Identifying & Treating Eating Disorders in Athletes

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 greatly between activities and are particularly prevalent in lean sports than non-lean sports.

Females in aesthetic sports are at high risk for dieting. 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. Examples of aesthetic sports include gymnastics, diving, figure skating, dancing and ballet.

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

It’s important to acknowledge that both aesthetic and weight-dependent sports are both considered lean sports, or sports that place heavy emphasis on achieving and maintaining a lower body weight due to the belief that lower body weight improves performance. This belief can push athletes into believing there is an athletic advantage to cutting as much weight as possible and encouraging unhealthy means to accomplish weight reduction. The cycle of disordered eating behavior can become reinforced through athletic accolades, awards and encouragement from fellow athletes and coaches.

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. In a study of NCAA athletes, it’s estimated that 34.75% of women are at risk for anorexia nervosa, compared to 9.5% of men and women and men had an equal risk of bulimia at 38%.

It’s also important to keep in mind that athletics goes beyond just sports activities, where there is typically two or more people competing. Some athletes may not participate in sports, and instead participate in other athletic activities like rock climbing, biking, running, etc. where they are not in direct competition with anyone else, but may still experience an eating disorder similarly to their peers in sports.

Compulsive Exercise in Athletes

Physical fitness is a set of attributes that are either health or skill-related. It can also be defined as a state of wellbeing with a low risk of premature health problems, and the energy to participate in activities of daily living. In public health, it is one of the most important predictors for good health and the prevention of lifestyle-related diseases. While physical fitness is overall positive, for those suffering from an eating disorder, physical fitness can morph into compulsive exercise.

Compulsive exercise is described as a craving for physical training, resulting in uncontrollable excessive exercise behavior with harmful consequences, including injury and impaired social relations. Compulsive exercise is commonly observed in patients with eating disorders, with approximately 40% of patients with eating disorders compulsively exercising. Compulsive exercise is associated with medical complications, including overuse injuries and fractures. It can also disrupt a patient’s treatment and is associated with higher rates of dropout from treatment programs, longer inpatient treatment stays, poorer outcomes and quicker relapse.

Unfortunately, it is difficult to differentiate between healthy and compulsive exercise in athletes, with most athletes, coaches and clinicians not identifying compulsive exercising until athletic performance declines or physical symptoms like weight loss, fatigue and amenorrhea are present.

Predisposing Factors

There are many different predisposing factors that may lead to an athlete either being predisposed to an eating disorder or more likely to participate in a particular sport with increased incidences of eating disorder development.

One example is perfectionism. Perfectionism is a common attribute among athletes, and perfectionism is associated with all-or-none 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.

Another example is external pressure from coaches, peers or parents. More broadly, this pressure can also come from social media and society’s perception of what an athlete is. The pressure an athlete experiences in their environment 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 in order to conform to what people expect of an athlete.

Other predisposing factors

• 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

Medical Complications for Athletes

Medical complications are largely the same for athletes and non-athletes, with one unique complication being the development of relative energy deficiency in sport (RED-S), a condition of low energy availability affecting male and female athletes of all levels and ages. Low energy availability (LEA), a mismatch between an athlete’s energy intake (diet) and the energy expended in exercise, leaving inadequate energy to support the functions required by the body to maintain optimal health and performance.

RED-S has been proposed as a replacement for or 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.

The health consequences of RED-S are far reach, affecting almost the entire body, including:

• Endocrine system
• Skeletal system
• Cardiovascular system
• Gastrointestinal system
• Immune system
• Metabolism
• Hematologic system
• Growth and development
• Mental health
• Menstrual function

RED-S can also have performance consequences, including decreased endurance, increased injury risk, decreased training response, impaired judgement, decreased coordination, decreased concentration, irritability, depression, decreased muscle strength and decreased glycogen stores.

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. Screening questionnaires can be beneficial for identifying an eating disorder, but athletes are less likely to be forthcoming in order to avoid limitations in sports activities. Unfortunately, there are also coaches who may willingly ignore or be unaware of eating disorder symptoms or may even go as far as to limit clinicians' access to athletes.

Recommended screening questionnaires include the following, which have all been shown to helpful screening tools for providers in identifying eating disorders among athletes:

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

Treating Eating Disorders in Athletes

A period of absence from a sport during treatment is often necessary. 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. If the medical complications of an eating disorder are severe, it’s vital that a patient enters an inpatient medical stabilization unit specializing in eating disorder care. Severe eating disorders can have disastrous and potentially lethal effects. Care should never be delayed until after the athletic season is over.

Like any other patient, an athlete experiencing extreme eating disorder complications should have a multi-disciplinary team ready to help them re-enter their life and return to their sport. Physical therapy can help guide the athlete back into a slowly graded increase in athleticism as the eating disorder improves.

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.

Psychotherapy can facilitate discussion on the appropriateness and role a sport plays in a patient’s life. It may be recommended that an athlete stop participating in a given sport or activity, as they may not be well suited for it, and instead take up a new sport or activity that would be more in line with their body type. Alternatively, they can be encouraged to participate in their desired activity on a non-competitive level, where the stakes are lower.

Resources

• Caspersen, C. J., Powell, K. E., & Christenson, G. M. (1985, March–April). Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Reports, 100(2), 126–131.
• Ghoch, M., Soave, F., Calugi, S., & Dalle Grave, R. (2013). Eating Disorders, Physical Fitness and Sport Performance: A Systematic Review. Nutrients, 5(12), 5140–5160.
• Ghoch, M. E., et al. (2013). Eating disorders, physical fitness, and sport performance: a systematic review. Nutrients, 5:12.
• Giel KD, Hermann-Wener A, Mayer J, et al. 2016. Eating disorder pathology in elite adolescent athletes. International Journal of Eating Disorders.
• 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.
• Lichtenstein, M. B., Hinze, C. J., Emborg, B., Thomsen, F., & Hemmingsen, S. D. (2017). Compulsive exercise: links, risks and challenges faced. Psychology Research and Behavior Management, Volume 10, 85–95.
• 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, 8:47.
• 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., et al. (2014). The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). Br J Sports Med, 48, 491-97.
• Murphy SM. The sport psych handbook. Champaign: Human Kinetics; 2005.
• Werner A, Thiel A, Schneider S, Mayer J, Giel KE, Zipfel S. Weight-control behaviour and weight-concerns in young elite athletes- as systematic review. J Eat Disord. 2013;1:18.

Last Reviewed: December 2023 by Dennis Gibson, MD, FACP, CEDS