Eating disorders and disordered eating on wrestling sport: a systematic review | BMC Nutrition

According to the findings of the included studies in this systematic review, wrestlers were more prone to exhibit disordered eating behaviors than athletes in other sports [20, 28, 48, 52, 69]Similarly, other studies have shown that wrestlers are at higher risk of exhibiting eating disorder than those in other sports which is consistent with the research findings discussed in this systematic review [20, 28, 48, 52, 69]. According to the study of Enns et al. [20], wrestlers were at higher risk than swimmers and skiers, and in the study of Moore [48], they were at higher risk than basketball players. In a study on high school wrestlers, Oppligen et al. [54] conducted a statewide study of 713 high school wrestlers in Wisconsin to examine the weight control behaviors of wrestlers. The results showed that 43% of the wrestlers exhibited weight-loss behaviors that did not fully meet the criteria for bulimia nervosa, but were similar to that disorder. Also, bulimic behaviors were observed in 9% of Wisconsin high school wrestlers. Another study that was examined, conducted by Gorrell et al. [28], an online questionnaire was administered to 611 male athletes in the USA, aged 18 to 26. The study group consisted of athletes of competitive status, selected from NCAA Division I schools in the USA. Eating behavior disorder rates were presented according to the type of sport, and results from the Eating Disorder Examination Questionnaire (EDE-Q) indicated that 24% (n = 5) of the 21 wrestlers, representing 4.9% of the total study group, reported clinically restricted eating behavior. The study revealed that wrestling is one of the sports with the highest risk for eating disorders. Fasczewski et al. [22] revealed that involving 63 active male NCAA university wrestling students 35 participants (53.9%) reported at least 1 disordered eating behavior. In this study, 38% of participants were indicated a moderate (%16) or severe (%22) risk of eating disorder.

In a related study Marina R. Flores et al. (24, 25), found that 40.91% of the total participants were at risk for possible ED.

In the second dimension of first question in the research, the factors affecting the prevalence rate of eating disorders in wrestling were examined. The first reason was the desire of wrestlers to maintain their low body weight. Due to the laws of their sport, these athletes have an extra obligation to keep their low body weight [32, 75, 75].

Another factor was that concerns about body image and performance make wrestlers more likely to develop eating disorders. Weight reduction motivates athletes because they are evaluated by society not only for their performance but also for their appearance [71]. Research showed that individuals with negative body image will exhibit behaviors such as fasting, vomiting, excessive dieting and excessive training [38, 51, 64]. In a study proving this, a negative relationship was found between body satisfaction level and the rates of binge eating behavior and restricting behavior [63]. Considering these studies in which eating disorders were based on body image, with a study found that wrestlers have lower body satisfaction than other sports branches it was argued that wrestlers may be prone to display eating behavior disorders [19]. The articles reviewed in this study similarly suggested that body image concerns were one of the reasons why wrestlers were more likely to develop eating disorders [22, 50, 63]. Chapman and Woodman [9] found a significant difference in the prevalence of eating disorders in wrestlers compared to a non-athlete control group. This was attributed to the wrestlers’ desire to gain more muscle mass and create lower body fat mass. Another examined study conducted by Murray et al. [50] aimed to shed light on the issue of Muscularity-Oriented Disordered Eating (MODE) which is rapidly spreading among men. The Eating Disorder Examination Questionnaire was applied to the wrestler who was referred to an eating disorder specialist due to excessive weight loss. However, the participant did not meet the diagnostic criteria for eating disorders. The wrestler, who lost weight rapidly as a result of the diet program applied on his own to give importance to his body image and to make weight gain completely muscle-oriented, underwent a 1-week hospitalization. This study drew attention to body image anxiety and muscle-building orientation, and it was determined that the unhealthy diet program developed by the wrestler due to body image led to disordered eating. In a related study on body image, a cross-sectional study by Satterfield and Stutts [63] was conducted on 103 national university male wrestlers in the United States. This study aimed to examined the muscle-building motivation, body satisfaction and eating disorders behaviors of male university student wrestlers. A majority of participants reported that they have never spit (74%), spent a lot time in a sauna (60%), used laxatives (81%), used diet pills (89%), used diuretics (85%), or engaged in self-induced vomiting (80%) to lose weight. As a result, it found that wrestlers showed many unhealthy eating behaviors in order to build muscle, and appearance pressures had a negative effect on muscle building and eating behavior. General pressures, followed by sport appearance pressures, and then coach/teammate pressures were the strongest predictors of eating restricting behavior. In another study, conducted by Fasczewski et al. [22] involving 63 active male NCAA university wrestling students, the relationship between body image and eating disorders was examined. Data were collected using Eating attitudes test (EAT-26), Multidimensional body-self relations questionnaire-appearance scales (MBSRQ-AS), Hoffman gender scale (HGS) and Open-ended questions. A positive correlation was found between the risk of eating disorders and the scores of appearance self-importance and paying attention to body weight, and a negative correlation was found between body image satisfaction scores. 35 participants (53.9%) reported at least 1 eating behavior disorder (e.g. binging, vomiting, laxative use). According to the qualitative data collected from 23 wrestlers (46.9%) in the second stage of the study, the athletes associated wrestling with masculinity and described behavioral characteristics such as toughness, independence and courage. As a result, it has been concluded that the masculine characteristics labeled by the sport of wrestling may increase the risk of eating behavior disorders by putting pressure on weight control.

Performance anxiety and the pressure of competition were cited as other reasons why wrestlers were more likely to develop eating disorders [12, 70]. One of the studies examined in detail in this systematic review found that, in line with other study results, competitive pressures significantly affected eating habits in wrestlers [61]. Finally, the same study suggested that also rapid weight loss increased the prevalence of eating disorders in wrestlers.

The second question addressed in this systematic review was to examine whether the prevalence of eating disorders among wrestlers differed by age, gender or competition level. Oppliger et al. [55] found that high school wrestlers showed higher levels of eating disorder tendencies than college wrestlers. One of the studies included in the systematic review and examined in detail, Goswami et al. [29], investigated attitudes and practices related to eating disorders in children and adolescents. The study group for the research included 650 children who consisted of boys and girls, aged between 10 and 18 years, and engaged in one of the sports branches such as basketball, yoga, wrestling, judo, cricket, gymnastics, boxing, badminton, table tennis, and others. The study group was divided into two groups, the first group consisted of children aged 10–14 years, and the second group consisted of children aged 15–18. Data were collected using an open-ended questionnaire. As a result, although the scores for Binge eating behavior disorder were similar in both children and adolescents, the risk of developing behaviors related to Anorexia nervosa and Bulimia nervosa was found to be higher in the adolescent age group. 14.5% of the adolescents in Group 2 reported that they forced themselves to vomit after eating uncomfortably. It was reported that 31% (n = 45) of females in group 1 and 48% (n = 65) of females in group 2 regularly use diet pills. While the overall risk of eating disorders was 44.4% in women in group 1 and 59.7% in group 2, the risk was 19.96% among men in group 1 and 24.52% among men in group 2.

It is possible to examine the eating behavior disorders in wrestlers according to the gender factor as well. Giel et al. [27] stated that female athletes competing in weight-related disciplines, and male athletes competing in strength and endurance-oriented sports were at high risk. In research included in this study, Goswami et al. [29] determined that female adolescent athletes between the ages of 15–18 have a higher risk of developing an eating disorder than male athletes.

Another criterion thought to affect the risk of eating disorders was the level of competition. Sundgot-Borgen [69] stated that eating disorders are more common in elite athletes. There are studies supporting that the desire to eat in elite athletes is caused by emotional eating rather than hunger [17, 43]. The risk of eating disorder was predominantly observed in adolescent elite athletes, as supported by studies [35, 66]. Two of the studies included in the systematic review yielded results consistent with these findings (Marina R. [24, 25, 62]). A study with 382 elite athletes who were actively wrestling, aimed to see whether there is a relationship between emotional eating behaviors and mindfulness levels of wrestlers [62]. Data were collected using the Emotional Eating Scale (EES-TR) and Mindfulness Inventory for Sport (MIS). As a result, the scores of the national wrestlers on the emotional eating scale and its sub-dimensions were found to be higher than the non-national wrestlers. Moreover, this inclination also changes depending on whether the wrestlers are elite or not and whether they wrestle during the season or not [15, 62]. According to another study by Marina R. Flores et al. [24, 25], observed that training experience affected eating disorders in wrestlers. It was found that wrestlers with more training experience showed higher levels of bulimia and over-control behaviors.

The last question of the research was about the unhealthy weight control behaviors exhibited by wrestlers. It was thought that athletes may develop unhealthy ways to maintain their weight to increase their performance. In a study where a questionnaire was applied to 47 university wrestling athletes the study in which the most weight loss was 5.3 kg during the season (i.e., 6.9% of the wrestler’s weight was lost on average), wrestlers were indicated used by weight loss methods including in gradual diet (79.4%), increased exercise (75.2%), fasting (54.8%), sauna (27.6%) and rubber/plastic suits at least once a month (26.7%) [55]. Wrestling students displayed wrong behaviors such as using diet pills, sauna, plastic clothes, spitting, vomiting, and fluid restriction to lose weight [36, 63, 65]. In their studies, Kiningham and Gorenflo [36] found that wrestlers exhibit behaviors such as using sauna and spitting in addition to disordered eating behavior. 72% of high school wrestlers reported using at least one unhealthy weight loss method per week, such as restricting food and fluids [27, 36, 54, 65, 76]. In a survey study conducted among 1138 German elite adolescent athletes, found that 8% of the athletes tried to lose weight continuously, and 12% showed one or more compensatory behaviors (e.g., fasting, self-induced vomiting, use of laxatives, diuretics, and appetite suppressants). Fasczewski et al. [22] in their study, one-fourth of the sample (n=12, 24.5%) attributed the secret of being successful to weight control methods. These methods include increased exercise intensity, drinking only water, calorie restriction, vomiting, and use of laxatives. Similar to the results of this study, the study included in this systematic review and conducted by Satterfield and Stutts [63] found that approximately 77% of the wrestlers stated that they increased the amount of exercise to lose weight at least once a week.

In summary, this systematic review discussed the prevalence of eating disorders and disordered eating in wrestlers, the factors contributing to the development of these disorders, whether the prevalence of eating disorders and disordered eating in wrestlers varies by age, gender, competition level, and the types of unhealthy weight control behaviors exhibited by wrestlers. Considering all of this, the strategies that wrestlers, coaches, and sports organizations can implement to reduce the risk of eating disorders are becoming more important. For the effectiveness of this process, professional teams can implement screening and intervention strategies to detect and prevent eating disorders (ED) and disordered eating (DE) in athletes. Some of the methods that can be used as screening methods are as follows. Standardized self-report questionnaires; (Eating Disorders Inventory (EDI), Eating Disorder Examination (EDE-Q), and Eating Attitudes Test (EAT)), Self-developed questionnaires, Indirect measures (e.g., weight-for-height standards, weight-loss history, excessive injuries), Pre-participation examination (PPE) screening) [5]. Regular ED screening can be performed for athletes. If coaches can regularly monitor potential problems, referral to medical personnel will be faster when necessary.

In a similar vein, for appropriate weight management practices, athletes and coaches need to undergo training that will increase their knowledge and skills, and for athletes to develop a healthy lifestyle. Coaches are the first person source that athletes refer to for weight management [40]. With interdisciplinary studies, seminars on eating disorders, their harms and their prevention can be given to athletes both in clubs and in faculties of sports sciences. By providing integrated mental health education in schools and universities, awareness of eating disorders can be raised [46]. Sports psychologists can carry out psychological support studies on issues such as self-perception and body image toward teams. Intervention strategies should be implemented by an expert team focusing on improving athletes’ health and performance, considering athletes’ biological, psychological, and sociocultural factors. It is recommended that medicine, dieticians, mental health professionals, wrestling coaches, and wrestling management work together interdisciplinarity [56].

In the same manner, sports organizations can develop new rule approaches based on different body compositions instead of categorizing wrestlers solely based on weight. Categorizing wrestlers based on weight puts them under more pressure to lose weight, leading them to unhealthy methods [29, 36, 55, 63]. Instead, new rules can be suggested using body composition analysis. To prevent unhealthy weight loss practices, Sport-Governing Bodies (SGB) now require wrestlers to complete a weight certification process. This certification process consists of body composition tests (body fat percentage (BF%) and fat-free mass (FFM)) and urine-specific gravity tests. Especially studies are being conducted to determine the ideal body fat threshold for female wrestlers to maintain a regular menstrual cycle (The body fat percentage should not exceed 5% in male wrestlers and 12% in female wrestlers) [14, 33]. It is thought that this situation will especially benefit young wrestlers and protect them from harmful weight loss methods. because this method takes into account the developmental stages of young athletes. Since FFM is a desirable factor in terms of performance and is influenced by height, it is considered an effective method to minimize the impact of developmental fluctuations, especially in the later stages of growth [44].

Although there are factors such as genetics, environmental factors and personality traits that predispose athletes to eating disorders, sociocultural risk factors should also be taken into consideration [11, 46]. Cultural factors can lead to differences in how eating disorders appear. The concept of the ideal body, which is spread through mass media and tried to be created by the media, affects body perception [4]. Mohseny et al. [46] found that the prevalence of eating disorders in the Iranian population compared to other countries was higher than in Spain and Portugal but lower than in Italy and Turkey. This type of research is considered important because it will reveal the cultural risks of eating disorders. Addressing sociocultural risk factors is considered important in preventing the spread of eating disorders, especially among young people [79].

When considering treatment options, the unified therapy method can be used in the prevention and treatment of eating disorders [73],Grilo & Masheb, 2005; [59]. These therapies are recommended because eating behavior is affected by emotional states [59]. In particular, the emotion regulation model is associated with treating eating disorders in terms of understanding, recognizing, and accepting emotions. The emotion regulation method and the effort to establish a more rational relationship with recurring negative thoughts make this therapy important in the treatment of eating disorders [2, 21]. Likewise, mindful eating therapy methods are effective in treating eating disorders by preventing reactive eating [16, 53].

In addition, there is a lack of qualitative studies for a more detailed examination of wrestlers, weight control methods and the underlying causes. It is thought that qualitative analyses to be made in future studies will shed light on this issue.

Limitations

Firstly, the studies included in the research were limited to the English language only. There was no experimental research design in the articles reviewed. When the study designs were assessed, a limited number of randomized control group studies were used. Controversially, it is required to use more often that kind of the allocation in this field to avoid bias. Besides, we used five databases within a short period of time. A longer period of observation is required in the future and more checked databases could bring out more relevant articles to the review. Also, considering the search terms, this study was confined to 8 studies due to the inadequacy of the number of studies in the available databases. Despite searching five major databases (PubMed, Scopus, Web of Science, PsycINFO, and SPORTDiscus), the number of eligible studies was limited due to stringent inclusion criteria (e.g., publication years, keywords).