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Athletes and Eating Disorders:
Some Ramifications of the NCAA Study

Reprinted from Eating Disorders Review
November/December 1999 Volume 10, Number 6
©1999 Gürze Books

An Interview with Dr. Pauline Powers

During the National Collegiate Athletic Association (NCAA) Study on Athletes and Eating Disorders, 1,145 student athletes from 11 Division 1 schools were surveyed to determine the prevalence of eating disorders.1 EDR Board member Dr. Pauline Powers, Professor of Psychiatry at the College of Medicine, University of South Florida, Tampa, and a coauthor of the study, talked with us about some of the ramifications of the study.

EDR: Dr. Powers, can you give us a little background about the NCAA study?

Dr. Powers: The eating disorders field has long recognized a higher prevalence of eating disorders among athletes, particularly among elite athletes. Dr. Craig Johnson, Director of the Eating Disorders Program at Laureate Psychiatric Clinic and Hospital, Tulsa, was a driving force in the development of the collaborative study with the NCAA. He has a deep, longstanding interest in sports and eating disorders, and worked with Randy Dick, Director of the Sports Science Division at the NCAA, to design and carry out the study. Much work had to be done in the initial phase because there was resistance to the idea of examining the connection between athletics and eating disorders. Some schools were fearful that the problem was present and did not want to acknowledge it, but the other part was concern that the study would in some way interfere with the athletes' careers and interest in sports. As a result of these concerns, anonymity of the schools and athletes was assured. Investigators went on site to administer the questionnaires and the coaches were out of the room while the questionnaires were being filled out. All information obtained from individuals was pooled. I think that was why the collaborative study could be done, there was no way that the athlete or school could be identified.

EDR: The criteria for diagnosing eating disorders seemed very strict.

Dr. Powers: They were. The DSM-IV criteria are both a blessing and curse. A blessing because this is better for research, but also a curse because clinically a lot of people who have really severe eating disorders don't meet the DSM-IV criteria. In fact, about half of patients who come to specialty clinics don't meet the DSM-IV criteria. They are diagnosed with eating disorders not otherwise specified (EDNOS), even though they obviously have an eating disorder.

Gender Differences EDR: Your study uncovered a number of important differences between male and female athletes.

Dr. Powers: Yes, there were several. One of the findings upset me greatly, in fact so much so that I had to stop my data analysis and leave the house for a while. On every single item on the Rosenberg Self-Esteem Scales, women as a group had lower self-esteem than men did. On another scale, binge eating, 81% of women reported that they felt out of control during an episode of overeating. In contrast, only 45% of men felt they were out of control during an overeating episode. In general, the male athletes were less likely to consider an episode of overeating a problem. Other very important issues were body fat, amenorrhea, and body mass index (BMI). The female athletes wanted to have a body fat of 13% (mean), even though the normal range is from 17% to 25%. On average, their body fat was too low (mean: 15.4%). This finding was very important because a significant number of female athletes are at risk for osteoporosis. The men, who had a mean body fat content of 10.5%, also wanted to have lower body fat - a mean of 8.6%. However, although on the low side, their body fat was in the normal range, 10% to 15%. On a discouraging note, when Craig Johnson and I were involved with the Olympics and tried to demonstrate that female athletes need a certain amount of body fat, the committee evaluating the female athlete triad (osteoporosis, abnormal eating patterns, and amenorrhea) simply did not believe us.

EDR: Is the resistance due to emphasis on performance over health?

Dr. Powers: Yes. Craig Johnson calls this 'appearance-related and performance-related drive to thinness.' Here the athletes get a double dose: Not only are they trying to get thin because our society says you should appear thin, but the athletes also think being thinner, no matter what, improves performance. And there is good evidence that this is not the case

EDR: What about BMI in the study?

Dr. Powers: When you take the body mass index, which is so popular right now, and compare it for the female athletes with and without amenorrhea, there was no statistically significant difference. But there was a difference in body fat between those with and without amenorrhea. Amenorrheic women had significantly lower body fat levels than women with menses. We keep overlooking the problem with BMI. It is just a mathematically derived figure that doesnÕt reflect actual body composition.

EDR: BMI is the standard index, isn't it? It is easy to calculate.

Dr. Powers: It is easy to calculate, and people just believe it without evidence. BMI is a popular index of body fatness and I think it is great for epidemiologic studies; for example, it is helpful to know how many people are actually obese or underweight in our culture. But, for an individual, or for specific problems like this one, BMI is not helpful. It doesn't specifically assess body composition.

EDR: In this study, the BMIs seemed low.

Dr. Powers: A large number of the women athletes (173) had BMIs between 15 and 20. At the other extreme, 3 males had BMIs between 40 and 45, and 2 females and 26 males had BMIs between 35 and 40.

EDR: A Scandinavian study also involved eating disorders and athletes - how did it differ from the NCAA study?

Dr. Powers: Sundgot-Borgen both screened elite athletes and interviewed those at risk.(2) Such a two-stage design is ideal. However, the disadvantage of such a design in our case was that many people may not have wanted to participate, and it might have been much harder to get the NCAA to agree to the study.

The Future EDR: Can anything be done to help prevent eating disorders among athletes?

Dr. Powers: In terms of prevention, I still think we should keep working with coaches, with the Olympics Committee, with whomever we can get to listen, and keep trying to get the message across that lowering body fat content is not necessarily a goal if someone already has normal body fat. We should also be thinking about it from the athlete's perspective; that is, what really improves performance? Three elements are known to improve performance: muscle mass, genetics, and motivation. Within certain ranges, body fat isn't the key issue, although some people think it is. For individuals, we need to think about the long-term implications of participating in athletics. In some sports, somehow we have gotten the idea that over-exercising is good. It might or might not be good.

EDR: Is the message about healthy athletics getting through?

Dr. Powers: I tried to convince the Olympics Committee of the importance of athletes and the role models they represent to our teenagers. However, I don't think this issue resonated with the Committee at the time. Other groups have been trying to stress good bone health - this whole concept of the female athlete triad has been an attempt to get this particular idea across. It has had some effect, as in gymnastics, where they recognize that bone loss is a problem and have tried to make some interventions. Some gymnasts weigh more than they did in the past, but more prevention efforts are needed. Also on the plus side, many articles and books have been written about how to help athletes with eating disorders. Ron A. Thompson and Roberta Trattner Sherman have done much work in this area, and have published a very helpful book on how to help athletes continue in their sports, and how to get the coach to intervene in a way that is helpful and not a condemnation of the athlete.(3)

EDR: Dr. Powers, you see athletes in your practice - have you seen any positive changes?

Dr. Powers: Today parents are much more attentive to the long-term risks of disordered eating. When I explain the risks, particularly the risk of osteoporosis, they really don't want that to happen. I think that physicians need to work harder on educating parents and patients about the long-term risks. For the most part, people will listen. For someone who has an established eating disorder, that is different. However, in general, people who are hovering on the edge of an eating disorder are very impressed by the fact that they might be at risk for osteoporosis.

References:
1. Johnson C, Powers, PS, Dick, R. Athletes and Eating Disorders: The National Collegiate Athletic Association Study. Int J Eat Disord 1999; 6:179.
2. Sundgot-Borgen J. Risk and trigger factors for the development of eating disorders in female elite athletes. Med Sci Sports Exerc 1994;26(4):414.
3. Thompson, RA, Sherman RT. Helping Athletes with Eating Disorders, Human Kinetics Publishing Company, 1992.