Eating Disorders and Athletes

By Riley Nickols, PhD, CEDS

Sport is a great way to build self-esteem, promote physical conditioning, and demonstrate the value of teamwork, but not all athletic stressors are positive. The pressure to excel in sport and an overemphasis on body weight, body composition, and body shape can pose a significant risk for athletes.1,2,3 Athletic competition can also contribute to psychological and physical stress. When the pressures of athletic competition are added to an existing cultural emphasis on thinness, the risks increase for athletes to develop disordered eating, increasing an athlete’s vulnerability to develop an eating disorder thereafter.4,5

The prevalence rates for eating disorders have been shown to be higher in athletes compared to non-athletes and have been found to range from 6-45% in female athletes and 0-19% in male athletes.6 The wide range of prevalence rates found in athletes is likely due to studies using different methods of eating disorder assessment (i.e., EAT-26, EDE-Q, SCOFF, clinical interviews) and varying degrees of transparency of eating disorder symptoms when assessed. Though most athletes with eating disorders are female, male athletes are also at risk and suffer from this illness.7,8

Risk Factors for Athletes


  • Sports such as gymnastics, diving, bodybuilding, or wrestling that emphasize appearance, weight requirements, or muscularity.4,5
  • Sports that focus on the individual (gymnastics, running, figure skating, dance, diving) rather than the entire team (basketball, soccer).9
  • Endurance sports such as running, cycling, swimming.3,10
  • Overvalued belief that a lower body weight and body fat composition will improve performance.11,12,13
  • Early sport specialization including focused training for a sport since childhood.10,14
  • Participating in a higher competitive level as an athlete.15,16
  • An environment in which there is pressure to modify weight and/or to maintain precise control of body composition.25
  • Low self-esteem; perfectionism, family dysfunction; family members who have or have had eating disorders; chronic dieting; training and exercise that results in harmful health consequences or exercise for the purpose of weight loss; peer, family and cultural pressures to be thin and other traumatic life experiences such as a history of physical or sexual abuse.17,18,19,20,21,22,23
  • Coaches who focus primarily on success and performance rather than on the athlete as a whole person.24
  • An environment in which there is pressure to either lose or gain weight and/or to maintain close control of body composition.25
  • Pressure to perform, other teammates modeling eating disorder behaviors, injury, and team weigh-ins.24

Protective Factors for Athletes


  • Positive, person-oriented coaching style rather than negative, performance-oriented coaching style.26
  • Coaches, sport personnel, and parents who abstain from giving specific nutrition, weight, and/or body composition recommendations to athletes and, instead, refer to qualified professionals to provide such support.25
  • Coaches who support treatment recommendations.27
  • Awareness that eating disorders are present in all sports and can impact athletes of all genders, ages, competitive level, socioeconomic status, and athletes at all body weights, shapes, and sizes.28,29
  • Participation in a sport culture that emphasizes body functionality over body appearance has been suggested to be a protective factor for body image issues and disordered eating.30,31
  • Coaches who emphasize factors that contribute to personal success such as motivation, teamwork, dedication, commitment, and enthusiasm rather than body weight, shape, or body composition.32
  • Coaches who prioritize athlete’s mental health and cultivate a safe and supportive culture within their team.33
  • Having a strong coach/athlete relationship.34
  • Coaches who foster positive body image messaging and culture within their team.
  • Early detection and referral to qualified professionals for eating disorder evaluation are critical to preserve an athlete’s health and initiate timely, targeted treatment thereafter.25

Relative Energy Deficiency in Sport (RED-S)


In 2014, the International Olympic Committee (IOC) published the consensus statement Beyond the Female Athlete Triad: Relative Energy Deficiency in Sport whereby RED-S expanded upon the Female Athlete Triad’s three conditions: low bone mineral density, functional hypothalamic amenorrhea, and low energy availability (LEA). A primary tenet of RED-S is that any athlete, regardless of gender, sport, or competitive level can experience this syndrome.36,37

It is important for athletes and sport personnel to understand how RED-S can have damaging effects on all systems in the body, including psychological functioning. The RED-S framework includes more considerations due to low energy availability (LEA). LEA is a state in which the body does not have enough energy to support all of its functions. This leads to issues with reproductive health (menstrual dysfunction and low estrogen for females, low testosterone for males, decreased libido for those with LEA), cardiovascular functioning (unstable vital signs, bradycardia or tachycardia due to LEA), immune functioning, growth and development, hematological, gastrointestinal , and metabolic functioning. Psychological consequences can either precede RED-S or may worsen by RED-S.36,37

Treatment Considerations


Given the serious physical and psychological consequences that can result from eating disorders, it is important to seek professional help as soon as possible. The treatment of an athlete who struggles with disordered eating or an eating disorder requires working with a multidisciplinary team of health and mental health professionals who ideally have expertise treating both eating disorders and athletes. A treatment provider’s dual specialization of eating disorders and athletes can be beneficial to an athlete during treatment due to the provider’s awareness and sensitivity to the unique demands and challenges of sport. This treatment team may include a physician, psychiatrist, mental health provider, and dietician. With the athlete’s consent, it can be beneficial for the athlete’s treatment team to communicate with sport personnel (i.e., coach, athletic trainer, strength and conditioning coach) throughout treatment to coordinate care. Collectively, it can be determined if modifications to an athlete’s sport participation are warranted to support an athlete’s health and treatment targets.36

Learn more about treatment here.
Learn more about finding treatment providers in your area here.

Sources


[1] Gorrell, S., Nagata, J. M., Hill, K. B., Carlson, J. L., Shain, A. F., Wilson, J., Alix Timko, C., Hardy, K. K., Lock, J., & Peebles, R. (2021). Eating behavior and reasons for exercise among competitive collegiate male athletes. Eating and weight disorders : EWD, 26(1), 75–83. https://doi.org/10.1007/s40519-019-00819-0

[2] Godoy-Izquierdo D., Ramírez M.J., Díaz I., López-Mora C. (2021). A systematic review on exercise addiction and the disordered eating-eating disorders continuum in the competitive sport context. International Journal of Mental Health Addiction, 1–33. https://doi.org/10.1007/s11469-021-00610-2

[3] 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

[4] Chapa, D. A., Johnson, S. N., Richson, B. N., Bjorlie, K., Won, Y. Q., Nelson, S. V., Ayres, J., Jun, D., Forbush, K. T., Christensen, K. A., & Perko, V. L. (2022). Eating-disorder psychopathology in female athletes and non-athletes: A meta-analysis. International Journal of Eating Disorders, 55(7), 861–885. https://doi.org/10.1002/eat.23748

[5] Chapman, J., & Woodman, T. (2015). Disordered eating in male athletes: A meta-analysis. Journal of Sports Sciences, 34(2), 101–109. https://doi.org/10.1080/02640414.2015.1040824

[6] Bratland-Sanda, S., & Sundgot-Borgen, J. (2013). Eating disorders in athletes: Overview of prevalence, risk factors and recommendations for prevention and treatment. European Journal of Sport Science, 13(5), 499–508. https://doi.org/10.1080/17461391.2012.740504

[7]Eichstadt, M., Luzier, J., Cho, D., & Weisenmuller, C. (2020). Eating disorders in male athletes. Sports Health: A Multidisciplinary Approach, 12(4), 327–333. https://doi.org/10.1177/1941738120928991

[8]Rousselet, M., Guérineau, B., Paruit, M. C., Guinot, M., Lise, S., Destrube, B., Ruffio-Thery, S., Dominguez, N., Brisseau-Gimenez, S., Dubois, V., Mora, C., Trolonge, S., Lambert, S., Grall-Bronnec, M., & Prétagut, S. (2017). Disordered eating in French high-level athletes: association with type of sport, doping behavior, and psychological features. Eating and weight disorders : EWD, 22(1), 61–68. https://doi.org/10.1007/s40519-016-0342-0

[9] Firoozjah, M. H., Shahrbanian, S., Homayouni, A., & Hower, H. (2022). Comparison of eating disorders symptoms and body image between individual and team sport adolescent athletes during the COVID-19 pandemic. Journal of Eating Disorders, 10(1). https://doi.org/10.1186/s40337-022-00644-4

[10] Sundgot-Borgen, J., & Torstveit, M. K. (2004). Prevalence of eating disorders in elite athletes is higher than in the general population. Clinical Journal of Sport Medicine, 14(1), 25–32. https://doi.org/10.1097/00042752-200401000-00005

[11] Joy, E., Kussman, A., & Nattiv, A. (2016). 2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management. British Journal of Sports Medicine, 50(3), 154–162. https://doi.org/10.1136/bjsports-2015-095735

[12] Kontele, I., Vassilakou, T., & Donti, O. (2022). Weight pressures and eating disorder symptoms among adolescent female gymnasts of different performance levels in Greece. Children, 9(2), 254. https://doi.org/10.3390/children9020254

[13] Ravi, S., Ihalainen, J. K., Taipale-Mikkonen, R. S., Kujala, U. M., Waller, B., Mierlahti, L., Lehto, J., & Valtonen, M. (2021). Self-Reported Restrictive Eating, Eating Disorders, Menstrual Dysfunction, and Injuries in Athletes Competing at Different Levels and Sports. Nutrients, 13(9), 3275. https://doi.org/10.3390/nu13093275 

[14] Daley, M. M., Shoop, J., & Christino, M. A. (2023). Mental Health in the Specialized Athlete. Current reviews in musculoskeletal medicine, 16(9), 410–418. https://doi.org/10.1007/s12178-023-09851-1

[15] Fochesato, R., Guidotti S., & Pruneti, C. (2021). Risk of developing eating disorders through the misperception of the body image and the adoption of bad eating habits in a sample of young volleyball athletes. Archives of Food and Nutritional Science, (5)7–17. https://doi.org/10.29328/journal.afns.1001027

[16] Kong, P., & Harris, L. M. (2014). The sporting body: Body image and eating disorder symptomatology among female athletes from Leanness focused and nonleanness focused sports. The Journal of Psychology, 149(2), 141–160. https://doi.org/10.1080/00223980.2013.846291

[17] Pelc, A., Winiarska, M., Polak-Szczybyło, E., Godula, J., & Stępień, A. E. (2023). Low Self-Esteem and Life Satisfaction as a Significant Risk Factor for Eating Disorders among Adolescents. Nutrients, 15(7). https://doi.org/10.3390/nu15071603 

[18] Frieiro, P., González-Rodríguez, R., & Domínguez-Alonso, J. (2022). Self-esteem and socialisation in social networks as determinants in adolescents’ eating disorders. Health & Social Care in the Community, 30(6), e4416–e4424. https://doi.org/10.1111/hsc.13843

[19] Abbott, W., Brett, A., Brownlee, T. E., Hammond, K. M., Harper, L. D., Naughton, R. J., Anderson, L., Munson, E. H., Sharkey, J. V., Randell, R. K., & Clifford, T. (2020). The prevalence of disordered eating in elite male and female soccer players. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity, 26(2), 491–498. https://doi.org/10.1007/s40519-020-00872-0

[20] Rienecke, R. D., Johnson, C., Le Grange, D., Manwaring, J., Mehler, P. S., Duffy, A., McClanahan, S., & Blalock, D. V. (2022). Adverse childhood experiences among adults with eating disorders: Comparison to a nationally representative sample and identification of trauma profiles. Journal of Eating Disorders, 10(1). https://doi.org/10.1186/s40337-022-00594-x

[21] de Barse, L. M., Tharner, A., Micali, N., Jaddoe, V. V. W., Hofman, A., Verhulst, F. C., Franco, O. H., Tiemeier, H., & Jansen, P. W. (2015). Does maternal history of eating disorders predict mothers’ feeding practices and preschoolers’ emotional eating? Appetite, 85, 1–7. https://doi.org/10.1016/j.appet.2014.10.031

[22] Patton, G. C., Selzer, R., Coffey, C., Carlin, J. B., & Wolfe, R. (1999). Onset of adolescent eating disorders: Population based cohort study over 3 years. BMJ, 318(7186), 765–768. https://doi.org/10.1136/bmj.318.7186.765

[23] Schaumberg, K., Bulik, C. M., & Micali, N. (2023). Patterns of maladaptive exercise behavior from ages 14–24 in a longitudinal cohort. Journal of Child Psychology and Psychiatry. https://doi.org/10.1111/jcpp.13844

[24] Arthur-Cameselle, J., Sossin, K., & Quatromoni, P. (2016). A qualitative analysis of factors related to eating disorder onset in female collegiate athletes and non-athletes. Eating Disorders, 25(3), 199–215. https://doi.org/10.1080/10640266.2016.1258940

[25] Wells, K. R., Jeacocke, N. A., Appaneal, R., Smith, H. D., Vlahovich, N., Burke, L. M., & Hughes, D. (2020). The Australian Institute of Sport (AIS) and National Eating Disorders Collaboration (NEDC) position statement on disordered eating in high performance sport. British journal of sports medicine, 54(21), 1247–1258. https://doi.org/10.1136/bjsports-2019-101813

[26] Biesecker, A. C., & Martz, D. M. (1999). Impact of Coaching Style on Vulnerability for Eating Disorders: An Analog Study. Eating Disorders, 7:3, 235-244. 10.1080/10640269908249289

[27] Selby, C. L., & Reel, J. J. (2011). A coach’s guide to identifying and helping athletes with eating disorders. Journal of Sport Psychology in Action, 2(2), 100–112. https://doi.org/10.1080/21520704.2011.585701

[28] Macpherson, M. C., Harrison, R., Marie, D., & Miles, L. K. (2022). Investigating coaches’ recognition of symptoms of eating disorders in track athletes. BMJ open sport & exercise medicine, 8(3), e001333. https://doi.org/10.1136/bmjsem-2022-001333

[29] Neglia A. (2021). Nutrition, Eating Disorders, and Behavior in Athletes. The Psychiatric clinics of North America, 44(3), 431–441. https://doi.org/10.1016/j.psc.2021.04.009

[30] Lunde, C., & Gattario, K. H. (2017). Performance or appearance? Young female sport participants’ body negotiations. Body Image, 21, 81–89. https://doi.org/10.1016/j.bodyim.2017.03.00

[31] Soulliard, Z. A., Fitterman-Harris, H. F., Perry, J. E., Poe, L. M., & Ross, M. J. (2021). Differences in body appreciation and functionality appreciation outside of and directly following sport among collegiate student-athletes. The Sport Psychologist, 35(4), 320–328. https://doi.org/10.1123/tsp.2020-0175

[32] Sundgot-Borgen, J., Meyer, N. L., Lohman, T. G., Ackland, T. R., Maughan, R. J., Stewart, A. D., & Müller, W. (2013). How to minimise the health risks to athletes who compete in weight-sensitive sports review and position statement on behalf of the Ad Hoc Research Working Group on body composition, health and performance, under the auspices of the IOC Medical Commission. British Journal of Sports Medicine, 47(16), 1012–1022. https://doi.org/10.1136/bjsports-2013-092966 

[33] Bissett, J. E., Kroshus, E., & Hebard, S. (2020). Determining the role of sport coaches in promoting athlete mental health: a narrative review and Delphi approach. BMJ open sport & exercise medicine, 6(1), e000676. https://doi.org/10.1136/bmjsem-2019-000676

[34] Coker-Cranney, A., & Reel, J. J. (2015). Coach pressure and disordered eating in female collegiate athletes: Is the coach-athlete relationship a mediating factor? Journal of Clinical Sport Psychology, 9(3), 213–231. https://doi.org/10.1123/jcsp.2014-0052

[35] Borowiec, J., Banio-Krajnik, A., Malchrowicz-Mosko, E., & Kantanista, A. (2023). Eating disorder risk in adolescent and adult female athletes: the role of body satisfaction, sport type, BMI, level of competition, and training background. BMC Sports Science, Medicine and Rehabilitation, 15:91 https://doi.org/10.1186/s13102-023-00683-7

[36] Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., Meyer, N., Sherman, R., Steffen, K., Budgett, R., & Ljungqvist, A. (2014). 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

[37] Otis, C. L., Drinkwater, B., Johnson, M., Loucks, A., & Wilmore, J. (1997). American College of Sports Medicine position stand. The Female Athlete Triad. Medicine and science in sports and exercise, 29(5), i–ix. https://doi.org/10.1097/00005768-199705000-00037