Using a <40 threshold value for the ORTO-15, 67.9% were at risk for Orthorexia, a more restrictive threshold value of <35 determined 17.7% prevalence across student-athletes with significant differences across sex [ <40: χ(1,1,090)2 = 4.914, p = 0.027; <35: χ(1,1,090)2 = 5.923, p = 0.015). Overall, ED risk (EAT-26 and/or pathogenic behavior use) resulted in a 20.9% prevalence, with significant differences across sex (χ2 = 11.360, p < 0.001) and sport-type category (χ2 = 10.312, p = 0.035). Multiple logistic regressions indicated a significant association between EAT-26 subscales scores and Orthorexia, and between Orthorexia positivity, ORTO-15 scores, and risk for EDs. Conclusions: Risk for Orthorexia and ED is present in collegiate student-athletes. While healthy and balanced eating is important, obsessive healthy eating fixations may increase the risk for EDs in athletes. More education and awareness are warranted to minimize the risk for Orthorexia and EDs in student-athletes.
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Affiliation(s)
- Nancy A Uriegas
- Department of Exercise Science, University of South Carolina, Columbia, SC, United States
| | - Zachary K Winkelmann
- Department of Exercise Science, University of South Carolina, Columbia, SC, United States
| | - Kelly Pritchett
- Department of Health Sciences, Central Washington University, Ellensburg, WA, United States
| | - Toni M Torres-McGehee
- Department of Exercise Science, University of South Carolina, Columbia, SC, United States
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Godoy-Izquierdo D, Ramírez MJ, Díaz I, López-Mora C. A Systematic Review on Exercise Addiction and the Disordered Eating-Eating Disorders Continuum in the Competitive Sport Context. Int J Ment Health Addict 2021. [DOI: 10.1007/s11469-021-00610-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
AbstractExercise addiction (EA) affects a considerable number of individuals who regularly perform exercise-sport activities. The co-occurrence of EA manifestations and the continuum of disordered eating-eating disorders (EDs) is so common in sports that a deeper understanding of them as comorbidities is warranted. The aim of this review is to provide an up-to-date overview and synthesis of the research on the relationship between maladaptive exercise and dysfunctional eating in the sport context. A systematic review was conducted following the PRISMA guidelines. A total of 22 empirical studies (23 articles) with young and adult female and male athletes from several sports and competition levels was included. EA in conjunction with eating disturbances is frequent among athletes, yet the prevalence rates are inconsistent. Existing evidence suggests that EA is a relevant outcome of ED pathology among athletes, supporting the classical secondary type of EA. However, research also reveals that excessive exercising plays a central role in the psychopathology of disordered eating. There is a need for further quantitative research addressing the features and correlates of the EA-EDs dyad, qualitative research on the subjective experiences of athletes with disordered exercise and eating, longitudinal and experimental research to establish possible causal paths and attempts to develop comprehensive conceptual models of EA and its co-occurrence with EDs, in order to improve the identification, prevention, and management of this dyadic condition in the sport context.
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Kuikman MA, Mountjoy M, Burr JF. Examining the Relationship between Exercise Dependence, Disordered Eating, and Low Energy Availability. Nutrients 2021; 13:2601. [PMID: 34444761 PMCID: PMC8398044 DOI: 10.3390/nu13082601] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/23/2021] [Accepted: 07/24/2021] [Indexed: 12/18/2022] Open
Abstract
Both dietary and exercise behaviors need to be considered when examining underlying causes of low energy availability (LEA). The study assessed if exercise dependence is independently related to the risk of LEA with consideration of disordered eating and athlete calibre. Via survey response, female (n = 642) and male (n = 257) athletes were categorized by risk of: disordered eating, exercise dependence, disordered eating and exercise dependence, or if not presenting with disordered eating or exercise dependence as controls. Compared to female controls, the likelihood of being at risk of LEA was 2.5 times for female athletes with disordered eating and >5.5 times with combined disordered eating and exercise dependence. Male athletes with disordered eating, with or without exercise dependence, were more likely to report signs and symptoms compared to male controls-including suppression of morning erections (OR = 3.4; p < 0.0001), increased gas and bloating (OR = 4.0-5.2; p < 0.002) and were more likely to report a previous bone stress fracture (OR = 2.4; p = 0.01) and ≥22 missed training days due to overload injuries (OR = 5.7; p = 0.02). For both males and females, in the absence of disordered eating, athletes with exercise dependence were not at an increased risk of LEA or associated health outcomes. Compared to recreational athletes, female and male international caliber and male national calibre athletes were less likely to be classified with disordered eating.
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Affiliation(s)
- Megan A. Kuikman
- The Human Performance and Health Research Laboratory, Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, ON N1G 2W1, Canada;
| | - Margo Mountjoy
- Department of Family Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8P 1H6, Canada;
| | - Jamie F. Burr
- The Human Performance and Health Research Laboratory, Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, ON N1G 2W1, Canada;
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Athlete-Specific Treatment for Eating Disorders: Initial Findings from the Walden GOALS Program. J Acad Nutr Diet 2020; 120:183-192. [DOI: 10.1016/j.jand.2019.07.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Indexed: 11/18/2022]
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