Eating disorders or disordered eating amongst National Collegiate Athletic Association (NCAA) student-athletes is a cause for concern for universities, coaches, athletic trainers and most importantly the young men and women who are suffering from the pressures of being a student-athlete. As a result, many of these student-athletes have to seek guidance and counseling at an early time in their collegiate career. The purpose of this conceptual paper is to indicate the warning signs and symptoms of disordered eating assist in understanding the classification of such symptoms and to discuss the preventative measures to be taken to reduce the risk of eating disorders. Strategies for improving and assessing the current well0being of students-athletes and the different types of disordered eating are discussed.

Keywords: disordered eating, intercollegiate athletics, student-athlete, symptoms, mental disorders, eating practices, risk factors, diagnoses, anorexia nervosa, bulimia nervosa

NCAA, national collegiate athletic association; AN, anorexia nervosa; BN, bulimia nervosa; EDNOS, eating disorder not otherwise specified; BMI, body mass index

Intercollegiate student-athletes represent a unique, identifiable group of young men and women amongst a student population.¹ Intercollegiate athletic opportunities are beneficial to thousands of young adults wishing to continue their athletic endeavors and obtain a college degree. Benefits include but are not limited to the following: increase in self-esteem, body image, encouragement for physical activity, sense of belonging, goal setting, team organization and time management. However the culture of sports presents risk factors as well as protective factors regarding each student-athlete’s overall health.² Athletes can suffer from psychological and physical issues including stress, more specifically in today’s world; there is a high risk of student-athletes developing an eating disorder or disordered eating (disordered eating is categorized as unhealthy eating practices and behaviors that meet the symptoms for an eating disorder).³ The Diagnostic and Statistical Manual of Mental Disorders (1994) defines a clinical eating disorder to three diagnoses: (1) anorexia nervosa (AN), (2) bulimia nervosa (BN), and (3) eating disorder not otherwise specified (EDNOS). AN is referred to as involving a significant weight loss, leaving the individual at a Body Mass Index (BMI) of 17.5 or below, including a drive for being thin, body image distortion and loss of menses in women.² BN involves episodes of eating followed by self-inflicted vomiting or over-exercise and a negative body image.² And EDNOS is the largest diagnostic category consisting of a wide range of AN and BN symptoms, but has several indicators outside of the classification category.² It is essential for intercollegiate athletic departments and university employees to understand the basics of eating disorders and the potential risks associated with each issue. In each student-athlete handbook, there needs to be a wellness service model incorporated that aims to cultivate each student-athlete to enhance their overall college student awareness.¹ The following student-athlete wellness service model will create an overview and philosophy of dysfunctional eating and eating disorders incorporating goals, guidelines and a treatment and intervention protocol for an athletic department to adhere to. 

Guidelines within an athletic department

1. The department of athletics advocates health and wellness development for healthy responsible student-athletes with the primary goal of making each student-athlete aware of the potential risks and concerns about dysfunctional eating behaviors and disordered eating.
2. The department of athletics recognizes the signs and symptoms of dysfunctional eating and eating disorders to be a major issue in which many student-athletes across the country will meet at least once in their tenure as a student-athlete.
3. Intercollegiate student-athletes are at a higher risk of developing or producing patterns of unhealthy or disordered eating due to the demands and stress of their specific sport.
4. Disordered eating can have a mild to severe effect pending on the individual at risk of the disorder. Pre-college education will be essential to preventing disordered eating and any other eating disorders a student-athlete may come into contact with.³ There are two primary categories associated with disordered eating:
5. Medically – disordered eating can have a short-term or long-term effect on each student-athlete that can increase the risk of sport injuries or even fatality. All organs and muscles can be affected in the human body.
6. Psychologically – eating disorders can cause a person to have an increased risk of depression, low self-esteem, over-thinking, and self-destructive behaviors.
7. The University is responsible for the overall health and wellness of each of our student-athletes and will provide privacy, immediate care and counseling regarding each individual issue. 

Athletic department objectives

1. Implement an effective and efficient wellness service model in which the athletic departmental staff will assure the overall health and wellness of each individual student-athlete through knowledge of potential risks and issues associated with being a student-athlete.
2. The Athletic Departmental Wellness Team will be comprised of the entire Athletic Training Department as well as three athletic counselors available through the department of athletics.
3. Each member will provide any services to any student-athlete that is in need of physical or emotional distress. These members will provide knowledge, create dietary plans, workout routines, as well as diagnose and provide an adequate treatment plan if necessary concerning each individual’s privacy.

Diagnostic and statistical manual of mental disorders (1994)

1. Anorexia nervosa: Refusal to maintain a body weight at or above a minimally normal weight for student-athlete’s age and height. Intensified fear of gaining weight or becoming fat, even though the person is underweight. Disturbance in the bodily image of his/her own body, shape or evaluation.
2. Bulimia nervosa: Recurrent episodes of binge eating in which it is characterized by one or all of the following:

1. Eating in a discrete period of time (within any two hour period).
2. Lack of control in how much this person is eating.
3. Self-induced vomiting, misuse of diuretics, or excessive exercising.

3. Eating disorder not otherwise specified: this specific category is for eating disorders that do not specifically meet the criteria for the other two eating disorders. All of the criteria for anorexia nervosa except despite significant weight loss, the current weight is in normal range. All of the criteria met for bulimia nervosa except that binge eating and self-induced vomiting occurs at a frequency of less than twice a week or for three months.

Behavioral and physical signs of disordered eating⁴

Anorexia nervosa

Behavioral Signs

1. Avoidance of social eating situations.
2. Student-athlete reporting of feeling fat/heavy despite being normal or underweight.
3. Obsession with exercise and hyperactivity.
4. Constant need of perfectionism or lack of self-esteem when he/she does not finish first.
5. Anxiety and/or depression concerning athletic events.
6. Decline in athletic and academic performance due to physical or emotional declination.

Physical Signs

1. Amenorrhea (lack of menstrual periods).
2. Dehydration.
3. Fatigue.
4. Stress Fracture – Injuries associated with fragile bones/muscles.
5. Weakness and/or dizziness.
6. Hypotension (Low blood pressure).

Bulimia nervosa

1. Behavioral signs
2. Excessive exercise beyond practices.
3. Depression and mood fluctuations.
4. Low self-esteem.
5. Drug and/or alcohol abuse.
6. Binges or eats large meals, then disappears.

Physical Signs

1. Callous on knuckles.
2. Dental or gum issues including poor breath.
3. Red puffy eyes.
4. Frequent sore throats.
5. Low weight despite eating large amounts of food.
6. Muscle cramps and/or weakness in muscles and body.
7. Electrolyte abnormalities.
8. Swollen parotid glands (base of jaw).

High-risk athletes and athletic teams

All student-athletes are at risk to engage in dysfunctional eating; however the following teams and athletes on each team are more at risk due to the demands and body level needed for elite competition:

1. Cheerleading
2. Rowing
3. Gymnastics
4. Swimming and Diving
5. Track and Field
6. Tennis
7. Cross Country
8. Volleyball
9. Women’s Basketball
10. Women’s Soccer
11. Wrestling
12. Softball
13. Women’s Lacrosse 

Prevention of eating disorders

1. Preventative nutritional and psychological education sessions will be provided for all student-athletes in an orientation meeting as advised with the student-athlete handbook.
2. State University athletic teams that are considered to be at “high risk” for potential eating disorders will receive further informational knowledge sessions for eating disorders: swimming and diving, track and field, cross country, gymnastics and wrestling.
3. State University Athletic Training staff and athletic counselors will have completed all training courses essential to identifying disordered eating and services for counseling student-athletes suffering from a dysfunctional eating disorder.
4. Coaches will be encouraged to initiate nutritional and body image education throughout the year while utilizing resources from the State University Wellness Team.
5. Any concerns by coaches or athletic personnel shall be reported to the team physician and/or athletic training office. 

Treatment and management

The University and Athletic Department has established a Wellness Team to provide help for individuals who have identified themselves or have been identified by others as having disordered eating. The team is available 24/7 to assist any and all individuals for treatment and guidance. 

Referral

Reasonable Suspicion: An athletic trainer and/or coach having a strong suspicion that an athlete may have a disordered eating condition. This theory shall be based but not limited to the following:

1. Behavioral patterns observed on road trips by the head coach or athletic trainer in which student-athlete makes frequent trips to the bathroom during or following team meals or an athlete who does not eat during meals.
2. Teammates expression of concerns regarding an individual including frequent bathroom trips, excessive exercise, and not eating throughout the day.
3. Over-obsession with not wanting to gain weight or get fat or the need to exercise. 

Athletic admission

Athlete admits concerns of disordered eating to a coach, athletic trainer or teammate. Athlete has been receiving treatment either by physician, counselor or dietician. 

Protocol for concerns

1. Sport coaches and/or teammates shall report all concerns about the student-athlete in question to the Athletic Trainer in charge of the sport.
2. Athletic Trainer or professional who has a comfortable rapport with the student-athlete will share the observations and concerns with the student-athlete in a caring and non-threatening manner.
3. A teammate may also be present that is close to the student-athlete sharing his/her concerns directly with the student-athlete.
4. Any referrals, if necessary, can and will be made to the appropriate parties and personnel needed to maintain a healthy lifestyle. 

Authorization of health information

1. An authorization of disclosure of health information for coordination of services must be signed by the student-athlete in order for the Wellness Team and any other individual to discuss treatment of disordered eating.
2. Members of the Wellness Team will collaborate and develop a treatment plan for student-athlete with a monitoring system in place provided by head coach, teammate and regular check-ins with the team trainer.
3. Student-athlete suffering from disordered eating will meet with team trainer and Wellness Team (if necessary) daily to monitor treatment compliance until the issue is resolved.
4. If condition is more severe: a more restrictive treatment setting will be necessary to monitor student-athlete.
5. If the student-athlete resists treatment, the following may need to be considered: Suspension from athletic activities; and formulation of rehabilitation services.
6. All student-athletes suspected of or suffering from disordered eating must be able to comply with treatment recommendations so that he/she will be medically able to participate in his/her sport as would be required for injury or illness.
7. Student-athlete will be cleared by following all treatment guidelines and satisfaction is mandated by the team physician and Wellness personnel.
8. Parental contact will only be allowed per approval by student-athletes signature on parent contact authorization form.

To apply an effective and accessible approach to prevention, identification and treatment of student-athlete disordered eating. State University Athletic Department has established a Wellness Team to provide help for any individual who have identified or have been identified by others as having disordered eating. The team is comprised of multiple individuals in counseling and athletic training to assist student-athletes with a treatment plan for disordered eating. To diagnose and provide a personal treatment plan for student-athletes suffering from symptoms and/or disordered eating. The University’s Wellness Service Model must be incorporated into the Student-Athlete Handbook for all student-athletes and athletic departmental staff to be aware of. The service model will serves as a protocol and preventable source for possible eating disorders within athletics. Assistance of any and all student-athletes will be readily available to advise and prepare adequate treatment plans for disordered eating. The sooner these student-athletes are educated regarding potential risks and issues, especially with disordered eating, the sooner each student-athlete and/or personnel will recognize a problem. Student-athletes are at a greater risk than non-athletes for various eating disorders; athletes not only struggle with the same social pressures but athletes foster a sense of body image and ability for their bodies to perform at a high level.⁵ The NCAA Sports Medicine Handbook⁶ has indicated in its studies, that it is the responsibility of each NCAA member institution to protect the well-being of student-athletes by providing a safe and healthy environment. State University and the Student-Athlete Wellness Service Model will provide awareness for all student-athletes and athletic departmental staff regarding the potential risk of disordered eating.⁷

None.

The auhtor declares there is no conflicts of interest.

1. Watson JC, Kissinger DB. Athletic participation and wellness: Implications for counseling college student-athletes. 2007.
2. Etzel EF, Carter JE. Counseling and psychological services for college student-athletes. 2009.
3. Etzel EF, Watson JC, Visek AJ, et al. Understanding and promoting college student athlete health: Essential issues for student affairs professionals. 2006. p. 1–29.
4. Voelker DK. Weight pressures: What coaches need to know? Game Plans: Coaching Advancement Program Newsletter. 2012;8(5):2–3.
5. Hellmich N. Athletes’ hunger to win fuels eating disorders. USA Today. 2006.
6. NCAA Sports Medicine Handbook. National Collegiate Athletic Association. 2014.
7. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edition. Washington DC. 1994. p. 1–915.