Self-Reported Restrictive Eating,Eating Disorders,Menstrual Dysfunction,and Injuries in Athletes Competing at Different Levels and Sports

The purpose of this study was to investigate the prevalence of self-reported restrictive eating, current or past eating disorder, and menstrual dysfunction and their relationships with injuries. Furthermore, we aimed to compare these prevalences and associations between younger (aged 15–24) and older (aged 25–45) athletes, between elite and non-elite athletes, and between athletes competing in lean and non-lean sports. Data were collected using a web-based questionnaire. Participants were 846 female athletes representing 67 different sports. Results showed that 25%, 18%, and 32% of the athletes reported restrictive eating, eating disorders, and menstrual dysfunction, respectively. Higher rates of lean sport athletes compared with non-lean sport athletes reported these symptoms, while no differences were found between elite and non-elite athletes. Younger athletes reported higher rates of menstrual dysfunction and lower lifetime prevalence of eating disorders. Both restrictive eating (OR 1.41, 95% CI 1.02–1.94) and eating disorders (OR 1.89, 95% CI 1.31–2.73) were associated with injuries, while menstrual dysfunction was associated with more missed participation days compared with a regular menstrual cycle (OR 1.79, 95% CI 1.05–3.07). Our findings indicate that eating disorder symptoms and menstrual dysfunction are common problems in athletes that should be managed properly as they are linked to injuries and missed training/competition days.     

Bone-mineral density and other features of the female athlete triad in elite endurance runners: a longitudinal and cross-sectional observational study

Low bone-mineral density (BMD) is associated with menstrual dysfunction and negative energy balance in the female athlete triad. This study determines BMD in elite female endurance runners and the associations between BMD, menstrual status, disordered eating, and training volume. Forty-four elite endurance runners participated in the cross-sectional study, and 7 provided longitudinal data. Low BMD was noted in 34.2% of the athletes at the lumbar spine, and osteoporosis in 33% at the radius. In cross-sectional analysis, there were no significant relationships between BMD and the possible associations. Menstrual dysfunction, disordered eating, and low BMD were coexistent in 15.9% of athletes. Longitudinal analysis identified a positive association between the BMD reduction at the lumbar spine and training volume (p=.026). This study confirms the presence of aspects of the female athlete triad in elite female endurance athletes and notes a substantial prevalence of low BMD and osteoporosis. Normal menstrual status was not significantly associated with normal BMD, and it is the authors' practice that all elite female endurance athletes undergo dual-X-ray absorptiometry screening. The association between increased training volume, trend for menstrual dysfunction, and increased loss of lumbar BMD may support the concept that negative energy balance contributes to bone loss in athletes.     

Anxiety of young female athletes with disordered eating behaviors

The aim of this study was to investigate the prevalence rate of disordered eating behaviors in young female athletes and to compare the anxiety levels of the athletes with or without disordered eating behaviors. Female athletes (n=243) of 15 to 25 years old from the city, Edirne, in Turkey participated our study. Disordered eating behaviors and anxiety levels of participants were evaluated by the Eating Attitudes Test (EAT-40) and State-Trait Anxiety Inventory. Disordered eating behaviors was reported as 40 (16.7%) among all athletes. Both state and trait anxiety scores were higher in athletes with disordered eating behaviors than the athletes without disordered eating behaviors (p=0.01). The athletes who engage in leanness and non leanness sports were reported as having similar EAT-40 scores and anxiety scores. In conclusion, athletes with disordered eating behaviors have higher state and trait anxiety scores.     

The prevalence of disordered eating, menstrual dysfunction, and low bone mineral density among US collegiate athletes

The purpose of this study was to examine the prevalence of disordered eating (DE), menstrual dysfunction (MD), and low bone mineral density (BMD) among US collegiate athletes (n = 112) representing 7 different sports (diving, swimming, x-country, track, tennis, field hockey, and softball) and determine differences in prevalence existed between athletes participating in lean-build (LB) and non-lean build (NLB) sports. DE and MD were assessed by a health, weight, dieting, and menstrual history questionnaire. Spinal BMD was determined via dual energy x-ray absorptiometry. Twenty-eight athletes met the criteria for DE, twenty-nine for MD, and two athletes had low BMDs (using a Z score below -2.0). Ten athletes met the criteria for two disorders (one with disordered eating and low BMD and nine with disordered eating and menstrual dysfunction), while only one athlete met the criteria for all three disorders. Using a Z score below -1.0, two additional athletes met the criteria for all three disorders and three more athletes met the criteria for a combination of two disorders. With the exception of MD, which was significantly more prevalent among LB vs. NLB sports (P = 0.053), there were no differences between the groups in the prevalence of individual disorders or combinations of disorders. These data indicate that the combined prevalence of DE, MD, and low BMD among collegiate athletes is small; however, a significant number suffer from individual disorders of the Triad.     

Eating patterns and meal frequency of elite Australian athletes

We undertook a dietary survey of 167 Australian Olympic team athletes (80 females and 87 males) competing in endurance sports (n = 41), team sports (n = 31), sprint- or skill-based sports (n = 67), and sports in which athletes are weight-conscious (n = 28). Analysis of their 7-day food diaries provided mean energy intakes, nutrient intakes, and eating patterns. Higher energy intakes relative to body mass were reported by male athletes compared with females, and by endurance athletes compared with other athletes. Endurance athletes reported substantially higher intakes of carbohydrate (CHO) than other athletes, and were among the athletes most likely to consume CHO during and after training sessions. Athletes undertaking weight-conscious sports reported relatively low energy intakes and were least likely to consume CHO during a training session or in the first hour of recovery. On average, athletes reported eating on approximately 5 separate occasions each day, with a moderate relationship between the number of daily eating occasions and total energy intake. Snacks, defined as food or drink consumed between main meals, provided 23% of daily energy intake and were chosen from sources higher in CHO and lower in fat and protein than foods chosen at meals. The dietary behaviors of these elite athletes were generally consistent with guidelines for sports nutrition, but intakes during and after training sessions were often sub-optimal. Although it is of interest to study the periodicity of fluid and food intake by athletes, it is difficult to compare across studies due to a lack of standardized terminology.     

Eating and weight disorders in the female athlete.

This paper presents an overview of eating disorders, including definitions, clinical criteria for appropriate diagnosis, and a discussion of the potential for increased risk for eating disorders in special populations of female athletes. This is followed by a discussion of the prevalence of eating disorders in normal and athletic populations. From this discussion, it seems clear that female athletes in endurance or appearance sports are at an increased risk for disordered eating. Finally, the paper focuses on related disorders--a triad associating eating disorders, menstrual dysfunction, and bone mineral disorders. It is clear that secondary amenorrhea is associated with malnutrition and disordered eating. Further, bone mineral disorders are related to menstrual dysfunction. Disordered eating may represent the initiating factor of this triad.     

Interrelationships of diet, athletic activity, menstrual status, and bone density in collegiate women

We undertook a case-control study to examine the effect of nutritional factors on menstrual function and bone density in collegiate athletes. Three groups, matched with respect to age, height, and weight, were studied: eumenorrheic collegiate athletes, oligomenorrheic collegiate athletes, and eumenorrheic sedentary collegiate control subjects. Menarche was delayed in the eumenorrheic (13.1 y) and oligomenorrheic (14.3 y) athletic groups compared with the sedentary control subjects (12.2 y) (p less than 0.05). Average bone density tended (p = 0.10) to be lower in the oligomenorrheic athletes (158 mg/mL) compared with the eumenorrheic athletes (184 mg/mL) or sedentary control subjects (173 mg/mL). Dietary fiber intake was significantly elevated (p less than 0.05) in the oligomenorrheic athletes (5.74 g/d) compared with the eumenorrheic athletes (3.62 g/d) or sedentary control subjects (2.97 g/d). We conclude that increased dietary fiber intake is associated with menstrual dysfunction of these collegiate athletes. These factors may contribute to decreased bone density.     

A preliminary survey of dieting, body dissatisfaction, and eating problems among high school cheerleaders

Cheerleading, a staple of American schools, has received little attention in scholarly research. This sport is considered "high risk" for development of eating disorders; therefore, female, high school cheerleaders (n = 156, mean age = 15.43 years) from the southeastern region were surveyed in this preliminary study to determine rates of dieting, body dissatisfaction, and eating problems. Almost one-half of the girls (46%) indicated they were currently trying to lose weight. Body dissatisfaction was significant by race [chi 2 (2, n = 153) = 9.270, p = .010] and was reported by 50% and 73.5% of Black and White girls, respectively. About 13% of girls had EAT-26 scores of 20 or higher (possible eating problems). On the Orientation to Exercise Questionnaire, a measure of subclinical eating disorders, those with eating problems (EAT-26 score of > or = 20) had significantly higher scores (M = 87.65, p = .0002) than those without problems (M = 76.05). Furthermore, scores increased by 69% for each unit increase in BMI (p = .0481, slope = +.6902). The cheerleaders did not appear at higher risk for eating problems than adolescent girls in general, but this age group is considered at "high risk" for eating disorders, so those who work with cheerleaders should be aware of warning signs.     

Relationship among Nutritional Intake,Anxiety, and Menstrual Irregularity in Elite Rowers

There is evidence showing that excessive mental stress is detrimental to the menstrual period, and it is known that many elite athletes are highly susceptible to mental anxiety. This study investigated the nutritional intake and mental anxiety of 104 relatively young elite endurance athletes aged 16 to 23 years and used a multiple logistic model to examine the factors that might be related to menstrual irregularity. Calcium intake was marginally associated with the occurrence of menstrual irregularities (odds ratio = 1.004, p = 0.030), whereas there were strong associations between body mass or state anxiety and menstrual irregularities in elite athletes (odds ratio = 0.557, p = 0.035 for body mass; odds ratio = 1.094, p = 0.006 for state anxiety). These results suggested that state anxiety would be an important factor causing menstrual irregularity in elite endurance athletes. It is recommended that elite athletes are monitored for anxiety levels and develop a strategy for stress management.     

Eating behaviors,nutritional status,and menstrual function in elite female adolescent volleyball players

Nutritional status, eating behaviors and menstrual function was examined in 23 nationally ranked female adolescent volleyball players using a health/weight/ dieting/menstrual history questionnaire, the Eating Disorder Inventory (EDI), and the Body Shape Questionnaire (BSQ). Nutrient and energy intakes (El) and energy expenditure (EE) were determined by 3-d weighed food records and activity logs. Iron (Fe), vitamins C, B12, and Folate status were assessed using serum and whole blood. Mean El (2248 +/- 414 kcal/d) was less than EE (2815 +/- 306 kcal/d). Mean carbohydrate (5.4 +/-1.0g/kg/d) and protein (1.1+/-0.3g/kg/d) intakes were below recommended levels for highly active women. Mean intakes for folate, Fe, Ca, Mg, and Zn were less than the respective RDAs/DRIs and almost 50% of the athletes were consuming less than the RDAs/DRIs for the B-complex vitamins and vitamin C. Three athletes presented with Fe deficiency anemia (Hb <12 mg/dL), while marginal vitamin B12 status (<200 pg/ml) and vitamin C status (<28 mmol/L) were found in 1 and 4 athletes, respectively. Approximately 1/2 of the athletes reported actively "dieting". Mean BSQ and EDI subscales scores were within the normal ranges; yet, elevated scores on these scales were reported by 26% and 35% of athletes, respectively. Past or present amenorrhea was reported by 17% of the athletes and 13% and 48%, reported past or present oligomenorrhea and "irregular" menstrual cycles, respectively. These results indicate that elite adolescent volleyball players are at risk for menstrual dysfunction and have energy and nutrient intakes that place them at risk for nutritional deficiencies and compromised performance.     

Rapid screening for disordered eating in college-aged females in the primary care setting.

PURPOSE: To identify an efficient, valid, and reliable instrument for use by primary care physicians during clinical encounters to screen female adolescents at risk for eating disorders. METHODS: We created a survey of 36 questions, including the Eating Attitude Test-26 (EAT-26) and additional test questions identified through focus groups and literature review. The EAT-26 is a valid and reliable tool to identify individuals with eating disorders (1). We randomly distributed the survey to 865 college freshman women residing in dormitories at the University of Florida. The EAT-26 portion of the survey was scored according to established protocol. A score of > or =20 identified individuals likely to have an eating disorder, including anorexia nervosa and bulimia nervosa. RESULTS: 402 women completed surveys for a response rate of 47%. Based on the EAT-26 scores greater than 20, 17% of our population had scores predictive of an eating disorder. Four test questions correlated with positive EAT-26 scores: "How many diets have you been on in the past year?"; "Do you feel you should be dieting?"; "Do you feel dissatisfied with your body size?"; and "Does your weight affect the way you feel about yourself?" CONCLUSIONS: These four test questions in written format screen for disordered eating among female college students in primary care settings.     

Peer Reviewed: Screening High School Students for Eating Disorders: Results of a National Initiative

Introduction

Early identification and treatment of disordered eating and weight control behaviors may prevent progression and reduce the risk of chronic health consequences.

Methods

The National Eating Disorders Screening Program coordinated the first-ever nationwide eating disorders screening initiative for high schools in the United States in 2000. Students completed a self-report screening questionnaire that included the Eating Attitudes Test (EAT-26) and items on vomiting or exercising to control weight, binge eating, and history of treatment for eating disorders. Multivariate regression analyses examined sex and racial/ethnic differences.

Results

Almost 15% of girls and 4% of boys scored at or above the threshold of 20 on the EAT-26, which indicated a possible eating disorder. Among girls, we observed few significant differences between ethnic groups in eating disorder symptoms, whereas among boys, more African American, American Indian, Asian/Pacific Islander, and Latino boys reported symptoms than did white boys. Overall, 25% of girls and 11% of boys reported disordered eating and weight control symptoms severe enough to warrant clinical evaluation. Of these symptomatic students, few reported that they had ever received treatment.

Conclusion

Population screening for eating disorders in high schools may identify at-risk students who would benefit from early intervention, which could prevent acute and long-term complications of disordered eating and weight control behaviors.     

Disordered eating and menstrual irregularity in high school athletes in lean-build and nonlean-build sports

The authors' purpose was to determine the prevalence and compare associations of disordered eating (DE) and menstrual irregularity (MI) among high school athletes. The Eating Disorder Examination Questionnaire (EDE-Q) and a menstrual-history questionnaire were administered to 423 athletes (15.7 +/- 1.2 y, 61.2 +/- 10.2 kg) categorized as lean build (LB; n = 146) or nonlean build (NLB; n = 277). Among all athletes, 20.0% met the criteria for DE and 20.1% for MI. Although the prevalence of MI was higher in LB (26.7%) than NLB (16.6%) athletes (P = 0.01), no differences were found for DE. For both sport types, oligo/amenorrheic athletes consistently reported higher EDE-Q scores than eumenorrheic athletes (P < 0.05). Athletes with DE were over 2 times as likely (OR = 2.3, 95%CI: 1.3, 4.2) to report oligo/amenorrhea than athletes without DE. These data establish an association between DE and MI among high school athletes and indicate that LB athletes have more MI but not DE than NLB athletes.     

Relationship between athletic performance and menstrual cycle

The female sex steroid hormones have multiple actions on body systems other than the reproductive axis. Female athletes, coaches, medical professionals, and researchers have long been concerned about the potential impact of menstrual cycle fluctuations in these hormones on components of athletic performance. Estrogen is known to affect the cardiovascular system, bone, and the brain; progesterone primarily influences thermoregulation and ventilation. Substrate metabolism is likely altered by both hormones. Net physiological effects can be either opposing or synergistic and are determined by the relative proportions of each. Nevertheless, investigations to date have not consistently demonstrated significant differences in aerobic capacity, anaerobic capacity, aerobic endurance, or muscle strength in any specific menstrual cycle phase. The course of some chronic diseases may vary slightly during the menstrual cycle, but the mechanism is currently unknown. Recent research in underlying hormonal causes for anterior cruciate ligament (ACL) injuries also is not convincing.     

Knowledge, attitudes, and behaviors regarding hydration and fluid replacement of collegiate athletes

The purpose of this study was to determine collegiate athletes' knowledge, attitudes, and behaviors concerning hydration and fluid replacement. A survey containing questions pertaining to demographics and knowledge, attitude, and behavior on hydration and fluid replacement was distributed to the athletes during team meetings and practices. A total of 139 out of 171 (81.3%) athletes participated in the study. The mean age of the athletes was 19.8 y. The mean score for knowledge, attitude, and behavior was 13.9 +/-1.8, 9.8 +/- 2.2, and 12.4 +/- 2.5, respectively, with higher scores indicating positive hydration knowledge, attitudes, and behaviors. Significant positive correlation was observed between knowledge, attitude, and behavior scores (P < 0.05). Significant difference (P < 0.05) was observed in the reported hydration behaviors between skilled (11.79 +/- 2.08) and endurance (12.71 +/- 2.63) athletes. Most athletes correctly answered the general hydration questions on the survey, but the majority did not correctly answer statements in regards to National Athletic Trainers' Association (NATA) and the American College of Sports Medicine (ACSM) position stands and lacked knowledge regarding appropriate use of sports drink. The results of this study identify specific areas of education for athletes with regards to hydration.     

Adolescent aesthetic athletes: A group at risk for eating pathology?

Previous research shows that leanness- and weight-dependent sports increase the risk of developing disturbed eating behaviour. This study investigated whether adolescent aesthetic athletes (n=68, M=14.6 years), particularly ballet dancers and figure skaters, exhibit more eating pathology compared to the general population. Furthermore, it was investigated whether sport-related factors have explanatory value for the dieting behaviour of aesthetic athletes. To asses eating pathology, reliable and valid self-report questionnaires were used including the Eating Disorder Inventory-II, the Children's Eating Disorder Examination-Questionnaire and the Dutch Eating Behaviour Questionnaire. Results show that female aesthetic athletes show more drive for thinness, features of bulimia, dieting behaviour and concerns about weight and shape compared to female adolescents from the general population. Concerning the explanation of dieting behaviour in aesthetic athletes, both sport-related factors (competition state anxiety) and general risk factors (eating concern) seem to be relevant. These results suggest that female aesthetic athletes show more disturbed eating behaviour and thoughts than female adolescents from the general population and therefore may have an enhanced risk of developing clinical eating disorders.     

Predictors of disordered eating in a sample of elite Division I college athletes

OBJECTIVE: The present study sought to investigate the relationship between a number of areas of elite student-athletes' lives and disordered eating. METHOD: We surveyed 1445 elite Division I athletes at 11 different institutions and in 11 different sports. Hierarchical regression was used to indicate specific areas of the participants' collegiate experience that may be associated with disordered eating attitudes and symptomatology. RESULTS: Results demonstrate that the variables entered into each model predicted between 40.5% and 46.4% of the variance for the restriction of food, body dissatisfaction, and drive for thinness. Categories of variables that generally predicted the most variance for each dependent measure were demographics, athletic involvement, and personality. Of the 11 sports included in the analysis, wrestling and gymnastics demonstrated elevated levels of drive for thinness, food restriction, and purging behavior compared to other athletes. DISCUSSION: Findings suggest that in elite athletes gender, ethnicity, sport, and self-esteem are associated with several behaviors and attitudes indicative of disordered eating.     

The Relationship between Obligatory Exercise and Eating Attitudes,and the Mediating Role of Sociocultural Attitudes towards Appearance during the COVID-19 Pandemic

A strong sociocultural context could affect an individual’s aesthetic standards. In order to achieve a socially recognized ideal appearance, obligatory exercisers might increase dieting behavior when exercise actions are disturbed, thereby placing the individual at risk of eating disorders. The current study mainly examined the relationship between obligatory exercise and eating attitudes during the COVID-19 pandemic, and considered the mediating role of externalized sociocultural attitudes towards appearance between the two. A total of 342 participants (175 females, 167 males) from various regions of China were invited to fill out the questionnaires including the Obligatory Exercise Questionnaire, the Sociocultural Attitudes Toward Appearance Questionnaire-3, and the Eating Attitudes Test. In total, 51.5% of the participants presented symptoms of an obligatory exercise behavior. Among them, males, young adults, and the participants with lower BMI had higher OEQ scores, whereas females and young adults had higher EAT-26 scores. Meanwhile, 9.4% of the participants might have had an eating disorder. The OEQ score was positively correlated with the EAT-26 total score as well as SATAQ-3 ‘Pressures’ and ‘Information’ subscales. In addition, the EAT-26 total score was positively correlated with the SATAQ-3 ‘Pressures’ and ‘Information’ subscales. Externalized sociocultural attitudes towards appearance served as a mediator between obligatory exercise behavior and eating attitudes, and the mediation effect accounted for 56.82% of the total effect. Obligatory exercise behavior may have an indirect effect on eating attitudes through sociocultural attitudes towards appearance. Given the sociocultural information and pressures, in order to maintain or pursue an ideal appearance, many people tend to keep a pathological diet. Thus, forming a positive and healthy social aesthetic orientation is beneficial in helping obligatory exercisers to develop reasonable eating habits.     

Female athlete triad in elite swimmers of the city of Rio de Janeiro,Brazil

ObjectiveFemale athlete triad (FAT) is a syndrome characterized by the simultaneous presence of disordered eating, amenorrhea, and osteopenia or osteoporosis. The aim of this study was to assess the prevalence of FAT in adolescent elite women swimmers.MethodsThe sample was composed of 78 athletes in the age range of 11–19 y from Rio de Janeiro (Brazil). The presence of disordered eating was assessed through three questionnaires (Eating Attitudes Test, Bulimic Investigatory Test Edinburgh, and Body Shape Questionnaire); the presence of menstrual dysfunctions, through a validated questionnaire; and bone dysfunctions, through assessment of bone mineral density by applying the method of dual-energy X-ray absorptiometry. The t test was used to compare means. The chi-square test was used to evaluate the association among categorical variables (P < 0.05). Pearson's coefficients of simple linear correlation between the variables of lean body mass and body mineral density at the spine (L1–L4) and overall in the body were calculated. Kaplan-Meier survival curves to estimate mean menarche age were obtained. All analyses were conducted in SPSS 13.0.ResultsThe athletes' mean age at menarche was 12.38 ± 0.2 y. It was verified that 44.9%, 19.2%, and 15.4% of the athletes met the criteria for disordered eating, menstrual irregularity, and low bone mass, respectively. Among participants, 47.4% (37 of 78) met one criterion of FAT, 15.4% (12 of 78) met two criteria, and 1.3% (1 of 78) met all three criteria, corresponding with the development of the syndrome. Only 35.9% (28 of 78) of the athletes did not present positive results for any of the criteria assessed.ConclusionThe prevalence of FAT was low. However, a significant number of athletes presented a partial status of FAT, especially of disordered eating. The present study suggests the need to monitor the causes of these disorders to create preventive actions that will reverse or avoid the development of the syndrome, thus preserving the athletes' health.     

Idiopathic edema and eating disorders: Evidence for an association

Using a computerized self-report questionnaire format incorporating the Eating Attitudes Test-26 (EAT-26) and a modification of the McKendry criteria for the diagnosis of idiopathic edema (IE), the authors surveyed a population of women students to determine the prevalence of IE symptoms and their relationship to abnormal eating attitudes and behaviors (AEAB). The mean age of 177 respondents was 20.8 years. IE symptoms were reported by 12.4% of respondents, and AEAB by 16.4%. The prevalence of IE symptoms was 37.9% in respondents with AEAB and 7.4% in normal respondents (p = .0001). A score of 11 or greater on the modified McKendry IE criteria had a sensitivity of .37, specificity of .93, positive predictive value of .5, and a negative predictive value of .89 for an abnormal EAT-26 score. Body mass index (BMI) scores were similar for all respondent groups. © 1993 by John Wiley & Sons, Inc.