Article Text

Cultural and environmental associations with body image, diet and well-being in NCAA DI female distance runners: a qualitative analysis
  1. Traci Lyn Carson1,
  2. Troy Tournat1,
  3. Kendrin Sonneville2,
  4. Ronald F Zernicke3,
  5. Carrie Karvonen-Gutierrez1
  1. 1 Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
  2. 2 Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
  3. 3 School of Kinesiology, University of Michigan, Ann Arbor, Michigan, USA
  1. Correspondence to Ms Traci Lyn Carson, University of Michigan School of Public Health, Ann Arbor, Michigan, USA; tlcars{at}


Objective We aimed to describe current and former National Collegiate Athletic Association (NCAA) Division One (DI) female distance runners’ experiences of perceived norms of body image and disordered eating in their sport, as well as the emergence and influence of coach–athlete power dynamics.

This manuscript reports a qualitative research study (consisting of interviews and thematic analysis) of women athletes’ experiences of perceived norms of body image and disordered eating in their sport. We also report athletes’ experiences of coach–athlete power dynamics.

Methods The study sample included 29 current and former female NCAA DI female distance runners, defined as competing in 800-metre distance or greater. Interviews were conducted, audio-recorded and hand transcribed. A thematic analysis was performed and presented.

Results Two major themes emerged: (1) sport body ideals and body image norms and myths that exist in the sport, and (2) the power dynamic between athletes and coaches. It is not clear whether sport body ideals and culture of running influences coaching culture, or whether the coaches—who maintain positions of power in the sport—perpetuate the culture. These themes likely feed into each other and reinforce the existing and dominant mentalities of the sport.

Conclusion Sport body image ideals and the power dynamic between coach and athlete may contribute to female athlete’s risk of disordered eating and body image disturbance. We call for the NCAA and athletic departments to develop and implement prevention and intervention programmes to prevent eating and body image disorders in this high-risk population.

  • eating disorder
  • female athlete triad
  • running
  • women in sport
  • qualitative

Statistics from


Over 15 000 women compete in National Collegiate Athletic Association (NCAA) Cross Country, with about 6000 competing at the division one (DI) level.1 Although the culture of corruption and maltreatment in elite female running has recently gained national media attention,2 research on the health status of female runners has been of interest since the 1970s, following the significant rise in female sport participation following the 1972 introduction of Title IX. Female distance runners experience a high risk of low energy availability (LEA), with or without disordered eating.3–7 The syndrome of Relative Energy Deficiency in Sport (RED-S) is recognised in the athlete population and physiological and psychological functioning caused by LEA in athletes.8Female distance runners continue to experience high risk of relative energy deficiency, due to the significant training volume and body weight pressures of the sport.9 While disordered eating is not prerequisite for relative energy deficiency, the prevalence of disordered eating among female runners is twice as high as non-athlete peers, ranging from 33% to 50% versus 8% to 17%, respectively.10–12 The epidemiology of RED-S is not well understood, in part due to organisational limitations on accessing this populations of athletes for research purposes.

The purpose of this study was to describe NCAA (DI) female distance runners’ experiences of perceived body image norms and disordered eating in their sport, as well as to capture athletes’ perceptions on coach–athlete power dynamics.

Methods and analysis

Note that more detailed methods (and results) are available as a web supplement (online supplemental appendix).

Supplemental material

Study sample

The study sample included 29 current and former female NCAA DI female distance (≥800 m) runners. Women were recruited through social media and email listservs, participants were aged ≥18, had to have participated in at least one full season of cross country or track and field at a DI institution and screened at risk of an eating disorder and/or the Female Athlete Triad. Runners currently undergoing inpatient treatment for an eating disorder and/or other psychological disorders and runners not fluent in English based on self-reported data were excluded from the study. Eligible women who did not participate (n=30) had similar average Low Energy Availability in Female Athletes Questionnaire (LEAF-Q) and Female Athlete Screening Tool (FAST) scores compared, to the total eligible sample (table 1). In-person and video interviews (lasting about 1 hour) were audio-recorded and hand transcribed (table 2). This study was approved by the University of Michigan Institutional Review Board.

Table 1

Interview data

Table 2

Example questions


Thematic analysis and codebook development

We used thematic analysis as a theoretically flexible method to organise, describe and interpret the data.13 Transcripts were read and reread13 and a codebook was created. Transcripts were double coded and coding discrepancies were reviewed until agreement was reached. ID numbers are used in the results section to identify block quotes and exact phrases by participants.


Note that more detailed results are available as a web supplement (online supplemental appendix 1).


The sample for this study includes 29 current and former NCAA DI female distance runners with a mean age of 24.6 years (range: 18–36) and representing 19 universities across the nation.


Two primary themes with subthemes emerged: (1) body ideals, norms and myths in the sport, and (2) the coach–athlete power dynamic, as it pertains to body and performance ideals and expectations. Additional subtheme content is included as online supplemental material.

Theme 1: sport body ideals

Women felt the sport of cross country and long-distance running had a deep and unspoken culture that supports the pursuit of thinness and pushing the body to extreme, unhealthy limits and that encourages restrictive eating and training that exceeded ‘healthy’ in pursuit of the perfect ‘runner body’ image and sport performance. Two subthemes within the sport body ideals theme emerged: the ideal ‘runner body’, and the ‘lighter is faster’ mentality.

Ideal ‘runner body’

Cultural norms and cues about body image and performance were mentioned as triggers for restrictive eating and body image disturbance. Women spoke about the elusive ‘runner-body’ type, characterised by ‘skinny legs and smaller thighs, but that are muscular and skinny…6-pack type abs, flat abs and that is what people kind of imagine’ (ID 41). Women’s relationship with their physical bodies was mentally and emotionally complex. As elite distance runners, women felt that their physical bodies represented dedication to the sport through achievement of the ‘ideal’ physical aesthetic. As one woman described, ‘you see certain body types as being portrayed as more successful’ (ID 13). In a similar way, women appeared to think that their physical bodies communicated their success in this sport to the world; if they could achieve the ‘ideal body’ then they were worthy of respect in the sport. It was a common belief that women who were ‘tiny’ (ID 36) and ‘who have long skinny legs’ (ID 41) were the ones who embodied the ideal female distance runner aesthetic that would ensure success in the sport.

Many women expressed that the culture and environment of long-distance running contributed to their desire to achieve a perfect ‘runner body’ and to control food and exercise. Participants noted a complex and competing interest between body size and health and performance. One woman discussed ‘looking healthy but thin’ versus ‘skinny’ (ID 18), and explained, ‘she (competitor) has a really big problem if she lost too much weight, but if it was not too much and she still looked healthy, then it was praised’ (ID 18). This ‘runner-body’ archetype had many overlapping features with the cultural ‘thin ideal’, that emphasises thinness, with the addition of lean muscle.14 15 Despite this distinction from the cultural body ideal, female athletes were not immune to structural and cultural-level messages that promoted thinness.

‘Lighter is faster’ mentality

Entangled with the notion of the ideal ‘runner body’ is the false belief that lower body weight positively correlates with improved sport performance. This idea is represented in the mantra ‘lighter is faster’ and reinforces the runner ‘body ideal’.

Interestingly, the idea that ‘lighter is faster’ appeared to emerge around puberty, the time of natural body weight and shape changes. This topic brought up discomfort and feelings of fear around that period of physical development, which often coincided with their adolescent weight gain. As one woman shared, ‘A lot of people have personal experience with that (ie, belief that lighter is faster); a lot of girls who are 11 or 12 are really fast, and you think you are going to get faster and you don’t’ (ID 53). One woman described her personal take on running performance and weight gain during puberty:

I felt like it was too early…that it reinforced a belief or idea that being that pre-pubescent state made you fast. It seemed with a lot of those girls, once they grew into their bodies, or once they actually went through puberty, they weren’t as fast, and I felt like that was even detrimental to my view on how things should be. (ID 41)

Discussions about ‘lighter is faster’ elicited a defensive reaction in some participants, and many described the physics of running and cited the inverse, that higher body weight correlated with slowness. Others understood the limitations of the ‘lighter is faster’ mentality, or as one woman noted ‘it’s only true to a point’ (ID 47). Further, many women realised that this idea was short-sighted, having witnessed the subsequent performance downfall related to long-term undereating and over exercise. One woman shared, ‘…you lose weight and start running better for a while, until you break. Until something breaks down physically or your body no longer has enough energy’ (ID 37). Another participant said, ‘…it is such a short-lived time that that makes you faster’ (ID 30).

The majority of the participants felt that they did not embody this unattainable ideal ‘runner body’ and had failed to reach full performance potential because they could not achieve this aesthetic. Further, it was clear that ‘lighter is faster’ was learnt early in women’s running careers and continued to be a pervasive belief throughout their running careers.

Theme 2: the coach–athlete relationship and power dynamic

Compared with coaches earlier in life, women described their collegiate coaching relationships in a more serious tone, revealing the intensity and ‘business-like’ environment of NCAA DI athletics. We identified two subthemes: Coaches Control and Body and Food Comments.

Coaches control

Concurrent with the need for validation and attention from coaches, it was clear that in many cases, this dynamic with collegiate coaches contributed to psychological harm and distress on the team. As noted above, the mentality of pursuing excellence at any cost was not limited to the individuals, but also observed in coach behaviour. One athlete described how it was common for a coach to prioritise team performance over the health of individual athletes, including situations where coaches knowingly allowed athletes struggling with disordered eating to continue competing, despite the harm it may have caused that woman:

Yeah, there is definitely an unhealthy thread through the running community in general…It is kind of known, I don’t know how true it is or not, that some teams have worse issues with the eating disorders than others, depends who the coach is, if they are running fine, they let it happen….I am more bothered by people who are in positions of power that see it and let it happen and don’t care about the health of the athlete, because they are competing well. (ID 43)

Women experienced this power dynamic by feeling that their running career was in the hands of coaches, describing ‘…fear or pressure to perform very well very quickly’ (ID 2), explaining that, ‘if you were doing really well you got a lot of positive feedback, you were really elevated and given a lot of attention; and when you weren’t, you were treated as if you weren’t trying hard enough…being in that environment makes you feel a little crazy’ (ID 2). Another woman echoed this saying, ‘they [coaches] still didn’t think that I was enough, like they still felt I wasn’t disciplined and still felt that I didn’t care enough’ (ID 18). Another woman added that ‘…his [the coach’s] relationship with everyone was distant, I felt like everyone was trying to win his approval, it was really hard to ever win his approval. That is kind of how it was with him’ (ID 30).

The impact of coaches on athlete’s mental health and well-being was substantial, leading some women to leave their teams and the sport entirely. It is clear that some coaches created a communication barrier with athletes as a way to influence athlete behaviour and maintain power and influence.

Body and food comments

In the coach–athlete relationship, body weight and shape pressures were a driving narrative. Body weight comments, combined with high pressure to gain coaches’ approval, contributed to women’s feelings of high anxiety around coaches. One athlete described the harmful environment created by the coaching staff on her college team:

The coaches there are really into, put a big emphasis on weight, especially the women; I don’t know why. Reinforcement of — if you were smaller you will be faster, it was pounded into us from day 1, and a lot of the girls on my team experienced disordered eating patterns. (ID 30)

One athlete even said, on retrospect, she probably would not have gone to her university because of the harmful body comments made by her coaches (ID 11). Athletes shared stories of ‘really awful stuff’ they heard of and witnessed; one woman reported hearing a coach say, ‘…if you jump up in the mirror you shouldn’t see anything moving’ (ID 53), another athlete said that her coach ‘sat down and told us (my team) we had a weight issue…and we all needed to push to be below 14% body fat’ (ID 43).

One athlete felt that she was able to avoid direct criticism from her coach because she was ‘small enough’, and therefore, she was ‘never the brunt of her [coach’s] wrath in terms of body size’ (ID 9). Other athletes received direct pressure to stay lean from coaches, with one athlete explaining, ‘he (head coach) sat me down before winter break and was like, ‘I am afraid you are going to gain weight over Christmas…’’ (ID 30). This same athlete added that her assistant coach also emphasised body shape, making comments about competitors’ body weight, saying things like ‘…oh look at her, she’s thick, and look at her, she’s really thin’ (ID 30).

Women reported shame tactics used by coaches to monitor athlete’s food intake by controlling meals and food choices, especially while travelling for competition. Women described examples of verbal and physical control by coaches to shame eating behaviours. One athlete described:

We would be out to eat for a meet or something out of town, if we would order something she didn’t approve of she would change our order for us or take stuff off our plates we weren’t allowed to eat. You had to be careful around campus, if she saw you eating somewhere she didn’t think was good, she would say something for sure. (ID 43)

Coaches used control over food and body image as an attempt to control team performance but may not have recognised the true harm in that approach. Overall, the coach–athlete power dynamic created an environment where women sought approval from coaches to validate recognition of their hard work; this was detrimental to athlete’s mental health and emotional security. Coaches used that to their advantage and withheld communication and attempted to influence body weight and size as a means to achieve desired performance outcomes.


Two major themes emerged from this research: (1) sport body ideals, body image norms and myths that persist in the sport, and (2) the coach–athlete power dynamic. It is not clear whether sport body ideals and the culture of running influences coaching culture, or if the coaches, who maintain positions of power in the sport, perpetuate the culture. These themes likely feed into each other and reinforce the existing and dominant mentalities of the sport.

It was evident that participants felt the sport of cross country had and continues to have cultural ideals and values that encouraged the pursuit of body ideals that are often harmful for athletes and that these ideals are exacerbated by power dynamics with coaches.

The emergence of the ideal ‘runner body’ subtheme is consistent with previous studies on eating disorder risk factors in female athletes.9 14 Sherman and Thompson emphasised that body type ideals may be heightened among elite athletes, as they often embody perfectionist attitudes that extend to their physical bodies.9 Most women expressed that the norm in the running community was to strive for both thinness and strength for sport performance and held the achievement of the largely unattainable runner body ideal as a perquisite to success. Further, Markula described this female athlete body paradox as a ‘series of contradictions’, where women are expected to be ‘firm but shapely, fit but sexy, strong but thin’.16 To achieve this ‘series of contradictions’, female athletes are put at risk of employing a combination of unhealthy and physiologically harmful tactics, including undereating, diet plans and exercise beyond what is required of their sport training.17 18

Importantly, our data showed that the ‘lighter is faster’ idea was learnt early on in women’s lives, including around the time of puberty, a vital period of development characterised by natural body weight and shape changes.

The coach–athlete relationship warrants immediate attention in the sport community. While the majority of women described a positive relationship with their high-school coaches, many women described relationships with their college coaches as tumultuous and anxiety provoking. The collegiate coach–athlete relationship appeared to have a business-like tone that was focused on performance outcomes and women reported a troubling level of emotional manipulation from college coaches, while simultaneously seeking the validation from these coaches. These findings support the need for continued attention to safeguarding in sport, which recognises negative influences on athlete health, well-being and integrity caused by non-accidental violence through harassment and abuse.19

One important source of psychological stress stemmed from athletes’ desire to gain praise and validation from college coaches in a way that was closely tied to athletes’ sense of self-worth. Our findings clearly showed that many collegiate coaches caused psychological harm to their athletes, including serious distress for many women. These experiences signal the critical need for structural changes in coaching mentality, and resources and psychological support services for athletes are warranted.

Further, coach’s comments about body weight and shape added additional pressures to women, regardless of whether they were the direct target of these comments. Body weight and food-related comments were a major source of resentment towards their coach and these comments contributed to a harmful team environment.20 21 Importantly, such comments were reported to be incredibly influential on an athletes’ eating and exercise behaviours.14 The 2016 IOC consensus statement: Harassment and abuse (non-accidental violence) in sport identified the coach and athlete power differential as a context that enables such harassment and abuse, and this was clearly exemplified in this sample of NCAA DI runners.19

The (IOC) consensus statement calls for urgent policy initiatives that illuminate clear mechanisms of action to prevent non-accidental violence of athletes, calling on stakeholders in sport to implement and monitor ‘safe sport’, or an ‘athletic environment that is respectful, equitable and free from all forms of non-accidental violence to athletes’.19 This IOC statement states that safe sport is a basic right of every athlete. The women in our study demonstrated how their safety and health was often not prioritised, particularly in instances of food and body weight policing. Notably, the IOC statement does not suggest appropriate consequences for perpetrators of athlete harassment and abuse, or address concerns of retaliation for athletes who report these acts. This is a great concern, as demonstrated by recent happenings in USA Gymnastics and the case of Mary Cain.2 Clear and consistent policies and regulations, as well as safe and accountable mechanisms of reporting concerns, are necessary to ensure athlete safety and well-being is consistent across collegiate institutions. There is an urgent need for higher-level systemic and structural changes, within and beyond sport, to enable the prioritisation of athlete health and well-being over monetary incentives.

Strengths and limitations

This is the first qualitative study to investigate factors associated with the onset of disordered eating and body image, and resulting psychological and physical health consequences, in NCAA DI female distance runners. Strengths of this study include the use of validated screening surveys, transcription of interviews by hand to minimise errors of software-based transcription services and double coding of all transcripts.

We acknowledge at least four limitations of the study. The study sample included a convenience sample of women; however, despite this, women represented 19 colleges and universities from diverse geographic regions of the USA. Given the investment of time for interviews, our sample size was modest, and it is possible that women with more severe experience with the topics of interest may have been more motivated to share their experiences and participate in the interview. Future research should include a more diverse sample of athlete experiences based on population-based samples. As our sample included only women participating at the collegiate level at DI institutions, future research should be expanded to include athletes across collegiate sport divisions, as well as high school and postcollegiate distance runners.


The findings revealed that among female distance runners, body image norms and myths persist, and the power dynamic between coach and athlete may contribute to a female athlete’s risk of disordered eating and body image disturbance, resulting in adverse health consequences. We call for the NCAA and university athletic departments to develop and implement prevention and intervention programmes to prevent eating and body image disorders in this high-risk population.

What are the new findings?

  • Two major themes, sport body image ideals and the power dynamic between coach and athlete, were associated with athlete’s perceived risk of disordered eating and body image disturbance.

  • Female distance runners reported serious adverse physical and psychological health consequences in conjunction with disordered eating and intense training.

How might it impact on clinical practice in the near future?

  • Our study identified factors that should be considered by those who develop prevention and intervention programmes for athletes with eating and body image disorders.

  • Our study has the potential to contribute to how coaches, team leadership and other athletic staff communicate with athletes on the topic of eating disorders.


I acknowledge doctoral committee members Sioban Harlow, Philippa Clarke and Brady West for their comments and feedback on the manuscript. Also, thank you to Emily Zheutlin and Halimat Olaniyan for their assistance with the interview transcription. My sincere thanks to all of the participants who shared their stories and made this research possible.


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Twitter @traci_Ccrson

  • Contributors The first author, TC, completed all data collection and the majority of writing of this manuscript. All coauthors contributed substantially to the conception and design of the study, provided important revisions and approved the manuscript. All authors understand that they are accountable for all aspects of the work and ensure the accuracy or integrity of this manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the University of Michigan Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Please contact Traci Carson ( for inquiries about this qualitative dataset.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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