Drive, passion, and determination are characteristics that enable athletes to push themselves both mentally and physically to excel in their respective sport. Athletes, especially elite athletes, are well akin to the notions of sacrifice in their lives and working hard to achieve their goals. In such a population, particularly adolescents and young adults, it is essential to ensure that these athletes are providing their bodies with the adequate nutrition to support their high levels of training and overall health. Energy availability is calculated as the energy intake (EI) less the energy cost of exercise relative to fat-free mass (FFM), in other words a failure to intake enough calories to support exercise expenditures. A decrease in EI, increase in exercise expenditure, or a combination of the two, can have a negative impact on an athlete’s performance and overall health.
Relative Energy Deficiency in Sport, otherwise known as RED-S, was first introduced by the International Olympic Committee (IOC) in 2014. RED-S is a syndrome that encompasses the myriad negative impacts of energy deficiency on both male and female athletes. Energy Deficiency in sport has often been thought to be a “female athlete only” problem known as the Female Athlete Triad (menstrual function, bone health, and energy availability). Although the components of the Triad are included in the RED-s model there is also a much broader range of symptoms that may be caused by energy deficiency in sport that do not discriminate between the sexes (figure 1). The RED-s model includes the negative impact that energy deficiency may have on gastrointestinal, immunological, endocrine, metabolic, hematological, and cardiovascular systems. RED-S can also have a psychological impact as well as cause a delay in growth and development, particularly in adolescent athletes. The negative impact of energy deficiency on bone development can cause stress injuries and some may be irreversible, potentially leading to osteoporosis. The negative performance effects of energy deficiency include decreased endurance, increased recovery time, irritability, difficulty concentrating, and a decreased training response (figure 2).
Although disordered eating and/or eating disorders are sometimes the cause of energy deficiency, it is important to note that it may also be a lack of knowledge on the athlete’s part for the number of calories they need to support their expenditures. A Registered Sports Dietitian (RD CSSD) plays a valuable role in estimating the needs of an athlete while considering resting metabolism and caloric expenditures from training. These professionals can also educate the athlete on exercise metabolism as well as fueling strategies for before, during, and after competition to meet elevated energy needs.
If an athlete is found to have a clinical eating disorder or disordered eating, a multidisciplinary approach is recommended. The treatment team should consist of a physician, psychologist or psychotherapist, registered dietitian, and in the case of an athlete, may also include a physical therapist, athletic trainer, and/or coach. Throughout treatment it can be helpful to closely involve the athlete’s coach so that the individual feels supported by not just his/her family, but also his/her athletic family, which can lead to a better prognosis and cooperation with treatment recommendations. It is also very helpful to have a treatment contract to be shared with the athlete, members of the coaching staff, and any other necessary individuals to eliminate confusion around level of activity, return to play, and other recommendations from the clinical team.
The signs and symptoms of RED-S vary athlete to athlete. However, some common symptoms for low energy availability may include: excessive fatigue, muscle loss, frequent illness or injury, stress fractures, menstrual dysfunction, inability to recover, and decrease in performance. It is important for coaches, trainers, and parents to be aware of these signs and symptoms to be able to intervene early. Early intervention is especially important for adolescent athletes since they are in their peak growth years. Education of young athletes around proper fueling practices can help prevent injury, promote growth, and boost overall performance.
About the author:
Laura Moretti, MS, RD, CSSD, LDN, completed a Master’s Degree in clinical nutrition as well as her didactic program in clinical dietetics at New York University’s Steinhardt School of Education, Department of Nutrition and Food Studies. She completed her dietetic internship at New York-Presbyterian Hospital including intensive training at the Weill Cornell Medical Center inpatient eating disorder treatment program. Laura recently moved to Boston from New York City to join the Sports Medicine Team at Boston Children’s Hospital where she is also the Dietitian for the Female Athlete Program. She previously worked as the Primary Nutrition Therapist at Columbus Park Collaborative and Appleman Nutrition in New York City. She possesses a specialty in sports performance based nutrition as well as treating low energy availability, disordered eating, and eating disorders in athletes. Laura has an extensive amount of experience in consulting and collaborating with local colleges, universities, professional sport, and dance facilities. She also is the consulting RD for the Boston Ballet Company. Laura is an active member of the Academy of Nutrition and Dietetics, International Academy of Eating Disorders, Massachusetts Dietetic Association, Collegiate and Professional Sports Dietitian Association, Co-Chair of the AED Sport and Exercise SIG, and the Sports, Cardiovascular, and Wellness Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics. On a personal note, Laura is a competitive triathlete as well as a Boston Marathon Qualifier.
Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. The IOC consensus statement: beyond the Female Athlete Triad– Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014 Apr;48(7):491-7. doi: 10.1136/bjsports-2014- 093502. PubMed PMID: 24620037. http://www.ncbi.nlm.nih.gov/pubmed/?term=red-s+bjsm
Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A, Ackerman K. RED-S CAT. Relative Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT). Br J Sports Med. 2015 Apr;49(7):421-3. PubMed PMID: 25896450. http://www.ncbi.nlm.nih.gov/pubmed/?term=red-s+bjsm
In the Victory Program at McCallum Place, athlete-patients are regularly reminded that an eating disorder is an injury – a metabolic injury. Similar to most physical injuries, eating disorders require proper treatment, rest, and rehabilitation to facilitate healing before it is safe and appropriate to return to sport. If an eating disorder is conceptualized as an injury, it can help to best inform treatment considerations (e.g., how and when to integrate training during treatment). Additionally, it is important to recognize that an eating disorder is an injury so that expectations during treatment and upon return to training or sport can be discussed and modified if needed.
Upon return to sport, a false sense of health and wellness can inappropriately be attributed to an athlete-patient by coaches, teammates, and sports medicine personnel due to the athlete-patient’s seemingly improved physical appearance after obtaining treatment to address complications from an eating disorder. Unlike a visible representation that can be apparent after an athlete sustains certain injuries (e.g., needing crutches after ACL surgery), a metabolic injury that results from an eating disorder is not always visible by the naked eye and, as a result, an athlete-patient may not appear as though he or she is still injured. Although metabolic injuries, such as eating disorders, can sometimes be more covert and the implications might be less observable compared to musculoskeletal injuries, individuals are in significant danger of relapse if treatment, support, and parameters upon returning to sport are not appropriate and consistent. Therefore, it is essential that coaches, athletic trainers, and sports medicine personnel are thoroughly informed by the athlete-patient’s treatment team about specific recommendations on how to best support an athlete-patient’s return to sport.
Similar to musculoskeletal injuries in sport, there are significant risks when sport training is incorporated too aggressively during eating disorder treatment as the athlete-patient remains physically and psychologically vulnerable. Additionally, a heightened risk for re-injury or relapse exists if sport training is introduced in an inappropriate or unsupported manner during the eating disorder treatment process. As such, it is imperative that a treatment team is sensitive and informed of how to best facilitate and support sport training into an athlete-patient’s treatment. Eating disorder treatment providers should remain current on recent research addressing recommendations for incorporating exercise into treatment and, if needed, obtain consultation from other experienced providers.
A serious injury can be both physically and psychologically traumatic for an athlete. A multitude of challenges are likely to follow after an athlete experiences an injury. For athletes who devote an immense amount of time, energy, and emotion to their sport and define their self-worth by their performance and success in athletics, a serious injury can be psychologically devastating. An athlete can experience a loss of identity as a result of needing to halt participation in sport due to an injury or eating disorder. An athlete is likely to encounter significant difficulties, especially if identity is largely, or entirely, comprised of “being an athlete” when participation in sport is abruptly stopped due to an injury (including an eating disorder). Specifically, if perceived value and worth are largely contingent on sport participation and accomplishments, an individual’s identity can be threatened when sport participation is disrupted by injury or when sport participation ends (e.g., retirement).
The need to abstain from sport training or competition can sometimes be similar to the stages of grief (i.e., denial, anger, bargaining, depression and acceptance; Kubler-Ross, 1969), therefore, providers must demonstrate sensitivity to the challenges the athlete-patient is likely to experience during treatment. Before identity is explored in treatment, it is critical the athlete-patient is able to mourn the temporary (or permanent) loss of sport. If an athlete-patient is not allowed to grieve the loss of sport, efforts to address his or her identity in treatment can inadvertently be interpreted as being dismissive of a distressing experience. Individuals who are either temporarily or permanently not able to participate in sport can perceive their identity as “an athlete” to no longer exist since they are not currently competing in sport. The factors that characterize an athlete are well-established, enduring traits that persist in the midst of an injury or after competitive sport participation ends. Recognizing that “being an athlete” is a trait, rather than a state, can be powerful in treatment, especially when an athlete-patient is unable to compete in sport or is not performing up to expectations.
A treatment team should be supportive and sensitive to the important role of sport in an athlete-patient’s life. In conjunction with supporting an athlete-patient’s identity as an athlete, an athlete-patient has a unique and important opportunity to develop a more expansive identity during treatment. With the help of an attuned clinician, an athlete-patient can recognize and develop other parts of his or her identity (e.g., sibling, son/daughter, cousin, student, friend, volunteer) that might have previously been superseded by an all-encompassing athlete identity.
The ability to develop a more robust identity and self-representation can help an individual securely answer questions such as, “Who am I without my sport?” when continued sport participation is in jeopardy or ends. This process is not intended to decrease the importance of sport in one’s life, but rather to increase the other parts of oneself that have been neglected or minimized in proportion to an individual’s athlete identity. When an individual is able to cultivate a broader sense of self, they are more likely to experience the setbacks and success in sport more easily than if their identity is solely as an athlete.
By Dani Gonzales, Psy.D., Sarah Archer, L.M.F.T., and Sammi Montag R.D.
Conflicting and Concurrent Literature
Whether rooting for elite athletes in the Olympics, getting fantasy football roster line-ups, or watching little league sports on weekends, it is clear that sports and athletes surround our daily lives. The topic of eating disorders within athlete populations has received increased attention over the past several decades. What is confusing about this topic is that prevalence rates of eating disorders in athlete populations ranges from as low as 1% to 62% across a variety of sports (Byrne & McClean, 2001). Even more confusing is the fact that studies indicate a variety of risks for developing eating disorders and treatment recommendations. This article aims to discuss three topics: 1.) the conflicting literature in regards to athletes at risk or struggling with eating disorders, 2.) specialized dietary approach for athletes, 3.) treatment recommendations and family-based interventions for athletes.
A comprehensive review of current literature suggests that as a field full of effective treatment providers, we largely disagree on our recommendations for this specific demographic population especially in regards to return to play. One camp of the argument suggests that athletes are at greater risk for developing eating disorders when compared to nonathletes (Hausenblaus & Carron, 1999; Sundogt-Borgen, 1994; Zucker, Womble, Williamson, & Perrin, 1999). The other camp defends that sport serves to protect athletes from developing eating disorders (DiBartolo & Shaffer, 2002; Gutgesell, Moreau, & Thompson, 2003; Hausenblaus & McNally, 2004; Reinking & Alexander, 2005). What is agreed upon is that the qualities which make an athlete desirable are also traits found in individuals with eating disorders, such as excessive exercise, (over) compliance, perfectionism, denial of discomfort, working through the pain, commitment, and high achievement (Thompson and Sherman, 1999).
One of the most important areas of concern and motivation for athletes and their caregivers is the decision and clearance to return to play. Currently, there is no clear consensus regarding recovery criteria for athletes with eating disorders. For female athletes with eating disorders, the Female Athlete Triad and openness to fuel for additional exercise can generally be a good guideline to follow (Joy, Kussman, & Nattiv, 2016). Clinicians and their treatment team providers should also incorporate dietary recommendations, BMI, bone mineral density labs, medication compliance, and therapeutic feedback from the families involved, as well as coaches before a decision is reached. It is recommended that families and coaches also form a written agreement to implement before return to play is initiated. These return to play contracts have demonstrated specific guidelines in which the athlete is to meet with the appropriate treatment team providers, follow daily meal plan, agreement to weigh-in, and limitation of workout/play time.
Specialized Dietary Approach
An adolescent athlete entering treatment for an eating disorder is set apart by their desire to return to their sport for the enjoyment rather than a means of weight loss. We see many teens that identify as athletes, however, who began their sport in the context of the eating disorder as a way to facilitate weight loss. The primary target, upon entering treatment, for any of our athletes is medical stabilization and movement towards weight restoration (if applicable). Once medically cleared, the treatment team is able to develop a reintegration plan which ideally includes feedback and buy in from the coach. A primary distinguisher that the dietary staff at UC San Diego-Eating Disorder Center for Treatment and Research (UCSD-EDC) looks for in regard to the athlete’s readiness to transition back into their sport, is an understanding of increased caloric needs and the willingness to fuel nutritionally to meet the physical demands of their sport. In addition, it is imperative for the athlete to have a mentality orientated toward recovery in order to slowly rehabilitate from their metabolic injury. Transition back into their sport requires close observation by a primary care physician to oversee vitals and a registered dietitian to monitor weight trends and the quality and quantity of intake.
In an attempt to prevent relapse, many aspects of recovery must be taken into consideration with the treatment discharge of an adolescent athlete. Key components that need to be addressed include the continued growth of adolescents requiring a moving goal weight range, the necessity for continued nutritional fueling for the energy requirements of their sport, and identifying essential adjustments to nutritional intake with an increase in training and/or intensity. Each of these components is vital for continued recovery as well as optimal athletic performance.
Application of Treatment via Family-Based Interventions
As treatment providers for pediatric and adolescent programs, challenging patients with fear foods, restaurant outings, and coping ahead for the return to school is both commonplace and necessary to challenge the eating disorder and promote recovery. At the same time, due to the fears surrounding exercise and the impact on weight gain, medical and mental stability, many treatment programs are cautious about the right time to return patients to their sport or allow exercise as an integral treatment component. However, following the current data that indicates exercise can not only promote our patient’s mental well-being but also increase recovery rates (Arthur-Cameselle & Quatromoni, 2014), we now recognize the importance of sport in our patient’s lives and when medically appropriate encourage its return.
While we know from research that athletes in lean sports are more at risk for developing an eating disorder (Cameselle & Quatromoni, 2014; Joy, Kussman, & Nattiv, 2016), it is evident that more and more athletes are at risk for developing an eating disorder. At UCSD-EDC we have also seen an increase in our overall student athlete admissions across multiple sports. These athletes range from water polo players, swimmers, runners, soccer players to dancers and with support from the parents, our athletes plan on returning to sport. Rather than being hesitant to have these middle and high school aged athletes return to their sport, the treatment team, comprised of parents and clinicians, now use it both as a motivator and goal at the onset of treatment.
To lay the ground work, we provide psychoeducation to the real experts on these patients: their parents. We discuss the impact of sport on the eating disorder, risk factors such as signs of overtraining and following the evidence based Family Based Treatment model, and allow the parents to decide if and when they feel their child is ready to return to their sport. With feedback from our medical, dietary, and therapeutic members of the treatment team, parents create a plan for return to sport and slowly increase their child’s participation while our team closely monitors their medical and psychiatric stability.
As our adolescent athletes are still in school and live at home with their parents, parent psychoeducation of Sport and Eating Disorders is paramount, in that they are the primary source of supervision of meals and exercise for these athletes. At UCSD-EDC, we firmly believe the parents are the key to not only the re-feeding process, supervision, and reduction of eating disorder behaviors, but additionally, the ones to oversee the return to exercise. While the treatment team provides expertise and focuses on medical stability, our goal is to continue to empower and charge the parents in the task of supervising their child’s healthy return to sport.
Similar to the model laid out at the Victory Program within McCallum Place, we also look to coaches, trainers, and athletes as having a role within the FBT “family” as they have direct access to the patient and are often highly respected by the student athlete. Whether it’s speaking to coaches directly or providing trainings to athletic directors and trainers, our aim is to provide our patient’s athletic “family” with knowledge and skills to effectively manage the athlete’s return to sport.
At the UCSD-EDC we take a unique approach. While we aim to empower parents and educate coaches, we also provide a curriculum for our athletes that is focused on the areas of psychoeducation, Body Image, Cognitive Behavior Therapy and Dialectical Behavior Therapy. Our primary goals include, challenging myths related to eating disorders and sports, openly discussing the athlete’s specific concerns related to body image while having our patient develop and utilize skills that help them more effectively regulate mood and anxiety. While medical stability is always the number one priority, we firmly believe both the physical and mental health benefits of our patient’s returning to their sport can outweigh the risks if carefully executed with the goal of maintaining the athlete’s health. While the return to sports can play a positive role in an adolescent’s life, we also know that building leadership skills, mastery, and increasing self-esteem assist in one’s long-term recovery. At UCSD-EDC we are dedicated to developing quality based programs founded on empirically supported research that help guide parents and the adolescent athlete by expanding their knowledge of healthy nutrition and positive sport performance.