The study, published in Discover Psychology, was led by Leo C. M. Cheung of the Sports Nutrition & Monitoring Centre at the Hong Kong Sports Institute, working alongside colleagues from the institute and the Department of Sports Science and Physical Education at The Chinese University of Hong Kong. The team administered the Eating Attitudes Test-26, or EAT-26, a twenty-six item self-report instrument that has served as the workhorse of eating-attitude screening since the 1980s. Respondents rate statements about food preoccupation, dieting behavior, and eating-related guilt on a six-point scale, and a total score of twenty or above conventionally flags a need for clinical follow-up. The instrument does not diagnose anorexia nervosa or bulimia, but it reliably identifies individuals whose attitudes toward food have drifted into territory associated with those conditions.

Statistically, the headline number is the overall at-risk proportion of 4.0 percent. Beneath that aggregate, however, the researchers uncovered a series of gradients that tell a more interesting story than any single prevalence figure could. Female athletes registered a risk proportion of 7.1 percent, roughly four times the 1.7 percent observed in male athletes, a sex difference consistent with the broader epidemiological literature in which women carry a substantially higher burden of eating pathology. Yet even the female figure remained modest, suggesting that the structured environment of Hong Kong’s elite sport system, with its professional nutrition support, may buffer some of the pressures that push other populations toward restriction.

The more striking patterns emerged when the researchers stratified their sample by dieting history, age, and self-perceived body image. Athletes who reported previous dieting experience scored significantly higher on the EAT-26 than those who had never dieted, with mean scores of 8.08 plus or minus 9.03 compared with 4.92 plus or minus 5.73, a difference that reached statistical significance at the five percent level. This finding matters because dieting attempts are widely understood as a gateway behavior; in athletes, a single episode of deliberate caloric restriction can spiral into chronic under-fueling, and under-fueling in turn drives the syndrome known as Relative Energy Deficiency in Sport, which degrades bone density, endocrine function, and performance itself.

Age produced an equally compelling signal. Athletes under nineteen years old scored significantly higher than their older counterparts, with mean EAT-26 values of 9.24 plus or minus 11.21 versus 5.33 plus or minus 5.71. Pearson correlation analysis confirmed a weak but significant negative association between age and EAT-26 score, with a correlation coefficient of -0.234 and a p-value below 0.05. In plain terms, the younger the athlete, the more disordered the eating attitudes tended to be. The authors point to this developmental window as a critical target for intervention, and the logic is sound: adolescence is precisely the period when body image consolidates, when sport-specific pressures about weight class and aesthetics intensify, and when nutritional habits harden into lifelong patterns.

Body image proved to be the strongest single correlate in the dataset. Participants rated their self-perceived body image on a nine-point scale, and those scoring below the midpoint of five showed markedly elevated EAT-26 scores, averaging 11.08 plus or minus 7.88, compared with 5.41 plus or minus 6.99 among athletes who rated their body image at five or above. The difference was significant at the one percent level, and Pearson analysis revealed a moderate negative correlation of -0.344 between body image and EAT-26 score with a p-value below 0.001. Athletes who felt worse about their bodies, in other words, consistently harbored more disturbed attitudes toward eating, independent of the sport they played.

To disentangle the overlapping effects of age and body image, the team ran a multiple linear regression, and both variables survived as independent negative predictors of EAT-26 scores. Age carried a standardized coefficient of -0.228 with a p-value below 0.05, while self-perceived body image carried a standardized coefficient of -0.344 with a p-value below 0.001. Because both predictors point in the same direction, the regression supports a coherent risk profile: the athlete most likely to exhibit problematic eating attitudes in this sample is young, has experimented with dieting, and holds a negative view of her own body. That profile gives sports medicine staff something actionable, because every one of those characteristics can be screened for during routine athlete monitoring.

Methodologically, the study is a descriptive, cross-sectional survey, and the authors classify it as Level V evidence, the lowest rung on the clinical evidence ladder. Cross-sectional designs capture a single moment in time, which means they can identify associations but cannot establish whether poor body image causes disordered eating or vice versa, nor can they track how risk evolves across an athlete’s career. The sample size of 100, while respectable for a single-institute study, is small enough that subgroup estimates, particularly the 1.7 percent figure for male athletes, rest on a handful of individuals. The researchers themselves frame the work as a foundation for tailored health education programs and differentiated screening rather than as a definitive prevalence estimate.

Even with those caveats, the study adds a valuable data point to a literature that the authors describe as frequently contradictory. Prevalence estimates for disordered eating among athletes vary wildly across studies, driven by differences in sport type, assessment tools, cultural context, and how risk is defined. High-risk sports such as gymnastics, distance running, and weight-class combat disciplines consistently show elevated rates, but pooled figures are notoriously unstable. By anchoring the Hong Kong data to a standardized instrument and a defined at-risk threshold, the study gives regional sport bodies a benchmark against which future surveillance can be measured, and it suggests that the often-cited narrative of an eating-pathology epidemic in elite sport may require regional calibration rather than blanket assumptions.

The practical implications ripple outward from the institute itself. Screening programs that incorporate the EAT-26, a simple body-image rating, and a question about dieting history could be embedded into existing athlete health checks at negligible cost, flagging young athletes with poor body image for early nutrition counseling before attitudes calcify into behavior. The research, which received no external funding and was approved by the Research Ethics Committee of the University of Hong Kong School of Professional and Continuing Education, emerged from an MSc project in Sport and Exercise Nutrition, a reminder that some of the most immediately useful findings in sports science come from practitioners working directly with athletes rather than from large-scale trials. For coaches and parents watching a teenage athlete quietly shrink portions or fixate on body shape, the study’s message is direct: age, dieting history, and body dissatisfaction together form the earliest warning system, and acting on that warning early is far easier than treating an eating disorder once it takes hold.

Subject of Research: Disordered eating risk factors among Hong Kong Chinese athletes

Article Title: A cross-sectional study of eating attitudes in Hong Kong athletes

Article References: Cheung, L. C. M., Sze, J. W. H., Siu, F. P. L., Li, S. L., Pun, G. T. K., Lau, J. T. Y., O’Reilly, J., & Kuo, M. J. (2026). A cross-sectional study of eating attitudes in Hong Kong athletes. Discover Psychology. https://doi.org/10.1007/s44202-026-00848-8

Image Credits: AI Generated

DOI: 10.1007/s44202-026-00848-8

Keywords: disordered eating, EAT-26, Hong Kong athletes, body image, sports nutrition, eating disorder risk, cross-sectional study, adolescent athletes, dieting behavior, sport psychology, Relative Energy Deficiency in Sport, athlete screening

The phenomenon of RED-S is characterized by an insufficient energy availability, which is rooted in the imbalance between dietary energy intake and the energy expended during physical activity. For ultra-endurance athletes who frequently train at high intensities for prolonged periods, the risk of entering a state of energy deficiency is heightened. This complex issue can lead to serious physiological disruptions, including hormonal imbalances and impaired metabolic function, which ultimately compromise athletic performance and overall well-being.

One of the striking findings reported in the review is the relationship between RED-S and mental health issues, particularly among athletes in the ultra-endurance community. It has been demonstrated that energy deficiency can contribute to anxiety, depression, and increased stress levels, creating a vicious cycle that can severely hamper an athlete’s performance. This relationship underscores the importance of a holistic approach when addressing the health of ultra-endurance athletes, where both physical and psychological aspects are considered in tandem.

The review also highlights the significant variations in the presentation of RED-S symptoms among male and female athletes. While both genders experience similar physiological consequences, the manifestation of symptoms may differ due to hormonal factors and societal pressures. Female athletes, in particular, may face greater scrutiny regarding their body image, which can exacerbate the risk of energy deficiency. Addressing these gender-specific issues is crucial for creating effective prevention and treatment strategies tailored to the unique needs of ultra-endurance athletes.

Nutritional strategies play a critical role in preventing and managing RED-S among ultra-endurance athletes. Maintaining a sufficiently high caloric intake, alongside a well-balanced diet rich in essential nutrients, is paramount for sustaining performance and health. The review emphasizes the need for athletes to work with registered dietitians or nutritionists who specialize in sports nutrition, ensuring they receive personalized advice that accounts for their unique training regimens and energy expenditure demands.

Moreover, the role of education and awareness cannot be overstated. Athletes, coaches, and support personnel must be well-versed in the warning signs of RED-S and understand the implications of energy deficiency on both performance and health. Training programs should incorporate educational components that inform athletes about the importance of energy balance, proper nutrition, and self-care strategies, fostering a culture that prioritizes physical and mental well-being.

In recent years, there has been a significant shift towards a more supportive and empathetic approach in the athletic community concerning mental health. This shift is paramount for addressing issues related to RED-S, as athletes may feel pressured to conform to certain body standards or performance expectations. Creating an open dialogue around mental health within the realm of ultra-endurance sports is essential for breaking the stigma associated with seeking help and fostering an environment where athletes feel comfortable discussing their challenges.

In addition to mental health considerations, the review points to the role of technology in monitoring athletes’ health and performance. Wearable devices and apps can aid in tracking energy expenditure, nutrient intake, and physiological responses, providing valuable insights that can inform nutrition and training regimens. Coaches and athletes alike can harness this technology to create more data-driven, personalized approaches to training that prioritize energy balance and overall health.

The review by Colangelo et al. also presents a call to action for organizations governing ultra-endurance sports, urging them to develop comprehensive guidelines and policies that address issues related to RED-S. These measures could include mandatory nutrition education for athletes and coaches, as well as protocols for identifying and managing energy deficiency in competitive settings. A proactive stance from governing bodies would contribute significantly to raising awareness and reducing the incidence of RED-S among athletes.

Cross-disciplinary collaborations are essential for tackling the multifaceted nature of RED-S in ultra-endurance sports. An alliance between sports scientists, nutritionists, psychologists, and trainers can generate a wealth of knowledge and strategies that address the variables contributing to energy deficiency. By integrating expertise from diverse fields, the sports community can develop more robust frameworks for preventing and managing RED-S, ultimately enhancing athlete health and performance.

Furthermore, examining cultural and societal influences on the perception of body image within the context of ultra-endurance sports is critical. Athletes, especially emerging talents, are often subjected to unrealistic ideals propagated by media and social platforms, leading to unhealthy behaviors in their pursuit of success. Addressing these influences through advocacy and positive representation can help empower athletes to embrace diverse body shapes and sizes as they strive for excellence in their respective sports.

As the conversation surrounding RED-S continues to evolve, the importance of community support cannot be overstated. Peer support networks can play a vital role in helping athletes navigate the challenges they face, providing a platform for sharing experiences and coping strategies. Fostering an inclusive environment that encourages athletes to connect and support one another can be a powerful determinant in promoting health and performance standards.

The rich tapestry of ultra-endurance sports presents unique challenges that demand attention and action, particularly concerning RED-S. The insights derived from the review by Colangelo et al. shed light on the various dimensions of this condition, offering a comprehensive understanding of its implications. By prioritizing education, open dialogue, personalized nutrition, and mental health advocacy, the sports community can pave the way for healthier, more resilient athletes.

In summary, the exploration of RED-S within ultra-endurance sports reveals a landscape fraught with complexities that require a concerted effort from all stakeholders involved. Through collective awareness and a commitment to athlete well-being, the potential for a healthier future in ultra-endurance sports is within reach.

Subject of Research: The presentation of Relative Energy Deficiency in Sport (RED-S) in ultra-endurance sports.

Article Title: Exploring the presentation of REDs in ultra endurance sport: a review.

Article References:

Colangelo, J., Smith, A., Henninger, K. et al. Exploring the presentation of REDs in ultra endurance sport: a review.
J Eat Disord 13, 210 (2025). https://doi.org/10.1186/s40337-025-01381-0

Image Credits: AI Generated

DOI: 10.1186/s40337-025-01381-0

Keywords: Relative Energy Deficiency in Sport (RED-S), ultra-endurance sports, nutrition, mental health, energy balance.