The malnourished athlete – guidelines for interventions

Finn Skårderud, Terje Fladvad, Heidi Holmlund, Ina Garthe, Lars Engebretsen About the authors

The health team for eating disorders at Olympiatoppen has established guidelines for the clinical encounter with malnourished top athletes. The guidelines include advice on therapeutic approaches and criteria for exclusion from competitions.

There is a solid body of empirical evidence of a relatively high prevalence of problematic eating behaviour and clinical eating disorders in sports in general and in top athletics (1 – 3). We have established guidelines for how health workers and other parts of the support apparatus should deal with such phenomena (4). The draft guidelines have been presented to several institutions within Norwegian top athletics, and the working group has used the input provided in the process. Here, we wish to comment on the guidelines and the experience obtained to date.

How should the interventions be organised?

Conflicts may occur between sports representatives, who envisage good chances of success for an athlete on the one hand, and health personnel who emphasise the athlete’s health on the other. In the guidelines presented, it is a premise that health should take precedence over performance. Vagueness and uncertainty often result in a misconceived wait-and-see attitude. The role of trainers and managers includes having familiarity with such phenomena and an open attitude internally, and seeking advice. It is essential to be present as a trustworthy person, but trainers and managers should not assume the role of therapist.

It will be relevant to refer top athletes to the sports community’s own health services, such as the authors’ team under the auspices of Olympiatoppen. As a rule, facilitation of physical activity will be a very relevant intervention, but for many athletes this requirement to reduce the level of activity will not be sufficient to promote their motivation to cooperate. If the problems are perceived as being of a limited nature, assistance by a clinical nutritionist or another resource person with equivalent competence will be appropriate. The athletes and their support apparatus can easily obtain information from the project Healthy sports for girls,, which, aside from knowledge dissemination, is a low-threshold service that also operates an advisory telephone hotline.

When an athlete has been diagnosed with an eating disorder, specific treatment is required. It is essential to clarify the distribution of responsibilities, and identify who will have the primary medical responsibility. The professionals must maintain sufficient communication between them to evince a modicum of shared understanding and attitudes in their relationship with the athlete and his or her family.

Guidelines for training and competitions

Athletes with problems related to their weight and eating behaviour must be assessed on an individual basis. It may be necessary to change their training schedule, ban them from training or exclude them from competitions. We wish to underscore that such decisions must be taken after a comprehensive assessment and that the guidelines are not absolute, but advisory. They contain general and specific guidelines (4). The general guidelines represent attitudes and are of a more generic nature, saying for example that young people should be subject to a stricter assessment than adults, and that possible consequences for the team and the sports community should be taken into account in addition to the individual athlete.

The specific guidelines are subdivided into absolute («Red light») and more relative («Yellow light») criteria for exclusion from competitions. An example of an absolute criterion, i.e. indicating that the athlete should be excluded from all competitions, is fulfilment of the criteria for the diagnosis anorexia nervosa. Examples of «Yellow light», i.e. indicating active assessment of exclusion from competitions, include amenorrhoea for more than six months in adult women and for more than three months in athletes under 18, a Body Mass Index (BMI) below 18.5 and/or less than 12 % body fat in women and less than 5 % in men, in combination with low testosterone levels.

The experience we have gained after publishing these guidelines over a year ago has been of a highly positive nature. Feedback includes reports by health personnel stating that they perceive decision-making to be simpler than before. They feel more confident and that the force of their arguments has increased, since they can refer to concrete guidelines. Individual athletes who have been excluded from competing have typically reacted with disappointment, but we have mainly seen that the interventions have been met with understanding. Many have also underscored the assumed preventive effect. We have seen how athletes have taken responsibility for improving their diet to avoid restrictions and exclusion from competitions in particular.

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