Behind the athletic body: a clinical interview study of identification of eating disorder symptoms and diagnoses in elite athletes

Abstract

Eating disorders are more prevalent in athletes than in the general population and may have severe consequences for sports performance and health. Identifying symptoms can be difficult in athletes because restrictive eating and slim body images are often idealised in a sports setting. The Eating Disorders Examination Questionnaire (EDE-Q) and the SCOFF (Sick, Control, One stone, Fat and Food) questionnaire (SCOFF) are widely used generic instruments to identify symptoms of eating disorders. This study aimed to investigate the instruments’ validity and explore eating disorder symptoms in a sample of athletes.A sample of 28 athletes (25 females) competing at a national level was interviewed based on the diagnostic criteria for eating disorders. We interviewed 18 athletes with a high score on EDE-Q and 10 with a low score. All interviews were transcribed and analysed from a general inductive approach. We identified 20 athletes with an eating disorder diagnosis, while 8 had no diagnosis. EDE-Q found 90% of the cases, while SCOFF found 94%. EDE-Q found no false-positive cases, while SCOFF found one.The qualitative results showed that most athletes reported eating concerns, restrictive eating, eating control (counting calories), weight concerns, body dissatisfaction (feeling fat and non-athletic), excessive exercise and health problems (eg, pain, fatigue).In conclusion, EDE-Q and SCOFF seem valid instruments to screen athletes’ samples but may fail to find 6%–10% cases with eating disorders. Despite athletic bodies and normal body mass index, many athletes report severe eating problems and dissatisfaction with weight and body appearance. Implementation of regular screening may identify these symptoms at an early stage.

A Review of Mental Health Issues in High-Performance and Elite-Level Cycling

“…These are underlined by qualitative work from Lichtenstein et al, which revealed psychosocial pressures from a cyclist's family: "My father says that cyclists starve themselves. He says I shouldn't weigh more than 60 kg" [34]. Such findings raise concerns for athlete wellbeing, as do data from our review showing extreme weightloss practices, like fasting [32], supplement use [32,33,35], and purging [33,35].…”

“…The papers in our results discuss mental health issues or evidence of psychiatric symptomatology per ICD-11 classifications. These included ED in eight studies [30][31][32][33][34][35][36][37], depression in five [30,32,[38][39][40], anxiety disorder in two [38,40], sleep wake disorders in two [38,41], SUD in two [30,38], and ADHD in one [42]. However, with the exception of three instances of secondary analysis [36,39,42] and one cohort of n = 122 cyclists [35], primary investigations had relatively small sample sizes; this is not atypical since practical and logistical challenges can occur when recruiting elite-level or highperformance athletes [43].…”

“…Lichenstein, Johansen, Runge, Hansen, Holmberg, and Tarp, 2021 [34] Mixed-method investigation of n = 28 Danish athletes, including n = 4 female cyclists. Participants had previously completed the Eating Disorders Examination Questionnaire and the Sick, Control, One, Fat and Food questionnaire and subsequently participated in qualitative interviews.…”

“…Alongside proneness to clinical ED, these could conceivably include cardiovascular issues [51], depression [32], SUD [52], overtraining syndrome (OTS) [53], and exercise addiction (EXD) [44]. Significantly, whilst the latter is not classified in ICD-11 [27], secondary EXD has previously been noted in high-performance cyclists [54] and excessive exercise and harmful training protocols were identified in several reviewed articles [e. g. [33,34,39]].…”

Body Mass Index trends in men’s Grand Tour cycling events from 1992-2022: Implications for athlete wellbeing and regulatory frameworks

“…The BMI trends in our data and evidence of harmful behaviours and attitudes in cycling suggest that multifactorial regulatory measures may be required. To that end, screening tools can help identify ED symptomatology in various sporting disciplines [7,49], which could prove bene cial if implemented within elite-level cycling. Nonetheless, as Ribel et al discuss, self-reported instruments might not necessarily be reliable because deleterious weightmanagement practices may be normalised [11] and diagnostic tools would need to be adapted to account for inherent gender biases [50].…”