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Eating Disorders Among Athletic Females By Nancy Clark

In 1986, The American College of Physicians estimated that anorexia and bulimia affect 10% to 15% of adolescent girls and young women (2). Among athletes, eating problems and pathogenic disorders affect as many as one-third of females but only very few males (1, 5, 8). One might guess that athletic girls and women who participate in sports emphasizing leanness (i.e., running, gymnastics, wrestling, and light-weight crew) would be at particular risk for developing an eating disorder. However, research suggests that eating disorders are prevalent not only among athletes in weight-related sports but also among tennis and field hockey players and other nonweight-oriented activities (12).

A brief review of the literature indicates the following:

Three percent of almost 700 athletes in midwestern colleges met the diagnostic criteria for anorexia; 21.5% met the criteria for bulimia (6).
Thirty-two percent of 182 collegiate female athletes from a variety of sports reported some type of weight-control behavior defined as pathogenic, be it anorexia, bulimia, laxative abuse, excessive exercise, crash dieting, or other unhealthy weight-loss practices (12). Gymnasts, field hockey players, and distance runners reported the highest incidence of eating concerns.
Responses to the Eating Disorders Inventory suggested food problems or preoccupation with weight among 20% of female athletes in sports that emphasized leanness (ballet, body building, cheerleading, gymnastics), 10% of all athletes, and 6% of nonathletes (5).
Among adolescent female athletes in Switzerland, 11% of the swimmers, 1% of the gymnasts, and 6% of the controls were extremely preoccupied with weight (as measured by the Eating Disorders Inventory), Thirty-eight percent of the swimmers, 1% of the gymnasts, and 9% of the controls scored high on the body dissatisfaction scale of the EDI. The authors concluded that disturbances in eating behaviors are not limited to sports that emphasize leanness (4).
Thirty-four percent of the nation's top female runners reported a history of eating disorders, with 25% having had a BMI of less than 17, suggestive of an anorexic physique (8).
In a survey of 494 girls (ages 9-18), 58% perceived themselves as being overweight, although only 15% actually were overweight according to medical standards. Among the 9-year-olds, 30% expressed a fear of getting fat. This fear became increasingly prevalent with age; among the 18-year-olds, 87% reported fear of fat. Thirty-one percent of the 9-year-olds reported binge eating, as did 100% of the 18-year-olds (10).
Among ballet dancers, 80% of those with recent stress fractures had weights less than 75% of ideal and showed a greater incidence of eating disorders (9).

Obviously, dieting, binge eating, and food obsessions are not confined to the overweight population; they are also prevalent practices among normal-weight and thin females, athletes included. Among athletes, many strive to he thinner than their natural weight in the belief that a lower weight will enhance athletic performance (12). They exercise excessively and eat spartanly to attain this often unrealistic goal. Diet restrictions commonly lead to binges. The cycle deepens, and food becomes the fattening enemy. Some suffer from anorexia, others bulimia; many yo-yo between the two. The athletes lose sight of the fact that food contributes to good health, top performance, and athletic longevity.

Anorexia

Anorexia is characterized by a pursuit of thinness. The person is obviously emaciated and often disguised as a very thin athlete. The American Psychiatric Association's (3) definition of anorexia includes

intense fear of becoming obese, which does not diminish as weight loss progresses;
disturbances of body images, e.g., claiming to "feel fat" even when emaciated;
weight loss at least 25% of original body weight or, if under 18 years of age, weight loss of 25% of original body weight plus projected weight gain expected from growth charts;
refusal to maintain body weight above a minimal, normal weight for age and height;
and no known physical illness that would account for weight loss.

Among their peers, anorexics are often considered "perfect athletes." They train harder and more than their teammates and can be seen working out at all hours of the day or night. They often push themselves to outstanding goals that bring fame and glory to their team, school, or club. Coaches often overlook the emaciated physique, denying that an athlete who performs so well could be sick.

Some anorexics look "perfectly thin," but more likely they are unattractively scrawny and wasted. (Family and friends may have trouble making that distinction.) They often have a layer of fine body hair, easily noticeable on their faces and arms. They tend to wear bulky clothes to hide their thinness and complain about the cold (even when the temperature is comfortable for others). They consume an abnormally spartan amount of food in comparison to the energy they expend. (You may never see them eating in public; if you do, you'll notice that they push the food around on a plate to fool you into thinking they are eating.) They often have other compulsive behaviors, such as studying very hard or working long hours.

Bulimia

Bulimia is characterized by a fear of food. The person may have a normal weight but abnormal eating behaviors. The definition used by the American Psychiatric Association (3) includes these characteristics:

1 . Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete time period, usually less than 2 hours)
2. At least three of the following:

Consumption of highly caloric, easily ingested food during a binge
Inconspicuous eating during a binge
Termination of such eating episodes by abdominal pain, sleep, social interruption, or self-induced vomiting
Repeated attempts to lose weight by severely restrictive diets, self-induced vomiting, or use of cathartics or diuretics
Weight fluctuations greater than 10 pounds due to alternate binges and fasts

3. Awareness that the eating pattern is abnormal and fear of not being able to stop eating voluntarily
4. Depressed mood and self-deprecating thoughts after eating binges

Bulimic behavior can be more subtle than that of anorexics. Common symptoms include blood-shot eyes, swollen glands, and bruised fingers (from inducing vomiting). The athlete may eat a hearty meal, then rush to the bathroom and use running water to cover the sound of her vomiting. She may hide laxatives and display other secretive behaviors. Bulimics may even resort to petty stealing of money, from teammates to support their addiction.

Predisposing Factors to Eating Disorders

Eating disorders are common among people who grew up in dysfunctional families-in particular, families with alcohol problems (7). People with eating disorders often have a compulsive desire for control and perfection, two characteristics common to adult children of alcoholics (13). If as children they couldn't control their (alcoholic) parent, they now may strive to control their weight (get rid of all body fat), their food (eat minimal calories), and their training (take no rest days). They may exercise compulsively or eat compulsively (if bulimic) and may be better described as compulsive exercisers rather than dedicated athletes. An athlete, after all, incorporates good nutrition and rest days into an optimal training program.

Dietary Treatment

A medical team that includes a physician, sport nutritionist, and psychological therapist (all skilled in working with people with eating disorders) is optimal for the long-term treatment of eating disorders. The team goals are to establish a normal eating pattern appropriate for the athlete's energy expenditures; modify abnormal attitudes toward food, weight, and eating; develop alternative coping strategies; increase self-esteem; and improve family communication.

During the initial interview, the athlete will undoubtedly feel embarrassed about her abnormal eating behaviors. Hence, the professionals should try to make her feel at ease in an accepting, nonjudgmental atmosphere, letting her know that she is only one of many who struggle with food issues and that they have helped others like her. The athlete must clearly understand that she is responsible for changing her abnormal eating behaviors; the team's only job is to provide helpful information, guidance, and support.

Although the athlete undoubtedly wants to lose weight, the first step is to relearn how to eat normally. Often, the athlete has a warped body image and is unaware that she has no weight to lose. In such cases, body fat measurements can help identify a realistic weight goal. Even if an athlete is overweight, dietary restriction is inappropriate at this time and incompatible with breaking the binge-purge cycle, because restrictive diets commonly precipitate binges (11). Guidelines for an appropriate, yet safe (i.e., not conducive to weight gain) caloric intake will help the athlete to realize that she is supposed to eat (unlike in her self-imposed, crash-diet regimen).

Initially, eating may seem safest if it's mechanical with few decisions to be made. The American Dietetic Association's exchange lists can be helpful; also try menus based on unit portions, such as one cup of yogurt, a frozen dinner, a single-serving box of cereal, an apple. This structure can reduce anxiety about overeating. Meals should be dealt with one at a time, to reduce anxiety and overwhelming fears of becoming fat. With constant reassurance that food contributes to health, high energy, and top performances, the athlete can practice eating healthfully just as she practices her sport-as an integral part of her training program.

Preventing Eating Disorders

To help prevent problems, a sport nutritionist or registered dietitian should work with athletic females to teach them how to lose weight healthfully or to maintain a realistic weight. When left on their own, athletes tend to crash-diet, then binge, thus falling prey to the vicious cycle of starve/binge routines that set the stage for severe eating disorders.

Tips for Helping Athletes With Eating Disorders

Anorexia and bulimia are self-destructive eating behaviors that may signal underlying depression and can be life-threatening. Here are some tips for approaching the delicate subject:

Approach the athlete gently but persistently, saying that in watching her you have observed that she seems to have a problem with food. Stress that you're concerned about her health. A bulimic will often open up with this approach, but an anorexic may try to deny any problem. She's perfectly fine, she insists. However, she may be concerned about her loss of concentration, light-headedness, or chronic fatigue. These health changes are more likely to be a stepping-stone to accepting help, because the athlete clings to food and exercise for feelings of control and stability.
Don't discuss weight or eating habits. The anorexic takes great pride in being perfectly thin and may dismiss your concern as jealousy, thinking that you probably yearn to be as successful with weight control. Remember that the starving or bingeing is not the most important issue. Rather it is a smoke screen hiding the fundamental problem-problems with life.
Focus on the athlete's unhappiness as the reason for seeking help. Point out how anxious, tired, or irritable she has been. Emphasize that she doesn't have to be that way.
Be supportive and listen sympathetically, but don't expect the athlete to open up and trust you right away. Give it time, but constantly remind her that you are concerned and that you believe in her ability to resolve the problem.
Give her a written list of resources for professional help. Although the athlete may deny that there's a problem now, she may admit despair at another moment. Post a list of local resources (with a tear-off phone number at the bottom) in the locker rooms, bathrooms, and dining halls.

If local resources are inadequate, contact one of these national organizations.

Anorexia Nervosa and Associated Disorders (ANAD) Box 271
Highland Park, IL 60035
Phone 708-831-3438
ANAD runs a national system of free support groups and referral lists of
psychotherapists.

National Anorexic Aid Society (NAAS)
1925 East Dublin-Granville Road
Columbus, OH 43229
Phone 614-436-1112
NAAS provides referral services in the United States, Canada, and Great Britain. It also offers a newsletter and additional information on eating disorders.

Anorexia and Bulimia Treatment and Education Center (ABTEC) 621 South New Ballas Road
Suite 7019B
St. Louis, MO 63141
Phone 314-569-6898
ABTEC offers a national referral service, self-help groups, and information on eating disorders. Send a self-addressed, stamped envelope, three stamps, and $1 for details.

Don't deal with the problem alone. If you feel that you're making no headway and the athlete is becoming more self-destructive, seek help from one of her family members, a medical professional, or a health service. Make an appointment with a mental health counselor and bring the athlete there yourself. Tell the athlete that you choose to involve other people because you care about her. If you are overreacting and there really is no problem, this health professional will be able to ease your mind.

Talk to someone about your own emotions if you feel the need. Remember that you are not responsible and can only try to help. Your power comes from using community resources and health professionals, such as a guidance counselor, a nutritionist, a member of the clergy, or an eating disorders clinic.

References

1. Eating disorders in young athletes: a round table. Phys. Sportsmed. 13(11):89-106; 1985.
2. American College of Physicians. Eating disorders: anorexia and bulimia. Ann. Intern. Med. 105:790-794; 1986.
3. APA. Diagnostic and statistical manual of mental disorders III-R, 3rd ed. rev. Washington, DC: American Psychiatric Association; 1987.
4. Benson, J.; Allemann, Y.; Theintz, G.; Howard, H. Eating problems and calorie intake levels in Swiss adolescent athletes. Int. J. Sports Med. 11(4):249-252; 1990.
5. Borgen, J.; Corbin, C. Eating disorders among female athletes, Phys. Sportsmed. 15(2):89-95; 1987.
6. Burckes-Miller, M.; Black, D. Male and female college athletes: prevalence of anorexia and bulimia nervosa. Athletic Training 23:137-140; 1988.
7. Clark, N. letter Phys. Sportsmed. 15(8):24; 1987.
8. Clark, N.; Nelson, M.; Evans, W. Nutrition education for elite female runners. Phys. Sportsmed. 16(2):124-135; 1988.
9. Frusztajer, N.; Dhuper, S.; Warren, M.; Brooks-Gunn, J.; Fox, R. Nutrition and the incidence of stress fractures in ballet dancers. Am. J. Clin. Nutr. 51:779-783; 1990.
10. Mellin, L. Responding to disordered eating in children and adolescents. Nutr. News 51(Summer):5-7; 1988.
11. Polivy, J.; Herman, C.P. Dieting and binging: a causal analysis. Am. Psychol. 40:193-201; 1985.
12. Rosen, L.W.; McKeag, D.B., Hough, D.O.; Curley, V. Pathogenic weight-control behavior in female athletes. Phys. Sportsmed. 14:79-86; 1986.
13. Woititz, J. Adult children of alcoholics. Pompano Beach, FL: Health Communications; 1983.

Excerpted from The Athletic Female, 1993, Arthur J. Pearl, editor.