Final LIT REVIEW IN SEMINAR ON ED

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Running head: EATING DISORDERS AND FEMALE ATHLETES
Biopsychosocial Model of Eating Disorders among Female Athletes
Jillian Baillargeon
University of Massachusetts Lowell

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Abstract
This literature review paper examines the biological, psychological, and social factors that
contribute to an eating disorder in female athletes. As well as explore female athletes who are
marginalized and stigmatized in their sport environment for having a serious mental disorder.
The many literatures helped support the subtopics within this paper of what female athletes are at
more of a risk that others. The study by Sherman and Thompson, 2001 suggested that eating
disorders only occur in athletes who are predisposed through the combinations of biological,
personality, familial, and sociocultural factors. Hinton and Kubas, 2005 concluded that other
personality characteristics such as excessive control and obsessionality may play roles in the
development of disordered eating. The purpose of this paper was to inform health care providers
on female athletes with eating disorders. While they may well understand most of the medical
complications that result from an eating disorder, the psychological and social factors are areas
they might be unfamiliar with. Therefore, through this paper health care providers can be better
informed on the biological, psychological, social, and even personality factors that accompany
an eating disorder.

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Biopsychosocial Model of Eating Disorders among Female Athletes
The prevalence rate of eating disorders is high among female athletes (Sherman and
Thompson, 2001). Female athletes of all levels of sport ability ranging from adolescents in
middle school and high school, to young adults in college, and elite and professional levels
(Greenleaf et al., 2009) develop unhealthful eating behaviors from a multitude of factors
including biological, psychological, and social factors. In addition, it is suggested from across
these literatures (e.g., Blackmer et at, 2011; Greenleaf et al, 2009; Hulley and Hill, 2001;
Scoffier et al, 2010; Skowron and Frielander, 1994) that eating disorders among female athletes
can start at any age. While an eating disorder can be diagnosed at any age, it can also develop
within any sport. This includes but not limited to sports such as basketball, cheerleading, cross
country, dance, field hockey, gymnastics, ice skating, softball, soccer, swimming and diving,
tennis, and track and field (e.g., Holm-Denoma et al, 2009; Karin de Bruin et al, 2011; Scoffier
et al, 2010; and Sherman and Thompson, 2001). Competitive female athletes of all ages, from
middle school to professionals, are more likely to develop an eating disorder, disordered eating
behaviors and unhealthful relationships with food compared to club athletes, independent
exercisers, and non-exercisers (Holm- Denoma et al., 2009). This paper will also discuss eating
disorders such as anorexia nervosa, bulimia nervosa, excessive exercise, binge eating, and eating
disorders not otherwise specified. Before discussing the biological, psychological, and social
factors, consideration needs to be brought to these female athletes that they are marginalized for
their mental illness.

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Marginalization
Male athletes are labeled as having a women's problem if they do report their eating
disorder (Sherman and Thompson, 2001). Female athletes are marginalized because of their
eating disorder in their sport. Being body conscious is one of the early signs of developing an
eating disorder (Sherman and Thompson, 2001) and if men become body conscious then they are
perceived as less of a man (Griffiths et al., 2014). Women are already marginalized, but to then
get diagnosed with an eating disorder adds more feelings of feeling abnormality. To marginalize,
from the Merriam Webster Dictionary, 2014 means to put someone in an unimportant position
and feel powerless from a group or society. Female athletes especially college female athletes
have to balance a lot in their lives such as school, work, and other life demands but to then have
an added stressor of feeling rejected by their peers can have a bad impact to their overall well-
being (Skowron and Friedlander, 1994). Churruca, et al, 2014 conducted a study of adults with
eating disorders who participated in a Q methodology study online. The Q methodology used
both qualitative and quantitative techniques. This particular Q methodological study explored
constructions of bulimia. The first step of a Q methodological study to put together a set of items
or statements about the topic, in this particular study it was bulimia. The subtopics of the
statements in this study included: bulimia as a problem, bulimia as a solution, bulimia as a
choice, bulimia as a person, bulimia as normative, and bulimia as marginalized (Churruca et al.,
2014). The participants were mostly women, but consisted of men also. From the subtopics some
of the specific statements were: bulimia as uncontrolled behavior, bulimia is a distressing mental
illness, bulimia is a way to lose weight, self-medicating with food, the pathological pursuit of
thinness, being the best at being thin, and extreme behavior verse mentally ill. There was two

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main findings from this study. The findings were that men can in fact develop bulimic behaviors
as well as bulimia being a very serious mental illness.
Despite that results do show that both men and women can develop an eating disorder,
women are still at a higher risk for disordered eating and eating disorders (Holm-Denoma et al.,
2009). Furthermore, there is no evidence suggesting that the prevalence of disordered eating in
athletes is declining (National Collegiate Athletic Association and American College of Sports
Medicine c.f. Sherman and Thompson, 2009). Holm-Denoma et al., (2009) expanded on this
statistic by doing a meta-analysis and found that women in sports are at an increased risk for
developing an eating disorder. One of the implications of the study was that varsity and club
athletes at the university did not represent the different body types in the different sports well
because there was no gymnastics and figure skating teams (Holm-Denoma et al., 2009). This is
an implication because certain sports may be associated with higher levels of eating disorders
than others (Holm-Denoma et al., 2009). In conclusion, there are a multitude of factors as
mentioned previously that can contribute to the development of an eating disorder such as the
type of sport. The psychological and social factors later in this paper will discuss why the type of
sport the female athlete participates in has a strong correlation with eating disorders.
Female athletes who are diagnosed with eating disorders may deal with more
marginalization than non-athletes. This is because of the interpersonal pressure they may place
on themselves along with the biological, psychological, and social factors that contribute.
Interpersonal meaning the type characteristics within the personality the athlete may have in
which this can be determinant factor on whether the athlete is at a greater chance in developing
an eating disorder. Sherman and Thompson, (2001) explained that female athletes may have a
strong drive on pleasing their coaches, parents, as well as accepting nothing less than a perfect

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performance. The psychological and social factors will be discussed later in this literature review
in relation to these attributes. In addition to what Churruca et al., (2014) conducted, Hinton and
Kubas , (2005) did a similar study using the ATHLETE questionnaire to also determine what
kind of behaviors may result in an eating disorder. The participants were undergraduate college
female athletes from a Division 1 university. This questionnaire measured six factors such as
drive for thinness and performance, social pressure on eating, performance perfectionism, social
pressure on body shape, and team trust. Given the six psychological and social factors the results
were consistent and valid in which there is a direct association with disordered eating behaviors
and female athletes. The factors mentioned above in the study is what these female athletes deal
with mentally and emotionally. Most of these women are successful not just in their sport, but in
other areas of their life as well (Sherman and Thompson, 2001). Having these constant negative
self perceptions only lowers their self- esteem and overall quality of life (Sherman and
Thompson, 2001).
These female athletes with eating disorders are marginalized and not in the mainstream.
They are stigmatized for their mental illness as being weak physically and mentally, self-
centered, wanting attention, disgusting, and less of a woman (Griffiths et al., 2014). Not being in
the mainstream, meaning they have different behaviors about food so to others this could be
viewed as not being normal. So much is expected from female athletes from doing well in
school, having a job, and to be role models to other female athletes. When these women are
suffering from a severe mental disorder such as an eating disorder it may be harder for them to
balance the other aspects of their life well (Griffiths et al., 2014). Marginalization among female
athletes with eating disorders may imply to their peers that they are physically and mentally
weak. Even when the athlete makes a full recovery from the eating disorder they might always

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be labeled as the athlete with the eating disorder. When this label is upon them it may become
their new identity rather than being looked at as a holistic person with other qualities (Griffiths et
al., 2014). The next section of this paper will discuss the biological factors that accompany the
development of an eating disorder.
Biological Factors
While psychological and social factors are a bigger part to contribute to an eating
disorder, biological factors are also a part to contribute to the onset of an eating disorder (e.g.
Blackmer et al, 2011; Churruca et al, 2014; Greenleaf et al, 2009; Griffiths et al, 2014; Skowron
and Friedlander, 1994). The biological aspects include body mass index and body fat. Three
different articles (Churruca et al., 2014; Malinauskas et al, 2007; Reel et al, 2014) discuss the
body mass index and body fat within their studies. In the study done by Malinauskas et al.,
(2007) found that body mass index and body fat contributed to psychological factors. The
psychological factors will be discussed later. If the athlete already struggles with anxiety, low
self-esteem, and or body dissatisfaction then they may have the drive for thinness to lower their
body mass index and body fat (Reel et al, 2013). This implies that if female athletes are not
satisfied with their biological appearance they may use unhealthful eating habits to change their
body composition.
Furthermore, the kind of sport the female athlete is in may determine whether they are at
a higher risk for developing disordered eating or an eating disorder. Malinauskas et al., (2007)
and Reel et al., (2013) both did studies similar on how body mass index and body fat correlates
with what sport the athlete is in and whether or not they are at a high risk for developing an
eating disorder. On the other hand, Hausenblas and McNally (c.f. Malinauskas et al, 2007)

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argued that athletes have less of a chance in developing an eating disorder or disordered eating
symptoms because they have a healthier psychological functioning compared to non-athletes.
Warren et al., (1989) went further with this opposition in their study about disordered eating
patterns in competitive female athletes with a focus on cross country runners and gymnasts. The
participants were 82 female athletes from a Division 1 program, but only 74 volunteered for the
study while the remaining athletes were controls. The Eating Disorders Inventory (EDI) and
Eating Attitudes Test (EAT) were used in the study. The results that were found was that cross
country runners and gymnasts differed from each other. Warren et al, (1989) found that from the
EDI and EAT cross country runners reported less symptoms of disordered eating than female
non-athletes and gymnasts. Because gymnastics is a sport in which the athlete is being judged on
physical appearance, there is a higher chance of these athletes developing disordered eating. One
hypothesis suggested by Warren et al, (1989) is that gymnasts may become preoccupied with
their body mass index and body fat because the nature of the sport requires lean physiques for
optimal performance or at least this is how the gymnast perceives as the only option in being
successful. In conclusion, female cross country runners are at a lower risk for body
dissatisfaction than gymnasts (Warren et al., 1989). This may be because runners do not have to
be judged on physical appearance. This includes other sports such as volleyball that may be at a
lower risk for disordered eating because low body weight is not always an important factor for
achieving athletic success (Rosen et al., 1986 c.f. Warren et al., 1989). On the oppositional side,
(Clark et al, 1988 c.f. Warren et al, 1989) surveyed female elite runners and the results reported a
history of anorexia nervosa and disordered eating. In conclusion, so say that the biological
factors such as body mass index and body fat determine whether the athlete develops an eating
disorder or not is not consistent or valid. While gymnastics may correlate with a higher risk of

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developing unhealthful eating behaviors than other sports such as cross country or volleyball
because of the nature of the sport other factors such as psychological and social are factored in.
In conclusion of biological factors, a sport like gymnastics may have athletes with more
muscular build and have a drive to be thin regardless of their biology and the judging criteria of
the sport on appearance. On the other end, a sport such as cross country distance running does
not have an emphasis on appearance to possibly cause distorted body image and eventually over
time the athlete may become thinner than other athletes due to the nature of running. Overall,
athletes with their own biological make up may want to try and change their body composition if
they feel their body mass index or body weight is the reason for a decrease in performance. The
psychological factors are discussed in the next section on why some female athletes are more at
risk of an eating disorder than others.
Psychological Factors
The psychological factors of an eating disorder in female athletes are still unclear
according to Hinton and Kubas, 2005. But rather across these literatures are hypotheses about
what can constitute toward an eating disorder. This may include self-perception of how the
athlete perceives herself out of sport and within her sport as well as the personality of the athlete
such as feelings of inadequacy and anxiety. While Hinton and Kubas, 2005 suggest that
psychological factors are unclear, their ATHLETE Questionnaire as mentioned previously, was
designed to assess psychological factors associated with disordered eating in athletes (Hinton and
Kubas, 2005). Joining sports results in positive outcomes such as higher self esteem and overall
emotional and physical well-being (Hinton and Kubas, 2005). But these female athletes as stated
by previous studies (e.g. Holm-Denoma et al, 2009; Karin de Bruin et al, 2011; Reel et al, 2013;
Skowron and Friedlander, 1994) that there is enough data to support the hypothesis that female

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athletes are at a greater risk for developing an eating disorder more so than non-athletes (Hinton
and Kubas, 2005).
The ATHLETE questionnaire tested six different areas within varsity female athletes
from three different Division 1 universities in nine different sports. The athletes ages ranged
from 18-22. The athletic trainers administered the questionnaires to the athletes without the
coaches in the room. The six different areas in the questionnaire that were measured were body
dissatisfaction, drive for thinness, interoceptive awareness, perfectionism, ineffectiveness, and
interpersonal distrust. Three additional areas were tested as well, but they are societal factors that
include social pressure on body shape, social pressure on eating behaviors, and the important of
being an athlete to self-concept (Hinton and Kubas, 2005). While the six different areas were
listed that the questionnaire tested, the Eating disorder inventory was also used in this study
along with other measures. The Eating Disorder Inventory (EDI) included a drive for thinness
construct which is the desire to be leaner to improve performance or appearance and using
excessive and compulsive training above what is require from the athlete (Hinton and Kubas,
2005). The other six constructs' descriptions includes dissatisfaction with body appearance and
body effectiveness related to performance, lack of control and feeling powerless regarding
playing time, training, and performance, excessive personal expectations for superior
achievement and/or avoidance of failure, reluctant to form close relationships with teammates
because of competition for roster positions, playing time, scholarships, and attention from coach,
and the inability to recognize physical hunger and overtraining (Hinton and Kubas, 2005).
Female athletes put a great deal of pressure on themselves by using the fitness level of their
bodies as a way of determining their athletic success. One of the results from this study was the
60% of female athletes reported wanting to lose five pounds, and 30% were trying to lose weight

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for their sport (Hinton and Kubas, 2005). This drive to want to lose weight while already being
highly physically active may increase the chances of the athlete to develop an eating disorder.
(Skowron and Friedlander, 1994). The female athletes in literatures previously mentioned still
want to lose weight whether it is to increase sport performance or wanting to become thinner not
related to sport in which this case society has to be blamed for. The desire in wanting to become
thinner among the female athlete will be discussed in the next subtopic. One other factor that
could be included is whether the athlete has been dealing with an eating disorder before joining a
sport. This factor may be out of scope for this paper, but will be taken into consideration.
In continuation of the ATHLETE questionnaire by Hinton and Kubas, 2005 there were
five distinct psychological factors such as drive for thinness, social pressure on eating,
performance perfectionism, social pressure on body shape, and team trust. The athletes had to
decide on how much the statements were true to them or not. Some of the statements that were
included was, I would be more successful in my sport if my body looked better, I train more than
is required by my sport to burn more calories, I feel uncomfortable eating in front of my friends
(non-athletes), coach, family, teammates, No matter how successful I am, I never feel satisfied,
My friends, coach, family, teammates, or society makes me feel fat, Being an athlete is my most
meaningful ability, and lastly, It is hard to get close to my teammates because we are constantly
competing against each other. The end results from this study indicates that five psychological
factors were affirmatively associated with disordered eating behaviors in female athletes (Hinton
and Kubas, 2005). Limitations of this study were that the study relied on self-reported attitudes
and eating behaviors and the truthfulness and accuracy of the self-reported responses are subject
to question (Hinton and Kubas, 2005). For future research the ATHLETE will be used in
studying the etiology of disordered eating in female athletes (Hinton and Kubas, 2005). While

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the multitude of the many psychological factors are supported by the research in which how
some female athletes may be at a higher risk than others, societal factors account for last part in
the biopsychosocial model.
Social Factors
The sports culture, explained by Reel et al., 2013 brings greater demands to the
individual female athlete such as body weight, shape, size, sports that emphasize thinness,
muscularity, or a particular build. On the other hand, being a part of a sports team can bring
many positives into the athlete’s life. Making new friends, feeling a sense of belongingness,
camaraderie, and benefits physically are just some of positives an athlete can gain. In fact, sports
can enhance mental well-being as well (Blackmer et al., 2011). While sports have many
advantages, the environment of sports may also increase the risk for disordered eating, distorted
body image, and eating disorders (Reel et al., 2013). Petrie and Greenleaf, 2012 c.f. Reel et al.,
2013 explained that even when the athletes specific sport may require weigh-ins, judging criteria,
fitting into fitted uniforms, the psychological and personality factors of the athlete could be a
strong influence in whether they are at risk. The people in the athlete’s life has a direct
relationship with developing unhealthful eating behaviors. Sherman and Thompson, 2001 further
explain that needing to please the coach, teammates, or the family correlates highly with the
athlete doing so by losing weight to get faster or because they think they are too fat. From these
societal influences, they can bring body concern which can result in anxiety in regards to athletic
performance and start the disordered relationship with food cycle (William et al., 1995 c.f.
Sherman and Thompson, 2001). If the pressures do not come from the sport environment such as
to lose weight or body fat to perform better than it can come from the athlete (Sherman and
Thompson, 2001) The societal pressures in sport might always exist due to the nature of sports

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being competitive and with the athletes in these sports usually having the drive to achieve
excellence it again refers back to the biological and psychological factors. This implies that some
athletes may not feel any of these social pressures whereas others may be affected entirely.
Eating disorders and disordered eating not only affects the athlete mentally, but also physically
by resulting in long term health effects from inadequate nutrition. This last section in the
literature review discusses the long term health effects from eating disorders such as anorexia
nervosa, bulimia nervosa, eating disorders not otherwise specified, and disordered eating
patterns.
Long Term Health Effects
Being an athlete is physically demanding on the body, but to then have an eating disorder
in which the body is not getting proper nutrients is an even greater demand from the body. Jill
Thein-Nissenbaum, 2013 did a study on the long-term consequences of the female athlete triad.
The Female Athlete Triad (FAT) is comprised of three components, disordered eating,
amenorrhea, and osteoporosis (Thein-Nissenbaum, 2013). These three components is what health
care providers and athletic trainers should examine the athlete for. The female athlete triad may
not always result in an eating disorder or vice verse. Morgenthal, 2002 explains that because of
the hard physical training the athlete puts her body through, the body responds by making these
regular systems irregular. This means the loss of the menstrual cycle, hormones like estrogen and
progesterone decrease, constant fatigue, depression, decreased performance, and other endocrine
abnormalities (Morgenthal, 2002). Moreover, Williams et al. 1995 c.f. Morgenthal, 2002
concluded that the athletes training might not be enough to produce these irregular systems
unless low caloric intake is present.

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The female athlete triad may not be the only result from inadequate nutrients, fertility and
cardiovascular problems are also at risk. Female athlete triad effects athletes in the high school,
collegiate, and elite levels (Thein-Nissenbaum, 2013). In conclusion to the female athlete triad
both the reproductive and skeletal (osteoporosis) systems are severely affected. Cardiovascular
disease osteoporosis, and fertility and pregnancy problems are just a few of the many health
outcomes from anorexia nervosa in the female athlete (Meczekalski et al., 2013). Meczekalski et
al., 2013 found that 80% of patients with eating disorders reported cardiac complications and
osteoporosis was commonly diagnosed in teenagers before achieving their peak bone mineral
density. In conclusion to these findings across these studies when the athlete restores her weight
to a normal range she might always deal with cardiovascular problems and may never gain full
bone density back. As previously mentioned, the result from osteoporosis is bone mineral density
never being restored again, (Morgenthal, 2002) therefore these women may always have a higher
risk for stress fractures along with other chronic irregularities.
As studies have shown that eating disorders can affect the female athlete at any age, the
female athlete triad can be diagnosed at any age. In an article by Sherman and Thompson, 2006
on the International Olympic Committee Medical Commission Position Stand on the Female
Athlete Triad: A Case Example explores the female athlete triad in elite and professional female
athletes. This study explored the three components of the triad just as previous studies have
done, but the results of this particular study stand out. Other results from previous studies found
correlations between female athletes and whether they were at risk or not in developing
disordered eating or an eating disorder from the biological, psychological, and social factors. But
the results from this study by Sherman and Thompson, 2006 was that the Olympic Committee

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Medical Position stand found strategies for managing the issues and problems regarding the
referral, evaluation, and treatment of the female athlete triad.
Conclusion
The biological, psychological, and social factors among female athletes and eating
disorders all have a significant role in whether the athlete develops unhealthful relationships with
food. Each of the different literatures explored not only the biopsychosocial model, but other
factors related. Some opposing viewpoints throughout this literature review was that female
cross country runners may show symptoms and the developments of an eating disorder, but other
articles argued that because cross country runners are not in an judging criteria sport such as
gymnastics they are at a less risk. But what if an athlete doesn't meet full criteria for a clinical or
subclinical eating disorder then what category in the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition would this athlete fall into? The implications of this literature review
paper is the lack of comparison throughout the paper between varsity athletes, club, athletes,
independent exercisers, and non- athletes there was. As well as going not further in depth on
specific areas within the subtopics. Because this literature review has a length requirement,
expanding on other possible factors that could contribute to an eating disorder could not be done.
Not always being able to arrive at a conclusion was difficult because of the complexity of the
topic. For the future, more research should be done on female athletes with anxiety, depression,
obsessive compulsive disorder, and addictive behaviors to determine if they are at a higher,
lower, or the same risk of developing an eating disorder compared to female athletes without
other mental disorders. Moreover, future research should also be done on female athletes and
marginalization.

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