a master’s project mp 2016.pdflfa leanness focused athletes ... athletes goal german young olympic...

Running Head: EATING DISORDERS AND ATHLETICS 1

Eating Disorders and Body-Type Specific Sports

A Master’s Project

Presented to

The Faculty of the Adler Graduate School

In Partial Fulfillment of the Requirement for

the Degree of Master in Art

Adlerian Counseling and Psychotherapy

By:

Mackenzie Sinard

Chair: Hal Pickett

Reader: Richard Close

February 2016

EATING DISORDERS AND ATHLETICS 2

Abstract

This literature review will explore the connection between certain athletes and sports and their

risks for disordered eating behaviors or even eating disorders. It is hypothesized that certain

sports put athletes at a greater risk for developing disordered eating behaviors as well as eating

disorders. After reviewing the literature, there is enough evidence to support a correlation

between type of sport and eating disorders. A combination of certain characteristics, behaviors,

attitudes, and team atmosphere combine to put certain athletes at a greater risk.


Table of Contents

Introduction ................................................................................................................................... 4

Body-Type Specific Sports ........................................................................................................... 7 Gymnastics .............................................................................................................................................. 8 Gymnastics Summary .......................................................................................................................... 14 Wrestling ............................................................................................................................................... 15 Wrestling Summary ............................................................................................................................. 23 Ballet ...................................................................................................................................................... 24 Ballet Summary .................................................................................................................................... 35 Body-Type Specific Sports Conclusion ............................................................................................... 36

Eating Disorders.......................................................................................................................... 36 Eating Disorders: General ................................................................................................................... 40 Eating Disorders: Anorexia Nervosa .................................................................................................. 41 Eating Disorders: Bulimia Nervosa .................................................................................................... 44 Eating Disorders Conclusion ............................................................................................................... 48

Male and Female Athletes .......................................................................................................... 48 Athletes: Both Genders ........................................................................................................................ 51 Athletes: Males ...................................................................................................................................... 58 Athletes: Females .................................................................................................................................. 62 Male & Female Athletes Conclusion ................................................................................................... 66

Final Summary ............................................................................................................................ 66

References .................................................................................................................................... 74


Eating Disorders and Body-Type Specific Sports

Introduction

Research has shown that certain sports may put participating athletes at a greater risk for

developing an eating disorder (ED). Only certain sports, however, seem to have this effect, in

particular, body-type specific sports. The terms aesthetic sports, appearance based sports, weight

dependent sports and other terms are used to describe the types of sports discussed throughout

the literature. For the purposes of this review, the definition of body-type specific sports should

be understood to mean “sports in which aesthetics are critical to the judging or scoring process,

sports where the athlete has to make weight for competition and sports in which low body fat is

deemed advantageous to performance” (Baum, 2006, p. 3).

Individual psychology is the lens through which this review is written. According to

Powers and Griffith (2007), individual psychology:

Give[s] emphasis to (a) each person as a UNIQUE VARIANT of human possibility in his

or her style of approaching the problems of social living (Comparative); (b) the UNITY

of the organism and the personality as an indivisible whole, indivisibly EMBEDDED in a

social and historical situation (Individual); and (c) the agency of the person, a “soul” to

be understood by a focus on PURPOSE, not process (Psychology). (p. 57)

There are also three universal goals that each and every person strives for: significance

(geltungstreben), safety (sicherheit), and belonging (gemeinschaftsgefühl). It is in using these

ideas the writer will examine the hypothesis at hand.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is used to diagnose

ED. The lifetime prevalence rates for women are 0.4-0.9% for Anorexia Nervosa (AN), 1-1.5%

for Bulimia Nervosa (BN), and 0.8-3.5% for Binge Eating Disorder (BED), while for men they


are 0.3% or a 10:1 ratio (women to men), 0.5% or a 10:1 ratio and 2.0%, respectively (American

Psychiatric Association [APA], 2013; Galli, Reel, Petrie, Greenleaf, & Carter, 2004). Baum

(2006), found that those rates increased for athletes, with AN rates as high as 3% and BN rates as

high as 21.5% according to DSM-III-R criteria. Eating disorders (ED) have one of the higher

mortality rates among mental disorders. Every decade, AN claims 5% while BN claims 2% of

patients. The lifetime mortality rate of both AN and BN combined is 2-10% (Anshel, 2004). A

cause of mortality often overlooked in this group is suicide; however, 12 out of every 100,000

with AN will commit suicide per year, and those with BN are at “an elevated risk” according to

the DSM-V (APA, 2013, p. 349).

How do body-type specific sports affect the occurrence of ED? The literature showed a

significant relationship between ED and body-type specific sports. The sports included are

ballet, gymnastics, and wrestling. Gender was also a key factor in looking at athletics and eating

pathology. This research was important because it is considered healthy by most to be involved

in sports, and vast majorities of people participate in sports under that assumption. The death

rates of eating disorders increased the importance of determining the relationship, as certain

athletes are risking their lives for their sports. Since a relationship was found, recognition and

understanding of the problem will lead to preventative measures, such as education of coaches,

athletes, and parents, as well as governing bodies, could be taken to prevent further loss of life.


Table 1

Key of Abbreviations

Abbreviation Meaning

ED Eating Disorder

DSM-(# of Ed.) Diagnostic & Statistical

Manual of Mental Disorders

AN Anorexia Nervosa

BN Bulimia Nervosa

BED Binge Eating Disorder

ICB Inappropriate Compensatory

Behavior(s)

BMI Body Mass Index (kg/m2)

WAG Women’s Artistic Gymnastics

ERG Elite Rhythmic Gymnastics

HS High School students

G Gymnastics participant group

C Control Group

USG Urine Specific Gravity

UOSM Urine Osmolality

OWI Official pre-competition

Weigh-In

BMLs Body Mass Lost group

nBMLs No Body Mass Lost group

MWL Most Weight Lost

MWL% Most Weight Lost as a % of

current weight

PSG Post Season weight Gain

PSG% Post Season weight Gain as a

% of current weight

WWL Weekly Weight Lost

WWL% Weekly Weight Lost as a % of

current weight

LWC Lightweight Class

MWC Middleweight Class

HWC Heavyweight Class

LFA Leanness Focused Athletes

NLFA Non-Leanness Focused

Athletes

GOAL German young Olympic

Athletes’ Lifestyle & health

management study


Body-Type Specific Sports

Sports are assumed by many to be considered a healthy way to encourage children to

grow into healthy adults. “Fair play, teamwork, enjoyment, achievement, and life lessons are all

attainable through sports participation” (Haggen, 2002, p. 280). Sports participation usually

begins at an early age, and should offer all of these things to the athletes. This opportunity

should not be limited to those deemed gifted or talented at a given sport or activity. On the

contrary, Alfred Adler believed that heredity was not all there was, stating, “It is not true that

with heredity the last word is said, that the chromosomes are inexorable determinants of

subsequent genius” (Adler, 2012, p. 100). Though stated in the pre-World War II era, these

words still ring true. Has research not yet found genetics to be the absolute, especially when it

comes to the brain? Thus one can agree with Alfred Adler when he stated, “In most cases

exceptional performance can’t be accounted for by talent alone when early measures of the talent

in question are assessed as approximately equal” (2012, p. 100). There are countless anecdotal

accounts of athletes’ early challenges being overcome to get to the elite level. Those are the

stories many people truly appreciate; those who strove to achieve despite some deficit.

According to comments by Gladwell in Alfred Adler Revisited (2012), the research showed that

outcome is predicted more by “the elements of opportunity, practice, intelligence thresholds and

work ethic” (p. 100) and not how initially talented the person might have been. Modern research

and Alfred Adler have found, “the important thing is not what one is born with, but what use one

makes of the equipment” (p. 101).

If sports participation need not depend on innate talent and should offer a person healthy

opportunities, then something is amiss among body-type specific sports. According to

Thompson and Sherman (1999), “A growing population of athletes is suffering from AN, BN


and other disordered eating patterns” (p. 320). It appeared that all athletes are at some risk, but

“sports that place an emphasis on a thin shape or small size for purpose of appearance and/or

performance appear to be at more risk for developing disordered eating” (p. 320). Gymnastics

and ballet both fall into this category. Wrestling also appeared in the literature due to the weight

classes used to determine who will wrestle whom. Klinkowski, Korte, Pfeiffer, Lehmkuhl, &

Salbach-Andrae (2008) found that ED rates, when compared to technical or ball sports, were

much higher in aesthetic sports at 42% versus 17% and 16% respectively. Further evidence that

there may be something about these sports must be explored.

Gymnastics

Female artistic gymnastics participation in just the United States is estimated to be over

52,000 (Poudevigne et al., 2003). Children are encouraged to enroll in classes “as early as 18

months” due to the idea that “for the most part children develop their fundamental movement

skills between ages 2 and 5” (At what age, n.d.), and it is deemed beneficial to take advantage of

this period for learning the basics that will provide a solid foundation for a possible career (At

what age, n.d.). According to Barker-Ruchti, and Tinning (2010), “Women’s Artistic

Gymnastics (WAG) [involves] performing routines of intricate acrobatic and rhythmic activities

on four apparatus including the vault, uneven bars, balance beam, and floor” (p. 229), all of

which require a tremendous amount of skill and strength. Despite the athletic demands on the

body, over the past 30 years, there has been a growing trend showing that U.S. Olympic female

gymnasts “have become significantly smaller in terms of body size and weight” (Sherman, 1996,

p. 338). Many of the uniforms, worn by both the men and women, may cover much of the body

but still leave little to the imagination. The need for judges to see form and technique, as well as

the fact that loose clothing could hinder performance, are common reasons given for the tight fit.


Barker-Ruchti and Tinning (2010) used an ethnographic design to examine “how

gymnasts’ experiences are shaped by WAG and how this may lead to compliance and

disappointment” (p. 230). Researcher observations, participant observations and interviews were

used to obtain data. The participants consisted of n=7 Australian elite gymnasts and n=2

coaches.

Barker-Ruchti and Tinning (2010) found that indeed WAG in its structure at this

particular gym did inspire negative traits in the gymnasts. Those gymnasts who participated

“came to embody submissiveness and dependence, as well as the notion of body-as-machine” (p.

245). The enclosure and the distribution of the gymnasts within this space “allowed the coaches

to easily observe, control, and regulate their athletes” (p. 245) making the very space they

practice part of the submission. In order to be truly proficient, the amount of practice and

repetition had “stabilized an identity [in the gymnasts] that was marked by diligence, submission

and perfectionism” (p. 246). All of this might make a great elite gymnast, but this does not make

a healthy, whole human being. Indeed, Barker-Ruchti and Tinning (2010) concluded that, “the

degree of the discipline and submissiveness required by gymnasts is key in preventing these

athletes from reflecting upon themselves as individuals, their conduct, as well as their sport, and

thus using their experiences as a space to invent themselves” (p. 246). These girls are turning

into wonderful gymnasts but are being deprived of the opportunity to grow as individual

personalities, to be something other than athletic machines or to feel significant outside of the

gymnast role.

Bucholz, Mack, McVey, Feder and Barrowman (2008) studied the BodySense Project, (a

three month intervention program) and intervention effects on several gymnastics clubs from

Ontario, Canada. They looked at a total of N=62 gymnasts’ ages 11-18, with n=31 in the control


group, and n=31 among the group receiving the intervention program. The instruments used

were the Body Esteem Scale for Adolescents and Adults (BESAA; Mendelson, Mendelson, &

White, 2001), the Eating Attitudes Test (EAT-26; Garner, Olmsted, Bohr, & Garfinkel, 1982),

the Climate in Sport Setting Scale (CISS; Bucholz, Mack, Steringa & Matthias, 2003), the Socio-

cultural Attitudes Towards Appearance Questionnaire (SATAQ; Heinberg, Thompson, &

Stormer, 1995), Self-Efficacy Over Dieting Pressures in the Sports Club (SEODPSC; Neumark-

Sztainer, Sherwood, Coller, & Hannona, 2000), and the Pressure to be Thin subscale of the

CISSS was given to athletes, coaches and parents.

Before beginning the program, some pre-intervention rates were gathered. All groups

(athletes, parents and coaches) “perceived significant pressures to be thin in the sport

environment” (Bucholz et al., 2008, p. 319). Over 50% of both coaches and athletes reported

that they believed that having a lower body weight seemed to help athletes succeed, and close to

one-third (30%) of both athletes and coaches believed that normal, female pubescent

development “was viewed as a disadvantage to gymnasts in the club” (Bucholz et al., 2008, p.

319). With girls reaching puberty and menarche (onset of menstruation) at earlier ages, this view

cannot be healthy for the gymnasts’ natural development physically or mentally. It cannot be

easy to hear or think that one’s body, the female body, is somehow unnatural or shameful.

The overall results of the study showed a general reduction in pressure from their clubs to

be thin. There were, however, no significant changes in the scores on the BESAA, EAT-26 or

SATAQ (Bucholz et al., 2008). When looking at the Pressure To Be Thin subscale in the CISS,

the researchers found that 51% of athletes and 53% of coaches agreed with the item, “in my

[athlete’s] club, having a lower body weight seems to help an athlete succeed” (Bucholz et al.,

2008, p. 316). The item “having breasts and hips is seen as a disadvantage for gymnastics


performance” (Bucholz et al., 2008, p. 316) received 32% of athletes’ agreement and 36% of

coaches’ agreement, showing a trend among both athletes and coaches of a potentially harmful

view of the normalcy of the development of the female body, even after the program. The

results of the general questionnaire looking at an athletes’ perception of their own weight status

showed trends toward disordered eating behaviors, with 11% and 27% reporting thinking of

themselves as overweight and worrying about the way they look, thus it is no surprise that 39%

reported dieting behaviors. Another 4% reported actually vomiting after having eaten and

another 10% sometimes having the impulse to do so after meals, showing trends toward

disordered eating behaviors and impulses among the athletes themselves. Perhaps the perception

that thin will win is stronger among coaches and athletes than previously expected.

Klinkowski et al., (2008) investigated “the current psychopathology and psychological

distress in female elite rhythmic gymnasts” (p. 109). The total number of participants were

N=159 female athletes divided into three groups: elite rhythmic gymnastics participants (ERG)

n=51, Anorexia Nervosa patients (AN) n=55, and high school students (HS) n=53. The

instruments used were anthropometric measurements, such as the calculation of the Body Mass

Index (BMI=kg/m2) and questions on menstruation, and the Symptom Checklist-90 (SCL-90-R;

Franke, 2002).

Klinkowski et al. (2008) did not find what they had expected to find. There were no

psychological similarities between the ERG and AN groups; however, similar physical attributes

were observed. The ERG group was found to have a higher BMI than the AN group (18.4 vs

15.4), but the ERG group had a lower BMI than the HS group (18.4 vs 20.2). This shows a trend

among the ERG group of being thinner than high school girls, which is of concern, but not being

thin enough or showing symptomology severe enough to warrant diagnosis of AN. Although the


researchers used the cut-off age of 15 years old, they did find that more girls in the ERG

(2=17.6, p=0.000) group experienced no or delayed menarche than the HS group. They

discovered that 7.8% of the ERG group met criteria for amenorrhea; however, 43.1% were not

classified as such, despite no menarche, as the cut-off age requirement had not been met. This

trend may not have been significant for this particular study, but perhaps using more measures of

AN symptoms, new criteria for AN diagnosis and taking into account that menarche can happen

as soon as 10-years-old now, would strengthen the findings (2008). There is also a difference

between WAG and Women’s Rhythmic Gymnastics, which could account for the different

findings. While WAG focuses on four apparatuses, needing strength, agility and balance,

Women’s Rhythmic Gymnastics focuses mainly on floor routines set to music, needing

flexibility, hand-eye coordination and grace (IGM Gymnastics, n.d.). It could be that these two

types of gymnastics’ cultures differ enough to further research these differences, and to use said

research to further understand eating behaviors and attitudes amongst all female gymnasts.

Poudevigne et al. (2002) wanted to see “whether girls who enroll in gymnastics classes

differ in body dissatisfaction at the outset of their participation in gymnastics when compared

with age-and percent body fat-matched girls not enrolled in such classes” (p. 245). The design

was a longitudinal matched study using controls that matched each participant in age, percent

body fat, height, weight and BMI. The participants were a total of N=108 girls aged 4-8, with

two groups: the gymnastics participant group (G) n=54 and the control group (C) n=54. The

measurements used included BMI, body composition using a Dual-Energy X-ray

Absorptiometry (DXA), and the children’s Body Figure Rating Scale (BFRS; Collins, 1991).

The DXA uses the Experimental Pediatric Whole Body Analysis Software to determine “total


body bone mineral content, fat-free soft tissue mass, and fat mass” (Poudevigne et al., 2002, p.

246).

Poudevigne et al. (2002) found encouraging results. The G group and C group did not

differ significantly on the ratings of ideal body size (t53=-9.066, =0.948), on actual body size

(t53=-0.551, =0.588), or body dissatisfaction (t53=-0.442, =0.660; p. 247). There were

significant moderate, positive correlations between the ratings of actual body size and weight,

age, and height with the older and taller girls selecting a larger ideal body figure and girls with a

larger BMI selecting smaller ideal body figures and having higher body dissatisfaction scores.

The results show that, at least in this study, the “idea that young girls who are dissatisfied with

their body and want to be smaller are more likely to enroll in gymnastics class” (p. 248) is just

not the case. These results show that wanting to participate in gymnastics does not indicate that

there is already some kind of pathology or body-type that seeks out the sport; perhaps there is

something that occurs once the child is in the sport for some undetermined amount of time. This

implies that pre-screening toddlers entering sports for eating or body image pathology may be a

waste of time, and efforts on screening should take place after some time spent participating in

the sport.

Sherman (1996) studied the relationship between body mass index (BMI) and athletic

performance. Sherman (1996) specifically looked at the “nature of the relationship between

thinness and performance in elite gymnastics” (p. 339). This relationship has long been used as

reasoning for the weight disturbances in many athletic clubs, and many coaches and athletes

believe that lower BMI will result in better performance. Sherman looked at the top N=34

finishers (two gave incomplete data) at the 1991 World Gymnastics Championships, using the

all-around competition scores to determine the top 36 out of 233 competitors, involving 17 out of


40 countries. Measures used were the gymnasts’ BMI and final rank. The gymnasts’ final rank

was determined by the all-around score, which averages the scores from the vault, balance beam,

uneven bars, and floor exercise.

Sherman (1996) found that the relationship between athletic performance and BMI level

was curvilinear. There was a trend toward thinner athletes performing better; however, the

athletes who performed the best were neither the thinnest nor the heaviest of those competing.

The relationship shows that the effect of thinness eventually reached a point of diminished

returns, meaning that lower BMI was related to better performance but performance was more

negative as BMI became very low. Of those gymnasts who ranked first, second, and third, they

ranked 27th, 8th, and 19th respectively for BMI. The two gymnasts with the lowest BMI

finished 29th and 30th out of the final 34 (1996, p. 341). This could mean that there is a point

where any continued weight loss may result in the deterioration of the athlete’s performance due

to the weight loss being at the expense of lean tissue and body fluids, which are essential to a

healthy athlete. At this point, it may be that the athlete becomes too unhealthy and weak to

perform at the desired (elite) level. There must be a balance between health and performance,

and this knowledge could help athletes so they do not develop unhealthy habits.

Gymnastics Summary

It appears that it is not only the athletes who are contributing to the pressures to be thin in

their clubs. It is also coaches and sometimes parents who do not seem to be sufficiently educated

about normal female development. There is also denial among all groups associated, as

“prominent gymnasts and gymnastics governing bodies have been known to deny the existence

of eating disorders among their athletes” (Baum, 2006, p. 3). Knowing that these athletes tend to

be submissive and perfectionistic, it is unlikely that individual gymnasts will come forward when


the authority figures all around them do not admit to a problem. This further encourages the

myth among gymnastics clubs in particular that “thin is going to win” (de Bruin, Oudejans,

Bakker, & Woertman, 2011, p. 202) despite Sherman’s (1996) study showing that it is only to an

extent that this is true. It would appear that Sherman in particular supported Alfred Adler in that

it is usually the middle, or less expected group who comes out on top. In the effort to belong in

their gymnastics culture, and in the end to feel significant amongst peers, gymnasts are following

the lead of those who would teach them that normal body development that the female form in

and of itself is detrimental to the achievement of their goals. This is aiding in the development

of psychologically and physically unhealthy women. To be a gymnast is to be a machine. To be

a gymnast is to be genderless, even though the sport is divided by sex. The male gymnasts are

not researched nearly as often as female gymnasts, making it difficult to say whether the males

are experiencing these same difficulties. It is possible, and likely, that they are. These women

are experts at the four apparatus on which they perform and should be respected no less for the

agility, balance, strength, and endurance needed to be so. To be a gymnast one could lose one’s

sense of individuality that is part of something bigger than the next competition. Those who do

find the right balance of strength and grace will find their way to the top, if they can avoid the

pitfalls and challenges of WAG culture.

Wrestling

“One month into the start of the 1997 collegiate wrestling season, three wrestlers died

while attempting rapid weight-loss regimens” (Ransone & Hughes, 2004, p. 162). Wrestling is

quickly becoming a sport in the spotlight for males and for the development of ED and

disordered eating behaviors. While research on males and ED has been lacking in the past, it is

increasing, now offering a glimpse into the world of the male with ED. In wrestling, the weight


category system was initially designed in order to “reduce the risk of injury between opponents

and provides opportunities for athletes of all sizes to compete on an equal level” (Ööpik,

Timpmann, Burk & Hannus, 2013, p. 621). As the sport has evolved, however, many have come

to believe that it “is necessary to qualify for the lowest weight category possible to gain a

competitive advantage” (p. 621). In order to do this, an alarming number of athletes will attempt

unhealthy tactics to “make weight” or to “cut weight”. This is also referred to as “cutting”

among wrestlers, and refers to “the process of losing weight to qualify for a weight class below

the wrestler’s natural weight. This may occur acutely over several days or over a more

prolonged period” (Oppliger, Steen, & Scott, 2003, p. 32). Cycling weight, or weekly weight

lost, is the “amount of weight lost in (the) 5 days prior to a weigh-in. This weight is typically

regained during several days after the weigh-in and before the process is repeated” (p. 32).

Wrestling is a popular sport with many, and since it is thought to offer athletic opportunities to

those who might not otherwise participate in a sport, this emphasis on weight and the

classification of athletes based on weight class has put these athletes at a greater risk for eating

disorders, and in time, death.

Ööpik et al. (2013) looked at Greco-Roman wrestlers and their hydration status. The first

purpose of the study was to assess urine specific gravity (USG), or the density of urine compared

with the density of water (Urine Specific Gravity, 2009). USG is measured to ensure

euhydration (normal state of body water content; Euhydration, 2009), and “urine osmolality

(UOSM) in national and international-level Greco-Roman Wrestlers at the time of official pre-

competition weigh-in (OWI)” (Ööpik et al., 2013, p. 621). Urine osmolality is “a measure of the

number of dissolved particles per unit of water in the urine. A more accurate measure of urine

concentration than specific gravity, urine osmolality is useful in diagnosing renal disorders of


urinary concentration and dilution and in assessing status of hydration” (Urine Osmolality,

2009). The second purpose of the study was to “compare the urine indexes of hydration status of

those wrestlers who reduced body mass before the competition with those who did not” (Ööpik

et al., 2013, p. 621). They used a cross-sectional observation method. Participants were a total

of n=51 out of 89 possible Greco-Roman wrestlers at the Estonian Championship in 2009. The

measures used included a questionnaire looking at sports career, length of sport participation,

BMI measured and whether they cut weight for this competition. Urine samples were also

collected to measure USG and UOSM one hour before up to the end of OWI (1.5 hours).

Ööpik et al. (2013) found that there were two groups to be compared: those who lost

body mass (BMLs) and those who did not lose body mass (nBMLs). A total of n=42 (82%) of

all the wrestlers investigated “appeared to be hypohydrated at the time of OWI if a USG value of

≤ 1.020 as an indicator of a euhydrated status” (p. 623) was used. This means a majority of the

wrestlers were under hydrated at the time they were about to compete. Not surprisingly, the

number of those with hypohydration was significantly higher in those who lost body mass than

those who did not. Out of those measured, n=14 (27%) wrestlers appeared “seriously

hypohydrated at the time of OWI and the prevalence of serious hypohydration was 5.3 times

greater in the BML group than in the nBML group” (p. 623). There was also a strong positive

correlation between USG and UOSM values, meaning they are both good measures of hydration

status, validating their use in this study. Out of those who lost body mass, 58% of that body

mass lost before the OWI, was recovered prior to the beginning of competition, and the “extent

of body mass gain during 16 h[ours] of recovery in the BMLs (by 2.5kg on average) exceeded

that observed in the nBMLs (0.7kg) by approximately 3.6 times” (p. 623) meaning these athletes


are fluctuating in body mass by great amounts in short amounts of time, which can cause serious

damage to the body.

Ransone and Hughes (2004) looked at weight fluctuations and possible implications of

the NCAA’s new weight certificate program among college wrestlers over a period of two years.

They specifically sought to “determine the fluctuations in total body weight of the elite

competitive wrestler throughout an athletic season and to investigate how much weight a

wrestler loses in the 24 hours before a competitive match and gains after a match” (p. 162). The

study was longitudinal, and participants were N=78 male collegiate athletes from four major

United States universities from the 1999-2000 season, and the 2000-2001 season. The methods

involved a pretest that included a “physical examination, health history, and body-composition

measurements” (p. 162). The wrestlers then reported 24 hours before, one hour before and 24

hours after each match to measure total body weight. They also reported one month before the

season, every two months during the season, and one month after the season for body fat

percentage using skin folds.

The results showed significant loss of weight by the wrestlers. They found a significant

difference, F(2,154)=229.99, p<.0001, between wrestlers’ mean weights 24 hours before, 1 hour

before and 24 hours after competition, at 73.93kg ± 11.62kg, 72.53kg ± 11.66kg and 73.65kg ±

13.58kg respectively. A significant difference, t(77)=56.21, p<.0001, also existed “between body

weight 24 hours before and 1 hour before a match” (p.163). There was also a significant

difference, t(77)=54.93, p<.001, in terms of body weight between one hour before and 24 hours

after a match. These findings suggested that wrestlers lose significant amounts of weight before

a competitive match and gain significant amounts of weight after competitive matches

throughout entire seasons. Thus, the wrestlers’ weight is constantly going from extreme losses to


extreme gains in very short periods of time, sometimes in just one hour to one day. This gives a

good picture of just how often and for how long these wrestlers are cycling weight and how

much they lose each time. These dramatic losses and gains can wreak havoc on the body’s

internal systems, some of which could be permanent.

Oppliger, Steen, and Scott (2003) looked at general weight loss practices among

collegiate wrestlers. The sole purpose of this study was to “examine the WM (weight

management) behaviors of a stratified random sample of collegiate wrestlers after the

implementation of the NCAA’s new weight control rules” (p. 30), which were implemented

during the 1998-1999 season. Participants included 43 schools or programs and the sole measure

was a survey tool. This survey included demographic information, competitive performance, the

extent of weight loss, weight loss methods, sources of information on weight cutting, and the

assessment of eating behaviors related to the DSM-IV criteria for BN.

Oppliger et al. (2003) found that on average, the most weight lost (MWL) was 5.3 ±

2.8kg. While 12.1% of Division 1 (D1) wrestlers and 12.9% of Division 3 (D3) wrestlers cycled

more than 6% of their weight, 22.9% of Division 2 (D2) wrestlers were that extreme (p. 33).

Post-season weight gain (PSG) was significantly higher among D2 wrestlers, as was PSG as a

percent of their current weight (PSG%), with 38.1% of D2 wrestlers regaining greater than

6.8kg, with 31.6% of D1 and 27.5% of D3 wrestlers regaining the same amount. As far as

frequency of cutting, there was a wide range, with 16% reporting not cutting weight at all and

26.6% cutting weight more than ten times (2003, pp. 35-36). Freshmen showed a wider range,

with 11.6% reporting not cutting weight and 40% cutting weight more than ten times. When

comparing class level and weight cycling, freshmen were almost twice as likely (21.2%) as all


upperclassmen (11.0%) to cycle 6% or more of their weight. In all three divisions, freshmen had

a greater MWL and MWL% than all upperclassmen.

Wrestlers used a wide range of weight loss methods. Among the healthier methods

available to them, 79.5% reported using gradual dieting, and 75.2% increased exercise three or

more days per week. Of the less healthy options, 45.5% restricted food intake, and 20.5%

restricted fluids. The more dangerous options included fasting and using saunas and rubber-

plastic suits (5-8%), use of diet pills once per month or more (3.9%), use of laxatives once per

month or more (3.2%), use of diuretics once per month or more (2.8%), vomiting (1.9%) and the

use of enemas (1.2%; Oppliger et al., 2003).

The wrestlers were divided into weight class groups to compare them. The lightweight

group (LWC) was made up of the three lowest classes: 125, 133, and 141-pounds. The

middleweight group (MWC) was made up of the middleweight classes: 149-, 157-, and 165-

pounds, and the heavyweight (HWC) was made up of the three heaviest classes: 174-197 pounds.

As might be expected, the measures for MWL%, WWL% (weekly weight lost % of current

weight), and PSG%, the LWC group was “significantly more extreme” than the MWC, and the

MWC was more extreme than the HWC (Oppliger et al., 2003, p. 37).

The survey tool asked wrestlers about primary sources of information for weight loss and

weight cutting. Fellow wrestlers were ranked by 60% of wrestlers, coaches by 55%, and 10%

health professionals as a “very influential/influential source” (Oppliger et al., 2003, p. 37). As

far as the NCAA’s new program, 40.2% of “athletes’ weight loss behaviors were influenced by

the new NCAA rules” (p. 37). This shows that the NCAA has a good amount of influence, and

that to really make an impact they should reach out to individual wrestlers and their coaches to

truly enact change.


While many wrestlers appear to exhibit BN related behaviors, only one wrestler met all

five criteria for BN using the DSM-IV. Four wrestlers met three to four criteria for BN. Whether

these wrestlers would meet criteria using the DSM-V for BN, BED, Avoidant or Restrictive Food

Intake Disorder or Other Specified Feeding or Eating Disorders is unknown. A replication of

this study in present day could show rates among the new disorders and perhaps higher or lower

rates of ED based on the new DSM-V, depending upon whether the new rules truly are making a

difference (2003).

Kiningham and Gorenflo (2001) examined the weight loss methods of high school

wrestlers. The purpose of the study was to “determine the overall prevalence of potentially

harmful weight loss practices among Michigan high school wrestlers at all levels of success and

competition” (p. 810). Participants included 156 Michigan high schools with a total of N=2,532

wrestlers ages 14-18. The instrument used was a survey covering weight loss behaviors.

While “only 48% of wrestlers estimated that they would lose weight during the season,

over 50% had actually lost at least 5lbs, and 5% at least 20lbs over the season” (Kiningham &

Gorenflo, 2001, p. 812). The MWL five days before a match averaged 6lbs, with 62% losing

more than 5lbs, and 16% losing more than 10lbs (p. 811). Wrestlers reported fasting longer than

24 hours before a match (11%) with the average length of time 12 hours. One quarter of

wrestlers restricted food at least three to four times per week, and 2% took diet pills, diuretics, or

laxatives at least weekly. The wrestlers received nutritional information from coaches (78%),

parents (42%), doctors (37%), nurses (25%) and sources not listed on the survey (58%). Despite

this knowledge of nutrition, 72% used at least one, 52% used at least two, and 12% used at least

five “potentially harmful weight loss methods each week during the wrestling season” (p. 812).

All of these methods would be considered inappropriate compensatory behaviors (ICB) by the


DSM-V, and too many of these wrestlers are using more than one. Just like previous research,

coaches have more of an impact than those that might hold more accurate information, making

them ever more important in this problem.

Lakin, Steen and Oppliger (1990) examined the nutritional practices, weight loss

methods, and eating behaviors of high school wrestlers. The purpose of the study was to

“examine the prevalence of binge eating and bulimic behaviors, nutrition practices and weight

loss methods [used] among high school wrestlers” (pp. 225-226). General self-report

questionnaires were given to N=716 high-school wrestlers participating in summer wrestling

camps at Midwestern University.

They found that, for total weight fluctuation, 55% lost more than 1.4 kg during the entire

season. Looking at the methods used to achieve this weight loss, they found that a majority,

84%, increased their exercise time, while 75% restricted their food intake. The next popular

methods were gradual dieting with 66% and the use of heated wrestling rooms (dehydration)

being used by 65% of the wrestlers. Use of dehydration methods such as restricting fluids and

use of plastic or rubber suits were at 41% and 40%, respectively, while other harmful methods

such as vomiting and the use of laxatives or diuretics were used by 4% and 3% of wrestlers,

respectively (1990). The majority of methods involved the loss of fluids or dehydration, which

is extremely dangerous, especially for an athlete, who uses up high amounts of fluids and

electrolytes while performing.

The athletes were also asked for sources of information on nutrition and weight loss

methods. The vast majority received information from within the wrestling community, with

87% coming from coaches, 77% from fellow wrestlers and 58% from former wrestlers. Parents

or physicians informed another 57% and 41%, respectively. With less than 50% of their


information coming from a truly educated source, it is easy to see why the athletes were “prone

to several myths about basic nutrition” (p. 228). It is becoming clear that accurate education

within the wrestling community could be a helpful option.

Lakin et al. (1990) also found ED and disordered eating patterns. About 2.8% of the

wrestlers met criteria for a diagnosis of BN using the DSM-III criteria. According to DSM-III-R

criteria, 1.4% could be diagnosed with BN, and combining the two (DSM-III and DSM-III-R),

1.4% met criteria for BN (1990). Looking at overall prevalence rates for the general population,

these percentages are quite high, in particular for males.

Wrestling Summary

Wrestling is a sport that “physically… demands endurance, muscular strength, flexibility

and motor coordination” (1990, p. 223). These needs seem to go against many of the methods

used to make weight, as “harmful weight loss practices appear to be pervasive throughout the

sport of wrestling at all levels of competition” (Kiningham & Gorenflo, 2001, p. 812). These

methods usually involve the loss of critical body fluids, over short periods of time, followed by

intense, intake of calories and fluids immediately before and after a competitive match. The

problem is that “replenishing body fluids may take 24-48 hours, muscle glycogen replenishment

may take 72 hours and replacing lean tissue may take even longer” (“Weight 'Cutting,” p. 6),

making these practices even more obsolete. The consequences of these practices, or

hypohydration, “can compromise cardiovascular function, heat dissipation, and exercise

performance” (Ööpik et al., 2013, p. 624) all of which are key to a highly competitive

performance. If the hypohydration becomes chronic, such as with a long-term career in

wrestling using such dangerous methods, it could cause chronic illnesses. Unlike gymnastics,


and often ballet, there seems to be less denial among professionals and governing bodies for the

wrestling community.

In 1998, the NCAA stepped up and stepped in. According to Oppliger et al. (2003), the

NCAA added six pounds to each of the ten weight classes, moved weigh-ins closer to the start of

competition, and body fat was assessed at the beginning of the season, resulting in a minimum

competition weight, and the wrestlers were given until early December to make that

predetermined weight. This is a step in the right direction; however, this system was put into

place in 1998, and what little research that has been done since then still shows high rates of

disordered eating patterns among wrestlers. According to the research, fellow wrestlers, and

coaches have a great amount of influence and should therefore start to be held accountable for

how they coach these wrestlers. Their health, body, and mind are in these coaches’ hands. It is

time they take responsibility and start encouraging their athletes to be whole, socially involved

persons. More research should be applied to the atmosphere and environment these wrestlers are

dealing with, to better understand how the new NCAA rules and other programs could be more

effective.

Ballet

On June 30, 1997 Boston Ballet Corps de Ballet member Heidi Guenther passed away

suddenly from apparent heart complications; she was twenty-two years old (Diesenhouse, 1997).

Her death brought another side of ballet out into the light. ED in ballet is not a new phenomenon.

In 1984, a ballerina was quoted as having said, “A dancer can look pretty terrible in tights unless

she’s pared her weight down to the absolute minimum. There’s no middle ground” (Thomas,

Keel, & Heatherton, 2011, p. 216). Given this attitude, it might be surprising to know that when

Maria Taglioni (1804-1884), one of ballet’s first premier ballerinas, danced the first La Sylphide


in 1832, dancers were told to hide their lanky arms by curving them (Jacob, 1981). When Maria

was dancing the barre work used to begin with the grands battements (upward thrust of the leg)

with 48 plies (to bend, bending of the knees) going last; then moving to floor work (Paskeva,

1992). Late in the 1970s and early 1980s, the grands battements were switched to the end of

barre which resulted in dancers having thinner, more toned, muscular thigh muscles, thus

creating a drastic change from the larger, over-developed thigh muscles of dancers in Maria’s

day (Jacob, 1981).

Ballet requires flexibility, muscular strength and endurance, all while looking graceful.

While it is very much like other sports, “the aesthetic requirements of body image beyond the

functional requirements for dance are fundamentally different” (Anshel, 2004, p. 116). There are

arguments about what they wear or do not wear (tights, tutus, etc.) that are used as excuses for

the increased amount of disordered eating behaviors found in the ballet culture. In this culture,

“dancers who fail to meet and maintain a predetermined ideal body composition are rapidly

‘deselected’ from professional participation” (Anshel, 2004, p. 116) which makes body image

more important. Retirement age is in the mid-thirties to rarely in the early 40s, and “age 21 years

is the point at which it is determined whether a dancer will become ‘successful’, after which time

these chances are greatly diminished” (Anshel, 2004, p. 116) making the problems of ballet

culture those of young women and girls.

Thomas et al. (2011) looked at serious injuries and disordered eating patterns among

adolescent ballet dancers. The purpose of the study was “to determine whether adolescent

dancers who exhibited disordered eating behaviors (a) were more likely to endorse injuries, and

(b) spent a greater number of days away from ballet to recuperate from injuries” (p. 217). The

subjects consisted of a total of N=239 adolescent female ballet students who attended one out of


five possible summer intensive programs in the United States. In order to assess disordered

eating behaviors, a self-report survey was used (Heatherton & Nichols, 1995). To assess injuries

the focus was on tendonitis and fractures which are “the most common injuries reported by ballet

dancers” (p. 217).

The results showed a wide range of disordered eating behaviors with an increased

amount of injuries with time spent recuperating. Out of those who reported disordered eating

behaviors, the most common was fasting (29.3%), followed by self-induced vomiting (9.6%) and

then laxative use (4.2%). When it came to injuries, almost one-third of dancers (27.2%) had

been medically treated for tendonitis, and 25.1% reported being treated for a broken bone. Stress

fractures were experienced by 15.1% of the dancers, making injuries prevalent among this

sample of adolescent ballet dancers (Thomas et al., 2011).

Thomas et al., (2011) also found relationships for disordered eating and injuries, and

disordered eating and days spent out with injury. There was a positive lifetime history of injury

(p=0.004) associated with vomiting. They also found that “the more lifetime disordered eating

behaviors participants reported, the greater number of injury types they indorsed (Spearman’s

=0.17, p=0.01)” (p. 219). With 15-30% of dancers experiencing injuries, it is not too surprising

that nearly three-quarters (71.2%, n=89) of dancers who reported injuries took time off to heal,

with the median number of days off to recuperate at 14.0 days. Those who reported a lifetime

history of self-induced vomiting took a “median of 22.8 more days out of role” (p. 219) at 36.8

days off to recuperate, than those who did not vomit. Fourteen days, none-the-less a whole

month, absent can mean a lot of choreography and training missed, which could give another

dancer the opportunity to take an injured dancer’s place. Since a bad enough injury has the


potential to set back or end a career, it could help for these dancers to learn healthier eating

behaviors for both their health, and their careers.

Annus and Smith (2009) hypothesized that “specific learning about thinness in dance

class is an important aspect of the risk process” for eating disorders (p. 50). The first purpose of

the study was to look at possible relationships “among specific learning about thinness in dance

class, thinness/restricting expectancies and higher levels of eating disorder symptomology” (p.

52). The second purpose was to “study women across a wide range of dance class experience

levels” (p. 52). The participants consisted of N=501 undergraduate college students. A total of

four instruments were used: the Eating Disorder Examination-Questionnaire (EDE-Q; Fairburn

& Beglin, 1994), the Body Dissatisfaction and Drive for Thinness subscales of the Eating

Disorder Inventory-2 (EDI-2; Garner, Olmsted & Polivy, 1983), the Thinness and Restricting

Expectancy Inventory (TREI; Hohlstein et al., 1998), and a dance experience questionnaire,

which was developed by the authors of the study to determine level of experience and

participation.

Disordered eating behaviors were found among the women participating. A total of n=95

(19%) reported having at least one objective binge episode within the last month. Second most

common was vomiting at least once within the last month at 6% (n=30), followed by 5.4%

(n=27) using diuretics, and 2.6% (n=13) using laxatives within the last month, all of which are

dangerous weight-loss methods, regardless of sport participation (Annus & Smith, 2009).

In order to compare the groups, dancers and non-dancers were parsed out, with a total of

n=232 (46%) of women having studied dance at some point. Out of that group, about 20.26%

(n=47) had danced semi-professionally and only 4.31% (n=10) had danced professionally at one

time. This small percentage of elite dancers is not surprising given that college age and the age


of a dancers’ prime time to succeed are the same. The average age dancers began was 7.78 years

old, continuing to dance for an average of 6.06 years, and quitting dance after about 13.73 years.

This means that the average participant in dance is spending some of the most important

developmental years being influenced by participation in this culture (Annus & Smith, 2009).

This study also gave questionnaires to a total of N=398 dance instructors. When asked if

they emphasized weight or shape in class, 25.88% (n=103) agreed that they did a moderate

amount, with 12.31% (n=49) admitting to often actually making comments about students’

weight or shape. Lastly, 19.60% (n=78) reported to be at least moderately critical of students’

weight and shape. That might help explain why, when dancers were asked about their

classmates, 8.04% (n=32) reported that almost half of their classmates used dangerous

compensatory behaviors (i.e., vomiting, laxatives, etc.) and 8.54% (n=34) reported that half their

classmates had an eating disorder (Annus & Smith, 2009). The instructors are role models and

influential in these dancers’ lives, and in this case, are not using that influence in a healthy and

encouraging manner.

Comparing length of dance experience, learning in dance class and eating disturbance,

they found that “mere involvement [in dance] was unrelated to eating disorder symptomology

but reports of thinness related learning in dance class did relate to symptom level” (Annus &

Smith, 2009, p. 57). Total thinness-related learning in dance class was indeed found to have a

significant relationship with a drive for thinness, EDE-Q total scores, thinness-restricting

expectancies, as well as the presence of both binge eating and purging. This study also found

that the higher levels of dance classes experienced more thinness-related learning than the lower

levels of dance classes, which suggests thinness-related learning is more prevalent in the higher

levels of dance classes, such as pre-professional schools. The authors considered the study


consistent with the eating disorder expectancy theory, which states that “dance class-related

experiences about the benefits of thinness and dieting contribute to the formation of

reinforcement expectancies regarding thinness and dieting, and the expectancies are the proximal

influence on symptomatic behavior” (Annus & Smith, 2009, p. 57). These girls are learning a

beautiful performance art centuries old, and yet they are also learning discouragement, low self-

esteem, and negativity. They seem to be taught that in order to have significance as a ballet

dancer, one must be a certain shape, and that shape is thin. The very environment that should be

encouraging them to blossom into whatever type of ballet dancer they might be, expects them to

conform or leave.

Toro, Guerrero, Sentis, Castro and Puértolas (2009) sought out possible risk factors or

problems concerning eating disorders and ballet students. The main purpose of the study was to

“establish the prevalence of ED in a Spanish population of dance students and to assess whether

certain specific factors related to the ballet school situation might be associated to ED

symptoms” (p. 41). The subjects were divided into three groups for comparison. The dancers

were from the Barcelona Theatre Institute’s Dance Conservatoire, with n=76 girls in both the

intermediate level dance class and normal secondary/pre-university studies, and a group of n=29

students continuing their artistic training at the school after completing their secondary studies.

The third, comparison group, was comprised of a total of N=453 adolescent females from the

general population of Barcelona. The instruments used were the Eating Attitude Test (EAT-26;

Garner, Olmsted, Bohr, & Garfinkel, 1982), the Questionnaire on Influences on Body Shape

Model (CIMEC in Spanish; Toro, Salamero & Martínez, 1994), the Eating Disorders Assessment

Questionnaire (CETCA in Spanish; Toro et al., 2005) and BMI (2009).


The overall finding in this study was that this particular group of adolescent female dance

students “showed prevalences of ED and risk eating behaviors similar to those found in

adolescents from the general [Barcelona] population” (Toro et al., 2008, pp. 45-46). These

findings are different from other studies of this kind in this respect. They did find significant

relationships between “specific dance school situations and the presence of ED” with “an EAT-

26 score suggestive of risk” being “significantly associated with feeling quite or highly

pressurized regarding choice of food, physical appearance, weight control and artistic

performance” (Toro et al., 2008, p. 44).

Toro et al. (2008) found results that differed from past studies, but the authors offered

three possible explanations or characteristics of this group that may have offset the usual risk

factors. The first explanation was that more dancers in this group ate all of their meals every

day. The second was that far more dancers in this group saw themselves as thin as opposed to

fat, and lastly, the “dancers’ perceived social body image was better” (p. 46). It would seem that

risks for disordered eating depend a great deal on the characteristics of particular schools. It

should also be pointed out that the study included both ballet and Spanish dancers, which are two

completely different styles of dance. The authors admit that, “the body silhouettes typical of

these two disciplines are not exactly the same” (p. 48) and they are quite right. Ballet has a

different body silhouette from every other type of dance, thus to try and combine them for the

purpose of a study does not really make sense. The results give great insight into the problem, in

that it gave possible explanations for why certain schools may or may not have a problem with

disordered eating behaviors amongst their dancers. If specific characteristics of schools with low

prevalence rates could be found, then they could be used to help other schools or companies with

high rates to make positive changes.


Ringham et al. (2006) compared female ballet dancers to three groups of different levels

of eating disorder pathology. The purpose of this work was threefold: first to examine the rates

of bulimia nervosa and bulimic behaviors amongst dancers, second to examine a wide range of

eating disorders and third to compare “eating behaviors and attitudes of ballet dancers with those

displayed by women with AN and BN who are not professional dancers” (p. 504). They

compared n=29 female ballet dancers to n=44 females with no eating pathology, n=25 females

with AN, and n=47 females with BN. The instruments used were the Structured Clinical

Interview for DSM Axis I Disorders (SCIDI; First et al., 1997), a Weight History Interview

(WHI; Lilenfeld et al., 1998), the Eating Disorder Inventory (EDI; Garner, Olmsted & Polivy,

1983) and BMI.

Using the DSM-IV-TR criteria, there was a high prevalence rate of ED among the

dancers. They found that 83% of the dancers reported some form of eating pathology while 28%

had a lifetime history of either or both disorders. The category of eating disorder not otherwise

specified was also included, and it was found that 55% of the dancers fit this diagnosis, making it

the most prevalent (Ringham et al., 2006, p.505). Unlike previous studies, “rates of AN and BN

were similar in this sample (6.9% vs 10.3%, respectively), with AN + BN being as prevalent as

each disorder alone” (Ringham et al., 2006, p. 505). About two-thirds (65.5%) reported a history

of bulimic behaviors, with 41.4% binge eating, 31.0% vomiting, 31.0% abusing diet pills, and

24.1% abusing caffeine in some form. Ballet dancers and the eating disorder participants

showed similar levels of “eating pathology on the EDI” and also “did not differ significantly

from individuals with eating disorders on any of the subscales” (Ringham et al., 2006, p. 506) of

the EDI. Those subscales include the drive for thinness, Bulimia, body dissatisfaction,

introceptive awareness, ineffectiveness, maturity fears, perfectionism, and interpersonal distrust.


The results support the idea that “dancers share behavioral, and psychological characteristics

with non-dancing individuals with eating disorders” (Ringham et al., 2006, p. 507). In other

words, ballet dancers are more similar to those with eating disorders than those in the control

group with no eating pathology.

Thomas, Keel and Heatherton (2005) looked at the relationship between disordered

eating patterns among dancers and the level at which they are dancing. Specifically, they wanted

to find out whether “ballet school affiliation with a national professional ballet company,

regional professional ballet company, or no performing troupe would be associated with the level

of disordered eating attitudes and behaviors of its students” (p. 264). The sample included

N=239 female ballet students, ages 13 to 18 years old, who were attending five summer ballet

workshops. They were placed into categories based on the level of the school: national, regional,

and local. Of the five programs in the study, two were national, two were regional and one was

local. They used a 26-item version of the Eating Disorder Inventory (EDI; Garner, Olmsted &

Polivy, 1983), a questionnaire, and BMI (Thomas et al., 2005).

Overall, there were no significant differences in students’ BMI across school type.

Nationally affiliated schools did have significantly higher rates of weight dissatisfaction and

dieting when compared with the regional schools (Thomas et al., 2005). Both the locally

affiliated and nationally affiliated students “reported significantly higher EDI total, Drive for

Thinness, and Perfectionism scores compared with regional students” (Thomas et al., 2005, p.

265). The national schools reported one-third of the students had eating disorders, which was

twice the rate of schools that were not affiliated with any performance troupe. This could mean

that the elite ballet schools have a different eating or weight culture. When looking at specific

weight-loss methods, nationally affiliated students were significantly more likely to fast than


local students, and were three to four times more likely to practice self-induced vomiting than

other school types (Thomas et al., 2005), again showing the elite ballet students tend to take

more extreme measures. The national and local programs had significantly higher rates in the

measures of disordered eating attitudes than their regional counterparts, while the national

students scored significantly higher in measures of disordered eating behaviors than both

regional and local programs (Thomas et al., 2005). While local students may have similar

attitudes to the national students, it would seem that they do not follow through like the national

students tend to. Here we see a real difference between the levels of schools, and that being

associated with a national performance troupe may put a dancer at increased risk than one who

stayed regional or local.

Anshel (2004) looked at the rate differences in eating patterns between adolescent ballet

dancers and non-dancers. The first objective was to compare disordered eating patterns, selected

dispositions, and dysfunctional attitudes “previously linked to disordered eating patterns” (p.

119). The secondary objective was to possibly “determine the characteristics that predispose

ballet dancers for developing disordered eating patterns” (p. 119). The sample included n=57

female ballet dancers from four studios in Sydney, Australia, and n=51 female non-dancers from

area high schools. Both the Eating Disorder Inventory-2 (EDI-2; Garner, 1991) and the Food

Intake Attitude Survey (FIAS) were used. The FIAS was developed for this study in order to

“assess attitudes and behaviors specifically relevant to disordered eating in dancers that are not

included in the EDI” (p. 120).

Significant differences were found between the dancer and non-dancer groups. There

were significant differences on the Drive for Thinness subscale (F=7.07, p<0.05), the

Perfectionism subscale (F=4.06, p<0.05) and the Body Dissatisfaction subscale (F=6.60,


p<0.05), with dancers scoring higher on all three than non-dancers (Anshel, 2004). A

relationship was found between dancers and the Drive for Thinness and Perfectionism subscales.

Dancers found to be at risk for a disordered eating pattern by “scoring above the mean on the

Drive for Thinness subscale” were more likely to then also score above the mean for the

Perfectionism subscale (Anshel, 2004, pp. 123-125). Dancers therefore, tend to have a higher

need to be thin, tend to be more perfectionistic, and tend to be more dissatisfied with their

bodies. For both dancers and non-dancers, body dissatisfaction was significantly associated with

being at risk for an eating disorder. On the Importance of Physique scale, “dancers perceive[d]

their level of fitness and body shape [as] significantly more important than their non-dancer

peers” (Anshel, 2004, p. 126), which would make sense since their bodies are their livelihood.

The Determinants of Eating scale, which looked at sources of information, showed that dancers

were “more influenced by significant others and the links between eating and exercise to body

shape and weight than non-dancers” (Anshel, 2004, p. 126) which is in contrast to the Weight

Control Behaviors scale. Not only were dancers engaging in weight control behaviors, but to a

greater extent and intensity than the non-dancers. The weight control behaviors used were:

avoiding certain foods (62.9%), constant dieting (29.6%), skipping meals or fasting (25.9%),

self-induced vomiting (14.8%) and use of laxatives or diuretics or diet pills (11.1%). Weight

control behaviors were found to be highly correlated with Drive for Thinness (r=.77, p<0.01),

suggesting a relationship between the pursuit of thinness and engaging in weight control

behaviors. Based on these results, Anshel (2004) concluded that dancers were at a higher risk

than non-dancers for developing eating disorders than those who did not participate in dance.


Ballet Summary

It looks as though ballet dancers are at an elevated risk for developing eating disorders.

The higher level the program; the higher the levels of eating disorders, which would make elite

professional ballerinas at the highest risk. This sub-population is also more like those with

eating disorders than those without. This may be due to the fact that “scores for athletes are

based on ratings by judges rather than by objective performance measures” (Thompson &

Sherman, 1999, p. 320), meaning their aesthetic appeal is up for judgment along with their

technical prowess. While one could argue professional ballet includes no judges, they use a

narrow definition of a judge. One does not need a clipboard and badge to be a judge. The

competition in ballet is fierce, not only between companies but within them as well, and it starts

early on at the schools that feed them. “At one of the most elite ballet schools in the U.S., the

School of American Ballet, only 5% of the young dancers who matriculate at age 8 actually

complete the training program at age 17” (Thomas, Keel & Heatherton, 2005, p. 264), and that is

just the school. This gives them a small window of time to be successful, and those that do make

it through the highly competitive programs enter the more intensely competitive world of the

professional companies all over the world. Instead of being allowed to compete against

themselves, to be the best they can be by taking on the task at hand, they are constantly

competing with others to reach some imagined top. Dancers have even been known to sabotage

other dancers via body shaming, or worse. In order to belong in this culture, in order to have job

security and in order to feel significant in this ballet culture, thin is the only way to go. This

mistaken belief is encouraged in these girls from a young age, all the way through their

development. No wonder so many end up on a ‘neurotic hunger-strike’. This atmosphere of


severe competition is creating unhealthy, and eventually unhappy dancers, which is so ironic, as

the art they perform is one that should uplift any spirit.

Body-Type Specific Sports Conclusion

Body-type specific sports research shows an elevated risk for inappropriate eating

behaviors and ED for those participating in gymnastics, ballet and wrestling. Female gymnasts

are losing their sense of individuality and are learning unhealthy attitudes toward the female

body as it develops naturally. Male wrestlers are cycling larger proportions of weight in shorter

amounts of time, even with new regulations and guidelines in place. Female ballet dancers are

risking health and career for a dated aesthetic ideal. With all three sports, the higher, elite levels

appear to be at the highest risk, meaning those that make the global stage are more likely to have

some kind of unhealthy attitude toward body weight or shape. Those that make the global stage

are also more likely to become role models for younger generations, creating a cycle of

unhealthy habits. In order to break this cycle, the atmospheres of the individual clubs, teams,

troupes or companies must be examined further to determine what is causing this elevated risk in

these sports.

Eating Disorders

“Eating disorders, and, in particular, anorexia nervosa (AN) have morbidity and mortality

rates that are among the highest of any mental disorders, and are associated with significant

functional impairment” (Herpertz-Dahlmann, Seitz & Konrad, 2011, p.177). To Alfred Adler,

psychological disorders (or neurosis) could be summed up in two words: “yes, but”. Expanding

upon those words, he said, “…by ‘yes’ I mean that the neurotic person recognizes common sense

[however] it is always followed by “but” …in this but you find the whole strength of the neurotic

symptoms” (Adler, 1956, p. 302). In this case, the neurotic symptoms make up the category of


psychological disorders known as ED. The patient often knows that they need to eat (common

sense), but they cannot, and in some sports, the sport itself becomes the excuse.

In his brief work titled Neurotic Hunger-Strike, Alfred Adler explains his view of AN.

AN in essence is “an attempt by means of an exaggerated abstinence…to retard the development

of the female bodily form” (Adler, 2012, p. 260). Today, this can be seen in women’s

gymnastics and in ballet, with curves of any kind being seen as aesthetically displeasing, and

possibly career ending. Many have suggested that part of AN, and BN could be due to need for

attention or control. Indeed, Alfred Adler believed that this may be true, stating that, “everything

is at once centered about [him or] her and [his or] her will dominates the situation in every

respect” (Adler, 2012, p. 260). The treatment alone could consume the attention of an entire

family for a lifetime, which gives the one afflicted a great deal of control over them. Eventually,

the consequences of this “exaggerated abstinence” become clear; the common sense should tell

the person to choose another path. Alfred Adler explains the course of the disorder, saying that,

“the importance of the nourishment is first over-evaluated and then we have the fear of the taking

of nourishment so that finally, … there is no other alternative but of either adopting the

hesitating attitude, of a truce, or of retreating before the demands of society” (Adler, 2012, p.

261). These three options are really the only options research shows ED follows: continue with

the disorder until the body gives out, get help, or suicide.

While this all seems to paint a dark and selfish portrait of those with ED and other

disorders, it is not the whole truth of it. If the layers are peeled back, “we see definitely reflected

the old infantile feelings of inferiority in connection with the demands of life” (Adler, 2012, p.

261). Susan Belangee (2006) proposes that the symptoms and behaviors related to ED could be

the “self-focused methods a person adopts to compensate for or to overcome the strong


inferiority feelings” (p. 6). The problem ED presents is that of perfection; a delusion presented

to its victims in the form of a forever, unattainable goal. Alfred Adler discusses striving for

perfection, but in a healthy, social manner. To him, “the impetus from minus to plus never ends.

The urge from below to above never ceases” (Adler, 1956, p. 103); the below always being the

feeling of inferiority, and the above being the feeling of superiority. Finding perfection generally

entails a combination of safety, a sense of belonging and a sense that one has some personal

significance in the world. In the case of mental disorders, Alfred Adler says that, “we see this

goal of superiority in them also, but it tends in a direction which is opposed to reason to the

extent that we cannot recognize in it a proper goal of perfection” (1956, p. 107-108). In ED

specifically, Belangee (2006) agrees, saying that ED “may be an example of striving for

superiority (i.e., on the useless side) because the person is focused solely on her or himself and

preoccupied with fears of gaining weight and getting fat, rather than expending energy outside of

the self” (p. 7). She goes further, saying that “it is possible that the preoccupations with weight,

fat, and dieting serve as safeguards that enable an individual to avoid fully participating in life’s

tasks of work, social relationships, and intimate relationships and thereby avoid the chance of

getting hurt or failing in some aspect of life” (p. 7). In the case of failure, the blame can always

be placed on the disorder or the symptoms, thereby safeguarding the individual’s self-esteem.

The improper or fictional goal of ED is a body weight or shape that is non-conducive to general

health, none-the-less participating in a physically demanding sport, making its pursuit useless.

The American Psychological Association (2013) changed the criteria for AN in the DSM-

V. First, there must be a “restriction of energy intake relative to requirements, leading to a

significantly low body weight in the context of age, sex, developmental trajectory, and physical

health. Significantly low weight is defined as a weight that is less than minimally normal or, for


children and adolescents, less than that minimally expected” (p. 338). Second there is “an

intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with

weight gain, even though at a significantly low weight” (pp. 338-339). Third, there is a

“disturbance in the way in which one’s body weight or shape is experienced, undue influence of

body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of

the current low body weight” (p. 339). There are two types, the restricting type and the binge-

eating/purging type. The weight requirements have been turned into severity levels: mild

(BMI>17 kg/m2), moderate (BMI>16-16.99 kg/m2), severe (BMI>15-15.99 kg/m2), and extreme

(BMI>15 kg/m2). Other characteristics that have been found to be associated are overly

restrained expression, feelings of ineffectiveness, concerns about eating in public, a strong desire

to control one’s environment, limited social spontaneity, and inflexible thinking (2013).

The criteria for BN have also changed in the DSM-V. According to the new DSM-V, a

binge-eating episode has two characteristics: “eating in a discrete period of time, an amount of

food that is definitely larger than what most individuals would eat in a similar period of time

under similar circumstances” and “a sense of lack of control over eating during the episode”

(APA, 2013, p. 345). These episodes are then followed by “recurrent inappropriate

compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse

of laxatives, diuretics or other medications; fasting; or excessive exercise” (APA, 2013, p. 345).

The time frame is at least once per week for three months, on average. Lastly, “self-evaluation is

unduly influenced by body shape weight” (2013, p. 345). As with AN, there are now four

severity levels: average of 1-3 episodes of ICB per week (mild), average of 4-7 ICB per week

(moderate), average of 8-13 ICB per week (severe), and an average of 14 or more ICB per week

(extreme) (2013).


Eating Disorders: General

Belangee, Sherman and Kern (2003) “investigated the relationship between lifestyle

personality attributes and eating disorder symptoms and behaviors in a nonclinical population”

(abstract, p. 461). According to Griffith and Powers (2007), the lifestyle is the:

Unique and self-consistent unity in movement (thought, feeling, action) of the individual,

created in early childhood in the context of genetic possibility and environmental

opportunity (soft determinism), organized and given direction by the subjectively

conceived goal, based upon guiding fictions and following guiding lines that are relied

upon and reinforced through training, self-training, and the rehearsal of character (p. 63).

The participants included N=60 undergraduate students, with n=41 females, n=15 males and n=4

gender neutral responders. The materials used were the BASIS-A Inventory (Wheeler, Kern, &

Curlette, 1993) and the EDI-2 (Garner, 1991).

Three significant relationships were discovered. The first relationship was between Drive

for Thinness and Wanting Recognition. The relationship was positive, meaning that, “as the

need for approval increased, the drive for thinness similarly increased” (Belangee et al., 2003, p.

467). Second, there was a significant and positive relationship between Perfectionism and

Wanting Recognition, which meant that “as the need for approval increased, the tendency toward

higher levels of perfectionism also increased” (Belangee et al., 2003, p. 267). Last, there was

also a significant and positive correlation between Perfectionism and Being cautious, meaning

that the higher the level of distrust the higher the level of perfectionism. It would appear that the

Lifestyle traits of wanting recognition, perfectionism and the need for approval are significantly

related to ED behaviors and symptoms.


Eating Disorders: Anorexia Nervosa

Herpertz-Dahlmann, Seitz and Konrad (2011) reported on the general etiology of AN.

When it comes to heritability, they found that “the lifetime risk for first-degree relatives of

patients with AN, or patients with BN to develop an ED themselves is 7- to 12- fold higher than

in families of healthy controls “ (p. 178). Twin studies have shown “liability rate(s) between 50-

75% for AN and between 30-80% for BN…” (p. 178). Perfectionism, obsessiveness and rigidity

were listed as “robust traits in adults and adolescents with AN” (p. 179), which is consistent with

previous research and the DSM-V.

They looked closer at the relationship between ED and the increased occurrence of onset

during puberty. Genetic factors could possibly get “switched on” at that age. There is also the

factor of increased stressful life events that occur during puberty. Then there is the figurative

explosion of hormonal changes that happen at that age. They found that “puberty-related

maturation [was] demonstrated in the brain regions of the hippocampus and amygdala” both of

which are associated with “long term course of ED” (Herpertz-Dahlmann et al., 2011, p. 179).

There is also the fact that “gonadal steroids have been shown to directly alter affective

processing as well as neurotransmitters such as dopamine, serotonin, opioids, oxytocin, and

vasopressin” (Herpertz-Dahlmann et al., 2011, p. 179).

Herpertz-Dahlmann, Seitz and Konrad (2011) also found that “starvation and emaciation

induce complex physiological and psychological reactions involving central and peripheral

[nervous system] mechanisms” (p.179). They explain that, “the aim of the starvation-induced

changes in metabolism is conserving energy; however, these changes might provoke

neurochemical abnormalities that reinforce premorbid traits or behaviors in AN patients and can

even worsen the course of the illness” (p. 179). These changes have been shown to cause


dramatic loss of global brain volume, meaning both grey and white matter are missing, with 5-

20% of grey matter missing from the whole brain (2011). The anterior cingulated cortex,

hippocampi, and the temporal parietal and prefrontal regions seem to be hit the hardest, resulting

in deficits in cognition. Fortunately, these affects appear to be reversible upon sufficient weight

gain. There is also a “link between amenorrhea in patients with a chronic course of the disorder”

(p. 180), which involves deficits in recall, verbal and working memory, visual reproduction,

math, oral language and reading skills. Dysfunctional neural activation patterns are seen in

functioning MRI’s of AN patients. The frontoparietal and anterior cingulate as well as the limbic

and reward related neural networks are primarily effected. This is seen in both starved patients

as well as recovered anorexia patients (2011). Those “AN patients showed difficulties in

discriminating between positive and negative feedback associated with altered striatal

activation…[resulting in] an impaired food response” (p. 180). These affects are irreversible,

and could mean the changes are resulting in permanent changes to how AN patients, past and

present, experience food.

Huas et al. (2010) looked at the mortality rates of severe anorexia nervosa patients over a

ten-year span. The purpose of the study was to “determine a standard mortality ratio, to describe

causes of death, to identify predictors of fatal outcome…and to identify clinical signs that could

alert the clinician to the risk for death and/or possible targets for treatment at admission” (p. 63).

The subjects were N=539 female consecutive in-patients who met DSM-IV criteria for AN and

were hospitalized for the first time in the ED unit at the Clinique des Mentales et de l’Encéphale

(CMME) at Saint-Anne Hospital in Paris, France. The time frame was January 1988 to July

2004. The fatal outcome came from the National Institute of Statistics and Economics (Institut

National de la Statistique et des Etudes Economiques, INSEE), and the causes of death came


from CépiDc (Centre d’Epidemiologie sur les causes médicales de Déces, the French

epidemiological center collecting data on causes of death). They collected the Crude Mortality

Rate (CMR) by dividing the number of deaths by the total number in the cohort. The

Standardized Mortality Ratio (SMR), or expected number of deaths, “was obtained by applying

age, gender, and five-year specific mortalities for the general French population…to the

corresponding cumulative person-year in the study cohort” (p. 65).

There were a total of 40 deaths over the span of the study. The CMR was 7.5%, with the

average age at death 35.9 years. The SMR was a 10.6 which is “comparable to that for

Hodgkin’s disease and is even higher than the SMR for Schizophrenia patients” (Huas et al.,

2010, p. 67). Cause of death for 40% (n=16) was listed as AN, and 32.5% (n=13) of deaths were

“attributed to either AN alone (n=2) or to its somatic complications (7 cardiac arrests, 3 cachexia

and 1 infection)” (Huas et al., 2010, p. 68). The second highest cause of death was suicide at

17% (n=7), with the frequency of attempts at 71.4% (n=5) for those who completed the act.

Suicide attempts among those who died of other causes were 50% and 26.1% for those who did

not die (2010).

One of the goals of the study was to possibly determine admission predictors of

mortality. In the bivariate analysis, death was found to be significantly associated with older

age, lower desired BMI, and greater intensity of eating disorder behaviors (EDI scores). The

multivariate analysis found that those same three factors were “significantly associated with a

greater risk of death” (Huas et al., 2010, p. 68).

A second goal of the study was to find lifetime predictors of mortality. The bivariate

analysis pursed out nine variables that were “significantly associated with death” (Huas et al.,

2010, p. 67): longer duration of ED, greater number of hospitalizations, history of suicide


attempt, lower minimum BMI since puberty, history of abortion, pre-menarche ED, self-induced

vomiting, rumination, and diuretic use. The multivariate analysis found that three variables

remained significant: history of suicide attempt, longer duration of ED, and diuretic use (2010).

Strauch and Erez (2009) sought to “examine how restrictive thoughts and behaviors arise

and are maintained through a consideration of the life tasks proposed by Alfred Adler” (p. 203).

In this case, the term restriction is meant to “refer to the manner in which individuals with

anorexia nervosa respond to the demands of various life tasks” (p. 204). This restriction

“becomes a representation of the individual’s holistic response to feelings of inferiority that

extends beyond the anorexia nervosa” (p. 204), and pervades the individuals whole life

experience.

Strauch and Erez (2009) found restriction in all three major tasks of life. In the work

task, there are obsessive thoughts and avoidance of workplace relationships. These behaviors in

turn reinforce feelings of doubt and criticism, disconnection from the self and colleagues, and

high levels of perfectionism. In the social task, the individual may limit sharing and connecting

with others, have few close friends, and may isolate from others. In this case, the “restrictive

symptoms can lead to extreme self-involvement, which would serve the purpose of avoiding

social and community interactions” (p. 206). With the intimate relationship task, there tends to

be an “…emphasis on controlled and rule-bound behaviors for both the individual and the

partner in respect to sexual issues, and a general avoidance of going out or engaging with the

partner authentically” (p. 206).

Eating Disorders: Bulimia Nervosa

Mehler (2011) reviewed the medical complications associated with BN that complicate

recovery. Purging or ICB is usually achieved through self-induced vomiting or the misuse of


either diuretics or laxatives or both, all of which cause serious damage to several parts of the

body.

Stomach acid is extremely corrosive and many with BN put their body into continuous

contact with it through self-induced vomiting. Cheilosis, a form of stomatitis, causes the pallor

(lightening) and maceration (softening) of the mucosa and angles of the mouth, as well as

leaving linear fissures in severe cases that may leave scars. Pharyngeal soreness is also common,

due to the chronic irritation caused from purging continuously (2011). Gingivitis or gum disease

is also very common, the most obvious symptom is usually bleeding or bloody gums. Dental

caries, periodontal disease and dental erosions also occur due to the erosion of enamel. It is

generally accepted that, “visible enamel destruction occurs after about two years of regular

episodes of vomiting” (Mehler, 2011, p. 96). Sialadenosis, or the hypertrophy of the salivary

glands, seems to relate to the enamel erosion, with severity of enamel erosion correlating with

the severity of sialadenosis. In 10-50% of BN patients, there is a “painless unilateral or bilateral

swelling of the salivary glands” (Mehler, 2011, p. 96).

Esophageal complications can include esophagitis, esophageal erosions, ulcers and

bleeding due to consistent contact with stomach acid. A more serious complication is Barrett’s

Esophagus, which consists of “the replacement of normal squamous epithelium [a sheet of

flattened scalelike cells, attached together at the edges] with columnar epithelium [single layer of

prismatic cells taller than they are wide] as a result of chronic gastroesophageal reflux”

(Columnar epithelium, 2012; Mehler, 2011, p. 96; Squamous epithelium, 2009). Getting this

diagnosis correct is important as about 10% of cases progress to adenocarcinoma of the

esophagus, which is often fatal. There is also the possibility of the severe complication of

Esophageal rupture. Boerhaave’s Syndrome, while rare, has a mortality rate of 20% when it


does occur. The symptoms can include severe chest pain, painful swallowing, tachypnea and

tachycardia, and a left sided pleural effusion on chest radiography (2011).

Ipecac is often used in ICB, but it can be extremely toxic, even fatal when abused. Ipecac

contains “five alkaloid constituents which are toxic to cardiac and skeletal muscle” (Mehler,

2011, p. 97) with emetine and cephaline being the two most prevalent. Emetine has a long half-

life of 56 hours, so it can build up in the system easily with repeated use, meaning that eventually

one dose could be fatal. Repeated abuse can cause “irreversible cardiomyopathy with resultant

symptoms of congestive heart failure, ventricular arrhythmias and sudden death” (Mehler, 2011,

p. 97). Since the cardiac muscles are most affected by the toxic constituents, the result is that the

heart tissues become too damaged to continue working. Neuromyopathy, or stiffness and

weakness of the muscles, is also a severe side effect that is extremely painful. This is generally

reversible upon cessation of abuse.

Laxatives are also a common method used to purge, causing severe and sometimes

permanent damage. This method is common, though it is not as effective as might be expected

since “only about 10-12% of the ingested calories are lost as a result of laxative use, because

laxatives have little effect on the small intestine, the primary site of caloric absorption” (Mehler,

2011, p. 97). There are five categories of laxatives: bulk, osmotics, surfactants, emollients and

stimulants. The most abused and the most associated with most of the medical complications

found are the stimulant laxatives. Abuse can cause Melanosis coli or the browning of the colonic

mucosa (mucous in the colon) (2011). Cathartic Colon Syndrome is also a result of abuse, and is

characterized by the loss of normal colonic peristalsis, or a dilated and weak colon. This can

cause slowed or absent transit through some, or all of the, colon, which can become irreversible

with long-term abuse (2011).


Diuretics are also abused in order to purge. The three most commonly used classes of

diuretics are thiazide, loop and potassium-sparing. Thiazide diuretics cause an “inhibition of

sodium chloride reabsorption in the distal renal tubule” (Mehler, 2011, p. 99) which can wreak

havoc on electrolyte levels in the blood. Consequences include hypokalemia (low levels of

potassium), metabolic alkalosis (elevated levels of serum bicarbonate), hyperglycemia (high

levels of glucose), hyperuricemia (high levels of uric acid), hyperlipidemia (high levels of

lipids), hyponatremia (low levels of sodium), and hypercalcemia (high serum calcium). Loop

diuretics “act on the kidney in the thick ascending loop of Henle and therein inhibit the

reabsorption of sodium” (Mehler, 2011, p. 99). This results in hypokalemia, metabolic alkalosis,

hypos magnesemia (low magnesium), hypocalcemia (low serum calcium), and hyperuricemia.

The last category, potassium-sparing, “causes loss of sodium and water without causing a loss of

potassium” (Mehler, 2011, p. 99) which causes hyperkalemia (high levels of potassium), and

metabolic acidosis (high levels of acid). The most prominent problems with diuretics are

dehydration and resultant electrolyte imbalance. Hypokalemia is found in about 5% of BN

patients and may be related to or predispose them to cardiac arrhythmias (2011). Pseudo-Bartter

Syndrome, another consequence of diuretic abuse:

consists of hypokalemia, metabolic alkalosis, hyperaldosteronism [“overproduction of

aldosterone, a hormone that controls sodium and potassium levels in the blood”

(Hyperaldosteronism, 2008)], normal blood pressure and hyperplasia [“an increase in the

number of cells of a body part that results from an increased rate of cellular division”

(Hyperplasia, 2009)] of the kidneys juxtaglomerular apparatus [“…involved in the

secretion of renin and EPO in response to blood pressure changes and is important in


autoregulation of certain kidney functions (Juxtaglomerular apparatus, 2009)] has been

linked to low chloride channels. (Mehler, 2011, p. 99)

This condition can be reversed upon the cessation of the purging behaviors and if normal weight

is achieved (2011).

Eating Disorders Conclusion

The literature showed that eating disorders come with many severe, damaging effects,

some of which are permanent. These disorders have very high mortality rates, especially among

AN patients. They also cause severe damage to several important bodily functions, including the

heart’s ability to beat properly. Certain personality traits have shown to be correlated to ED,

including perfectionism. The avoidance of the life tasks and the useful side of life (social

interest) also leads to an incomplete life, with tasks avoided or pursued improperly. There are

also several other possible diagnoses that have yet to really be researched. The new DSM-V

includes Avoidant or Restrictive Food Intake Disorder, BED and Other Specified Feeding or

Eating Disorders, all of which have the possibility of leading to the previously mentioned

medical complications. While BED has been studied in the past, and has a yearly prevalence rate

of 1.6% for females, and .8% for males (APA, 2013, pp. 350-353), there is still little known

about the prevalence rates of Avoidant or Restrictive Food Intake Disorder or Other Specified

Feeding or Eating Disorder. New research is underway which is important, as the consequences

of these disorders are extreme, and prevention should be paramount in populations at higher risk.

Male and Female Athletes

Many people participate in sports at some point in their lifetime. There are several types,

including “endurance, aesthetic, weight dependent, ball games, power sports and technical”

(Galli, Reel, Petrie, Greenleaf & Carter, 2011, p. 58). Self-esteem and psychological rewards


have long been associated with athletic activity (Findlay & Bowker, 2007), but women have only

just begun to break out on the national, elite level with all types of sports, not simply those

deemed acceptable for “ladies”.

Ahead of his time, Alfred Adler saw the different treatment women received which lead

to the concept of “masculine protest”. In his work entitled The Science of Living (2011), he said:

The usual case is for boys to be overvalued and the girls to be treated as if they could not

accomplish anything. These girls will grow up always hesitating and in doubt.

Throughout life they will hesitate too much, always remaining under the impression that

only men are really able to accomplish anything. (p. 45)

This hesitating attitude or “yes, but” attitude can result in neuroses or mental disorders. This is

also a discouraging place to begin life, and so the female is envious of the male. She is envious

of “the superior social position of the male sex” (p. 149) and Alfred Adler said

This attitude is quite understandable, if we look at things impartially we can see that in

our culture the men are always in the lead; they are always more appreciated, valued and

esteemed than women. Morally this is not right and ought to be corrected. (p. 149)

The feminist and civil rights movements have moved society toward this moral correction, and

there is hope for the future as these movements continue to push forward.

It is not a great leap to think Alfred Adler would approve of women participating in

sports. Indeed, he felt that it was “fitting for them to develop like men in many ways, and to

have a job like men” and that “the equality of the sexes must be fitted into the natural scheme of

things” (Adler, 2011, pp. 150-151). Thus, the female “role” must be shifted to include tasks that

in the past may have been considered masculine. Alfred Adler said that, “in girls fighting and

scuffling, climbing and chasing, exaggerated achievements in sports, as well as dreams of these


activities, point to dissatisfaction with the feminine role and to the ‘masculine protest’” (Adler,

1956, p. 49). Thus the feminine role has slowly morphed into something more tolerable for the

female. Even in the 1930’s, Alfred Adler saw some shifting, stating, “the girl, under the

influence of our present-day cultural pressures, develops a pronounced feeling of inferiority and

pushes on vigorously. She thus discloses a more thorough training which often gives her marked

traits of greater energy” (Adler, 1956, p. 49) and indeed, the world has seen some female athletes

absolutely defy the odds against her. Today women participate in every sport available,

including hockey, rugby, and football, sports that are often considered the “manliest” of sports.

America will see a National Women’s Hockey League within the next several years, a leap

forward for women on the national, elite level. The Olympics give one a good idea of how many

sports women are now competing in on the international, elite level.

Surely those who one would consider talented, or elite, did not necessarily begin that

way. The elite athlete, in particular, is pushed on from a young age, but it seems those who work

hardest come out on top. When considering talent for anyone, Alfred Adler said, “the

development of a personality cannot be foretold from the phenomena of physical inheritance.

The inherited instruments with which we fight the battle of life are very varied. How we use

these instruments, however, is the important thing” (Adler, 2012, p. 104). So, it is not heredity

or how one begins life, but how those particular talents given are honed and used. Certainly,

Alfred Adler felt, “it is probable that an organism equipped with deficient organs, with

inadequate tools, will actually develop a better and more ingenious technic to combat the rigors

of its environment” (Adler, 2012, p. 106). Many examples exist, and most often make the best

stories of perseverance and hard work. The national coverage of the Olympics gives great


anecdotal evidence of this, as they most often cover stories of athletes overcoming great odds to

be at the Games.

With both sexes now participating in such a wide array of sports, it can also be expected

that both sexes may fall prey to any negative aspects of those sports. Though elite athletes are

found to have higher self-esteem than non-athletes (Findlay & Bowker, 2007), there are people

who “tend to expect athletes in some sports to exhibit a characteristic body size or shape”

(Thompson & Sherman, 1999, p. 323). When it comes to these expectations, many think of

female athletic clubs, however, the “trend towards body consciousness is also increasingly true

for men. There has been a rise in the number of young males who seem preoccupied with their

body image” (Baum, 2006, p. 2). If equality of the sexes is to occur among sport that means

there may also be an equality of disordered eating behaviors and detrimental expectations that go

with the societal demands upon them. With the societal changes between the sexes in the last

several decades, Marven Nelson (1991) contends that these changes:

Have become a major threat to many heterosexual men. Therefore, they must find ways

to assert their masculine strength and deny evidence of weakness. The result is often an

exaggerated masculine protest in which men are driven to display a macho “superiority”

which endeavors to reject the feminine radical within. (p. 493)

While the females seek to either eliminate the female body (gymnastics) or idealize it in frailty

(ballet), the males are forced to be “real men” and to meet extreme demands as well.

Athletes: Both Genders

Kong and Harris (2015) researched relationships between type of sport participation and

possible problems with body image or disordered eating behaviors. The purpose of the study

was to “investigate how different levels of competition (elite, recreational; or noncompetitive)


and participation in leanness (LFA) or non-leanness (NLFA) sports influence the prevalence of

dieting behaviors, disordered eating, and level of body dissatisfaction for female athletes” (p.

144). Participants were a total of N=320 females ages 17 to 30, whom participated in leanness-

focused sports (n=174) or non-leanness focused sports (n=146). The leanness-focused athletes

(LFA) were mostly in dance, or performance sports/gymnastics (60.9%) and the non-leanness-

focused athletes (NLFA) participated mostly in ball sports (41.8%). Out of the total number of

participants, n=128 were in the elite level, n=112 were in the recreational level and n=80 were in

the noncompetitive level. The instruments used were the Eating Attitudes Test (EAT-26;

Garner, Olmsted, Bohr, & Garfinkel, 1982), BMI and the Figure Rating Scale (FRS; Stunkard,

Sorensen, & Schulsinger, 1983).

The general characteristics of the athletes were as one might expect. The elite athletes

(M=9.91 yrs, SD=0.46) reported participating in their sports for significantly longer than both the

recreational (M=7.84, SD=0.48) and noncompetitive (M=8.12, SD=0.57) groups (F(2,314)=5.65,

p=.004, partial 2=.035). Not only did the LFA group train for significantly more hours

(M=12.45 hrs, SD=9.48) than the NLFA group (M=8.97 hrs, SD=6.56), but they also reported

significantly lower BMI’s than the NFLA group (M=21.1, SD=2.18 vs M=21.8, SD=2.22). This

means that elite athletes in sports that focus on leanness are working more hours and have a

lower BMI than elite athletes in other sports. These long hours could possibly be to achieve the

lean body shape desired (2015).

Kong and Harris (2015) then compared EAT-26 scores of the athletes. The total scores

were higher for the LFA group (M=17.62, SD=16.56) than the NFLA group (M=7.42, SD=8.37).

Comparing competitive levels, the elite athletes were found to have more disordered eating

symptoms (M=17.75, SD=18.27) than both the recreational level (M=10.65, SD=9.51) and the


noncompetitive level (M=8.56, SD=10.27). They also found a “significant interaction between

sport type and sport level, where differences between elite, recreational, and noncompetitive

athletes from leanness focused sports was larger compared to those competing in non-leanness

focused sports, F(2,314)=4.52, p=.012, partial 2=.028” (Kong & Harris, 2015, p. 149). Those in

the LFA group had a higher percentage (35.1%, n=61 vs 8.9%, n=13) of scores on the EAT-26

that were ≥ 20. Those who were considered elite athletes were twice as likely (n=43, 33.6%) to

score ≥ 20 when compared with the recreational (n=19, 17.0%) and noncompetitive (n=12,

15.0%) groups. Out of the 74 participants that were in the at risk range on the EAT-26, over half

were in the elite and LFA group (n=39, 52.7%). As for weight-loss methods used, the LFA

group reported engaging in self-induced vomiting (21.3%) more than the NFLA group (9.6%).

The LFA group also reported more laxative use (22.4%) when compared to the NLFA group

(9.6%). Both elite athletes and those who participate in leanness-focused sports are

demonstrating more ED and disordered eating behaviors than their ball-game playing

counterparts (2015).

Kong and Harris (2015) also compared the groups’ FRS scores. Overall, the “elite

athletes reported significantly leaner figures (M=3.69, SD=1.07) compared to recreational

(M=4.18, SD=1.06), p<.001, and noncompetitive athletes (M=4.23, SD=.93), p<.001” (p. 152).

Both the LFA group (M=2.67, SD=.094) and the elite group (M=2.50, SD=.90) preferred

significantly leaner ideal figures than the other groups. Those athletes that fit both the elite

group and the LFA group reported significantly leaner ideal figures (M=2.20, SD=0.863) than

any of the other groups, with all of their means falling at or below 3.00. Looking at ideal sport

figures, again the LFA group (M=2.82, SD=0.081) identified significantly leaner ideal sporting

figures than the NFLA group (M=3.38, SD=0.84). The LFA group was also found to show


greater general body dissatisfaction (M=1.25, SD=1.17) compared to the NFLA group (M=1.00,

SD=0.863), as well as sporting body dissatisfaction (M=1.09, SD=1.22 vs M=0.68, SD=1.09).

Not only are the elite and leanness-focused athletes aspiring to leaner ideal body figures in sport,

but they are also unhappy with their bodies in general, which could be creating increased

motivation to use inappropriate compensatory behaviors to achieve that goal (2015).

Schnell, Mayer, Diehl, Zipfel and Thiel (2014) used the German Young Olympic

Athletes’ Lifestyle and Health Management (GOAL) Study to look at athletes’ risk taking

behaviors. The purpose of their particular study was to “identify groups of athletes who are

particularly willing to take risks and the possible determinants of athletes’ risk acceptance”

(abstract, p. 165). Their research comes out of the GOAL Study by Thiel, Diehl, Geil, Schnell,

Schubring, Mayer, Zipfel and Schneider (2011), which consisted of quantitative and qualitative

methods.

The quantitative study consisted of a total of N=1,138 athletes across 51 sports. The

athletes played “one of the Winter Olympics 2010 or the Summer Olympics 2012 sports”, were

the ages of 20 to 23, and competed “at least at the lowest national squad (in Germany D/C squad)

or a corresponding team level” (Thiel et al., 2011, p. 3). The questionnaire used consisted of 85

items covering “the athletes’ health state, health-related behavior, lay health representations

including subjective concepts toward nutrition as well as their health-related social networks,

socio-demographics, and discipline-specific information” (Thiel et al., 2011, p. 4).

The qualitative section was a multi-case study approach. The sports consisted of artistic

gymnastics, biathlon, handball and wrestling. The subjects were 24 German elite athletes, with

12 females and 12 males distributed equally amongst the sports. The methods consisted of “in

depth semi-structured interviews, health related biographical mappings, health related network


mappings, focused interviews, participant observation, and document analysis” (Thiel et al.,

2011, p. 6).

Using this GOAL Study (2011), Schnell, Mayer, Diehl, Zipfel and Thiel (2014) assessed

risk perceptions and the social roles of the athletes. Concerning the fulfillment of the social role

as an athlete, those athletes who reported a strong athletic identity showed a significantly higher

“willingness to take physical risks” (p. 168). When looking at the fulfillment of the non-sports

roles of social life, those athletes “with a distinct athletic identity were more willing to take risks

if they did not find it important to fulfill non-sports roles of social life” (p. 168). Furthermore,

“if these athletes were perfectionists, then they were also more willing to take risks regarding

their physical health” (p. 168). The athletes’ risk perception and risk acceptance were related,

with athletes that had high-risk perception (> 4.20) having significantly lower risk acceptance

when compared to those with low risk perception. Athletes that perceived high degrees of

pressure from their social environment to fulfill the athlete-related role expectations were more

willing to take risks in general (2014). It could be then that getting athletes to engage in other

roles, or tasks of life, could lessen their need to take risks.

Schnell et al. (2014) also looked at physical long-term risks. They found two high-risk

groups. The first high-risk group consisted of athletes who “paid both exceptional attention to

their sports environment and little attention to non-sports environments” (p. 169). The second

group at high-risk was the “highly perfectionistic athletes with a strong athletic identity for

whom it was important to also fulfill role expectations from their environments outside the sport

system” (p. 169). There were also two low-risk groups for physical long-term risk. Those

“athletes who did not place extremely high importance on the ‘fulfillment of their social role as

an athlete’ and also ascribed high importance to the ‘fulfillment of their non-sports role of social


life’” (p. 169) made up the first low-risk group. The second low-risk group consisted of “athletes

who show a mid-level athletic identity, perceived many health risks, and received little pressure

from their social environment” (p. 169). The low risk groups seem to have found more of a

balance between their life tasks, and by not viewing their sport as their work task, or placing too

much importance upon it, they have a lower need to take physical risks. Knowing this could

help those that fall into the high-risk categories for physical risk to develop healthier attitudes

and habits.

Schnell et al. (2014) also parsed out risk groups for psychosocial risk acceptance. The

first group at high-risk were those “athletes who both attached great importance to the fulfillment

of their athletic role and simultaneously were very perfectionistic” (p. 170). The second high-

risk group consisted of “athletes with a strong athletic identity and an average degree of

perfectionism…if they paid only little attention to their health and their life after their sports

career” (p. 170). The athletes that were at the lowest risk were those that “attached the least

importance to their role as an athlete” (p. 170). Again, the low risk group places lower

importance upon the sport role, apparently shielding them from high psychosocial risk taking.

Findlay and Bowker (2007) studied the relationship between self-concept and self-esteem

in adolescents that participate in sports. Specifically, they wanted to explore the “effect of the

level of sports participation (elite, competitive, and non-athlete) and the intensity of the activity

(strenuous, moderate, and mild) on self-concept and self-esteem” (p. 31) as well as the

“moderating role of gender and sport orientation on self-concept” (p. 31). The Sport Activity

Questionnaire (SAQ; Bowker, Gadbois, & Cornock, 2003), Physical Self Description

Questionnaire (PSDQ; Marsh, Richards, Johnson, Roche, & Treymayne), Leisure Time Exercise

Questionnaire (LTEQ; Godin & Shepard, 1985), and the Sport Orientation Questionnaire (SOQ;


Gill & Deeter, 1988) were the instruments used to explore four domains of self-concept: physical

competence, physical appearance self-concept, global, physical, and general self-esteem. A

sample of N=351 adolescents, from elite sports (n=171), competitive sports (n=216) and general

classrooms (n=145), were then divided into levels of sports participation (elite, competitive &

none), the intensity of the activity (strenuous, moderate & mild), gender, and sport orientation

(win, goal & competitive).

The initial analysis showed that this sample of adolescents were quite active. Overall,

adolescents were found to participate in two sports on average, and boys (M=2.19) were

participating in more than girls (M=1.78), with mild participation 4.3 times per week, moderate

activity 3.6 times per week and strenuous activities taking place 4.4 times per week. They found

that boys reported significantly more strenuous and moderate activity, higher competitive, win

and goal orientation and higher perceived physical competence, appearance self-concept and

global physical self-esteem, however, there was no difference for general self-esteem between

the genders (Findlay & Bowker, 2007, pp. 33-34). This could be due to the inferiority feelings

that girls have from being discouraged in participation in the ‘masculine’ realm of sports.

Findlay and Bowker (2007) next analyzed the level of interaction between gender and the

intensity of activity and the level of athleticism. The analysis showed that “the level of

athleticism was the only consistent predictor of self-concept and self-esteem…” (p. 34).

Strenuous activity was a predictor of high physical competence self-concept for girls, and “girls

who participated in strenuous activity had higher physical competence than did girls who did

not” (p. 34), however, strenuous activity did not affect the levels of self-concept for boys. After

univariate analysis, significant effects of athleticism were found on appearance self-concept

(F(2,377)=26.43, p<.001, 2=.12), general self-esteem (F(2,377)=22.74, p<.001, 2=.11), global


physical self-esteem (F(2,377)=22.86, p<.001, 2=.11), and physical competence self-concept

(F(2,377)=113.17, p<.001, 2=.37). Those that participated in any level of competitive sport

reported higher self-esteem as well as higher self-concept than those who did not participate in

sports (2007). These results show what many expect of sports. Sports, in general, are expected

to allow children to master themselves physically and psychosocially. Those girls that do

participate in ‘masculine protest’ by participating in any level of sport appear to benefit from

positive effects on important aspects of healthy development.

Findlay and Bowker (2007) then analyzed the relationship between self-concept and sport

orientation. Athletes that reported a higher win orientation (e.g., hate to lose, or feel winning is

most important) had lower global physical self-esteem while those with a higher competitive

orientation (e.g., thrive on competition and enjoy competing against others) had a higher global

physical self-esteem (2007). A competitive orientation was also positively related to physical

competence while a win orientation had the opposite effect. Winning all the time is not possible,

so it makes sense that those that seek superiority through winning may find disappointment quite

often. Athleticism and competition orientation were also positive predictors for appearance self-

concept (2007). Concerning general self-esteem, level of athleticism was predictive, and higher

competition and goal orientations had higher self-esteem. Again, those with a higher win

orientation had lower general self-esteem (2007). Athletics, self-esteem and self-concept are

related and they affect each other in different ways, but an athletes' attitude is an important

factor.

Athletes: Males

Goltz, Stenzel and Schneider (2013) aimed to “identify disordered eating behaviors and

body image dissatisfaction, and their relationship to BF [body fat] percentage, among male


athletes in high risk sports for eating disorders” (p. 238). The subjects were N=156 male athletes

from Brazil who were 18 years or older. There were three classes of sports, with n=52

participants in each category. Jiu-jitsu, judo, karate and rowing made up the weight class sports.

The leanness-focused group consisted of athletics, swimming, triathlon, and horse racing.

Lastly, the aesthetic ideals group competed in ballet, dance, artistic gymnastics, and skating. The

instruments used were the Eating Attitudes Test (EAT-26; Garner, Olmsted, Bohr, & Garfinkel,

1983), the Bulimic Investigatory Test, Edinburgh (BITE. Henderson & Freeman, 1987), and the

Body Shape Questionnaire (BSQ; Cooper, Taylor, Cooper, & Fairburn, 1987).

Disordered eating behaviors as well as body image dissatisfaction were found amongst

the participants. Training volume was the highest amongst the leanness-focused group, with a

median of 24 hours per week, though the weight class group had trained for a longer period than

the leanness-focused group, with 11.0 and 6.5 years, respectively. Almost one-third (27.6%,

n=43) of the athletes displayed disordered eating behaviors. The weight class sports had the

highest rates (30.8%), followed by the leanness-focused sports (26.9%), and the aesthetic ideals

sports (25.0%); however, EAT-26 scores were higher in the leanness-focused sports than in the

weight class sports group (2013). These rates show that ED is not just a female problem, and

that all three body-type specific sports categories show high rates for male athletes. Body image

scores, which have been associated with disordered eating behaviors, were found in 14.7%

(n=23) of the athletes. Athletes that did report high body dissatisfaction also had higher BF

percentages than those who had low body dissatisfaction scores (2013). Not only are these male

athletes exhibiting the behaviors of ED, they are also showing the psychological dissatisfaction

with their bodies that often coincides ED symptomology.


Galli, Reel, Petrie, Greenleaf, and Carter (2011) looked at male athletes and body image.

Male dissatisfaction with body image occurs along two pathways: too much body fat or not

sufficiently muscular. The initial purpose of the study was to “develop a preliminary measure of

weight pressures…” (p. 50). The second purpose was to explore “the relationship between

various demographic variables (e.g., sport type) and weight pressures” (p. 50). The last goal of

the study was to “determine the relative contribution of weight pressures when considered in

combination with other predictors, in explaining bulimic symptomology and the drive for

muscularity in male athletes” (p. 50). The study looked at N=203 male athletes from three

NCAA Division I institutions from the United States, participating in a variety of sports. The

athletes were all asked to fill out demographic information, the Weight Pressures Scale for Male

Athletes (WPS-M; developed for this study), the Rosenberg Self-Esteem Scale

(RSES;Rosenberg, 1965), the Appearance Evaluation (AE), and Appearance Orientation (AO)

subscales of the Multidimensional Body-Self Relations Questionnaire (MBSRQ; Cash,

Winstead, & Janda, 1986), the Fear, Sadness, Guilt, and Hostility subscales from the Positive and

Negative Affect Schedule-Expanded Form (PANAS-X; Watson & Clark, 1991), the Bulimia

Test-Revised (BULIT-R; Thelen, Mintz, & Vander Wal, 1996), the Drive for Muscularity Scale

(DMS; McCreary & Sasse, 2000), and the Marlowe-Crowne Social Desirability Scale Form B

(Reynolds, 1982).

Significant differences were found between different sport categories. The sports were

divided into six categories: endurance (n=39), aesthetic (n=7), weight dependent (n=2), ball

game (n=45), power sports (n=104), and technical (n=6). Three groups (aesthetic, weight

dependent, and technical) were excluded from analysis due to small sample sizes. Endurance

sports (M=2.89, SD=1.04) as well as power sports athletes (M=3.04, SD=1.18) “reported more


appearance pressures than ball game athletes (M=2.42, SD=0.83)” (2011, p. 58). Power athletes

(M=4.05, SD=1.26) also reported feeling more pressures from coaches and teammates than both

athletes in endurance (M=2.77, SD=1.03) or ball game sports (M=2.99, SD=0.94) (2011).

Athletes experienced “significantly more weight pressures from coaches and teammates

(M=3.44, SD=1.29) than weight pressures related to appearance (M=2.83, SD=1.10)” (Galli et

al., 2011, p. 60). The PANAS-X subscales of Fear, Sadness, and Guilt, were found to have a

significant (p<.01) positive relationship with the appearance pressures factor. The appearance

pressures factor also had a negative correlation with the RSES. It was also found that more

weight pressures related to appearance (=.221, p=.000) as well as more pressures from coaches

and teammates (=.251, p=.002) predicted a stronger drive for masculinity. If the athlete had

lower self-esteem (=-.246, p<.01) and also felt more weight pressures from coaches and

teammates (=.156, p=.05), they were more likely to show BN symptomology (2011). The

results of this study lead the researchers to conclude that, “male athletes may unconditionally

accept the weight rules and guidelines set forth by their coaches in such a way that their body

change behaviors operate independently of negative body image or affect” (Galli et al., 2011, p.

62). These results are found in sports categories not generally considered to be body-type

specific. Perhaps the societal pressure, and the ‘masculine protest’, to be an exaggeratedly

muscular, powerful, real man is reaching farther into sports than previously thought.

Antonia Baum (2006) looked at disordered eating in the male athlete. She points out that

since ED in males is less prominent, that it is “therefore in danger of being missed” (p. 1).

Disordered eating has been found in the same high-risk sports categories as with female athletes,

those being sports where there is a need to make weight, aesthetic sports, and those where low

body fat is deemed an advantage. One major difference between females and males with low


body fat is that males can sustain around 1% body fat without medical complications, while

females must sustain at least 17% body fat. Males have also tended to present with partial

syndromes more often than females who tend to present full disorders. Despite these differences,

ED presents and is treated similarly with both males and females. Wrestling, in particular, has a

high prevalence rate of disordered eating. According to Baum, purging is often done as a “team

activity or with the full knowledge and support of their teammates” and it also appeared that if

coaches were aware, they looked the other way (p. 4). This creates an atmosphere or team spirit

of unhealthy habits that are deemed acceptable and normal. Baum also acknowledged that,

especially in the adolescent years, athletes often participate in more than one sport, as many have

a limited season. She found that some of the more dramatic weight shifts were observed in

transition from one sport season to another. Football players in particular drop the most

significant amounts of weight when leaving the football season and entering the wrestling season

(2006). This is possibly due to the differences in the type of muscle and strength needed for each

sport. With this rise in ED among male athletes, it is imperative that equality of the sexes

reaches more into research as well.

Athletes: Females

De Bruin, Oudejans, Bakker and Woertman (2011) looked at the relationship between

body image and disordered eating in high school, female athletes. De Bruin et al. believed that

“for athletes body image should be divided into an athletic and a daily life body image,

especially in relation to eating-related problems” (p. 203). Therefore, they embarked upon two

studies.

The first study involved the creation of the Contextual Body Image Questionnaire for

Athletes (CBIQA) and determining the internal validity of said measure. This questionnaire was


designed as a “multidimensional body image in daily life and sport” (de Bruin et al., 2011, p,

204), with 30 questions divided into four sub-types: appearance, muscularity, thin-fat self-

evaluation and thin-fat perceived opinions of others. Each set was asked twice under the

category of body image in daily life and in sport life (2011). The subjects were n=152 females

participating in four sports categories, and n=45 Bachelor’s students in physical education “who

participated in sports besides their educational sport” (de Bruin et al., 2011, p. 204). The four

categories were: aesthetic sports, endurance sports, weight class sports, and ball sports. The

results of this study found the internal validity and reliability to be “quite satisfactory” (de Bruin

et al., 2011, p. 205).

Since the CBIQA was internally valid and reliable, they proceeded to the second study.

This second study had three main goals. The first was to determine the external validity of the

new measure. The second was to “confirm that it is sensible and useful to take such a more

dynamic and contextual perspective on body image in relation to disordered eating” (de Bruin et

al., 2011, p. 203). The last aim was to “gain insight into the degree to which each of the body

images would contribute to disordered eating in athletes” (de Bruin et al., 2011, p. 203). The

Visual Analogue Scales (VAS; Brown, 2006), Body Image and Body Change Inventory (BIBCI;

Ricciardelli & McCabe, 2000), Body Areas subscales of the Multidimensional Body-Self

Relations Questionnaire (MBSRQ; Cash, 2000), and the Somatomorphic Matrix (Gruber, Pope,

Borowiecki, & Cohane, 2000) were used to determine Body Image. The Eating Disorder

Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994)) was also used, and general

background characteristics were gathered. They gave the questionnaire to N=52 highly

competitive female athletes who participated in “various sports in which leanness, low-weight

and/or appearance are considered to be important” (de Bruin et al., 2011, p. 206).


The external validity was found to be adequately demonstrated, and there was disordered

eating found among the participants. Comparing athletes’ backgrounds without ED to those with

ED, there were significant differences found for the attitude towards food (Z= -5.07, p<.001),

amenorrhea (Z= -2.98, p<.01), and the EDE-Q (Z= -3.44, p<.01). They found that “athletes with

disordered eating reported more amenorrhea, they were significantly more tense towards food

and scored significantly higher on eating disorder symptomology than the control group without

disordered eating” (de Bruin et al., 2011, p. 209). They next compared differences between ED

and no ED between and within body image types. When it came to daily life body image,

“athletes with disordered eating were more negative about their appearance (Z= -3.42, p<.01)

and had more negative thin-fat self-evaluations (Z= -2.76, p<.01)” (de Bruin et al., 2011, p.210).

For the athletic life body image, “athletes with disordered eating were also more negative about

their appearance [Z= -3.00, p<.01], muscularity [Z= -2.54, p<.05], and thin/fatness self [Z= -

2.52, p<.05] in sport than athletes without disordered eating” (de Bruin et al., 2011, p. 210).

Those with ED seem to be more negative about both body image types when compared to those

without ED.

De Bruin et al., (2011) then compared the components of the athletic and daily life body

images. They found that there were more positive ranks for the appearance pair, which indicates

lower scores for perceived appearance in sport than in daily life. They also found more negative

ranks for the other pairs, “pointing towards higher (read: more negative) scores on the other body

components in sport” (p. 210). Looking at those components within the subgroup of those with

no ED, there were “significant differences suggesting a more negative athletic body image…for

thin-fat others, significantly higher (read: more negative) scores in sport than in daily life were

found” (p. 210). Last, they looked at the degree to which the body images might contribute to


ED. There were significant correlations with “daily life appearance, r= -.47, p<.01 and daily life

thin-fat self, r= .52, p<.01, indicating relationships between more ED symptomology and

evaluating oneself as less beautiful and more fat in daily life, respectively” (p. 210). For the

athletic body image, “significant relationships were established with appearance, r= -.51, p<.01,

muscularity, r= .42, p<.01 and thin-fat self, r= .61, p<.01” (p. 210). In other words, female

athletes do have two separate body image profiles, one for sport and one for daily life. It appears

that the athletic body image was more negative in general than the daily life body image for

female athletes (2011).

Davison, Earnest, and Birch (2004) looked at young girls’ weight concerns and

participation in aesthetic sports. They hypothesized that participation in aesthetic sports would

be associated with elevated weight concerns and that the longer a girl participates, the more

weight concerns she might have. The study was longitudinal, looking at girls (and their mothers)

at ages five (n=197) and seven (n=192). Information was collected on sports participation, and

background, and the Weight Concerns Scale (WCS; Killen, Taylor, Hayward, et al., 1994) was

administered.

General sports participation amongst the girls was varied. The highest percentage (18%)

participated in gymnastics. The next popular was soccer at 12%, closely followed by dance with

11%. Swimming (9%) and softball (8%) had the smallest participation percentages (2004).

Just as they hypothesized, Davison et al., (2004) found higher weight concerns amongst

those who participated in aesthetic sports. When compared to the no-sports group, the aesthetic

group had significantly higher weight concerns (F(1,187)=5.71, p<.05 at age 5; F(1,191)=4.43, p<.05

at age 7). Girls who participated in non-aesthetic sports only, did not participate in sports, or

participated in aesthetic sports at one age or the other, all had significantly lower weight


concerns than girls who participated in aesthetic sports at both ages (F(1,191)=5.70, p<.05). Even

those girls who participated in aesthetic sports at one age or the other still showed significantly

higher weight concerns (F(=1,191)=5.69, p<.05) than those who did not participate in sports, or just

participated in non-aesthetic sports (2004). This means there is something about the aesthetic

sports that is different in some way than the other sport categories or not participating in sports at

all. Exploring possible aspects of these sports could help explain this relationship further so as to

prevent unhealthy weight concerns from developing in future athletes.

Male & Female Athletes Conclusion

Participation in sports is generally healthy, though several factors can put an athlete at

risk. Since sports involve the use of the body in demanding ways, athletes do tend to be more

preoccupied with their bodies, whether female or male. As Alfred Adler said, “the neurotic

purpose is the enhancement of the self-esteem, for which the simplest formula can be recognized

in the exaggerated ‘masculine protest’. This formula, ‘I want to be a real man’, is the guiding

fiction” (Powers & Griffith, 2007, p. 67), and indeed the research shows an increase in

disordered eating behaviors amongst males. There is a separation between the athletic or sports

body image or concept for both males and females, which could be helpful for further research,

prevention measures and treatment options. Also, figuring out why certain sports seem to offer

healthier physical and psychosocial outcomes could help attend to problems in sports where

athletes are at greater risk.

Final Summary

Certain sports and certain characteristics put athletes at an increased risk for eating

disorders than the rest of the population. All three sports looked at, gymnastics, wrestling, and

ballet, increased the athletes’ risk of developing an eating disorder and all three showed higher


rates of eating disorders than control groups. There is also a misconception among all three that

lower body weight or BMI will increase the athletes’ chances for success, however this

relationship is curvilinear (Sherman, 1996, p. 341).

The most prominent problem in the research was sample size. In one case, the body-type

specific sports could not be included in the analysis due to small sample size (Galli et al., 2011).

If this problem could be remedied, the studies would be more reliable. Until then, it is hard to

say that the relationships found can definitely be applied to the broader population. Some of the

studies also failed to distinguish between specific types of dance or gymnastics. Definitions of

sport types or styles are important to make sure the research is consistent. The use of outdated

diagnostic materials also came up in the research, making it more important to replicate studies

with updated diagnostic materials and larger sample sizes. As this topic gains ground, the

research must be that much more valid and reliable to help create better understanding of this

complex problem.

The other predominant problem with the research is looking at both sexes equally. Males

participate in both gymnastics and ballet, however they are rarely researched on the same level as

females. Females participate in weight class sports on a greater scale than ever before. The

research, however, fails to take the expansion of participation of the sexes in all sports into

account. Examples include the GOAL study (Thiel et al., 2011), which was one of the few

studies to look at the sexes equally. Goltz et al. (2013) included an aesthetic ideals group with

52 males participating, and De bruin et al. (2011) included weight class sports in their study of

female athletes. In order to better understand the relationship between body-type specific sports

and disordered eating, it is important to include both sexes, as the research has shown that this

problem affects both.


Eating disorders have very high morbidity and mortality rates, and the consequences to

the health of the affected person are severe. Those consequences can be permanent, and in more

cases than many think, they result in death. Even with the high rates among males, being a

female does put an athlete at a higher risk. When it comes down to it, if one were to “view the

world of athletics as a microcosm of the world at large, we would predict that white female

athletes in sports that focus on form or appearance for their scoring and/or emphasize a thin, lean

body to enhance athletic performance would be most at risk” (Thompson & Sherman, 1999, p.

318). If this is the case, then what, if anything is currently being done to combat this problem in

these high-risk sports?

Gymnastics has taken some steps forward. USA Gymnastics has implemented

prevention efforts, including “the use of psychological and nutritional consultants, information

and training for coaches, recognition of the relationship between body weight, menstruation and

performance (female athlete triad), and educational programming for athletes” (Thompson &

Sherman, 1999, p. 332). There are also individual programs cropping up, such as the BodySense

Project included in the research by Bucholz et al. (2008). This project is a “positive body image

initiative for female athletes” (p. 315) that includes the athletes, their parents, coaches and all

club staff in the project.

The program offers education on ten BodySense Basics: What We Believe (eating

attitudes and beliefs), The Facts (accurate information about body health), Respect for the

Individual (unique body size and shape), A Positive Approach to Food (resisting pressures to

diet), Natural and Healthy Bodies (physical activity for enjoyment), Positive Self-Esteem

(helping the athlete feel good about herself), Speaking Up (encouraging assertion in athletes),

Coping in Healthy Ways (stress management), Role Modeling (modeling attitudes and


behaviors), and Balance (promoting balance between sport participation and life outside of

sport). This program has been professionally endorsed by: the Coaching Association of Canada,

the Canadian Association for the Advancement of Women in Sport and Physical Activity, and

Gymnastics Canada. Even with all the endorsements, the program still ran into road blocks,

saying that, “some organizations felt that being associated with a program about eating disorders,

even through participation in a prevention initiative, might be construed as that their sport

“causes” disordered eating” (Bucholz et al., 2008, p. 319). Unfortunately, it might be too late to

hide that their sport, at the least, puts females at a higher risk for disordered eating.

Wrestling has also seen some changes coming down from organizations. The NCAA

implemented new rules in 1998, and according to Ransone and Hughes (2004), the “weight-

certification program appears to have influenced the volume of body-weight gains and losses by

wrestlers…” (p. 164). In fact, both the NCAA and the American College of Sports Medicine

have urged for “greater cooperation among coaches, exercise scientists, physicians, dietitians,

and wrestlers to use research and education to determine the best medically sound system for

selecting a weight class” (Weight 'Cutting' Waning, 2003, p. 6). In 2008, the National Athletic

Trainer’s Association published a position statement, with the objective of providing

recommendations for the detection, prevention, and comprehensive management of disordered

eating in athletes to help with this dire situation. In the end, it will come down to those in

contact with the athletes the most to make the right decisions.

Ballet is a different story, as competition is within the ballet community. There are no

national competitions, and therefore, there are no true governing bodies like the NCAA or USA

Gymnastics. There are only individual schools, programs, and companies. Thomas, Keel, and

Heatherton (2011) suggested “screening injured dancers” as that “has the potential to reveal


covert eating disorders”, reasoning that those “who do not spontaneously volunteer their

symptoms to professionals typically do disclose them when explicitly queried” (p. 220). They

also felt that ED prevention programs specifically oriented to dance could have the potential to

prevent both ED and the correlated injuries. Programs on the individual level could focus on

pointing out that disordered eating behaviors may actually “backfire” in the end, causing them to

not only cause bodily harm and injury, but they will lose precious days dancing. On the

individual level, those days lost could mean the difference between mastering a needed skill or

not in class; competing for a part in the next performance; performing in the corpse de ballet; or

having a career or not. On the organizational level, “dance injuries cost ballet companies

$549,812 annually, [and] these data suggest that ED prevention expenditures could be in part

offset by the financial benefit of injury reduction” (p. 220). Adding preventative measures will

save schools and companies money in the long run, making excuses harder to come by.

What it seems to come down to is the environments in which these athletes are being

fostered. These athletes are seen as just that: an athlete and nothing more. As seen in the

research, this attitude can be detrimental to the individual athlete, the person behind the talent.

Indeed, Alfred Adler said, “a partial phenomenon, such as talent, a gift, an endowment, can be

properly evaluated and properly understood only when the total is first known and thoroughly

understood” (Adler, 2012, p. 102) and surely each person deserves to be treated as a whole

being. Sports participation begins in early childhood, and as Alfred Adler says,

No one has ever seen a normal child, and one can find some organic defect in everyone.

What is important is the sense of defect which the child feels because he has an

inadequate organ, and more particularly, what that child’s environment says about his

defect. (p.109)


The environment in which these kids are growing must be one of encouragement, not one that

discourages normal development or the growth of potential talent. Alfred Adler says of the

talented child, “by constantly giving him tests of his prowess, usually useless ones, one runs the

risk of serious damage to his self-confidence and self-esteem. At any rate, a pathological

ambition is bound to develop” (p. 112) and surely that is seen in the research. The environments

these particular sports offer to children are turning out pathological behavior at the least, and

death at the worst. These children grow-up in environments that are unhealthy, so that by the

time those select few make it to the elite level, they are adults with ED or disordered eating

behaviors.

Paul Haggen (2002) argued that, “family resilience can be recognized and promoted by

analyzing family involvement as a team” (abstract, p. 279), and perhaps the opposite could also

be true, using family atmosphere as a teacher for sports teams. He states that the “family is the

training ground for the development of people” (p. 281), but if children are spending from about

3.6 to 4.4 days per week, usually in two sports (Findlay & Bowker, 2007), the team is also acting

as a training ground for developing these children. The coaches act as interim parents and

teammates become siblings. Just like each family has its own atmosphere that shapes each

individual within, each team or company has its own atmosphere. Haggan (2002) likens family

atmosphere to team spirit, saying that “the players sense and adapt to the prevailing climate and

philosophy and a ‘Team Spirit’ emerges” (p. 282). Having a healthy atmosphere or team spirit is

key to having healthy athletes.

Haggan (2002) also discusses the difference between true teamwork and competition.

Competition calls on one to take on others, while teamwork calls on one to take on the task at

hand. This could also be called horizontal versus vertical movement. According to Griffith and


Powers (2007), horizontal movement “evokes an image of task-centered, egalitarian problem

solving”, while vertical movement “is the pursuit of prestige and status, focused on a goal of

self-evaluation” (p. 56). All three sports discussed have a combination of teamwork and

individual competition involved. Each involves a team or company, which seeks to improve as a

whole. On the team, there are individuals with individual goals, who may compete in individual

events or weight classes. This in itself is not bad; it is how these individuals take on the task of

individual improvement that matters. They have the choice between horizontal or vertical

movement. The atmosphere or spirit of the team could help to determine which path each athlete

takes. Children start these sports sometimes before starting school, and the team has a great

influence on them.

So the answer to the problem must lie at the beginning, and the beginning of sports lies in

the schools and programs that introduce children to the sport. Alfred Adler (2012) felt, “most

necessary to the development of a child into a useful social being are a good relation with the rest

of humanity and the feeling that he [or she] is equal to other children\” (p. 112), and so coaches,

teachers and parents should encourage this in their child athletes. As far as the modern school is

concerned, “it must not criticize or punish, but try to mould, educate, and develop the social

interest of children” (Adler, 2011, p. 178) and this should apply to any athletics program as well.

Weighing children in front of others, or the team, or criticizing a young person’s body shape or

size is no way to encourage an athlete to be their best self. Programs must foster feelings of

safety and belonging while at the same time encouraging them to find their significance in the

sport of their choice. Assuming a child might not be suited to a sport before they are given the

chance to try is a tragedy. How many Maria Taglioni’s have been overlooked for their body

shapes or sizes? How many men did not try out for wrestling because they did not feel they


could make weight or achieve the right body type? How many talented female gymnasts were

overlooked because they developed a normal, curvy, female body? One cannot judge so called

talent so quickly, and one cannot judge what body shape or size might be great at a sport. “The

great accomplishments, the really worthwhile achievements, have been made by individuals

whose equipment was poor” (Adler, 2012, p. 106).


References

Adler, A. (1956). The Individual Psychology of Alfred Adler: A systematic presentation in

selections from his writings (H. L. Ansbacher & R. R. Ansbacher, Eds.). New York, NY:

Basic Books.

Adler, A. (2011). The science of living. Mansfield Centre, CT: Martino Publishing.

Adler, A. (2012). Character and talent. In J. Carlson, M. P. & Maniacci (Eds.), Alfred Adler

revisited, (pp. 99-113). New York, NY: Taylor & Francis.

Adler, A. (2012). Neurotic hunger-strike. In J. Carlson, M. P. & Maniacci (Eds.), Alfred Adler

revisited, (pp. 99-113). New York, NY: Taylor & Francis.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Washington, DC: Author

Annus, A., & Smith, G. T. (2009). Learning experiences in dance class predict adult eating

disturbance. European Eating Disorders Review, 17(1), 50-60.

Anshel, M. H. (2004). Sources of disordered eating patterns between ballet dancers and non-

dancers. Journal of Sport Behavior, 27(2), 115-133.

Barker-Ruchti, N., & Tinning, R. (2010). Foucault in leotards: Corporeal discipline in women's

artistic gymnastics. Sociology of Sport Journal, 27(3), 229-249.

Baum, A. (2006). Eating disorders in the male athlete. Sports Medicine, 36(1), 1-6.

Belangee, S. E. (2006). Individual psychology and eating disorders: A theoretical application.

Journal of Individual Psychology, 62(1), 3-17.

Belangee, S. E., Sherman, M. F., & Kern, R. M. (2003). Exploring the relationships between

lifestyle personality attributes and eating disorder symptoms and behaviors in a non-

clinical population. Journal of Individual Psychology, 59(4), 461-474.


Bond, C. M., Bonci, L. J., Granger, L. R., Johnson, C. L., Malina, R. M., Milne, L. W., & . . .

Vanderbunt, E. M. (2008). National Athletic Trainers' Association position statement:

Preventing, detecting, and managing disordered eating in athletes. Journal of Athletic

Training (National Athletic Trainers' Association), 43(1), 80-108.

Bowker, A., Gadbois, S., & Cornock, B. (2003). Sports participation and self-esteem: Variations

as a function of gender and gender role orientation. Sex Roles, 49, 47-58.

Brown, J. D. (2006). Male body image: Testosterone’s response to body comparisons (Doctoral

dissertation). Retrieved from

http://oaktrust.library.tamu.edu/bitstream/handle/1969.1/3818/etd-tamu-2006A-PSYC-

Brown.pdf.

Bucholz, A., Mack, H., Steringa, E., & Matthias, M. (2003). Sport climate, body image, and

eating attitudes in elite female gymnasts. [Paper presented at the International Conference

on Eating Disorders], Colorado, USA.

Buchholz, A., Mack, H., McVey, G., Feder, S., & Barrowman, N. (2008). BodySense: An

evaluation of a positive body image intervention on sport climate for female athletes.

Eating Disorders, 16(4), 308-321. doi:10.1080/10640260802115910

Cash, T. F., Winstead, B. A., & Janda, L. H. (1986). The great American shape-up. Psychology

Today, 20, 30-37.

Cash, T. F. (2000). User’s manual for the multidimensional body-self relations questionnaire

(3rd. rev. ed.). Retrieved February 25 2016 from http://www.body-images.com

Collins, M. E. (1991). Body figure perceptions and preferences among preadolescent children.

International Journal of Eating Disorders, 10, 199-208.

Columnar epithelium. (2012). Farlex Partner Medical Dictionary. Retrieved November 10, 2015


from http://medical-dictionary.thefreedictionary.com/columnar+epithelium

Cooper, P., J., Taylor, M., J., Cooper, Z., & Fairburn, C., G. (1987). The development and

validation of the body shape questionnaire. International Journal of Eating Disorders, 6,

485-494.

Davison, K. K., Earnest, M. B., & Birch, L. L. (2002). Participation in aesthetic sports and girls'

weight concerns at ages 5 and 7 years. International Journal of Eating Disorders, 31(3),

312-317. doi:10.1002/eat.10043

de Bruin, A., Oudejans, R. D., Bakker, F. C., & Woertman, L. (2011). Contextual body image

and athletes' disordered eating: The contribution of athletic body image to disordered

eating in high performance women athletes. European Eating Disorders Review, 19(3),

201-215. doi:10.1002/erv.1112

Diesenhouse, S. (1997, October). Dance; in a Darwinian world of weight control. The New York

Times. Retrieved from: http://www.nytimes.com/1997/10/12/arts/dance-in-a-darwinian-

world-of-weight-control.html.

Euhydration. (2009). Medical Dictionary. Retrieved November 10 2015 from http://medical-

dictionary.thefreedictionary.com/euhydration

Fairburn, C. G., & Beglin, S. J. (1994). Assessment of eating disorders: Interview or self-report

questionnaire? International Journal of Eating Disorders, 16, 363-370.

Findlay, L. C., & Bowker, A. (2009). The link between competitive sport participation and self-

concept in early adolescence: A consideration of gender and sport orientation. Journal of

Youth & Adolescence, 38(1), 29-40. doi:10.1007/s10964-007-9244-9.

http://medical-dictionary.thefreedictionary.com/columnar+epithelium

http://www.nytimes.com/1997/10/12/arts/dance-in-a-darwinian-world-of-weight-control.html

http://www.nytimes.com/1997/10/12/arts/dance-in-a-darwinian-world-of-weight-control.html

http://medical-dictionary.thefreedictionary.com/euhydration

http://medical-dictionary.thefreedictionary.com/euhydration


First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997).

Structured clinical interview for DSM-IV Axis I disorders, (SCID-I). Washington, D.C.:

American Psychiatric Press, Inc.

Franke, G. (2002). SCL-90-R. Die symptom checkliste. [SCL-90-R. The Symptom-Checklist by

L.R. Derogatis - manual of the German version].

Galli, N., Reel, J. J., Petrie, T., Greenleaf, C., & Carter, J. (2011). Preliminary development of

the weight pressures in sport scale for male athletes. Journal of Sport Behavior, 34(1),

47-68.

Garner, D. M. (1991). Eating disorder inventory-2. Odessa, FL: Psychological Assessment

Resources.

Garner, D. M., Olmsted, M. P., & Polivy, J. (1983). Development and validation of a

multidimensional eating disorder inventory for anorexia nervosa and bulimia.


Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The Eating Attitudes Test:

Psychometric features and clinical correlation. Psychological Medicine, 12, 871-878.

Gill, D., L., & Deeter, T., E. (1988). Development of the sport orientation questionnaire.

Research Quarterly for Exercise and Sport, 59, 191-202.

Godin, G., & Shepard, R., J. (1985). Gender differences in perceived physical self-efficacy

among older individuals. Perceptual and Motor Skills, 60, 599-602.

Goltz, F. R., Stenzel, L. M., & Schneider, C. D. (2013). Disordered eating behaviors and body

image in male athletes. Revista Brasileira De Psiquiatria (São Paulo, Brazil: 1999),

35(3), 237-242. doi:10.1590/1516-4446-2012-0840


Griffith, J., & Powers, R. (2007). The lexicon of Adlerian psychology: 106 terms associated with

the individual psychology of Alfred Adler (2nd ed.). Port Townsend, WA: Adlerian

Psychology Associates.

Gruber, A. J., Pope, H. G., Borowiecki, J. J., & Cohane, G. (2000). The development of the

somatomorphic matrix: A bi-axial instrument for measuring body image in men and

women. In K. Norton, T. Olds, & J. Kollman, (Eds.), Kinanthropometry VI, (pp. 217-

231). Adelaide, AU: International Society for the Advancement of Kinanthropometry.

Haggan, P. (2002). Family resilience through sports: The family as a team. The Journal of

Individual Psychology, 58(3), 279-289.

Heatherton, T. F., & Nichols, P. (1995). Body weight, dieting, and eating disorder symptoms

among college students, 1982 to 1992. American Journal of Psychiatry, 152(11), 1623.

Heinberg, L. J., Thompson, J. K., & Stormer, S. (1995). Development and validation of the

sociocultural attitudes towards appearance questionnaire. International Journal of Eating

Disorders, 17, 81-89.

Henderson, M., & Freeman, C., P. (1987). A self-rating scale for bulimia. ‘The BITE’. British

Journal of Psychiatry, 150, 18-24.

Herpertz-Dahlmann, B., Seitz, J., & Konrad, K. (2011). Aetiology of anorexia nervosa: from a

'psychosomatic family model' to a neuropsychiatric disorder? European Archives of

Psychiatry & Clinical Neuroscience, 261, 177-181. doi:10.1007/s00406-011-0246-y.

Hohlstein, L. E., Smith, G. T., & Atlas, J. G. (1998). An application of expectancy theory to

eating disorders: Development and validation of measures of eating and dieting

expectancies. Psychological Assessment, 10, 49-58.


Huas, C. C., Caille, A. A., Godart, N. N., Foulon, C. C., Pham-Scottez, A. A., Divac, S. S., & . . .

Falissard, B. B. (2011). Factors predictive of ten-year mortality in severe anorexia

nervosa patients. Acta Psychiatrica Scandinavica, 123(1), 62-70. doi:10.1111/j.1600-

0447.2010.01627.x

Hyperaldosteronism. (2008). Gale Encyclopedia of Medicine. Retrieved November 10 2015 from

http://medical-dictionary.thefreedictionary.com/hyperaldosteronism

Hyperplasia. (2009). Mosby's Medical Dictionary, (8th ed.). Retrieved November 24 2015 from

http://medical-dictionary.thefreedictionary.com/hyperplasia

IGM Gymnastics. (n.d.). What is the difference between rhythmic and artistic gymnastics?

Author. Retrieved January 07, 2016, from

http://igmgymnastics.com/rhythmicartisticgymnasts.html

Jacob, E. (1993). Dancing: The all-in-one guide for dancers, teachers, and parents (Rev. ed.).

New York, NY: Variety Arts.

Juxtaglomerular apparatus. (2009). Mosby's Medical Dictionary, (8th ed.). Retrieved November

24 2015 from http://medical-dictionary.thefreedictionary.com/juxtaglomerular+apparatus

Killen, J. D., Taylor, C. B., Hayward, C., Wilson, D. M., Haydel, K. F., Hammer, L. D.,

Simmonds, B., . . . & Kraemer, H. (1994). Pursuit of thinness and onset of eating disorder

symptoms in a community sample of adolescent girls: A three-year prospective analysis.


Kiningham, R. B., & Gorenflo, D. W. (2001). Weight loss methods of high school wrestlers.

Medicine and Science in Sports and Exercise, 33(5), 810-813.

http://medical-dictionary.thefreedictionary.com/hyperaldosteronism

http://medical-dictionary.thefreedictionary.com/hyperplasia

http://igmgymnastics.com/rhythmicartisticgymnasts.html

http://medical-dictionary.thefreedictionary.com/juxtaglomerular+apparatus


Klinkowski, N., Korte, A., Pfeiffer, E., Lehmkuhl, U., & Salbach-Andrae, H. (2008).

Psychopathology in elite rhythmic gymnasts and anorexia nervosa patients. European

Child & Adolescent Psychiatry, 17(2), 108-113. doi:10.1007/s00787-007-0643-y

Kong, P., & Harris, L. M. (2015). The sporting body: Body image and eating disorder

symptomatology among female athletes from leanness focused and nonleanness focused

sports. Journal of Psychology, 149(2), 141-160. doi:10.1080/00223980.2013.846291

Lakin, J. A., Steen, S., & Oppliger, R. A. (1990). Eating behaviors, weight loss methods, and

nutrition practices among high school wrestlers. Journal of Community Health Nursing,

7(4), 223.

Lilenfeld, L.R., Kaye, W. H., Greeno, C. G., Merikangas, K. R., Plotnicov K., Pollice, C., Rao,

R., Strober, M., Bulik, C. M., & Nagy, L. (1998). A controlled family study of anorexia

nervosa and bulimia nervosa: Psychiatric disorders in first-degree relatives and effects of

proband comorbidity. Archives of General Psychiatry, 55(7), 603-610.

Marsh, H., W., Richards, G., E., Johnson, S., Roche, L., & Treymayne, P. (1994). Physical self-

description questionnaire: Psychometric properties and a multitrait-multimethod analysis

of relations to existing instruments. Journal of Sport and Exercise Psychology, 16, 270-

305.

McCreary, D.R., & Sasse, D.K. (2000). An exploration of the drive for muscularity in adolescent

boys and girls. Journal of American College Health, 48, 297-304.

Mehler, P. S. (2011). Medical complications of bulimia nervosa and their treatments.

International Journal of Eating Disorders, 44(2), 95-104. doi:10.1002/eat.20825

Mendelson, B. K., Mendelson, M. J., & White, D. R. (2001). Body-Esteem Scale for adolescents

and adults. Journal of Personality Assessment, 76, 90-106.


Nelson, M. O. (1991). Another look at masculine protest. Individual Psychology: Journal of

Adlerian Theory, Research & Practice, 47(4), 490-497.

Neumark-Sztiner, D., Sherwood, N. E., Coller, T., & Hannona, P. J. (2000). Primary prevention

of disordered eating among preadolescent girls: Feasibility and short-term effect of a

community-based intervention. Journal of the American Dietetic Association, 100, 1466-

1473.

Ööpik, V., Timpmann, S., Burk, A., & Hannus, I. (2013). Hydration status of Greco-Roman

wrestlers in an authentic precompetition situation. Applied Physiology, Nutrition &

Metabolism, 38(6), 621-625. doi:10.1139/apnm-2012-0334

Oppliger, R. A., Nelson Steen, S. A., & Scott, J. R. (2003). Weight loss practices of college

wrestlers. International Journal of Sport Nutrition & Exercise Metabolism, 13(1), 29.

Paskevska, A. (1992). Both sides of the mirror the science and art of ballet (2nd ed.).

Pennington, NJ: Princeton Book.

Poudevigne, M. S., O'Connor, P. J., Laing, E. M., Wilson, A. R., Modlesky, C. M., & Lewis, R.

D. (2003). Body images of 4–8-year-old girls at the outset of their first artistic gymnastics

class. International Journal of Eating Disorders, 34(2), 244-250. doi:10.1002/eat.10157

Ransone, J., & Hughes, B. (2004). Body-weight fluctuation in collegiate wrestlers: Implications

of the national collegiate athletic association weight-certification program. Journal of

Athletic Training, 39(2), 162-168.

Reynolds, W. M. (1982). Development of reliable and valid short forms of the Marlowe-Crowne

Social Desirability Scale. Journal of Clinical Psychology, 38, 119-125.


Ricciardelli, L. A., & McCabe, M. P. (2000). Psychometric evaluation of the body image and

body change inventory: An assessment instrument for adolescent boys and girls.

(Unpublished manuscript). Melbourne: Deakin University.

Ringham, R., Klump, K., Kaye, W., Stone, D., Libman, S., Stowe, S., & Marcus, M. (2006).

Eating disorder symptomatology among ballet dancers. International Journal of Eating

Disorders, 39(6), 503-508. doi:10.1002/eat.20299

Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton

University Press.

Schnell, A., Mayer, J., Diehl, K., Zipfel, S., & Thiel, A. (2014). Giving everything for athletic

success! – Sports-specific risk acceptance of elite adolescent athletes. Psychology of

Sport & Exercise, 15(2), 165-172. doi:10.1016/j.psychsport.2013.10.012

Sherman, R. A. (1996). Body mass index and athletic performance in elite female gymnasts.

Journal of Sport Behavior, 19(4), 338.

Squamous epithelium. (2009). Mosby's Medical Dictionary, (8th ed.). Retrieved November 10

2015 from http://medical-dictionary.thefreedictionary.com/squamous+epithelium

Strauch, M., & Erez, M. (2009). The restrictive personality: Anorexia nervosa and Adlerian life

tasks. Journal of Individual Psychology, 65(3), 203-211.

Stunkard AJ, Sorensen T, & Schulsinger F. (1983). Use of the Danish Adoption Register for the

study of obesity and thinness. In S. S. Kety (Ed.), The genetics of neurological and

psychiatric disorders, (pp. 115-120). New York, NY: Raven Press.

Thelen, M. H., Mintz, L. B., & Vander Wal, J. S. (1996). The bulimia test-revised: Validation

with DSM-IV criteria for bulimia nervosa. Psychological Assessment, 2, 219-221.

http://medical-dictionary.thefreedictionary.com/squamous+epithelium


Thiel, A., Diehl, K., Giel, K. E., Schnell, A., Schubring, A. M., Mayer, J., & . . . Schneider, S.

(2011). The German young Olympic athletes' lifestyle and health management study

(GOAL Study): Design of a mixed-method study. BMC Public Health, 11(1), 410-419.

doi:10.1186/1471-2458-11-410

Thomas, J. J., Keel, P. K., & Heatherton, T. F. (2005). Disordered eating attitudes and behaviors

in ballet students: Examination of environmental and individual risk factors.

International Journal of Eating Disorders, 38(3), 263-268. doi:10.1002/eat.20185

Thomas, J. J., Keel, P. K., & Heatherton, T. F. (2011). Disordered eating and injuries among

adolescent ballet dancers. Eating and Weight Disorders: EWD, 16(3), e216-e222.

Thompson, R. A., & Sherman, R. (1999). Athletes, athletic performance, and eating disorders:

Healthier alternatives. Journal of Social Issues, 55(2), 317-337.

Toro, J., Salamero, M., & Martínez, E. (1994). Assessment of sociocultural influences on the

aesthetic body shape model in anorexia nervosa. Acta Psychiatrica Scandinavica, 89,

147-151.

Toro, J., Galilea, B., Martinez-Mallén, E., Salamero, M., Capdevila, L., Mari, J., & ... Toro, E.

(2005). Eating disorders in Spanish female athletes. International Journal of Sports

Medicine, 26(8), 693-700.

Toro, J., Guerrero, M., Sentis, J., Castro, J., & Puértolas, C. (2009). Eating disorders in ballet

dancing students: Problems and risk factors. European Eating Disorders Review, 17(1),

40-49.

Urine osmolality. (2009). Medical Dictionary. Retrieved November 10 2015 from http://medical-

dictionary.thefreedictionary.com/urine+osmolality

Urine specific gravity. (2009). Mosby's Medical Dictionary, (8th ed.). Retrieved November 10

http://medical-dictionary.thefreedictionary.com/urine+osmolality

http://medical-dictionary.thefreedictionary.com/urine+osmolality


2015 from http://medical-dictionary.thefreedictionary.com/urine+specific+gravity

Watson, D., & Clark, L. A. (1991). Self-versus peer-ratings of specific emotional traits: Evidence

of convergent and discriminant validity. Journal of Personality and Social Psychology,

60, 927-940.

Weight 'cutting' waning among college wrestlers. (2003). Eating Disorders Review, 14(5), 6-1.

Wheeler, M., Kern, R., & Curlette, W. (1993). The BASIS-A Inventory. Highlands, NC: TRT

Associates.

http://medical-dictionary.thefreedictionary.com/urine+specific+gravity

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