If a person severely restricts his diet and exercises for hours each day, he has an eating disorder. If another does exactly the same but it is because she wants to make the lightweight rowing team (which has an upper weight limit), she’s a committed athlete. When the two overlap, and an athlete presents with eating disorder symptoms, how do we distinguish between the demands of the sport and the illness?
I’ve been interested in the distinctions we make between disordered and non-disordered eating and exercise behaviours for a while now. Recently, when I was browsing through articles, I came across a literature review by Werner et al. (2013) (open access) of studies examining weight-control and disordered eating behaviours in young athletes.
The authors start by noting the sheer lack of research that has actually been done in this area. This is worrying: typical onset of eating disorders is during adolescence, and research indicates that athletes are more likely to develop these disorders, leaving young athletes in what appears to be a high-risk position.
Werner et al. searched for studies that included the following:
- “Elite athletes” (defined as representing national teams or squads)
- Athletes still competing at the time of assessment
- Athletes were, on average, under 25 years of age
This review specifically examined studies that investigated “weight concerns” and “weight control behaviour.” Notably, the authors decided against seeking out studies on athletes with eating disorder diagnoses. On the one hand, this is a shame because I’d be really interested to see where exactly the line is drawn between “reasonable” eating and exercise habits as part of the sport, and an eating disorders. However, bearing in mind that the excuse of “it’s for my sport” might cover up disordered behaviours and so prevent a diagnosis, I can see why the authors made this decision. An electronic search of databases came up with only 15 articles that met the above criteria.
The review found that young elite athletes are no more at risk for disordered weight concerns or weight-control behaviour than the non-athletes; however, there was a lot of variation in findings among the different studies.
The problem was that these variations occurred in very specific contexts, making it hard to draw broader conclusions. For example, Rouveix et al. (2007) found that female judo athletes were more likely to display weight-control behaviours, whereas Ferrand et al. (2005) found that female synchronised swimmers were no more likely to engage in weight-control behaviours, but were more concerned about their weight, than non-athletic controls.
This is indicative of a broader issue with studies into young athletes and disordered eating. Some studies were very specific, such as looking at one sport or one gender, making it difficult to draw broader conclusions. A couple of studies had very small sample sizes (one was as small as 10), and another study didn’t properly distinguish between athletes and controls, with some of the controls regularly exercising up to four times a week. Really, what this review highlighted was the sheer lack of data in this area.
The authors also reviewed the studies to look at whether the type of sport impacted disordered eating habits, differentiating between leanness-sports and non-leanness sports. Again, there was conflicting data, with three studies suggesting that individuals engaging in leanness-sports were more at risk than non-athletic controls and four studies suggesting no difference. Overall, the authors concluded that the evidence pointed towards athletes in leanness-sports being more at risk for weight-control behaviours. Moreover, these behaviours did appear to be more prevalent in sports involving weight classes, where the athlete has to be a certain weight to compete in a category (giving credence to my suspicions about the imaginary rower).
An interesting point that the results of the review raised was the difference between male and female eating concerns: Whilst both males and females exhibited disordered eating habits and increased concern with body image, males were more likely to be trying to “bulk up,” while females were more likely to be trying to lose weight and so fitting in more easily to the ED diagnostic criteria.
A FINE LINE
The authors concluded that although weight control and weight concern behaviour is prevalent among elite athletes, there is not enough evidence to indicate that the prevalence is higher than in non-athletes. However, in sports that emphasize leanness, such as dancing, there is a higher prevalence of disordered eating.
The problem with all these studies is that they looked at disordered eating behaviours and body image concerns but struggled to separate out the behaviours demanded by the sport itself. Can these ever be properly separated? At high levels, almost all sports involve some kind of focus on the body, both in terms of exercise and eating habits. Therefore, when looking at exercise, weight concerns, and eating habits, it becomes difficult to determine when and if these behaviours have gone beyond the demands of the sport, crossing the line into disordered behaviour.
As mentioned above, the review actually had an unexpected result, one that went against the authors’ hypothesis that young elite athletes would be more at risk from weight control and weight concern: Several studies found that the control participants were in fact more likely to exhibit disordered behaviours. This suggests that participating in elite sports might even be a protective factor from eating disorders:
Comparing athletes with non-athletes or controls, the majority of studies, several of which were large scale, found either no difference or an even lower risk of athletes for pathogenic weight concerns or weight-control behaviour. Only one study could show a higher prevalence of pathogenic weight concerns but not weight-control behaviour in athletes.
I liked the explanation for these results that Martinsen et al. (2009) put forward — the distinction between appearance and performance. Athletes manage their eating and exercise to enhance their performance, and therefore (in theory) would not want to do anything to damage their body. The controls, on the other hand, would not have this concern. Restrictive eating generally causes a drop in energy: For the athlete this would be catastrophic, for someone merely pursuing weight loss this might be considered “worth it.”
So would that be the “fine line” between athletic demands and disordered behaviour? Is it the distinction between improvement in performance and physical and/or psychological dysfunction?
Hopefully, there will be future research exploring this topic more in depth. Interestingly, Werner et al. have recently published their own study into disordered eating and young athletes called “The German Young Olympic Athletes’ Lifestyle and Health Management Study” (open access), and I’ll be looking out for their future publications.
Werner, A., Thiel, A., Schneider, S., Mayer, J., Giel, K., & Zipfel, S. (2013). Weight-control behaviour and weight-concerns in young elite athletes – a systematic review. Journal of Eating Disorders, 1 (1) DOI: 10.1186/2050-2974-1-18
Martinsen, M., Bratland-Sanda, S., Eriksson, A., & Sundgot-Borgen, J. (2009). Dieting to win or to be thin? A study of dieting and disordered eating among adolescent elite athletes and non-athlete controls. British Journal of Sports Medicine, 44 (1), 70-76 DOI: 10.1136/bjsm.2009.068668