The Australian Institute of Sport (AIS) and National Eating Disorders Collaboration (NEDC) position statement on disordered eating in high performance sport

The impact of low energy availability risk on pre-competition physiological function in Chinese female combat athletes

BACKGROUND

Low energy availability (LEA) can negatively impact athletes' physiological function and performance. This study aims to examine the prevalence of LEA in Chinese female combat athletes and monitor changes in physiological function and performance during the pre-competition period.

METHOD

We assessed the incidence of low energy availability (LEA) and eating disorder (ED) risks in 84 female combat athletes (judo, freestyle wrestling, and sanda) from Beijing using the Low Energy Availability in Females Questionnaire (LEAF-Q) and the Eating Disorder Examination Questionnaire (EDE-Q). From this group, 11 judo athletes who were preparing for competition were selected and divided into a low energy availability (LEA) group and a non-LEA group based on their energy availability levels. Dietary intake, training energy expenditure, body composition, resting metabolic rate, blood markers, and special judo fitness tests were monitored at 4 weeks, 2 weeks, and 0 weeks before the competition.

RESULTS

Among the 84 athletes, 45.2% of athletes (n = 38) were at increased risk of LEA, and 21.4% of athletes (n = 18) were classified as high in eating disorder risk. There were no significant differences in LEA and ED risk between elite and recreational athletes. Among the 11 athletes preparing for competition, 6 athletes (45.5%) were in a state of LEA at the initial stage (4 weeks before the competition), and by the competition week, all 11 athletes exhibited LEA. Additionally, athletes in the LEA group experienced significant reductions in VO2 and resting metabolic rate at 0 week of the competition compared to 4 weeks prior (p < 0.05). Thyroid function indicators and IGF-1 levels of LEA group also significantly decreased (p < 0.05). After completing the four-week pre-competition weight loss, heart rate recovery during the special judo fitness test improved significantly in both the LEA and non-LEA groups (p < 0.05).

CONCLUSION

The current study identified a risk of LEA among Chinese female combat sport athletes, with no significant difference in the prevalence of LEA between elite and recreational athletes. It is essential for Chinese coaches and sports medicine staff to implement LEA-related nutritional education across all performance levels. Moreover, preventive measures during training are recommended to mitigate the impact of LEA on physiological function during the pre-competition weight loss phase.

Psychiatric treatment preferences of sports psychiatrists for athlete-patients across competitive levels: a 2024 update

OBJECTIVES

Only two small, prior studies ascertained psychiatric treatment preferences for athletes among sports psychiatrists. This study aims to build upon and update those results by describing comprehensive psychiatric treatment preferences and rationales for those preferences, across competitive levels of athletes, among practicing sports psychiatrists.

METHODS

In 2024, organizations with large concentrations of sports psychiatrists were provided an invitation regarding an anonymous, web-based survey on psychiatric treatment preferences in working with athletes with mental health symptoms and disorders.

RESULTS

Seventy-five respondents who identified as psychiatrists or psychiatrists in training and who had treated athlete-patients within the past 3 years completed the survey. Top choices of psychiatric medications for athletes included bupropion for depression without anxiety; escitalopram for depression with anxiety, generalized anxiety disorder, and social anxiety disorder; sertraline for obsessive-compulsive disorder, panic disorder, and post-traumatic stress disorder; melatonin for insomnia; methylphenidate extended release osmotic-controlled release oral delivery system for attention-deficit/hyperactivity disorder; aripiprazole for bipolar spectrum disorder (manic/hypomanic phase); lamotrigine for bipolar spectrum disorder (depressive and maintenance/prophylaxis phases); and aripiprazole for psychotic disorders. Regarding side effects, respondents reported being most concerned about sedation/somnolence, weight gain, and reduction in performance. The majority of respondents indicated they order a variety of medical evaluations at least as often or more often with athletes compared to non-athletes. The first choice of psychotherapy setting was individual psychotherapy, followed by family therapy, and then a tie between couples therapy and group therapy. The preferred type of psychotherapy was cognitive behavioral therapy followed by a tie among behavioral therapy, dialectical behavioral therapy, and mindfulness.

CONCLUSION

Sports psychiatrists tend to prefer medications that are relatively more energizing and less likely to cause weight gain. They undertake medical evaluations for their athlete-patients with relatively great frequency. Their preferred psychotherapy types are skills-based and can be completed within relatively short time-frames.

Integrative Field-Based Health and Performance Research: A Narrative Review on Experimental Methods and Logistics to Conduct Competition and Training Camp Studies in Athletes

Field-based sport research involves studies that collect data from athletes and/or teams during competition and/or their daily training environments. Over the last decade, sport-specific field-based research projects have significantly increased in number and complexity, partially owing to the further development of more portable measurement equipment (e.g., indirect calorimetry, desktop blood/gas analyzers, portable laboratories, etc.) and/or wearable or consumable technologies (e.g., smart watches, sensors, core temp pills, etc.). However, given these rapid advances and novelty, challenges remain in the validity and applicability of these devices. Unfortunately, there are no global ethical or best-practice standards for the use of portable devices and/or wearables in sport; however, this review will outline various opportunities and challenges. Many decision trade-offs are required when designing field-based research studies to balance gold-standard scientific rigor and strict research control with highly applied, but less-controlled, "real-world" conditions. To our knowledge, there are no narrative reviews that take a wholistic view of the logistical and methodological considerations of field-based research in athletes. Accordingly, this review takes a multi-disciplinary methodological approach (physiological, nutritional/energetic, biomechanical, musculoskeletal, cognitive, and psychosocial factors), along with the logistical considerations involved in project planning, research design, and ethics of field-based research with elite athletes and/or teams. We also provide practical guidance for characterizing the extreme demands of elite training and competition to support research that ultimately catalyzes improved understanding of the limits of human capacity. We hope this review can serve as a practical guide for researchers undertaking elite athlete field-based research.

Factors predicting disordered eating and the prevalence of eating disorders in adolescent elite athletes, trained athletes and a reference group: a prospective controlled two-step study

OBJECTIVE

To prospectively examine the prevalence of diagnosed eating disorders (ED-diagnosis), ED-symptoms and factors predicting ED-symptoms in three male and female high school student groups: elite athletes, trained athletes and a non-athlete reference group at baseline (T1) and 1-year follow-up (T2).

METHODS

A survey was administered at baseline (T1) (n=1186) and 1-year follow-up (T2) (n=1144) (step-one). Participants classified with ED-symptoms by the Eating Disorder Examination Questionnaire (EDEQ 6.0) at T2 were invited to a diagnostic interview (step-two).

RESULTS

Prevalence of ED-diagnosis for males and females were 6.9% and 9.3% in elite athletes, 5.9% and 11.2% in trained athletes and 3.0% and 11.9% in references, respectively. No group differences were statistically significant. Male references had more ED-symptoms compared with elite and trained male athletes (EDEQ-global score 0.81 vs <0.55), while elite female athletes had fewer ED-symptoms compared with trained female athletes and female references (EDEQ-global score 1.14 vs >1.59). Trained female athletes increased ED-symptoms over time, whereas elite female athletes consistently had fewer ED-symptoms in comparison. High ED-symptom presentation was predicted by high body mass index and more psychological distress in males, whereas for females, ED-symptoms were predicted by lower resilience, more psychological distress and being a non-athlete reference.

CONCLUSION

No statistically significant group differences in the prevalence of ED-diagnosis were observed between elite athletes, trained athletes and a non-athlete reference group. Female elite athletes had fewer ED-symptoms compared with other female groups, and male references had more ED-symptoms compared with male athlete groups. Preventive measures that address psychological resilience and distress should be considered.

TRIAL REGISTRATION NUMBER

NCT04003675.

Case Report: From disordered eating to an eating disorder-a case study of an orienteering athlete with anorexia nervosa and the shortcomings of the multidisciplinary approach

This case study explores the transition from disordered eating (DE) to an eating disorder (ED) in a 23-year-old female orienteer. Despite her talent as an athlete, her eating habits and training practices led to significant health concerns. After following an ovo-lacto vegetarian diet for 3 years, she exhibited symptoms of DE, including low energy intake (1,200 kcal/day), low body weight (50.1 kg, BMI: 16.9), and amenorrhea. Her condition deteriorated over 2 years, resulting in a diagnosis of anorexia nervosa (AN) by February 2023. During the treatment process, the athlete utilized a multidisciplinary approach that included dietitians, psychologists, and physicians. Despite achieving some initial progress, including a slight increase in body weight and the return of menstruation in July 2022, her health declined after psychological consultations were halted, leading to a further decrease in body fat and persistent low serum iron levels. This case highlights the importance of continuous monitoring, timely intervention, and a coordinated multidisciplinary team in addressing DE and ED in athletes. It also highlights the significance of effective communication among healthcare professionals and the need for comprehensive treatment strategies that include psychological, nutritional, and medical support. This study highlights the significance of early detection, suitable intervention, and the prevention of long-term health complications, such as decreased bone density and cardiovascular issues, in athletes with DE and ED.

Diet, risk of disordered eating and running-related injury in adult distance runners: A systematic review and meta-analysis of prospective cohort studies

OBJECTIVES

To determine whether diet and disordered eating risk contribute to running-related injury risk in adult (≥18 years) distance runners.

DESIGN

Systematic review and meta-analysis.

METHODS

Random effects meta-analyses of prospective cohort studies compared dietary intake and disordered eating risk in distance runners with and without running-related injury. Quality of evidence was assessed using an adapted Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Fifteen studies (n = 5942 runners, 2364 female) were included, with nine studies in the meta-analyses. Sex differences were observed for total energy and total fat intake (both p = 0.01). Moderate certainty evidence indicated injured female runners had lower energy and fat intake than uninjured runners (mean difference [95 % confidence interval] = -449 kcal/day [-696, -202] and -20 g/day [-31, -9], respectively, both p < 0.001). Moderate certainty evidence suggested injured runners (combined sexes) had lower dietary fibre intake compared to uninjured runners (-3 g/day [-5, -0], p = 0.04). Other dietary factors (protein, carbohydrate, calcium, alcohol intake and disordered eating risk) did not influence injury risk (low-moderate certainty evidence).

CONCLUSIONS

Moderate certainty evidence indicates female distance runners with lower energy and total fat intakes are at increased risk of running-related injury, as are runners (combined sexes) with lower dietary fibre intake. Future research should include long duration, high quality prospective cohort studies in male and female runners with clearly defined athletic abilities, consistent injury definition, and standardised statistical analyses.

REVIEW REGISTRATION

PROSPERO # CRD42022323627.

Risk of Low Energy Availability, Disordered Eating, and Menstrual Dysfunction in Female Collegiate Runners

CONTEXT

Collegiate female distance runners may be at risk for low energy availability (LEA) due to increased exercise energy expenditure with or without decreased energy intake. Furthermore, this population has an increased risk of disordered eating (DE), which can lead to LEA and negative health consequences, such as menstrual dysfunction (MD).

OBJECTIVE

To (1) investigate risk of LEA, DE, and MD; (2) compare DE, training volume, and weight dissatisfaction between female collegiate runners at risk and those not at risk for LEA; and (3) compare the risk for LEA between National Collegiate Athletic Association Division I, II, and III female collegiate runners.

DESIGN

Cross-sectional study.

SETTING

Free-living conditions.

PATIENTS OR OTHER PARTICIPANTS

A total of 287 female runners who competed on a National Collegiate Athletic Association Division I, II, or III cross-country team, track team, or both.

MAIN OUTCOME MEASURE(S)

Participants completed a 45-item questionnaire that included the Low Energy Availability in Females Questionnaire (LEAF-Q) and the Disordered Eating Screen for Athletes (DESA-6).

RESULTS

We observed that 54.4% (n = 156) of runners were at risk for LEA (LEAF-Q score ≥ 8), 40.8% (n = 117) were at risk for DE (DESA-6 score ≥ 3), and 56.5% (n = 162) reported MD (LEAF-Q menstrual function subsection score ≥ 4). Athletes at risk for LEA had higher DESA-6 scores than athletes not at risk for LEA (P < .001). Athletes at risk for LEA had greater weight dissatisfaction than those not at risk for LEA ( = 15.92, P = .001). Higher weekly training volume was not associated with risk for LEA ( = 4.20, P = .11).

CONCLUSIONS

A substantial percentage of collegiate female runners were found to be at risk for LEA and DE and to report MD. These findings demonstrate that the risks for DE, MD, and weight dissatisfaction are associated with risk for LEA.

Further Validation for a Measure of Disordered Eating in an Independent Sample of Male and Female Elite Athletes: The Athletic Disordered Eating (ADE) Scale

BACKGROUND

Elite athletes experience unique pressures and cognitions associated with disordered eating, which may not be appropriately captured by existing tools. The Athletic Disordered Eating (ADE) scale is a recently developed and first measure of disordered eating specifically developed and validated in current and former athletes. This study aimed to provide further validation for the ADE in an independent sample of elite athletes.

METHOD

Participants were 237 elite athletes (M Age = 26.1, SDAge = 8.6; 75.9% female; 73.0% current athletes) participating in various sports across Australia and the United States. Participants completed an online survey including the ADE, demographic questions, and other measures of eating disorder symptoms (Eating Disorder Examination-Questionnaire Short-form, Clinical Impairment Assessment), and related constructs. Twenty-five athletes also completed a clinical interview to determine eating disorder caseness.

RESULTS

The four-factor structure of the ADE from the original validation was confirmed. Further, the ADE demonstrated adequate measurement invariance across male and female current and former athletes; internal consistency for the total score and each subscale; convergent and discriminant validity; and criterion-related validity-with a score of 40 balancing sensitivity and specificity against other scales with established cut-offs for a likely eating disorder. The high-risk cut-off (ADE ≥ 33) had high sensitivity but low specificity in identifying eating disorder cases, as confirmed by the clinical interview.

DISCUSSION

The ADE is a low-time-burden screening tool for disordered eating, validated in independent samples of diverse athletes. It should be considered for future use in screening, early identification, and monitoring treatment progress in elite athletes.

Exercise and mind-body exercise for feeding and eating disorders: a systematic review with meta-analysis and meta-regressions

PURPOSE

To develop a systematic review with meta-analysis to summarize the effectiveness of exercise, regular physical activity, and mind-body exercise on harmful exercise habits, psychological factors, and quality of life in people clinically diagnosed with feeding and eating disorders.

MATERIAL AND METHODS

Randomized clinical trials and pilot randomized clinical trials were considered.

RESULTS

Twelve studies were included. No studies evaluated athletes. No studies examined regular physical activity as the targeted intervention. Quality of life could not be meta-analyzed. Overall, meta-analyses showed that exercise or mind-body exercise was not more effective than controls in reducing depression symptoms, harmful exercise habits, eating behaviors, or emotional regulation skills. However, important methodological and clinical issues were detected in the included studies. This affected the certainty of evidence of the meta-analyzed outcomes which ranged from low to very low. No studies reported in sufficient detail their interventions to be replicated.

CONCLUSIONS

Overall, exercise and mind-body exercise may be ineffective in improving meta-analyzed outcomes. However, the certainty of evidence ranged from low to very low and the body of knowledge in this field needs to be increased to reach robust conclusions.

Early intervention in eating disorders: introducing the chronopathogram

Eating disorders (EDs) pose significant challenges to mental and physical health, particularly among adolescents and young adults, with the COVID-19 pandemic exacerbating risk factors. Despite advancements in psychosocial and pharmacological treatments, improvements remain limited. Early intervention in EDs, inspired by the model developed for psychosis, emphasizes the importance of timely identification and treatment initiation to improve prognosis. Challenges in identifying prodromal phases and measuring the duration of untreated illness highlight the complexity of early intervention efforts in EDs. Current research focuses on reducing the duration of untreated eating disorder (DUED) and understanding the cognitive and behavioral symptoms preceding ED onset. However, current early intervention programs for EDs showed mixed results, necessitating further investigation. We introduce here the chronopathogram, a tool that may aid in precisely investigating the role of development in EDs. A chronopathogram is a graphical representation of pathological events as they unfold over time. Understanding the neurodevelopmental aspects of EDs and utilizing tools like the chronopathogram can aid in tracking the unfolding of symptoms over time, facilitating early detection and intervention efforts. Overall, addressing the key factors influencing the onset and course of EDs is essential for effective early intervention in these conditions.Level of evidence: Level V narrative review.

Balancing Performance and Health in Elite Hungarian Athletes: The Relationship Among Disordered Eating Risk, Body Composition, and Nutrition Knowledge

BACKGROUND

disordered eating (DE) and eating disorders (ED) can negatively impact athletes' health, wellbeing, and athletic performance.

OBJECTIVE

this cross-sectional study aims to assess DE risk, body composition, and nutrition knowledge among elite Hungarian athletes.

METHODS

DE risk was assessed using DESA-6H and EAT-26 scales, nutrition knowledge through the Abridged Nutrition for Sport Knowledge Questionnaire (A-NSKQ), and body composition with the OMRON BF511 device. The data were analyzed using Kendall's tau correlations, Mann-Whitney U tests, and ROC analysis.

RESULTS

a total of 71 athletes participated (39.4% males, mean age = 24.8 years, SD = 4.8 years and 60.6% females, mean age = 24.3 years, SD = 4.3 years). At-risk scores on the DESA-6H scale were recorded for nine athletes (12.7%), while 32.4% scored in the risk zone on the EAT-26, with female athletes in aesthetic, endurance and weight-dependent sports being most affected. Low BF was observed in four males and four females. Nutrition knowledge (49.1%) was below the acceptable threshold. DESA-6H significantly correlated with EAT-26 scores, BMI, sports nutrition knowledge, and A-NSKQ total scores. A statistically significant difference by gender was found in the EAT-26 total score (p = 0.019, d = 0.65). Risk groups significantly differed in A-NSKQ scores (p = 0.026, d = 0.511) and sport nutrition knowledge, specifically (p = 0.016, d = 0.491). Using EAT-26 to identify at-risk athletes and the DESA-6H recommended cut-off, the ROC analysis showed a sensitivity of 29.1% and a specificity of 95.7%.

CONCLUSIONS

insufficient nutrition knowledge plays a role in being at-risk for DE and ED. These results underscore the need for early detection, early sport nutrition education across all elite athletes, with particular attention to female athletes in aesthetic, endurance and weight-dependent sports, and for monitoring these athletes to prevent DE. Further work is warranted to optimize screening tools such as EAT-26 and DESA-6H for elite athletes.

Examination of the Clinical Utility of Eating Disorder and Disordered Eating Screening Tools in Young Athletes: A Scoping Review

Background and Purpose

Many screening tools are used to identify eating disorders (ED) and disordered eating (DE) in individuals. The purpose of this scoping review was to identify the most commonly used ED/DE screening tools for young male and female athletes.

Study Design

Scoping Review.

Methods

Following the Johanna Briggs Institute scoping review guidelines, PubMed, CINAHL Complete, PsycInfo, SPORTdiscus, and Web of Science Core Collection databases were searched using keywords related to eating disorder, disordered eating, athletes, and screening. Included articles were randomized controlled trials, cohort studies, or cross-sectional studies published in English between 2011-2023; included primarily non-aesthetic athletes aged 14-24 years; and utilized an ED/DE screening tool for diagnostic purposes. Articles were excluded if analysis of ED/DE was a secondary purpose or < 20 athletes participated. Tools utilized and demographic and outcomes data were extracted and qualitatively analyzed.

Results

Thirty articles were included. The Eating Attitudes Test-26 (EAT-26), the Sick, Control, One, Fat, Food (SCOFF) questionnaire, and the Eating Disorder Inventory (EDI) were most used among all included articles. Three articles examined only males and used a variety of tools. Five articles utilized a tool specifically designed for athletes: the Eating Disorder Screen for Athletes (EDSA), Brief Eating Disorder in Athletes Questionnaire (BEDA-Q) or the ATHLETE questionnaire.

Discussion

While the EAT-26 is most used for diagnosing ED/DE risk within young athletes, clinical utility of screening tools for male athletes is varied. Combinations of tools utilized for examining ED/DE risk in athletes are not agreed upon. Continued research is needed to assess the clinical utility of screening tools that identify ED/DE risk specifically in athletes. Tool adjustment or development for male athletes may be necessary.

Level of Evidence

2a.

Application of the IOC Relative Energy Deficiency in Sport (REDs) Clinical Assessment Tool version 2 (CAT2) across 200+ elite athletes

OBJECTIVE

This cross-sectional retrospective and prospective study implemented the 2023 International Olympic Committee Relative Energy Deficiency in Sport (REDs) Clinical Assessment Tool version 2 (CAT2) to determine the current severity of REDs (primary outcome) and future risk of bone stress injuries (BSI, exploratory outcome) in elite athletes.

METHODS

Female (n=143; 23.3±4.3 years) and male (n=70; 23.1±3.7 years) athletes (performance tier 3 (52%), tier 4 (36%), tier 5 (12%)) participated in a baseline CAT2 (with minor modifications) assessment, including a self-report questionnaire (menstrual function (females), BSI, Eating Disorder Examination Questionnaire (EDE-Q)), bone mineral density (BMD via DXA) and fasted blood analysis (triiodothyronine (T3), testosterone, cholesterol). Athletes were assigned a green, yellow, orange or red light via CAT2. The prospective risk of new self-report of physician-diagnosed BSI was assessed over a subsequent 6-24 months.

RESULTS

REDs prevalence was 55% green, 36% yellow, 5% orange and 4% red light. The CAT2 identified a greater prevalence of amenorrhoea and BSI and lower T3, testosterone and BMD (p<0.01) in red, orange and yellow (those with REDs) versus green light. ORs for a prospective self-reported BSI (majority physician diagnosed) were greater in orange vs green (OR 7.71, 95% CI (1.26 to 39.83)), in females with severe amenorrhoea (OR 4.6 (95% CI 0.98 to 17.85)), in males with low sex drive (OR 16.0 (95% CI 4.79 to 1038.87)), and athletes with elevated EDE-Q global scores (OR 1.45 (95% CI 0.97 to 1.97)).

CONCLUSION

The CAT2 has high validity in demonstrating current severity of REDs, with increased future risk of self-reported BSI in athletes with a more severe REDs traffic light category.

What Do We Know About the Energy Status and Diets of Pre-Professional and Professional Dancers: A Scoping Review

BACKGROUND/OBJECTIVES

Dancers require adequate nutrition support for growth and development during the pre-professional stage, as well as to fuel classes and rehearsals and to enhance performance for both pre-professional and professional dancers. The aim of this study is to understand the energy status and diet of pre-professional and professional dancers in the genres of ballet, contemporary, musical theatre, and opera.

METHODS

Electronic databases (n = 9) and grey literature were searched for primary studies with no time limit. Screening and data extraction were completed by two reviewers.

RESULTS

Twelve studies were included for pre-professional (n = 7) and professional (n = 5) dancers. The genres identified were ballet (n = 11) and contemporary (n = 1), with no studies on musical theatre or opera. Studies on pre-professional ballet and contemporary dancers indicated a negative energy balance and low energy availability. Pre-professional ballet dancers had lower energy intakes than professional dancers. Professional dancers had lower BMI and body fat percentages. Macronutrients were mostly reported using the acceptable macronutrient distribution range for carbohydrates (38-56%E), protein (12-17%E), and total fat (26-42%E). Iron and calcium were the main micronutrients of concern.

CONCLUSIONS

Accredited sports dietitians are recommended to support pre-professional and professional dancers to optimize their diet for health and performance. Further investigation is needed to quantify and assess dancers' dietary intake using sports nutrition guidelines for reference.

Comparing Population-General and Sport-Specific Correlates of Disordered Eating Amongst Elite Athletes: A Cross-Sectional Study

BACKGROUND

Despite the high prevalence of disordered eating and eating disorders amongst elite athletes, it remains unclear whether risk factors and psychological processes align with those in the general population or if there are unique sport-factors associated with heightened risk. This cross-sectional study investigated if sport-specific factors (including pressures and psychological processes) explained additional variance in elite athletes' disordered eating symptoms, controlling for established population-general risk factors. Current elite athletes (N = 178, 72.4% female, mean age = 23.9, standard deviation age = 7.0) completed online surveys assessing disordered eating, body dissatisfaction, perfectionistic traits, population-general and sport-specific pressures, as well as general (thin-ideal, muscular-ideal) and athlete-specific (drive for leanness for performance, athletic identity) psychological processes.

RESULTS

Disordered eating was highly prevalent, with 78.2% of athletes reporting at least moderate risk, 46.4% at least high risk, and 20.6% very high risk. Controlling for demographic covariates and population-general pressures, sport-specific pressures explained significant additional variance (13.5%) in disordered eating. Even when controlling for perfectionistic traits, greater weight pressures in sport (β = .35) was uniquely associated with greater disordered eating. In a separate multivariate analysis controlling for covariates and general psychological processes, athlete-specific psychological processes explained significant additional variance (15.5%) in disordered eating. Even when controlling for body dissatisfaction, greater drive for leanness for performance (β = .17) and athletic identity (β = .13) were uniquely associated with greater disordered eating.

CONCLUSIONS

These findings support evidence that elite athletes may experience dual pressures and psychological processes associated with disordered eating: those congruent with appearance-oriented models and others independent of appearance. This duality should be considered in the modification of interventions for disordered eating in elite athletes.

KEY POINTS

1. Disordered eating was highly prevalent in a sample of 178 elite adult athletes, with 78.2% reporting at least moderate risk for having related symptoms or behaviours. 2. Greater weight pressures in sport was significantly associated with greater disordered eating, even when controlling for demographic covariates and population-general appearance-related pressures from family and the media. 3. Both appearance-based (drive for thinness, body dissatisfaction) and non-appearance (drive for leanness for performance, athletic identity) psychological processes were uniquely associated with greater disordered eating.

Prevalence of disordered eating and its relationship with rapid weight loss amongst male and female combat sport competitors: A prospective study

OBJECTIVES

To compare prevalence and change scores of disordered eating (DE) in combat sport athletes by sex and explore the potential relationship between rapid weight loss (RWL) and DE scores.

DESIGN

Prospective study based on 24 events (September 2022-2023).

METHODS

A body mass (BM) questionnaire was completed at ~1 day post-competition providing pre-competition BM data for -7 days, -24 h, and weigh-in. The Athletic Disordered Eating (ADE) online questionnaire was completed at ~7 and ~28 days post-competition, providing overall DE and four subscale scores (food and energy control, bingeing, body control, and body discontent).

RESULTS

There were 122, 132, and 89 respondents for the BM (77 % male), and ADE questionnaires at 7 (79 % male), and 28 days (74 % male). A large proportion of males' (83 %) and females' (89 %) DE scores were moderate to very high; minimal (17 % vs. 11 %), moderate (36 % vs. 32 %), high (37 % vs. 36 %), and very high (11 % vs. 21 %). Comparing DE change scores in males and females indicated deterioration (5 % vs. 0 %), improvement (3 % vs. 25 %, p = 0.013), and no difference (92 % vs. 75 %). Body discontent change score showed a significant sex difference (p = 0.014), with females improving (42 % vs. 17 %, p = 0.035) and males deteriorating (35 % vs. 4 %, p = 0.008). Correlation analyses were significant for RWL -7 days and males' food control score (R = 0.22, p = 0.031).

CONCLUSIONS

Moderate to very high DE indications were identified in 4 of every 5 combat sport competitors. A sex-specific change in body discontent is evident, and most competitors struggle with their food-body relationship post-competition, irrespective of RWL magnitude.

Are Sub-elite Athletes at Higher Risk of Eating Disorders, Exercise Addiction, Depression, and Low Energy Availability Compared With Elite Athletes?

OBJECTIVE

The main objective of this study was to investigate the risk of eating disorders, exercise addiction, depression, and low energy availability (LEA) in Danish female and male elite compared with sub-elite athletes.

DESIGN

A cross-sectional study.

SETTING

An online survey.

PARTICIPANTS

A total of 410 elite athletes (mean age 20.1 years, 51% females) and 206 sub-elite athletes (mean age 21.3 years, 52% females) from 15 different sports.Assessment of Risk Factors: Eating Disorders, exercise addiction, depression, and LEA.

MAIN OUTCOME MEASURES

The Sick Control, One Stone (6.5 kg), Fat, Food, the Eating Disorder Examination-Questionnaire, the Exercise Addiction Inventory, the Major Depression Inventory, and the Low Energy Availability in Females Questionnaire or the Low Energy Availability in Males Questionnaire.

RESULTS

We found that more female sub-elite athletes compared with elite athletes had risk of eating disorders (EDs) (37.4% vs 23.4%; P < 0.012) and the same was found for males (23.2% vs 10.4%; P = 0.005). More athletes with risk of EDs had risk of exercise addiction (12.8 vs 5.4%, P = 0.006), depression (27.3 vs 4.2%, P < 0.001), and LEA (females 55.1 vs 40.7%, P = 0.024, and males 29.4 vs 13.7%, P = 0.036, respectively) compared with athletes without risk of EDs.

CONCLUSIONS

Sub-elite athletes have a higher risk of eating disorders compared with elite athletes. Regular screening of ED symptoms and associated conditions in elite and especially sub-elite athletes may ensure early identification.

Do Swedish rock-climbers exhibit more eating disorder and body dissatisfaction symptoms than non-climbers? A cross-sectional study

OBJECTIVES

The inclusion of rock-climbing in the Olympic Games has increased participation in the sport and attention to athletes' health. In sports where the importance of low body weight is considerate, there is an increased risk of developing eating disorders (EDs). There is sparse research on EDs among rock-climbers. The primary aim was to map ED symptoms among rock-climbers compared with controls. The secondary aim was to analyze differences in body dissatisfaction. Comparisons between rock-climbing levels and sexes were performed.

DESIGN

This is a cross-sectional study in a larger prospective longitudinal study series, CLIMB: Climber's Longitudinal attitudes towards Injury, Mental health and Body image, using baseline data.

PARTICIPANTS

Swedish rock-climbers, at an advanced and elite level according to the International Rock Climbing Research Association, participated. Participants were at least 13 years old. 183 rock-climbers partook with a mean age of 29.5 (SD=9.1) with two participants under 15 years old. 180 controls partook with a mean age of 29.0 (SD=8.9). There were no control participants under 15 years of age.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data was gathered through a self-report questionnaire collecting the primary outcome measure, ED symptoms (Eating Disorders Examination Questionnaire (EDE-Q) V.6.0) and the secondary outcome measure, body dissatisfaction (Body Shape Questionnaire-8C).

RESULTS

There were no differences between rock-climbers and controls regarding ED symptoms. Symptoms were higher among female rock-climbers (26%) than male (5.8%). Regarding body dissatisfaction, the control group reported higher levels compared with rock-climbers. At least a mild concern was observed in 13.3% of male rock-climbers, compared with 47.4% of females.

CONCLUSIONS

Although there was no difference in the EDE-Q V.6.0 between rock-climbers and controls, females reported significantly more symptoms than men. Regarding body dissatisfaction, female rock-climbers exhibited higher levels of dissatisfaction than males. Further, higher levels of dissatisfaction were reported in controls, especially in men, where symptoms were three times higher than rock-climbers.

TRIAL REGISTRATION NUMBER

NCT05587270.

An appetite to win: Disordered eating behaviours amongst competitive cyclists

Competitive cyclists may be vulnerable to disordered eating (DE) and eating disorders (ED) due to perceived body composition optimisation and external influences within cycling culture and from stakeholders. Therefore, this study aimed to assess DE and ED risk in competitive cyclists using the Eating Attitudes Test (EAT-26), explore differences in responses based on sex, discipline and level of competition, and to gain insights into contributing factors towards DE via open-ended survey questions. In total, 203 participants completed a mixed-method questionnaire. Eating disorders were reported by 5.7% ( n = 11) of participants, with three being historic cases. The median (inter-quartile range) EAT-26 score was 8 (12) of a total possible score of 78. Disordered eating risk was observed in 16.7% of participants due to an EAT-26 score ≥20. Female participants had significantly higher scores than male participants (12.5 ± 17.5 vs. 6.5 ± 10.0; p = .004). There was no significant difference between road cyclists and off-road cyclists (7.0 ± 13.25 vs. 8.0 ± 10.5; p = .683). There was a significant difference in scores between novice/club/regional and national/elite/professional cyclists (6.0 ± 11.25 vs. 10.5 ± 12.0; p = .007). Thematic analysis of open-text responses found that the social environment of competitive cycling contributed towards DE behaviours and body image issues. These findings indicate competitive cyclists do appear to be an ‘at risk’ population for DE/ED. Therefore, there is need for stakeholders to enhance nutritional services, nutrition education and create supportive athlete environments.

Prevalence of Eating Disorders among Competitive Rowers

Internationally, few studies have been written on the prevalence of eating disorders among rowers, and there is no research on the subject in Hungary. This is particularly important in weight-related sports such as rowing. The aim of this study is to assess the prevalence of eating disorders among rowers. A quantitative cross-sectional study was conducted in the summer of 2023. In a non-random convenience sampling, our target population consisted of certified competitive rowers (n = 222). In addition to socio-demographic, performance-related questions, the anonymous, self-completed questionnaire used the validated The Eating Disorder Inventory (EDI). Results were considered significant when p < 0.05. A total of 57 lightweight (25.67%) and 165 openweight (74.33%) rowers participated in the study. On the perfectionism subscale and the interoceptive awareness subscale, rowers competing in the lightweight category scored significantly higher (p = 0.03; p = 0.05). Scores on the EDI subscales, gender and BMI data did not show significant relationships. Overall, rowers in the openweight group scored higher on the bulimia subscale, but no rowers who met all criteria and could be identified as having eating disorders. Rowers who have only competed in national championships and not in international competitions were more likely to reduce stress levels by eating. The study showed that the prevalence of eating disorders among rowers is no higher than in the general population. However, continued assessment, further extensive research and education of rowers is essential in this area, as weight-related sports will always be a risk group for eating disorders.

Exploring the continuum of eating behaviour, from 'normal' to disordered eating

Eating is a distinct behaviour in humans, in that they must consume food to provide sufficient energy for the body to function and to ensure survival. Behaviours around food consumption can range from 'normal' to disordered, where some people may develop eating patterns that suggest a preoccupation with food or weight. This preoccupation can lead to inappropriate compensatory behaviours, such as purging or excessive exercise, or dysphoric mood following food consumption. This article discusses the continuum between 'normal' eating behaviours and eating disorders, with a focus on binge eating behaviour and binge eating disorder. The author also describes the use of a screening tool for identifying binge eating behaviour and suggests ways in which nurses might support patients in addressing disordered eating behaviours.

Multi-organ transcriptome atlas of a mouse model of relative energy deficiency in sport

Insufficient energy intake to meet energy expenditure demands of physical activity can result in systemic neuroendocrine and metabolic abnormalities in activity-dependent anorexia and relative energy deficiency in sport (REDs). REDs affects >40% of athletes, yet the lack of underlying molecular changes has been a hurdle to have a better understanding of REDs and its treatment. To assess the molecular changes in response to energy deficiency, we implemented the "exercise-for-food" paradigm, in which food reward size is determined by wheel-running activity. By using this paradigm, we replicated several aspects of REDs in female and male mice with high physical activity and gradually reduced food intake, which results in weight loss, compromised bone health, organ-specific mass changes, and altered rest-activity patterns. By integrating transcriptomics of 19 different organs, we provide a comprehensive dataset that will guide future understanding of REDs and may provide important implications for metabolic health and (athletic) performance.

Risk for low energy availability, disordered eating and sleep disturbance among female football players

PURPOSE

Low energy availability (LEA) and mental health issues are prevalent among female athletes and can have adverse effects on health and sports performance. This study aimed to assess energy availability and, mental health status (depression, anxiety, sleep deprivation, drug misuse, alcohol misuse, and disordered eating) among female football players. Despite the availability of validated tools for the triads and REDs, few studies have focused on the prevalence of LEA and mental health in female football players. Furthermore, limited information is available on LEA and its consequences in India.

METHODS

Professional female football players (n=25) aged 19-30 years were recruited using incidental sampling. LEA was estimated based on energy availability [energy intake - activity energy expenditure] and LEA female questionnaire (LEAF-Q). Sports mental health assessment tool-1 (SMHAT-1) was used to assess the mental health status. Descriptive statistics and chi square test were used to test the hypotheses.

RESULTS

According to the factorial method and LEAF-Q, 24% and 12% of players had LEA, respectively. LEA symptoms, such as decreased gastrointestinal and menstrual function, were observed in 16% of participants, while 8% had a history of injury. 44% of the participants exhibited poor mental health. Sleep disturbance (12%) and disordered eating (44%), were among the most common mental health issues. No significant difference was found between LEA, disordered eating, and sleep disturbance.

CONCLUSION

Female football players were more likely to develop LEA and mental health disorders, such as disordered eating and sleep disturbance. LEA was not linked with disordered eating or sleep disturbance. Early detection of LEA and effective intervention enhances the health and performance of female football players.

Assessment of Sex-Specific Associations between Athletic Identity and Nutrition Habits in Competitive Youth Athletes

Given the psychological aspects of sports nutrition, understanding one's athletic identity (AI) may improve targeted nutrition education. Therefore, the purpose of this study was to examine nutrition habits and AI among uninjured youth athletes. Athletic Identity Measurement Scale (AIMS) and custom Sports Nutrition Assessment for Consultation (SNAC) scores collected prospectively at local sporting events were retrospectively assessed via Mann-Whitney, Kruskal-Wallis, logistic regression, and ANCOVA tests (95% CI). Among 583 athletes (14.5 ± 2.1 years; 59.9% female), the total AIMS scores did not differ by sex (males 39.9 ± 7.2; females 39.3 ± 7.5; maximum 70). The Social Identity (p = 0.009) and Exclusivity (p = 0.001) subscores were higher in males, while the Negative Affectivity subscores were lower (p = 0.019). Females reported frequent associations between SNAC and AIMS, particularly Negative Affectivity, which was positively associated with stress fracture history (p = 0.001), meal-skipping (p = 0.026), and desiring nutrition knowledge (p = 0.017). Males receiving weight recommendations reported higher Negative Affectivity subscores (p = 0.003), and higher total AIMS scores were observed in males with fatigue history (p = 0.004) and a desire for nutrition knowledge (p = 0.012). Fatigue and stress fracture history predominated in high-AI males and females, respectively, suggesting that poor sports nutrition may present differently by sex. As suboptimal nutrition was frequently related to high Negative Affectivity subscores, these habits may increase following poor sports performance.

A systematic review and meta-synthesis of qualitative research investigating disordered eating and help-seeking in elite athletes

OBJECTIVE

Elite athletes are at elevated risk for disordered eating and eating disorders; however, little is known about risk and maintaining factors, or barriers and facilitators of help-seeking in this cohort. This systematic review synthesized qualitative findings regarding possible risk and maintaining factors for disordered eating, as well as barriers to and facilitators of help-seeking in elite athletes.

METHOD

We conducted a search for qualitative studies that included experiences with body image concerns or disordered eating in elite athletes. A systematic search of CINAHL, PsychINFO, MEDLINE, and Scopus databases identified 828 articles, with 87 retained after title and abstract screening, and 38 included in the review. Quality appraisal was conducted using the checklist for appraising qualitative research (CASP). Data were extracted from each article, including demographic information (e.g., biological sex, age, sport type, level of competition, current, or former athlete) and the text under the "results" or "findings" section. Meta-themes were identified using inductive thematic meta-synthesis.

RESULTS

The extracted data indicated that most studies sampled female athletes from the United States and UK. Eight meta-themes were identified: (1) the power imbalance; (2) hyperfocus on body, food, and exercise; (3) rigidity; (4) the athlete's balance; (5) the athlete identity; (6) overvaluation and oversimplification; (7) shame, fear, and stigma; and (8) knowledge, education, and self-identification.

DISCUSSION

These findings highlighted gaps in the demographic representation of specific groups in this research (e.g., males, para-athletes, and ethnic diversity) and propose hypotheses of how sport pressure might contribute to athletes' experiences with disordered eating.

PUBLIC SIGNIFICANCE

Disordered eating and body image concerns are prevalent and can have debilitating impacts for elite athletes; however, help-seeking is rare for this population. It remains unclear what factors contribute to disordered eating and/or inhibit help-seeking among elite athletes versus the general population. Understanding athletes' perspectives will inform the modification of prevention and treatment strategies to address athlete-specific factors.

Major Dietary Patterns, Exercise Addiction, and Eating Disorders Among a Sample of Physically Active Young Adults

Background

Regular exercise has been widely acknowledged for its numerous health benefits, including improvements in physical fitness, body function, and mental well-being. However, excessive exercise and unhealthy dietary patterns can lead to adverse effects on individuals' physical and psychological well-being. This study aimed to examine the association of dietary patterns, exercise addiction, and eating disorders among physically active young adults.

Method

In this cross-sectional study, a total of 200 physically active young adults aged 18-35 years were included. The participants' dietary intake was assessed using a validated semi-quantitative food frequency questionnaire (FFQ) consisting of 80 food items. To determine dietary patterns, factor analysis was employed. Exercise addiction was evaluated using The Exercise Addiction Inventory (EAI) and Exercise Dependence Questionnaire (EDQ), and eating disorders were assessed using The Eating Disorder Examination-Questionnaire Short (EDE-QS).

Result

Three main dietary patterns were identified: western, healthy, and traditional dietary patterns. The western dietary pattern was associated with increased waist-to-hip ratio (P = .01) that remained significant after adjustment for confounders (eg, age, gender, BMI, and physical activity P = .03), while the adherence to traditional dietary pattern was linked to higher waist circumference and body shape index (P < .05). Participants that followed the healthy dietary pattern showed a higher score of EAI and body shape concern (P = .04). Furthermore, in structural equation modelling (SEM), eating disorder was identified as a significant positive predictor of exercise addiction (r = .17, P < .05).

Conclusion

According to our finding, those with the higher adherence to healthy dietary pattern had higher scores of exercise addiction and body shape concern. Also, eating disorder was a potential predictor of exercise addiction among young physically active individuals. Further research and targeted interventions are needed to better understand these complex relationships and develop effective strategies to promote healthy behaviors and mitigate the risk of adverse outcomes.

An Umbrella Review of Body Image Concerns, Disordered Eating, and Eating Disorders in Elite Athletes

Background/Objectives: Several systematic reviews and meta-analyses have been conducted to date indicating a high prevalence of disordered eating in elite athletes and associated risk factors. However, the substantial time burden associated with locating and comparing these reviews, which are varied in methodology and sampling focus, may be a barrier for informing policy and best practice as well as directing future research. This umbrella review aimed to provide a summary of evidence across published reviews regarding the prevalence and risk factors for disordered eating (including body image concerns and eating disorders) in elite athletes. Methods: Five databases (CINAHL, PsycINFO, MEDLINE, Scopus, and SPORTDiscus) were systematically searched for peer-reviewed systematic reviews and meta-analyses that met the following inclusion criteria: (1) investigated prevalence and risk factors for disordered eating, (2) included a sample of elite athletes, and (3) available in English. The included studies underwent data extraction and risk of bias assessment using the AMSTAR 2. Results: The initial search identified 1828 articles that were screened for title and abstract and then full text, leaving 24 systematic reviews (including 10 meta-analyses). Disordered eating was prevalent across elite athletes, including males and females and across sport type. Elite athletes were at elevated risk for disordered eating and eating disorders but at lower risk for body image concerns versus non-athlete controls. Several risk factors were identified, including female gender, competing in lean sports, and experiencing career changes. Few reviews or meta-analyses examined perceived pressures within the sporting environment, and most had substantial risk of bias concerns. Conclusions: Elite athletes are at risk for the spectrum of disordered eating, and all should be considered for primary prevention and screening. Further research is needed regarding sport-specific versus general pressures and mediators of risk to better inform interventions.

Untangling the relationships between age, gender, type of sport, perfectionistic self-presentation and motivation on body satisfaction: a cross-sectional study on aesthetic and non-aesthetic female and male athletes aged 10 to 22 years

Objectives

To explore the relationships between age, gender, type of sport, perfectionistic self-presentation and motivation on body satisfaction among young athletes in one aesthetic sport (gymnastics) and one non-aesthetic sport (basketball). The study hypothesise that (1) age, gender and type of sport (aesthetic or non-aesthetic) will predict body satisfaction scores, (2) autonomous motivation will positively be related to body satisfaction and (3) perfectionistic self-presentation will negatively be related to body satisfaction.

Design

Cross-sectional.

Method

209 athletes (132 gymnasts and 77 basketball players) aged 10-22 (median=13) years were recruited. After data screening, 200 athletes were included in analyses (females: n=155; males: n=45). Participants completed an online survey, which assessed demographic information, athlete motivation (Behavioural Regulation in Sport Questionnaire), perfectionistic self-presentation (Perfectionistic Self-Presentation Scale-Junior Form) and body satisfaction (Body Appreciation Scale-2).

Results

Hierarchical multiple regression showed age, self-assigned gender, and two facets of perfectionistic self-presentation (ie, perfectionistic presentation and non-disclosure of imperfection) to predict reported levels of body satisfaction significantly. Subsequently, adding motivational variables did not improve the model. A moderation analysis showed that the relationship between non-disclosure of imperfection and body satisfaction was significantly moderated by gender.

Conclusions

Two facets of perfectionistic self-presentation were associated with reported body satisfaction. Additionally, the relationship between non-disclosure of imperfection and body satisfaction appears to differ between female and male athletes. Researchers should move beyond sport types and identify factors (eg, perfectionistic self-presentation) at the individual and environmental levels that can protect young athletes' body satisfaction.

Eating disorder symptoms and weight pressure in female rowers: associations between self-concept, psychological well-being and body composition

BACKGROUND

Female rowers may be at risk of eating disorders and high weight pressure.

AIM

The purpose of the study was to investigate the prevalence of disordered eating symptoms and weight-related pressure and the associations with self-concept, psychological well-being, socio-demographic data, experience, performance level and body composition in female fixed-bench rowers.

METHODS

Female rowers (n = 208; age ranged mean ± SD 23.6 ± 6.5 years) completed the SCOFF scale, Weight-Pressures in Sport-Females (WPS-F), Physical Self-Concept Questionnaire and the Ryff scales of psychological well-being and provided information on their experience and level of competition. In a subgroup of 115 athletes, body composition was assessed using bioimpedance.

RESULTS

It was found that 42.3% of the athletes scored ≥ 2 on SCOFF and mean ± SD value of WPS-F score was 3.65 ± 0.82. Stepwise regression analysis revealed that self-concept of strength and pressure from teammates and the uniform were associated with higher ED symptoms, whereas better psychological well-being in terms of autonomy, self-concept of attractiveness, and age were protective factors for ED symptoms. BMI, athletes' physical condition, strength, and experience were associated with more weight-related pressure and better self-concept of attractiveness and physical well-being of autonomy were significantly associated with less pressure. In body composition analysis, higher extra cellular water, self-acceptance, and physical condition were associated with more weight-related pressure in female rowers, being attractiveness and the environmental mastery protective elements.

CONCLUSIONS

The prevalence of ED symptomatology and weight-related pressure are high in female fixed bench rowing. The psychological factors of well-being and self-concept, team environment, body image concerns and body composition analysis should be considered to promote healthy eating behaviours in female rowers.

Personal risk factors and types of sport associated with drive for thinness and drive for muscularity in NextGen athletes

Introduction

Professional and student-athletes are at risk of developing symptoms of eating disorders (ED), including drive for thinness and muscularity due to personal risk factors (e.g., low self-esteem) and sport-specific characteristics (e.g., sport requirements). However, limited studies have focused on ED symptoms among NextGen athletes (identified in Canada as élite or relève) who compete at the provincial, national, and international levels but are not yet part of national teams. As such, they have access to fewer financial resources and support from their sport federations, which can create additional stress for these athletes. The present study aimed to identify personal risk factors and types of sports associated with (a) drive for thinness and (b) drive for muscularity in NextGen athletes.

Methods

These athletes (n = 254) aged between 14 and 25 years old completed an online questionnaire. Perfectionism, self-esteem in sport, drive for thinness, and drive for muscularity were, respectively, assessed by the Multidimensional Inventory of Perfectionism in Sport, the Sport State Self-Esteem Scale, the Eating Attitude Test-26, and the Drive for Muscularity Scale. Other personal risk factor (e.g., athletic status) were measured using in-house questions. Each personal risk factor was included in two multiple linear regressions, respectively, to determine which factors were most associated with drive for thinness and drive for muscularity.

Results

Analyses revealed that perfectionist aspirations during training were linked to a stronger desire for thinness. In addition, not being in school or not having a job were also linked to a stronger desire for thinness. Several variables were found to be associated with a greater desire for muscularity: being a male athlete, playing team sport, weight category sport or endurance sport (as opposed to esthetic sport), having elite status, being less satisfied with one's current sporting performance and having higher perfectionist aspirations during training.

Discussion

This study offers initial insights into the factors influencing EDs among NextGen athletes, which provides a foundation for deeper exploration and the creation or modification of targeted interventions. These findings can guide sport organizations in creating guidelines and programs to better support the next generation of national athletes (e.g., create programs to help athletes maintain investments outside).

Menstrual cycle disorders as an early symptom of energy deficiency among female physique athletes assessed using the Low Energy Availability in Females Questionnaire (LEAF-Q)

Physique competitions are weight-sensitive sports in which stage presentation, aesthetic appearance and posing ability of the athletes are judged rather than physical performance. The aim of this study was to assess low energy availability among female physique athletes by using the LEAF-Q. The study involved 104 females who were physique athletes. Monthly cycle disorders were reported in 58.65% of the women, that is periods stopped for three consecutive months or longer (amenorrhea). This situation occurred before the research was conducted in 43.27% of athletes and during the research in 15.38%. The physique athletes claimed that menstruation changes occurred when there was an increased exercise intensity, frequency or duration. Absence from training due to injury was reported by 27.88% of the women. The LEAF-Q identified 46.15% of the physique athletes as at risk (score ≥ 8) of low energy availability and the physiological consequences related to RED-S. Women who had menstrual cycle disorders were younger and did more training per week. Among women with menstrual disorders, cramps or stomach ache which cannot be related to menstruation occurred more frequently (p = 0.004). Absence from training or lack of participation in competition due to injuries occurred more frequently in the score ≥ 8 group (p = 0.024) thank the ≤ score 8 group. In the score ≥ 8 group menstruation changes, that is less bleeding or cessation of menstruation (p = 0.035), occurred more frequently when there was an increase in exercise intensity, frequency or duration (p = 0.002).

The Effect of Sleep on the Health and Dietary Behaviours of GAA Athletes

Decreased sleep quality and duration is associated with an array of negative health outcomes. Evidence suggests athletes are susceptible to sleep inadequacies that may in turn affect their health and dietary behaviours. This study aimed to explore the sleep profile of both male and female Gaelic games players, at an elite and sub-elite level and compare how poor sleep relates to subjective health complaints and food cravings. One hundred and seventy Gaelic games players completed the Pittsburgh Sleep Quality Index (PSQI), Subjective Health Complaints Inventory (SHC) and Food Cravings Questionnaire-Trait-Reduced (FCQ-T-r). Participants were categorised into two groups: poor sleepers (PSQI ≥ 5) and good sleepers (PSQI < 5). Outcome measures of health and food cravings were analysed across the groups, Mann-Whitney U tests were used to assess differences, and Spearman's rank-order correlations were used to determine relationships between variables. Sixty-seven % of athletes were categorised as poor sleepers. There were no significant differences in PSQI scores across genders (p = 0.088) or playing level (p = 0.072). Poor sleepers experienced significantly increased SHC (p < 0.001) and female athletes had significantly more SHC compared to males (p < 0.001). Female athletes experienced more food cravings than males (p = 0.013). However, there were no significant differences in food cravings between good and poor sleepers (p = 0.104). The findings suggest a high prevalence of poor sleepers amongst GAA athletes. Furthermore, a significant relationship exists between poor sleep and health complaints with females at a higher risk of worsened health complaints and higher food cravings. Sleep screening and education interventions to enhance sleep in GAA athletes are advocated.

Adolescent athletes have better general than sports nutrition knowledge and lack awareness of supplement recommendations: a systematic literature review

Nutrition knowledge (NK) impacts food choices and may be improved through educational programmes. Identifying knowledge gaps related to NK among adolescent athletes may guide future nutrition education programmes. This review aimed to systematically review the level of NK in adolescent athletes based on the currently available published literature. The protocol for this review was registered with PROSPERO (CRD42022321765). A literature search was conducted in April 2022 using MEDLINE, CINAHL, SPORTDiscus, Web of Science and SCOPUS databases. The study design was not restricted, provided that a quantitative NK score was reported for adolescent athletes. Studies were limited to the English language and published between 2010 and April 2022. Studies were assessed for quality and risk of bias using the Academy of Nutrition and Dietetics Quality Appraisal Checklist. Data extracted included demographics, questionnaire name, number of items, validation status and mean total and subsection NK scores. Meta-analyses were inappropriate due to the heterogeneity of NK assessment tools; therefore, results were presented narratively. Thirty-two studies that assessed NK of 4553 adolescent athletes and 574 comparison participants were included. Critical appraisal of studies resulted in neutral rating 'moderate quality' for most (n 30) studies. Studies lacked justification for sample size and often used inadequately validated questionnaires. NK scores ranged from poor (33·3 %) to excellent (90·6 %). The level of NK across studies is difficult to determine due to heterogenous questionnaires often lacking appropriate validation. NK should be assessed using tools validated in the relevant population or revalidated tools previously used for other populations.

Can period-related symptoms predict menstrual manipulation among Australian female cyclists?

This study explored the extent of menstrual manipulation and its associated impact on period-related symptoms and training disruptions in Australian Female Cyclists. 205 female cyclists, from recreational to elite level, participated in an online "Female Cyclist Questionnaire (FCQ)". The FCQ utilised a series of validated questionnaires to obtain demographic information and menstrual function of the respondents, and to investigate their menstrual manipulation habits and perceptions on how their period-related symptoms affected their well-being, mood, energy and training tolerance. More than 80% of the cyclists reported that their period-related symptoms impacted upon training and 41% made training adjustments based on these symptoms. Two-thirds of respondents thought their training should be phase-controlled yet only half discussed their hormonal cycles with their coaches. Menstrual manipulation was predicted by reduced "workout tolerance" in these cyclists (odds ratio = 0.632). Half of the respondents reported compromised ability to tolerate high-intensity interval training with period-related symptoms. Period pain, increased irritability, lower energy levels and more sugar cravings were commonly reported but did not predict menstrual manipulation. The data indicated that period-related symptoms are present in Australian female cyclists across all levels of participation. However, the perceived impact to training and subsequent behavioural changes varied among individuals.

Testing general sociocultural and coach-related appearance pressures as the factors associated with disordered eating in competitive female athletes participating in various sports

The aim of the present study was to test the sociocultural Petrie and Greenleaf's (2007) model of disordered eating (DE) in competitive female athletes. Specifically, we tested a model of general sociocultural and coach-related pressures towards body weight and appearance of female athletes as the factors associated with athletes' DE through the mediators such as internalization of appearance ideals and overweight preoccupation. 515 athletes participated in this study. The mean age of the sample was 19.0 ± 5.9 years. Athletes were provided with study measures on general sociocultural and coach-related appearance and body weight pressures, internalization of appearance ideals, overweight preoccupation and DE. Path analyses showed that general sociocultural pressures were associated with DE directly and through internalization of appearance ideals and overweight preoccupation. Pressures from coaches were associated with DE through overweight preoccupation and through the internalization of appearance ideals and overweight preoccupation. The models were invariant across body weight sensitivity in sports and age groups. These results inform DE prevention for female athletes. It is important to increase resistance to sociocultural pressures and pressures from coaches in DE prevention programmes for female competitive athletes of all ages and participating in sports irrespective of sports group (weight-sensitive or less weight-sensitive).

Australian elite sport coaches' mental health literacy of eating disorders, orthorexia, and muscle dysmorphia in athletes: A qualitative study

Athletes have an increased risk of developing eating disorders (EDs) compared to non-athletes. Coaches are in a unique position to identify symptoms and promote timely support; however, research has not yet explored coaches' mental health literacy about DSM-5 EDs and related orthorexia and muscle dysmorphia conditions in elite athletes. Eighteen Australian elite sport coaches from aesthetic, weight-class, and endurance sports participated in individual semi-structured interviews to investigate their mental health literacy of EDs and related conditions. Four themes emerged from the data. Theme 1 (knowledge of EDs and related conditions) highlighted coaches' awareness of maladaptive perfectionism as a key risk factor, limited awareness of EDs without observable weight loss, and conceptualisation of EDs as a nutritional issue. Theme 2 (facilitators to managing EDs) highlighted the helpfulness of building trust with athletes, accessing support staff, emphasising body functionality, and lived experience. Theme 3 (barriers to managing EDs) highlighted coaches' challenges with communicating about body image, responding to denial, and funding constraints. Theme 4 (future ED education and training) highlighted coaches' desire for in-person, interactive training and to support junior-level coaches. These findings may assist in developing tailored educational resources to improve coaches' ability to identify and manage eating-related concerns in athletes.

Low Energy Intake Leads to Body Composition and Performance Decrements in a Highly-Trained, Female Athlete: The WANDER (Woman's Activity and Nutrition during an Extensive Hiking Route) Case Study

OBJECTIVE

This case study's purpose was to quantify energy intake vs energy expenditure during a thru-hiker's trek and assess its relationship to performance and health.

METHODS

A highly trained, female thru-hiker (Age (yrs): 62, Ht (cm): 157, Wt (kg): 53.5, BMI (kg/m2): 21.7, %BF: 26.0) embarked on a 4-month journey through the Pacific Crest Trail, USA. The athlete's body composition and 3-day diet record were assessed before (PRE) and after the hike (POST). During the hike, she tracked her diet and performance daily and completed a wellness survey each time she reached a town-check point. Data were analyzed for descriptive (weekly averages, means ± SD) and frequency statistics.

RESULTS

She spent 10 wk (∼70 days) on the trail and hiked 1,506.35 km (26.1 ± 3.2 km/day) with an estimated energy expenditure of ∼2334 ± 351 kcal/day. During the hike, she under consumed calories (1285.3 ± 103 kcal) and dietary carbohydrate (169.5 ± 19.5g), fat (49.7 ± 5.8g), protein (41.9 ± 4.8g; 0.8 g/kg), fiber (11.8 ± 2.1g) and sodium (1642.4 ± 298.6 mg) when compared to ultra-endurance nutrition recommendations. She was unable to complete the trail due to fatigue and anthropometric changes. By POST, she had decreased total mass (PRE: 53.5 kg vs POST: 48.4 kg), BMI (PRE 21.6 vs POST: 19.5), fat-free mass (PRE: 39.6 vs POST: 38.8), and body fat (PRE: 26% vs POST: 19.6%) when compared to PRE.

CONCLUSION

Trail-related challenges combined with high energy expenditures led to low nutrient intake which contributed to trail-ending injuries and performance decrements. Research aimed at addressing the barriers associated with thru-hike fueling is needed to identify nutritional opportunities to support hikers' performance and reduce injury risks.

The "Young Athlete Body Project"-A pilot study evaluating the acceptability of and results from an eating disorder prevention program for adolescent athletes

BACKGROUND

The high frequency of eating disorders (EDs) in sports speaks of a need for early-stage preventive measures.

OBJECTIVES

This study evaluated the acceptability of an age, sex, and sports adapted version of the "Body Project" and changes in mental health symptoms.

METHODS

This noncontrolled pilot study included a class of athletes from 18 sports (N = 73, 13-14 years) at a sport-specialized junior high school in six small-group workshops. We interviewed 34 athletes on program acceptability, and all athletes responded to questionnaires at pretest, posttest, and 6-month follow-up including the Body Appreciation Scale 2-Children, Social Attitudes towards Appearance Questionnaire-4 revised, Eating Disorder Examination Questionnaire Short form-12 modified, and questions about body appearance pressure (BAP).

RESULTS

Athletes found the program acceptable and beneficial, but some missed physically oriented activities or did not identify with the focus, particularly boys. There were acceptable levels in mental health constructs before the workshops. There were temporary changes in the percentage of boys experiencing "BAP in society" by -14.8% points (95% CI: -.6 to .0, p = .04), % in total group experiencing "BAP at school" by +11% points (95% CI: .0-.2, p = .05), thinness idealization by girls (g = .6, p = .002) and total group (g = .4, p = .006), and muscularity idealization by boys (g = .3, p = .05) and total group (g = .23, p = .04).

DISCUSSION

Athletes experienced benefits from the Young Athlete Body Project. Seeing stabilization in outcomes may mean a dampening of the otherwise expected worsening in body appreciation and ED symptoms over time.

PUBLIC SIGNIFICANCE

Adolescent athletes are at risk for developing EDs. Due to lack of prevention programs for this group, we adapted and evaluated a well-documented effective program, the Body Project, to fit male and female athletes <15 years. The athletes accepted the program and experienced participation benefits, with stronger acceptance among girls. Our promising findings encourage larger scaled randomized controlled trials to further evaluate a refined version this program among very young athletes.

Eating Behavior Disorders and Disordered Eating Habits in Spanish High-Performance Women's Olympic Wrestling Athletes

Eating disorders (EDs) are a significant health issue in combat sports. This study investigated the differences between the different types of female wrestlers and the frequency at which EDs occur in the elite population, and it also sought to establish which factors are predictors of EDs. This study was comprised of 22 elite, female wrestlers who were selected based on the following inclusion criteria: having previously been the Spanish champion, being part of the Spanish national team, participating in at least one international championship, and having a history of ED. Data collection involved five questionnaires: demographic data, the Eating Attitudes Test-26 (EAT-26), the Bulimic Investigatory Test, the Edinburgh (BITE), the Eating Disorders Inventory (EDI-3), and the Depression, Anxiety, and Stress Scale (DASS-21). The results revealed diverse levels of depression, anxiety, and stress, with BITE scores indicating abnormal eating patterns. Group comparisons exposed significant distinctions in eating behaviors based on competition and training experience. Regression analyses showed competition and training experience as predictors of bulimia severity and symptoms. The study revealed prevalent extreme weight-control practices, including fasting, diuretic and laxative use, and binge eating. This research emphasizes the importance of EDs in Olympic wrestling, urging a comprehensive approach involving education, support, and policy implementation by coaches, health professionals, and sports organizations to prioritize athletes' well-being and discourage unhealthy weight-control practices.

Mental Health and Disordered Eating in Athletes

Disordered eating (DE) and eating disorders (EDs) are more prevalent in athletes than non-athletes, and can cause devastating health and performance consequences. Although they can affect any athlete, DE/EDs are more common among women and athletes in lean sports, where there is a perceived competitive advantage to being lean. The sports medicine provider plays a crucial role in screening, diagnosis, and treatment of DE/ED. Treatment should involve a multidisciplinary team with a physician, dietitian, and mental health provider. Preventative efforts should seek to educate athletes and their coaches/support staff and should foster a healthy environment, which deemphasizes weight or body image.

Low Energy Availability, Disordered Eating, Exercise Dependence, and Fueling Strategies in Trail Runners

Under fueling, disordered eating (DE), exercise dependence (EXD), and high training demands relative to energy intake may increase the risk of low energy availability (LEA) in endurance and ultra-endurance athletes. The purpose of this study was to evaluate the prevalence of LEA risk and relationship with risk of DE, EXD, and fueling habits during training and competition in endurance runners. Trail runners between the age of 18-40 (n = 1,899; males: n = 510, females: n = 1,445) completed a 45-question survey using Qualtrics that included training and racing characteristics, questions regarding carbohydrate intake during training and competition, the Low Energy Availability in Females Questionnaire (LEAF-Q), the Disordered Eating Screen for Athletes (DESA-6), and the Exercise Dependence Scale-21 (EDS-21). Among all runners, 43% of runners were at risk for LEA, 43% were at risk for DE, and 87.3% reported symptoms related to EXD. LEAF-Q scores were positively correlated with EDS-21 (r = 0.33, p < 0.001) and DESA-6 scores (r = 0.29, p < 0.001). From the population, 47.6% of athletes reported taking in less than the recommended carbohydrate guidelines during endurance events lasting > 2.5 hours. In females, athletes at risk for LEA appear less likely to fuel sufficiently than athletes not at risk for LEA (p < 0.001). Risk of LEA, DE, and EXD appears to be high in endurance runners. Furthermore, meeting carbohydrate recommendations during training and competition should be emphasized to avoid negative health outcomes associated with LEA in endurance runners.

Assessing the presence and motivations of orthorexia nervosa among athletes and adults with eating disorders: a cross-sectional study

PURPOSE

Orthorexia nervosa involves restricting diet based on quality rather than quantity. Although orthorexia is well reported in many at-risk populations, limited data addresses its presence in individuals with eating disorder history (EDs) or athletes. We aimed to identify the presence and potential drivers of orthorexia in adults with EDs and endurance athletes, compared to control subjects.

METHODS

Participants ≥ 18y included: people with a diagnosed eating disorder (ED as per DSM-5); endurance athletes (training/competing ≥ 5 h/week); or control subjects. Participants (n = 197) completed an online survey assessing orthorexia (eating habits questionnaire, EHQ), eating motivations (TEMS-B) and compulsive exercise (CET).

RESULTS

ED had the highest orthorexia symptom severity (92.0 ± 3.02, n = 32), followed by athletes (76.2 ± 2.74, n = 54) and controls (71.0 ± 1.80, n = 111) (F (2) = 18.2, p < 0.001). A strong positive correlation existed between weight control motives and higher orthorexia symptom severity (r = 0.54, 95% CI [1.35, 2.36], p < 0.001), while a weak negative association existed between Hunger and Pleasure motives and higher orthorexia symptom severity (r = 0.23, 95% CI [- 2.24, - 0.34], p = 0.008; r = 0.26, 95% CI [- 2.11, - 0.47], p = 0.002, respectively). A moderate positive relationship was found between CET and orthorexia symptom severity (95% CI [1.52, 3.12], p < 0.001).

CONCLUSION

Adults with ED history and endurance athletes have greater orthorexia symptom severity compared to control. Clinicians working with at-risk populations should screen patients and be aware of red-flags of orthorexic traits, desire to control weight, and compulsive exercise behavior.

LEVEL OF EVIDENCE

III: Evidence obtained from cohort studies.

Investigating pre-professional dancer health status and preventative health knowledge

Introduction

Dance is a highly demanding physical pursuit coupled with pressure to conform to aesthetic ideals. Assessment of health status and preventative health knowledge of pre-professional dancers may help inform educational strategies promoting dancers' health and career longevity. The aim of this research was to establish a baseline understanding of dance students at a single pre-professional institution based on metrics focused on current health, nutrition, lifestyle, and wellbeing while also gauging knowledge of longer-term health implications.

Methods

Adopting a cross-sectional study design, the Dance-Specific Energy Availability Questionnaire was tailored for Australian participants and administered online.

Results

The response rate was 59.5% (69/116 eligible students) and the survey was completed in full by 63 students. Mean BMI was 20 kg/m2, although among females, 47% had a BMI < 20 (range 16 to 25 kg/m2), and at their lowest reported weight BMI was 14 to 25 kg/m2. Over a third had either experienced (31%) or were currently experiencing (3.4%) secondary amenorrhea (period absence ≥ 3 consecutive months). Most dancers did not exclude food groups, however, 24% had been advised to exclude particular foods in the past, mostly by dance teachers. A large percentage used nutritional supplements (68%) with 60% supplementing with iron and more than half (53%) taking two or more supplements. Only 25% had ever utilised a qualified dietitian, although 16% reported a history of eating disorders and 25% reported vegetarian or vegan eating patterns. REDs risk scores ranged from -16 to +16 points with negative scores indicating LEA and higher risk of REDs. The mean score for males was 5.2 (SD = 3.9) and 2.1 (SD = 5.9) for females, with 33.3% producing a negative score.

Conclusion

Results provide insight to health knowledge and particular issues pertinent for dancers and highlights the need for specific education strategies to promote a preventative health focus for those entering a pre-professional programme. This study also highlights the need for improved awareness of LEA and REDs among all practitioners working with dancers along with cultural and structural changes within the broader dance community to help protect and promote the wellbeing of dancers.

Body dissatisfaction, disordered eating and exercise behaviours: associations with symptoms of REDs in male and female athletes

Objectives

Disordered eating and compulsive exercise behaviours are common among athletes and can increase the risk of relative energy deficiency in sport (REDs). Contrarily, the prevalence of muscle dysmorphia and its relationship with REDs are unknown. This cross-sectional study aimed to evaluate associations of all three with REDs symptoms.

Methods

Elite and subelite Icelandic athletes (n=83, 67.5% females) answered the Low Energy Availability in Females/Males Questionnaires (LEAF-Q/LEAM-Q), Eating Disorder Examination-Questionnaire Short (EDE-QS), Exercise Addiction Inventory (EAI) and Muscle Dysmorphic Disorder Inventory (MDDI). Body composition was assessed via dual-energy X-ray absorptiometry; resting metabolic rate via indirect calorimetry; and blood samples were drawn for analysis of nutrition and hormonal status. Females were compared based on LEAF-Q total score (≥8 (at risk) vs <8). Simple linear regression was applied to evaluate associations of (a) testosterone with other objective measures and LEAM-Q scores in males; and (b) LEAF-Q/LEAM-Q scores with EDE-QS, EAI and MDDI scores.

Results

In total, 8.4% of participants scored above cut-off on EDE-QS, 19.3% on EAI and 13.3% on MDDI. Females with LEAF-Q total score ≥8 had higher median scores on EDE-QS, EAI and MDDI compared with those scoring <8. Testosterone was positively associated with iron and inversely with total iron-binding capacity but was not associated with scoring on any of the administered questionnaires.

Conclusion

Drive for muscularity and aesthetic physique may play a role in the complex presentation of REDs. Screening for muscle dysmorphia, in addition to disordered eating and compulsive exercise, could therefore facilitate early detection of REDs.

Eating Disorder Risk and Pathogenic Behaviors Among Collegiate Student-Athletes

CONTEXT

Eating disorders (EDs) are a cluster of behavioral conditions characterized by uneasy thoughts and behaviors that grow into severe or persistent eating disturbances. The demands on student-athletes may create mental and physical stressors that increase the likelihood of EDs and disordered eating.

OBJECTIVE

To examine the ED risk through eating attitudes and behaviors in male and female student-athletes and across various sport types (endurance, aesthetic, power, ball or team, or technical sports).

DESIGN

Cross-sectional study.

SETTING

Collegiate athletics.

PATIENTS OR OTHER PARTICIPANTS

National Collegiate Athletic Association Division I and II student-athletes (n = 2054; males = 631; females = 1423) from 40 institutions.

MAIN OUTCOME MEASURE(S)

Participants completed a web-based demographic survey and the Eating Attitudes Test-26 (EAT-26). Multiple χ2 analyses examined participants classified as at risk for EDs. Independent-samples t tests and a 1-way analyses of variance compared sex and sport type across EAT-26 totals and subscale (Dieting, Bulimia, and Oral Control) scores.

RESULTS

Overall, 25.3% (n = 520/2054) of student-athletes were classified as at risk for EDs. Differences were found between sex and ED risk (χ21,2054 = 32.9, P ≤ .01; 17.3% [n = 109/631] males, 28.9% [n = 411/1423] females) and across ED risk and sport type (χ24,2054 = 13.4, P = .01). When examining females only, we observed differences across ED risk and sport type (χ24,1423 = 13.4, P ≤ .01). No differences were evident across ED risk and sport type for males. Differences were seen between sex and binge eating (χ21,2054 = 6.8, P = .009), sex and diet pill use (χ21,2054 = 19.6, P ≤ .01), and sport type and diet pill use (χ24,2054= 12.2, P = .016), excessive exercise (χ24,2054 = 32.1, P ≤ .01), and losing more than 20 lb (9 kg) in the last 6 months (χ24,2054 = 10.2, P ≤ .037).

CONCLUSIONS

Student-athletes in the collegiate setting are at risk for EDs. Medical professionals, such as athletic trainers, need to be educated on the potential risk factors that may lead to EDs. Protocols for prevention, screening and recognition, and referral should be developed for student-athletes at risk for EDs.

Mental health considerations for athlete removal from play and return to play planning

Abstract: Introduction: Athletes experience the same mental health disorders as the general population. When mental health symptoms or disorders are experienced more acutely, there may be occasions when the treating team needs to decide if it is in the best interest of the athlete to be removed from the sport environment for treatment and recovery. If an athlete has been away from the sport environment due to mental health symptoms or disorders, the treating team should be deliberate and collaborative in guiding their return. Removal-from-play (RFP) and return-to-play (RTP) decisions involving an athlete who has experienced mental health challenges can be complex. Methods: The literature around athlete mental health was reviewed to explore contributing and mitigating factors to mental health challenges in this population. General psychiatric recovery trajectories for selected mental illnesses were reviewed to inform RTP planning through and beyond illness episodes. The literature related to RFP and RTP for athletes in terms of specific physical factors (concussion and musculoskeletal injury) and mental health factors (specifically, depression, anxiety, and eating disorders) was also reviewed. Results: A scoping overview of athlete- and sport-specific factors yielded a framework that can be used to guide athlete support, RFP and RTP planning through and beyond mental health-related sport interruption. Conclusion: When mental health symptoms and disorders are present, decisions guiding RFP and RTP should be guided by clinical assessment of safety, stability and function. Due to the complex nature of mental disorders and the interaction of sport elements, it is recommended that sports psychiatrists are involved in the assessment and management process.

Review of the scientific rationale, development and validation of the International Olympic Committee Relative Energy Deficiency in Sport Clinical Assessment Tool: V.2 (IOC REDs CAT2)-by a subgroup of the IOC consensus on REDs

Relative Energy Deficiency in Sport (REDs) has various different risk factors, numerous signs and symptoms and is heavily influenced by one's environment. Accordingly, there is no singular validated diagnostic test. This 2023 International Olympic Committee's REDs Clinical Assessment Tool-V.2 (IOC REDs CAT2) implements a three-step process of: (1) initial screening; (2) severity/risk stratification based on any identified REDs signs/symptoms (primary and secondary indicators) and (3) a physician-led final diagnosis and treatment plan developed with the athlete, coach and their entire health and performance team. The CAT2 also introduces a more clinically nuanced four-level traffic-light (green, yellow, orange and red) severity/risk stratification with associated sport participation guidelines. Various REDs primary and secondary indicators have been identified and 'weighted' in terms of scientific support, clinical severity/risk and methodological validity and usability, allowing for objective scoring of athletes based on the presence or absence of each indicator. Early draft versions of the CAT2 were developed with associated athlete-testing, feedback and refinement, followed by REDs expert validation via voting statements (ie, online questionnaire to assess agreement on each indicator). Physician and practitioner validity and usability assessments were also implemented. The aim of the IOC REDs CAT2 is to assist qualified clinical professionals in the early and accurate diagnosis of REDs, with an appropriate clinical severity and risk assessment, in order to protect athlete health and prevent prolonged and irreversible outcomes of REDs.

2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs)

Relative Energy Deficiency in Sport (REDs) was first introduced in 2014 by the International Olympic Committee's expert writing panel, identifying a syndrome of deleterious health and performance outcomes experienced by female and male athletes exposed to low energy availability (LEA; inadequate energy intake in relation to exercise energy expenditure). Since the 2018 REDs consensus, there have been >170 original research publications advancing the field of REDs science, including emerging data demonstrating the growing role of low carbohydrate availability, further evidence of the interplay between mental health and REDs and more data elucidating the impact of LEA in males. Our knowledge of REDs signs and symptoms has resulted in updated Health and Performance Conceptual Models and the development of a novel Physiological Model. This Physiological Model is designed to demonstrate the complexity of either problematic or adaptable LEA exposure, coupled with individual moderating factors, leading to changes in health and performance outcomes. Guidelines for safe and effective body composition assessment to help prevent REDs are also outlined. A new REDs Clinical Assessment Tool-Version 2 is introduced to facilitate the detection and clinical diagnosis of REDs based on accumulated severity and risk stratification, with associated training and competition recommendations. Prevention and treatment principles of REDs are presented to encourage best practices for sports organisations and clinicians. Finally, methodological best practices for REDs research are outlined to stimulate future high-quality research to address important knowledge gaps.