Disordered Eating/Relative Energy Deficiency in Sport

Risk factors for disordered eating in sport include the following:

• Participation in sports in which lean body physique is felt by some to be advantageous (e.g., cross country, track)
• Participation in sports in which artistic quality, in addition to technical skill, is felt to be important (e.g., gymnastics)
• Anxiety or depression
• Family members with disordered eating
• Perfectionism

Complications that may result from disordered eating in sport include:

• Changes in menstrual cycles (either not starting menstruation at all by the expected age, no longer getting menstrual cycles, or getting menstrual cycles less often, lighter, or for a shorter duration than usual)
• Low bone mineral density, which can result in stress fractures or other bone stress injuries and eventual osteoporosis
• Abnormal levels of electrolytes such as potassium
• Dehydration
• Problems with the cardiovascular system (heart and blood vessels)
• Mental health conditions and suicide
• Weakened immune system
• Changes in metabolism

Note that some people reference the term “Female Athlete Triad”, which is becoming outdated.  However, the idea still applies that the three elements of the Triad, disordered eating, menstrual cycle changes, and lowered bone mineral density, can occur in athletes who are not eating enough calories to fuel their activity levels.

A newer term being used is RED-S (Relative Energy Deficiency in Sport).  The International Olympic Committee has used the “RED-S” terminology since 2014.  This term is preferred over Female Athlete Triad in recognition of the fact that male athletes can suffer from disordered eating as well (though it is a more common problem in females).  Additionally, the RED-S term conveys that there are more than just three issues when it comes to underfueling in sport.

The ultimate treatment for disordered eating in sport is increased caloric intake.  Any athlete suffering from signs and symptoms of disordered eating should be referred for professional help to a sports medicine physician, pediatrician, family medicine physician, internal medicine physician, psychiatrist, psychologist/therapist/counselor, and/or registered dietician.  Disordered eating is a serious concern that can have life-threatening consequences if unaddressed.

In the mean time, parents and coaches can be helpful via the following:

• Educate athletes on the energy demands of their sport.
• Create an environment that supports eating at least three meals and one to two snacks daily.  Talk about having a regular breakfast, full lunch at school, and a pre-practice snack to provide energy for training.

Question: One of our top athletes looks like she lost quite a bit of weight.  She’s not having any problems with the training but I think she might be having a problem with food.  She rarely eats at our team functions and I hear from some of her teammates that she skips school lunch. How should I approach this?
Answer:   Have a private meeting with the athlete and discuss your observations and concern for the athlete’s health.  Discuss how under-fueling (i.e., dieting) can lead to drops in performance, injury, and health problems such as irregular menstruation, anemia, and low bone density.   Ask the athlete what she typically eats on a training day.  Many athletes will report eating a “healthy diet” by avoiding “junk food”, soda, and drinking “lots of water” but do not know how much food/fuel their bodies need to support their training.  Sometimes this can result in eating very small portions or skipping meals because there is nothing “healthy to eat”.  This is a frequent excuse for avoiding school lunch or fast food meals.  Also, drinking water to excess can be a concern.  Excessive water intake can result in eating small portions causing low calorie intake, can mask hunger, or can cover up food avoidance.  Share a sample training day menu based on the athlete’s weight (MENU HERE) and point out areas for improvement.
 

Question:  Last season we had several girls injured with stress fractures.  This year at our team meeting we talked about preventing stress fractures and how not having a period can be a warning sign.   Today one of my athletes told she has not had a period for a few months.   In addition to suggesting she see her physician, is there anything else I can do?
Answer:  One of the risk factors for irregular periods is not eating enough calories to meet the demands of training. You can discuss with her what and how much she normally eats on a training day.  Key fueling times are the 3 meals and a pre/post workout snack.  Some athletes eat healthy, but not enough.  Share the sample training day menu posted on the WIAA website  (MENU HERE) for an example of what, when, and how much she needs to eat to fuel her training.
 

Question: I am concerned about one of my athletes, who has lost quite a bit of weight and has stopped getting her period.  I sent her to a doctor, but the doctor was not concerned and said the athlete could continue competing.  Is there anything else I should do?
Answer:  Some professionals are not sufficiently educated about disordered eating to fully understand the seriousness of its long-term consequences.  You should have your athlete see a different provider who is knowledgeable about disordered eating. Types of professionals to whom you should consider sending your athlete include:  physicians (family medicine, internal medicine, pediatrics, sports medicine, or psychiatry), registered dieticians, psychologists or other licensed therapists, school counselors, and athletic trainers.  Additionally, the coach is the one who determines the athlete’s workouts.  Thus, the coach can cut back on the amount of training the athlete does, even if she is officially ‘cleared’ to return to sport.

Question:  I am concerned about an athlete that I coach, but she and her parents refuse to get help.  How can I convince them, and what else should I do? 
Answer:  Talk about the potential negative consequences of disordered eating with the athlete and her parents.  Explain that the athlete could develop life-long struggles with eating disorders and other mental health problems.  The sooner disordered eating is addressed, the more likely it is to permanently resolve.  Also, explain that irreversible bone loss and osteoporosis are more likely to occur the longer insufficient calorie intake goes on.  Additionally, you should insist that she see a professional prior to her continuing to participate on the team.

Further video examples of athletes who have struggled with disordered eating are available on the International Olympic Committee website here: http://www.olympic.org/hbi.  Feel free to share these with your athletes and their parents.   

MYTH: Runners are the only athletes who develop eating disorders.
FACT:  It is true that athletes in sports in which leanness is emphasized (e.g., cross country, track and field, gymnastics, figure skating, diving, swimming) are more likely to develop eating disorders.  However, we see athletes in any and all sports develop eating disorders.

MYTH: Only girls develop eating disorders. 
FACT:  Athletes across genders develop eating disorders. Eating disorders in boys often happen in sports such as wrestling, cross country, and track and field, but it can happen to athletes of any gender in any sport.

MYTH: If an athlete’s performance has not started suffering, then they must not have a problem.  
FACT:  Even if an athlete’s performance has not started to suffer yet, it eventually will.  Not taking in enough calories to match activity level is not sustainable in the long-run.

MYTH: It is normal for female athletes to stop menstruating. 
FACT:  It is never normal for an athlete with a uterus to stop menstruating, and it often means that the athlete is not taking in enough calories to match her activity level.  There are serious health risks, especially bone loss, to not menstruating.  Research shows that after three years of not menstruating, bone loss is likely to be permanent.  Loss of future reproductive function could also occur.  Any athlete who has been without a menstrual period for three months should be referred to a physician for an evaluation.

MYTH: It is normal for female athletes to have changes in their menstrual patterns when exercising heavily. 
FACT:  It is NOT normal for athletes to stop menstruating or to have lighter menstruation or lighter flow, even during heavy training.  

MYTH:  If athletes are not losing weight, they are probably eating enough.
FACT:  Weight loss does not always happen when an athlete under-eats.  The body can compensate by slowing down metabolism.   Fifty percent of the time when an athlete restricts calories, menstrual cycle changes are the first symptoms to appear. Thus, discussions with athletes about the menstrual cycle are extremely important.  

MYTH: If an athlete who loses their period goes on the birth control pill to start menstruating, her bones will be protected.  
FACT:  An athlete is likely to start menstruating again by going on the birth control pill, but if she has not started eating more, then this is just treating the symptoms and not the underlying problem.  No medication, including birth control, has been shown to restore bone loss.  

MYTH: If an athlete is not eating enough to match activity level, they are aware of what they are doing.  
FACT:  Denial is powerful.  Athletes will very often feel that they are being as healthy as possible, and that meticulous attention to diet is a sign of dedication to sport.  Coaches, parents, and professionals will need to help the athlete see the problems with the behaviors.  It will probably take time, education, and convincing for the athlete to see there is a problem.

MYTH: An athlete who eats “healthy,” is a top performer on the team, and excels in class is unlikely to have an eating disorder.
FACT: Traits that are desirable in an athlete can make them more at risk of developing an eating disorder.  Mental toughness, pursuit of excellence, performance despite pain, commitment to training, and being a team player  are very similar to excessive exercise, perfectionism, denial of discomfort, asceticism, over-compliance, and  being self-less.   What looks like a “good athlete” may also be a person with a serious eating problem.