Risk Factors and Prevalence of Eating Disorders in Male Athletes

There are many factors that can contribute to the breakdown of a healthy relationship between an athlete’s diet and mental health, putting them at risk for Eating Disorders (ED). In fact, ED are one of the most common psychiatric pathologies in elite athletes (Karrer et al., 2020). 

ED are defined as “behavioral conditions characterized by severe and persistent disturbance in eating behaviors and associated distressing thoughts and emotions” (American Psychiatric Association, 2021). Athletes of both sexes are more likely than their non-athlete peers to develop eating disorders (Martinsen & Sundgot-Borgen, 2013; Mancine et al., 2020). 

However, the prevalence of these disorders in male athletes is largely overlooked, as most research is directed towards ED in female athletes (Karrer et al., 2020), and these disorders are stereotyped as a “female problem” (Eichstadt et al., 2020). This commonly held stereotype, male gender norms, and the athletic identity of a male being “strong, stoic, and self-sacrificing” may deter male athletes who are suffering with these disorders from seeking help (Eichstadt et al., 2020). 

 

The prevalence of these disorders in male athletes is largely overlooked, most research is directed towards ED in female athletes

 

There are several gender-specific differences related to the prevalence, risk factors, and potential interventions for ED in athletes. This article aims to shed light on the specificities of ED in male athletes to increase awareness and education for coaches, trainers, parents, and the athletes themselves. 

 

Prevalence and Risk Factors
Most research assessing the risk factors of ED in athletes has been examined primarily in female athletes, but there have been a few studies looking specifically at ED in male athlete populations. 

About 20% of male athletes adopt risk behaviors for eating disorders (RBED) as a means to improve their body composition (Fortes et al., 2020). Improved sport performance is the most frequently stated reason for dieting among male athletes, with between 84-91% of elite athletes believing that decreased weight could be attributed to better sport performance (Karrer et al., 2020). These risk behaviors can include long periods without food intake, using medication for appetite suppressant or diuretic effects, wearing clothing that contributes to extra dehydration, and self-induced vomiting (Fortes et al., 2020) (see Figure 1). 

 

Figure 1. Prevalence and risk factors associated with ED in male athletes

 

There are several risk factors that are associated with the prevalence of ED in male athletes. For example, male athletes who participate in “weight-sensitive” sports may be at higher risk for developing ED than male athletes who participate in non-weight sensitive sports (Karrer et al., 2020). Athletes who compete in a sport, such as wrestling, that divides athletes into “weight classes” report more psychological pressure to be lean, a higher drive for thinness, higher levels of dietary constraint, and higher levels of bulimic behaviors than athletes who competed in less weight-sensitive sports, such as soccer or other team sports (Karrer et al., 2020). 

 

 

Athletes who compete in sports such as wrestling, that divided into “weight classes,” reported more psychological pressure to be lean

 

One study found up to 50% of male athletes who participated in weight-sensitive sports had disordered eating (DE) (Rouselet et al., 2017). The pressures for these athletes to enter and remain in a specific weight class may “normalize” certain practices that would be considered DE. The male athletes who suffer from these disorders are at risk for being overlooked, and sometimes even positively reinforced, for these dangerous behaviors (Eichstadt et al., 2020). 

 

One study found up to 50% of male athletes who participated in weight-sensitive sports had disordered eating (DE) 

 

Psychological features of athletes may also serve as a risk factor for developing ED, DE and RBED. Whereas ED involve psychological disorders that are recognized by the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5), DE is a condition that involves behaviors similar to those found in ED to a lesser intensity or frequency, but that can still be dangerous to the individual (Fuller, 2022). 

Studies show a direct linear relationship between competitive anxiety, defined as “the tendency to perceive competitive situations as threatening and to respond to them with feelings of apprehension and tension” (Martens, 1977), and risk behaviors for eating disorders (RBED) in male athletes. Specifically, the stress perception an athlete can feel both during competition, and also the negative thoughts about the competition, were associated with the “triggering” of RBED (Fortes et al., 2020). Other psychological risk factors can include low self-esteem (Dakanalis et al., 2016), depression (Grossbard et al., 2013), and the fear of negative evaluation (Dakanalis et al., 2014) (see Figure 2).

 

Figure 2.  Psychological risk factors in athletes 

 

Consequences of ED in Male Athletes
The literature on athlete’s health and performance consequences of ED is mainly focused on female athletes, although males also suffer health consequences. These consequences may be harder to recognize in males, as they don’t have the obvious physical symptoms of low energy availability (EA) such as amenorrhea in female athletes (Karrer et al., 2020), and are not yet well understood (Mountjoy et al., 2018). 

Some health concerns that have been identified in male athletes include reduction in testosterone (Mountjoy et al., 2018) and reduced bone mineral mass (Karrer et al., 2020). In addition to the physical health challenges, low testosterone, DE, depression, and stress may affect each other reciprocally (Karrer et al., 2020). Furthermore, EDs have the highest fatality rate of any mental health disorder, which is shown to be even higher in men than it is for women. One in five patients with anorexia nervosa, a type of ED, dies by suicide (Markey et al., 2022) (see Figure 3). 

 

Figure 3. Consequences of ED in Male Athletes

 

EDs have the highest fatality rate of any mental health disorder

 

Treatment and Prevention for ED in Male Athletes
Because of the dire consequences and outcomes that accompany EDs, it is necessary to ensure proper treatment for athletes who are suffering from these disorders. However, the ability to recognize and report these disorders in athletes, especially males, is challenging. Studies suggest that the current tools that are used to assess eating disorders among the general population are not appropriate for use with athletes for several reasons (Rousselet et al., 2017). 

 

Current tools used to assess eating disorders among the general population are not appropriate for use with athletes for several reasons 

 

The preoccupation with dieting and food behaviors that is generally seen as “disordered” may be part of the sporting culture, and therefore may not always point to ED (Karrer et al., 2020). Also, BMI which is often used as an indicator for ED may be skewed for athletes, as increased muscle mass will increase an athlete’s BMI, regardless of their body fat percentage (Karrer et al., 2020). In other words, an athlete with a low body fat percentage may be suffering from ED, but will not be diagnosed as such because their muscle mass gives the illusion of an elevated BMI, and therefore they will not meet the criteria. And finally, male athletes are likely to underreport their struggles with ED in self-report questionnaires (Rousselet et al., 2017). 

Because of these challenges with recognizing ED in male athletes, it may be important to equip athletes with the skills necessary to appropriately confront these conditions. Some researchers are claiming that coping skills may be able to mediate the relationship between competitive anxiety and RBED in athletes. Helping athletes develop coping skills to manage their competitive anxiety under stressful conditions is a key concept of sport psychology training. 

 

Coping skills may be able to mediate the relationship between competitive anxiety and RBED in athletes

 

These skills help athletes to regulate their emotions that are caused by stressors, such as a big game or competition (Pons et al., 2018). The use of coping strategies in athletes has been shown to mediate the relationship between competitive anxiety and negative emotions, and promote adaptive behaviors, in an effort to improve sport performance (Wadey et al., 2014; Pons et al., 2018). Beyond improvement in performance, coping skills may be able to be used as a tool to help athletes avoid RBED (Fortes et al., 2020). 

 

Coping strategies in athletes mediate the relationship between competitive anxiety and negative emotions, improving sports performance 

 

Although this may be one tool, the use of coping skills should not be the only preventative and treatment measure for athletes who are suffering from ED. The International Olympic Committee releases regular consensus statements that reflect the updated information on treatment options available for athletes who suffer from ED. 

How Coaches and Sport Psychology Professionals Can Help
Despite the lack of recognition in research, male athletes are at risk for ED, DE, and RBED. By understanding certain risk factors that contribute to the development of RBED, such as sport type and psychological factors, parents, coaches, and sport psychology professionals may be able to take appropriate and necessary action to help athletes who may be at risk for developing such disorders. 

 

References 

American Psychiatric Association (2021). What Are Eating Disorders? https://www.psychiatry.org/patients-families/eating-disorders/what-are-eating-disorders

Dakanalis, A., Clerici, M., Caslini, M., Gaudio, S., Serino, S., Riva, G., & Carrà, G. (2016). Predictors of initiation and persistence of recurrent binge eating and inappropriate weight compensatory behaviors in college men. International Journal of Eating Disorders, 49(6), 581–590. https://doi.org/10.1002/eat.22535

Dakanalis, A., Timko, C. A., Favagrossa, L., Riva, G., Zanetti, M. A., & Clerici, M. (2014). Why Do Only a Minority of Men Report Severe Levels of Eating Disorder Symptomatology, When so Many Report Substantial Body Dissatisfaction? Examination of Exacerbating Factors. Eating Disorders, 22(4), 292–305. https://doi.org/10.1080/10640266.2014.898980

Eichstadt, M., Luzier, J., Cho, D., & Weisenmuller, C. (2020). Eating Disorders in Male Athletes. Sports Health: A Multidisciplinary Approach, 12(4), 327–333. https://doi.org/10.1177/1941738120928991

Fortes, L. D. S., Nascimento Junior, J. R. A. D., Freire, G. L. M., & Ferreira, M. E. C. (2020b). Does coping mediate the relationship between competitive anxiety and eating disorders in athletes? Psicologia – Teoria e Prática, 22(3). https://doi.org/10.5935/1980-6906/psicologia.v22n3p74-91

Fuller, K. (2022, June 29). Difference Between Disordered Eating and Eating Disorders. Verywell Mind. https://www.verywellmind.com/difference-between-disordered-eating-and-eating-disorders-5184548

Grossbard, J. R., Atkins, D. C., Geisner, I. M., & Larimer, M. E. (2013). Does depressed mood moderate the influence of drive for thinness and muscularity on eating disorder symptoms among college men? Psychology of Men & Masculinity, 14(3), 281–287. https://doi.org/10.1037/a0028913

Karrer, Y., Halioua, R., Mötteli, S., Iff, S., Seifritz, E., Jäger, M., & Claussen, M. C. (2020b). Disordered eating and eating disorders in male elite athletes: a scoping review. BMJ Open Sport & Exercise Medicine, 6(1), e000801. https://doi.org/10.1136/bmjsem-2020-000801 

Mancine, R., Kennedy, S., Stephan, P., & Ley, A. (2020). Disordered Eating and Eating Disorders in Adolescent Athletes. Spartan Medical Research Journal. https://doi.org/10.51894/001c.11595

Markey, C. (2022). Eating Disorders Affect Boys and Men Too. U.S. & World Report News. https://health.usnews.com/health-news/blogs/eat-run/articles/eating-disorders-and-body-image-issues-in-boys-and-men

Martens, R. (1977). Sport Competition Anxiety Test. Human Kinetics Publishers.

Martisen, M., & Sundgot-Borgen, J. (2013). Higher Prevalence of Eating Disorders among Adolescent Elite Athletes than Controls. Medicine & Science in Sports & Exercise, 45(6), 1188–1197. https://doi.org/10.1249/mss.0b013e318281a939

Mountjoy, M., Sundgot-Borgen, J. K., Burke, L. M., Ackerman, K. E., Blauwet, C., Constantini, N., Lebrun, C., Lundy, B., Melin, A. K., Meyer, N. L., Sherman, R. T., Tenforde, A. S., Klungland Torstveit, M., & Budgett, R. (2018). IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. British Journal of Sports Medicine, 52(11), 687–697. https://doi.org/10.1136/bjsports-2018-099193

Rousselet M, Guerineau B, Paruit MC, et al. Disordered eating in French high-level athletes: association with type of sport, doping behavior, and psychological features. Eat Weight Disord 2017;22:61–8