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Athletes meeting diagnostic criteria for diagnosed eating disorder (Anorexia Nervosa, Bulimia Nervosa, OSFED) and electrolyte disturbances Athletes with severe physical complications associated with weight loss and lack of EA Includes cardiac dysrhythmias, major edema, fainting At least 3 of the “alarm criteria” outlined previously

Source: Adapted from The Malnourished athlete guidelines for interventions (Skarderud et al. 2012) greatest predictors of normal menstrual functioning. Adequate EI in of itself, as well as its effects on normalizing estrogen levels, can improve BMD, though not all losses may be recovered. Resistance training should be included as a treatment for improving BMD, given its role as a stimulus for increasing bone density, as well as recommendations for appropriate

vitamin supplementation. Bone nutrient supplementation is outlined in the following section.

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For individuals with eating disorders, simply adding calories to the diet may not be successful given the psychological distress associated with eating. The practitioner(s) need to ascertain the scope of disordered eating or eating disorder that may exist and utilize the treatment team approach as outlined in the earlier section. The role of the dietitian or nutritionist in this process includes the principles outlined for dietary management of disordered eating and eating disorders. The nutritionist should help to ensure appropriate macro- and micronutrient intake as well as adequate EI; they also serve a role in normalizing food behaviors. Progress may be slow and can take months, even years if the eating disorder is severe. The athlete should be educated on the importance of proper nutrition intake for overall health, for proper bone and menstrual functioning, as well as the role nutrition plays on performance. The nutritionist can support the development of a healthy relationship with food, including the integration of principles of mindful eating and intuitive eating. Finding what motivates the athlete to work toward adequate EA will be useful in establishing goals and objectives.

Overall low EA is the underlying factor in the Female Athlete Triad and RED-S. Health consequences of low EA are significant and a team approach is needed to address the various physiological disturbances. The weight lossist plays an integral role in supporting the athlete in achieving sufficient EA, both through dietary recommendations and meal planning, as well as by normalizing healthy eating patterns. The process is ongoing and can take an extended period of time, but it is essential the athlete understands the significant role nutrition plays in optimizing health and performance.

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