Eating disorders are considerably more prevalent in the athletic community than in the general population . This makes the identification of athletes with eating disorders, and those at risk for developing eating disorders, particularly important.
In a sample of 1259 Norwegian male and female athletes and non-athlete controls, it was reported that a significantly higher proportion of athletes had an eating disorder, compared non-athlete controls . The most common eating disorders included anorexia nervosa, bulimia nervosa, binge eating disorder, and anorexia athletica . In females, prevalence of eating disorders has been reported to be 2-3x higher in athletes, compared with non-athlete controls [1, 2]. Eating disorder rates are profoundly higher in aesthetic and weight-dependent sports in both females, and males [1, 3, 4]. In some studies, up to 70% of athletes in weight class sports were dieting or exhibiting abnormal eating behavior to lose weight prior to competition . Perhaps the most well-known disordered eating trifecta in sport is the female athlete triad.
The Female Athlete Triad
The female athlete triad, or “the Triad”, is characterized by 1) low energy availability (with or without disordered eating), 2) menstrual dysfunction, and 3) low bone mineral density . The prevalence of the Triad in “lean sports” (those that emphasize weight categories or aesthetics, such as ballet, gymnastics, or endurance running) is 2-3x higher than in non-lean sports . A recent meta-analysis on prevalence of the Triad in athletes across all levels of activity reported a relatively small percentage exhibiting all 3 triad conditions (0%-15.9%), but the prevalence of any 2 or any 1 of the Triad conditions ranged from 2.7% to 27.0% and 16.0% to 60.0%, respectively . Yes, up to 60% of female athletes can be experiencing a facet of the Triad, and nutritional knowledge (or lack thereof) is not to blame. A sample of 48 endurance athletes, 11 trampoline gymnasts and 32 untrained controls, were classified of being either “at risk” or “not at risk” based on their triad symptoms . There were no differences in nutritional knowledge between athletes who were classified as “at risk”, compared to those who were “not at risk,” . Research suggests that acquiring adequate nutritional knowledge probably won’t change dietary behavior in female athletes [19, 20]. However, lack of knowledge regarding the negative health consequences of the Triad could, potentially, be a contributor to the prevalence of the disorder .
Signs and symptoms commonly observed in the Triad include: rapid weight loss, eating restriction or routine fasting, and use of diet pills; cessation of menstruation in a eumenorrheic female; stress fractures and overuse injuries that heal more slowly than anticipated. Coaches, parents, health care professionals, and fellow teammates should be aware of any of these signs and symptoms and discuss any concerns with the athlete privately . A fantastic in-depth review published in 2017 outlines signs, symptoms, diagnoses, and treatment strategies for young females experiencing the Triad .
Relative Energy Deficiency in Sport (RED-S)
Also in 2014, a panel of experts assembled by the International Olympic Committee proposed an expanded conceptualization of the Triad under the term “relative energy deficiency in sport”, . The syndrome of “relative energy deficiency in sport”, or RED-S, represents an expansion beyond the mere three entities of “the Triad” (energy availability, menstrual function and bone health) in that it is a syndrome that can affect many aspects of physiological function, health and athletic performance. RED-S refers to impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular health caused by relative energy deficiency . If the term “relative energy deficit in sport” is new to you, you’re not alone; in a survey sampling 285 NCAA head athletic trainers, only 1/3 of them had heard of the term “relative energy deficiency in sport,” despite the trainers having been AT-certified for 18 years on average . Just because the disorder has been historically titled “the female athlete triad” doesn’t mean that males can’t adopt disordered eating patterns and/or RED-S, as well.
Disordered Eating in Males
Although male athletes have a lower prevalence of disordered eating than female athletes, they still have a far higher prevalence than male non-athletes . The pattern of medical conditions seen in the male athlete appears analogous to that seen in female athletes diagnosed with the Triad . These conditions include low energy availability with or without disordered eating, reduced sex steroids including testosterone, and impaired bone health . Regardless of the terminology used to describe it, it’s clear that energy balance is a critical element of athlete health and performance. Male adolescent athletes competing in ball or team sports such as football, soccer, and ice hockey tend to have sufficient energy intakes [7-10]. Periods of inadequate energy intakes and/or nutrient deficiencies are observed in athletes participating in sports that emphasize leanness or weight restriction (wrestling, judo, horse-racing) [11-13].
Despite exercising 5x more hours/week, energy intake in adolescent male cyclists was comparable to that of their control counterparts, and appeared to fall below their recommended intake levels . Additionally, intake of important vitamins and minerals like calcium, vitamin D, iron, and B vitamins, were below recommendations for both cyclists and controls . Another study among 61 male cyclists demonstrated comparable results; the cyclists had elevated disordered eating behaviors compared with age-matched controls and exhibited poor intake of each food group compared with nutritional recommendations . Research suggests that eating disorders and body dissatisfaction in other male endurance athletes, including runners [25, 26] and triathletes , is more common than in non-athlete controls.
Educating coaches, particularly male coaches, on eating disorders and optimal nutrition for sport may be a crucial aspect for reducing athlete disordered eating risk. In a survey of 227 high school coaches of female athletes, a significant difference between male and female coaches was found; male coaches were more likely than female coaches to talk to athletes about eliminating certain foods from their diets and about achieving an ideal body for performance in their sport. Males coaches were also less likely to believe that skipping one or two meals per day was a threat to health or performance . Although this study focused on coaches of female athletes only, it would be a mistake to assume that the research doesn’t also apply to coaches of male athletes.
Conclusion and Practical Applications
Eating disorders are devastating psychiatric conditions. Eating disorders have an unacceptably high mortality rate and invoke considerable morbidity among those affected . Given the pressure to achieve a body composition that optimizes athletic performance, athletes are at a greater risk than the general population for development of eating disorders . Although females are typically affected more commonly than males , both sexes are at risk, particularly in sports where leanness offers a competitive athletic advantage [1,2, 14, 29-32]. To prevent and treat disordered eating, it’s essential that unwavering support for athlete health is consistent across the multidisciplinary team (coaches, administrators, trainers, teammates, parents, etc.). The National Collegiate Athletic Association (NCAA) has developed educational materials for coaches, athletic administrators and athletes in an effort to prevent eating disorders; 10 strategies that aim to reduce the likelihood of disordered eating are listed below :
- Be aware of the symptoms of disordered eating.
- Consult a registered dietitian who specializes in sport, particularly a Board Certiﬁed Specialist in Sports Dietetics (CSSD) to prescribe appropriate nutrition for optimal sport performance.
- De-emphasize weight: Be aware of how you are communicating to athletes about weight and performance. Focus on ways for athletes to enhance their performance that do not involve weight.
- Keep an open dialogue with athletes about the importance of nutrition and staying injury-free for optimal athletic performance.
- Recognize that body composition and training required for optimal health and performance is not identical for all athletes.
- Screen student-athletes before the start of the season for risk factors of disordered eating using a validated screening instrument.
- Ensure that all stakeholders (coaches, strength and conditioning coaches, athletic trainers, student-athletes, student-athlete affairs administrators and athletics department staff) are educated about the factors that put athletes at risk for disordered eating.
- Understand your institution’s referral protocol for student-athletes who are in need of assistance with nutrition or disordered eating issues.
- Encourage help-seeking for all mental health concerns, including disordered eating.
- Develop a plan with other stakeholders (such as university counseling services or a sports registered dietitian) for ways to identify and treat student-athletes with eating disorders.
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