The Athletes' Relationships with Training scale (ART): A self-report measure of unhealthy training behaviors associated with eating disorders.

OBJECTIVE: Several studies indicate that eating-disorder (ED) psychopathology is elevated in athletes compared to non-athletes. The assessment of excessive exercise among athletes is a challenge because, compared to non-athletes, athletes are required to train at higher intensities and for longer periods of time. However, individuals participating in competitive sports are still susceptible to unhealthy physical-activity patterns. Most ED assessments were developed and normed in non-athlete samples and, therefore, do not capture the nuances of athletes' training experiences. The purpose of the current study was to develop and validate a clinically useful, self-report measure of unhealthy training behaviors and beliefs in athletes, the Athletes' Relationships with Training Scale (ART). METHOD: The initial item pool was administered to N = 267 women collegiate athletes who were participating in an ED prevention program study and N = 65 women athletes who were in ED treatment. RESULTS: Factor analyses indicated the ART had a four-factor structure. Factorial and construct validity of the ART were demonstrated. ART scores significantly predicted health care utilization and differed between athletes with an ED versus athletes without an ED. For athletes in ED treatment, ART scores significantly decreased from treatment admission to discharge. DISCUSSION: The ART showed evidence of strong psychometric properties and clinical utility. The ART could be helpful for clinicians and athletic trainers to help gauge whether athletes are engaging in unhealthy training practices that may warrant clinical attention and for tracking clinical outcomes in athletes with EDs who are receiving treatment.

The IOC consensus statement: beyond the Female Athlete Triad--Relative Energy Deficiency in Sport (RED-S).

Protecting the health of the athlete is a goal of the International Olympic Committee (IOC). The IOC convened an expert panel to update the 2005 IOC Consensus Statement on the Female Athlete Triad. This Consensus Statement replaces the previous and provides guidelines to guide risk assessment, treatment and return-to-play decisions. The IOC expert working group introduces a broader, more comprehensive term for the condition previously known as 'Female Athlete Triad'. The term 'Relative Energy Deficiency in Sport' (RED-S), points to the complexity involved and the fact that male athletes are also affected. The syndrome of RED-S refers to impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular health caused by relative energy deficiency. The cause of this syndrome is energy deficiency relative to the balance between dietary energy intake and energy expenditure required for health and activities of daily living, growth and sporting activities. Psychological consequences can either precede RED-S or be the result of RED-S. The clinical phenomenon is not a 'triad' of the three entities of energy availability, menstrual function and bone health, but rather a syndrome that affects many aspects of physiological function, health and athletic performance. This Consensus Statement also recommends practical clinical models for the management of affected athletes. The 'Sport Risk Assessment and Return to Play Model' categorises the syndrome into three groups and translates these classifications into clinical recommendations.

Gender differences in high school coaches' knowledge, attitudes, and communication about the female athlete triad.

The objective of this study was to assess high school coaches' knowledge, attitudes, communication, and management decisions with respect to the Female Athlete Triad and to determine whether results are patterned by coach gender. Data were obtained through an online survey of high school coaches (n = 227). Significant differences were found between male and female coaches in certain attitudes and communication behaviors related to eating and menstrual irregularity. School or district level policies may help reduce these differences and may help mitigate the health consequences for athletes related to possible differential prevention and detection of the comorbidities of the Female Athlete Triad.

Primary and secondary exercise dependence in a community-based sample of road race runners.

The purpose of our study was to examine exercise dependence (EXD) in a large community-based sample of runners. The secondary purpose of this study was to examine differences in EXD symptoms between primary and secondary EXD. Our sample included 2660 runners recruited from a local road race (M age = 38.78 years, SD = 10.80; 66.39% women; 91.62% Caucasian) who completed all study measures online within 3 weeks of the race. In this study, EXD prevalence was lower than most previously reported rates (gamma = .248, p < .001) and individuals in the at-risk for EXD category participated in longer distance races, F(8,1) = 14.13, p = .01, partial eta squared = .05. Group differences were found for gender, F(1,1921) 8.08, p = .01, partial eta squared = .004, and primary or secondary group status, F(1,1921) 159.53, p = .01, partial eta squared = .077. Implications of primary and secondary EXD differences and future research are discussed.

Exercise in Eating Disorders Treatment: Systematic Review and Proposal of Guidelines.

INTRODUCTION: Although exercise is an effective intervention for many psychological health issues, it has often been overlooked as a potential adjunct to eating disorder (ED) treatment. Thus, our objective was to summarize the literature by synthesizing themes identified in clinical studies and explicit guidelines or recommendations for the use or management of exercise in ED interventions into a proposed set of guidelines for the use of exercise in ED treatment. METHODS: A literature search in exercise science, health psychology, and the ED literature was conducted. The focus was to obtain articles that reported on therapeutic effects and/or guidelines for the therapeutic use of exercise in individuals with ED. RESULTS: Our review identified 11 core themes describing techniques that have been successful in using exercise therapeutically in ED treatment. These 11 guidelines are as follows: employ a team of relevant experts, monitor medical status, screen for exercise-related psychopathology, create a written contract of how therapeutic exercise will be used, include a psychoeducational component, focus on positive reinforcement, create a graded exercise program, begin with mild-intensity exercise, tailor the mode of exercise to the needs of the individual, include a nutritional component, and debrief after exercise sessions. CONCLUSION: Our review identifies specific guidelines that may enhance ED treatment outcomes. It is the first to summarize divergent literature and synthesizes previous successes that may guide the use of therapeutic exercise in some, but not all ED patients. This review provides a practical set of guidelines for the clinical management and therapeutic use of exercise in ED treatment by focusing on empowering individuals with exercise as a tool for healthy living.

Coaches' knowledge and management of eating disorders: a randomized controlled trial.

PURPOSE: It has been suggested that programs regarding early identification and prevention of eating disorders (ED) among athletes are unlikely to succeed without their coaches' endorsement and participation. Therefore, we developed a 1-yr intervention aiming to prevent the development of ED among adolescent elite athletes by targeting athletes and their coaches. The separate part of the intervention targeting the coaches was designed to provide knowledge and strategies regarding healthy nutrition, eating behavior, and ED (symptoms, identification, management, and prevention). In this trial, we examined the effect of the educational program on the coaches' knowledge and management index in three content areas (nutrition, weight regulation, and ED). We also examined their subjective evaluation of their ED knowledge. METHODS: All Norwegian Elite Sport High Schools were included (intervention group (n = 9) and control group (n = 7)). Seventy-six coaches employed at and coaching first year student athletes at the different schools were followed for three school years (2008-2011). At pretest and posttest (9 months after intervention), they completed a questionnaire regarding nutrition, weight regulation, and ED. RESULTS: Intervention coaches had higher knowledge index scores than control coaches for weight regulation (6.2 ± 1.7 vs. 4.8 ± 1.3, P < 0.001), ED (including recognition and management) (19.3 ± 4.4 vs. 16.5 ± 5.0, P = 0.004), and total knowledge (weight regulation, ED, and nutrition) (35.0 ± 7.2 vs. 31.6 ± 8.0, P = 0.021) at posttest. Moreover, the coaches likelihood of describing knowledge of ED as "somewhat good" or better was seven times higher for intervention than control coaches at posttest (OR = 7.1, 95% CI, 2.2-23.2, P = 0.001). CONCLUSION: Intervention coaches had higher index scores on total knowledge, weight regulation, and ED (including recognition and management) than control coaches. The intervention also was successful in producing effects on the coaches' subjective evaluation of their ED knowledge.

The influence of exercise identity and social physique anxiety on exercise dependence.

BACKGROUND: Previous research has identified exercise identity and social physique anxiety as two independent factors that are associated with exercise dependence. AIMS: The purpose of our study was to investigate the unique and interactive effect of these two known correlates of exercise dependence in a sample of 1,766 female runners. METHODS: Regression analyses tested the main effects of exercise identity and social physique anxiety on exercise dependence. An interaction term was calculated to examine the potential moderating effect of social physique anxiety on the exercise identity and exercise dependence relationship. RESULTS: Results indicate a main effect for exercise identity and social physique anxiety on exercise dependence; and the interaction of these factors explained exercise dependence scores beyond the independent effects. Thus, social physique anxiety acted as a moderator in the exercise identity and exercise dependence relationship. DISCUSSION: Our results indicate that individuals who strongly identify themselves as an exerciser and also endorse a high degree of social physique anxiety may be at risk for developing exercise dependence. CONCLUSIONS: Our study supports previous research which has examined factors that may contribute to the development of exercise dependence and also suggests a previously unknown moderating relationship for social physique anxiety on exercise dependence.

MCMI-II profiles of women with eating disorders: a cluster analytic investigation.

A three-factor model of personality pathology was investigated in a clinical sample of 183 female patients in an outpatient eating disorders treatment program. Cluster analysis of MCMI-II personality scales (Millon, 1987) yielded three distinct personality profiles, which were consistent with previous studies. First, 16.9% of the sample comprised a High Functioning cluster, which manifested no clinical elevations on the MCMI-II and had significantly lower scores on the Eating Disorder Inventory (EDI; Garner; 1991) scales than the other two clusters. Second, 49.1% of the sample comprised an Undercontrolled/Dysregulated cluster. Finally, the remaining 34% of the sample comprised an Overcontrolled/Avoidant cluster. This final cluster had significantly higher EDI Ineffectiveness scale scores than the Undercontrolled/Dysregulated cluster group. Cluster membership was not associated with eating disorder subtype, suggesting that there is considerable variance in personality pathology within eating disorder diagnostic categories.

Examining the construct validity of the Eating Disorder Inventory.

The construct validity of the Eating Disorder Inventory (EDI) was examined in 3 samples. An archival clinic sample (n = 318) of women completed the EDI, a structured interview, and the Millon Clinical Multiaxial Inventory-II (MCMI-II). Confirmatory factor analyses (CFAs) indicated that neither null nor 1-factor models of the EDI fit item-level or item-parcel data. The proposed 8-factor model did not fit at the item level but did fit item-parcel data. Reliability estimates of the 8 scales ranged from .82 to .93, and low-to-moderate interscale correlations among the eating and weight-related scales provided partial support for convergent validity. EDI personality scales showed moderate interscale correlations and were associated with MCMI-II scales. A final CFA of the EDI scales supported a 2-factor model (Eating and Weight, Personality) of the 8 EDI scales. Strong associations between depression and several EDI scale scores were found in a treatment study sample (n = 50). The archival clinic sample scored significantly higher on the 8 EDI scales than the nonpatient college comparison sample (n = 487).

Trends in eating disorder symptomatology in an outpatient clinic: 1988-1998.

Eating disorders treatment has been altered by changes in the health care system. In addition, there has been a major emphasis on prevention in recent years. Yet, there are few investigations of the effects of these changes on the severity of patients' symptomatology at intake. This study examined differences in symptoms among women who presented to an outpatient clinic between 1988 and 1998. Patients were divided into Cohort 1 (1988-1992) and Cohort 2 (1993-1998). Patients with anorexia nervosa (AN) in Cohort 2 had significantly lower body mass indices (BMIs) at intake. Moreover, a greater number of patients with AN in Cohort 2 had BMIs

Moderators of the association between exercise identity and obligatory exercise among participants of an athletic event.

Previous research has connected exercise identity with obligatory exercise, yet to date no empirical studies have identified moderator variables of this association. The current study included participants of an athletic event (full marathon, n=582; half marathon, n=1,106; shorter distance, n=733) who completed questionnaires about exercise behaviors, obligatory exercise, and internalization of both the thin-ideal and athletic-ideal body shapes. General linear model analyses were conducted to examine the exercise identity-obligatory exercise relationship; moderator variables included gender, internalization of the thin-ideal body shape, and internalization of the athletic-ideal body shape. After controlling for the effects of body mass index, age, and distance group, the three-way interaction of exercise identity, gender, and internalization of the athletic-ideal body shape predicted obligatory exercise. Findings suggest that women who report high identification with exercise and high value on having an athletic physique may be vulnerable to obligatory exercise.

Practical use of the International Olympic Committee Medical Commission Position Stand on the Female Athlete Triad: a case example.

UNLABELLED: The female athlete triad consists of the interrelated problems of disordered eating, amenorrhea, and osteoporosis, and it is believed to affect female athletes in all sports and at all levels of competition. OBJECTIVE: The current article highlights the Position Stand on the Female Athlete Triad of the International Olympic Committee's Medical Commission (IOCMC). METHOD: The literature related to disordered eating, energy availability, amenorrhea, and bone loss in athletes is briefly reviewed. A hypothetical case is presented to illustrate some of the common issues and problems encountered when working with athletes affected by the triad, such as the effect of weight on performance in "thin" sports, coach involvement, sport participation by symptomatic athletes, and treatment resistance/motivation. RESULTS: Strategies recommended by the position stand for managing those issues and problems are presented regarding the referral, evaluation, and treatment phases of the management process. CONCLUSION: Implications of the position stand are discussed in terms of the IOCMC's endorsement of the athlete's health being primary to her performance.

NCAA coaches survey: the role of the coach in identifying and managing athletes with disordered eating.

The primary objective of the present study was to survey collegiate coaches with respect to how female athletes with disordered eating or eating disorders are identified, how coaches are involved, and the identification criteria used. An additional objective was to determine how symptomatic athletes are managed regarding treatment and sport participation. Participants were 2,894 coaches representing 23 sports. Findings indicated that athletic trainers, teammates, and coaches are frequently involved in identification. Eating disorder symptoms were most often used to identify symptomatic athletes, and athletes from high-risk sports were more often identified. Coaches rated symptoms as being serious, both in terms of how they affect the athlete's health and her athletic performance, with amenorrhea being a notable exception. Implications of the study were discussed in terms of education and training of coaches and athletic trainers.

The female athlete triad.

The Female Athlete Triad is a syndrome of the interrelated components of disordered eating, amenorrhea, and osteoporosis. Sometimes inadvertently, but more often by willful dietary restriction, many female athletes do not ingest sufficient calories to adequately fuel their physical or sport activities, which can disrupt menstrual functioning, thereby increasing their risk of bone loss. Although its prevalence is unknown, the Female Athlete Triad is believed to affect many athletes at all ages and all sport competition levels. Even though the Triad affects athletes in all sports, girls and women in sports that emphasize a thin or small body size or shape appear to be most at risk. This article focuses on the risks of the Female Athlete Triad for middle- and high-school-age female athletes as well as the unique issues related to the identification, management, and treatment of the various components of the Triad in this special adolescent subpopulation.