Intersection of mental health issues and Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the IOC consensus on REDs.

Overall athlete health is a stated priority by the International Olympic Committee (IOC), yet it can be difficult for athletes to safely balance nutritional needs, training load, recovery, social interactions, expectations and other demands. The effect of energy intake and, especially, low energy availability (LEA) on athlete mental health, is understudied. In this narrative review, we examine research that has included psychological factors and mental health variables when investigating the effect of LEA, dieting/restrictive eating and Relative Energy Deficiency in Sport (REDs), since the 2018 IOC consensus statement on REDs. Based on currently available data, early psychological indicators associated with problematic LEA are mood changes, fatigue and psychological conflict. More severe mental health outcomes associated with REDs are reduced well-being, elevated anxiety, depressive symptoms and eating disorders. We propose a psychological model that helps structure how possible risk factors (eg, body dissatisfaction, environmental demands or increased training load) and moderating (eg, gender, sport) and/or potential mediating (eg, social climate, self-esteem) factors are associated with LEA and ultimately REDs. The current scientific literature underscores the importance of including mental health factors when screening for REDs and for developing a clinical approach to address the psychological sequelae of REDs once diagnosed. An interdisciplinary perspective is recommended. Lastly, and importantly, the athlete perspective urges clinicians to not underestimate the drive for success and denial of health consequences that athletes demonstrate when pursuing their sport goals.

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.

Mental health problems in elite sport: the difference in the distribution of mental distress and mental disorders among a sample of Norwegian elite athletes.

Objectives: To, based on diagnostic interviews, investigate the distribution of mental disorders among a sample of Norwegian elite athletes with 'at-risk scores' on a self-report questionnaire measuring symptoms of mental health problems. Then, to investigate the relationship between 'at-risk scores' and diagnosed mental disorders. Methods: A two-phase, cross-sectional design was used. In phase 1, 378 elite athletes completed a questionnaire, including validated self-report psychiatric instruments assessing symptoms of mental disorders. In phase 2, we assessed the 30-day presence of the same disorders through diagnostic interviews with the athletes with 'at-risk scores' using the fifth version of the Composite International Diagnostic Interview. Results: Two hundred and eighty athletes (74.1%) had an 'at-risk score,' and 106 of these athletes (37.9%) completed diagnostic interviews. Forty-seven athletes (44.3%) were diagnosed with a mental disorder. Sleep problems (24.5%) and obsessive-compulsive disorder (OCD) and OCD-related disorders (18.9%), mainly represented by body dysmorphic disorder (BDD), were most common. Anxiety disorders (6.6%), eating disorders (5.7%) and alcohol use disorder (≤4.7%) were less frequent. Affective disorders, gambling and drug use disorder were not present. Results from self-report questionnaires did not, in most cases, adequately mirror the number of mental disorders identified using diagnostic interviews. Conclusions: Using self-report questionnaires to map mental distress among elite athletes can be beneficial. If the aim, however, is to investigate mental disorders, one should move beyond self-report questionnaires and use diagnostic interviews and diagnostic instruments. In our study, sleep problems and BDD were the most prevalent. Longitudinal studies are needed to investigate these findings further.

Mental health among elite athletes in Norway during a selected period of the COVID-19 pandemic.

OBJECTIVE: To investigate the prevalence of mental health problems and satisfaction with life among different groups of elite athletes during a selected period of the COVID-19 pandemic and examine how COVID-19 related consequences were associated with these variables. DESIGN: Cross-sectional data collection during a selected period of the COVID-19 pandemic in Norway. PARTICIPANTS: 378 elite athletes, mean age 26.86 (range 18-59), 159 females and 219 males, divided into Olympic-level and Paralympic-level athletes (n=194) and elite and semielite athletes (n=184). MAIN OUTCOME MEASURES: Hopkins Symptoms Check List - 10; symptoms of anxiety and depression; Bergen Insomnia Scale; Eating Disorder Examination Questionnaire Short; Canadian Problem Gambling Index and Satisfaction with Life Scale. In addition, we included specific COVID-19 questions (eg, financial concern, keeping daily routines, perceived coping and motivation). RESULTS: Symptoms of insomnia (38.3%) and depression (22.3%) were most prevalent within the sample. Symptoms of eating disorders more prevalent among female athletes (8.8% vs 1.4%) while symptoms of gambling problems were higher among male athletes (8.6% vs 1.3%). Olympic and Paralympic athletes reported lower levels of anxiety and depression symptoms than elite and semielite athletes. Financial concerns were associated with an increased risk of mental health problems, while daily routines and perception of coping were associated with less mental health problems and higher satisfaction with life. CONCLUSION: Symptoms of insomnia and depression were the two most common mental health problems reported during this selected phase of the COVID-19 pandemic. Elite and semielite athletes reported financial concerns as a risk factor for mental health problems at a larger degree than Olympic and Paralympic athletes.

Communication quality between the medical team and the head coach/manager is associated with injury burden and player availability in elite football clubs.

OBJECTIVES: We investigated medical staff interpretations and descriptions of internal communication quality in elite football teams to determine whether internal communication was correlated with injuries and/or player availability at training and matches. METHODS: Medical staff from 36 elite football clubs across 17 European countries produced 77 reports at four postseason meetings to provide their perceptions of internal communications in their teams. They also recorded data on individual players' exposure to football and time-loss injuries. RESULTS: The injury burden and incidence of severe injuries were significantly higher in teams with low quality of communication between the head coach/manager and the medical team (scores of 1-2 on a 5-point Likert scale) compared with teams with moderate or high-quality scores (scores of 3-5; p=0.008 for both). Teams with low scores had 4%-5% lower training attendance (76% vs 83%, p=0.001) and less availability at matches (82% vs 88%, p=0.004) compared with teams with moderate or high communication quality scores. CONCLUSIONS: The quality of internal communication within a team was correlated with injury rates, training attendance and match availability.

Are adolescent elite athletes less psychologically distressed than controls? A cross-sectional study of 966 Norwegian adolescents.

INTRODUCTION: Psychological distress is increasing among adolescents and clusters with other mental health problems such as eating problems. The aim of this study was to investigate the prevalence of psychological distress among young elite athletes and age-matched controls and whether prevalence figures may be attributed to perfectionism and eating problems. METHODS: First-year athletes from all Norwegian elite sport high schools (n=711) and 500 students from randomly selected ordinary high schools were eligible for this cross-sectional study. In total, 611 athletes and 355 student controls provided self-report data about psychological distress, perfectionism, and eating problems (ie, body dissatisfaction and a drive for thinness), as well as their physical training/activity. RESULTS: A significantly higher proportion of controls scored above the cutoff point for marked psychological distress. Physical activity above the recommended levels for this age group predicted psychological distress among the controls, while the opposite was found in the student elite athlete sample. In both samples, perfectionistic concerns, ie, concern over mistakes, predicted overall psychological distress. However, among elite athletes, perfectionistic concerns were particularly associated with clinically significant psychological distress. Moreover, the impact of eating problems was negligible. CONCLUSION: Results from this study highlight the need to target the maladaptive perfectionistic concerns to prevent psychological distress among young athletes as well as among their age-matched nonathlete counterparts.

Psychosocial stress factors, including the relationship with the coach, and their influence on acute and overuse injury risk in elite female football players.

BACKGROUND: The relationship between specific types of stressors (eg, teammates, coach) and acute versus overuse injuries is not well understood. OBJECTIVE: To examine the roles of different types of stressors as well as the effect of motivational climate on the occurrence of acute and overuse injuries. METHODS: Players in the Norwegian elite female football league (n=193 players from 12 teams) participated in baseline screening tests prior to the 2009 competitive football season. As part of the screening, we included the Life Event Survey for Collegiate Athletes and the Perceived Motivational Climate in Sport Questionnaire (Norwegian short version). Acute and overuse time-loss injuries and exposure to training and matches were recorded prospectively in the football season using weekly text messaging. Data were analysed with Bayesian logistic regression analyses. RESULTS: Using Bayesian logistic regression analyses, we showed that perceived negative life event stress from teammates was associated with an increased risk of acute injuries (OR=1.23, 95% credibility interval (1.01 to 1.48)). There was a credible positive association between perceived negative life event stress from the coach and the risk of overuse injuries (OR=1.21, 95% credibility interval (1.01 to 1.45)). CONCLUSIONS: Players who report teammates as a source of stress have a greater risk of sustaining an acute injury, while players reporting the coach as a source of stress are at greater risk of sustaining an overuse injury. Motivational climate did not relate to increased injury occurrence.

International Olympic Committee consensus statement on youth athletic development.

The health, fitness and other advantages of youth sports participation are well recognised. However, there are considerable challenges for all stakeholders involved-especially youth athletes-in trying to maintain inclusive, sustainable and enjoyable participation and success for all levels of individual athletic achievement. In an effort to advance a more unified, evidence-informed approach to youth athlete development, the IOC critically evaluated the current state of science and practice of youth athlete development and presented recommendations for developing healthy, resilient and capable youth athletes, while providing opportunities for all levels of sport participation and success. The IOC further challenges all youth and other sport governing bodies to embrace and implement these recommended guiding principles.

Impact of Mindfulness Training on Physiological Measures of Stress and Objective Measures of Attention Control in a Military Helicopter Unit.

Objective: This study sought to determine if mindfulness training (MT) has a measurable impact on stress and attentional control as measured by objective physiological and psychological means. Background: Periods of persistent, intensive work demands are known to compromise recovery and attentional capacity. The effects of 4-month MT on salivary cortisol and performance on 2 computer-based cognitive tasks were tested on a military helicopter unit exposed to a prolonged period of high workload. Methods: MT participants were compared to a wait list control group on levels of saliva cortisol and performance on a go-no go test and a test of stimulus-driven attentional capture. Participants also reported mental demands on the go-no go test, time of wakeup, sleep duration, quality of sleep, outcome expectancies, physical activity level, self-perceived mindfulness, and symptoms of depression and anxiety. Results: The results from a mixed between-within analysis revealed that the MT participants compared to the control group had a larger pre to post increase in high- and low-cortisol slopes, and decrease in perceived mental demand imposed by the go-no go test. Conclusion: MT alleviates some of the physiological stress response and the subjective mental demands of challenging tasks in a military helicopter unit during a period of high workload.

Preventing eating disorders among young elite athletes: a randomized controlled trial.

PURPOSE: To examine the effect of a 1-yr school-based intervention program to prevent the development of new cases of eating disorders (ED) and symptoms associated with ED among adolescent female and male elite athletes. METHODS: All 16 Norwegian Elite Sport High Schools were included (intervention group [n = 9] and control group [n = 7]). In total, 465 (93.8%) first-year student athletes were followed during high school (2008-2011, three school years). The athletes completed the Eating Disorder Inventory 2 and questions related to ED before (pretest), immediately after (posttest 1), and 9 months after the intervention (posttest 2). Clinical interviews (Eating Disorder Examination) were conducted after the pretest (all with symptoms [n = 115, 97%] and a random sample without symptoms [n = 116, 97%]), and at posttest 2, all athletes were interviewed (n = 463, 99.6%). RESULTS: Among females, there were no new cases of ED in the intervention schools, while 13% at the control schools had developed and fulfilled the DSM-IV criteria for ED not otherwise specified (n = 7) or bulimia nervosa (n = 1), P = 0.001. The risk of reporting symptoms was lower in the intervention than in the control schools at posttest 1 (odds ratio [OR] = 0.45, 95% confidence interval [CI] = 0.23-0.89). This effect was attenuated by posttest 2 (OR = 0.57, 95% CI = 0.29-1.09). The intervention showed a relative risk reduction for current dieting (OR = 0.10, 95% CI = 0.02-0.54) and three or more weight loss attempts (OR = 0.47, 95% CI = 0.25-0.90). Among males, there was one new case of ED at posttest 2 (control school) and no difference in the risk of reporting symptoms between groups at posttest 1 or 2. CONCLUSION: A 1-yr intervention program can prevent new cases of ED and symptoms associated with ED in adolescent female elite athletes.

The development of the brief eating disorder in athletes questionnaire.

PURPOSE: The objective of this study is to design and validate a brief questionnaire able to discriminate between female elite athletes with and without an eating disorder (ED). METHODS: In phase I, 221 (89.5%) adolescent athletes participated in a screening including the Eating Disorder Inventory-2 (EDI-2) and questions related to ED. All athletes reporting symptoms associated with ED (n = 96, 94.1%) and a random sample without symptoms (n = 88, 86.3%) attended the ED Examination Interview. On the basis of the screening, we extracted items with good predictive abilities for an ED diagnosis to the Brief ED in Athletes Questionnaire (BEDA-Q) versions 1 and 2. Version 1 consisted of seven items from the EDI-Body dissatisfaction, EDI-Drive for thinness, and questions regarding dieting. In version 2, two items from the EDI-Perfectionism subscale were added. In phase II, external predictive validity of version 1 was tested involving 54 age-matched elite athletes from an external data set. In phase III, predictive ability of posttest assessments was determined among athletes with no ED at pretest (n = 53, 100%). Logistic regression analyses were performed to identify predictors of ED. RESULTS: Version 2 showed higher discriminative accuracy than version 1 in distinguishing athletes with and without an ED with a receiver operating characteristics area of 0.86 (95% confidence interval (CI), 0.78-0.93) compared with 0.83 (95% CI, 0.74-0.92). In phase II, the accuracy of version 1 was 0.77 (95% CI, 0.63-0.91). In predicting new cases, version 2 showed higher diagnostic accuracy than version 1 with a receiver operating characteristic area of 0.73 (98% CI, 0.52-0.93) compared with 0.70 (95% CI, 0.48-0.92). CONCLUSION: The BEDA-Q containing nine items reveals good ability to distinguish between female elite athletes with and without an ED. The BEDA-Q's predictive ability should be tested in larger samples.

Cognitive activation theory of stress (CATS): from fish brains to the Olympics.

The Cognitive Activation Theory of Stress (CATS) offers formal and systematic definitions of the terms and concepts used in stress research. The stress response depends on acquired expectancies to the outcome of the stimulus and the available responses. The stress response itself is an alarm, an increase in arousal necessary for performance and adequate reactions to challenges. The response is healthy and necessary for survival. Only when sustained over time may potential health risks occur. The basic rules for when stress occurs are the same across cultures and species, from fish to Olympic performance in humans. The important dimensions for health are positive expectancies of outcome (coping), control, and safety, for all individuals in all species.

Elite athletes' experiences of the motivational climate: the coach matters.

Recent research investigating the effect of the motivational climate has found that even elite athletes benefit from a mastery climate. The purpose of the present study was to obtain a deeper understanding of the importance of the climate surrounding an athlete and the role of the coach for elite athletes by conducting in-depth interviews with a group of athletes (n=7). The athletes also completed the Perception of Success Questionnaire (POSQ) and Perception of Motivational Climate Questionnaire (PMCQ) to measure motivational indices. All the athletes were very high on task orientation and moderate to high on ego orientation. Most of the athletes perceived a high mastery climate and a low performance climate. The athletes emphasized the importance of the coach as the creator of the climate, as well as their preference for a supportive and caring climate. This speaks for an emphasis on a mastery climate for elite athletes.

Empowerment Through the Sport Context: A Model to Guide Research for Individuals with Disability.

Our purpose is to propose a model of "Empowerment through the sport context" to guide psychosocial research in disability sport. We discuss the concept of empowerment in relation to sport for individuals with disabilities. Expanding upon the work of Hutzler (1990), we include three levels of empowerment (societal, group, and individual level) in our approach. Important moderators are age of onset of disability, gender, and type of disability. Important mediators are (a) at the individual level, achievement goals, identity, and self-efficacy; (b) at the group level, motivational climate, group identity, and collective efficacy; and finally, (c) at the societal level, the cultural context and political efficacy. Several methodological considerations are discussed, and various solutions are suggested. We also discuss the critiques that have emerged in relation to the use of the empowerment concept.