Eating disorders and body dissatisfaction prevention in female athletes Abstract Eating disorders

Eating disorders and body dissatisfaction prevention in female athletes

Abstract
Eating disorders (ED) are more prevalent among female athletes than in the general population. The aim of this study is to perform an analysis of existing ED prevention programmes in general population and sports, and to design an ED prevention programme for adolescent female athletes. The method of this study is literature review. Controlled studies that have been effective after at least a 6 month follow-up and have been published in years 2008 – 2018 have been included: 3 studies of ED prevention in athletes and 2 studies concerning ED prevention in general population have been analysed. It has been concluded that effective ED prevention programmes for athletes feature one or more of the following elements: information about sport nutrition, extreme dieting, ED, pressures to be thin, cognitive dissonance based tasks, mental training, enhancing self-esteem. Based on the analysis, an ED prevention programme for adolescent female athletes has been designed.
Keywords: prevention, female athlete, eating disorders

1. Introduction
Clinical eating disorders (ED) and sub-clinical eating disorders or disordered eating behaviours (DEB) in athletes is a widely researched topic, and it has been found that athletes comprise a population at a high risk for developing ED and DEB: it has been reported that the prevalence of ED and DEB among male athletes is 0-19% and among female athletes it is 6-45%. ED is higher among male and female elite athletes than among adolescents in the general population and higher in female athletes than in male athletes: the estimated prevalence of ED is 14% among female adolescent athletes and 3.2% among male athletes. Also, adolescent female athletes are at a high risk of developing ED than adult female athletes. It has been reported that among the USA female college football players, 20% are at risk of developing ED. Especially prone to the risk of developing ED are female elite athletes who participate in leanness-focused sports.

ED and DEB can affect the female athlete’s performance and cause health problems due to the physical and psychological aspects of ED and DEB. One of the conditions caused by ED and DEB is the female athlete triad consisting of insufficient energy intake, which leads to irregular menstruation or amenorrhea and decreased bone density or osteoporosis. Female athlete triad’s possible effects on health are stress fractures, decreased ability to produce bone tissue, to maintain muscle mass, replace damaged tissue and recover from injury.

In female athletes the development of ED is closely connected to body image (BI). Body image is a construct consisting of multiple dimensions that refer to one’s perception and attitudes towards the size and shape of one’s body. Body dissatisfaction (BD) consists of negative beliefs about one’s body and is experienced when one perceives their body as not meeting the society’s standards of body shape and/or size. Body dissatisfaction is the most prevalent risk factor in developing ED and excessive dieting.

The data concerning prevalence of BD among athletes varies. There are studies reporting that athletes have a better BI than people in the general population and vice versa. It has been suggested that because athletes are more likely to have a body that resembles the cultural ideal, their BI is more positive than BI in the general population. However, in athletes, two types of BI can be distinguished: appearance-based BI and performance-based BI. While the appearance-based BI might closely resemble the cultural beauty standards, different sport types have their own cultural body ideals and female athletes often strive to attain those standards.

The female athletes constitute a population at risk of developing ED, therefore effective prevention must be implemented to halt the process of ED development. There is no known singular cause of ED. Genetic, biological, environmental and psychological factors all contribute to and interact in the development of ED. However, there are several risk factors for the development of ED and DEB: pressure to be thin, the thin-ideal internalization, media exposure, thinness expectancies, perfectionism, negative emotionality/neuroticism and negative urgency. Sport participation can produce some of the risk factors associated with the development of ED. In order to develop a prevention programme adapted to female athletes, the sport-specific ED risk factors must be examined and addressed.

1.1. Sport-specific risk factors for ED and BD in female athletes
Participation in leanness focused sports
ED and DEB is more prevalent in female athletes participating in leanness focused sports (antigravitation, aesthetic and endurance sports) than female athletes participating in nonleanness focused sports. A recent study found that 49% of female elite athletes who participate in leanness focused sports are at an increased risk of developing ED. Among the female college equestrian athletes, 42% are at risk of developing an ED. In track and field, long distance runners have a higher prevalence of behavioural symptoms associated with ED than athletes competing in other events. Also, female athletes participating in leanness focused sports have a higher prevalence of BD than female athletes participating in nonleanness focused sports.

However, there is also research suggesting that BI does not differ across sport types and that there are more predictive risk factors than the type of sport. It has been found that BMI is a predictive factor for BD across all types of sport, higher BMI being associated with greater BD, therefore leanness focused sport participants may actually have a healthier BI due to having a lower BMI. Nevertheless, Kong and Harris (2015) have observed that female athletes participating in leanness focused sports have greater performance-based BD than athletes from nonleanness focused sports. It has been reported that among the USA female college equestrian athletes, two thirds perceive their body images as significantly larger than their actual size and want to be significantly thinner. The authors of the study have explained the results with the sport being aesthetically oriented and athletes’ perceived pressure to be thin.
Coach related pressure to lose weight
Often coaches are the ones putting pressure on athletes to lose weight. In a study done in Australia, it has been found that 60% of female athletes have experienced coach-related pressure to lose weight. The pressure to be thin is the greatest risk factor for developing BD and ED for female gymnasts and ballet dancers – gymnasts have reported that coaches often make negative comments about their body shape and size, monitor the changes of their weight and advise restricting their food intake.

Thin-ideal internalization
The thin-ideal internalization is a risk factor for developing ED and is associated with BD and bulimic symptoms. A study done in Brazil revealed that among adolescent female track and field athletes, 25.3% are dissatisfied with their body and the thin-ideal internalization is greater in athletes who are dissatisfied with their body. Also, the athletes were more concerned about achieving the thin-ideal than a sport-type specific ideal. It has been reported that among college swimmers and gymnasts the thin-ideal internalization is one of the factors related to BD.

Extreme dieting
Extreme dieting is prevalent among female athletes due to the presumption that a lower body mass leads to better performance. However, insufficient energy intake can lead to the development of female athlete triad and it negatively affects athlete’s health and performance. It has been reported that in female athletes dieting is connected to BD. In a study exploring ED in former rhythmic gymnasts, it has been found that during their sport career, athletes believed that strict dieting and food restriction is not only normal, but essential to high performance. This attitude has been explained as stemming from the coach-related, parent and peer pressure to be thin. All the participants of the study reported being preoccupied with their body appearance.

Objectification
Female bodies become sexually objectified once girls reach puberty and their body changes. As women grow and develop, their bodies are increasingly looked at, commented and judged. It is especially true for athletes competing in front of spectators. The media often enhances the objectification of female athletes by mirroring existing norms and creating new ones. The sports media tend to create a sexualized portrayal of female athletes, emphasizing their femininity not strength, while the male athletes are portrayed as strong and competent.

Commenting female athlete’s body is one of the factors enhancing objectification. University athletes that have been verbally criticized about their body shape and/or weight are at a greater risk for developing an ED than athletes who have not experienced critical comments.

1.2. Characteristics of effective ED prevention programmes: analysis of previous reviews
ED prevention programmes have been developed with a growing frequency in the last two decades, and effective prevention programmes are emerging. Multiple reviews have focused on the qualities of effective ED prevention programmes.

The design of effective prevention programmes includes multiple sessions held in a group setting, with interactive materials and tasks. For athletes, a sports team based prevention may be effective.

The content of ED and BD prevention programmes should include cognitive dissonance tasks, media literacy, enhancing one’s self-esteem and computer based tasks. Also, it has been found that effective ED prevention programmes are based on the Cognitive behavioural theory and aim at reducing one or more of the ED risk factors – the thin-ideal internalization, perceived pressure to be thin, BD, dieting and negative affect. It can be done by delivering information about healthy nutrition, sociocultural factors associated with beauty standards and doing a media analysis. ED prevention should not only reduce the risk factors, but also promote protective factors – factors that have the opposite effect of risk factors and that disrupt the process of risk factors creating negative impact. Some of the protective factors in ED prevention are body-appreciation, mindfully caring about oneself, experiencing body’s functionality, self-compassion, perceived autonomy and freedom, having a positive self-image.

It has been found that physical activity is a preventive factor for BD and ED. However, physical activities should be organised with the aim to enhance body-appreciation and to experience the body’s functionality, not to gain results in sport or lose weight.

ED prevention programmes for athletes should be should be carried out as an early intervention before the possible onset of ED, intervention should be directed towards not only the athletes but also coaches and sport administrators in order to bring positive change in the sport environment. Sessions should be interactive with athletes completing practical tasks. The programme setting should serve as a space for athletes to express their feelings and share their experiences. Prevention should focus on educating athletes about proper energy intake and the risks associated with extreme dieting. Coaches should be educated on the female athlete triad, the symptoms, risks and consequences of extreme dieting and ED. Guidelines for addressing ED among athletes should be developed for national and international sport organizations.

2. Methods
The method used in this study was literature review. For the review, controlled studies published between years 2008-2018 that have been effective after at least a 6-month follow-up after the intervention were included. 3 studies concerning female athletes met the criteria and 2 studies concerning ED prevention in general population were included, although more met the criteria. The study by Stice, Shaw, Becker & Rhode has been analysed based on its focus on cognitive dissonance approach that has been reported as effective in ED prevention. A study by Yager & O’Dea has been analysed based on the characteristics of the participants – they were male and female trainee health education and physical education teachers, the future sport educators.

3. Findings
3.1. Studies on effective ED prevention programmes in general population
Dissonance-based Interventions for the Prevention of Eating Disorders: Using Persuasion Principles to Promote Health.
In this study dissonance-based intervention (DBI) for ED is reviewed, a programme consisting of 4 weekly 1-hour sessions is introduced and results from research on DBI are published.

Dissonance based tasks are effective in reducing the thin-ideal internalization, a risk factor for ED. In DBI the participants are not so much taught or instructed as actively engaged. By completing verbal, written and behavioural exercises aimed at criticizing the thin-ideal, cognitive dissonance is produced and the participants experience a shift of their initial attitudes towards the thin-ideal. In DBI participants complete self-affirmation tasks, do homework between the sessions, write essays, take part in role-play and engage in discussions concerning the societal pressures to attain the thin body ideal. An essential attribute of this programme is that the participants are encouraged to share their personal experience about being pressured to be thin, the costs of pursuing the thin-ideal and difficulties resisting the thin-ideal.

DBI for ED prevention has been proven to be effective at significantly reducing ED symptoms and risk factors by six independent research groups. DBI is effective in both general and high-risk groups. Also, it was found that DBI can be successfully carried out by various facilitators, not only by trained researchers. It has been found that at a 1-year follow-up there have been significant reductions in thin-ideal internalization, dieting and bulimic symptoms compared to a control group. At a 3-year follow-up there has been a decrease in BD, negative affect, psychosocial impairment and ED and DEB onset compared to an assessment only control group.

A controlled intervention to promote a healthy body image, reduce eating disorder risk and prevent excessive exercise among trainee health education and physical education teachers.
In this study 2 ED and BI intervention programmes have been examined. The participants of the study were 170 trainee health education and physical education teachers, their M age 21.6 (SD = 2.3). Based on previous findings, they were considered a population at risk of developing ED and BD. Three groups were formed: the control group where participants completed a didactic health education study course, Intervention 1 where the participants engaged in a self-esteem and media literacy health education study course and Intervention 2 where participants took part in a self-esteem, media literacy and cognitive dissonance based study programme completing online and computer-based tasks and activities. All 3 study programmes were completed over a 12 week semester with one session weekly.

The control group participants received education on human birth, growth and development, anthropometric measures, child and adolescent self-esteem and self-concept, nutrition and suicide prevention.

Intervention 1 participants took part in lectures on the same subjects as the control group but additional topics were included: weight issues in children and adolescents, BMI, body acceptance and promoting a positive BI in schools. Also, Intervention 1 included interactive student-centred, problem-based activities designed to increase the participants’ health and awareness of the subject. Media literacy and cognitive dissonance activities with the goal of reducing the thin-ideal internalization and the muscular-ideal internalization were included.

Intervention 2 participants were provided a similar content as Intervention 1, but there was a stronger emphasis on dissonance based activities: the students voiced counter attitudinal statements about the cultural body ideals, completed written assignments and took part in discussions and online forums.

The results show that Intervention 2 was the most effective: males improved significantly in self-esteem, BI and Drive for Muscularity, females improved significantly on Drive for Thinness and excessive exercise. For female participants, the effects were consistent at 6-month follow-up, the male population was not evaluated on the bases of poor retention. The greater effect of Intervention 2 has been explained by the inclusion of more cognitive dissonance activities.