The Athletes' Relationships with Training scale (ART): A self-report measure of unhealthy training behaviors associated with eating disorders

Preventing eating pathology among elite adolescent ballet dancers: a pilot trial of the Athlete Body Project

Adolescent ballet dancers are commonly recognized as aesthetic athletes who are at higher risk for body dissatisfaction, disordered eating, and eating disorders. Although athletic participation can generally protect against negative mental and physical health outcomes, idealization of a body ideal specific to ballet can confer unique vulnerability for eating pathology. Despite this known vulnerability, rigorous efforts to prevent eating pathology among young dancers are lacking. Previously, we reported on a trial of the Female Athlete Body Project adapted for professional female ballet dancers. The current study tested a subsequent adaptation, the Athlete Body Project (ABP), tailored for younger dancers, including a version for boys. This non-randomized, uncontrolled pilot trial tested ABP among boys and girls in two elite ballet schools (N = 23), formatted in-person and via video-conferencing. Program delivery met benchmarks for feasibility and acceptability across gender and delivery formats, and dancers provided positive qualitative feedback. Overall results suggest the potential of ABP in intervening on pre-post eating pathology and body appreciation, and significantly decreasing drive for muscularity among young ballet dancers. Taken together, this pilot work addresses a gap in the field and advances the needed development of eating disorder prevention programming for young, high-risk aesthetic athletes.

Measuring exercise in eating disorder patients: a Delphi study to aggregate clinical and research knowledge

BACKGROUND

Exercise is a prominent feature of most eating disorders, and has been shown to have a number of detrimental effects on treatment outcome. There is some disagreement in the literature regarding the construct of compulsive exercise, and assessment and treatment varies significantly. This study therefore aimed to aggregate expert clinicians' and researchers' views on how to define and measure compulsive exercise in eating disorder patients. The expert panel was also asked about questionnaire design, and possible problems when measuring compulsive exercise.

METHOD

This study used the Delphi method to establish consensus amongst an expert panel. Three successive rounds of questionnaires were distributed to the panel over a period of six months. The first round consisted of four open-ended questions regarding the definition and measurement of compulsive exercise in eating disorder patients. For Round 2, 70 statements were derived from the answers, and panelists were asked to rate each item on a Likert-based scale. An 85% consensus level was chosen. In Round 3, 44 statements were re-rated by the panel.

RESULTS

Seventeen of 24 participants completed all three rounds of the study. Consensus was achieved for 63% of the items, while 18.5% reached near consensus, and 18.5% did not reach consensus after Round 3. The panel agreed on a number of important aspects of compulsive exercise. Several suggestions regarding the format of a questionnaire assessing this behavior were also endorsed. The panel further identified common difficulties when assessing compulsive exercise in eating disorder patients, notably a lack of consensus still apparent in the literature.

CONCLUSION

The current findings constitute a further step towards a unified definition of compulsive exercise, and contribute important suggestions to the measurement of this behavior.

Prevalence of Female and Male Athlete Triad Risk Factors in Ultramarathon Runners

OBJECTIVE

To identify the prevalence of male and female athlete triad risk factors in ultramarathon runners and explore associations between sex hormones and bone mineral density (BMD).

DESIGN

Multiyear cross-sectional study.

SETTING

One hundred-mile ultramarathon.

PARTICIPANTS

Competing runners were recruited in 2018 and 2019.

ASSESSMENT OF RISK FACTORS

Participants completed a survey assessing eating behaviors, menstrual history, and injury history; dual-energy x-ray absorptiometry for BMD; and laboratory evaluation of sex hormones, vitamin D, and ferritin (2019 cohort only).

MAIN OUTCOME MEASURE

A Triad Cumulative Risk Assessment Score was calculated for each participant.

RESULTS

One hundred twenty-three runners participated (83 males and 40 females, mean age 46.2 and 41.8 years, respectively). 44.5% of men and 62.5% of women had elevated risk for disordered eating. 37.5% of women reported a history of bone stress injury (BSI) and 16.7% had BMD Z scores <-1.0. 20.5% of men had a history of BSI and 30.1% had Z-scores <-1.0. Low body mass index (BMI) (<18.5 kg/m 2 ) was seen in 15% of women and no men. The Triad Cumulative Risk Assessment classified 61.1% of women and 29.2% of men as moderate risk and 5.6% of both men and women as high risk.

CONCLUSIONS

Our study is the first to measure BMD in both male and female ultramarathon runners. Our male population had a higher prevalence of low BMD than the general population; females were more likely to report history of BSI. Risk of disordered eating was elevated among our participants but was not associated with either low BMD or low BMI.

A systematic review of instruments for the assessment of eating disorders among adults

PURPOSE OF REVIEW

The availability of psychometrically sound assessment instruments for assessing eating disorder symptomatology is crucial for both clinical practice and research. The purpose of the current review is to provide the reader with a list of psychometrically validated assessments for adults that are available within the field of eating disorders. Eating disorder interviews and self-report questionnaires were identified using online literature searches, reviewing previous review articles, and via research and/or clinical experience of the authors. The focus of the review was on (1) standard assessments that were frequently used in eating disorder research (such as the Eating Disorder Examination and Eating Attitudes Test), and (2) newer assessments that were developed over the past 5 years. Information compiled on each instrument included the purpose of the assessment, scores that can be derived, psychometric information, translations in other languages, and availability for use in research and clinical settings.

RECENT FINDINGS

Several recent trends in assessment instruments were identified including updates based upon Diagnostic and Statistical Manual criteria, briefer assessments, assessments for specific populations, and assessment of specific clinical features observed in people with eating disorders.

SUMMARY

The current review provides eating disorder clinicians and researchers a guide for making informed decisions about the selection of eating disorder assessments.

Exercise Addiction in the Sports Context: What Is Known and What Is Yet to Be Known

Exercise addiction (EA) involves excessive concerns for exercise routines, an abusive practice, and the inability to control one’s own behavior, as well as the presence of psychological processes that are typical of behavioral addictions such as abstinence. EA is further associated with an alteration of the individual’s personal, social, and professional functioning and a higher risk for several pathologies, including physical injury, psychological distress, and eating disorders. The present work presents a narrative scoping review of the state of the art and the main findings of the research on EA, with a focus in the athletic population. The prevalence of EA risk, between 1 and 52% and up to 80% when co-occurring with eating disturbances, is also reviewed. Additionally, some of the explanatory models proposed to date and their power and limitations in terms of their capacity for a consensual operationalization and characterization of EA, and thus for the optimal exploration and management of this condition, are discussed. Finally, some deficiencies in the research on EA are noted which are to be addressed to successfully respond to the intervention and prevention needs that occur both in the general context of exercise-sports practice and the specific context of competitive athletes.

A Systematic Review on Exercise Addiction and the Disordered Eating-Eating Disorders Continuum in the Competitive Sport Context

Exercise addiction (EA) affects a considerable number of individuals who regularly perform exercise-sport activities. The co-occurrence of EA manifestations and the continuum of disordered eating-eating disorders (EDs) is so common in sports that a deeper understanding of them as comorbidities is warranted. The aim of this review is to provide an up-to-date overview and synthesis of the research on the relationship between maladaptive exercise and dysfunctional eating in the sport context. A systematic review was conducted following the PRISMA guidelines. A total of 22 empirical studies (23 articles) with young and adult female and male athletes from several sports and competition levels was included. EA in conjunction with eating disturbances is frequent among athletes, yet the prevalence rates are inconsistent. Existing evidence suggests that EA is a relevant outcome of ED pathology among athletes, supporting the classical secondary type of EA. However, research also reveals that excessive exercising plays a central role in the psychopathology of disordered eating. There is a need for further quantitative research addressing the features and correlates of the EA-EDs dyad, qualitative research on the subjective experiences of athletes with disordered exercise and eating, longitudinal and experimental research to establish possible causal paths and attempts to develop comprehensive conceptual models of EA and its co-occurrence with EDs, in order to improve the identification, prevention, and management of this dyadic condition in the sport context.

Development and Validation of the Eating Disorders Screen for Athletes (EDSA): A Brief Screening Tool for Male and Female Athletes

OBJECTIVES

To develop and validate the Eating Disorders Screen for Athletes (EDSA), a brief eating disorders screening tool for use in both male and female athletes.

METHODS

Data from Division I athletes at a Midwestern university (N=434) were used to conduct exploratory factor analysis (EFA) by gender. Data from athletes competing at various levels at universities across the United States (N=862) were then used to conduct confirmatory factor analysis (CFA) and receiver operator characteristic (ROC) curve analysis by gender. Athletes from a range of lean and non-lean sports were included. Gender-specific empirically derived cut-offs on the Eating Disorder Examination-Questionnaire were used to classify high eating disorder risk for ROC curve analysis. Measurement invariance by gender, level of competition, and sport type was also examined.

RESULTS

A six-item, one-factor structure for the EDSA was supported by EFA and CFA in both genders, and internal consistency was good for both male (α=. 80) and female athletes (α=.86). ROC curve analyses indicated that the EDSA was highly accurate in predicting eating disorder risk status and identified a score of 3.33 as the optimal cut-off for both male (sensitivity=.96, specificity=.80) and female athletes (sensitivity=.96, specificity=.64). Results also supported strong measurement invariance for the EDSA by gender, level of competition (Division I versus club), and sport type (lean versus non-lean).

CONCLUSIONS

The EDSA shows promise as a brief screening tool to identify male and female athletes at risk for eating disorders.

The Australian Institute of Sport (AIS) and National Eating Disorders Collaboration (NEDC) position statement on disordered eating in high performance sport

Identification, evaluation and management of disordered eating (DE) is complex. DE exists along the spectrum from optimised nutrition through to clinical eating disorders (EDs). Individual athletes can move back and forth along the spectrum of eating behaviour at any point in time over their career and within different stages of a training cycle. Athletes are more likely to present with DE than a clinical ED. Overall, there is a higher prevalence of DE and EDs in athletes compared with non-athletes. Additionally, athletes participating in aesthetic, gravitational and weight-class sports are at higher risk of DE and EDs than those in sports without these characteristics. The evaluation and management of DE requires a cohesive team of professional practitioners consisting of, at minimum, a doctor, a sports dietitian and a psychologist, termed within this statement as the core multidisciplinary team. The Australian Institute of Sport and the National Eating Disorders Collaboration have collaborated to provide this position statement, containing guidelines for athletes, coaches, support staff, clinicians and sporting organisations. The guidelines support the prevention and early identification of DE, and promote timely intervention to optimise nutrition for performance in a safe, supported, purposeful and individualised manner. This position statement is a call to action to all involved in sport to be aware of poor self-image and poor body image among athletes. The practical recommendations should guide the clinical management of DE in high performance sport.

Mental health in elite athletes: International Olympic Committee consensus statement (2019)

Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as evidenced by mental health symptoms and disorders increasing the risk of physical injury and delaying subsequent recovery. There are no evidence or consensus based guidelines for diagnosis and management of mental health symptoms and disorders in elite athletes. Diagnosis must differentiate character traits particular to elite athletes from psychosocial maladaptations.

Management strategies should address all contributors to mental health symptoms and consider biopsychosocial factors relevant to athletes to maximise benefit and minimise harm. Management must involve both treatment of affected individual athletes and optimising environments in which all elite athletes train and compete. To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.

Education, dissemination, and the science of eating disorders: Reflections on the 2019 International Conference on Eating Disorders: Editorial to accompany IJED Virtual Issue in honor of the 2019 International Conference on Eating Disorders

OBJECTIVE

This virtual issue of the International Journal of Eating Disorders highlights recently published research that aligns with the broad themes of the 2019 International Conference on Eating Disorders (ICED), held in New York, NY, USA.

METHODS AND RESULTS

We selected articles that were published between 2017 and 2019 that complement the content of the keynote and plenary sessions. We also curated additional articles from early career scholars, given that an important component of the annual ICED is to foster the development and training of the next generation of eating-disorder clinicians and researchers.

DISCUSSION

We hope that this virtual issue will spark more in-depth discussion and reflection on the topics, questions, and critical advances in the field of eating disorders that were presented at the 2019 ICED.

The Athletes' Relationships with Training scale (ART): A self-report measure of unhealthy training behaviors associated with eating disorders

OBJECTIVE

Several studies indicate that eating-disorder (ED) psychopathology is elevated in athletes compared to non-athletes. The assessment of excessive exercise among athletes is a challenge because, compared to non-athletes, athletes are required to train at higher intensities and for longer periods of time. However, individuals participating in competitive sports are still susceptible to unhealthy physical-activity patterns. Most ED assessments were developed and normed in non-athlete samples and, therefore, do not capture the nuances of athletes' training experiences. The purpose of the current study was to develop and validate a clinically useful, self-report measure of unhealthy training behaviors and beliefs in athletes, the Athletes' Relationships with Training Scale (ART).

METHOD

The initial item pool was administered to N = 267 women collegiate athletes who were participating in an ED prevention program study and N = 65 women athletes who were in ED treatment.

RESULTS

Factor analyses indicated the ART had a four-factor structure. Factorial and construct validity of the ART were demonstrated. ART scores significantly predicted health care utilization and differed between athletes with an ED versus athletes without an ED. For athletes in ED treatment, ART scores significantly decreased from treatment admission to discharge.

DISCUSSION

The ART showed evidence of strong psychometric properties and clinical utility. The ART could be helpful for clinicians and athletic trainers to help gauge whether athletes are engaging in unhealthy training practices that may warrant clinical attention and for tracking clinical outcomes in athletes with EDs who are receiving treatment.