Prevalence of Low Energy Availability and Disordered Eating in Athletes

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To date, no published studies have examined the prevalence of low energy availability among female athletes. Such research likely would prove difficult to conduct because it would necessitate accurately assessing energy intake and exercise energy expenditure. The limitations inherent in self-reported energy intake (eg, food records) and energy expenditure (eg, activity records) are well documented [20], and the expense or lack of generalizability involved in more direct measures (eg, metabolic feeding studies, doubly labeled water, whole room cal-orimetry) render such assessments impractical. Nonetheless, if it is assumed that most female athletes with disordered eating also are experiencing low energy availability, one can garner an estimate, albeit indirect, of prevalence.

Current estimates of the prevalence of disordered eating, including pathogenic weight control behaviors and subclinical and clinical eating disorders, range from less than 1% to 62% in female athletes [2,21,22] and 0% to 57% in male athletes [21,22]. These wide-ranging estimates are due to differences in screening instruments and assessment tools (eg, self-report questionnaires versus in-depth interviews), definitions of ''eating disorders'' employed (eg, few have used the DSM-IV criteria), and athletic populations studied (eg, collegiate versus high school athletes, elite athletes versus recreational athletes versus physically active people). Only four studies have used large (N > 400) heterogeneous samples of athletes and employed validated measures of disordered eating (Table 2) [23-26]. The remainder employed inadequate sample sizes, examined single sports, or used inappropriate measures of disordered eating, all of which can bias prevalence estimates.

Research suggests that the prevalence of disordered eating is higher in sports that emphasize a lean physique or a low body weight (ie, thin-build sports [23,25-27]). It has been hypothesized that the body weight demands of these

Table 2

Summary of prevalence studies including large, heterogeneous samples of athletes and validated assessments of disordered eating





Beals and Manore (2002)

Johnson, Powers, and Dick (1999)

425 female collegiate athletes athletes (883 men and 562 women) from 11 NCAA Division I Schools

Sundgot-Borgen (1993)

Sundgot-Borgen et al. (2004)

EAT-26 and EDI-BD

1445 collegiate EDI-2 and questionnaire developed by the authors using DSM-IV criteria

522 Norwegian elite female athletes

660 Norwegian elite female athletes

EDI and in-depth interview developed by the author based on DSM III criteria A 2-stage screening process including a questionnaire developed by the authors, including subscales of the EDI, weight history, and self-reported history of eating disorders (stage 1) followed by a clinical interview using the EDE (stage 2)

3.3% and 2.4% of the athletes self-reported a diagnosis of clinical anorexia and bulimia nervosa; 15% and 31.5% of the athletes scored above the designated cutoff scores on the EAT-26 and EDI-BD None of the men met the criteria for anorexia or bulimia nervosa; 1.1% of the women met the criteria for bulimia nervosa. 9.2% of the women and 0.01% of the men met the criteria for subclinical bulimia; 2.8% met the criteria for subclinical anorexia. 5.5% of the women and 2% of the men reported purging (vomiting, using laxatives or diuretics) on a weekly basis 1.3%, 8%, and 8.2% were diagnosed with anorexia nervosa, bulimia nervosa, and anorexia athletica 21% (n = 21) of the female athletes were classified "at risk'' after the initial screening. Results of the clinical interview indicated that 2% met the criteria for anorexia nervosa, 6% for bulimia nervosa, 8% for eating disorders not otherwise specified (EDNOS) and 4% for anorexia athletica

Abbreviations: EAT-26, Eating Attitudes Test-26 [86]; EDI, Eating Disorder Inventory [87]; EDI-BD, Body dissatisfaction subscale of the EDI [87]; EDI-2, Eating Disorder Inventory 2 [88]; EDE, Eating Disorder Examination [89].

Data from Beals KA. Disordered eating among athletes: a comprehensive guide for health professionals. Champaign (IL): Human kinetics; 2004.

sports, and the pressure to achieve an ideal body weight, whether real or perceived, causes a female athlete to become overly concerned with her body weight and develop disordered eating behaviors [18,25].

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