Study on Eating Disorders in Cheerleaders

Search Strategies

The search engines that were used were Pubmed, Cinahl and Google Scholar.  The words used in the search were cheer, cheerleading, feeding disorders, eating disorders, body image issues, body image dissatisfaction, collegiate, college, gymnastics, dance, ballet, female, coed, flyer.  The exclusion criteria was if the article was not about athletes, aesthetic sports or similar activities, and if the research was not related to feeding and eating disorders, body image dissatisfaction or social physique anxiety.

Introduction

Athletics is a culture in which a person is judged based off of their abilities and performance.  Sport type can be defined as an aesthetic sport, (i.e., dance, gymnastics, swimming, figure skating, cheerleading; sports that are affected by “beauty”) or a non-aesthetic sport, (i.e., basketball, softball, volleyball, soccer, field hockey, tennis; sport where appearance does not affect the overall performance)(1).  Aesthetic sports have both male and female participants, with the females being judged more for their appearance.  Research has shown that the aesthetic sport population has a higher risk of eating disorders because of the pressures that coincide with the sport environment.  The new Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria will be defined, along with the overview on cheerleading as a sport.  Aesthetic collegiate sports will be reviewed along with the stressors associated with them.  The intent is to express the reasoning for why collegiate cheerleading teams need to be more thoroughly researched and find the differences between the different squad type pressures.

Current Diagnostic Criteria

There have been many different studies throughout the years on eating disorders (ED) and body image dissatisfaction (BID), but the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), a guide for diagnosis mental disorders that is used by health care professionals, has now changed the criteria and has added new categories.  The new topic of feeding and eating disorders is not highly recognized yet due to the lack of research and knowledge about the new areas developed.  The DSM-IV, 2000, categorized just EDs, the disorders defined were anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified(2).  The current edition has added the feeding and eating disorders; pica, rumination, avoidant / restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding and eating disorder, and unspecified feeding and eating disorder.  The DSM-V also defines body dysmorphic / distortion disorder, with a subcategory defined as obsessional jealousy.  The conditions are stated that they are not to be associated with another medical condition or another mental disorder.

Pica is defined in the DSM-V as the persistent eating of nonnutritive or nonfood substances(3).  The eating habits need to last longer than a month to be considered pica as a condition.  A larger component is understanding that the behavior does not belong to a social or cultural norm.  Pica seems to have an increased prevalence in individuals with an intellectual disability.  The comorbidities included autism spectrum disorder, schizophrenia, obsessive compulsive disorder, trichotillomania and excoriation(3).  There needs to also be the concern for gastrointestinal and other health related effects.  The behaviors can occur at any age and there is not difference between gender as to who has a higher prevalence of the behaviors.  Pica is a condition that can effect physical function, as far as social function is concerned it is stated that pica is not often the cause alone for social impairment(3).

Rumination is defined in the DSM-V as the repeated regurgitation of food, to be considered the condition the habit needs to occur for at least a month.  The food that is regurgitated can be re-chewed, swallowed or spit-out.  The condition cannot be associated with a previous gastrointestinal condition or another medical condition.  The prevalence for rumination is not conclusive but it does depend on the group that is being studied.  IT is also higher in groups that have had a life event that is considered high stress.  The group that has the highest occurrence of rumination is typically in infants and children.  Rumination is also a condition that most likely will be comorbid with another condition.

Avoidant / restrictive food intake disorder (ARFID) is defined as a lack of interest in eating foods or certain types of foods based off certain characteristics and there is a persistent failure to obtain the nutrients and or the energy intake that is required(3).  There could be an associated fear of consequences from eating certain foods.  This is not a condition that occurs because of lack of food or because of cultural or social practices.  There are certain cultures that have a presentation similar to avoidant / restrictive food intake disorder, (i.e., United States, Canada, Australia and Europe,) the condition is not to be diagnosed from those cultural practices.  The intake is predominantly supplement based.  The prevalence tends to be higher in infants and children than adults.  The clinical presentation may take a long time to surface after the actual condition begins(3).  There are no differences in gender in infancy for the prevalence of avoidant / restrictive food intake disorder.  The highest prevalence in males is when the person also is diagnosed with autism spectrum disorder; whereas for women, it is common during pregnancy but it does not normally meet the criteria for the full condition(3).  The condition is comorbid with anxiety disorders, obsessive-compulsive disorder, or neurodevelopmental disorders(3). From the nature of the comorbities, the condition can be triggered by familial anxiety. Or from mothers with an eating disorder(3).  The decreased nutrient intake can lead to physical impairment to development.  The condition can also lead to social difficulties and that can heavily affect the persons family life(3).

Anorexia nervosa (AN) is defined in the DSM-V as the restriction of energy intake from the fear of weight gain or becoming fat(3).  The fear of weight gain or becoming fat, which interferes with weight gain because the person’s weight is already significantly low, a weight that is less than minimally normal for fully developed individuals; whereas in children, it is weighing less than expected(3).  The individual with anorexia nervosa does not see that there is a need for weight gain because the evaluation on themselves is negative.  There are two subtypes of anorexia nervosa, restricting type and binge-eating / purging type(3).  The restricting subtype is where the person primarily uses diet or fasting either alone or in conjunction with excessive exercise.  The binge-eating / purging type is described as the individual recurring in episodes of binge eating (excessive eating) or purging, where the individual could potentially misuse laxatives, enemas or diuretics, or could self-induce vomiting for weight loss(3).  Anorexia nervosa is broken up into severity based off of the current body mass index (BMI) for adults and based off of the BMI percentile for adolescents, mild (BMI > 17 kg/m²), moderate (BMI 16-16.99 kg/m²), severe (BMI 15-15.99 kg/m²), extreme (BMI < 15 kg/m²)(3).  There is a higher prevalence in females than males and the condition normally occurs between puberty and 40 years old.  Individuals with anorexia nervosa have a distorted view of themselves, either thinking they are too fat in certain areas, when they are not(3).  They may also demonstrate certain tendencies that are abnormal, like constant weigh-ins or measuring certain body parts(3) .  They could also do frequent mirror checks to see if they appear fat in the mirror.  Individuals that exhibit anxiety disorder or obsessive tendencies as children have an increased risk of anorexia nervosa(3).  The individual’s self-esteem is influenced, normally negatively, by what the individual perceives in the mirror.  Signs and symptoms for anorexia nervosa could require laboratory testing where leukopenia, anemia, elevated blood urea nitrogen levels, hypercholesterolemia, hepatic enzyme elevation, hypomagnesemia, hypozincemia, hypophosphatemia, hyperamylasemia, elevated serum bicarbonate, hypochloremia, hypokalemia, low serum thyroxine, decreased triiodothyronine, elevated T₃ levels, females: low serum estrogen, males: low serum testosterone, sinus bradycardia, low bone mineral density (BMD), reduction in resting metabolic rate (RMR)(3).  There are also physical signs and symptoms to look for when dealing with a potential anorexia nervosa case, signs of starvation (emaciation), there could be peripheral edema, potential hypercarotenemia amenorrhea in mature females and menarche could potentially be delayed in prepubertal females, hypertrophy of salivary glands and potential enamel erosion or scars / calluses on their hands from the constant contact with teeth (binge-eating / purging subtype)(3).  Individuals with anorexia nervosa could still function normally but there is the potential for social isolation, this is associated with being unable to fulfill their full potential in the academic setting or the social / career setting(3).  There is a high suicide risk associated with anorexia nervosa as well as bulimia nervosa.  When someone is diagnosed with anorexia nervosa or bulimia nervosa they should be evaluated for the risk of suicide, including finding I there are any attempts at suicide(3).

Bulimia nervosa (BN) is defined by the DSM-V as a condition that consists of episodes of binge eating (discreetly eating or having a ack of control while eating) followed by inappropriate compensatory behaviors(3).  The behaviors are to prevent weight gain and commonly are self-induced vomiting, the use of diuretics or laxatives not for the original intent of the medication, fasting or excessive exercise(3).  There is constant self-evaluation along with depressive symptoms or anxiety and low self-esteem(3).  There are four categories that describe the severity of bulimia nervosa; mild, moderate, severe and extreme.  Mild being 1-3 episodes of inappropriate compensatory behaviors a week, moderate is 4-7 episodes inappropriate compensatory behaviors a week, severe is 8-13 inappropriate compensatory behaviors a week and severe is 14 or more inappropriate compensatory behaviors a week(3).  The condition is predominantly in females, at a 10:1 ratio(3).  Laboratory testing to help with diagnosing bulimia nervosa could find electrolyte abnormalities, hypokalemia, hypochloremia, hyponatremia, elevated serum bicarbonate, elevated serum amylase.  Physically the individual may not have any severe distortion but an oral exam will yield loss of dental enamel, the teeth may appear chipped and there could be increased dental carries from the recurring vomiting(3).  For both anorexia nervosa and bulimia nervosa there is an increased risk for cardiovascular complications, in bulimia nervosa specifically the individuals may use syrup of ipecac to help the individual induce an episode of vomiting(3).  There is typically a high prevalence of substance abuse associated with bulimia nervosa, it is also associated with individuals with anorexia nervosa, particularly the individuals with the binge eating / purging subtype(3).

Binge eating disorder (BED) is defined by the DSM-V as recurring episodes of binge eating.  The episodes of binge eating occur at least once a week for three months(3).  Binge-eating is associated with eating faster than they normally do, the individual may also eat too much, making the individual feel abnormally full or eating large amounts when they are not actually feeling a amount of hunger, eating alone out of embarrassment and also feel ashamed with themselves for the amount they ate(3).  There are four categories that describe the severity of binge eating disorder, similar to bulimia nervosa; mild, moderate, severe and extreme.  Mild being 1-3 episodes of binge eating behaviors a week, moderate is 4-7 episodes binge eating behaviors a week, severe is 8-13 binge eating behaviors a week and severe is 14 or more binge eating behaviors a week(3).  The prevalence is the same between males and females, and the condition is normally in adolescents or young adulthood but can occur later in adulthood.  Binge-eat normally occurs in individuals of normal weight, over-weight or obese weight; it is not to be confused with obesity(3).  The individuals with binge-eating disorder do not enjoy the eating habits they have, in reality they are ashamed of the binge-eating episodes(3).

The DSM-V also describes other specified feeding and eating disorders (OSFED), and also unspecified feeding and eating disorders (UFED)(3).  OSFED is a category to help a clinician when there are symptoms communicated by the patient but there is no specific FED that the criteria fits.  The clinician can use OSFED but needs to follow up the diagnosis with a specific reason why they have not been able to give the patient a clear diagnosis of another FED(3).  The DSM-V discusses the different reasons as atypical anorexia nervosa, bulimia nervosa of low frequency and or limited duration, binge eating disorder of low frequency or limited duration, purging disorder, night eating disorder(3).  UFED is defined as a category for patients that have symptoms that cause distress or impairment to the patient’s life; either social or occupational, but the symptoms do not meet the inclusion criteria for the other FEDs(3).  The diagnosis of UFED is used when the clinician does not want to provide any reasoning as to why the patient does not have a specific diagnosis(3).

Body image dissatisfaction is defined in the DSM-V as a preoccupation with one’s body, the preoccupation is normally associated with a perceived defect or flaw and can cause behaviors like mirror checking, excessive grooming, skin picking reassurance seeking or comparative behaviors to others around them(3).  Body image is defined as a multidirectional idea that is affected by attitude, perception and behavior(4).  The symptomology normally begins in the teenage years, two-thirds normally have the disorder prior to the age of 18, and the early onset (i.e., before 18 years old) has the increased risk of suicide(3).  There is no increased prevalence in either gender, but males tend to preoccupations with musculature and genitalia, whereas females will potentially have an associated eating disorder(3).  When asked to rate themselves for overall performance and appearance, women will rate themselves lower than men(5).  The main comorbidity is depressive disorder, social anxiety disorder, obsessive compulsive disorder, or substance abuse is another potential(3).  There is a lot of psychosocial problems associated because the individual has negative thoughts on the way they look it affects their ability to interact with those around them(3).  Another condition is obsessional jealousy, and that is defined by the DSM-V as a non-delusional preoccupation with the partners perceived infidelity(3).  Like BID, there can be repetitive behaviors that affect one’s social or occupational functioning.  Also, objectification theory has been researched and is where the culture in which women are treated like a body and not a person, the “body” essentially is just an inanimate object that those around them use for pleasure(6).  The body is to be thought of as a separate entity from the person and is used as an instrument(6).  Women are taught about the way they should act by the culture they grew up in, women are expected to understand that there are gender roles and some cultures still enforce submissiveness, modesty and thinness; there is an overall understanding of the requirements to look appealing(1).

Collegiate Cheerleading

Cheerleading is a sport that was predominantly in the United States but it has started to make its way to other countries(7).  Cheerleading has both positions for males and females and it incorporates routines and cheers, which include tumbling (acrobatic skills that either move forward, backward or sideward and can have a rotational element) and stunts (building pyramids with one person at the top show casing different skills).  There are opportunities to join either an all-girl cheerleading squad or a coed cheerleading squad.  In an all-girl cheerleading squad there are three bases (the person on the bottom) and one flyer (the person that is held up and performs the acrobatic skill in a stunt).  Cheerleading calls for a smaller individual that stands on the shoulders and on their partners hands performing high flying stunts(7).  In the coed cheerleading squad, the male positions are predominantly bases, while the females are typically flyers.  Unlike the all-girl squads, the coed squads have only one base, the male, who is throwing, catching and holding the flyer.  Cheerleaders make appearances predominantly at football and basketball games, along with pep-rallies and advertising events, where they perform their group routines and stunts.

Pressures Among Collegiate Females

Weight pressures in athletics occur often, whether it be from the coach, teammates, sport ideals or family.  Torres-McGehee et al explained weight pressures as the external pressures on body image dissatisfaction that indicate an increased risk for developing eating disorder thoughts and behaviors(8).  Weight related anxiety can be associated with the society and environment the athletes are immersed in and that creates similar concerns that are common among non-athletes(9).  Female athletes experience pressure change their body weight, shape or size to meet perceived athletic ideal(10).  When an athlete feels that they do not meet the ideal for body image then that predisposed them to disordered eating (i.e., restrictive eating) in attempt to become more lean and have the “skinny” look(10).  Teams can have weigh limits to make the team and then also have weigh-ins to maintain the spot on the team, that stress can lead athletes to partake in drastic techniques to loss weight(11).

It has also been discussed that anxiety in uniform can have an effect on the athletes in aesthetic sports(10).  An aesthetic sport being a sport that appearance has an effect on.  Aesthetic sport uniforms are typically form fitting and/or show large amounts of body areas (i.e., stomach, back, legs and arms).  In gymnastics, dance and figure skating the athletes wear a leotard, swimming the athletes wear bathing suits.  Dance and figure skating also have a variety of costumes that they can wear depending on the style or performance they are giving.  Cheerleaders wear either a two-piece or one-piece uniform, both involving either a short, tight skirt or short and a tight top.  Over the last 10-15 years the uniforms have become more and more revealing, moving from the one piece to the two piece(8).  There is an increased pressure to maintain an aesthetically pleasing figure due to the form fitting uniforms.  This can cause the athletes to be fearful of not having a flat stomach or not feeling skinny enough.

The social aspect puts collegiate athletes at a high risk for FEDs and BID.  It has been found that teammates take up a large portion of the pressures in athletes, as do coaches(10-12).  It has also been found that females have a higher prevalence of eating disorders than males(13).  Typically, the largest stress comes from coaches, judges and teammates (male or female)(8, 10).  Aesthetic athletes are sometimes seen for only their looks and not their athletic ability, the way the media portrays the athlete is how society is going to see them(1).

Aesthetic Sport Literature

Cheerleaders have been identified to have similar characteristics as dance, gymnastics and weightlifters; they have been placed in a category of sport where leanness is emphasized.  Aesthetic sports have demands that are unique to each environment as pertained to body weight, shape and size(10).  A very large amount of female athletes have reported difficulty with disordered eating(14).  Elite athletes have a high risk of eating disorders and for females that can lead to an increased risk of developing symptoms associated with the Female Athlete Triad(15).

Gymnasts tend to have the highest rate of eating disorder risk at about 50% , cheerleading and auxiliary are similar in the percentage of eating disorder risk(8).  In collegiate auxiliary units, (dancers, color guard, majorettes) 29% were at risk for eating disorders the research also stated that the auxiliary units had a higher risk for body image dissatisfaction(16).  It has also been found that 26.1% of a collegiate gymnastics and swimming team sample were found to have subclinical eating disorder tendencies (8, 17).  Of the 26.1% found in the group, over 6% met the criteria for a clinical eating disorder (6.9% sub-threshold bulimia nervosa, 15.4% non-binging bulimia nervosa, 7.7% binge eating disorder)(10).  It has been found that aesthetic athletes are at a higher risk of eating disorder than those athletes that take part in non-aesthetic sports or non-athletes(9).  Gymnasts and swimmers were also found to have a higher prevalence of eating disorders (4.7%) as compared to non-lean sports (21.4%) (18).  Aesthetic sport athletes (i.e., gymnastics) had a higher prevalence of eating disorders than endurance athletes, also technical sports and ball sports had a lower prevalence(17).  Professional dancers have high rates of both negative body image and also disordered eating patterns(1).  Dancers have been found to have negative body image, one study found that 99% of their sample had self-consciousness and body image negativity when they were wearing revealing costumes(19).

Sports that practice in front of a mirror tend to have higher rates of social physique anxiety(20).  It has been stated that there are sociocultural and sport related stressors but there are also stressors within the athlete (i.e., personality and psychological) that can have an effect on the prevalence of disordered eating and body image dissatisfaction(10).  Aesthetic sports (i.e., swimming, tennis, gymnastics, cheerleading) are show to have high objectification from peers and spectators(1).

Current Cheerleading Research

Cheerleading as a whole is very similar to other sports (i.e., gymnastics, dance and figure skating) because it incorporates difficult routines and stunts as discussed by Ryan et al (1995).  Cheerleading incorporates a considerable amount of gymnastics and stunting and those similarities are shown to predispose cheerleaders to endure similar pressures to lose or maintain weight for better performance abilities (5, 11).  There has been a statement made that weight expectations, which may either be personal or made by others, may differ between the different positions on the cheer squad (i.e., flyer, back spot, base)(8).  It has been reported that a cheerleaders stunt partner can cause negative body image because the partner has the ability to notice weight gain(11, 12).  It has been shown that 30% of cheerleaders find that their stunt partner has an influence on the way they perceive themselves because the partner has noticed weight gain(10).  One study found that 88.2% of males in the studied population said that there should be a weight limit(11).

The two main positions on a cheer squad, flyers and bases, each have their own unique ideal for body type.  Flyers are typically the smallest in stature and overall size due to the requirements of the position(8).  Also because flyers are expected to be small so they can be thrown and held easier, that means the smallest and lightest individuals will be the ones that are chosen as partners in coed squads(11). It was also stated in that article that flyers had the greatest risk of eating disorder at 36.1%, with seniors being the most likely to have eating disorder prevalence risk(8).  Bases are typically the largest in regards to BMI and back spots are in the middle(8).  A revealing uniform can have more consequences than is understood, the cheerleaders that feel dissatisfied with their appearance put themselves at and increased risk for BID and disordered eating; which also puts them at risk for the female athlete triad that can lead to a distorted menses and/or decreased bone health(21).

Cheerleaders were found to have a higher rate of laxative use as compared to other aesthetic athletes, they had the lowest incidence of binge eating and was about average among the studied subjects with using vomiting as a weight loss technique(8).  The stressors on cheerleaders may come from both social and cultural ideal, the pressures can drive cheerleaders to seek a unrealistic body shapes and weights(8).  It has been confirmed that female cheerleaders would like to weigh less than their actual weight, some cheerleaders wanted to decrease their weight by as much as 14lbs(11).  Cheerleaders may have a high prevalence of body image dissatisfaction because of frequent media coverage, evaluations on their physique or the aesthetic quality and also the intensity that is required in their workouts(8).  It was also stated that cheerleaders are judged on their talents and their aesthetic aspects.  Tryout weight limits may be used to ensure that larger, heavier, and less-than-ideal females do not make cheerleading squad(11).

Measures Used in Literature

Cheerleading, feeding and eating disorder / body image dissatisfaction research predominantly uses survey based measures.  The studies will typically get appropriate demographics through a questionnaire.  Only one study found used an interview method on females between the ages of 15-20(22) .  In the current research the measures used were the Eating Attitudes Test(6, 8, 23-25), Gender-Specific BMI Figural Stimuli Silhouette(8, 26), Weight Pressures Scale for Females Athletes(10), 12-item perceived sociocultural scale(10), Sociocultural Attitudes Towards Appearance Questionnaire-3(10, 27), Body Parts Satisfaction Scale-revised(10), 9-item Dietary Intake Scale(10), 36-item Bulimia Test revised(10, 17, 28-30), 12-item Marlowe-Crowne Social Desirability Scale(10), Body Appreciation Scale(31), Eating Disorder Inventory(11, 12), Eating Disorder Inventory-2(6, 31), Self-Objectification Questionnaire(31), Social Physique Anxiety Scale(11, 12, 20, 25, 32, 33), CHEER Questionnaire(11, 12), Eating Disorder Examination Questionnaire(15, 34), ATHLETE Questionnaire(35), Rosenberg Self Esteem Scale(23), Multidimensional Body-Self Relations Questionnaire(27), The 50-item Questionnaire for Eating Disorder Diagnosis(17, 28, 29), Perceived Sociocultural Perception Scale(6, 10), Objectified Body Consciousness Scale(6), Body Shape Questionnaire(4), International Physical Activity Scale(4), Body Shape Questionnaire(24), Peer Norms Scale(24), Physical Self-Efficacy Scale(20), Positive and Negative Perfectionism Scale for Athletes(25), Ideal Body Stereotype Scale-revised(34), Dutch Restrained Eating Scale(27, 34), Body Image Questionnaire(30).  The limitations often stated by the studies were that there was a low response rate and that the truthfulness of the participants cannot be monitored.

Clinical Relevance

Cheerleading is a growing sport and it is a sport that is not regulated by the NCAA.  Torres-McGehee et al (2012) discusses that until cheerleading is regulated by the NCAA, the coaches and regulating bodies will need to screen for eating disorders and body image issues(8).  There will also need to be policies put in place for education for coaches so they then know what to look for in the athletes.  Majority of the studies done on cheerleading have not been done in the collegiate setting, so even if the NCAA were to regulate the sport there would not be a lot of data out there on the prevalence of FEDs and BID in that group.  Cheerleaders also have the potential for professional possibilities (i.e., National Football League and National Basketball League) where it has been shown that body image is a very large part of making the squad.  With the overwhelming research done on other aesthetic sports, and cheerleading being considered an aesthetic sport and having very similar stressors, cheerleading needs to be more understood.