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Anna Melin, Monica Klungland Torstveit, Louise Burke, Saul Marks and Jorunn Sundgot-Borgen

Disordered eating behavior (DE) and eating disorders (EDs) are of great concern because of their associations with physical and mental health risks and, in the case of athletes, impaired performance. The syndrome originally known as the Female Athlete Triad, which focused on the interaction of energy availability, reproductive function, and bone health in female athletes, has recently been expanded to recognize that Relative Energy Deficiency in Sport (RED-S) has a broader range of negative effects on body systems with functional impairments in both male and female athletes. Athletes in leanness-demanding sports have an increased risk for RED-S and for developing EDs/DE. Special risk factors in aquatic sports related to weight and body composition management include the wearing of skimpy and tight-fitting bathing suits, and in the case of diving and synchronized swimming, the involvement of subjective judgments of performance. The reported prevalence of DE and EDs in athletic populations, including athletes from aquatic sports, ranges from 18 to 45% in female athletes and from 0 to 28% in male athletes. To prevent EDs, aquatic athletes should practice healthy eating behavior at all periods of development pathway, and coaches and members of the athletes’ health care team should be able to recognize early symptoms indicating risk for energy deficiency, DE, and EDs. Coaches and leaders must accept that DE/EDs can be a problem in aquatic disciplines and that openness regarding this challenge is important.

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Trent Stellingwerff

-S) ( Mountjoy et al., 2014 ) and the Female Athlete Triad ( Joy et al., 2014 ) tools during the majority of the training year in the general preparation phase, and a low (RED-S tool) or moderate risk assessment (Triad tool) during the competition phases. Many of the health-based assessment parameters of both

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Louise M. Burke, Bronwen Lundy, Ida L. Fahrenholtz and Anna K. Melin

 = fat-free mass. Although LEA has been promoted for well over a decade as a key factor in the Female Athlete Triad ( De Souza et al., 2014 ; Nattiv et al., 2007 ) and underpins RED-S ( Mountjoy et al., 2014 , 2018 ), the concept is still not fully appreciated by sports science/medicine professionals

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Monica Klungland Torstveit, Ida Fahrenholtz, Thomas B. Stenqvist, Øystein Sylta and Anna Melin

. ( 2014 ). 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013 . British Journal of Sports

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Sarah Staal, Anders Sjödin, Ida Fahrenholtz, Karen Bonnesen and Anna Katarina Melin

cooperation of the dancers participating in this study and the support of the Royal Danish Ballet. The authors declared that they have no conflicts of interest. References Ackerman , K.E. , & Misra , M. ( 2011 ). Bone health and the female athlete triad in adolescent athletes . The Physician and

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Jennifer Sygo, Alexandra M. Coates, Erik Sesbreno, Margo L. Mountjoy and Jamie F. Burr

. , & Thevis , M. ( 2018 ). Nutrition status of young elite female German football players . Pediatric Exercise Science, 30 ( 1 ), 157 – 167 . doi:10.1123/pes.2017-0072 10.1123/pes.2017-0072 Brown , K.N. , Wengreen , H.J. , & Beals , K.A. ( 2014 ). Knowledge of the female athlete triad, and

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Margo L. Mountjoy, Louise M. Burke, Trent Stellingwerff and Jorunn Sundgot-Borgen

prevention and treatment programs from IFs all the way down to grassroots sports. The term “RED-S” was coined by the International Olympic Committee in 2014 ( Mountjoy et al., 2014 ), expanding the female athlete triad model to recognize that low energy availability (LEA), which underpins both the triad and

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Anna K. Melin, Ida A. Heikura, Adam Tenforde and Margo Mountjoy

, EDs/DE, and low BMD referred to as Female Athlete Triad risk factors ( Nattiv et al., 2013 ). In an early study by Marcus et al. ( 1985 ) investigating menstrual function and bone health in elite female distance runners and controls, BSI was more frequent in amenorrheic versus eumenorrheic women, and

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David R. Hooper, William J. Kraemer, Rebecca L. Stearns, Brian R. Kupchak, Brittanie M. Volk, William H. DuPont, Carl M. Maresh and Douglas J. Casa

volumes of aerobic exercise were accompanied by a reduction in the basal concentrations of sex hormones in men, just as it was in women. Since then, the female athlete triad has been firmly established, 2 but comparable studies in men continue to lag behind. Later, this condition in men was termed the

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Daniel Martin, Craig Sale, Simon B. Cooper and Kirsty J. Elliott-Sale

. The influence of reproductive hormones on muscle strength . Biol Rhythm Res . 2004 ; 35 : 235 – 244 . doi:10.1080/09291010412331335788 10.1080/09291010412331335788 2. De Souza MJ , Nattiv A , Joy E , et al . Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play