By Riley Nickols, PhD, CEDS

Sport is a great way to build self-esteem, promote physical conditioning, and demonstrate the value of teamwork, but not all athletic stressors are positive. The pressure to excel in sport and an overemphasis on body weight, body composition, and body shape can pose a significant risk for athletes.1,2,3 Athletic competition can also contribute to psychological and physical stress. When the pressures of athletic competition are added to an existing cultural emphasis on thinness, the risks increase for athletes to develop disordered eating, increasing an athlete’s vulnerability to develop an eating disorder thereafter.4,5

The prevalence rates for eating disorders have been shown to be higher in athletes compared to non-athletes and have been found to range from 6-45% in female athletes and 0-19% in male athletes.6 The wide range of prevalence rates found in athletes is likely due to studies using different methods of eating disorder assessment (i.e., EAT-26, EDE-Q, SCOFF, clinical interviews) and varying degrees of transparency of eating disorder symptoms when assessed. Though most athletes with eating disorders are female, male athletes are also at risk and suffer from this illness.7,8

Risk Factors for Athletes

  • Sports such as gymnastics, diving, bodybuilding, or wrestling that emphasize appearance, weight requirements, or muscularity.4,5
  • Sports that focus on the individual (gymnastics, running, figure skating, dance, diving) rather than the entire team (basketball, soccer).9
  • Endurance sports such as running, cycling, swimming.3,10
  • Overvalued belief that a lower body weight and body fat composition will improve performance.11,12,13
  • Early sport specialization including focused training for a sport since childhood.10,14
  • Participating in a higher competitive level as an athlete.15,16
  • An environment in which there is pressure to modify weight and/or to maintain precise control of body composition.25
  • Low self-esteem; perfectionism, family dysfunction; family members who have or have had eating disorders; chronic dieting; training and exercise that results in harmful health consequences or exercise for the purpose of weight loss; peer, family and cultural pressures to be thin and other traumatic life experiences such as a history of physical or sexual abuse.17,18,19,20,21,22,23
  • Coaches who focus primarily on success and performance rather than on the athlete as a whole person.24
  • An environment in which there is pressure to either lose or gain weight and/or to maintain close control of body composition.25
  • Pressure to perform, other teammates modeling eating disorder behaviors, injury, and team weigh-ins.24

Protective Factors for Athletes

  • Positive, person-oriented coaching style rather than negative, performance-oriented coaching style.26
  • Coaches, sport personnel, and parents who abstain from giving specific nutrition, weight, and/or body composition recommendations to athletes and, instead, refer to qualified professionals to provide such support.25
  • Coaches who support treatment recommendations.27
  • Awareness that eating disorders are present in all sports and can impact athletes of all genders, ages, competitive level, socioeconomic status, and athletes at all body weights, shapes, and sizes.28,29
  • Participation in a sport culture that emphasizes body functionality over body appearance has been suggested to be a protective factor for body image issues and disordered eating.30,31
  • Coaches who emphasize factors that contribute to personal success such as motivation, teamwork, dedication, commitment, and enthusiasm rather than body weight, shape, or body composition.32
  • Coaches who prioritize athlete’s mental health and cultivate a safe and supportive culture within their team.33
  • Having a strong coach/athlete relationship.34
  • Coaches who foster positive body image messaging and culture within their team.
  • Early detection and referral to qualified professionals for eating disorder evaluation are critical to preserve an athlete’s health and initiate timely, targeted treatment thereafter.25

Relative Energy Deficiency in Sport (RED-S)

In 2014, the International Olympic Committee (IOC) published the consensus statement Beyond the Female Athlete Triad: Relative Energy Deficiency in Sport whereby RED-S expanded upon the Female Athlete Triad’s three conditions: low bone mineral density, functional hypothalamic amenorrhea, and low energy availability (LEA). A primary tenet of RED-S is that any athlete, regardless of gender, sport, or competitive level can experience this syndrome.36,37

It is important for athletes and sport personnel to understand how RED-S can have damaging effects on all systems in the body, including psychological functioning. The RED-S framework includes more considerations due to low energy availability (LEA). LEA is a state in which the body does not have enough energy to support all of its functions. This leads to issues with reproductive health (menstrual dysfunction and low estrogen for females, low testosterone for males, decreased libido for those with LEA), cardiovascular functioning (unstable vital signs, bradycardia or tachycardia due to LEA), immune functioning, growth and development, hematological, gastrointestinal , and metabolic functioning. Psychological consequences can either precede RED-S or may worsen by RED-S.36,37

Treatment Considerations

Given the serious physical and psychological consequences that can result from eating disorders, it is important to seek professional help as soon as possible. The treatment of an athlete who struggles with disordered eating or an eating disorder requires working with a multidisciplinary team of health and mental health professionals who ideally have expertise treating both eating disorders and athletes. A treatment provider’s dual specialization of eating disorders and athletes can be beneficial to an athlete during treatment due to the provider’s awareness and sensitivity to the unique demands and challenges of sport. This treatment team may include a physician, psychiatrist, mental health provider, and dietician. With the athlete’s consent, it can be beneficial for the athlete’s treatment team to communicate with sport personnel (i.e., coach, athletic trainer, strength and conditioning coach) throughout treatment to coordinate care. Collectively, it can be determined if modifications to an athlete’s sport participation are warranted to support an athlete’s health and treatment targets.36

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