You may not know an athlete with an eating disorder, but chances are good that a teammate or fellow athlete you know exhibits disordered eating. Forty-percent of National Collegiate Athletic Association (NCAA) member institutions reported at least one case of eating disorders, but there appears to be a much greater prevalence of athletes with disordered eating (1). It’s estimated that over 30% of female athletes and 10% of male athletes exhibit behaviors that put them at risk for developing an eating disorder (2). Unfortunately, eating disorders are often romanticized among the sport media and inadvertently encouraged by athletic coaches and trainers. Many sports add to this with an importance of leanness. This acts as an affirmation to an athlete’s decision to take excessive measures such as disordered eating to lose weight or maintain a very low body weight.

Disordered eating includes any of the following behaviors: unhealthy dieting, severe caloric restriction, use of meal supplements, anorexic or bulimic behavior (i.e. laxative and diet pill use), cycles of binge-eating, and self-induced vomiting (3).
Disordered eating is sometimes referred to as a “benign” form of anorexia nervosa (self-imposed starvation), or bulimia nervosa (binge eating followed by vomiting, laxative use, or excessive exercise). Athletes experience noticeable weight loss and food aversions without the full physical and psychological criterion of an eating disorder (4,5). Sub-clinical eating disorder or anorexia athletica are other terms to describe an athlete’s reduction in energy intake and high physical performance leading to a reduction in body mass. Disordered eating is of serious concern because it can result in some of the same health consequences of eating disorders and increases the chance an athlete will develop a full-blown eating disorder.

So why are athletes at risk for disordered eating? Unlike in eating disorders, athletes do not only strive for a reduction in body mass because of excessive concern for their appearance or body shape, but their desire to optimize their performance and please coaches, trainers and/or fellow athletes (6,7). The character traits of athletes are similar to those of individuals with eating disorders: perfectionists, achievement-oriented and physically active. It is hypothesized that some sports may attract athletes with pre-existing eating disorders because the athletic environment values those characteristics and may tolerate eating disorder behaviors at their onset (5). In a small number of athletes, eating disorders are an attempt to resolve performance fears; in other words, some athletes perceive being disqualified due to an eating disorder more acceptable than failing as an athlete (5).

Achieving an extremely low body weight is a recent trend in sports such as road cycling, climbing, long-distance running and ski jumping. Athletes who participate in these sports recognize that their athletic performance is not limited to their physical abilities or just plain skills. Low body weight and a low body mass index (BMI) are thought to be advantageous for athletes (6) and coaches and athletes understand the importance of having maximum strength and endurance for each pound of body weight (4).

Some athletes are actually required to weigh-in for their sport, such as wrestling and rowing, which adds another motive to lose weight with disordered eating. While most rowers and wrestlers do not develop a clinically diagnosed eating disorder to make weight, one study found that 37% of athletes reported that the primary reason they developed anorexia nervosa was to meet weigh-in limits for their sport (8). This is to say what may begin as disordered eating to lose weight can become an obsession that leads to a serious disease.

It’s also common for athletes to develop serious misconceptions about optimal nutrition to enhance their performance or safe ways to lose weight. Debra Vinci, a professional who works with the Husky Sport Nutrition Program at the University of Washington, admits that disordered eating can be associated with limited or incorrect views on proper sport nutrition (6). Some athletes think it’s normal to get all their energy from “foods” designed for athletes: an energy bar for breakfast, a protein-supplement drink for lunch and dinner, and a gel as a snack. Perhaps you heard or read somewhere that high-protein shakes will maximize your muscle mass while helping you cut weight. Or that high-carbohydrate food is really not needed to preserve glycogen stores. Eating this way leaves little room for some of the essential nutrients found only in whole foods and a complete balanced diet.

One of the first concerns regarding disordered eating in athletes is the risk it puts them at for developing a diagnosable eating disorder. There is convincing evidence that individuals who developed an eating disorder were first excessive exercisers (78%) or competitive athletes (60%). It also appears that certain sports attract athletes with pre-existing eating disorders. Among female elite runners, 34% have reported disordered eating patterns and 13% have reported a history of anorexia nervosa. There is evidence that participating in sports or a path of strenuous physical activity might disrupt the body’s normal mechanisms of energy balance and play a disease-producing role in developing an eating disorder (5).

Physical consequences of disordered eating are more noticeable in female athletes, thus lending to a larger body of research. The female athlete triad, first recognized by the American College of Sports Medicine in 1992, is the most studied effect of disordered eating and eating disorders among females. The triad resembles disordered eating, amenorrhea, and osteoporosis and generally occurs after periods of dieting, increased training, injury, or frequent fluctuations in body weight (5,10,11). Amenorrhea is the absence of three or more menstrual periods. Since most females have to maintain at least 17% body fat in order to menstruate, amenorrhea is actually a goal for many athletes (2). It serves as a convincing measure that they are achieving a low enough body weight to cause this interruption in their bodies’ normal physiological function. Amenorrhea is a significant precursor to osteoporosis as it can result in immediate (irreversible) bone loss because of reduced bone density and mineral content. Estrogen levels are affected by a loss of menstruation as well. The levels in amenorrheic females have been shown to drop to that of postmenopausal women resulting in a rapid bone loss in the spine, at times so severe spinal bone density is comparable to that of 70 to 80 year old women (12).

Males and females alike may suffer from a variety of consequences due to the energy restriction of disordered eating. Loss of lean tissue muscle mass, anemia, electrolyte imbalances, disturbance in immune and endocrine (gland secretion) functions, skeletal injuries, depression and obsession with food and weight loss may occur (7,11,12). Disordered eating and prolonged energy restriction will actually decrease an individual’s resting metabolic rate as the body adapts to the shortage of nutrients and energy. Therefore, if an athlete goes through a period of severe energy restriction and weight loss, future weight loss will be more difficult and weight gain may actually ensue (7,11).

The consequences of disordered eating should not be taken lightly, making identification of the syndrome crucial. Sometimes an athlete will experience trouble concentrating, depression, obesessional thinking or social withdrawal, but misinterpret those symptoms as emotional disturbances rather than the results of disordered eating (5). Although it’s hard to identify or admit a personal pattern of disordered eating, it’s important to understand the warning signs so the appropriate steps are taken if you detect someone you know may be at risk. The following are a few of the physical or symptomatic signs to look for:

• Unusual eating habits or patterns (i.e. eating the same foods all the time, severely restricting the amount of food eaten at one time, or periods of binge-eating)
• Rapid weight loss
• Bloating or edema (swelling of body tissues)
• Puffy cheeks or swollen salivary glands
• Evidence of self-induced vomiting (sores on the knuckles or the back of hand)
• Severe muscle cramping
  Hair loss or thinning
• Frequent weighing
• Claiming guilt about eating
• Exercise far beyond normal training regimen

If any of these symptoms become visible, it’s important that steps be taken. Much of the time, an athlete will not admit to disordered eating or its subsequent problems. Referral to a coach, trainer or professional that deals with eating disorders, such as a registered dietitian (R.D.) is essential. Athletes must be ensured that receiving help may be the single most important thing that can be done to achieve or sustain their level of athletic performance.

Appropriate weight loss or maintenance of low body weight is achievable in safe, effective manners. RDs and sports professionals can often offer sound advice that will decrease the risk of developing disordered eating. Competitive sports will continually push for slender appearance, low body weight and body fat percentage among athletes. It’s important that coaches, trainers, and the media avoid a message of support towards excessive weight loss and exercise behaviors so that fewer athletes develop eating behaviors that only lend themselves to a poorer athletic performance in the end.

References
1. Current Comment: Eating disorders-anorexia and bulimia: Fall 1996. Available at: http://www.acsm.org. Accessed February 2, 2005.
2. Johnson C, Powers PS, Dick R. Athletes and eating disorders: the national collegiate athletic association study. Int J Eat Disord. 1999 Sep;26(2):179-88.
3. Neumark-Sztainer. School-based programs for preventing eating disturbances. J School Health. 1996;66:64-71.
4. Smith NJ. Excessive weight loss and food aversion in athletes simulating anorexia nervosa. Ped 1980;66(1):139-142.
5. Garner DM, Rosen LW, Barry D. Eating disorders among athletes. Sports Psych. 1998;7(4):839-854.
6. Vinci, DM. Effective nutrition support programs for college athletes. Int J Sport Nutr. 1998;8:308-320.
7. Sudi K et al. Anorexia athletica. Nutr. 2004;20:657-661.
8. Sundgot-Borgen J. Risk and trigger factor for the development of eating disorders in female elite athletes. Med Sci Sports Exer. 1994; 26:414-419.
9. Current Comment: Menstrual cycle dysfunction: October 2000. Available at: http://www.acsm.org. Accessed February 2, 2005.
10. Manroe MM. Nutritional needs of the female athlete. Clin Sports Med. 1999; 18(3):549-562
11. Herbold NH, Frates SE. Update of nutrition guidelines for the teen: trends and concerns. Curr Opin Pediatr. 2000; 12(4):303-309.
12. Yeager KK, Agostini R, Nattiv A, Drinkwater B. The female athlete triad: disordered eating, amenorrhea, and osteoporosis. Med Sci Sports Exer. 1993; 25(7):775-777.

Andrea Reichert loves running, cycling and anything outdoors (especially in the winter). She received a MPH in nutrition from the University of Minnesota. In college she was a rower, to which she attributes her initial interest in sports nutrition. Her new love is snowboarding and is a member of NSP. Other interests include cooking, sustainable agriculture, and traveling. She lives in Minneapolis where she works as a registered dietitian in an eating disorders unit. Feel free to contact her: areichert@spu.edu.