Weight loss practices and eating behaviours among female physique athletes: Acquiring the optimal body composition for competition.

Little is known about weight loss practices and eating behaviours in female physique athletes. This study investigated the weight loss history, practices, and key influences during the pre-competition period in a large cohort of female physique athletes stratified by division and experience level. Eating attitudes and behaviours were assessed to identify whether athletes were at risk of developing an eating disorder. Using a cross-sectional research design, female physique athletes (n = 158) were recruited and completed an anonymous online self-reported survey consisting of two validated questionnaires: Rapid Weight Loss Questionnaire and Eating Attitudes Test-26. Irrespective of division or experience, female physique athletes used a combination of weight loss practices during the pre-competition phase. Gradual dieting (94%), food restriction (64%) and excessive exercise (84%), followed by body water manipulation via water loading (73%) were the most commonly used methods. Overall, 37% of female physique athletes were considered at risk of developing an eating disorder. Additionally, 42% of female physique athletes used two pathogenic weight control methods with 34% of Figure novice athletes indicating binge eating once a week or more. The coach (89%) and another athlete (73%) were identified as key influences on athletes' dieting practices and weight loss. The prevalence of athletes identified with disordered eating symptoms and engaging in pathogenic weight control methods is concerning. In future, female physique athletes should seek advice from registered nutritionists to optimise weight management practices and minimise the risk of developing an eating disorder.

Introduction

Physique athletes are solely judged on aesthetic appearance rather than physical performance [1] and are therefore unique compared to many other aesthetic [2] and weight-sensitive sports [3]. Traditionally, bodybuilding was the only division available for women, however in recent years, further divisions have been introduced to facilitate females with differing physique traits and aspirations [4] including Bikini Fitness and Figure [5]. Female physique athletes (FPA) are not required to be a specific body weight, instead athletes are judged on successfully acquiring a symmetrical and well-proportioned body composition consisting of low-fat mass (FM) and high lean body mass (LBM) [6]. For example, athletes competing in the Figure division are required to have lower levels of FM and greater LBM than the Bikini Fitness division (see [5] for a review of division requirements).

Current practices to acquire optimal body composition for competition are, at present, not well-understood. Consumption of small and frequent meals, combined with rigorous training practices for approximately 11–32 weeks pre-competition have been documented [4,7-10]. However, others show problematic behaviours including extreme dieting, intentional fasting, laxative use, and self-induced vomiting [4,11]. Furthermore, in the final 7-days prior to competition, also known as ‘peak week’, there is an emphasis on carbohydrate, fluid, and salt manipulation [12-14]. At present, case reports (n = 1) [9,10,15] and studies using larger sample sizes have assessed the weight loss history and dietary practices [16,17] across multiple time-points during a competitive season, however these studies have not captured the frequency of such practices or established other lesser reported practices, which may be used to acquire optimal body composition for competition (e.g., laxatives, water loading and salt manipulation). Delineating the methods used and possible psychological and physical health implications are important, so that FPA can be provided with targeted support that enables safe and effective manipulation of body composition. Recent research in female and male combat sport athletes [18] and powerlifters [19] report coaches to be the primary influence on weight management practices. However, at present, studies investigating key influencers in FPA are limited and should now be explored. Identifying key influencers of practices will offer insights into the reliability of their sources.

Engaging in any dieting or weight loss may put athletes at risk of relative energy deficiency in sport (RED-S) and associated health consequences such as menstrual dysfunction and poor psychological health (for a review see [20]). Repeated engagement with these practices may increase the likelihood of disordered eating (DE) and eating disorders (ED) [21]. Disordered eating begins with voluntary energy restriction, leading to chronic dieting, poor body image, and frequent weight fluctuations using high-risk weight management strategies, ultimately increasing the risk of clinical ED—known as the continuum model of DE [22]. Although it is important to investigate DE and ED in FPA, limited studies have been conducted in physique sports [23] especially with regards to assessing the risk between experience levels and/or divisions [4].

Experience level could influence the likelihood of athletes engaging in aggressive weight loss practices and subsequent DE/ED development [24]. For example, athletes with greater experience may be placed under increased pressure to become leaner from self-expectations and other competitors [25], while others suggest that experienced athletes might better manage expectations [26]. Moreover, the division-specific body composition requirements for competition [5] could also influence strategies for weight management and development of DE/ED. Nevertheless, the influence of both experience level and division remains unexplored.

This study aimed to investigate the weight loss history, practices and influential sources of dieting during the pre-competition period in a large cohort of FPA. A secondary aim was to determine the extent of DE symptoms among FPA, in order to identify whether these athletes were at risk of developing an ED. It was hypothesised that those athletes competing in the Figure division and novice athletes would experience greater weight fluctuations, use acute weight loss practices more frequently and report more DE symptoms compared to Fitness athletes and experienced athletes. Based on previous data from weight-sensitive sports, it was also hypothesised that coaches would be the main influences on dieting and weight loss practices instead of qualified personnel (irrespective of division and experience).

Materials and methods

Recruitment and selection criteria

FPA were recruited from social media advertisement, forums, word-of-mouth, fitness centres and UK-based bodybuilding organisations (June 2017 to July 2018). Inclusion criteria were females aged 18–65 years and participation in a physique competition (previous 12 months). Exclusion criteria included previously diagnosed with an ED, had used, or were currently using, banned substances. By completing the survey, participants provided consent and where informed involvement was voluntary, anonymous and confidential. The study was approved by the University Ethical Review Board in the United Kingdom (17/TLA/003).

Study design

Using a cross-sectional research design, participants completed an anonymous online self-report survey (Bristol Online Survey© software 2013, Bristol, England) comprising two validated questionnaires (Rapid Weight Loss Questionnaire (RWLQ) [18] and Eating Attitudes Test (EAT-26) [27] to assess weight loss history, practices and DE symptoms, respectively.

Although these questionnaires have not been validated directly in FPA, both questionnaires have been previously utilised in weight-sensitive populations with good sensitivity, specificity and excellent internal consistency (RWLQ: Cronbach’s alpha = 0.98) (EAT-26: Cronbach’s alpha = 0.90) [18,27]. For constructive validity, the survey was reviewed by two registered practitioners (Sport and Exercise Nutrition Register and Association for Nutrition), and pilot-tested by an experienced international FPA (+5 y competitive experience). Minor syntax, additional words/terminology and formatting modifications were made to the RWLQ questionnaire to ensure appropriateness for physique sports.

Participants

A total of 191 FPA accessed the survey, of which 178 (93%) completed it. Twenty FPA were excluded (due to not meeting the inclusion criteria and missing data) resulting in 158 FPA in the final analysis and representing the following divisions: Fitness novice (Bikini Fitness and Women’s Fitness with ≤1 year of competition experience; n = 62; 39%), Fitness experienced (Bikini Fitness and Women’s fitness with >2 years of competition experience; n = 53; 34%), Figure novice (Figure and Physique with ≤1 year of competition experience; n = 19; 12%) and Figure experienced (Figure and Physique with >2 years of competition experience; n = 24; 15%). Previous studies in this population have recruited much smaller cohorts (e.g. n = 26 [11]; n = 14 [28] and hence the recruitment achieved in the current study provided the largest representation to date.

Rapid weight loss questionnaire

Weight management was assessed using questions derived from the RWLQ, which comprises 21 items and has three subscales: Participant’s characteristics (i.e., “at what age did you start competing? and “how many times did you compete in your last season?”), weight and diet history (i.e., “what is the most weight you have lost?” and “what is the most weight you have re-gained in the 7-days after competition?”) and weight loss behaviours (i.e., “I use gradual dieting”, “I use excessive exercise”, “I skip 1 or 2 meals a day” and “I use water loading”). FPA indicated agreement using a 5-point Likert Scale: “Never used” (0) and “Always” (3) (with a total score possible of 54 points) on weight loss behaviours questions. The RWLQ scoring system indicates the higher the score obtained, the more aggressive the weight loss behaviours. This questionnaire was selected because FPAs are known to use weight as a reference for progression and use of acute weight loss practices [11]. The degree of key influential sources of dieting derived from the RWLQ was also assessed ranging from “non-influential” to “very influential”.

Eating Attitude Test-26

Eating attitudes and behaviours were assessed using EAT-26 [27] consisting of three subscales: Dieting (13 items), eating preoccupation (6 items) and oral control (7 items). This 26-item questionnaire asks about pathological eating behaviours and concerns about weight and is a widely used screening instrument for ED risk [29]. Participants rated their agreement with statements such as “I find myself preoccupied with food” and “I am terrified of being overweight”. Responses were prepared on a 6-point Likert scale anchored by “never” (1), “rarely” (2), “sometimes” (3), “often” (4), “usually” (5) and “always” (6). Additionally, the frequency of pathogenic weight control methods (PWCM) including binge eating, self-induced vomiting and laxatives, diet pills and diuretics (water pills) use was assessed. A total EAT-26 score >20 cut off point is indicative of being at risk for ED.

Statistical analysis

Statistical Package for the Social Sciences v.23 (SPSS Inc, Chicago, IL) was used for analysis. Continuous data (participant characteristics, weight loss and diet history) was expressed as mean and standard deviations (mean±SD) with ranges, unless otherwise stated, whilst categorical data (frequency and the degree of influence of weight loss practices) were expressed as absolute numbers (n) and percentages (%). Continuous data was checked for the assumption of normality and equality of variances using Kolmogorov-Smirnov and Levene’s test, respectively [30]. When normality was met, a two-way between subject’s ANOVA compared the variability of mean values across; experience level [26] and division (Fitness and Figure). Bonferroni post-hoc test was used for pairwise comparisons. Where the assumption of normal distribution was violated, the Mann Whitney test was used.

To assess relationships between the total EAT-26 score and the subscales scores of the EAT-26 and potential risk factors associated with weight history (i.e., weight regain), Spearman’s rank correlations (rs) were used. In total, the study recruited from four groups: Bikini Fitness (n = 107), Figure (n = 42), Women’s Fitness (n = 6) and Physique athletes (n = 3). Due to insufficient respondents from Women’s Fitness and Physique athletes, divisions were grouped collectively into “Fitness” (Bikini Fitness and Women’s Fitness) and “Figure” (Figure and Physique), owing to the similarities in preparation and proximity in body composition requirements. The significance level was set at P<0.05 for all statistical analyses.

Results

Participant characteristics

Participant characteristics are presented in Table 1. In total, 99% of respondents reported losing weight for past competitions and participating in 2±1 competitions (range: 1–8) in the previous season. Irrespective of division, novice athletes were younger (27±7 vs. 30±7 years, F1,154 = 6.73, P = 0.01), shorter (163.4±6.4 vs. 165.4±6.2 cm, F1,154 = 7.74, P<0.01) and lighter than experienced athletes (53.8±4.9 vs. 56.1±5.8 kg, F1,154 = 7.59, P<0.01). No main effect of division was identified (P >0.05).

Table 1

Participant characteristics and weight loss experience for competition across divisions and experience.

Athletes (n = 158)	Age (years)*	Height (cm)*	Most recent competition weight (kg)*	Times competed last season (n)	Age at first competition (years)	Typical diet length (weeks)	Competition level % (n)
Fitness Novice (n = 62)	27 ± 6 (18–45)	164.4 ± 6.5 (153–178.0)	53.7 ± 5.1 (45–65)	2 ± 1 (1–6)	26 ± 7 (17–45)	15 ± 4 (4–25)	R: 69.4 (43)N:21.0 (13)I:8.1 (5)PRO: 1.6 (1)
Fitness Exp (n = 53)	30 ± 7a (20–45)	165.4 ± 6.2a (152–175.3)	55.3 ± 5.4a (44–68)	2 ± 1 (1–6)	27 ± 7 (18–43)	14 ± 6 (2–25)	R: 60.4 (32)N:18.9 (10)I: 11.3 (6)PRO: 9.4 (5)
Figure Novice (n = 19)	29 ± 7 (20–45)	160.1 ± 5.2 (149.8–170.0)	54.1 ± 4.2 (44.4–62.0)	3 ± 2 (1–8)	28 ± 7 (19–45)	15 ± 5 (7–32)	R: 63.2 (12)N:31.6 (6)I:5.3 (1)PRO: 0 (0)
Figure Exp (n = 24)	32 ± 6c (23–44)	165.4 ± 6.5c (155–178.0)	57.8 ± 6.5c (48.5–70.0)	3 ± 1 (1–6)	28 ± 6 (21–42)	14 ± 3 (10–20)	R: 45.8 (11)N:29.2 (7)I: 20.8 (5)PRO: 4.2 (1)
Combined	29 ± 7 (18–45)	164.4 ± 6.4 (149.8–178.0)	54.9 ± 5.5 (44–70)	2 ± 1 (1–8)	27 ± 7 (17–45)	15 ± 5 (2–32)	R: 62 (98)N: 22.8 (36)I: 10.8 (17)PRO 4.4 (7)

R = regional, N = national, I = International, PRO = professional.

*significant main effect between experience levels.

^ = Typical diet length prior to competition.

R = Regional level, N = National, I = International and PRO = Professional level athlete. Exp = Experienced physique athletes.

a denotes significant difference from Fitness Novice, P< 0.05.

b denotes significant difference from Fitness Exp, P< 0.05.

c denotes significant difference from Figure Novice, P< 0.05.

d denotes significant difference from Figure Exp, P< 0.05.

Values are presented as mean ± SD and include the range in brackets.

Weight loss history

Weight and diet history across divisions and experience levels, is presented in Table 2. Division had a main effect on absolute weight regain in the 7-days after competition (2.7±1.5 vs. 2.4±1.7 kg, F1,151 = 4.65, P = 0.03) and relative weight regain (F1,149 = 8.07, P<0.01) with Figure athletes reporting the greatest relative weight regain (5.5%) in the 7-days after competition. No interactions were detected for absolute or relative weight regain in the 7-days after competition. Division and experience level had no effect on usual absolute and relative weight loss (P>0.05). There was a division by experience interaction for most weight loss (F1,152 = 4.38, P = 0.03) with increases in absolute values from Figure novice athletes (8.4±2.4kg) to Figure experienced athletes (10.1±3.6 kg). The opposite was observed, however, between Fitness novice (10.0±4.3 kg) to Fitness experienced (8.8±4.7 kg). There was no main effect for division or experience level in competition week weight loss (P>0.05) but a significant interaction (F1,136 = 4.46, P = 0.04) was identified. Rapid weight loss score showed no difference between division (F1,153 = 1.10, P = 0.30) nor between experience levels (F1,153 = 1.10, P = 0.30) and no interaction (F1,153 = 0.02, P = 0.90). Relative weight regain was weakly correlated with the total EAT-26 score (r = 0.21, P = 0.01), subscales; dieting score (r = 0.20, P = 0.01), and bulimia score (r = 0.20, P = 0.01).

Table 2

Female physique athlete (n = 158) responses to weight loss and eating behaviour questions stratified by division and experience level.

	Fitness Novice (n = 62)	Fitness Exp (n = 53)	Figure Novice (n = 19)	Figure Exp (n = 24)	Overall (n = 158)
* Weight usually regained in the week 7-days after competition (kg)?	2.4 ± 1.7 (0.2–8.5)	2.3 ± 1.7 (0–8.0)	3.3 ± 1.6a (1.0–6)	2.3 ± 1.3 b (0–5.7)	2.5 ± 1.7 (0–8.5)
* Relative weight usually regained 7-days after competition (%)?	4.1 ± 3.0 (0–15.9)	4.0 ± 2.7 (0.7–14.0)	5.6 ± 2.8a (2.0–11.4)	5.4 ± 3.2b (0.7–14.7)	4.5 ± 3.0 (0–15.9)
# * Most weight lost (kg)?	10.0 ± 4.3 (0–20)	8.8 ± 4.7a (1.5–21.0)	8.4 ± 2.4a (5–15)	10.1 ± 3.6bc (4–20)	9.4 ± 4.2 (0–21)
Most relative weight lost (%)?	13.7 ± 6.2 (0–35.1)	15.0 ± 6.1 (6.0–34.4)	14.9 ± 4.4 (7.0–22.2)	16.0 ± 6.3 (2.8–28.2)	14.6 ± 6.0 (0–35.1)
Usual weight loss (kg)?	8.4 ± 3.9 (0–17.5)	7.6 ± 3.8 (1.5–21.0)	8.0 ± 1.9 (5.5–12.7)	8.2 ± 3.7 (0–15)	8.0 ± 3.6 (0–21)
Usual relative weight loss (%)?	13.0 ± 5.7 (0–25.9)	11.7 ± 4.8 (2.8–25.3)	13.0 ± 2.9 (9.7–21.9)	12.7 ± 5.3 (0–21.1)	12.5 ± 5.1 (0–25.9)
# How much weight do you usually lose in competition week (kg)?	1.52 ± 1.02 (0–5)	1.46 ± 0.84a (0–4)	1.70 ± 1.34a (0–5)	1.25 ± 0.68bc (0–3)	1.48 ± 0.96 (0–5)
What was your last off-season weight (kg)?	63.7 ± 6.6 (50.0–82.0)	63.0 ± 8.3 (49.4–83.0)	60.9 ± 5.8 (52.2–70)	64.1 ± 6.2 (52–79.0)	63.2 ± 7.1 (49.4–83.0)
RWLS score	22.3 ± 7.1 (7.3–48.2)	21.3 ± 7.3 (10–43.2)	23.4 ± 7.8 (13–45.7)	23.2 ± 8.7 (11.5–42)	22.2 ± 7.5 (7.30–48.20)
EAT-26 score	19.0 ± 12.6 (2.0–54.0)	17.3 ± 15.2 (0–55)	22.0 ± 12.7 (2–54)	18.2 ± 13.1 (1–54)	18.6 ± 13.5 (0–55)
EAT-26 score (≥ 20 cut off) (%)	38.8	36.1	42.2	21.0	36.8
EAT-26 score (< 20 cut off) (%)	60.5	63.2	58.0	79.4	63.5
Dieting score	11.2 ± 7.9 (0–33)	11.0 ± 10.2 (0–33.0)	12.8 ± 8.8 (1–33)	13.0 ± 13.6 (0–33)	11.2 ± 8.9 (0–33)
Bulimia and food preoccupation score	4.1 ± 3.8 (0–15)	3.2± 3.5 (0–14)	5.4 ± 3.6a (1–12)	4.6 ± 4.9b (0–13)	4.1 ± 3.7 (0–15)
Oral control score	3.4 ± 2.8 (0–11)	2.8 ± 2.8 (0–10)	3.4 ± 3.1 (0–10)	4.6 ± 4.2 (0–8)	3.1 ± 2.8 (0–11)
No use of PWCM (%)	0	0	15	32	7.0
Use of 1 PWCM (%)	41	28.5	45	20	37.3
Use of 2 PWCM (%)	45.9	53.8	25	24	42.4
Use of 3 PWCM (%)	13.1	7.7	15	24	13.3

*significant main effect between divisions,

#division by experience interaction.

a denotes significant difference from Fitness Novice, P< 0.05.

b denotes significant difference from Fitness Exp, P< 0.05.

c denotes significant difference from Figure Novice, P< 0.05.

d denotes significant difference from Figure Exp, P< 0.05.

Exp = Experienced physique athletes. RWLS = Rapid Weight Loss Score, EAT = Eating Attitude Test, PWCM = Pathogenic Weight Control Methods. Most weight loss is the most weight ever cut before a physique competition. Usual weight loss is the weight usually cut before a physique competition. Most relative weight loss is the percentage (of the individual’s off-season weight) that was mostly cut for a physique competition. Usual relative weight loss is the percentage (of the individual’s off-season weight) that is usually cut for a physique competition.

Values are presented as mean ± SD and include the range in brackets.

Weight loss methods and sources of influence

Frequency analysis of weight loss practices prior to competition is illustrated in Figs 1 and 2 (n = 157). There was no differences between division or experience on any of the weight loss practices; that is, all groups equally practiced similar methods to acquire optimal body compositions (P = 0.65). For the combined group 94.0% ‘always’ or ‘sometimes’ engaged in gradual dieting (Fig 1A), whilst 84.0% ‘always’ and ‘sometimes’ increased exercise levels (Fig 1C) and 64.0% purposely ‘always and ‘sometimes’ restricted foods (Fig 1D). In particular, carbohydrate restrictions were ‘always’ and ‘sometimes’ practiced by 70.0% of all athletes (Fig 1B). Water loading in the final pre-competitive period was reported by > 70.0% of the Fitness groups and Figure novice athletes, compared to 58.4% of Figure experienced athletes. Furthermore, 44.0% of all athletes ‘regularly’ used salt manipulation, with 60.0% of Figure novice athletes ‘always’ or ‘sometimes’ using this method prior to competition (Fig 1E). For the combined group skipped meals (86.0%), fasting (91.7%) and laxatives (90.5%) were ‘almost never’ or ‘never used’, however Figure novice ‘always’ or ‘sometimes’ used skipped meals (26.4%) and fasting (36.9%) (Fig 2). Overall, use of sauna (4.3%) (Fig 2H), sweatsuits (3.1%) (Fig 2A), and hot baths (4.4%) (Fig 2G) were ‘always ‘or ‘sometimes ‘used.

Fig 1

Frequency analysis of weight loss methods.

A = Gradual dieting B = Carbohydrate restrictions; C = Increasing exercise; D = Food restrictions; E = Salt manipulations, F = Water loading; G = Diuretics and H = Diet pills. Fit Nov = Fitness novice athletes, Fit Exp = Fitness experienced athletes, Fig Nov = Figure novice athletes, Fig Exp = Figure experienced athletes and Comb = Combined female physique athletes.

Fig 2

Frequency analysis of weight loss methods.

A = Sweatsuits; B = Skipping meals; C = Fasting; D = Self-induced vomiting; E = Nicotine; F = Laxatives; G = Hot baths; and H = Sauna. Carbohydrate and fat blockers and Enema were not illustrated here due being used less than 9% by combined groups. Fit Nov = Fitness novice athletes, Fit Exp = Fitness experienced athletes, Fig Nov = Figure novice athletes, Fig Exp = Figure experienced athletes and Comb = Combined female physique athletes.

The three most influential individuals on dieting and weight loss across all groups were the coach, another physique athlete and partners (Table 3). While the coach had the greatest influence across combined groups with 88.6% of all athletes reporting “quite” and “very influential”, a high prevalence reported that parents (59.5%), professional practitioners (82.2%) and nutritionists (52.2%) provide ‘no’ or ‘little’ influence on practices.

Table 3

Frequency analysis of the persons who are influential on the dieting practices and weight loss of female physique athletes (n = 158) stratified by division and experience level.

Persons	Not influential %					A little influential %					Unsure %					Quite influential %					Very influential %
	Fit Nov	Fit Exp	Fig Nov	Fig Exp	C	Fit Nov	Fit Exp	Fig Nov	Fig Exp	C	Fit Nov	Fit Exp	Fig Nov	Fig Exp	C	Fit Nov	Fit Exp	Fig Nov	Fig Exp	C	Fit Nov	Fit Exp	Fig Nov	Fig Exp	C
Coach	8.1	15.1	0	4.2	8.9	0	3.8	0	0	1.3	0	1.9	5.3	0	1.3	21.0	20.8	15.8	16.7	19.6	71.0	58.5	78.9	79.2	69.0
Doctor	77.4	82.7	94.7	83.3	82.2	11.3	9.6	0	8.3	8.9	6.5	5.8	5.3	8.3	6.4	1.6	0	0	0	0.6	1.9	2.6	0	0	1.9
Internet	30.6	30.2	42.1	25.0	31.0	12.9	30.2	10.5	20.8	19.6	8.1	3.8	5.3	12.5	7.0	29	24.5	21.1	37.5	27.8	19.4	11.3	21.1	4.2	14.6
Another athlete	12.9	11.3	10.5	4.2	10.8	12.9	13.2	10.5	12.5	12.7	1.6	1.9	15.8	0	3.2	45.2	45.3	36.8	45.8	44.3	27.4	28.3	26.3	37.5	29.1
Friends	38.7	39.6	68.4	33.3	41.8	29.0	26.4	15.8	29.2	26.6	4.8	5.7	0	4.2	4.4	17.7	22.6	0	20.8	17.7	9.7	5.7	15.8	12.5	9.5
Partner	25.8	22.6	47.4	16.7	25.9	12.9	24.5	0	16.7	15.8	6.5	9.4	0	4.2	6.3	21.0	30.2	15.8	25.0	24.1	33.9	13.2	36.8	37.5	27.8
Parents	64.5	56.6	68.4	45.8	59.5	12.9	18.9	15.8	25.0	17.1	1.6	3.8	0	4.2	2.5	16.1	15.1	10.5	16.7	15.2	4.8	5.7	5.3	8.3	5.7
Training partner	37.1	45.3	52.6	33.3	41.1	16.1	20.8	10.5	25.0	18.4	8.1	7.5	0	0	5.7	25.8	18.9	26.3	20.8	22.8	12.9	7.5	0	20.8	12.0
Nutritionist/dietitian	45.9	45.3	84.2	58.3	52.2	13.1	5.7	0	8.3	8.3	9.8	11.3	0	0	7.6	13.1	18.9	0	16.7	14.0	18.0	18.9	15.8	16.7	17.8

Fit Nov = Fitness novice athletes, Fit Exp = Fitness experienced athletes, Fig Nov = Figure novice athletes, Fig Exp = Figure experienced athletes and C = Combined female physique athletes.

Disordered eating symptoms

Nearly 40.0% (n = 56) of participants indicated a score ≥ 20 cut-off value and were therefore classified as having DE symptoms and at risk of developing an ED. There was no difference in the total EAT-26 score between novice and experienced athletes (19.2±12.1 vs. 17.1±13.9; P>0.05). Similarly, there was no difference in the total EAT-26 score between Fitness and Figure athletes (18.8±13.9 vs. 16.5±10.2; P>0.05). Oral control and dieting sub-scale scores from the EAT-26 test showed no differences between division or experience (P>0.05). There was a main effect, however, between divisions on bulimia and food preoccupation score where Figure athletes scored greater than Fitness athletes, irrespective of the experience (3.8±3.7 vs. 4.7±3.7; P = 0.01).

Pathogenic weight control methods

The magnitude of PWCM, as a measure to control weight (Fig 3), were assessed using the behavioural section of the EAT-26 [27]. For the combined group, 42.4% used two out of three PWCM (laxatives, diet pills and diuretics, and binge eating), while 13.3% used all methods to manage their weight. Laxatives, diet pills and diuretics were the most popular methods to manage weight amongst all FPA (Fig 2C) with a large percentage of Fitness novice (77.1%), Fitness experienced (76.9%), Figure novice (77.0%) and Figure experienced (80.0%) athletes reporting their use once a month or more. Likewise, binge eating occurred once a month or more for 63.3% of all FPA. Of those, 14.8% of Fitness novice, 3.8% Fitness experienced, 35.0% of Figure novice and 0.0% Figure experienced athletes indicated binge eating once a week or more (Fig 3A). Self-induced vomiting (Fig 3B) occurred once a month or more in 21.3%, 26.9%, 15.0% and 20.0% of Fitness novice, Fitness experienced, Figure novice and Figure experienced athletes, respectively.

Fig 3

Frequency analysis of pathogenic weight control methods used by physique athletes from the Eating Attitude Test-26 questionnaire.

A = Binge Eating; B = Self-induced vomiting; C = Laxatives, diet pills and diuretics (water pills) use. Fit Nov = Fitness novice athletes, Fit Exp = Fitness experienced athletes, Fig Nov = Figure novice athletes, Fig Exp = Figure experienced athletes and Comb = Combined female physique athletes.

Discussion

This study provides data that assesses the weight loss history and frequency of practices in FPA alongside influential sources of dieting and DE symptoms. The results show that irrespective of division or experience level, FPA use gradual dieting, restricting foods, excessive exercise and acute body water manipulation weight loss practices in pre-competition which provides additional knowledge on dieting procedures among this group. Coaches and other athletes were identified as the key influencers of dieting and weight loss practices. Furthermore, 37% of FPA were considered at risk of developing an ED. Lastly, almost half of the athletes used two PWCMs with over a third of Figure novice athletes reporting binge eating once a week or more.

In the present study, almost all (99%) FPA (n = 157) reported losing weight pre-competition, which was similar to previous studies assessing weight loss history [9,10,16,17]; although, the magnitude of weight loss varied. In particular, Fitness novice athletes (10 ± 4.3 kg) lost more weight (in absolute values) than Fitness experienced athletes (8.8 ± 4.7 kg), with the opposite observed for Figure athletes (experienced = 10.1 ± 3.6 kg; novice = 8.4 ± 2.4 kg). Anecdotally, in their first year of competing, Fitness novice athletes present with more FM than Fitness experienced athletes and therefore lose more weight prior to competition. However, this remains speculative and warrants future research. Furthermore, Figure experienced athletes may place greater emphasis on increasing LBM during the off-season (and therefore also may experience concomitant increases in their levels of FM) compared to a Figure novice athlete [15] which subsequently requires greater weight loss as they enter the pre-competition phase. A number of athletes reported regaining significant body weight, with Figure athletes reporting the greatest relative weight regain (5.5%) in the 7-days after competition compared to Fitness athletes (4.1%). Interestingly though, the greatest weight individual regain was reported by a Fitness novice athlete, who increased body mass by 15.9% (8.5 kg) in the first 7-days post-competition indicating that individual variability within groups was apparent. A reasonable explanation for the greater relative weight regain in Figure athletes may be due to the higher frequency of binge eating self-reported by Figure athletes (47%) compared to the Fitness athletes (18.6%) and the greater score of bulimia and food preoccupation in Figure athletes compared to Fitness athletes observed in the present study [31]. Our findings confirm previous observations in FPA [32,33], which show similar rapid changes in body mass post-competition. Rapid changes to post-competition body mass could be explained by rebound hyperphagia, which often occurs in response to chronic and intensive periods of energy restriction [34,35] and may increase the risk for obesity and cardiometabolic diseases in later life [36].

In preparation for competition, FPA implement gradual dieting, food restrictions, excessive exercise and water loading. In attempting to lose weight, restrictive eating and excessive exercise is implemented and could potentially affect metabolic [32] and endocrine health such as menstrual dysfunction [9] thus increasing the risk of RED-S [17]. Our findings also confirm and extend recent work from Chappell and Simper (2018) [12] showing that a high proportion of FPA will ‘always’ or ‘sometimes’ use carbohydrate, salt, and fluid manipulation in the final 7-days pre-competition. However, it is worth noting that Chappell and Simper (2018) [12] did not separate athletes into respective divisions, which could be important because of the different body composition requirements [5]. Water loading (i.e., consuming approximately ~10 litres of water per day for 3–5 days), followed by reduced water intake each day leading into the competition with complete fluid restriction over the 10–24 hours before the performance on the stage [37], was used by >70% of the FPA in this study. Despite the high prevalence, water loading in isolation has been suggested to be a safe and effective method to increase urine production for a maximal fluid driven weight loss in combat sports [38]. However, this practice when combined with diuretics and electrolyte manipulation presents additional dangers including hyponatremia, which has resulted in a number of fatalities [39,40] and is not a recommended method to regulate weight [41]. A unique finding of our study was the higher prevalence of diet pills and diuretics (32 and 27%, respectively) to lose body water compared to previous work, which did not report these methods [11]. A possible explanation for the disparity between studies could be due to our larger sample size (n = 26 versus n = 158, respectively) and the addition of new divisions in recent years which require specific body composition requirements [5].

FPA reported coaches and other physique athletes to be the greatest influences on their dieting and weight loss efforts, whilst medical doctors and nutritionists were not seen as influential (Table 3). This agrees with other studies on weight-sensitive sports [4,7,18]. For example, Chappell et al., (2018) [7] reported that 14 out of 16 FPA used a coach for guidance with training, dietary practices and feedback on their physique. A possible explanation for why coaches appear to be highly influential is that many former athletes become coaches toward the end of their careers [37]. This might result in systemic cultural attitudes toward aggressive weight loss practices being preserved within physique sports, although, at present, this is anecdotal and warrants further investigation. If this is the case, collectively these data highlight the need for coaches to be adequately educated regarding safe and effective methods of weight management in an attempt to improve the health and well-being of athletes. Bodybuilding and fitness organisations should consider providing continuing professional development courses from suitable professionals for members and encourage the support of multidisciplinary teams (i.e., registered sports psychologists and sports nutritionists/dietitians). In addition, online resources (41%) were ‘quite’ and ‘very’ influential methods of information for athletes. Seeking information from internet resources has previously been shown to be a significant predictor of ED [42,43] and therefore highlights the importance of educating athletes correctly, as unregulated online advice could be detrimental to training, performance and health.

Our data show that 37% of the combined group scored greater than the cut-off value for the EAT-26 questionnaire. The proportion of FPA considered at risk of ED in this study strongly agrees with Whitehead et al., (2020) (using a comparable EDI questionnaire) which showed that 50% of Australian FPA were identified with DE [4] and Money-Taylor et al., (2021) [44] (using a similar screening tool to that of the present study) which showed that 57% of international FPA were identified with DE symptoms. Furthermore, the overall total EAT-26 score of 19 with Figure novice athletes scoring higher than the other groups (22 vs. 17–19). This finding suggests Figure novice athletes are at greater risk for ED than Figure experienced, and Fitness groups. Due to the specific demands of the Figure division (i.e., lower FM and higher FFM than the Fitness division), novice athletes beginning Figure competitions may be exposed to body composition requirements that are more challenging to achieve [45]. It is also possible that women may be susceptible or already exhibit DE symptoms, as they enter physique sports, in hope of alleviating these symptoms. As such, it is speculative whether long-term engagement in the sport provides a protective effect from ED risks in FPA [46]. Although, EAT-26 questionnaire has been validated in other athletic groups, further work to validate it in this specific population is necessary.

For PWCM, over 40% percent of all athletes engaged with laxatives, diet pills and diuretics, and binge eating to manage weight, whilst 13% of athletes reported engaging with all PWCM. These percentages are similar to those reported previously on FPA [4,47]. FPA commonly experience pressures to remain extremely lean [25], which can lead to cycling between restrictive eating behaviours and excessive exercise, to repeated binge eating episodes [23]. This is of particular interest considering FPA repeat weight cycling episodes and therefore may experience higher rates of obesity and cardiometabolic disease later in life [36]. A recent observation suggests that athletes who have an underlying predisposition to developing an ED are more attracted to participate in physique sports [37]. For example, key psychopathological traits underpinning the development of DE are often seen in physique sports [24,26]. Our data showed high levels of food restraint amongst all participants (approximately 40% reported ‘always’ food restricting), which is in agreement with a recent report [23] who revealed higher eating restraint in FPA compared to healthy controls before, during and post dieting. Moreover, Mathisen and Sundgot-Borgen (2019) [23] reported that 2 (6%) and 9 (28%) out of 33 Scandinavian FPA (at the time of the study) had currently or have previously been diagnosed with an ED diagnosed by health personnel. These findings have serious implications for FPA and those managing these athletes such as coaches with respect to detecting DE early. Thus, education programmes should encourage organisations, coaches and physique athletes themselves to seek support from multidisciplinary professionals on the identification, prevention and management of DE/ED, and this should apply to all female athletes adhering to the extreme modern body ideal emphasising a lean and muscular aesthetic look.

Although the overall sample size in our study (n = 158) was substantially larger than previous cross-sectional studies in this population (n = 26 [11]; n = 14 [28], the small number of participants competing in Women’s Fitness and Physique divisions meant that it was not possible to analyse the differences between every division. However, it must be acknowledged that athletes competing in Women’s Fitness, Wellness and Physique divisions are more likely to engage with prohibited substances given the expectations to achieve less FM and greater LBM [48-50]. Moreover, RWLQ used in this study was primarily developed for combat sports athletes, and thus may lack specificity for aesthetic sports. Therefore, this screening tool needs to be validated in physique sports and to complement non-validated questions for the exploration of novel practices (i.e., low-fibre diets). Additionally, athletes gave self-reported responses and therefore may have over or under-reported weight loss and DE behaviours [51]. Although EAT-26 has been validated in athletic groups and widely used in physique and bodybuilding populations [24,52], on its own it does not yield a specific diagnosis of an ED. For a diagnosis to occur, a follow up clinical interview should be performed with those who score ≥20, however, this was beyond the scope of this study. Finally, although the EAT-26 questionnaire contains components which could be interpretated as pathological eating behaviours (i.e., ‘I engage in dieting behaviour’ and ‘Aware of the calorie content of foods that I eat’), these could well be normal behaviours which are required to compete in physique sports, rather than being indicative of DE per se. As such, distinguishing between true pathological and non-pathological behaviours eating behaviours should be carefully considered when interpretating the DE symptoms results.

In an attempt to further understand the weight management of FPA and potential risks of acute and chronic health outcomes, future work should i) validate EAT-26 questionnaire in physique athletes, ii) assess dietary intake using weighed food inventory and food diaries, alongside training practices (modality, training volume and loads) during the pre-competition phase and iii) collect blood samples and other measurements for analysis of markers relating to metabolic, renal and endocrine health (especially on changes in competition week). Using qualitative techniques to characterise the physical and psychological health implications when participating in physique sports (i.e., lived experiences) could also further understanding.

Conclusion

Irrespective of division or experience, FPA used various weight loss practices including gradual dieting and acute body water manipulation in the pre-competition phase. Figure novice athletes reported most weight loss pre-competition, alongside significant increases in weight gain post-competition, indicating patterns of weight cycling. Coaches and other athletes had most influence on athletes’ practices. Finally, 37% of FPA were at risk of developing ED with 42% using two PWCM throughout the season. Therefore, we encourage FPA and coaches to utilise appropriate expertise (e.g., registered nutritionists and psychologists) when preparing for competition. This might reduce the risks associated with severe weight loss practices evident in this population.

18 Jun 2021

PONE-D-21-15998

Weight loss practices and eating behaviours among female physique athletes: Acquiring the optimal body composition for competition

PLOS ONE

Dear Dr. Alwan,

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Reviewer #1: The work is interesting, considering the popularity of this sport, and it short existence – hence limited publications on health effects. Still – there are a few detailed publications already, which seems not too familiar to the current authors considering the poor refers to this previous work. Hence, my main feedback relates to the vague knowledge of previous findings, or at least incomplete use of references. Also, considering the increased number of publications studying physique athletes, references to bodybuilders should be de-emphasized. E.g.; Line 55-56: here many more publications should be referred to; Mathisen et al 2019; Helms et al 2019; Hulmi et al 2017; Trexler et al 2017; Petrizzo et al 2017; Halliday et al 2016. Acknowledging these authors work, and the current knowledge, these should be referred to more often throughout the manuscript, and also brought up for comparison in the discussion (rather than claiming no one else has studies the phenomena at quest). As many of these already is in the reference list, it seems the authors have not read the work done – this applies specifically to the request for future studies in line 131-137!

The strength of the current study is the additional knowledge it provides on dieting procedures, which should be the main focus; adding to the details we now know about health effects from participation in this sport.

Abstract: the authors conclude that all used evidence-based methods for dieting, however this is not presented or discussed in the manuscript -neither do I find any reason to claim this, considering the results presented.

Introduction

Line 60; weight loss history has been presented previously; e.g. Mathisen et al 2019.

Line 62; both mental and physical health implications are important.

Line 69-70; while the quote is not wrong, it is more accurate to say that all situations leading to low energy availability will possibly result in RED-s – as such, any dieting attempt will be a high-risk scenario.

Line 73; I assume the authors means DE (disordered eating) in the beginning of the sentence.

Line 76, and 89-91; most of the previous mentioned work has evaluated DE and ED, and even selfreported EDs diagnosed by health personnel (Mathisen et al 2019).

Line 100-1001; exclusion criteria is an ED, but the study aim to study the frequency of risk for EDs? As previous studies have found rather high prevalence of EDs in this athlete group, there will be a rather biased sample if exclusion criterion is a diagnosis of ED.

Do the authors have any hypothesis? Specifically explaining the rationale to compare athletes according to disciplines and to experience!

Methods

line 122: definition for the different experience-categories needs to be clarified.

RWLQ needs a proper presentation; e.g. how many items, tha Chronbachs-alpha in the current sample. The latter also relates to the presentation of the EAT-26.

EAT-26 also should be presented with Chronbachs-alpha for the current sample.

Line 165: Do the author mean they will study relations between a total score and a subscale-score of the EAT-26?

It would be interesting (and relevant) to see the different physique categories represented in the sample; only two are mentioned, being those with few participants, hence grouped to two other overall categories)

General remark regarding tables; please indicate which results are significant different to each other, not the variables name.

Table 1: tha variable “typical diet length” misses unit of measurement

Line 186-187: Althoug presented in table 2, the period of time which the regain refers to, should be mentioned in the text

Table 2: There is a need for more thourugh explanation of the variables; what are usual weight lost and what is most weight lost (or for what time frame?); what is relative weight lost?

Line 216-219: please consider rephrasing, as the content is not easy to understand. More than 80% never used the methods, still the majority of novice figure athletes did?

Any information on the competence of the coaches? (as these are found most influential on dieting practces?!)

Discussion:

(this is not the first report on DE or ED!)

Line 21: “as a result” does not fit into context here.

Figure athletes had the largest relative weight regain – discuss implications, and please add time-perspectives when presenting weight regain results.

Line 35-38: while the claims raised regarding the risk of RED-s is correct, the authors needs to acknowledge that the main reason for risk of RED-s in their athletes is attempts to lose weight, and the fact that they did lose weight (i.e. low energy availability)

Line 50-52 (and lines leading up to this): considering the harm by using weight-reduction methods relying on electrolyte balances, the authors should emphasise the potential health threat, rather than encourage more studies to fine a “safe method”. This sort of method is not recommended as a weight regulation practice (e.g. see publications by the IOC expert group on REDs).

Line 60; please refer the authors of the publication directly in the text

Line 85-89; the literature repeatedly reveal that females are more prone to ED than males, hence, a comparison to male bodybuilders seems not relevant. There are more reports on ED or atheltes at ED-risk in previously mentioned and recommended references! To follow up on this; the line 90-94 therefor needs to be re-evaluated - e.g. Mathisen et al 2019 reported numbers with previous or current ED diagnosed by health personnel) Line 105-109; here too, Mathisen et al 2019 revealed higher eating restrains compared to control group before, throughout and after dieting period.’

Line 131-137: most of the requested information for future studies, are already presented in previous publications; e.g. weighed food records, blood samples, techniques to characterize physical changes and body composition; please see previous listed references

One finding deserves more focus; Novice fitness athletes lost more weight than experienced ones; opposite within figure athletes. Discuss possible reasons to this observation.

The conclusion would do better with a shorter summary and implications.

Reviewer #2: Thank you to the authors for submitting their paper titled Weight loss practices and eating behaviours among female physique athletes: Acquiring the optimal body composition for competition. Herein they describe their cross-sectional study examining weight loss behaviours and disordered eating symptoms in a large sample of competitive female physique athletes, as well as sources used to obtain weight loss practices. Results showed a high percentage of participants demonstrated increased disordered eating behaviours via the EAT-26 and a variety of weight loss behaviours through the RWLQ. Overall the paper is well structured, clear, and mostly concise, presenting a well developed background and justification for the study, clear methods and results.

Apart from some minor suggestions presented below, my major comment is in regards to the interpretation and discussion of findings. The nature of physique competition preparation requires athletes to undertake many behaviours and practices which are interpreted as pathological in eating disorder questionnaires (in this case the EAT-26) when in fact they are just inherent components of competition preparation. Examples include knowing the calorie content of food I eat (item 6), particularly avoid high carbohydrate foods (item 7), think about burning up calories when I exercise (item 11), display self-control around food (item 19), and engage in dieting behaviour (item 23). Distinguishing these inherent components from true pathological qualities is a challenge in this line of research. As such, I feel a more nuanced, balanced approach to the discussion is required.

In addition to this, the inclusion criteria indicate participants resistance trained at least 5 times per week, which is a very high training frequency. I am concerned that such a criteria would exclude a large number of FPA which would introduce a selection bias. There may also be an argument that this high frequency criteria may lead to a biased recruitment of athletes who over-exercise and are at risk of disordered eating/exercise behaviours.

Specific comments are as follows:

Abstract

Line 37 - The use of evidence-based practices by participants was not highlighted in the manuscript, so I feel it would not be appropriate to include here in the abstract.

Introduction

Lines 45-52 - It may be beneficial to the reader if you were able to provide more context to the different division of competition. What distinguishes the different divisions (Body composition/leanness? Muscularity? Other?). Given your examination aims to compare based on division, this information would be useful for readers.

Line 111 - It is common to report the Cronbach's alpha of the included questionnaires. As the RWLQ was adapted for the population under investigation, I would suggest this measure of internal consistency be reported.

Line 129 - please include the number of items in the RWLQ. It would also be helpful if an idea of the participant characteristic questions are given (section 1). Detail around what kind of weight loss behaviours are included in the questionnaire would give the reader more context. Admittedly this is presented in the results, however for clarity having that detail here is useful.

Results:

Table 1 - Typical diet length (column 7): presumably this is measured in weeks. I suggest this should be indicated for clarity.

Table 1 legend - * indicates main effect for division. Please clarify this, as the text in the previous paragraph (line 174-179) indicates no effect of division which if I am reading correctly contradicts the table.

Weight loss history (beginning line 185) - Unclear why weight regain is presented first here in the text, but not first in table 2. I would suggest consistency in presentation order makes the results more reader-friendly.

Figures - Is it possible to amend the y-axes labels on the figures to include the weight loss method? For example, Figure 1A "gradual dieting frequency (%)". I feel this would make the figures easier to read without having to go back and forth to the figure legends.

Discussion

Line 82 - Argument regarding inexperience places athletes at greater risk of DE. Could this argument be expanded? Why would inexperience increase risk for DE/ED? Is there some protective effect in remaining in the sport, longevity helps alleviate symptoms/risk? Perhaps the lower risk in more experienced participants suggests those at risk do not remain in the sport? A similar argument is briefly presented regarding muscle dysmorphia symptoms in bodybuilders in Mitchell et al (2017) http://dx.doi.org/10.1016/j.bodyim.2017.04.003

Lines 79-114 - following from my main comment above, this section in particular requires some thought or at least balance regarding the limitations of the EAT-26 in distinguishing pathological behaviours from inherent components of competition preparation. Line 106 regarding food restraint, perhaps food restraint is simply a requirement to continually achieve fat loss in preparation for a show.

Limitations paragraph (lines 116-130) - I think worth including the limitation surrounding the EAT of distinguishing pathological from non-pathological behaviours in this particular population. Perhaps a suggestion for future research could be to validate the EAT-26 in physique athletes?

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Reviewer #2: Yes: Lachlan Mitchell

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5 Aug 2021

PONE-D-21-15998

Weight loss practices and eating behaviours among female physique athletes: Acquiring the optimal body composition for competition

PLOS ONE

Dear Dr. Alwan,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Although the work is considered to be interesting, several substantive points have been raised during the review process. Please carefully consider the comments provided as they indicate areas that need to be refined.

Please submit your revised manuscript by July 30, 2021, 11:59pm EST. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://hes32-ctp.trendmicro.com:443/wis/clicktime/v1/query?url=https%3a%2f%2fwww.editorialmanager.com%2fpone%2f&umid=fea4fa62-af1d-4bd7-b784-0a3d48fdda92&auth=e7d0e2218e6161c78f47b51039a961804123edc5-8392d4a5a1947ba4bf1630553f0692d1dda960c8 and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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The data contains information which can lead to identifying of participants. Considering the small number of physique athletes recruited in some of the divisions, competitive levels and organisations it was deemed necessary to not share the larger data set (outside of the institution or with people outside of the research team) in the ethical application. The details of research ethics committee are Liverpool John Moores [17/TLA/003]

Response to reviewer comments

Reviewer 1:

The work is interesting, considering the popularity of this sport, and it short existence – hence limited publications on health effects. Still – there are a few detailed publications already, which seems not too familiar to the current authors considering the poor refers to this previous work. Hence, my main feedback relates to the vague knowledge of previous findings, or at least incomplete use of references. Also, considering the increased number of publications studying physique athletes, references to bodybuilders should be de-emphasized. E.g.; Line 55-56: here many more publications should be referred to; Mathisen et al 2019; Helms et al 2019; Hulmi et al 2017; Trexler et al 2017; Petrizzo et al 2017; Halliday et al 2016. Acknowledging these authors work, and the current knowledge, these should be referred to more often throughout the manuscript, and also brought up for comparison in the discussion (rather than claiming no one else has studies the phenomena at quest). As many of these already is in the reference list, it seems the authors have not read the work done – this applies specifically to the request for future studies in line 131-137! The strength of the current study is the additional knowledge it provides on dieting procedures, which should be the main focus; adding to the details we now know about health effects from participation in this sport.

Thank you for your positive and constructive comments. We have included and developed further the suggested references throughout the manuscript, which we hope has provided a more balanced overview of the key findings in this area. These now feature more consistently throughout the manuscript. For example, we have added more relevant studies (on female physique athletes) between lines 59-60 (Whitehead et al., 2020, Chappell et al., 2018, Rohrig et al., 2017, Halliday et al., 2016, and Petrizzo et al., 2017) and 63-64 in the introduction (Halliday et al. 2016, Petrizzo et al., 2017, Tinsley et al., 2019, Hulmi et al., 2016, and Mathisen et al., 2019) and line 310 in the discussion (Halliday et al., 2016, Petrizzo et al., 2017, Hulmi et al., 2016, and Mathisen et al., 2019) to reduce the emphasis on bodybuilders. Furthermore, we have added the reference Mathisen and Sundgot-Borgen (2019) for comparisons with regard to eating restraint in the discussion between the lines 407-409. Lastly, we have edited lines 440-444 of future research directions and tried to highlight better the novelty of our work in the manuscript.

Abstract

The authors conclude that all used evidence-based methods for dieting, however this is not presented or discussed in the manuscript -neither do I find any reason to claim this, considering the results presented.

We thank the reviewer for highlighting this point. We have now changed this to ‘acute and chronic weight loss practices’ on line 38 in the abstract. Additionally in the manuscript we also present it as acute and chronic on line 232-233 in the results and line 301-302 in the discussion. We feel that we have described the practices they are undertaking e.g., water loading (acute) and gradual dieting (chronic) and hope this now reflects the results.

Introduction

Line 60; weight loss history has been presented previously; e.g. Mathisen et al 2019.

We thank the reviewer for this suggestion. We have now inserted into the manuscript studies by Hulmi et al., 2016 and Mathisen et al., 2019 and other case reports by Petrizzo et al., 2017, Haliday et al., 206, and Tinsley et al., 2019. The manuscript now reads as follows between lines 63-68 in the introduction:

“At present, case reports (n=1) [12,14] and studies using larger sample sizes have assessed the weight loss history and dietary practices [14,15] across multiple time-points during a competitive season, however these studies have not captured the frequency of such practices or established other lesser reported practices, which may be used to acquire optimal body composition for competition (e.g., laxatives, water loading, and salt manipulation).”

Line 62; both mental and physical health implications are important.

Thank you for making this suggestion. We have made the following change on line 68 in the introduction:

“Delineating the methods used and possible psychological and physical health implications are important,….”

Line 69-70; while the quote is not wrong, it is more accurate to say that all situations leading to low energy availability will possibly result in RED-s – as such, any dieting attempt will be a high-risk scenario.

We thank the reviewer for this suggestion and we agree with this comment. This has now been replaced (on line 75 in the introduction) with:

‘Engaging in any dieting or weight loss may put athletes at risk of relative energy deficiency in sport…….’.

Line 73; I assume the authors means DE (disordered eating) in the beginning of the sentence.

We apologise for this error. This is now corrected (on line 79 in the introduction) to:

“Disordered eating…”.

Line 76, and 89-91; most of the previous mentioned work has evaluated DE and ED, and even self reported EDs diagnosed by health personnel (Mathisen et al 2019).

We thank the reviewer for highlighting this point. We have now included the study by Mathisen et al., 2019 on line 83. We acknowledge previous work has been done on the prevalence of ED and DE, however, we were attempting to highlight that, limited studies have been conducted in the area and this is especially the case when comparing the different divisions and experience level. We understand how this may not have been clear and as such the sentence (on lines 82-84 in the introduction) is rewritten to the following:

“…..limited studies have been conducted in physique sports ‘[22], especially with regards to assessing the risk between experience levels and/or divisions [4].’

Hopefully this has will be clearer to the reader.

Line 100-1001; exclusion criteria is an ED, but the study aim to study the frequency of risk for EDs? As previous studies have found rather high prevalence of EDs in this athlete group, there will be a rather biased sample if exclusion criterion is a diagnosis of ED.

We thank the reviewer for this valuable comment. We would like to highlight that the aim of this study was to assess the extent/prevalence of DE symptoms and not the frequency of risk for ED. Please see line 95 in the introduction for the study aim. Regarding the decision to exclude participants with an eating disorder, we were advised by the University ethics committee to exclude participants previously diagnosed ED’s. Furthermore, we believe that recruiting athletes who may not have recognised that they have DE symptoms will add to the current knowledge, and by doing so investigate a previously unreported issue in the sport

Do the authors have any hypothesis? Specifically explaining the rationale to compare athletes according to disciplines and to experience!

Thank you for this question. We agree that including a hypothesis will be a positive addition to the manuscript and this is now included between lines 96 to 101 in the introduction:

“It was hypothesised that those athletes competing in the Figure division and novice athletes would experience greater weight fluctuations, use acute weight loss practices more frequently and report more DE symptoms compared to Fitness athletes and experienced athletes. Based on previous data from weight-sensitive sports, it was also hypothesised that coaches would be the main influences on dieting and weight loss practices instead of qualified personnel (irrespective of division and experience).”

We have attempted to explain the rationale in the introduction and so to avoid unnecessary repetition and streamline the writing, we hope this is considered appropriate. For example, between lines 85-92 we have attempted to explain the rationale why exploring difference between experience levels and between divisions is important.

Methods

line 122: definition for the different experience-categories needs to be clarified.

A definition of experience levels was originally included in the statistical analysis section; however, we agree this will be better suited within the participants section in the methods. This section (between line 133-137 in the participant section of the methods) now reads:

“……representing the following divisions: Fitness novice (Bikini Fitness and Women’s Fitness with ≤1 year of competition experience; n = 62; 39%), Fitness experienced (Bikini Fitness and Women’s Fitness with >2 years of competition experience; n = 53; 34%), Figure novice (Figure and Physique with ≤1 year of competition experience; n = 19; 12%) and Figure experienced (Figure and Physique with >2 years of competition experience; n = 24; 15%).”

RWLQ needs a proper presentation; e.g. how many items, tha Chronbachs-alpha in the current sample. The latter also relates to the presentation of the EAT-26.

The amount of items of the RWLQ is now included in the RWLQ section of the methods on line 143:

“….from the RWLQ, which comprises of 21 items and has three subscales:…”

We have now included the Cronbach’s-alpha on line 122 in the Study design of the methods and this now reads:

“Both questionnaires have been previously utilised in aesthetic and weight-sensitive populations with good sensitivity, specificity and excellent internal consistency (RWLQ: Cronbach's alpha = 0.98) (EAT-26: Cronbach's alpha = 0.90) [18,27].”

EAT-26 also should be presented with Chronbachs-alpha for the current sample.

We thank the reviewer for this suggestion. In line with the previous comment we have included this on line 122 in the Study design of the methods section.

Line 165: Do the author mean they will study relations between a total score and a subscale-score of the EAT-26?

We agree that this sentence is not clear. We have now replaced (line 179-180) with:

“…. relationships between the total EAT-26 score and the subscales scores of the EAT-26 and potential risk factors associated with weight history (i.e., weight regain)”.

It would be interesting (and relevant) to see the different physique categories represented in the sample; only two are mentioned, being those with few participants, hence grouped to two other overall categories)

We thank the reviewer for this suggestion. We agree that this could be an interesting insight into the population recruited and we have therefore included (between line 181-182 in the statistical analysis section) the following statement:

“In total, the study recruited from four groups: Bikini Fitness (n=107), Figure (n=42), Women’s Fitness (n=6) and Physique Athletes (n=3)”.

Results

General remark regarding tables; please indicate which results are significant different to each other, not the variables name.

We thank the reviewer for highlighting this and we have now added alphabetic symbols for significance on the results as well as adding an asterisk or hashtags to the variables in Table 1 and 2 on line 196 and 220-221.

Table 1: the variable “typical diet length” misses unit of measurement

have now added “(weeks)” into column 7 in Table 1 on line 196.

Line 186-187: Although presented in table 2, the period of time which the regain refers to, should be mentioned in the text

We have referred to this earlier in the manuscript in the section Rapid weight loss questionnaire section on line 145-146. We agree that ‘weight regain in the 7-days after competition’ could be repeated in the results and is therefore inserted in on line 204, 206-207 and line 207-208 in the results section.

Table 2: There is a need for more thorough explanation of the variables; what are usual weight lost and what is most weight lost (or for what time frame?); what is relative weight lost?

Thank you for this suggestion. We have now added a section below Table 2 explaining (relative) usual weight loss and (relative) most weight loss in more detail, to allow the reader to understand the results better. This now reads:

“Most weight loss is the most weight ever cut before a physique competition. Usual weight loss is the weight usually cut before a physique competition. Most relative weight loss is the percentage (of the individual’s off-season weight) that was mostly cut for a physique competition. Usual relative weight loss is the percentage (of the individual’s off-season weight) that is usually cut for a physique competition.”

Line 216-219: please consider rephrasing, as the content is not easy to understand. More than 80% never used the methods, still the majority of novice figure athletes did? Any information on the competence of the coaches? (as these are found most influential on dieting practces?!)

We thank the reviewer for raising this comment. We have rephrased (on lines 242-244) this to:

“For the combined group skipped meals (86.0%), fasting (91.7%), and laxatives (90.5%) were ‘almost never’ or ‘never used’, however Figure novice ‘always’ or ‘sometimes’ used skipped meals (26.4%) and fasting (36.9%)…”.

Unfortunately, we do not have any data on coaches because we did not recruit coaches.

Discussion:

(this is not the first report on DE or ED!)

We apologise for this omission and have now changed (see line 299-300 in the discussion) it this section to:

“This study provides data that assesses the weight loss history and frequency of practices in FPA alongside influential sources of dieting and DE symptoms”.

Line 21: “as a result” does not fit into context here.

We have changed this to “Moreover” on line 305 in the discussion.

One finding deserves more focus; Novice fitness athletes lost more weight than experienced ones; opposite within figure athletes. Discuss possible reasons to this observation.

Thank you for this suggestion. We have changed this section and it now reads (between lines 313-319):

“Anecdotally, in their first year of competing, Fitness novice athletes present with more FM than Fitness experienced athletes and therefore lose more weight prior to competition. However, this remains speculative and warrants future research. Furthermore, Figure experienced athletes may place greater emphasis on increasing LBM during the off-season (and therefore also may experience concomitant increases in their levels of FM) compared to a Figure novice athlete, which subsequently requires greater weight loss as they enter the pre-competition phase.”

Figure athletes had the largest relative weight regain – discuss implications, and please add time-perspectives when presenting weight regain results.

We thank the reviewer for highlighting this comment. The time frame has now been added on line 321 and 323.

We have also highlighted the potential reason why relative weight regain in the 7-days after competition is greater in figure than fitness athletes and lines 324-328 in discussion now read as: “A reasonable explanation for the greater relative weight regain in Figure athletes may be due the higher frequency of binge eating self-reported by Figure athletes (47%) compared to the Fitness athletes (18.6%) and the greater score of bulimia and food preoccupation in Figure athletes compared to Fitness athletes observed in the present study"

In order to provide implications of the effects of weight cycling on health we have added (on line 332-333): “…and may increase the risk for obesity and cardiometabolic diseases in later life [34]”

Line 35-38: while the claims raised regarding the risk of RED-s is correct, the authors needs to acknowledge that the main reason for risk of RED-s in their athletes is attempts to lose weight, and the fact that they did lose weight (i.e. low energy availability)

Thank you for this suggestion. We agree this was not clear and this sentence (lines 334-337 in the discussion) has now been restructured to read:

“In preparation for competition, FPA implement gradual dieting, food restrictions, excessive exercise and water loading. In attempting to lose weight, restrictive eating and excessive exercise is implemented and could potentially affect metabolic [32] and endocrine health such as menstrual dysfunction [9] thus increasing the risk of RED-S [17].”

Line 50-52 (and lines leading up to this): considering the harm by using weight-reduction methods relying on electrolyte balances, the authors should emphasise the potential health threat, rather than encourage more studies to fine a “safe method”. This sort of method is not recommended as a weight regulation practice (e.g. see publications by the IOC expert group on REDs).

We thank the reviewer for this remark. We agree and the sentence has therefore been removed on line 348-350. We have also added the reference from IOC expert group to emphasise the danger of using such methods. This reads as following:

“However, this practice when combined with diuretics and electrolyte manipulation presents additional dangers including hyponatremia ,which has resulted in a number of fatalities [39,40] and is not a recommended method to regulate weight [41]”.

Line 60; please refer the authors of the publication directly in the text

We have now added the authors name directly in the sentence line 359 in the discussion so it reads;

“This agrees with other studies on weight-sensitive sports [4,14,37]. For example, Chappell et al., (2018) [7] reported….”.

Line 85-89; the literature repeatedly reveal that females are more prone to ED than males, hence, a comparison to male bodybuilders seems not relevant. There are more reports on ED or atheltes at ED-risk in previously mentioned and recommended references! To follow up on this; the line 90-94 therefor needs to be re-evaluated - e.g. Mathisen et al 2019 reported numbers with previous or current ED diagnosed by health personnel) Line 105-109; here too, Mathisen et al 2019 revealed higher eating restrains compared to control group before, throughout and after dieting period.’

We thank the reviewer for raising this valuable point. Although we are aware many female studies have been investigated using different tools of measurement of DE and ED, we believe that it is appropriate to also compare studies using similar tools as explained on line 386. We agree that the Mathisen study is an important reference to use in this discussion and we have now added this into manuscript in two different places (line 406-412):

“Our data showed high levels of food restraint amongst all participants (approximately 40% reported ‘always’ food restricting), which is in agreement with a recent report [23] who revealed higher eating restraints in FPA compared to healthy controls before, during and post dieting”.

“Moreover, Mathisen and Sundgot-Borgen (2019) [23] reported that 9 (28%) and 2 (6%) out of 33 Scandinavian FPA (at the time of the study) had currently or have previously been diagnosed with an ED diagnosed by health personnel.”

Line 131-137: most of the requested information for future studies, are already presented in previous publications; e.g. weighed food records, blood samples, techniques to characterize physical changes and body composition; please see previous listed references

We thank the reviewer for making this remark and we would like to clarify further.

The second future research suggestion we suggested was aimed at assessing dietary practices alongside training practices. This sentence has now been updated to enhance clarity:

“…assess dietary intake using weighed food inventory and food diaries alongside training practices (modality, training volume and loads) during the pre-competition...”.

Whilst we are aware there are many studies that have assessed dietary intake in the pre-competition phase including Halliday et al., 2016, Mathisen et al., 2019, Petrizzo et al., 2017, Tinsley et al., 2019 and Longstrom et al., 2021, we are also aware that limited studies have completed this assessment alongside training practices. Documentation of training practices in FP athletes is mostly reliant on metabolic equivalent data (Halliday et al., 2016; Petrizzo et al., 2017; Hulmi et al., 2016), which provides estimates of exercise energy expenditure, but does detail the specific training they perform. It is therefore unknown if/how training variables are manipulated by female physique athletes who are actively engaging in weight loss in order to achieve their body composition aspirations for competition.

With regard to the third research suggestion. We have now amended the sentence, so it reads:

“…collect blood samples and other measurements for analysis of markers relating to metabolic, renal, and endocrine health (especially on changes in competition week)”.

Whilst previous work has assessed some blood/saliva markers in their studies such as Hulmi et al., 2016 (Endocrine markers and metabolic markers), Trexler et al., 2017 (Endocrine and appetite hormones) and Rohrig et al., 2017 (vitamins, metabolic and endocrine markers) our suggestion is to provide a comprehensive profile of markers that indicate metabolic, renal, and endocrine status, with particular reference to competition week.

Hulmi has taken measurements of metabolic markers (e.g., T3 and TSH) and endocrine markers (e.g., oestradiol and testosterone), at three time points, in different phases of the competitive season (baseline, pre-competition and post-competition). Trexler took measurements of endocrine hormones (e.g., insulin and testosterone using saliva) just before competition and post-competition, and Rohrig assessed a small profile of endocrine, lipid and metabolic markers every month leading into competition. As such, we believe that it is necessary for more studies to assess clinical blood markers in FPA as this could contribute to our understanding of RED-S and renal function. We are also aware that no study to date has assessed changes in the competition week, which is likely to be a crucial window given the dietary manipulation such as carbohydrate restriction and loading, salt and fluid manipulation etc. as shown by Chappell et al., (2017).

The conclusion would do better with a shorter summary and implications.

We thank the reviewer for this suggestion; this has now been refined and now reads:

“Irrespective of division or experience, FPA used a combination of acute and chronic weight loss practices pre-competition. Figure novice athletes reported most weight loss pre-competition, alongside significant increases in weight gain post-competition, indicating patterns of weight cycling. Coaches and other athletes had most influence on athletes’ practices. Finally, 37% of FPA were at risk of developing ED with 42% using two PWCM throughout the season. Therefore, we encourage FPA and coaches to utilise appropriate expertise (e.g., registered nutritionists and psychologists) when preparing for competition. This might reduce the risks associated with severe weight loss practices evident in this population. “

Reviewer #2:

Thank you to the authors for submitting their paper titled Weight loss practices and eating behaviours among female physique athletes: Acquiring the optimal body composition for competition. Herein they describe their cross-sectional study examining weight loss behaviours and disordered eating symptoms in a large sample of competitive female physique athletes, as well as sources used to obtain weight loss practices. Results showed a high percentage of participants demonstrated increased disordered eating behaviours via the EAT-26 and a variety of weight loss behaviours through the RWLQ. Overall the paper is well structured, clear, and mostly concise, presenting a well developed background and justification for the study, clear methods and results.

Thank you for these positive comments.

Apart from some minor suggestions presented below, my major comment is in regards to the interpretation and discussion of findings. The nature of physique competition preparation requires athletes to undertake many behaviours and practices which are interpreted as pathological in eating disorder questionnaires (in this case the EAT-26) when in fact they are just inherent components of competition preparation. Examples include knowing the calorie content of food I eat (item 6), particularly avoid high carbohydrate foods (item 7), think about burning up calories when I exercise (item 11), display self-control around food (item 19), and engage in dieting behaviour (item 23). Distinguishing these inherent components from true pathological qualities is a challenge in this line of research. As such, I feel a more nuanced, balanced approach to the discussion is required.

We thank the reviewer for this valuable and fair comment. We have reflected on this and believe it is important to include in the discussion of this manuscript. We have therefore considered this in the manuscript between lines 433-439 and reads:

“Finally, although the EAT-26 questionnaire contains components which could be interpretated as pathological eating behaviours (i.e., ‘I engage in dieting behaviour’ and ‘Aware of the calorie content of foods that I eat’), these could well be normal behaviours which are required to compete in physique sports, rather than being indicative of an DE per se. As such, distinguishing between true pathological and non-pathological behaviours eating behaviours should be carefully considered when interpretating the DE symptoms results.”

In addition to this, the inclusion criteria indicate participants resistance trained at least 5 times per week, which is a very high training frequency. I am concerned that such a criteria would exclude a large number of FPA which would introduce a selection bias. There may also be an argument that this high frequency criteria may lead to a biased recruitment of athletes who over-exercise and are at risk of disordered eating/exercise behaviours.

We apologise, we accidentally misreported our inclusion criteria. We have now amended this in the manuscript, and it now reads:

“Inclusion criteria were females aged 18-65 years and participation in a physique competition (previous 12 months).”

We have included this extract from our ethics application to show our actual inclusion criteria: “ C4a. What are the inclusion criteria? (Please include information on how you will ensure that your participants will be informed of your inclusion criteria and how you will ensure that any specific inclusion criteria are met)

“Participants will be females between 18 and 65 years of age, and have been competed previously on stage in the last two competitive seasons. Participants will receive this information verbally, on recruitment poster and/or on the participant information form when finding out about the study. When conducting the study, the demographic information will include a question on age and competing history so that any participants not meeting the inclusion criteria can be removed from the study. If they meet the inclusion criteria, an option “Take me to the survey” will be clicked, and participant can continue to the survey. “[17/TLA/003 Liverpool John Moores University Ethics committee] “

Line 37 - The use of evidence-based practices by participants was not highlighted in the manuscript, so I feel it would not be appropriate to include here in the abstract.

Thank you for this comment. We have now changed this to “acute and chronic weight loss practices” on line 38 in the abstract. We feel that we have described the practices they are undertaking e.g., water loading (acute) and gradual dieting (chronic) and hope this now reflects the results.

Introduction

Lines 45-52 - It may be beneficial to the reader if you were able to provide more context to the different division of competition. What distinguishes the different divisions (Body composition/leanness? Muscularity? Other?). Given your examination aims to compare based on division, this information would be useful for readers.

We have now added a sentence which reads:

“For example, athletes competing in the Figure division are required to have lower levels of FM and greater LBM than the Bikini Fitness division (see [5] for a review of division requirements)”.We hope this provides some useful information for readers, whilst not adding excessively to the word limit imposed by the journal.

Line 111 - It is common to report the Cronbach's alpha of the included questionnaires. As the RWLQ was adapted for the population under investigation, I would suggest this measure of internal consistency be reported.

We thank the reviewer for highlighting this point. This is now included on line 122 and states: “…excellent internal consistency (RWLQ: Cronbach's alpha = 0.98) (EAT-26: Cronbach's alpha = 0.90) [18,27]”.

Line 129 - please include the number of items in the RWLQ. It would also be helpful if an idea of the participant characteristic questions are given (section 1). Detail around what kind of weight loss behaviours are included in the questionnaire would give the reader more context. Admittedly this is presented in the results, however for clarity having that detail here is useful.

We thank the reviewer for making this suggestion. This now reads (line 143-144):

“…which comprises 21 items and has three subscales: Participant’s characteristics (i.e., “at what age did you start competing? and “how many times did you compete in your last season?”)”

Results:

Table 1 - Typical diet length (column 7): presumably this is measured in weeks. I suggest this should be indicated for clarity.

We thank the reviewer for spotting this missing unit. We have now added the unit “(weeks)” to Table 1 in column 7 on line 196.

Table 1 legend - * indicates main effect for division. Please clarify this, as the text in the previous paragraph (line 174-179) indicates no effect of division which if I am reading correctly contradicts the table.

We thank the reviewer for highlighting this error. Below Table 1, we have now replaced ‘division’ with ‘experience’ reflecting our results provided in participant characteristics section.

Weight loss history (beginning line 185) - Unclear why weight regain is presented first here in the text, but not first in table 2. I would suggest consistency in presentation order makes the results more reader-friendly.

We thank the reviewer for spotting this. We agree and have now changed the order for a more coherent and consistent presentation of results.

Figures - Is it possible to amend the y-axes labels on the figures to include the weight loss method? For example, Figure 1A "gradual dieting frequency (%)". I feel this would make the figures easier to read without having to go back and forth to the figure legends.

We thank the reviewer for this suggestion, and we agree. This has now been changed on the Y-axis for a better presentation of graphs in “Fig 1.tiff”, “Fig 2.tiff” and “Fig 3.tiff”

Discussion

Line 82 - Argument regarding inexperience places athletes at greater risk of DE. Could this argument be expanded? Why would inexperience increase risk for DE/ED? Is there some protective effect in remaining in the sport, longevity helps alleviate symptoms/risk? Perhaps the lower risk in more experienced participants suggests those at risk do not remain in the sport? A similar argument is briefly presented regarding muscle dysmorphia symptoms in bodybuilders in Mitchell et al (2017) https://hes32-ctp.trendmicro.com:443/wis/clicktime/v1/query?url=http%3a%2f%2fdx.doi.org%2f10.1016%2fj.bodyim.2017.04.003&umid=fea4fa62-af1d-4bd7-b784-0a3d48fdda92&auth=e7d0e2218e6161c78f47b51039a961804123edc5-6cce90e9e58d8f2533ef7b60928430176ffc7324

Thank you for raising this valuable point. We have reflected on the reasoning behind this and expanded this discussion between the lines 378-384. In addition, we have used the Mitchell et al., (2017) reference to support the possible reason. This now reads:

“Due to the specific demands of the Figure division (i.e., lower FM and higher FFM than the fitness division), novice athletes beginning Figure competitions may be exposed to body composition requirements that are more challenging to achieve [43]. It is also possible that women may be susceptible or already exhibit DE symptoms, as they enter physique sports, in hopes of alleviating these symptoms. As such, it is speculative whether long-term engagement in the sport provides a protective effect from ED risks in FPA.”

Lines 79-114 - following from my main comment above, this section in particular requires some thought or at least balance regarding the limitations of the EAT-26 in distinguishing pathological behaviours from inherent components of competition preparation. Line 106 regarding food restraint, perhaps food restraint is simply a requirement to continually achieve fat loss in preparation for a show.

Thank you for this really useful suggestion. We have added another sentence in the limitation paragraph between the lines 433-439 that reads:

“Finally, although the EAT-26 questionnaire contains components that could be interpretated as pathological eating behaviours (i.e., “I engage in dieting behaviour’ and ‘Aware of the calorie content of foods that I eat’), these could well be normal behaviours that are required to compete in physique sports, rather than an DE per se. As such, distinguishing between true pathological and non-pathological behaviours eating behaviours should be carefully considered when interpretating the DE symptoms results”.

Limitations paragraph (lines 116-130) - I think worth including the limitation surrounding the EAT of distinguishing pathological from non-pathological behaviours in this particular population. Perhaps a suggestion for future research could be to validate the EAT-26 in physique athletes?

We thank the review for this comment, and we agree. We have now inserted (on line 441-442 in the future research directions of the discussion): “….., future work should i) validate the EAT-26 questionnaire in physique ….’

Submitted filename: Response to reviewers .docx

Click here for additional data file.

18 Oct 2021

PONE-D-21-15998R1Weight loss practices and eating behaviours among female physique athletes: Acquiring the optimal body composition for competitionPLOS ONE

Dear Dr. Alwan,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Specifically, please address the minor revisions as described by reviewer #1.

Please submit your revised manuscript by November 29, 2021. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Cherilyn N. McLester, PhD

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear authors

Thank you for considering the recommendations I made in the previous review. I find the manuscript improved, and have only minor remarks:

Does «chronic gradual dieting» mean that they were always on a kcal-reduced diet, or that they gradually decreased kcal-intake during the contest dieting period? If it means the latter, I suggest to omit the word “chronic”.

Line 149-150: I suggest you also add information on the total score range for the questionnaire.

Table 2: please add similar explanation on what numbers represent, as done in table 1 (and I suggest you add this to the header/the text in the title of the table): “Values are presented as mean ± SD and include the range in brackets”.

Line 283: Laxative use is mentioned as a frequent pathogenic weight control method, however the relevant question in the EAT-26 questionnaire asks about laxatives, diet pills and diuretics in the same question. As such it would be more precise to mention all these methods in the relevant section of the text and figure 3, including in the discussion. Laxative use is previously found to be less frequently used (previous mentioned references), however diet pills and diuretics are more frequently used (the latter also being anecdotally/taken from personal insight to the sport). This is underscored by the finding you specifically mention in the discussion line 350-352.

Paragraph initiated from line 374: here shortly addressing whether the EAT-26 is valid to capture DE-risk in physique athletes is recommended (I notice this has been addressed in the “limitation” of the paper, however I find It reasonable to shortly address here too, to quickly draw attention to such a dilemma).

Paragraph from line 386: First, the explanation for discrepancies presented in line 389 needs clarification (I personally did not automatically understand what the authors meant). Second; I find the most obvious reason for the discrepancies between the studies that there are different sexes in the two studies (Pickard studied male bodybuilders, you study female physique athletes). Taking the items in the EAT-26 into consideration, it is not very typical for a male body builder to respond positive to the questions in the relevant questionnaire (they are not preoccupied of being thinner, or afraid of eating/afraid of sugar or food. Not even on when being on a diet). I understand that you find it interesting to compare to a study which have used the same questionnaire, however, I find it difficult or at least less relevant, as there are obvious reasons to why there are discrepancies in your finding (type of sport i.e. bodybuilding versus fitness sports, sexes included, a questionnaire that not very well captures the issue at quest within these type of sports).

Thank you.

Reviewer #2: Thank you to the authors for addressing all of my previous comments. Well done on the preparation of this manuscript.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: Yes: Lachlan Mitchell

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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4 Dec 2021

PONE-D-21-15998R1

Weight loss practices and eating behaviours among female physique athletes: Acquiring the optimal body composition for competition

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear authors

Thank you for considering the recommendations I made in the previous review. I find the manuscript improved, and have only minor remarks:

We thank this reviewer for their extremely thorough review and are grateful for the comments that have improved this manuscript. We are pleased to hear the reviewer feels that the manuscript has improved, and we have now attempted to address further comments in hopes the reviewer now considers the revised manuscript worthy of publication.

Does «chronic gradual dieting» mean that they were always on a kcal-reduced diet, or that they gradually decreased kcal-intake during the contest dieting period? If it means the latter, I suggest to omit the word “chronic”.

We appreciate the reviewer’s line of thinking here. It is indeed the latter. We decided to omit “chronic” from weight loss practices throughout the manuscript.

Line 149-150: I suggest you also add information on the total score range for the questionnaire.

We thank the reviewer for this suggestion. Unfortunately, we do not have this information as it is not provided in the original paper by Artioli et al., (2010).

RWLS is based on scores from weight and diet history and the weight loss behaviours questions. As an example, in the weight and diet history questions, athletes will receive 1 point per kg of weight they lose, while on the weight behaviours questions, answers will be scored between 0-4. As such, it is very difficult to provide a precise range. However, we have reported: “The RWLQ scoring system indicates the higher the score obtained, the more aggressive the weight loss behaviours” on line 149-150.

Table 2: please add similar explanation on what numbers represent, as done in table 1 (and I suggest you add this to the header/the text in the title of the table): “Values are presented as mean ± SD and include the range in brackets”.

We would like to thank the reviewer for bringing this to our attention. This has now been corrected. “Values are presented as mean ± SD and include the range in brackets” has been added in the title of the table 2 on line 221. We have also replicated this explanation in table title of table 1 on line 196-197 for consistency.

Line 283: Laxative use is mentioned as a frequent pathogenic weight control method, however the relevant question in the EAT-26 questionnaire asks about laxatives, diet pills and diuretics in the same question. As such it would be more precise to mention all these methods in the relevant section of the text and figure 3, including in the discussion. Laxative use is previously found to be less frequently used (previous mentioned references), however diet pills and diuretics are more frequently used (the latter also being anecdotally/taken from personal insight to the sport). This is underscored by the finding you specifically mention in the discussion line 350-352.

Thank you for noting our error in reporting. This has now been corrected in the results, discussion, figure 3 title, and the y-axis on the figure 3.

For example, this has been corrected on line 282-283: “For the combined group, 42.4% used two out of three PWCM (laxatives, diet pills and diuretics, and binge eating), while 13.3% used all methods to manage their weight. Laxatives, diet pills and diuretics….. “

Paragraph initiated from line 374: here shortly addressing whether the EAT-26 is valid to capture DE-risk in physique athletes is recommended (I notice this has been addressed in the “limitation” of the paper, however I find It reasonable to shortly address here too, to quickly draw attention to such a dilemma).

We thank the reviewer for this comment and agree with this point. We have included: “Although, EAT-26 questionnaire has been validated in other athletic groups, further work to validate it in this specific population is necessary” on line 389-391 to acknowledge this issue.

We have now also included this additional detail in the methods section of the study design on line 120 where we directly talk about using the EAT-26 questionnaire.

Paragraph from line 386: First, the explanation for discrepancies presented in line 389 needs clarification (I personally did not automatically understand what the authors meant).

Second; I find the most obvious reason for the discrepancies between the studies that there are different sexes in the two studies (Pickard studied male bodybuilders, you study female physique athletes). Taking the items in the EAT-26 into consideration, it is not very typical for a male body builder to respond positive to the questions in the relevant questionnaire (they are not preoccupied of being thinner, or afraid of eating/afraid of sugar or food. Not even on when being on a diet). I understand that you find it interesting to compare to a study which have used the same questionnaire, however, I find it difficult or at least less relevant, as there are obvious reasons to why there are discrepancies in your finding (type of sport i.e. bodybuilding versus fitness sports, sexes included, a questionnaire that not very well captures the issue at quest within these type of sports).

We thank the reviewer for raising this point. We agree that a better study could be used to make comparisons to here. We have now removed these sentences from the manuscript and have included a recent study on line 376 (Money-Taylor et al., 2021) which recruited female physique athletes and used a similar screening tool to our study.

Thank you.

Reviewer #2: Thank you to the authors for addressing all of my previous comments. Well done on the preparation of this manuscript.

We thank this reviewer for their thorough and constructive review and are grateful for the comments that have improved this manuscript.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

28 Dec 2021

Weight loss practices and eating behaviours among female physique athletes: Acquiring the optimal body composition for competition

PONE-D-21-15998R2

Dear Dr. Alwan,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Cherilyn N. McLester, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the feedback on my last comments. I find the paper much improved, and it brings attention to important issues for this specific, increasingly popular sport. I have no further important comments, and recommend publication of the manuscript.

The last minor comment from me does not need to be followed up on by replies, but could be considered for additional change.

In the last review, I asked for the total score range of the “Rapid Weight loss questionnaire”, and the authors responded with a thorough explanation. Nevertheless, it would be helpful information to add comments on the possible total range for the weight behaviour subscales, as this will help us evaluate the results obtained from this questionnaire. Without this information, I would be not that intuitive to know if a total score of 22 is “knocking out the scale” or comes with medium intensity (With the information provided; if the questionnaire consists of 21 items, and a score range from 0-5 (running from 0 to 4, line 149), I’d assume there would be a total score possible of 84 points?)

Please check line 376: cut-off for what instrument? (I assume it is the EAT-questionnaire)

Line 406-407; swop the numbers; 28% had previously and 6% had currently been diagnosed with ED.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

3 Jan 2022

PONE-D-21-15998R2

Weight loss practices and eating behaviours among female physique athletes: Acquiring the optimal body composition for competition

Dear Dr. Alwan:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Cherilyn N. McLester

Academic Editor

PLOS ONE