Findings from a web content analysis of resources targeting sporting coaches aimed at educating or upskilling on eating disorders and disordered eating in athletes

Background Eating disorders (ED) and disordered eating (DE) are highly prevalent in athletes. Coaches can play a role in the prevention of EDs and DE behaviours and are well placed to support athletes with an ED. However, coaches feel under-qualified and lack time and resources for supporting athletes and it is unclear the quality of training and resources available to upskill coaches in this space. Therefore, a web-based content analysis was undertaken to determine the type and source of online education resources currently available to coaches to help identify, prevent, manage and refer on for ED/DE behaviours. Methods Three major search engines were searched using a combination of the following terms: (1) DE or ED resource and (2) coaches or sport. Included websites were specific for DE/EDs in athletes; targeted at coaches or sporting organisations; written in the English language; and published by a reputable site. Results Twenty four out of 600 websites met inclusion criteria. The main reasons for exclusion were irreputable sites and websites not targeting coaches. The majority of included webpages were from professional bodies (n = 17) and targeted coaches (n = 24) and sporting organisations (n = 15), with an average quality rating of 4.2 out of 6. All websites provided educational resources but none provided official training. The most common topics discussed on these websites was ED/DE signs and symptoms (n = 17), and the effects of ED/DE on performance, mental and physical health (n = 11). Conclusion Few reputable online resources were identified in the current review. There is a need for more comprehensive education and training resources aimed at coaches and athletic organisations to help prevent, identify, manage and refer on for ED/DE behaviours. Supplementary Information The online version contains supplementary material available at 10.1186/s40337-021-00512-7.

Background Eating disorders (EDs) have one of the highest mortality rates of all mental illnesses worldwide [1]. Eating disorders are diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) [2], with criteria generally relating to restriction of energy intake or binge eating, fear of gaining weight or distorted body image, and/or compensatory behaviours such as purging or vomiting, laxative or diuretic use and excessive exercise. Over the past 20 years, the prevalence of EDs has increased globally with a point-prevalence of 7.8% between the period of 2013-2018, over double that of 2000-2006 [3]. In addition to EDs, rates of disordered eating (DE) behaviours that do not meet ED diagnostic thresholds, such as restricted eating, binge eating, and the use of laxatives or diuretics [4,5], are also increasing, with the prevalence of DE even higher than ED [6][7][8]. DE predisposes individuals to developing an ED so it is important to aim interventions at both DE and ED.
Athletes across a range of sports, particularly those that are aesthetic e.g. dance, or weight-dependent e.g. combat sports, are at an increased risk for developing ED or DE due to the strong focus on manipulating energy and nutrient intake for the purposes of making weight, manipulating body composition, and improving athletic performance [9]. The prevalence of EDs and DE is higher in both male and female athletes compared to the general population ranging from 6 to 45% in athletes compared to 3-15% of the general population [9]. Variations in DE within the athletic population can be mostly attributed to sex differences, type of sport (e.g. aesthetic, endurance, ball sports or weight dependent) and level of sport (pre-elite or elite) [7,[10][11][12]. Interestingly, some control populations do report higher prevalence of ED and DE than athletes [13,14], which may be due to athlete populations under-reporting EDs and DE due to the belief that their restrictive behaviours are the norm [15]. Therefore, appropriate prevention, identification, and management approaches within the sporting environment are essential to identify those at risk.
The behaviours associated with EDs and DE can lead to health complications affecting many body systems including cardiovascular, gastrointestinal, endocrine, and neurological [16,17]. Such complications may present as rapid weight loss, under-performing, fatigue, poor sleep, loss of menstrual cycle, low mood or irritability, and behavioural signs such as eating in secret [18]. EDs can also affect a person's ability to perform everyday tasks and maintain positive relationships with others which can adversely impact on their overall quality of life [19,20]. Health consequences such as electrolyte imbalances, dehydration, mental health issues, increased risks of illness and injury, and reduced training capacity, strength and endurance can all affect athletes specifically [21], as well as severe medical complications including risk of death.
Sporting coaches have frequent contact with athletes and their role within an athlete's sporting experience is key to their performance and health outcomes [22]. This places coaches in an ideal position to identify and support athletes with DE or EDs [23]. Additionally, coaches can play a preventative role by encouraging positive body image ideals [24,25] and providing education opportunities for their athletes regarding appropriate nutrition [26]. This is an important role given that body dissatisfaction and weight control behaviours such as dieting are among the strongest contributing risk factors to the development of eating disorders. Evidence has shown that education needs to focus on reducing weight stigma, promoting healthy conversations about weight and eating behaviours, educating about potential health and performance consequences, and how to identify and refer at-risk athletes [27]. However, professional development in EDs and supporting athletes with ED or DE is often not a mandatory part of gaining coaching qualifications [23]. Additionally, coaches often lack time and resources to attend additional training or apply screening procedures [23,28]. Likewise, sporting organisations have roles in supporting athletes and coaches with respect to promoting a culture that supports healthy nutrition behaviours, positive body image and reducing stigma associated with DE by educating athletes and coaches [15,29].
There is a growing body of resources available on the internet aimed at educating sporting professionals and organisations on EDs and DE. While there is increasing use of the internet as a source of information, internet searches are currently unable to filter evidence-based nutrition information from pseudoscience [30]. This is concerning given that sporting coaches and organisations may not be equipped with the nutrition literacy to discriminate high quality nutrition and DE evidence. Therefore, it is important to investigate the type and quality of resources available online that target coaches and organisations with the goal of educating on DE and EDs and their associated risk factors.
Therefore, the primary aim of the current study was to undertake a web-based content analysis to determine the type and source of online education resources currently available to coaches to help identify, prevent, manage and refer on for ED and DE behaviours. A secondary aim was to evaluate the overall quality and content of these resources.

Website search
A website search was undertaken in December 2020, using a structured protocol developed by the research team, informed by previous studies [31,32]. The search included three primary search engines (Google, Yahoo and Bing). These three search engines were used to allow a broad scope of websites and to ensure a complete review of content for those looking for information or support in the area of DE and EDs in athletes. In addition, a comparative analysis of search engines stated that Google, Yahoo and Bing were the most utilised search engines [33]. This study reported that directories (a collection of human reviewed websites arranged by topic) can impact the search results on each engine and when using different search engines, the results are varied in each search. For this reason, it was important that three search engines were used.
The search terms for the website review included two sets of terms used in combination: [1] disordered eating resource or eating disorder resource and (2) coaches or sport. These search terms were informed by pilot searches and chosen as they were in line with what coaches or organisations would likely search.
To be included in the web content analysis, the website resources needed to meet the following criteria: (1) The website needed to be specific for DE and EDs in athletes including information about identification, prevention, management, and referral; (2) targeted at coaches or sporting organisations; and (3) written in the English language. All levels of sport (i.e. recreational, collegiate, and competitive) for individual and team athletes were included. Only resources published by a reputable site were included in the review including sporting organisations, health organisations or an individual provider such as an Accredited Practising Dietitian, Psychologist or Medical practitioner.
Exclusion criteria were: blogs that were not from reputable sources, journal articles, commercial websites, paid advertisement and gym publications, and websites that were not specific to EDs and DE in athletes. Blogs and gym publications were first screened to determine if the information was provided by an individual with a suitable health-related qualification e.g. medical practitioner, dietitian or psychologist, before determining eligibility in the review. Those written by health or fitness organisations were not included if they were not written by an author with a health-related qualification. Journal articles were excluded as the aim of the study was to identify freely available, consumer resources rather than academic-focussed publications.
A pilot search was conducted to determine the number of websites that would be included in the screening for each search. The first 50 results were screened during the pilot test. From this it was determined that only the first 20 websites would be included in the screening process as after the first two pages no websites met the inclusion criteria. This allowed screening to be consistent with other website analysis papers which have noted that it was rare for an individual to search past the first two pages [31]. Google was searched first and then the same search strategy replicated in Yahoo and Bing. A second researcher completed a quality check of the search to ensure no websites were missed by replicating 25% of the search terms on all three search engines.

Data extraction
Data extraction was performed by two reviewers (SG and RG) using an extraction template developed specifically for the purpose of the current review by the research team. The type of data extracted included: website description, title information, a summary of information, qualification, origin, type of information, resource description, target reader and referral pathways. The data extraction template was piloted using the first five websites and modifications were made to the data extraction template following review by the research team. Data extraction was then completed for all remaining websites and checked by a third reviewer for any discrepancies.

Critical appraisal
Included websites were critically appraised using the JBI Critical Appraisal Checklist for Text and Opinion Papers for grey literature [34]. This tool includes six quality assessment statements including items relating to the source and references to existing literature. Websites that satisfied greater than 50% of the quality assessment items (i.e. had a score of four or more out of six) were classed as adequate quality and those which scored three or less were deemed inadequate quality.

Data synthesis
Once the website review was completed and data extracted, data was synthesised descriptively and reported as a narrative review using summary statistics only. This included number and proportion of resources and reporting of narrative data such as type of resource or qualification of author.

Results
The initial search identified 600 websites. Following de-duplication, 24 met the inclusion criteria and were included in the data extraction phase (refer to Fig. 1). Most of the search findings that were excluded were either peer-reviewed journal articles, general blog articles or were not authored by a health professional deemed qualified to educate or upskill on eating disorders. Common websites that were identified as duplicates from the searches on Google, Yahoo and Bing included: National Eating Disorders Association (NEDA), National Eating Disorders Collaboration (NEDC), the Australian Institute of Sport (AIS), Sports Dietitians Australia (SDA), and UK Sport.
The authors of the majority of websites were professional bodies (n = 17), including the NEDC, AIS, SDA, the National Collegiate Athletic Association and the British Association of Sport and Exercise Medicine. Other authors included psychologists (n = 4), doctors (n = 1), exercise physiologists (n = 2), dietitians (n = 1), and counsellors (n = 1) (see Table 1). Only websites from three countries met inclusion criteria, these included the USA (n = 15), Australia (n = 7) and the UK (n = 2). All included websites targeted coaches, while 15 websites targeted organisations as well as coaches (Table 1). No websites were targeted to sporting organisations only.
The quality assurance check identified that twenty of the 24 included websites were scored as adequate, with scores ranging from 3 to 6 (mean 4.2) refer to Additional file 1. The main reasons for lower quality scores was not naming an author(s) (n = 16) and no reference to the existing literature through a reference list (n = 17). Question 6 on the checklist was marked as yes for all, as none of the websites provided any information that was incongruence with the existing literature, therefore no defence of incongruence was needed. Those of higher quality clearly identified the source of the opinion and the source had good standing in the field of eating disorders. Higher quality websites also ensured the interests of the relevant population were the central focus of the opinion, had strong logic in the opinion expressed and made reference to the extant literature.
All websites provided a written resource; however, some websites also provided additional resources (Table 1) including an infographic (n = 2), or a Youtube video (n = 2). The information provided on websites was most commonly presented as a webpage only (n = 14), a downloadable resource e.g. a PDF or infographic (n = 6), a toolkit (n = 3), or a YouTube video (n = 2). All websites (n = 24) provided educational resources; with one also providing an interactive resource and one a skill building resource. The content covered across websites was varied (Fig. 2). The most commonly covered topics on ED and/or DE included: signs and symptoms (n = 17); the effects of ED/ DE on performance, mental and physical health (n = 11); definitions of ED/DE (n = 10); risk factors (n = 6); athlete-specific related risk factors (n = 8) treatment (n = 7); and where to learn more (n = 7). Some websites specifically focused on information for coaches and sporting communities and included topics such as: the role of the coach (n = 9); how to respond and communicate to athletes about ED (n = 9); education and advice for coaches (n = 2); and how to promote a healthy sport system (n = 4). Only a fifth (n = 5) of the websites provided sex-specific risks; all other websites were targeted at males and females together. Other websites focused on more sport specific conditions such as relative energy deficiency in sport (RED-S) (n = 2), and low energy availability (LEA) (n = 1). Only one website targeted its content toward aesthetic sports specifically, with all other websites targeting athletes in general. A detailed summary of the target reader and content included can be found in Table 2.
The majority (n = 19) of websites provided brief information to coaches and organisations on ED and DE characteristics. These resources were short, succinct and primarily used dot points to summarise information. However, five of the websites provided a greater quantity of information through a PDF style manual or Pow-erPoint presentation. These types of resources would be more time and labour intensive for coaches and organisations to review; however, offered more comprehensive insights.
Almost all of the websites included reference to additional resources or support including linking to ED screening questionnaires, links to organisations which provide assistance/support or names of websites and organisations providing further information, such as referral options for athletes. Included websites also linked to printable resources and over half included a health professional referral for coaches and organisations who were concerned about an athlete, which included dietitians, doctors, counsellors, nurses and psychologists.

Discussion
The current web-review is the first to investigate the availability of, and content within, online education resources targeted at coaches to help identify, prevent, manage and refer on for ED and DE behaviours. This website content review found that while there are some credible online    Of the total number of websites identified in the initial search, only a small percentage (4%) were considered suitable for inclusion in this web-content analysis, namely, was suitable for a consumer population and was authored by a reputable individual or organisation. Considering the prevalence of ED and DE in athletes and the role that coaches and organisations can play in the prevention, identification and management of these conditions [23], the lack of evidence-based, consumer friendly, credible resources and websites is a major gap in the area of ED education. Of the resources that were included in this review, many would be suitable resources for sporting organisations to provide their coaches to improve their awareness of the signs and symptoms of ED and DE. Due to the plethora of web-based information where it may be difficult to identify sources of pseudo nutrition, it is recommended that coaches and sporting organisations identify reputable resources and websites by identifying reputable organisations such as SDA, NEDC and NEDA, or qualified professionals such as medical professionals, psychologists or dietitians, who are qualified to provide information on this topic. A strength of the currently available resources is that most of the resources included in this review were rated as adequate quality. However, future resources could improve their quality by clearly identifying the source of the content (author) and making reference to peer-reviewed literature. It is also recommended that these resources be easily accessible with further focus on important information regarding prevention and screening which were covered only in a handful of websites.
While educating coaches on signs and symptoms of ED or DE was a common theme, few resources included information on how to formally screen for EDs and only half included information on how to refer to a healthcare professional, such as a doctor, psychologist or dietitian, if an athlete identified as being at risk of an ED. This is important to include in resources of this kind to assist coaches and organisations to take action for athletes they are concerned about. It is also significant as early identification and treatment is associated with more optimal treatment outcomes [35,36]. A survey of collegiate coaches in the US identified that coaches most commonly refer to sports medicine personnel within the team, such as athletic trainers or a team physician, rather than refer externally. These team personnel may or may not be trained to manage ED or DE thus influencing the potential management provided [23]. In contrast, a survey of high school coaches in the US identified that 50% or more of coaches would choose to talk with the athlete first or contact the athletes parents prior to referral [37]. In addition, a survey of coaches from the UK identified some disparities in coaches approaches to managing athletes with ED or DE [38], with some involved in the referral of athletes to healthcare professionals while others perceived it was not part of their role. The variable findings in referral and management procedures suggest that coaches and organisations require further support and education regarding the identification of, and referral for, ED and DE [39,40]. Despite this, resources retrieved in the current review did not provide sufficient information on this topic.
The majority of resources in this web-review provided brief written information on ED and DE. Time has previously been identified as a barrier for coaches to attend further training or undertake further education on ED [28]. Therefore, there are benefits to having brief resources available to educate coaches and sporting organisations on ED and DE. However, for coaches and sporting organisations to obtain a thorough understanding of EDs, including risk factors, physical, mental and performance consequences, and the appropriate screening, communication and referral pathways for EDs, resources need to extend beyond brief written resources. The DE in high performance sport position statement that was released by the AIS and the NEDC proposes that education programs should have multiple targets e.g. coaches, support staff members and athletes, and should be an initial comprehensive education program followed by regular refresher education sessions. Despite this, none of the resources identified in this review provided comprehensive education or training programs, highlighting the urgency for growth in this space if we are to make progress with reducing the prevalence of EDs and DE in sport. Future research including qualitative approaches should assess the needs of coaches and sporting organisations regarding ED education and training to identify the best approaches and information to provide. This should include exploration of the barriers and facilitators to education to appropriately tailor training and resources to the needs of the population.
The higher prevalence of ED and DE in athletes has previously been identified [9], highlighting the need for a cultural shift to occur within sporting organisations as a whole and not just rely on coaches to seek out information themselves. Of the resources identified in this review, no single resource provided sufficient detail about what kind of information is required by organisations and coaches to help with the prevention, identification and management of DE in athletes. Future research should work with organisations and coaches to identify potential barriers and facilitators to change within the system. Additionally, more resources are required to be targeted at the organisational level as it is not only the individual responsibility of coaches, but the whole organisation, to support athletes as well as coaching staff.
There are several strengths to the current review. Firstly, this is a novel study as it is the first of its kind to explore what easily accessible resources are available to coaches and sporting organisations to help them support athletes with ED and DE. This review was modelled from previous web content analysis methodologies and used a systematic approach. It also provides novel insights into the need for more comprehensive education and training to become available for coaches and for sporting organisations to create more supportive environments for the prevention and support of athletes with ED and DE. The limitations of the current review include the restriction to English language only, this may have affected the searches and limited the countries of origin of the websites included. This may mean that the results are not generalisable to countries outside the US, UK and Australia. Only websites deemed reputable were included, this may have resulted in some bias.

Conclusions
This review identified few reputable online resources for coaches and organisations in the area of eating disorders. Overall, there is a need for more comprehensive education and training resources for coaches and for organisations to help them support athletes with an ED or athletes displaying DE behaviours. Findings from the current review have identified the need for further investigation and discussions with coaches and organisations to determine what information they require, the preferred format of education and training and any barriers and facilitators to implementation. Organisations and health professionals need to be responsive to the needs of coaches to develop appropriate ED and DE resources to further facilitate change in this area.