Harmful Dieting Affects Both Genders

By Natalie Bickford, MS

We go into a lot more detail in Run Fast. Cook Fast. Eat Slow about eating disorders (EDs) in female athletes and the Female Athlete Triad. We have recently gotten inquiries from coaches and concerned parents about the lack of information for male athletes. We would love to address that here and reassure male runners, struggling with disordered eating habits, that they are not alone. The content and information within the Run Fast. Eat Slow. cookbooks will also help young men develop a healthier relationship with food.

It’s often assumed that EDs only affect female athletes, but they are also very prevalent in male athletes. In fact, only in 1994 were males able to meet the DSM criteria for anorexia after removing ‘amenorrhea’ as diagnostic criteria (1). This goes to show how our culture has largely focused on women and ignored men in this department.

Statistics on Eating Disorders in Athletes

Athletes are 2-3 times more likely than the average individual to develop an eating disorder (BED) (2).
Males constitute 25% of individuals with anorexia and about 40% of those with binge eating disorder (2).
A study on 583 male and female triathletes showed that 11% of participants were preoccupied with food and weight, 23% were engaging in restrictive calorie-controlling behaviors, and 100% of the sample were unhappy with their current BMI (4).
Of all NCAA institutions, only about 7% employ a full time Registered Dietitian (RD) within the sports program and they are all D1 level.

An Interview with an Expert

I interviewed Dr. Paula Quatromoni, DSc, MS, RD, LDN who is one of the nation’s top minds on the intersection of sports nutrition and eating disorders. She is a Nutrition professor at Boston University and a senior consultant for Walden Behavioral Care.

Why are eating disorders in male athletes on the rise? How common is it?

ED’s in males are increasing because of the increasing pressure in our culture to perform combined with the fact that more males are coming forward and seeking treatment. Some ED treatment facilities don’t even accept men and there are only three ED programs in the country that offer athlete-specific treatment programs. This is how under-recognized the issue has been.

ED’s are so secretive, poorly understood, and under-treated that we only know about a fraction of the cases. A lot of men who have EDs, specifically BED, don’t know what it is or that it is a disorder and don’t know that there is help available. These are obstacles to early intervention and treatment.

Male eating disorders are so poorly understood and there is so little awareness, in general and in sport. The data in the literature only reflect people who come into treatment; yet there are so many people who struggle with ED’s in silence that are not accounted for in the statistics. Nonetheless, there is data showing that ED’s in males are on the rise.

What is the most common type of eating disorder in males?

Binge Eating Disorder (BED) is the most prevalent type of ED in males yet it often goes undetected because it is so poorly understood. In general, eating disorders are described as maladaptive coping mechanisms for stress. The hallmark of BED is an experience of loss of control over eating behavior (the binge episode) that occurs in response to a stressful trigger or negative emotional state. The binge soothes the emotional pain but is followed by extreme feelings of guilt and shame. There is often a lot of negative self-talk and low self-worth that accompanies this phase – ‘I’m supposed to be dieting! Now I’m a failure.” BED is characterized by a cycle of restrict, binge, feel better, feel guilt, restrict again on a weekly or sometimes daily basis. When they come into treatment, patients describe that they feel exhausted by the cycle that has consumed their life and their ability to function.

BED is hard to detect with naked eye. Those affected by BED do not fit the stereotypical eating disorder appearance of being markedly underweight; they usually appear at a relatively consistent weight or have a larger body size. They may be experiencing discrimination, bullying, shame or other psycho-social factors that contribute to BED. For athletes, there is additional pressure to be a certain body shape or size for sport and athletes may be receiving direct advice to lose weight and/or increase training to improve performance or gain a competitive edge. Without access to a sports dietitian to assess, plan and monitor appropriate goals and strategies, athletes may go to extremes, particularly when under stress or feeling desperate to measure up to performance expectations. The body’s natural response to starvation to is seek food. So an athlete who is intentionally dieting, unintentionally under-fueling or chronically restricting his diet by “clean eating” or following an elimination diet (like gluten-free, vegan, ketogenic, etc) is putting himself at risk for BED.

How do eating disorders differ in males and females? What are the risk factors?

Male and female athletes with ED’s share some similar characteristics that are common in the sports environment: competitive nature, driven by performance goals, committed to sport, extremely disciplined with training and diet. These interpersonal characteristics can also fuel an eating or exercise disorder when an athlete is under stress and/or has a predisposing mental health condition like anxiety or depression. Other stressors like academics, finances, scholarships, relationships, and sports injuries increase an athlete’s vulnerability. Athletes are more likely to under-report their symptoms and/or consider them to be benign, perhaps even required in order to be elite.

The tendency to recognize eating disorders in females more readily than in males, and to recognize anorexia nervosa more readily than BED, makes the detection of eating disorders in male athletes more challenging. In general, males with ED’s tend to have a worse prognosis than females because they tend to wait longer before they come into treatment. By the time they seek help, males are often sicker and have more serious health consequences. We need to do better about raising awareness and identifying risk in males.

Are eating disorders more common in a certain age group?

In my clinical experience, ED’s do not discriminate. They affect all genders, a variety of racial/ethnic groups and occur in all sports. They occur in adults, adolescents and now in children. Stereotypes and stigma that depict eating disorders only as underweight, adolescent females, female but not male athletes, or athletes only in “lean,” weight-based or aesthetic sports are misinformed.

College-age adolescents and young adults constitute a high risk category. The life transition to college can involve a lot of stress related to the need to establish a support system and build new relationships. The college setting can increase ED risk related to social expectations, dating culture, substance use/abuse, academic stress, role modeling of unhealthy eating or exercise behaviors, etc… College athletes have to manage all of that along with the pressures of competitive sport, putting them at increased risk for an ED.

The signs of undernutrition are sometimes quite visible in female athletes, described by the Female Athlete Triad. What are the signs in male athletes?

One point to remember is that some people experience disordered eating or compulsive exercise patterns that may not meet the diagnostic criteria for a clinical eating disorder. Nonetheless, they are at risk of malnutrition and they are at risk for developing a full blown eating disorder. For this reason, assessment and early intervention are very important eating disorder prevention strategies for individuals displaying these habits.

As well, there are many athlete eating disorder cases that don’t fall into the classic Female Athlete Triad or anorexic picture. Amenorrhea is certainly a common symptom in females with anorexia nervosa, but that symptom is not always present. In fact, it is no longer required as part of the diagnostic criteria. As well, consequences to bone health are not the only cause for concern.

With better research, we now know that the health consequences of eating disorders in sport are far greater than the Female Athlete Triad suggests. In 2014, the clinical picture was redefined as Relative Energy Deficiency in Sport (RED-S), removing the stereotype attached to female sex. RED-S occurs when energy intake chronically falls short of energy requirements and/or when energy expenditure (through training and exercise) chronically exceeds energy intake from diet. RED-S affects both male and female athletes and has consequences that affect every organ system of the body including the heart, brain, endocrine, immune and reproductive systems.

Because the physical damage of RED-S can be invisible to the eye or may be detected quite late in the syndrome, it is essential to focus not just on physical signs, but on the behavioral signs like mood changes, affect, social engagement versus isolation, and ability to focus and perform in school. An athlete who stops attending social events, won’t eat in public, refuses to eat restaurant or dining hall food, or exhibits signs of anxiety or depression is of concern.

What advice do you have for parents and coaches?

Eating disorders are life-threatening conditions. They have the highest death rate of any psychiatric disease. A major cause of death associated with eating disorders is suicide. The keys to effective treatment and recovery from an eating disorder are early identification and timely intervention. For these reasons, do not ignore the signs you observe or any concerns that you have. It is important to trust your gut and act on your concerns to avoid delaying a diagnosis and treatment plan. Treatment for eating disorders involves a multidisciplinary team that includes a physician, therapist or other mental health professional, and a registered dietitian. For athletes, it is important to find professional providers who have expertise in eating disorders and also in sports/sports medicine.

Our research shows that athletes who have struggled with an eating disorder report that one factor that contributed to their ability to seek and accept help was being addressed by someone in their life who was important to them who expressed concern. People tend to dismiss the warning signs and some even consider what they are seeing a sign of an athlete’s commitment and dedication to their sport. It is important to trust your gut, and ask a professional for advice if you are unsure about what to do. Coaches may turn to their athletic trainer, school nurse or school counselor. Parents should discuss concerns with their child’s pediatrician and may seek the advice of a Registered Dietitian. Parents who notice signs and symptoms of an eating disorder have authority to say to their child, “I am concerned. Let’s make an appointment with your doctor to get a professional evaluation.”

Many people are uncomfortable thinking about raising their concerns with someone who they think might be experiencing an eating disorder, fearing that they will say the wrong thing. But ignoring the warning signs is dangerous and jeopardizes the athlete’s well-being. Choosing not to act also silently condones the disordered behavior. Do not wait until a dramatic weight loss is apparent, the athlete suffers an injury, or something more catastrophic happens.

My advice is to have a calm and caring conversation in private. Start it by saying, “I’m really concerned about you because I’ve noticed XYZ (state the specific behavioral signs you have observed)… Is something going on? Can you talk about it with me, or with someone else who can help?” Stick to firm facts and observations while you express your concerns. Offer an empathic, understanding, non-judgemental tone of support. Do not try to diagnose or label the individual as having an eating disorder. Show your unconditional support by acknowledging, “It can be really hard for an athlete to get the proper nutrition they need or to manage the competitive pressures of sport. Sometimes, we need help.” Expect that the athlete may deny any problem and attempt to dismiss your concerns. Denial is a characteristic feature of the disorder. Let them know that you are there for them, keep the door open for follow up conversations, and check back in a few days to revisit the discussion.

Athletes work hard at keeping their personal and emotional struggles a secret, particularly if the sports culture expects or rewards invincibility and frames mental health struggles as a sign of weakness. The “man-up” messages and the “win at all cost” mentality inside some sports environments are examples of cultures where eating disorders stay hidden. Coaches and team leaders who actively work to create and sustain an open culture of acceptance and positivity that is free from stigma, stereotypes, body-shaming or bullying can help to lower risks for eating disorders in sport. It is important for athletes to have access to trusted professionals whose doors are open where they can come in and say, “I’m having a hard time. Can we talk?” On a college campus, these roles may be filled by coaches, assistant coaches, athletic trainers, counselors, dietitians, captains, teammates, academic advisors, and resident advisors in the dorm.

How can we increase awareness of eating disorders in males?

Compared to other public health concerns, eating disorder research is extremely underfunded. Athletes are understudied in ED research, and research on EDs in males is practically non-existent. Clearly, we need more research. But in the meantime, we need to write about it, talk about it, teach parents, coaches and athletes about it, and have male athletes share their lived experiences with eating disorders in sport. Part of the work is to raise awareness, address the stigma, and break the stereotypes so men feel more comfortable speaking out about it. We need to acknowledge the diversity of eating disorders and disordered eating -- they are more common than you think and they occur in all sports, body shapes and sizes.

As well, we need nutrition education, mental health counseling and wellness teams in athletic and collegiate environments. This means that we need access to trained professionals inside the sports culture to monitor the risks and to do the work of prevention and intervention. We need ongoing education for coaches, athletes, parents, and professionals. It’s important to work collaboratively and to formulate action plans for addressing eating disorders in sport.

Words from a College Coach

We wanted to finish with some insightful words from Dylan Sorensen, the Assistant Coach at Stanford University for Track & Field / Cross Country - Men’s Distance.

“From my perspective, having run in college (at Georgetown) and then having coached now here at Stanford, the greatest insight I have is the intersection between developing a trusting relationship with an athlete and clear communication about how to achieve their goals in both life and running.

For example, I am incredibly grateful that the athletes with whom I've worked with feel confident enough in their relationship with me that they are willing to share the struggle with which they face each day. I can't stress enough how important it is to foster that relationship between athlete and coach. I fully believe that having a healthy relationship with eating will make everything in life better, from having more consistent sleep and developing consistency with training, to even improving the ability to pay better attention in class and building more positive relationships with friends/family.

The underlying message is that, when in doubt of a potential destructive relationship with eating, reach out to your coach or mentor, as in this sport, there is a good chance they've dealt with it through their own experiences and can empathize. I meet with each of my athlete's 1-on-1 every 12-15 days and make it a point to talk about how their nutrition planning has gone as it is so crucial to not just success in running, but happiness in life. Every relationship has an ebb and flow, including the one each person has with food!”

Additional resources:

Interview with Dr. Quatromoni and David Proctor

Joey Julius - a Penn State football player who suffered from an ED

Rachael Steil who is the author of the book Running in Silence.

Tale of Two Runners: A Case Report of Athletes’ Experiences with Eating Disorders in College

RED-S The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport

References:

Natalie is a nutritionist and personal chef in Portland, OR who specializes in women's health and sports nutrition. She loves creating simple, nourishing meals and recipes to fuel your life. Find Natalie at nataliecooks.com.

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Eating Disorders in Male Athletes