Sports Medicine Research: In the Lab & In the Field: Risk Factors For Eating Disorders (Sports Med Res)


Wednesday, September 21, 2011

Risk Factors For Eating Disorders

A longitudinal investigation of sports-related risk factors for disordered eating in aesthetic sports

Krentz EM, Warschburger P. Scand J Med Sci Sports 2011 [Epub ahead of print]

For years we have appreciated that athletes participating in elite aesthetic sports (e.g., rhythmical gymnastics, figure skating, dance) are at higher risk for disordered eating. Based on cross-sectional studies, the potential risk factors for disordered eating in sports have been merged into a model that is based on nonathletic populations and emphasizes societal pressures from the sports environment. Krentz & Warschburger hypothesized that these models need to consider the risk factors unique to the sports environment. Unfortunately, these risk factors have not been thoroughly evaluated in longitudinal studies. Therefore, the authors examined sports-related risk factors for disordered eating in a 1-year longitudinal study among 65 adolescent elite-level athletes (38 females and 27 males) from aesthetic sports (e.g., gymnastics, figure skating, ballet). The authors initially recruited 97 participants but could only collect follow-up data on 65 athletes; fortunately, they found no baseline differences between the athletes lost to follow-up and those who completed the study. Athletes completed, at baseline and 12-month follow-up, several surveys to screen for disordered eating, assessment of emotional distress from missing exercise sessions, sports-related body dissatisfaction, assumption that dieting enhances performance, and social pressure from the sports environment. Age, sex, and body mass index did not predict changes in disordered eating scores. A change in the desire to be leaner to improve sports performance was associated with changes in disordered eating. Furthermore, the desire to be leaner to improve sports performance at baseline was predictive of disordered eating and not vice versa.

This study provides support for previous cross-sectional studies that found that dieting behaviors are related to perceived performance benefits of being leaner more so than sports-related body dissatisfaction. The authors acknowledge that many more longitudinal studies will be needed to gain a better understanding of disordered eating among athletes; including longer studies, larger cohorts, and studies of other sports (e.g., team sports). Even with the need for further research we need to be aware that athletes in aesthetic sports are at greater risk for disordered eating if they believe that weight loss can enhance their performance. It is important for clinicians, coaches, and parents to keep this possible risk factor in mind when discussing performance enhancement with our elite aesthetic athletes; and until we know more we should probably be conservative with this issue for all our athletes. As sports medicine clinicians we should help educate our coaches and parents about being sensitive to disordered eating among males and females. Furthermore, we should have conversations with parents or coaches that suggest an athlete may benefit from losing weight. Eating disorders represent a challenging area when working with young athletes and we should strive to provide an environment that minimizes the risk for disordered eating and helps athletes that we suspect have an eating disorder. Pushing the issue to the back burner is not helping our patients. What are your experiences with athletes wanting to be leaner to improve performance?

Written by: Jeffrey B. Driban
Reviewed by: Stephen Thomas

Related posts:
Genetic Associations of Recovery from Eating Disorders
Eating Disorders in Adolescents


Whitney M said...

As a cross-country coach, I have seen how putting on weight has influenced a few of my athletes performances. Their weight gain is something that my fellow coaches and I noticed and discussed with each other, but never upfront with the individual athletes. We've also known a few of our athletes who will go without eating lunch and then come to practice and wonder why they feel so rough. Our stance has always been consume a healthy diet, but by diet we do not mean counting calories or cutting back. We encourage them to eat healthfully and make sure they are getting enough fuel for their body. We joke with them that because they are runners they can eat whatever they like!
Disordered eating is tough to talk about with your athletes. Discussing what should and should not be done as a group may be a more desirable way of approaching the idea, so to not make anyone feel like they are being singled out.

Jeffrey B. Driban, PhD, ATC, CSCS said...

Hi Whitney: With your comment in mind do you talk to the team as a group (or even the parents) about healthy eating and the concept that being leaner doesn't necessarily equal improved sports performance?
Thanks for the comment!

Natalie Kramer said...

Recognizing eating disorders, especially at an elite level, is challenging because even though an athlete is lean does mean they have an associated eating disorder. Even more challenging than the recognition, is discussing eating disorders with an athlete who is at risk. These athletes are bright and can sense what are attempting assess even if you make your best efforts as a clinician to avoid the direct question of “Do you have an eating disorder?” I think the evaluation tools described in this article are valuable to monitor high-risk athletes over a period of time, but clinicians need to be aware that most athletes will know in a second what the survey is assessing for. Athletes trying to hide an eating disorder will answer the questions how they know they should answer the question, therefore making survey useless.

I think the best way to approach eating disorders is from a sports performance, energy balance, and injury prevention stance. I know in my practice, talking to an athlete about decreases in power output or risk of stress fracture instead of their weight or what they ate for lunch is much more productive. These conversations come off as less threatening and the athlete is usually more willing to see the team physician and/or nutritionist. It is important to continue to evolve the way we look at eating disorders (i.e. eating disorder vs disorder eating or the Female Athlete Triad) for the health of our female (and male) athletes.

Jeffrey B. Driban, PhD, ATC, CSCS said...

Hi Natalie: I couldn't agree more. Your approach of focusing on sports performance and injury prevention instead of weight is a good way of shifting the athlete's perspective away from a mentality that being leaner equals improved sports performance.

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Shandi Lyn said...

As an athletic trainer, there are many hats that we can wear in our job. At schools where there are a lot of resources (ex. sports nutritionists, psychologists etc), our role is not as hefty in certain areas. For clinicians in schools with less resources, we become THE resource for many of these topics. This makes it important for clinicians to be able to understand how to handle situations like eating disorders.

As a former gymnast, there was a lot of emphasis on appearance and the best way to approach gymnasts about weight was on a sports performance aspect. Now as an athletic trainer, I think it is important to use resources available. I also believe that it is important to know how to handle the situation without the help because of the trust relationship that is built with athletes and their athletic trainer.

Meghan Melinchak, ATC said...

I always worry when an athlete's weight becomes an issue because I personally never know the right way to approach the topic. As a female and someone who has struggled with their weight I find it difficult to find the balance between knowing there may be a problem, and not wanting to offend anyone. This matter can only become more complicated when you add the influence of a pushy coach and/or the pressures of competition and the situation can become life threatening very quickly.

Jeffrey B. Driban, PhD, ATC, CSCS said...

Meghan: I couldn't agree more. I've had times when I've needed to talk with my team physicians about how to raise these issues with an athlete (especially when there is a pushy coach involved). Sometimes the teammates, especially on a small team, will start talking about a possible problem among each other or will approach you about it and that can be a sign to know that you're not the only one concerned. I've

Hailey Love said...

Shandi, I definitely agree with your statement on varying resources in different settings. At my clinical assignment, the sports medicine budget pays for each athlete that consults with the nutritionist. Obviously those of higher importance meet with the nutritionist, and our sports medicine staff provides services to the others. After being exposed to two female athletes with eating disorders, both stemming from the coach, I quickly learned the fine lines and importance of this issue. I recently found 2 great resources that I have been very beneficial on this topic. If anyone is interested, there are two position statements by the NATA; one on healthy weight management and another on eating disorders. They both provide great information on educating an athlete that wants to drop weight, as well as one struggling with eating disorders. Overall I felt this article was very applicable to the large number of athletes with eating disorders as the pressure to succeed is continuously rising.

Jeffrey B. Driban, PhD, ATC, CSCS said...

Thanks for the comment Hailey. I agree those are excellent position statements.

For anyone that is interested, you can find them here:

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