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Chapter 13
Eating Disorders:
When Rations
Become Irrational
By Karen D. Cogan
Overview
 What are the diagnosable eating disorders
athletes suffer from?
 Why do eating disorders develop?
 What places some athletes at risk for developing
eating disorders?
 How can athletes with eating disorders be
identified?
 What are the intervention strategies used to help
athletes with eating disorders?
Disordered Eating
 Does not meet criteria
for anorexia or bulimia
 Disturbances in eating
behavior that cause
distress
 Dissatisfaction with
body shape or size
Anorexia Nervosa
 Refusal to maintain a minimally normal body
weight based on age and height.
 Intense fear of gaining weight or becoming fat.
 Body image disturbance. The way in
which one’s body weight, shape, or size is
experienced.
 In women, absence of at least three consecutive
menstrual cycles (amenorrhea) or no menstrual
periods by age 16.
(Criteria from DSM-IV-TR)
Two Types of Anorexia
 Restricting anorexia:
Lose weight through severe dieting, fasting, and
excessive exercise.
 Binge-eating/purging anorexia:
Maintain a below-average weight and engage in
binge eating, purging, or both.
Bulimia Nervosa
 A cycle of binge eating and purging.
 Bingeing:
Eating large quantities of food in one sitting, much
more than most people would eat.
 Purging:
Self-induced vomiting; fasting; misuse of laxatives,
diuretics, or enemas; or excessive exercise.
(Criteria from DSM-IV-TR)
(continued)
Bulimia Nervosa (cont)
 A feeling of lack of control over eating behavior
during eating binges, often followed by a sense of
guilt that leads to purging.
 Minimum average of two binge-eating episodes a
week for at least three months.
(Criteria from DSM-IV-TR)
Eating Disorder, NOS
 Eating disorder, not otherwise specified (NOS)
• Sometimes athlete has most of, but not all, the
characteristics of an eating disorder.
• Such cases are diagnosed as eating disorders,
but as “not otherwise specified” (NOS).
• An example is an athlete who has all the
characteristics of anorexia nervosa, except he or
she is of a normal weight.
Nondiagnosable Problems
 Overeating
• Involves bingeing without the purge cycle.
• Food can be used to deal with negative emotions.
• Appearance alone is not an indicator of
overeating.
Female Athlete Triad
 Identified by the American College of Sports
Medicine (ACSM, 1997) and researcher Kimberly
Yeager and colleagues (1993).
 Consists of three components:
1. Disordered eating
2. Amenorrhea
3. Osteoporosis
 Disordered eating leads to negative energy
balance, which the body interprets as starvation.
(continued)
Female Athlete Triad (cont)
 The starving body shuts down the reproductive
capability (menstruation). Estrogen production
decreases.
 Decreases in estrogen and dietary intake of
calcium signal the bones to release calcium to
replace low blood levels. This may result in bone
loss or formation of unhealthy (low-density) bone.
Obligatory Exercise
 Excessive or
compulsive
 Will exercise despite
injury, fatigue, or
personal demands
 Shares characteristics
of those with
disordered eating:
compulsions and
rituals, rigid diets,
perfectionism, and
control over the body
Biogenetic Factors of Eating Disorders
 Malfunction in pituitary gland? (No research
evidence for this hypothesis.)
 There is a relationship with disturbed eating
behaviors in parents.
 Is it related to depression, which is also
genetically linked?
 No clear explanation yet of the role of
biogenetic factors.
Psychological Factors of Eating Disorders
 Several psychological factors have been related
to eating disorders:
• Perfectionism, especially in high-level sports
• Obsessive-compulsive traits
 Some researchers view eating disorders as an
addiction. Food is the abused substance.
 But there are differences. An alcoholic can
abstain from alcohol, but we all need food to
survive.
Environmental Factors of Eating Disorders
 Culture
• The societal norm keeps shifting toward a lean, thin ideal.
• Athletes face additional pressures concerning ideal body
makeup, especially in sports such as figure skating and
gymnastics.
 Media: Ideal standards may be impossible to attain.
 Gender roles: There may be stress caused by the
conflict between traditional notions of femininity and
the expectations of athletes.
(continued)
Environmental Factors
of Eating Disorders (cont)
 Community: May
reinforce unhealthy
approaches to eating
(e.g., wrestlers, jockeys).
 Peers: Some teammates
may teach each other
unhealthy means of
maintaining weight.
(continued)
Environmental Factors
of Eating Disorders (cont)
 Coaches:
Inadvertent comments about an athlete’s weight and
physical appearance can contribute to the
development of eating disorders.
 Family:
An emphasis on weight, appearance, and weight loss
at home can influence the development of eating
disorders.
Athletes at Risk
 DSM (2000) reports the prevalence rate of anorexia
nervosa is 0.5% for adolescent and young females.
No rate is reported for men.
 A prevalence rate of 1 to 3% for bulimia nervosa is
reported for the general population of adolescent and
young females. A rate of less than 1% is reported for
males.
 In general, men develop eating disorders at about a
tenth the rate of women, but they face unique
challenges to maintain weight in a healthy manner in
many sports (e.g., football, wrestling).
(continued)
Athletes at Risk (cont)
 A survey of elite female Norwegian athletes by
Sundgot-Borgen (1993) indicated that 1.3% met the
DSM criteria for anorexia nervosa and 8% for bulimia
nervosa.
 A survey of 1,445 American athletes by Craig
Johnson of the Eating Disorders Clinic (1999) found
rates of 9.2% of female athletes with bulimia nervosa
and 2.85% with anorexia nervosa.
 These rates are higher than that found in the general
population.
Risk: Type of Sport
 The type of sport plays a role in assessing risk.
Discuss the risks in the following sports as
classified by Sundgot-Borgen (1994):
• Endurance: rowing, cycling
• Aesthetic: figure skating, gymnastics
• Weight dependent: wrestling, judo
• Ball-game sports: volleyball, basketball
• Power sports: discus, weightlifting
• Technical sports: golf, shooting
Identifying Disordered Eating
 The following signs may indicate an athlete is
having problems with disordered-eating behavior:
• Expressed concerns about being fat
• Fear of becoming obese
• Discomfort with compliments
• Dichotomous thinking
• Depressed mood
• Negative thoughts (guilt)
• Avoidance of fat, protein, dairy
Warning Signs of Anorexia Nervosa
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Weight loss
Extremely thin appearance
Lanugo
Refusal to maintain a minimal normal weight
Denial
Avoidance of eating with others
Refusal to eat; stating, “I’m not hungry”
Eating only tiny portions at meals
Hair loss
Complaints of being cold all the time
Warning Signs of Bulimia Nervosa
 Wide fluctuations in weight over short time spans
 Wearing baggy clothing to camouflage weight
changes
 “Chipmunk cheeks” (swollen salivary glands)
 Sores on the back of hands from purging
 Candy or laxative wrappers in the trash can
 Patterns of eating large quantities of food and then
disappearing into the bathroom
 Bloodshot eyes, especially after trips to the bathroom
Medical Symptoms
 Many of these symptoms can only be diagnosed
by qualified professionals
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Laxative abuse
Diet-pill abuse or dependence
Hair loss
Brittle nails
Diminished muscle mass
Loss of menstrual periods
Gastrointestinal problems
Tooth-enamel loss or tooth decay (stomach acid from
vomiting damages teeth)
(continued)
Medical Symptoms (cont)
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Difficulty absorbing fat, protein, and calcium
Tears in the esophagus
Anemia
Ulcers
Cardiac complications
Heart arrhythmias
Bone loss
Dizziness or fainting
Electrolyte imbalance
Dehydration
Risk-Reduction Strategies
 De-emphasize weight. Weight monitoring by
coaches in unnecessary.
 Eliminate group weigh-ins which are potentially
the most destructive form of monitoring.
 Eliminate unhealthy subculture aspects of the
sport.
(continued)
Risk-Reduction Strategies (cont)
 Treat each athlete individually.
 Offer guidelines for appropriate weight loss.
 Control the contagion effect. Losing weight can
become “contagious” if losing weight becomes
the norm.
Prevention
 Ideally, sports
organizations such as
collegiate, Olympic, and
professional sports
programs will help the
most athletes by putting in
place programs to prevent
the development of eating
disorders in athletes.
 A variety of suggestions
are in chapter 13.
Treatment Options
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Individual therapy
Medications (antidepressants)
Group therapy
Family therapy
Treatment team
Inpatient treatment
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