In part one of this 2-part article, we explored the incidence of mental health disorders in athletes and learned that they are just as much at risk as the general population at large. In part two, we look at the most 'at-risk' sports and explore the best pathways forward for athletes seeking to regain maximum mental well being. MORE
Eating right – not wrong – for long-term well being
Eating disorders are common in athletes; how do they change over time and do the risks diminish when athletes retire from competition?
With Christmas and New Year already a memory, many athletes will be contemplating the (hopefully more normal!) 2021 season ahead. And as part of that, , the topic of shedding excess pounds may well spring to mind. No matter what the sport, carrying an excess of body fat reduces sport performance, particularly in sports such as running or cycling, or where running is an integral part of the sport (eg soccer, baseball etc) – primarily by lowering the power-to-weight ratio (see this article for a more in-depth discussion of power-to-weight). With the cumulative effect of seasonal festivities and training restrictions due to lockdowns in recent months, it likely that more athletes than usual will be thinking of some kind of weight (fat) reduction plan. Caution is required however because for some athletes (particularly female athletes), the desire to reduce body fat can lead to unhealthy and even destructive eating practices in the longer term.
Eating disorders in athletes
Over the past three decades, it has become a well established fact that participation in competitive sports has the potential to increase the risk of eating disorders and disordered eating in athletes(1,2). It’s true of course that disordered eating and eating disorders affect the psychological and physical health of millions of people across the globe worldwide(3); however, understanding and tackling the problem in athletes may be especially important because a regimented diet and intense exercise is more often than not an integral part of the athlete’s competitive sport – and can also be symptoms factors in disordered eating and psychological eating disorders(4).
Research suggests there are a multitude of factors that combine together to increase the risk of an athlete developing disordered eating behaviors. In particular, the ‘theoretical-etiological’ model developed experimentally over a number of years outlines eight factors/mediators that are deemed to be either risk factors or causal risk factors(5). These are shown below in table 1.
Table 1: The ‘theoretical-etiological’ model risk factors for developing or sustaining an eating disorder in athletes(5)
- Sport pressures – to perform and ‘look’ like other athletes.
- Societal pressures – to desire conform to a perceived ‘norm’.
- Internalization – the incorporation of an external, often unattainable body shape ideal into how one measures one’s own self-worth.
- Body dissatisfaction – being currently dissatisfied with one’s own body size/shape.
- Negative affect – feelings of anxiety and guilt.
- Restrained eating – the attempted and successful behavior of limiting food intake in terms of quantity and type.
- Adopting eating behaviors of peers and family.
- Binge eating and bulimia – the symptoms of overeating and compensatory behaviors.
Are athletes always at risk?
How much of the propensity to develop an eating disorder is down to the pressure of a competitive environment and how much is intrinsic to the personality of the athlete themselves? If much of the risk of developing disordered eating patterns is down to the pressures of a sport environment and because a regimented diet and intense exercise is an integral part of the athlete’s competitive sport, we might expect that when athletes retire from competition, the incidence of eating disorders would decline markedly. However, if much of the drive towards disordered eating is intrinsic, there might be little difference. Until recently, there was almost no data on athletes tracking them longitudinally through time to observe the prevalence of eating disorders when athletes move out of competition – either into complete retirement or into recreational activity. However, newly published research by US scientists provides some fascinating answers(6).
From sport to retirement
In this study, researchers investigated how the known psychological risk factors (see table 1) for developing or sustaining an eating disorder changed over time in 194 collegiate female athletes who were actively competing, to six years later, when the women had retired from competition. Although a significant number of both male(7) and female athletes are known to suffer from eating disorders, the researchers chose to study female athletes as the risk of an eating disorder in these athletes is particularly high. Studies show that the prevalence of clinical eating disorders ranges from 2.0% to 19.9% (depending on the sport), while the prevalence of sub-clinical eating disorders ranges from 7.1% to 49.2%(6)!
The data from the athletes showed that from the initial point of assessment when the athletes were competitive to the second assessment six years later in retirement, over half (51%) of the athletes still had disordered eating patterns. More worryingly still, 23.5% of the athletes who had maintained healthy eating patterns during competition moved to the ‘disordered’ classification when they retired. When interviewed, the athletes who had maintained disordered eating patterns despite retiring were found to have dietary intent, pressure to exercise and change appearance, body satisfaction, and internalization as the main driving factors behind their continuing behaviors.
More evidence for persistence
Further evidence for the persistence of eating disorders in athletes long after retiring comes from a study published a couple of months ago on 218 former NCAA Division-I female collegiate athletes who had suffered from bulimia (a serious eating disorder characterized by binge eating followed by purging, either through vomiting or laxative use) during their athletic careers, and who had been retired from competitive sport for 2-6 years(8).
In retirement, all the participants completed a questionnaire which assessed the ex-athletes’ levels of social and cultural pressures experienced related to body and appearance, thin-ideal internalization, body dissatisfaction, dietary restraint, feelings of anxiety and guilt, and bulimic symptomology. Through statistical modeling, the authors examined the direct and indirect relationships among these variables while controlling for body mass index (BMI) and years since retirement. The results clearly showed that despite no longer being exposed to the sport pressures that are known contribute to eating disorders, these female athletes continued to experience their bulimic symptoms long into retirement.
Conclusions and practical advice
The data from these two recent studies strongly suggests that many of the drivers for eating disorders in athletes are difficult to switch off once they have become established. So while the sport environment may contribute to the development of an eating disorder, once established it appears to easily become ‘locked in’, making it difficult for athletes to shake off their unhealthy habits, even long into retirement. In a paper titled ‘Disordered Eating in Active and Athletic Women’(9), the authors explain that prevention is the key to addressing the problem of disordered eating in athletes (both male and female), and that education is a necessary first step. In particularly, all athletes, parents, coaches, athletic administrators, training staff and doctors need to be educated about the risks and warning signals of disordered eating, which are shown in table 2.
Table 2: Warning signals of disordered eating in athletes(9)
- A preoccupation with food, calories and weight
- Repeated expressed concerns about being or feeling fat, even when weight is average, or below average
- Increasing criticism of one’s body
- Secretly eating, or stealing food
- Eating large meals, then disappearing, or making trips to the bathroom
- Consumption of large amounts of food not consistent with the athlete’s weight
- Bloodshot eyes, especially after trips to the bathroom
- Swollen parotid glands at the angle of the jaw, giving a chipmunk-like appearance
- Vomiting, or odor of vomiting in the bathroom
- Wide fluctuations in weight over short periods
- Periods of severe calorie restriction
- Excessive laxative use
- Compulsive, excessive exercise that is not part of the athlete’s training regimen
- Unwillingness to eat in front of others (eg teammates on road trips)
- Expression of self-deprecating thoughts following eating
- Wearing layered or baggy clothing
- Unexplained mood swings
- Appearing preoccupied with the eating behavior of others
- Continuous drinking of diet soda or water
If you are a coach, parent, carer or colleague/friend of an athlete, and notice these behaviors, you should avoid mentioning calorie restriction/starving/bingeing as being the main issue because this approach is likely to result in denial or rejection. Instead, and focus on the health concerns and physical symptoms the athlete may be experiencing. These may include light-headedness, chronic fatigue, lack of concentration, repeated bouts of illness/infection, poor skin and hair condition etc.
Don’t discuss weight or eating habits directly but instead share your concerns about the athlete’s physical symptoms and try to offer a list of sources of professional help. Although the athlete may deny the problem to your face, they may secretly be desperate for help. For a more in-depth discussion of prevention and management/treatment recommendations for eating disorders, readers are also directed to this excellent paper: National Athletic Trainers’ Association Position Statement: Preventing, Detecting, and Managing Disordered Eating in Athletes, which can be downloaded in full for free.
- Psych Men & Masculin. 2008;9(4):267
- Clin J Sport Med. 2004 Jan; 14(1):25-32
- Curr Psychiatry Rep. 2012 Aug; 14(4):406-14
- Eur Eat Disord Rev. 2011 May-Jun; 19(3):174-89
- PLoS One. 2020; 15(5): e0232979
- Int J Eat Disord. 2020 Dec 31. doi: 10.1002/eat.23456. Online ahead of print
- BMJ Open Sport Exerc Med. 2020 Oct 23;6(1):e000801
- J Sport Exerc Psychol. 2020 Nov 18;1-10
- Clinics in Sportsmedicine 1994; (13)2 532-537