3.1. Convergent Mixed Methods Results
Both qualitative and quantitative results have been combined to provide insight into the interrelationship of how COVID-19 has affected current and former athletes’ relationship with food and their body (Figure 1).
Current and former athletes found that changes to their exercise and training were the most significant factor in affecting both their perception of their body and their relationship with food over this time. Reduced training or exercise meant energy balance shifts with subsequent food changes. This was described to result in increased binges, restriction, guilt, shame or increased/decreased control over food. Many described body composition changes that created negative affect towards their body shape and size. Even in the absence of body changes, the fear of anticipatory body changes was enough to indicate a worsened body image. The coding tree summarises the main influences that affected changes to body image and relationship with food in Figure 2.
3.2.1. Worsened Body Image
A worsened body image was often conflated with body changes, including weight gain or muscle loss, due to exercise and energy balance changes. For many current and former athletes, the ability to exercise was intricately related to the way they perceived their body. Less exercise, training or competitions ensured that participants were fearful of weight gain. It was noted that for current athletes, loss of muscle mass in addition to fat gain was a further stressor as one current athlete described, “I am so much less able to exercise. This means I'm worried that I'm losing fitness, and the more I lose fitness and strength, the more my body changes…I'm feeling sad about being bigger than others...” One current weight class athlete reported that their preoccupation with energy and calories had increased with the fear of their body composition changing, “I usually train 4 hrs a day and never have to think about weight or calories I burn unless I’m cutting weight for a competition. I am usually very lean when training and working full time. I exercise every day now, but my energy expenditure is way lower and I love food. I eat well and have a little treat every night and I’m fit, but my body has changed and I’m not as lean as usual, which is a little uncomfortable.”
A current athlete with an ED described how their symptomatology was worse at the start of isolation, “My eating disorder voice has gotten significantly louder. However, it was a lot worse at the beginning of our stay at home order (March 13th) than now.” For others, a changing environment and being at home created body preoccupation and greater comparison to others through social media, as one current athlete reported, “I’ve been way more conscious of how I dislike some features and way more obsessive, especially with how many posts are on social media.” For a former athlete, video programs such as Zoom, created additional body dissatisfaction and stress, “I hate attending Zoom meetings because I compare myself to others on the screen.” A former athlete noticed body changes and was trying to accept these changes but finding it hard to find clothes to fit their body, “I’ve gained weight and I have very few clothes left that fit comfortably. Online shopping is hard when you don’t know your new size and you can’t picture clothes that look good on skinny models looking good on me. Gaining a significant amount of weight has challenged who I feel I am and that itself makes me feel guilty.”
3.2.2. Worsened Relationship with Food
A worsened relationship with food was often attributed to a perceived lack of control or loss of control. Control was commonly used to describe how individual’s relationship with food had changed. It was described to be both a coping strategy in addition to something that participants felt they had lost. In an uncertain and unprecedented time, both current and former athletes described attempting to control food to provide a sense of agency over their life, as one former athlete described, “In this chaotic time I have found food to be a pillar of control - so I feel as if I am exerting greater control over aspects of my diet which is getting somewhat stricter than normal.” For a current athlete, they felt that their eating had become out of their control, leading to a complex psychological affect of guilt, shame and stress, “I feel now that I have less willpower to control what I eat. This means I am eating more rubbish, and feeling worse about it afterwards. Before the pandemic I used more energy worrying about what I ate, but at least some of it was productive energy, i.e. I would do meal planning etc. Now my mental health has diminished I have less energy to do that so I am eating more junk, and feeling the effects in my body (both real physical effects and worry about gaining weight etc) but feeling pretty powerless to do anything about it. The lack of ability to exercise and play my sport worsens these feelings.”
Others reported that their living situations had changed or that they were not coping with either (a) an increase to access of food at home, or (b) a decrease to food access in their communities. A former athlete described the change to the way they shop for food and the affect this has had on their relationship with food, “I have a lot of anxiety around food and am out of my routine. I have to shop for a couple of weeks at a time instead of getting fresh veg every few days. I can't have meals with friends so I sometimes just can't be bothered dealing with the anxiety of food just for myself.” A current athlete described moving back home had reduced their food options, “…coming home from college and not having the freedom of my own food choices.” Whilst a former athlete described how they found the increased access to food at home stressful, “I am living back home with my parents and have access to a wider variety of food, including ‘bad’ foods. I feel like I lack the control to be in this environment.”
3.3.3. Additional COVID-19 Challenges
Current and athletes differed in their reliance on peers, family and friends. For current athletes it was the loss of support that these people were able to give to them that made COVID-19 more challenging whereas with former athletes it was the loss of socialising through sport and social events that felt challenging. The change in exercise/training/competitions was of the most significance for both current and former athletes. A current athlete described how changes to their exercise has highlighted their motivation behind their sport, “I am not able to train all the time. Which is something I use to make sure I don’t gain weight.” Former athletes described that exercise was previously used a tool to assist their mental health. As one participant described, “I can't access a pool to train. I don't compete anymore but still feel most safe in the water and deal with my anxiety by swimming, it's made it so much harder not to be able to swim.”
For another current athlete, this time was made more challenging as it gave additional time to reflect on some of the more nuanced challenges they are facing in their sport, “I have quite limited access to training resources at the moment. I already felt like a bit of an impostor because I go to big international competitions but I represent a country which is very weak in my sport, and I'm an amateur who works full time, and I can't train as much or to the same level as professional athletes from other countries and this is reflected in my body, my sports ability, and my results. I already felt kind of unworthy of going to these competitions, like I'm not a real athlete (I thought twice about even doing this survey). Now I can see Instagram stories etc both from people I know personally representing other countries and people I only know by reputation, and see how much harder they are training than I am, it worsens those feelings of inadequacy.” Another current athlete reflected on how the postponement of the Olympics has increased the financial pressure they found themselves under, “[This] has extended the amount of time I have to financially support myself before the Olympics, while training at a high level. Have had to seek further employment to get myself through an extra year.”
Other athletes described that their reliance on social media in the absence of physical competition had increased. Sites such as Strava were used to compare training distance and speed as a way to increase pressure and social comparison, “Comparison to others exercise has increased with more time to look on Strava” in addition to, “It seems like everyone is working out more. Seeing their workout summaries on Strava makes me feel guilty about how I look and the shape I’m in.” For others, sport without physical competition was no longer worth the time and energy, “[It’s challenging] finding ways to be active without being super ‘competitive.’ For me, if I’m not ‘training’ hard it’s a waste of time.”
During the pandemic, some participants described how they were finding it challenging to transition or retire from sport, whilst others described the difference between this and other times of transition such as injuries. A current athlete described, “COVID-19 has affected my general mental health quite a lot through isolation and anxiety. I think this is having as much of an effect on my fitness and relationship with my body as anything else. It's different from an injury because at least with an injury you can train the rest of your body, and other people know how to help. Everyone is going through this at the same time so there isn't a stable support to lean on. I feel like everyone else is staying on top of things and I am not.” For one former athlete, they reflected on how their previous sporting transitions has given them a level of resilience to cope with unprecedented times such as this, “My sporting resilience in the face of uncertainty has actually done me a world of good. Sitting with the unknown of selection has taught me to sit with uncertainty and control why [sic: what] I can control - and remove my focus from the rest.”
3.2.4. Improved or Maintained Body Image
For those who reported their body image was about the same, it was not uncommon to describe a paradox where both positive and negative aspects of body image were described. A current athlete explored the duality of feeling both negative and positive about their body, “[I’m] feeling less fit but also being more patient and understanding with myself.” Another current athlete described this paradox through their body image being conflated with their body composition, “I’ve lost weight but some [of] it has been muscle, so I feel neutral.” This paradox was further described by a former athlete, “It’s been a constant struggle and I’ve still be able to exercise and eat healthy.” For others, they found that their body image had not changed due to the previous work they have overcome in improving their relationship with their body. A former athlete described how actively working on their body image in athletic transitions has provided resilience in these difficult times, “I’ve done extensive body image and food relationship work since retiring from sport. These unprecedented circumstances have proven that the work I have done has proven beneficial. I don’t feel fear for my body changing, although I know had this been a couple year ago, it would have consumed my thoughts.”
A current athlete experienced improved body image through gratitude and appreciation for what their body is capable of since being injured, “[I’ve] been able to train consistently without distractions and injuries again. And therefore appreciate what my body is doing for me and allowing me to train.” A former athlete felt their body image had improved despite exercising less as they experienced gratitude for their health and less social comparison, “I’m not as active working from home, however, I am grateful for my body and how I have been able to stay healthy during this time. I am not able to physically compare myself to people every day which has helped me too surprisingly.” For others, being removed from their sporting cultures or social groups meant they experienced less objectification and body shaming, “[I’m] not so preoccupied with looks because I'm by myself and nobody can see my body to judge it.” This was experienced by both current and former athletes, “…I don’t have to see people in public and worry about how they perceive me.”
3.2.5. Improved or Maintained Relationship with Food
For participants who experienced a maintained relationship with food, it was not always a positive maintenance. A current athlete described how reduced access to their supermarket had provided temporary relief to symptoms aligned with binge eating disorder despite the underlying psychological features remaining unaddressed, “Limiting grocery shopping to once or twice a week prevents me from going to the supermarket late in the evening if a binge urge kicks in, I make sure to only shop when I’m in a healthy food mindset so I don't buy anything I would normally binge on, therefore there isn't any of my go to binge foods in the house even if the urge does arrive.” A former athlete described the battle they continue to face with their relationship with food, “I still think about food and I still monitor my body and I can tell I am not exercising but I also don’t give a s**t. It feels like I will NEVER get to a good place with food so why bother?” A current athlete further described the paradox of both positive and negative aspects of their relationship with food coexisting, “I would say I go through phases of eating really well then have a bad day where I over eat.” For others, it was a time to reflect on how far they had come in healing their relationship with food and were grateful for its consistency through this transient time, “I have worked extremely hard to repair my relationship with food, and I am seeing how steadfast that work is proving to be. I feel free and flexible with my nutrition which is a very good thing considering grocery stores have empty aisles and foods I usually buy are not always available. Thankfully, I feel confident to make other food decisions that will still nourish my body well without guilt or fear.”
An athlete described how the pandemic had afforded them more time to learn about nutrition and have gratitude for their food, “I have spent more time cooking meals from scratch. Finding meals that are healthy and learning about the nutritional benefits.” This was further explored in a participant’s appreciation for the resources they were able to access, “I am grateful that we have resources in Australia to be able to make nutritious meals in this situation.” A former athlete described using this time for growth and learning to reconnect with their body cues through intuitive eating, “I’m trying to use this time to ditch dieting mentality and try intuitive eating. Earlier during lockdown I was very hard on myself but I’m easing up.” A change in living environment was a positive change for a former athlete who found their parents role modelled a more balanced diet, “Living with parents recently, who eat a more balanced diet than I do.”
3.3.1. Quantitative Descriptive Statistics & EAT-26 Reliability
Descriptive data on continuous variables including; age, height, weight, total EAT-26 scores and subscales are described in Table 2. with corresponding internal consistency reliability statistics (Cronbach’s alpha). The reliability of the EAT-26 total score for the total sample population (n=204) was 0.92 and 0.83 for para athletes (n=4). Values above 0.7 are considered acceptable (40).
Table 2. Descriptive Statistics for Sex and Athletics Status with EAT-26 total score and subscale scores
|
Current Athletes
Females (n=78)
|
Former Athletes
Females (n=97)
|
Current Athletes
Males (n=15)
|
Former Athletes
Males (n=14)
|
M (SD)
|
alpha
|
M (SD)
|
alpha
|
M (SD)
|
alpha
|
M (SD)
|
alpha
|
Age
|
25.0 (8.5) a
|
|
27.0 (7.4) a
|
|
26.0 (11.2)
|
|
29.5 (6.5)
|
|
Height
|
166.5 (7.3) b
|
169.0 (7.5)c
|
176.0 (8.8) b
|
181.0 (7.5) c
|
Weight
|
61.0 (9.1) a,b
|
65.0 (12.5) a,c
|
68.0 (10.2) b,d
|
83.0 (11.1) c,d
|
EAT-26
Total Score
|
7.5 (13.4) b
|
0.93
|
6.0 (11.8)
|
0.91
|
2.0 (7.5) b
|
0.88
|
3.5 (3.0)
|
0.45
|
Dieting
Subscale
|
5.0 (8.8) b
|
0.92
|
4.0 (7.6)
|
0.88
|
1.0 (7.5) b
|
0.78
|
2.0 (3.1)
|
0.75
|
Bulimia
Subscale
|
1.0 (3.0)
|
0.70
|
0.0 (3.1) c
|
0.81
|
0.0 (2.3)
|
0.86
|
0.0 (0.6) c
|
0.45
|
Oral Control Subscale
|
1.0 (3.4)
|
0.76
|
1.0 (2.5)
|
0.58
|
2.0 (1.1)
|
*
|
2.0 (1.1)
|
*
|
a Significant difference between females
b Significant difference between current athletes
c Significant difference between former athletes
d Significant difference between males
* Violates reliability model assumptions (inadequate sample size)
Non-parametric Independent Samples Mann Whitney U tests were conducted between groups, significance was indicated by p<0.05. There was a significant difference between current male and female athletes in the total EAT-26 score (Males: M=2.0, n=15; Females: M=7.5, n=78), U=781, z=2.06, p=0.04, r=0.21; and in the dieting subscale (Males: M=1.0, n=15; Females: M=5.0, n=78), U=850, z=2.78, p=0.005, r=0.29.
21.1% of participants had EAT-26 scores suggestive of an ED, there was a significant difference between males and females (Males: M=3.0, n=29; Females: M=6.0, n=198), U=3234, z=2.37, p=0.018, r=0.17, but no significant difference between groups of athletic status, individual vs team sports, type of sport or level of competition (Table 3.). The difference between males and females was only significant through the dieting subscale scores (Males: 1.0, n=29; Females: M=5.0, n=175), U=3508, z=3.32, p=0.001, r=0.23.
Table 3. Descriptive Statistics of EAT-26 Scores Indicative of an Eating Disorder
Athletic Status (n=204)
|
18% current athletes (n=17)
|
25% former athletes (n=26)
|
Individual vs Team Sport (n=204)
|
19% individual athletes (n=26)
|
25% team sport athletes (n=17)
|
Type of Sport (n=204)
|
16% endurance athletes (n=14)
19% ball sport athletes (n=11)
36% aesthetic athletes (n=4)
|
0% antigravitational athletes (n=0)
14% power athletes (n=8)
25% technical athletes (n=2)
|
Highest Level of Competition (n=204)
|
26% club level athletes (n=9)
26% national level athletes (n=20)
|
16% state level athletes (n=5)
15% international athletes (n=9)
|
3.3.3. COVID-19 Responses & EAT-26
A series of categorical COVID-19 questions were asked regarding relationship with food, body image and challenges over this time. The results are presented in Table 4 and indicate the percentages of respondents for each category (worse/same/better; yes/no). EAT-26 total score was compared to these response groups and significant differences assessed. Kruskal-Wallis H Tests were conducted to assess non-parametric one-way between groups analysis of variance between COVID-19 questions 1 and 2, EAT-26 scores and athletic categories. Mann-Whitney U Tests were conducted for question 3, as it only had 2 categorical response options. Bonferroni adjustments were applied when comparing multiple groups.
Table 4. COVID-19 Categorical Responses vs. Athletic Status and Sex and difference within response groups
|
All participants (n=198)
|
Current Athletes
Females (n=77)
|
Former Athletes
Females (n=93)
|
Current Athletes
Males (n=14)
|
Former Athletes
Males (n=14)
|
%, n
|
EAT-26
M (SD)
|
%, n
|
EAT-26
M (SD)
|
%, n
|
EAT-26
M (SD)
|
%, n
|
EAT-26
M (SD)
|
%, n
|
EAT-26
M (SD)
|
1. How has your body image changed since COVID-19?
|
Worse
|
34.8
(n=69)
|
9.0 (13.4)a
|
42.9
(n=33)
|
8.0 (14.4)
|
34.4
(n=32)
|
15.0 (12.9)b
|
14.3
(n=2)
|
15.0 (12.7)
|
14.3
(n=2)
|
4.0
(2.8)
|
Same
|
50.5
(n=100)
|
5.0 (11.4)a
|
42.9
(n=33)
|
7.0 (13.6)
|
52.7
(n=49)
|
4.0 (11.1)b
|
71.4
(n=10)
|
2.0 (6.9)
|
57.1
(n=8)
|
3.5
(2.7)
|
Better
|
14.6
(n=29)
|
5.0 (8.1)
|
14.3
(n=11)
|
8.0 (10.7)
|
12.9
(n=12)
|
5.0
(5.9)
|
14.3
(n=2)
|
2.0 (1.4)
|
28.6
(n=4)
|
4.5
(4.0)
|
2. How has your relationship with food changed since COVID-19?
|
Worse
|
32.8
(n=65)
|
13.0 (14.5)a
|
46.8
(n=36)
|
10.5 (14.3)
|
28.0
(n=26)
|
21.0 (14.6)b
|
14.3
(n=2)
|
13.0 (15.6)
|
7.1
(n=1)
|
9.0
(0.0)
|
Same
|
53.0
(n=105)
|
5.0 (9.7)a
|
41.6
(n=32)
|
6.0 (13.3)
|
55.9
(n=52)
|
4.0
(7.9)b
|
71.4
(n=10)
|
4.0 (6.7)
|
78.6
(n=11)
|
3.0
(2.0
|
Better
|
14.1
(n=28)
|
7.5 (9.1)
|
11.7
(n=9)
|
7.0 (11.5)
|
16.1
(n=15)
|
8.0
(8.5)
|
14.3
(n=2)
|
1.5 (0.7)
|
14.3
(n=2)
|
8.5
(3.5)
|
3. Has anything made things more challenging for you over this time?
|
Yes
|
62.6
(n=124)
|
6.0 (12.7)
|
76.6
(n=59)
|
7.0 (13.2)
|
54.8
(n=51)
|
11.0 (13.0)b
|
57.1
(n=8)
|
2.0 (1.8)
|
42.9
(n=6)
|
2.0
(3.7)
|
No
|
37.4
(n=74)
|
6.0 (10.6)
|
23.4
(n=18)
|
9.0 (14.5)
|
45.2
(n=42)
|
4.0
(9.0)b
|
42.9
(n=6)
|
11.0 (9.8)
|
57.1
(n=8)
|
4.5
(2.5)
|
a p<0.05 for within group difference for all participants
b p<0.05 for within group difference for former female athletes
3.3.4. Body Image Changes During COVID-19
When looking at all participants, there was a significant difference in EAT-26 total score between those who perceived their body image to have gotten worse as a result of COVID-19 and those who perceived it to have stayed the same, χ2 (2,198) =8.01, p=0.018. The group who perceived worsened body image had a higher median EAT-26 score (M=9.0, SD=13.4) compared to the group who perceived it stayed the same (M=5.0, SD=11.4). This was also the case in former female athletes, χ2 (2,81) =7.93, p=0.019 with those experiencing worsened body image having a higher median EAT-26 (M=15.0, SD=12.0) compared to the group who perceived their body image stayed the same (M=4.0, SD=11.1). There were no significant differences between categories in current female athletes, current male athletes or former male athletes. There was also no significant differences across rows in their EAT-26 scores.
3.3.5. Relationship with Food Changes During COVID-19
When looking at all participants, there was a significant difference in EAT-26 total score between those who perceived their relationship with food to have gotten worse during COVID-19 compared to those who perceived it stayed the same, χ2 (2,198) =15.5, p=0.000. The group who perceived their relationship with food to have gotten worse had a higher median EAT-26 score (M=13.0, SD=14.5) compared to the group who perceived it stayed the same (M=5.0, SD=9.7). This was also seen in former female athletes, χ2 (2,81) =15.8, p=0.000, with those experiencing worsened body image having a higher median EAT-26 (M=21.0, SD=14.6) compared to the group who perceived body image stayed the same (M=4.0, SD=7.9). There were no significant differences between categories in current female athletes, current male athletes or former male athletes. There were no significant differences between categories in current female athletes, current male athletes or former male athletes. There was also no significant differences across rows in their EAT-26 scores.
3.3.6. Other Results
Former female athletes who perceived things had been made more challenging during COVID-19 had significantly higher EAT-26 scores (M=11.0, SD=13.0) than those who did not perceive COVID-19 to be challenging (M=4.0, SD=9.0), U=813, z=-1.997, p=0.046, r=0.21. No other group had significant differences. There were no significant differences between highest sporting competition (club, state, national, international) and EAT-26 scores (p=0.428); last competition for former athletes (1 month to 30 years +) and EAT-26 scores (p=0.937); sporting categories (endurance, antigravitational, ball sports, power, weight class, aesthetic, technical, other) and EAT-26 scores in current (p=0.149) or former athletes (p=0.519). Additionally, both body image (p=0.673) and relationship with food (p=0.386), current athletes were not significantly different between EAT-26 scores and response categories.