Direct and indirect impact of low energy availability on sports performance.

Low energy availability (LEA) occurs inadvertently and purposefully in many athletes across numerous sports; and well planned, supervised periods with moderate LEA can improve body composition and power to weight ratio possibly enhancing performance in some sports. LEA however has the potential to have negative effects on a multitude of physiological and psychological systems in female and male athletes. Systems such as the endocrine, cardiovascular, metabolism, reproductive, immune, mental perception, and motivation as well as behaviors can all be impacted by severe (serious and/or prolonged or chronic) LEA. Such widely diverse effects can influence the health status, training adaptation, and performance outcomes of athletes leading to both direct changes (e.g., decreased strength and endurance) as well as indirect changes (e.g., reduced training response, increased risk of injury) in performance. To date, performance implications have not been well examined relative to LEA. Therefore, the intent of this narrative review is to characterize the effects of short-, medium-, and long-term exposure to LEA on direct and indirect sports performance outcomes. In doing so we have focused both on laboratory settings as well as descriptive athletic case-study-type experiential evidence.

Are Sub-elite Athletes at Higher Risk of Eating Disorders, Exercise Addiction, Depression, and Low Energy Availability Compared With Elite Athletes?

OBJECTIVE: The main objective of this study was to investigate the risk of eating disorders, exercise addiction, depression, and low energy availability (LEA) in Danish female and male elite compared with sub-elite athletes. DESIGN: A cross-sectional study. SETTING: An online survey. PARTICIPANTS: A total of 410 elite athletes (mean age 20.1 years, 51% females) and 206 sub-elite athletes (mean age 21.3 years, 52% females) from 15 different sports.Assessment of Risk Factors: Eating Disorders, exercise addiction, depression, and LEA. MAIN OUTCOME MEASURES: The Sick Control, One Stone (6.5 kg), Fat, Food, the Eating Disorder Examination-Questionnaire, the Exercise Addiction Inventory, the Major Depression Inventory, and the Low Energy Availability in Females Questionnaire or the Low Energy Availability in Males Questionnaire. RESULTS: We found that more female sub-elite athletes compared with elite athletes had risk of eating disorders (EDs) (37.4% vs 23.4%; P < 0.012) and the same was found for males (23.2% vs 10.4%; P = 0.005). More athletes with risk of EDs had risk of exercise addiction (12.8 vs 5.4%, P = 0.006), depression (27.3 vs 4.2%, P < 0.001), and LEA (females 55.1 vs 40.7%, P = 0.024, and males 29.4 vs 13.7%, P = 0.036, respectively) compared with athletes without risk of EDs. CONCLUSIONS: Sub-elite athletes have a higher risk of eating disorders compared with elite athletes. Regular screening of ED symptoms and associated conditions in elite and especially sub-elite athletes may ensure early identification.

Assessment of eating disorder symptoms, compulsive exercise, body dissatisfaction and depression in Swedish national team gymnasts, with a one-year follow-up.

PURPOSE: The purpose of this study was to explore changes in symptoms of eating disorders, compulsive exercise, and depression, between two assessments 12 months apart, among elite gymnasts. METHOD: Factors related to the development of mental health symptoms in male and female Swedish national team gymnasts were investigated using baseline and 1-year follow-up scores in two subscales of the Eating Disorders Inventory 3; drive for thinness and body dissatisfaction, two subscales of the Compulsive Exercise Test; avoidance and rule-driven behavior and exercise for weight control, and the Montgomery-Åsberg Depression Rating Scale-Self report (MADRS-S). Linear mixed models were used to investigate the influence of drive for thinness, exercise for weight control, avoidance and rule-driven behavior, and MADRS-S on body dissatisfaction. RESULTS: Body dissatisfaction increased from baseline to the follow-up assessment, while drive for thinness and depression remained stable. Symptoms of eating disorders and depression were generally low in this group of elite gymnasts at both assessments. Drive for thinness, exercise for weight control, and symptoms of depression were associated with body dissatisfaction. DISCUSSION: Our findings indicate that there were no significant changes over time in eating disorders and depression symptoms but significant associations with body dissatisfaction. Furthermore, we found independent effects of drive for thinness, exercise for weight control and symptoms of depression for body dissatisfaction.

Low energy availability reduces myofibrillar and sarcoplasmic muscle protein synthesis in trained females.

Low energy availability (LEA) describes a state where the energy intake is insufficient to cover the energy costs of both exercise energy expenditure and basal physiological body functions. LEA has been associated with various physiological consequences, such as reproductive dysfunction. However, the effect of LEA on skeletal muscle protein synthesis in females performing exercise training is still poorly understood. We conducted a randomized controlled trial to investigate the impact of LEA on daily integrated myofibrillar and sarcoplasmic muscle protein synthesis in trained females. Thirty eumenorrheic females were matched based on training history and randomized to undergo 10 days of LEA (25 kcal · kg fat-free mass (FFM)-1  · day-1 ) or optimal energy availability (OEA, 50 kcal · kg FFM-1  · day-1 ). Before the intervention, both groups underwent a 5-day 'run-in' period with OEA. All foods were provided throughout the experimental period with a protein content of 2.2 g kg lean mass-1  · day-1 . A standardized, supervised combined resistance and cardiovascular exercise training programme was performed over the experimental period. Daily integrated muscle protein synthesis was measured by deuterium oxide (D2 O) consumption along with changes in body composition, resting metabolic rate, blood biomarkers and 24 h nitrogen balance. We found that LEA reduced daily integrated myofibrillar and sarcoplasmic muscle protein synthesis compared with OEA. Concomitant reductions were observed in lean mass, urinary nitrogen balance, free androgen index, thyroid hormone concentrations and resting metabolic rate following LEA. These results highlight that LEA may negatively affect skeletal muscle adaptations in females performing exercise training. KEY POINTS: Low energy availability (LEA) with potential health and performance impairments is widespread among female athletes. We investigated the impact of 10 days of LEA on daily integrated myofibrillar and sarcoplasmic muscle protein synthesis in young, trained females. We show that LEA impairs myofibrillar and sarcoplasmic muscle protein synthesis in trained females performing exercise training. These findings suggest that LEA may have negative consequences for skeletal muscle adaptations and highlight the importance of ensuring adequate energy availability in female athletes.

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.

2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs).

Relative Energy Deficiency in Sport (REDs) was first introduced in 2014 by the International Olympic Committee's expert writing panel, identifying a syndrome of deleterious health and performance outcomes experienced by female and male athletes exposed to low energy availability (LEA; inadequate energy intake in relation to exercise energy expenditure). Since the 2018 REDs consensus, there have been >170 original research publications advancing the field of REDs science, including emerging data demonstrating the growing role of low carbohydrate availability, further evidence of the interplay between mental health and REDs and more data elucidating the impact of LEA in males. Our knowledge of REDs signs and symptoms has resulted in updated Health and Performance Conceptual Models and the development of a novel Physiological Model. This Physiological Model is designed to demonstrate the complexity of either problematic or adaptable LEA exposure, coupled with individual moderating factors, leading to changes in health and performance outcomes. Guidelines for safe and effective body composition assessment to help prevent REDs are also outlined. A new REDs Clinical Assessment Tool-Version 2 is introduced to facilitate the detection and clinical diagnosis of REDs based on accumulated severity and risk stratification, with associated training and competition recommendations. Prevention and treatment principles of REDs are presented to encourage best practices for sports organisations and clinicians. Finally, methodological best practices for REDs research are outlined to stimulate future high-quality research to address important knowledge gaps.

Preventing Disordered Eating in Teenage Ballet Students: Evaluation of DancExcellent, a Combined CBT and Nutrition Education Intervention.

BACKGROUND: Disordered eating (DE) behaviors are relatively common among high-level dancers, especially in classical ballet. At the same time, interventions aimed at reducing DE behaviors in this population are scarce. METHODS: An 8-week exploratory preventive intervention for DE behaviors was carried out in a high-level ballet school for 40 teenagers aged 12-15 years (77.5% female). Both risk factors (perfectionism) and potentially protective factors (self-esteem, self-compassion) for the development of DE behaviors were considered. The intervention was created specifically for this study and consisted of five cognitive behavior therapy (CBT) workshops and four nutrition workshops. Additional components included newsletters for pupils and educational sessions and social media interactions with staff and parents. The intervention comprised two phases (control and intervention periods), with students acting as their own controls. Standardized questionnaires were completed before and after both phases. RESULTS: Questionnaire results did not indicate any changes in reported perfectionism, self-esteem, or self-compassion, nor were symptoms of DE affected during either the control or intervention periods. CONCLUSIONS: The intervention did not yield any discernible impact. However, it was affected by the onset of the COVID-19 pandemic, which limits our ability to draw conclusions about intervention effectiveness. Evaluations with pupils offer several considerations for future improvements.

The cytokine profile of menstrual blood.

INTRODUCTION: The menstrual cycle is regulated by a complex interplay between endometrial epithelial cells, endothelial cells, immune cells, and sex hormones. To communicate, cells secrete cytokines that have multiple and diverse effects on recipient cells. Knowledge of how these cells interact in the uterus is insufficient. Menstrual blood is easily accessible and provides a source to study menstrual cycle physiology. This study aimed to determine the cytokine profile in menstrual blood plasma and investigate the differences in cytokine profiles between menstrual and peripheral blood plasma. Several previous studies indicate an improved chance of embryo implantation after endometrial scratching. Consequently, our secondary aim was to compare the menstrual blood cytokine profile before and after luteal phase endometrial scratching. MATERIAL AND METHODS: Nineteen healthy donors collected menstrual blood for the first 24 hours of menstruation in two sequential cycles. Matched peripheral blood was taken at the same time. An endometrial biopsy was performed at cycle day 7-9 post ovulation in between the two collection times. A Luminex multiplex assay was performed in one batch analyzing a predetermined group of cytokines in plasma. RESULTS: Peripheral blood plasma and menstrual blood plasma showed substantial significant differences in cytokine profile. In menstrual blood plasma, C5/C5a, interleukin-6 (IL-6), IL-1ß, and CXCL8 were detected in high concentrations, whereas IL-2, IL-12p70, XCL1/Lymphotactin, and interferon-γ were low. The most pronounced median differences between menstrual and peripheral blood plasma were found for IL-6, IL-1ß, and CXCL8. The cytokine profiles of menstrual blood plasma were similar between the individual donors and did not differ over two subsequent cycles. None of the cytokines analyzed in menstrual blood plasma differed significantly before or after luteal phase endometrial scratching (P < .01). CONCLUSIONS: Our results demonstrate that the menstrual blood cytokine profile is distinctly different from peripheral blood plasma and that the inter-individual difference in menstrual blood cytokine profile in healthy donors is limited and stable over time. The small injury caused by an endometrial biopsy does not change the cytokine profile in the subsequent menstrual cycle. Our study provides new insights into menstrual cycle physiology.

Prevalence of Surrogate Markers of Relative Energy Deficiency in Male Norwegian Olympic-Level Athletes.

The syndrome of Relative Energy Deficiency in Sport (RED-S) includes wide-ranging effects on physiological and psychological functioning, performance, and general health. However, RED-S is understudied among male athletes at the highest performance levels. This cross-sectional study aimed to investigate surrogate RED-S markers prevalence in Norwegian male Olympic-level athletes. Athletes (n = 44) aged 24.7 ± 3.8 years, body mass 81.3 ± 15.9 kg, body fat 13.7% ± 5.8%, and training volume 76.1 ± 22.9 hr/month were included. Assessed parameters included resting metabolic rate (RMR), body composition, and bone mineral density by dual-energy X-ray absorptiometry and venous blood variables (testosterone, free triiodothyronine, cortisol, and lipids). Seven athletes (16%) grouped by the presence of low RMR (RMRratio < 0.90) (0.81 ± 0.07 vs. 1.04 ± 0.09, p < .001, effect size 2.6), also showed lower testosterone (12.9 ± 5.3 vs. 19.0 ± 5.3 nmol/L, p = .020) than in normal RMR group. In low RMRratio individuals, prevalence of other RED-S markers (-subclinical-low testosterone, low free triiodothyronine, high cortisol, and elevated low-density lipoprotein) was (N/number of markers): 2/0, 2/1, 2/2, 1/3. Low bone mineral density (z-score < -1) was found in 16% of the athletes, all with normal RMR. Subclinical low testosterone and free triiodothyronine levels were found in nine (25%) and two (5%) athletes, respectively. Subclinical high cortisol was found in 23% of athletes while 34% had elevated low-density lipoprotein cholesterol levels. Seven of 12 athletes with two or more RED-S markers had normal RMR. In conclusion, this study found that multiple RED-S markers also exist in male Olympic-level athletes. This highlights the importance of regular screening of male elite athletes, to ensure early detection and treatment of RED-S.

Energy Availability in Athletics: Health, Performance, and Physique.

The reported prevalence of low energy availability (LEA) in female and male track and field athletes is between 18% and 58% with the highest prevalence among athletes in endurance and jump events. In male athletes, LEA may result in reduced testosterone levels and libido along with impaired training capacity. In female track and field athletes, functional hypothalamic amenorrhea as consequence of LEA has been reported among 60% of elite middle- and long-distance athletes and 23% among elite sprinters. Health concerns with functional hypothalamic amenorrhea include impaired bone health, elevated risk for bone stress injury, and cardiovascular disease. Furthermore, LEA negatively affects recovery, muscle mass, neuromuscular function, and increases the risk of injuries and illness that may affect performance negatively. LEA in track and field athletes may occur due to intentional alterations in body mass or body composition, appetite changes, time constraints, or disordered eating behavior. Long-term LEA causes metabolic and physiological adaptations to prevent further weight loss, and athletes may therefore be weight stable yet have impaired physiological function secondary to LEA. Achieving or maintaining a lower body mass or fat levels through long-term LEA may therefore result in impaired health and performance as proposed in the Relative Energy Deficiency in Sport model. Preventive educational programs and screening to identify athletes with LEA are important for early intervention to prevent long-term secondary health consequences. Treatment for athletes is primarily to increase energy availability and often requires a team approach including a sport physician, sports dietitian, physiologist, and psychologist.

Nutritional Intake in Elite Cross-Country Skiers During Two Days of Training and Competition.

This study investigated the energy, macronutrient, and fluid intakes, as well as hydration status (urine specific gravity), in elite cross-country skiers during a typical day of training (Day 1) and a sprint skiing competition the following day (Day 2). A total of 31 (18 males and 13 females) national team skiers recorded their food and fluid intakes and urine specific gravity was measured on Days 1 and 2. In addition, the females completed the Low Energy Availability in Females Questionnaire to assess their risk of long-term energy deficiency. Energy intake for males was 65 ± 9 kcal/kg on Day 1 versus 58 ± 9 kcal/kg on Day 2 (p = .002) and for females was 57 ± 10 on Day 1 versus 55 ± 5 kcal/kg on Day 2 (p = .445). Carbohydrate intake recommendations of 10-12 g·kg-1·day-1 were not met by 89% of males and 92% of females. All males and females had a protein intake above the recommended 1.2-2.0 g/kg on both days and a postexercise protein intake above the recommended 0.3 g/kg. Of the females, 31% were classified as being at risk of long-term energy deficiency. In the morning of Day 1, 50% of males and 46% of females were dehydrated; on Day 2, this was the case for 56% of males and 38% of females. In conclusion, these data suggest that elite cross-country skiers ingested more protein and less carbohydrate than recommended and one third of the females were considered at risk of long-term energy deficiency. Furthermore, many of the athletes were dehydrated prior to training and competition.

International Association of Athletics Federations Consensus Statement 2019: Nutrition for Athletics.

The International Association of Athletics Federations recognizes the importance of nutritional practices in optimizing an Athlete's well-being and performance. Although Athletics encompasses a diverse range of track-and-field events with different performance determinants, there are common goals around nutritional support for adaptation to training, optimal performance for key events, and reducing the risk of injury and illness. Periodized guidelines can be provided for the appropriate type, amount, and timing of intake of food and fluids to promote optimal health and performance across different scenarios of training and competition. Some Athletes are at risk of relative energy deficiency in sport arising from a mismatch between energy intake and exercise energy expenditure. Competition nutrition strategies may involve pre-event, within-event, and between-event eating to address requirements for carbohydrate and fluid replacement. Although a "food first" policy should underpin an Athlete's nutrition plan, there may be occasions for the judicious use of medical supplements to address nutrient deficiencies or sports foods that help the athlete to meet nutritional goals when it is impractical to eat food. Evidence-based supplements include caffeine, bicarbonate, beta-alanine, nitrate, and creatine; however, their value is specific to the characteristics of the event. Special considerations are needed for travel, challenging environments (e.g., heat and altitude); special populations (e.g., females, young and masters athletes); and restricted dietary choice (e.g., vegetarian). Ideally, each Athlete should develop a personalized, periodized, and practical nutrition plan via collaboration with their coach and accredited sports nutrition experts, to optimize their performance.

Pitfalls of Conducting and Interpreting Estimates of Energy Availability in Free-Living Athletes.

The human body requires energy for numerous functions including, growth, thermogenesis, reproduction, cellular maintenance, and movement. In sports nutrition, energy availability (EA) is defined as the energy available to support these basic physiological functions and good health once the energy cost of exercise is deducted from energy intake (EI), relative to an athlete's fat-free mass (FFM). Low EA provides a unifying theory to link numerous disorders seen in both female and male athletes, described by the syndrome Relative Energy Deficiency in Sport, and related to restricted energy intake, excessive exercise or a combination of both. These outcomes are incurred in different dose-response patterns relative to the reduction in EA below a "healthy" level of ∼45 kcal·kg FFM-1·day-1. Although EA estimates are being used to guide and monitor athletic practices, as well as support a diagnosis of Relative Energy Deficiency in Sport, problems associated with the measurement and interpretation of EA in the field should be explored. These include the lack of a universal protocol for the calculation of EA, the resources needed to achieve estimates of each of the components of the equation, and the residual errors in these estimates. The lack of a clear definition of the value for EA that is considered "low" reflects problems around its measurement, as well as differences between individuals and individual components of "normal"/"healthy" function. Finally, further investigation of nutrition and exercise behavior including within- and between-day energy spread and dietary characteristics is warranted since it may directly contribute to low EA or its secondary problems.

Low RMRratio as a Surrogate Marker for Energy Deficiency, the Choice of Predictive Equation Vital for Correctly Identifying Male and Female Ballet Dancers at Risk.

Ballet dancers are reported to have an increased risk for energy deficiency with or without disordered eating behavior. A low ratio between measured (m) and predicted (p) resting metabolic rate (RMRratio < 0.90) is a recognized surrogate marker for energy deficiency. We aimed to evaluate the prevalence of suppressed RMR using different methods to calculate pRMR and to explore associations with additional markers of energy deficiency. Female (n = 20) and male (n = 20) professional ballet dancers, 19-35 years of age, were enrolled. mRMR was assessed by respiratory calorimetry (ventilated open hood). pRMR was determined using the Cunningham and Harris-Benedict equations, and different tissue compartments derived from whole-body dual-energy X-ray absorptiometry assessment. The protocol further included assessment of body composition and bone mineral density, blood pressure, disordered eating (Eating Disorder Inventory-3), and for females, the Low Energy Availability in Females Questionnaire. The prevalence of suppressed RMR was generally high but also clearly dependent on the method used to calculate pRMR, ranging from 25% to 80% in males and 35% to 100% in females. Five percent had low bone mineral density, whereas 10% had disordered eating and 25% had hypotension. Forty percent of females had elevated Low Energy Availability in Females Questionnaire score and 50% were underweight. Suppressed RMR was associated with elevated Low Energy Availability in Females Questionnaire score in females and with higher training volume in males. In conclusion, professional ballet dancers are at risk for energy deficiency. The number of identified dancers at risk varies greatly depending on the method used to predict RMR when using RMRratio as a marker for energy deficiency.

Within-Day Energy Deficiency and Metabolic Perturbation in Male Endurance Athletes.

Endurance athletes are at increased risk of relative energy deficiency associated with metabolic perturbation and impaired health. We aimed to estimate and compare within-day energy balance in male athletes with suppressed and normal resting metabolic rate (RMR) and explore whether within-day energy deficiency is associated with endocrine markers of energy deficiency. A total of 31 male cyclists, triathletes, and long-distance runners recruited from regional competitive sports clubs were included. The protocol comprised measurements of RMR by ventilated hood and energy intake and energy expenditure to predict RMRratio (measured RMR/predicted RMR), energy availability, 24-hr energy balance and within-day energy balance in 1-hr intervals, assessment of body composition by dual-energy X-ray absorptiometry, and blood plasma analysis. Subjects were categorized as having suppressed (RMRratio < 0.90, n = 20) or normal (RMRratio > 0.90, n = 11) RMR. Despite there being no observed differences in 24-hr energy balance or energy availability between the groups, subjects with suppressed RMR spent more time in an energy deficit exceeding 400 kcal (20.9 [18.8-21.8] hr vs. 10.8 [2.5-16.4], p = .023) and had larger single-hour energy deficits compared with subjects with normal RMR (3,265 ± 1,963 kcal vs. -1,340 ± 2,439, p = .023). Larger single-hour energy deficits were associated with higher cortisol levels (r = -.499, p = .004) and a lower testosterone:cortisol ratio (r = .431, p = .015), but no associations with triiodothyronine or fasting blood glucose were observed. In conclusion, within-day energy deficiency was associated with suppressed RMR and catabolic markers in male endurance athletes.

The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad.

BACKGROUND: Low energy availability (EA) in female athletes with or without an eating disorder (ED) increases the risk of oligomenorrhoea/functional hypothalamic amenorrhoea and impaired bone health, a syndrome called the female athlete triad (Triad). There are validated psychometric instruments developed to detect disordered eating behaviour (DE), but no validated screening tool to detect persistent low EA and Triad conditions, with or without DE/ED, is available. AIM: The aim of this observational study was to develop and test a screening tool designed to identify female athletes at risk for the Triad. METHODS: Female athletes (n=84) with 18-39 years of age and training ≥5 times/week filled out the Low Energy Availability in Females Questionnaire (LEAF-Q), which comprised questions regarding injuries and gastrointestinal and reproductive function. Reliability and internal consistency were evaluated in a subsample of female dancers and endurance athletes (n=37). Discriminant as well as concurrent validity was evaluated by testing self-reported data against measured current EA, menstrual function and bone health in endurance athletes from sports such as long distance running and triathlon (n=45). RESULTS: The 25-item LEAF-Q produced an acceptable sensitivity (78%) and specificity (90%) in order to correctly classify current EA and/or reproductive function and/or bone health. CONCLUSIONS: The LEAF-Q is brief and easy to administer, and relevant as a complement to existing validated DE screening instruments, when screening female athletes at risk for the Triad, in order to enable early detection and intervention.

Disordered eating and eating disorders in aquatic sports.

Disordered eating behavior (DE) and eating disorders (EDs) are of great concern because of their associations with physical and mental health risks and, in the case of athletes, impaired performance. The syndrome originally known as the Female Athlete Triad, which focused on the interaction of energy availability, reproductive function, and bone health in female athletes, has recently been expanded to recognize that Relative Energy Deficiency in Sport (RED-S) has a broader range of negative effects on body systems with functional impairments in both male and female athletes. Athletes in leanness-demanding sports have an increased risk for RED-S and for developing EDs/DE. Special risk factors in aquatic sports related to weight and body composition management include the wearing of skimpy and tight-fitting bathing suits, and in the case of diving and synchronized swimming, the involvement of subjective judgments of performance. The reported prevalence of DE and EDs in athletic populations, including athletes from aquatic sports, ranges from 18 to 45% in female athletes and from 0 to 28% in male athletes. To prevent EDs, aquatic athletes should practice healthy eating behavior at all periods of development pathway, and coaches and members of the athletes' health care team should be able to recognize early symptoms indicating risk for energy deficiency, DE, and EDs. Coaches and leaders must accept that DE/EDs can be a problem in aquatic disciplines and that openness regarding this challenge is important.