By Emilie Burgess, MS, RDN, CSSD, LDN
Disordered eating (DE) is a growing concern among all athletes, and if left untreated, can progress to a clinical eating disorder (ED) (Bonci, 2008). DE/EDs are metabolic injuries that can bench an athlete if not treated appropriately or intercepted early enough (Hynes, 2018). Eating disorders have one of the highest mortality rates of all psychiatric disorders and yet many athletic departments still do not screen for these potentially life-threatening illnesses.
While athletes and the general population share many predisposing factors for DE/EDs including negative body image, cultural factors, and societal pressures, athletes have additional stressors within the athletic realm such as those pertaining to performance and aesthetics. These unique pressures can include striving for leanness, vulnerability around under-fueling and overtraining, and exposure to messages which promote dieting to maintain a muscular ideal (Hynes, 2018). The reality of disordered eating and eating disorders among athletes is that athletes are more likely to underreport their symptoms to avoid judgement for “not being mentally tough,” or concern over being pulled from their sport.
Due to the high prevalence and risk of athletes developing DE or ED, facilitating early interventions and implementing screening protocols within the collegiate setting is essential. Sports medicine providers need to be attuned to concerns that often arise within this population, such as: sport injuries, impaired recovery, electrolyte abnormalities, hormone irregularities, and low energy availability in both male and female athletes (Bonci, 2008).
Where Do We Start?
There are numerous preventative measures that collegiate programs can put in place. These may include policies and protocols around body composition testing, determining who has access to this data and the inclusion of registered dietitians on staff to help educate athletes on proper fueling for sport. Utilizing such preventative measures will set a strong foundation for athletic departments. The next step is then screening to identify those at risk for the development of an eating disorder as well as those who may already be struggling.
Eating disorder screening assessments for every athlete should be required as part of their pre-participation physical. In most collegiate settings, ED screenings are only offered to freshmen and transfer athletes. However, this protocol leaves unscreened athletes vulnerable (Hynes, 2018). Though there are numerous eating disorder screening tools available, few are validated for athletes specifically and those that are, are not validated for male athletes. Three screening tools that have been utilized in the athletic setting include: the SCOFF, EAT-26, and the DESA-6.
The SCOFF is a 6-question assessment that has been utilized and studied for years, and has been found to be a reliable screening tool (Morgan, 1999). The SCOFF is not designed to diagnose an eating disorder, but rather to flag an individual for further clinical evaluation. While the NCAA website lists the SCOFF as an eating disorder screening tool, it should be noted that the SCOFF is not the most relevant in addressing an athlete’s comprehensive experience, and in particular, the experience of male athletes (Hynes, 2018).
The EAT-26 (Eating Attitudes Test) is a self-report questionnaire to measure concerns and symptoms around eating disorder behaviors. Like the SCOFF, it is primarily used to screen for risk, not to diagnose, and its use is also limited in that the EAT-26 is not validated for athletes (Hynes, 2018).
Lastly, the DESA-6 (Disordered Eating Screen for Athletes) was published in 2021 (Kennedy, 2021). This is a 6-question evaluation that aims to identify disordered eating, specifically in athletes, both male and female. This tool is very easy to use and can be administered by athletic trainers, physicians, registered dietitians, and any other sport or healthcare professional. It has also shown to be a promising tool in identifying risk for DE among athletes in all sports, though its validation is limited to an age range of 13-19. More research needs to be done to further validate this athlete-specific screening tool in additional age groups (Kennedy, 2021).
Screening for both disordered eating and eating disorders leads to improved treatment outcomes among athletes. On the ground level of every collegiate athletic department, there should be eating disorder experts advocating for disordered eating and eating disorders to be treated as seriously as other sports injuries.
What Should a Collegiate Athletic Program Have in Place?
During pre-season medical screenings, a DE/ED screening tool should be administered and a protocol in place for identified athletes to be further monitored and evaluated for sport clearance and medical stability. Support staff including athletic trainers and strength and conditioning coaches are also key players in identifying DE/EDs. The support staff may hear or notice certain behaviors that could flag an athlete for DE/EDs. If a support staff member is concerned about an athlete, protocols should be in place so those staff members know who to immediately contact within the sports medicine department.
Identified athletes should be referred to and begin working with an Eating Concerns Team (ECT) for a timely intervention and on-going care. An ECT should consist of a sports medicine doctor, certified athletic trainer, sports psychologist, sports dietitian, and a licensed mental health counselor or behavioral health expert due to the medical and psychological complexities of these issues. If an ECT is not present or able to be built within the athletic department, the athlete should then be referred to licensed professionals within the campus health service center or an off-campus outpatient care team, ensuring that a dietitian, physician, and mental health professionals are involved.
Regular ECT meetings should occur to discuss cases as they develop for a collaborative and effective treatment approach. Discussions should address ongoing care, athletes returning to sport, or even advocating for an athlete to be admitted to a higher level of care. There will be instances where an individual will require more intensive clinical care, and when those athletes are identified, steps such as contacting eating disorder treatment facilities, working with their family members, and creating a treatment contract should be taken.
The ECT should be charged with developing policies, protocols, and necessary supporting elements for those athletes struggling with DE/EDs to ensure that early intervention and proper care can be provided. Protocols should include the school’s Office of Disability Services to support athletes that need further intervention for recovery, and to ensure their eligibility is protected. The Office of Disability Services can provide additional guidance on how to best accommodate athletes in crisis – especially those that might be asked to consider a leave of absence.
In summary, research indicates that athletes are at an increased risk for disordered eating and eating disorders, regardless of gender, the sport played, or level at which the athlete competes. Screening for early identification as well as creating a comprehensive multi-disciplinary ECT team within an athletic department provides a supportive space for identified athletes to receive the care they need and deserve.
As members of the athletic department, it is the support staff’s role to support student-athletes by working collaboratively and being up to date on the latest education, research, and training. It is the staff’s responsibility to be aware of DE/EDs, intervene as soon as possible, and have the training to be able to address these significant concerns effectively.
To find an eating disorder treatment program or clinicians in your area visit:
For further information on Eating Disorder screening and program development within your athletic department refer to: www.hynesrecovery.com
This article was written by a Collegiate and Professional Sports Dietitian Association Registered Dietitian (RD). To learn more about sports nutrition and CPSDA, go to www.sportsrd.org
Bonci, C. M., Bonci, L. J., Granger, L. R., Johnson, C. L., Malina, R. M., Milne, L. W., Ryan, R. R., & Vanderbunt, E. M. (2008). National athletic TRAINERS’ Association position Statement: Preventing, detecting, and Managing Disordered eating in athletes. Journal of Athletic Training, 43(1), 80–108. https://doi.org/10.4085/1062-6050-43.1.80
Hynes, MSW, D., Swain, MD, A. F., Bennett, PhD, CEDS, S., & Quatromoni, DSc, RD, LDN, P. (2018). Program and Evaluation Plan for Campus-Based Eating Disorder Services [PDF]. East Falmouth, MA: Hynes Recovery Services.
Kennedy, S. F., Kovan, J., Werner, E., Mancine, R., Gusfa, D., & Kleiman, H. (2021). Initial validation of a screening tool for disordered eating in adolescent athletes. Journal of Eating Disorders, 9(1). doi:10.1186/s40337-020-00364-7
Morgan, J. F., Reid, F., & Lacey, J. H. (1999). The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ (Clinical research ed.), 319(7223), 1467–1468. https://doi.org/10.1136/bmj.319.7223.1467
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