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A SYSTEMATIC REVIEW OF EATING DISORDER PREVENTION

AND PREVENTATIVE PROTOCOLS FOR ELITE FEMALE ATHLETES

IN INDIVIDUAL SPORTS

An Applied Doctoral Project submitted

TAYLOR LARSEN

February 2022

UNIVERSITY OF ARIZONA GLOBAL CAMPUS

Upon the recommendation of the Faculty and the approval of the Board of Trustees, this

Applied Doctoral Project is hereby accepted in partial fulfillment of the requirements for the

degree of

DOCTOR OF PSYCHOLOGY

Approved by:

_________________________________________

Todd D. Fiore, PhD

Committee Chair

Committee Member:

Heather Pederson, EdD

Taylor Larsen

2022

iii

A Systematic Review of Eating Disorder Prevention and Preventative Protocols for Elite

Female Athletes in Individual Sports

Taylor Larsen

Abstract

Female athletes are at a great risk of developing an eating disorder due several risk factors.

The purpose of this systematic literature review was to explore what sport psychology

preventative interventions are effective for eating disorders within elite female individual-

sport athletes, and to create best-practice recommendations for preventing eating disorders

within this population. This project synthesized and analyzed literature related to preventing

eating disorders among the elite female individual sport population, and determined which

interventions were most effective and why. The results indicated sport psychology

interventions such as athlete modified healthy weight focus interventions (AM-HWI) and

athlete modified cognitive-behavioral-dissonance-based interventions (AM-CBT) were most

effective at preventing eating disorders. Findings also suggested that interventions such as

providing prevention education to coaching staff and athletes were also effective with

prevention. The findings were integrated into a pamphlet that can be distributed to coaches

and practitioners with the purpose of educating elite coaching staff and peers on the warning

signs, risk factors, and ways to assist athletes with eating disorders.

Keywords: eating disorders, eating disorders among athletes, prevention of eating

disorders, prevention of eating disorders among athletes

Acknowledgments

To my husband, who is my best friend and greatest support, thank you for

continuously supporting me and believing in me when I did not. You have helped me learn

what that I am capable of anything if I put my mind to it. Your unwavering support and love

have kept me motivated throughout this whole process. To my family, thank you for pushing

me to do and be better. To my chair, Dr. Todd Fiore, for his consistent support and

understanding. I could not have finished this project if it was not for you pushing me,

keeping me laughing, reminding me of my writing skills, and calming my overthinking. I

have yet to meet anyone who has your nuanced ability to push someone while also remaining

so supportive. To my committee member, Dr. Heather Pederson for all your contributions in

helping to make this project successful. Thank you to all the professors, peers, friends, and

family members that have encouraged me along the way.

Dedication

To my father, who has recently passed away and unfortunately will not get to read

this. Thanks for always inspiring and believing in me. Your incredible work ethic has been

my model for working hard and remaining dedicated this this project.

TABLE OF CONTENTS

CHAPTER I: INTRODUCTION ................................................................................ 10

GENERAL STATEMENT ............................................................................................. 11

JUSTIFICATION STATEMENT ..................................................................................... 12

PURPOSE OF THE PROJECT ........................................................................................ 13

IMPORTANCE OF THE PROJECT ................................................................................. 14

CONCEPTUAL FRAMEWORK ..................................................................................... 15

Rise in Female Sport Participation ..................................................................... 16

General Risk Factors for Eating Disorders ......................................................... 17

The Concept of Prevention Science .................................................................... 19

OVERVIEW OF THE PROJECT APPROACH .................................................................. 19

PROJECT QUESTIONS ................................................................................................ 21

DEFINITION OF TERMS ............................................................................................. 21

ASSUMPTIONS, LIMITATIONS, AND DELIMITATIONS ................................................. 24

Assumptions ........................................................................................................ 24

Limitations .......................................................................................................... 25

Delimitations ....................................................................................................... 25

SUMMARY ................................................................................................................ 26

CHAPTER II: REVIEW OF THE LITERATURE ................................................... 27

SEARCH STRATEGY .................................................................................................. 27

Summary of Sources ........................................................................................... 29

EATING DISORDERS ................................................................................................. 29

Historical Examples of Eating Disorders ............................................................ 30

Diagnostic History of Eating Disorders .............................................................. 32

Common Medical Complications of Eating Disorders ....................................... 33

Common Behavioral and Psychological Characteristics of Eating Disorders .... 37

Prevalence Rates and High-Risk Populations ..................................................... 41

Eating Disorders Among Athletes ...................................................................... 42

Athlete Risk Factors ............................................................................................ 43

Athlete Health and Performance Concerns ......................................................... 45

Highest-Risk Athletes ......................................................................................... 48

Elite Female Individual Sport Athlete Risk Factors Leading to the Need for

Prevention ....................................................................................................................... 48

Sport Psychologists Addressing the Need for Prevention .................................. 49

WOMEN’S PARTICIPATION IN SPORTS ...................................................................... 51

History of Title IX and Growth of Women’s Sports .......................................... 52

Impact of Women in Athletics ............................................................................ 53

Implications of Growth in Women’s Sports ....................................................... 53

PREVENTION SCIENCE FRAMEWORK ........................................................................ 55

Classification of Prevention ................................................................................ 55

Prevention Science and Eating Disorders ........................................................... 57

High-Risk Population.......................................................................................... 59

Elite Female Individual-Sport Athletes and Prevention Science ........................ 60

KNOWLEDGE GAPS .................................................................................................. 60

Lack of Studies on High-Risk Female Athletes and Prevention ......................... 61

Prevalence Rates ................................................................................................. 62

SUMMARY ................................................................................................................ 63

CHAPTER III: PROJECT APPROACH .................................................................... 65

PROJECT APPROACH ................................................................................................ 65

OVER-ARCHING RESEARCH QUESTIONS ................................................................... 66

POPULATION AND SAMPLE ....................................................................................... 66

ETHICAL CONCERNS ................................................................................................ 67

LITERATURE COLLECTION ....................................................................................... 68

INCLUSION CRITERIA ............................................................................................... 69

EXCLUSION CRITERIA .............................................................................................. 69

ANALYSIS OF LITERATURE ....................................................................................... 70

TRUSTWORTHINESS AND QUALITY OF RESULTS ....................................................... 71

SUMMARY ................................................................................................................ 71

CHAPTER IV: FINDINGS AND RECOMMENDATIONS ..................................... 73

FINDINGS ................................................................................................................. 73

Sample................................................................................................................. 74

Literature/Sample Collection .............................................................................. 75

Data Collection ................................................................................................... 83

EVALUATION OF FINDINGS ....................................................................................... 85

Themes ................................................................................................................ 86

ADDRESSING OVER-ARCHING RESEARCH QUESTIONS ............................................. 92

Which Eating Disorder Prevention Interventions Have Been Effective for Sport

Psychologists Working with the Athletic Population? ................................................... 93

Why are These Interventions Effective? ............................................................. 94

DISCUSSION OF FINDINGS ........................................................................................ 96

Overall Suggestions for Preventing Eating Disorders Among Athletes ............. 96

Unexpected Findings .......................................................................................... 97

Importance of Findings for Research and Practice ............................................. 98

RECOMMENDATIONS .............................................................................................. 100

Limitations of the Study.................................................................................... 101

Implications for Practice ................................................................................... 103

Recommendations for Future Research ............................................................ 104

CONCLUSION .......................................................................................................... 105

APPENDIX- EATING DISORDER PREVENTION EDUCATION FOR ATHLETES AND

COACHING STAFF .............................................................................................................. 106

APPENDIX (CONT.) - EATING DISORDER PREVENTION EDUCATION FOR ATHLETES

AND COACHING STAFF ....................................................................................................... 108

REFERENCES .......................................................................................................... 109

CHAPTER I: INTRODUCTION

Eating disorders have been identified as the most severe mental illness due to high

rates of morbidity and mortality (Bar et al., 2016; Conviser et al., 2018; Fewell et al., 2018).

The lifetime prevalence rate of eating disorders among athletes has shown to be as high as

three times the lifetime rate of eating disorders among non-athletes (Fewell et al., 2018).

There are several beliefs regarding why the prevalence rate is much higher in the athletic

population. Researchers have indicated multiple risk factors play a role in athletes developing

eating disorders (Coelho, 2014; De Bruin & Oudejans, 2018; Frogley et al., 2018). These risk

factors include: (a) personality characteristics, (b) an emphasis on body type in relation to

success within the sport, (c) competing in sports that involve weight cutting, (d) the level of

exposure of an athlete’s body while participating in the sport, and (e) the level of appearance

pressure in relation to their sport (Bar et al., 2016; Conviser et al., 2018; Fewell et al., 2018;

Frogley et al., 2018; Langmesser & Verscheure, 2019).

Coaches often do not understand the nuances of eating disorder behaviors,

which leads to the need for a clinician to intervene (Dao Le, 2017). Sport

psychologists can assist in detecting eating concerns early and can utilize clinical

experience to assist in prevention and intervention (Papathomas & Capicotto, 2017).

The combination of several risk factors and high rate of athletes diagnosed with

eating disorders is causing a need for effective sport psychology prevention

interventions. This project aimed to identify the most effective sport psychology

eating disorder prevention interventions through utilizing a systematic review of the

literature.

General Statement

The prevalence of eating disorders among athletes is a serious concern within the

field of sports psychology and among researchers studying athletes (Bar et al., 2016; Roy et

al., 2019). Both male and female athletes may struggle with eating disorders; however,

previous studies indicated female elite athletes are twice as likely to develop eating disorders

when compared to male elite athletes (Koman, 2018; Fewell et al., 2018; National Eating

Disorder Association, 2018). The prevalence of eating disorders is higher in elite athletes

when compared to the general population, with an estimated prevalence rate of 25.5% among

collegiate athletes (Dao Le at al., 2017; Frogley et al., 2018; Papathomas & Capicotto, 2017).

It is important to note that the prevalence rate is higher in elite athletes (collegiate or

professional) athletes when compared to non-elite athletes and the general population

(Papathomas & Capicotto, 2017). Previous studies revealed no difference in prevalence for

youth, high school, and recreational athletes when compared to non-athletes (Bar et al., 2016;

Frogley et al, 2018).

Elite female athletes have been identified as the most at-risk for developing eating

disorders for several reasons, such as: (a) the pressure to perform well, (b) a tendency for

perfection, (c) an overemphasis on body type in relation to sport success, and (d) a sport

culture that normalizes unhealthy eating behaviors (Dao et al., 2017; De Bruin & Oudejans,

2017; Fewell et al., 2017). Another risk factor that may lead to female elite athletes having

the highest risk for eating disorders is the athlete’s sport. Sports that focus on the individual

rather than the entire team have shown to have higher rates of athletes with eating disorders

when compared to team sports (Frogley et al., 2018; Koman, 2018; Papathomas & Capicotto,

2017; Roy et al., 2019). This project explored sport psychology eating disorder prevention

interventions for elite female individual-sport athletes. This project aimed to develop best-

practice prevention intervention protocols based on the findings to assist in preventing eating

disorders within the highest needs population.

The combination of high prevalence rates and high-risk factors for female elite

athletes have caused a need for sport psychologists to develop appropriate preventative

interventions (Fewell et al., 2017; Sudano & Miles, 2017). Researchers have conducted

studies to assess for effective prevention strategies; however, there is a gap in knowledge

regarding which interventions are considered best practice recommendations for sport

psychologists (Bar et al., 2016; Fewell et al., 2017; Papathomas & Capicotto, 2017). This

project attempted to fill this gap in knowledge and aimed to identify sport psychology best-

practice recommendations for preventing eating disorders within the highest-risk athletic

population of elite female individual-sport athletes. Findings from this project may assist

sport psychologists in developing a better understanding of prevention interventions and may

lead to fewer eating disorder diagnoses within a high-risk athletic population.

Justification Statement

This project focused on the general problem of the high prevalence rate of eating

disorders among athletes resulting in diminished performance, lowered quality of life, poorer

health, and a higher risk for mortality (Bar et al., 2016; Borgen-Sundgot & Klungland, 2004).

The specific problem addressed in this project was the lack of sport psychology best practice

recommendations for preventing eating disorders within the athletic population (Borgen-

Sundgot, 2004; Galmiche et al., 2019; Sudano & Miles, 2017). Researchers have focused on

the treatment of eating disorders in sport. Specific evidenced-based therapeutic modalities

such as: Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy

(ACT), and Dialectic Behavioral Therapy (DBT) have shown to be highly effective for

treating athletes struggling with eating disorders (Ziegler, n.d.; Beals, 2004).

Researchers have identified effective treatment practices, but ongoing debates

continue regarding ways to prevent athletes from developing eating disorders (Bratland-

Sanda & Borgen-Sundgot, 2013). Some researchers focus on eating disorder prevention

within the general population, but there is little research on eating disorder prevention within

athletics (Joy et al., 2016). This project focused on examining effective eating disorder

prevention protocols and may be beneficial to the field by identifying best-practices for

preventing eating disorders in sport to combat the high rates of athletes diagnosed with eating

disorders. This project addressed the lack of sport psychology best practice prevention

interventions by identifying recommendations within the highest risk athletic population.

Purpose of the Project

The purpose of this systematic literature review was to explore what sport psychology

preventative interventions are effective for eating disorders within elite female individual-

sport athletes, and to create best-practice recommendations for preventing eating disorders

within this population. A systematic literature review method combines the findings of both

qualitative and quantitative studies to address the research question (Harden, 2010). This

project addressed the problem of sport psychologists lacking best-practice protocols for

eating disorder prevention and resulted in best-practice recommendations for eating disorder

prevention. Protocols derived from this project could assist sport psychologists, coaches, and

athletes in combating the risk factors associated with athletes developing eating disorders and

possibly lower the overall rates of athletes diagnosed. Eating disorders can create a

disturbance in an athlete’s peak performance (Fewell et al., 2017; Roy et al., 2019). This

project may assist in preventing athletes from deterring from their peak performance due to

their eating disorders. It also may help in combating the number of death incidents related to

eating disorders by using preventative protocols obtained in this project.

Importance of the Project

Eating disorders in sport is a critical topic necessary to research in the sport

psychology field, as these disorders are considered the deadliest psychological illness due to

a 10% mortality rate without appropriate and effective treatment (Bar et al., 2016; Dao et al.,

2017; Insel, 2012; Papathomas & Capicotto, 2017). The high prevalence rate of athletes

struggling with eating disorders indicates a need for more sport psychologists to develop

treatment and prevention interventions (Sudano & Miles, 2017; Bar et al., 2016; Hildebrandt,

2005; Beals, 2004). However, the sport psychology field lacks best-practice

recommendations for preventing eating disorders within the athletic population (Curie,

2010). Exploring what sport psychology preventative interventions have been effective for

athletes in the past may assist in addressing the lack of best-practice recommendations. The

results of developing best-practice prevention protocols could lead to fewer athletes needing

eating disorder treatment.

Researchers have assessed for sport psychology best-practices for eating disorder

treatment, but there is a gap in the literature regarding the prevention of eating disorders in

the sport setting (Conviser et al., 2018). Other studies have identified best practices for

coaches and parents regarding eating disorder prevention, but this research does not reflect

best practices for sport psychologists (Sherman & Thompson, 2001; Bar et al., 2016; Curie,

2010). Researchers have assessed overall best-practices for eating disorder prevention, but

the research lacks focus within the athletic setting (Doa et al., 2018; Shaw et al., 2009; Stice

et al., 2008). This project offered a unique approach to preventing eating disorders within the

sport setting by focusing specifically on effective prevention protocols for sport

psychologists. The results of this project may contribute to the sport psychology field by

allowing more sport psychologists to obtain knowledge on best-practice for eating disorder

prevention. The implications from the project’s findings could change the way sport

psychologists approach eating disorder prevention within the athletic setting, particularly

among elite female individual-sport athletes. More sport psychologists utilizing best-

practices for preventing eating disorders may lower the number of athletes diagnosed with

eating disorders.

Conceptual Framework

Three unique concepts formed the framework for this project: (a) a rise in female

sport participation, (b) general risk factors for eating disorders, and (c) the concept of

prevention science. The context of the increase in female sport participation highlights the

need to address the rising prevalence rate of eating disorders within the elite female

individual-sport athletes. Risk factor associated with eating disorders play a central part in

prevention development and may assist sport psychologists in selecting appropriate

prevention interventions (De Bruin & Oudejans, 2018; Offord & Kraemer, 2000). The

framework of prevention science provides a knowledge base for understanding preventative

intervention described in this project.

Eating disorders in elite athletes are a concern to sport psychologists. Female athletes

at the elite level experience eating issues at higher rates than non-athletes (Bar et al., 2016;

De Bruin & Oudejans, 2018; Papathomas & Capicotto, 2017). Female athletes competing in

sports that focus on the individual (e.g., gymnastics, running, figure skating, dance, or

diving) at the elite level and involved in aesthetic, weight class, and gravitational sports are at

the highest risk for developing an eating disorder and are, therefore, identified as “high risk”

(Borgen-Sundgot & Torstveit, 2010; Constantz & Mason, 2010; De Bruin & Oudejans, 2018;

Haase, 2009; Krentz & Warschburger, 2011; National Eating Disorder Association, 2018).

Diagnosing eating disorders in elite female athletes is a challenge. Over half of elite athletes

engage in eating disorder behaviors, which makes the behavior seem acceptable and adaptive

to winning within the sport setting (Bar et al., 2016; De Bruin & Oudejans, 2018).

Encountering an elite athlete struggling with eating issues is highly likely in a sport

psychologist’s career, and it is almost a certainty when working with female athletes

participating in lean and aesthetic sports (Frogley et al., 2018; Papathomas & Capicotto,

2017). A sport psychologist plays a critical role in the coaching staff, as a clinical

background assists in noticing nuanced potential eating disorder behaviors amongst the

athletes (Bar et al., 2016; De Bruin & Oudejans, 2018; Frogley et al., 2018). Given the

limited efficacy of many eating disorder treatment programs, as well as the high relapse rates

following treatment, there is a need for prioritizing prevention in high-risk populations (Bar

et al., 2016; Beals, 2004; Bratland-Sanda & Borgen-Sundgot, 2013; Papathomas &

Capicotto, 2017). This project explored prevention interventions that sport psychologists can

utilize to assist in combating the high prevalence rate of eating disorders within elite female

individual-sport athletes.

Rise in Female Sport Participation

Female participation in sports has increased remarkably since the institution of Title

IX in 1972. Title IX protects people from discrimination based on sex in education programs

or activities that accept federal financial assistance (National Collegiate Athletic Association,

2018). Title IX has resulted in increased female athlete sport participation opportunities at the

collegiate level by 545% (Women’s Sport Foundation, 2018). Since Title IX’s passage in

1972, the number of females competing in high school sports jumped from 295,000 to nearly

3.2 million (Women’s Sport Foundation, 2018). Female collegiate sport participation went

from fewer than 30,000 to over 193,000 since 1972 (National Collegiate Athletic

Association, 2018). Current studies indicate 2.8% of female collegiate athletes get drafted

into professional sports, which is an increase since 1972 (Women’s Sport Foundation, 2018).

As the rate of female collegiate sports participation continues to grow, researchers have

noticed the impact sports play in a female collegiate athlete’s life (National Eating Disorder

Association, 2018).

Studies have supported that athletes, particularly within the female elite athlete

population, are at an increased risk of developing an eating disorder. Prevalence studies

indicating a 12-month prevalence rate of 31% among elite female athletes, a rate of 6%

among amateur female athletes, and a rate of 0.4% among females that do not participate in

sports (American Psychological Association, 2013; Galmiche et al., 2019; National Eating

Disorder Association, 2018; Rice et al., 2016). The prevalence of eating disorders in elite

female individual-sport athletes has likely risen with the increased influx of female collegiate

athletes (De Bruin & Oudejans, 2018; National Eating Disorder Association, 2018). This

project focused on athletes who are at a high risk of developing an eating disorder, including

elite female individual-sport athletes.

General Risk Factors for Eating Disorders

Eating disorders are complex and affect a variety of individuals. The most common

eating disorders (Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder) affect up

to 30 million people in the United States during a given year (Eating Recovery Center, 2020).

These disorders have the highest mortality rate of any mental illness with one person dying in

the United States every 62 minutes as a direct result from an eating disorder (National Eating

Disorder Association, 2018). The recent expansion of eating disorder diagnostic criteria in

the Diagnostic and Statistical Manual-5 allows more individuals to receive treatment

covered by their insurance companies (American Psychological Association, 2013). The

exact cause of eating disorders is unknown, and as with other mental illnesses there may be

many causes (National Eating Disorder Association, 2018).

The idiopathic nature of eating disorders has led researchers to focus on identifying

risk factors to better understand correlates associated with eating disorder diagnoses (Eating

Recovery Center, 2020). Researchers have identified broad risk factors associated with

developing eating disorders, including biological, psychological, and sociocultural factors

(De Bruin & Oudejans, 2018; Haase, 2009; National Eating Disorder Association, 2018).

Biological factors include age, genetic predisposition, and sex (Haase, 2019). Psychological

factors include body image dissatisfaction, mental illness, a history of trauma, poor self-

esteem, and specific personality traits (Papathomas & Capicotto, 2017). Sociocultural factors

include experiencing weight stigma, limited support networks, appearance ideal

internalization, and participation in activities that encourage thinness (National Eating

Disorder Association, 2018). These risk factors are associated with eating disorders in

general. However, there are also risk factors specific to athletes that increase an athlete’s risk

of developing an eating disorder (Bruin et al., 2018; Coelho et al., 2014). Researchers have

supported the belief that athletes experience a higher rate of eating disorders than the general

population due to additional risk factors (De Bruin & Oudejans, 2018; Frogley et al., 2018).

Addressing athlete risk factors that contribute to eating disorders may help sport

psychologists select appropriate prevention interventions (De Bruin & Oudejans, 2018).

These specific athlete risk factors will be explored further in Chapter II.

The Concept of Prevention Science

The framework of prevention science is relevant to understand the concept of

prevention intervention and how it relates to this project. Prevention science is a research

framework that focuses on how to prevent and/or moderate negative medical, social, and

emotional impacts before they occur (Brady et al., 2020). Prevention science research is

focused primarily on the systematic study of potential risk factors and protective factors of

dysfunction or health (Koepsell et al., 2011). Prevention interventions aim to counteract risk

factors and reinforce protective factors to disrupt processes that contribute to human

dysfunction (Brady et al., 2020). This project was developed in part based on prevention

science theory, which focuses on a preventative approach that aims to address risk factors to

combat the high prevalence rate of athletes diagnosed with eating disorders. This project

utilized the strategy of prevention trials targeting primarily those at high risk by focusing on

elite female individual-sport athletes. Chapter II will further describe how prevention science

relates to the development and implementation of this project.

Overview of the Project Approach

The purpose of this systematic literature review was to explore what sport psychology

preventative interventions are effective for eating disorders among elite female individual-

sport athletes, and to create best-practice recommendations for preventing eating disorders

within this population. The review included articles that focused on sport psychology eating

disorder prevention within the athletic setting. The subject of this literary review was

interventions implemented by sport psychologists to aid in lowering the number of athletes

diagnosed with eating disorders. The project examined and specified why specific

interventions obtained better results than others to recommend the best sport psychology

practices for implementing a prevention protocol with athletes. The search was expanded to

include preventative interventions implemented by coaches and training staff, as their

practices are beneficial for sport psychologists to recommend to coaching staff who have

concerns about rates of eating disorders on their teams.

This systematic review used PRISMA protocols to ensure the review was exhaustive

and comprehensive. The protocol included: (a) identifying a research question, (b) defining

inclusion and exclusion criteria, (c) searching for empirical studies, (d) selecting studies

based on criteria, (e) extracting raw data in the studies, (f) evaluating the risk of bias for the

studies selected, (g) presenting results from the studies selected, and (h) assessing the quality

of evidence from each empirical study (Choi et al., 2019). The research method chosen for

this project was a systematic literature review. The purpose of the review was to provide a

thorough, rigorous review of current research that was systematically synthesized and

analyzed to answer the research questions. Identified inclusive and exclusive criteria assisted

in determining articles used for this project. This systematic approach not only analyzed,

collected, and interpreted findings from several studies, but it also developed an overarching

interpretation of the findings (Lachal et al., 2017). The goal of this project was to lead to new

understandings and recommendations for sports psychologists and those who specialize in

eating disorders.

Project Questions

This project will address the following overarching questions:

1. Which eating disorder prevention interventions are effective for sport psychologists

working with the athletic population?

2. Why are these interventions effective?

3. What are best-practice recommendations for sport psychologists to prevent eating

disorders within the athletic population, particularly with respect to the elite female

individual-sport population?

Definition of Terms

The following terms are defined to give context to better understand the way in which

these terms are used throughout the project.

Anorexia nervosa (AN): Characterized by persistent caloric intake restriction, fear of

gaining weight/becoming fat, persistent behavior impeding weight gain, and a disturbance in

perceived weight or shape (Thompson, 2014).

Avoidant/restrictive food intake disorder (ARFID): Characterized by a significant

eating disturbance as manifested by persistent failure to meet appropriate nutritional and/or

energy needs. This disorder differs from anorexia by not including a preoccupation with fears

of weight gain and it does not include any distress about body shape or size (National Eating

Disorder Association, 2018).

Binge-eating disorder: Recurrent episodes of binge eating without compensatory

behaviors but with marked distress with the binge eating (Thompson, 2014).

Body Dysmorphia: Preoccupation with one or more perceived defects in appearance

that are not observable or appear slight to others (American Psychological Association,

2013).

Bulimia nervosa: Recurrent binge eating, recurrent inappropriate compensatory

behaviors to prevent weight gain (for example, induced vomiting and excessive exercise),

and self-evaluation unduly influenced by shape and weight (Thompson, 2014).

Compulsive Exercise: A craving for physical training, resulting in uncontrollable

excessive exercise behavior with harmful consequences (Lichtenstein, 2018).

Co-Occurring Disorder: Referring to the condition in which an individual has an

existing mental illness in combination with another mental illness (National Eating Disorder

Association, 2018).

Diabulimia: Referring to an eating disorder in a person with diabetes who

intentionally restricts insulin as an attempt to lose weight (National Eating Disorder

Association, 2018).

Eating Disorders: A persistent disturbance of eating related behaviors that result in

the altered consumption or absorption of food that impairs health or psychosocial functioning

as outlined by the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders

(DSM-5; American Psychiatric Association, 2013). This project includes the following

categories of eating disorders: Anorexia Nervosa, Bulimia Nervosa, Avoidant/Restrictive

Food Intake Disorder, Binge-Eating Disorder, and Other Specified Eating Disorder.

Elite Athlete: For this project, the term “elite athlete” references the competition level

of an athlete. Elite athletes represent athletes competing at the highest level of competition.

These athletes compete at the national, international, collegiate, and/or professional level

(Swann et al., 2015).

High-risk athletes: Athletes with a high incident rate of eating disorders (Koman,

2018).

Individual Sport: A sport in which participants compete as individuals. Individual

sports emphasize personal mastery and self-discipline, as success and/ or failure in sport falls

on the individual athlete. Examples include tennis, track, swimming, dive, gymnastics,

wrestling, powerlifting, figure skating, body building, golf, etc. (Constantz & Mason, 2010).

Orthorexia: Referring to an eating disorder involving an unhealthy obsession with

healthy eating (National Eating Disorder Association, 2018).

Other Specified Eating Disorder: This disorder encompasses individuals who do not

meet strict criteria for anorexia or bulimia but still have significant eating disorder behaviors.

This disorder can also be described as an atypical and/or subclinical anorexia and/or bulimia

(National Eating Disorder Association, 2018).

Prevention intervention: A systematic process that promotes healthy environments

and behaviors and reduces the likelihood of an eating disorder diagnosis (Bar et al., 2016).

There are different classifications for prevention interventions based on when they occur in

relation to the development of the eating disorder. The classifications include primary,

secondary, and tertiary (Mrazek et al., 1994). There are also different types of prevention

interventions based on the targeted population receiving the intervention. Interventions

targeting an entire population are considered universal and interventions targeting one or

more subgroups in a population determined high-risk are considered specific (Dao Le et al.,

2017).

Risk-factors: Characteristics at the biological, psychological, family, community, or

cultural level that precede and are associated with a higher likelihood developing a disorder

(De Bruin & Oudejans, 2018).

Team Sport: A sport in which participants compete as a team and sport success and/or

failure depends on teammates, rather than an individual. Team sports emphasize the virtue of

working together and team cohesion. Examples include basketball, volleyball, rugby, water

polo, handball, lacrosse, football, hockey, baseball, etc. (Constantz & Mason, 2010).

Assumptions, Limitations, and Delimitations

All studies include specific limitations, assumptions, and delimitations (Simon,

2011). Some of these variables are within the researcher’s control and others are outside the

researcher’s control. These variables can affect inferences drawn from a study. This project

included specific limitations, assumptions, and delimitations that play a part in influencing

the findings.

Assumptions

Assumptions are influences outside the researcher’s control that utilize concepts

accepted as true, or at least plausible (Simon, 2011). One assumption of this project was that

there was an adequate amount of literature about prevention interventions for eating disorders

to address the research questions. It was assumed that athletes were responsive to specific

prevention protocols utilized in the review and no other confounds played a part in their

response to treatment. Another assumption was that all athletes, coaches, and sport

psychologists were capable of engaging in prevention interventions.

Limitations

A limitation is a restriction in a study a researcher cannot control (Simon, 2011). A

limitation of this project is researcher bias. Researcher bias may influence this project in the

determination of eligibility and ineligibility of studies included in the review, as the

researcher determines if literature meets the criteria. The project’s conclusions were based on

the interpretations of findings from the researcher’s perspective. One way to combat

researcher bias is through the process of bracketing. Bracketing is a method used in research

to alleviate researcher bias through the process of setting aside personal experiences, bias,

preconceived notions, and previous knowledge on the research topic (Tufford & Newman,

2010). Bracketing was used in this project to mitigate the potentially deleterious effects of

researcher bias through practicing reflexivity and epoche. Any researcher biases that may

have influenced the results of the project were noted during data analysis.

The data collection in this project was limited to the researcher’s database access.

Another limitation of this project was the constraints of its generalizability. This project

focused on eating disorder prevention within the athletic setting. Therefore, the findings of

this project may not translate to populations outside of athletes. Efforts were made to

overcome the limitation of limited database access through utilizing Google Scholar and

interlibrary loan services to obtain articles not available through the University of Arizona

Global Campus Library databases.

Delimitations

Delimitations in research reflect the scope of the study, as well as its boundaries

(Simon, 2011). A delimitation of this project included the focus on female athletes. Results

from this project reflected data from female athletes and may not be applicable for male

athletes. The scope of this project included prevention interventions implemented in the

United States and utilized studies focusing on eating disorder preventions within the athletic

population. Therefore, studies focusing on prevention strategies within the general population

as well as studies outside of the United States were not included in this project. The findings

of this project may generalize to other athlete populations in the United States, but the

applicability to the general population and areas outside the United States may be reduced.

Summary

This chapter described how eating disorders are a substantial concern among elite

female individual-sport athletes as a result of the prevalence rate and health consequences

related to these conditions (Bar et al., 2016; Galmiche et al., 2019; Greenleaf et al., 2009). It

is important that sport psychologists, who have responsibility for the physical and mental

health and safety of elite athletes, are well educated on best practices for eating disorder

prevention (Bar et al., 2016; Papathomas & Capicotto, 2017). However, the sport psychology

field lacks best practices for prevention interventions related to eating disorders. This project

aimed to fill the gap of knowledge by identifying sport psychology best practice

recommendations for preventing eating disorders within the highest risk athletic population

of elite female individual-sport athletes

using a systematic literature review.

The results may change the way sport psychologists approach eating disorder

prevention within the athletic setting, which may lower the number of athletes diagnosed

with eating disorders. Chapter II includes a description of search strategies utilized, a

Literature Review of studies relevant to the research questions of this project and a summary

of this project’s potential contribution to the literature.

CHAPTER II: REVIEW OF THE LITERATURE

This chapter includes a review of the existing academic literature that provides a

foundation for the relevance of this project’s proposed topic. The purpose of this project was

to explore what sport psychology preventative interventions are effective for eating disorders

within the elite female individual-sport athletic population and to create sport psychology

best-practice recommendations for preventing eating disorders among this population. This

chapter presents an exploration of the elite female individual-sport athletic population, the

relevance of sport psychology best-practices for eating disorder prevention, and the

applicability of prevention sciences to eating disorder prevention among elite female

individual-sport athletes. Historic, seminal, and modern literature will provide a background

of the concepts and issues relevant to understanding the project.

This chapter includes a discussion on the relevance of sport psychologists addressing

eating disorder risk factors and highlights the importance of eating disorder prevention within

the elite female individual-sport athlete population. This chapter’s literature review provides

an academic foundation for the project approach as well. The following review introduced

available research on eating disorders among the female athletic population in general and

within the elite female individual-sport athletic population, risk factors associated with eating

disorders, and research on preventative sciences and how this applies to the sport psychology

field.

Search Strategy

The search strategy for this project began after creating a literature review component

outline, which aided in the development of keywords used in search databases. Keywords

included but were not limited to: eating disorders, eating disorders among athletes,

prevention of eating disorders, prevention of eating disorders among athletes, prevalence of

eating disorders in athletes, sport psychology and eating disorders, sport psychology eating

disorder prevention, sport psychology prevention for highest risk athletes, risk factors

related to eating disorders, athletes at the highest risk for eating disorders, and prevention

science and eating disorders. To collect relevant scholarly and professional literature for the

review, searches were conducted in several search engines and databases using keywords

identified. Several different online databases were accessed through the University of

Arizona Global Campus library, including: ProQuest, ERIC, EBSCOHOST, and SAGE

databases. Some literature was retrieved via inter-library loans. The Taylor & Francis Online

professional database held by the Association for Applied Sport Psychology (AASP) was

searched for professional literature. The American Psychological Association and the

National Eating Disorder Association professional association database sources were also

utilized. Finally, Google Scholar and general internet searches were completed as well.

Sources of information included peer-reviewed journal articles, professional literature, books,

grey literature, theses, dissertations, and conference papers.

Most of the literature reviewed in this chapter were scholarly, peer-reviewed sources;

however, a few were from professional literature in the Association for Applied Sport

Psychology journal archives written by experts in the field. The professional literature was

reviewed and approved by the Association for Applied Sport Psychology. In each case, the

reason for including professional sources was to provide the most current information on the

topic discussed in areas where the scholarly literature was deficient. This project made efforts

to identify works published in the past five to ten years, except for important seminal and

historical works. The reason for limiting the search to literature from the stated timeframe

was to describe current perspectives in the field and to highlight recent related research.

To collect scholarly literature for the review, searches were conducted in several

search engines and databases to obtain different types of literature. Table 1 provides an

overview of the dates and types of literature obtained during the review.

Table 1.

Summary of Sources

This table provides an overview of the dates and types of literature obtained during the

search process.

Year of Publication < 2016 2016 - 2021 No Date (N.D.)

# % # % # %

Peer Reviewed Journals 39 30.2% 35 27.3% 0 0%

Other Journals or Periodicals

10 7.6% 16 12.4% 3 2.4%

Reports / Government Sources

5 3.8% 7 5.4% 4 3.2%

Scholarly Books

5.4%

2.3%

TOTAL

47.0%

47.4%

5.6%

Eating Disorders

Eating behaviors are a necessary component of human life, but when placed within

psychological and social contexts, they can become very complex and detrimental to one’s

health and well-being (Hesse-Biber et al., 2006). Abnormal eating behaviors are classified on

a continuum which range from disordered eating behaviors to diagnosable eating disorders.

All aspects of the abnormal eating behaviors scale can have substantially negative health

consequences, which can be seen by the fact that eating disorders have the highest mortality

rate of any mental illness (American Psychiatric Association, 2013). Historical evidence

reveals eating disorders are not a new diagnostic phenomenon (Muhlheim, 2020).

Historical Examples of Eating Disorders

The earliest historical descriptions of people experiencing symptoms consistent with

modern-day eating disorders date back to Hellenistic (323 B.C.-31 B.C.) and medieval times

(5th-15th century A.D.) (Muhlheim, 2020). Purification through the denial of physical needs

and the material world was a cultural theme during these time periods. There were reports of

upper-class Roman females starving themselves to death in quest of holiness in the

Hellenistic period, and there were also reports of extreme self-induced fasting that often led

to premature death by starvation during the medieval times (Lyons, 2018). The motivation

for fasting in the Hellenistic and medieval times appears to be different than the current

motivation of a drive for thinness that leads today’s discussions of eating disorders

(Muhlheim, 2020). The practice of starvation and fasting during this time period was

described as “holy anorexia” and differed from anorexia nervosa. Holy anorexia related to a

mix of spiritual and material beliefs.

Reports of bulimia date back to the time of Caesar (700 B.C.), when rich ancient

Romans overindulged at lavish banquets and then relieved themselves by vomiting to allow

themselves to return to the feast and continue eating (Davis & Nguyen, 2014). Examples of

bulimia are also noted in the general Roman population, as citizens reportedly induced

vomiting to purge their system and eat more during meals. Reports described purging as a

medical practice that physicians in Egypt, Greece, Rome, and Arabia would prescribe to

prevent diseases believed to come from food during medieval times (Muhlheim, 2020). The

motivation for purging during the Hellenistic and medieval times appears to be different than

the current motivation of an attempt to prevent weight gain that leads today’s discussions of

eating disorders (Davis & Nguyen, 2014). The first case of purging bearing a resemblance to

modern bulimia nervosa is a case described by Pierre Janet in 1903, in which a female patient

displayed dietary restriction, fear of fatness, efforts to purge for weight loss purposes, and

episodes of binge eating (Muhlheim, 2020). In 1960, two psychiatrists from the United States

published several case histories that provided examples of modern bulimia nervosa, and in

1970 British psychiatrist Gerald Russell published a case series of 30 patients who reported

self-induced vomiting to mitigate the effects of overeating (Davis & Nguyen, 2014). As more

reports were published on anorexia and bulimia nervosa, it led to identifying a need for

creating diagnostic criteria for the disorders.

Public eating disorder awareness was nearly nonexistent in the United States until the

1980s. Karen Carpenter was one of the first reported celebrity casualties of an eating disorder

(Latson, 2016). She died at the age of thirty-two in 1983 due to heart failure related to her

struggle with anorexia. Carpenter’s death raised awareness of the dangers of eating disorders,

which until then had been poorly publicized or understood (“Let’s get real,” 2018).

Carpenter’s death encouraged other celebrities to speak out about their personal struggles

with eating disorders, which led to further public awareness. After exposing the need for

eating disorder treatment in the 1980s, college counseling centers began expanding their

counseling services due to more individuals seeking treatment (Latson, 2016). Counseling

centers received funding to treat these individuals, so clinicians began utilizing treatments

such as refeeding protocols and talk therapy to help patients recover (National Eating

Disorder Association, 2018).

Diagnostic History of Eating Disorders

Anorexia nervosa was the first eating disorder included in the first edition of the

Diagnostic and Statistical Manual of Mental Disorders (DSM-I). The disorder was

categorized as a psychophysiological gastrointestinal reaction based on emotional factors that

were believed to play a causal role (Deans, 2011). The DSM’s second edition was published

in 1968 and anorexia was recategorized as a Feeding Disturbance (American Psychiatric

Association, 2013). The DSM-III was released in 1980 and eating disorders debuted as its

own diagnostic category under the rubric of disorders of infancy, childhood, or adolescence

(Deans, 2011). This version of the DSM began to expand on the types of eating disorders as

diagnoses such as anorexia nervosa, pica, rumination disorder, the concept of bulimia, and

atypical eating disorders were all included in this version (American Psychiatric Association,

2013).

With the publication of the DSM-IV in 1994, bulimia nervosa appeared in its current

form, with the required feature of shape and weight concerns associated with the condition,

and binge eating disorder was also mentioned for the first time (Muhlheim, 2020). The DSM-

5 in 2013 created a new umbrella category for both eating disorders and Feeding and Eating

Disorders of Infancy or Early Childhood, as they both were included under the category of

Feeding and Eating Disorders (Deans, 2011). This version of the DSM also included newer

diagnoses such as Avoidance Restrictive Food Intake Disorder (ARFID), Binge Eating

Disorder (BED), and Other Specified Feeding or Eating Disorder (OSFED) (American

Psychiatric Association, 2013; Deans, 2011; Muhlheim, 2020). The development and

evolution of eating disorder diagnoses has led to more research on the topic. Researchers

have assessed for common behavioral and psychological characteristics between the different

diagnoses.

Common Medical Complications of Eating Disorders

Eating disorders are complex and potentially devastating conditions that can have

serious consequences for health, productivity, and relationships. They can affect every cell,

tissue, and organ in the body (Cost et al., 2020; Milano, 2020). If not stopped, starving,

stuffing, and purging can lead to irreversible damage and even death (National Eating

Disorder Association, 2018). Addressing both the medical and psychological concerns

related to eating disorders is a critical aspect to eating disorder recovery. The medical

dangers associated with anorexia nervosa, bulimia nervosa, ARFID, BED, and OSFED may

differ depending on the individual and severity of the disorder.

Anorexia nervosa is considered the highest medical risk mental health disorder with a

mortality rate of 10% (Insel, 2012; National Eating Disorder Association, 2018). It is

considered a life-threatening disorder due to the affects starvation has on the body and brain

(Mehler, 2014). Many women and men with this disorder die from starvation, metabolic

collapse, cardiac arrest, refeeding syndrome, and suicide (Insel, 2012; Mehler, 2014).

Individuals with anorexia nervosa, binge-purge subtype are at highest risk medically, as they

face serious metabolic challenges that occur from electrolyte imbalances associated with

starvation and purging (Ekern, 2018). It is common for individuals struggling with anorexia

to have medical concerns such as: anemia, fainting, dizziness, compromised immune

functioning (e.g., getting sick often), gastrointestinal issues (e.g., abdominal pain,

constipation, and diarrhea), dysregulation of body temperature, disturbance or loss of

menstruation in girls and women, increased risk of infertility for both men and women,

kidney failure, osteoporosis, cardiac issues, and sudden death (Insel, 2012; Mehler, 2014;

National Eating Disorder Association, 2018).

Medical complications associated with bulimia nervosa can take a considerable toll

on the body. It is common for an individual struggling with bulimia nervosa to have medical

issues, as the disorder has detrimental effect on soft tissues, electrolyte levels, and overall

functioning (Mehler, 2014). The health ramifications include: impacting an individual’s skin

color and texture, hemorrhaging of the eyes and ears, dental decay, damage to the throat,

erosion of the esophagus, dysregulation in electrolytes and metabolic stability, cardiac

instability, reproductive issues, aspiration, and respiratory distress (Mehler & Rylander,

2015). These complications may lead to death, if not taken seriously, as the disorder has a

mortality rate of 3.9% (National Eating Disorder Association, 2018).

ARFID is considered a serious eating disorder and has health risks similar to anorexia

nervosa. Both anorexia and ARFID are characterized by an inability to meet nutritional

needs; therefore, they have similar health consequences (National Eating Disorder

Association, 2018). There are several serious medical risks associated with ARFID. The risks

include anemia, malnutrition, reduction in bone density, growth failure, electrolyte

imbalances, gastrointestinal issues, menstrual irregularities, reproductive complications,

abnormal metabolic findings, dizziness, fainting, dry skin, fine hair on the body, feeling cold

all the time, thinning of hair on the head, muscle weakness, cold and mottled hands and feet,

swelling of the feet, poor wound healing, and impaired immune functioning (Mehler &

Rylander, 2015: Zimmerman & Fisher, 2017). Researchers suggest individuals diagnosed

with ARFID are more likely than those with other eating disorders to have longer hospital

stays, rely more on tube feeding for nutrition, and struggle more with gaining weight during

their hospitalization (Mehler, 2014). The cardiac, nutritional, and metabolic disturbances

associated with ARFID can cause unexpected death; therefore, this disorder must be taken

seriously (Caporuscio, 2019).

BED is the most common eating disorder in the United States, it has an overall

prevalence rate of 11% within the female population and 7.5% within the male population

(Center for Discovery, n.d.; Ekern, 2016; National Eating Disorder Association, 2018). The

death risk of those with BED is not as imminent as those with other eating disorders. The

death risk associated with BED is prolonged and normally associated with weight gain and

obesity related complications (Ekern, 2016). One in five deaths in the United States is

associated with obesity (Ekern, 2016; Masters et al., 2016). Therefore, it is important to

assess the medical complications of weight gain associated with this disorder. The disorder

may lead to Type II diabetes, high blood pressure, high blood cholesterol, gallbladder

disease, heart disease, certain cancers, joint pain, gastrointestinal issues, sleep apnea,

polycystic ovary syndrome, and fertility issues (Masters et al., 2016; National Eating

Disorder Association, 2018; Ross, 2012). Medical complications associated with BED may

not immediately follow the binge-eating behavior, but they are no less serious.

OSFED is an eating disorder classification for those who do not meet diagnostic

criteria for any other eating disorder. Individuals diagnosed with OSFED may present with

disturbed eating habits, a distorted body image, fear of gaining weight, and overvaluation of

body shape and weight (Todisco, 2018). The health risks associated with OSFED are

numerous and varied, as this disorder involves any number of maladaptive eating or

exercising behaviors (Eating Recovery Center, n.d.). Individuals with specific subtypes of

OSFED are at a higher health risk, including those with orthorexia, body dysmorphia,

exercise compulsion, and diabulimia (Center for Discovery, n.d.; Todisco, 2018). Some of

the health risks include organ failure, osteoporosis, muscle weakness and loss, fatigue,

electrolyte and metabolic imbalances, tooth decay, gastrointestinal issues, high blood

pressure, high cholesterol, heart disease, and Type II diabetes (Mehler & Rylander, 2015;

National Eating Disorder Association, 2018). A common misconception about OSFED is that

it is not severe, and these individuals do not need treatment (National Eating Disorder

Association, 2018). Delaying treatment of OSFED can result in developing co-occurring

disorders or worsening the severity of the current disorder (Center for Discovery, n.d). The

mortality rate for OSFED is 5.2% and these individuals are at an increased risk for suicide

(Mehler & Rylander, 2015; National Eating Disorder Association, 2018). Though lacking

specific diagnostic criteria, OSFED is a serious disorder, nonetheless.

There are several similar medical complications associated with the following eating

disorders: anorexia nervosa, bulimia nervosa, ARFID, BED, and OSFED. These medical

complications include cardiac concerns, metabolic irregularities, electrolyte imbalances,

gastrointestinal issues, and potential death (Ekern, 2016; Insel, 2012; Mehler & Rylander,

2015; National Eating Disorder Association, 2018). The medical management of these eating

disorders often involve close medical and weight monitoring, electrolyte supplementation,

refeeding protocols, medication management, and metabolic monitoring (American Brain

Society, n.d., National Eating Disorder Association, 2018). All eating disorder treatments

involve creating treatment plans for both psychological and medical symptoms (National

Institute of Mental Health, n.d.). Psychological characteristics of eating disorders are

important to address, as researchers suggest the root cause of eating disorders are from a

complex mixture of biological but mostly psychological and sociocultural factors (American

Brain Society, 2019).

Common Behavioral and Psychological Characteristics of Eating Disorders

Eating patterns are influenced by several factors including environmental, biological,

and cultural factors (National Eating Disorder Association, 2018). Eating disorder patterns

can be caused by feelings of distress or concern about body shape, weight, or size. Eating

disorders are described as illnesses in which people experience severe disturbances in their

eating behaviors and related thoughts and emotions (Parekh, 2017). Individuals with eating

disorders are typically preoccupied with food, body image, and their weight. A person with

an eating disorder may have started out by eating smaller amounts of food than usual, but at

some point, the urge to eat less or more can spiral, and the maladaptive patterns of eating can

escalate and become out of control (Muhlheim, 2020). Behavioral and psychological

characteristics of eating disorders can differ depending on the type of eating disorder.

Anorexia nervosa is characterized by a persistent restriction on food intake, an intense

fear of gaining weight or becoming overweight, and a distorted perception of body weight or

shape. An individual struggling with anorexia will have a body weight that is below a

minimally normal level for age, sex, and physical health (American Psychiatric Association,

2013). Maladaptive behaviors such as excessive exercising, fasting, misusing laxatives and

diuretics, and making continual efforts to intake a significantly small number of calories are

all present for an individual struggling with anorexia (National Eating Disorder Association,

2018). Maladaptive psychological characteristics include a tendency for perfectionism, a

need for feeling in control of food intake, high levels or anxiety, and obsessive-compulsive

personality traits (Mayo Clinic, 2018).

Bulimia Nervosa is extreme excessive eating behavior (binging) accompanied with

a purging behavior to prevent an increase in weight (American Psychiatric Association,

2013). As with anorexia, there is an abnormal view of one’s body shape and size with

bulimia. For an individual to meet criteria for bulimia one must engage in purging behavior

at least twice a week for three months (National Eating Disorder Association, 2018).

Maladaptive behaviors involve binging, which is the consumption of abnormally large

amounts of food (well beyond what someone would eat in one sitting), and purging, which is

a compensatory behavior that has the purpose of losing weight such as vomiting, laxative

use, or diuretic use (Muhlheim, 2020). Psychological characteristics of bulimia include

anxiety, preoccupation with weight, depressed moods, shame, guilt, and feelings of loss of

control (National Eating Disorder Association, 2018).

ARFID is a newer diagnosis in the DSM-5 that is similar to anorexia in that both

disorders involve limitations in the amount or type of food consumed, but ARFID does not

involve any distress about body shape or size, or fears of fatness (National Eating Disorder

Association, 2018). Most children go through phases of selective eating, but ARFID is

diagnosed if a child is not consuming enough calories to grow and develop properly or if an

adult is not consuming enough to maintain basic body function. Behavioral characteristics of

ARFID include engaging in highly selective eating habits, disturbed feeding patterns

typically related to sensitivity of food textures, colors, and smells, eating at an abnormally

slow pace, and having a general lack of appetite (Walden Behavioral Care, n.d.).

Psychological characteristics of ARFID include general anxiety, a fear of choking, vomiting,

or food poisoning, and a need to be in control of one’s food intake (National Eating Disorder

Association, 2018). It is not uncommon for ARFID to show up in individuals with a history

of early traumatic experiences with food, attention-deficit issues, autism, anxiety, and an

intellectual disability (McQuillan, 2020).

BED is characterized by recurrent episodes of eating large quantities of food, a

feeling of loss of control during the binge, experiencing shame and guilt afterwards, and not

regularly using unhealthy compensatory measures to counter the binge eating (National

Eating Disorder Association). Some common behavioral characteristics include individuals

appearing uncomfortable eating around others, engaging in frequent diets, body checking in

the mirror, and a disruption of normal eating behaviors such as eating throughout the day

with no planned mealtimes (American Psychological Association, 2013). Individuals may

isolate themselves during mealtime due to shame associated with the amount of food they

eat. The psychological characteristics of BED include an individual having a fear of eating

food in public, anxiety, feeling a loss of control, isolation, depression, feelings of shame and

guilt, extreme concern with body weight and shape, and feelings of low self-esteem (National

Association of Eating Disorders, 2018).

OSFED is known as a catch-all category that includes a wide range of symptoms. It is

the most common eating disorder diagnosis representing an estimated 32% to 53% of all

people with eating disorders (Machado et al., 2013). This disorder includes disorders that do

not fit the full criteria for any other eating disorders. Some examples of OSFED include

atypical anorexia, binge eating disorder with a low frequency and limited duration, bulimia

with low frequency and limited duration, purging disorder, orthorexia, and night eating

syndrome (Ornstein et al., 2013). Behavioral characteristics of this disorder include refusal to

eat certain foods, comments about feeling fat or overweight, binge eating, purging behaviors,

food rituals, skipping meals, stealing or hoarding food, drinking excessive amounts of non-

caloric beverages, using excessive amounts of mouthwash, mints, and gum, hiding body with

baggy clothing, and excessive exercising (National Eating Disorder Association, 2018). The

psychological characteristics of OSFED include low self-esteem, depression, feeling a loss of

control, anxiety, strong need for approval, little motivation to engage in relationships or

activities, irritation, and engaging in extremely self-critical internal thoughts (Ornstein et al.,

2013).

The criteria for specific eating disorders are all different, but there appears to be

several common behavioral and psychological characteristics between each of them. The

disorder OSFED has several common characteristics to all the disorders, as the criteria for

this disorder includes subclinical characteristics of every eating disorder (Ornstein et al.,

2013). The behavioral characteristic of isolating and making attempts to control

compensatory behaviors and/or food intake appears to be common between each of the

disorders (National Association of Eating Disorders, 2018). The disorders Anorexia nervosa,

ARFID and EDNOS all can include the characteristic of making attempts to control one’s

intake (McCallum Place, n.d.). The disorders Bulimia nervosa and BED can include the

characteristic of making attempts to control compensatory behaviors (American

Psychological Association, 2013). The disorder bulimia nervosa involves purging due to fear

of weight gain and BED can involve compensatory behaviors such as compulsive exercise

and the use of laxatives to make up for an excessive number of calories consumed (National

Association of Eating Disorders, 2018).

A common theme exists among psychological characteristics of discomfort when

eating with others, shame and guilt, isolation, and preoccupation with weight and body shape

for all disorders, except for ARFID (as ARFID does not include a preoccupation with weight

and body shape) (American Psychological Association, 2013; National Eating Disorder

Association, 2018). Several of the disorders include the psychological characteristic of

anxiety and a feeling of a loss of control (Ornstein et al., 2013). Shame and guilt and low

self-esteem appear to be common psychological characteristics between anorexia nervosa,

bulimia nervosa, BED, and EDNOS (American Psychological Association, 2013). There are

common behavioral and psychological characteristics that may assist in identifying and

diagnosing eating disorders (National Association of Eating Disorders, 2018). Prevalence

rates and high-risk populations are important to discuss to understand the impact eating

disorders have on certain populations.

Prevalence Rates and High-Risk Populations

Researchers have conducted epidemiology studies to identify causes, risk factors,

impacts, and effects eating disorders have on certain populations (Bar et al., 2016; Smink et

al., 2012). The lifetime prevalence rates for adult females indicate up to 3% will suffer from

anorexia nervosa, 1-4% from bulimia nervosa, and 4% from BED (Farrar, 2014). Females

have a higher prevalence rate of eating disorders when compared to males. There is an

estimated prevalence ratio of 4.2:1 females to males diagnosed with anorexia nervosa and

11.4:1 females to males diagnosed with bulimia nervosa (Tetyana, 2012). The disparity rates

between males and females are large, and this is likely due to females having more risk

factors related to socio-cultural pressures to be thin (National Eating Disorder Association,

2018).

Epidemiological studies show eating disorders are not distributed randomly among

the population, as some individuals are more at risk than others. Females constitute the most

vulnerable group due to their high prevalence and incidence rate (Smink et al., 2012).

Females experience pressure from the culture to look a certain way and to weigh a certain

amount. Social media has played a part in effecting how women are perceived, which can

add more pressure for females to be thin (Monks et al., 2020). Eating disorders

predominantly occur in industrialized and developed countries, which indicates females

living in Western countries as being at-risk (Coelho et al., 2014). This evidence demonstrates

that sociocultural factors play an important role in the distribution in eating disorders (Hoek,

2002). Sociocultural factors such as Western cultural appearance standards concerning

female body image has shown to be linked to an increased risk of developing an eating

disorder (Izydorczyk & Sitnik-Warchulska, 2018). Some studies indicate female athletes

seem to be more effected by this sociocultural factor when compared to female non-athletes

(Coelho et al., 2014). This may be due to athletes feeling pressure to fit a performance ideal

weight, stressing to meet sport specific body image demands, and feeling the need to

conform to coaching staff’s weight and body size expectations (Thompson, 2014).

Eating Disorders Among Athletes

Athletics have many benefits for individuals, as they help with developing a work

ethic, teach the importance of teamwork, and can build self-esteem. However, not all athletic

stressors are positive. Athletic competition can be a factor contributing to severe

psychological stress, as the pressure to win and an emphasis on body weight and shape can

be a toxic combination for athletes (Thompson et al., 2020). When the pressures of athletic

competition are added to a current cultural emphasis on thinness, the risks increase for

athletes to develop an eating disorder (National Eating Disorder Association, 2018; Sandgren

et al., 2020). Athletes may feel the need to engage in disordered eating behaviors such as

restricting, skipping meals, compulsive exercise, and purging to lose weight to hit their

weight goals in hopes to enhance their performance.

There is conflicting research indicating whether female athletes are more at risk for

developing eating disorders when compared to non-athlete females in general (Coehlo et al.,

2014). However, researchers have shown elite female athletes are three times more likely to

have an eating disorder than a female non-athlete due to several specific risk factors (Bar et

al., 2016; Thompson, 2014). There are several well-known female athletes diagnosed with

eating disorders. Famous gymnasts Kathy Johnson, Nadia Comaneci, Christy Henrich, Cathy

Rigby, and Christy Phillips have all spoken about their struggles with eating disorders

(Ekern, 2012). National level gymnast Christy Henrich died at a weight of 47 pounds in 1994

due to multiple organ system failure related to anorexia nervosa (Deardorff, 1994). She was

the first well known United States gymnast to die of an eating disorder (Farrar, 2014). Cathy

Rigby, an Olympic gymnast in 1972, battled anorexia nervosa and bulimia for twelve years

and went into cardiac arrest on two occasions as a result of it (Deardorff, 1994). Christy

Phillips has spoken out about her struggle with anorexia nervosa following a coach’s

comment stating she needed to watch her weight when she was ninety-three pounds (Farrar,

2014). Athletes sharing their narratives and experiences of their eating disorders has brought

attention and awareness to the high prevalence rate of eating disorders within the athletic

population.

Athlete Risk Factors

Eating disorders are complex and caused by several contributing factors. Gender is

one factor, as the female to male ratio of athletes struggling with eating disorders is ten to

one (Sports Dietitians, 2015; Striegel-Moore et al., 2009). Female athletes are at high risk for

eating disorder onset (Bar et al., 2016; Coelho et al., 2014; National Eating Disorder

Association, 2018). These results do not mean men do not struggle with eating disorders.

Men are at risk of developing an eating disorder as well; however, the incidence and

prevalence rates are much higher within the female population and research indicates females

are significantly more susceptive to eating disorders when compared to males (Lichtenstein,

2018; National Eating Disorder Association, 2018; Sports Dieticians, 2015). This project

focused on the female athlete population.

There are several sport specific risk factors for female athletes. One is the specific

sport of play. Sports emphasizing appearance, individual performance, weight requirements,

muscularity, or body weight as a performance indicator put athletes at a greater risk for

developing an eating disorder (Lichtenstein, 2018; Offord & Kraemer, 2000). These sports

include gymnastics, diving, bodybuilding, wrestling, cross country, and swimming. Athletes

may experience extreme pressure to lose weight, diet, or compulsively exercise to reach their

ideal appearance and weight, especially if they believe this will directly improve their

performance (Voelker et al., 2016). Another sport factor is whether the sport is considered a

team or an individual sport. Female athletes involved in individual sports are at a higher risk

for developing an eating disorder (Coelho et al., 2014; Lichtenstein, 2018; National Eating

Disorder Association, 2018). Individual team sports include gymnastics, running, figure

skating, dance, and diving. Athletes involved in individual sports may feel immense pressure

to control all factors influencing their peak performance. This may be due to not having

teammates to rely on and buffer the performance pressure (Lichtenstein, 2018; Stewart, n.d.).

Sports that focus on individual performance tend to reinforce athletes with an internal locus

of control. These athletes may attempt to control their eating patterns, body weight, and

amounts of exercise in hopes to directly influence their competition outcomes (Bar et al.,

2016; Coelho et al., 2014).

The level of competition in sport is another specific sport factor. Females who have

trained for a sport since childhood and compete at an elite level (i.e., collegiate, national club,

and professional level) are at the highest risk for an eating disorder (Borgen-Sundgot &

Torstveit, 2004). Elite athletes experience more pressure to perform as their finances,

livelihood, and reputation may be on the line. Professional athletes tend to have

characteristics of perfectionism, which is a characteristic correlated to eating disorders

(Muhlheim, 2020; National Eating Disorder Association, 2018). This project explored eating

disorder prevention among elite female individual-sport athletes, as they are at the highest

risk for developing an eating disorder (Bar et al, 2016; Borgen-Sundgot & Torstveit, 2004;

Coelho et al., 2014; Lichtenstein, 2018; National Eating Disorder Association, 2018). The

relationship among sports, exercise and eating disorders has received increasing attention.

This attention has sparked researcher interest in examining the health and performance

concerns associated with athletes struggling with eating disorders.

Athlete Health and Performance Concerns

Female athletes are often body conscious regarding weight and appearance (Coelho,

2014). They may feel the pressure to achieve and maintain an unrealistic body shape and

size. They also may experience demands to be thin to maximize their performance from

parents and coaching staff. Athletes may go to extremes with manipulating eating behaviors

and engaging in overexercise with the belief that it will enhance their performance (Bar et al,

2016; Borgen-Sundgot & Torstveit, 2004; Coelho et al., 2014). These extremes can impact

an athlete’s overall health and it can impede performance long term.

Eating disorders may have serious effects on an athlete’s health physically and

mentally. Restricting types of disorders may result in malnutrition, which can cause the loss

of menstruation and lead to the loss of calcium and bone density (Currie, 2010; National

Eating Disorder Association, 2018). Athletes not receiving adequate nutrition and lacking

bone density are at a greater risk for stress fractures and injuries (Bar et al., 2016; Coelho et

al., 2014). They are more likely to get sick and miss games due to compromised immune

functioning (Insel, 2012; Mehler, 2014; National Eating Disorder Association, 2018). There

are several other negative medical consequences associated with malnutrition that can hinder

an athlete’s quality of performance.

Athletes with severe cases of eating disorders are at risk for more serious health

problems. Athletes with eating disorders may become dehydrated due to electrolyte

imbalances. Dehydration can lead to athletes sitting out of their sport due to cramping, injury,

dizziness, and fainting (Mehler, 2014; National Eating Disorder Association, 2018). Athletes

restricting food intake are at a greater risk for developing anemia, which can cause muscle

weakness, fatigue, hemorrhaging, easy bruising, tachycardia, and lightheadedness (Insel,

2012; Mehler, 2014). Athletes may experience other serious medical complications such as

gastrointestinal issues (i.e, abdominal pain, constipation, and diarrhea), dysregulation of

body temperature, infertility, kidney failure, osteoporosis, metabolic irregularities,

hemorrhaging of the eyes and ears, dental decay, damage to the throat, erosion of the

esophagus, cardiac instability, aspiration, respiratory distress, and sudden death (Cost et al.,

2020; Ekern, 2018; Insel, 2012; Mehler, 2014; Muhlheim, 2020; National Eating Disorder

Association, 2018). There are severe medical complications associated with eating disorders

among athletes, therefore it is imperative to not take these disorders lightly.

Athletes with eating disorders not only suffer physical health consequences but they

also may suffer from mental health issues. Eating disorders may involve considerable

psychological impairment and distress, depending on the level of severity. Eating disorders

are often associated with other psychological disorders such as depression, anxiety, substance

abuse, personality disorders, and obsessive-compulsive disorder (National Eating Disorder

Association, 2018). Athletes with eating disorders may experience decreased concentration,

which affects their overall performance (Lichtenstein, 2018). It is common for athletes to

experience obsessive thoughts regarding eating, food, exercise, and weight (National Eating

Disorder Association, 2018). These obsessions may cause severe distraction and lead to

deteriorating athletic performance. Athletes may experience social isolation due to shame

associated with their disorder, which can lead to long term social impairment (Borgen-

Sundgot & Torstveit, 2010; Currie, 2010).

Eating disorders have direct effect on an athlete’s performance. At first athletes may

believe they can perform well despite their eating disorder, but eventually the athlete’s eating

disorder begins to affect their performance and their health may begin to deteriorate. After

extended periods of restriction, an athlete’s agility, VO2 capacity, and speed decreases

(McCallum Place, n.d.). Malnutrition and lack of carbohydrates results early glycogen

depletion, fatigue, and it causes the body to resort to using protein as fuel (Borgen-Sundgot

& Torstveit, 2010; McCallum Place, n.d.). Inadequate protein intake and reservations lead to

muscle wasting, injury, weakness, and fatigue (National Eating Disorder Association, 2018).

Athletes may lose the ability to concentrate on the game and may struggle to play with

emotion due to negative emotional affect and the effects their eating disorder has on their

body overall (Insel, 2012; Mehler, 2014).

Highest-Risk Athletes

There are specific factors that impact the prevalence of eating disorders within the

female sport setting. One factor is the level and type of sport participation (Borgen-Sundgot,

2004). Studies indicate higher incidence and prevalence rates of eating disorders among high

level elite sport participation (Borgen- Sundgot & Torstveit, 2010). High level elite sport

participation includes athletes competing at the national club, collegiate, and professional

level (Borgen-Sundgot, 2004; National Eating Disorder Association, 2018; Thompson,

2014). Athletes competing in sports where leanness or a specific body weight is important

are more prone to developing eating disorders when compared to athletes competing in sports

where these factors are considered less important (Borgen-Sundgot, 2012). Athletes

competing in sports that focus on the individual rather than the entire team have a higher rate

of eating disorders compared to individuals competing in team sports (Currie, 2010;

Thompson, 2014). Individual sports include sports that focus on the individual rather than the

entire team. Some common individual sports include gymnastics, running, figure skating,

dance, swimming, and diving. Team sports include basketball, soccer, rugby, volleyball, and

lacrosse.

Elite Female Individual Sport Athlete Risk Factors Leading to the Need for Prevention

There are several correlates related to the high prevalence rate of eating disorders

among the athletic population. These include individual and sport specific factors (National

Eating Disorder Association, 2018). There is little prevention research on elite female

athletes participating in individual sports, even though this population has been identified as

having the highest risk (Bar et al., 2016; Levine, 2018; Pearson & Rivers, 2019). The

extensive list of female athlete specific correlates, risk factors, and vulnerabilities calls for a

need to address the issue of the high prevalence rate of eating disorders amongst the elite

female individual sport athletic population. Prevention studies may assist in lowering the

overall prevalence rate amongst this population by determining which prevention

interventions are most effective for prevention and why (Levine, 2018).

Sport Psychologists Addressing the Need for Prevention

Sport psychologists play a crucial role in treatment and prevention of eating disorders

within the athletic setting. The role of a sport psychologist is to provide support and

encouragement to athletes while also challenging eating disorder thoughts and behaviors

(Petrie, 2020; Stewart, n.d.). It is important sport psychologists have specialized training to

be competent in understanding the pressures of competition, the multifaceted issues that

influence athletic performance, and encouraging a balanced approach to training and

competition (McCallum Place, n.d.). It is certain that a sport psychologist will encounter an

athlete struggling with an eating disorder throughout their career, especially for those

working in individual sports that emphasize weight loss (Papathomas & Capicotto, 2017).

Sport psychologists must have knowledge on eating disorders; as they often play a

key role in identifying eating problems and facilitate help for athletes in need or support;

however, they should not practice beyond their scope of training (Stewart, n.d.). Sport

psychologists should encourage open conversations about eating behaviors and use their

awareness of the performance-oriented sport culture as an intervention to bring attention to a

disordered eating issue (McCallum Place, n.d.; Papathomas & Capicotto, 2017). They also

should be aware of an athlete’s early warning signs indicating an eating disorder; as sport

psychologists can implement primary prevention strategies (Arthur-Cameselle et al., 2017). It

has shown to be beneficial for sport psychologists to educate athletes and support staff on

eating disorder early warning signs and symptoms; as peer athletes and support staff are

closest in proximity to the athletes and are more likely to notice performance, behavioral, and

eating changes (Coelho, 2014; Levine, 2018).

Sport psychologists can facilitate prevention interventions to combat the high rates of

eating disorders amongst the elite female individual-sport athletic population. Programs such

as Athletes Targeting Healthy Exercise and Nutrition Alternatives (ATHENA), Preventive

Education Aimed at Eating Disorders, Athlete Modified-Dissonance Based Prevention (AM-

DBP), and Athlete Modified-Healthy Weight Intervention have been implemented by sport

psychologists to assist in eating disorder prevention among athletes (Becker et al., 2012;

Coelho, 2012; Stewart, n.d., Voelker & Petrie, 2019). Researchers have identified a

correlation between athletes experiencing less eating disorder symptoms after receiving each

of these interventions (Bar et al., 2016; Becker et al., 2012). While correlation studies exist,

very few studies assess for the overall effectiveness rate for each of these treatments (Becker

et al,. 2012; Wein, 2018). This has caused an issue in identifying best practice

recommendations for sport psychologists addressing eating disorder prevention (Bar et al.,

2016; Koman, 2018; Pearson & Rivers, 2019; Thompson, 2019). This project further

explored the literature on prevention interventions to determine which eating disorder

prevention interventions are most effective and why in Chapter IV.

This project aimed to identify the most effective prevention interventions sport

psychologists can utilize to lower the eating disorder prevalence rate amongst the elite female

individual-sport athletic population. The passing of Title IX led to an explosion in the

number of female athletes participating in sports. This increase led to more female athletes

becoming vulnerable to eating disorders; therefore, identifying best practices for preventative

interventions are needed now more than ever (Burtka, 2019; National Eating Disorder

Association, 2018).

Women’s Participation in Sports

Female participation in sports has increased immensely across all competitive levels

since the institution of Title IX in 1972 (Women’s Sport Foundation, 2018). Title IX protects

people from discrimination based on sex in athletic programs or activities that receive

Federal financial assistance (National Collegiate Athletic Association, 2018). It also strives

to promote gender equity by encouraging athletic programs to establish an environment that

is free of gender bias and encourages promoting fair and equitable athletic programs (Office

for Civil Rights, 2015). Prior to Title IX only 1% of college athletic budgets went to

women’s sports programs and male athletes outnumbered female athletes twelve to one

(Women’s Sport Foundation, 2018).

Title IX opened doors and removed barriers for girls and women. Female athletes and

their sports programs still have fewer teams, scholarships, and lower budgets than their male

counterparts, but that has not stopped female sport participation from growing. Female sport

participation has grown by 1057% at the high school level and by 614% at the college level

since the implementation of Title IX (National Collegiate Athletic Association, 2018). Title

IX heavily impacted athletic programs and the lives of millions of females. Prior to the

application of Title IX in 1974, fewer than 300,000 females played high school sports, today

the more than 3.1 million females engage in high school sports (Simpson, 2012). Specific

sports became more popular since the Title IX changes, such as: women’s basketball,

volleyball, soccer, softball, cross country, tennis, track and field, golf, and swimming

(Women’s Sport Foundation, 2018).

History of Title IX and Growth of Women’s Sports

Title IX was first developed and passed by congress in 1972 and originally had no

mention of equal opportunity for sports, as it only focused on academic equality (Women’s

Sport Foundation, 2018). In 1973 Sports Illustrated published a series on women in sport to

highlight several ongoing gender concerns in sport, including: the issue of gross inequity and

quality of women’s versus men’s sport programs, the accepted belief that sports were not

essential and too risky for females, and that females were missing out on learning important

life skills by not being involved in sports (Edwards, 2010). In 1974 congress passed the

Javits Amendment, which expanded Title IX to include athletics (Anderson & Osborne,

2008). Although Title IX was passed there were still ongoing issues regarding the equality of

men’s and women’s sports, as men’s teams were continuing to get more funding for coaching

staff, equipment, training services, and locker rooms (Edwards, 2010). It wasn’t until 1992

when the National Association of Collegiate Women’s Athletic Administrators (NACWAA)

created and endorsed a more specific definition of gender equality in sports, which led to

increasing Title IX compliance regarding gender equality in sports (Kane et al., 2013).

The increase in Title IX compliance had a significant impact on the number of

females participating in sports, as the number of females participating in sports went from

one in twenty-seven to one in five (Women’s Sports Foundation, 2018). The statue created

tremendous gains for female athletes by raising visibility and cultural acceptance of women

in sports, creating social bonds for women, and creating more leadership roles (Brake, 2016).

There are still gender inequities in sport, however, the inequity gap has closed significantly

when compared to the gap in the 1970s to the 1990s (Edwards, 2010). The evolution of Title

IX changed the face of women’s athletics.

Impact of Women in Athletics

Title IX created a revolution in women’s sports as the increase in funding allowed

for better coaching staff, equipment, and training; therefore, quality of play in women’s

sports has increased dramatically (Burtka, 2019; Edwards, 2010). The increase in female

sport participation at the college level created a tipping point for elite athletics, as there were

more opportunities for women to cultivate their skills that could eventually land them on a

national or Olympic team (Lind, 2016). The rise in women participating in sports and the

escalation in the quality of play has led to increases in competitiveness in elite level female

sports (Brake, 2016). The heightened levels of competitiveness in female elite sports have led

to increased pressure for females to perform at their highest level (Bar et al., 2016; Burtka,

2019).

Implications of Growth in Women’s Sports

Since the rise in female participation in sports, providers and researchers began to

examine the role sports have in a female athlete’s life (Lind, 2016). The increase in women

participating in sports has led sports medicine health care providers to become more aware of

the unique health concerns, such as eating disorders, within the female athletic population

(Reinking & Alexander, 2005). There is conflicting research on this topic as some experts

believe sports are a protective factor against the development of an eating disorder, while

others believe sports place female athletes at a higher risk of developing an eating disorder

(Bar et al., 2016; Lichtenstein, 2018; Reinking & Alexander, 2005).

Reviews of current literature indicate that female collegiate athletes are more

likely to exhibit eating disorder pathology when compared to male athletes and non-athletes,

with White females having the highest risk (Bar et al., 2016; Moreland et al., 2018;

Thompson, 2019). Researchers identified that it is not athletic participation that increases a

female’s risk of an eating disorder; rather it is the participation in particular sports that

increase the risk of developing an eating disorder (Galmiche et al., 2019; Joy et al., 2016;

Moreland et al., 2018; Thompson, 2019). Eating disorders are complex, multifaceted, and

have several contributing factors such as sociocultural, psychological, biological,

environmental, and behavioral (Bar et al., 2016; Constantz & Mason, 2010; Thompson,

2019). Female athletes are under the same sociocultural pressure as female non-athletes to

obtain an ideal body, but they also have added pressure related to succumbing to the

performance and aesthetic requirements of their sport (Thompson, 2019). Researchers have

shown that female athletes have a higher incidence and prevalence rate of eating disorders if

they participate in individualized sports that emphasize diet, appearance, size, weight

requirements, and an overvalued belief that lower body weight will improve performance

(National Eating Disorder Association, 2018; Thompson, 2019).

Athletes competing in elite levels of competition have a significantly higher risk

for developing an eating disorder due to the extreme pressure for perfection, enhancing

performance, and hitting ideal standards related to body size and image (Bar et al., 2016;

Coelho, 2014). The prevalence rate of eating disorders within the athletic population has

risen over the years, this is likely due to Title IX leading to more females participating in

higher level high-risk sports (Javed et al., 2013; Lichtenstein, 2018; McLean, 2002). As

female sport participation continues to rise within the elite level, more female athletes remain

at an increased risk of developing eating disorders (Coelho, 2014; National Eating Disorder

Association, 2018). The increase in female athletes diagnosed with eating disorders has led to

more research on the effects the disorders have on performance, early identification, and

treatment (Bar et al., Coehlo, 2014, National Eating Disorder Association, 2018). However,

there remains a gap in research on the effectiveness of prevention programs (Stewart et al.,

2014; Stice et al., 2017; Voelker & Petrie, 2019). To combat the increasing risk of female

elite athletes, preventative interventions and protocols were explored utilizing a prevention

science framework.

Prevention Science Framework

Prevention science is a conceptual framework utilized for studying the prevention of

human disfunction (Coie et al., 1993). The overall goal of prevention science is to prevent or

moderate major human dysfunctions. This can be done by mitigating or eliminating the

causes of the disorder. Prevention science is focused on the systematic study of potential

precursors of dysfunction, which includes the study of risk factors and protective factors.

Risk factors are variables associated with an increased probability of onset, greater severity,

and a longer period of mental health problems. Protective factors include conditions that

increase resistance to risk factors of a disorder. Prevention science aims to identify

interventions to counteract risk factors and reinforce protective factors, which will in turn

disrupt the processes that contribute to human dysfunction (Coie et al., 1993).

Classification of Prevention

There are several ways to classify prevention. Prevention is defined by a systematic

process that promotes healthy environments and behaviors and reduces the likelihood of an

illness (Bar et al., 2016). This project will utilize the most common classification scheme

proposed by the Commission on Chronic Illness in 1957 (Dao Le et al., 2017; Mrazek et al.,

1994). The scheme is based on primary, secondary, and tertiary prevention. This

classification scheme identifies interventions according to when they occur in relation to the

development of an illness.

Primary prevention occurs before any symptoms or behaviors develop (Coie,1993).

Primary prevention aims to decrease the number of new cases of a disorder which leads to

lowering the incidence rate (Mrazek, 1994). Secondary prevention occurs when an already

identified disorder (in the early stages) is addressed before it becomes severe (Langmesser &

Verscheure, 2009). Secondary prevention aims to lower the rate of established cases of a

disorder in a population which leads to lowering the prevalence rate (Mrazek, 1994). Tertiary

prevention occurs after a disorder has clearly impacted an individual and attempts to keep the

disorder from getting worse or progressing any further (National Eating Disorder

Association, 2018). Tertiary prevention aims to decrease the amount of disability associated

with a disorder (Mrazek, 1994).

Gordon (1987) believed that disease prevention and health promotion programs could

be based solely on empirical relationships. This led him to create a different classification

system for preventative measures. Gordon’s classification system was based on a risk-benefit

perspective, meaning the risk to an individual of getting a disease must be weighed against

the risk, cost, and discomfort of the preventative intervention (Mrazek, 1994). Gordon’s

system included three categories: universal, selective, and indicated preventative measures.

These categories represented the population groups who would be most optimal to receive

the interventions.

The different types of preventative measures, including universal, selective, and

indicated aim to utilize prevention interventions based on a type of population. Universal

prevention refers to approaches designed for an entire population without regard to individual

risk factors (Coie et al., 1993). Selective prevention refers to strategies targeted to one or

more subgroups of a population determined to be at high risk (Dao Le et al., 2017; Raich et

al., 2010). Indicated prevention refers to strategies targeted to those found to manifest a risk

factor or condition that puts them, individually, at higher risk for the development of a

disorder (Mrazek, 1994). Selective and indicated prevention are similar, however, indicated

prevention involves teaching individuals with an already occurring eating disorder how to

engage in healthy non-disordered ways of eating, the appropriateness of exercise, and ways

to maintain a healthy weight (National Eating Disorder Collaboration, n.d.). Selective

prevention focuses on interventions for individuals not yet experiencing an eating disorder

(Mrazek, 1994).

There are several considerations when determining the type of prevention and

preventative measure to utilize when working with a population. The purpose of the

intervention should be considered before determining if a primary, secondary, and tertiary

prevention is appropriate. If the purpose of prevention is to lower the incidence rate, then a

primary intervention is appropriate. If the purpose of the prevention is to lower the

prevalence rate, then a secondary prevention is beneficial. If the purpose of the prevention is

to enhance the quality of life for an individual already suffering from a disorder, then a

tertiary prevention is optimal. Determining preventative measures includes considering if

preventative measures are meant for an overall population, a higher risk population, or an

extreme risk individual population.

Prevention Science and Eating Disorders

Eating disorders have become a public health concern, however public health

professionals have yet to widely address the issue (Austin, 2012; Bar et al., 2016; Levine,

2019). Prevention science literature is a tool used by practitioners to assist in examining of

what has been achieved in the field so far (Austin, 2012). Recent evidence has documented

eating disorders occurring at increasing rates in both males and females, rising mortality rates

for people diagnosed with eating disorders, and high treatment costs (Austin, 2016; Levine,

2019; Worsfold et al., 2018). Researchers are conducting ongoing research on the efficacy of

specific prevention protocols in response to the rising prevalence and mortality rates and

medical costs associated with eating disorders (Bar et al., 2016; Stice et al., 2014). Eating

disorder prevention has become an important focus due to the serious medical and

psychological effects eating disorders have on individuals. Eating disorders may result in

chronicity and relapse over one’s lifetime, impaired social functioning, increased risks for

depressive disorders, anxiety disorders, substance abuse, health problems, cardiac arrest, and

obesity (Levine, 2018; Stice et al., 2014).

Prevention science operates from a frame of reference that risk factors have a

compounding effect on an individual and have additive effects on illness vulnerability

(Levine, 2018). It is believed the probability of disease may increase as a function of the

number, duration, and harmfulness of the risk factors encountered (Brady et al., 2020; Coie et

al., 1993). Optimally, prevention interventions should be targeted early, when the risk factor

of interest predicts dysfunction (Bar et al., 2016; Coie et al., 1993). Prevention science trials

target high risk populations based on the theory that some people are at high risk for

dysfunctional development by virtue of their exposure to severe or multiple risk factors

(Koepsell et al., 2011).

High-Risk Population

Eating disorders occur in people of all ages (Bar et al., 2016). They occur across all

socio-economic groups and cultures (National Eating Disorder Association, 2018). However,

there are some groups of people with a particularly high level of risk within this broad

demographic. The definition of a high-risk population is a population of individuals that are

more likely than others to get a particular disorder. A high-risk population typically is a

population with several risk factors, which make the individual more susceptible to

developing an eating disorder (Pelzman, 2014). Females, in general, are at a higher risk for

developing eating disorders when compared to men (National Eating Disorder Association,

2018).

Amongst the general female population, the prevalence of eating disorders is highest

among females who participate in elite level sports (Bar et al., 2016; Borgen-Sundgot, 2012).

Females participating in elite sports are three times more likely to have an eating disorder

when compared to the general female population (Koman, 2018). Researchers have indicated

that elite female athletes are at a higher risk due to not only having female risk factors, but

elite female athletes also have sport specific risk factors and more pressure to have a specific

body type related to their sport performance (Coelho et al., 2014; National Eating Disorder

Association, 2018). Elite female athletes appear to have the highest prevalence rate when

compared to other female athletes participating in lower competitive sports (Bar et al., 2016;

Brady et al., 2020). Elite female athletes are more vulnerable to eating disorders due to the

pressure to have a sport specific body type to perform at an elite status (Koman, 2018).

Prevention science may assist in addressing the issue of the high prevalence and incidence

rate of eating disorders amongst elite female individual sport athletes.

Elite Female Individual-Sport Athletes and Prevention Science

Elite female individual-sport athletes are identified as the most vulnerable and the

highest-risk population to develop an eating disorder due to several risk factors, the pressure

to perform at an elite status, and the need to meet sport specific body ideals (Bar et al., 2016;

Weir, 2018). Prevention science can help better understand ways to address the concern of

the elite female individual-sport athletic population having eating disorders at high rates

(Scott et al., 2019). Primary prevention efforts aim to prevent the emergence of an illness or

disorder by influencing correlates and risk factors contributing to the development of an

eating disorder (Coelho, 2014). Meta-analytic reviews of published prevention trials

indicated that larger intervention effects tended to emerge for protocols focusing on indicated

prevention strategies when compared to universal and selective prevention strategies

(Chithambo, 2017; Coelho, 2014; Stice, 2013). These specific indicated prevention

interventions will be further explored in Chapter IV.

Knowledge Gaps

There are several knowledge gaps regarding the topic of eating disorder prevention

within the elite female individual-sport athletic population. There is some empirical data on

the extent of the issue of eating disorders amongst the elite female individual-sport athletic

population, but there is very little data on the effectiveness of prevention (Bar et al., 2016;

Coelho, 2014; Pearson & Rivers 2019). Very few studies focus on the highest-risk athletes,

such as elite female athletes competing in individual sports (Weir, 2018; Pearson & Rivers,

2019; Thompson, 2019).

There is also a gap in research regarding the length of time prevention interventions

work for combating eating disorders amongst the female athlete population (Bar et al., 2016).

There is a research-practice gap among researchers and clinicians, which makes it hard to

assess the efficacy of prevention interventions due to the lack of implementing the

preventions within the sport setting (Bar et al., 2016; Tetyana, 2012). This has left many

sport psychologists unsure of the best approach to eating disorder prevention within the

athletic setting (Hildebrandt, 2005; Weir, 2018; Stewart, n.d.). There is also a lack of

consistency for prevalence rate data, as the prevalence rate of female athletes with eating

disorders varies between studies (Weir, 2018; Pearson & Rivers, 2019).

Lack of Studies on High-Risk Female Athletes and Prevention

There is a lack of sport science and research conducted on elite female individual-

sport athletes, which makes it challenging to develop evidence-informed approaches to

preventative interventions (Emmonds et al., 2019). The lack of research on this population

also leads to a gap in knowledge regarding the efficacy rate of prevention strategies within

this population (Bar et al., 2016; Stewart et al., 2019). The research-practice gap is a concern

regarding assessing the efficacy and practicality of preventative interventions. This may be

due to the lack of dissemination and promotion of evidence-based prevention programs (Bar

et al.,2016; Pearson & Rivers, 2019; Tetyana, 2012). There are general studies that focus on

universal eating disorder prevention interventions within female athletes in general, however

it is not known if these interventions are effective for selective and indicated prevention

(Emmonds et al., 2019; Pearson & Rivers 2019). The very few prevention studies amongst

the elite female athletic population lack evidence for how long the prevention treatment

works (Bar et al., 2016; Gorrell et al., 2019). It would be ideal to find prevention

interventions that will have a long-term impact on the elite female individual-sport athletic

population.

Prevalence Rates

While literature shows conflicting evidence to prove female athletes are more at risk

of developing an eating disorder when compared to the non-athlete female population;

research indicates that sport specific athletes competing at an elite level are at a higher risk of

developing an eating disorder overall (Lichtenstein, 2018). However, the prevalence rate

among these elite athletes varies widely in research (Mancine et al., 2020). Factors such as

sample sizes, comparison groups, appropriate instruments for measurement, and confounding

variables may be leading to the inconsistent reports of prevalence rates (Coelho et al., 2014;

Thompson, 2019). Inadequate sample sizes may be skewing the prevalence rates due to

increasing the sampling error and making the sample statistic more variable. An inadequate

of number of comparison groups may also be leading to the wide prevalence rate.

A lack of focus on specific environmental elements that predispose athletes may be

leading to a failure to account for confounding variables, which may be threatening interval

validity of the studies. An inadequate measurement instrument may be contributing to the

wide variety of prevalence rates. Most studies assessing the prevalence rate for female

athletes with eating disorders utilized a self-report measurement to assess for the presence of

an eating disorder (Bar et al., 2016; Coelho et al., 2014). This becomes problematic for

athletes who are reluctant to report any eating disorder symptoms due to fears related to the

stigma of having an eating disorder within the sporting arena. Additional research that

addresses the concern of a lack of sample sizes, comparison groups, focus on confounding

variables, and appropriate measurement instruments are needed to further investigate the

accuracy of reported prevalence rates amongst the female athletic population.

Summary

While there is conflicting evidence indicating that athletes in general seem to have

similar risks of developing eating disorders as non-athletes, the elite female individual-sport

population present a higher prevalence rate of eating disorders than the general population

(Borgen-Sundgot, 2012; Bullard, 2015; Emmonds et al., 2019). As a result of the 1972 Title

IX mandate, more female athletes are participating in individual elite level sports today than

in the past (De Bruin & Oudejans, 2018; National Collegiate Athletic Association, 2018;

National Eating Disorder Association, 2018; Women’s Sport Foundation, 2018). The rise in

the number of female athletes at the highest risk for developing an eating disorder has created

a need for focusing on prevention strategies due to prevalence rates also rising (Lichtenstein,

2018; Thompson, 2019).

Prevention science utilized at an optimal level focuses on early prevention or

prevention before an individual starts to develop symptoms and it targets highest-risk

populations (Brady et al., 2020; Coie et al., 1993; Koepsell et al., 2011). Sport psychologists

can play a crucial part in enhancing an athlete’s overall mental health and can be the key

individual involved in implementing eating disorder prevention interventions (Stewart, n.d.).

There is research on sport psychology prevention programs, but there are inconsistencies in

the level of effectiveness and the outcomes (Bar et al., 2016; Thompson, 2019). There is also

a lack of implementation and promotion of such programs (Arthur-Cameselle et al., 2017:

Stewart, n.d.) There are currently no sport psychology best practice guidelines for eating

disorder prevention, which puts sport psychologists in a tough position when it comes to

addressing the need for eating disorder prevention (Papathomas & Capicotto, 2017). A

further assessment of prevention intervention efficacy literature was conducted in Chapter IV

to better identify potential best practices for sport psychologists.

The purpose of this systematic literature review was to explore what sport psychology

preventative interventions are effective for eating disorders within elite female individual-

sport athletes, and to create best-practice recommendations for preventing eating disorders

within this population. This project focused on primary prevention with indicated prevention

measures to target combating the prevalence rate of eating disorders amongst the indicated

highest-risk population. Protocols revealed by the project may contribute to the sport

psychology field by providing sport psychologists guidance on how to best address the need

for eating disorder prevention amongst the highest-risk female athletic population. The

identified protocols will be promoted within several athletic settings to encourage

implementation. These results may assist sport psychologists in combating the risk factors

associated with athletes developing eating disorders and possibly lower the overall rates of

athletes diagnosed.

This project utilized a Systematic Literature Review to identify the most effective

eating disorder prevention interventions for Sport Psychologists working with the highest

risk female athlete population. Literature was synthesized, analyzed, compared, contrasted,

and combined to answer this project’s research question. This approach was chosen to

identify, synthesize, summarize, and evaluate existing research findings on this topic to assist

in making the available evidence more accessible to sport psychologists. Chapter III further

discusses this project’s specific procedures followed and the overall approach.

CHAPTER III: PROJECT APPROACH

The purpose of this chapter is to introduce the project approach for this systematic

literature review regarding sport psychology best practice recommendations for preventing

eating disorders within the athletic population. This chapter reviews the project’s research

questions, project approach, inclusion and exclusion criteria, literature collection method, and

an analysis of the data. There is currently a lack of sport psychology best practice prevention

interventions for eating disorders (Bratland-Sanda & Borgen-Sundgot, 2013; Joy et al.,

2016). The purpose of the systematic literature review was to synthesize and analyze what

sport psychology preventative interventions are effective for eating disorders within female

individual elite sports, and to create best-practice recommendations for preventing eating

disorders within this population. Protocols revealed by the project attempt to assist sport

psychologists in combating the risk factors associated with athletes developing eating

disorders and possibly lower the overall rates of athletes diagnosed.

Project Approach

The approach for this project was a systematic literature review. The review used

Liberati et al.’s (2009) Preferred Reporting Items for Systematic Reviews (PRISMA)

method. The PRISMA method assists researchers in ensuring their reviews are transparent

and they follow an evidence-based set of items through using the PRISMA checklist and

flow diagram (Moher et al., 2009). The project followed the specific seven step protocols for

the PRISMA method, which included: conducting a database search (selection), identifying

terms, determining inclusion and exclusion criteria, collecting literature, removing duplicate

literature, screening (and rescreening) literature for eligibility, and reviewing and analyzing

the literature (Liberati et al., 2009). This protocol assisted the researcher in identifying,

sorting, and analyzing literature that contains data pertinent to eating disorder prevention

interventions within the elite athletic population.

Over-arching Research Questions

This project addressed the following overarching questions:

1. Which eating disorder prevention interventions have been most effective for sport

psychologists working with the athletic population?

2. Why are these interventions most effective?

3. What are best-practice recommendations for sport psychologists to prevent eating

disorders within the athletic population, particularly with respect to elite female

athletes in individual sports?

The findings from this systematic data collection and analysis were used to identify best-

practice recommendations that sport psychologists, coaching staff, and athletes may assist in

lowering the eating disorder prevalence rates among the elite female athletes in individual

sports population.

Population and Sample

No human participants were directly involved in this project, which was consistent

with the systematic literature review methodology. Literature was extracted, synthesized, and

analyzed from published literature instead of extracting data from a participant sample. The

literature included for this project included material on eating disorders within the female

athletic population with a specific focus on eating disorder prevention programs for sport

psychologists. Elite female athletes were chosen for this project as they have easy access to

sport psychology services. Sport psychologists are more likely to be included in the coaching

staff for teams that have funding to support their services. Elite sports teams tend to have

higher funding which means they are more likely to hire sport psychologists. Therefore, the

protocol pamphlet resulted from this project was created and formulated for sport

psychologists and practitioners working with the elite female athletic population.

Ethical Concerns

No human participants were directly involved in this project. This project involved

collection and analysis of peer-reviewed literature pertaining to eating disorder prevention

for elite female athletes. Results were produced from samples of literature; therefore, no

protocols related to human participation were necessary. The project had no ethical concerns

regarding the sample population, as no human participants were used in the project. A

systematic literature review is exempt from protocols such as obtaining informed consent,

protecting participant confidentiality, and securing participant data. The project did not have

ethical concerns regarding human participants, but that does not mean it was free from all

limitations. Researcher bias was an ethical concern, as the researcher determined the

eligibility and ineligibility of the literature included in the review. The project’s conclusions

were based on the interpretations of findings from the researcher’s perspective, which may

have exposed the results to bias. Bracketing was used to mitigate the potentially deleterious

effects of researcher bias. Bracketing is the process of setting aside any researcher biases,

experiences, preconceived notions about the research topic (Fischer, 2009). Bracketing was

executed through the process of reflexivity and epoche. Reflexivity required continual

researcher self-reflection to ensure personal bias and experiences were not interfering with

the objective research process (Dodgson, 2019). Epoche is the process of suspending all

judgement related to the research topic (Fischer, 2009). Any researcher biases that may have

influenced the results of the project were noted for transparency purposes.

Literature Collection

The instrumentation for the systematic literature review included information sources.

Information sources for the project included electronic databases, an excel spreadsheet to

manage data, and the PRISMA checklist and flow chart. The PRISMA checklist and flow

chart guided the researcher in obtaining relevant and appropriate literature, as well as

identifying themes, strengths, and gaps in the literature (Moher et al., 2009). The PRISMA

checklist and flow chart provided an evidence-based set of items for reporting in the

systematic review, and it was used as a basis for evaluations of interventions, therefore it was

appropriate for this project (Liberati et al., 2009).

The literature collection process included collecting relevant scholarly and

professional literature through an internet search. The University of Arizona Global Campus

library’s online databases were accessed, including: ProQuest, ERIC, EBSCOHOST, and

SAGE databases. Inter-library loans by The University of Arizona Global Campus librarians

assisted in retrieving literature. The Taylor & Francis Online professional database

administered by the Association for Applied Sport Psychology (AASP) was searched for

professional literature. The American Psychological Association and the National Eating

Disorder Association professional association database sources were utilized. Google Scholar

and general internet searches were used. Sources of information included peer-reviewed

journal articles, professional literature, books, grey literature, theses, dissertations, and

conference papers. Keywords and Boolean phrases were searched. The keywords and phrases

included but were not limited to: eating disorders, eating disorders among athletes,

prevention of eating disorders, prevention of eating disorders among athletes, prevalence of

eating disorders in athletes, sport psychology and eating disorders, sport psychology eating

disorder prevention, risk factors related to eating disorders, and prevention science and

eating disorders. Literature that fit the eligibility criteria was collected and analyzed.

Inclusion Criteria

Establishing inclusion and exclusion criteria is a standard practice for a systematic

literature review (Patino & Ferreira, 2018). Inclusion criteria are a set of predefined

characteristics used to identify literature included in a research project (Salkind, 2010). These

criteria include the essential characteristics that the researcher should abide by to answer the

project questions. The literature compiled by this literature review was primarily based on

peer-reviewed scholarly and professional literature. The inclusion criteria included studies

focusing on elite female athletes over the age of eighteen that concentrated on eating

disorders. Studies were collected by utilizing the PRIMA method protocols. All studies

relevant to addressing the project questions were included in this review. This project’s

research question aimed to identify best practices for eating disorder prevention within the

elite female individual-sport population, however, due to the lack of an adequate number of

studies on this specific population; literature was expanded to focus on the elite female

athletic population.

Exclusion Criteria

Exclusion criteria is another critical component of a systematic literature review. It

includes criteria that meets the inclusion criteria but presents with additional characteristics

that could interfere with the success of the project (Patino & Ferreira, 2018). The primary

exclusion criteria for this project included articles with a publication date exceeding five

years prior to the completion of this project, or prior to 2016. The year 2016 was chosen due

to the lack of literature available within the last 5 years; therefore, a six year time lapse was

deemed appropriate to conduct this SLR. Literature exceeding this limit was not considered

unless it was seminal literature. Literature not written in English was not considered for this

project, as interpretations of the findings may have been convoluted. Studies focusing on

males, non-athletes, children under the age of eighteen, and recreational athletes were

excluded. Literature not directly relevant to the project questions were not included in this

review.

Analysis of Literature

Literature that met the inclusion and exclusion criteria was analyzed to answer the

project’s research questions. As data was collected and literature was reviewed, an Excel

spreadsheet was filled out to track categories that allowed for the researcher to easily identify

the sample size, intervention types, and results of the studies. As the analysis continued,

common themes emerged from the literature and were tracked on a master chart and then

were tabled separately for further evaluation and assessment.

The PRISMA flow chart was utilized to track all searches of databases, registers, and

other sources used in the project. It also assisted with organizing the literature that was

identified, screened, and included in this project. The PRISMA protocol checklist was used

to ensure protocols were followed while collecting literature for this project. This included

identifying clear objectives and rationale for this study. It also included determining

eligibility criteria, a search strategy, ways to manage data, and identifying the selection and

data collection processes. The PRISMA flow chart also provided protocols for data synthesis.

It provided a framework to describe and synthesize the findings from the data collection. The

PRISMA protocols allowed for a structured method of data collection and data syntheses.

The results of the analyses were expected to indicate which sport psychology prevention

interventions are most effective for elite female athletes participating in individual sports.

The analysis of literature is not the only important aspect of a SLR. Trustworthiness is

important to consider, as this can play a part in the quality of the results.

Trustworthiness and Quality of Results

Trustworthiness refers to the degree of confidence in data, interpretation, and

methods exists to ensure the quality of the project (Connelly, 2016). A systematic literature

review is considered an objective method to collect, analyze, synthesize, and interpret

literature from research (Liberati et al., 2009). Trustworthiness is a critical component of a

systematic literature review, as it assists in determining the level of objectivity involved in

the research process. Trustworthiness is typically measured by addressing a project’s

credibility, transferability, dependability, and conformability (Moher et al., 2009). However,

the trustworthiness of this systematic literature review was based on the principled actions of

the researcher. Researcher bias in evaluating the findings was considered to ensure

trustworthiness in this project. Bias was mitigated through bracketing and practices of

reflexivity and epoche. Reflexivity was practiced through the researcher using a journal to

track the research process. The trustworthiness of this project depended on the quality of the

literature reviewed, as well as properly following protocol from the PRISMA method.

Specific criteria such as ensuring articles were scholarly, professional, and peer reviewed

assisted in ensuring there was trustworthiness of the literature.

Summary

The purpose of this systematic literature review was to explore what sport psychology

preventative interventions are effective for eating disorders within elite female individual-

sport athletes, and to create best-practice recommendations for preventing eating disorders

within this population. The findings were assessed and used to determine which interventions

could be considered best-practice recommendations for elite female athletes competing in

individual sports. This systematic literature review used the PRISMA standardized method to

screen for eligible literature and to provide a map to identify relevant articles. Chapter IV

will further discuss the findings from this systematic review. It includes a discussion on the

PRISMA flow chart, summarizes findings from the review, describes pertinent tables and

charts and further evaluates the findings from the project to determine appropriate

recommendations.

CHAPTER IV: FINDINGS AND RECOMMENDATIONS

The purpose of this chapter is to synthesize and analyze literature related to

identifying sport psychology practices to prevent eating disorders among elite female

individual-sport athletes. This project entailed gathering peer-reviewed research on the

efficacy of current sport psychology prevention interventions implemented with elite female

athletes. The results of this project informed a protocol pamphlet to educate athletes and

coaching staff on sport psychology eating disorder prevention (see Appendix). The pamphlet

will be presented in several athletic settings and online to assist in combating the high

prevalence rate of eating disorders within elite female individual-sport athletes. This chapter

presents the findings of this systematic literature review (SLR) and is divided into three

sections: (a) findings (including sample and data collection process); (b) evaluation of

findings (including themes, literature and conceptual framework, suggestions based on

literature, and unexpected findings; importance of findings for research and practice); and (c)

recommendations (including limitations and implications for practice, and recommendations

for future research).

Findings

This section is divided into two sections: the sample and the data collection. Peer-

reviewed literature served as the sample for this SLR. This project’s sample of human

participants within the peer-reviewed literature were assessed to determine inclusion, or

exclusion with reason(s). The literature collected from this study was used to answer the

research questions. The PRISMA SLR protocols were utilized during the data collection

process. Figure 1 in this section displays the PRISMA Flow Diagram of the data collection

process.

Sample

No human participants were directly involved in this systematic literature review. The

participant demographics from the literature analyzed were a determining factor in whether

studies met the inclusion criteria or were excluded, as only studies conducted in the United

States focusing on elite female individual sport athletes over the age of eighteen that

concentrated on eating disorders were analyzed. All studies relevant to addressing the project

questions were included in this review. Thus, studies were included if the units of study were

adult elite individual sport female athletes.

The studies needed to be written in English, with full text access available to the

researcher. Studies were excluded if participants were minors, if they identified as a male, or

were not published prior to 2016. The year 2016 was chosen due to a lack of studies from

2017-2022. The purpose of this SLR was to explore what sport psychology preventative

interventions are effective for eating disorders within elite female individual-sport athletes,

and to create best-practice recommendations for preventing eating disorders within this

population. Qualitative, quantitative, and mixed methods studies were all included in the

SLR.

Sample and PRISMA Protocol

This systematic literature review (SLR) followed the specific PRISMA protocol

guidelines to collect the data necessary to obtain the findings of this study. Specific samples

of literature were selected to be included in the study to best represent the population of elite

individual sport female athletes. The data collected included criteria that was determine

during the PRISMA process. Further description of the selected sample and data collection

process is described below.

Literature/Sample Collection

The PRISMA protocol guidelines were followed as a framework for the literature

collection process of this project. This allowed for a structured and organized method of data

collection. Specific samples of literature were selected to be included in the project to best

represent the population of elite individual sport female athletes. The data collected included

criteria that was determined during the PRISMA process. Further description of the selected

sample and data collection process is described below.

Figure 1

PRISMA Data Collection

PRISMA 2009 Flow Diagram

This is a modified version of Moher et al.’s (2009) original PRISMA Flow Diagram.

Records identified through database searching

(n = 625)

Sc re

en in

g In

cl ud

E lig

ib ili

Id en

tif ic

at io

Additional records identified through other sources

(n = 5)

Records after duplicates removed (n = 361)

Records screened (n = 361)

Records excluded (n = 329) )

Full-text articles assessed for eligibility

(n = 32)

Full-text articles excluded, with reasons

(n=11)

Studies included in qualitative synthesis

(n =21)

Reasons excluded Under age 18 (n = 3)

Male only participants (n = 2) Not Published within 5 years (n=3)

Included non-elite female individual sport athletes (n=3)

Table 2

21 Included Articles in SLR

Author/Year Study

Design

N Intervention(s) Research Findings

Voelker & Galli

(2019)

Qualitative

31 ATHENA, AM- CBT, AM-HWI, The Victory Program, education to coaching staff, and destigmatizing discussing eating disorders.

Each intervention was effective in reducing eating disorder symptoms; however athletes preferred the Healthy Weight program the most.

Bundă & Bratu (2016)

Qualitative

8 Education to coaching staff, early diagnostics, and destigmatizing discussing eating disorders.

Coaches’ education on recognizing how an emphasis on bodyweight, thinness and disregarding an athlete’s health is the most important factor in developing an eating disorder. Early diagnostics allow for early intervention and prevent the disorder from getting worse. Stigma associated with eating disorders must be removed so athletes do not feel they are being treated as a negligible cost, which deters them from receiving prevention and treatment.

Bruin (2017)

Qualitative 7 Education to coaching staff and early intervention.

Coaches being educated allows for them to have better management skills and is correlated with early intervention with athletes.

Mountjoy et al.

(2018)

Qualitative 23 Education to coaching staff, peer led education, AM-CBT, Gender Specific Programs, and inclusion of sport policy and regulations in prevention.

Coaches being educated on symptoms and ways to identify eating disorder behaviors has been helpful in early prevention. Peer-based eating disorder/body image/education and cognitive dissonance- based programs have shown promise in preventing eating disorders among the athletic population.

Thompson (2019)

Qualitative 5 Education to coaching staff and athletes, challenging attitudes, beliefs, and behaviors associated with eating disorders (AM-CBT), body image, and the emphasis on leanness, early detection for symptoms by coaching staff, and destigmatizing discussion on eating disorders.

Coaches being educated leads to earlier detection and prevention. Challenging attitudes, beliefs, and behaviors associated with eating disorders, body image, and the emphasis on leanness is helpful with athletes not believing misconceptions about eating disorders enhancing performance. Destigmatizing talking about eating disorders may lead to athletes seeking help earlier.

Coelho et al. (2016)

Qualitative 14

Preventative education aimed at coaches and athletes, ATHENA, nutrition and psychological interventions, AM-CBT and AM-HWI.

Preventative education for athletes and coaches decreased the prevalence of eating disorders. ATHENA was effective at reducing eating disorder behaviors. AM- DPB and AM-HWI reduced dietary restraint, shape, and weight concerns. Both reduced the risk of ED but HWI was preferred by athletes.

Power et al.

(2020) Qualitative

21 Preventative education

aimed at athletes and coaches

Preventative education for athletes and coaches was effective if it focused on: proper nutrition, maladaptive eating patterns and their health consequences, learning how to address eating disorder issues, restriction leading to decreased athletic performance, and teaching athletes how to evaluate maladaptive eating and exercise behaviors.

Stranberg & Quatromoni

(2017)

Qualitative

Preventative education aimed at a multidisciplinary team and athletes.

Having a multidisciplinary team educated on eating disorders helps with early detection and preventative education. Education focusing on how much food is necessary for peak performance was helpful with decreasing eating disorder behaviors.

Rosa- Caldwell (2018)

Quantitative 51 Preventative education for athletes and coaching staff.

NCAA athletes were surveyed to assess how much they know about ED symptoms. The average score was 69%; only 23% getting above 80%, despite the athletes believing their knowledge was good. There is a need for more efforts to improve awareness through educational programs for both athletes and coaching staff.

Chang (2019)

Qualitative 11 Annual screening, CBT therapy, and prevention education for athletes and coaching staff.

Annual screening, CBT therapy, and prevention education for athletes and coaching staff are all beneficial for reducing the prevalence rate of eating disorders among collegiate athletes.

Stewart et al. (2019)

Mixed Methods

481 Female Athlete Body (FAB) project interventions, which is an AM-CBT based intervention.

Linear mixed effects models with team as a cluster level variable and study condition as a between‐subjects variable revealed significantly reduced dietary restraint in FAB teams relative to control teams. FAB teams also reported significantly fewer objective and subjective binge episodes than control teams. Finally, FAB teams showed significantly lower thin‐ ideal internalization and increased BMI at 18‐ months.

Stewart et al. (2017)

Mixed Methods

481 FAB, which is an AM- CBT based intervention

FAB participants had a decrease in weight in shape concerns compared to control participants. The FAB program was effective in increasing body satisfaction, ED awareness, ED prevention, and lowering modifiable risk factors.

Conviser et al.

(2018)

Qualitative 13

The Victory Program at McCallum Place

The Victory Program which includes: a multidisciplinary team, efforts for early detection and referral, educational programs for all multidisciplinary staff and athletes, efforts to destigmatize the discussion on eating disorders, and encourages the usage of ED assessments throughout the year has found to be effective in lowering the rate of unhealthy eating behaviors.

Voelker & Petrie (2021)

Qualitative 116 Bodies in Motion- AM- CBT and Compassion Based Interventions

The Bodies in Motion Program (a form of dissonance based intervention) has qualitative data demonstrating promise for improving athlete’s body image and reducing eating disorder risks.

Joy et al. (2016)

Qualitative 8 Prevention education for coaches and athletes

Studies on prevention education programs for athletes resulted in improved bulimic pathology and increased the number of athletes seeking medical care due to concerns about eating disorder symptoms.

Bar et al. (2016)

Qualitative 5 AM-HWI, AM-CBT, and prevention education for coaching staff and athletes

Both AM-HWI and AM- CBT participants had a decrease in weight and body-imagine concerns compared to control participants.

Stice et al. (2021)

Mixed

Methods

15 AM-HWI, AM-CBT, and prevention education programs

AM-HWI had little to no significant impact on decreasing the number of athletes with developing an onset of EDs. AM- CBT programs significantly reduced future onset of EDs in multiple trials.

Stice et al. (2017)

Quantitative 680 AM-HWI, AM-DPB, and prevention education for coaching staff and athletes

Both AM-HWI and AM- CBT participants had a decrease in weight and body-imagine concerns compared to control participants.

Hines et al. (2019)

Qualitative 10 Prevention education focused on athletes and coaching staff and destigmatizing seeking help for EDs.

Participants educated identified more appropriate potential symptoms of an eating disorder than those who were uneducated; however, education was not correlated with whether an individual sought help for an ED or not. This may indicate a need to focus on destigmatizing seeking help for treatment.

Scott et al. (2019)

Mixed

Methods

24 Prevention education for athletes/teammates only.

Teammates are an important source of influence on athletes eating attitudes and behaviors. Participants who were a part of a peer led athlete prevention education program tended to be more vigilant against unhealthy eating behaviors and endorsed more healthy eating practices.

Data Collection

This project followed the specific seven-step protocol for the PRISMA method,

which included: (a) identifying a research question, (b) defining inclusion and exclusion

criteria, (c) searching for empirical studies, (d) selecting studies based on criteria, (e)

extracting raw data in the studies, (f) evaluating the risk of bias for the studies selected, (g)

presenting results from the studies selected, and (h) assessing the quality of evidence from

each empirical study (Choi et al., 2019). This protocol assisted the researcher in identifying,

sorting, and analyzing literature that contains data pertinent to eating disorder prevention

interventions within the elite athletic population. This process included creating a map to

answer the over-arching project questions.

The literature collection process included collecting relevant scholarly and

professional literature through an internet search. The University of Arizona Global Campus

library’s online databases were accessed, including ProQuest, ERIC, EBSCOHOST, and

SAGE databases. Inter-library loans by The University of Arizona Global Campus librarians

assisted in retrieving literature. The Taylor & Francis Online professional database produced

by the Association for Applied Sport Psychology (AASP) was searched for professional

literature. The American Psychological Association and the National Eating Disorder

Sandgreen et

al. (2020)

Mixed

Methods

17 Preventative education aimed at coaches and athletes, ATHENA, nutrition and psychological interventions, AM-CBT and AM-HWI.

The study concluded the complex nature of the prevention interventions, combined with a lack of evaluation data and poor methodological quality, limits the scaling and refinement of many interventions

Association professional association database sources were utilized. Google Scholar and

general internet searches were used. Sources of information included peer-reviewed journal

articles, professional literature, books, grey literature, theses, dissertations, and conference

papers. Keywords and Boolean phrases were searched. The keywords and phrases included

but were not limited to eating disorders, eating disorders among athletes, prevention of eating

disorders, prevention of eating disorders among athletes, prevalence of eating disorders in

athletes, sport psychology and eating disorders, sport psychology eating disorder prevention,

risk factors related to eating disorders, and prevention science and eating disorders. Literature

that fit the eligibility criteria was collected and analyzed (see Table 2).

Literature Search Results

Searches using the search terms and Boolean phrases for this review resulted in 625

peer-reviewed articles and five additional records identified through other sources. After all

databases were thoroughly searched with the Boolean phrases and duplicate articles were

removed, 361 articles remained. 329 articles were excluded because the title and or abstract

had no relation to elite female athletes participating in individual sports, the publication date

was not within six years of the current date, the researcher did not have full access to the

works’ content, the articles were not published in English, or the participants were under the

age of 18. This left 32 studies that were then reviewed in-depth to assess for inclusion and

exclusion based on reason(s). After all studies were thoroughly scanned, 11 were excluded

and 21 were determined eligible and analyzed (see Figure 1). The remaining 21 studies were

included in this SLR and consisted of 14 qualitative, two quantitative, and five mixed-

methods studies.

Evaluation of Findings

To analyze and evaluate the literature, the researcher compiled and created a master

data collection chart in Microsoft Excel that tabled information from the 21 articles into the

following descriptive rows: (a) author(s) and date; (b) study design; (c) participant number;

(d) prevention intervention; (e) main research findings; (f) themes; and (g) suggestions. Table

2 demonstrates a truncated chart of this information. This master chart assisted the researcher

in comparison, synthesis, and analysis of data from all 21 studies, which resulted in the

identification of five themes.

The five themes were categorized into two different categories including:

protocolized prevention interventions and non-protocolized prevention interventions (see

Table 3). Thorough analysis of the data also revealed several overlapping suggestions,

limitations, and contradictory findings. The findings were evaluated to determine the best

answer to this project’s research questions. After analysis of the literature, findings reflected

several effective eating disorder prevention interventions among the elite female sport

population.

Table 3 Category of Themes

Protocolized Prevention Intervention

Non-protocolized Prevention Intervention

CBT/AM-DBP Prevention Education AM-HWI The Victory Program ATHENA

Themes

A total of five different prevention intervention themes emerged from this project.

Results from the studies indicated these five prevention interventions were effective with the

prevention of eating disorders among the elite female individual sport population. Each

intervention has its own individualized approach. The five themes emerged from this project

were: (a) athlete modified cognitive-behavioral-dissonance-based interventions (AM-CBT),

(b) athlete modified healthy weight focus interventions (AM-HWI), (c) the Victory Program

at McCallum Place (VPMP), (d) Athletes Targeting Healthy Exercise and Nutrition

Alternatives (ATHENA), (e) prevention education (PE) aimed at coaches, multidisciplinary

staff, and athletes that focuses on nutrition, destigmatizing the discussion around eating

disorders, eating disorder symptom and warning signs education.

Description of Themes

The themes that emerged were consistent with literature on effective eating disorder

prevention interventions previously implemented among female elite athletes. The specific

themes included eating disorder prevention interventions that were found to be effective

when implemented directly among female elite athletes participating in individual sports. The

interventions require either a trained sport psychologist, a coaching staff member, or elite

female athlete peer to conduct the intervention. Each intervention requires its own specific

protocols or directions to be successfully implemented. Table 4 includes an overview of each

theme and the studies discussing the efficacy of each theme.

AM-CBT Intervention.

Cognitive behavioral preventative interventions focus on identifying unhealthy

thinking patterns related to weight and diet within sport and challenging them to ensure

healthier thinking patterns are guiding an athlete’s behaviors. The intervention focuses on

challenging unhealthy thinking patterns and reframing thoughts around weight and diet from

a healthier perspective (Bunda & Bratu, 2016; Voelker & Galli, 2009). This intervention is

typically conducted by a sport psychologist trained in this type of intervention (Bruin, 2017).

This intervention requires reframing cognitions based around eating and diet, which leads to

better behavioral decisions based around food and diet choices (Bunda & Bratu, 2016). There

are different cognitive behavioral interventions. One specific effective cognitive behavioral

intervention for preventing eating disorders among elite female athletes is cognitive-

dissonance-based interventions (Bunda & Bratu, 2016; Bruin 2017). Cognitive-dissonance-

based interventions create psychological discomfort to motivate an individual to reduce

cognitive discord by changing their beliefs (NEDA, 2018). A sport psychologist will do this

by creating an environment in which an athlete will become motivated to no longer idolize an

unhealthy sociocultural ideal.

Dissonance based prevention interventions focus on critiquing the thin ideal within a

sport, which reduces the pursuit of the unhealthy ideal (Mountjoy et al., 2018). This

intervention attempts to produce attitudinal change by altering neural representation of

valuation to thin and unhealthy models within sport. Altering the beliefs and cognitive

representations around a thin ideal then leads to athletes not glorifying this ideal (Thompson,

2019). This intervention is led by trained sport psychologists to assist athletes in developing

healthier attitudes towards their sport ideals (Coelho et al., 2014). This leads to athletes

creating and working towards a healthier ideal body type for their sport, rather than focusing

on a thin and unhealthy ideal (Mountjoy et al., 2018).

AM-HWI Intervention.

The healthy weight prevention intervention focuses on providing elite female athletes

with factual and correct information about their sport ideals (Bar et al., 2016). The belief is

that the more educated the athletes are on healthy weight for their best performance, the less

likely they are to idealize a thin athlete ideal (Voelker & Galli, 2009). This can lead to less

athletes making dramatic changes to their weight and diet as they are aware that this deters

them from reaching their peak performance body ideal (Coelho et al., 2014). This

intervention is conducted by a trained sport psychologist (Bar et al., 2016).

This program endorses healthy changes in dietary intake and physical activity, targets

to increase body satisfaction by teaching athletes to manage their weight with healthy and

balanced means (Stewart et al., 2004). Participants in this program evaluate eating and

exercise habits via self-monitoring and then commit to small, manageable changes to diet and

exercises through home assignments (Stice, 2001). This allows for participants to make small

manageable lifestyle changes to promote healthier lifestyles. The athlete modified healthy

weight focus prevention intervention assists athletes in both behavioral change strategies and

assists in increasing self-efficacy; which is presumed to contribute to decreased body

dissatisfaction, negative affect and eating disorder pathology (Bar et al., 2016; Stice, 2001).

VPMP Intervention.

The Victory Program at McCallum Place is a specialized program that focuses on

athlete specific eating disorder risks and concerns (Conviser et al., 2018; Thompson, 2019).

The treatment program is specified for gender, sport type, and sport level of competition

(Conviser et al., 2018). The program takes a multidisciplinary approach and includes several

professionals who work alongside with athletes including medical professionals, sport

psychologists, sport dietitians, strength and conditioning coaches, and specialized eating

disorder therapists (Thompson, 2019). Prevention education is believed to be the most crucial

part of eating disorder prevention among female athletes (Bar et al., 2016). Therefore, the

Victory Program makes attempts to educate athletes and coaching staff about the signs,

behaviors, and symptoms of eating disorders. The program also focuses on changing athletes’

attitudes and behaviors associated with eating disorders, body image, and body ideals

(Thompson, 2019; Voelker & Galli, 2009). Early identification of “at risk” athletes is another

crucial part in prevention. The program aims to provide education to those at the highest risk

for developing an eating disorder as a prophylactic. The Victory Program for prevention is

overall a multidisciplinary program that provides education on risks, symptoms, and warning

signs for both coaching staff and athletes (Thompson, 2019).

The ATHENA Program.

Another specific program identified from the literature review is the ATHENA

program. This program is an athlete centered program to prevent female athletes’ disordered

eating and body-shaping drug use, such as steroids and diet pills (Voelker & Galli, 2009;

Voelker & Petrie, 2021). Peers run the program and the content is gender specific (NEDA,

2018). The program is ran based on a group type of setting with 6 athletes in each group and

each group including one leader. The curriculum specifically targets modifiable risk and

protective factors related to eating disorders (Voelker & Galli, 2019). The program is

conducted during the athletes’ sport season and consists of 8 45-minute sessions integrated

into a team’s normal practice schedule. Topics such as: healthy sport nutrition, effective

exercise, drug use and other unhealthy behaviors’ effects on sport performance, media

images of females, and depression prevention are all discussed (Coelho et al., 2014; Voelker

& Galli, 2009). The group leaders direct most of the group activities, however, all group

members participate in the interventions. The groups are peer run, but they can be facilitated

by a sport psychologist or a trained coaching staff member. Studies have indicated the

ATHENA program may assist with developing healthier eating behaviors, reducing the

number of athletes reportedly abusing diet pills, and reducing the behavior of vomiting to

lose weight (Mountjoy et al., 2018; Voelker & Galli, 2009).

General PE.

General prevention education interventions focus on providing elite female athletes,

coaching staff, and other multidisciplinary staff with basic performance education on diet,

nutrition, exercise, and weight ideals for their sport (Bunda & Bratu, 2016; Bruin, 2017;

Mountjoy et al., 2018; Voelker & Galli, 2019). This intervention is based on the belief that

the more athletes, coaches, and staff are educated on what diet and body type make a peak

performance, the less likely they are to make drastic changes to enhance their performance

(Chang, 2019; Rosa-Caldwell, 2018; Thompson, 2019). This assists athletes in challenging

the fallacy that the thinner an athlete is, the better they will perform (Mountjoy et al., 2018).

These types of prevention education programs can be conducted by a sport psychologist, a

coaching staff member, or an elite female athlete peer (Bruin, 2017; Thompson, 2019). The

general prevention education is written in a way that athletes and coaches can understand,

rather than from a psychologist’s perspective. Therefore, the information is direct, clear, and

basic.

The literature reflected the reality that athletes often engage in unhealthy eating

behaviors due to not knowing the behaviors were unhealthy (Bar et al., 2016; Mountjoy et

al., 2018). Education programs focusing on nutrition teach athletes that eating disorder

behaviors lead to impairments in performance, which deters them from wanting to continue

the behaviors (Stranberg & Quatromoni, 2017). Coaching staff benefit from nutrition

education as well. If coaching staff are educated on proper nutrition, it may lead to them

identifying an athlete’s display of unhealthy eating behaviors (Power et al., 2020). This may

assist in coaching staff detecting, addressing, and intervening with an athlete developing

early unhealthy eating behaviors.

Table 4

Interventions Overview and Studies

Interventions Overview Studies

AM-CBT An intervention focused on identifying and restructuring illogical thoughts related to weight and exercise. This intervention can utilize dissonance-based training to assist in setting more realistic and healthier expectations of weight and health in sport.

Mountjoy et al., 2018; Thompson, 2019; Voelker & Galli, 2019; Sandgreen et al., 2020; Coelho et al., 2016; Chang, 2019; Stewart et al., 2019; Stewart et al., 2017; Voelker & Petrie, 2020; Bar et al., 2016; Stice et al., 2021; Stice et al., 2017

AM-HWI An intervention focusing on creating a sporting environment in which athletes are educated and are promoted to maintain a healthy weight for their peak performance in sport.

Voelker & Galli, 2019; Sandgreen et al., 2020; Coelho et al., 2016; Bar et al., 2016; Stice et al., 2021; Stice et al., 2017

VPMP A multidisciplinary approach that provides athletes and coaches with a specific training to ensure they are well educated about healthy weight, caloric intake, and appropriate amounts of exercise. It also focuses on challenging unrealistic goals and expectations in relation to an athlete’s weight and diet.

Conviser, 2018; Sandgreen et al., 2020; Coelho et al., 2016

ATHENA A specific protocolized peer athlete program focused on preventing female athletes’ disordered eating and body- shaping drug use (such as steroids and pills). It is a peer run and focuses on group processing and a discussion of prevention topics.

Voelker & Galli, 2019; Coelho et al., 2016; Sandgreen et al., 2020

General PE An intervention focusing on providing elite female athletes, coaching staff, and other multidisciplinary staff with basic performance education on diet, nutrition, exercise, and weight ideals for their sport.

Mountjoy et al., 2018; Thompson, 2019; Voelker & Galli, 2019; Sandgreen et al., 2020; Coelho et al., 2016; Bundă & Bratu; 2016; Bruin, 2017); Power et al., 2020; Stranberg & Quatromoni, 2017; Rosa- Caldwell, 2019; Chang, 2019; Bar et al., 2016; Joy et al., 2016; Stice et al., 2021; Stice et al., 2017; Hines et al., 2019; Scott et al., 2019

Addressing Over-arching Research Questions

The results of this systematic literature review were broken into two categories:

protocolized prevention interventions and non-protocolized prevention interventions.

Protocolized prevention interventions included detailed and specific procedural interventions

that require the administration from a sport psychologist, specific training, and precise

directions to be executed. Non-protocolized prevention interventions included interventions

that did not require either a sport psychologist or specific training to be executed. The

literature included in this project indicated five effective eating disorder prevention

interventions that can be implemented by a sport psychologist and one that can be

implemented by coaching staff and/or peer athletes.

The four interventions conducted by sport psychologists included: athlete modified

cognitive-behavioral-dissonance-based interventions, athlete modified healthy weight

interventions, the Victory Program, and the ATHENA program. Each of these interventions

and programs require a trained sport psychologist to either facilitate or conduct the specific

program or targeted intervention. The literature indicates that each protocolized prevention

intervention and program has its own level of effectiveness depending on several different

variables including but not limited to an athlete’s specific sport body ideal, the coaching

staff’s emphasis on healthy body image, level of individual competitiveness on the teams,

individualized perceived pressures for to perform well, and several others.

Non-protocolized prevention interventions included interventions that did not require

a trained sport psychologist to facilitate. Researchers have estimated that only 30-50 % of

Division I athletic programs contract with either full or part time sport psychologists (NCAA,

2018). Despite most professional sports teams having on-staff sports psychologists, it is

estimated that only 16% of athletes utilize sport psychology services due to ongoing stigma

associated with the service (Levine, 2019; Stranberg & Quatromoni, 2017). Sport

psychologists may not be accessible, have an established rapport with athletes, be supported

by coaching staff, or have the funding to run protocolized prevention intervention programs.

Therefore, it is important to acknowledge and identify non-protocolized prevention

interventions.

Which Eating Disorder Prevention Interventions Have Been Effective for Sport

Psychologists Working with the Athletic Population?

Analysis of the literature revealed that educational programs are the best method for

the primary prevention of eating disorders among coaching staff and peer athletes (Coelho et

al., 2014; Levine, 2019; Power et al., 2020; Scott et al., 2019; Stranberg & Quatromoni,

2017). This non-protocolized prevention intervention focuses on educating both athletes and

coaching staff on how to challenge attitudes, beliefs, and behaviors associated with eating

disorders, body image issues, and the unhealthy emphasis on leanness, learn early detection

for symptoms, and work towards destigmatizing the discussion around eating disorders

(Langmesser & Verscheure, 2019; Stranberg & Quatromoni, 2017). Bunda & Bratu (2016)

discussed the importance of early detection as being a key factor in primary prevention.

Appropriate prevention education programs would address this need. A major risk for

developing eating disorders involves an emphasis on a thin body ideal and its relationship to

the alleged improved athletic performance (Bruin, 2017; Mountjoy et al., 2018; Thompson,

2019). Coaching staff are urged to recognize that such an emphasis on bodyweight, thinness,

disregarding athlete’s health, and promoting a body negative environment may be the most

important factor in developing an eating disorder (Bunda & Bratu, 2016; Bruin, 2017;

Thompson, 2019). Therefore, it is encouraged that coaching staff promote a healthy and

positive environment for athletes to establish realistic body ideals, goals, and expectations

(Frogley et al., 2018; Langmesser & Verscheure, 2019).

Why are These Interventions Effective?

The literature indicates that prevention interventions may be more effective if they

address specific risk factors that are sport specific (Langmesser & Verscheure, 2019).

Athletes participating in sports that believe in a thin ideal appeared to be more receptive to

cognitive behavioral dissonance based and healthy weight prevention interventions (Bar et

al., 2016; Conviser et al., 2018; Fewell et al., 2018). Female athletes participating in

endurance-based sports, such as marathon running, seemed to be more receptive to healthy

weight and cognitive behavioral prevention interventions (Fewell et al., 2018; Frogley et al.,

2018; Langmesser & Verscheure, 2019). The Victory Program was effective in reducing

eating disorder behaviors among female athletes participating in the highest-risk sports that

emphasize appearance, weight requirements, and thinness (i.e.: gymnastics, diving, figure

skating, and ballet) (Bar et al., 2016; Bruin, 2017; Thompson, 2019; Voelker & Galli, 2009;).

This may be due to the program providing a multidisciplinary staff that provides a high level

of support for its participants (Conviser et al., 2018; Stewart et al., 2017; Voelker & Galli,

2009). Females participating in sports that focus heavily on aesthetics, such as bodybuilding,

appeared to be more responsive to the ATHENA program (Voelker & Petrie, 2019). The

ATHENA program focuses on prevention of both eating disorders and body-shaping drug

use (such as steroids and diet pills); therefore, the athletes may have more success due to the

program being more relevant to their sport.

Researchers have indicated that non-protocolized prevention interventions have

shown to be effective with athletes (Mountjoy et al., 2018; Sangreen et al., 2020; Voelker &

Galli, 2019;). Educating coaching staff and peers about eating disorder behaviors has proven

successful with preventing eating disorders due to coaching staff members and other athletes

becoming cognizant of warning signs and symptoms of eating disorders (Hines et al., 2019;

Rosa-Caldwell, 2018; Scott et al., 2019). Coaching staff and peers looking out for warning

signs, symptoms, and cognitions related to eating disorder tend to offer earlier intervention

prior to the athlete having a full-blown eating disorder (Chang, 2019; Joy et al., 2016).

Coaching staff and peers who promote a culture in which seeking help for an eating disorder,

discussion of the topic, and destigmatizing mental health and eating disorders, tend to see

less of a prevalence of eating disorders among their fellow athletes (Stranberg &

Quatromoni, 2017). The literature indicates that more prevention education coaching staff

and athletes have, the more likely early interventions will be implemented by coaching staff

and peers.

Discussion of Findings

Although contradictory findings were found regarding effective sport psychology

prevention interventions, the consensus is that all protocolized and non-protocolized

prevention interventions were more effective than control groups at lowering athlete reported

symptoms related to eating disorders. Despite contradictory findings, the overall suggestions

indicated that AM-CBT and AM-HWI were the most effective protocolized interventions for

preventing eating disorders among female elite athletes participating in individual sports. The

literature concluded that prevention education was the most effective non-protocolized

intervention. It is speculated that the non-protocolized intervention is highly effective due to

the low cost, accessibility to coaching staff and peers, and the critical role that coaches and

peers play in influencing athletes (Voelker & Galli, 2019). Overall, the literature provided

enough evidence to create possible suggestions for eating disorder prevention interventions

not only among sport psychologists but also among coaching staff and peers.

Overall Suggestions for Preventing Eating Disorders Among Athletes

Suggestions collected from the participants in the 21 studies were consistent with the

themes. The suggestions also included the need to destigmatize the discussion and thoughts

around eating disorders, focus on extending prevention education for family members and

athletes’ loved ones, change the culture around the myths and beliefs about weight in female

sports, and include more sport psychologists on staff. More sport psychologists on staff could

assist more athletes and teams receiving prevention interventions that are only implemented

by highly trained sport psychologists. Other suggestions included coaching staff having

specific eating disorder prevention protocols for when they identify an athlete who may be

experiencing warning signs or symptoms. Other suggestions gleaned from the studies

proposed that coaching staff immediately correct any misinformation about healthy body

weight, healthy ways to lose weight, and around the suggested appropriate amount of

exercise for peak performance (Chang, 2019; Hines, 2019; Stranberg & Quatromoni, 2017).

Coaching staff correcting athletes should start at a young age to assist in educating athletes

sooner rather than later. Considering the important role that coaches and athletes have on

each other when it comes to preventing eating disorders, it is crucial for information to be

accessible and readily available. There is a lack of available information about eating

disorders that provides coaches and athletes with information such as warning signs and risk

factors of an eating disorder (Chang 2019; Thompson, 2019). Given this need, this project

focused on utilizing the findings to create a pamphlet with prevention education.

Unexpected Findings

There were also unexpected findings found while this researcher conducted this SLR.

The research collected suggested that any type of protocolized or non-protocolized

prevention was more effective with preventing an eating disorder when compared to no

treatment in elite female athletes. Nevertheless, there were conflicting reports on whether

prevention protocols were effective for non-elite athletes. This may have been due to an

overall lack of research on the non-elite athletic population.

Several studies also contradicted each other by concluding AM-CBT was more

effective than AM-HWI interventions. However, there were several studies suggesting that

AM-HWI was more effective than AM-HWI (Power et al., 2020; Thompson, 2019). This

may have been due to the types of athletes being assessed. The interventions may be sport

specific, therefore, one sport may have success with one prevention intervention while the

other may not. Another thing to consider is individual factors. Certain individuals may have a

predisposition to respond better to one prevention intervention versus the other. Further

research should focus on determining what factors make AM-HWI or AM-CBT more

effective for certain athletes.

Additional studies indicated there were no other effective prevention studies with

preventing eating disorders among elite individual sport female athletes. However, these

studies were based on interview responses from elite athletes who had not yet experienced

either a protocolized or non-protocolized prevention intervention (Bar et al., 2016; Coelho et

al., 2016; Voelker & Galli, 2019). If an athlete has not received the treatment, it is an

assumption to state that the intervention works or doesn’t work. Anecdotal evidence and

personal opinion is not a credible resource to determine if there are any effective eating

disorder prevention interventions.

Importance of Findings for Research and Practice

It is important to review the conceptual framework of this SLR to fully understand the

importance of the findings for research and practice. Female participation in sports has

increased remarkably since the institution of Title IX in 1972. This has led to higher levels of

competition within women’s sports (National Collegiate Athletic Association, 2018). If Title

IX did not exist then perhaps there would be less athletes competing, which could possibly

lower levels of competition. Therefore, Title IX impacts the level of competition and level of

pressure elite female athletes experience. Biological factors related to being a female put

women, in general, at a higher risk of developing an eating disorder (NEDA, 2018).

However, there are also risk factors specific to athletes that increase an athlete’s risk of

developing an eating disorder (such as level of competition, motivation to win, and the

sport’s perception on low body weight and performance) (Bruin et al., 2018). Researchers

have supported the belief that female athletes experience a higher rate of eating disorders

than the general population due to these risk factors both adding up (De Bruin & Oudejans,

2018; Frogley et al., 2018). Prevention science is another important concept for this SLR.

Prevention interventions aim to counteract risk factors and reinforce protective factors to

disrupt processes that contribute to human dysfunction (Brady et al., 2020).

This project was developed based on the prevention science theory, which focuses on

a preventative approach that aims to address risk factors to combat the high prevalence rate

of athletes diagnosed with eating disorders. Despite the high prevalence rate of eating

disorders among female athletes, there is a lack of research on prevention interventions. This

project was conducted to address the lack of eating disorder prevention studies among female

athletes. This SLR attempted to clarify the conflicting information around whether

prevention protocols are helpful with preventing eating disorders among the elite female

athlete population, and to determine which interventions were most effective.

This SLR is important to the field of sport psychology because it summarizes current

studies that have researched whether prevention intervention protocols are effective with elite

athletes struggling with eating disorders. This adds to the body of knowledge in the field by

summarizing and synthesizing the few studies that exist on eating disorder prevention among

elite female athletes participating in individualized sports. The sport psychology field

currently lacks best practices for eating disorder prevention among elite female athletes. The

information gleaned from the studies indicate that there are specific sport psychologist

protocolized prevention interventions that are effective for preventing eating disorders (such

as AM-CBT and AM-HWI) (Caldwell, 2019). The research converges regarding general

prevention education being helpful for coaches and athletes; as it has been established that

100

coaches and athlete’s education on eating disorders are considered preventative factors (Bar

et al., 2016; Coelho et al., 2016; Stice, 2017). These findings also converge with the previous

findings that AM-CBT and AM-HWI have been effective for eating disorder prevention

among athletes. Due to the limitations of this project, it was not determined whether AM-

CBT or AM-HWI is most effective for eating disorder prevention among elite female

athletes. The data collected from this SLR indicated general prevention education was found

to be the most effective non-protocolized prevention intervention. This is helpful for the

field, as sport psychologists not fully trained for protocolized interventions can utilize non-

protocolized interventions. Also, a sport psychologist working with a team that cannot afford

protocolized interventions has another option that will still make an impact on combating the

prevalence rate of eating disorders among elite female athletes.

The findings of this project were utilized to assist sport psychologists provide

coaching staff and athlete peers with prevention education. A pamphlet was created based on

the data collected from this SLR. The pamphlet provides basic prevention education focusing

on athletes. It includes the role coaches and athletes play in eating disorder prevention, risk

factors for athletes, warning signs of an eating disorder, how to intervene as a coach and

peer, overall tips for coaches and athletes, and it includes national prevention resources for

athletes. This pamphlet was created to assist in making eating disorder prevention education

more accessible to coaches and athletes.

Recommendations

The final section of this chapter discusses limitations of the project and implications

for practice. The limitation for this project pertained to the generalizability as well as the

potential of researcher bias. The implication of researcher bias was addressed using

101

reflexivity and epoche. A reflection of the researcher’s experience with the SLR process was

included to ensure transparency and limit bias. The implications for generalizability included

placing the findings from the systematic literature review in the context of the elite female

individual-sport athlete population. The practical implications and application of project

themes that emerged from the findings are presented in the proposed pamphlet in the

Appendix.

Limitations of the Study

There were two limitations of this study related to the generalizability and validity of

the findings on eating disorder prevention amongst the elite female individual sport

population. There was minimal published literature that included research about elite

individual sport female athletes. (Bar et al., 2016). This population was chosen as it was

identified to be the highest risk population for developing an eating disorder, (Frogley et al.,

2018; Koman, 2018; Papathomas & Capicotto, 2017; Roy et al., 2019. This project likely

lacks generalizability due to the population being so specific. It is not known whether the

prevention interventions will work with more generalized athletes (i.e. males, non-elite

athletes, young athletes, athletes participating in team sports, etc.). While the findings had

generalizability for the highest risk population of athletes, it may lack generalizability for

athletes.

While the articles reviewed included mostly Division I NCAA athletes; the diversity

in race and culture resulted in some inconsistent and conflicting findings. For example,

despite Black athletes are 50% more likely than white athletes to exhibit bulimic behavior but

are less likely to be diagnosed with eating disorders than white athletes (NEDA, 2018). This

may be due to athletes who identify as people of color being significantly less likely than

102

white athletes to be asked about eating disorder symptoms (Becker et al., 2003; Hines et al.,

2019). Eating disorders tend to present differently in Black females than white females,

therefore the results of the prevention interventions may not have been valid. This project

focused on the highest risk elite women’s sports such as the following individual sports:

gymnastics, distance running, figure skating, dance, bodybuilding, diving, etc. According to

NCAA Race and Gender Demographics for the academic year of 2018, less than 2% of Black

athletes and 6% of other athletes of color participated in the identified individual sports.

While findings from this literature review indicated that most interventions were effective

with prevention, one must be cautious of generalizing the findings of this project across all

races and remain cognizant of the cultural and racial considerations when studying eating

disorder prevention interventions.

Researcher Bias

The trustworthiness of this systematic literature review was based on the principled

actions of the researcher. Researcher bias in evaluating the findings of this project was

considered to ensure trustworthiness in this project. The researcher’s closeness to the topic of

eating disorders among the athletic population likely resulted in having more knowledge and

experience with eating disorder prevention interventions than the public. The researcher’s

experiences could have affected the interpretation of the results. Bias was mitigated through

reflexivity and practices of bracketing and epoche throughout the PRISMA process,

interpretation and presentation of findings, and data production that were integrated into the

general prevention education pamphlet. Reflexivity was practiced through the researcher

using a journal to track the research process. The journal was reviewed and checked for bias

throughout the research process. Ensuring fidelity and commitment to the use of bracketing

103

permitted the researcher to set aside personal biases, presumptions, theories, and previous

experiences with eating disorder prevention interventions among the athletic population. A

master data collection chart was created as a bracketing technique. The data was transferred

directly from the literature to the chart without room for personal biases, experiences, or

assumptions.

Implications for Practice

This project may help the sport psychology field by highlighting the gap in research

regarding identifying the best sport psychology practices for preventing eating disorders

among the elite female athlete population. The findings of this SLR may assist sport

psychologists, coaching staff, and athlete peers in becoming more informed about effective

eating disorder prevention programs. Elite female athletes are at a high risk of developing an

eating disorder; therefore, the more sport psychologists, coaches, and peer athletes know

about prevention, the more interventions efforts can be made (Bar et al., 2016; Conviser et

al., 2018).

The Protocol Pamphlet: Extending Knowledge and Practice

The protocol pamphlet created from the findings of this project is proposed as a

medium to promote the sharing of evidence-based knowledge and resources for best practices

for prevention eating disorders among the elite female individual-sport population (see

Appendix). The goal of the pamphlet is to integrate the findings from this SLR and make the

knowledge more accessible to athletes and athletic support staff. The pamphlet will be shared

with athletes, coaching staff, and sport psychologists. The pamphlet provides coaching staff

and athletes education on the role coaches and athletes play in eating disorder prevention,

risk factors for athletes, warning signs of an eating disorder, how to intervene as a coach and

104

peer, overall tips for coaches and athletes, and it includes national prevention resources for

athletes. A pamphlet was chosen to provide education as it is low cost, easily accessible (can

be left in a locker room or be found online) and can reach individuals in need of education.

Recommendations for Future Research

Based on the findings and limitations of this project, future research should be

conducted determine the most effective eating disorder prevention interventions among the

elite female individual-sport population. Researchers have indicated which eating disorder

prevention interventions are effective. However, additional research would assist in

determining which interventions are most effective. For example, a study utilizing the five

different types of preventions could be conducted to measure which preventions led to higher

efficacy rates. More research should be conducted on elite female athletes, as the number of

studies are limited.

Several studies have contradicted one another regarding whether prevention protocols

help prevent eating disorders among athletes. One potential reason for the conflicting

literature could be due to prevention interventions being sport specific. Therefore, it may be

helpful to conduct research on which preventions are effective for specific sports and not

others. Another helpful direction of research would be to explore not only whether a

prevention is effective for a specific sport but determine the level of efficacy for each sport

for each specific intervention.

Longitudinal research should be conducted to conclude how long preventative

interventions are successful for elite female athletes and to determine ways to maintain the

positive effects of each effective protocol. This information could contribute to the field by

assisting sport psychologists, coaches, and trainers in having more education and knowledge

105

on preventative interventions and strategies when working with elite female athletes

participating in individual-sports.

Another recommendation for future research would be to include research on male

athletes as well as marginalized groups such as elite athletes that identify as people of color

or transgendered athletes. Researchers could include these populations when identifying

which sport psychology interventions are most effective for prevention eating disorders

amongst the general elite athletic population. This future research could answer the research

question focusing on which sport psychology eating disorder prevention intervention is most

effective in general with preventing eating disorders among the elite athletic population.

Conclusion

The purpose of this systematic literature review was to explore what sport psychology

preventative interventions are effective for eating disorders within elite female individual-

sport athletes, and to create best-practice recommendations for preventing eating disorders

among this population. This project gathered peer-reviewed research on the efficacy of

current sport psychology prevention interventions implemented with elite female athletes.

The results of this project informed a protocol pamphlet to educate sport psychologists,

athletes, and coaching staff on sport psychology eating disorder prevention interventions.

This chapter was divided into three sections: This chapter presents the findings of this

systematic literature review (SLR) through three sections: (a) literature collection, (b) an

evaluation of the findings, and (c) future recommendations. The population being studied

was elite female athletes participating in individual sports (i.e.: gymnastics, distance running,

figure skating, dance, bodybuilding, diving, etc.). Two main themes emerged from the peer-

106

reviewed literature which included protocolized prevention interventions and non-

protocolized prevention interventions.

Overall, both protocolized and non-protocolized prevention programs were effective

at preventing athletes from being diagnosed with an eating disorder and it most programs led

to a reduction in athlete’s having less eating disorder symptoms in general (Bar et al., 2016;

Conviser et al., 2018; Fewell et al., 2018). However, with less athletic programs having on-

site sport psychologists that are specifically trained in the protocolized interventions, it is

encouraged to push for non-protocolized prevention interventions as this can be more cost

effective, athletes may trust their coaches providing them with education versus a sport

psychologist with whom they do not have rapport, and it is less time consuming. These

findings were determined to be central to creating an educational pamphlet to educate sport

psychologists, athletes, and coaching staff on general eating disorder prevention education to

assist in addressing the high prevalence rate of elite individual sport athletes diagnosed with

eating disorders. Coaches and peer to peer athletes educating each other and continuing to

advance the discussion on the dangers of eating disorders in the athletic setting can provide a

safe environment to assist in destigmatizing athletes seeking help for eating disorders and can

lead to lowering the prevalence rate overall.

Appendix- Eating Disorder Prevention Education for Athletes and Coaching Staff

ABOUT

The outcomes from this SLR revealed non-protocolized interventions, such as general

prevention education for coaching staff and peer athletes, have shown to also be effective.

107

This is a pamphlet with basic prevention education for coaches and athletes to assist them

with identifying risk factors, learning warning signs, and knowing how to intervene.

108

Appendix (Cont.) - Eating Disorder Prevention Education for Athletes and Coaching Staff

109

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CHAPTER I: INTRODUCTION

General Statement
Justification Statement
Purpose of the Project
Importance of the Project
Conceptual Framework

Rise in Female Sport Participation
General Risk Factors for Eating Disorders
The Concept of Prevention Science

Overview of the Project Approach
Project Questions
Definition of Terms
Assumptions, Limitations, and Delimitations

Assumptions
Limitations
Delimitations

Summary

CHAPTER II: REVIEW OF THE LITERATURE

Search Strategy

Summary of Sources

Eating Disorders

Historical Examples of Eating Disorders
Diagnostic History of Eating Disorders
Common Medical Complications of Eating Disorders
Common Behavioral and Psychological Characteristics of Eating Disorders
Prevalence Rates and High-Risk Populations
Eating Disorders Among Athletes
Athlete Risk Factors
Athlete Health and Performance Concerns
Highest-Risk Athletes
Elite Female Individual Sport Athlete Risk Factors Leading to the Need for Prevention
Sport Psychologists Addressing the Need for Prevention

Women’s Participation in Sports

History of Title IX and Growth of Women’s Sports
Impact of Women in Athletics
Implications of Growth in Women’s Sports

Prevention Science Framework

Classification of Prevention
Prevention Science and Eating Disorders
High-Risk Population
Elite Female Individual-Sport Athletes and Prevention Science

Knowledge Gaps

Lack of Studies on High-Risk Female Athletes and Prevention
Prevalence Rates

Summary

CHAPTER III: Project Approach

Project Approach
Over-arching Research Questions
Population and Sample
Ethical Concerns
Literature Collection
Inclusion Criteria
Exclusion Criteria
Analysis of Literature
Trustworthiness and Quality of Results
Summary

CHAPTER IV: FINDINGS AND RECOMMENDATIONS

Findings

Sample

Sample and PRISMA Protocol

Literature/Sample Collection
Data Collection

Literature Search Results

Evaluation of Findings

Themes

Description of Themes

AM-CBT Intervention.
AM-HWI Intervention.
VPMP Intervention.
The ATHENA Program.
General PE.

Addressing Over-arching Research Questions

Which Eating Disorder Prevention Interventions Have Been Effective for Sport Psychologists Working with the Athletic Population?
Why are These Interventions Effective?

Discussion of Findings

Overall Suggestions for Preventing Eating Disorders Among Athletes
Unexpected Findings
Importance of Findings for Research and Practice

Recommendations

Limitations of the Study

Researcher Bias

Implications for Practice

The Protocol Pamphlet: Extending Knowledge and Practice

Recommendations for Future Research

Conclusion
Appendix- Eating Disorder Prevention Education for Athletes and Coaching Staff
Appendix (Cont.) - Eating Disorder Prevention Education for Athletes and Coaching Staff
References