This is the first study to present prevalence data on ED among adolescent male and female athletes representing almost all European sports and a sample of adolescent controls. The novelty of this study is the two-tiered design including both the questionnaire screening and clinical interview and the high prevalence of clinical ED among adolescent elite male and female athletes.
The Prevalence of ED Is High among Adolescent Elite Athletes
Our finding revealed a high prevalence of ED among adolescent elite athletes. The prevalence was higher than among the controls, although more controls than athletes self-reported symptoms associated with ED. In addition, many athletes underreported the use of unhealthy behaviors such as pathogenic weight control methods at the screening compared with the reported use in the clinical interview, which is consistent with previous studies on adult elite athletes (18,31,36).
Among the athletes, it has been reported that some look at their disordered eating (DE) behavior as a natural part of their sport and are not necessarily generally dissatisfied with their body shape or weight (6,21,36), do not realize that they have a problem (4), and thus do not report DE problems. In addition, it has been argued that the DE behavior may reflect a rational response to pressure to achieve a body shape that will ensure optimal performance and reflect dedication to their sport rather than psychopathology (6). Therefore, it seems reasonable that the specific psychological concerns of adolescent elite athletes are somewhat different to those of nonathletes presenting a similar clinical picture, and that prevalence studies based on self-reported questionnaires will not be able to distinguish these differences. Consequently, by using the clinical interview EDE and sport-specific questions, we were able to get more accurate information about the intensity and duration of the most severe symptoms being essential to diagnose ED among both the athletes and the controls. Case number 2 (Tables 4 and 5) is a good illustration of this. This female athlete had BN, but at the screening, she reported no use of pathogenic weight control methods, had scores below the cutoff for “at risk” at the EDI subscales BD and DT, and was only classified as “at risk” because of the present dieting. However, at the clinical interview, it was clear that her dieting behavior primarily was related to sport-specific weight concern. Moreover, her thoughts about weight, shape, and food were at such an intensity that they affected her self-worth and concentration and had resulted in key ED behaviors such as binging and self-induced vomiting. As a result, she met the DSM-IV criteria for BN. Subsequently, our use of a two-tiered approach confirms the difficulties that exist when it comes to identifying athletes at risk for ED, or those who already have developed an ED, and explains why it is important to use clinical interviews to assess the specific psychopathology of ED.
Because there are no previous studies that have used a two-tiered approach when investigating ED in adolescent elite athletes, it is difficult to compare the prevalence reported in our study with other studies. In general, comparing prevalence data is difficult because most studies use a variety of methodological approaches. Different populations are investigated (adolescent vs adult, collegiate vs elite vs recreational), and the number of athletes studied (n = size), the number and type of sports included, and which part of the training or competition season the data were collected vary between studies (36). Taking this into account, our findings are in accordance with the studies on older elite athletes using a two-tiered approach (7,35,38). However, the prevalence was, as expected, lower than found among older Norwegian elite athletes in 2004 (35). In contrast to our present study, Sundgot-Borgen and Torstveit (35) included the subclinical ED anorexia athletica (AA) in their prevalence study. Still, it may be argued that these athletes would have been diagnosed with EDNOS if AA had not been included. Furthermore, if AA was eliminated as a diagnosis and these athletes were classified as healthy, the percentage of ED would still be higher among both female (16.3%) and male (7.4%) athletes when using the same estimate calculation as we used in this present study. Similarly, Torstveit et al. (38) found a higher percentage of ED among adult female elite athletes as compared with the prevalence among the females in our study. Thus, although adolescence is considered to be the period of greatest vulnerability and the time when ED typically occurs, the prevalence of ED seems to be higher among adult elite athletes.
Several explanations may be relevant for the higher prevalence of ED among the adult elite athletes than the young elite athletes in this study, for example, longer duration of sport-specific demands such as competing in sports with weight class system and where the procedure during competitive events may allow use of extreme weight loss methods, physique-revealing uniforms, or competing in sports in which appearance and performance are being judged. In addition, frequent weight fluctuation has been suggested to be an important trigger factor for the development of ED in athletes (32). In our study, the athletes are in the beginning of their athletic career, whereas in Sundgot-Borgen and Torstveit’s study (35) the athletes were older and had been competing at the highest national and international level for years. Furthermore, and in contrast to previous studies on adult elite athletes (7,35,38), we found no difference in the prevalence of ED among athletes in weight-sensitive sports compared with less weight-sensitive sports. Although BD is considered an important symptom of ED (2), 50% of the athletes in our study diagnosed with an ED had BD scores above clinical values, but all reported sport-specific BD. Byrne and McLean (7) suggest that the demands of a sport to meet a particular body requirement alone, even without a high level of BD, may be enough to lead to the development of an ED. In addition, Torstveit et al. (38) found that even though the prevalence of ED was highest among athletes competing in weight-sensitive sports, fewer were dissatisfied with their bodies compared with athletes in less weight-sensitive sports and controls. This indicate that other factors than general BD may be essential for the development of ED among athletes, and it may be speculated that the higher prevalence among adult elite athletes is due to a longer duration of exposure to sports environment factors that can contribute to heightened concerns regarding weight and promote pathogenic weight control behaviors.
ED Diagnosis and the Severity
As expected, the most frequent ED was EDNOS, which is the most common ED encountered in outpatient (24) and inpatient settings (10). EDNOS is sometimes called the residual category in the DSM-IV classification because it is a “catch-all” category for eating problems that are considered to be of clinical severity but do not fulfill the criteria for AN or BN (22). EDNOS is therefore sometimes viewed as a “less severe” form of ED, but a recent study observed a crude mortality of 5.2%, similar to those found in AN (9). However, EDNOS is a residual category, and some of the athletes fulfilling the EDNOS criteria closely resemble cases of AN and BN, whereas others differ in terms of psychopathology and medical condition. As an example, one of the female athletes diagnosed with EDNOS reported fear of weight gain, loss of concentration due to bodyweight and shape and food concern, high BD, binge eating at least twice a week, and daily compulsive exercise (in addition to her planned sport-specific training) (case number 19, Tables 4 and 5). Because she reported vomiting only once a week for the last 3 months, she did not fulfill the criteria for BN. Another athlete (case number 12, Tables 4 and 5) did not report use of pathogenic weight control methods and had regular menstruation. However, she reported binge eating four times a week and fulfilled the psychological criteria for EDNOS (the binge ED). The many hours of training (16–20 h·wk−1) may explain her normal weight for age and height, despite the binge eating. Finally, case number 15 (Tables 4 and 5) fulfilled all the criteria for AN except that she had a normal weight for her age and height, and therefore, the correct diagnosis was EDNOS (partial or subclinical AN). In sum, this means that those who fulfill the EDNOS criteria differ in the degree of psychological and medical severity and chronicity. In addition to this, the characteristics of their competitive sport and the duration and intensity of the symptoms will influence the consequences of their ED behavior on acute and long-term health as well as performance (34).
Frequent binging and vomiting are examples of behavior that can lead to both health and performance consequences on a short- and long-term basis (4). For instance, bingeing generally results in gastric distention where the severity increases with an increase in the amount of food consumed during the binge (4), whereas purging by self-induced vomiting, laxative abuse, or diuretic abuse may lead to dehydration, acid–base and electrolyte imbalances, cardiac arrhythmia as well as different chronic physical problems (4). Furthermore, the combination of binging and compulsive exercise for young athletes will increase the risk of overtraining, chronic fatigue, illness, overuse injuries, and menstrual dysfunction (4).
ED athletes in this study reported use of pathogenic weight control methods ranging from not at all to daily. The same range was found for binge eating. The use of these methods and/or the extreme weight and body shape (related) stress experienced underline the acute need for treatment. Consequently, some athletes should be withdrawn from competition as well as training, whereas others can continue training during treatment (11). These challenge the type of treatment and prevention strategies that should be chosen, as well as the balance between taking risk behavior seriously, but do not morbidly challenge the behavioral or psychological traits that are common and accepted in some sports needed for success. It is therefore essential to determine whether the athletes’ abnormal eating and dieting behaviors are transient, safely managed behaviors associated with the specific demands of the sport or if the symptoms are more stable and represent a clinical ED (11,33).
Higher Prevalence of ED among Athletes Than Controls
In our study, we found a higher prevalence of ED among the athletes compared with the controls and general prevalence estimates (28). In addition to the unique pressure athletes face compared with nonathletic controls, the Elite Sport High School setting may be an additional factor that increases the risk for DE and the development of an ED. Some of the factors that may lay a high pressure on these young athletes to perform on the sport field as well as in the classroom are greater personal responsibility and maturation, perceived loss of social support, competing with the best athletes in the country, evaluation by coaches on an almost daily basis, increased training volume, lack of performance, and not being the best anymore. Some might also feel indebted to their family to achieve good results. For some, such sudden changes and high pressure might be experienced as traumatic events and serve as trigger conditions for the onset of ED. In addition, Barker and Galambos (3) found that moving away from home to attend college increased the likelihood of binge eating among young women. Other factors such as loss of coach or an illness or injury might also be conceptualized as traumatic events and trigger conditions (32).
Why more controls than athletes reported symptoms associated with ED without having an ED may be explained by the higher percentage of overweight (BMI), higher percentage with BD, and percentage reporting dieting (17). The fact that more female controls than athletes are classified as overweight in this study, with the focus on the importance of a lean body and the general experienced pressure of a thin ideal body, might have influenced the controls’ perception of their bodies and partly explain the high number with BD and DT scores above the cutoff for the “at-risk” criteria. Previous findings also indicate that females especially are dissatisfied with their bodies and tend to report DE or have high scores on the EDI without being actively dieting or using extreme methods to reduce or control weight (32). Also, the questionnaire being used may have had an effect. The EDI subscale BD is for instance not sport specific and assesses dissatisfaction with areas of the body such as stomach and hips that well-trained athletes most likely are generally satisfied with. Furthermore, the reasons for dieting or being dissatisfied with one’s own body may be different for males compared with females (16). In male athletes, high BD does not necessarily mean a desire to lose weight and or getting thinner. For instance, only 4 of our 17 male athletes with a BD score over the cutoff (≥10) present dieting, and only two of them were diagnosed with an ED (Table 4). The many false-positive male athletes and one false-negative athlete diagnosed with EDNOS also indicate that the questionnaires being used do not have the sensitivity to differentiate between male athletes who are dissatisfied with their body because they want to be more muscular, athletes who are dissatisfied because of the extra fat, or those with ED.
As expected, the use of a wide range of at-risk criteria for ED led to a high number of false positives, but more strict criteria could have resulted in too many false negatives (38). Because this study is part of an intervention aiming to prevent the development of ED, a high number of false negative would have been less advisable.
A cross-sectional study design has its limitations, but our use of a two-tiered approach by including the clinical interview EDE is considered to be the “gold standard” for diagnosing ED (7,13). Furthermore, all measurements have some weaknesses limiting their validity and reliability, but until more sport-specific measurements are developed, a two-tiered design is a good solution.
Because of ethical consideration, we prioritized to interview those classified as being “at risk” based on the questionnaire screening first. This resulted in a time difference from the screening to attending the interview between those “at risk” and not “at risk” and the athletes and controls. Because certain features of diagnostic importance in the interview are assessed over a 3-month period, and also a random selection of those diagnosed and not diagnosed with an ED was interviewed again by the second interviewer with complete agreement; we believe that this time difference most likely has not had any effect on the results. Because so many of the participants classified as healthy at the screening attended the clinical interview and only 5 of 218 were false negatives (all of them were athletes), we believe answering our questionnaire did not lead to focus more on weight, body shape, and dieting among the participants. Furthermore, when interviewing these five false-negative athletes, they all reported a history of ED, indicating that they were already experiencing ED when they fulfilled the questionnaire at screening.
The causes reported for athletes not attending school at the test day indicate that there are no reasons to believe that those not attending differed from the sample of athletes who participated in the study. Because we have no specific reasons for controls not attending school at the test day, we could speculate that some did not attend because of the test related to DE. However, it could also be due to ordinary reasons for not attending school. Based on this, we believe that the nonresponders did not skew the sample in any direction. Furthermore, the high response rate, the large number of sports included, and the fact that a representative sample of both those classified as “at risk” and healthy attended the clinical interview show that these data are generalizable to other adolescent elite athletes and controls. However, the lack of instruments designed for athletes may have had an effect on the prevalence of athletes classified as “at risk.” For instance, the BD scale might not be suited for those who are dissatisfied because they want to gain weight (increase muscle mass), which is of special interest for the male athletes representing ice hockey, team handball, alpine skiing, and some athletic events as well as discriminate between general BD and more sport-specific BD. Furthermore, because dieting is usually seen as the primary precursor to the development of DE and ED, we included the present dieting as one of our at-risk criteria. However, dieting in this special setting should maybe more correctly be considered as a “collection” factor for other symptoms not detected. Finally, it is worth noting that when comparing female athletes with ED in weight-sensitive sports and less weight-sensitive sports, we calculated the lowest detectable difference to 17.1% when the observed was 7.8%. The difference in these populations could only be detected if the number per group had been fourfold if the power had been at least 80%.
Our results support two previous important statements: 1) a clinical interview is the best available method to identify ED among both elite athletes and controls, and 2) there is a need for further development and validation of screening instruments designed for athletes. A sport-specific instrument should be designed for athletes in different kinds of sports and competition levels. Until this is established, clinical interviews should be used for accurate identification of ED.
Education about health and performance-related nutrition and body composition should be administered at an earlier age than high school. Females should especially be educated on the health and performance consequences of menstrual irregularities and the importance of seeking timely medical intervention at the first sign of abnormalities (5). Coaches as well as other athletic staff members are in a prime position to monitor their athletes’ behaviors and reactions, and therefore, mandatory education programs should be implemented on an annual basis. Finally, sports-governing organizations and federations should give support to the coaches and provide education for coaches, athletic staff, and athletes (36).
This study is the first to confirm that the prevalence of ED is higher among adolescent elite athletes than controls and higher in female than male adolescent elite athletes. It also confirms the difficulties that exist when it comes to identifying male and female athletes “at risk” for ED and the need for a clinical interview to identify athletes who already have developed an ED.
The authors thank Professor Roald Bahr for his helpful comments on this article and Professor Ingar Holme for his assistance with the statistical analysis. We also thank all the subjects and their coaches for full cooperation and support during this study, and Audun Erikson, Guro Røen, Laila Sundgot Schneider, Runi Børresen and Kristin Brinchman Lundestad with regard to the collection of data. The Oslo Sports Trauma Research Center has been established at the Norwegian School of Sport Sciences through generous grants from the Royal Norwegian Ministry of Culture, the South-Eastern Norway Regional Health Authority, the International Olympic Committee, the Norwegian Olympic Committee and Confederation of Sport, and Norsk Tipping AS. The project has been established through a grant from The Norwegian Olympic Sports Center (Olympiatoppen).
There are no potential conflicts of interest.
The results of the study do not constitute endorsement by the American College of Sports Medicine.
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Keywords:©2013The American College of Sports Medicine
ANOREXIA NERVOSA; BULIMIA NERVOSA; EDNOS; SPORT; ELITE; CLINICAL INTERVIEW