Initial validation of a screening tool for disordered eating in adolescent athletes

Balancing Performance and Health in Elite Hungarian Athletes: The Relationship Among Disordered Eating Risk, Body Composition, and Nutrition Knowledge

BACKGROUND

disordered eating (DE) and eating disorders (ED) can negatively impact athletes' health, wellbeing, and athletic performance.

OBJECTIVE

this cross-sectional study aims to assess DE risk, body composition, and nutrition knowledge among elite Hungarian athletes.

METHODS

DE risk was assessed using DESA-6H and EAT-26 scales, nutrition knowledge through the Abridged Nutrition for Sport Knowledge Questionnaire (A-NSKQ), and body composition with the OMRON BF511 device. The data were analyzed using Kendall's tau correlations, Mann-Whitney U tests, and ROC analysis.

RESULTS

a total of 71 athletes participated (39.4% males, mean age = 24.8 years, SD = 4.8 years and 60.6% females, mean age = 24.3 years, SD = 4.3 years). At-risk scores on the DESA-6H scale were recorded for nine athletes (12.7%), while 32.4% scored in the risk zone on the EAT-26, with female athletes in aesthetic, endurance and weight-dependent sports being most affected. Low BF was observed in four males and four females. Nutrition knowledge (49.1%) was below the acceptable threshold. DESA-6H significantly correlated with EAT-26 scores, BMI, sports nutrition knowledge, and A-NSKQ total scores. A statistically significant difference by gender was found in the EAT-26 total score (p = 0.019, d = 0.65). Risk groups significantly differed in A-NSKQ scores (p = 0.026, d = 0.511) and sport nutrition knowledge, specifically (p = 0.016, d = 0.491). Using EAT-26 to identify at-risk athletes and the DESA-6H recommended cut-off, the ROC analysis showed a sensitivity of 29.1% and a specificity of 95.7%.

CONCLUSIONS

insufficient nutrition knowledge plays a role in being at-risk for DE and ED. These results underscore the need for early detection, early sport nutrition education across all elite athletes, with particular attention to female athletes in aesthetic, endurance and weight-dependent sports, and for monitoring these athletes to prevent DE. Further work is warranted to optimize screening tools such as EAT-26 and DESA-6H for elite athletes.

Examination of the Clinical Utility of Eating Disorder and Disordered Eating Screening Tools in Young Athletes: A Scoping Review

Background and Purpose

Many screening tools are used to identify eating disorders (ED) and disordered eating (DE) in individuals. The purpose of this scoping review was to identify the most commonly used ED/DE screening tools for young male and female athletes.

Study Design

Scoping Review.

Methods

Following the Johanna Briggs Institute scoping review guidelines, PubMed, CINAHL Complete, PsycInfo, SPORTdiscus, and Web of Science Core Collection databases were searched using keywords related to eating disorder, disordered eating, athletes, and screening. Included articles were randomized controlled trials, cohort studies, or cross-sectional studies published in English between 2011-2023; included primarily non-aesthetic athletes aged 14-24 years; and utilized an ED/DE screening tool for diagnostic purposes. Articles were excluded if analysis of ED/DE was a secondary purpose or < 20 athletes participated. Tools utilized and demographic and outcomes data were extracted and qualitatively analyzed.

Results

Thirty articles were included. The Eating Attitudes Test-26 (EAT-26), the Sick, Control, One, Fat, Food (SCOFF) questionnaire, and the Eating Disorder Inventory (EDI) were most used among all included articles. Three articles examined only males and used a variety of tools. Five articles utilized a tool specifically designed for athletes: the Eating Disorder Screen for Athletes (EDSA), Brief Eating Disorder in Athletes Questionnaire (BEDA-Q) or the ATHLETE questionnaire.

Discussion

While the EAT-26 is most used for diagnosing ED/DE risk within young athletes, clinical utility of screening tools for male athletes is varied. Combinations of tools utilized for examining ED/DE risk in athletes are not agreed upon. Continued research is needed to assess the clinical utility of screening tools that identify ED/DE risk specifically in athletes. Tool adjustment or development for male athletes may be necessary.

Level of Evidence

2a.

Low Energy Availability Risk Is Associated with Anxiety in Female Collegiate Athletes

This study investigated the association between the risk of low energy availability, disordered eating, and anxiety in collegiate female athletes. Female athletes (n = 115) completed questionnaires that assessed disordered eating (Disordered Eating Screen for Athletes, DESA-6; and the Eating Disorder Examination Questionnaire Short, EDE-QS), anxiety (Generalized Anxiety Disorder-7) and the risk of low energy availability (Low Energy Availability in Females Questionnaire; LEAF-Q). The athletes were 19.9 ± 0.1 years old and presented with no anxiety (14.8%), mild (33.0%), moderate (24.3%), and severe (27.8%) anxiety. The EDE-QS scores revealed that 22.6% of the participants had a high risk of an eating disorder, while the DESA-6 scores revealed that 31.3% of the participants scored positive for a risk of disordered eating. The LEAF-Q total scores revealed that 68.7% of the participants were at risk of low energy availability. Increased GAD-7 scores were associated (p < 0.001) with measures of disordered eating (EDE-QS and DESA-6) and the risk of low energy availability (LEAF-Q total score). Non-parametric partial correlations demonstrated that anxiety (increased GAD-7 scores) correlated with the risk of low energy availability (increased LEAF-Q total scores) while controlling for eating disorder scores (EDE-QS) (r (112) = 0.353, p < 0.001), or while controlling for the risk of disordered eating (DESA-6 scores) (r (112) = 0.349, p < 0.001). In female collegiate athletes, both disordered eating and the risk of low energy availability were positively associated with increased anxiety.

The Development and Validation of a Disordered Eating Screening Tool for Current and Former Athletes: The Athletic Disordered Eating (ADE) Screening Tool

BACKGROUND

Current and former athletes are one of the most at-risk population groups for disordered eating (DE), impacting their dietary practices, body composition, performance and health during and following their athletic careers. Few comprehensive DE screening tools exist for this group. To help address this, the current study utilised a mixed-methods approach of Classic Test Theory (CTT) and Item Response Theory (IRT) to develop and validate a DE screening tool suitable for current and former athletes.

METHODS

Novel scale development methodologies were used to develop and assess the validity (content, face, cross-cultural, construct), test-retest reliability, internal consistency reliability, factor analysis and Rasch analysis of a new DE scale.

RESULTS

A new validated Athletic Disordered Eating (ADE) screening tool was created, with 17 items and four subscales (food control, bingeing, body control, body discontent), with an internal consistency reliability of 0.91, excellent content and construct validity, an Intraclass Correlation Coefficient of 0.97 and excellent Rasch model fit.

CONCLUSIONS

The ADE screening tool has been dually developed for research purposes and as a clinically applicable screening tool to detect DE in current and former athletes and is suitable for a global use across sporting categories, diverse genders and levels of competition.

The Prevalence of Stress Fractures and the Associated LEAF-Q Responses, Self-Reported Exercise Volume and Dietary Behaviors in Female Recreational Runners

Previous research suggests a high prevalence of low energy availability (LEA) and stress fractures (SF) among competitive female endurance athletes. However, much less is known about these issues among recreational female runners. This study aimed to assess the prevalence and number of self-reported SF and risk of LEA among noncompetitive, recreationally active female runners, aged 18 - 25 years. Additionally, it compared characteristics between females with a history of multiple SF vs. one or no SF, and between those 'at risk' vs. 'not at risk' of LEA. Female recreational runners (n=485) completed an online survey that included the Low Energy Availability in Females Questionnaire (LEAF-Q) and the Disordered Eating Screening Assessment (DESA-6). Thirty-three percent of participants reported ≥ 2 SF. Eighty-two percent of the ≥ 2 SF group were classified as 'at risk' of LEA (LEAF-Q score ≥ 8). In addition, ≥ 2 SF was associated with higher total LEAF-Q score, self-reported intentional food restriction for weight loss, and self-reported current eating disorder while weekly exercise duration was inversely associated with ≥ 2 SF. In conclusion, one-third of participants had multiple SF with a majority (82%) of this group classified as 'at risk' of LEA. Screening tools such as the LEAF-Q and DESA-6 are useful tools to identify characteristics associated with multiple SF in this demographic, especially questions regarding food restriction and the presence of a current or previous eating disorder.

Low Energy Availability, Disordered Eating, Exercise Dependence, and Fueling Strategies in Trail Runners

Under fueling, disordered eating (DE), exercise dependence (EXD), and high training demands relative to energy intake may increase the risk of low energy availability (LEA) in endurance and ultra-endurance athletes. The purpose of this study was to evaluate the prevalence of LEA risk and relationship with risk of DE, EXD, and fueling habits during training and competition in endurance runners. Trail runners between the age of 18-40 (n = 1,899; males: n = 510, females: n = 1,445) completed a 45-question survey using Qualtrics that included training and racing characteristics, questions regarding carbohydrate intake during training and competition, the Low Energy Availability in Females Questionnaire (LEAF-Q), the Disordered Eating Screen for Athletes (DESA-6), and the Exercise Dependence Scale-21 (EDS-21). Among all runners, 43% of runners were at risk for LEA, 43% were at risk for DE, and 87.3% reported symptoms related to EXD. LEAF-Q scores were positively correlated with EDS-21 (r = 0.33, p < 0.001) and DESA-6 scores (r = 0.29, p < 0.001). From the population, 47.6% of athletes reported taking in less than the recommended carbohydrate guidelines during endurance events lasting > 2.5 hours. In females, athletes at risk for LEA appear less likely to fuel sufficiently than athletes not at risk for LEA (p < 0.001). Risk of LEA, DE, and EXD appears to be high in endurance runners. Furthermore, meeting carbohydrate recommendations during training and competition should be emphasized to avoid negative health outcomes associated with LEA in endurance runners.

Disordered eating is not associated with musculoskeletal injury in university athletes

TAKE HOME MESSAGE

Musculoskeletal injuries and disordered eating are prevalent in varsity-level athletes but are not associated in our participants.

Review of the scientific rationale, development and validation of the International Olympic Committee Relative Energy Deficiency in Sport Clinical Assessment Tool: V.2 (IOC REDs CAT2)-by a subgroup of the IOC consensus on REDs

Relative Energy Deficiency in Sport (REDs) has various different risk factors, numerous signs and symptoms and is heavily influenced by one's environment. Accordingly, there is no singular validated diagnostic test. This 2023 International Olympic Committee's REDs Clinical Assessment Tool-V.2 (IOC REDs CAT2) implements a three-step process of: (1) initial screening; (2) severity/risk stratification based on any identified REDs signs/symptoms (primary and secondary indicators) and (3) a physician-led final diagnosis and treatment plan developed with the athlete, coach and their entire health and performance team. The CAT2 also introduces a more clinically nuanced four-level traffic-light (green, yellow, orange and red) severity/risk stratification with associated sport participation guidelines. Various REDs primary and secondary indicators have been identified and 'weighted' in terms of scientific support, clinical severity/risk and methodological validity and usability, allowing for objective scoring of athletes based on the presence or absence of each indicator. Early draft versions of the CAT2 were developed with associated athlete-testing, feedback and refinement, followed by REDs expert validation via voting statements (ie, online questionnaire to assess agreement on each indicator). Physician and practitioner validity and usability assessments were also implemented. The aim of the IOC REDs CAT2 is to assist qualified clinical professionals in the early and accurate diagnosis of REDs, with an appropriate clinical severity and risk assessment, in order to protect athlete health and prevent prolonged and irreversible outcomes of REDs.

Primary, secondary and tertiary prevention of Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the IOC consensus on REDs

Relative Energy Deficiency in Sport (REDs) is common among female and male athletes representing various sports at different performance levels, and the underlying cause is problematic low energy availability (LEA). It is essential to prevent problematic LEA to decrease the risk of serious health and performance consequences. This narrative review addresses REDs primary, secondary and tertiary prevention strategies and recommends best practice prevention guidelines targeting the athlete health and performance team, athlete entourage (eg, coaches, parents, managers) and sport organisations. Primary prevention of REDs seeks to minimise exposure to and reduce behaviours associated with problematic LEA. Some of the important strategies are educational initiatives and de-emphasising body weight and leanness, particularly in young and subelite athletes. Secondary prevention encourages the early identification and management of REDs signs or symptoms to facilitate early treatment to prevent development of more serious REDs outcomes. Recommended strategies for identifying athletes at risk are self-reported screening instruments, individual health interviews and/or objective assessment of REDs markers. Tertiary prevention (clinical treatment) seeks to limit short-term and long-term severe health consequences of REDs. The cornerstone of tertiary prevention is identifying the source of and treating problematic LEA. Best practice guidelines to prevent REDs and related consequences include a multipronged approach targeting the athlete health and performance team, the athlete entourage and sport organisations, who all need to ensure a supportive and safe sporting environment, have sufficient REDs knowledge and remain observant for the early signs and symptoms of REDs.

Prevention of eating disorders: 2021 in review

This review of 19 prevention-related publications in Eating Disorders during 2021 is framed by four models: (1) Mental Health Intervention Spectrum: health promotion → types of prevention → case identification/referral → treatment; (2) the prevention cycle: rationale and theory, shaped by critical reviews → clarifying risk and protective factors → program innovation and feasibility studies → efficacy and effectiveness research → program dissemination; (3) links between disordered eating (DE) and eating disorders (EDs); and (4) Kraemer and Jacobi's criteria for variable, causal risk factors (RFs). Twelve articles demonstrated the strengths and limitations of cross-sectional investigations of RFs for DE and EDs: five explored the role of trauma in activating genetic and psychological RFs (e.g., anxiety and experiential avoidance), while five suggest other variables meriting further evaluation: ergogenic supplement use, "feeling fat," internalized weight bias, food insecurity, and compulsive exercising. One article presents a pilot program that reduced risk factors in a high-risk group: professional ballerinas. Implications of the absence of efficacy, effectiveness, dissemination, and advocacy studies, along with the need to develop tailored programs for various high-risk groups, are discussed.

Contributing Factors to Low Energy Availability in Female Athletes: A Narrative Review of Energy Availability, Training Demands, Nutrition Barriers, Body Image, and Disordered Eating

Relative Energy Deficiency in sport is experiencing remarkable popularity of late, particularly among female athletes. This condition is underpinned by low energy availability, which is a byproduct of high energy expenditure, inadequate energy intake, or a combination of the two. Several contributing factors exist that may predispose an athlete to low energy availability, and therefore a holistic and comprehensive assessment may be required to identify the root causes. The focus of the current narrative review is to discuss the primary contributing factors as well as known risk factors for low energy availability among female athletes to help practitioners increase awareness on the topic and identify future areas of focus.

The relationship between disordered eating behaviors and injury rates in adolescent athletes

OBJECTIVE

To explore the relationship between disordered eating (DE) and significant sport injury in adolescent athletes.

METHOD

Responses to one item of the Disordered Eating Screen for Athletes and the Eating Attitudes Test (EAT-26) items, administered to n = 308 adolescent athletes, were analyzed with data on injury. Nonparametric statistics and multiple regression analysis were used to examine differences in DE rates amongst known injured adolescent athletes.

RESULTS

The EAT-26 scores of injured females, median score of 9, were significantly higher than all other groupings with H(3) = 17.26 p < .001, η²  = .047. Using regression analyses, injury significantly predicted a rise in EAT-26 score by five points in females, p = .01, R²  = .052.

DISCUSSION

This evidence suggests a relationship between adolescent female sport injury and DE, but no relationship between adolescent male sport injury and DE. These results demonstrate a need to screen for DE in athletes. Given a positive screen, athletes should be educated on the risks associated with relative energy deficiency and potentially referred to a practitioner with knowledge of the associated complications.

A systematic review of instruments for the assessment of eating disorders among adults

PURPOSE OF REVIEW

The availability of psychometrically sound assessment instruments for assessing eating disorder symptomatology is crucial for both clinical practice and research. The purpose of the current review is to provide the reader with a list of psychometrically validated assessments for adults that are available within the field of eating disorders. Eating disorder interviews and self-report questionnaires were identified using online literature searches, reviewing previous review articles, and via research and/or clinical experience of the authors. The focus of the review was on (1) standard assessments that were frequently used in eating disorder research (such as the Eating Disorder Examination and Eating Attitudes Test), and (2) newer assessments that were developed over the past 5 years. Information compiled on each instrument included the purpose of the assessment, scores that can be derived, psychometric information, translations in other languages, and availability for use in research and clinical settings.

RECENT FINDINGS

Several recent trends in assessment instruments were identified including updates based upon Diagnostic and Statistical Manual criteria, briefer assessments, assessments for specific populations, and assessment of specific clinical features observed in people with eating disorders.

SUMMARY

The current review provides eating disorder clinicians and researchers a guide for making informed decisions about the selection of eating disorder assessments.