THE PREVALENCE OF EATING DISORDERS AMONG FEMALE COLLEGIATE EQUESTRIAN ATHLETES A THESIS Submitted to the Faculty of the School of Graduate Studies and Research of California University of Pennsylvania in partial fulfillment of the requirements for the degree of Master of Science By Alexandra Marie Houck Research Advisor, Dr. Carol Biddington California, Pennsylvania 2009 ii iii ACKNOWLEDGEMENTS There are so many people who have helped me this year and through-out my life that deserve my recognition and gratitude. First, I would like to thank everyone who goes unmentioned here as there are so many people who have guided and changed my path in life for the better that it is impossible to name them all. As always, my whole family has always been a strong guiding light in my life and without them I would not have ever had the confidence or drive to even get my Masters degree. Being apart from them this year has been one of the most difficult challenges of my life and thanks to their constant encouragement, I now have the strength and confidence to make it on my own no matter how far or near I am to them. My family was also the beginning of my obsession with horseback riding; they sacrificed countless hours of going to horse shows, riding lessons, and rodeos in order to strengthen me as an equestrian and make me happy. Little did they know that they were helping me to build a sound foundation on which I would base this thesis study off of. All of the riding coaches that I had through-out my life (Linda, Andrea, and the endless fountain of knowledge iv and patience who is Holly Gilmore) helped to feed my obsession with horses and give it a purpose. They also taught me many important life lessons that have helped lead me to where I am today and for that I am forever thankful. I would also like to thank my previous professors and accredited certified instructors that I had through my undergraduate career. Without them I would not be half the athletic trainer I am today, nor would I be nearly as passionate about my profession. Also, if it weren’t for them I would have never ended up at Cal to get my Masters degree in the first place. To all of the friends that I have made in this past year…I would like to thank you all for all the good times and memories that I now have thanks to you. I would especially like to thank my classmates for inspiring me to explore the topic that I chose for my thesis. More importantly I would like to thank Dr. Carol Biddington. You once said to me “You will probably hate me by the end of this year because I push you so hard,” but believe me Carol I most definitely do not. Without your constant guidance and encouragement I would have probably rushed to finish my thesis instead of being comfortably happy to have finished v with time to spare. I must also thank my committee members, Dr. Margaret Marcinek and Ellen West. I would also like to thank all of the coaches, staff, and athletes at McGuffey High School. You all made what could have been a very scary experience of my first year as a practicing certified athletic trainer very delightful and encouraging. You have given more than you will ever know. Without you all I would have never met that man who I believe to be the love of my life. Jed, I love you and without you always telling me to work on my thesis I probably would have procrastinated until the end. Lastly, but most importantly, I would like to thank the equestrian athletes, coaches, and board of the Intercollegiate Horse Show Association. Without your involvement in this study, there would not have been a study at all. I hope the results of this thesis only help to improve the sport of horseback riding and make it more safe and enjoyable for everyone. vi TABLE OF CONTENTS Page SIGNATURE PAGE . . . . . . . . . . . . . . . ii ACKNOWLEDGEMENTS . . . . . . . . . . . . . . iii TABLE OF CONTENTS . . . . . . . . . . . . . . iv LIST OF TABLES . . . . . . . . . . . . . . . vii INTRODUCTION . . . . . . . . . . . . . . . . 1 METHODS . . . . . . . . . . . . . . . . . 6 Research Design. . . . . . . . . . . . . . 6 Subjects. . . . . . . . . . . . . . . . . . 6 Instruments . . . . . . . . . . . . . . . 7 Procedures . . . . . . . . . . . . . . . . 9 Hypotheses . . . . . . . . . . . . . . . 10 Data Analysis RESULTS . . . . . . . . . . . . . . 10 . . . . . . . . . . . . . . . . . 12 Demographic Data . . . . . . . . . . . . . Hypotheses Testing . 12 . . . . . . . . . . . 15 Additional Findings . . . . . . . . . . . . 18 vii DISCUSSION . . . . . . . . . . . . . . . . . Discussion of Results . 23 . . . . . . . . . . 23 . . . . . . . . . . . . . . 31 . . . . . . . . . . . . . 32 REFERENCES . . . . . . . . . . . . . . . . 34 APPENDICES . . . . . . . . . . . . . . . . 36 A. Review of the Literature . . . . . . . . . . 37 Equestrian Sports . . . . . . . . . . . . 39 Conclusions . Recommendations Intercollegiate Horse Show Association . . 39 . . . . . . 40 Disordered Eating . . . . . . . . . . . . 42 Types of Disordered Eating . . . . . . . 42 Causes of Disordered Eating . . . . . . . 48 Menstrual Irregularities . . . . . . . . . 52 Types of Menstrual Irregularities . . . . 52 Causes of Menstrual Irregularities . . . . 55 Riding for Form and Function Summary . . . . . . . . . . . . . . . 58 B. The Problem . . . . . . . . . . . . . . . 60 viii Statement of the Problem . . . . . . . . . 61 Definition of Terms . . . . . . . . . . . 62 Basic Assumptions . . . . . . . . . . . 65 Limitations of the Study . . . . . . . . . 65 Significance of the Study . . . . . . . . 66 . . . . . . . . . . . . 67 C. Additional Methods Eating Behaviors and Demographics Questionnaire (C1) . . . . . . 68 Institutional Review Board(C2) . . . . . . 74 . . . . . . . 81 Cover Letter Sent to Participants(C4) . . . . 83 Email Sent to IHSA Board(C3) REFERENCES ABSTRACT . . . . . . . . . . . . . . . . 86 . . . . . . . . . . . . . . . . . 89 ix LIST OF TABLES Table Page 1 Characteristics of Participants . . . . . . 12 2 Participants’ Class Rank . . . . . . . . . 12 3 Participants’ Oral Contraceptives Usage 4 . . . . . . . . . . . . . . . . 13 Participants’ Responses for Menstrual Regulation . . . . . . . . . . 13 5 Participants’ Main Event . . . . . . . . . 13 6 Participants’ Responses for Eating Binges . . . . . . . . . . . . . 14 7 Participants’ Responses for Vomiting . . . . 14 8 Participants’ Responses for Weight Control . . 14 9 Participants’ Eating Disorder Treatment . . . 15 10 Eating Disorder Issues . . . . . . . . . . 15 11 Pearson-Product Moment Correlation Between The Equestrians Age and Total Score . . . . . . . . . . . . . . 12 16 A One-Way ANOVA for Eating Disorders among Riding Events . . . . . . . . . . . 17 x 13 Pearson-Product Moment Correlation between The Equestrians BMI Scores and Total Score 14 . . . . . . . . . . . . 18 T Test Comparison between Binge Eating Responses for the EAT-26 Score . . . . . . . . . . . . 15 19 T Test Comparison between Weight Control Substance Use (WCSU) for the EAT-26. . . . . . . . . . . 16 20 T Test Comparison of Responses for the Eating Disorder Issues for EAT-26. . . . . . . . . . . . . . . 17 22 Coaches’ Ratings of the Seriousness of Eating/Dieting Behaviors for the Athlete’s Health and Performance . . . . . . 51 xi LIST OF FIGURES Figure 1 2 Binge Eating Responses for EAT-26 Page . . . . . 19 Substance Use Responses for EAT-26 . . . . . 20 3 Eating Disorder Issues for EAT-26 . . . . . 21 4 Proper Riding Position . . . . . . . . . . 41 1 INTRODUCTION For years females have been participating in athletics for both leisure and competition. There is no limit to the type of sports in which women may participate. From field hockey to softball, from motor bike racing to track, women can do it all. But one sport that is often overlooked when discussing female participants in sports is horseback riding (or equestrian sports). While equestrian sports have been in existence for years, and have continued to grow rapidly, the amount of research on equestrians is sparse. The few studies found by the researcher on equestrian sports mainly examined the different types of injuries that could be sustained by horseback riding. There is little research that pertains to potential psychological disorders of equestrians and the physiological effect. Female equestrians are at the same, if not greater, risk of sustaining injuries as athletes in other sports. It could even be hypothesized that equestrians are at a higher risk of injury since they are dealing with an animal that can at times be unpredictable, uncontrollable, and dangerous. However, it has yet to be determined if female equestrians have the same risk level or if they are even at 2 risk for developing psychological disorders that affect other female athletes. Eating disorders and the possibility of developing menstrual irregularities are among the major psychological concerns for female athletes. It has been demonstrated that 32% of female collegiate athletes practice pathogenic weight-control behaviors that could be associated with eating disorders.1 Furthermore, menstrual irregularities, like amenorrhea and oligomenorrhea, may be related to eating disorders. The potential for female riders to develop eating disorders as well as associated menstrual irregularities is present in equestrian sports. In the past, when horses were used as beasts of burden instead of a form of entertainment, it was important for riders to be lean, flexible, and strong so that they could move and work with the horse more efficiently. It is still important for modern day equestrians to be flexible and strong to be an efficient rider. While a lean physique may not be necessary for success in equitation, it is an important aspect in competition judging. In equestrian sports where riders are judged on their equitation(or riding position), pressure can be put on equestrian athletes to have a lean figure. 3 It is often unspoken knowledge that overweight riders are less likely to experience success in competitions than riders who have a lean build. Equestrians can feel the pressure to stay lean through many different outlets. Parents, coaches, teammates, and competition can all put unnecessary pressure upon equestrians to do whatever it takes to win in their division. It is also important to recognize that some equestrians could feel pressure to be lean from their coaches. Equestrians, like other female athletes, may avoid reporting symptoms of eating disorders for fear that their coaches would remove them from competition.2 Previous research has demonstrated that collegiate coaches consider behaviors that can be associated with eating disorders to be a serious matter as both the athlete’s health and performance are placed at risk.3 Thus if equestrian athletes are aware that their coaches feel strongly against behaviors associated with eating disorders, they will be less likely to report them. Although no evidence could be found in the literature that listed equestrian sports as being a lean or non-lean sport, research has been done to evaluate whether or not the type of sport (lean or non-lean) has an effect on the 4 prevalence of eating disorders. It has been found that 25% of lean sport athletes had more disordered eating symptoms and were at greater risk of developing an eating disorder compared to 2.9% in non-lean sports.4 Thus, if equestrians consider themselves to be in a lean sport, they may also be at a higher risk for developing an eating disorder and developing menstrual irregularities. Menstrual irregularities are a result of eating disorders and are often used as a criterion for detecting them.5 The commonly observed interval between menstrual cycles is 26-32 days, which represent a “normal” menstrual status.5 Therefore, cycles that are either shorter or longer than the “normal” range indicate eating disorders among female athletes.5 It has also been reported that athletes had more significantly long cycles (79%) than non-athletes (45%).6 This “normal” range is used in determining the presence or absence of both amenorrhea and oligomenorrhea.6,7 It has been stated that amenorrhea occurs almost 20 times more frequently in female athletes when compared to the general population, and it can exist in up to 50% of female athletes.6 Amenorrhea can also occur in normal weight females that have a low percentage of body fat.8 Thus, 5 female equestrians are also at risk for developing menstrual irregularities. When female equestrians go to the extremes to be lean in order to be competitive in their sport, they put themselves at risk. Whether they knowingly or unknowingly engage in disordered eating behavior, they must be made aware of it in order to encourage healthy training habits. Thus, it is most important for athletic trainers and those working with female equestrians to realize that these athletes may be risk for developing eating disorders and associated menstrual irregularities and help to guide them in a more appropriate path. This study will attempt to answer the following questions: 1)What is the relationship between age and eating disorders in collegiate female equestrians? 2)What are the differences between eating disorders and riding events among female equestrians? 3)What is the relationship between body mass index and eating disorders among female equestrians? 6 METHODS The purpose of this study is to discover whether or not there female the is a prevalence collegiate following of equestrians. subsections: eating This disorders section research will design, amongst include subjects, instruments, procedures, hypotheses, and data analysis. Research Design A descriptive design was used for this study. The independent variables were age, body mass index, and the type of riding event. The dependent variable was the scores on the eating disorders survey, the Eating Attitudes Test (EAT-26), and the results of the demographics survey. The strengths of this study are that a national survey was distributed and the instrument used by the researcher has demonstrated reliability9. One limitation of the study is that the population is limited to only female collegiate equestrians. Subjects The number of subjects that were included in this study was determined by how many surveys were returned from 7 a population of 6500, as long as they met the set criteria. Subjects (N=127) were female collegiate equestrian athletes, who competed in six different divisions: 1) hunter/jumper, 2) equitation, 3) dressage, 4) reining, 5) western pleasure, and 6) barrel racing/speed events. The sampling of this study was done by using all surveys that were returned from the collegiate female athletes of the Intercollegiate Horse Show Association (IHSA). Informed consent was not necessary as it was an electronic survey and consent was implied by the completion and return of the survey. Instrumentation The instrument that was used for this study was the Eating Attitudes Test (EAT-26), as well as a demographics section that has additional specific questions. The specific questions in the demographics portion pertained to the participant’s length of menarche, their usage of hormonal contraceptives to regulate menstruation, and the type of equestrian sport. The combination of the EAT-26, demographics section, and specific questions was titled the Eating Behaviors and Demographics Questionnaire (Appendix C1). Internal consistency reliability for the score of the Eating Attitudes Test have ranged between .70 and .88.9 8 Demographics include age, height, weight, and class rank. The athlete’s length of menarche, their usage of hormonal contraceptives to regulate menstruation, and the type of equestrian sport they participated in was analyzed through specific questions. Length of menarche was assessed by asking the participants, “On average, how long is your normal menstrual cycle (from the start of one period to the beginning of the next period)?” Use of hormonal contraceptives and their use to regulate menstruation as well as what riding event they participate in were also asked. The Eating Attitudes Test included 26 questions with an optional answer of either “always”, “usually”, “often”, “sometimes”, rarely”, or “never”. There are also four additional questions that asked about 1)binge eating, 2) self induced vomiting, 3) the use of weight controlling substances, and 4) past eating disorder treatment. For all questions (excluding #25) each of the responses were given the following value: 3 points for “always”, 2 points for “usually”, 1 point for “often”, and 0 points for “sometimes”, “rarely”, and “never”. For item #25 the responses were given the following values: 0 points for “always”, “usually”, and “often”, 1 point for “sometimes”, 9 2 points for “rarely”, and “3 points for “never”. After scoring the items the scores were added together. If the sum was greater than 20 then the participant was considered to have an eating disorder issue. Also if the participant answers “yes” to any of the four additional questions, they should also be considered to have an eating disorder issue. Procedures The California University Institutional Review Board for Protection of Human Subject Form (Appendix C2) was completed and approved. Upon receiving approval for the study from the Institutional Review Board, an email (Appendix C3) including a cover letter (Appendix C4) was sent out to the chairperson of the Intercollegiate Horse Show Association. The IHSA chairperson was then notified by the primary researcher of his/her willingness to participate in the study. Once clearance was allowed by the IHSA, a link to an electronic survey was sent out to all participants in the IHSA. The participants were also emailed a copy of the cover letter which described the study, indicated that they are not required to participate, confirm that their identities would remain unknown, and remind them that they have to be at least 18 years old to 10 participate. All surveys that were completed and returned to the researcher were then analyzed in the study. Hypotheses The level of significance used for testing the hypothesis was set at an alpha level of .05. Hypothesis 1: There will be a relationship between age and eating disorders. Hypothesis 2: There will be a difference between the different types of riding events for eating disorders. Hypothesis 3: There will be a negative relationship between BMI and eating disorders. Data Analysis The level of significance used for testing the hypothesis was set at an alpha level of .05. 1: A Pearson Product Moment Correlation was used to determine if there would be a significant relationship between age and eating disorders. 11 2: An ANOVA was used to determine if there would be a significant difference between riding events for eating disorders. 3: A Pearson Product Moment Correlation was used to determine if there would be a significant negative relationship between BMI and eating disorders. 12 RESULTS Demographic Data The sample consisted of female equestrians from the Intercollegiate Horse Show Association (n=127). Table 1 depicts the characteristics of the participants from this study. Table 1. Characteristics of Participants Characteristic Range Mean ± SD Age 18-29 20.08 ± 2.01 Height (inches) 60-72 65.30 ± 2.59 Weight (pounds) 100-230 BMI 16.95-33.67 22.33 ± 3.26 Menstrual Cycle Length (days) 18-70 29.34 ± 5.85 136.15 ± 22.85 Table 2 displays the class rank responses of the subjects. Table 2. Participants’ Class Rank Class Rank Frequency Percent Freshman 37 28.9% Sophomore 37 28.9% Junior 26 20.3% Senior 22 17.2% 5 3.9% Graduate Student 13 Table 3 displays the oral contraceptive use responses of the subjects. Table 3. Participants’ Oral Contraceptives Usage Oral Frequency Percentage Contraceptive Use Yes 65 50.8% No 62 48.4% Table 4 displays the oral contraception use for regulating menstruation. Table 4. Participants’ Responses for Menstrual Regulation Menstrual Frequency Percentage Regulation Yes 34 26.6% No 32 25.0% Table 5 displays the main equestrian event responses of the subjects. Table 5. Participants’ Main Event Event Frequency Percent Hunter/ Jumper 60 46.9% Equitation 42 32.8% Dressage 8 6.2% Reining 3 2.4% 13 10.2% 1 0.8% Western Pleasure Barrel Racing/ Speed Events 14 Table 6 displays the eating binge responses of the subjects. The range was between 1 and 20 with a mean score of 6.52 ± 6.72. Table 6. Participants’ Responses for Eating Binges Eating Binges Frequency Percentage Yes 30 23.4% No 96 75% Table 7 displays the vomiting (purging) responses of the subjects. The range was between 1 and 30 with a mean score of 5.56 ± 9.46. Table 7. Participants’ Responses for Vomiting Vomiting Frequency Percentage Yes 9 7% No 116 90.6% Table 8 displays the use of weight control substances (laxatives, diet pills, or diuretics) responses of the subjects. The range was between 1 and 180 with a mean score of 10.45 ± 39.96. Table 8. Participants’ Responses for Weight Control Weight Control Frequency Percentage Substances Yes 21 16.4% No 105 82% 15 Table 9 displays the past treatment for eating disorders history responses of the subjects. The range was between 2000 and 2006 with a mean score of 2003 ± 2.45. Table 9. Participants’ Eating Disorder Treatment Eating Frequency Percentage Disorder Treatment Yes 7 5.5% No 118 92.2% Table 10 displays the frequency of participants with an eating disorder issue based upon their responses. Table 10. Eating Disorder Issues Eating Frequency Disorder Issue Yes 48 No 79 Percentage 37.79% 62.2% Hypotheses Testing The level of significance used for testing the hypotheses was set at an alpha level of .05. Hypothesis 1: There will be a relationship between age and eating disorders. A Pearson correlation coefficient was calculated for the relationship between the participants’ age and the 16 total scores on the EAT-26 survey. A weak correlation that was not significant was found (r125= .026, p > .05), indicating that age is not related to the total scores on the EAT-26. The results of this analysis are presented below in Table 11. Table 11. Pearson-Product Moment Correlation Between The Equestrians Age and Total Score Variable N r P Age & 125 .026 .779 Total Scores Hypothesis 2: There will be a difference between the different types of riding events for eating disorders. The mean scores on the EAT-26 for each equestrian who participated in one of four events were compared using a one-way ANOVA. No significant difference was found (F3,118 = .211, p > .05). The equestrians’ scores on the survey did not differ significantly based on event. Equestrians who participated in hunter/jumper events had a mean score of 7.43 ± 8.46. Equestrians who participated in equitation events had a mean score of 7.43 ± 7.12. Equestrians who participated in dressage events had a score of 9.25 ± 8.45. Equestrians who participated in western pleasure 17 events had a mean score of 8.83 ± 9.60. The results of this analysis are presented below in Table 12. Table 12. A One-Way ANOVA for Eating Disorders among Riding Events Eating Sum of Df MS F P Disorders Squares Between Groups 41.98 3 13.99 Within Groups 7818.19 118 66.26 Total 7860.16 121 .211 .888 Hypothesis 3: There will be a negative relationship between BMI and eating disorders. A Pearson correlation coefficient was calculated to evaluate the existence of a negative relationship between the participants’ BMI and the total scores on the EAT-26 survey. A weak positive correlation that was significant was found (r115 = .114, p > .05), indicating that BMI is not negatively related to the total scores on the EAT-26. The results of this analysis are presented below in Table 13. 18 Table 13. Pearson-Product Moment Correlation between The Equestrians BMI Scores and Total Score Variable n r P BMI Scores & 115 .114 .225 Total Score Additional Findings Several tests were conducted using the total eating disorder scores and the responses to the last four questions on the EAT-26 survey in an attempt to discover additional findings. An independent samples t-test was conducted to compare the mean scores of the groups that answered “yes” and “no” to the question, “Have you gone on eating binges where you feel that you may not be able to stop?” for their disordered eating total scores. A significant difference was found between the two groups (t114 = -5.29, p < .05). The mean of the group that answered “no” was significantly lower (5.68 ± 6.68) than the mean of the group that answered “yes” (14.08 ± 8.22). The results of the analysis are presented below in Table 14 and Figure 1. 19 Table 14. T Test Comparison between Binge Eating Responses for the EAT-26 Score Binge n M SD t P Eating No 91 5.68 6.68 -5.29 Yes 25 14.08 .023 8.22 Figure 1. Binge Eating Responses for EAT-26 Another independent samples t-test was conducted to compare the mean scores of the groups that answered “yes” and “no” to the question, “Have you ever used laxatives, 20 diet pills, or diuretics (water pills) to control your weight or shape?” for their disordered eating total scores. A significant difference was found between the two groups (t113 = -5.82, p < .01). The mean of the group that answered “no” was significantly lower (5.74 ± 6.22) than the mean of the group that answered “yes” (15.74 ± 9.49). The results of this analysis are presented below in Table 15 and Figure 2. Table 15. T Test Comparison between Weight Control Substance Use (WCSU)Responses for the EAT-26 WCSU n M SD t No 96 5.74 6.22 -5.82 Yes 19 15.74 9.49 P .001 21 Figure 2. Substance Use Responses for EAT-26 A final independent samples t-test was conducted to compare the mean scores of the equestrians who had an eating disorder issue to those who did not, based on their scores on the EAT-26 survey. A significant difference was found between the two groups (t115 = 8.81, p < .001). The mean of the group that had an eating disorder issue was significantly higher (14.05 ± 8.85) than the group that did 22 not have an issue (3.80 ± 3.64). The results of this analysis are presented below in Table 16 and Figure 3. Table 16. T Test Comparison of Responses for the Eating Disorder Issues for EAT-26 EDI n M SD t P Yes 42 14.05 8.85 8.81 No 75 3.80 3.64 Figure 3. Eating Disorder Issues for EAT-26 .000 23 DISCUSSION Discussion of Results The focus of this study was to discover the prevalence of eating disorders among female collegiate equestrian athletes. The researcher evaluated whether or not age, type of riding event, and BMI had an effect on the prevalence of eating disorders. Hypothesis 1 stated that age would be significantly related to the prevalence of eating disorders. The researcher proposed that age would have an effect on the number of equestrians with eating disorders. There was no significant data showing that age was a predictor of eating disorders. Even though there is no significance in the data, age can still be a predictor of important signs of eating disorders. In previous research it was determined that subjects felt that their weight became a problem around the mean age of 22.2 years.10 Since having weight issues can be a predictor of eating disorders and 22.2 years old is well within the range found for the ages of collegiate equestrians in this study; age should still be considered when evaluating female equestrians for eating disorders. 24 Hypothesis 2 stated that there would be a difference between the riding events and eating disorders. The researcher proposed that events that put additional pressure on the equestrian to be lean (equitation, dressage, and western pleasure) would have a higher prevalence of eating disorders opposed to other events (hunter/jumper, reining, and barrel racing/speed events). Due to the lack of data, reining and barrel racing/speed events were not included in the analysis. There was no significant data showing that any one event would lead to a higher prevalence of eating disorders than another. Findings showed that there was only a 1.82 difference in mean scores for the EAT-26 between events. Although there is no significance in the data, this researcher still believes that this is an area that should continue to be evaluated due to the small number of responses for the survey. Although there was no significance found; athletic trainers, coaches, parents, and team mates should be aware that there may still be pressure to be thin put on equestrians based on the events that they participate in. Those working with equestrians should be educated on eating disorders and their prevalence in other female sports. 25 Attempts should be made to recognize and seek treatment for those equestrians who may have eating disorders or related issues. Hypothesis 3 stated that there would be a negative relationship between BMI and eating disorders. The researcher proposed that as BMI scores got lower the scores on the EAT-26 would increase and that BMI was a predictor of eating disorders in among female equestrians. The results showed that BMI and eating disorders were not significantly related. Although this data does not support the hypothesis that BMI and eating disorders are related, there has been previous research that does support this hypothesis. A study done by Reinking and Alexander4 showed that 25% of lean sport athletes had more disordered eating symptoms and were at greater risk of developing an eating disorder compared to 2.9% in non-lean sports. Also, lean sport athletes are more likely to have lower BMI values. Thus, if an athlete were to have a low BMI value, they would be at a higher risk of developing an eating disorder. Despite the fact that equestrian sports have yet to be defined as lean or non-lean, equestrians could still be at 26 risk for developing an eating disorder based on Reinking and Alexander’s research. If equestrians consider themselves to be in a lean sport and have lower BMI values because of this, they are placing themselves at risk. More research needs to be conducted to discover whether or not equestrian sports are considered to be lean or non-lean. Until then, athletic trainers, coaches, parents, and teammates need to be aware that participants with low BMI values are at risk for developing an eating disorder. These participants should be further evaluated and referred to a physician for treatment. In addition to hypothesis testing, analysis was also done on the total eating disorder scores and the responses to the last four questions on the EAT-26 survey. First, a comparison of the mean scores was conducted for the two groups who answered “no” and “yes”, to the question “Have you gone on eating binges where you feel that you may not be able to stop?”, for their total disordered eating scores. A significant difference was found between the two groups and mean of the group that answered “yes” was significantly higher than that of the group that answered “no”. 27 These results mean that female collegiate equestrians who use binge eating for weight control are at risk for eating disorders. Professionals who work with collegiate equestrians should be aware that binge eating is prevalent among them. They should thus be vigilant in recognizing the signs and symptoms of binge eating before it leads to more serious health issues related to binge eating and eating disorders. A second comparison that was conducted was between the mean scores of the groups that answered “yes” and “no” to the question, “Have you ever used laxatives, diet pills, or diuretics (water pills) to control your weight or shape?” for their disordered eating total scores. A significant difference was found between the two groups and the mean of the group that answered “yes” was significantly higher than the mean of the group that answered “no”. These results mean that female collegiate equestrians are, in some cases, not only using binge eating for weight control but also substances in attempt to ease their eating disorder issues. Both binge eating and the use of substances for weight control are used as diagnostic criteria for bulimia nervosa.11 In a study by Johnson et al12, 1.1% of the female athletes met the diagnostic 28 criteria for bulimia nervosa, 9.2% were diagnosed with sub clinical bulimia, and 38% could be considered at risk for developing bulimia. This study is comparable to Johnson’s research as 23.4% of participants said that they had used binge eating and 16.4% had said that they used substances as a form of weight control. Professionals who work with collegiate equestrians, then must also, be aware that the use of substances is prevalent among them. Like binge eating, the use of substances could lead to more serious health issues and eating disorders. The results from this study for binge eating and substance use compare to a study done by Rosen et al1, who found that 32% of a female collegiate athlete sample practiced pathogenic weight-control behaviors. In some cases, respondents who answered “yes” to these questions also had a score of more than 20 on the EAT-26 survey. Thus, these participants are not only dealing with an eating disorder issue, but are also currently performing eating disorder practices (like binge eating and substance abuse). The results from this analysis tell those who work with female collegiate equestrians that those who are practicing weight control behaviors are also most likely dealing with an eating disorder. Professionals must be 29 educated and work hard to recognize sign and symptoms of binge eating, substance abuse, and other eating disorder symptoms in order to prevent additional harm and get treatment from those who are already suffering. The final additional analysis that was conducted compared the mean scores of the equestrians who had an eating disorder issue to those who did not, based on their scores on the EAT-26 survey. A significant difference was found between the two groups; the mean of the group that had an eating disorder issue was significantly higher than the group that did not have an issue. This analysis showed that 37.79% of the female collegiate equestrians who participated in this survey are currently dealing with eating disorder issues. Of these equestrians who are dealing with eating disorder issues, nine answered “yes” to one or more of the four questions at the end of the EAT-26. Consequently, putting them at an even greater risk of developing or even currently having an eating disorder. This information correlates to multiple studies that found that 39.2% of female athletes met diagnostic criteria for bulimia nervosa (BN), 4.2% of female athletes met 30 diagnostic criteria for anorexia nervosa (AN), and 22.1% of ballet dancers and 18% of gymnasts had been diagnosed with eating disorders not otherwise specified (EDNOS).13,14 Although this study did not determine the presence of eating disorders or distinguish between them, it is still necessary to note and compare the percentage of eating disorder issues to the percentage of other female athletes who have been diagnosed with eating disorders. A descriptive analysis was also done which found the average menstrual cycle length among female collegiate equestrians. The mean and standard deviation was found to be 29.34 ± 5.85, which is a “normal” menstrual cycle length (26-32 days).5 This information does not correspond with the Williams et al5 study which reported that athletes had more significantly long cycles (79%) than non-athletes (45%). Although, it should be noted that of the 65 equestrians (50.8%) who are using oral contraceptives, 34 (26.0%) of them are using it for menstrual cycle regulation. So it is possible that the mean menstrual cycle length could be affected by the use of hormonal oral contraceptives for menstrual regulation. Further research needs to be conducted in order to distinguish how much the menstrual 31 cycle length in collegiate female equestrians is affected by oral contraceptive use. Conclusions Based on the results from Table 10 and Figure 3, of the 127 female collegiate equestrians that were surveyed 48 (37.79%) are dealing with an eating disorder issue. Despite the small sample size, this information shows that eating disorder issues and behaviors are present among female collegiate equestrians. These results reiterate previous research that shows the predominance of eating disorder issues among female collegiate athletes. The results also show that despite the lack-of-popularity of equestrian sports as a varsity collegiate sport, equestrians still suffer from the same eating disorder issues as other varsity level collegiate athletes. It should also be noted that since there was no difference found between events for the scores on the EAT26, the event that the rider participates in is not a valid predictor of whether or not the participant is at risk of having an eating disorder. Thus, athletic trainers, coaches, parents, and teammates must not be biased towards certain events and must treat all equestrians, no matter 32 what event they are in, as if they could develop an eating disorder. The demands being put on female equestrians to be lean combined with a negative body image mentality is driving female collegiate equestrians towards poor eating habits and behaviors associated with eating disorders. These equestrians continue to get away with practicing unhealthy weight control behaviors without being treated or even recognizing that they have a problem. Recommendations The results of this study are most definitely significant to equestrian sports and those who participate in the sport. This should lead those who work with equestrians to be more aware of the prevalence of eating disorders among female collegiate equestrians. Coaches and parents should be educated on the signs, symptoms, and health issues associated with eating disorders. Teammates should also be educated as they often spend more time together and may notice any eating disorder behaviors sooner than coaches or parents. This information is invaluable to athletic trainers and team physicians who work with female collegiate 33 equestrians as they are the ones who are most likely to recognize eating disorder symptoms in their athletes. Professionals must then be made aware of the prevalence of eating disorder issues among this population and include eating disorder screenings in their pre-participation exams. If equestrians are attending a college that does not provide athletic trainers for their sport, coaches should encourage their athletes to get physically cleared to participate in events by a physician prior to the beginning of the season. Perhaps then equestrians who are suffering from an eating disorder could be recognized and treated leading to a safer competitive setting. 34 REFERENCES 1. Rosen LW, McKeag DB, Hough DO, Curley V. Pathogenic weight control behaviors in female athletes. Physician Sportsmed. 1986;14:79-86. 2. Torstveit M, Rosenvinge J, Sundgot-Borgen J. Prevalence of eating disorders and the predictive power of risk models in female elite athletes: a controlled study. Scandinavian J Med Sci Sports. 2008;18:108-118. 3. Trattner R, Thompson R. NCAA Coaches Survey: The role of the coach in identifying and managing athletes with disordered eating. Eating Disorders. 2005;13:447-466. 4. Reinking M, Alexander L. Prevalence of disordered-eating behaviors in undergraduate female collegiate athletes and nonathletes. J Athletic Training. 2005; 40(1):47-51. 5. Williams N, Leidy H, Flecker K, Galucci A. Food attitudes in female athletes: Association with menstrual cycle length. J Sports Science. 2006;24(9):979-986. 6. Volk E. Female athletes and menstrual irregularities. Anabolic Pharmacology. 2002. Available at: http://www.anabolicpharamcology.com. Accessed September 15, 2008. 7. Lippincott Williams & Wilkins. 2006. Oligomenorrhea. Available at: http://www.wrongdiagnosis.com/symptoms/menstrual_irregul arities/book-causes-8e.htm. Accessed October 6, 2008. 8. Pinheiro A, Thorton L, Plotonicov K, et al. Patterns of menstrual disturbance in eating disorders. Int J Eat Disord. 2007;40:424-434. 9. Burnett K, Doninger G, Enders C. Validity evidence for eating attitudes test scores in a sample of female college athletes. Measurement Physical Education Exercise Science. 2005;9:35-49. 10. McAllister R, Caltabiano M. Self-esteem, body image and weight in noneating-disordered women. Psychological Reports. 1994;75:1339-1343. 35 11. Nordqvist C. What is an eating disorder? Types of eating disorders. 2008. Available at: http://www.medicalnewstoday.com/articles/105102.php. Accessed October 6, 2008. 12. Johnson C, Powers PS, Dick RW. Athletes and eating disorders: the natural collegiate athletic association study. Int J Eat Disord. 1999;26:179-188. 13. Burckes-Miller M, Black D. Male and female college athletes: Prevalence of anorexia nervosa and bulimia nervosa. Athletic Training. 1988;23:137-140. 14. Ravaldi C. Body image and eating disorders among nonelite athletes. Eating Disorders Review. 2003;14:8. 36 APPENDICES 37 APPENDIX A REVIEW OF THE LITERATURE 38 Review of the Literature The prevalence of eating disorders and menstrual irregularities is a topic that has been studied extensively over the past years, but there is a lack of literature to be found about the prevalence of these conditions among equestrian sports participants. Despite the lack of literature to be found on eating disorders and menstrual irregularities in equestrian sports, pressure is put on these athletes to have a lean and athletic build (in terms of both form and function)in order to place and win competitions. This pressure may put equestrians at risk for eating disorders. As important as it is to be lean in equestrian sports it is more necessary that these athletes be strong enough to work around and control horses at all levels and disciplines of competition…a task that is not easily done if the athlete is underweight or underdeveloped due to eating disorders. Recognition of potential eating disorders may help shed light on this in equestrian sports that often goes unnoticed or ignored. The topics that will be discussed in this literature review include: equestrian sports, eating disorders, and menstrual irregularities. A brief summary will also be included at the end of the literature review. 39 Equestrian Sports Equestrian sports range from many levels from amateur to Olympian and include many different events from fox hunting to barrel racing. Although equestrian sports may not be a varsity level sport in many colleges, it is still a fairly common club sport and has its own collegiate governing body. Intercollegiate Horse Show Association Established in April of 1967, the Intercollegiate Horse Show Association (IHSA)is the governing body that collegiate riding teams compete under in the United States. The goal of the IHSA is to promote competition between equestrians at all levels regardless of financial status.1 There are 300 member colleges in the IHSA with more than 6500 riders who compete at the regional and national levels as either an individual or team. The three major competitive events are hunter seat equitation, western horsemanship, and reining. One of the goals of the IHSA is to eliminate the costs of owning a horse so teams travel to surrounding schools and are randomly assigned a horse to ride. The riders are not allowed to use their own tack (saddle and bridle) and are not allowed warm-up time on their horse, so they are truly judged on their horsemanship 40 skills and riding ability since they generally have never ridden the horse that they are competing on before.1 Riding for Form and Function In competitive equestrian sports where the rider is judged on their equitation (riding form) there is often pressure put upon them by coaches, peers, and themselves to be lean. It is an unspoken but common idea that riders who are thin are often more likely to place then riders who are overweight or heavy set since a thin or lean build looks more ascetically pleasing while riding. Being lean also enables the rider to be more flexible and capable of moving with the horse in order to do certain tasks. But it is also important for riders to be strong enough to control a horse, weighting anywhere from 500-2000 lbs, while looking controlled and organized, and keeping their own body in proper riding position. The proper riding position enables the rider to be perfectly balanced on top of the horse and to move in sync with the animal without putting the horse off balance. In order to do this the rider must sit in the middle of the saddle, with the balls of their feet resting on the stirrups, their toes pointing forward, and their heels down. If the rider were to be seen from the side it would look like a line could be drawn from the rider’s 41 heels, to their hips, to their shoulders, and through the center of their head. It is also important that the rider keep their head up and looking forward towards where they are traveling, and that they keep their back straight.2 Figure 4 provides an example of the proper riding position.3 Figure 4: Proper Riding Position 42 Disordered Eating Types of Disordered Eating There are many different types of disordered eating that can affect both the general public and athletes. For the purpose of this study anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (EDNOS) will be described. Anorexia nervosa (AN) can be defined as a psychological disorder where the patient has a distorted body image with an irrational fear of being overweight.4 Seventy six percent of reported cases of AN list onset to be between the ages of 11 and 20; the later ages being that of many college aged undergraduate athletes.4 In a study done by Johnson et al5 on collegiate athletes, 9.2% of surveyed athletes had behaviors that were consistent with anorexia and 35% were at risk for developing anorexia. Furthermore, Burckes-Miller and Black6 reported that 4.2% of female athletes in their sample met diagnostic criteria for AN. Thus it is important to recognize that athletes are at risk for developing AN, and coaches, teammates, and the medical staff should be able to recognize signs and symptoms of it. 43 A person with AN generally weighs much less than they should (at least 15% or more below their ideal body weight based on age and height), has a BMI of 17.5% or less, has missed three consecutive menstrual periods, has a preoccupation with body shape and weight, and has a severe fear of putting on weight, according to DSM-IV-TR® Diagnostic and Statistical Manual of Mental Disorders.4 The physiological signs and symptoms of AN include but are not limited to: thin appearance, fatigue, abnormal blood counts, dizziness, brittle nails, thin hair, menstrual irregularities, constipation, dry skin, irregular heart rhythms, low blood pressure, dehydration, and low bone mineral density.7 Several emotional symptoms can also be present in patients with AN, like refusing to eat, denial of hunger, excessive exercise, difficulty concentrating, and a preoccupation with food.7 Recognition of these symptoms is most important, in order to diagnose and treat AN before it can lead to further health problems. Bulimia Nervosa (BN) is another type of eating disorder that can affect collegiate athletes. It is defined as a psychological disorder where the patient goes through regular bouts of over-eating which leads to guilt that causes them to purge (self-induced vomiting), 44 excessively exercise, or crash diet.4 In a study performed by Johnson et al5 that was mentioned before, 1.1% of the female athletes met the diagnostic criteria for bulimia nervosa, 9.2% were diagnosed with sub clinical bulimia, and 38% could be considered at risk for developing bulimia. Also, Burckes-Miller and Black6 reported that 39.2% of female athletes in their sample met diagnostic criteria for BN. Based off of these two studies, BN has a higher rate of occurrence in female athletes than AN. Female athletes that compete in lean sports also have a higher percentage of meeting diagnostic criterion for developing BN than non-lean sports.8 Thus making it all the more important that those surrounding female athletes at risk for developing BN be able to recognize the signs and symptoms. According to DSM-IV-TR® Diagnostic and Statistical Manual of Mental Disorders a patient must meet the following four criterions to be diagnosed with BN. The patient must: repeatedly binge-eat while feeling that they can’t stop or control their eating, repeatedly and inappropriately try to compensate for their over-eating (for example through use of laxative, excessive exercising, fasting, and purging), been binge-eating and 45 compensating at least twice a week for a consecutive 3 months, and over judge their weight and body shape.4 Physiological signs and symptoms of BN include: abnormal bowel functioning, damaged teeth and gums (due to excessive purging), swollen salivary glands in the cheeks (due to excessive purging), sores in the throat and mouth, bloating, dehydration, fatigue, dry skin, irregular heartbeat, sores, scars or calluses on the knuckles or hands, and either menstrual irregularities or loss of menstruation (amenorrhea).7 Behavioral and emotional symptoms of BN include: constant dieting, a feeling that they can't control their eating behavior, eating until the point of discomfort or pain, self-induced vomiting, laxative use, excessive exercise, unhealthy focus on body shape and weight, having a distorted, excessively negative body image, going to the bathroom after eating or during meals, hoarding food, and depression or anxiety.7 In a study done by Katzman and Wolchik9 a sample of female undergraduates were evaluated for bulimia, binge eating, or normal eating habits. It was found that bulimics had higher levels of the pathology based upon behavioral and personality variables (depression, selfesteem, and body attitudes) as well as a higher 46 preoccupation with dieting.9 Therefore, as well as bulimia being more prevalent among female athletes, bulimics also tend to have more emotional and behavioral symptoms. The final type of eating disorder (or disorders) that will be discussed is Eating Disorders Not Otherwise Specified (EDNOS). In a study done by Ravaldi10 that evaluated eating disorders among ballet dancers, gymnasts, and female controls, it was found that 22.1% of ballet dancers had EDNOS; which was significantly higher than AN at 1.8% and BN at 2.7%. Also, 18% of gymnasts in this study were diagnosed with EDNOS, while only 2.6% had AN.10 Based off of this information, it can be suggested that EDNOS is more prevalent among collegiate female lean-sport athletes. Thus making it all the more important that coaches, peers, and sports medicine staff are able to recognize it. Patients who suffer from EDNOS are classified into this type of disorder because although they may have symptoms of AN or BN, they do not meet the criteria for them.11 Female patients with an EDNOS must meet the following criteria: all the criteria for AN must be met except they have a regular menses, and despite a significant weight loss, the patient still maintains a 47 normal range BMI.12 Also, all criteria is met for BN except that the inappropriate compensating behavior (laxative use, excessive exercising, fasting, and purging) occurs less than twice a week for less than three months, the regular use of inappropriate compensating behaviors even with small amounts of food, and the repeated chewing and spitting out (not swallowing) of food.12 Additionally, patients with EDNOS often switch between different types of eating disorders, making it difficult to diagnose them.12 Female athletes with EDNOS can use techniques like excessive dieting, crash diets, fasting, excessive exercising, purging, or taking diuretics and laxatives. It was found in a study done by McAllister and Caltabiano, that 65.15% of women in their study used dieting as a form of weight loss.13 Also, Petrie14 concluded in his study that 18% of gymnasts reported using excessive exercise as their sole mean of weight-loss, and of 33 gymnasts who were classified as dieter/restrictors 18.2% reported only using dieting (without exercise) as their form of weight loss. Petrie’s finding were consistent with Burckes- Miller and Black6 who found that over half of the female college athletes in their sample used exercising 48 excessively as a form of weight control. Furthermore 15% of female athletes engaged in day-long fasts or fad diets.6 Based off of this information it can be concluded that exercise may be more frequently use by female collegiate athletes, as opposed to dieting and fasting, as a weight-loss method. Although there are many types of eating disorders with differing signs and symptoms for each, the causes of eating disorders can overlap between different types. Causes of Disordered Eating Disordered eating (DE) is a term to describe a spectrum of attitudes and behaviors like a preoccupation with body weight and shape, food restriction, and dieting as well as bingeing, vomiting, and the abuse of diuretics, laxatives and diet pills.8 Disordered eating in women can be caused by a combination of psychological, social, and physiological factors.15 Dissatisfaction with body shape in the stomach, hips, and thighs has been reported by 80% of women from ages 19-29 in a study done by McAllister et al.13 In athletes the pressures to be thin can also be influenced by pressures to lose weight to satisfy personal or coaches goals, peer pressure from teammates, the focus to have a 49 thin physique, personality characteristics like poor selfesteem, family dysfunction, sexual abuse, dieting, the types of sport they participate in, and the belief in the inverse relationship between body size and performance.8,15 In collegiate athletes, the mean age when subjects felt that their weight became a problem was 22.2 years old, as seen in a study performed by McAllister et al.13 In fact, according to Rosen et al,16 32% of a female collegiate athlete sample practiced pathogenic weight-control behaviors. Even more surprisingly, 70% of these athletes felt that these practices were harmless. The type of sport can also have an influence on whether or not the athlete is at risk for developing an eating disorder. In previous studies differences have been found between lean and non-lean sports in regards to DE. Lean sports consist of gymnastics, swimming/diving, track, cross-country, dance, and cheerleading, while non-lean sports consist of softball, volleyball, basketball, rugby, soccer, and field hockey. No evidence was found in the literature that lists equestrian sports as lean or non-lean sports. When comparing the risk of developing an eating disorder in lean to non-lean sports, Reinking and 50 Alexander15 found that 25% of lean sport athletes had more disordered eating symptoms and were at greater risk of developing an eating disorder compared to 2.9% in non-lean sports. This could be due to the fact that female athletes in non-lean sports feel that the positive effects of participating in sports outweigh the pressure of competitive collegiate athletics in regards to eating behaviors.15 Some athletes avoid reporting DE because they feel that if they do, it could lead to problems that might cause them to be ejected from the team or kept from playing.8 This is a thought that can be validated by Trattner and Thompson17 that identified the coaches rating of seriousness of eating disorders/ eating behaviors (see Table 17). If athletes are aware of how their coaches feel about eating disorders, they may be less likely to report such incidences. On the other hand, athletes in non-lean sports are more prone to self-report their experiences with eating disorders because they do not feel that it is a “natural” part of their sport.8 51 TABLE 17: Coaches’ Ratings of the Seriousness of Eating/Dieting Behaviors for the Athlete’s Health and Performance Behaviors Health SD Performance SD Greater Impact Self-induced 3.90* .41 3.85* .46 H* vomiting Laxative 3.83* .50 3.79* .53 H* abuse Diuretic 3.77 .55 3.75 .57 H abuse Fasting 3.39* .85 3.68* .66 P* Binge eating 3.24 .78 3.21 .80 H Skipping 2 2.15* .74 3.42* .70 P* meals/day Under eating 3.15* .79 3.35* .73 P* Weighing 3.08* .86 2.61 1.06 H* multiple times Excessive 3.05* .82 3.10* .85 P* exercise Eating fast 2.58* .79 2.82* .86 P* food frequently Skipping 1 2.05* .78 2.42* .87 P* meal/day Eating fast 1.55* .71 1.87* .87 P* food occasionally Note: Mean scores reflect ratings on a 4-point scale (1 = “not at all serious” to 4 = “very serious”). The symbol H indicates that the behavior was rated as more serious for the athlete’s health. The symbol P indicates the behavior was rated as more serious for the athlete’s performance. All behaviors noted with an * had paired samples t scores significant at <.0001. In conclusion, there are many different causes of eating disorders among collegiate female athletes. It is important that sports medicine personnel, coaches, and peers are aware of these causes so that persons at risk can be easily identified and treated before their disorders lead to further health problems. 52 Menstrual Irregularities Often menstrual irregularities are a result of eating disorders and are used as a criterion for detecting them.18 The median age at menarche is 12.9 years of age.19 The commonly observed interval between menstrual cycles is 2632 days, which was chosen by Williams et al18 to represent a “normal” menstrual status. As a result of their study of collegiate female athletes, Williams et al18 reported that cycles that are either shorter or longer than the “normal” range indicated eating disorders among female athletes. Williams et al18 also reported that athletes had more significantly long cycles (79%) than non-athletes (45%). Types of Menstrual Irregularities There are many types of menstrual irregularities that can affect both the general public and athletes alike. Menstrual disorders can include: amenorrhea, oligomenorrhea, luteal phase defects, dysmenorrhea, anovulation, abnormal or excessive uterine bleeding, and premenstrual syndrome.20, 21 For the purpose of this study amenorrhea (the primary menstrual irregularity) and oligomenorrhea will be described. 53 Amenorrhea can be defined as a lack of menstruation, although there is an inconsistency among the literature in defining the term.22 Volk explained the criteria for amenorrhea to be as follows: one menstrual period during the last ten months, less than three menstrual cycles per year, and the absence of periods from 3-12 months.22 In her review of literature, Volk also stated that amenorrhea occurs almost 20 times more frequently in female athletes when compared to the general population, and it can exist in up to 50% of female athletes.22 Besides the absence of menstruation, amenorrhea can also have symptoms like milky nipple discharge, headaches, vision changes, and excessive hair growth on the face and torso (hirsutism).23 Pinheiro et al24 explained in a review of the literature that women with amenorrhea also had a significantly lower BMI than those without amenorrhea. Amenorrhea can also present itself in different forms, primary and secondary amenorrhea. Primary amenorrhea is the absence of a menstrual period by age 16 with the presence of secondary sexual characteristics or by the age of 14 when there are also a lack or secondary sexual characteristics.21 Secondary amenorrhea is the absence of menstruation for three to six months after previously going 54 through menstruation.23 Since menarche occurs when body fat makes up 17% of body weight, secondary amenorrhea then occurs when body fat falls below 22% of body weight.25 Pinheiro et al24 stated that within patients with BN, 7-40% of patients presented with amenorrhea, 35.6% presented with secondary amenorrhea, and BN patients with a history of AN reported the highest frequency of secondary amenorrhea (77.1%). A study by Griffith et al26 also found that 60.6% of gymnasts and 59.8% of cross-country runners presented with amenorrhea. Among the participants of this study, 70% of amenorrheic athletes also had eating disorders. Lastly, amenorrhea can also occur in normal weight females that have a low percentage of body fat both prior to significant weight loss and can continue in AN patients after weight restoration.24 The second type of menstrual disorder to be discussed is oligomenorrhea. Oligomenorrhea can be defined as abnormal infrequent menstruation characterized by only 3 to 6 menstrual cycles per year.27 When menstruation does occur it is generally profuse, prolonged (up to 10 days), and loaded with clots and tissue; occasional spotting is also associated with oligomenorrhea.27 Oligomenorrhea is also 55 more frequent in BN patients, occurring in 37-64% of patients.24 Causes of Menstrual Irregularities The causes of menstrual irregularities can vary from patient to patient depending on the type or menstrual irregularity, the patient’s age, weight, sport, emotional stress, psychological factors, or a combination of factors. For example, Harlow and Matanoski28 reported that there was an association between life stressors and changes in weight and long menstrual cycles in college-aged women. Although several causes for menstrual irregularities exist most authors agree that hypothalamic dysfunction is the major cause. Since the hypothalamus releases gonadotrophin releasing hormone (GnRH)which regulates the release of gonadotrophins, like luteinizing hormone (LH) and follicle stimulating hormone (FSH), if it is not functioning properly these hormones would not be released. If LH and FSH aren’t released into the body, important sex hormones like estrogen and progesterone fail to be released. Without these hormones normal menstruation will not occur.22,25 56 Dietary choices can also lead to amenorrhea. When dietary sources (calories from fats and carbohydrates) are limited or restricted metabolic fuels are shunted and metabolic pathways are blocked. Without the proper metabolic balance the hypothalamus will malfunction and GnRH will not be properly released.22 Correlations have been found in athletes with diets low in fat and carbohydrates and menstrual irregularities.22 Poor diet choices as well as sport type can also lead to a low percentage of body fat, which in turn can also lead to amenorrhea for the same reason.22,23 As mentioned before menarche occurs when body fat makes up 17% of body weight, so when body fat falls below 22% of body weight amenorrhea may occur.25 Female athletes who practice restrictive eating habits because it is believed that lower body weight will result in greater performance levels are put themselves at high risk for menstrual irregularities.29 For example in a study done by Stokic et al19 that evaluated ballet dancers, it was reported that the ballet dancers had lower body weights and BMIs than the control group. Because of this, the ballet dancers also had a higher prevalence of amenorrhea (20%) and oligomenorrhea (10%) than the control group.19 57 It should also be noted that training volume and intensity can have an effect on the prevalence of menstrual irregularities. The term exercise-related menstrual irregularities (ERMI) has been given to menstrual irregularities that are caused by prolonged and extreme endurance exercises.22 These extended exercise sessions can lead to significant changes in gonadotrophin plasma levels, lower ovarian blood circulation, and an increase in metabolism causing changes in metabolic clearances of endogenous hormones.22 Athletes may also create a negative energy balance by burning more calories than they consume, causing dysfuncioning of the hypothalamus.25 Lastly, causes of menstrual irregularities can also differ depending on the type of eating disorder the patient has. For example Pinheiro et al24 explain that amenorrhea occurs in AN patients as a result of malnutrition-induced impairments in gonadotropin (principally luteininzing hormone (LH) secretory pattern). In BN patients as a result of low LH concentrations and reduced LH pulse frequency and low levels of estradiol and noradrenalin.24 58 Summary By participating in equestrian sports female athletes put themselves at risk for sustaining athletic injuries and illnesses. It is possible that they are also then at risk for developing eating disorders and menstrual irregularities. Thus the types and causes of eating disorders and menstrual irregularities were the main focus of this literature review. Eating disorders can include anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified. Researchers have attempted to find links between possible causes of eating disorders and situation factors that might predispose female athletes to them. Menstrual irregularities can sometimes be a symptom of eating disorders that are experienced by female athletes. Although research has shown that menstrual irregularities have a link to lean vs. non-lean sports, it still lacks in what factors can predispose female athletes to them. It is obvious that eating disorders and menstrual irregularities are related. The causes of these conditions in female athletes can range from sport type, body dissatisfaction, and physiological and psychological 59 disturbances. Thus it is important for the sports medicine staff surrounding female athletes to be aware of them, and be able to properly diagnose them. 60 APPENIDX B THE PROBLEM 61 The Problem Statement of the Problem Extensive research has been done that has evaluated the prevalence of eating disorders and menstrual irregularities among female athletes. Studies have attempted to find common variables among female sports that may cause an athlete to be more predisposed to developing an eating disorder. Researchers have even gone far enough to study the effects that these issues have on the female body in terms of the resulting health issues. Although research has been done to discover what sports or types of sports (lean vs. non-lean) could predispose an athlete, no research could be found as to whether or not female equestrian athletes are at risk for developing eating disorders and menstrual irregularities. Thus, the purpose of this study is to discover whether or not there is a prevalence of eating disorders amongst female collegiate equestrians. A secondary purpose of this study is to determine the average length of female collegiate equestrian’s menstrual cycle. The goal is to see if there are any significant variables that may increase the prevalence of eating disorders. 62 Definition of Terms: The following terms have been defined for the purposes of this study: 1) Amenorrhea- a lack of or abnormal cessation of menstruation, either: one menstrual period during the last ten months, less than three menstrual cycles per year, and the absence of periods from 3-12 months, can be either primary or secondary22 i. Primary Amenorrhea- the absence of a menstrual period by age 16 with the presence of secondary sexual characteristics or by the age of 14 when there are also a lack or secondary sexual characteristics ii. Secondary Amenorrhea- the absence of menstruation for three to six months after previously going through menstruation 2) Anorexia Nervosa (AN) - a psychological disorder where the patient has a distorted body image with an irrational fear of being overweight, according to DSM-IV-TR® Diagnostic and Statistical Manual of Mental Disorders,4 an AN patient: 63 a. weights much less than they should (at least 15% or more below their ideal body weight based on age and height) b. has a BMI of 17.5% or less c. has missed three consecutive menstrual periods d. has a preoccupation with body shape and weight e. has a severe fear of putting on weight 3) Body Mass Index- an index of a person’s weight in relation to height, calculated by multiplying the person’s weight in pounds by 705 and dividing by the square root of the height in inches 4) Bulimia Nervosa (BN)- according to DSM-IV-TR® Diagnostic and Statistical Manual of Mental Disorders,4 a patient with BN: a. repeatedly binge-eats while feeling that they can’t stop or control their eating b. repeatedly and inappropriately tries to compensate for their over-eating through use 64 of laxative, excessive exercising, fasting, or purging c. has been binge-eating and compensating at least twice a week for a consecutive 3 months d. over judges their weight and body shape 5) Disordered Eating- a spectrum of attitudes and behaviors like a preoccupation with body weight and shape, food restriction, and dieting as well as bingeing, vomiting, and the abuse of diuretics, laxatives and diet pills8 6) Eating Disorder- a psychological disorder where the patient has a distorted body image which leads them to consume an insufficient amount of nutrients to maintain normal, healthy life 7) Equestrian Sports- sporting events where an athlete participates as a team with a horse 8) Normal Menstrual Cycle- the functioning of reproductive organs and glands that prepare a women’s body for pregnancy and child birth, made up of three phases within 26-32 days17 65 9) Oligomenorrhea- abnormal infrequent menstruation characterized by only 3 to 6 menstrual cycles per year Basic Assumptions There were several basic assumptions that were made for the purpose of this study. 1) The subjects will answer all questions honestly and to the best of their knowledge. 2) The subjects will not receive assistance from any outside individual or source on any of the questions. 3) The sample is a representative of the population of female collegiate equestrians. Limitations of the Study: The following are possible limitations of the study: 1. The study only consisted of female collegiate athletes from the Intercollegiate Horse Show Association. 2. The study only consisted of subjects who are 18 years or older. 66 Significance of the Study: Professionals working around female equestrians should possess adequate knowledge of eating disorders. Since many equestrian sports teams do not have a sports medicine person on staff, it is even more important that coaches are able to recognize signs and symptoms in athletes that may be at risk. The timely identification of these topics is essential to decrease the risk of an athlete developing the adverse effects that result from eating disorders. Those surrounding female equestrians should also be able to recognize and refer at risk patients to the proper health care professionals. This study examined eating disorders among collegiate female equestrian athletes. Thus, this study provided results on this topic for female equestrian athletes and those who work with them. Furthering their education on eating disorders could potentially lead to increased health in the female equestrian population. 67 APPENDIX C ADDITIONAL METHODS 68 APPENDIX C1 Eating Behaviors and Demographics Questionnaire 69 EATING BEHAVIORS AND DEMOGRAPHICS QUESTIONNAIRE Please answer all questions honestly and to the best of your knowledge, without any assistance. Please understand that this questionnaire is voluntary. If you feel uncomfortable answering any question, please feel free to leave it blank. Age: Height: Weight: Class Rank: Freshman Senior Sophomore Junior Graduate Student • On average, how long is your normal menstrual cycle in days (from the start of one period to the beginning of the next period)? • Do you use a form of female hormonal contraceptive (ex. birth control pills, the patch, the shot)? Yes:________ No:________ • If you answered “yes” to the previous question, please answer the next question. Do you use this contraceptive to regulate your menstrual cycle? Yes:________ No:________ • Please place a check mark next to the ONE riding event that you consider to be your MAIN event from the following list. hunter/jumper reining Equitation western pleasure dressage barrel racing/speed events 70 Please circle a response for each of the following statements: 1. Am terrified about being overweight Always Usually Often Sometimes Rarely Never 2. Avoid eating when I am hungry Always Usually Often Sometimes Rarely Never 3. Find myself preoccupied with food Always Usually Often Sometimes Rarely Never 4. Have gone on eating binges where I feel that I may not be able to stop Always Usually Often Sometimes Rarely Never 5. Cut my food into small pieces Always Usually Often Sometimes Rarely Never 6. Aware of the calorie content of foods that I eat Always Usually Often Sometimes Rarely Never 7. Particularly avoid foods with high carbohydrate content (i.e. bread, rice, potatoes ,etc.) Always Usually Often Sometimes Rarely Never 8. Feel that others would prefer if I ate more Always Usually Often Sometimes Rarely Never 9. Vomit after I have eaten Always Usually Often Sometimes Rarely Never 10. Feel extremely guilty after eating Always Usually Often Sometimes Rarely Never 11. Am preoccupied with a desire to be thinner Always Usually Often Sometimes Rarely Never 12. Think about burning up calories when I exercise Always Usually Often Sometimes Rarely Never 13. Other people think that I am too thin Always Usually Often Sometimes Rarely Never 14. Am preoccupied with the thought of having fat on my body Always Usually Often Sometimes Rarely Never 71 15. Take longer than others to eat my meals Always Usually Often Sometimes Rarely Never 16. Avoid foods with sugar in them Always Usually Often Sometimes Rarely Never 17. Eat diet foods Always Usually Often Sometimes Rarely Never 18. Feel that food controls my life Always Usually Often Sometimes Rarely Never 19. Display self-control around food Always Usually Often Sometimes Rarely Never 20. Feel that others pressure me to eat Always Usually Often Sometimes Rarely Never 21. Give too much time and thought to food Always Usually Often Sometimes Rarely Never 22. Feel uncomfortable after eating sweets Always Usually Often Sometimes Rarely Never 23. Engage in dieting behavior Always Usually Often Sometimes Rarely Never 24. I like my stomach to be empty Always Usually Often Sometimes Rarely Never 25. Enjoy trying new rich foods Always Usually Often Sometimes Rarely Never 26. Have the impulse to vomit after meals Always Usually Often Sometimes Rarely Never Total Score_________ 72 Please respond to the following questions: 1) Have you gone on eating binges where you feel that you may not be able to stop? (Eating much more than most people would eat under the same circumstances) No______ Yes______ If yes, how many times in the last 6 months?______ 2) Have you ever made yourself sick (vomited) to control your weight or shape? No______ Yes______ If yes, how many times in the last 6 months?______ 3) Have you ever used laxatives, diet pills, or diuretics (water pills) to control your weight or shape? No______ Yes______ If yes, how many times in the last 6 months?______ 4) Have you ever been treated for an eating disorder? No______ Yes______ If yes, when? 73 Scoring the Eating Attitudes Test: For all items (except #25), each of the responses receives the following value: Always Usually Often Sometimes Rarely Never = = = = = = 3 2 1 0 0 0 For item #25, the responses receive these values: Always = 0 Usually = 0 Often = 0 Sometimes = 1 Rarely = 2 Never = 3 After scoring each item, add the scores for a total. If your total score is greater than 20, the participant has a disordered eating issue, and realistically should be seen by a counselor. If the participant answered “yes” to any of the last four yes/no questions, they are also considered to have a disordered eating issue. 74 APPENDIX C2 INSTITUTIONAL REVIEW BOARD 75 Date of Previous IRB Protocol 76 77 78 79 80 APPENDIX C3 EMAIL SENT TO IHSA BOARD 81 Naomi Blumenthal Hello, my name is Alexandra Houck and I am a graduate athletic training student at California University of Pennsylvania. As part of my graduate studies I am required to complete a thesis. The topic that I have chosen for my thesis is “The prevalence of eating disorders and menstrual irregularities in collegiate equestrian sports.” Being an equestrian myself I have felt the pressures to be thin and have been able to recognize a need for a study such as this. By completing this study I hope to shed a light on the prevalence of eating disorders and menstrual irregularities in equestrian sports (if there is a notable number to be found) so that healthy eating habits can be developed and encouraged among any suffering equestrians to promote a safer, healthier competitive environment. I had previously consulted with Robert Cacchione to inquire about getting the survey distributed to the equestrian participants in the IHSA. I spoke with him on the phone about my thesis and he was very excited and informed me that you were the lady to email about getting my survey sent out. We spoke about how the survey will remain anonymous and that I will not have any contact or way of knowing who participated in the survey, all I will receive back from the participants are the results of the survey. He also mentioned that the distribution of the survey may have to be approved by the IHSA board which meets in January, but time constraints on my thesis mean that I have to have the survey distributed in January. Thus this is something we may have to talk about and brainstorm over the phone. In order to complete this study though I am in need of subjects to complete a survey that is composed of questions concerning eating disorders and menstrual irregularities. The identity of the subjects will remain anonymous as it is important to legally protect their rights. The survey has not yet been set up or completed (and probably won’t be up and running until January of 2009) as I wanted to be sure that I had a subject basis first. I am hoping that the IHSA will see the importance of this study and will be willing to help out. Please contact me with any questions you may have about the survey and whether or not the IHSA will be able to help me complete my thesis study. My email address is hou1486@cup.edu and my personal cell phone # is (410) 428-6807. Please provide information I will need to conduct the study (i.e. contact person’s name, email, and phone). Thank you very much for the time you are taking to read and respond to my email, it is greatly appreciated. 82 APPENDIX C4 COVER LETTER TO PARTICIPANTS 83 Dear Participants: I am a master’s degree candidate at California University of Pennsylvania, requesting your help to complete part of my degree requirements. As a fellow equestrian, the researcher feels an honest concern that there may be a connection between equestrian sports and eating disorders (and the possible menstrual irregularities that can result from them). Thus I am conducting this study to see if any connection does exist. The results of this study (not including individual information) will be published in medical journals to inform the medical community if there is a possible connection between equestrian sports and eating disorders. The female equestrians of the IHSA have been chosen as the subjects for this study because the researcher feels that this group is the best representation of female collegiate equestrians across the nation. Please follow the link at the end of this letter to an online survey titled: Eating Behaviors and Demographics Questionnaire. The questionnaire consists of 38 questions, which will take about 5 to 10 minutes to complete. Due to this being a survey there is minimal risk involved as confidentiality will be maintained. All equestrians in the Intercollegiate Horse Show Association are being asked to complete this questionnaire, although you do have the right to choose not to participate or to discontinue participation at any time. If the participant chooses to discontinue the survey (by clicking the EXIT THIS SURVEY button on the top of the webpage) then all information will be discarded. Participants of this survey must be 18 years of age or older. The California University of Pennsylvania Institutional Review Board has approved this study for the Protection of Human Subjects. This approval is effective 02/04/2009 and expires 02/03/2010. This is an anonymous questionnaire and upon submission, neither your name nor email address will be attached to your answers. Your information will be kept strictly confidential and it will only be accessible to the primary researcher. All individual survey information will be stored on a password protected online database that only the primary researcher will have access to. Upon completion of the study all individual survey results will be deleted. By completion of the survey, you are giving 84 consent for me to use the results of your survey in the study. As an equestrian in the IHSA, your information and opinions regarding this topic makes your input invaluable. Please take a few minutes to fill out the anonymous questionnaire you will find by clicking on this link… http://www.surveymonkey.com/s.aspx?sm=AtE_2fHkisSgVpImZMZ_2 fr1eg_3d_3d If you have any concerns or questions please feel free to contact me through email at hou1486@cup.edu or by phone at (410)428-6807. Thank you for your time and consideration. Sincerely, Alexandra Houck, ATC California University of Pennsylvania 250 University Avenue California, PA 15419 Hou1486@cup.edu (410)428-6807 Carol Biddington, EdD Faculty Advisor Health Science and Sport Studies Biddington@cup.edu 724-938-4562 85 REFERENCES 1. IHSA History. IHSAINC.com. Available at: http://www.ihsainc.com/default.aspx?mid=12. Accessed September 15, 2008. 2. Rider Position. HorseRidingLessons.com. Available at: http://www.horseridinglesson.co.uk/RiderPosition.html. Accessed September 17, 2008. 3. NewRider.com. Available at: http://www.newrider.com/Kinder_Way/The_Rider/the_saddle. html. Accessed September 17, 2008. 4. Nordqvist C. What is an eating disorder? Types of eating disorders. 2008. Available at: http://www.medicalnewstoday.com/articles/105102.php. Accessed October 6, 2008. 5. Johnson C, Powers PS, Dick RW. Athletes and eating disorders: the natural collegiate athletic association study. Int J Eat Disord. 1999;26:179-188. 6. Burckes-Miller M, Black D. 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Menstruation and eating disorders among NCAA athletes. Eating Disorders Review. 2004:7. 27. Lippincott Williams & Wilkins. Oligomenorrhea. Available at: http://www.wrongdiagnosis.com/symptoms/menstrual_irregul arities/book-causes-8e.htm. Accessed October 6, 2008. 28. Harlow S, Matanoski G. The association between weight, physical activity, and stress and variation in the length of the menstrual cycle. American J Epidemiology. 1991;133:38-49. 29. Wolf AS, Marx K, Ulrich U. Athletic amenorrhea. Ann N Y Acad Sci. 1997;816:295-304. 88 ABSTRACT Title: THE PREVALENCE OF EATING DISORDERS AMONG FEMALE COLLEGIATE EQUESTRIAN ATHLETES Researcher: Alexandra M. Houck Advisor: Dr. Carol Biddington Date: May 2009 Research Type: Master’s Thesis Purpose: The purpose of this study was to determine a prevalence of eating disorders among female collegiate equestrian athletes. Problem: No research could be found as to whether or not female equestrian athletes are at risk for developing eating disorders and menstrual irregularities. It must be determined if this population is at risk so that they can be treated accordingly. Methods: A descriptive type of research was conducted. One hundred and twenty seven female collegiate equestrians from the Intercollegiate Horse Show Association volunteered for the study. The instrument used was the Eating Behaviors and Demographics Questionnaire. Findings: Equestrians who practice binge eating or purging have significantly higher eating disorder than those who do not. Equestrians who use substances for weight control have significantly higher eating disorders than those who do not. A significant number of female collegiate equestrian athletes have eating disorder issues. Conclusions: Eating disorders are prevalent in the female collegiate equestrian sport population.