Elite athletes: Effects of the pressure to be thin

Elite Athletes: Effects of the Pressure to be Thin S Byrne & N McLean Department of PsycholOgy, University of Western Australia.

Byrne, S., & McLean, N. (2002). Elite athletes: Effects of the pressure to be thin. Journal of Science and Medicine in Sport 5 (2): 80-94. This study represented the first attempt to examine the prevalence of eating disorders in a large sample of both male and female elite athletes compared to a matched control group of non-athletes. The subjects were 263 Australian elite athletes representing a variety of sports, and 263 non-athletes. All subjects were interviewed using the Composite International Diagnostic Interview and completed a number of self-report questionnaires. Both male and female athletes competing in sports that emphasise a lean body shape or a low body weight evidenced a significantly higher prevalence of eating disorders and eating disorder symptoms than other athletes and non-athletes. The results suggest that athletes do, in fact, have a higher prevalence of eating disorders than non-athletes. However, it is not so much being an athlete that places an individual at increased risk for developing an eating disorder; rather it is athletes competing in sports which emphasise the importance of a thin body shape or a low body weight who appear to be particularly vulnerable.

Introduction Elite athletes have b e e n identified as a g r o u p w h o m a y be s u b j e c t to particularly i n t e n s e p r e s s u r e to c o n f o r m to a n ideal b o d y shape. Athletes face the s a m e p r e s s u r e as m o s t people in m o d e r n society face, to c o n f o r m to a n a e s t h e t i c ideal w h i c h h a s b e c o m e i n c r e a s i n g l y lean a n d p h y s i c a l l y fit (Brownell, 1991; Rodin & Larson, 1992). But, in addition to this general societal p r e s s u r e , t h e y m a y face extra p r e s s u r e from within their s p o r t to achieve a n d m a i n t a i n a n ideal b o d y s h a p e . Athletes exist in a highly competitive culture, a n d m o r e a n d m o r e p r e s s u r e is being placed o n t h e m to m a n i p u l a t e their eating a n d weight in o r d e r to m a x i m i s e their p e r f o r m a n c e (Wilmore & Costill, 1992). This p r e s s u r e f r o m within the athletic s u b c u l t u r e is likely to be even m o r e i n t e n s e for athletes c o m p e t i n g in s p o r t s with weight restrictions (such as light-weight rowing) or s p o r t s t h a t require a lean b o d y s h a p e or a low b o d y weight for r e a s o n s of p e r f o r m a n c e or a p p e a r a n c e s u c h as ballet, g y m n a s t i c s or d i s t a n c e r u n n i n g . Sociocultural theories of eating disorders p r o p o s e t h a t p r e s s u r e to c o n f o r m to a n unrealistically t h i n a p p e a r a n c e plays a n i m p o r t a n t role in the developm e n t of eating disorders (Garner & Garfinkel, 1980; Wilfley & Rodin, 1995). If athletes are particularly s u b j e c t to t h e s e p r e s s u r e s , t h e n it m i g h t be expected t h a t elite athletes as a g r o u p will h a v e a relatively high prevalence of eating

80

Elilte Athletes: Effects of the Pressure to be Thin /

disorders, a n d athletes competing in sports which place a strong e m p h a s i s on leanness or a low body weight m a y have a n even higher rate of eating problems. In addition, since societal p r e s s u r e to be thin is t h o u g h t to be m u c h m o r e intense for females t h a n for males (Cash & Brown, 1987; Hsu, 1989; Rodin, Silberstein & Striegel-Moore, 1984; Silberstein, Striegel-Moore, Timko & Rodin, 1988), female athletes might be expected to have more eating problems t h a n male athletes. In the last 10 to 15 years, studies have b e g u n to investigate the extent of the problem of eating disorders in athletes. Generally, these studies have suggested a higher frequency of eating p r o b l e m s in athletes t h a n in n o n athletes, particularly in athletes competing in sports which e m p h a s i s e leanness or a low body weight (e.g., Sundgot-Borgen, 1993). However, m a n y of these studies have b e e n limited b o t h conceptually and methodologically. (For a review of previous studies of eating disorders in athletes see Byrne & McLean, 2001). The p r e s e n t s t u d y w a s designed to a d d r e s s these s h o r t c o m i n g s and, in doing so, develop a more complete picture of the frequency and p a t t e r n of eating disorders in elite athletes. In the first place, very few studies h a v e looked at differential rates of eating disorders across different sports, with m o s t studies pooling together athletes from a range of sports. The n a t u r e a n d d e m a n d s of sports vary significantly, and it is likely t h a t b e c a u s e of these different d e m a n d s sports m a y also vary in the degree to which they e m p h a s i s e t h i n n e s s and, therefore, the degree to which they exert p r e s s u r e on their athletes to be thin. If this is the case, a n d if this type of p r e s s u r e does have a n i m p a c t on the development of eating disorders, t h e n it might be expected t h a t the prevalence of eating disorders will vary from s p o r t to sport. There is a need to look m o r e closely at the degree of p r e s s u r e to be thin or lean t h a t is exerted in different sporting contexts and to examine the relationship between this p r e s s u r e a n d the prevalence of eating disorders. Secondly, little attention h a s b e e n paid to the development of eating disorders in male athletes. Yet there is s o m e evidence to indicate t h a t s o m e male athletes do develop s y m p t o m s of eating disorders (Dale & Landers, 1999; Theil, Gottfried & Hesse, 1993). The v a s t majority of the research in this a r e a h a s focused exclusively on female athletes. The p r e s e n t s t u d y focused on sports in which b o t h males and females compete. Thirdly, previous r e s e a r c h h a s too often b e e n limited by methodological p r o b l e m s s u c h as small s a m p l e sizes, lack of a d e q u a t e control groups, the u s e of u n s t a n d a r d i s e d or inappropriate m e a s u r e s , a n d inadequate statistical comparisons. We s o u g h t to a d d r e s s these issues by recruiting a large s a m p l e of elite athletes (both male and female) drawn from a variety of sports, and comparing t h e m with a m a t c h e d control group of n o n - a t h l e t e s using clinical interviews as well as a n u m b e r of psychometrically s o u n d self-report a s s e s s m e n t instruments. The design of the s t u d y m e a n t t h a t a n u m b e r of different c o m p a r i s o n s were able to be made. Firstly, the eating b e h a v i o u r s a n d attitudes of a large s a m p l e of elite athletes were c o m p a r e d with those of a m a t c h e d control group of non-athletes. On a second more specific level, differences in eating b e h a v i o u r s a n d attitudes within this b r o a d group of elite athletes were examined according to the n a t u r e and d e m a n d s of various sports. At a third

81

Elilte Athletes: Effects of the Pressure to be Thin

level, the s t u d y examined gender differences in eating disorders within different groups of elite athletes. Specifically, the p r e s e n t s t u d y aimed to answer the following r e s e a r c h questions: 1. Are eating disorders more prevalent in elite athletes t h a n in non-athletes? 2. Is there a higher prevalence of eating disorders in elite athletes competing in sports t h a t e m p h a s i s e a lean body s h a p e t h a n in athletes competing in sports t h a t place less e m p h a s i s on a lean body s h a p e ? 3. Do the gender differences in eating disorders t h a t exist in the n o r m a l population also exist in a s a m p l e of elite athletes?

Method Subjects The subjects were 263 elite athletes - 108 male athletes a n d 155 female athletes - between the ages of 15 a n d 36 years, a n d 263 m a t c h e d non-athlete controls. For the p u r p o s e s of this s t u d y a n elite athlete w a s defined as a n athlete who was a competitor at a national or international level in his or her sport, or a ballet dancer who w a s either a full-time m e m b e r of a professional ballet company, or a full-time ballet s t u d e n t attending a professional ballet school. Elite athletes were recruited from national and state t e a m s from all m a i n l a n d States of Australia a n d the Australian Capital Territory, after obtaining p e r m i s s i o n from their coaches, m a n a g e r s a n d / o r directors. In t e r m s of ethnicity, seven subjects were of Asian origin, with the remaining subjects (97%) being Caucasian. The athletes were drawn from 10 different sports: ballet, gymnastics, light-weight rowing, long distance running, diving, swimming, hockey, basketball, tennis a n d volleyball. These sports were chosen to provide for a c o m p a r i s o n between sports which place a strong e m p h a s i s on leanness, a n d sports which place less e m p h a s i s on leanness. They are also sports in which b o t h m a l e s a n d females compete at a n elite level. Ballet, gynmastics, light-weight rowing, long distance running, diving and swimming were classified as "thin-build" sports (sports which place strong e m p h a s i s on leanness or a low body weight), a n d basketball, hockey, tennis and volleyball were classified as "normal-build" sports (sports with less e m p h a s i s on leanness). 1 Table 1 displays the n u m b e r of male a n d female athletes recruited from each sport. E a c h athlete in the s t u d y was m a t c h e d with a non-athlete control subject, for gender, age (in years), ethnic group, and level of education. Every a t t e m p t was m a d e to m a t c h the control subjects as closely as possible to their athlete c o u n t e r p a r t s on the variables mentioned above. Forty percent of the elite athletes in the s a m p l e were high school students, a further 25% were university or college students, a n d 35% were neither high school nor tertiary students. Therefore, "control subjects were recruited from three m a j o r sources: high schools, tertiary institutions, a n d the general community. Non-athletes were not considered for the s t u d y if they trained for more t h a n 8 h o u r s each week in a particular sport, or if they were competing at a n elite level in a sport which was not represented in the p r e s e n t study. Of the athletes who were given p e r m i s s i o n to participate (two of the three professional ballet schools a n d three of the six State g y m n a s t i c s s q u a d s a p p r o a c h e d did not give p e r m i s s i o n for their athletes to take p a r t in the study),

82

Elitte Athletes: Effects of the Pressure to be Thin

Sport

Male

Female

N

Mean age In years (SD)

N

Mean age in years (SD)

Thin-build Gymnastics Ballet Light-weight rowing Diving Swimming Long distance running TOtal

12 10 15 6 4 8 55

15.7 22.6 23.3 16.0 17.8 19.0 19.7

(2.0) (7.9) (4.1) (1.1) (2.2) (4.3) (5.4)

21 39 7 14 8 5 94

15.5 17.5 21.9 16.4 16.2

(0.81) (4.4) (3.4) (2.8) (0,89)

17.4

(4.0)

Normal-build Tennis Volleyball Hockey Basketball Total

8 22 13 10 53

16.0 20.4 23.9 23.8 21.2

(1.4) (2.3) (2.7) (4,1) (4.1)

9 17 28 7 61

16.9 17.9 23.3 22.0 20.7

(3.8) (1.3) (3.6) (3.4) (4.1)

Overall total

108

20.4

(4.9)

155

18.7

(4.4)

Table 1:

Number and mean age of male and female athletes in each sport.

five declined to take part: one female diver, two female gymnasts, and one male and one female basketball player, resulting in a 2% refusal rate. All of the control subjects approached to participate in the study agreed to do so. Thin-build subjects were, on average, younger t h a n normal-build subjects, F (1, 259)=18.85, p< .001, and females, overall, were younger t h a n males, F (1, 259)=6.05, p< .05. Table 1 shows the m e a n age for each group of subjects. Design and measures

The study was divided into two phases. In the first phase all subjects were interviewed by a trained Clinical Psychologist (first author) using the Composite I n t e r n a t i o n a l Diagnostic Interview (CIDI; World Health Organisation, 1989) in order to identify subjects who met the Diagnostic and Statistical Manual of Mental Disorders, F o u r t h edition (DSM-IV; American Psychiatric Association, 1994) diagnostic criteria for anorexia nervosa, bulimia nervosa or a n Eating Disorder Not Otherwise Specified (ED-NOS) 2. The CIDI is a structured diagnostic interview, used for both clinical and epidemiologicat research, which can be administered (in part) and scored by computer. It has been found to be acceptable and appropriate across settings and cultures, and to have excellent inter-rater and procedural reliability (Cottler et al., 1991; Farmer, Katz, McGiffen & Bebbington, 1987; Janca, Robins, Bulcholz, Early, & Shayka, 1992; Janca, Robins, Cottler & Early, 1992; Peters & Andrews, 1995; Robins, 1988; Robins et al., 1988; Semler, Wittchen, Joschke, & Zaudig, 1987; Wittchen, 1994; Wittchen et al., 1991). Diagnostic sensitivity and specificity has also been reported to be satisfactorily high (77% and 99% respectively; Wittchen et al., 1991).

83

Elilte Athletes: Effects of the Pressure to be Thin

A measure of sociocultural pressure was also obtained in Phase I of the study by asking subjects to rate, on a scale from 0 to 10, the intensity of the perceived pressure to be thin or lean, either in their particular sport (in the case of athletes) or in their social group (in the case of non-athletes). Phase 2 involved a more fine-grained analysis and focused on specific eating attitudes and behaviours using a 2 (athlete vs non-athlete) x 2 (thin-build vs normal-build) x 2 (male vs female) mixed factorial design. A n u m b e r of selfreport measures were used, including the Drive for Thinness (DFT), Bulimia (B), and Body Dissatisfaction (BD) subscales of the Eating Disorders Inventory II (EDI-II; Garner, 1991); the Bnlimia Test-Revised (BULIT-R; Thelen, Farmer, Wonderlich & Smith, 1991) and the Restraint subscale of the Three Factor Eating Questionnaire (R; S t u n k a r d & Messick, 1985). These m e a s u r e s are widely used for assessing the cognitive and behavioural characteristics of eating disorders. They have been validated on samples of eating disorder patients, and on non-eating-disordered subjects (male and female); and they have also been used in previous studies of eating problems in athletes (Davis, 1992; Walberg & J o h n s o n , 1989; Warren, Stanton & Blessing, 1990). A n u m b e r of psychometric studies have provided considerable evidence for their reliability and validity (Crowther, Lilly, Craw-ford & Shepherd, 1992; Eberenz & Gleaves, 1994; Garner,1991; Gross, Rosen, Leitenberg & Willmuth, 1986; Raciti & Norcross, 1987; Shore & Porter, 1990; Wear & Pratz, 1987; Welch, Hall & Norring, 1990; Welch, Hall & Walkey, 1988; Welch, T h o m p s o n & Hall, 1993). Body Mass Index (BMI: weight (kgs)/ height (m) 2) was also calculated for each subject from self-reported estimates of height and weight, which have been shown to be consistently reliable and highly correlated with objective measures of body weight (Stunkard & Albaum, 1981).

Results Phase I

Perceived Intensity of Sociocultural Pressure When subjects were asked to rate the perceived intensity of pressure to conform to a lean body shape, a c o n t i n u u m effect was found. For both males and females, thin-build athletes perceived the most pressure to be thin or lean, followed by normal-build athletes, and then non-athlete controls. In addition,

Females

[]

Thin-build attlletes

Normal-build athletes

Males

Non-athletes

Figure 1: Mean ratings of the perceived intensity of pressure to be lean for each group of subjects.

84

Elilte Athletes: Effects of the Pressure to be Thin /

AN

BN 1 (2%) 0 0 1 (0.5%)

Male

TBathletes NB athletes Non-athletes Total

2 (4%) 0 0 2 (1%)

Female

TB athlete NB athlete Non-athletes Total

5 (5%) 0 0 5 (2%)

9 (10%) t (2%) 2 (1%) 12 (4%)

ED-NOS 1 (2%) 0 0 1 (0.5%) 15 (16%) 4 (6.5%) 7 (4.5%) 26 (8%)

Note. AN = anorexia nervosa; BN = bulimia nervosa; TB = thin-build; NB = normal-build

Table 2:

Number and percentage of subjects in each group with anorexia nervosa, bulimia nervosa and ED-NOS.

overall and within each group, females perceived more intense sociocultural pressure to be lean t h a n males. This c o n t i n u u m effect is illustrated in Figure 1.

Eating disorders Table 2 shows the prevalence of anorexia nervosa, bulimia nervosa and EDNOS found in each group. Among the females, 15% of the thin-build athletes, 2% of the normal-build athletes and 1% of the non-athletes evidenced anorexia nervosa or bulimia nervosa. A further 16% of the thin-build athletes, 7% of the normal-build athletes and 5% of non-athletes met the diagnostic criteria for ED-NOS. Five percent of the thin-build male athletes h a d anorexia nervosa or bulimia nervosa and another 1% met the criteria for ED-NOS. No eating disorders were identified a m o n g male normal-build athletes or male nonathletes. P h a s e II

Prior to the analysis, an examination of the data showed that the distributions of several of the m e a s u r e s of eating attitudes a n d behaviours were positively skewed. However, the use of transformed data in the multivariate analysis of variance m a d e no difference to the results, so for ease of interpretation the u n t r a n s f o r m e d data are reported here. Two cases, and the subjects to which they were matched, were excluded from the analysis (one male athlete had several missing values on the m e a s u r e s of eating disorder symptoms, and one female non-athlete was identified as a multivariate outlier), so the final subject pool for Phase II included 55 male thin-build athletes, 52 male normal-build athletes, 93 female thin-build athletes, 61 female normal-build athletes, 107 male non-athlete controls, and 154 female non-athlete controls.

Eating attitudes and behaviours (I) Comparison 1 : A t h l e t e s vs non-athletes Overall, for both males and females, athletes obtained significantly higher scores t h a n non-athletes on the Drive for Thinness (DFT), F (1, 257) = 35.75, 1~< .001, a n d Bulimia (B), F (1,257) = 11.38, 12< .01, subscales of the EDI-II,

85

Elilte Athletes: Effects of the Pressure t o be Thin

on the BULIT-R, F (1, 257) = 28.13, p< .001, and on the Restraint subscale of the TFEQ (R), F (1, 257) = 56.53, 12< .001. However, there was no significant difference between athletes and non-athletes on the Body Dissatisfaction (BD) subscale of the EDI-II, F (1, 257) = 0.51, p> .05. (ii) C o m p a r i s o n 2 - T h i n - b u i l d a t h l e t e s v s n o r m a l - b u i l d a t h l e t e s

For both males and females, athletes competing in thin-build sports obtained significantly higher scores t h a n athletes competing in normal-build sports on DFT, F (1, 259) = 17.75, 12< .001, B, F (1, 259) = 7.38, p< .01, BULIT-R, F (1, 259) = 8.88, p< .01, and R, F (1, 259) = 14.27, t~< .001. However, again there was no significant difference between thin-build athletes and normal-build athletes on BD, F (1, 259) = .06, 12> .05. (iii) C o m p a r i s o n 3 - G e n d e r d i f f e r e n c e s

For athletes, j u s t as for non-athletes, females obtained significantly higher scores than males on all of the dependent variables: DFT, F (1, 257) = 68.23, p< .001; B, F (1,257) = 12.11, p< .01; BD, F (1,257) = 167.41, p< .001; BULITR, F (1, 257) = 30.85, p< .001; R, F (1, 257) = 72.92, p< .001.

Body Mass Index Thin-build athletes, both male and female, had significantly lower BMI scores than either normal-build athletes (males: F (1, 105) = 44.88, p< .001, females: F (1, 153) = 113.45, p< .001) or controls (males: F (1, 54) = 14.35, p< .001, females: F (1, 93) = 37.79, p< .001). However, there were no differences in BMI between female normal-build athletes and non-athletes, F (1, 60) = 0.97, p> .05; and male normal-build athletes had higher BMI scores t h a n their nonathlete counterparts, F (1, 51) = 4.87, p< .05. The m e a n BMI of female thinbuild athletes fell into the underweight category whereas the m e a n BMI scores

Thin-build athletes Males

DFT

2.8

(3.75) a

1.83

(2.37) b

0.78

(1.34) c

0.79

(1.19) c

(1.29) a

0.56

(0.98) b

0.60

(0.93) c

0.42

(1.11) c

BD

3.82

(4.25)

3.69

(4.12)

3.13.

(5.68)

3.37

86

46.76 (11.62) a

47.40 (14.37) b

42.02

(9.69) c

40.33

(3.58) (7.47) c

R

6.93

(5.01) a

5.52

(4.36) b

3.62

(2.93) c

3.92

(3.41) c

BMI

20.7

(2.4) a

23.7

(2.2) b

22.5

(3.2) b

22.7

(2.7) b

DFT

8.15

(6.95) a

4.46

(4.72) b

3.35

(4.01) ¢

3.15

(4.18) c

B

2.21

(3.56) a

1.16

(1.74) b

0.82

(1.47) c

0.56

(1.19) c

(7.17)

9.69

(7.08)

BD

10.37

BULIT-R

61.57 (23.07) a

BMI

~ble 3:

Normal-build controls

0.87

R

Note.

Thin-build controls

B BULIT-R

Females

Normal-build athletes

~

12.09 18.6

(8.50)

11.16

50.61 (16.47) b

47.84 (13.76) ¢

11.15

(7.60)

46.79 (14.05) c

(5.55) a

9.26

(5.27) b

7.23

(4.98) ¢

6.87

(5.13) c

(2.0) a

22.0

(1.7) b

21.0

(2.4) b

22.0

(2.9) b

DFT = Drive for Thinness subscale of the EDIdl, B = Bulimia subscale of the EDI-II, BD = Body Dissatisfaction subscale of the EDI-n, BULIT-R= Bulimia Test-Revised, R = Restraint subscale of the Three Factor Eating Questionnaire, BMI = Body Mass index. Means in the same row that do not share superscripts differed at p < .01 in the MANOVA.

Mean scores (with standard deviations in parentheses) on measures of eating attitudes and behaviour and BMI for each group of subjects.

Elilte Athletes: Effects of the Pressure to be Thin

for the other groups wer~ within the healthy range (i.e., 20-25 kg/m2). Table 3 sets out the m e a n score and standard deviation on all the m e a s u r e s of eating attitudes and BMI for each group of subjects.

Discussion This study aimed to examine the effect of pressure to achieve and maintain an ideal body shape on the eating attitudes and behaviour of elite athletes. Descriptive data confirmed that athletes competing in sports that emphasise a lean body shape or a low body weight perceived themselves to be subject to the most intense pressure to be thin, followed by normal-build athletes and t h e n non-athletes. In addition, overall and within each group, females perceived that they were subject to more intense pressure t h a n males to conform to a lean body ideal. In line with this c o n t i n u u m effect, the groups who perceived themselves to be subject to increased p r e s s u r e to achieve a lean body shape showed higher rates of eating problems. Overall, for both males and females, the prevalence of eating disorders was significantly higher among athletes t h a n among non-athletes. In addition, athletes obtained significantly higher scores t h a n non-athletes on all of the m e a s u r e s of specific eating disorder symptoms (apart from Body Dissatisfaction) - that is, athletes had a higher drive for thinness, and higher levels of dietary restraint, and they engaged in more bulimic behaviours t h a n nonathletes, although they did not report higher levels of body dissatisfaction t h a n non-athletes. Within the athlete group itself, however, it was clear that the vast majority of eating problems were found in the thin-build athlete group. This group of athletes evidenced markedly higher rates of eating disorders and eating disorder symptoms t h a n normal-build athletes and non-athletes. The increased risk associated with being a thin-build athlete was not exclusively associated with females: males competing in sports with a strong emphasis on leanness were also shown to be prone to a n eating disorder. Only one previous study, by Sundgot-Borgen (1993), has allowed for a comparison to be made between 'thin-build' and 'normal-build' athletes and a control group of non-athletes with regard to the prevalence of diagnosable eating disorders, although this study focused exclusively on females. SundgotBorgen used questionnaire screening and s u b s e q u e n t clinical interviews to obtain prevalence data of eating disorders among a large sample (n=522) of Norwegian elite female athletes and non-athlete controls (n=448). A significantly higher percentage of athletes competing in the aesthetic sports (diving, figure skating, and gymnastics) and weight-dependent sports (judo, karate, and wrestling) were found to meet the criteria for eating disorders (25%) compared with athletes competing in other sports (12%) or controls (5%). With regard to the females in our study, a similar pattern of results emerged, with thin-build athletes evidencing the highest rate of eating disorders (15%) followed by normal-build athletes (2%) and t h e n non-athletes (1%). In general, however, we found lower prevalence rates t h a n Sundgot-Borgen in each category, and in our study there was relatively little difference between female normal-build athletes and non-athletes with regard to the rate of diagnosable eating disorders. It is not possible to make comparisons with existing data for the male athletes in our study, since there have been no previous studies of the prevalence of diagnosable eating disorders in male athletes. However, the

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prevalence of eating disorders in o u r non-athlete control g r o u p s is c o m p a r a b l e to the rates reported in the m o s t recent methodologically-sound epidemiological studies (Bushnell, Wells, Hornblow, Oakley-Browne & Joyce, 1990; Garfinkel et al., 1995; Hoek, 1993, 1995; Killen et al., 1994, Rand & Kaldau, 1992; Rastam, Gillberg & Garton, 1989; Rooney, McClelland, Crisp & Sedgwick, 1995; Warheit, Langer, Z i m m e r m a n & Biafora, 1993; Whitaker et al., 1990; Whitehouse, Cooper, Vize, Hill & Vogel, 1992). These studies have estimated the prevalence of anorexia nervosa and bulimia n e r v o s a in w o m e n to be less t h a n 1% a n d 1-2% respectively, with the prevalence of partial syndromes (ED-NOS) lying between 3 a n d 6%. In males, the prevalence rates are significantly (10-20 times) lower (Turnbull, Ward, Treasure, J i c k & Derby, 1996). The results of our s t u d y a p p e a r to suggest a relationship between the intensity of perceived p r e s s u r e to conform to a lean body s h a p e and the prevalence of eating disorders. However, o u r findings also indicate t h a t this p r e s s u r e does not work in isolation to affect eating attitudes or behaviour. The p a t t e r n described by the d a t a relating to the prevalence of eating disorders did not follow the s a m e evenly descending c o n t i n u u m described by the d a t a relating to perceived p r e s s u r e to be thin or lean. For example, normal-build athletes perceived t h a t they were subject to significantly m o r e p r e s s u r e to be thin t h a n non-athletes, yet there w a s only minimal difference between normalbuild athletes a n d n o n - a t h l e t e s in regard to the rates of eating disorders. There are several possible explanations for this observation. Firstly, there m a y be a threshold for sociocultural p r e s s u r e in regard to eating disorders. It m a y be t h a t at some point on the c o n t i n u u m of perceived p r e s s u r e there lies a threshold, beyond which the manifestation of a n eating disorder is m o r e likely to occur. While normal-build athletes m a y generally fall below this threshold, thin-build athletes m a y more consistently exceed it. Another possibility is t h a t specific protective or aggravating factors m a y interact with sociocultural p r e s s u r e to either exacerbate or m o d e r a t e the effect of this pressure. Protective factors, s u c h as high self-esteem, m a y m o d e r a t e the effect of intense p r e s s u r e to conform to a n ideal body shape, t h u s reducing the incidence of eating disorders. On the other hand, aggravating factors s u c h as low self-esteem, or high levels of perfectionism or competitiveness m a y w o r k to heighten the effects of sociocultural pressure. The idea of protective and aggravating factors t h a t tend to reduce or increase the expression of eating disorders in athletes is a largely unexplored area. F u r t h e r r e s e a r c h is needed to identify these factors, s o m e of which m a y be specific to athletes, a n d to m e a s u r e the extent of their influence. One finding of interest in the p r e s e n t s t u d y related to the m e a s u r e of body dissatisfaction. The Body Dissatisfaction subscale of the EDI-II was the only m e a s u r e t h a t did~ not discriminate between athletes a n d n o n - a t h l e t e s or between thin-build athletes a n d normal-build athletes. Athletes showed significantly higher rates of eating disorders t h a n non-athletes, without showing high levels of body dissatisfaction relative to non-athletes. In the s a m e way, thin-build athletes were no m o r e dissatisfied with their body s h a p e t h a n were n o r m a l - b u i l d athletes, despite evidencing more eating disorders a n d m o r e a b n o r m a l eating attitudes a n d b e h a v i o u r s t h a n normal-build athletes. This is of note b e c a u s e r e s e a r c h tends to indicate t h a t body dissatisfaction is central

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to the clinical picture of b o t h anorexia n e r v o s a a n d bulimia nervosa (Altabe & T h o m p s o n , 1992; Brown, Cash & Lewis, 1989; G a r n e r & Bemis, 1985) yet o u r results suggest that, in the case of elite athletes, body dissatisfaction m a y not necessarily be associated with disordered eating. O u r finding provides s u p p o r t for clinical reports which have observed t h a t even athletes with significantly disturbed eating p a t t e r n s do not report b o d y image distortion or high levels of body dissatisfaction (e.g., B r o o k s - G u n n & Warren, 1985; Le Grange, Tibbs, & Noakes, 1994; Mallick, Whipple, & Huerta, 1987; Parker, Lambert, & Burlingame, 1994; Szmukler, Eisler, Gillies, & Hayward, 1985). It m a y be t h a t some athletes a d o p t disordered eating practices whilst m a i n t a i n i n g a realistic sense of t h e m s e l v e s as being leaner than, or fitter than, their non-athlete counterparts. The athletes in our s t u d y were certainly leaner (had lower BMI scores) t h a n the non-athletes, and female thin-build athletes were clearly underweight by objective s t a n d a r d s . Thus, it is possible t h a t athletes expressed body satisfaction b e c a u s e they were, in reality, thinner t h a n the average person. This finding also fits with the view t h a t the p a t h w a y s to the development of eating disorders m a y be different for athletes t h a n for non-athletes (Byrne & McLean, 2000; Owens & Slade, 1987). For example, the d e m a n d s of a sport to m e e t a particular body r e q u i r e m e n t alone, even without a high level of b o d y dissatisfaction, m a y be enough to lead to the development of a n eating disorder. For a n elite athlete, disordered eating b e h a v i o u r m a y reflect a rational r e s p o n s e to p r e s s u r e to achieve a b o d y s h a p e which will e n s u r e optimal performance. In this way, for s o m e athletes, eating disorders m a y reflect dedication to their sport r a t h e r t h a n psychopathology.

Conclusion and Implications Our results suggest that, of all elite athletes, it is really only the thin-build group who are at increased risk of developing full-blown eating disorders. It is of note t h a t it w a s this group of athletes who perceived t h e m s e l v e s to be subject to the m o s t intense p r e s s u r e to be thin. Therefore, it is not so m u c h being a n athlete t h a t places an individual at risk for developing a n eating disorder. Rather, the risk involves being a n elite athlete in a sport which emp h a s i s e s the i m p o r t a n c e of a thin body s h a p e or a low body weight. This finding m a y explain w h y so m a n y previous studies have not detected a difference between s a m p l e s of athletes a n d n o n - a t h l e t e s on s t a n d a r d i s e d m e a s u r e s of eating attitudes or behaviours. These studies have either c o m p a r e d athletes competing in 'normal-build' sports with n o n - a t h l e t e s or have c o m p a r e d a n aggregate g r o u p of thin-build and normal-build athletes with non-athletes and this combination m a y have m a s k e d the effect. The relatively high rate of diagnosable eating disorders found in b o t h male a n d female thin-build athletes h a s specific implications for these athletes as well as for those professionals who are either directly or indirectly involved in their athletic p r o g r a m m e s , s u c h as coaches, administrators, selectors, sport psychologists a n d other health professionals. There is a clear need for r e s e a r c h which is a i m e d at developing a n d evaluating appropriate education, screening a n d intervention p r o g r a m m e s for this group of elite athletes. S u c h p r o g r a m m e s should not be confined to female athletes, b u t should also target male athletes competing in these sports. 89

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Methodological Considerations The m e t h o d s u s e d in this s t u d y represented a n i m p r o v e m e n t on those employed by the majority of previous research into eating disorders in athletes. Nevertheless, some potential limitations of the s t u d y m u s t be noted. Firstly, the cross-sectional design of the s t u d y did not allow for a full investigation of the relationship between involvement in sport at an elite level a n d the onset of eating disorder s y m p t o m s , l o n g i t u d i n a l studies are needed to clarify this relationship. Secondly, in the p r e s e n t s t u d y the CIDI was u s e d to identify cases of eating disorders, w h e r e a s the Eating Disorders E x a m i n a t i o n (EDE; Cooper & Fairburn, 1987), is generally considered to be the gold s t a n d a r d for diagnosing eating disorders a n d would n o r m a l l y be preferred. There are two m a i n r e a s o n s why the CIDI was t h o u g h t to be the m o s t appropriate i n s t r u m e n t to u s e in this study. Firstly, a m a j o r a d v a n t a g e of the CIDI was the preservation of anonymity, which was of p a r t i c u l a r relevance to athletes. Full face-to-face interviews m a y have inhibited the frank disclosure of s y m p t o m s in a group s u c h as elite athletes. Refusal r a t e s as high as 66% have b e e n reported in studies of athletes w h e n interviews are involved (Clarke a n d Palmer, 1983; Wilmore, 1995) a n d evidence from research in the field of addictions h a s suggested t h a t patients are m o r e likely to disclose sensitive information to a c o m p u t e r t h a n to a n interviewer (Duffy & Waterton, 1984; Lewis, 1992; Lucas, Mullin, L u n a & Mclnroy, 1977; Pelosi & Lewis, 1989). A second a d v a n t a g e of the CIDI is its simple a n d economical administration, requiring less time t h a n a full face-to-face interview. This m e a n t that, even in this large-scale study, every subject could be interviewed, rather t h a n j u s t those scoring above a cutoff score on the EDI. Finally, although all of the m e a s u r e s employed in the p r e s e n t s t u d y have been u s e d before in studies of athletes, these m e a s u r e s have not b e e n specifically tested for sensitivity, reliability or validity with a s a m p l e of elite athletes. There is a need for future r e s e a r c h to validate these m e a s u r e s with athletes a n d to identify the conditions u n d e r which self-reports of eating disorder s y m p t o m s in athletes are m o s t likely to be accurate.

Footnotes t

The term "thin-build" does not apply to the actual physiques of individual athletes, b u t is used to refer to sports which place a strong emphasis on leaImess or low body weight. Swimming was classified as a thin-build sport in the present study (despite one previous study having classified swimming as a sport with little emphasis on leanness; Borgen & Corbin, 1987) because a lean body m a s s is generally considered to be crucial for elite level performance in swimming, and at least two other previous studies have specifically targeted swimmers because of their strong concerns with weight and shape (Dummer, Rosen, Heusner, Roberts, & Counsilman, 1987; Rosenvinge & Vig, 1993). In addition, due to their costume, swimmers' bodies are often exposed to public view which may serve to heighten concern with weight and shape. 2 Subjects were classified as ED-NOS if: 1. For females, they met all of the criteria for anorexia nervosa except that they had regular menses. 2. They met all of the criteria for anorexia nervosa except that, despite significant weight loss, their current weight was in the normal range. 3. They met all of the criteria for bulimia nervosa except that their binge eating and inappropriate compensatoly m e c h a n i s m s occurred at a frequency of less t h a n twice a week, or for a duration of less t h a n 3 months. 4. They regularly used inappropriate compensatory behaviour after eating small amounts of food (e.g. self-induced vomiting after the consumption of 2 biscuits).

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