Prevention of eating disorders in female athletes

Dysfunctional eating attitudes and behaviors among French elite athletes: the impact of psychological characteristics and the sporting calendar

Background

Research on sport psychology suggests that athletes are at risk of developing dysfunctional eating attitudes and behaviors (DEAB), however the origins of these behaviors remain largely unexplored. The present study aims to identify factors (i.e., personality traits, anxiety levels, eating attitudes and behaviors, the internalization of sport thinness norms, and resilience) associated with the development of DEAB among female endurance athletes, in training and competition.

Method

A longitudinal follow-up study was conducted among 14 elite female athletes who were tested daily, weekly, and quarterly over 12 months in 2022, for a total of 545 measures. Participants completed questionnaires assessing personality traits, anxiety levels, eating attitudes and behaviors, the internalization of sport thinness norms, and resilience. Descriptive statistics were calculated for all study data, and odds ratios were conducted to compare the variance of psychological factors and sporting factors depending on the level of DEAB and the sport period. Significance was set at p < 0.05.

Results

Overall, 28% of our sample of athletes were identified with DEAB. Among those with DEAB, scores for agreeableness, anxiety, and competitive anxiety were significantly higher, while scores for resilience were significantly lower than those without DEAB. During the competitive season, scores for self-regulatory eating attitudes and the internalization of thinness norms were significantly higher than during the training period.

Conclusion

Our results suggest a greater probability of DEAB among athletes who exhibit the trait of agreeableness, experience anxiety during competition, and lack resilience. The competitive season was also identified as a period conducive for developing DEAB compared with the training period. Based on these results our study suggests preventive measures that can be implemented with athletes displaying these traits, with a particular emphasis during the competitive phase.

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.

Eating disorder risk assessment and sociocultural attitudes toward body image among Polish and Turkish professional female football players

Introduction

Football requires high physical fitness and often involves maintaining a specific physique, leading to harmful eating behaviors due to internal and external pressures. Cultural norms influence the prevalence and types of eating disorders (ED), with differences in eating habits, beauty standards, and socio-cultural pressures affecting ED development. This study assesses ED risk and analyzes socio-cultural attitudes toward body image among Polish and Turkish female football players.

Methods

The study was conducted from April to June 2024 and included 103 professional female football players aged 18–35 from Polish (n = 49) and Turkish (n = 54) clubs. Data were collected using the CAWI method via Google Forms. Participants completed EAT-26 and SATAQ-3 questionnaires, assessing ED risk and socio-cultural attitudes toward body image.

Results

40.8% of participants were at risk for ED. No differences in ED prevalence were found between groups of different nationalities. Polish footballers at risk of ED scored higher on the Internalization-Pressure and Information subscales and the overall SATAQ-3 score. A weak but significant positive correlation was found between SATAQ-3 and EAT-26 scores.

Discussion

The study finds no nationality-based differences in ED prevalence among professional female football players, but ED is widespread, affecting about 40% of players. Nutritional status impacts ED risk, with higher risk among underweight and overweight players. Polish players are more influenced by socio-cultural standards of body image promoted by mass media. The study underscores the need for regular screening and psychological support.

Are female athlete specific health considerations being assessed and addressed in preparticipation examinations? A scoping review and proposed framework

BACKGROUND

Preparticipation examinations (PPEs) are unstandardized screening tools routinely used to collect an athlete's baseline health information prior to the start of a new competitive season. However, many PPEs include minimal and often nonspecific questions related to the health concerns of female athletes. A lack of female athlete specific health questions could result in missed red flags and subsequent injury or illness. As such, the objectives of this scoping review were to (a) determine what female athlete specific health questions currently exist in PPEs in the scientific literature to prevent injury and illness, and (b) map the results against the health domains outlined in the International Olympic Committee (IOC) consensus statement supplement on the female athlete.

METHODS

We searched Embase, Scopus, CINAHL, Medline Ovid, and SPORTDiscus from inception to December 2022. Any study with female athlete specific health PPE questions or recommendations for questions (i.e., menstrual health, eating habits, musculoskeletal health, etc.) was included. Three reviewers independently screened titles and abstracts, followed by full text articles for eligibility and data extraction, with conflicts resolved by a third-party reviewer. Extracted data were summarized into 3 determined groupings.

RESULTS

Of the 1356 studies screened, 41 were included in this study. Forty studies (98%) included questions/recommendations related to menstrual health. Thirty-one studies (76%) had questions/recommendations concerning disordered eating/eating habits. Twenty-four studies (59%) referred to body weight/image, and 16 studies (39%) referred to musculoskeletal health. No studies included questions on all IOC female athlete health domains.

CONCLUSION

There is currently a gap in female athlete specific health content included in PPEs. A more comprehensive, standardized PPE with a focus on inclusion of female athlete specific health questions and considerations should be developed to improve health and optimal participation of female athletes around the world.

Menstrual cycle disorders as an early symptom of energy deficiency among female physique athletes assessed using the Low Energy Availability in Females Questionnaire (LEAF-Q)

Physique competitions are weight-sensitive sports in which stage presentation, aesthetic appearance and posing ability of the athletes are judged rather than physical performance. The aim of this study was to assess low energy availability among female physique athletes by using the LEAF-Q. The study involved 104 females who were physique athletes. Monthly cycle disorders were reported in 58.65% of the women, that is periods stopped for three consecutive months or longer (amenorrhea). This situation occurred before the research was conducted in 43.27% of athletes and during the research in 15.38%. The physique athletes claimed that menstruation changes occurred when there was an increased exercise intensity, frequency or duration. Absence from training due to injury was reported by 27.88% of the women. The LEAF-Q identified 46.15% of the physique athletes as at risk (score ≥ 8) of low energy availability and the physiological consequences related to RED-S. Women who had menstrual cycle disorders were younger and did more training per week. Among women with menstrual disorders, cramps or stomach ache which cannot be related to menstruation occurred more frequently (p = 0.004). Absence from training or lack of participation in competition due to injuries occurred more frequently in the score ≥ 8 group (p = 0.024) thank the ≤ score 8 group. In the score ≥ 8 group menstruation changes, that is less bleeding or cessation of menstruation (p = 0.035), occurred more frequently when there was an increase in exercise intensity, frequency or duration (p = 0.002).

Social Media Effects Regarding Eating Disorders and Body Image in Young Adolescents

The following study investigates how eating problems and young people's body image are affected by social media. As social media becomes more pervasive, young teenagers are exposed to many pictures, messages, and influencers encouraging unachievable body and beauty ideals. The study investigates the link between social media usage and the development of binge eating disorder patterns and undesirable body image judgments. It also sheds light on the influence that so-called social media influencers and celebrities have on encouraging disordered eating patterns and forming negative body image perceptions. On websites like Instagram and TikTok, exposure to deliberately selected photographs of "ideal" body types encourages body dissatisfaction and poor self-worth. The research emphasizes social media's possible harm to this vulnerable group's physical and mental health by examining pertinent literature and empirical evidence. It also looks at potential safeguards and methods for fostering good mental and physical health in early adolescents during pervasive social networking site use. Promoting fad diets, weight-loss aids, and the exaltation of extreme thinness aids in the normalization of harmful behaviours. Social media's negative consequences on eating disorders and body image in young teenagers are highlighted by this study in its conclusion. As a critical developmental stage, early adolescence is vulnerable due to the effect of social media, which could normalize unhealthy behaviours and maintain negative body image and insecurities. The findings underscore the need for targeted interventions and educational programs to mitigate the adverse effects of eating problems and young people's body image in light of social media.

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.

Differences in the Factor Structure of the Eating Attitude Test-26 (EAT-26) among Clinical vs. Non-Clinical Adolescent Israeli Females

In recent years, the diagnostic definitions of eating disorders (EDs) have undergone dramatic changes. The Eating Attitudes Test-26 (EAT-26), which is considered an accepted instrument for community ED studies, has shown in its factorial structure to be inconsistent in different cultures and populations. The aim of the present study was to compare the factor structure of the EAT-26 among clinical and non-clinical populations. The clinical group included 207 female adolescents who were hospitalized with an ED (mean age 16.1). The non-clinical group included 155 female adolescents (mean age 16.1). Both groups completed the EAT-26. A series of factorial invariance models was conducted on the EAT-26. The results indicate that significant differences were found between the two groups regarding the original EAT-26 dimensions: dieting, bulimia and food preoccupation, and oral control. Additionally, the factorial structure of the EAT-26 was found to be significantly different in both groups compared to the original version. In the clinical group, the factorial structure of the EAT-26 consisted of four factors, whereas in the non-clinical sample, five factors were identified. Additionally, a 19-item version of the EAT-26 was found to be considerably more stable and well suited to capture ED symptoms in both groups, and a cutoff point of 22 (not 20) better differentiated clinical samples from non-clinical samples. The proposed shortening of the EAT from 40 to 26 and now to 19 items should be examined in future studies. That said, the shortened scale seems more suited for use among both clinical and non-clinical populations. These results reflect changes that have taken place in ED psychopathology over recent decades.

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.

Effects of a 16-Week Digital Intervention on Sports Nutrition Knowledge and Behavior in Female Endurance Athletes with Risk of Relative Energy Deficiency in Sport (REDs)

Female endurance athletes are considered a high-risk group for developing Relative Energy Deficiency in Sport (REDs). Due to the lack of educational and behavioral intervention studies, targeting and evaluating the effects of the practical daily management of REDs, we developed the Food and nUtrition for Endurance athletes-a Learning (FUEL) program, consisting of 16 weekly online lectures and individual athlete-centered nutrition counseling every other week. We recruited female endurance athletes from Norway (n = 60), Sweden (n = 84), Ireland (n = 17), and Germany (n = 47). Fifty athletes with symptoms of REDs and with low risk of eating disorders, with no use of hormonal contraceptives and no chronic diseases, were allocated to either the FUEL intervention (n = 32) (FUEL) or a 16-week control period (n = 18) (CON). All but one completed FUEL, while 15 completed CON. We found strong evidence for improvements in sports nutrition knowledge, assessed via interviews, and moderate to strong evidence in the ratings concerning self-perceived sports nutrition knowledge in FUEL versus CON. Analyses of the seven-day prospective weighed food record and questions related to sports nutrition habits, suggested weak evidence for improvements in FUEL versus CON. The FUEL intervention improved sports nutrition knowledge and suggested weak evidence for improved sports nutrition behavior in female endurance athletes with symptoms of REDs.

Urinary incontinence in female athletes with inadequate eating behavior: a case-control study

INTRODUCTION AND HYPOTHESIS

Female athletes can develop symptoms of urinary incontinence (UI) as well as risk behaviors for eating disorders owing to the type of training and sports modality. Such symptoms are intensified by the demands for results and an idealized body composition. Our aim is to investigate the possible association between urinary incontinence and risk behaviors for eating disorders in female athletes.

METHODS

A case-control study was conducted with 270 female athletes who answered the International Consultation on Incontinence Questionnaire (ICIQ-SF) and the Eating Attitudes Test (EAT-26). Different sports modalities and their respective impact levels were considered in the study. Female athletes were divided into two groups, i.e., athletes with UI (case group) and those without UI (control group). Multiple logistic regression was used to calculate associated factors.

RESULTS

From all variables included in the study, only abnormal eating behavior was found to be associated with UI according to the multiple logistic regression test. Participants with UI were 2.15-fold more likely to have risk behaviors for eating disorders.

CONCLUSIONS

Female athletes with UI were more likely to have risk behaviors for eating disorders. Multidisciplinary teams that provide care for these athletes should be attentive to symptoms that may not appear to be associated at first glance but may reflect a condition that needs to be treated.

Eating Behaviours in Sportswomen from the Silesian Training in Different Sports Disciplines

Eating disorders are characterized by abnormal, unhealthy eating habits, and disordered body image. In severe cases, it can cause serious health consequences, including cardiac problems, osteoporosis, infertility, or missing menstrual periods. In women competitively training sports, the main cause for disordered eating behaviours are factors associated with dissatisfaction with their appearance and body image and a need to reduce body weight. Factors related to dissatisfaction with one's own appearance and body image, a need to reduce body weight, a negative perception of themselves and their bodies, the pressure in sports circles, and stress are predictors for eating disorders. The aim of the study was to compare eating behaviours, body satisfaction, and taking various actions related to body mass reduction among women training competitively in volleyball, athletics, gymnastics, and young women not participating in sports.

MATERIAL AND METHODS

The study covered a group of girls and young women from the Silesian, Poland, who represented three sports disciplines (volleyball, athletics, and gymnastics), of which 30 girls were used as a control group (B). The study was conducted using a study questionnaire.

RESULTS

The study participants ate regularly and consumed all food groups during a week. The majority of girls from A1 (83.33%), A3 (53.33%), and B (80%) groups expressed their dissatisfaction with their body weight. In the group of gymnasts, a positive correlation was noted between the need to reduce body weight and regular eating (r = 0.449; p = 0.013). In the group of volleyball players, it was demonstrated that the higher the competitive experience and the greater the training load, the more regular their eating was (r = 0.475; p = 0.009).

CONCLUSIONS

The importance of a diagnosis of early signs of eating disorders in girls and women as a basic component contributing to FAT development implies that further studies in this area, as well as education of the entire sports circle are necessary.

Body mass index and quality of life in individuals with polycystic ovary syndrome: Dysmorphic concerns and eating disorders as mediators

Objective

Weight issues, dysmorphic concerns and eating disorders are common among individuals with polycystic ovary syndrome (PCOS) and are linked to poor quality of life (QoL). The goal of the current study was to examine whether the association between body mass index (BMI) and QoL was mediated by dysmorphic concerns, examining also the relations with eating disorder symptomatology.

Methods

Questionnaires were administered to 435 individuals with PCOS aged between 18 and 40 years (M = 27.62; SD = 4.83) to measure dysmorphic concerns, eating disorder symptoms and QoL. Participants were also asked to report their height and weight to compute their BMI.

Results

Structural equation modeling was used to observe the relationship between the variables. The results revealed a direct relationship between QoL, BMI, dysmorphic concerns and eating disorder symptomatology. In addition, dysmorphic concerns were related to BMI and eating disorder symptomatology. Furthermore, the results showed the mediating role of dysmorphic concerns and eating disorder symptoms in the relationship between BMI and QoL.

Conclusion

The current results highlight the potential importance of harmful relationships with one's own body and food, explaining why weight issues may be linked to different levels of QoL in PCOS individuals. The implications of these findings are discussed.

The impact of dieting culture is different between sexes in endurance athletes: a cross-sectional analysis

Background

Frequent dieting is common in athletes attempting to achieve a body composition perceived to improve performance. Excessive dieting may indicate disordered eating (DE) behaviors and can result in clinical eating disorders. However, the current nutrition patterns that underly dieting culture are underexplored in endurance athletes. Therefore, the purpose of this study was to identify the sex differences in nutrition patterns among a group of endurance athletes.

Methods

Two-hundred and thirty-one endurance athletes (females = 124) completed a questionnaire regarding their dieting patterns and associated variables.

Results

The majority of athletes did not follow a planned diet (70.1%). For endurance athletes on planned diets (n = 69), males were more likely follow a balanced diet (p = 0.048) and females were more likely to follow a plant-based diet (p = 0.021). Female endurance athletes not on a planned diet (n = 162) were more likely to have attempted at least one diet (p < 0.001). Male athletes attempted 2.0 ± 1.3 different diets on average compared to 3.0 ± 2.0 for females (p = 0.002). Female athletes were more likely to attempt ≥ three diets (p = 0.022). The most common diet attempts included carbohydrate/energy restrictive, plant-based, and elimination diets. Females were more likely to attempt ketogenic (p = 0.047), low-carbohydrate (p = 0.002), and energy restricted diets (p = 0.010). Females made up the entirety of those who attempted gluten-/dairy-free diets (F = 22.0%, M = 0.0%).

Conclusions

Being a female athlete is a major determinant of higher dieting frequency and continual implementation of popular restrictive dietary interventions. Sports dietitians and coaches should prospectively assess eating behavior and provide appropriate programming, education, and monitoring of female endurance athletes.

Disordered eating in collegiate English equestrian athletes in aesthetic and nonaesthetic disciplines

Little is known about the rates of disordered eating behaviors in the athletes who compete in the disciplines that comprise collegiate English Equestrian sports. Importantly, in some subdisciplines, riders' scores depend upon judges' assessment of their appearance while riding, rather than upon solely objective measures such as time to complete a course. The purpose of the present research was to 1) assess the current rate of disordered eating behaviors in college equestrian athletes, 2) test whether certain disciplines of English riding (i.e., those that focus on aesthetics or non-aesthetics) at the collegiate level have higher rates of disordered eating behaviors, and 3) test whether these athletes face different pressures for appearance and weight if they specialize in aesthetic riding disciplines. English equestrian student athletes from across the United States (N = 330; 97 % female) and from the following disciplines were surveyed: equitation (aesthetic), dressage (aesthetic), hunters (aesthetic), jumpers (non-aesthetic), and eventing (non-aesthetic). The results suggest a high prevalence of disordered eating in the sport (35 % met cut off for disordered eating using the EAT-26). Findings suggest similar rates of disordered eating behaviors between the aesthetic and non-aesthetic disciplines. Findings also indicate that student athletes in aesthetic disciplines were much more likely to say that they were weighed by coaches and pressured to lose weight. Thus, the current study lends empirical support to the notion that coaches can be a source of pressure for these athletes. Issues of addressing disordered eating in coaching and future research are discussed.

Self Reported History of Eating Disorders, Training, Weight Control Methods, and Body Satisfaction in Elite Female Runners Competing at the 2020 U.S. Olympic Marathon Trials

Athletes participating in endurance sports report frequent attempts to lose weight and greater training volumes in attempt to gain a competitive advantage. Increased exercise energy expenditure through training, weight periodization, and prevalence of eating disorder (ED) may affect energy availability. Low energy availability (LEA) is associated with negative physiological effects and an increased risk of bone fractures and illness in athletes. This study investigated the relationship between self-reported history of an ED with training, body satisfaction, and weight-control methods among female Olympic marathon trials participants. Female runners (n = 146; 30.8 ± 5.0 years of age) who participated in the 2020 U.S. Olympic Team Trials Marathon completed an online questionnaire examining training volume, weight-control methods, and self-reported diagnosis of an ED. 32% of participants reported previous ED while 6% reported a current ED and were grouped together based on a self-reported lifetime diagnosis of ED (current or past) or no ED for further analysis. A Chi-square analysis indicated a statistical difference when p ≤ 0.05. Runners who reported ED were significantly more likely to experience weight dissatisfaction (χ2 _3,146 = 9.59, p = .022) and restricting or reducing food in the three months prior to the marathon (χ2 _5,146 = 17.58, p = .004). Consistent with previous literature, a substantial percentage of participants reported ED. This investigation suggests that ED may be associated with weight control methods and feelings of body dissatisfaction in competitive female runners.

Examination of the Prevalence of Female Athlete Triad Components among Competitive Cheerleaders

The purpose of this study was to examine individual and combined Female Athlete Triad components within collegiate cheerleaders, an at-risk group. Cheerleaders (n = 19; age: 20.3 ± 1.2 years) completed anthropometric measurements, health history questionnaires, resting metabolic rate, the eating disorder inventory-3 and symptom checklist, blood sample, and DXA scan. Participants completed dietary and exercise logs for 7 days and used heart rate monitors to track daily and exercise energy expenditure. Proportions were calculated for low energy availability (LEA) risk, disordered eating risk, and pathogenic behaviors. Chi-square analysis was used to determine the difference between cheerleaders who experience low EA with or without disordered eating risk. All cheerleaders demonstrated LEA for the days they participated in cheerleading practice, 52.6% demonstrated LEA with eating disorder risk and 47.4% demonstrated LEA without eating disorder risk, 52.6% self-reported menstrual dysfunction, 14% experienced menstrual dysfunction via hormonal assessment, and 0% demonstrated low bone mineral density. Overall, 47.7% presented with one Triad component, 52.6% demonstrated two Triad components using self-reported menstrual data, and 10.5% demonstrated two Triad components using hormonal assessments. All cheerleaders displayed LEA. These findings support the need for increased education on the individual components of the Triad and their potential consequences by qualified personal.

Findings from a web content analysis of resources targeting sporting coaches aimed at educating or upskilling on eating disorders and disordered eating in athletes

BACKGROUND

Eating disorders (ED) and disordered eating (DE) are highly prevalent in athletes. Coaches can play a role in the prevention of EDs and DE behaviours and are well placed to support athletes with an ED. However, coaches feel under-qualified and lack time and resources for supporting athletes and it is unclear the quality of training and resources available to upskill coaches in this space. Therefore, a web-based content analysis was undertaken to determine the type and source of online education resources currently available to coaches to help identify, prevent, manage and refer on for ED/DE behaviours.

METHODS

Three major search engines were searched using a combination of the following terms: (1) DE or ED resource and (2) coaches or sport. Included websites were specific for DE/EDs in athletes; targeted at coaches or sporting organisations; written in the English language; and published by a reputable site.

RESULTS

Twenty four out of 600 websites met inclusion criteria. The main reasons for exclusion were irreputable sites and websites not targeting coaches. The majority of included webpages were from professional bodies (n = 17) and targeted coaches (n = 24) and sporting organisations (n = 15), with an average quality rating of 4.2 out of 6. All websites provided educational resources but none provided official training. The most common topics discussed on these websites was ED/DE signs and symptoms (n = 17), and the effects of ED/DE on performance, mental and physical health (n = 11).

CONCLUSION

Few reputable online resources were identified in the current review. There is a need for more comprehensive education and training resources aimed at coaches and athletic organisations to help prevent, identify, manage and refer on for ED/DE behaviours.

Competitive trait anxiety and general self-esteem of athletes according to the sport type and gender

Traditionally, anxiety has been interpreted as a negative emotional state characterized by nervousness, worry, fret, uncertainty and vague fear which could have an adverse effect on sports achievement. On the other hand, sport type and its specific nature and demands, may also be connected with the level of state and trait anxiety. This study aimed to investigate potential differences in the competitive trait anxiety level and general self-esteem according to gender in sports of different contact level. The sample consisted of 1024 (590 males and 434 females) young athletes. Independent variables were sport contact level (non-contact, contact and collision sports) and gender. Dependent variables were measured by the adjusted versions of Sport Competition Anxiety Test and Rosenberg Self-Esteem Scale. Basic descriptive statistics was calculated for all the groups, and the differences between them were established using χ² test and MANOVA. The results suggest significant differences in trait competitive anxiety per sport type, gender and their interaction, and no differences in the general self-esteem level. The current study reveals that not only the intensity but also the intergroup relationship of a sport contact level (non-contact, contact and collision sports) is gender determined. These findings are important in psycho-diagnostic procedure and choosing appropriate coping strategies for athletes.

Eating disorders in sport. Update and proposal for an integrated approach

Eating disorders are a group of conditions which have a huge impact on the health and performance of athletes. The aetiology of eating disorders is multifactorial, being influenced by genetic and environmental factors, but also involving psychological factors and factors specific to the practising of sport. Eating disorders are highly prevalent in sport, particularly in disciplines involving endurance, those that have weight-categories or those where low weight is a competitive advantage and aesthetics are important. Athletes with eating disorders need to be assessed and receive early, comprehensive treatment. Close monitoring of nutritional status is vital, especially with female athletes. Prevention is crucial and plays an invaluable role in this type of disorder, but represents a significant challenge for all professionals who look after athletes. Priority needs to be given to implementing structured nutrition training programmes for the athlete and their entourage to help prevent eating disorders.

Differences in attitudes, behaviours and beliefs towards eating between female bodybuilding athletes and non-athletes, and the implications for eating disorders and disordered eating

Background

Female athletes participating in sports emphasising aesthetics are potentially more prone to developing disordered eating (DE) and eating disorders (EDs) than non-athletes, males, and those participating in sports with less emphasis on leanness. Despite this, female bodybuilding athletes have received little attention.

Aim

To investigate differences in eating attitudes, behaviours and beliefs in female bodybuilding athletes and a non-athlete group.

Methods

A cross-sectional study design was used with the eating attitude test-26 (EAT-26) distributed to 75 women (49.3% bodybuilding athletes; 50.7% non-athletes) and the female athlete screening tool (FAST) distributed to the female bodybuilding group only.

Results

Demographic characteristics revealed no significant difference in age, stature or body mass index (P = 0.106 to 0.173), though differences in body mass were evident (P = 0.0001 to 0.042). Bodybuilding athletes scored significantly higher (P = 0.001) than non-athletes on the EAT-26 questionnaire, with significantly more athletes (56.8%) being labelled as ‘at risk’ of an ED than non-athletes (23.7%, P = 0.001). Responses to the FAST questionnaire indicated female bodybuilding athletes have high preoccupation with their body mass; engage in exercise to alter their body mass; and disclosed negative perceptions of themselves.

Conclusion

In all, female bodybuilding athletes demonstrate behaviours associated with DE and EDs as well as a preoccupation with nutrition intake, exercise, and strategies to alter their appearance. These findings have important implications for those managing female bodybuilding athletes such as strength and conditioning coaches, athletic trainers, nutritionist and dietitians with respect to detecting DE and EDs as well as minimising the risk factors.

Specific dietary practices in female athletes and their association with positive screening for disordered eating

BACKGROUND

To determine if following specific diets was associated with reporting behaviors that are consistent with disordered eating compared to non-diet-adherent athletes. We hypothesized that athletes adhering to specific diets were more likely to report disordered eating than those not following a diet.

METHODS

One thousand female athletes (15-30 years) completed a comprehensive survey about athletic health and wellness. Athletes were asked to specify their diet and completed 3 eating disorder screening tools: the Brief Eating Disorder in Athletes Questionnaire, the Eating Disorder Screen for Primary Care, and self-reported current or past history of eating disorder or disordered eating. Descriptive statistics were calculated for all study measures and chi-squared tests assessed relationships between athletes' dietary practices and their responses to eating disorder screening tools. Statistical significance was defined as p < 0.05.

RESULTS

Two hundred thirty-four of 1000 female athletes reported adherence to specific diets. 69 of the 234 diet-adhering athletes (29.5%) were excluded due to medically-indicated dietary practices or vague dietary descriptions. Of the 165 diet-adherent athletes, 113 (68.5%) screened positively to ≥1 of the 3 eating disorder screening tools. Specifically, athletes practicing a low-carbohydrate diet were more likely to report disordered eating vs. athletes without dietary restrictions (80% vs. 41.8%; p < 0.0001).

CONCLUSION

Specific diet adherence in female athletes may be associated with reporting behaviors that are consistent with disordered eating. Health practitioners should consider further questioning of athletes reporting specific diet adherence in order to enhance nutritional knowledge and help treat and prevent eating disorders or disordered eating.

Commentary on Vulnerability and Resilience to Activity-Based Anorexia and the Role of Dopamine

Activity-based anorexia (ABA) is a commonly used rodent model of anorexia nervosa that is based on observations made in rats decades ago. In recently published work, we describe using this paradigm to model vulnerability and resilience to anorexia nervosa in mice, where vulnerability is characterized by hyperactivity and life-threatening weight loss and resilience is characterized by adaptation and weight stabilization. Using genetically modified hyperdopaminergic mice, we also demonstrate that increased dopamine augments vulnerability to ABA. Here, we briefly review our findings and discuss how obtaining vulnerable and resilient phenotypes enhances utility of the ABA model for understanding the neurobiological basis of anorexia nervosa. We comment on our dopamine findings and close by discussing implications for clinical treatment.

Relative energy deficiency in sports (RED-S): elucidation of endocrine changes affecting the health of males and females

The purpose of this review is to present a different perspective of the relative energy deficiency syndrome, to improve understanding of associated endocrine alterations, and to highlight the need for further research in this area. The term "female athlete triad" was coined over 25 years ago to describe three interrelated components: disordered eating, menstrual dysfunction, and low bone mass. The syndrome's etiology is attributed to energy intake deficiency relative to energy expenditure required for health, function, and daily living. Recently, it became clear that there was a need to broaden the term, as the disorder is not an issue of only three interrelated problems but of a whole spectrum of insults resulting from low energy availability (LEA; i.e., insufficient energy availability to cover basic physiological demands) that can potentially affect any exerciser, irrespective of gender. The new model, termed relative energy deficiency in sport (RED-S), has received greater scrutiny in sports medicine due to its effects on both health and performance in athletes of both sexes. RED-S results from low-energy diets (intentional or unintentional) and/or excessive exercise. Energy deficiency reduces hypothalamic pulsatile release of gonadotropin-releasing hormone, this impairing anterior pituitary release of gonadotropins. In women, reduced FSH and LH pulsatility produces hypoestrogenism, causing functional hypothalamic amenorrhea and decreased bone mass. In men, it reduces testosterone and negatively affects bone health. Moreover, LEA alters other hormonal pathways, causing physiological consequences, such as alteration of the thyroid hormone signaling pathways, leptin levels, carbohydrate metabolism, the growth hormone/insulin-like growth factor-1 axis, and sympathetic/parasympathetic tone. This review explains and clarifies the effects of RED-S in both sexes.

Preventing Nutritional Disorders in Adolescents by Encouraging a Healthy Relationship With Food

Nutritional disorders, including overweight, underweight, and/or nutrient deficiency, are a significant cause of morbidity and mortality. These disorders are frequently related to abnormal patterns of eating and/or physical activity, which commonly begin in adolescence and persist into adulthood. Abnormal eating and exercise behaviors may stem from an unhealthy relationship with food, which often takes root in preadolescence or early adolescence. To prevent eating disorders, overweight, underweight, and nutritional deficiencies in adolescence and beyond, health care providers need to proactively support early adolescents and their caregivers to develop a healthy relationship with food and their bodies. Anticipatory guidance, nutrition and exercise counseling, and encouragement of body positivity and healthy self-image during the vulnerable period of early adolescence can prevent maladaptive behaviors from emerging later on. Advocacy beyond the health care setting is also needed to ensure that adolescents are exposed to consistent and positive nutritional messaging. In this position article, authors from both the Nutrition/Obesity Committee and the Eating Disorder Committee of the Society of Adolescent Health and Medicine provide practical recommendations for health care professionals to guide their young patients and caregivers toward a flexible, balanced, and satisfying approach to nutrition that will lead to physical and emotional wellness throughout their lifetimes.

Body Composition Changes over Multiple Academic Years in Female Collegiate Soccer Players

Body composition plays a key role in overall health and sports performance and its assessment is an important part of many athletic programs. The purpose of this study was to describe longitudinal changes in body composition for collegiate female soccer players in order to provide data to inform future training and nutrition interventions for this population. A linear mixed-model (LMM) approach was used to analyze four years of pre- and post-season body composition data, including total mass, fat-free mass (FFM), fat mass, and body fat percentage (%BF) for 49 athletes. Athletes gained an average of 0.5 kg FFM during the season (p < 0.05) and increased total mass, FFM, fat mass, and %BF (2.5 kg, 1.1 kg, 1.7 kg, and 1.7%, respectively; p < 0.05) over four years. Freshmen experienced a 1.5 kg gain in total mass pre- to post-season (p < 0.05), while no changes in total mass or body composition were seen in other grade levels. Gains in %BF during the off season between Freshman and Sophomore years represented negative changes in body composition that should be addressed further. These results can help interdisciplinary athlete care teams optimize training programs in this population by understanding what changes are expected over multiple years. Normalizing these changes may also help the promotion of realistic body composition goals and the development of positive training and dietary habits.

Disordered Eating Attitudes, Anxiety, Self-Esteem and Perfectionism in Young Athletes and Non-Athletes

Eating disorders are associated with short and long-term consequences that can affect sports performance. The purposes of this study were to investigate whether female athletes, particularly gymnasts and footballers, exhibit more eating problems compared to female non-athletes, and to identify individual personality characteristics including anxiety, self-esteem, and perfectionism as possible contributors to eating disorder risk. In a sample of 120 participants, 80 adolescent female athletes were compared to a control condition of 40 non-athletes (mean age 17.2 ± 2.82). Participants responded to a questionnaire package to investigate the presence of disordered eating (SCOFF) and psychological variables in relation to disordered eating symptoms or eating disorder status. Subsequently, anthropometric measures were obtained individually by trained staff. There were statistically significant differences between conditions. One of the most important results was the score in SCOFF (Mann-Whitney = 604, p < 0.05; Cohen's d = 0.52, r = 0.25), being higher in control than in the gymnast condition. These results suggest that non-athlete female adolescents show more disturbed eating behaviours and thoughts than female adolescents from aesthetic sport modalities and, therefore, may have an enhanced risk of developing clinical eating disorders.

The Australian Institute of Sport (AIS) and National Eating Disorders Collaboration (NEDC) position statement on disordered eating in high performance sport

Identification, evaluation and management of disordered eating (DE) is complex. DE exists along the spectrum from optimised nutrition through to clinical eating disorders (EDs). Individual athletes can move back and forth along the spectrum of eating behaviour at any point in time over their career and within different stages of a training cycle. Athletes are more likely to present with DE than a clinical ED. Overall, there is a higher prevalence of DE and EDs in athletes compared with non-athletes. Additionally, athletes participating in aesthetic, gravitational and weight-class sports are at higher risk of DE and EDs than those in sports without these characteristics. The evaluation and management of DE requires a cohesive team of professional practitioners consisting of, at minimum, a doctor, a sports dietitian and a psychologist, termed within this statement as the core multidisciplinary team. The Australian Institute of Sport and the National Eating Disorders Collaboration have collaborated to provide this position statement, containing guidelines for athletes, coaches, support staff, clinicians and sporting organisations. The guidelines support the prevention and early identification of DE, and promote timely intervention to optimise nutrition for performance in a safe, supported, purposeful and individualised manner. This position statement is a call to action to all involved in sport to be aware of poor self-image and poor body image among athletes. The practical recommendations should guide the clinical management of DE in high performance sport.

Primary Ovarian Insufficiency in the Prepubertal Adolescent: A Case Report

Although there are many etiologies for delayed puberty in adolescent-aged girls, the pediatric provider should consider primary ovarian insufficiency if estradiol remains undetectable despite elevated levels of gonadotropins. Adolescent girls with this diagnosis will need holistic care from their primary care provider, focusing on both their medical and psychosocial needs. The following case study describes a 14-year-old girl who was referred to pediatric endocrinology for delayed puberty, in the setting of increased gonadotropins and undetectable estradiol. The differential diagnosis, evaluation, and management of primary ovarian insufficiency are reviewed as well as potential long-term health considerations.

Eating Disorders in Athletes: From Risk Management to Therapy

BACKGROUND

Balanced sporting activity should be considered a resource in the treatment of eating disorders (ED), in particular of the BED and in obesity and, if conducted and guided by expert preparers and rehabilitators, in some forms of anorexia and in bulimia.

OBJECTIVE

To assess the role of excessive physical activity, predominantly interfering with daily activities by ultimately resulting in greater energy consumption leading to weight loss, and study the diagnostic criteria of bulimia and anorexia nervosa.

METHODS

A number of literature studies also report the presence of ED among athletes. A 2004 study reported that the prevalence of eating disorders in sports would be 13.5% compared to 4.5% of the control subjects.

RESULTS

In general, nutrition is used as a tool for improving performance not only of athletes but also of technicians and coaches. But in the presence of factors of vulnerability towards ED, the tendency to manipulate the weight can result in an eating disorder or the so-called athletic anorexia or the RED-S.

CONCLUSION

It is important to emphasize that not only do professional athletes suffer from it, but also good-looking amateurs and laypersons.

Body Image Concern and Eating Disorder Symptoms Among Elite Icelandic Athletes

The aim of this study was to analyse body image concerns and symptoms of eating disorders in elite Icelandic athletes according to their sex, and sport practiced. The participants were 755 athletes (24.8 ± 3.5 years in age) who compete at the highest possible level in Iceland. Representing 20 different sports, they were divided into five sports groups. Three questionnaires were used: the Body Shape Questionnaire to assess body image concerns; the Bulimia Test-Revised to assess the main symptoms of bulimia; and the Eating Disorder Examination Questionnaire to identify disordered eating attitudes and behaviours. A chi-squared test was used to analyse differences in prevalence of body image concern and eating disorders, a t-test for the differences between men and women, and a one-way ANOVA to compare the different sports. The main findings were that 17.9% of the athletes presented severe or moderate body image dissatisfaction, and 18.2% (25.3% of the women) were above the clinical cutoff for body image concern. Women’s scores were higher than men’s (whole sample and ball games) in all variables except restraint. These results seem to point to the existence of a real problem that athlete, coaches, doctors, and institutions need to take into account.

Factors Associated with Disordered Eating Behaviors among Triathletes

CONTEXT

Although there is little data currently available concerning the primary factors associated with disordered eating behaviors among triathletes, these athletes may be at greater risk. Sports medicine professionals are in a unique position to identify athletes with disordered eating risks.

METHODS

The purpose of this cross-sectional survey study was to identify the prevalence of disordered eating attitudes and behaviors among a national convenience sample of triathletes. A secondary purpose was to identify "triathlon-specific factors" and "competitive athlete-factors" potentially associated with disordered eating behaviors. The authors hypothesized that certain triathlon-specific factors and competitive athlete factors would be associated with increased rates of self-reported disordered eating behaviors.

RESULTS

In a respondent sample of 1,033 adults, multiple competitive athlete factors were associated with a higher risk for disordered eating, whereas triathlon-specific factors were not.

CONCLUSIONS

In this study sample, disordered eating was not specifically associated with triathlon-specific factors. Rather, disordered eating behaviors were found to be more often associated with associated competitive athlete factors, particularly in the many leanness sports such as running.

Disordered eating in French high-level athletes: association with type of sport, doping behavior, and psychological features

PURPOSE

Over the last few years, disordered eating in athletes has received increasing attention. According to several studies, athletes could be more vulnerable to disordered eating and some characteristics specific to the athletic community could be in favour of an increased risk of poor body image and disturbed eating habits in athletes. However, the literature is sparse and some methodological issues in studies have been pointed out. In this context, we aimed at determining the prevalence of disordered eating in French high-level athletes using clinical interviews of three different clinicians and identifying what are the factors associated with disordered eating in athletes.

METHODS

In France, all athletes registered on the French high-level list have to undergo a yearly evaluation. Data collected during the somatic assessment, the dietary consultation, and the psychological of the yearly evaluation were used. Multivariate analysis was performed for identification of factors associated with disordered eating.

RESULTS

Out of the 340 athletes included, 32.9% have been detected with a disordered eating. They were difficult to detect by clinicians, as usual criteria did not seem to be reliable for athletes. Competing in sports emphasizing leanness or low body weight was associated with disordered eating; however, gender was not.

CONCLUSION

These results highlight the need for the development of specific screening tools for high-level athletes. Furthermore, the identification of factors associated with disordered eating could improve early detection and prevention program effectiveness.

2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management

Eating disorders, such as anorexia nervosa and bulimia nervosa, can have devastating effects on both the health and performance of athletes. Compared to non-athletes, both female and male athletes are at higher risk of developing an eating disorder. This is especially true for athletes participating in sports where low body weight or leanness confers a competitive advantage. Screening for disordered eating behaviours, eating disorders and for related health consequences should be a standard component of preparticipation examinations, and team physicians should be knowledgeable of the updated diagnostic criteria for eating disorders in the Diagnostic and Statistical Manual-V. Athletes with eating disorders should undergo thorough evaluation and treatment by an experienced multidisciplinary team. Team physicians play a critical role in decision-making on clearance for participation and return to play. Using evidence-based guidelines for clearance and return to play encourages transparency and accountability between the sports medicine care team and the athlete. Efforts to prevent eating disorders should be aimed at athletes, coaches, parents and athletic administrators, and focused on expanding knowledge of healthy nutrition in support of sport performance and health.

Health in older women athletes

Physical activity has been identified as a protective factor against a wide spectrum of diseases, but little is known about the link between older women's health and their professional involvement in sport in the past. The aim of this narrative review is to characterize and summarize the available data concerning the influence of physical activity on morbidity and mortality in former female athletes. Concerning bone health, it seems that physical activity in the past can be protective against osteoporosis in postmenopausal women, but these data come from observational studies only. Also the cardiovascular system appears to benefit in older women from regular sport in the past. This refers mainly to better heart efficiency, and improved endothelial function and metabolic profile. The incidence of different types of neoplasms, especially breast cancer, is also decreased in former athletes. Professional sport, on the other hand, acts negatively on the pelvic floor and is a risk factor for urinary incontinence. The overall effect on mortality is difficult to assess, because of many parameters, such as the sport's intensity, variety of the sport and exposure to extreme danger in some disciplines. Also, caution should be kept in interpretation of the data because of the shortage of well-designed studies.