Primary prevention

In terms of prevention, the focus of attention should be on those risk factors most amenable to alteration, in particular, the pressure on athletes to manipulate eating behaviours and body weight in the belief that this will enhance performance and for them to appear thin. Prevention of extreme dieting and EDs, and the treatment of EDs can be organised into three categories. Primary prevention involves education and instruction designed to prevent the onset of extreme dieting and the development of EDs. Secondary prevention focuses on early identification of athletes who are at risk for DE/EDs and follow-up treatment, while tertiary prevention includes treatment of athletes with EDs. Since minimising risk is the aim of this article, treatment is not discussed here, but has been well described elsewhere.29

The goal of primary prevention should be to protect athletes from factors that can predispose them to the use of extreme dieting and or development of EDs. Since a high prevalence of adolescent elite athletes are using extreme dieting and meet the criteria for clinical ED,3 ,10 primary prevention should be initiated as early as 9–11 years of age.

Educating those involved with weight-sensitive sports

Healthcare professionals working with athletes who may be at risk of EDs should possess knowledge and understanding of the following matters.

• Have a firm understanding of the principles of normal growth and maturation, including sexual, skeletal, somatic and behavioural development occurring at this critical stage in the life cycle. This understanding should include the potential changes in self-perceptions and concerns for appearance, especially in aesthetic sports in which physical appearance may be part of the judging process, as well as how training and performance might be affected.

• Be aware of the challenges of the complex association between dieting, energy availability and nutrition, body composition and performance.

• Have good knowledge of the physical, psychological and behavioural symptoms/characteristics and consequences of extreme dieting and EDs (as are summarised in tables 1 and 2).

• Be qualified and experienced in the detection, diagnosis and treatment of DE and EDs.

While it is usually assumed that sport scientists, nutritionists and other healthcare providers have the knowledge and skill as well as established systematic pathways regarding the identification and approach of an athlete at risk for DE and EDs, this is not always the case.5 Even physicians and physical therapists lack this knowledge: studies show that only 48% of physicians and 43% of physiotherapists, respectively, report that they know how to identify athletes with one or more of the triad components.42 Therefore, educating healthcare providers about these issues is needed.

It may be tempting to equate performance with health. Coaches might not recognise that an athlete who is performing well is also exhibiting signs of EDs. Thus, coaches also require knowledge and practical skill related to at-risk athletes.

Athletic trainers and coaches require knowledge about

• how to optimise nutrition, body composition and performance;

• the principles of physical growth, biological maturation and behavioural development occurring at this critical stage in the life cycle;

• risk factors and consequences related to extreme dieting and EDs (eg, menstrual dysfunction for women, hormonal changes in men, growth and development);

• loss of tissue can cause disastrous performance setbacks;

• how psychological factors relate to health and athletic performance;

• dieting and weight issues should not be a theme from the coach, but should be presented according to the athlete's wish. In such cases, the coach should take the athlete's initiative seriously and refer to professional help. In this respect, the possibility of increasing weight and a change in the competition weight class should also be discussed with the athlete. For young growing athletes and lean adult athletes the focus should be on performance enhancement via non-dieting strategies, including improved nutrition, improved health, mental and psychological approaches and physical aspects;

• how to approach athletes with body composition and/or ED problems.

Athletes need knowledge about

• how to optimise energy and nutrient intake and combine this with optimal training;

• how eating behaviour relates to training, performance and body composition;

• health and performance consequences of extreme dieting, DE behaviour, menstrual dysfunction and low BMD;

• the notion that seeking help for a DE/ED behaviour is acceptable and that early intervention may help to prevent escalation of EDs and/or the female triad conditions;

• that weight loss does not necessarily lead to improved performance.

In summary, education is needed at all levels and we suggest that each federation of the different weight-sensitive sports should have sport-specific position statements with guidelines related to optimising nutrition and body composition. To reduce the risk of extreme dieting and EDs mandatory educational programmes for healthcare providers, athletes, coaches/athletic trainers and other athletics staff members should be implemented on an annual basis.

Guidelines for athletes in weight-sensitive sports who want/need to reduce weight or change body composition

Most athletes competing at a high level in weight-sensitive sports are fit and lean, but want to reduce weight to compete in a lower weight class or in the belief that a performance benefit will follow and consider this as ‘part of the game’. If the athlete is already lean and/or is under 18 years of age, the coach and healthcare team should motivate the athlete to improve strength and power and compete in a higher weight class. Athletes engaged in aesthetic sports know that extra fat will influence the judges’ score and a significant number of these athletes are chronic ‘dieters’ although they are still growing.17 Thus, athletes in weight-sensitive sports who seek to lose weight, change weight class or reduce fat mass, should be guided by healthcare professionals. Recent data by Sundgot-Borgen and Garthe2 indicate that a controlled weight-loss intervention in elite athletes does not increase the risk for DE or EDs when guided by a professional sport nutritionist. As for recommendations for weight loss/change in body composition, the authors agree with the recommendations suggested in the recent IOC position stand on nutrition.2 However, for the purpose of this article, the recommendations are slightly modified, as listed below:

• A thorough body composition assessment is necessary prior to intervention. Objective measurements of body mass and fat mass should be made by qualified individuals using recommended techniques as outlined in Ackland et al.1

• While prioritisation of weight-loss interventions during the off-season is recommended, this is not always practical or realistic. It is the responsibility of the healthcare provider to discuss the timing of weight loss with the coach if it is thought inappropriate. Furthermore, a carefully timed, and to some extent more conservative approach to weight loss may be necessary should it coincide with a period of intense training.

• While there are several effective approaches to support an athlete's weight loss, a ‘one size fits all’ approach is not supported. Choosing the most appropriate dietary assessment and intervention for an individual athlete is the responsibility of the sport nutritionist/dietitian who should take care not to harm the athlete or burden them with unnecessary recording of food intake.

• Any history or current status of menstrual function for female athletes, or other indicators of low BMD, such as stress fractures, warrant an objective measure of BMD using dual energy e-ray absorptiometry (DXA).

• A nutritional assessment should include blood and urinary markers of nutrient deficiencies. If blood tests indicate specific micronutrient issues (eg, iron, vitamin B₁₂ or vitamin D deficiencies) it is the responsibility of the sport nutritionist/dietitian to assist the athlete with appropriate dietary adjustments, safe and effective supplementation, and monitoring. A multivitamin/mineral supplement and ω-3 fatty acids may be provided during weight-loss interventions to assure sufficient micronutrient and essential fat intake.

• Female athletes should consume sufficient energy to avoid menstrual irregularities (>30–45 kcal/kg/day) and a gradual weight loss at approximately 0.5 kg/week is generally recommended.6 To induce a weight loss of 0.5 kg/week an energy deficit of about 500 kcal/day is needed, but there will be individual differences in how this is achieved. Depending on the training phase, this energy deficit is most likely induced by a combination of decreased energy intake and increased energy expenditure. However, if weight-loss attempts are made during intense training, then adding extra training for weight loss is not recommended. Smaller, perhaps intermittent, deficits are still possible but monitoring of performance, immune and psychological parameters is essential.

• Adjustment of nutritional intake should be made in cooperation with a sport nutritionist/dietitian. Throughout this process, the role of overall good nutrition practices in optimising performance should be emphasised. Daily meal plans should contain 1.5–2 g/kg of protein, at least 3–5 g/kg of carbohydrate and ≥15–20% of total energy intake from fat, although this regime depends on the sport (eg, endurance athletes need more carbohydrate). The focus should be on foods with a low energy density but high nutrient density to provide satiety. While variety ensures nutrient adequacy, some athletes prefer consistently similar meals, especially for breakfast and lunch. Thus, depending on the athlete, consistency and a frequent meal pattern are key, ensuring that the athlete is not fatigued during training. Recovery meals containing carbohydrates (approximately 1 g/kg) and protein (about 20–25 g or 0.25 g/kg) should be encouraged within 30 min after training sessions to optimise recovery, and these should include a variety of foods. To avoid extra energy by adding a recovery meal, it is recommended that the recovery meal is one of the planned meals for the day.

• To maintain muscle mass during phases of energy deficits, extra protein,43 possibly in combination with strength training, is recommended.44

• It has been suggested that the proportion of body fat should be no lower than 5% for men and 12% for women after weight loss.2 ,45 However, some athletes are better able than others to tolerate a low body fat without hormonal disturbances and/or other health and performance related impairments. A basic problem is the limited measurement accuracy obtainable using today's techniques.1

• Changes in body composition should be monitored on a regular basis including a period of at least 2 months after the weight or body fat goal has been reached to detect any continued or unwarranted losses or weight fluctuations. If a history of DE/ED is present, a more intense and longer follow-up is suggested. Weight-class athletes are encouraged not to be more than ∼3% over their competition weight and to lose no more than 2% in rapid precompetition weight loss (depending on time from weigh-in to competition and on recovery strategies).

• For some athletes, health and performance can benefit from a gain in lean body mass, even if it means they move up a weight class. The weight gain period should be controlled and stabilised after the athlete has reached his/her goal. If an increased lean mass is the goal, a modest positive energy balance combined with strength training may be the optimum strategy.

To minimise the threat to health and performance, many sports have adopted codes of practice for making weight. This is strongly encouraged as one of the most important prevention strategies for minimising the prevalence of and risks associated with ED.

Body composition assessment

Although it may seem simple to specify a minimum acceptable body fat content, the absence of a reliable method for body composition assessment precludes this option. Different measurements are available, but all come with their own assumptions and problems, and there is no universally accepted gold standard.1 Furthermore, responsibility for body composition measurements falls within different professional realms—which include the sports scientist, dietitian and clinician—in different situations. For example, asynchronous diurnal variation in stature and mass affects all measures, sufficient to alter body mass index (BMI) by 1 unit in a typical adult in a 24 h period, even in the absence of exercise-induced dehydration. Hydration status affects most measurements, so standardisation of hydration status is essential. DXA scans offer repeatable estimates of fat, lean and bone mineral masses, but results are specific to the manufacturer and software revisions and are not necessarily interchangeable. Software algorithms predicting fat and fat-free soft tissues may become unstable in highly muscular and very lean individuals. With appropriate operator training, fat patterning by anthropometry and ultrasound offers a promising approach and merits further investigation.1 ,46 ,47 For all approaches there is a need for quality-assured measures that take account of intratester and intertester error. Therefore, we recommend that skinfolds or DXA be used to monitor changes in body composition with interventions that seek to induce weight loss or change body composition.5 Although suggestions as to the optimal body fat content for various sports may be found in some textbooks, none of these are evidence based. Likewise, critical values for body fat and existing guidelines are also not evidence based, although 12% and 5% have been suggested as critical values for female and male athletes, respectively.2 ,48 Given the variability between individuals and the errors inherent in assessment of body fat content, it seems unlikely that a single critical value can ever be identified. Nonetheless, the values stated above may serve as a useful guide.

Regulations

The magnitude of impairment caused by acute weight-loss strategies seems to depend on the time from weigh-in to competition and recovery strategy used.49 Most athletes in Olympic weight-class sports have 2–3 h to recover from weigh-in.2 The weight-class system (few weight classes/categories that are separated by many kilograms) and the timing of weigh-in (a long time period from weigh-in to competition starts compared with only one weigh-in during tournaments) and procedure during competitive events may encourage athletes to use extreme weight-loss methods.2 To prevent athletes from striving towards unrealistic weight goals to perform well, the authors suggest modification of some regulations within different weight-sensitive sports. These modifications are related to weigh-in times, number of weight classes, use of BMI or other metric as a cut-off value for participation, and subjective judging. The suggested modifications should be discussed with the individual international federations. As can be seen in table 3, the number of weight classes differs from one competition to the other and the weigh-in time for some of the sports encourages the athletes to lose extreme amounts of weight.

Based on a review of the literature concerning rapid weight loss and EDs and on practical experience, the following modifications have been suggested by the group.

• A weigh-in time of not more than 2–3 h before competition should be implemented. In sports such as wrestling and taekwondo it will be more difficult for the competitors to rapidly lose a great amount of weight.

• Sports federations should have the same weight categories at national and international competition.

• More weight categories should be implemented, especially in the low-weight and middle-weight classes and, particularly, in the female weight classes.

• There should be a sufficient number of weight categories and all international and national competitions should use the same categories. Changing to a lower weight class during season should not be accepted. This could lead to less weight fluctuations and fewer occasions of weight fluctuation.

• Accepting some discretion in the weight allowance (eg, 1–2 kg overweight limit) during the season in smaller tournaments might reduce the frequency of weight loss.

• There is a need for a ‘competition certificate’ where athletes must have a minimum body mass and percentage of fat or sum of skinfolds measured at an agreed and appropriate hydration level. However, in this regard there is a need for research on how to apply the most valid and reliable methods for measuring percentage of fat and hydration status.5

In other sports, for example in ski jumping, the BMI is currently used in the regulations to counteract the low weight tendency. This was an important first step in ski jumping,50–,52 based on cooperative work of the International Federation of Skiing (FIS) with the IOC. However, further research and common discussions among experts from the fields of sports medicine, biomechanics/aerodynamics and from sports practice are necessary to develop the grounds on which regulations can be based to ensure effective protection of athletes’ health and that are designed to last for longer periods, consider fairness and practicability, and that are transparent for the audience. The cooperation between the FIS and the IOC concerning ski jumping can be seen as a role model for other sports in which changes to the regulations can be used as an effective tool for supporting the primary goal of the IOC medical code (ie, the protection of the athlete’s health), which is also the primary aim of all International Federation Medical Commissions.

In aesthetic sports, such as rhythmic gymnastics, synchronised swimming, figure skating and diving, there are no published articles on the ‘risks’ of judging in aesthetic sports. We know that judges comment on body type and are influenced by the perceived aesthetics of the performer. Athletes also report starting to diet due to judges’ comments after competitive events. A more objective judging system has been implemented in figure skating and this has been widely accepted. It is expected that this will de-emphasise the focus on leanness at least to some extent.

Secondary prevention

The main goals in secondary prevention should be to identify athletes better with extreme dieting and EDs, to introduce education and treatment, to limit the progression (of extreme dieting) and to reduce the severity and duration of EDs. It has been suggested that earlier treatment results in fewer health risks for the athlete and also an earlier return to training and competition.11

Measurement methods to identify DE include self-report, observation, symptom checklists and clinical interviews.4 Different screening instruments have been developed over time to make it easier to identify people at risk of developing EDs and to assist in diagnosis of these disorders.

Practitioners should proceed with caution when considering the use of self-report psychometric questionnaires such as the Eating Disorder Inventory, Eating Attitude Test and the Eating Disorder Examination Questionnaire to screen for behavioural and cognitive characteristics of DE in athletes.53–,55 Although the questionnaires have been widely used to screen athletes for DE, they have not been tested for external validity with athletic populations and, consequently, may result in inaccurate information.7 Therefore, there is a need for development and validation of the existing questionnaires and probably development of new sport-specific screening tools. Such tests must be reliable, sensitive, specific and acceptable to the screening population and subject to quality assurance. At present, a combination of standardised surveys and clinical interview is regarded as the optimum method to identify EDs among elite athletes,3 ,56 while true AN, BN and EDNOS in athletes can be diagnosed only through clinical interview.

Failure to meet all criteria for AN or BN should not deter the healthcare provider from offering early and comprehensive intervention, because early recognition and intervention with EDNOS can prevent athletes from developing AN or BN.11 Even in the absence of a clinical ED, restrictive and purging behaviours are of concern because they reduce energy availability. Histories of these behaviours are of interest because their effects on bone are cumulative. However, it is important not to overdiagnose in the highly motivated athlete whose controlled eating behaviour is part of a carefully regulated lifestyle for optimal performance.

Recognition of DE/EDs

It is important for healthcare teams and coaches to know that athletes usually mention problems related to extreme dieting or EDs only when asked directly or when they are extremely tired, when performance is levelling off, and when they are highly concerned for their health. Generally, the athlete may describe symptoms that do not necessarily point to an ED, such as headaches, constipation, diarrhoea, sleeping problems, breathing problems, dizziness, sadness or tiredness. Regardless of which complaints/symptoms are presented during the first consultation, the health professional should search for possible underlying causes. Questions about food intake, dieting methods and training should be straightforward and concrete (table 4). Since athletes with DE rarely self-identify due to secrecy, shame, denial and fear of the possible consequences,11 specific questionnaire items designed to assess DE behaviours and attitudes have been incorporated into the medical history portion of the preparticipation physical examination (PPE) to facilitate the detection process. Optimum screening times occur at the PPE and annual health check-ups. Other opportunities occur when athletes are evaluated for related problems, such as amenorrhoea, stress fractures or recurrent injury or illness.11 The decision to implement a compulsory periodic health evaluation must be taken by the International Federations.59 However, as advised in the IOC position stand (2005) if suspicions of DE are raised from interpretation of questionnaire results, an in-depth personal interview by a member of the healthcare team should follow for a more accurate interpretation of circumstances. Until valid screening instruments are available we suggest that when healthcare providers suspect DE or EDs, an Anthropometric, Biochemical, Clinical, Dietary and Environmental (ABCDE) Assessment be used to evaluate athletes (table 4).

As suggested in the ACSM female athlete position stand and IOC position stand, athletes considered to be ‘at risk’ should meet with a sports nutritionist/dietitian and those who are not able to improve their eating habits/behaviour should be referred to a clinician for further assessment of EDs.11 ,41 To assess energy availability, practitioners should assess training days (3–7 days) and include both prospective dietary records, possibly in conjunction with 24 h recalls and/or digital photography to increase validity. Exercise energy expenditure should be adjusted to energy expended at rest and daily activity, because energy availability is defined as the energy remaining after exercise energy expenditure has been subtracted from energy intake. This is especially critical when athletes train more than 1–2 h/day. Finally, if possible metabolic equivalent values should be confirmed by measures of oxygen consumption or other objective method. While daily activities vary among athletes depending on their level of competitiveness, assessments should include some measure of non-exercise adaptive thermogenesis (NEAT) or spontaneous physical activity (SPA) to evaluate the extent to which the resting component needs to be adjusted and to identify the extent to which athletes expend energy doing occupational tasks outside of organised exercise training. Unfortunately, assessing energy availability is difficult and may not be valid or reliable due to under-reporting of energy intake as well as over-reporting of exercise energy expenditure.

The evaluation of body composition should be conducted by a trained member of the support staff. As shown in table 4 it is important to ask questions related to nutrition, body image issues inside and outside the sports arena and weight control, and psychological status as well as assessing overall well-being to diagnose a possible ED.

In line with the ACSM female athlete triad position stand and the IOC position stand, we recommend that when one triad disorder is present (such as amenorrhoea), the healthcare provider should screen for other triad disorders (such as LEA and low BMD).11 ,41 We also agree on the recommendation regarding obtaining a DXA assessment in those female athletes with a cumulative total of 6 months or more of hypo-oestrogenism, DE or EDs, and/or a history of stress fractures or fractures from minimal trauma. The ACSM suggests re-evaluations recommended in 12 months in those with persistent triad disorders. For elite athletes we suggest re-evaluation after 6 months.

When to raise the alarm?

The last IOC position stand on the female triad states that ‘if the ED specialist recommends treatment, the athlete should be considered ‘injured’ and must agree to treatment in order to continue training and competition’,41 and ‘For those affected athletes who agree to treatment, eligibility to continue training and competition while symptomatic would be determined on an individual basis by treatment staff.’ At a minimum, the athlete would have to receive medical and psychological clearance, and would be required to follow a prescribed set of health maintenance criteria. These criteria would be determined on an individual basis, and would generally include, but not be limited to

• Complying with the treatment plan, and progressing towards therapeutic goals;

• Maintaining weight or achieving an appropriate level of body fat recommended by the treatment team;

• For female athletes, accepting/agreeing that resumption of menses or achieving menarche is needed for good health as well as a requirement for the continuation to participate in sport;

• Failing to meet the above criteria, the athlete would be withdrawn from training and competition;

• For those affected athletes who refuse treatment, training and competition would be withheld until they agree to participate in treatment.41

Thus, referring to the IOC position stand,41 in the case of extreme dieting and EDs the ‘eligibility to continue training and competition while symptomatic would be determined on an individual basis by the treatment staff’. Our group also suggests declaring athletes with DE or ED as ‘injured’ and agree with the recommendation from the former position stand. Based on the existing recommendations for how to handle female athletes with one or more of the triad components and on requests from team physicians, coaches and elite athletes, the Norwegian Olympic Training Center (Health Department) developed, published and has now practiced for a year more concrete criteria than those listed in the existing IOC position stand. These criteria were developed for female and male athletes. Based on the positive feedback from team physicians, coaches and athletes we suggest being more concrete when it comes to maintaining weight or percentage of body fat recommended by the treatment team. A modified version of the recommendations for raising alarm and ‘no start’ criteria that have been developed and used at the Norwegian Olympic Training Center is presented in table 5.59 It is recommended that support staff in other countries also follow these guidelines, or to use them as a starting point for further developing this difficult field of sports medicine.

As can be seen in table 5, we suggest a body fat cut-off value of 5% for men and 12% for women. As stated previously, this guideline requires verification using more robust studies, and its use in the meantime must acknowledge the scope for individual differences. Also, instead of saying the athlete ‘must agree that resumption of menses or achieving menarche’, the Norwegian recommendations suggest that adult and adolescent athletes with amenorrhoea for more than 6 and 3 months, respectively, are not allowed to compete if this symptom is combined with other symptoms of extreme dieting or EDs (table 5). As a result of their ‘ED injury’ the athlete's mental and physical health may be in serious jeopardy and continuing to compete may distract the athlete from devoting the attention needed for treatment.29 This is problematic and there is no evidence in terms of best practice regarding specific criteria for raising alarm or when to return to training and competition. The group, therefore, suggests applying the regulations from the Norwegian Olympic Committee until we have some evidence-based criteria.59 The examination, evaluation and decision regarding training and return to play must be based on picture total assessment of the athlete's health and the requirement in his/her sport. We also suggest that athletes who are not allowed to compete are evaluated after 4–6 weeks of suspension and new decisions are made based on the athlete's condition and behaviour.

Tertiary prevention

Treatment of an athlete with an ED should utilise a multidisciplinary intervention, which normally involves a physician, a gynaecologist, a sport nutritionist/dietitian, a physical therapist, an exercise scientist and in some cases, a psychiatrist or a psychologist. In addition, coaches and parents may be part of the treatment team if they have a positive relationship with the athlete. The younger the athlete, the more the involvement of the family is recommended. The primary goals of treatment should be to optimise energy availability, to control and manage the athlete's DE behaviour, to restore normal hormone levels and to monitor and treat other medical complications resulting from EDs.7 ,41 In terms of possible treatment initiatives for the athlete with DE behaviour and/or EDs, we refer to recent publications dealing with these issues.7 ,29 ,60

Education

Developing and implementing education programmes that challenge the definition of optimum body composition and promote self-acceptance, healthy eating and reasonable training and recovery in athletes have been expected to be effective in prevention.61 ,62 Randomised controlled trials (RCTs) aimed at preventing extreme dieting and the development of ED are lacking. However, a recent RCT that examined the effect of a 1-year school-based intervention programme on the development of new cases with ED, or symptoms associated with ED among adolescent elite athletes, was performed in Norway.19 First-year students (n=465, 93.8%) attending elite sport high schools (n=16) were randomised at the school level to intervention or control groups. There were no new cases of ED among girls in the intervention schools, while 13% at the control schools (p=0.001) at post-test 2 (1 year after the end of the intervention) had developed ED. The intervention showed a relative risk reduction of 90% for current dieting (OR 0.10, 0.02–0.54) and 53% reduction for repeated attempts at weight loss (≥3; OR 0.47, 0.25–0.90). Interestingly, among boys, there was no difference in the risk of reporting symptoms between groups at post-test 1 or 2. At post-test 2 there was only one new case of ED among the boys (belonged to a control school). Results from this study show that it is possible to prevent the development of new cases of ED and symptoms associated with ED in female elite athletes.19 However, more studies are needed, and intervention programmes need to be sport and gender specific. Furthermore, new education programmes/strategies should be evaluated routinely to determine their effectiveness with respect to changing knowledge, attitudes and behaviours.

Modification of regulation

The suggested modifications are based on the results from policies and procedures by governing bodies of US men's collegiate wrestling in the late 1990s that seem to have been effective in reducing unhealthy weight-loss behaviours and promoting competitive equity.63 Also, a call has gone out for the International Judo Federation (IFJ) to implement regulations to improve weight management behaviours among judo athletes, and for these regulations to be adapted by all national and regional federations.20 In contrast, the FIS employed a different strategy for preventing extreme dieting among ski jumpers.64 Instead of policing athlete behaviours, the FIS removed the motivation for ski jumpers to pursue extreme weight-loss objectives by penalising athletes when their BMI fell below a specific value. Finally, the suggested regulations are based on years of experience with elite athletes representing leanness sports. We have suggested that more objective judging should be implemented in the aesthetic sports. The removal of the overall impression score now adopted in figure skating is expected to de-emphasise the focus on leanness and that modification of some of the regulations in weight-class sports will reduce the number of athletes practicing extreme dieting and, therefore, the number of athletes at risk for developing EDs. However, problems persist despite new rules and regulations. New regulations should be carefully considered, and hypothetically tested and discussed among expert groups to evaluate their possible impact. The data from ski jumping shows that extreme approaches have probably been resolved but there are lingering issues.

Raising alarm and ‘no start’ criteria

To develop evidence-based criteria within this field is almost impossible and it is, therefore, the group's suggestion that the alarm and no start criteria developed and practiced by the Norwegian Olympic Training Center are applied in weight-sensitive sports.59