Evidence-Based Comprehensive Psychological, Nutritional and Medical Care

Resources for Athletes

Eating disorders can have adverse effects on an athlete’s health and sport performance, and thus require treatment. Additionally, there are other eating- and exercise-related problems that have been identified in athletes that can also have deleterious effects on an athlete’s health and performance. Because they do not always meet diagnostic criteria for an eating disorder, they have been described as “subclinical.” Regardless of how they are classified, such problems must be treated not only because of their health consequences, but also because they can progress to clinical eating disorders if left untreated. These problems or conditions include Anorexia Athletica, Muscle Dysmorphia, and the Female Athlete Triad.

Anorexia Athletica: Anorexia athletica is an older term that was used by Sundgot-Borgen in Norway to describe an unhealthy weight loss process found in some female athletes. The process typically involved attitudes and behaviors characteristic of anorexia and bulimia, such as fear of weight gain, restriction of caloric intake, a weight loss of at least 5% of body weight, and extensive/compulsive exercise. Such athletes also often engaged in binge eating and the use of pathogenic weight loss methods. Some of these athletes would probably be diagnosed as Eating Disorder Not Otherwise Specified today.

Muscle Dysmorphia: “Reverse anorexia” is a term that was first used by Pope and colleagues, who later changed the term to “muscle dysmorphia.” It involves a preoccupation with not being muscular enough despite having considerable muscularity. Individuals (usually males) with this problem often (mis)perceive their body as being much smaller than it actually is. To compensate, they often spend hours daily in the gym lifting weights and may resort to taking anabolic steroids. Many of these individuals display many eating disorder symptoms if not the actual disorders.

Female Athlete Triad: In 1997, the American College of Sports Medicine (ACSM) defined the Triad as including disordered eating, amenorrhea, and osteoporosis but changed it in 2007 from a categorical system of diagnosis to one that was more dimensional. That is, “Disordered Eating” was replaced with the term “Energy Availability,” while “Amenorrhea” and “Osteoporosis” were replaced with “Menstrual Function” and “Bone Mineral Density” to reflect the fact that the Triad components can vary along a continuum. Energy availability involves the energy that is left (available) after the body has accounted for all physical activity. If energy availability is persistently low, there may not be enough energy to run normal bodily processes, such as reproduction. In such a case, the body can stop producing adequate levels of estrogen, resulting in menstrual dysfunction. Because estrogen is necessary for bone health and growth, loss of bone density can occur, which increases the risk of stress fractures, other fractures, and musculoskeletal injuries. Menstruation must be restored through increased caloric intake, decrease physical activity, or both. The severity of the disordered eating is reflected in the athlete’s inability or unwillingness to make the necessary eating and exercise adjustments.

Special Considerations for Sport

Although anorexia nervosa can begin at any age, most often it has its onset around ages 13-14 and 17-18. These are not only high risk times for the development of anorexia, but they are also a time in the life of some adolescents when they become more serious about sport participation and may move to a higher level of competition. With such a move, pressures and expectations regarding sport performance may increase. The belief in the sport world that the thinner/leaner athlete performs better is alive and well in sport. Participation in a sport that emphasizes a thin body/shape or low weight might be attractive to a young athlete who, for whatever reason, has a need to lose weight or be thin. An endurance sport that requires a heavy training load might be even more attractive In such a circumstance, the sport may be used to "legitimize" attaining or maintaining a suboptimal (unhealthy) weight.

Participants in weight-class sports are probably more at risk for practicing pathogenic weight loss methods, which may lead to the development of bulimia nervosa or other eating disorders. Athletes in the "combative" weight-class sports (i.e., boxing, judo, taekwondo, wrestling, etc.) may be at increased risk because they attempt to compete at weight classes below their normal weight by "cutting weight" before the required weigh-in for their competitions. Many weight cutting strategies involve dehydration techniques that are essentially compensatory behaviors that are associated with bulimia nervosa. For many athletes, the practice of such behaviors can increase the probability of developing bulimia nervosa. More generally, athletes in nonlean sports tend to experience more body dissatisfaction than athletes in lean sports. Perhaps as a consequence, such athletes are more likely to use pathogenic weight loss methods, which again can increase their risk of bulimia nervosa and other eating disorders.

Unhealthy exercise has been described most often as "excessive exercise," but numerous other terms such as "compulsive" or "obligatory" have also been used to describe unhealthy or symptomatic exercise. Some affected individuals have even been described as having an "exercise addiction." Regardless of how unhealthy exercise is described, it is often a significant problem for many if not most eating disorder patients. Although unhealthy exercise is sometimes difficult to assess and manage in non-athletes, it can be even more difficult in athletes. Part of the difficulty is that training loads in most sports today would be considered “excessive” by most non-sport standards. Certainly, the training required in most sports today would be more than is necessary for health and perhaps more than is necessary for certain fitness levels. Such levels of training are considered by many in the sport world to be necessary for optimal sport performance. Given this, it is ironic that too much training for some endurance athletes can result in "overtraining" syndrome (staleness) in which a decrement in sport performance is a common symptom. One of the difficulties with athletes with eating disorders is to determine when training loads for a particular athlete are necessary for sport performance and when such training is being used symptomatically by an athlete with an eating disorder to lose weight or to “undo” the effects of eating. In essence, this involves the nature of the relationship between the athlete’s disorder and his/her sport. That relationship must be appropriately assessed in order to determine how sport training (exercise) will be managed during treatment. This is only one of the many reasons why athletes constitute a special subpopulation of eating disorder patients and need specialized approaches to identification, management, and treatment. The Victory Program at McCallum Place provides these specialized approaches.

Why Athletes with Eating Disorders Need to be in Treatment

Psychological Reasons

  • Recovery for athletes with eating disorders without treatment is unlikely.
  • Without treatment, the athlete can become isolated
  • Over time, the athlete will deteriorate physically and psychologically.
  • Performance in athletes with eating disorders is eventually negatively affected.
  • Poorer performance increases pressure on the athlete.
  • The disorder is apt to be the athlete’s way to deal with pressure.
  • An increase in pressure on the athlete increases the need for the disorder.

 Medical Reasons

  • Medical complications are common and potentially life-threatening in athletes with eating disorders.
  • Many athletes with eating disorders and anorexia athletica have fluid, electrolyte, and energy imbalances, increasing the risk of cardiovascular compromise while competing.
  • Postponing treatment can lead to worse outcomes.
  • Malnutrition has a significant impact on thinking in athletes with eating disorders - affecting concentration, the ability to see things in context, and impair judgment.
  • Malnutrition can lead to both brittle bones and metabolic compromise and increased risk of muskuloskeletal injury.
  • A compulsion to exercise and over train may make stabilization difficult in athletes with eating disorders without structure and support.

 

Treating Eating Disorders: Anorexia  •   Bulimia  •   Binge Eating  •   Emotional Eating  •   Compulsive Exercising

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