Eating disorders in male elite athletes

Halioua Robin^1*, Karrer Yannis^1*, Seifritz Erich¹, Claussen Malte Christian^1,2,3
1 Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry Zurich, Zurich, Switzerland
² Private Clinic Wyss AG, Münchenbuchsee, Switzerland
³ Psychiatric Services Grisons, Chur, Switzerland

* Shared autorship

Among elite athletes disordered eating (DE) behavior as well as eating disorders (ED) are one of the most common mental illnesses. According to Sundgot-Borgen et al. [1] DE can be illustrated by a continuum ranging from performance-oriented eating and exercise behaviors to subclinical EDs and clinical EDs such as Anorexia nervosa (AN) and Bulimia nervosa (BN) along with other medical complications and impairment of performance.
While there are several studies involving female elite athletes, male elite athletes suffering from DE have been largely ignored in the last decades. This may have several reasons. Firstly, eating disorders may still be considered a female problem, and secondly the prevalence of DE of male elite athletes is rather low compared to the prevalence of female elite athletes. This is of concern as male elite athletes seem to have a much higher rate of DE compared to the general population [2,3,4]. Existing literature shows high rates of pathological eating behaviors in male elite athletes with prevalence rates of clinical eating disorders up to 32.5% [2,3,4].
There are several factors, that seem to contribute to the development of DE in male elite athletes. Thompson et al [5] argued that personality traits needed to be a good athlete are similar to those found in anorexic patients. However, the sporting environment itself should also be considered a potential risk factor [6]. The evidence supports an association between performance pressure and disordered eating as higher levels of competition have been associated with more DE symptoms [7,8] and more aggressive weight loss behavior [8]. As with female athletes, participation in leanness sports in male athletes is associated with higher pressure to be lean [3], higher drive for thinness [3], higher level of dietary constraint [3], higher engagement in bulimic behaviors [3] and higher prevalence of disordered eating [1,3]. In contrast to female elite athletes, male elite athletes seem to report less body dissatisfaction even when gender neutral or male specific questionnaires are used [7,9,10]. The reason why male elite athletes are more likely to be satisfied with their bodies than female elite athletes may be the closer embodiment of the western sociocultural ideal as a result of the intensive training. Nevertheless, body dissatisfactions also seem to affect disordered eating in male elite athletes, but current findings are mixed.
In 2014, the International Olympic Committee presented a consensus statement on the Relative Energy Deficiency in Sport (RED-S), which was intended to provide a broader understanding of a syndrome that was formerly known as female athlete triad. As it also affects male athletes, the term RED-S is more comprehensive. The etiological factor of RED-S is a low energy availability, an relative energy deficiency between dietary energy intake and energy expenditure in exercise to support homeostasis, health, growth and sporting activities [6]. Since male athletes show no diagnostic hallmarks such as amenorrhea, special attention should be paid to the occurrence of signs and symptoms of RED-S [3,4].
At present, there are no validated questionnaires for the assessment of disordered eating or RED-S in male elite athletes. There is also no evidence-based approach for the management of disordered eating in male elite athletes and data concerning the prognosis are missing completely. Future research should address these gaps in knowledge.

Corresponding authors

Robin Halioua
Department of Psychiatry,
Psychotherapy and Psychosomatics,
University Hospital of Psychiatry Zurich,
Zurich, Switzerland
robin.halioua@pukzh.ch

Yannis Karrer
Department of Psychiatry,
Psychotherapy and Psychosomatics,
University Hospital of Psychiatry Zurich,
Zurich, Switzerland
yannis.karrer@uzh.ch

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