Eating disorders

Eating disorders are a group of disorders that must meet specific criteria established by the American Psychiatric Association. The two most commonly diagnosed eating disorders are anorexia nervosa and bulimia nervosa. Disordered eating, on the other hand, refers to patterns of eating that are not considered normal but don’t meet the specific diagnostic criteria for a given eating disorder.

Eating disorders in girls and women became the focus of considerable attention beginning in the 1980s. Men constitute about 10% or less of the reported cases. Anorexia nervosa has been considered a clinical syndrome since the late 19^th century, but bulimia nervosa was first described in 1976.

Anorexia nervosa is a disorder characterized by:

• Refusal to maintain more than the minimal normal weight based on age and height,
• Distorted body image,
• Intense fear of fatness or gaining weight,
• Amenorrhea.

Females from ages 12 to 21 are at greatest risk for this disorder. Its prevalence in this group is likely less than 1%.

Bulimia nervosa, originally termed bulimarexia, is characterized by:

• Recurrent episodes of binge eating,
• A feeling of lack of control during these binges,
• Purging behaviour, which can include self-induced vomiting, laxative use, and diuretic use.

The prevalence of bulimia in the population at greatest risk, again adolescent and young adult females, is generally considered to be about 4% and possibly closer to 1%.

It is important to realize that a person might exhibit disordered eating and yet not meet the strict diagnostic criteria for either anorexia or bulimia. As an example, the diagnosis of bulimia requires that the individual average a minimum of two binge-eating and purging episodes a week for at least three months. What about the person who meets all the criteria, except that bingeing and purging occur only once per week? Although this person cannot technically be diagnosed as having bulimia, her or his eating is certainly disordered and is a potential cause for concern. Thus, the term “disordered eating” has been used to describe those who do not meet the strict criteria for an eating disorder but who do have abnormal eating patterns.

The prevalence of eating disorders in athletes is controversial. Numerous studies have used either self-report or at least one of two inventories developed to diagnose disordered eating: the Eating Disorders Inventory(EDI) and the Eating Attitudes Test(EAT). Results have varied because not all studies used the strict standard diagnostic criteria for either anorexia or bulimia. As in the general population, female athletes are typically at a much higher risk than male athletes, and certain sports carry higher risks than others. The high-risk sports can generally be grouped into three categories:

1)      Appearance sports, such as diving, figure skating, gymnastics, bodybuiding, and ballet;

2)      Endurance sports, such as distance running and swimming;

3)      Weight-classification sports, such as horse racing(jockeys), and martial arts.

Self-reports or invertories do not always provide accurate results. In a study of 110 elite female athletes representing seven sports, EAT results showed that no athlete fell within the disordered eating range of the inventory. But in the subsequent two-year period, 18 of these athletes received either inpatient or outpatient treatment for eating disorders. In a second study of 14 nationally ranked middle- and long-distance runners who completed the EDI, only three were shown to have possible problems with disordered eating, and none were shown to have eating disorders. In follow-up, seven subjects were subsequently diagnosed as having an eating disorder: four with anorexia nervosa, two with bulimia nervosa, and one with both. People with eating disorders, by their very nature, are secretive. We cannot realistically expect those with eating disorders to identify themselves, even with anonymity is ensured. For the athlete, this need for secrecy might be heightened by fear that a coach or a parent will learn of the eating disorder and not allow the athlete to compete.

Even though research is limited, it seems appropriate to conclude that athletes are at higher risk for eating disorders than the general population. Existing evidence likely does not reflect the seriousness of this problem in athletic populations. Although research data are not yet available, the prevalence might be as high as 60% or more in the specific high-risk athletic populations listed earlier.

Eating disorders generally are considered to be addictive disorders and are extremely difficult to treat. The physiological consequences are substantial and can include death. Considering this, along with the emotional distress suffered by the athlete, the extraordinary costs of treatment($5,000- $25,000 per month for hospital inpatient treatment), and the effect on those closest to the athlete, eating disorders must be considered among the most serious problems facing female athletes today, paralleling the seriousness of anabolic steroid use in male athletes.

Warning signs for anorexia nervosa and bulimia nervosa
Anorexia nervosa	Bulimia nervosa
Dramatic loss in weight	A noticeable weight loss or gain
A preoccupation with food, calories, weight	Excessive concern about weight
Wearing baggy or layered clothing	Bathroom visits after meals
Relentless, excessive exercise	Depressed mood
Mood swings	Strict dieting followed by eating binges
Avoiding food-related social activities	Increased criticism of one’s body

In 1990, the National Collegiate Athletic Association developed a list of warning signs for anorexia nervosa and bulimia nervosa, which is presented in the table above. When an eating disorder is suspected, it is important to recognize the seriousness of the disorder and refer the athlete to a person specifically trained in dealing with eating disorders. Most athletic trainers, coaches, and even physicians are not trained to provide professional help to those with serious eating disorders. Most of the athletes who experience eating disorders are very intelligent, come from an upper-middle-class or higher socioeconomic level, and are very good at denying that they have a problem. These athletes are unfortunate vicitims of the unhealthy emphasis on extreme leanness promoted by the media and the challenges of attaining the optimal weight for their sport. Training eating disorders is extremely difficult, and even the best-trained professionals are not always successful. Some extreme cases end in suicide or premature death from failure of the cardiovascular system. Immediate professional help should be sought for an athlete suspected of having an eating disorder.

Female athletes are at higher risk than nonathletes for disordered eating and eating disorders for several reasons. Perhaps most important, there is tremendous pressure on athletes, particularly female athletes, to get their weight down to very low levels, often below what is appropriate. This weight limit can be imposed by the coach, trainer, or parent or can be self-imposed by the athlete. In addition, the personality of the typical elite female athlete closely matches the profile of the female at high risk for an eating disorder(competitive, perfectionistic, and under the tight control of a parent or other significant figure such as coach). Furthermore, the nature of the sport or activity largely dictates those at high risk. As previously mentioned, athletes in three categories are at high risk: appearance sports, endurance sports, and weight-classification sports. Added to these risks are the normal pressures imposed by the media and culture on young women, whether they are athletes or not.