Part One of this series introduced The Female Athlete Triad, a syndrome described by the American College of Sports Medicine (ACSM) in 1992, as the combination of three disorders that can all decrease women’s physical performance and cause morbidity and mortality [1]. The three components are disordered eating, amenorrhea, and osteoporosis, and they are interrelated to each other in their origins, development, and ultimate consequences. The disordered eating usually occurs first, which leads to the menstrual dysfunction, and osteoporosis [2]. This article focuses on disordered eating and its relationship in The Female Athlete Triad.

Putting the Terminology into Order
According to the ACSM, the term disordered eating includes a variety of abnormal eating behaviors that are used by women to lose weight. The behaviors range from food restriction, fasting, bingeing and purging, the use of diet pills, laxatives, diuretics, and certain thought patterns to the DSM-IV (the American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders) defined disorders of anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (ED, NOS). A new term called anorexia athletica (AA) has even been proposed to describe athlete’s eating disorders that do not fit into the above mentioned disorders [3]. Female athletes, as opposed to male athletes, are especially at risk because eating disorders affect women 10 times as often as men [4]. The exact incidence of disordered eating is difficult to quantify. Typically, women deny they have an eating disorder, or if they do have one, will not report it [5]. Percentages of female athletes with eating disorders in the literature vary from 15% to as high as 72%. These statistics are incredibly high when it appears that the incidence of eating disorders in the general population are 5-10% [6]. Although the ACSM suggests that women who participate in sports based upon appearance and requiring low body weight like dance, gymnastics, and distance running are more susceptible to developing disordered eating patterns, women who participate in a “wide range of physical activities” are potentially at risk [1].

How and Why
The ACSM suggests that disordered eating may develop from psychological problems prior to a woman’s involvement in athletics. It is also possible that women become involved in athletics in order to lose weight. A recent survey of 101 exercising women revealed that their primary reason for exercise was not to be physically fit or healthy, but for weight management and to improve their appearance [7]. Factors that can predispose an athlete to disordered eating include focusing on an ideal weight, pressure from coaches, family members, and from the athlete themselves to achieve, social isolation that comes from exclusive involvement in a sport, family history of disordered eating, and society expectations [8]. Traits like perfectionism and compulsiveness that are common to “type-A” personalities and high level athletes are also associated with disordered eating [2]. In addition, athletes are more prone to body image concerns because they have a heightened body awareness [2]. A study on risk and trigger factors for eating disorders in elite female athletes in Norway identified several conditions that precipitated eating disorders: dieting at an early age, recommendations by coaches to lose weight, unsupervised dieting that results in fad and crash diets, feeling that menarche was reached too early (when in reality it wasn’t), early start of sports-specific training, and traumatic events like the loss of a coach, an injury, or an illness [9].

Anorexia Nervosa
AN is an eating disorder characterized by self-imposed weight loss and a distorted attitude toward eating and weight. It usually occurs in girls after puberty, but occasionally can occur before menarche or later in life [10]. Most women with AN believe that they are obese, even though they may be emaciated. Only when their weight falls low enough to induce amenorrhea, do they feel somewhat satisfied [11]. As a matter of fact, one of the diagnostic criteria for AN is amenorrhea [12]. Other diagnostic criteria include refusal to maintain body weight at or above 85% of normal weight for age and height; intense fear of gaining weight or becoming fat, even when underweight; and 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 denial of the seriousness of the current low body weight.

Bulimia Nervosa
BN involves loss of control over eating and extreme concern about body shape and weight which results in binge eating and purging. The purging can be in the form of vomiting, use of laxatives, diuretics, enemas, fasting, or extreme exercise [12]. This disorder is usually seen in young, adult women after menarche [10]. Bulimics weight can fluctuate greatly and they are usually normal in weight or slightly overweight [10].

Warning Signs
Disordered eating patterns do not automatically develop into the diagnosed eating disorders, but they are all dangerous in their own ways. Recognizing the signs and symptoms is the first step to prevention. Warning signs like an athlete repeatedly asking or talking about weight should be noticed, especially if their weight is normal or below average [13]. Continuing to lose weight even when an ideal weight is met is reason for concern. Eating secretly or hoarding food and the opposite – not eating or eating very little should be a red flag. Athletes who leave a room immediately after eating on a consistent basis should be suspected.

More Disorders Result from Disordered Eating
Disordered eating results in many harmful conditions for the female athlete. The combination of low caloric intake and the resulting fluid and electrolyte reduction decreases endurance, strength, reaction time, speed, and concentration. These conditions impair athletic performance and increase the risk for injuries [2]. In addition, the harmful physiological side effects of food restriction can manifest themselves in amenorrhea, osteoporosis, and possibly even death. The next article in this series will explore how disordered eating can result in amenorrhea. For additional information and help, call the American Anorexia & Bulimia Association at (212) 734-1114, the National Association of Anorexia Nervosa and Associated Disorders at (708) 831- 3438, or the National Anorexic Aid Society at (614) 436-1112.

References
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2. West, R.V., The female athlete. The triad of disordered eating, amenorrhoea and osteoporosis. Sports Med, 1998. 26(2): p. 63-71.
3. Sundgot-Borgen, J., Prevalence of eating disorders in elite female athletes. Int J Sport Nutr, 1993. 3(1): p. 29-40.
4. Yates, A., Biologic considerations in the etiology of eating disorders. Pediatr Ann, 1992. 21(11): p. 739-744.
5. Thein, L.A. and J.M. Thein, The female athlete. Journal of Orthopedic and Sports Physical Therapy, 1996. 23(2): p. 134-148.
6. Wiggins, D.L. and M.E. Wiggins, The female athlete. Clin Sports Med, 1997. 16(4): p. 593-612.
7. Cash, T.F., P.L. Novy, and J.R. Grant, Why do women exercise? Factor analysis and further validation of the Reasons for Exercise Inventory. Percept Mot Skills, 1994. 78(2): p. 539-544.
8. Grooms, A.M., The female athlete triad. J Fla Med Assoc, 1996. 83(7): p. 479-481.
9. Sundgot-Borgen, J., Risk and trigger factors for the development of eating disorders in female elite athletes. Med Sci Sports Exerc, 1994. 26(4): p. 414-419.
10. Lucas, A.R. and D.M. Huse, Behavioral disorders affecting food intake: anorexia nervosa and bulima nervosa, in Modern Nutrition in health and disease, M.E. Shils, J.A. Olson, and M. Shike, Editors. 1994, Lea & Febiger: Malvern, PA. p. 977-983.
11. Johnson, C. and D.L. Tobin, The diagnosis and treatment of anorexia nervosa and bulimia nervosa among athletes. Athletic Training, 1991. 26(Summer 1991): p. 119-128.
12. American Psychiatric Association: Diagnostic Criteria from DSM IV, . 1994: Washington, D.C. p. 251-254.
13. Grandjean, A.C., Eating disorders- the role of the athletic trainer. Athletic Training, 1991. 26(Summer 1991): p. 105-112.