Jorunn Sundgot-Borgen

Prevalence of eating disorders in elite athletes is higher than in the general population

ObjectiveThe objectives of the study were to examine the prevalence of anorexia nervosa (AN), bulimia nervosa (BN), anorexia athletica (AA), and eating disorders not otherwise specified (ED-NOS) in both male and female Norwegian elite athletes and a representative sample from the general Norwegian population. DesignA 2-step study including self-reported questionnaire and clinical interview. Setting/ParticipantsThe entire population of Norwegian male and female elite athletes (n = 1620) and controls (n = 1696) was evaluated for the presence of eating disorders (EDs). Main Outcome MeasurementBased on the results of the questionnaire, all athletes and controls classified as at risk for EDs, and a representative sample of athletes and controls classified as healthy participated in the clinical part of the study to determine the number of subjects meeting the Diagnostic and Statistical Manual of Mental Disorders-IV criteria for EDs. ResultsMore athletes (13.5%) than controls (4.6%; P < 0.001) had subclinical or clinical EDs. The prevalence of EDs among male athletes was greater in antigravitation sports (22%) than in ball game (5%) and endurance sports (9%; P < 0.05). The prevalence of EDs among female athletes competing in aesthetic sports (42%) was higher than that observed in endurance (24%), technical (17%), and ball game sports (16%). ConclusionsThe prevalence of EDs is higher in athletes than in controls, higher in female athletes than in male athletes, and more common among those competing in leanness-dependent and weight-dependent sports than in other sports. A collaborative effort among coaches, athletic trainers, parents, physicians, and athletes is optimal for recognizing, preventing, and treating EDs in athletes.

Risk and trigger factors for the development of eating disorders in female elite athletes

This study examined risk factors and triggers for eating disorders in female athletes. Subjects included were all of the elite female athletes in Norway (N = 603), ages 12-35 yr, representing six groups of sports: technical, endurance, aesthetic, weight dependent, ball games, and power sports. The Eating Disorder Inventory was used to classify individuals at risk for eating disorders. Of the 117 athletes defined at risk, 103 were administered a structured clinical interview for eating disorders. A comparison group was also interviewed, consisting of 30 athletes chosen at random from a pool not at risk and matched to the at-risk subjects on age, community of residence, and sport. Ninety-two of the at-risk athletes met criteria for anorexia nervosa, bulimia nervosa, or anorexia athletica. The prevalence of eating disorders was higher in sports emphasizing leanness or a specific weight than in sports where these are less important. Compared with controls, eating disordered athletes began both sports-specific training and dieting earlier, and felt that puberty occurred too early for optimal performance. Trigger factors associated with the onset of eating disorders were prolonged periods of dieting, frequent weight fluctuations, a sudden increase in training volume, and traumatic events such as injury or loss of a coach.

The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S)

Protecting the health of the athlete is a goal of the International Olympic Committee (IOC). The IOC convened an expert panel to update the 2005 IOC Consensus Statement on the Female Athlete Triad. This Consensus Statement replaces the previous and provides guidelines to guide risk assessment, treatment and return-to-play decisions. The IOC expert working group introduces a broader, more comprehensive term for the condition previously known as ‘Female Athlete Triad’. The term ‘Relative Energy Deficiency in Sport’ (RED-S), points to the complexity involved and the fact that male athletes are also affected. The syndrome of 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. The cause of this syndrome is energy deficiency relative to the balance between dietary energy intake and energy expenditure required for health and activities of daily living, growth and sporting activities. Psychological consequences can either precede RED-S or be the result of RED-S. The clinical phenomenon is not a ‘triad’ of the three entities of energy availability, menstrual function and bone health, but rather a syndrome that affects many aspects of physiological function, health and athletic performance. This Consensus Statement also recommends practical clinical models for the management of affected athletes. The ‘Sport Risk Assessment and Return to Play Model’ categorises the syndrome into three groups and translates these classifications into clinical recommendations.

Prevalence of eating disorders and the predictive power of risk models in female elite athletes: a controlled study

The purposes of this study were to examine the percentage of female elite athletes and controls with disordered eating (DE) behavior and clinical eating disorders (EDs), to investigate what characterize the athletes with EDs, and to evaluate whether a proposed method of screening for EDs in elite athletes does not falsely classify sport‐specific behaviors as indicators of EDs. All athletes representing the national teams at the junior or senior level, aged 13–39 years (n=938), and age‐group matched, randomly selected population‐based controls (n=900) were invited to participate. From the screening data, a random sample of athletes (n=186) and controls (n=145) were subjects for a clinical interview. More athletes in leanness sports (46.7%) had clinical EDs than athletes in non‐leanness sports (19.8%) and controls (21.4%) (P<0.001). Variables predicting clinical EDs, and thus candidates for valid screening procedures, were menstrual dysfunction in leanness athletes, self‐reported EDs in non‐leanness athletes, and self‐reported use of pathogenic weight control methods in controls. Hence, statistically based risk factors are not universally valid, but specifically related to athletes and non‐athletes, respectively.

Current status of body composition assessment in sport: review and position statement on behalf of the ad hoc research working group on body composition health and performance, under the auspices of the I.O.C. Medical Commission.

Quantifying human body composition has played an important role in monitoring all athlete performance and training regimens, but especially so in gravitational, weight class and aesthetic sports wherein the tissue composition of the body profoundly affects performance or adjudication. Over the past century, a myriad of techniques and equations have been proposed, but all have some inherent problems, whether in measurement methodology or in the assumptions they make. To date, there is no universally applicable criterion or ‘gold standard’ methodology for body composition assessment. Having considered issues of accuracy, repeatability and utility, the multi-component model might be employed as a performance or selection criterion, provided the selected model accounts for variability in the density of fat-free mass in its computation. However, when profiling change in interventions, single methods whose raw data are surrogates for body composition (with the notable exception of the body mass index) remain useful.

International Olympic Committee consensus statement on youth athletic development

The health, fitness and other advantages of youth sports participation are well recognised. However, there are considerable challenges for all stakeholders involved—especially youth athletes—in trying to maintain inclusive, sustainable and enjoyable participation and success for all levels of individual athletic achievement. In an effort to advance a more unified, evidence-informed approach to youth athlete development, the IOC critically evaluated the current state of science and practice of youth athlete development and presented recommendations for developing healthy, resilient and capable youth athletes, while providing opportunities for all levels of sport participation and success. The IOC further challenges all youth and other sport governing bodies to embrace and implement these recommended guiding principles.

Participation in leanness sports but not training volume is associated with menstrual dysfunction: a national survey of 1276 elite athletes and controls

Objective: To examine the prevalence of menstrual dysfunction in the total population of Norwegian elite female athletes and national representative controls in the same age group. Methods: A detailed questionnaire that included questions on training and/or physical activity patterns, menstrual, dietary, and weight history, oral contraceptive use, and eating disorder inventory subtests was administered to all elite female athletes representing the country at the junior or senior level (aged 13–39 years, n  =  938) and national representative controls in the same age group (n  =  900). After exclusion, a total of 669 athletes (88.3%) and 607 controls (70.2%) completed the questionnaire satisfactorily. Results: Age at menarche was significantly (p<0.001) later in athletes (13.4 (1.4) years) than in controls (13.0 (1.3) years), and differed among sport groups. A higher percentage of athletes (7.3%) than controls (2.0%) reported a history of primary amenorrhoea (p<0.001). A similar percentage of athletes (16.5%) and controls (15.2%) reported present menstrual dysfunction, but a higher percentage of athletes competing in leanness sports reported present menstrual dysfunction (24.8%) than athletes competing in non-leanness sports (13.1%) (p<0.01) and controls (p<0.05). Conclusions: These novel data include virtually all eligible elite athletes, and thus substantially extend previous studies. Age at menarche occurred later and the prevalence of primary amenorrhoea was higher in elite athletes than in controls. A higher percentage of athletes competing in sports that emphasise thinness and/or a specific weight reported present menstrual dysfunction than athletes competing in sports focusing less on such factors and controls. On the basis of a comparison with a previous study, the prevalence of menstrual dysfunction was lower in 2003 than in 1993.

The female athlete triad: Are elite athletes at increased risk?

PURPOSE The aim of this study was to examine the percentage of elite athletes and controls at risk of the female athlete triad. METHODS A detailed questionnaire, which included questions regarding training and/or physical activity patterns, menstrual history, oral contraceptive use, weight history, eating patterns, dietary history, and the Body Dissatisfaction (BD) and Drive for Thinness (DT) subscales of the Eating Disorder Inventory (EDI), was prepared. The questionnaire was administered to the total population of female elite athletes in Norway representing the national teams at the junior or senior level, 13-39 yr of age (N = 938) and non-athlete controls in the same age group (N = 900). After exclusion, a total of 669 athletes (88%) and 607 controls (70%) completed the questionnaire satisfactorily. RESULTS A higher percentage of controls (69.2%) than athletes (60.4%) was classified as being at risk of the Triad (P < 0.01). A higher percentage of controls than athletes reported use of pathogenic weight-control methods and had high BD subscale scores (P < 0.001). However, more athletes reported menstrual dysfunction and stress fractures compared with controls (P < 0.05). A higher percentage of both athletes competing in leanness sports (70.1%) and the non-athlete control group (69.2%) was classified as being at risk of the Triad compared with athletes competing in non-leanness sports (55.3%) (P < 0.001). Furthermore, a higher percentage of athletes competing in aesthetic sports (66.4%) than ball game sports (52.6%) was classified as being at risk of the Triad (P < 0.001). CONCLUSIONS More athletes competing in leanness sports and more non-athlete controls were classified as being at risk of the Triad compared with athletes competing in non-leanness sports.

Eating Disorders in Female Athletes

SummaryEating disorders can lead to death. The prevalence of subclinical and eating disorders is high among female athletes, and the prevalence of eating disorders is higher among female athletes than nonathletes. Athletes competing in sports where leanness or a specific bodyweight is considered important are more prone to develop eating disorders than athletes competing in sports where these factors are considered less important. It appears necessary to examine true eating disorders, the subclinical disorders and the range of behaviours and attitudes associated with eating disturbances in athletes, to learn how these clinical and subclinical disorders are related. Because of methodological weaknesses in the existing studies, including deficient description of the populations studied and the methods of data collection, the best instrument or interview method is not known. Therefore, more research on athletes and eating disorders is needed. Suggestions of the possible sport specific risk factors associated with the development of eating disorders in athletes exist, but large scale longitudinal studies are needed to learn more about risk factors and the aetiology of eating disorders in athletes at different competitive levels and within different sports. Further studies are required on the short and long term effects of eating disorders on athletes’ health and athletic performance.

Aspects of disordered eating continuum in elite high-intensity sports.

Dieting is an important risk factor for disordered eating and eating disorders. Disordered eating occurs on a continuum from dieting and restrictive eating, abnormal eating behavior, and finally clinical eating disorders. The prevalence of eating disorders is increased in elite athletes and for this group the cause of starting to diet is related to (a) perception of the paradigm of appearance in the specific sport, (b) perceived performance improvements, and (c) sociocultural pressures for thinness or an “ideal” body. Athletes most at risk for disordered eating are those involved in sports emphasizing a thin body size/shape, a high power‐to‐weight ratio, and/or sports utilizing weight categories, such as in some high‐intensity sports. In addition to dieting, personality factors, pressure to lose weight, frequent weight cycling, early start of sport‐specific training, overtraining, injuries, and unfortunate coaching behavior, are important risk factors. To prevent disordered eating and eating disorders, the athletes have to practice healthy eating, and the medical staff of teams and parents must be able to recognize symptoms indicating risk for eating disorders. Coaches and leaders must accept that disordered eating can be a problem in the athletic community and that openness regarding this challenge is important.