Eating disorders are affecting female athletes and there is a need to educate coaching staffs and athletic trainers in the processes of prevention, detection, and management of the disordered eating in female athletes. The incidence of eating disorders varies widely, but the conditions continue to increase in female athletics. Bonci et al. (2008) [1] estimated that 35% of female athletes were at risk for anorexia nervosa and 38% were at risk for bulimia nervosa. Byrne and McLean estimated that 31% of elite females in "thin-build" sports had clinical eating disorders, compared to the 5.5% of the mainstream population. Sundot-Borgen and Torstveit estimated that 25% of female elite athletes in endurance sports, aesthetic sports, and weight-class sports had clinical eating disorders. These numbers are compared to 9% of the general population.

Dancers had the higher rates of eating disorders. These athletes were more preoccupied with thoughts of eating and body image than non-athletes and non-dancers. Female collegiate dancers are not only at risk because of their participation in dance but also because they are college students (Carter & Rudd 2005) [2]. College women are more likely to develop disordered eating than other age groups because of the increased pressure and competition to succeed associated with the college environment. These females are in a new atmosphere, away from home, and these factors may amplify the risks. The sports that have the highest number of eating disorder were ballet, gymnastics, and cheerleading (Torres-McGehee et al. 2009) [4]. The two most common eating disorders are anorexia and bulimia nervosa. "These eating disorders are complicated by dysfunction of multiple physiologic systems, nutritional deficiencies, and psychiatric diagnoses.

Anorexia nervosa is distinguished as the extreme of food restricting behaviors and is manifested as a refusal to maintain normal body weight for age and height. Bulimia anorexia refers to a cycle of food restriction or fasting followed by binging and purging. Both of these disorders are characterized by body weight preoccupation, excessive self-evaluation of weight and shape, and an illusion of control gained by manipulating weight and dietary intake. These commonalities show us why 50% of patients with anorexia nervosa develop bulimic symptoms and some patients who start out as a bulimic develop anorexic symptoms as well" (Bonci et al. 2008) [1].

Recognizing and Preventing Eating Disorders

There are two ways to identify if a woman has an eating disorder. "The first one would be psychological and behavioral characteristics, some examples would be: dieting, self-critical- specifically concerning body weight, size and shape in addition to performance." (Bonci et al. 2008 Table 4.) [1] "The other way to detect an eating disorder is physical signs and symptoms, some of those examples would be: dehydration, hypotension, stress fractures, dental decay, hair loss, dry skin, brittle hair and nails, fatigue and abdominal pain." (Bonci et al. 2008 Table 4.) [1] "According to NCAA Bylaw 17.1.5 ("Mandatory Medical Examination"), prior to participation in any practice, competition or out-of-season conditioning activities, student-athletes who are beginning their initial season of eligibility shall be required to undergo a medical examination or evaluation administered or supervised by a physician."(Torres-McGehee et al. 2009 p. 7) [4]

An additional way to prevent eating disorders in female athletes involves education athletes about eating disorders. "Every year there should be mandatory programs for the athletes, coaches, certified athletic trainers, and other athletic staff members. Some of the common questions that should be known are: Who is at risk? What are the barriers to identifying problems at an early stage? What are the signs, symptoms, and medical complications? What are the medical and performance consequences? What resources are available to help symptomatic athletes? How is treatment accessed? How should certified athletic trainers, coaches, teammates, and CSOs respond to an athlete suspected of having an eating disorder? What are the best preventive measures?

Athletes need to be educated on the importance of optimal nutrition to reduce the risk of medical and performance problems associated with prolonged energy and nutrient deprivation. Athletes also need education related to health and performance consequences of menstrual irregularities and the importance of seeking timely medical intervention at the first sign of abnormalities. The educational program should be evaluated routinely to determine the program's effectiveness in changing the knowledge level, attitudes, and behaviors of athletes as well as those participating in their health maintenance and performance enhancement."(Bonci et al. 2008 p. 7) [1]"Anorexia nervosa has the highest mortality rate of any psychiatric illness, estimated at 10% within 10 years of diagnosis. First is cardiac arrest, starvation, other medical complications and suicide, the secondary risk is death.

In bulimia nervosa the mortality rate is lower; approximately 1% within 10 years of diagnosis. Nevertheless, the stats may be deceiving, as patients frequently move between diagnostic categories over the course of their illness. As previously mentioned 50% of patients with anorexia develop bulimic symptoms but still have the primary diagnosis of anorexia." (Bonci et al. 2008 p. 9) [1] Malnutrition is an unbalanced diet or poor nutrition. "Malnutrition decreases metabolic rate and causes abnormalities in the cardiovascular, reproductive, skeletal, thermoregulatory, gastrointestinal, and other systems. In the end these abnormalities can be very dangerous and problematic for athletes who continue to train intensively in an energy-deficient or nutrient-deficient state." (Bonci et al. 2008 p. 9) [1]

Detecting Eating Disorders

In order to assist female athletes who may be at risk for eating disorders early detection is important especially eating disorders such as anorexia and bulimia. Self reporting of eating disorders is rare among athletes due to secrecy, shame, denial, and fear of punishment; early detection requires the development and implementation of a confidential and accessible screening program. One screening method is the Pre-participation Physical Examination. The PPE provides clinicians an opportunity to screen for eating and body weight disturbances.

Other screening processes include medical history questionnaires which are a sensitive and productive screening tool. This questionnaire gathers useful medical history such as dietary restraint, body weight fluctuations, weight control behaviors, body weight and shape satisfaction or dissatisfaction, nutritional beliefs and practices, typical eating patterns, exercise habits, and musculoskeletal injuries with special references to stress injuries involving bones.

In female athletes, additional questions are necessary to screen for menstrual dysfunction. These questions include age of menarche, length and frequency (number of cycles per year) of periods, regularity of periods since menarche, date of last menstrual period, amount of flow, frequency and duration of amenorrhea, and use of oral contraceptive. (Bonci et al. 2008 p. 12) [1]

Managing Eating Disorders

Once the athlete is absorbed by disordered eating most of them are not able overcome the problem alone. The female may think that this is the way to make life easier when in fact it is not. At this stage in the development of the eating problem they will need assistance from people close to them to overcome the eating problem. "The first process in overcoming an eating disorder is that the initial contact should come from an authority figure, someone that the athletes knows and trusts to ensure that the intervention is facilitated with sensitivity and compassion. There should be NO criticism at all. Once it is confirmed the next step is to get a detailed medical history review and physical examination. After all of the tests and labs the health care team will be able to figure out what the appropriate place for treatment will be and to make sure best possible management for the athlete will be." (Bonci et al. 2008 p. 15) [1] It is easier for someone to accept help for a condition if they know the person, are able to trust them, and know that the person who is helping has expertise related to the eating disorder(s).

During this process the female athletes may feel like everyone is against them. This is why they are driven to eating disorders which are a 'quick' fix. The three factors that may contribute to eating disorders include genetics, social, and psychological problems. Psychological problems include: low self esteem, lack of self control, depression, anxiety, loneliness, anger, or history of abuse, whether it is physical or emotional. Social factors include: that our present culture believes that the 'perfect body' is thin and that people focus on the outer appearance of other's instead of the inner qualities. The third factor is genetics which deals with family history.

Conclusions

Eating disorders are causing problems in lives of female athletes. The pressure to be thin and athletic may be burden for many women athletes. These factors may cause them to participate in binging or purging to maintain or lose weight. Anorexia and Bulimia are two of the most prevalent types of eating disorders. These disorders are serious diseases that may severely damage female bodies or even cause death. Eating disorders are very complex and complicated conditions that may start from various causes. Once eating disorders becomes a habit the disorder takes over the person's life which may create a self-effecting cycle of physical or emotional damage.