Eating Disorders and Athletics
Background
Eating disorders are severe mental health conditions that are more prevalent in athletes compared to the general population. These conditions are characterized by intense preoccupation with food, body weight, and body shape, which can lead to behaviors such as starvation, fasting, binging, and purging behaviors like self-induced vomiting and excessive exercise (1). An estimated 6%-49% of female athletes and 0-19% of male athletes have an eating disorder, and over 35% of athletes exhibit some sort of disordered eating behavior (1). While younger individuals are already at a higher risk, competitive sports present a unique environment that poses particular stressors, thereby increasing the risk to athletes.
Sam Huizenga, University of Michigan, Dietetic Intern at RCBM, explains why eating disorders in competitive athletes are prevalent, what steps can be taken to prevent them from occurring, and the role of an interdisciplinary treatment team during recovery
Sports-Specific Risk Factors for Developing an Eating Disorder
There are several unique attributes of competitive athletics that put individuals at increased risk for developing an eating disorder. The following is a non-exhaustive list of risk factors (1).
- Weight cycling and frequent dieting
- Negative/strict attitudes from coaches about body image and food intake
- Competing in a weight-class, weight-sensitive, or aesthetic sport like wrestling, cross country, or gymnastics
- Perfectionist personality traits tend to be higher in athletes, which can increase the risk
- Taking time off due to a serious injury can lead to changes in body weight and composition, which can lead to compensatory restricting behavior
- Starting a sport young
- Peer pressure from teammates to conform to a particular body image
Signs and Symptoms of Eating Disorders in Athletes 
Eating disorders can present themselves in a variety of different ways in an athletic setting. The following list includes some common complications of eating disorders to look out for (1,2)
- Anemia or iron deficiency
- Electrolyte imbalances
- Low bone mineral density
- Increased injury frequency
- Rapid weight loss
- Decrease in performance
- Amenorrhea in female athletes
- Low libido in male athletes
- Extreme fatigue
- Cardiac abnormalities and arrhythmias
How Can an Eating Disorder be Prevented?
Although athletes are at increased risk, the medical team can take several steps to prevent eating disorders from developing in this population. Early identification of disordered eating behaviors is essential in this environment (1). Disordered eating behaviors should be identified during an initial consultation and properly addressed via nutrition education. The education may focus on avoiding extreme dieting and on what athletes need to fuel their bodies. The registered dietitian should provide this before the athlete begins their first competitive season in college athletics (1,2). Additionally, athletes must understand that achieving a lower body weight does not mean that their performance will improve, and it may even be counterproductive in some cases. However, there are scenarios where athletes must either gain or lose weight to perform a specific position or role in their respective sport. In these situations, it is essential that the interdisciplinary team, including the sports dietitian, athletic trainer, strength coach, sports medicine physician, and coach, is all on the same page and provides the athlete with a plan on how to achieve this outcome. Finally, coaches must understand how to identify the risk and trigger factors of eating disorders and how to recognize the signs and symptoms (1).
What Does Treatment and Return to Play Look Like?
If an athlete is diagnosed with an eating disorder, they must receive treatment from an interdisciplinary team of medical professionals. Treatment may include therapeutic modalities such as cognitive behavioral therapy, nutritional counseling, and nutrition education to address the disordered eating behaviors present. Athletes who have an eating disorder often have to miss time to recover. Once the athlete makes meaningful progress in therapy, a return-to-play protocol is necessary to facilitate a safe return to competition (1,2). The four main factors (in order of importance) that the treatment team should consider in a return-to-play protocol are medical stability, nutritional stability, abstinence from disordered eating behavior, and consideration of the psychological stressors associated with a competitive athletics environment (2). Medical stability involves correcting issues such as anemia, low bone mineral density, electrolyte imbalances, and cardiac abnormalities (2). Nutritional stability requires the athlete to consume enough calories to maintain a healthy weight despite an increased training load (2). Training should begin with a low volume and intensity, and a strength coach or exercise physiologist should oversee the implementation of the training program (1). If the athlete is non-compliant with the return-to-play protocol and continues to relapse, retirement from their sport may need to be considered.
Key Takeaways
Eating disorders in athletics represent a serious threat to both the physical and mental health of athletes. The pressures of competitive sports, ranging from performance expectations to body image ideals, create an environment in which eating disorders and disordered eating are prevalent. Prevention through education, multidisciplinary support, and awareness among coaches and sports medicine staff is essential to reduce the prevalence of these conditions. When eating disorders do develop, timely and comprehensive treatment carried out by an interdiscliplinary team is key to recovery and a safe return to sport. By prioritizing athlete health over performance outcomes, competitive athletics can foster a culture that supports both physical excellence and mental well-being.
References
- Bratland‐Sanda S, Sundgot‐Borgen J. Eating disorders in athletes: Overview of prevalence, risk factors and recommendations for prevention and treatment. European Journal of Sport Science. 2012;13(5):499-508.
- Currie A. Sport and eating disorders - understanding and managing the risks. Asian Journal of Sports Medicine. 2010;1(2).
