Identifying and Treating Eating Disorders in Athletes

By Jeana Cost, MS, LPC, CEDS

One in three NCAA athletes is at risk for bulimia, and one in three female NCAA athletes is at risk for anorexia nervosa. These findings highlight how common eating disorders are in sports, especially those that emphasize weight, leanness or appearance. With early intervention, education and compassionate, evidence-based care, athletes can recover while safeguarding their health and performance.

Eating Disorders in Athletes

When reading about risk factors for eating disorders, participating in sports is often cited. However, the prevalence of eating disorders and disordered eating behavior can vary significantly between activities and are particularly prevalent in lean sports compared to non-lean sports.

When looking at athletics overall, it’s estimated that up to 45% of female athletes and 19% of male athletes struggle with an eating disorder. A study of NCAA athletes determined that around 34.75% of women are at risk for anorexia nervosa, compared to 9.5% of men; women and men had an equal risk of bulimia at 38%.

What are Lean Sports?

Lean sports are those in which leanness and/or a specific body weight are considered essential for performance. This includes:

  • Endurance
  • Aesthetic
  • Weight class
  • Anti-gravitation

Lean sports place a heavy emphasis on achieving and maintaining a lower body weight, due to the belief that a lower body weight improves performance. This belief can lead athletes to believe that there is an athletic advantage to cutting as much weight as possible, encouraging unhealthy means to achieve weight reduction. The cycle of disordered eating behavior can become reinforced through athletic accolades, awards and encouragement from fellow athletes and coaches.

Aesthetic sports

Aesthetic sports involve judging an individual or team performance using a complex set of rules, including appearance, which is a major factor in the judging. Female athletes in aesthetic sports are more likely to diet. Examples of aesthetic sports include:

  • Gymnastics
  • Diving
  • Figure skating
  • Dance and ballet

Weight-dependent sports

Weight-dependent sports also have high levels of eating disorders. Weight-dependent sports divide athletes into different weight classes and include sports like:

  • Wrestling
  • Karate
  • Judo

Many males and females in weight-dependent sports utilize compensatory behaviors like dehydration, vomiting, laxatives and diuretics.

Pursuit of Peak Performance

Not all athletes are motivated by competition alone. While some providers assume competition with other athletes is the primary driver for disordered eating, many athletes are instead driven by a desire to improve their own performance – even when they are not competing. This internal pressure can lead to behaviors aimed at enhancing:

  • Distance
  • Speed
  • Strength
  • Elevation
  • Endurance

Over time, the ongoing pursuit of peak performance may unintentionally place an athlete’s health at risk.

Predisposing Factors

Many factors can increase an athlete’s risk of being predisposed to an eating disorder or more likely to choose a sport with an increased incidence of eating disorder development.

Perfectionism

Perfectionism is a common attribute among athletes, and perfectionism is associated with all-or-nothing thinking. Perfectionist athletes may develop disordered eating behaviors to ensure they are meeting certain weight or shape goals to avoid being perceived as undedicated to the sport. They may also experience performance anxiety, and the eating disorder becomes a way to relieve anxiety.

Performance pressure

The pressure an athlete experiences in their environment – from coaches, peers, parents or social media – may result in an eating disorder, since athletes may feel compelled to look or eat a certain way or commit to a certain amount of training to conform to what people expect of an athlete.

Positive feedback

If athletes are engaging in disordered eating but are performing at a high level, the encouragement of parents, teammates and coaches may inadvertently maintain the eating disorder.

Other predisposing factors

There are other factors that can predispose an athlete to an eating disorder:

  • Low self-esteem
  • Social isolation
  • Rejection sensitivities
  • Body weight dissatisfaction
  • Chronic dieting or frequent weighing
  • Anxiety or mood disorders
  • Family history of eating disorders
  • Body dysmorphia
  • Participation in sports to please others

Low Energy Availability and Relative Energy Deficiency in Sports

Low energy availability (LEA) is a mismatch between the body’s energy intake and the energy expended, leaving inadequate energy to support the functions required by the body to maintain optimal health and performance.

LEA is the primary cause of relative energy deficiency in sport (RED-S), a condition where athletes do not have enough energy to meet training needs. RED-S can also impact performance, including:

  • Decreased endurance
  • Increased injury risk
  • Decreased training response
  • Impaired judgement
  • Decreased coordination
  • Decreased concentration
  • Irritability
  • Depression
  • Decreased muscle strength
  • Decreased glycogen stores

Female athlete triad

RED-S is proposed as an expansion of what’s known as the “female athlete triad” — the combination of disordered eating, amenorrhea and osteoporosis — to acknowledge a wide range of outcomes and the application to male athletes.

Medical Complications of RED-S

LEA and RED-S can cause a wide range of serious health issues, including menstrual irregularities, cardiovascular and endocrine dysfunction and weakened bones. These complications can affect both physical performance and long-term health, making early detection and intervention essential. Because RED-S has replaced the female athlete triad, there is a lack of research about RED-S in males.

Menstrual abnormalities

LEA causes suppression of gonadotropin-releasing hormone, follicle-stimulating hormone, and luteinizing hormone, causing hypothalamic amenorrhea. Menstrual abnormalities can also contribute to cardiovascular issues.

Up to 20% of exercising females are affected by menstrual abnormalities, while ballet dancers and endurance runners report rates as high as 44% and 51% respectively. Low body fat percentage, exercise stress and endocrine dysfunction contribute to menstrual dysfunction in athletes.

Cardiovascular dysfunction: Hyperlipidemia

Amenorrheic athletes also develop elevations in cholesterol and low density lipoprotein which are related to low estrogen.

Endocrine dysfunction

Studies of LEA in male athletes experience endocrine dysfunction, including low leptin, insulin, triiodothyronine (T3) and testosterone levels, resulting in decreased metabolism.

Compromised bone health

Females with LEA exhibit worse bone mineral density and strength as well as thinner cortical bone, all of which may contribute to the development of bone stress injuries.

Other complications of RED-S

Other complications of RED-S include issues with:

Identifying Eating Disorders in Athletes

Diagnosing an eating disorder in an athlete is not notably different from diagnosing an eating disorder in a non-athlete. Athletes may be at varying risk of RED-S:

  • Low risk: has a healthy physique, doesn’t resort to unhealthy diet or exercise strategies and is in overall good health
  • Moderate risk: has lost a significant amount of weight in the past month (5-10% of their body mass), has irregular periods or a history of stress fractures.
  • High risk: uses extreme techniques to lose weight or have signs of a serious medical conditions

Screening questionnaires

Screening questionnaires can be beneficial for identifying an eating disorder, but athletes are less likely to be forthcoming to avoid limitations on sports activities.

  • Athletic Milieu Direct Questionnaire (AMDQ)
  • Eating Disorders Screen for Athletes (EDSA)
  • The Disordered Eating Screen for Athletes (DESA-6)

Treating Eating Disorders in Athletes

Treatment for athletes with eating disorders can include taking a temporary break from sports, occupational therapy and evidence-based eating disorder care. These interventions support physical health and emotional healing while helping the athlete recover and return to their sport safely.  

Taking a break from sports

During eating disorder treatment, it is often necessary to take time away from sports. It’s important that clinicians, coaches and loved ones emphasize that entering treatment and being unable to participate in the sport will help the patient return a better athlete.

Occupational therapy

Occupational therapy can also be beneficial for helping the patient integrate back into their life after treatment and in their various occupations – particularly how they will reintegrate into their role on a team or pursue their athletic goals.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a first-line treatment for eating disorders. CBT is a form of psychotherapy that focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop effective coping mechanisms. CBT can also help athletes manage and cope with the unique stressors of being an athlete.

Resources

  • Caspersen, C. J., Powell, K. E., & Christenson, G. M. (1985). Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. PubMed, 100(2), 126–131. https://pubmed.ncbi.nlm.nih.gov/3920711
  • Ghoch, M. E., Soave, F., Calugi, S., & Grave, R. D. (2013). Eating Disorders, Physical Fitness and Sport Performance: A Systematic review. Nutrients, 5(12), 5140–5160. https://doi.org/10.3390/nu5125140
  • Giel, K. E., Hermann‐Werner, A., Mayer, J., Diehl, K., Schneider, S., Thiel, A., & Zipfel, S. (2016). Eating disorder pathology in elite adolescent athletes. International Journal of Eating Disorders, 49(6), 553–562. https://doi.org/10.1002/eat.22511
  • Johnson, C., Powers, P. S., & Dick, R. (1999). Athletes and eating disorders: The national collegiate athletic association study. International Journal of Eating Disorders, 26(2), 179–188. https://doi.org/10.1002/(sici)1098-108x(199909)26:2
  • Lichtenstein, M. B., Hinze, C. J., Emborg, B., Thomsen, F., & Hemmingsen, S. D. (2017b). Compulsive exercise: links, risks and challenges faced. Psychology Research and Behavior Management, Volume 10, 85–95. https://doi.org/10.2147/prbm.s113093
  • Mancine, R. P., Gusfa, D. W., Moshrefi, A., & Kennedy, S. F. (2020). Prevalence of disordered eating in athletes categorized by emphasis on leanness and activity type – a systematic review. Journal of Eating Disorders, 8(1). https://doi.org/10.1186/s40337-020-00323-2
  • Mehler, P. S., & Andersen, A. E. (2022). Eating Disorders: A Comprehensive Guide to Medical Care and Complications (fourth edition). Johns Hopkins University Press.
  • Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., Meyer, N., Sherman, R., Steffen, K., Budgett, R., & Ljungqvist, A. (2014b). The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine, 48(7), 491–497. https://doi.org/10.1136/bjsports-2014-093502
  • Murphy, S. (2004). The Sport Psych Handbook. Human Kinetics.
  • Werner, A., Thiel, A., Schneider, S., Mayer, J., Giel, K. E., & Zipfel, S. (2013). Weight-control behaviour and weight-concerns in young elite athletes – a systematic review. Journal of Eating Disorders, 1(1). https://doi.org/10.1186/2050-2974-1-18
  • Cabre, H. E., Moore, S. R., Smith-Ryan, A. E., & Hackney, A. C. (2022). Relative energy deficiency in sport (RED-S): scientific, clinical, andpractical implications for the female athlete. German Journal of Sports Medicine, 73(7), 225–234. https://doi.org/10.5960/dzsm.2022.546
  • Holtzman, B., Kelly, R. K., Saville, G. H., McCall, L., Adelzedah, K. A., Sarafin, S. R., Nikam, P., Meneguzzi, I., McIntyre, A., Kraus, E. K., & Ackerman, K. E. (2024). Low energy availability surrogates are associated with Relative Energy Deficiency in Sport outcomes in male athletes. British Journal of Sports Medicine, bjsports-109165. https://doi.org/10.1136/bjsports-2024-109165
Written by
Jeana Cost, MS, LPC, CEDS

Jeana Cost, MS, LPC, CEDS

Jeana Cost is the Vice President of Operations and Clinical Services of the ACUTE Center for Eating Disorders & Severe Malnutrition. In her role, she is tasked with ensuring an excellent patient…

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