The purpose of this study was to evaluate the association between urinary incontinence and disordered eating, in elite female athletes. A cross-sectional study was done including 100 young and healthy women: 50 elite athletes aged 24.54 ± 3.05 years and 50 non-athletes aged 20.84 ± 2.02 years. The International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form was used to screen urinary incontinence. The Eating Attitude Test-26 Questionnaire was used to screen disordered eating. Data was analyzed using Odds ratios with 95% confidence intervals (95% CI) to estimate the association between UI and disordered eating. Statistical analysis revealed that Prevalence of urinary incontinence in elite athletes and non- athletes was 29.6% and 14.4%; P < 0.001 respectively. Prevalence of eating disorder in elite athletes and non- athletes was 13.5% and 4.6%; P < 0.001 respectively. Urinary incontinence was associated with disordered eating only in the athletes. After adjustment for age, type of sport, Sports practice frequency (hours/week), athletes with disordered eating presented increased odds of urinary incontinence of any type over non-athletes (OR = 9.23; 95% CI: 0.93-90.8). The study concludes that athletes with disordered eating were three times more likely to present urinary incontinence than women without disordered eating.
According to the definition, Urinary incontinence (UI) is demarcated as “the complaint of any involuntary leakage of urine” and also has shown to be most common among athletes exclusively in sports involving high-impact activities [1].In this regardurinary incontinence (UI) is a delinquent among females, precisely causing a negative impact on their quality of life [2].
The most evident type of urinary incontinence seen in women is stress urinary incontinence (SUI), distinct as “involuntary loss of urine during coughing, sneezing, or physical exertion such as heavy lifting, sporting activities, or any sudden change of positions.” Comparatively, the other type of incontinence seen in women is urge urinary incontinence (UUI), demarcated as involuntary loss of urine associated with a sudden, strong desire to void (urgency), and can occur alone or in combination with SUI referred to as mixed incontinence [1].
The rate of prevalence of urinary incontinence is found to be between 10% and 56% in women aged between 15 and 64 years. Rate of prevalence were found to be lower when the ICS definitions of symptoms causing social and hygienic problems were introduced. despite vaginal delivery being the utmost evident risk factors for development of urinary incontinence its prevalence rate was high and proven in young nulliparous physically fit females. According to a study Bo et al, found that 26% of young physical education students had urinary leakage during different forms of physical activities [3].
And also, studies done on a large scale from Norway revealed Eating disorder (ED) prevalence rates is of over 30% for aesthetic sports athletes, 11% for ball game sports athletes and 5–9% for non athletes [4].In general, studies have proposed a higher frequency of eating problems in athletes than in nonathletes, particularly in athletes competing in sports that emphasize leanness or a low body weight [5].It has been postulated that hypothalamic amenorrhea attributable to intensive exercise, eating disorders, or a combination of both, resulting in low estrogen levels may contribute to urinary incontinence in female athletes. On the other hand, there is little evidence supporting the common belief that there is an association between low estrogen and prevalence of urinary incontinence [3].
Female elite athletes, in order to optimize body size and composition for competitive success, showed to have abnormal disordered eating attitudes and behavior’s such as, restrictive eating, fasting, frequent skipping meals, use of diet pills, laxatives, diuretics, enemas, overeating, binge-eating and purging. Which may indirectly result in lack of some important key macro and micro-nutrients, important for proper skeletal muscle function. Consequently, it can be assumed that disordered eating also may weaken skeletal muscles, including the pelvic floor muscles. And also, prevalence of disordered eating have been shown to be higher in female athletes compared to non-athletes. Regardless of an increased risk of both UI and disordered eating in female athletes, only few studies have showed the association between UI and disordered eating. Thus the purpose of this study is to evaluate the prevalence of urinary incontinence and its association with disordered eating in female elite athletes [1].
Project started after the grant of permission from the ethical committee members The subject included were divided into two groups; Group A-(50) – female elite athletes, Group B-(50) – female non- athletes. 50 elite female athletes (AG) aged 15–48 years, actively competing in their respective national teams for at least one year and who had reached an state, national or international competition level were included. A control group of 50 non-athlete females, exercising twice weekly or less were recruited in high schools, universities and public areas. Exclusion criteria were pregnancy at the time of the study or during the past year, any illnesses.
UI was assessed by the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF). The questionnaire includes three scored items. The first item assesses frequency of leakage (0, never to 5, all the time), the second item assesses amount of leakage (0, none to 6, a large amount) and, the third item determines the overall impact of UI on health related quality of life (a numeric scale is used, rang-ing from 0, not at all, to 10, a great deal). A fourth non-scored item asks about the patient’s perception of the type of leakage. Positive responses to involuntary loss of urine associated with coughing, sneezing, physical activity or exercise was classified as stress uri-nary incontinence (SUI). Involuntary loss of urine before reaching the toilet was classified as urgency urinary incontinence (UUI). The Eating Attitude Test-26 questions (EAT-26), is a self-report survey that is widely used and validated as a reliable screening tool for eating disorders in both adolescents and adults. The EAT-26 consists of 26 forced-choice Likert-scale items. Total scores on the EAT-26, ranging from 0 to 78, are derived as a sum of the composite items. A score that is 20 or a “yes” response to any of the four supplemental behavioral questions identifies disordered eating, is suggestive of an eating disorder, and is considered a positive screen.19 –21 A score more than equal to 20 has been shown to have a sensitivity of 88% and a specificity of 96% in diagnosing individuals with eating disorders-26. The retest reliability of the EAT-26 is high with an coefficient range of 0.84 to 0.94
Explain the two questionnaires to the subjects i.e, international classification of urinary incontinence (ICUI) and Eating Attitude Test-26 (EAT-26).The scores of the two questionnaires i.e, International Consultation on Incontinence Questionnaire (ICIQ-UI-SF) and Eating Attitude Test-26 (EAT-26) in elite female athletes was evaluated using Odds ratios with 95% confidence intervals (95% CI)
Statistical analyses were conducted using SPSS (IBM Corp. Released 2014. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.). Categorical data are presented as counts and proportions and continuous data as mean and standard deviation (SD). Chi-square test was used to test the independency between categorical variables. The magnitude of the association between urinary incontinence and disordered eating was estimated using odds ratio (OR) with 95% confidence intervals (CI) through binary logistic regression models. Estimates were adjusted for age, sports frequency, smoking and alcohol intake. Significance level was set at 0.05 for two-sided tests.
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24.54 (3.05) | 20.84 (2.02) | < 0.0001 |
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12.3 (6.0) | 3.6 (4.3) | <0.001 |
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35(70) | 05(10) | <0.0001 |
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05(10) | 08(16) | 0.2799 |
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05(10) | 07(14) | 0.2440 |
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48(96) | 19 (38) | <0.0001 |
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| 10 (20.8)15 (31.2) | 25 (52.0)02 (4.16) | <0.0001 | |
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<0.0001 | |
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| 01 (2.08)30 (62.5) | 04 (8.33)13 (27.0) | <0.0001 |
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| Ref. fig 118.75(3.60-97.4) | Ref. fig 213.2 (1.31-132.0) | Ref. fig 39.23 (0.93-90.8) |
The aim of our study was to evaluate urinary incontinence and its association with disordered eating in female elite athletes. Elite female athletes were 3 times more likely to present urinary incontinence than non- athletes without disordered eating.
And also, prevalence of any UI, SUI and UUI was found to be higher in elite female athletes. The prevalence of eating disorder was found to be higher in elite athletes than non-athletes.
Previous studies reported that, different trends of disordered eating prevalence were seen between female athletes from different sports.
Similar study reported that the prevalence rates of disordered eating in elite athletes vary from 3% in ball game[9] sports athletes to 32.2% in athletes competing in weight-sensitive sports [8]. The reason, for this wide range of prevalence of disordered eating described in the literature can be due to different sample sizes, type of sports included, use of different definitions, investigations at different seasons, investigators (coach, researchers), age groups and psychological factors [10].
Previous studies have hypothesizedthat disorders eating also may weaken the skeletal muscles, including the pelvic floor muscles due to the lack of some macro and micro-nutrients important for proper skeletal muscle functioning [8], consequently may result in UI in elite athletes.
Previous studies have reported that two studies, one in a small sample of female runners and another in a large sample of elite female athletes, found a higher prevalence of UI in athletes with disor-dered eating than in those with non-disordered eating. However, these studies did not report the magnitude of the association between UI and disordered eating and did not control for confound-ing factors.
Hence, in the present study, athletes with disordered eating presented 3 times higher odds of UI after adjusting for potential confounders, suggesting that disordered eating could play a role in UI in female athletes. The association of eating disorder with urinary incontinence can be well explained as high-level female elite athletes, lack proper nutrition in order to optimize body size and composition for competitive success, and results in abnormal eating attitudes such as, restrictive eating, fasting , frequent skipping of meal, use diet pills, laxatives, binge-eating and purging [6, 7].Which may compromise the intake of essential macro (carbohydrates, proteins) and micro-nutrients (vitamins B and D)21 needed to support proper skeletal muscle function. A suboptimal intake of carbohydrates could result in premature muscle glycogen depletion during train-ing and competition, leading to muscle fatigue. Also, the lack of some key micronutrients, such as iron, vitamin D and calcium have been referred to play an important role on skeletal muscle function. Striated muscles of the pelvic floor, including the ure-thral sphincter muscle, contribute to the urethral support system and increase in maximal urethral closure pressure during increases in intra-abdominal pressure [1]
Present study spreads awareness of urinary incontinence and disordered eating in elite female athletes. The association of disordered eating is strongly associated with urinary incontinence and hence further evaluation of PFM can also be studied,
Elite athletes presented a high prevalence of urinary incontinence. Athletes with disordered eating were 3 times more likely to report urinary incontinence than women without disordered eating. Both urinary incontinence and disordered eating can have a negative impact on the athletes “wellbeing”. We therefore recommend that elite female athletes should be screened for both UI and disordered eating. Prevention and treatment strategies for both conditions in female athletes should be evaluated in future studies.
The authors thanks all the women for their participation in this study, and the sports federations and coaches for their collaboration.
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