Eating disorders in sports: a view

contemplating the male athlete

Perturbações do comportamento

alimentar no desporto: uma visão com

foco sobre o atleta masculino

Dânia Oliveira Moura

ORIENTADO POR: Dr. Filipe Ferreira

COORIENTADO POR: Mestre Helena Trigueiro e Mestre Rita Giro

TRABALHO COMPLEMENTAR: REVISÃO TEMÁTICA

1.º CICLO EM CIÊNCIAS DA NUTRIÇÃO | UNIDADE CURRICULAR ESTÁGIO FACULDADE DE CIÊNCIAS DA NUTRIÇÃO E ALIMENTAÇÃO DA UNIVERSIDADE DO PORTO

TC PORTO, 2020

i

“Daria tudo o que sei pela metade do que ignoro.”

René Descartes

ii

Abstract

Eating disorders are among the most pernicious psychiatric diseases. Not

only are they responsible for a significant negative impact on quality of life but

they are also associated with psychiatric comorbidities and high mortality rates,

constituting a major public health concern.

The significant psychological, physical and time demands of athletic

training and competition may place athletes at a higher risk for disordered eating

behaviours and eating disorders, compared to non-athletes. Even though the

prevalence of eating disorders is higher in females, male athletes are also

vulnerable. However, males have been underrepresented in research.

It is undeniable that there is an association with inadequate dietary intake

and eating disorders. Considering that athletic performance and recovery from

exercise are enhanced by optimal nutrition, eating disorders can be responsible

for a variety of negative outcomes to health and sports performance. Indeed, it is

suggested that such disorders could sabotage athletic careers, with the male

athlete being prone to the same repercussions as the female athlete.

More research and education to effectively prevent and manage these

diseases is warranted. Considering the toll that these clinical conditions can take

on an athlete’s life, this review explores eating disorders in sports, with a special

focus on the male athlete.

Keywords: nutrition; psychiatry; mental health; behaviour; low energy

availability.

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Resumo

As perturbações do comportamento alimentar estão entre as doenças

psiquiátricas mais perniciosas. Não só são responsáveis por um impacto negativo

na qualidade de vida, como estão associadas a comorbilidades psiquiátricas e altas

taxas de mortalidade, constituindo uma grande preocupação de saúde pública.

As exigências do treino e da competição, a nível psicológico, físico e de

tempo, podem colocar o atleta em maior risco para desenvolver comportamentos

alimentares conturbados e perturbações do comportamento alimentar. Apesar da

prevalência das perturbações do comportamento alimentar ser mais elevada nas

mulheres, o atleta masculino também está vulnerável. No entanto, os homens têm

sido sub-representados na pesquisa.

A ingestão alimentar inadequada apresenta inegavelmente uma associação

com as perturbações do comportamento alimentar. Considerando que o

desempenho e a recuperação desportiva podem ser aprimorados por uma nutrição

adequada, as perturbações do comportamento alimentar podem ser responsáveis

por uma variedade de consequências negativas, tanto para a saúde como para o

rendimento desportivo. De facto, sugere-se que estas perturbações sabotem

carreiras desportivas, sendo que o atleta masculino está propenso às mesmas

repercussões. É necessária mais pesquisa e educação, de forma a prevenir e gerir

estas doenças de forma mais eficaz. Considerando o impacto que estas condições

clínicas podem causar na vida de um atleta, esta revisão explora as perturbações

do comportamento alimentar no desporto, com foco especial sobre o atleta

masculino.

Palavras-Chave: nutrição; psiquiatria; saúde mental; comportamento; baixa

disponibilidade energética.

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List of Acronyms

AN – Anorexia Nervosa

APA – American Psychiatric Association

ARFID - Avoidant/Restrictive Food Intake Disorder

BED – Binge Eating Disorder

BN – Bulimia Nervosa

DEB – Disordered Eating Behaviours

DSM-5 - Diagnostic and Statistical Manual of Mental Disorders 5th edition

EA – Energy Availability

ED – Eating Disorder

FA – Female Athlete

FFM – Fat-Free Mass

LEA – Low Energy Availability

MA – Male Athlete

ON – Orthorexia Nervosa

OSFED - Other Specified Feeding or Eating Disorders

RED-S - Relative Energy Deficiency in Sport

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Summary

Abstract and Keywords .................................................................. ii

Resumo e Palavras-Chaves ............................................................ iii

List of Acronyms ........................................................................ iv

Introduction .............................................................................. 1

Objectives ................................................................................ 1

Methodology .............................................................................. 2

Overview of Eating Disorders........................................................... 2

Sport Involvement ....................................................................... 5

Male Athlete Considerations ........................................................... 7

Low Energy Availability ................................................................. 9

Prevention of Eating Disorders ....................................................... 11

Critical Analysis ........................................................................ 13

Conclusions ............................................................................. 15

References .............................................................................. 16

1

Introduction

The health benefits of physical activity are widely established. However,

athletes’ participation in sports can also prompt thoughts, emotions and

behaviours which endanger their health. Eating disorders (EDs) are severe

unintentional disruptions in a person’s eating behaviour with significant

prevalence. They are defined by behavioural, psychological, and physical

symptoms(1, 2), and are caused by multiple factors that interact differently in each

person, resulting in diverse symptoms, experiences, and perspectives(3-6). It is now

established that they represent one of the major public health problems due to

their negative health impact associated with comorbidities, as well as high

mortality rates(7, 8). Anorexia Nervosa (AN) and Bulimia Nervosa (BN) are the most

identifiable clinical EDs(2).

Athletes comprise a unique population. They are widely regarded as a

special subgroup of healthy individuals with physically demanding lifestyles. They

live in a competitive environment with many myths surrounding body weight and

performance, which may prompt an increased risk for EDs and low energy

availability (LEA)(9). There is interest in prevention since ED treatment is

challenging and outcomes are somewhat limited. Scientific efforts have mainly

focused on certain types of sport and on the female athlete (FA), not assigning

enough attention to the male athlete (MA), who has been understudied and whose

EDs can be just as hazardous.

Objectives

The aims of this paper were to provide an overview of the characterization,

pathogenesis, complications, and epidemiology of EDs; to investigate the

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influence of sports and implication on the MA; as well as to review the literature

about prevention measures and identify points for future research.

Methodology

A literature search was conducted in the online scientific databases PubMed

and Scopus, in addition to a manual search of relevant journals, between March

and June 2020. The keywords used were a combination of the following: “eating

disorders”, “disordered eating”, “sports”, “athletes”, “male”, “anorexia

nervosa”, “bulimia nervosa”, “orthorexia nervosa”, “low energy availability”,

“prevention”. The relevance of publications was firstly judged based on titles and

abstracts. There were 130 papers that remained, including some retrieved articles

considered relevant, with dates varying between 1987 and 2020. Additionally,

some bibliographic sources were used, including technical books.

Overview of Eating Disorders

EDs are psychiatric disorders defined by the American Psychiatric

Association (APA) as persistent abnormal eating or eating-related behaviour,

which can only be diagnosed using strict criteria. Its onset usually occurs in

adolescence (about 18 years old) and they are often long-standing. EDs have a

negative impact on quality of life, since they significantly impair physical health

and/or psychosocial functioning(2, 10). Its most common associated psychiatric

comorbidities are depression, anxiety, substance abuse, and obsessive-compulsive

disorder(11, 12). EDs can be subclinical or clinical. Individuals who display subclinical

symptoms are said to exhibit disordered eating behaviours (DEB)(13). DEB are

characterized by a wide spectrum (between optimized nutrition and an ED) of

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maladaptive eating and weight control behaviours and attitudes, including:

starvation, fasting, frequent skipping of meals, overeating, binge eating, self-

induced vomiting, use of diet pills, laxatives, diuretics, and excessive use of

sauna(13, 14). These are considered clear risk factors for developing a clinical ED,

whenever the behaviour is continued(15). Regarding clinical EDs, the 5th edition of

Diagnostic and Statistical Manual of Mental Disorders (DSM-V)(2) reclassified them

as “feeding and eating disorders” and contemplated in it: Pica; Rumination

Disorder; Avoidant/Restrictive Food Intake Disorder (ARFID); AN; BN; Binge Eating

Disorder (BED); and Other Specified Feeding or Eating Disorder (OSFED). Pica is

characterized by a persistent ingestion of non-nutritive, non-food substances and

may coexist with any other ED; Rumination Disorder by a repeated regurgitation

of food; ARFID by avoidance and aversion to food and eating; AN by the refusal to

maintain normal body weight for age and height, with or without purge,

considered the extreme of restricting behaviour; BN by a cycle of food restriction

or fasting followed by binging and purging, leading the patient to adopt extreme

measures to try to mitigate the amount of food ingested; BED by recurrent

episodes of binge eating accompanied by a sense of loss of control over eating,

but without recurrent inappropriate compensatory behaviours; and lastly, OSFED

which are considered atypical EDs and include, for example, Atypical AN, Purging

Disorder, and Night Eating Syndrome. Concerning “body type”, it is important to

note that patients can be underweight, normal weight, or overweight, as body

weight is not contemplated in the criteria for diagnosis of any ED. The obsession

with healthy food and proper nutrition has also been considered an ED by Bratman

et al.(16), who defined Orthorexia Nervosa (ON) as an excessive preoccupation with

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eating healthy food. In particular, individuals with ON have similar cognitive traits

as those with AN and/or obsessive-compulsive disorders(17). However, ON is not

formally recognized as an ED by the APA, and DSM-5 did not include it as a

psychiatric diagnosis due to the lack of robust empirical data required for proper

diagnostic recognition(18). There are some suggestions that the DSM-5 should

modify the category of OSFED and define new types of EDs, with this one displaying

emerging impact. Nonetheless, ON behaviours may be a gateway to develop a

clinical ED(19).

The pathogenesis of EDs is multifactorial, with environmental and individual

factors, including genetics, playing important roles(20, 21). The importance of

“inherited vulnerabilities” was first recognized in a 1998 paper(22) from the Journal

Science, and the role of genetics got more attention when a 2015 family study(3)

identified that twin-based heritability is estimated to be of 50-60%, higher than

that of breast cancer(23). Moreover, oxytocin receptor genotype polymorphisms

and poor maternal care were found to interact with DEB(5). Regarding AN, a 2019

genome-wide association study(24) identified eight significant loci, showing

overlapping associations with DNA that controls different metabolic features.

Another study from 2020(25) suggests that patients use a different region of the

brain from healthy people when selecting foods and that facing food can be

anxiety-inducing. Therefore, the more researchers investigate, the more they find

evidence that the disease’s biological roots run deep.

EDs are associated with nutritional deficiencies and somatic complications

in multiple organic systems, such as anaemia, arteriosclerosis, hypertension, high

cholesterol and triglycerides(26-29). The more chronic and severe the ED, the

greater the likelihood of serious complications that can emerge at any time during

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the course of the illness(30). When purging is present, there is risk for additional

complications such as dehydration, acid-base abnormalities, and cardiac rhythm

disturbances(31). Patients frequently move between diagnostic categories over the

course of their illness and diagnostic migration from AN to BN may be as high as

36%(3, 32). A 2019 simulation modelling study(1) in the US, estimated that

approximately 1 in 7 males and 1 in 5 females develops an ED by the age of 40.

Nevertheless, epidemiological studies across the world indicate that only a

minority of individuals who meet diagnostic criteria seek treatment

(approximately 20%), with this number probably decreasing when referring to

athletes(33). EDs are associated with high mortality rates, mainly due to premature

death from organ system failure and suicide(34). AN has the highest mortality rate

of all psychiatric diseases, approximately 5 deaths per 1000 person-years(35, 36). In

Portugal, a nationwide study(37) from 2000 to 2014, reported a total of 4485

hospitalizations with an associated ED: AN was the most frequent (almost 50%),

and both BN and AN had the most common suicide attempt-related

hospitalizations (10% vs. 5%, respectively). A 2020 nationwide administrative

database analysis(38) showed that the risk of mortality in male AN patients is more

than double that of females.

Sport Involvement

Several studies(39-43) suggest that athletes are at higher risk for EDs than

non-athletes, probably due to the high stakes athletes face, whether it be the

drive to win, financial success, or the inherent emphasis on body

composition/weight within the sport’s environment(31, 44). The prevalence of EDs

in sports varies widely, in the range of 6%–45% in FAs and 0%-19% in MAs, and may

6

be a significant predictor of sport dropout(45, 46). Despite certainly being

underrated, prevalence rates seem to be higher among elite athletes, particularly

FAs(47, 48). However, Palermo and Rancourt(49) suggest that individuals engaging in

sports at a “non-competitive” level may be an under-identified and under-served

population in terms of ED risk. Moreover, some studies(50-52) also hint at a particular

vulnerability of collegiate athletes, given the transition to the college’s

environment often far from home. Nevertheless, methodological considerations

should be emphasized when discussing the published prevalence studies, since

existing publications face challenges, such as the variety of assessment

instruments and definitions used.

The prevalence seems to be particularly higher in athletes competing in

sports where body composition could be considered a necessary step to gain an

advantage, such as weight-class, aesthetic, and endurance sports(9, 45). Sundgot-

Borgen and Torstveit(41) found a prevalence of EDs of 42% in aesthetic sports, 24%

in endurance sports, and 16% in team sports. These are predominantly sports of

an individual nature. Suggested sport-specific risk factors include frequent weight

regulation, dieting, personality traits, earliness of sport-specific training, injuries,

symptoms of overtraining, threat perception, the impact of coaching behaviour,

teammate modelling of DEB, and team weigh-ins(6, 53, 54). The personality traits

that seem to be more strongly influenced by DEB are perfectionism and

competitiveness, with perfectionism strongly correlated with bulimic

symptomatology(55, 56). The same happens with compulsive exercise, a common

feature among patients with EDs, correlated with more severe psychopathology,

worse treatment outcome, and a higher risk of relapse(57, 58). Concerning reported

symptoms, the most common are preoccupation with thoughts about food and

7

eating, irritability, mood swings, sleep disturbance, social withdrawal, weakness,

and gastrointestinal discomfort, which inevitably compromise sport

performance(59, 60). Regarding frequent psychiatric disorders, it is unclear whether

depression drives DEB or whether EDs are a driving force for depression

symptoms(61). Some effects associated with malnutrition and purging like

dehydration, hypokalaemia, muscle cramps, metabolic alkalosis, and oedema are

often noticed on the athlete’s blood tests, in particular with an observed decrease

in potassium and creatinine levels(32, 62). In some cases, athletes may only present

vague medical complaints, muscle fatigue, or dehydration(41). Nevertheless, it

must be considered that such consequences could be enough to result in a second

versus first place in a competition. Available evidence(63) concerning ON suggests

that athletes are at an increased risk and Kiss-Leizer et al.(64) found that athletes

displayed a significantly higher ON tendency to that of controls. A recent cross-

sectional study(17) among athletes competing in endurance sports even suggested

a correlation between endurance sports and ON.

Male Athlete Considerations

In fact, a higher prevalence of EDs is observed among females compared to

males, in both athletic and non-athletic populations(45). However, BED appears to

be more common in males(65). The literature even suggests that EDs occur more

frequently in MAs than in non-athletic male controls(41, 48, 66). Most studies were

conducted in females only, given that men were believed to be at a much lower

risk. However, the focus of recent research has also started to shift towards men,

bringing a new perspective to the field. Indeed, EDs do occur in the MA, but are

concurrently less prominent than in FAs because they can far more easily sustain

8

dramatically lower body fat (in the order of 1%) without profound medical

sequelae, while FAs must maintain about 17% body fat to avoid amenorrhea(67, 68).

Therefore, it can be even more difficult to detect an ED in the MA, in addition to

the fact that most diagnostic-criteria are gender-biased and there is a general

tendency to underreport symptoms(44, 69).

Susceptibility of MAs to DEB seems to be higher in sports such as distance

running, wrestling, bodybuilding, horseracing, rowing, and ski jumping(70-75).

Regarding horseracing, for instance, male jockeys appear to be more susceptible

than their female counterparts to develop an ED, since women are naturally

lighter and smaller(44). Extreme weight-loss methods such as the use of saunas,

excessive exercising to the point of sweating, and dieting were very commonly

reported behaviours practiced by male jockeys(76). Body consciousness is

increasing in men, with a rise in the number of young males who seem preoccupied

with their body image and these concerns seem to involve muscularity and muscle-

enhancing goals(45, 77-80). Recent measures, such as the Muscularity Oriented Eating

Test(81), have been developed to assess muscularity-oriented disordered eating.

A meta-analysis(82) reported more DEB in the athletic than in the control

groups across all categories of sport, but particularly amongst aesthetic and

weight class-dependent sports. However, team sports are not to be neglected

(neither concerning MAs nor FAs): male team sport players could also be a group

of risk for EDs development. A 2019 study(83) conducted in male team players

observed that 14% of the subjects presented symptoms of EDs. Moreover, a 2020

prevalence study(84) in elite soccer players came to warn about the risk for male

reserve players, since they scored higher for perfectionism, may have lower levels

of self-esteem and feel more pressure to perform better, than first-team players.

9

Nevertheless, it is known that attaining maximal muscle mass with minimal body

fat is of great importance to all ball sports.

MAs and FAs who develop an ED share some characteristics, although

increasing evidence suggests certain disparities(12, 85). Studies specific to males

suggest that they are more concerned with leanness and muscularity (foundations

of society’s ideal male body), which may, in extreme cases, lead to muscle

dysmorphic disorder(79, 86). Also, they may be under a unique risk for unhealthy

exercise, especially if they have been overweight in the past, for sports injury,

and for substance abuse(77, 87, 88). MAs are more likely to use substances including

opioids and ergogenic aids to improve performance, with this last one being

strongly associated with DEB(88, 89). Regarding sports injury, this might be the main

risk factor for psychological distress, and a cohort study(90) found that high-school

athletes with DEB were twice as likely to have a sports-related musculoskeletal

injury during a sports season than their female counterparts. Available evidence

also suggests that males may be less likely to seek treatment, to be diagnosed,

and to access treatment (even with similar clinical severity), than females(91-93).

Low Energy Availability

Energy availability (EA) is defined as the amount of daily energy intake

minus exercise-induced energy expenditure normalized to the individual’s fat-free

mass (FFM)(94). LEA is a situation of insufficient energy remaining to cover basic

physiological demands(95). In the pursuit of optimizing performance, athletes may

adhere to rigid diets and excessive exercise regimens, becoming malnourished

enough to enter a state of LEA(96). Inadequate dietary intake appears to be the

first symptom of the onset of an ED, since it typically involves restrictive eating

10

behaviours(97, 98). Athletes experiencing LEA are at a greater risk for developing a

diagnosed ED, or may experience LEA due to DEB(99, 100). Melin et al.(101) reported

clinical LEA in 20% of elite female distance runners, and 25% were clinically

diagnosed with an ED. In 2014, the International Olympic Committee published a

consensus statement(102), updated in 2018(99), introducing a more comprehensive

term to the pre-existing Female Athlete Triad, named Relative Energy Deficiency

in Sport (RED-S). It describes a syndrome in which LEA can lead to multiple medical

problems, not only in women but also in men. The uncoupling of EA with energy

expenditure negatively affects immunological, neuroendocrine, haematological,

cardiovascular, metabolic and gastrointestinal health, impairing metabolic rate,

menstrual function in women, bone health, immunity, and protein synthesis, as

well as interfering with exercise performance(99, 102). Clinical studies(103, 104) on

eumenorrheic subjects have reported that even a short period of EA (5 days) below

30 kcal/kg FFM/day, can cause severe complications.

In the MA, the mechanism is still inconclusive. However, medical

complications can affect all organ systems. It has been reported that energy

deficiency may lead to hormonal disturbances, including reduced testosterone,

with associated symptoms of hypogonadal state and with potential health

implications related to fertility, bone health, and metabolic function, along with

impaired training capacity(100). From research available to date, it appears that

those disturbances observed return to baseline very quickly, differently to the

slow return to baseline observed in women(105). A 2020 review(106) highlighted that

LEA is prevalent across male athlete populations, in particular endurance and

weight class athletes, being a potentially serious threat to bone, endocrine and

metabolic health. Thus, a “MA triad” does exist but rarely comes to attention,

11

because the reproductive consequences are not as easily perceived in men, as

menstrual disorders are(45). A consensus statement concerning this issue is likely

to be published in the near future(107). A 2019 cohort study(108) with endurance

MAs, found a high prevalence of risk for LEA, with approximately 80% of

participants under some degree of risk. This shows the impact LEA may also have

on MAs. Notwithstanding, much remains unknown about LEA in the MA.

Prevention of Eating Disorders

Primary prevention involves education and instruction to prevent extreme

dieting and the onset of EDs, which should be initiated as early as 9–11 years of

age(109). In addition to athletes, educational programs should be aimed at

parents/families and all athlete support personnel, including coaches and athletic

administrators. Education should focus on expanding knowledge of healthy

nutrition in support of sport performance and health, including EA and RED-S, as

well as sectors outside of the sport’s domain(12, 100, 110). Such strategies may play a

vital role in diminishing some of the secrecy surrounding these disorders and

specifically the conspiracy of silence so often seen among coaches and trainers.

Due to their frequent interactions with athletes, coaches are undeniably in a

unique position to detect unhealthy attitudes and behaviours. However, they may

also juggle a combination of role demands and conflicts, which may have a

significant impact on the origin of DEB in the athlete(44). Also, teammates can play

an important role both in primary and secondary prevention, through verbal and

non-verbal communication about what behaviours are normative and desirable,

and symptomatic individuals are frequently identified by them(111, 112). Teammates

can exert either a positive or a negative influence: the first, via supportive

12

teammate friendships, and the second through modelling of teammates’ DEB or

inciting pressure to lose weight/change shape(6, 113-115). A 2020 longitudinal

mediation study(116) highlighted that athletes with poor psychological well-being

(i.e., low self-esteem, high anxiety and depression) are more susceptible to the

negative influence.

For secondary prevention, screening should be a standard component and

team physicians should be knowledgeable of the updated diagnostic criteria for

EDs in the DSM-V(12). However, information obtained simply from observing the

behaviour of individual athletes cannot be underestimated(32). It is important to

note that, when athletes seek professional help, they are more likely to seek help

from doctors because of decreased performance, rather than because of

symptoms of clinical problems(117). Any athlete seeking to intentionally modify

body composition should be provided with professional counselling, ensuring a

time-limited nutritional treatment plan with safe and effective guidelines that

end with re-establishing adequate EA and weight stability, and injured athletes

should be encouraged to maintain optimal EA for optimal rehabilitation(100, 118).

The lack of immediate consequences may fail to provide sufficient incentive to

change behaviour, especially for young athletes(119, 120). Therefore, motivation to

recover is a critical factor in treatment(99) and the desire to be healthy enough to

participate in sport again was identified by Arthur-Cameselle et al.(121) as a

treatment motivator. With early intervention and treatment, recovery is possible,

as are performance achievements once the athlete restores their health, regains

weight, and rebalances emotional well-being(50).

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Critical Analysis

EDs are very complex multi-factorial psychiatric disorders with several

implications and consequences. The male and female experience can be fairly

different, partly as a consequence of gender, but also in how EDs develop, are

acknowledged and treated(122, 123). DEB and EDs in males may present themselves

differently than in females, appearing to be more oriented towards muscularity,

since males are more likely to focus on achieving the idealized masculine shape

(acquisition of muscle mass, with minimum adiposity) than on thinness per se.

Evidence points to an unparalleled increase in the prevalence of male EDs, with

data suggesting that certain DEB may be increasingly more rapidly in males than

in females(1, 124, 125). However, stigma and shame continue to contribute to

underreporting and delayed care(126). Determining when behaviours and attitudes

specific to diet and exercise are progressing to pathogenic levels consistent with

an ED is even more challenging in sports, and coaches, teammates, and families

clearly play important roles(32, 67). It is crucial to promote awareness of this subject

and to establish a network of qualified professionals, in order to avoid progression

to the clinical phase of the disease and prevent long-lasting physiological and

psychological consequences. However, in the absence of specific gender

guidelines, males are likely to be dismissed from the best practice management

of EDs. Therefore, much remains to be done in order to provide a better

understanding of prodromal signs and illness trajectory, enabling early detection,

effective prevention and treatment of conditions related to EDs. More studies are

required, as EDs have been neglected in research and funding, in proportion to

the public health burden that they incur(127). These future studies should be

14

carried out primarily with the aim of establishing their true prevalence,

epidemiology, specific risk factors, and exploring RED-S concerns. In addition,

they should determine energetic nuances involved in metabolic and reproductive

suppression, poor bone health, and to address whether the current female cut

points for LEA are appropriate for use in male populations. These studies must be

conducted using appropriate sample sizes and methodologies that are specifically

suitable for each gender, with a more fine-grained analysis of each sport, including

team sports. Longitudinal research is also needed to identify early signs of somatic

complications and psychiatric comorbidities, as well as genetic studies. These can

provide a bigger picture of what these disorders are, by looking at what is

happening both in the brain and metabolically, and perhaps in other ways that

have not yet been explored. Additionally, it could be relevant to conduct

prospective studies to follow-up athletes and examine the course of the disorder.

Lastly, the onset of ON must be investigated more deeply, identifying diagnostic

criteria, and comparing different questionnaires used to assess it.

Following the strange period during which the world has lived in lockdown,

athletic events around the world have stopped and athletes have had to adopt

social withdrawal measures, thus interrupting their training and preparation

routines for competitions. Therefore, lifestyle changes and induced stress, food

insecurity and uncertainties about the future, may be responsible for inevitable

physical, technical and psychological damage(128-130). A greater awareness has

surfaced in relation to matters of anxiety, depression, and low self-esteem, and

their possible long-lasting effects(131, 132). Consequently, there is an even bigger

need for particular attention and support to be provided to vulnerable individuals,

15

specially to those with an ED, since they are at a significant risk for an increase in

symptomatology and/or diminished access to treatment(129, 130, 133, 134).

Conclusions

EDs in athletes are potentially debilitating psychiatric conditions with

significant medical, psychological, and athletic performance consequences. They

are likely underrecognized, underreported, and underdiagnosed. EDs appear to be

more prevalent in athletes than in the general population, particularly in females

and among sports where leanness confers a competitive advantage. Nevertheless,

both other sports and the MA must not be forgotten, since the impact of EDs in

these groups is significant. Moreover, EDs can cause or be caused by LEA, which

underpins RED-S and has many health and performance consequences.

EDs can outlive participation in sports, with significant associated morbidity

and mortality. Athlete health and welfare must be the main focus; therefore

efforts should be directed to prevention and identification of cases as early as

possible. For primary prevention, education is the best evidence-based method.

The ultimate goal to offer effective treatment to all individuals should be

imperative; however, it remains elusive. Coaches, staff, and other professionals

involved, are encouraged to monitor athletes for signs and symptoms of EDs.

The surrounding stigma has overshadowed the field, perhaps more so among

MAs. Despite the prevalence and toll that EDs have on society, we face significant

limitations. As such, much work in the form of rigorous scientific studies is still

needed to allow for a better understanding and management of this class of

disorders, improving our ability to prevent, detect, and treat them. We must see

athletes as the human beings they are and provide them with proper care.

16

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