Narrative review: Mental health, eating disorder risk, and disordered eating patterns among Lebanese national taekwondo players

Why this study matters

Taekwondo is a combat sport with weight categories. The authors write that its athletes face hard training, weight loss before competitions, fear of injury and pressure from coaches, fans and sponsors, and that these can leave them open to depression, anxiety and eating disorders. They say the relationship between eating disorders, disordered eating and psychotic disorders in athletes is unclear and under-studied, and that Lebanon has no mental health or nutrition recommendations written for martial arts athletes. They describe the study as the first of its type in Lebanon and the Middle East.

What the researchers did

The study was a cross-sectional survey: each person was assessed once. It ran from January to July 2023 and first involved 161 athletes, reached through the Lebanese Taekwondo Federation and the national team. Of these, 45 did not meet the entry criteria and 6 declined, leaving 110 participants. All were Lebanese black belts, and the entry criteria allowed ages 11 to 64. They were players, coaches or both. There were 74 male and 36 female participants, with a mean age of 24.28 years. One of the nine authors lists the federation as an affiliation.

Each participant filled in a questionnaire that included two screening tools. Such tools flag people who may have a problem. They do not diagnose. The first was the Sport Mental Health Assessment Tool 1 (SMHAT-1), developed by the International Olympic Committee, which screens athletes for anxiety, depression, sleep disturbance, disordered eating and other conditions. The second was the Eating Attitudes Test (EAT-26), in which a score of 20 or more was taken as a risk of an eating disorder. In this review, “disordered eating” means a positive SMHAT-1 screen and “eating disorder risk” means that EAT-26 score.

What they found

On the SMHAT-1, 14.5% of the athletes were at or above the threshold for anxiety and 13.6% for depression, and 10% reported thoughts of self-harm. Sleep disturbance was flagged in 24.5%, alcohol misuse in 12.7% and symptoms consistent with attention deficit hyperactivity disorder (ADHD) in 32.7%. Risk of psychosis, which the authors class as a severe mental illness, was flagged in 13.6%. Disordered eating was flagged in 33.6%. On the EAT-26, 15.5% were at risk of an eating disorder. By sex, anxiety was flagged in 27.8% of female and 8% of male athletes, depression in 30% and 5%, and disordered eating in 50% and 25.7%.

Mental health screens and disordered eating tended to occur together. Of the athletes flagged for anxiety, 81.3% were also flagged for disordered eating, against 25.5% of those not flagged. For depression the figures were 80.0% and 26.3%. The authors report that depression and psychosis risk were associated with both eating outcomes, and anxiety with disordered eating only.

The researchers also calculated odds ratios, which compare the odds of an outcome in two groups. A value above 1 means higher odds. For eating disorder risk, the odds ratio for athletes at risk of psychosis was 11.8, with a 95% confidence interval (the range in which the true value probably lies) of 1.3 to 100. For disordered eating, it was 29 for ADHD symptoms (5 to 158). Athletes whose income had fallen in the economic crisis were less likely to be at eating disorder risk (odds ratio 0.11). The authors call that result paradoxical and say it needs cautious interpretation.

Strengths and limits

The study used two published questionnaires that the authors describe as validated, one of them designed for athletes. The authors add that the sample covers a considerable part of Lebanon’s small pool of national-level black belts.

The authors list several limits. The design cannot show that one thing caused another. Answers were self-reported, and no clinical diagnosis was made to confirm a positive screen. The questionnaires took 20 to 40 minutes, which the authors say may have affected motivation and accuracy. Participants were a convenience sample, meaning people who were easy to reach, and all were black belts, so the results may not apply to lower-level or recreational practitioners.

The article is not always consistent. For example, the abstract links reduced income to higher eating disorder risk, while the tables and the regression model show lower risk. The confidence intervals are wide, so the size of each association is uncertain.

What it adds to research on fighter health

The study adds screening figures for one combat sport in a country where, the authors say, this had not been done before. In this group, positive mental health screens and disordered eating were associated. The study does not show which came first. Its participants were taekwondo players and coaches, not boxers, kickboxers or mixed martial arts fighters. The authors call for further research and for support that combines psychological and nutritional care.