Table 5

Criteria for raising alarm and ‘no start’ decisions

Alarm criteria
 Women with a BMI below 18.5 and/or body fat percentage below 12% and primary or secondary amenorrhoea
Men with a BMI below 18.5 and/or body fat percentage below 5% and low testosterone
The BMI is widely used as a measure for ‘relative body weight’ and well known, but it should always be complemented by sitting height (s) measurement and determination of the Comic Index (C=s/h) by which the MI can be calculated, which considers individual leg length. In this case percentage of fat refers to DXA results. A problem not solved today is sufficient accuracy of field methods for fat determination. It has to be considered that accuracy of currently available field methods for total body fat determination is not sufficient and that also laboratory methods have limited accuracy1
 Amenorrhoea ≥6 months (>3 months for athletes younger than 18 years)When amenorrhoea is related to restrain eating or low energy availability over time. Athletes using birth control pills, with regular cycles and values below 12% should also be considered ‘alarm criteria’
 Reduced BMD (either from last measurement or Z-score ≤−1)Use BMD values from L2–L4 scans
 Athletes with physical complications based on the medical assessmentComplications such as, electrolyte imbalance, fatigue, stress fracture should be assessed as a possible expression of low energy availability over time
 Uncooperative athletes or those showing a lack of progress in treatment
 Athletes having a negative effect on other team members (dieting behaviour, bingeing and purging and instable mood)Athletes who exhibit behaviours such as restrictive eating, maintenance of low weight, and excessive focus on matters pertaining to weight and food
 Athletes unable to maintain a positive energy balance over time, no responsiveness to training, or showing fatigue and intolerance
No start criteria
 Athletes of both sexes who meet the criteria for anorexia nervosa or severe other eating disorders such as bulimia nervosa with frequent vomiting and with electrolyte disturbancesA ban in this case is justified both by explicit consideration of the athlete's overall health, and of the more overarching goal of a sport founded on sound values and principles
 Athletes with serious physical complications of weight loss/lack of energy availability, such as cardiac dysrhythmias, major oedema (swelling) in the body or fainting
 At least three of the criteria described above as ‘alarm criteria’
  • BMI, body mass index; BMD, bone mineral density; DXA, dual energy e-ray absorptiometry; MI, mass index.