Eating Disorders in Collegiate Athletes: A Literature Review

I. Introduction:

The transition from high school to college can be challenging for collegiate student athletes.1 Student athletes face high levels of stress related to external pressures from their coaches, teammates, and parents to excel as an athlete.1 Additionally, student athletes also face physiological stress on their bodies due to long practices, strength training, and sleep deprivation due to early morning practices.2 For most athletes, sports participation has been a healthy and productive way to relieve stress for most of their lives.  Some student athletes learn to manage stress, while others have a more difficult time finding healthy ways to cope.

 Although it has been well documented that the prevalence of eating disorders is higher among athletes when compared to non-athletes, athletic participation alone does not cause an individual to develop an eating disorder.3-5 However, it has been indicated that athletic participation can create a high-risk environment for individuals who are genetically and psychologically vulnerable.3 The purpose of this literature review is to examine the benefits of nutritional services for collegiate student athletes by highlighting the relationship between collegiate athletic participation and the development of an eating disorder.

III. Prevalence:

According to the National Eating Disorder Association (NEDA), eating disorders are psychological disorders characterized by “abnormal or disturbed eating habits.” 6 In the United States, approximately 20 million women and 10 million men have met diagnostic criteria for an eating disorder at some point in his or her life, yet only 1 in 10 individuals ever receive treatment.6,7  

Many collegiate student athletes fail to seek treatment for fear that he or she may be suspended from athletic participation in order to seek treatment.8 This is also a concern for male athletes because the mental illness could be viewed as a sign of weakness by coaches, teammates, opponents, and/or self.9   Other student athletes may be uneducated about the warning signs and symptoms of eating disorders. In a study conducted by the National Collegiate Athletic Association (NCAA), more than one third of division one student athletes, most of these being female, reported beliefs and behaviors that placed that at a significant risk for developing anorexia nervosa.8

Sungot-Borgen, and Torstveit, compared the prevalence of clinical and sub-clinical eating disorders in elite Norwegian male and female athletes to the general population.4 In their study, approximately 13.5% of the athletes had clinical or sub-clinical eating disorders, compared to 4.6% of the general population.4 Within the population of elite athletes, the prevalence of clinical and sub-clinical eating disorders was higher in female athletes than males, and in athletes who competed in weight-dependent or lean sports, such as gymnastics, wrestling, and cross country.

IV. Diagnostic Criteria

 Anorexia is the most common eating disorder observed in collegiate athletes.8 The diagnostic criteria for anorexia includes two subtypes: restricting type and binge-eating and purging type.10 The diagnostic criteria for anorexia have undergone three significant changes. First, the definition of a “significantly low weight” has been updated from an 85% weight loss to “less than minimally normal weight in adults or less than expected weight in children and adolescents”. 3,10 This low weight is caused by a restriction of energy intake and/or increased physical activity, both exceeding an individual’s needs to maintain a healthy lifestyle.10 In addition, patients no longer have to explicitly voice a fear of gaining weight or disturbance in body image; this can now be inferred from patient behaviors and attitudes during initial assessments.10 This change is particularly helpful because many patients deny symptoms and neglect to acknowledge the disordered eating behaviors that they engage in, resulting in the lack of a clear diagnosis. Lastly, amenorrhea has been removed to provide a more inclusive diagnosis of anorexia, which now is diagnosable in men, postmenopausal women, and adolescents with delayed menstrual cycles.10 Warning signs and symptoms of anorexia include sudden weight loss, denial of unhealthy behaviors, body dissatisfaction, obsessive compulsive exercise habits, fatigue, insomnia, co-morbid anxiety or depression, fear of gaining weight, body dissatisfaction, orthorexia, dieting, ridged rituals associated with food, poor concentration, and hair loss. 3,10

Bulimia Nervosa is characterized by a reoccurring pattern of binge eating and compensatory behaviors, such as self-induced vomiting to undo the calories consumed.11 The main difference between anorexia binging/purging type and bulimia is that individuals with bulimia are typically within normal weight ranges.11 This makes bulimia more difficult to detect and diagnose because it is easier to hide the disordered eating behaviors with a seemingly healthy body weight.11 Warning signs and symptoms of bulimia nervosa are similar to those of anorexia. In addition to weight fluctuations, the disappearance of large amounts of food in short periods of time, frequent trips to the bathroom immediately after meals, and eating alone or in secret are also common warning signs.3,11

Binge eating disorder is the most newly recognized diagnosis in the DSM-V. The criteria for binge eating disorder includes recurrent episodes of binge eating at least once a week for three months or more on average, along with a sense of lack of control during each episode, and lack of compensatory behaviors that are commonly associated with anorexia nervosa and bulimia nervosa.12 In other words, individuals with binge eating disorder do not try to purge away calories through the use of laxatives, diuretics, and exercise. Warning signs and symptoms for binge eating disorder include eating large quantities of food when not physically hungry, eating until uncomfortably full, self-medicating with food, eating alone or in secret, hiding food, lack of control over eating, and feelings of guilt and shame.12

Otherwise specified feeding or eating disorder (OSFED), is diagnosable in an individual who may present with many of the symptoms of other eating disorders recognized by the DSM-V, but do not meet full diagnostic criteria.13 OSFED can be particularly dangerous because individuals do not think that his or her mental illness is bad enough to seek treatment. When these individuals do not seek treatment when warning signs and symptoms present themselves, they have often already progressed into advanced stages eating disorder when they finally do seek help.

V. Risk Factors Associated with Athletic Participation:

There is not one single source that causes an individual to have an eating disorder.14 Instead, the evidence suggests that the onset of an eating disorder is due to a combination of an individual’s psychological health, genetic make-up, and environment.14 Borgen and Torstveit explain, “Athletes constitute a unique population, and the impacts of factors such as training, eating pattern, extreme diets, restriction of food intake, and psychopathological profile must be evaluated differently from this impact in nonathletes.”4 As previously mentioned, participation in sports that emphasize a lean body type or require a low body weight, such as swimming, cheerleading, track and field, cross country, and wrestling may not be suitable for certain individuals.4 Other potential environmental triggers may include pressure to perform, a team diet culture, vigorous training regiments, an uninvolved coaching staff, individual injuries, and personal dissatisfaction with performance.

VI. Potential Consequences and Complications of Eating Disorders:

There are very serious physiological and psychosocial complications and consequences that arise from eating disorders. Malnutrition, fatigue, injury, compromised immunity, decreased endurance, strength, speed, dehydration, loss of menstrual cycle, depleted fuel stores, bone loss, delayed wound  healing, altered gastrointestinal functioning, electrolyte disturbances and organ failure, are some of the most common consequences in collegiate athletes with eating disorders.1,3,12 For many athletes, a diagnosis is confirmed by a fainting spell or stress fracture due to dehydration, ketosis, electrolyte imbalances, or bone deterioration.3

VII. Treatment

Eating disorder treatment is a very intricate and complex process. Evidence suggests that eating disorders are most successfully treated when an individual receives coordinated care from a recovery team composed of a therapist, registered dietician, and medical physician .1-4 Student-athletes also benefit from supportive coaches, trainers, teammates, family, and friends.4

Before treatment begins, it must be determined whether or not the athlete is physiologically and psychologically stable enough to participate in practices and games.3 This evaluation is preferably done by a dietician and/or psychologist who is specialized in eating disorder treatment.3 If the athlete is medically or mentally unstable, excessive physical activity will do more harm than good. It can be difficult for an athlete to cooperate with his or her recovery team. Resistance in treatment is normal and expected. Many student-athletes with an eating disorder are upset by the thought of taking time off to heal. Professionals often try to parallel the onset of an eating disorder with an injury, which can help to minimize the guilt and shame that the athlete may be feeling.3,13 When a student-athlete understands that they are not to blame for their illness, he or she is more likely to fully embrace the recovery process.

VIII. Prevention

Eating disorder prevention is something that is highly undervalued and highly overlooked on college campuses nation-wide. College students are vulnerable to inadequate nutrition due to skipped meals, limited finances, limited cooking skills, and unlimited access to foods that are high in fat, low in fiber, low in nutritional value, and low in variety.2 Student-athletes are specifically vulnerable to inadequate nutrition due to overly restrictive diets and rigorous.2 Consequently, many athletes find themselves fatigued, overworked, malnourished, and injured. In the worst-case scenario, physical, social, and academic stress can manifest itself in the form of an eating disorder. Research suggests that athletes with more nutrition knowledge make better food choices, which results in better health, well-being, and athletic performance.2

In order to minimize risk, it is important for professionals involved in the NCAA to be able to recognize individual personality and genetic vulnerabilities and environmental elements they are consistent with a triggering environment. 2 Without proper education, coaches and trainers will be unable to properly identify warning signs. Increased awareness and education can be one of the most effective tools to prevent the onset of an eating disorder.  As with any other chronic disease or disorder, it is easier to prevent the onset of an eating disorder than it is to cure it.3 Proper prevention resources have the potential to minimize disordered eating patterns and prevent the illness from occurring.

IX. Conclusion:

There are many benefits of providing nutritional services for collegiate student-athletes. In the most ideal situations, nutritional services are able to provide each student-athlete with nutrition education and individualized care. Nutritional services have the potential to prevent malnutrition, fatigue, poor energy, and disordered eating in student-athletes. Student-athletes who are trying to gain or lose weight to improve athletic performance may benefit from close monitoring by a sports dietician. Nutritional services may also provide athletes who are exhibiting signs of an eating disorder. Early intervention in disordered eating patterns can keep an individual from transitioning into a clinical eating disorder. Without intervention, eating disorders can be fatal, and student-athletes are often left to fight a battle that cannot be won alone. When the proper treatment is received, student-athletes have the ability to fully recover and maximize his or her performance on and off of the field. Universities are spending an unnecessary amount of money on sports uniforms, practice facilities, advertising, and equipment, among other things. There is little room in the budget for eating disorder prevention, intervention, and treatment, despite the fact that it is affecting many athletes nation-wide. In addition to the expenses listed above, many universities also have comprehensive physical therapy and injury rehab programs. It is time for universities to implement the same kind of treatment programs for individuals who suffer from eating disorders. 3


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