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 calibre and ability.

The Australian Institute of Sport supports the early identification and prevention of disordered eating in athletes within the high performance sporting system.

Disordered eating (DE) and eating disorders (EDs) are complex and can affect the health (mental and physical) and performance of athletes. The AIS has partnered with the National Eating Disorders Collaboration (NEDC) to produce a position statement to assist sporting organisations to address this serious,but often misunderstood area.

35992_Disordered-Eating-Position-Statement.pdf

There is a spectrum of eating behaviours in high performance sport that spans from optimised nutrition through disordered eating to clinically diagnosed eating disorders.

Question and answer with AIS Chief Medical Officer, Dr David Hughes.

Signs and symptoms

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 core multidisciplinary team (doctor, sports dietitian and psychologist) for further assessment and support. 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.

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 and to be informed of effective communication channels for concerns. Some warning signs can occur early (behavioural changes) whereas others such as weight changes may occur later in the person’s trajectory of DE.

Behavioural changes

• 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

Physical changes

• 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 and 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

Psychological changes

• Persistent and/or declining mental health
• Increased attention to and/or criticism of one’s body
• Feeling out of control with regard to food
• Body image dissatisfaction and distortion

Personal attributes which underpin successful performance, combined with the sport environment, may leave athletes vulnerable to disordered eating.

Common questions

What is disordered eating?

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.

DE in an athlete sits on a spectrum between optimised nutrition and an ED, and may include some of the criteria for diagnosis of an ED. Both DE and dieting behaviour are common indicators for developing an ED.

Spectrum of eating behaviour

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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

What is the difference between disordered eating and eating disorders?

The 2019 International Olympic Committee (IOC) consensus statement on mental health in elite sport compares characteristics of ED versus DE (Reardon et al. 2019)

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, however, there are health and performance implications regardless of where an athlete falls along the spectrum, as 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. Feeding and eating-related disorders are defined by specific criteria published in the American Psychiatric Association’s (2013) Diagnostic and Statistical Manual of Mental Disorders (5th edition, DSM-5).

What is the relationship between disordered eating and low energy availability?

Disordered eating and low energy availability can occur together, or in isolation. Identification of one necessitates the investigation of the other.

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Low Energy Availability (LEA) - LEA in athletes can occur due to causes other than DE/ED

• Misguided attempts to lose body mass/body fat
• Lack of time, resources or knowledge to meet the increased energy requirements of heavy training or competition

DE/ED is a common cause of LEA in athletes

Disordered Eating/ Eating Disorders (DE/ED) - Not all DE/ED involve sufficient or consistent energy restriction to meet criteria for LEA

Energy Availability = the amount of energy available to support the body’s health and function activities once the energy committed to exercise has been subtracted from dietary energy intake.

= (Energy intake - Energy cost of exercise)/Fat free mass

Low Energy Availability occurs when there is a mis-match between energy intake and exercise load, leaving insufficient energy to cover the body’s other needs. This may lead to a decrease in metabolic rate and reduction in activity of many body systems, and underpins the Relative Energy Deficiency in Sport (RED-S) syndrome.

The DSM-5 recognises the following ED:

• Anorexia Nervosa
• Bulimia Nervose
• Binge Eating Disorder
• Other specified feeding and eating disorders
• Avoidant/Restrictive Food Intake Disorder

Are there health and performance consequences of disordered eating?

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

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, the brain is particularly vulnerable to inadequate fuel for its brain function. A person with DE may struggle to make decisions, solve problems and regulate their emotions. Restricted eating, malnourishment, and excessive weight loss can lead to changes in brain chemistry, resulting in increased symptoms of depression and anxiety.

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.

Is there such thing as 'high 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. Successful performance in these sports generally involves individual, or combinations of, features such as low body mass, leanness, high power to 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.

Everyone in the high performance sports system has a role as early identifiers of disordered eating. Education and literacy is required around risk factors, warning signs and red flags.

Experiencing an eating disorder

Jessica Smith OAM is a former elite para-swimmer who represented Australia at the 2004 Athens Paralympic Games. Jessica lived with an eating disorder for the majority of her international swimming career and is now an advocate for positive body image, dedicating her life to raising awareness around diversity and disability.

“I battled with an eating disorder for the entirety of my swimming career”.

Contact

For more information please contact disorderedeating@ausport.gov.au