Bulimia nervosa is a prevalent eating disorder seen in both athletic and non-athletic populations. The primary characteristic include cycles of uncontrollable eating followed by periods of purging which may include self-induced vomiting, and the use of laxatives, diuretics, and compulsive exercising to rid the body of the excess calories.
Although individuals suffering from bulimia have the same desire to be thin as those suffering from anorexia nervosa ,there are differences between the two. One of the main differences is that an individual suffering from anorexia nervosa consumes very limited calories whereas the individual suffering from bulimia nervosa may consume as many as 5000kcal in one sitting (Beals, K., 2004).
It isn’t that the individual with bulimia does not want to be thin by controlling her diet. In fact after a binge cycle, the individual may go several days with only limited food or fasting because of the guilt felt from the binge eating. Whereas the individual with anorexia nervosa has extreme discipline to severely restrict her caloric intake, the individual with bulimia will eventually give in to her hunger.
However, instead of eating a normal portion of food at this point, the individual may lose control of her eating. Rather than stopping at a regular portion size of food, this individual may continue to eat actually consuming multiple meals over several hours.
The amount of food consumed may fluctuate greatly throughout the day with the individual reducing portions during the day only to lose control late at night and engage in binging behavior. Because of this fluctuation in food intake day to day and week to week, an athlete with bulimia nervosa may actually look like she is within a normal weight range.
It is because athletes with bulimia nervosa may resemble healthy athletes in weight and in their activity levels; these athletes have the ability to more easily disguise their eating disorder. In fact, one behavior that differentiates non-athletic individuals with bulimia from athletes with bulimia is the athlete’s use of exercise as the predominant purging method (Beals, K., 2004).
Because excessive exercise is a normative behavior in competitive athletes, exercising as a way for athletes with bulimia to burn excess calories fits in to the normal athlete profile. Unfortunately, this is another way for athletes to keep their eating disorder hidden and much more difficult for coaches and sports medicine professionals to identify these individuals.
Factors that may Contribute to Eating Disorders in Athletes
So just what might be the factors in sport that may drive, precipitate, or encourage disordered eating behaviors in athletes? According to Ray, R. & Wiese-Bjornstal, D.M., (1999) there are multiple factors that may be involved including:
• Weight restrictions either by sport or by coach
• Judging criteria that emphasize thin and stereotypically attractive body builds
• Performance demands that encourage very low percentage body fat
• Coaches applying pressure to lose weight
• Peer pressure to try pathogenic weight loss techniques
For female athletes, the message that a lean body correlates to improved performance seems to be one of the driving forces that may start an athlete on the cycle of losing weight. Whether the message is correct or not becomes irrelevant. The only significant perception is what the athlete believes to be correct. One comment by a coach that an athlete needs to lose weight can start an athlete on a dangerous path.
Even if a coach does not apply pressure to a female athlete to lose weight, sometimes the sport itself will apply the pressure. For example, there are a group of sports known as “thin-build” sports. These are sports in which low body weight is thought to give a competitive edge to the performer (Beals, K.A., 2004).
These include sports in which the performer is judged as in gymnastics, diving, figure skating and competitive cheerleading as well as sports in which a low body weight is thought to provide an edge to the performer as in distance running, swimming, and cross-country skiing. In these sports, athletes may apply pressure to themselves to reduce weight for either appearance or performance.
Although there are healthy and safe ways to lose weight, these methods take time and may take weeks to accomplish. Unfortunately, individuals who are told to lose weight or who believe they need to lose weight to improve performance may opt for quicker unhealthier methods.
For the athlete with bulimia nervosa, the behaviors may include restricting calories to the point where the hunger drives the individual back to eating. However, whereas most people are able to stop when they have a feeling of fullness, these individuals are unable to stop the eating frenzy. Out of control overeating is one pathological behavior of an individual with bulimia nervosa.
To counteract the excess calories, the individual then participates in more dangerous weight loss behaviors to rid the body of the excess food so that it is not stored as fat. This is how the individual with bulimia can manage to have a normal weight range regardless of the eating disorder.
Does Losing Body Weight Enhance Performance?
The problem for many athletes is that many coaches and athletes believe that weight loss is directly correlated to improved performance. This has yet to be proven for specific sports.
Because weight charts are not a reliable and/or accurate source for determining an athlete’s healthy weight, sports medicine professionals will opt for measuring the athlete’s body fat percentage. Body fat is a component of overall body composition. The body’s composition can be divided between lean tissue (muscle, water, bone) and fat tissue.
It is critical that coaches and athletes understand the difference between scale weight and body fat percentage. If an athlete is concerned about her scale weight, she needs to get her body fat percentage measured. If it is in a healthy range, she needs to be counseled to not drop additional weight.
If the athlete is insistent that she still needs to drop weight, she needs to be counseled as to the physiological risks of dropping more weight, and determine what the driving force is behind her desire to lose weight (i.e., coach’s comment, poor self-image, peer pressure). If she may be at risk for an eating disorder or if an eating disorder is already suspected, she needs to be referred to an experienced counselor.
If the athlete’s body fat is in a higher than average range, then she should be counseled as to how to safely and effectively lose body fat without losing muscle mass in the process. Learning how to safely lose weight is an important step in the process of healthy weight loss that may be missing when comments are made to athletes about losing weight.
Psychological and Behavioral Characteristics of Athletes with Bulimia Nervosa
What is unique about the athlete with bulimia nervosa is her relationship with food. Whereas an individual with anorexia nervosa sees food as the enemy, the athlete with bulimia nervosa may actually have a conflicted relationship with food. On the one hand, the individual loves and may be obsessed with eating large portions of food. But on the other hand, the individual hates the food she has consumed because she has not been able to control her food consumption.
A number of psychological and behavioral characteristics have been identified in athletes with bulimia nervosa including (Thompson, R.A. & Trattner Sherman, R., 1993):
• Binge eating
• Fear of being discovered
• Agitation when bingeing is interrupted
• Dieting that is unnecessary for appearance, health, or sport performance
• Evidence of vomiting unrelated to illness
• Excessive exercise beyond that required for the athlete’s sport
• Excessive use of the restroom
• Going to the restroom or “disappearing” after eating
• Self-critical, especially concerning body, weight, and sport performance
• Secretive eating
• Stealing (food, laxatives)
• Substance abuse (whether legal, illegal, prescribed, or over-the-counter drugs or medications
• Use of laxatives, diuretics, or both that are not prescribed by a physician
According to Beals, K. (2004) the bingeing actually leaves the athlete feeling anxious and ashamed. In order to rid herself of the emotional feelings of the binge eating, the athlete will then purge herself of the excessive food. The purging then relieves the athlete of the guilt and shame of overeating thus completing the binge-purge cycle.
After the purging, the athlete may then reset her goals with a determination to control her portion sizes to avoid the endless cycle. However, the obsession with losing weight may take over and rather than opting for the behaviors of a healthy weight loss plan, the athlete may be overtaken once again by pathological disordered eating behaviors which starts the cycle all over again.
Fear of Being Discovered
Fear is an emotion that is central to the athlete suffering from bulimia nervosa. The athlete may choose to skip meals with her teammates out of fear that she may not be able to control her food consumption in their presence. The paralyzing fear that accompanies this athlete may actually drive her to other disordered eating behaviors.
Eventually hunger will overtake the athlete (usually late at night) and the athlete may choose to eat. Although the athlete’s initial goal may be to eat a normal portion of food, the eating disorder may take over and the athlete may not be able to control the amount consumed.
For example, the athlete may choose to go out at night (always alone) to a fast food restaurant to get a meal. However, rather than just getting food at one restaurant, the athlete may quickly consume the food and then drive to a second, third, and possibly fourth. The out-of-control consumption of food is done alone and in secret.
It is the fear of losing control that can be really difficult for an athlete with bulimia especially when the athlete is travelling with their team on a road trip (overnight trips). When on road trips, athletic teams typically dine together as a group in restaurants for each meal. This group setting can create an incredible amount of stress for an athlete with bulimia.
Not only is controlling portion size difficult, the athlete also has the added challenge of how to purge the food after eating without being noticed. Frequent bathroom trips after eating tend to get noticed by teammates and coaches.
Additional stress is placed on the athlete at night because athletes are typically grouped together in hotel rooms where bathrooms are shared. For an athlete whose choice of purging is self-induced vomiting, this type of environment can make the athlete even more anxious.
Physical Symptoms of Athletes with Bulimia Nervosa
Many of the physical symptoms that an athlete with bulimia nervosa may experience are related to either malnutrition (during possible starvation times) and to the effects of purging. These symptoms may include the following (Thompson, R.A. & Trattner Sherman, R., 1993):
• Callus or abrasion on the back of the hand from inducing vomiting
• Dental and gum problems
• Edema, complaints of bloating
• Electrolyte abnormalities
• Muscle cramping associated with dehydration
• Frequent weight fluctuations with associated mood changes including irritability
• Gastrointestinal problems
• Menstrual irregularity
• Low weight despite eating large volumes of food
• Swollen parotid glands
For the athlete who chooses self-induced vomiting as her method of purging, a number of physiological effects occur. First is the large amount of fluid that is lost during vomiting that may lead to dehydration and electrolyte imbalances. It is these imbalances that can bring on muscle cramping in the extremities.
Esophageal irritation, perforation, and esophageal and stomach ulcers are also possible side effects of self-induced vomiting due to the acidic nature of the stomach acid that is moved through the esophagus during vomiting. The stomach acid also has an effect on teeth and may cause erosion of tooth enamel.
Last, calluses and/or abrasions may be present on the back of the fingers and/or hand. This occurs from the scraping of teeth on the back of the fingers/hand while the athlete attempts to trigger her own gag reflex.
If the athlete combines starvation with bingeing, the athlete may also suffer from a loss of lean muscle mass, decrease in metabolic rate (due to the loss in muscle mass), and reduction in bone mineral density. All of these physiological effects can take a toll on the athlete’s body as well as her ability to perform.
There is also research that indicates that athletes who are undernourished are at increased rate for injury and have longer recovery times (Beals, K., 2004). If the athlete chooses excessive exercise as a method of ridding her body of excessive calories, the athlete may put herself at further risk for a number of overuse injuries including tendinitis, stress fractures, and muscle strains.
Understanding how to recognize an athlete with a possible eating disorder or disordered eating is important information for all coaches and those working with athletes to understand. Because the physiological and mental effects of an eating disorder can be so destructive on both the health and performance of the athlete, immediate referral and medical treatment are necessary to treat the disorder and bring the athlete back to full health.
Beals, K.A. (2004). Disordered Eating Among Athletes: A Comprehensive Guide for Health Professionals. Human Kinetics: Champaign, IL.
Ray, R. & Wiese-Bjornstal, D.M. (1999). Counseling in Sports Medicine. Human Kinetics: Champaign, IL.
Thompson, R.A. & Trattner Sherman, R. (1993). Helping Athletes with Eating Disorders. Human Kinetics: Champaign, IL.