By Andrew Walen, LCSW-C, LICSW, CEDS
May 2019 in the British Journal of Sports Medicine, the International Olympic Committee (IOC) published its consensus statement on mental health in elite athletes. It should not come as a shock to anyone in the world of athletics that there is a strong correlation with elite athletes and mental health struggles, especially eating disorders.
According to the statement, up to 19% of male athletes and up to 45% of female athletes meet criteria for disordered eating or eating disorders. Those numbers are likely under-reported as researchers found athletes are more prone to denial of symptoms than the general population, especially males. In addition, both male and female athletes traditionally meet criteria for muscle dysmorphia rather than an eating disorder based on symptoms found in the Diagnostic and Statistical Manual V. Eating disorder behavior in this population is often missed by clinicians as the discussion of weight, a typical red flag for eating disorders, is less prominent than muscularity. Concordantly, eating disorders are common in athletes who use appearance and performance enhancing drugs such as steroids, amphetamines or amphetamine-like substances, caffeine and caffeine-related derivatives, and stimulants like synthetic cathinones and ephedrine.
Diagnosing an eating disorder in an elite athlete is made more difficult because disciplined and regimented eating and exercise is normal and expected as part of their competitive training. In addition, preoccupation with weight and shape is part of the athletic experience, as is having low body fat and high muscle mass, even in female athletes.
The IOC shares that a useful assessment for eating disorders in elite athletes is the concept of Low Energy Availability (LEA). LEA leads to decreasing levels of performance due to inadequate fueling of their body. The result in females includes interruption of their menstrual cycle and low bone density. Males test with low testosterone levels and lowered bone density as well. The IOC suggests using the term Relative Energy Deficiency in Sport (RED-S) which addresses the global impact of psychological and physical functioning in athletes of all genders suffering from dehydration, electrolyte imbalance, early glycogen depletion, loss of muscle mass, and injuries such as stress fractures, and especially slow healing injuries. By reframing the terminology of eating disorders as disorders of sport-related injury and illness, the IOC hopes more athletes from amateur ranks to professional will agree to seek treatment with reduced stigma.
Especially important for loved ones and clinicians alike to note, the IOC states unequivocally that while psychotherapy is important, “Clinicians should not compromise on delivering other appropriate treatment, including medications and hospitalization as necessary, during psychotherapy with elite athletes.” While an elite athlete and those who have sacrificed so much for them may believe that taking time off for recovery is not an option, the words of the IOC speak clearly and definitively that the health of the athlete must come first. Take time off, get healthy physically and emotionally, and hopefully be the best you can be once again.