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.

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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.
3.2. Studies on effective prevention programmes for female athletes
Long-term outcomes of the ATHENA (athletes targeting healthy exercise & nutrition alternatives) programme for female high school athletes.
In this study the focus was not only on ED prevention but also on the reduction of alcohol, drug and tobacco use in female high-school athletes. The study was carried out in 18 high schools in the USA, Oregon and Washington, M age of participants was 15.4 (SD = 1.2) in the experimental group and 15.3 (SD = 1.2) in the control group. The types of sport in the control and the experimental group were also matched.
The experimental group took part in the ATHENA prevention programme. The ATHENA programme consists of 8 weekly 45-minute sessions integrated in the sports team’s practice. The athletes were organized in approximately 6 person squads with one of them as a leader in each squad. The leader had been coached before the session and led approximately 70% of the ATHENA assignments. The content of this programme addresses the consequences of substance abuse, sport nutrition and effective training. The ATHENA also addresses depression, using cognitive restructuring tasks. In order to challenge the media influences, participants remade magazine advertisements. Athletes practiced refusal skills and learned about health norms. Also, at each session, the athletes received a health goal to complete during the week until the following session. The control group received informative pamphlets concerning DEB, drug use and sport nutrition.
The study reports that the ATHENA had positive long-term effects on female athletes’ use of diet pills, laxatives and diuretics and self-induced vomiting. Also, the behaviour became less prevalent over time, in comparison with previous follow-up assessments. Also, when athletes were asked to choose the most healthy and attractive female silhouettes, they chose significantly heavier silhouettes than the control group suggesting that their thin-ideal internalization is lower.

Can we reduce eating disorder risk factors in female college athletes? A randomized exploratory investigation of two peer-led interventions.
This study explores the effectiveness of two peer-led ED prevention programmes adapted for female college athletes: athlete-modified dissonance prevention (AM-DP) based on the guidelines developed by Stice, Shaw, Becker & Rhode, 2008, and athlete-modified healthy weight intervention (AM-HWI). Participants were 157 female college athletes competing in 9 different sports, their M age = 18.94 (SD = 1.04). Athletes with ED were excluded from the programme, because they needed ED treatment not prevention. The programme was adapted to each sport team based on the BI concerns specific to different sport types. Team members were randomised so that half were assigned to AM-DBP and half to AM-HWI. Interventions were carried out during 3 weekly 60-80 minutes sessions. The sessions were carried out in a group setting, each group consisting of 2-14 athletes, they were peer led by a team member and athletes from other teams.
The AM-DBP sessions consisted of tasks aimed at challenging the sport-specific thin-ideal, gaining insight of the risks of female athlete triad and sharing their experiences of being pressured to pursue the sport-specific thin-ideal. Athletes completed written tasks, did homework, engaged in discussions, role plays and self-affirmation tasks. This programme differs from DBP by exploring topics concerning the athletic population in particular: the sport-specific thin-ideal and information on female athlete triad.

The AM-HWI also included the two topics specific to female athletes – the sport-specific thin-ideal and female athlete triad. The intervention consisted of information, discussions and written tasks on the sport-specific thin ideal and athlete-specific healthy-ideal, optimal energy intake based on the activity level, female athlete triad, healthy nutrition and dietary restriction. Each athlete completed a 3 day food and exercise diary and developed healthy nutrition and sleep goals.

The results suggested that both prevention programmes reduced thin-ideal internalization, dieting, bulimic behaviour, shape and weight concern and negative affect at 6 weeks and bulimic behaviour, shape concern and negative affect at a 1 year follow-up (Becker et al., 2012).
Preventing eating disorders among young elite athletes: a randomized controlled trial.This 1 year intervention programme has been developed to prevent ED in young male and female athletes and focuses on educating both athletes and coaches. The programme is based on the social-cognitive framework, it aims to strengthen intrinsic motivation and mastery, to enhance self-esteem by enhancing self-efficacy and bring change in both individual and school organization level. Cognitive dissonance principles are also used.
The participants were adolescent athletes from all 16 Norwegian Elite Sport high schools, 9 of the schools were randomized to the intervention group and 7 of them as well as 2 regular high schools were the control group and did not receive any intervention. The number of participants in the experimental group was 348 athletes and 65 coaches, in the control group: 263 athletes, 36 coaches and 355 students from the 2 regular high schools. Athletes with ED were not participating in the study.
The intervention programme consisted of mental training (relaxation, visualisation, self-talk), education on healthy nutrition, psychological and physiological development in adolescence. Athletes participated in four 90-minute sessions over a 1-year period and engaged in communication with the researchers via e-mail and a closed Facebook group. Each week during the last 6 months of the intervention, a different Norwegian elite athlete shared his or her experiences concerning self-esteem, self-efficacy and mental training. Also, athletes were encouraged to write three positive events unrelated to sport every day for a specific time period.
The education programme for coaches was developed to inform coaches about self-esteem, self-efficacy, mental training, sport nutrition, body composition and the identification, management and prevention of ED. Information was also provided to parents, school administrators and teachers.
The results of the study suggest that the intervention programme has been successful at preventing new cases of ED and reducing ED risk factors among female elite athletes. Also, the education programme for coaches has shown a self-reported increase of knowledge about ED. In male athletes no differences in ED emergence were observed between the control and experimental group.
4. Results, Conclusions and Recommendations
The review of the 5 effective ED prevention programmes has revealed common aspects of effective ED prevention: cognitive dissonance based tasks – challenging and criticizing the thin-ideal and self-affirmation tasks, the sessions were carried out in a group setting, there were multiple sessions, education on ED, human development and healthy nutrition was provided and the participants were actively engaged in the programme via writing assignments, homework, role play, online communication and discussion.
Although ED prevention is being increasingly studied, there remain few effective ED prevention programmes for athletes. ED is more prevalent among female athletes than in the general population. ED in female athletes can lead to development of female athlete triad. There are multiple sport-specific ED risk factors: participation in leanness focused sports, coach related pressure to lose weight, thin-ideal internalization, extreme dieting and objectification. In order to prevent female athletes from developing ED, the impact of these risk factors should be reduced by developing and implementing effective prevention.
Based on the analysis of previous reviews of ED prevention programmes and the review done in this study, a prevention programme for adolescent female athletes has been developed. The programme is not intended for athletes with ED, as they need treatment not prevention. An overview of the prevention programme is presented in the table no.1.
Table 1. ED prevention programme for adolescent female athletes
Week Educational lecture Practical tasks
1. ED prevalence in sport, general risk factors, symptoms, prevention. Mental training: enhancing performance and well-being. Discussion: current knowledge of ED, opinion on mental training.
Mental training: breathing, relaxation.

2. BI in sport and in general. The sociocultural pressures to be thin, sport-specific body ideals. Attributes of positive BI. Discussion: experience concerning BI, pressure to be thin in everyday and sport settings.

Dissonance based task: counter-attitudinal written task
Mental training: breathing, relaxation.

3. Extreme dieting. Female athlete triad. Optimal energy intake, healthy BMI.
Discussion: sharing experience and opinion on dieting, the role of nutrition in sport.
Mental training: breathing, visualisation.

4. Participation in leanness focused sports and coach related pressure to lose weight. A guest elite athlete sharing her experience about being pressured to lose weight and overcoming it. Discussion: experience of coach-related pressure to be thin, questions to the guest.

Dissonance based task: writing a letter to oneself highlighting one’s positive physical and personality traits.

Mental training: breathing, visualisation.
5. Thin-ideal internalization. Healthy sport-specific ideal. The positive effect of mindfulness on sport performance and well-being. Discussion: the experience of thin-ideal internalization.

Dissonance based task: verbal critique of the thin-ideal based on facts learned in the previous sessions.
Mental training: mindfulness meditation.

6. Objectification. Comments on female athlete’s body. Media portrayal of the female athlete’s body (visual examples): sexualized versus strong. Comparing the representation of female and male athletes. Discussion: experience of hearing comments about one’s body, opinion on female athletes’ portrayal in sports media.
Dissonance based task: writing a letter to the editor of a sports magazine recommending a less objectified representation of female athletes
Mental training: mindfulness meditation
7. Self-compassion and self-acceptance as a step toward a more positive BI. A guest elite athlete sharing her experience with BI issues and self-acceptance. Discussion: sport environment and self-compassion, questions to the guest.

Dissonance based task: expressing pride and gratitude to oneself for all the work put into training, school and other activities.
Mental training: mindfulness meditation.

8. Overview of the programme, everyday actions towards a positive BI. Discussion: stating the changes in attitude and knowledge the programme has brought.

Dissonance based task: a written or verbal resolution to use the acquired knowledge to act against the ED risk factors and practice self-acceptance.
Mental training: mindfulness meditation.

The study done by Martinsen, et al. (2014) has shown that mental training has positive effects on ED prevention and reduction of ED risk factors. This prevention programme will primarily focus on mental training with the aim to enhance emotion regulation skills, self-compassion and mindfulness: mental skills that have not been extensively researched in connection with ED prevention. The programme focuses on reducing the sport specific ED risk factors and enhancing protective factors. Based on the promising results of cognitive dissonance based prevention, dissonance based tasks are included. Also, an emphasis is put on sharing personal experience, as in the prevention programme.

The programme is intended to be carried out in 8 weekly 1-hour sessions, each session includes both educational lecture and practical tasks, 20-40 minutes each part, based on the subject of the session. No homework assignments are given due to the usually busy schedule athletes have. However, athletes would be presented with addition online information sources on the subject covered in the session. The groups should consist of 6-8 participants in order to enhance active participation.