title: The Impact of Eating behaviours and Training Practices on Health in Female Physique Athletes: A Multi-Method Exploration
Creators: name: Alwan, N
Publisher: name: Liverpool John Moores University
Year: 2024

description: Female physique (FP) athletes are judged subjectively on aesthetic appearance and posing ability. Typically, an annual season is divided into an off-season (which can last a number of months to even a year) and an in-season which involves a pre-competition phase (approximately 12-24 weeks), competition week (normally the final 7 days prior to competition) and a recovery phase. Engaging in prolonged and/or acute weight loss practices can induce physiological and psychological strain that may result in negative long-term consequences. The profile of weight history and dieting behaviours used by FP athletes is still largely unknown. Additionally, few studies have assessed the physiological, psychological and social health implications involved in physique sports across different phases of the annual season. Therefore, the main aim of this thesis was to investigate the impact of eating and training practices on health implications in FP athletes. Understanding these aspects will promote awareness regarding the requirements to be a FP athlete, whilst also ensuring physique athletes’ health and welfare is optimal.

Study 1 (Chapter 3) investigated the weight loss history, practices and influential sources of information about dieting during the pre-competition phase in 158 FP athletes stratified by division and experience level. It was aimed to determine the relationship between experience level and division, and weight management practices. This is crucial for determining whether there is a need for tailored awareness and targeted education for FP athletes with varying levels of experience competing in different divisions. Eating attitudes and behaviours were assessed to identify whether athletes were at risk of developing an eating disorder. Using a cross-sectional research design, FP athletes completed an anonymous online self-reported survey consisting of the Rapid Weight Loss Questionnaire and Eating Attitudes Test-26. 
Athletes reported using chronic gradual dieting (94%), food restriction (64%) and excessive exercise (84%), followed by acute body water manipulation via water loading (73%). There were no associations between division or experience and these practices. Nevertheless, division significantly impacted absolute (P&lt;0.01), and relative (P=0.03) weight regain with Figure athletes (a specific division within female physique sports) showing the greatest increase in body mass (5.5%) 7-days following competition. Overall, 37% of FP athletes were at risk of developing an eating disorder, mirroring rates in other leanness-focused elite sports (35% out of 61 athletes (Kong and Harris, 2014), but higher than the general population (3-10% out of 2444 male and female individuals) (McEnery et al., 2016). Additionally, 42% of FP athletes used two pathogenic weight control methods (Laxatives, diet pills and diuretics use and binge eating) with 34% of Figure novice athletes (≤1 year of competition experience) indicating binge eating at least once a week. The coach (89%) and other athletes (73%) were identified as key influences on athletes’ dieting practices and weight loss. Although most female athletes acquire their body composition using acute and chronic methods, the prevalence of athletes identified with disordered eating symptoms and engaging in pathogenic weight control methods is concerning.

Having quantified a high prevalence of the use of gradual dieting, food restrictions and excessive exercise during pre-competition in study 1 (Chapter 3), study 2 (Chapter 4) aimed to document self-reported dietary intake, training practices and psychological states during the pre-competition phase in FP athletes. In an observational study design, nine free-living natural (i.e., drug-free) FP athletes completed a three-day weighed food diary, training diary and perceived well-being and mood states questionnaires for three days at three separate time-points (-12 weeks, -4 weeks and -1 week) prior to competition. 

A reduction in BM (60.9 ± 8.1 kg to 55.6 ± 8.9 kg, Δ5.3kg ± 3.4; P &lt; 0.01; effect size [ES] = 0.59, 95% CI= -0.36 to 1.53) coincided with reductions in absolute mean energy intake (1738 ± 236 kcal.day-1 to 1379 ± 285 kcal.day-1, P=0.03; ES=1.31, 95% CI= 0.29 to 2.32), protein intake (166 ± 14 g.day-1 to 137±30 g.day-1; P=0.02; ES=1.20; 95% CI= 0.20 to 2.20), and fat intake (48.7 ± 14.5 g.day-1 to 35.5 ± 17.85 g.day-1, P=0.03; ES=0.77; 95% CI= -0.19 to 1.73), with no changes in carbohydrate intakes or any nutrient relative values from -12 weeks to -1 week pre-competition (P&gt;0.05). Macronutrient distribution did not differ between time-points (P&gt;0.05), except for energy intake per meal between -12WK (188.7  142.6 kcal.day-1and -1WK (152.5  134.1 kcal.day-1; 95% CI=1 to 71 kcal.day-1, F2,14 = 5.43, P=0.04). Assessing timing and quantity of within-days macronutrients intakes of pre-competition is crucial for understanding if and how these athletes distribute their nutrition, to support the performance, recovery, and adaptation goals of training. Alongside dietary changes, FP athletes increased total aerobic training duration per day (99 ± 68 to 168 ± 85 min.day-1; P=0.02; ES=-0.85, 95% CI= -1.82 to 0.11) from -12 weeks to -4 week pre-competition, and reduced resistance training loads (1555  672 to 377  161 arbitrary units (AU); P&lt;0.01; ES=2.30, 95% CI = 1.11 to 3.49) from -12 weeks to -1 weeks pre-competition. Within the mood sub-scales, vigour was significantly reduced from -12WK (8 ± 3 AU) to -1WK (5 ± 2 AU; 95% CI=0 to 6 AU; P=0.01; ES=1.09, 95% CI = 0.10 to 2.08). These data suggest FP athletes elicit moderate decreases in BM prior to competition via moderate to large adjustments to energy and training practices. Consequently, only vigour was affected in nine FP athletes during pre-competition.

Study 3 (Chapter 5) was a case report assessing the physiological and psychological responses of an experienced FP athlete during the phases of the in-season, representing a late pre-competition phase (Phase 1: -4 weeks before competition), a competition week (Phase 2: -1 week and -2 days before competition) and a recovery phase (Phase 3: +4 and +12 weeks after competition). The athlete experienced a rebound of body mass (+10 kg, +19% from Phase 1) and hyperinsulinemia (&gt;174 pmol.L-1) during the 12 weeks of recovery (Phase 3). Potential health consequences associated with relative energy deficiency in sport were also observed, as evidenced by self-reported oligomenorrhea (presented at the start of the study), suppressed RMRratio (0.90) (the ratio of RMR measured to predictive RMR using the Harris-Benedict equation BM equation), free triiodothyronine (2.6-3.0 pmol.L-1) and testosterone concentrations (0.3 nmol.L-1) when comparing against clinical reference values, and increased mood disturbance (total mood disturbance score = 35-39 AU) in Phase 2. This data showed that after a 12-week overfeeding recovery period following prolonged energy restriction, an experienced international-level FP athlete exhibited rebound hyperphagia. Additionally, some psychological and physiological negative effects observed in the pre-competition phases did not fully recover at 12 weeks post-competition (Phase 3).

Competitive physique sports can place physiological and psychological demands on the athlete (Study 2 and Study 3: Chapter 4 and 5), however, exploratory studies on the lived experiences of FP athletes, especially in relation to health, wellbeing and social life, are scarce. The purpose of this study (Chapter 6) was therefore to shift the lens to a qualitative approach and explore ten FP athletes’ personal lived experiences within the sport (during their recovery phase or in the off-season). A two-part semi-structured interview was completed. Using a six-step thematic analysis, the overall theme of this study was a ‘dynamic physical, psychological and social rollercoaster experience’. Within this, five key subthemes were identified: Starting the journey, body changes, public success with private isolation, physical and psychological tension and aftercare which manifest themselves uniquely at different stages of the ‘rollercoaster experience’. Participants also provided suggestions for the management of health and welfare in physique sports, which included tailored regulations and coach education. Findings offer insights into the complex interplay between the body composition ideal, culture and dieting practices, and how this results in biological, psychological, and social health implications. 

Taken together, this thesis provides observational insights into the weight management of FP athletes by assessing both eating and training practices, along with an exploration of the physiological and psychological effects in physique sports. The findings of this thesis serve as a call to action to the bodybuilding and fitness organisations, in enhancing the education packages for athletes themselves and key stakeholders in the sport. Moreover, future research should design, implement and pilot test a multidisciplinary support system in the organisations to identify how FP athletes can be best supported throughout the annual season.