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Last year I wrote a piece on the various “dark sides” of cycling, and in recognition of National Eating Disorders Week, I wanted to revisit one of the biggest elephants in the room in endurance sports: body image and Eating Disorders (EDs).
First, what exactly is an Eating Disorder?
Eating Disorders are extreme disturbances in an athlete’s thoughts, feelings, and behaviors that can be related to weight, body image, and food. Negative and unrealistic thoughts, attitudes, and beliefs held by athletes in regard to their bodies and food tend to fuel behaviors that can be harmful and even life threatening. Within the general category or eating disorders most related to athletes, the DSM-V has identified specific disorders such as: Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder. Anorexia Nervosa is an eating disorder characterized by self-induced starvation and excessive weight loss (this can also include overtraining). Bulimia Nervosa is an eating disorder characterized as bingeing (excessive or compulsive consumption of food) and purging (getting rid of food). Binge Eating Disorder is characterized as recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. Lastly, an athlete with an eating disorder is dominated by their need to be thin or lack of control over food — this obsession consumes the athlete’s thoughts, drives, behaviors, and decisions related to sport and life in general.
Therefore, I wanted to take the opportunity to share more information in an effort to bring awareness and attention to these topics. This past fall I attended a workshop on Eating Disorders and Body Image in sport, which made the wheels in my head start turning. Thankfully, the presenter Christine Selby, Ph.D. was open to sharing more valuable insights for this piece. Dr. Selby is an Associate Professor of Psychology at Husson University in Bangor, Maine and is a licensed psychologist. She is a certified eating Disorder specialist with the International Association of Eating Disorders Professionals and certified consultant with the Association for Applied Sport Psychology, and a former pro cyclist herself.
Dr. Keim: How does the culture of sport and society impact body image in endurance athletes? And why?
Dr. Selby: For females especially the dual cultures of sport and the larger society has the potential of placing a greater degree of stress on the athletes. Males, certainly, are not immune but to date the pressure seem to affect females to a greater degree. Society has a particular expectation of women that right now is referred to as the “thin ideal”— usually thin overall, but feminine as defined by curves (hips and breasts), and not muscular.
Each sport usually has its own expectations in terms of body shape and size, and while for endurance sports the ideal is certainly thinner than in other sports, there is still the expectation that there is muscle so the athlete can perform well. If the two sets of expectations are at odds for the athlete then they may feel a strong psychological tension about which ideal to honor: fit into the societal expectation or the sport expectation. An interesting line of research has indicated that for some athletes their body image may be fine while they are participating in their sport and around others in the sport, but when outside of the context of sport their body image may suffer because their body does not conform to societal expectations.
Dr. Keim: Do you feel that endurance sports such as cycling have created an unhealthy and unrealistic athletic image that puts athletes at risk for developing issues such as Eating Disorders (EDs)? And if so, how?
Dr. Selby: The tricky part about this question is that truly any sport can place an unhealthy and unrealistic expectation on athletes if the athlete does not normally (or cannot easily achieve) have the body shape and size expected in the sport. Certainly the smaller and leaner the expectation, the greater the risk as at a certain point many athletes will have to engage in extreme practices (e.g., reduction in caloric intake, increase in training/practice times) in order to achieve the “right” body type.
Dr. Keim: Do you think it is up to the teams, coaches, and federations to make resources available and to not allow athletes (who are struggling with EDs) to compete in sport events?
Dr. Selby: Unequivocally, yes. Since EDs have the highest mortality rate (particularly anorexia nervosa) than any other psychiatric disorder and since athletes maybe at higher risk for developing an ED than the general population, participation in sport when athlete is “clearly struggling with an ED” should not be allowed to participate unless a treatment team has cleared them to. Many organizations (e.g., IOC, NCAA) have statements about eating disorders and body image and the importance of being sure that the health of athlete is a priority. Unfortunately, however, when winning and/or money is on the line then health goes out the window. This does not rest entirely on the shoulders of the national governing bodies, however. Many athletes themselves, especially at the elite level, will participate no matter what the cost, including their health and well-being. We’ve seen this to a certain degree with the focus on concussion in contact sports and athletes admitting to trying to manipulate the baseline measure so that if they do get a concussion and are tested again, they won’t be pulled from competing.
The reality is that EDs are often “unseen” — you don’t wear a cast or a neck brace and you cannot tell by looking at someone if they have an ED. EDs are relatively easy to hide to a certain extent.
Unfortunately, at some point the athlete will no longer be able to hide it and by that point their health may be severely compromised.
Dr. Keim: What are some suggestions to help with growing the awareness and education around challenges related to body image and EDs in endurance sports such as cycling?
Dr. Selby: Articles such as this help. Any way to get information in front of athletes and others involved in the training and care is ideal. The more EDs are talked about as being serious, life threatening, and potentially career-ending disorders the more likely it is that athletes in any sport will take EDs and their risks more seriously. The other thing that is important is for coaches and others to treat mental health issues of any kind like a physical injury. If a physical injury is suspected the athlete is referred to the appropriate professional for evaluation and treatment. The same should occur if a mental health disorder is suspected — which also means that coaches, trainers and other personnel need to be trained in recognizing signs and symptoms of common disorders, which would include EDs.
An eating disorder is not a “diet gone bad” or a “phase” and the only ones who can determine if an athlete is at risk for an ED is a licensed mental health or medical professional. Ideally they will have a strong background in the diagnosis and treatment of people with EDs, and secondarily they will also have a background in working with athletes.
Overall, I think a change in the culture of sport in general but particularly in endurance sports or other sports where body size and weight are a factor is what is needed. Among many there is still the ideal that “you can’t be too thin” or that a particular body size or weight expectation is such an intrical part of the sport that everyone involved is reluctant to change perspective.
Next, I had the opportunity to interview one of my coaching colleagues Corey Hart, Ph.D. I felt it would be valuable to gain perspective from a cycling coach on these topics. Dr. Hart is well-known in the competitive cycling world as one of the top coaches in the world for professional and development athletes. Dr. Hart received his Ph.D. in exercise and sport science at the University of Utah and is currently a research fellow at the Mayo Clinic in the Division of Endocrinology, Diabetes, and Nutrition.
Dr. Keim: As a former professional cyclist and now cycling coach, do you feel that issues with body image and EDs have increased over the years? If so, why and how?
Dr. Hart: In general, I believe that issues with body image and EDs are equally prevalent compared to 20 years ago. Perhaps the only difference is that we have more educated professionals who are capable to work with athletes on these issues. While there are more trained professionals who can better treat issues with body image and ED, it remains difficult to penetrate team environments where directors and staff members constantly insult riders about their weight.
Dr. Keim: Do you think that body image and EDs are related to the issues with Performance Enhancing Drugs (PEDs), as in the need to be thin correlates with increased use of PEDs (part of performance enhancement is being thinner)?
Dr. Hart: To my knowledge, there is no evidence that EDs and PEDs are well correlated. It seems that athletes who use PEDs have a different underlying psychological rationale to cheat the system, whereas athletes with EDs are attempting to “fit in” or assimilate with an expected norm in the sport.
Dr. Keim: How prevalent do you think EDs are in cycling (men and women)? Do you feel that the culture of cycling celebrates unrealistic and unhealthy images of “thin” athletes and enables EDs?
Dr. Hart: Riebl et al. (2007) found that ~20% of male cyclists had an ED, and that less than half of those men with ED recognized their behavior as unhealthy. Haakonssen et al. (2015) documented that more than half of the women in their study felt their current body weight was not ideal for competition. While I don’t believe the sport of cycling outright celebrates unrealistic phenotypes in athletes, I believe there is a general underlying expectation of how lean a cyclist, both male and female, should “look”. For example, the stereotypical cyclist who is “on form” should carry little to no subcutaneous fat on their arms and legs, let alone in their mid-section. However, the distribution of subcutaneous fat is very heterogeneous between individuals, so the pre-conceived body image that many coaches, directors, and athletes have in mind is largely misconstrued. Perhaps the larger problem is that the health of an athlete, who is clearly malnourished, yet performing well, never comes into question. Winning is prioritized over welfare of the athlete. In other words, the short-term success of an athlete with an ED is celebrated, while the potential long-term health consequences of the athlete are entirely neglected.
Dr. Keim: What are some of the negative side effects on one’s performance if an athlete continues to train/race with anorexia or is “addicted” to exercising and training? What has been your experience working with athletes with these issues?
Dr. Hart: Beyond the physiological hormonal imbalances, these athletes tend to find it difficult to balance their life after sport. They tend to be so strongly tethered to the sport, which allows them to maintain an expected body image, that they cannot adopt a new way of life that is sustainable. Typically they find difficulty in securing a new professional career, their relationships suffer, and they become depressed. In some cases they will live vicariously through friends, spouses, or partners, and unintentionally influence others with bad behaviors.
Dr. Keim: Do you think it is up to the teams, coaches, and federations to make resources available and to not allow athletes to train and/or compete?
Dr. Hart: This goes back to my aforementioned comment regarding placing the welfare of the athlete before winning. If an athlete is found to have a life-threatening heart condition, such as hypertrophic cardiomyopathy, we watch these athletes very closely and prevent them from competing if it appears that the condition is not stabilizing. Why is an ED any different? We may not have sufficient epidemiological evidence to support an increased risk of mortality when an ED is present, but we can pragmatically determine that the long-term consequences are not healthy. And yes, it’s a team effort to work with an athlete who has an ED, but the team should consist of trained professionals, as opposed to in-house staff with vested interests.
Dr. Keim: What advice would you give other coaches and athletes (and federations/teams) on the issue of EDs for athlete’s performance and overall well-being?
Dr. Hart: Most importantly, if you feel that an athlete of yours has an ED, seek assistance from the appropriate certified professional who has the training and experience to manage the care for EDs. Too many coaches have taken on the “all-knowing” role with their athletes, or they create a small group of coaches who may have non-professional certifications in nutrition. Eating Disorders are a serious medical condition, requiring skilled medical professionals and well-trained psychologists.
Yes, eating disorders impact both female and male athletes.
No, talking about an eating disorder will not create a disorder. Just like talking about suicide will not increase someone’s chances of taking their own life. We need to talk it about. We need to break the stereotypes and debunk the myths.
Remember, out of all the mental illnesses eating disorders are the most fatal.
Where do we go from here?
Education, awareness, proper resources, and creating a safe and supportive culture where athletes can talk about their physical and psychological challenges. If you need help, ask for it. Asking for help is a sign of courage and strength, not weakness.
For more information on Eating Disorders visit the National Eating Disorders Association (NEDA) website: https://www.nationaleatingdisorders.org