COVID-19 Lowered Physical Activity and Increased Psychological Distress
The global outbreak of COVID-19 has resulted in closure of multiple recreational facilities (e.g., gyms) around the world. Many individuals are not able to participate in their regular individual or group physical activities. According to the World Health Organization (WHO), under such conditions, many people tend to be less physically active, have longer screen time, irregular sleep patterns, as well as worse diets, potentially resulting in weight gain, and loss of physical fitness, which can have a distinct impact on athletes (1). COVID-19 has also been associated with significantly higher levels of psychological distress, which can have a negative effect on people’s functioning in different domains, overall well-being, and quality of life (2).
COVID-19 Disruption of Routines
In particular, COVID-19 has significantly disrupted the routines of school and sports for adolescents (e.g., in-person training activities, organized sporting events), which can affect their usual eating behaviors, body image, and exercise patterns. Adolescence is a developmental growth period with a normally expected increased focus on body weight, which can lead to disordered eating (DE), eating disorders (ED), and body image concerns (3). Thus, adolescents (and especially athletes, who have more regimented eating and exercise behaviors) may be particularly vulnerable to these concerns during this unusual lockdown period.
The DE to ED Spectrum
Results from international studies that have addressed DE (altered dieting practices) during the first year of the pandemic suggest that there is large inter-individual variability in dietary changes (4, 5). For individuals experiencing persistent increases in unhealthy diet choices, there are important public health implications associated with Body Mass Index (BMI), gender, quality of life, living conditions, physical activity, and other dietary behaviors (4, 5).
DE can range on a spectrum from minor deviations away from normal eating patterns to major alterations in eating behaviors. These major alterations, often contributed to by a combination of genetic (family history) and environmental causes (e.g., COVD-19 stress), can result in individuals meeting the full diagnostic criteria for a primary ED, as defined by the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) (6), outlined below. EDs are associated with certain risk factors which may be especially developmentally relevant for adolescent athletes (e.g., age of ED onset is usually in adolescence, ED effects on the developing body can significantly interfere with an adolescent’s athletic performance).
Anorexia Nervosa (AN)
Per the DSM-5 (6), AN is defined as: a restriction of energy intake, leading to a significantly low body weight; intense fear of gaining weight, or persistent behavior that interferes with weight gain; and disturbance in body image, or lack of recognition of the seriousness of the current low body weight. Research indicates that individuals with a family history of AN, have childhood anxiety traits, and pursue avocations that encourage
thinness (e.g., elite athletes), are at an increased risk for developing AN (6).
Bulimia Nervosa (BN)
Also per the DSM-5 (6), BN is defined as: recurrent episodes of binge eating (feeling lack of control when eating a large amount of food in 2 hours); recurrent compensatory behaviors to prevent weight gain (e.g., vomiting); these behaviors occur at least once a week for 3 months; self-evaluation is unduly influenced by body shape/weight; and the disturbance does not occur exclusively during episodes of AN. Research indicates that individuals with a family history of BN, have childhood obesity, subsequently attempted to restrict food and/or overexercise (e.g., through sports), but ended up binging later, are at increased risk for developing BN (6).
A cross-cutting symptom of the above primary types of EDs is the concern about body image, which is the internal representation of an individual's external appearance (e.g., self-evaluations of one’s physical appearance) (7). Given that appearance is an integral part of one’s identity, and it plays a role in social situations, body image is an important aspect of life for most people, and particularly for those individuals who are at risk for, or are experiencing, an ED (8). When these concerns are combined with environmental pressures (e.g., to be an elite athlete, competing with peers on measures of appearance and performance), body image can become even more ingrained, as it is linked to their identity (e.g., as an athlete).
Another aspect of an athlete’s identity includes how they respond to the unique pressures of their specific sport. Petrie and Greenleaf formulated a theoretical etiological model of eight mediating factors in the development of DE in athletes (9, 10). One factor is the type of sport (individual vs. team sports; lean vs. non-lean sports). Individual sports tend to be ones that emphasize leanness (11), with the belief that lower body weight improves performance (e.g., track and field, martial arts, wrestling) (11). Alternatively, team sports tend to be ones that are non-lean (12), in that they do not require a low body weight in order for an athlete to be competitive (e.g., basketball, soccer, volleyball) (12). Lean sports may increase risk for DE because athletes may engage in pathogenic weight-control behaviors to achieve a lower body weight (13). A recent systematic review (14) of the prevalence of DE in athletes categorized by emphasis on leanness and activity reported that six out of the seven included studies found a significant increase in DE rates among lean sport types, compared to non-lean sport types (14).
Sports can be further divided into six subgroups: aesthetic, weight-dependent, endurance, ball game, power, and technical sports (15). Of these categories, aesthetic, weight-dependent, and endurance sports are typically considered lean sports, whereas ball game, power, and technical sports are considered non-lean sports. In particular, aesthetic sports, which are judged by a complex set of rules favoring appearance (e.g., ballet, gymnastics), have been shown in sport-specific studies to have a higher prevalence of DE and ED compared to other sport subgroups (16–18). Weight-dependent sports, which divide competitors into different categories based on their weight (e.g., wrestling, martial arts), have similarly been shown to have a higher ED pathology than those in other sport subgroups (19, 20). Endurance sports typically associate lower body weight with a higher level of competition (e.g., track and field-running, cross-country skiing) (21). As a result, athletes may utilize DE to achieve a body weight that is too low, resulting in an energy imbalance with the high metabolic requirements of their aerobic training (22, 23).
Another sport-specific factor to consider is peer competition, which can exacerbate DE, EDs, and distorted body image (24). While both team and individual sports require competition, cooperation is much more prevalent in team than in individual sports. Team athletes have to compete (for starting roles) while also cooperating (for team success) with the same teammates. Thus, it is possible that team athletes’ additional goal of cooperation more evenly balances out the goal of competition, compared to individual athletes’ sole requirement for competition (25). Additionally, peer competition can lead athletes to deny the seriousness of their concerns, and if they do seek help from a doctor, it is more likely due to complaints of decreased performance, rather than the symptoms of an ED, per se (25).
Although EDs are often thought of as feminine illnesses, epidemiological studies indicate that males are also at-risk for developing EDs (26–28). Most notably, adolescent males may be less likely to seek treatment than females due to an overall higher degree of shame and stigma related to their EDs (29–31). Further, physicians and other health care providers may be less likely to recognize disordered eating symptoms in adolescent males due differences in symptom presentation (e.g., male focus on muscle, vs. female focus on weight) (30, 31).
These gender-specific pressures can overlap with the above-noted sport-specific pressures. A systematic review (32) of risk factors for eating psychopathology included a study which examined the relationship between gender, type of sport (lean vs. non-lean), body dissatisfaction, and self-esteem, with DE behaviors in Division 1 college athletes (32). They found that participating in lean sports was associated with increased DE and body dissatisfaction for male athletes, but not female athletes (33). This unique vulnerability for male athletes, in addition to the factors related to lower likelihood of treatment for males (e.g., stigma, shame, provider misconceptions), suggests that male athletes should be targeted by coaches for prevention and early intervention for DE, ED, and distorted body image (34).
Adolescent Athletes-Additional COVID-19 Challenges
In addition to the above-noted challenges (i.e., pubertal development, focus on exercise, food, and body image, sport-specific pressures, gender-specific pressures) outside of COVID-19 (3), the pandemic has created additional concerns for adolescent athletes with EDs. Touyz and colleagues reported on the exacerbation of EDs during the beginning of lockdown (in 2020) (35). For many individuals with AN, lack of access to the usual forms of exercise (e.g., going to the gym) heightened concerns about gaining weight, leading to further restriction and emaciation, which increased their potential for experiencing more serious COVID-19 complications (35). If the body is too physically compromised from AN and COVID-19 (e.g., respiratory weakness, heart conditions, decreasing endurance, inability to perform skills), it is possible the person may not recover enough to participate in athletics again. For many individuals with BN during this same time period, increased access to food while in quarantine at home, without the normal athletic exercise routine to balance out the calorie intake, resulted in reported weight gain that they fear may hinder their athletic performance (35).
Furthermore, recent research on the psychological impact of the COVID-19 pandemic specifically on elite athletes suggests that levels of perceived stress and negative emotions during the lockdown (in 2021) are higher in athletes who experience changes in their: 1) motivation to compete (decrease from pre-pandemic); 2) stress-management (lowered coping abilities from pre-pandemic); and 3) post-pandemic performance expectations (maintain their usual high pre-pandemic standards, without allowance for COVID-19 interruptions) (36). Conversely, positive emotions during the lockdown are higher in athletes who experience no changes in their competition motivation, stress-management, or post-pandemic performance expectations (36).
The exacerbation of both physical and psychological symptoms of adolescent athletes with ED during the pandemic have unfortunately been further impacted by delays in timely treatment. Healthcare systems have reported prolonged waitlists, increased referrals, and deprioritized status for sub-acute conditions, contributing to less services for everyone (37, 38). While access to evidenced based treatment (EBT) for EDs was challenging for many individuals before COVID-19, the lockdown has imposed further barriers (e.g., travel, insurance limits).
Aim of the Present Study
COVID-19 thus presents specialized issues for adolescent athletes, particularly those at risk for, or experiencing, DE, ED, and associated negative body image. Sport-specific pressures, especially those related to individual sports (e.g., strict weight requirements, revealing sports attire, aesthetic judgments), may exacerbate these concerns. An additional factor to consider is the gender of the athletes, with males typically experiencing more barriers to treatment than females. The aim of the present study was therefore to compare ED symptoms and body image between individual and team sport adolescent male athletes who were geographically located in one of the most affected areas of Iran during COVID-19.