I
f you’ve ever watched coverage of the Olympics, then you know that clips of fierce athletic competition are interspersed with touching stories. These narratives showcase what athletes have overcome to participate in the Games. Watching the best athletes in each nation compete and learning their stories can inspire us all to dedicate ourselves to achieving goals in our own lives.
Elite Athletes and Eating Disorder Risk
Elite athletes are inspiring and remarkable in their respective sports. But they are also subject to stressors, societal pressures, and circumstances that lead to less-than-optimal relationships with food. Several Olympians, including climber – Janja Garnbret, cross-country skier – Jessie Diggins, and marathon runner – Molly Seidel have shared their experiences with eating disorders or impressions of how these conditions interface with their sport.
We have written previously about the higher prevalence of eating disorders in athletes compared to non-athletes. Several classes of athletes are at particular risk of developing eating disorders. For example, participants in sports that emphasize aesthetics, such as dance, gymnastics, diving, and figure skating are at heightened risk. Sports that use weight classes, like wrestling and bodybuilding, and endurance sports, including running, cycling, and swimming also confer added risks.
These same groups of athletes are at risk for something else: low energy availability.
What is low energy availability?
Low energy availability refers to a condition where individuals do not intake enough energy to support their everyday biological functions and their level of intentional exercise. People with eating disorders, such as anorexia nervosa and atypical anorexia nervosa, experience low energy availability. However, this problem can also oftentimes occur unintentionally – that is, without a particular drive or desire for thinness – in athletes and those who participate in intense physical training.
No matter the reason, insufficient energy intake is associated with a range of medical and psychological consequences.
Medical and Physical Consequences
Over time, low energy availability can lead to relative energy deficiency in sport (RED-S), formerly referred to as the female athlete triad. RED-S is a condition describing menstrual dysfunction, poor bone density, and disordered eating.
Though menstrual dysfunction is a hallmark symptom of RED-S in female athletes, RED-S is now recognized in athletes of any gender, sex, sport, and ability-level. The terminology “female athlete triad” was updated to RED-S to address the misconception that the condition can only affect female athletes. The term RED-S also encompasses a broader range of symptoms, not just the triad (menstrual dysfunction, bone loss, and disordered eating).
These symptoms should be taken seriously and addressed promptly. If left unaddressed, low energy availability and RED-S can cause long-term health issues like amenorrhea (absence of menstrual cycle) and osteoporosis (weak, brittle bones that increase fracture risk).
Bone Health
Bone health is an especially important consideration for adolescents and young adults, who are in a developmental window for bone building. Bone is a living tissue that is continuously being built up and broken down in the body. Up until around age 30, bone is being accrued (built up at a faster rate than it is being broken down). After this stage of peak bone mass around 30 years old, bone starts to be lost at a faster rate than it is built. If adolescents and young adults do not build enough bone before age 30, they may be susceptible to breaks and frailty later in life. Additionally, amenorrhea and disordered eating are added risk factors for osteoporosis.
Amenorrhea (Absent Menstrual Cycle)
On the surface, having an absent menstrual cycle may not seem like a serious problem for those who are not imminently planning to become pregnant. In reality, the absence of a period in an otherwise healthy young woman is a serious sign of hormonal imbalance. Amenorrhea has lasting impacts on cardiovascular health, bone accrual, and future fertility.
Psychological Consequences
While RED-S may be a result of disordered eating and a drive for thinness, unintentional low energy availability may in and of itself lead to the psychological elements of disordered eating behaviors.
From the Minnesota semi-starvation study of 1944, we learned that reduced availability of food may cause some of the psychological effects seen in eating disorders including:
- Increased thinking about (i.e., preoccupation with) food and eating
- Depression
- Unusual eating behaviors
- Binge eating
Irregular eating patterns may be severe enough to rise to the level of a clinical eating disorder, such as anorexia nervosa and bulimia nervosa. However, disturbances in eating patterns may also be “sub-clinical.” This means that the severity and persistence do not rise to the level of a diagnosable eating disorder. Nonetheless, disordered eating is serious. It can lead to physical and psychological consequences, and the development of a clinical eating disorder if unaddressed.
Serious athletes are at a higher risk of developing disordered eating compared to non-athletes. Yet, it is still difficult to determine which comes first – low energy availability or disordered thoughts about food and body image.
Athletic consequences
Low energy availability not only leads to health problems but also hinders athletic performance in a myriad of ways including:
- Decreased muscle strength
- Decreased endurance
- Impaired coordination
- Difficulty concentrating
- Increased risk of injury
- Increased risk of illness
Especially in cases of injury, consequences of low energy availability may completely prevent an athlete from participating in their sport. Many healthy-weight athletes believe that losing weight will help them improve their athletic performance. But this clearly comes with risk and no guarantee of improvement. In fact, female athletes who have disordered eating habits during their athletic career may have shorter sports careers than those who do not experience disordered eating. For optimal performance and longevity in sport, athletes (of all levels) must eat enough nutrient-dense food to support their training load.
Preventing and treating RED-S
Early identification and intervention of RED-S can prevent lasting health consequences. Primary treatment includes increasing energy availability by decreasing energy expenditure and/or increasing caloric intake. Implementing a regular eating pattern is critical.
Other add-on treatments may be necessary depending on the presentation of symptoms and may include:
- Supplementation with calcium and vitamin D to support bone health
- Avoidance of oral contraceptive pills that induce an artificial menstrual cycle
- Iron supplementation
- Cognitive behavioral therapy
- Specialized eating disorder treatment
Speak to your doctor if you believe you may have low energy availability or RED-S.
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