Introduction and Definitions

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

The Australian Institute of Sport (AIS) is Australia’s peak high performance sport agency. The National Eating Disorders Collaboration (NEDC), an initiative of the Australian Government Department of Health, promotes nationally consistent, evidence-based responses to Disordered Eating (DE) and Eating Disorders (ED) in Australia. Both organisations are committed to ensuring the safety and welfare of all high performance athletes. 

The AIS and NEDC have collaborated to provide these guidelines for athletes, coaches, support staff, clinicians and sporting organisations. The guidelines support the prevention and recognition of DE, and promote early intervention to optimise nutrition for performance in a safe, supported, purposeful and individualised manner. This position statement is a call to action to all involved in sport to be aware of poor self-image and poor body image among athletes. Sporting organisations should develop sport-specific positions and guidelines that foster a healthy sport system for athletes. The practical recommendations in this document are intended to guide the clinical management of DE in Australian high performance sport, putting in place a core multidisciplinary team (CMT) comprised of doctor, sports dietitian and psychologist. The clinical treatment and management of EDs is outside the scope of this document. There are further resources available in the National Practice Standards for Eating Disorders¹ , the Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of EDs (2014)² and the UK National Institute for Health and Care Excellence guideline on EDs Recognition and Treatment (2017).³ In addition, the Australia and New Zealand Academy for Eating Disorders clinical practice and training Standards are due for publication in 2020.^4-6 

This document contains detailed discussion of each of the key themes of Background, Assessment, Prevention, and Creating A Healthy Sport System. Key position statements and concepts arising from this material are highlighted throughout the document in break-out boxes. A summary of all position statements and key concepts can be found at the end of Part Four.

Definitions

Organisations and Teams

Australian Institute of Sport (AIS)

The Australian Institute of Sport is Australia’s peak high performance sport agency. The AIS leads and enables a united and collaborative high performance sport system that supports Australian athletes to achieve international podium success.

National Eating Disorders Collaboration (NEDC)

The National Eating Disorders Collaboration is an initiative of the Australian Government Department of Health that develops a nationally consistent, evidence-based approach to the prevention and management of eating disorders in Australia.

Core Multidisciplinary Team (CMT)

A team of professional practitioners (doctors, dietitians, psychologists) who collaborate in the management of disordered eating cases. In the Australian case this would be a sports doctor or general practitioner, an accredited sports dietitian and a registered psychologist or endorsed sport psychologist.

High Performance Athlete

A high performance athlete is considered to be any athlete within the Australian performance pathway ranging from junior and senior elite level and including para and able-bodied athletes. From here on the high performance athlete will be referred to as the athlete.

Dietary and Eating Terms

Optimised Nutrition

Optimised nutrition involves a safe, supported, purposeful and individualised approach. It promotes healthy body image and thoughts about food, and is adaptable to the specific and changing demands of an athlete’s sport.

Energy Availability (EA)

Energy availability is the amount of energy that is available to support the body’s activities for health and function once the energy commitment to exercise has been subtracted from dietary energy intake. Energy availability = (Energy intake – Energy cost of exercise)/Fat free mass.

Low Energy Availability (LEA)

LEA occurs when there is a mismatch between energy intake and exercise load, leaving insufficient energy to cover the body’s other needs. It may arise from inadequate energy intake, increased expenditure from exercise, or a combination of both; and is either advertent or inadvertent.

Relative Energy Deficiency in Sport (RED-S)

RED-S is the syndrome of impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular health that arises from low energy availability.

Eating disorder (ED)

A serious, but treatable mental illness with physical effects that can affect any individual. Feeding and eating-related disorders are defined by specific criteria published in American Psychiatric Association’s (2013) Diagnostic and Statistical Manual of Mental Disorders (5th edition, DSM-5) which include problematic eating behaviours, distorted beliefs, preoccupation with food, eating and body image, and result in significant distress and impairment to daily functioning (e.g., sport, school/ work, social relationships)

Avoidant Restrictive Food Intake Disorder

A new DSM-5 diagnosis previously referred to as “Selective Eating Disorder.” ARFID is similar to anorexia in that both disorders involve limitations in the amount and/ or types of food consumed, but unlike anorexia, ARFID does not involve any distress about body shape or size, or fears of fatness.

Anorexia Nervosa

Characterized by weight loss (or lack of appropriate weight gain in growing children); difficulties maintaining an appropriate body weight for height, age, and stature; and, in many individuals, distorted body image.

Bulimia Nervosa

Characterised by a cycle of binge eating and compensatory behaviours such as self-induced vomiting designed to undo or compensate for the effects of binge eating.

Binge Eating Disorder

Characterized by recurrent episodes of eating large quantities of food (often very quickly and to the point of discomfort); a feeling of a loss of control during the binge eating episode; experiencing shame, distress or guilt afterwards; and not regularly using unhealthy compensatory measures (e.g., purging) to counter the binge eating.

Other Specified Feeding or Eating Disorders (OSFED)

An eating disorder classification used when all required criteria for a diagnosis have not been met but are problematic for health and daily functioning. OSFED includes five categories: Atypical Anorexia Nervosa, Bulimia Nervosa (of low frequency and/ or limited duration), Binge Eating Disorder (of low frequency and/or limited duration), Purging Disorder, and Night Eating Syndrome. All of these may be particularly relevant for athletes who are not underweight and/or where episodes of bingeing or compensatory behaviours are less frequent than required for a diagnosis.

Other Conditions;

Disordered eating (DE)

Disordered eating is any eating behaviour that is not optimised. DE may range from what is commonly perceived as normal dieting to reflecting some of the same behaviour as those with eating disorders, but at a lesser frequency or lower level of severity

Orthorexia

Obsession with proper or ‘healthful’ eating. Although being aware of and concerned with the nutritional quality of the food eaten isn’t a problem in and of itself, people with orthorexia become so fixated on so-called ‘healthy eating’ that they actually damage their own well-being.

Atypical Anorexia Nervosa

Atypical anorexia includes those individuals who meet the criteria for anorexia but who are not underweight despite significant weight loss. Research studies have not found a difference in the medical and psychological impacts of anorexia and atypical anorexia. Even if all the DSM-5 criteria for anorexia are not met, a serious eating disorder can still be present. This is an OSFED presentation that may be easily masked in the HP sports context but which presents serious risk.

Disordered Eating in Athletes

"Disordered eating in an athlete sits on a spectrum between optimised nutrition and an eating disorder"

DE in an athlete sits on a spectrum between optimised nutrition and an ED (Figure 1). An individual with DE may regularly engage in behaviours such as skipping meals, compulsive eating, compulsive exercise and/or restrictive eating but without meeting all required criteria for an ED. Both DE and dieting behaviour are common indicators for developing an ED.^{7 10} The 2019 International Olympic Committee (IOC) consensus statement on mental health in elite sport compares characteristics of ED versus DE (Table 1.)¹¹ DE may involve short-term restrictive diets, which progress to chronic energy or nutrient restriction, binge eating, active and passive dehydration, use of laxatives, diuretics, vomiting, and diet pills with or without excessive training. Individual athletes can move back and forth along the spectrum of eating behaviour at any point in time over their career and within different stages of a training cycle (e.g. during the off-season, pre-season, when injured). Athletes are more likely to present with DE than a clinical ED.^{11 12 13} However, there are health and performance implications regardless of where an athlete falls along the spectrum, and risks increase when DE worsens into a diagnosable ED. Behaviour that was previously ‘encouraged and rewarded’ such as losing weight to enhance performance, may result in a failure to maintain adequate energy availability required for training and competition demands. These behaviours may not have been maladaptive at first, but may develop into problematic eating behaviour and worsen to reflect ED psychopathology. Familiarisation with ED diagnostic criteria among members of an athlete’s support network facilitates appropriate questions about eating behaviour. The associations between body composition manipulation, EA, nutrition, psychosocial status, body image, health and performance are complex.¹⁴ Evaluation and management requires a professional and cohesive team.

Figure 1: The spectrum of eating behaviour in the high performance athlete from optimised nutrition to disordered eating to eating disorders.

Optimised Nutrition

Safe, supported, purposeful and individualised nutrition practices that best balance health and performance

Disordered Eating

Problematic eating behaviour that fails to meet the clinical diagnosis for an eating disorder

Eating Disorder

Behaviour that meets DSM-5 diagnostic criteria for a feeding and eating disorder

Table 1: Characteristics of eating disorders versus disordered eating in elite athletes – reprinted with permission from The IOC Consensus Statement on Mental Health in Elite Sport (Reardon et al. 2019).

Reprinted with permission from The IOC Consensus Statement on Mental Health in Elite Sport (Reardon et al. 2019).

DE and low energy availability (LEA) can occur together, or in isolation (see Figure 2). Identification of one necessitates the investigation of the other. LEA may be difficult to recognise since an athlete may be stable in weight but deficient in energy.¹⁴ The assessment of energy availability (EA) is complicated by errors in the measurement of its component parts and failure to account for other factors such as dietary quality and within-day energy spread.¹⁵ Added complexity in working with athletes comes from sport-specific pressures and individual comorbidities as well as cultural, familial, individual, and genetic/ biochemical factors.¹⁶ As shown in Figure 2, DE may exist with or without low energy availability , which underpins the syndrome of Relative Energy Deficiency in Sport (RED-S) as described by an expert panel of the International Olympic Committee.

Figure 2: Eating disorders/disordered eating can occur in the absence or presence of low energy availability.

Health and Performance Consequences of Disordered Eating Behaviour

"Inappropriate eating practices can have detrimental effects on sports performance"

In addressing the health and performance consequences of DE or an ED, health must be the priority. Inappropriate eating practices can have detrimental effects on sports performance. One of the health risks of DE or EDs is the potential development of relative energy deficiency in sport (RED-S).⁷ In addition to the direct impairment of physiological and psychological function, DE can increase the risk of illness and injury, compromise training quality and consistency and indirectly interfere with competition goals.¹⁶ If DE is in conjunction with LEA, there may be suppression of physiological processes, resulting in impairments of bone health, menstrual function, endocrine, metabolic and hematological status, growth and development, psychological well-being, and cardiovascular, gastrointestinal and immunological systems (Figure 3A).

Figure 3A: Health Consequences of Relative Energy Deficiency in Sport (RED-S) showing expanded concept of The Triad to acknowledge a wider range of outcomes and the application to male athletes (*Psychological consequences can either precede RED-S or be the result of RED-S).

 

The long-term consequences of LEA are particularly critical to the adolescent athlete, affecting the accrual of peak bone mineral density (BMD) and stature, neurological¹⁸ and reproductive system development.¹⁴ Even without LEA, there may be other consequences of DE behaviours including electrolyte imbalances, dehydration, nutritional deficiencies, gastrointestinal problems (dental, gingival, bleeding, ulceration, bloating, constipation) and mental health issues (depression, anxiety, personality disorders, substance abuse, self-harm and suicidal ideation).¹⁹

When starved of energy, the body responds by reducing its metabolic rate. Since the human brain operates at a very high metabolic rate, and uses a substantial portion of total energy and nutrient intake,²⁰ the brain is particularly vulnerable to inadequate fuel for its brain function.²¹ A person with DE may struggle to make decisions, solve problems and regulate their emotions.²² Restricted eating, malnourishment, and excessive weight loss can lead to changes in brain chemistry, resulting in increased symptoms of depression and anxiety.²³ All of these may affect the athlete’s performance, their ability to engage in day-to-day tasks, their capacity for insight into problems associated with their eating, and their ability to engage with psychological treatments.

 

Performance consequences (Figure 3B) of DE may arise from interrupted or less effective training (e.g. increased illness and injury, reductions in training capacity, recovery and adaptation) as well as acute impairments on competition day from inadequate fueling for the event (e.g. reduction in co-ordination, concentration, mood, strength and endurance).¹⁶ Studies using different methodologies across different sports have reported detriments to performance due to persistent energy deficiency, which may or may not encompass DE. For example, elite male and female distance runners with markers of LEA reported 4.5 times more bone injuries and a 10-fold increase in missed training days due to injury, compared to those with normal EA.

Figure 3B: Potential Performance Effects of Relative Energy Deficiency in Sport (*Aerobic and anaerobic performance). (Reproduced from reference)

 

Meanwhile, a cross-sectional survey of 1000 female athletes across a range of sports found increased odds of performance impairments (decreased training response, impaired judgement, decreased coordination, decreased concentration, irritability, depression and decreased endurance performance) in those judged to have LEA.²⁵ Separate longitudinal investigations of elite female endurance athletes showed a reduction in maximal aerobic capacity and running speed after just two months of LEA, while swimmers with LEA demonstrated a 10% decrease in speed during a 400 m time trial after a 12 week training block in contrast to an 8% increase in performance noted in those with adequate EA.

 

Prevalence and Contributing Factors to Disordered Eating in Athletes

"Disordered eating can occur in any athlete, in any sport, at any time, crossing boundaries of gender, age, body size, culture, socio-economic background, athletic caliber and ability"

DE can occur in any athlete, in any sport, at any time, crossing boundaries of gender, age, body size, culture, socio-economic background, athletic caliber and ability. The estimated prevalence of DE and/or ED in athletes ranges from 0 – 19% in males and 6 – 45% in females.¹¹ Overall, there is a higher prevalence of DE and EDs in athletes compared to non-athletes²⁷ but sport-specific demands and individual characteristics of the athlete lead to a wide variation in prevalence of DE and ED across different sports.¹⁷ Much of the prevalence data regarding DE in athletes originates from studies of Scandinavian cohorts and North American collegiate athletes, predominantly featuring Caucasian and able-bodied populations.^{7 28} There is a paucity of prevalence data in para-athletes with further research and understanding required to adequately address and inform best practice in this population.²⁹ An environment in which there is pressure to either lose or gain weight and/or to maintain meticulous control of body composition may contribute to an increased prevalence of DE and ED's. Athletes may be underweight, normal weight or overweight, irrespective of DE or EDs.³⁰ Personal attributes and pressures for athletes which underpin successful performance, such as perfectionism or obsessive traits, combined with the sport environment may leave athletes vulnerable to DE.

Higher Risk Sports

Three categories of sports, defined as aesthetically judged, gravitational and weight class, are consistently identified as high risk for the development of DE and EDs (Table 2).¹⁴ Successful performance in these sports generally involves individual, or combinations of, features such as low body mass, leanness, high power: weight ratio, subjective judgements on appearance and rapid weight loss for weigh-ins. It should be remembered however that athletes are at risk of DE and ED across all sports and these high-risk categories are neither exclusive nor exhaustive. Risk factors for DE and EDs in high performance athletes can be seen in Table 3. 

Table 2: Weight sensitive sports classified into three main groups at risk for decreased EA.

Table 3: Risk factors for disordered eating and eating disorders in high performance athletes.

Biological Risk Factors

• Age
• Stages of growth, development or puberty
• Genetic risk factors e.g. ED, addictions in family
• Precocious growth or development
• Growth or development that is significantly different from the average

Psychological Risk Factors

• Body dissatisfaction, body image distortion
• Low self-esteem
• Personality traits e.g. perfectionism
• Obsessive-compulsive tendencies/traits
• Neuroticism (depression, anxiety, emotional lability)
• Harm avoidance
• Heightened stress reactivity
• Inflexible, rule-drive, drive for order and symmetry
• Risk taking behaviour

Socio-cultural Risk Factors

• Eating pressures/modelling
• Peer pressure re: physical appearance or weight
• Influence of the media
• ‘Thin ideal’, ‘muscularity ideal’ or ‘fit ideal’
• Direct or perceived pressure to modify appearance or weight
• Weight/appearance-based teasing, bullying
• Social isolation
• Experiences of weight stigma, including in health care and within sporting environments

Sport-specific Risk Factors

• Transition periods: - Early start of sport-specific training - Making a senior team at a young age - Retirement (forced or voluntary) - Non-selection or de-selection - Injury, illness, surgery, time away from sport and training
• Changes in weight/body shape following injury/illness
• Pressures (perceived or real) to change body shape or composition
• Weight cycling
• Patterns of restriction or disordered behaviours
• Coaching behaviour and accepted ‘norms’ within sport
• Rules and regulations in sports
• Performance optimisation pressure
• Use of supplements, nutritional and ergogenic aids
• Body composition testing, weighing and measuring
• Public displays of ‘results’ in common areas e.g. training environment
• Media and social media pressure (perceived or real) to look a certain way

Gender-based Factors

• Media driven gender stereotypes
• Drive for muscularity/leanness/thinness
• Anabolic-androgenic steroid use
• Gender diversity

Other Risk Factors

• Chronic disease related to caloric utilisation e.g. diabetes, thyroid
• Co-occurring conditions e.g. Coeliac disease, other gastrointestinal conditions
• Para athletes
• LGBTQI+
• History of trauma
• History of food insecurity
• Major life transitions e.g. moving away from home, moving between schools, moving overseas

Early Identification of Disordered Eating

"Everyone in the sport system has a role to play in recognition and early intervention, and anyone can refer athletes to, and/or consult with, any member of the core multidisciplinary team"

DE in athletes can occur at any time; both precipitating, or being precipitated by, challenges in the athlete’s life as well as occurring during a time of successful performance.²⁷ DE may manifest in a variety of ways that are unique to the individual. Rapport between the athlete and service provider, or knowledge of the athlete’s baseline health and function can be helpful in the identification of DE and EDs. While there is a growing openness and support for mental health concerns in elite sport,^{11 35} barriers to early identification and treatment of DE and ED still exist. ^{11 13 36} Athletes’ shame, stigma and fear of discrimination prevent them from disclosing problematic behaviour and seeking help, whereas limited knowledge about ED symptoms and reluctance to ask specifically about eating problems inhibit providers’ detection of DE and ED.³⁷ It is widely accepted that the early identification and appropriate management of DE leads to better outcomes.³⁸ EDs have one of the highest mortality rates amongst all mental illness, which underscores the importance of prevention efforts, timely detection and specialised treatment.³⁹

Everyone in the sport system has a role to play in recognition and early intervention (‘early identifiers’), and anyone can refer athletes to, and/or consult with, any member of the CMT (doctor, sports dietitian and psychologist) for further assessment and support.¹⁹ Rapport between the athlete and his or her support network (coach, training partners or teammates, service providers) is important in recognising and evaluating DE and EDs.¹⁹ It is important for all personnel involved in the sport to be aware of the risk factors and warning signs or red flags of DE and EDs (see Tables 3 and 4). Personnel should also be informed of effective communication channels for concerns. Some warning signs (Table 4) can occur early (behavioural changes) whereas others such as weight changes may occur later in the person’s trajectory of DE.

Periodic evaluation can assist with early recognition of athletes who may be at risk and/or are exhibiting early signs of DE. Steps can then be taken to mitigate risk and prevent development of an ED. The goals of assessment are to identify DE or EDs, investigate the presence of LEA/RED-S and its consequences, and manage acute and chronic complications in the athlete. Evaluation should include nutritional, physical and psychological parameters. Where DE behaviours are recalcitrant and/or when an ED is detected, care involves complex, coordinated management of acute and chronic complications. Referral for specialised medical treatment, external to the National Sporting Organisation (NSO), National Institute or Academy of Sport, club or other performance environment, is advised.

Table 4: Warning signs or red flags for disordered eating and eating disorders in athletes.

• Preoccupation with food, calories, body shape and weight

• Polarised/dichotomous thinking (including but not limited to thoughts about food, body or exercise)

• Avoidance of food-related social activities

• Restrictive eating e.g. cutting down or cutting out food groups, nutrients, reducing overall energy intake, counting, measuring and weighing food

• Bathroom visits after meals

• Evidence of binge eating (large amounts of food purchased/consumed, evidence of food wrappers hidden in the bin or another location)

• Restriction followed by binge eating

• Secretive behaviour regarding food intake and/or exercise behaviour

• Increasing rigid or inflexibility in situations

• Wearing baggy or layered clothing that hides body shape

• Relentless, excessive exercise

• Exercise through injury/illness with inadequate recovery

• Bone stress injury

• Hormone dysfunction (including dysregulated menstrual cycle, libido & erectile function)

• Frequent illness

• Low body fat

• Dehydration

• Bad breath, sore gums or signs of enamel loss on teeth

• Swelling around jaw

• Skin effects, including dry skin, fine hairs growing around the face, or signs of calluses on the knuckles

• Unexpected weight gain beyond that expected from growth/development/puberty

• Dramatic or rapid weight loss or gain or fluctuation

• Persistent and/or problematic poor mental health

• Increased attention to and/or criticism of one’s body

• Feeling out of control in regards to food

• Body image dissatisfaction and distortion

The Core Multidisciplinary Team

"The CMT of Doctor, Sports Dietitian and Psychologist forms the cornerstone of professional assessment and management of athletes on the spectrum of eating behaviour"

The recommended CMT is comprised of the doctor, sports dietitian and psychologist, and together they coordinate the prevention, assessment, management and maintenance care in possible DE cases. As per the Olympic Movement Medical Code, all activities of the CMT should be based on the premise that the health and welfare of athlete are pre-eminent and prevail over competitive, economic, legal or political considerations.⁴⁰ Each member of the CMT provides expertise in a mutually supportive manner (see Figure 4) to deliver optimal care for the athlete in a safe, supported, individualised and purposeful way, governed by the ethos, ‘do no harm.’ Doctors, sports dietitians and psychologists working within sport, despite not always self-identifying as experts in this field, need to have an awareness of DE and EDs and regularly seek professional development in this area.

Figure 4: CMT management by a Doctor, Sports Dietitian and Psychologist: The CMT drives the assessment for DE of an athlete, which may involve some overlap between disciplines depending on the trigger for recognition of DE and the individual case characteristics.

Medicine

- History

- Examination

- Investigations

- Referrals

Nutrition

- Screening tools: questionnaire, interview

- Diet history assessment

- Special diets

- Allergies/intolerances/restrictions

- Eating behaviour

- Eating/food attitudes/beliefs

- EA assessment: RMR + DXA body composition for FFM

Psychology

- Screening tools and questionnaires

- Personality and risk factors

- Suicide risk assessment

- Protective factors

The CMT works with the athlete, coach and support staff to investigate and manage health, performance and return to play (RTP) considerations. The unique circumstances of each case are taken into account, along with sport specific demands. With the athlete’s permission and respecting patient confidentiality, the ideal management model includes regular and collaborative communication between the CMT and coach. Further input may be sought from a range of specialists including an endocrinologist, gynecologists', psychiatrist, sport scientist, physiotherapist, occupational therapist, social worker, pediatrician and/or specialist ED service (see Figure 5).^{14 38} Where providers are external to the sport system, the CMT plays a central role in ensuring all parties are aligned and working effectively in the best interests of the athlete. The CMT is responsible for ensuring continuity of care. This includes effective collaboration between physical and mental health services, private and public health services, sport and community-based services and between professional disciplines.

Disordered Eating Flow Chart

Figure 5: DE flow chart: Recognition of DE and referral of an athlete for assessment and management, primarily by the CMT within the context of a healthy sport system.

Members of the CMT may not have specialised skills in the treatment and management of EDs. Regardless, under the Core Workforce Competencies in the National Practice Standards for Eating Disorders¹ , all CMT members should have the skills to be able to contribute to a comprehensive assessment and identify a clinical ED, to refer the person to appropriate service providers (in the comm​unity, intensive or inpatient settings as required), to ensure continuity of care between service providers and to provide ongoing management to a person while they are waiting for treatment. CMT members should seek professional assistance as required, through clinical supervision and/or tertiary consultation with the relevant state or territory specialist ED service. Any clinician providing treatment for an ED should do so in accordance with the appropriate clinical standards. These include the Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of EDs (2014)² and the UK National Institute for Health and Care Excellence guideline on EDs Recognition and Treatment (2017).³ In addition, the Australia and New Zealand Academy for Eating Disorders clinical practice and training Standards are due for publication in 2020.^4-6

Early intervention should assess potential contributors and causes of DE (i.e. individual and environmental risk factors) and aim to minimise risk of developing an ED. Treatment or tertiary intervention typically focuses on addressing and reducing factors which maintain or perpetuate DE or ED, with the intention to ensure the athlete’s safe return to full sport participation. Recovery is considered to be achieved when those affected are indistinguishable from their healthy counterparts on all ED measures.⁴¹ This includes: the athlete no longer meets diagnostic or screening criteria for any ED or for DE; the athlete is no longer engaging in any DE behaviours; the athlete is in good physical health with optimised nutritional intake for levels of activity; the athlete has positive attitudes towards themselves, food, their body, their ability to express emotions and to interact socially, and; the athlete has a quality of life which includes the ability to engage in work, sport, education where relevant, and leisure.⁴¹ Regardless of where an athlete falls along the eating behaviour spectrum, the treatment goal is to shift them towards recovery, through the demonstration of healthy eating behaviour, anxiety reduction and appropriate body image.

It is crucial that there are well defined roles and a clear communication strategy within the CMT and across relevant stakeholders. A designated member of the CMT should ideally coordinate the flow of information across the team and with relevant sports staff.

Assessment of Disordered Eating in Athletes

"The combination of screening tools and clinical interviews form a foundation for DE identification in athletes"

Clinical judgement and an understanding of the high performance sport context is crucial in distinguishing acceptable from problematic behaviours. DE and dieting may be well-established in the sport culture (i.e. endorsed and/or normalized while not necessarily safe or appropriate). Unhealthy environmental cultures contribute major risk factors towards the precipitation and perpetuation of DE and EDs.

Warning signs in the general population may be masked within the sporting environment. For example, a disciplined training diet and preoccupation with body weight and shape may reflect a specific sport culture, changes in, or absolutely low, levels of body fat may be balanced by muscle to present an acceptable body weight, and excessive exercise is easily hidden by demanding training programs.^{42 43} Appropriate training or supervision is required to apply DSM-5 diagnostic criteria to individuals in high performance sport. A comprehensive review of ED diagnoses is outside of the scope of this position statement. Although a number of tools have been developed to screen for DE and EDs in the general population, validated and specialised tools for use in sport across varied athlete populations are limited in number and quality.^{33 44 45} Current recommendations for DE assessment include using self-report screening tools followed by an interview-based assessment, and sport-specific versus general approaches where available.^{11 13} Thus the combination of screening tools and clinical interviews form a foundation for DE identification in athletes.

Practitioner familiarity with an individual athlete facilitates the identification of relevant changes from their prior or usual behaviour. Whenever feasible, and with the athlete’s permission, assessment may involve interviewing others in the athlete’s support network, including coaches, teammates, family and friends. Seeking observations and potential concerns of others’ helps to triangulate athletes’ self-reported behaviours. The quality of the athlete support network should be assessed and decisions made regarding the requirement for education or other resources. The development of trust and a therapeutic alliance is critical during initial contact to evaluate DE behaviour. This is facilitated by active listening and well-developed interviewing skills.

Screening Tools and Questionnaires

There are a range of screening tools and questionnaires available to assist the assessment of DE in athletes. The Eating Disorder Examination (EDE) is regarded as the gold standard for clinical interview for diagnostic purposes of EDs in the general population.⁴⁶ The EDE 17.0 is the newest form which reflects changes to ED classifications in the DSM-5.⁴⁷ The Eating Disorder Examination Questionnaire 6.0 (EDE-Q 6.0) is a short form screening tool based on the EDE 17.0 and is acceptable for use in practice. The EDE-Q 6.0 should form part of a comprehensive assessment of the athlete. Additional tools including the Athletic Milieu Direct Questionnaire Version 2 and Physiological Screening Test, The Brief Eating Disorder in Athletes Questionnaire Version 2, and the Eating Attitudes Tes-26; all provide discrimination between athletes with and without EDs.^{45 48-51} However, there are several limitations of these tools for EDs, particularly for male athletes, and care should be taken to ensure the tool is appropriate for the athlete.⁵²

The assessment of LEA in athletes is also problematic since, although the concept is robust in principle, a quantitative assessment of EA is time consuming and marred by errors of reliability and validity in calculating its main components (energy intake and exercise energy expenditure).¹⁵ The assessment of EA is complicated by errors in the measurement of its component parts and failure to account for other factors such as dietary quality and with-in day spread.¹⁵ The Low Energy Availability in Females Questionnaire is a validated screening tool which may indicate the need for more in-depth assessments such as the measurement of resting metabolic rate or hormonal status.⁵³ However, it is noted that this questionnaire has been principally developed from endurance-trained populations and is unlikely to be as specific and sensitive in other sporting groups

In a review of measurement tools used with athletes, Pope et al. (2015) identified five measures, including the Eating Attitudes Test-26 (EAT-26), Eating Disorder Inventory-2 (EDI-2), Bulimia Test-Revised (BULIT-R), Questionnaire for Eating Disorder Diagnosis (QEDD), and the Eating Disorder Examination (EDE), none of which were developed for use with an athlete population. Though used less often in athlete research, only three measures have been specifically created for administration with athletes – the Weight Pressures in Sport Scale for Male Athletes (WPSS-A), the ATHLETE Questionnaire (AQ) and the Athletic Milieu Direct Questionnaire (AMDQ). Among these, the EAT-26 and QEDD have demonstrated validity.^{51 54 55}

It appears that the need for athlete-targeted screening tools is even more critical in male athletes. Chapman and Woodman (2016) commented on this while performing a meta-analysis to examine whether male athletes exhibited higher levels of DE than non-athletic cohorts. They concluded that the EAT-26 was the only tool that differentiated male athletes from nonathletes and, therefore, DE assessment tools more specifically suitable for males are required.⁵⁶ Male-oriented concerns about body image and eating appear to be distinctly different of those of females.⁵⁷ Limitations of the current screening tools for EDs, particularly for male athletes, include the focus on drive for thinness while lacking a focus on drive for muscularity. Although clinicians may continue to use existing DE and ED screening tools, further work on athlete-focused resources should be considered a priority. Further work to increase the validity of existing DE screening tools in broader athletic populations is underway while new screening assessment tools are in the validation phase.

Nutrition

Nutritional Assessment

An athlete identified with possible DE should be referred to a sports dietitian for nutritional assessment of DE, EDs and LEA (See Table 5). The sports dietitian who is adequately trained in ED screening and assessment may be the first to identify concerning eating behaviours and/or thoughts and would engage the CMT to ensure a comprehensive assessment of the athlete is completed. The sports dietitian can conduct screening questionnaires and interviews; complete a diet history and nutritional assessment; assess for the presence of special diets and restrictions/intolerances/allergies; perform an EA assessment; evaluate risk factors and warning signs of DE or EDs and assess where an athlete is on the spectrum of eating behaviour (see Figure 1). An athlete may be stable in weight but deficient in energy. Weight should not be the sole focus of the multimodal assessment of DE. The sports dietitian aims to understand the psychological component to food choices; the athlete’s views of their body and how these thoughts may impact on food selection. In some cultures and countries, food security may overlay food choice and eating behaviours. A sports dietitian will look to challenge and monitor the athlete’s capacity to move along the spectrum. This is an important component of initial and ongoing nutrition assessments in both the presence and absence of an ED. Tracking where an athlete sits on the spectrum of eating behaviour helps a sports dietitian to better understand the athlete and apply appropriate and targeted nutrition interventions. An athlete’s ability or inability to follow nutrition advice/recommendations also provides further information as to where the athlete sits on the spectrum.

Table 5: A nutrition assessment of the athlete with possible DE includes information on a range of issues.

Behavioural

• Current eating patterns
• Eating behaviour history
• Special diets followed, particularly if the diet involves avoidance of certain foods and/or if the range of foods to be avoided has increased over time
• Specific food restrictions in place, whether for medical or for personal reasons
• Food rules and beliefs
• Flexibility or rigidity around food or nutrient intake
• Current and past nutritional supplement use
• Social interaction with food and meals (any isolation or withdrawing)
• Compensatory behaviours (e.g. vomiting, laxative use, diet pills etc)

Physical

• Pathogenic weight control practices
• Adequacy of current dietary intake including overall energy, macro- and micro-nutrients
• Current and past history of weight and body composition (are these stable or do they fluctuate)
• Active pursuit of changes in body composition, including the time-course and methods of achieving these changes
• Training load and phase

Medical

• Review of biochemistry
• Food allergies and intolerances
• Menstrual history, current menstrual pattern
• Medication (including combined oral contraceptive pill)
• Gastrointestinal complications
• Family history of dieting, eating disorders, mental health issues, relationship with food
• EA assessment (with various methods including RMR and DXA body composition for FFM)

Emotional

• Food and eating attitudes
• Current and past relationship with food and body
• Amount of time spent thinking about food, weight and body image
• Body image, past and present (considering both athlete and general population body image)

Nutrition for health and performance

Manipulation of nutrition practices, including the short-term implementation of special dietary strategies around competition periods, plays a valuable role in helping athletes to achieve their performance goals. Nevertheless, nutrition for athletes needs to encompass considerations of both health and performance, often needing to find a balance between opposing practices or goals. The characteristics of optimised nutrition in an athlete include: