The Active Female: Health Issues Throughout the Lifespan 2008th Edition

13. Screening for Disordered Eating and Eating Disorders in Female Athletes

Jennifer J. Mitchell  and Jacalyn J. Robert-McComb 


Department of Family and Community Medicine, Texas Tech University Health Sciences Center School of Medicine, 3601 4th Street, MS8143, Lubbock, TX 79430, USA


Department of Health, Exercise, and Sports Sciences, Texas Tech University, 3204 Main Street, Lubbock, TX 79409, USA

Jennifer J. Mitchell (Corresponding author)


Jacalyn J. Robert-McComb



Low energy availability appears to be the key etiologic abnormality central to the pathologies seen in the Female Athlete Triad. The energy deficit comes from either increased exertion or inadequate intake of nutrition, either through disordered eating (inadvertent or purposeful) or one of the pathologic eating disorders. It is important to educate female athletes about this concerning scenario as early intervention can limit morbidity and mortality from it. It is important for those interacting with female athletes, both recreational and competitive, to screen for disordered eating/eating disorders (DE/ED) which could lead to low energy availability. With proper education, screening can be done informally by virtually anyone who interacts with female athletes. In the formal setting, question-based tools are available to facilitate the process. Several of these tools are discussed in this chapter. Any athlete who screens positively for possible DE/ED should be referred to a physician and/or mental health provider for further evaluation.


Low energy availabilityFemale athlete triadMenstrual disordersEating disordersScreening female athletes for the triad of disorders

13.1 Learning Objectives

Upon completion of reading this chapter, the reader will be able to:

·               Understand how disordered eating and eating disorders impact energy availability and health in the female athlete.

·               Become aware of the estimated prevalence of disordered eating and eating disorders in female athletes.

·               List some of the sport-related and nonsport-related risk factors for disordered eating and eating disorders.

·               Understand reasons for and methods of screening for disordered eating and eating disorders in the female athlete in both informal and formal settings.

·               Become aware of screening tools that are utilized for disordered eating and eating disorders in general and specifically in athletes.

13.2 Introduction

There is no clearly defined standard of methods or timing for screening female athletes for disordered eating (DE) or eating disorders (ED). Several screening tools are available, but no consensus exists yet concerning the optimal tool for use with athletes. Various opportunities present themselves for screening athletes for disordered eating/eating disorders (DE/ED), but no single time has proven most advantageous. Screening may be performed in various ways, but it is optimal to gather as many objective pieces of evidence as possible, since denial by the athlete is often a large component of DE/ED. Ultimately, ideal screening is specific to each athletic level and entity, whether recreational or competitive. This chapter discusses various methods and timing of screening female athletes for disordered eating and eating disorders.

13.3 Research Findings

13.3.1 Energy Availability Related to Disordered Eating and Eating Disorders

The American College of Sports Medicine Position Stand on the Female Athlete Triad describes the interrelationships between energy availability, menstrual function, and bone mineral density. For each of these three areas, each athlete may be described along a continuous spectrum between health and disease. At the disease end of the spectrum lie eating disorders, functional hypothalamic amenorrhea, and osteoporosis. Low energy availability appears to impair both reproductive and skeletal health. These pathological conditions typically exist subclinically until a pathological event manifests [1]. An athlete may be at various points along the three spectra between health and disease and typically will not manifest all three disorders at the same time [2].

Low energy availability may occur from disordered eating (DE) or a true eating disorder (ED). Disordered eating encompasses various abnormal eating behaviors that are inadvertent, such as inadequate refueling, or they may be intentional. An eating disorder is a clinical mental disorder meeting diagnostic criteria as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Eating disorders include anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified [3]. Binge-eating disorder will be included as a separate eating disorder in the DSM-V to be published in mid-2013.

Energy availability is the energy remaining for body functions after that used for exercise is subtracted from total energy intake. Continuous low energy availability with or without disordered eating can impair health. Ways an athlete’s available energy may be reduced include: increased energy expenditure with excessive exercise, reduction of energy intake, abnormal eating behaviors such as binging and purging or use of laxatives or diuretics, or eating disorders which are often accompanied by other psychiatric illnesses [1].

13.3.2 Prevalence of Disordered Eating/Eating Disorders in Athletes

It is difficult to know the exact prevalence of DE/ED in female athletes as the majority of studies have various flaws including the use of nonstandard diagnostic procedures, small sample sizes, lack of or inadequate control group(s), inadequate statistics, and/or heterogeneous athlete population [14].

There have only been two, well-controlled studies utilizing DSM-IV criteria for diagnosis of EDs. These were conducted with elite athletes and demonstrated 31 % prevalence in athletes compared to 5.5 % in the control population for the first study and 25 vs. 9 % in the second study. Other studies have shown secondary amenorrhea to be as high as 69 % in dancers and 65 % in long distance runners versus 2–5 % in the general population [1].

The first study to look at the combined prevalence of disordered eating, menstrual dysfunction, and low bone mineral density in college females, demonstrated that the number of athletes suffering from all three disorders of the triad was small (1–3 athletes out of 112). However, a significant number suffer from the individual disorders of the female athlete triad [2].

A more recent systematic review of 65 studies evaluating the prevalence of the individual and combined components of the triad verified that initial study. It showed a relatively small percentage of athletes (0–15.9 %) exhibited all three components of the triad. The prevalence of any two triad conditions ranged from 2.7 to 27 %. The prevalence of any one condition was highest, from 16 to 60 %. The recommendation from that review is that additional research on the prevalence of the triad using objective and/or self-report/field measures is necessary to more accurately describe the extent of the problem [5].

13.3.3 Risk Factors for Disordered Eating/Eating Disorders

There are multiple risk factors, which predispose an athlete to DE or ED. This list includes four major groups of factors as in Table 13.1.

Table 13.1

Risk factors for disordered eating/eating disorders [16]

I. Nonsport-related factors

A. Biological factors

1. Pubertal status

2. Pubertal timing

3. Body mass index

B. Psychosocial factors

1. Body image dissatisfaction

2. Mood disorders

3. Low self-esteem

4. Perfectionism

5. Family dysfunction

C. Sociocultural factors

1. Perceived pressure to conform to an unrealistic standard of thinness

II. Sport-specific factors

A. Sports that emphasize

1. Appearance

2. Thin body build

3. Low body weight

B. Sports that require weight classifications

C. Early sport-specific training

Further evaluation of the sport-specific factors seems warranted given conflicting data. Studies in 2002 (Byrne and Mc Lean) and 2006 (Sundgot-Borgen and Torstveit) indicate that EDs are more likely to occur in athletes in leanness sports such as gymnastics, cross country and figure skating compared with athletes in non-leanness sports and controls. This was again verified in 2008 by Torstveit, Rosenvinge, and Sundgot-Borgen in a study with 186 athletes compared to 145 controls. EDs were more common in athletes in leanness sports (46.7 %) compared to non-leanness sports (19.8 %) and controls (21.4 %) [7]. Beals provides evidence to question the long held belief that EDs are more common in athletes in leanness sports in the small study of 112 athletes mentioned above. She specifically notes that the percentages of individuals with DE and bone mineral density disorders, individually or in combination, were similar between lean build and non-lean build sports. The implication from this is that all female athletes, regardless of sport, should be screened for components of the female athlete triad and intervention should begin early to prevent development of the full triad [28].

In any event, avoiding external pressure on the athlete to lose weight is essential to avert preoccupation with dieting as it is considered to be the number one trigger for EDs [16].

13.3.4 Screening for Disordered Eating/Eating Disorders

In the last 5 years, two position stances from major sports medicine associations have been developed that address screening athletes for DE/ED, yet still no clear standard exists as to the optimal method and tool for screening [16]. Screening can occur at a common entry point to athletic participation such as during pre-participation physical examinations (PPEs), but should also be an ongoing process throughout the span of an athlete’s participation. This ongoing process is particularly applicable to recreational athletes who participate in exercise clubs, individual activities, and “weekend warrior” activities. The screening process should be viewed as a two-step process [910]. Once an athlete screens positively or if a concern exists, the athlete should be referred for further medical and psychological or psychiatric evaluation. Reasons to Screen

The hope behind screening is to identify athletes who likely have significant levels of eating pathology and require further assessment. Screening can be a complex and challenging task, but the sports medicine team must keep in mind the reasons why screening is important. These include [1611]:

·  Prevention of DE/ED; the most effective way to decrease the incidence of eating disorders is to prevent them.

·  Early intervention when DE/ED exists to minimize impacts on health and performance; the longer an ED is allowed to persist and progress without treatment, the greater the health and performance detriments.

·  Athletes tend to deny or do not realize a problem exists.

·  Athletes are unlikely to come forward on their own, so complications from low energy availability can go unrecognized until a major event such as a stress fracture occurs. There are several reasons why the athlete may not come forward including guilt, shame, fear of losing a scholarship, or fear of losing playing time [6]. Screening Practices

With no clearly defined standard for screening athletes for DE/ED, practices fall across a wide spectrum that includes: no specific screening, a few general questions at the time of PPE, utilization of a self-report questionnaire screening tool (SRQST) at PPEs, or the use of a SRQST combined with an interview by a trained mental health provider.

A 2012 study evaluated PPE forms utilized at 257/347 NCAA Division I universities for efficacy in screening for the female athlete triad. It compared those forms to the 12 items recommended by the Female Athlete Triad Coalition for screening females for the triad [12]. Only 25 universities (9 %) had nine or more of the 12 recommended items on their forms [13].

Another study has shown that only 60 % of Division I schools, which responded to the study, screened for eating disorders during PPEs. Of those that did screen, <6 % used a standardized self-report questionnaire [14].

Because the goal of the PPE is to facilitate optimal performance for athletes while ensuring the best possible health for the athlete both today and in her future, it has been suggested to implement a separate supplemental health questionnaire specific to female athletes. It is felt that this method would allow health care providers to narrow in on female-specific issues. It might be implemented before, during, or shortly after PPEs on campus [15].

An interesting innovation in screening female athletes for DE/ED is the physiologic screening test consisting of 18 items (4 measurements and 14 questions). It has been validated and has the potential to be combined with one of the athlete-specific questionnaires (see Table 13.4) to create a two-step screening process in an attempt to minimize false positives and false negatives prior to psychological referral [8]. Functionality of Screening Tools

What makes a screening tool useful is functionality as well as validity. SRQSTs seem more functional than interviewer applied tools. However, they are subject to report bias, as athletes tend to be not as forthright with these as in a one-on-one interview [216]. The interview tools are more appropriate for an in-depth evaluation, in search of a specific diagnosis, but they are time intensive and require education on the part of the interviewer. They are most useful as the second step in evaluation, once an initial screening tool is positive or when there is reason to suspect DE/ED in an athlete [10].

In the athletic arena, time is frequently an issue. It is essential for a screening tool to be focused and time limited. Formal screening tools are ideally brief, self-report questionnaires with simple cut-off scores that indicate a level of dysfunction concerning for pathology in the athlete [16].

One must be assured that the tool utilized, when interpreted as positive, truly indicates an issue for which further evaluation and time requirements will be needed.

Once a screening tool is positive, the athlete should then have a more formal evaluation to determine whether true pathology exists or risk factors for pathology are present. This includes a detailed medical, nutritional, and reproductive history and physical examination with lab evaluation by a physician and referral to a psychologist or psychiatrist [1217]. The ideal tool for further evaluation is a structured interview. Eating disorders exam (EDE) has been identified as the gold-standard tool for identification of eating disorders in general [81618]. During the one-on-one interview, the athlete must feel secure and not threatened [6].

In organized sports, the PPE is a common entry point for evaluation of athletes. Screening at that time is of utmost importance, but it is not the only opportunity to diagnose DE/ED. Screening female athletes for DE/ED needs to by a dynamic, ongoing process, throughout the span of recreational and competitive activity. It should not occur in a vacuum, only at the time of a PPE.

Recreational athletes can also fall into low energy availability from DE/ED. A less formal approach to screening may be applicable in their case.

13.3.5 Screening Settings

Screening for disordered eating or eating disorders (DE/ED) in athletes occurs in both informal settings, mostly by observation and interaction with athletic trainers and coaches, and formal settings, typically with a team physician or primary care provider or when referred to a psychologist or psychiatrist. Informal Settings

The informal setting occurs in the athlete’s day-to-day routine while interacting with athletic trainers, coaches, administrators, teammates, teachers, family, and friends. For recreational athletes, informal screening may occur with personal trainers, group exercise leaders, and gym personnel. The ideal is for all individuals interacting with athletes to be educated on recognizing concerning patterns of behavior and exercise (nutrition issues, over-exercising, etc.). Once educated on what to look for, he/she can feel empowered to approach the athlete in an effort to assist her. Written policies on dealing with suspected eating disorders are recommended and adequate resources to assist the athlete are ideal [1920].

Each individual interacting with the athlete has the opportunity to informally screen the athlete for DE/ED. Whether they actually do, often depends upon their level of education and whether they are alert to a potential issue with the athlete [621].

Direct questioning can be utilized, however the nature of eating disorders tends to be secretive. It is likely that the individual will not readily disclose the embarrassing symptoms of an eating disorder, such as vomiting or laxative use. The intensity of questioning has to be balanced between the relationship of the athlete with the person probing and the athlete’s readiness to disclose her illness. Thus, the allied health professional sometimes must read between the lines and look for physical and behavioral characteristics that may signify an eating disorder.

·               Some physical findings include [161722]:

·               Poor exercise tolerance including dehydration, cramping, pre-syncope, and bradycardia

·               Hair, skin, or teeth changes including lanugo, alopecia, dry skin, callouses on hands and/or loss of tooth enamel from induction of vomiting

·               Gastrointestinal upset including bloating, diarrhea or constipation, abdominal discomfort

·               Complaints of menstrual irregularities

·               Once the athlete’s trust is gained, a variety of questions can be utilized to attempt to further delineate behavioral characteristics.

·               Areas to be explored include [161722]:

·               Eating behaviors such as binging, purging, eating in secret, recurrent dieting

·               A history of or current mood disorder to include sadness, depression, or anger

·               Use of extreme weight control measures to include starvation, use of diuretics, use of laxatives, use of saunas

People close to the athlete often contribute barriers to recognition of the issue. This is often inadvertent, but can also be intentional.

These barriers include [11]:





In order to minimize barriers, it is critical to maintain an environment that promotes the clear expectation that DE/ED will be addressed with the intent to promote optimal health and performance for the entire team. This may minimize the concern for a “telltale” environment.

It is a responsibility of those who are close to the athlete to help recognize DE/ED and initiate further evaluation and assistance [11]. Once it is recognized that assistance is needed, screening becomes formalized in the clinical setting with the team physician or primary care provider. Formal Settings

The formal, structured setting occurs during pre-participation examinations and in the clinical setting. In the formal setting, SRQSTs are best utilized. A questionnaire tool is especially helpful as it can be difficult for the provider to remember the myriad of questions recommended for picking up on subtleties in order to discover DE or recognize an athlete attempting to hide an ED.

13.3.6 Pre-participation Examinations

The main benefit of screening during PPEs is that medical personnel are able to quickly review the responses to the tool utilized, and potentially, they can immediately refer the athlete who screens positively. All new athletes are required to have a PPE, so all would be screened, at least, in this format. The disadvantage of screenings during PPEs is that they often occur in a station-centered setting, such as in an athletic training room. This provides minimal privacy and confidentiality in completion of questionnaires and in further discussions with the individual athlete. Although, in order to enhance confidentiality and improve efficiency, some universities are shifting to having athletes complete health histories either before arrival on campus or on web-based sites [23]. As technology and the patient-centered medical home (PCMH) advance, a web-based data center in an electronic health record may become the standard. The PCMH promotes organizing care around patients, working in teams, and coordinating and tracking care over time [24].

Another negative aspect of screening at PPEs is that there are typically multiple other forms to complete. The athlete may then rush through the DE/ED screening tool, not taking the time to answer accurately [1113].

Female athletes often feel uncomfortable discussing disordered eating during PPEs and are more likely to withhold information [11]. This is another reason why screening females with a supplemental form within the first few weeks of arrival on campus may be a better method.

An additional concern arises in settings where PPEs are only required at entry and not yearly. In a study of NCAA Division I universities, of the 257 (74 %) schools that participated, only 32 % require an annual PPE. In this case, if the athlete develops risk factors for DE/ED after her freshman year PPE, it may go undetected until a significant health event occurs, if at all [13].

13.3.7 Clinical Encounters

The other formal setting where the female athlete may be encountered is in the clinical setting when presenting for routine health care or for an acute illness or injury. The clinician then has the opportunity to screen for components of the female athlete triad, including those that set the athlete up for low energy availability (DE/ED). A full medical, reproductive, and skeletal health history should be taken as well as an appropriate physical examination looking for classic signs of eating disorders [1217].

Questions to be asked during the history should also include nutrition questions incorporating weight and dieting history, current exercise regimen looking for any recent changes in intensity or amount, and mood-related questions.

Physical complaints and findings such as amenorrhea, gastrointestinal disturbances, low body mass index, bradycardia, orthostatic hypotension, skin changes, and laboratory studies can help diagnose an eating disorder [25]. However, during the early course of an eating disorder, physical examination, and laboratory findings may be normal.

Again, there are time constraints in the clinical setting and the provider is likely to focus specifically on the illness, injury, or well woman examination at hand and not expand the history to include elements important in identifying ED/DE and female athlete triad disorders. Health providers (athletic trainers, team physicians, sports medicine fellows, physician assistants, nurse practitioners) working with female athletes need to remember to focus on their medical roots to complete an entire history and physical examination looking for symptoms and signs of DE/ED and female athlete triad disorders.

13.3.8 Tools

There are multiple screening tools for disordered eating and eating disorders in the literature. Some are specific to athletes, while others are general nutritional DE/ED screening tools. Most of the general tools are validated, but few of the tools specific to athletes have been validated in female athletic populations [111].

A screening tool may save time obtaining the athlete’s history either before or as a part of a PPE or in the setting of a clinical visit with the physician. Questions may be incorporated into the PPE form or a supplemental screening tool may be utilized. The American College of Sports Medicine Position Stand on the Female Athlete Triad and the National Athletic Trainers’ Association Position Statement on Preventing, Detecting and Managing Disordered Eating in Athletes make the recommendation for screening during PPEs, but provide no guidance on any particular tool [16]. It is generally felt that a supplemental tool directed specifically at female athletes may ultimately be the recommended ideal.

The SRQST is utilized as a first step. These tools are not designed to diagnose an eating disorder so athletes who screen positively, should then be further evaluated by a physician for medical evaluation and referred to a psychologist or psychiatrist. During that visit it is likely that one or more interview-based tools will be utilized to determine if the diagnosis of an eating disorder is appropriate.

13.3.9 General Screening Tools for Disordered Eating/Eating Disorders, Nonathlete Specific (Table 13.2)

Table 13.2

General screening tools for disordered eating/eating disorders, not athlete specific



Key points


EAT-26 [1016]

1982 revised from original EAT-40, 1979

Most widely used standardized self-report measure of symptoms and concerns characteristic of EDs specifically

Score of 20 or more—interview by a qualified professional to evaluate for diagnostic criteria for ED; concurrent validity; good discriminate validity ChEAT-children’s version

Web-based; easily accessible; free

SCOFF questionnaire [2627]


5 questions; 1–2 min to complete

Two or more + responses, 100 % sensitivity

Eating disorders exam-questionnaire (EDE-Q) [2730]


Self-completed, question form of EDE

Yes; criterion validity

Widely used measure of eating disordered behavior

36 items; 15 min to complete

Overestimates binge-eating frequency compared to EDE

Eating disorder invenory-3 (EDI-3) [93133]


Developed from EDI (1983) and EDI-2 (1991)

Clausen validating in 2011 EDI-C children’s version

91 questions; 12 subscales; 6 composite scores

20 min to complete

Cost associated

Eating disorder screen for primary care (ESP) [34]


4 questions; 1–2 min to complete

As effective as SCOFF

Bulimia test-revised BULIT-R [1635]

Revised 1991

Bulimia nervosa screening; 28 question

Content construct criteria

NEDA screening program [36]

Yearly, March

Evaluates resources of colleges and universities; online screen for students


Self-report questionnaire screening tools; not used to diagnose ed’s

First step in a two stage process Self-Report Questionnaire Screening Tools


This is the most widely used standardized self-report measure of symptoms and concerns characteristic of eating disorders specifically. It has three subscales: dieting, bulimia and food preoccupation, and oral control. EAT-26 is a refinement of the original EAT-40 that was first published in 1979. This tool is easily accessible as it is web-based and free. Scoring instructions are included on the website. It can be administered in group or individual settings and does not have to be administered by a mental health or medical professional. A score of 20 or more should prompt referral for interview by a qualified professional to determine whether diagnostic criteria for an ED exist. It is valid and reliable. Ch-EAT is the version used in children [10].

SCOFF Questionnaire

This was developed in 1999 in Great Britain as a quick and easy to remember screening tool for clinicians. The use of a mnemonic with yes/no responses, similar to the CAGE questions for alcoholism, is intended to simplify screening. There are five questions, which take between 1 and 2 min to administer. In the original study, two or more positive answers provided 100 % sensitivity [26]. One question is written in Queen’s English referring to weight in stones. An “Americanized” version, with the value in pounds, was developed for use in research comparing SCOFF to another screening tool [27].

Eating Disorders Exam-Questionnaire (EDE-Q)

This tool was devised in 1994 and is a self-completed questionnaire form of the EDE, which is an interview-based tool administered by a qualified professional to diagnose eating disorders. It is a widely used measure of eating disordered behavior. The tool consists of 36 items and takes about 15 min to complete. It focuses on the past 28 days and is scored using a 7-point scale. The four subscales included are restraint, eating concern, weight concern, and shape concern. It has good criterion validity. Compared to the EDE, it does tend to overestimate binge-eating frequency [2730].

Eating Disorder Inventory-3 (EDI-3)

This was developed in 2004 as an expansion and improvement upon Eating Disorder Inventory-2 (EDI-2) from 1991 and the original EDI in 1983. At the time, EDI-2 was already recognized as a standard self-report measure for ED assessment in the international health care community. EDI-3 evaluates for psychological traits and symptoms relevant to the development and maintenance of anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified. It consists of 91 items broken into 12 subscales (broken down into ED risk scales versus psychological scales) and provides 6 composite scores. On average, it takes about 20 min to complete. This tool can be accessed through the Internet, but there is a cost associated. EDI-C is available for use with children [93133].

Eating Disorder Screen for Primary Care (ESP)

This was developed in 2003 in Great Britain in an attempt to generate a short screening tool that could both rule in and rule out EDs. It consists of four questions and takes 1–2 min to complete. It is not validated. One study compared it directly to SCOFF and it was found to be equally effective [34].

Bulimia Test-Revised (BULIT-R)

This is a 28-question tool that is easy to score and is well validated. It is a revision from the original BULIT. This instrument has been shown to be a reliable and valid measure for identifying individuals who may suffer from bulimia nervosa both in clinical and nonclinical populations [1635].

National Eating Disorders Association (NEDA) Screening Program

This is an online eating disorder screening. There are two separate questionnaires; one for college students and one for the general population. It provides a free, anonymous self-assessment to gauge one’s risk of an eating disorder. It takes only a few minutes and consists of a series of questions designed to indicate whether clinical help may be needed. After completing a screening, if indicated, participants will receive referral information through NEDA’s Helpline for personal evaluation by a medical professional and treatment. This is considered a good resource for people who may need help or know someone who may need help and don’t know where to begin. NEDA also provides the annual Collegiate Survey Project, each year in March. This is a compilation of responses from 165 colleges and universities concerning on-campus resources for eating disorder-related programs [36]. Interview-Based Tools

The clinical interview is the assessment tool of choice when diagnosing eating disorders as it allows for more detailed questioning. It is part of the second step in evaluation when a screening tool is positive (Table 13.3) [16].

Table 13.3

Interview-based tools—administered by qualified professional; second stage after screening



Key points


Eating disorders exam (EDE) [162829]

1987 revised 1993

Interview-based, semi-structured interview


Gold standard of eating disorder assessment, specifically AN and BN

Good criterion validity

28 day time frame, prior 4 weeks

Questionable construct validity

62 items; 2 behavioral indices; 4 subscales

Not in athletic population

30–60 min to administer


Interview for diagnosis of eating disorders (IDED)-IV [916]

1990 revised 1998

Semi-structured interview

Not in athletic population

Specifically for diagnosing EDs, not DE; based on DSM-IV criteria

Good reliability and validity

AN Anorexia nervosa, BN Bulimia nervosa

Eating Disorders Exam (EDE)

This semi-structured interview is recognized as the method of choice for diagnosing eating disorders, specifically anorexia nervosa and bulimia nervosa. It was developed in 1987 and revised in 1993. The interviewer, not the subject, rates the severity of symptoms. It focuses on a 28-day time frame over the previous weeks. There are 62 items and it can take over an hour to administer. There are two behavioral indices (overeating and methods of extreme weight control) and four subscales (restraint, eating concern, shape concern, and weight concern). Administration is by a clinician with specific training in the use of this interview [162829].

Interview for Diagnosis of Eating Disorders (IDED)-IV

This semi-structured interview was revised in 1998, after the original in 1990, for the purpose of discriminating between eating disorders and subthreshold syndromes, which it does. It has good reliability and validity. The rater uses severity scales on a diagnostic checklist that leads directly to the differential diagnosis using DSM-IV criteria. It is a reasonable alternative to EDE [916].

If a generalized screening tool will be used, EAT-26 or EDE-Q are the most widely used self-report questionnaires. When time and resources are available or an athlete screens positively, the interview-based EDE is an ideal. Self-Report Questionnaire Screening Tools, Athlete Specific (Table 13.4)

Table 13.4

Self-report questionnaire screening tools, female athlete specific



Key points


Female athlete Screening tool FAST [37]


33 questions


To identify DE and atypical exercise and eating behaviors

Internal reliability; concurrent validity to EDI and BULIT-R

Health, weight, dieting, and menstrual history questionnaire HWDMHQ [2]

2002 updated 2006

First study to assess combined prevalence of all three components of female athlete triad


Developed from:

EDI symptom checklist


Physiologic screening test (PST) [8]


18 items:


Four Physiologic measurements

14 Questions

15 min to complete

Validated; better than EDI-2 and BULIT-R

Female athlete triad coalition screening questionnaire [12]


Internet accessible


12 questions: nutrition, 8; menses, 3; bone health, 1

If positive, follow by in-depth evaluation with detailed

history of 19 questions and full medical evaluation

Athletic milieu direct questionnaire AMDQ [91038]


19 questions


Designed to assess DE/ED

Compared to EDI-2 and BULIT-R, superior results on 7 of 9

epidemiologic analyses

First instrument to operationalize the construct of DE

Not validated in a clinical population



Female athletes at three division I universities


6 subscales from EDI, modified to athletes

Developed to assess psychological predictors of disordered

eating in female athletes

Construct validity confirmed by convergent and discriminate validity

There are a limited number of tools, which have been designed specifically for female athletes. Some of the tools available screen both athletes and college students whether female or male. Another method of screening is through questions incorporated into a PPE form. In those, typically any nutrition questions will be directed at females and males. The following section of the form then has questions specific to females. Unless this is clearly delineated, this can be confusing for the athletes during completion of their history.

Female Athlete Screening Tool (FAST)

This tool was developed in 2001 to identify disordered eating and atypical exercise and eating behaviors among female athletes. It has 33 questions. It has internal reliability and concurrent validity to EDI and BULIT-R [37].

Health, Weight, Dieting, and Menstrual History Questionnaire (HWDMHQ)

This was the first study to assess the combined prevalence of all three components of the female athlete triad. The study showed that very few athletes demonstrate all three components, but a significant number suffer from the individual disorders of the triad. It was developed from the EDI symptom checklist and EDE-Q in 2002 and revised in 2006 [2].

Physiologic Screening Test

This tool was developed in 2003 to provide a physiologic screening test, specifically for collegiate female athletes competing at a high level, in order to detect DE/ED. It takes 15 min to complete and consists of 18 items: 14 questions and 4 physiologic measurements (percent body fat, waist:hip ratio, standing diastolic blood pressure, enlarged parotid glands). It outperformed the EDI-2 and BULIT-R on the false-negative rate, negative predictive value, yield, overall accuracy, and validity [8].

Female Athlete Triad Screening Questionnaire

This is a questionnaire available, free of charge, on the Internet. The Female Athlete Triad Coalition is sponsored by several sports medicine organizations and has existed since 2002.

The initial screen has 12 questions: nutrition, 8; menses, 3; bone health, 1.

If positive, an in-depth evaluation with a detailed history of 19 questions and a full medical evaluation are recommended [12].

Athletic Milieu Direct Questionnaire (AMDQ)

This was designed in 2000 to assess DE/ED in female athletes. It is the first instrument to operationalize the construct of DE. It consists of 19 questions evaluating behaviors relevant to weight management, diet, and exercise. It has not been clinically validated, but compared to EDI-2 and BULIT-R it has superior results on seven of the nine epidemiologic analyses [91038].


This tool was developed in 2005 to be administered to female athletes at three Division 1 universities. It is used to recognize psychological predictors of DE. There are six subscales from EDI, which were modified to athletes [39]. Non-gender-Specific Eating Disorder Tools (Table 13.5)

Table 13.5

Self-report questionnaire screening tools, athlete specific



Key points


College health-related information survey CHRIS [40]


College student athletes

F, M

Based on juvenile wellness and health survey (JWHS)

32 questions broken into four areas: mental health, 9; eating problems, 13; risk behaviors, 4; performance pressure, 6

Needs further validation

Survey of eating disorders among athletes SEDA [41]


33 questions; self-reported eating pathology

F, M

Athletic environment-related risk factors

Not validated in athletic population

Student athletes and students

De Palma [41]


ID pathologic eating in college students and athletes


16 questions; 8 from SEDA and 8 from DSED-diagnostic survey EDs

PPE monograph [42]


4 questions related to weight; 3 questions related to menses

F, M

International Olympics committee screening [43]


Athlete periodic health evaluation (PHE) form

F, M

11 Nutrition questions for both sexes

Female-specific questions: 6 menses, 2 bone health, 1 STI

Stanford website [17]


Questions as part of PPE questionnaire

F, M

College Health Related Informational Survey (CHRIS)

This was developed in 2003 as a new screening instrument for college student athletes. It was based on the Juvenile Wellness and Health Survey. There are 32 questions broken down into four areas: mental health, 9; eating problems, 12; risk behaviors, 4; performance pressure, 6.

De Palma

This was devised in 2001 as a discriminate analysis tool to identify college students and student athletes at low, moderate, or high risk of pathologic eating. It was not given any specific title so is referred to here by the first authors last name. It has 16 questions, 8 each from two different previously used instruments, diagnostic survey of eating disorders (DSED) and survey of eating disorders among athletes (SEDA). It takes about 2 min to complete and 2 min to score. The items are short and relatively nonconfrontational [41].

Survey of Eating Disorders Among Athletes (SEDA)

This is a survey of collegiate females and males, who are both athletes and students. It consists of 33 questions related to self-reported eating pathology. It has not been validated in an athletic population [41].

Standardized PPE forms are directed at both female and male athletes. There are a myriad of those types of forms available. The following will discuss two of the more commonly used forms and an example of an Internet-based PPE form located online for the athlete to complete in advance of arrival for a PPE. Many collegiate athletic departments are beginning to utilize this technology. Given that the health care system is moving toward a PCMH, where patient information is stored electronically with ongoing updates, online storage of electronic data recorded in a PPE form may eventually be a recommended best practice. The National Committee for Quality Assurance is promoting the PCMH to allow for organizing care around the patient, working in health teams, and coordinating and tracking care over time [24]. The ability for health care providers to access the athlete’s information electronically may improve the quality of care they receive and may make research related to athletes easier.

Pre-participation Physical Evaluation, Fourth Edition

The latest revision of this form occurred in 2010. It has four questions concerning weight issues that are directed at both females and males. There are three questions related to menses [42].

International Olympic Committee Periodic Health Evaluation of Elite Athletes

This form has 11 nutrition and weight-related questions for both females and males. There are nine questions directed at the female athlete’s reproductive and/or skeletal health (6 menses, 2 bone health, 1 sexually transmitted infections) [43].

First Year Varsity Athletics Pre-participation Medical Examination form for Stanford University Department of Athletics

This is an 85 question PPE form for athletes entering into the Stanford University system. It is designed for female and male athletes. There are nine questions covering weight/nutrition/eating habits, two questions for males only concerning the reproductive system and five questions for females regarding menses [23].

When a self-report screening tool is utilized, the timing and setting for its use must be considered. The tools that appear to be most useful are FAST, AMDQ, and HWDMHQ. The Physiologic Screening Test appears to have potential. However, ongoing validation of these tools must continue to occur. If screening occurs during PPEs the use of a supplemental tool for female athletes is optimal.

13.4 Contemporary Understanding of the Issues

Screening female athletes for disordered eating and eating disorders is a complex issue. Those involved with active females need to encourage screening on multiple levels, both formally and informally, utilizing a combination of timing and methods (observation, standardized SRQST, interviews). Screening needs to occur as an ongoing process, not only occurring as an isolated event during pre-participation examinations. Education of those involved with female athletes, on all levels, will help in ongoing informal recognition of signs and symptoms of disordered eating and eating disorders. This is essential because the longer that low energy availability is allowed to exist, the greater the health and performance impairments that occur and the more difficult they are to treat.

For competitive athletes, formal screening should occur, either immediately before, during, or immediately after, PPEs. A national standard should be encouraged, with a supplemental SRQST specific to females rather than questions incorporated in the PPE form that is utilized for both males and females. The athletic trainer or team physician or both should then review the tool. Those athletes who screen positively should be evaluated, beyond the standard pre-participation exam, by the team physician or primary care provider. This evaluation should include a detailed medical, reproductive and skeletal history, physical examination incorporating examination for findings specific to those with eating disorders and appropriate labs and additional studies. A referral to a mental health professional should also occur for further evaluation and diagnosis whether an eating disorder exists. The mental health provider is likely to utilize a battery of tests evaluating various risk factors for eating disorders including mood screening. The gold standard for evaluation of an eating disorder is the interview-based EDE.

Physicians need to be reminded to screen female athletes for risk factors for low energy availability during routine health visits and those for acute illness or injury. The supplemental self-report questionnaire should be specific to the female athlete. Validated tools include FAST, HWDMH, and PST [2837].

Those that are female athlete specific, but have not been validated include AMDQ, Female Athlete Triad Coalition Questionnaire, and ATHLETE.

If for some reason a female athlete-specific questionnaire cannot be utilized, consideration should be given to a tool to screen for eating disorders in a general population that is inexpensive and easily accessible such as EAT-26.

The ideal will be to have a consensus on a nationally or internationally recognized SRQST with validation of that tool. This will help with standardized early recognition and treatment for disordered eating and eating disorders in an effort to optimize energy availability, health and performance in female athletes.

13.5 Future Directions

The sports medicine community can serve its female athletes well by developing a consensus related specifically to screening for disordered eating and eating disorders. A standardized form/tool that the athlete completes prior to PPE or a physician’s visit for a health issue would be ideal. The challenge has been twofold: to find a consensus about questions that need to be asked on a survey tool and to achieve validation of any such tool. A supplemental form specific to the female athlete could prove to be the most functional. A method of rapid assessment of that form would then allow the provider to determine whether further referral should be made the same day, or if ongoing monitoring may be needed. Incorporation of physiologic variables into a screening tool shows promise and should be further evaluated.

Simplified education programs for all people who interact with athletes should be developed and distributed nationally in an effort to identify disordered eating and eating disorders early. Methods of screening for these conditions should be covered in these programs so that screening will become an ongoing process in both informal and formal settings where female athletes are encountered. Further, programs of education and screening should be expanded into junior high and high schools to identify issues of low energy availability as early as possible.

A PCMH designed specifically for athletes may prove to enhance the overall care provided throughout the career of a competitive athlete. This would include ongoing updates of the athlete’s sport specific and basic medical health data in an electronic format. This allows for organizing care around the athlete, working in health teams, and coordinating and tracking care over time as recommended for all Americans by the National Committee for Quality Assurance.

13.6 Concluding Remarks

Low energy availability, as a consequence of disordered eating or eating disorders in female athletes, is a significant health concern. It is a key component of the female athlete triad and can lead to menstrual disorders and changes in bone health. The athletic health care community needs to address this health concern beginning in junior high school and high school and continuing through the lifetime of the active female. The best method of management is through a combined approach with screening both informally through observation and formally during pre-participation examinations and other interactions of female athletes with health care providers, in order to prevent the consequences of disordered eating and eating disorders. Eating disorders can lead to significant health complications including death.

For formal screening, the best tool is one that is confidential, inexpensive, readily accessible, and validated in a female athlete population. A promising step forward will be a nationally agreed upon standardized self-report supplemental questionnaire specific for female health concerns related to low energy availability.

13.7 Questions











13.8 Answer Key













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