Sport Related Risk Factors

Many in sport believe that weight or body fat reduction enhances sport performance, and so there can often be pressure to lose weight.  Unfortunately, sometimes unhealthy and risky eating behaviors may be encouraged for weight loss.  These behaviors more typically damage performance rather than enhance it.  Due to the focus on leanness in many sports, athletes may develop competitive thinness with peers, and may feel added pressure to lose weight.  This is known as the contagion effect and may include subcultural expectations to look a certain way, known as the “sport body ideal.”  Another concern, especially common among female athletes, is the revealing nature of sport uniforms, which in turn increases body image concerns.  Individuals who participate in the Aesthetic/Lean/Judged sports, such as gymnastics, diving, and figure skating, are at the highest risk for unhealthy body image and eating difficulties.  Further, there seems to be a parallel between “good athlete” traits and eating disorder characteristics, so that coachable, perfectionist, and compliant athletes may be at greater risk for the development of eating concerns.  Finally, identification of eating concerns in sport is more challenging and may delay early intervention and treatment.

iStock_000015504497SmallDetermining Unbalanced Exercise

There are many indicators that “unbalanced”, “unhealthy”, “compulsive” or “damaging” exercise is occurring.  Excessiveness can show up in frequency, duration, or intensity of exercise.  Exercise should be considered unbalanced if:

•  Exercise continues despite illness or injury

•  Exercise interferes with balanced activities and relationships

•  Exercise is rigid: must exercise in a narrowly defined way or at a certain time

•  Exercise is a rigid obligation: must happen regardless of any life circumstance of higher importance

•  Exercise is the primary and only means of coping with stress

• Exercise reduction leads to withdrawal symptoms such as: agitation, anxiety, anger, insomnia, appetite changes, feelings  of guilt, etc.

Unbalanced exercise can be observed in patterns of activity and in patterns of exercise versus appropriate nourishment to sustain the activity level.  Asking specific questions about exercise can reveal patterns and asking specific questions about the physical, social, mental, and emotional consequences of exercise or not exercising can also shed light on unbalanced exercise.  It is not only external or behavioral patterns which indicate “unbalanced” exercise, but also “internal” responses and motives which illuminate the depth of potential problems with exercise.

How Does One Know if an Athlete is Struggling With an Eating Disorder?

When someone is struggling with an eating disorder, the signs and symptoms will show up in all areas of life: physical, social, mental, emotional, and spiritual.  The symptoms are straightforward and many of them are observable, yet those suffering with eating disorders are most often experts at hiding their struggles and minimizing their symptoms.  They have many reasons to keep their struggle secret.  Athletes have additional motives in keeping the illness hidden, as they don’t want their participation restricted.  Some eating disorder signs and symptoms in an athlete are as follows:

• Actions suggesting need for perfection

• Low self-esteem, which motivates need for achievement & perfection

• Extreme sensitivity

• Obsessive & compulsive behaviors

• Over-achievement

• Lack of self-confidence

• Drastic weight changes

• Changes in eating habits

• Excessive exercising or over-training

• Frequent trips to the bathroom

• Refusal to share feelings

• Frequent excuses

• Lying

• Chewing a lot of gum

• Excessive drinking of liquids, especially diet drinks

• Avoiding food or serious restriction

• Guilt feelings after eating

• Social isolation

• Watching what others eat

• Loss of interest in enjoyable activities

• Binge-eating with no weight gain

• Comments about purging food or calories

• Weakness, fainting, etc.

• Red eyes

• Calluses & blisters on knuckles

• Comparison of body, beauty, etc.

•  Comments of body dissatisfaction or body hatred

• Depression

• Tendency to order food in small and insufficient amounts

• Solving other’s problems, but ignoring one’s own

• Avoiding any contention at all

• Self-harm or suicidal thoughts

• Wearing baggy clothes to hide body

• Avoiding responsibility

• Preoccupation with food

• Defensiveness about food, weight, etc.

• Obsession with dieting, calorie-counting, low-fat foods, diet pills, laxatives, etc.


How Do I Know if I am an Unbalanced Exerciser?

• Do I exercise at inappropriate times or settings?

• Does exercise negatively impact my relationships?

• Do I exercise despite illness or injury?

• Does exercise negatively impact my psychological or physical health?

• Does exercise interfere with everyday activities, such as work or school?

• Do  I exercise in order to create an energy deficit despite normal or low weight?

•  Do I feel significant anxiety or guilt if I don’t exercise?


Consequences of Unbalanced Exercise

The consequences of unbalanced exercise can be serious.  Consequences include development of compulsive exercise disorder, impaired balance in life and consequent reduction in general quality of life, premature loss of career as an elite athlete, physical, skeletal, and internal organ damage, including cardiac arrest and death.  These potential consequences outweigh the temporary consequence of potential and illusive fear of loss of “peak performance.”  Some of the many consequences of unbalanced exercise include the following:

• Decreased bone density (Osteopenia or Osteoporosis, depending on severity)

• Stress Fractures:  Overuse injury that occurs when muscles are fatigued & unable to absorb added shock, which then transfer overloaded stress to the bone, resulting in a fracture

• Hormonal Changes:  Loss of menstrual period for females, low testosterone level for males

• Recurrent injuries (Soft tissue strains)

• Decreased immunity (Intense exercise for extended periods of time decreases the strength of the auto-immune system)

• Overtraining Syndrome or Staleness (failure to make expected training gains)

• Female Athlete Triad:  Low energy availability, menstrual irregularities, & bone loss

• Dehydration, Heat Stroke, Hyponatremia• Potentially lethal cardiac events (Sudden Arrhythmia Death Syndrome, Prolonged QT Interval)

• Added stress when responsibilities & relationships are sacrificed for exercise

• Depression, anxiety, irritability when exercise is sole coping behavior

• Rationalize exercise for “health” when actually putting health at greater risk

• Isolation or withdrawal due to exercise compulsion• Depression due to Overtraining Syndrome

• Exercise to compensate for or legitimize eating

• Exercise to maintain negative energy balance (despite hunger, intentionally eat less if unable to exercise)

•  Increased risk of development of eating difficulties or eating disorders


Tips for Coaches in Protecting the Athlete From the Damage of Unbalanced Exercise

Coaches play a critical role in not only the performance of the athletes they coach, but in the general health and development of those under their tutelage and example.  Their impact is on the “person,” not just the “performance.”  The importance of development of character as an individual transcends the importance of performance as an athlete.  With this great opportunity and power comes responsibility to watch out for the health and welfare of the athlete far beyond performance.  That balance between “pushing the performance now” versus “longer term performace” and overall health is a fine line. To aid in this difficult yet rewarding responsibility, coaches may consider the following:

• Do pre-athletic screening exams for eating disorders

• Focus on the whole athlete, not just athletic performance

• Know that weight loss does not equal performance enhancement

• Loss of menstruation is a sign of physical dysfunction, not a sign of effective training

• Avoid comments and comparisons on weight, body image, and appearance

• Focus on health, not weight

• Know that quick weight loss results in loss of lean muscle which equals decreased performance

• Don’t be afraid to talk to an athlete about your concerns

• Enlist support within the community (athletic trainers, sports psychologist, ED specialists, dietitians, physicians)

• Assure the struggling athlete gets professional help

• Allow time for athletes to eat and hydrate

• Don’t encourage extra or excessive training or workout sessions

• Don’t allow sick or injured athletes to train or compete

• Provide sound nutrition education

• Don’t encourage crash or fad diets in preparation for competition

• Don’t do body composition tests or group weigh-ins.  These shame individuals!

• Provide ongoing education; the coach’s perspective has a critical impact on athletes’ perceptions

• Use common sense education; convey the seriousness of eating disorders without highlighting war stories

• Don’t glamorize eating disorders or place them on a pedestal

• Address emotional, social, & physical aspects of eating disorders

• Focus on sport-specific information (nutrition, sports performance, & body composition)

•  Use your positive influence to nurture the athlete towards healthy living in addition to athletic performance


Approaching an Athlete:  What Not To Do

• Don’t confront the athlete in a group of people or in the presence of others

• Don’t be judgmental; don’t tell the athlete that what he or she is doing is “sick” or “crazy”

• Don’t follow the athlete in an effort to “catch” them in eating disorder behavior

• Don’t give advice about weight loss, exercising, or appearance beyond your own expertise in sport training

• Don’t label someone with an eating  disorder because there are some signs.  Leave that to diagnostic experts.

• Don’t get into an argument or battle of wills

• Don’t promise to keep secrets

• Don’t try to police the athlete’s eating or force the athlete to either eat or not eat

• Don’t let the athlete monopolize your time & energy

• Don’t try to fix the athlete’s problems and don’t attempt to help them by yourself.  Expand the circle of support.


How to Approach the Athlete

Who:  Who should approach the athlete when a potential eating or “over exercising” concern is identified?  An individual in a position of authority as part of the Sport Management Team is best equipped to approach the athlete.  The individual who has the best rapport and closest relationship with the athlete is ideally positioned to address concerns.   A fellow teammate should NOT be the one to approach an athlete as there is no power behind the intervention, it may create a dependent relationship, and it could exacerbate an already competitive relationship or contribute to the development of a competitive relationship.  Be prepared for a negative response, including denial, when first approaching an athlete with concerns.

When:  As soon as an individual close to the athlete identifies a potential problem, based on the presence of a number of signs and symptoms.  Early identification results in fewer and less severe complications, less resistance to treatment, and faster, easier, and more positive treatment outcome.

How:  In approaching an athlete, express concern and ask how the athlete feels, both physically and psychologically.  The athlete needs to know that people care and that others will not criticize or embarrass them.  Focus on the athlete’s well-being, and approach the athlete gently, with no accusations.  Ask, rather than tell.  Assess, rather than judge.  One goal of intervention includes maximal sensitivity and minimal invasiveness.

Speak to the athlete privately and allow time to talk.  Express your concern to the athlete and calmly share the specific observations that arouse your concern.  Allow the athlete time to respond, and listen in a non-judgmental manner.  Keep your focus on the concerns you have observed.  If the information you receive suggests an eating disorder and/or excessive exercise, share with the athlete that a) you think the athlete may have a problem, and b) you are concerned about the athlete’s health and well-being.

Be prepared to offer resources, including counseling, dietary, physician, and community referrals.  Assist the athlete in making parents and other support systems aware of the concern.


Refusal of Treatment

It is imperative that the athlete be encouraged to accept treatment as soon as reasonably possible.  However, sometimes despite best efforts, athletes may refuse treatment.  If the athlete initially refuses treatment, don’t push too hard unless you suspect the athlete is at risk medically.  Make continued sport involvement contingent on the athlete seeking and complying with treatment and physical health.  Allow the athlete to remain a part of the team by attending practices and competitions. Don’t “kick the athlete off the team.”

Suspension from the team is the last resort as the athlete may continue to train on their own, which may be more dangerous as there is no monitoring.  Suspension may deprive the athlete of their primary source of positive feelings and self-esteem.  The athlete may view suspension as an attempt by others to control, and thereby respond with frustration and increased resistance.  If all attempts to persuade an athlete to evaluation and treatment fail, there is no alternative but suspension.

Enlisting a Support Network

The Sport Management Team has a responsibility to inform parents of concerns, ensure the athlete is seeking treatment, and use athletic participation as appropriate leverage for seeking treatment. Comprehensive Release of Information forms for the full treatment team (therapist, dietitian, physician, athletic trainer, coach) should be in place to ensure coordination of care.

Ongoing communication between team members is essential as the support network becomes a united front against the eating disorder illness — not the athlete.  A treatment plan devised through ongoing communication should include criteria for athletic participation.  Ongoing communication also ensures appropriate boundaries are maintained throughout treatment.  Each team member supports and encourages the treatment approach and clear communication ensures that various treatment team members are not undermined.  Abiding appropriate boundaries also prevents the athlete from receiving mixed messages.  When there is a concern or question, support network members defer to the treatment team for consultation.


The Exercise Balance by P. Powers & R. Thompson (2008), Gurze Books.  

Eating Disorders in Sport by R. A. Thompson & R. T. Sherman (2010), Routledge.

Eating Disorders:  Physical, Social & Emotional Consequences.  Secondary education lesson plans about eating disorders, Foundation for Change (2001).  

Helping Athletes with Eating Disorders by R. A. Thompson, & R. T. Sherman (1993), Human Kinetics Publishers.  

Eating Disorders and Athletes:  A Handbook for Coaches edited by S. C. Holliman (1991), Kendall/Hunt Publishing Co.