Athlete Body Image and Eating Disorders: A Systematic Review of Their Association and Influencing Factors
Highlights
- The relationship between athletes’ body image and eating disorders is complex and inconclusive.
- The association between athletes’ body image and eating disorders may be influ-enced by different factors such as gender, age, and sports event.
- The main findings demonstrate that even if athletes feel satisfied with their body image, eating disorders may still develop.
- The main findings highlight that female athletes, particularly young female ath-letes, and athletes involved in sports associated with leanness are more prone to eating disorders and body dissatisfaction.
Abstract
:1. Introduction
2. Materials and Methods
2.1. Searching Strategy
2.2. Eligibility Criteria
- -
- P (population): participants who are defined as athletes;
- -
- I (intervention): any interventions;
- -
- C (comparison): any comparisons;
- -
- O (outcomes): any outcomes related to eating disorders and body image;
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- S (study design): observational designs and any other designs that possibly report disorders and body image (even if it was only part of descriptive statistics).
2.3. Data Extraction
2.4. Quality Assessment
2.5. Data Process
3. Results
3.1. Study Selection
3.2. Study Characteristics
Category | Study | Design | Sample (n) | Female % | Aesthetic Sports % | Body Image Measure (Interpretation) | Eating Disorder Measure (Interpretation) | Key Findings | Quality |
---|---|---|---|---|---|---|---|---|---|
Studies evaluating the effect of body image on eating disorders | de Bruin, Oudejans [37] | Controlled trials | 68 gymnasts and 85 schoolgirls (n = 153) | 100% | 44.4% | Body Image Questionnaire, BIQ (-) | Six items of the Bulimia Test-Revised, BULIT-R (-) | Both elite and non-elite gymnasts have a positive body image, but frequent dieting behavior still exist. | High |
Cusack, Petrie [45] | Longitudinal analysis | Male collegiate athletes (n = 452) | 0% | 1.5% | Use the five items as individual indicators on the latent variable of body satisfaction (-) | Eating Disorder Examination Questionnaire Short, EDEQ-S (higher scores indicate higher levels of eating disordered symptomatology) | Body satisfaction is a major antecedent of eating disorders in male athletes. | High | |
Satterfield and Stutts [49] | Cross-section | NCAA male wrestler (n = 103) | 0% | 0% | Body Parts Satisfaction Scale for Men, BPSS–M (higher scores indicate more satisfaction with body image) | Eating Pathology Symptoms Inventory, EPSI (higher scores indicate more severe eating disorders) | Male wrestlers exhibit relatively high body satisfaction; however, they engage in numerous unhealthy weight- loss behavior in their quest for muscle development. | High | |
Pallotto, Sockol [47] | Cross-section | Female Division I college athletes (n = 212) | 100% | 3.25% | Body Image Satisfaction Scale, BISS (higher scores indicate more dissatisfaction with body image) | Eating Attitudes Test, EAT-26 (higher scores indicate more severe eating disorders) | Weight pressure from parents, peers, and the media is directly associated with body dissatisfaction and indirectly linked to eating disorders through the internalization of thinness and muscular ideals. | High | |
Petrie and Moore [48] | Cross-section | Male collegiate athletes (n = 1975) | 0% | 1.37% | Body Parts Satisfaction Scales, BPSS (higher scores indicate more satisfaction with body image) | Eating Disorder Examination Questionnaire, EDEQS (higher scores indicate more severe eating disorders) | Greater athlete satisfaction with their current weight, shape, and thinness during the COVID-19 transition was associated with a reduction in eating disorders. | High | |
Paixao, Oliveira [50] | Cross-section | Portuguese young female athletes (n = 142) | 100% | 100% | Cognitive Fusion Questionnaire Body Image, CFQ-BI, and Perfectionistic Self-Presentation Scale-Body Image, PSPS-BI (higher scores indicate greater level of self- presentation) | Eating Disorder Examination, EDE-Q (higher values indicating higher severity of eating psychopathology) | In aesthetic athletic girls, preoccupation with body image-related thoughts may be associated with the desire to present an idealized body image to others, potentially resulting in eating disorders attitudes and behavior. | Moderate | |
Gibson, Hindle [54] | Cross-section | Elite rugby union players in New Zealand (n = 26) | 0% | 0% | - | EDI-3 include DT, bulimia, and body dissatisfaction | Although rugby players are considered by society to have the “ideal” tall muscular physique, they are still at increased risk of body dissatisfaction and eating disorders when they face sports-related stress. | Moderate | |
Voelker, Gould [53] | Cross-section | Five US states female figure skaters (n = 272) | 100% | 100% | Contour Drawing Rating Scale, CDRS (-) | Eating Attitudes Test, EAT-26 (-) | General body dissatisfaction in athletes is a significant predictor of eating disorders. | High | |
Anderson, Petrie [46] | Cross-section | 280 NCAA, Division-I, female collegiate gymnasts, and 134 swimmers and divers (n = 414) | 100% | 67.6% | Body Satisfaction (higher scores indicate more satisfaction) | The 9-item Dietary Intent Scale, DIS, and 10-item Dutch Restrained Eating Scale, DRES (higher scores indicated more restraint in eating behavior) | The negative mood, body dissatisfaction, and dietary restriction of athletes were directly related to symptoms of bulimia. | High | |
Francisco, Narciso [40] | Controlled trials | Portugal adolescents (n = 725) | 62.5% | 33.8% | Contour Drawing Rating Scale, CDRS (-) | Eating Disorder Examination-Questionnaire, EDE-Q (-) | Body image was the strongest predictor of eating disorders. | High | |
Studies evaluating the effect of eating disorders on body image | Neves, Meireles [42] | Controlled trials | 40 elite athletes, 245 non-elite athletes and 128 non-athlete adolescents (n = 413) | 73.6% | 100% | Body Shape Questionnaire, BSQ (the higher the total score, the greater the body dissatisfaction) | Eating Attitudes Test-26, EAT-26 (the higher the score, the higher the risk of eating disorders) | In the arts program, among elite, non-elite, and non-athletes, risk behaviors for eating disorders were the factor most strongly associated with body dissatisfaction. | High |
Rosendahl, Bormann [43] | Controlled trials | 576 young German athletes and 291 non-athletes (n = 867) | 43.9% | (-) | Body image and body ideal were measured with male and female silhouettes representing different weight categories (-) | Eating Attitude Test, EAT-26 (EAT 0–9 are defined as subjects with normal eating behaviors and attitudes, and EAT > 10 as subjects with eating disorders behavior and Attitudes) | Athletes who had dieting experiences reported dissatisfaction with their body shape and weight more frequently than those who did not, as well as eating disorder behaviors and attitudes. | High | |
de Bruin, Oudejans [38] | Controlled trials | 19 athletics with eating disorders and 33 athletics without eating disorders (n = 52) | 100% | 100% | Contextual body image questionnaire for athletes, CBIQA Visual Analogue Scales, VAS Body-Self Relations Questionnaire, MBSRQ (-) | Eating disorder examination questionnaire, EDE-Q (-) | On a daily basis, athletes with eating disorders were more negative about their appearance than athletes without eating disorders. | High | |
Michou and Costarelli [41] | Controlled trials | 74 Greek Female basketball players and 80 nonathletes female (n = 154) | 100% | 0% | Body- Self-Relations Questionnaire, MBSRQ (-) | Eating Attitudes Test, EAT-26 (-) | There were no significant differences in DE attitudes between female basketball players and non-players; however, DE attitudes in the whole group of women (n = 154) were significantly positively associated with anxiety levels and unhealthy body image. | High | |
Costarelli and Stamou [36] | Controlled trials | 20 taekwondo and judoka athletes and 40 non-athletes (n = 60) | 76.7% | 0% | Multidimensional Body-Self Relations Questionnaire, MBSRQ (-) | Eating Attitudes Test, EAT-26 (-) | In comparison to non-athletes, athletes exhibited higher emotional intelligence and healthier body image, with no significant differences in attitudes toward eating disorders. | High | |
Goltz, Stenzel [55] | Cross-section | 52 competing in weight-class sports, 52 in sports with aesthetic ideals, and 52 competing in athletics, swimming, triathlon, and horse racing (n = 156) | 0% | 33.3% | Body Shape Questionnaire, BSQ (the score range is used to determine body image) | Eating Attitudes Test, EAT-26 and Bulimic Investigatory Test Edinburgh, BITE (the score interval determines whether there is an eating disorder) | Nearly a quarter of the athletes displayed eating disorder, associated with dissatisfaction with their body image. Athletes with higher body fat were more likely to experience dissatisfaction with their body image. No significant variations in eating behavior and body image were observed among athletes in different sports categories. | High | |
Salbach, Klinkowski [52] | Cross-section | 50 elite rhythmic gymnasts, 58 female patients with AN, and 56 high school girls (n = 164) | 100% | 100% | The Test for Detecting Body Image Distortion in Children and Adolescents (-) | EDI-2 (-) | People with anorexia nervosa are more likely to have a distorted body image than elite rhythmic gymnasts and high school students. | High | |
Studies stratified by gender | Pinto, Dolan [44] | A mixed method | Elite male artistic gymnastics (n = 17) | 0% | 100% | Muscle Silhouette Measure, MSM, and Male Body Checking Questionnaire, MBCQ (higher scores indicative of a higher frequency of body checking behaviors) | Eating Attitude Test, EAT-26, Bulimic Investigatory Test, BITE, and Binge Eating Scale, BES (0–17 points overeating, 18–36 moderate symptoms, 27–46 represents severe) | Eating disorders are not common among male elite gymnasts. | Moderate |
Blackmer, Searight [56] | Cross-section | Varsity athletes at a midwestern university (n = 103) | 54.4% | (-) | Body Uneasiness Test, BUT (-) | Eating Attitudes Test, EAT-26 (-) | Female athletes scored significantly higher than male athletes on all measures related to eating disorders and body image | High | |
Milligan and Pritchard [57] | Cross-section | American Western Athletic Conference (n = 176) | 56% | 8.5% | Body Shape Questionnaire, BSQ (higher scores indicating greater body dissatisfaction) | Eating Attitude Test, EAT-26 (20 points cut-off value to decide) | The order in which eating disorder behaviors were predicted was body dissatisfaction, self-esteem, and types of sports (thin or non-thin), while for men, the order in which eating disorder behaviors were predicted was body dissatisfaction. | Moderate | |
Kristjánsdóttir, Sigurðardóttir [15] | Cross-section | 43 aesthetic athletes, 116 endurance athletes, 76 weight-class athletes, 140 fitness athletes, and 380 ball athletes (n = 755) | 33.9% | 5.7% | Body Shape Questionnaire, BSQ (higher score indicates greater level of body dissatisfaction) | Bulimia Test-Revised, BULIT-R and Eating Disorder Examination Questionnaire, EDE-Q (higher score reflects a greater eating-related pathology) | Female athletes exhibit higher scores in body image concerns compared with their male counterparts, and they are more susceptible to eating disorders than male athletes. | High | |
Salbach, Klinkowski [52] | Cross-section | 50 elite rhythmic gymnasts, 58 female patients with AN, and 56 high school girls (n = 164) | 100% | 100% | The Test for Detecting Body Image Distortion in Children and Adolescents (-) | EDI-2 (-) | People with anorexia nervosa are more likely to have a distorted body image than elite rhythmic gymnasts and high school students. | High | |
Studies stratified by age | Borowiec, Banio-Krajnik [35] | Controlled trials | Polish female adolescents (12–18 years) and adult athletes (19–30 years) (n = 241) | 100% | 23.2% | Feelings and Attitudes Toward Body Scale—by Orbach and Mikulincer (higher scores indicate more satisfaction with body image) | The Eating Attitudes Test, EAT-26 (higher scores indicate more severe eating disorders) | Compared with adult athletes, the risk of eating disorders in adolescent athletes was significantly linked to body satisfaction and the types of sports. Among adolescent athletes, the risk of eating disorders was most closely associated with participating in lean, non-aesthetic sports. | High |
Baceviciene, Jankauskiene [16] | Controlled trials | Lithuanian athletes (n = 1003) | 51.3% | 13.56% | Multidimensional Self-Relations Questionnaire Appearance Scale, MBSRQ-AS and Body Appreciation Scale 2, BAS-2 (-) | Eating Disorder Examination Questionnaire 6, EDE-Q 6 (higher score indicates more frequent DE behaviors, more severe weight and size problems) | Adolescent female athletes exhibit a higher susceptibility to body dissatisfaction and eating disorders compared with adult female athletes. In contrast, adult male athletes experience more frequent eating disorders and concerns about being overweight compared with adolescent male athletes. | High | |
Studies stratified by race | Johnson, Crosby [20] | Cross-section | NCAA (n = 1445) | 38.9% | - | Include in EDI-2 | Eating disorders inventory, EDI-2 (these subscales range from 0 to 21 for drive and for thinness, and from 0 to 27 for body dissatisfaction) | White female athletes were more likely to report body dissatisfaction and eating disorder behaviors than black female and male athletes. | High |
Studies stratified by sports events | Kong and Harris [18] | Controlled trials | Australian elites and recreational sporting organizations and clubs (n = 320) | 100% | 54.4% | Figure Rating Scale, FRS (-) | Eating Attitudes Test, EAT-26 (-) | Athletes from leanness-focused sports reported higher levels of body dissatisfaction and greater symptoms of eating disorders than those with non-leanness-focused sports. | High |
Reinking and Alexander [51] | Cross-section | 84 collegiate athletes and 62 non athletes (n = 146) | 100% | - | Include in EDI-2 | Eating disorders inventory, EDI-2 (-) | Lean-sport athletes had a higher risk of body dissatisfaction and eating disorders compared with athletes in non-lean sports. | High | |
Goldfield [17] | Controlled trials | 20 competitive female bodybuilders and 25 recreational female weight training athletes (n = 45) | 100% | 44.4% | Six-item Drive for Bulk scale was developed as a modification of the Body Dissatisfaction scale of the EDI (-) | Eating Disorder Inventory, EDI (-) | In contrast to female athletes engaged in recreational weight training, competitive bodybuilders reported significantly higher incidences of overeating, excessive focus on weight or body shape, strict dieting, and strenuous exercise to control their weight. | High | |
Pietrowsky and Straub [19] | Controlled trials | 48 male athletes and 32 non-athletes (n = 80) | 0% | 0% | Body Image Assessment, BIA (-) | Fragebogen zum Essverhalten, FEV (scores more than 7 indicate a high degree of restrained eating behavior, and less than 4 points on that scale were classified as unrestrained eaters) | Adult lightweight rowers scored highly on eating restraint compared with heavy-weight rowers, and reported higher levels of body dissatisfaction when hungry than when full. | High | |
Firoozjah, Shahrbanian [39] | Controlled trials | Iranian male adolescent athletes (n = 124) | 0% | 0% | Body-esteem scale for adolescents and adults, BESAA (higher scores indicate more positive body-esteem) | Eating attitudes test-26, EAT-26 (clinical cut-off score of ≥20 indicates eating disorders) | During COVID-19, individual athletes are more likely to suffer from eating disorders and distorted body image than team athletes. | High | |
Anderson, Zager [34] | Controlled trials | 68 male recreational and competitive bodybuilders and 50 non bodybuilders (n = 118) | 0% | 57.6% | Include in EDI-2 | Eating Disorders Inventory, EDI-2 (-) | Bodybuilders had higher body satisfaction than non-bodybuilders, but no difference was found in the risk of eating disorders. | High | |
Goltz, Stenzel [55] | Cross-section | 52 competing in weight-class sports, 52 in sports with aesthetic ideals, and 52 competing in athletics, swimming, triathlon, and horse racing (n = 156) | 0% | 33.3% | Body Shape Questionnaire, BSQ (the score range is used to determine body image) | Eating Attitudes Test, EAT-26 and Bulimic Investigatory Test Edinburgh, BITE (the score interval determines whether there is an eating disorder) | Nearly a quarter of the athletes displayed an eating disorder associated with dissatisfaction with their body image. Athletes with higher body fat were more likely to experience dissatisfaction with their body image. No significant variations in eating behavior and body image were observed among athletes in different sports categories. | High | |
Smith, Gay [21] | Cross-section | American Cheerleaders (n = 268) | 100% | 100% | Sex-Specific Figural Stimuli Silhouette, SIL (-) | Eating Attitudes Test, EAT-26 (-) | Cheerleaders are at risk for eating disorders and dissatisfied body image regardless of sporting level. | High |
3.3. Assessment of Quality
3.4. The Relationship between Eating Disorders and Body Image
3.4.1. Potential Effect of Athletes’ Body Image on Eating Disorders
3.4.2. Potential Effect of Eating Disorders on Athletes’ Body Image
3.5. Potential Influencers of the Association
3.5.1. Role of Gender
3.5.2. Role of Age
3.5.3. Role of Race
3.5.4. The Role of Sports Events
4. Discussion
4.1. The Association between Eating Disorders and Body Image
4.2. Influencers of the “Body Image—Eating Disorders” Association
4.2.1. Gender
4.2.2. Age
4.2.3. Sports Events
4.3. Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Data Availability Statement
Conflicts of Interest
Appendix A
Authors | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|
Criteria—Quantitative Studies | Smith et al. (2022) [21] | Firoozjah et al. (2022) [39] | Neves et al. (2016) [42] | Voelker et al. (2014) [53] | Francisco et al. (2013) [40] | Blackmer et al. (2011) [56] | Anderson et al. (2011) [46] | Reinking and Ale xander (2005) [51] | Johnson et al. (2004) [20] | Anderson et al. (1996) [34] |
1. Clearly stated aims | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
2. Participant eligibility and recruitment strategy clearly documented | Y | Y | Y | Y | N | P | N | Y | Y | Y |
3. Main features of population/design described | Y | Y | P | Y | Y | Y | Y | Y | Y | Y |
4. Non-responders (and non-participants) described | Y | Y | N | N | N | N | N | Y | N | N |
5. Presence of a control group | N | Y | Y | N | Y | N | N | N | N | Y |
6. Main limitations identified and acceptable | Y | Y | P | Y | Y | Y | Y | Y | Y | N |
7. Sample size justified | Y | Y | N | N | Y | N | Y | N | Y | Y |
8. No evidence of selective reporting of results | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
9. Statistical methods described | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
10. Statistical methods appropriate | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
11. Measures relevant, validated and described adequately | Y | Y | Y | Y | Y | Y | Y | Y | Y | P |
12. Results discussed adequately | Y | Y | Y | Y | Y | Y | Y | Y | Y | P |
Total Score | 22 | 24 | 18 | 18 | 20 | 17 | 18 | 22 | 20 | 18 |
Authors | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Criteria—Quantitative Studies | Petrie & Moore (2023) [48] | Borowiec et al. (2023) [35] | Baceviciene et al. (2023) [16] | Pallotto et al. (2022) [47] | Cusack et al. (2022) [45] | Satterfield and Stutts (2021) [49] | Paixao et al. (2021) [50] | Pinto et al. (2020) [44] | Kristjánsdóttir et al. (2019) [15] | Gibson et al. (2019) [54] | Goltz et al. (2013) [55] |
1. Clearly stated aims | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
2. Participant eligibility and recruitment strategy clearly documented | P | Y | Y | Y | Y | N | N | Y | Y | N | Y |
3. Main features of population/design described | Y | Y | Y | Y | Y | Y | Y | P | Y | Y | Y |
4. Non-responders (and non-participants) described | N | N | Y | N | N | N | N | N | N | N | Y |
5. Presence of a control group | N | Y | Y | N | N | N | N | N | N | N | N |
6. Main limitations identified and acceptable | N | Y | Y | Y | Y | Y | Y | N | Y | N | P |
7. Sample size justified | Y | Y | Y | Y | Y | P | N | N | Y | Y | Y |
8. No evidence of selective reporting of results | Y | Y | Y | Y | Y | Y | Y | Y | P | Y | Y |
9. Statistical methods described | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
10. Statistical methods appropriate | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
11. Measures relevant, validated and described adequately | Y | Y | Y | Y | Y | Y | Y | P | Y | P | Y |
12. Results discussed adequately | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
Total Score | 17 | 22 | 24 | 20 | 20 | 17 | 16 | 14 | 19 | 15 | 21 |
Authors | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|
Criteria—Quantitative Studies | Salbach et al. (2007) [52] | Milligan and Pritchard (2006) [57] | Kong and Harris (2015) [18] | Michou and Costarelli (2011) [41] | de Bruin et al. (2011) [38] | Rosendahl et al. (2009) [43] | Goldfield (2009) [17] | Costarelli and Stamou (2009) [36] | Pietrowsky and Straub (2008) [19] | de Bruin et al. (2007) [37] |
1. Clearly stated aims | P | Y | Y | Y | Y | Y | Y | Y | Y | Y |
2. Participant eligibility and recruitment strategy clearly documented | Y | N | Y | P | N | Y | P | Y | P | p |
3. Main features of population/design described | Y | Y | Y | Y | P | Y | Y | Y | N | Y |
4. Non-responders (and non-participants) described | N | N | Y | Y | N | N | N | N | N | N |
5. Presence of a control group | N | N | Y | Y | Y | Y | Y | Y | Y | Y |
6. Main limitations identified and acceptable | Y | Y | Y | P | Y | P | Y | P | N | N |
7. Sample size justified | Y | N | Y | N | N | N | N | N | Y | Y |
8. No evidence of selective reporting of results | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
9. Statistical methods described | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
10. Statistical methods appropriate | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
11. Measures relevant, validated and described adequately | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
12. Results discussed adequately | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
Total Score | 19 | 16 | 24 | 20 | 17 | 19 | 19 | 19 | 17 | 19 |
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Terms | Search Terms |
---|---|
Term A | “Athlete” OR “Professional Athletes” OR “Athlete, Professional” OR “Athletes, Professional” OR “Professional Athlete” OR “Elite Athletes” OR “Athlete, Elite” OR “Athletes, Elite” OR “Elite Athlete” OR “College Athletes” OR “Athlete, College” OR “Athletes, College” OR “College Athlete” |
Term B | “Body image” OR “body dissatisfaction” OR “body satisfaction” OR “body esteem” OR “body appreciation” OR “appearance” OR “body functionality” OR “body preoccupation” OR “body shame” OR “body awareness” OR “body anxiety” OR “interocept *” OR “shape concern” OR “shape dissatisfaction” OR “weight concern” OR “weight dissatisfaction” |
Term C | “eating disorder *” OR “disordered eat *” OR “diet *” OR “bing *” OR “purg *” OR “anorex *” OR “bulim *” OR “bigorex *” OR “muscle dysmorp *” OR “adonis complex *” OR “manorex *” |
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Li, Q.; Li, H.; Zhang, G.; Cao, Y.; Li, Y. Athlete Body Image and Eating Disorders: A Systematic Review of Their Association and Influencing Factors. Nutrients 2024, 16, 2686. https://doi.org/10.3390/nu16162686
Li Q, Li H, Zhang G, Cao Y, Li Y. Athlete Body Image and Eating Disorders: A Systematic Review of Their Association and Influencing Factors. Nutrients. 2024; 16(16):2686. https://doi.org/10.3390/nu16162686
Chicago/Turabian StyleLi, Qingqing, Hansen Li, Guodong Zhang, Yang Cao, and Yun Li. 2024. "Athlete Body Image and Eating Disorders: A Systematic Review of Their Association and Influencing Factors" Nutrients 16, no. 16: 2686. https://doi.org/10.3390/nu16162686
APA StyleLi, Q., Li, H., Zhang, G., Cao, Y., & Li, Y. (2024). Athlete Body Image and Eating Disorders: A Systematic Review of Their Association and Influencing Factors. Nutrients, 16(16), 2686. https://doi.org/10.3390/nu16162686