Weekly Victory Program Literature Review

Written by Ron A. Thompson, PhD, FAED, CEDS

One shortcoming of research in the area of athletes and eating disorders involves the lack of information related to the decisions regarding when an athlete with an eating disorder should be withheld from training and competition and when it is safe for the athlete to return to their sport. Recent articles in the British Journal of Sports Medicine describes practical information that can be helpful to the clinician in making these decisions. The first article was authored by an American College of Sports Medicine (ACSM) group (De Souza et al., 2014) and focused on treatment and return to play issues related to the Female Athlete Triad—Energy Availability, Menstrual Function, and Bone Health. De Souza et al. proposed a practical risk stratification point system to be used by clinicians for making decisions regarding sport participation, clearance for sport, and return to sport training and competition.

In a second article related to clearance criteria for sport participation, an International Olympic Committee (IOC) Medical Commission group has provided a consensus statement on what has been termed Relative Energy Deficiency in Sport (RED-S; Mountjoy et al., 2014). The consensus statement goes beyond the typical issues characteristic of the Triad in that it “refers to impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health caused by relative energy deficiency.” It also extends these issues to male athletes, non-caucasion athletes, and athletes with disability. Perhaps most important, RED-S provides a practical risk assessment model for sport participation that can be used by clinicians to make those difficult decision regarding whether an athlete should be training and competing, in addition to treatment recommendations. Athletes are placed in one of three groups depending on their symptoms. For example, athletes in the high risk group are to be prohibited from training and competing. Characteristics of athletes in this group would include anorexia nervosa, other serious psychological or physiological conditions, or extreme weight loss techniques leading to life threatening conditions. Athletes in the moderate risk category would include those with prolonged abnormally low body fat, substantial weight loss (5-10% of body mass in 1 month), attenuation of expected growth/development in adolescents, abnormal menses, history of stress fractures, ECG/Lab abnormalities, and lack of progress in treatment, as well as other issues/problems. Athletes in this group “should be cleared for sport participation only with supervised participation and a medical treatment plan,” with re-evaluation at regular intervals of one to three months, depending on the athlete’s clinical status. Athletes believed to be in the low risk group are not restricted regarding sport training and competition. As a follow-up to RED-S, this IOC Medical Commission group is proposing a RED-S assessment instrument, which should be available soon.


De Souza, M.J., Nattiv, A., Joy, E., Misa, M., Williams, N.I., Mallinson, R.J., Gibbs, J.C., et al., (2014). 2014

Female athlete triad coalition consensus statement on treatment and return to play of the Female

Athlete Triad. British Journal of Sports Medicine, 48, 289-308.

Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., Meyer, N., Sherman,

     R., et al. (2014). The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy

Deficiency in Sport (RED-S). British Journal of Sports Medicine, 48, 491-497.

Ron A. Thompson is a psychologist in Bloomington, Indiana, specializing in the treatment of eating disorders. He is also a consulting psychologist for the Athletic Department at Indiana University and has served as a consultant on eating disorders to the NCAA and on the Female Athlete Triad with the International Olympic Committee Medical Commission (IOCMC). He coauthored the Disordered Eating section of the IOC MC’s Position Stand on the Female Athlete Triad, the NCAA Coaches Handbook: Managing the Female Athlete Triad, and Managing Student-Athletes’ Mental Health Issues for the NCAA. Dr. Thompson recently became a member of the NCAA Mental Health Task Force as the eating disorder representative on the committee. Dr. Thompson also assisted in the development of the Healthy Body Image Project for the 2010 Youth Olympic Games. His publications include the books Bulimia: A Guide for Family and Friends, Helping Athletes with Eating Disorders, The Exercise Balance, and Eating Disorders in Sport. He has presented lectures and workshops at more than 110 regional, national, and international meetings, including presentations at the United States Olympic Training Center, the Dutch Olympic Training Center, and the Swedish Sports Federation. Dr. Thompson is a Fellow in the Academy for Eating Disorders (AED), where he cofounded the AED’s Special Interest Group on Athletes. Dr. Thompson and colleague Dr. Roberta Sherman jointly received the AED’s 2008 Leadership Award for Clinical, Administrative, and Educational Service.