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.
WHICH ATHLETES?
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.
MAIN FINDINGS
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.
References
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
Emma, thank you for the great post and I’m excited to have you contribute to the blog!
What I meant to ask but forgot to do so after publishing the post was the following: In the post, it seems like you imply that there’s a line between disordered eating behaviours that are excusable for the sport and those that are “diagnosable”?
You wrote:
“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?”
But I would argue that a lot of the time, it is both. It IS disordered eating behaviour that negatively impacts psychological function BUT may, in many cases, lead to improved performance. I’d say that just because it is done under the legitimate guise of improving athletic performance (and I think it is legitimate if you are an athlete and this is something you value) doesn’t mean it is not disordered and doesn’t impact one’s psychological well being.
In other words, I don’t think they are mutually exclusive. I don’t think there’s a line — I think there’s a big, big grey area.
I actually completely agree- looking back, I definitely could have phrased that better in the article. The thing I really find interesting with research into athletics and eating disorders is that it forces us beyond the ‘eating disorders are purely associated with weight loss’ stereotype. As you say, these are disordered behaviours that can negatively impact psychological well being- but they’re being used as part of a drive to make the body perform physically at a high level. It’s a drive towards a physical, rather than a primarily visual ideal- I feel like this is something that hasn’t been fully explored or recognised in current clinical conceptions of eating disorders, hence the significant grey area.
A good way of examining the relationship between disordered eating and the demands of athletic performance in athletes could be a long-term study into behaviours among ex-athletes once they’ve finished playing their sport. I couldn’t find anything along these lines browsing research databases, but maybe one day!
I found this really interesting. I have been bulimic for about ten years, and I have been distance running for about twelve years. Everyone in my family runs marathons, it’s something we do to bond with each other, and my experience of it is largely positive. I ran cross country and track in middle and high school, and in college and now post-college, I run marathons, as well. In the world of treatment, this has caused numerous issues, as the prevailing explanations that the professionals gave for my reluctance to give up running was because I must be “addicted” to it, because I’m trying to manage my unhealthy emotions, because I’m trying to lose weight, because I can’t handle my anxiety, because I’m trying to gain approval from my family, etc. In inpatient treatment, they would continually try to get me to agree to give up running forever, and I would tell them I really did not think that was feasible, that I would try to be more moderate and to eat more appropriately for what I ran, but that given our disagreement on the issue, I would rather spend my limited time discussing my binging and purging, which I felt was more dangerous. And they SERIOUSLY couldn’t get past this, and I felt trapped and invalidated. Now I am more moderate with running, my treatment team still hates it, but we mostly table it because it’s not something I’m willing to change and from a damage control perspective, it’s not the first priority.
Anyways, what I guess I’m trying to get across is that people with eating disorders can have complex relationships with exercise. Athletes who get eating disorders can still like to exercise for reasons other than eating-disordered ones. Sometimes, I use running as a motivating factor in recovery and will convince myself not to restrict or binge/purge when I have a race coming up. It’s not ideal, but one size doesn’t fit all, as could be said for most areas of treatment. I’m not saying I’d advocate that people with eating disorders go out and train for marathons… you know, do as I say and not as I do, but just that telling an athlete that they have to give up what they love forever and go for 2 20-minute walks a week (beyond the immediate need for medical stability) can be depressing and really end up pitting the client against the treatment team, earning us that lovely “treatment-resistant” label.
Thanks so much for your comment Katie! I can really relate to your experiences. So much!
“Anyways, what I guess I’m trying to get across is that people with eating disorders can have complex relationships with exercise. Athletes who get eating disorders can still like to exercise for reasons other than eating-disordered ones. Sometimes, I use running as a motivating factor in recovery and will convince myself not to restrict or binge/purge when I have a race coming up.”
Absolutely! Different motivations are not mutually exclusive. I also found running to motivate me to recover. And I would “punish” myself by not allowing myself to run if I binged/purged or restricted for example.
I also found it really, really invalidating when everyone automatically assumed that my exercise was solely ED-motivated and that I was “addicted” and that simply was not the case. I can write an essay providing all the evidence why that was not the case (e.g., to lose weight, I stopped running and I never exercised much at low weights, I never had exercise-related injuries/always listened to my body, etc.).
I find the almost immediate disbelief/mistrust that I’ve encountered from clinicians really, really annoying, to say the least. I find it is almost like, if you are an athlete or just simply like exercising a lot, but have had an ED, people will always mistrust your motivations for exercise. Just like if you have had an ED and are vegetarian or vegan. Sure, some people do it as a “passable” excuse to eat less (I did, for a bit over a year with regard to vegetarianism), but that doesn’t mean EVERYONE with an ED does that.