Within-day energy deficiency and reproductive function in female endurance athletes.

We aimed to estimate and compare within-day energy balance (WDEB) in athletes with eumenorrhea and menstrual dysfunction (MD) with similar 24-hour energy availability/energy balance (EA/EB). Furthermore, to investigate whether within-day energy deficiency is associated with resting metabolic rate (RMR), body composition, S-cortisol, estradiol, T3 , and fasting blood glucose. We reanalyzed 7-day dietary intake and energy expenditure data in 25 elite endurance athletes with eumenorrhea (n = 10) and MD (n = 15) from a group of 45 subjects where those with disordered eating behaviors (n = 11), MD not related to low EA (n = 5), and low dietary record validity (n = 4) had been excluded. Besides gynecological examination and disordered eating evaluation, the protocol included RMR measurement; assessment of body composition by dual-energy X-ray absorptiometry, blood plasma analysis, and calculation of WDEB in 1-hour intervals. Subjects with MD spent more hours in a catabolic state compared to eumenorrheic athletes; WDEB < 0 kcal: 23.0 hour (20.8-23.4) vs 21.1 hour (4.7-22.3), P = .048; WDEB < -300 kcal: 21.8 hour (17.8-22.4) vs 17.6 hour (3.9-20.9), P = .043, although similar 24-hour EA: 35.6 (11.6) vs 41.3 (12.7) kcal/kg FFM/d, (P = .269), and EB: -659 (551) vs -313 (596) kcal/d, (P = .160). Hours with WDEB <0 kcal and <-300 kcal were inversely associated with RMRratio (r = -.487, P = .013, r = -.472, P = .018), and estradiol (r = -.433, P = .034, r = -.516, P = .009), and positively associated with cortisol (r = .442, P = .027, r = .463, P = .019). In conclusion, although similar 24-hour EA/EB, the reanalysis revealed that MD athletes spent more time in a catabolic state compared to eumenorrheic athletes. Within-day energy deficiency was associated with clinical markers of metabolic disturbances.

Low-energy density and high fiber intake are dietary concerns in female endurance athletes.

Low or reduced energy availability (LEA) is linked to functional hypothalamic oligomenorrhea/amenorrhea (FHA), which is frequently reported in weight-sensitive sports. This makes LEA a major nutritional concern for female athletes. The aim of this study was to describe dietary characteristics of athletes with LEA and/or FHA. Endurance athletes (n = 45) were recruited from national teams and competitive clubs. Protocols included gynecological examination, body composition, eating disorder evaluation, and 7-day dietary intake and EA assessment. Athletes with disordered eating behavior/eating disorders (n = 11), menstrual dysfunction other than FHA (n = 5), and low dietary record validity (n = 4) were excluded. Remaining subjects (n = 25) were characterized by EA [optimal: ≥ 45 kcal (188 kJ)/kg fat-free mass (FFM)/day (n = 11), LEA: < 45 kcal (188 kJ)/kg FFM/day (n = 14)] and reproductive function [eumenorrhea (EUM; n = 10), FHA (n = 15)]. There was no difference in EA between FHA and EUM subjects. However, FHA and LEA subjects shared the same dietary characteristics of lower energy density (ED) [(P = 0.012; P = 0.020), respectively], and fat content [(P = 0.047; P = 0.027), respectively]. Furthermore, FHA subjects had a lower intake of carbohydrate-rich foods (P = 0.019), higher fiber content (P < 0.001), and drive for thinness score (P = 0.003). Conclusively, low ED together with high fiber content may constitute targets for dietary intervention in order to prevent and treat LEA and FHA in female athletes.

Energy availability and the female athlete triad in elite endurance athletes.

The female athlete triad (Triad), links low energy availability (EA), with menstrual dysfunction (MD), and impaired bone health. The aims of this study were to examine associations between EA/MD and energy metabolism and the prevalence of Triad-associated conditions in endurance athletes. Forty women [26.2 ± 5.5 years, body mass index (BMI) 20.6 ± 2.0 kg/m(2), body fat 20.0 ± 3.0%], exercising 11.4 ± 4.5 h/week, were recruited from national teams and competitive clubs. Protocol included gynecological examination; assessment of bone health; indirect respiratory calorimetry; diet and exercise measured 7 days to assess EA; eating disorder (ED) examination; blood analysis. Subjects with low/reduced EA (< 45 kcal/kg FFM/day), had lower resting metabolic rate (RMR) compared with those with optimal EA [28.4 ± 2.0 kcal/kg fat-free mass (FFM)/day vs 30.5 ± 2.2 kcal/kg FFM/day, P < 0.01], as did subjects with MD compared with eumenorrheic subjects (28.6 ± 2.4 kcal/kg FFM/day vs 30.2 ± 1.8 kcal/kg FFM/day, P < 0.05). 63% had low/reduced EA, 25% ED, 60% MD, 45% impaired bone health, and 23% had all three Triad conditions. 53% had low RMR, 25% hypercholesterolemia, and 38% hypoglycemia. Conclusively, athletes with low/reduced EA and/or MD had lowered RMR. Triad-associated conditions were common in this group of athletes, despite a normal BMI range. The high prevalence of ED, MD, and impaired bone health emphasizes the importance of prevention, early detection, and treatment of energy deficiency.

Adolescent elite athletes' cigarette smoking, use of snus, and alcohol.

The purpose was to examine cigarette smoking, use of snus, alcohol, and performance-enhancing illicit drugs among adolescent elite athletes and controls, and possible gender and sport group differences. First-year students at 16 Norwegian Elite Sport High Schools (n = 677) and two randomly selected high schools (controls, n = 421) were invited to participate. Totally, 602 athletes (89%) and 354 (84%) controls completed the questionnaire. More controls than athletes were smoking, using snus, and drinking alcohol. Competing in team sports was associated with use of snus [odds ratio = 2.8, 95% confidence interval (CI) 1.6 to 4.7] and a similar percentage of male and female handball (22.2% vs 18.8%) and soccer players (15.7% vs 15.0%) reported using snus. For controls, not participating in organized sport was a predictor for smoking (odds ratio = 4.9, 95% CI 2.2 to 10.9). Female athletes were more prone to drink alcohol than males (46.3% vs 31.0%, P < 0.001). Only, 1.2% athletes and 2.8% controls reported use of performance-enhancing illicit drugs. In conclusion, use of legal drugs is less common among athletes, but this relationship depends on type of sport and competition level. The association between team sports and use of snus suggests that sport subcultures play a role.

Adipositas athletica: a group of neglected conditions associated with medical risks.

At the 2008 Olympics, the body weight of the athletes varied from 28 to 181 kg and many Olympic athletes therefore today have a stature far from the ancient Greek athletic ideals. Athletes and sports associated with leanness and their medical problems have been researched extensively. However, there has been less focus on those athletes, who may gain a competitive advantage by having excess body fat, being large or oversized. The present review introduces for the first time the concept of Adipositas athletica and gives a description and classification of these athletes. Adipositas athletica is defined as having a higher than "athletic normal" (Greek Olympic ideals) fat mass and being an elite athlete. The condition is divided into subgroups based on the intent or non-intent to increase body fat per se. Another factor is the intent to increase body mass as well as increasing physiological factors such as strength or endurance. It is concluded that most of the sports-medicine community-physicians, researchers and nutritionists - has neglected these oversized and obese athletes, their long- and short-term morbidity and mortality, their eating problems and the use of performance-enhancing drugs. Although some data on overweight and obese athletes exist, the most remarkable finding when reviewing the literature is the paucity of data. Many unanswered questions remain and great strides remain to be made.

Are former female elite athletes more likely to experience urinary incontinence later in life than non-athletes?

The aim of the present study was to investigate whether former female elite athletes are more likely to experience urinary incontinence (UI) later in life than non-athletes and to assess possible risk factors for UI in athletes. Three hundred and thirty-one former elite athletes (response rate 81%) and 640 controls replied to a postal questionnaire including validated questions on UI. While competing in sport, 10.9% and 2.7% of the former elite athletes reported stress urinary incontinence (SUI) and urge incontinence, respectively. Presently, 36.5% of the former elite athletes and 36.9% of the controls reported SUI. 9.1% and 9.4% reported urge incontinence. Among former elite athletes, those with two or three children were more likely than nulliparous women to have UI now. Also, among former athletes, UI was more common in women with vs those without UI while competing (odds ratio 8.57, 95% confidence interval: 3.55-20.71). Age, menopause and being regularly physically active now were not associated with UI in either group. Based on this study, the prevalence of UI does not seem to be higher in former athletes than in controls. However, the results indicate that UI early in life, as reported during elite sport, is a strong predictor of UI later in life.

Aspects of disordered eating continuum in elite high-intensity sports.

Dieting is an important risk factor for disordered eating and eating disorders. Disordered eating occurs on a continuum from dieting and restrictive eating, abnormal eating behavior, and finally clinical eating disorders. The prevalence of eating disorders is increased in elite athletes and for this group the cause of starting to diet is related to (a) perception of the paradigm of appearance in the specific sport, (b) perceived performance improvements, and (c) sociocultural pressures for thinness or an "ideal" body. Athletes most at risk for disordered eating are those involved in sports emphasizing a thin body size/shape, a high power-to-weight ratio, and/or sports utilizing weight categories, such as in some high-intensity sports. In addition to dieting, personality factors, pressure to lose weight, frequent weight cycling, early start of sport-specific training, overtraining, injuries, and unfortunate coaching behavior, are important risk factors. To prevent disordered eating and eating disorders, the athletes have to practice healthy eating, and the medical staff of teams and parents must be able to recognize symptoms indicating risk for eating disorders. Coaches and leaders must accept that disordered eating can be a problem in the athletic community and that openness regarding this challenge is important.

Dieting to win or to be thin? A study of dieting and disordered eating among adolescent elite athletes and non-athlete controls.

OBJECTIVE: To examine the prevalence of dieting, reasons for dieting and prevalence of disordered eating among adolescent elite athletes and age-matched controls, and to examine the differences between athletes competing in leanness and non-leanness sports. METHODS: First-year students of 16 different Norwegian Elite Sport High Schools (athlete group, n = 682) and two randomly selected ordinary high schools from a county representative of the general Norwegian population (control group, n = 423) were invited to participate in this cross-sectional study. A total of 606 athletes and 355 controls completed the questionnaire, giving a response rate of 89% and 84%, respectively. The questionnaire contained questions regarding training patterns, menstrual status and history, dieting, use of pathogenic weight control methods and the drive for thinness (DT) and body dissatisfaction (BD) subscales from the Eating Disorders Inventory. MAIN OUTCOME MEASURE: Disordered eating, defined as meeting one or more of the following criteria: DT score > or =15 (girls) and > or =10 (boys), BD score > or =14 (girls) and > or =10 (boys), body mass index <17.9 kg/m(2) (girls) and <17.5 kg/m(2) (boys), current and/or > or =3 previous efforts to lose weight, use of pathogenic weight control methods and self-reported menstrual dysfunction. RESULTS: A higher prevalence of control subjects were dieting and classified with disordered eating compared with the athletes. An improvement of appearance was a more common reason for dieting among controls compared with athletes. No differences in dieting or disordered eating were found between leanness and non-leanness sports athletes. CONCLUSIONS: Self-reported disordered eating is more prevalent among controls than adolescent elite athletes, and losing weight to enhance performance is an important reason for dieting among adolescent elite athletes.

Physical fitness, bone mineral density and associations with physical activity in females with longstanding eating disorders and non-clinical controls.

AIM: To examine (i) aerobic fitness, muscular strength, and bone mineral density (BMD) in female inpatients with longstanding eating disorders and non-clinical controls, and (ii) associated and explanatory factors for BMD among the inpatients. METHODS: Adult females with DSM-IV anorexia nervosa (AN), bulimia nervosa (BN) or eating disorders not otherwise specified (EDNOS) (n=59, mean(SD) age 30.1(8.5) yrs and ED duration 14.3 yrs) and non-clinical age-matched controls (n=53, mean(SD) age 31.3(8.3) yrs) accepted participation in this cross-sectional study. Measurements included accelerometer assessed and self reported amount of different types of physical activities, VO2max on treadmill, 1RM in leg and chest press, and BMD in lumbar spine (L2-L4), femur neck and total body analyzed by DXA. RESULTS: Muscular strength and BMD were lower in patients with AN, not in patients with BN or EDNOS, compared to controls. Aerobic fitness did not differ between patients and controls. BMD in the patients was positively associated with body weight, muscular strength and self reported high impact PA (min.w-1), not self reported general weight-bearing PA (min.w-1) or accelerometer assessed PA (counts.min). History of AN (28%) and muscular strength (9%) contributed significantly to explain the variance in total body BMD. CONCLUSION: Muscular strength and only high impact PA are associated with BMD in patients with longstanding ED. An implication of this is the need for more specific guidelines regarding types of PA recommended for this patient population. Special considerations should be made for severely malnourished patients, and for patients with osteoporosis.

Physical activity in treatment units for eating disorders: clinical practice and attitudes.

OBJECTIVE: Physical activity (PA) in eating disorders (ED) may be harmful, but in a therapeutic setting also beneficial. The purpose of this survey was to examine these contradictory aspects of PA in ED specialist treatment settings. We examined whether 1) PA is assessed by the unit, 2) the units have guidelines for managing excessive PA, 3) the units have staff with higher education and special competence in PA and exercise science, 4) how units regard PA in ED, 5) whether regular PA is integrated in the treatment programs, and 6) how the units rate the role of PA in the treatment of ED compared with other mental disorders. METHODS: Of the 49 units located in Scandinavia and the United Kingdom, 41 (84%) responded to a questionnaire. RESULTS: In 28 units (68%) PA was assessed regularly. Excessive PA was considered a harmful symptom in ED, and most units reported guidelines to manage excessive PA. Thirty-two units included PA in their treatment programmes. Clinicians found PA most relevant in the treatment of obesity and, except for binge eating, less for ED. CONCLUSION: PA was more commonly integrated in treatment compared to previous studies. Future research should address how to manage excessive PA, and the potential beneficial role of PA in the treatment of ED.

Participation in leanness sports but not training volume is associated with menstrual dysfunction: a national survey of 1276 elite athletes and controls.

OBJECTIVE: To examine the prevalence of menstrual dysfunction in the total population of Norwegian elite female athletes and national representative controls in the same age group. METHODS: A detailed questionnaire that included questions on training and/or physical activity patterns, menstrual, dietary, and weight history, oral contraceptive use, and eating disorder inventory subtests was administered to all elite female athletes representing the country at the junior or senior level (aged 13-39 years, n = 938) and national representative controls in the same age group (n = 900). After exclusion, a total of 669 athletes (88.3%) and 607 controls (70.2%) completed the questionnaire satisfactorily. RESULTS: Age at menarche was significantly (p<0.001) later in athletes (13.4 (1.4) years) than in controls (13.0 (1.3) years), and differed among sport groups. A higher percentage of athletes (7.3%) than controls (2.0%) reported a history of primary amenorrhoea (p<0.001). A similar percentage of athletes (16.5%) and controls (15.2%) reported present menstrual dysfunction, but a higher percentage of athletes competing in leanness sports reported present menstrual dysfunction (24.8%) than athletes competing in non-leanness sports (13.1%) (p<0.01) and controls (p<0.05). CONCLUSIONS: These novel data include virtually all eligible elite athletes, and thus substantially extend previous studies. Age at menarche occurred later and the prevalence of primary amenorrhoea was higher in elite athletes than in controls. A higher percentage of athletes competing in sports that emphasise thinness and/or a specific weight reported present menstrual dysfunction than athletes competing in sports focusing less on such factors and controls. On the basis of a comparison with a previous study, the prevalence of menstrual dysfunction was lower in 2003 than in 1993.

Low bone mineral density is two to three times more prevalent in non-athletic premenopausal women than in elite athletes: a comprehensive controlled study.

OBJECTIVE: To compare bone mineral density (BMD), investigate factors associated with BMD, and examine the prevalence of low BMD in athletes and non-athletic controls. METHODS: The study included a questionnaire (part I), measurement of BMD (part II), and a clinical interview (part III). All Norwegian female athletes on national teams (n = 938) and an aged matched random sample of non-athletic controls (n = 900) were invited to participate. The questionnaire was completed by 88% of athletes and 70% of controls. A random sample of these athletes (n = 300) and controls (n = 300) was invited to participate in parts II and III. All parts were completed by 186 athletes (62%) and 145 controls (48%). RESULTS: Mean (standard deviation) total body (TB) BMD was higher (p<0.001) in athletes (1.21 (0.09) g/cm2) than in controls (1.18 (0.08) g/cm2), and higher (p<0.001) in high impact (HI) sports athletes than in medium impact (MI) and low impact (LI) sports athletes. In athletes, body weight and impact loading sports were positively associated, and percent body fat and eating disorders were negatively associated with TB BMD. Body weight and weight bearing activities were positively associated and menstrual dysfunction was negatively associated with TB BMD in controls. A higher percentage of controls (28.3%) than athletes (10.7%) had low BMD (p<0.001). CONCLUSION: Female elite athletes have 3-20% higher BMD than non-athletic controls and HI sports athletes have 3-22% higher BMD compared with MI and LI sports athletes. Low BMD is two to three times more common in non-athletic premenopausal women than in elite athletes.

Normal bone mass in bulimic women.

The aim of this study was to examine the relationship among exercise, menstrual function, and bone mineral density (BMD) in different groups of age-matched patients with eating disorders. Dieting and eating disorder history, physical activity history, and menstrual history were assessed by clinical interview in 43 bulimic and 13 anorectic young women as well as in 17 healthy control subjects (18-29 yr). BMD was assessed by dual x-ray absorptiometry. All the anorectics but only 30% of the bulimics exercised regularly from the onset of their eating disorder (P < 0.01), mainly using aerobic dancing and running. All of the anorectics had been amenorrheic since the start of their symptoms, and 68% of the bulimics had a history of menstrual dysfunction. Within the exercise subgroups of bulimic patients, there was no significant relationship between BMD and current or previous menstrual function. Anorectic patients had lower BMD than bulimics and controls in all skeletal regions studied (P < 0.01). Bulimic patients who had exercised regularly during their illness had higher total body BMD than bulimics classified as sedentary (P < 0.01). Bulimics who had exercised regularly or intermittently since the onset of their eating disorder had higher BMD than sedentary bulimics in the lumbar vertebrae, femoral neck, and legs (P < 0.05). It appears that weight-bearing exercise can prevent or attenuate bone loss at specific skeletal sites in normal weight bulimic patients, but not in anorectics.

Eating disorders in female athletes.

Eating disorders can lead to death. The prevalence of subclinical and eating disorders is high among female athletes, and the prevalence of eating disorders is higher among female athletes than nonathletes. Athletes competing in sports where leanness or a specific bodyweight is considered important are more prone to develop eating disorders than athletes competing in sports where these factors are considered less important. It appears necessary to examine true eating disorders, the subclinical disorders and the range of behaviours and attitudes associated with eating disturbances in athletes, to learn how these clinical and subclinical disorders are related. Because of methodological weaknesses in the existing studies, including deficient description of the populations studied and the methods of data collection, the best instrument or interview method is not known. Therefore, more research on athletes and eating disorders is needed. Suggestions of the possible sport specific risk factors associated with the development of eating disorders in athletes exist, but large scale longitudinal studies are needed to learn more about risk factors and the aetiology of eating disorders in athletes at different competitive levels and within different sports. Further studies are required on the short and long term effects of eating disorders on athletes' health and athletic performance.

Risk and trigger factors for the development of eating disorders in female elite athletes.

This study examined risk factors and triggers for eating disorders in female athletes. Subjects included were all of the elite female athletes in Norway (N = 603), ages 12-35 yr, representing six groups of sports: technical, endurance, aesthetic, weight dependent, ball games, and power sports. The Eating Disorder Inventory was used to classify individuals at risk for eating disorders. Of the 117 athletes defined at risk, 103 were administered a structured clinical interview for eating disorders. A comparison group was also interviewed, consisting of 30 athletes chosen at random from a pool not at risk and matched to the at-risk subjects on age, community of residence, and sport. Ninety-two of the at-risk athletes met criteria for anorexia nervosa, bulimia nervosa, or anorexia athletica. The prevalence of eating disorders was higher in sports emphasizing leanness or a specific weight than in sports where these are less important. Compared with controls, eating disordered athletes began both sports-specific training and dieting earlier, and felt that puberty occurred too early for optimal performance. Trigger factors associated with the onset of eating disorders were prolonged periods of dieting, frequent weight fluctuations, a sudden increase in training volume, and traumatic events such as injury or loss of a coach.

Prevalence of eating disorders and the predictive power of risk models in female elite athletes: a controlled study.

The purposes of this study were to examine the percentage of female elite athletes and controls with disordered eating (DE) behavior and clinical eating disorders (EDs), to investigate what characterize the athletes with EDs, and to evaluate whether a proposed method of screening for EDs in elite athletes does not falsely classify sport-specific behaviors as indicators of EDs. All athletes representing the national teams at the junior or senior level, aged 13-39 years (n=938), and age-group matched, randomly selected population-based controls (n=900) were invited to participate. From the screening data, a random sample of athletes (n=186) and controls (n=145) were subjects for a clinical interview. More athletes in leanness sports (46.7%) had clinical EDs than athletes in non-leanness sports (19.8%) and controls (21.4%) (P<0.001). Variables predicting clinical EDs, and thus candidates for valid screening procedures, were menstrual dysfunction in leanness athletes, self-reported EDs in non-leanness athletes, and self-reported use of pathogenic weight control methods in controls. Hence, statistically based risk factors are not universally valid, but specifically related to athletes and non-athletes, respectively.

[Physical activity and reproductive health]. / Fysisk aktivitet og reproduktiv helse.

BACKGROUND: The purpose of this article is to review the present knowledge about physical activity and reproductive health. METHODS: Medline and manual search for articles related to exercise and menstrual function, and exercise and pregnancy were performed. RESULTS: Repetitive intensive exercise with increased stress hormone utilisation seems to partly explain the disturbances in the hypothalamic-pituitary-adrenal axis. The prevalence of menstrual irregularities is higher among athletes who participate in sports in which leanness is considered important for performance. Most of the studies concerning exercise-induced amenorrhoea have focused on low body weight and low fat ratio of body weight. However, energy drain and nutrient deficiency have been found to be important variables explaining menstrual irregularity in athletes. Loss of bone mass is related to menstrual irregularities hence it is important that menstrual irregularity not is considered a "normal" aspect of being an athlete. There are a number of positive effects and a few hypothetical risks related to exercise during pregnancy. There are no clinically controlled studies allowing us to draw conclusions about the effect of intensive training during pregnancy. INTERPRETATION: Physically active women should be aware of the importance of sufficient energy intake to keep their regular menstrual cycle. Moderate exercise during pregnancy is recommended.

Prevalence of eating disorders in elite female athletes.

This study examined the prevalence of eating disorders (ED) and the possible difference between ED symptoms and true ED by using questionnaires as compared with an interview and clinical evaluation in Norwegian elite female athletes (n = 522) from 35 sports and nonathletic controls (n = 448). In addition to the 117 athletes classified as "at risk" to develop ED, 90 subjects were randomly chosen, comprising 30 athletic controls, 30 at-risk nonathletes, and 30 nonathletic controls. All were interviewed and clinically examined. A significantly higher number of athletes (18%) than controls (5%) were found to actually suffer from ED, particularly athletes competing in sports in which leanness or a specific weight were considered important. When results from the screening study were compared to those from the interviews and clinical examinations, a significant underreporting of ED among athletes was demonstrated. The athletes also reported the use of other pathogenic methods in the screening study compared to what they reported in the interview. Nonathletes more correctly reported the use of pathogenic methods but overreported the prevalence of ED. Thus the issue of using questionnaires alone or in combination with personal interview/clinical examination merits further investigation.

Nutrient intake of female elite athletes suffering from eating disorders.

This study assessed the nutrient intake and eating behavior in Norwegian female elite athletes suffering from eating disorders (ED) who met the criteria for anorexia nervosa (AN), anorexia athletica (AA), or bulimia nervosa (BN). The subjects included 7 AN, 43 AA, 42 BN, and 30 controls. Three-day and 24-hr food records were used to assess energy and nutrient intake. Results revealed that a significant number of AN and AA athletes have diets too low in energy and nutrients, the mean intake for energy and CHO being lower than recommended for active females. A significant number did not reach the protein level recommended for athletes. In addition, there were low intakes of several micronutrients, most notably calcium, vitamin D, and iron. The energy and nutritional inadequacy, combined with the use of purging, are of major concern since the athletes in this study were relatively young. It is unknown whether the abnormal eating pattern is a consequence of ED or is typical of top level athletes.

Eating disorders, energy intake, training volume, and menstrual function in high-level modern rhythmic gymnasts.

This study examined clinical and subclinical eating disorders (EDs) in young Norwegian modern rhythmic gymnasts. Subjects were 12 members of the national team, age 13-20 years, and individually matched nonathletic controls. All subjects participated in a structured clinical interview for EDs, medical examination, and dietary analysis. Two of the gymnasts met the DSM-III-R criteria for anorexia nervosa, and 2 met the criteria for anorexia athletica (a subclinical ED). All the gymnasts were dieting in spite of the fact that they were all extremely lean. The avoidance of maturity, menstrual irregularities, energy deficit, high training volume, and high frequency of injuries were common features among the gymnasts. Ther is a need to learn more about risk factors and the etiology of EDs in different sports. Coaches, parents, and athletes need more information about principles of proper nutrition and methods to achieve ideal body composition for optional health and athletic performance.